Introduction:Viscoelastic properties of skin in coloured ethnic groups are less favourable compared to Caucasians for executing Keystone flaps. Keystone flaps have so far been evaluated and reported only in Caucasians. The potential of Keystone flaps in a coloured ethnic group is yet unknown.Aim:This article reviews the experience to reconstruct skin defects presenting in a coloured ethnic group, by using Keystone flaps, with a review of existing literature.Design:Uncontrolled case series.Materials and Methods:This retrospective review involves 55 consecutive Keystone flaps used from 2009 to 2012, for skin defects in various locations. Patient demographic data, medical history, co-morbidity, surgical indication, defect features, complications, and clinical outcomes are evaluated and presented.Results:In this population group with Fitzpatrick type 4 and 5 skin, the average patient age was 35.73. Though 60% of flaps (33/55) in the series involved specific risk factors, only two flaps failed. Though seven flaps had complications, sound healing was achieved by suitable intervention giving a success rate of 96.36%. Skin grafts were needed in only four cases.Conclusions:Keystone flaps achieve primary wound healing for a wide spectrum of defects with an acceptable success rate in a coloured skin population with unfavorable biophysical properties. By avoiding conventional local flaps and at times even microsurgical flaps, good aesthetic outcome is achieved without additional skin grafts or extensive operative time. All advantages seen in previous studies were verified. These benefits can be most appreciated in coloured populations, with limited resources and higher proportion of younger patients and unfavorable defects.

The use of perforator-based flaps as freestyle pedicled flaps for traumatic defects has been limited. We explored this possible application in small to moderate sized traumatic defects presenting in the delayed phase, with distinct oedema and induration in the potential flap donor area and posttraumatic vessel disease. Attempts to skeletonize perforator vessels are likely to compromise the flap perfusion, and inadequate dissection is likely to limit mobility of the indurated tissues in the flap. Conventionally, an axial pattern pedicled or a free flap would be needed in such cases, thus increasing its magnitude. We used the freestyle technique to cover traumatic defects by retrograde dissection of pedicled perforator-based flaps. As the surgery was performed in the delayed phase, the tissues were indurated and a larger tissue cuff was preserved around the pedicle than would be our practice in elective surgery. In addition, flap dimensions were planned larger than the defect to be closed. The donor defect was either skin grafted or closed primarily. Our study included 11 cases at various sites over the body. All flaps survived, though 3 flaps encountered major complications, 2 of which needed reoperation. None of the flaps failed completely. The pedicled perforator-based flap provides the surgeon with additional reconstructive options in the setting of trauma. These flaps can be safely harvested using indurated tissue; thus in selected cases, a free flap can be avoided, and reliable cover can be provided with a pedicled flap. Nevertheless, clinical judgment is essential to assess the potential vascular territory of the flap.

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