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Original Article Plastic and Aesthetic Research

The keystone-design perforator-based flap

for leg defects: a synthesis of philosophies

Jerry R. John , Jyoshid R. Balan , Satyaswarup Tripathy , Ramesh Kumar Sharma ,
1
1
1
2
Chandan Jadhav 1
1 Department of Plastic Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India.
2 Department of Plastic Surgery, Sushruta Institute of Plastic Surgery, Elite Hospitals, Thrissur 680007, Kerala, India.
Address for correspondence: Dr. Jerry R. John, Department of Plastic Surgery, Post Graduate Institute of Medical Education and
Research (PGIMER), Sector–12, Chandigarh 160012, India. E-mail: jerryrjohn@hotmail.com

ABSTRACT
Aim: The classical keystone-design flap, although elegantly employed for various trunk defects, has
limited movement on the leg. This study aims to modify the keystone–design flaps for leg defects.
Methods: A keystone-design flap, in which perforators are identified and dissected, is described
specifically for elliptical defects overlying the tibia. Results: It retains the unique advantages of both the
perforator island flap concept as well as the keystone-design philosophy. Conclusion: The technique
as well as the possibilities of raising such flaps over various areas of the leg is outlined.

Key words:
Flap, keystone, leg defect, lower extremity reconstruction, perforator island flap

INTRODUCTION A modification is proposed, which combines the
philosophies of perforator‑based flaps and the
Leg defects can be intriguing to treat. Paucity of local keystone‑design, to maximize flap advancement.
tissue has necessitated free flaps especially in the lower
third. Reconstructive options have increased with the METHODS
arrival of perforator‑based flaps. These island flaps
are versatile in design. Chiefly, the types of movement From April 2012 to March 2013, a total of five patients
described are V‑Y advancement and propeller. The underwent the keystone perforator‑based flap. All of
perforator anatomy of the leg is well elucidated. them had defects with limited soft tissue remained over
The keystone‑design flaps were introduced by Behan. the leg, exposing the tibia. All flaps survived without
[1]
Four types are described. In the classical technique, very complications. Two of these are illustrated below.
limited elevation of the flap from its bed is performed. Surgical planning and technique
Perforators from the bed of the flap are presumed, Perforators over the leg are Doppler marked
but never identified. Keystone flaps have come up as preoperatively. This is essential for flap planning,
the chief local option for reconstruction of various especially over the area adjacent to the defect.
defects over the trunk. However, difficulties have A keystone‑design flap is marked on the skin adjacent
[2]
been encountered in using this flap for lower extremity to the defect. The flap is located on the medial calf for
reconstruction. [2] a defect on the upper leg, and on the lateral aspect for
a defect on the lower leg [Figure 1]. Factors involved in
Access this article online flap planning are dermatomal territory, laxity of local
Quick Response Code: skin, and distribution of Dopplered perforators. The
Website: outer curvilinear part of the keystone‑design is incised
www.parjournal.net
first to the subfascial level. This incision also doubles
as the exploratory incision for finding perforators. In
DOI: contrast to Behan’s concept, subfascial dissection is
10.4103/2347-9264.139704 performed, and all perforating vessels identified. One or
more dominant perforators are preserved. The rest of

70 Plast Aesthet Res || Vol 1 || Issue 2 || Sep 2014