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- Presentation
Keystone Island Perforator Flap for Lower Leg Reconstruction
Description
The speaker introduces the Keystone Island Perforator Flap as a favorite, highly useful option for lower-leg reconstruction, especially when linear closure would be too tight. He explains that the flap was described by Felix Behan and is named for its trapezoidal shape, which resembles a keystone in an arch. The talk emphasizes three practical versions of the flap as a stepwise plan A, B, and C: the standard keystone flap, adding a fascial incision at the trailing edge to increase mobility, and, if needed, using opposing flaps. The vascular basis comes from perforators connecting deep and superficial circulation, and the flap is designed longitudinally to capture more perforators, though a single perforator may be enough. He stresses that circumferential islanding improves blood supply, making the flap robust, often painless, and highly reliable, with reported success around 98% and very low necrosis rates. Design principles include making the width at least the size of the defect, often wider in high-tension areas, and using a 90-degree orientation off the defect. The procedure is described as simple, with no undermining, closure with tension-distributing sutures, and dressings/compression as desired. He shows multiple examples on the ankle, dorsum of foot, pretibial area, calf, neck, and back, noting that these flaps tend to heal well and are useful when wounds are not suitable for second-intent healing. Complications are acknowledged, especially dehiscence, which can often be resutured successfully, while flap necrosis is rare. Postoperative advice includes taking it easy for about two weeks and leaving sutures in for roughly three weeks.
View moreConclusions
- Keystone island perforator flaps are presented as a highly reliable option for closing high-tension wounds, especially on the lower leg.
- The flap works by distributing tension over a wider area while preserving robust perfusion from underlying perforators.
- A major practical advantage is that the technique is surgically efficient because it requires little or no undermining.
- The flap can be designed simply by matching or exceeding the defect width and orienting it longitudinally to capture perforators.
- Type I, fascia-incising, and double-opposing variations provide a stepwise escalation if a basic keystone flap is not enough.
- Reported outcomes suggest very high success rates, with overall flap success around 98% and very low flap necrosis rates.
- Complications do occur, but the most common issue is dehiscence, which can often be managed by resuturing.
- In this presentation, the author concludes that keystone flaps are generally more dependable than alternatives such as propeller flaps or free flaps for many lower-extremity closures.
- Postoperative care is relatively straightforward, with sutures typically left in place for about 21 to 28 days and activity limited only modestly.
- Overall, the research and clinical experience presented support keystone flaps as a robust, versatile, and low-complication reconstruction method for challenging defects on the legs and elsewhere.
- Behan F, Findlay M, Lo CH. The Keystone Perforator Island Flap Concept. Churchill Livingstone/Elsevier.
- Copyright © The Author(s) 2020. World J Clin Cases. 2020 May 26; 8(10): 1832-1847. doi:10.12998/wjcc.v8.i10.1832.#10.12998/wjcc.v8.i10.1832
- Clin Plast Surg. 2010;37:553–570. doi:10.1016/j.cps.2010.06.006.#10.1016/j.cps.2010.06.006
- Outcomes of the Keystone Island Perforator Flap: A Systematic Review.#10.1055/s-0042-1745744
- Journal of Reconstructive Microsurgery. Vol. 38 No. 9/2022. Fig. 1 Keystone flap illustration.
- Justiano H, Eisen DB. Closure of dehisced operative sites without wound freshening results in acceptable rates of repeat dehiscence and infection. Br J Dermatol. 2009 Oct;161(4):953-8. doi:10.1111/j.1365-2133.2009.09387.x.#10.1111/j.1365-2133.2009.09387.x
- Evolving Concepts of Keystone Perforator Island Flaps (KPIF): Principles of Perforator Anatomy, Design Modifications, and Extended Clinical Applications.#10.1097/prs.0000000000002208