The Keystone Island Flap: Use in Large Defects of the Trunk and Extremities in Soft-Tissue Reconstruction

Abstract

The keystone flap can be applied to large defects of the trunk and extremities, obviating the need for either microsurgical techniques or extensive operative time while achieving primary wound healing. Despite minor complications, the 97 percent reconstructive success rate compares well to published rates of microsurgical tissue transfers but has several advantages: short operative times, high reproducibility, ease of use, and favorable aesthetic outcome. The authors conclude that the keystone flap is a reliable and effective reconstructive surgical technique for reconstruction of soft-tissue defects.

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

“…28 Previous modifications include a "yin yang" reconstruction, 29 including partial undermining and interdigitation of bilateral keystone flaps, 7 and the "omega variant," where both limbs of a single keystone are folded into a horseshoe shape. 30 Although there is a significant reduction in flap loss and partial necrosis, these complications may still occur 10,21,26 ; however, most can be treated conservatively or with minor intervention. A comparison with other sarcoma flap reconstructions at the Mayo Clinic over the past 5 years (n = 127 patients) shows that 9 percent were free flaps and the remainder were locoregional pedicled flaps.…”

“…These flaps are executed as a single multiperforator fasciocutaneous advancement flap based on random fasciocutaneous or musculocutaneous perforators. 10 Principles in vascular anatomy and perforator vascular territories (perforasome) 2 can be used to reappraise the vascular basis of the keystone flap and modifications of the flap design to maintain vascular integrity.…”

Reconstruction for basal cell carcinoma in an anatomical region where the sun does not shine: an attractive option!

“…6 Khouri et al reported a 35.7% complication rate in a cohort of 28 patients with a keystone flap for a large soft tissue defect to the trunk and extremities but only 2 patients had partial flap necrosis and 1 required a skin graft for wound closure. 7 In our case, with potentially difficult and challenging anatomical territory, we achieved a stable, durable, excellent aesthetic and sensate reconstruction. We used a unilateral keystone flap for perianal soft tissue reconstruction.…”

Soft Tissue Coverage in Abdominal Wall Reconstruction

“…The flap is designed as a large 3:1 ellipse parallel to the long axis of the defect. 2 The blood supply to the flap is based on cutaneous perforators that shift toward the defect when the flap is advanced. Once the leading edge of the keystone flap is inset the donor site is closed on itself from the poles of the long axis of the flap to the side of the flap remote from the defect.…”