Keystone Island Flap: An Alternative Reconstructive Option to Free Flaps in Irradiated Tissue

Abstract

There is a low complication rate using Keystone flaps (this double VY is a clinical development from Diffenbach's original work of 1848(1)) and this technique is particularly useful in achieving wound healing especially after irradiation treatment. This surgical technique once mastered is easy to perform. Another bonus is that there is minimal use of postoperative analgesia. Additional XRT is well tolerated by the patients with minimal evidence of wound complications, while achieving an acceptable aesthetic appearance.

Evolving Concepts of Keystone Perforator Island Flaps (KPIF): Principles of Perforator Anatomy, Design Modifications, and Extended Clinical Applications

“…These environments have been considered a relative contraindication to the use of keystone island flaps 10 ; however, these complex wound reconstructions can be successfully applied following careful selection, planning, and execution. 22 Longer incisions and potential for scarring can be addressed by minimizing tension at the incision line, use of progressive tension sutures, aligning scars within aesthetic units, and limiting dissection as necessary. In most cases, limited deep dissection and undermining reduces the morbidity and potential scarring compared with conventional perforator flaps.…”

Extensive Mine-Shrapnel and Gunshot Wound Closure Using Keystone Island Perforator Flaps

“…According to our data, the average time to complete this surgery is 68 minutes. The work of Behan et al 8,13 and Khouri et al 7 fully confirms this finding, although the authors noted that the operating time may also depend on the size of the defect. Other perforator island flap methods take up to 120 minutes.…”

“…This method significantly reduces rehabilitation time and material costs. 5,7,12,13 In terms of the selected artery, the keystone flap method is much better than free flaps or perforator flaps in operation time. According to our data, the average time to complete this surgery is 68 minutes.…”

“…12 The relatively simple design of local perforator keystone island flaps and the elimination of the need for invasive x-ray diagnostics during flap preplanning allow us to recommend this technique for the adequate recovery of lost tissue with complete skin-fascial coverage, a minimum operational risk, and excellent functional and aesthetic results in patients with military injuries. 2,3,7,13 Other advantages of this method include a more stable blood supply to the displaced tissues with rapid postoperative recovery of perfusion compared with other types of flap procedures; minimal damage to the donor area; acceptable functional and aesthetical results in the restored area; and a good “cost-effectiveness” parameter. 5,7,11,14 …”

The Keystone Flap for Lower Extremity Defects

“…1 The unique flap design exploits skin laxity within the flap, around the primary defect, and around the secondary defect. 4 As with all flaps, the keystone flap requires adjacent tissue laxity for success. V-Y advancement performed at the distal ends of the secondary defect further decreases the length and width of the secondary defect and facilitates closure.…”