Research Article| Volume 60, ISSUE 8, P888-891, August 2007

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



      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.


      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.


      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.


      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.


      The presence of perforators and subcutaneous network distributed throughout the body create an environment which makes this flap universally applicable and extremely reliable.


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        • Behan F.C.
        The keystone design perforator island flap in reconstructive surgery.
        ANZ J Surg. 2003; 73: 112-120
        • Behan F.
        • Sizeland A.
        • Porcedu S.
        • et al.
        Keystone island flap: an alternative reconstructive option to free flaps in irradiated tissue.
        ANZ J Surg. 2006; 76: 407-413
        • Pelissier P.
        • Santoul M.
        • Pinsolle V.
        • et al.
        The keystone design perforator island flap. Part I: anatomic study.
        J Plast Reconstr Aesthet Surg. 2007; 60: 883-887
        • Bertelli J.A.
        Neurocutaneous axial island flaps in the forearm: anatomical, experimental and preliminary clinical results.
        Br J Plast Surg. 1993; 46: 489-496
        • Bertelli J.A.
        • Pagliei A.
        The neurocutaneous flap based on the dorsal branches of the ulnar artery and nerve: a new flap for extensive reconstruction of the hand.
        Plast Reconstr Surg. 1998; 101: 1537-1543
        • Taylor G.I.
        • Gianoutsos M.P.
        • Morris S.F.
        The neurovascular territories of the skin and muscles: anatomic study and clinical implications.
        Plast Reconstr Surg. 1994; 94: 1-36
        • Niranjan N.S.
        • Price R.D.
        • Govilkar P.
        Fascial feeder and perforator-based V Y advancement flaps in the reconstruction of lower limb defects.
        Br J Plast Surg. 2000; 53: 679-689
        • Geh J.L.
        • Niranjan N.S.
        Perforator-based fasciocutaneous island flaps for the reconstruction of axillary defects following excision of hidradenitis suppurativa.
        Br J Plast Surg. 2002; 55: 124-128

      Linked Article

      • The keystone design perforator island flap. Part I: Anatomic study
        Journal of Plastic, Reconstructive & Aesthetic SurgeryVol. 60Issue 8
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          The keystone design perforator island flap has been described as a curvilinear shaped trapezoidal design flap that is essentially two V–Y flaps end-to-side. Viability of the flap is thought to be supported by the subcutaneous vascular network and fascial and muscular perforators. The aim of this study was to assess the vascularisation of this flap and the behaviour of the skin paddle when submitted to important traction forces.
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