Keystone Flap: Overcoming Paradigms

Abstract

Background: The physiology and geometry of the keystone flap (KF) are the main factors that support its development. This study reports our experience using the KF and proposes the concept of pedicular area. Methods: A prospective cohort study was conducted from October 2014 to December 2016, in which 112 KF procedures were performed with an average follow-up time of 10 months. The conclusions drawn from clinical observations were compared with the findings of a literature review. Results: One hundred twelve flaps were performed in 89 patients (45 men and 44 women) with an average age of 64 years (range, 3–89 years). The flap survival rate was 100%. The term pedicular area (PA) was coined to describe a flap segment that remains attached to its bed without vascular detriment and whose location can be randomly selected. In this study, the PA could be reduced up to a 10%, which means that over 90% of each flap was dissected without any harm. Conclusions: The KF is a safe, cost-effective technique with better results when compared with other reconstructive procedures. Although research is still needed to better understand the physiological adaptations of KF, the clinical evidence supports its use in many reconstructive scenarios.

Reconstruction of the Defect at Temporal Hairline by a Scalp Keystone Island Flap: Clinical Experience on 14 Cases

“…With the flexible design and with a convenient operation, the keystone island has been widely applied and developed in the field of reconstruction surgery in previous decades. [14][15][16] In the cases presented here, the connection of the scalp keystone island flap with surrounding tissue was excised except for the superficial temporal fascia pedicle in the caudal direction. Compared with other scalp flaps, this creates more mobility with the advantage of a smaller dissection and less damage.…”

The UQ Flap: A Novel Modification of the Keystone Flap

“…6,7 Due to vascular dependence on perforators, caution is necessary in areas surgically or traumatically dissected. 4,8…”

Keystone design perforator island flaps for coverage of non-oncological periarticular defects surrounded by the zone of injury

“…KDPIF reconstruction has expanded from simple to complex defects throughout the body because of its evident advantages, including its simple defect-adaptive design, easy reproducibility, high level of safety, and short procedural time. [2][3][4][6][7][8][9] Relative contraindications for KDPIF reconstruction include traumatic, irradiated, and inflammatory defects. 3,9 These defects differ from oncological defects in that the surrounding tissues have a tendency to be under the zone of injury and are usually accompanied by wound infection.…”

“…Given that the recruitment of tissue laxity is the principal biomechanical consideration in KDPIF reconstruction, a primary defect without surrounding tissue laxity is exchanged for a secondary defect with sufficient laxity in all margins to enable primary closure. 8,20,22 V-Y advancement flaps at either end of the KDPIF facilitate the recruitment of laxity, and skin tension is redistributed perpendicular to the direction of maximal wound tension. 3,[6][7][8]20,22 Therefore, we believe that the KDPIF should be designed on the edge of the defect that has greater tissue laxity because this facilitates distribution of the tension required for closure throughout the periphery.…”

“…Among various local flaps, the keystone design perforator island flap (KDPIF) devised by Behan 6 in 2003 has been applied to various fields of reconstructive surgery in the past decade because of its design simplicity, robust vascular supply, and easy reproducibility. 3,[7][8][9] The KDPIF, similar to the perforator-based island flap first described by Kim et al 10 in 2010, does not require microsurgical perforator dissection, allowing for a safe and rapid operation. 2,3,6,7 In numerous studies of KDPIF reconstruction, the causes of defects were usually oncological (after skin and soft tissue tumor removal), 3 and few reports have described periarticular defect coverage.…”