The keystone island flap: use in large defects of the trunk and extremities in soft-tissue reconstruction

Microsurgical perforator flaps are useful in an array of reconstructive scenarios, but their technical complexity, steep learning curves, and prolonged operative times may limit their widespread adoption. Alternatively, the keystone island flap combines perforator-based vascularity with relative simplicity of nonmicrosurgical tissue rearrangement. This article reviews the authors' reconstructive experience using the keystone flap to reconstruct large trunk and extremity defects.

The authors performed a retrospective chart review of patients undergoing keystone flap reconstruction between 2002 and 2008. Patient demographic data, medical histories, comorbidities, surgical indications, defect characteristics and locations, hospitalization, complications, and follow-up care were evaluated and are presented in this article as an uncontrolled case series.

Twenty-eight patients underwent keystone flap reconstruction. The average wound size measured 15.0 ± 11.7 × 13.0 ± 7.9 cm (250.5 ± 379.4 cm2). The average length of stay, including tumor resection, was 6.36 ± 6.68 days. A 35.7 percent overall complication rate was noted; partial and total flap loss was observed in only 7 percent of patients. One patient (3 percent) failed reconstruction and required alternative wound closure.

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.