The keystone design perforator island flap. Part II: clinical applications

Background: This curvilinear- and trapezoidal-shaped flap essentially consists of two conjoined V-Y flaps end to side. The vascular supply is supported by the subcutaneous vascular network and is dependent on fascial and muscular perforators. A review of 15 clinical cases was performed to assess the reliability and versatility of the flap. Methods: Twelve keystone flaps were performed following excision of skin tumours or post-traumatic defects in various locations, from the head and neck region, the trunk and the limbs. Results: No flap necrosis, even partial, was observed regardless of the site and the type of keystone used. Patients were almost pain free in the postoperative course. The aesthetic results are quite satisfactory, as the flap is aligned locally without evidence of the 'pincushioning' appearance sometimes seen around island reconstructions. Discussion: Elevation of the flap seems to evenly distribute the tensional forces without undermining. The flap is particularly useful in the repair of defects following skin cancer removal. Bulk is not a problem and good skin cover is achieved. Conclusion: The presence of perforators and subcutaneous network distributed throughout the body create an environment which makes this flap universally applicable and extremely reliable. (c) 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.