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Cohen-Shohet et al. Plast Aesthet Res 2019;5:28 I http://dx.doi.org/10.20517/2347-9264.2019.030 Page 7 of 13

Figure 8. Lateral malleolar wound after resection of a recurrent melanoma

Figure 9. Large propeller flap was designed on the peroneal artery perforators. This was isolated on a single perforator and rotated into
the wound. The blue “X” denotes the location of the peroneal artery perforator

and lateral joint capsule. A large propeller flap was designed on the peroneal arteries [Figure 9]. This was
rotated 180 degrees to fill the distal defect [Figure 10]. Figure 11 shows the flap healed post-operatively.
There is good coverage over the joint, which is soft and supple and has full range of motion.

Keystone flaps
Although originally described for trunk defects, there is a limited but important role in lower extremity
reconstruction. The keystone flap is based on fasciocutaneous perforators. The flap is designed so that each
limb of the flap is 90 degrees from the longitudinal axis of the flap. This has been described throughout
the literature for lower extremity defects mostly in the setting of oncologic reconstruction [26-28] with good
outcomes. Limitations of the keystone flaps include limited advancement and no rotational movement.

Sequential perforator flaps: Kiss flap technique
A persisting problem in lower extremity perforator flaps is the donor site. They often cannot be closed
primarily and may require skin grafting, which can have negative cosmetic outcomes, especially in
[29]
African American or Asian populations. The Kiss flap, described by Zhang et al. , is based on the goal of
harvesting multiple skin paddles and rearranging them side by side for defect reconstruction. This then