The keystone flap as an esthetic alternative for nasal soft tissue restoration

A keystone island perforator advancement flap can be relatively pain free, esthetic pleasing, and have minimal vascular complications, with all this achieved efficiently. Although considered as a reliable reconstructive option virtually throughout the body, current evidence that would confirm its validity when used solely for nasal soft tissue restoration is sparse.

Over the past 5 years, keystone flaps were used in 25 patients to close defects following nasal skin cancer excision or scar revision. Demographic data for this retrospective chart review included etiology, defect dimensions, nasal subunit involvement, and complications when so employed.

A total of 26 keystone flaps were used to close 25 defects encompassing all nasal subunits except the soft triangle and columella. Additionally, no nasal rim nor alar base repairs were attempted. Only relatively narrow defects (10.9 + 3.4 mm) were closed; and to achieve reach, especially within the lower lateral or alar subunits, 14 (53.8%) flaps included the underlying nasalis muscle to preserve circulation. Complications were unusual, with the most common being retraction of the alar rim in 5 (20%) patients, which typically receded significantly and required no secondary procedures.

A keystone flap is a local flap option using adjacent nasal tissues to match nasal color and texture, and can be quickly completed in a single operative stage. Scars can be well hidden in crevices or along subunit boundaries that will be esthetically acceptable. Limitations may be major contour deformity sequalae and moderate or larger sized defects cannot be so closed.