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Commentary Of the five cases in this series, two are detailed in the
article and describe elliptical defects of 20 cm × 9 cm
Dina Gofstein , Jonathan Bank 2 and 16 cm × 7 cm. Only limited defects that required a
1
1 Department of Plastic Surgery, The Tel Aviv Sourasky Medical local flap advancement of up to three centimeters were
Center, Tel Aviv University, Tel Aviv 64239, Israel. included, as the authors contend that this is the maximal
2 Department of Surgery, Division of Plastic Surgery, University of possible advancement of the flap without skeletonization.
Pennsylvania Health Systems, Philadelphia, PA 19104, USA.
Behan was the first to describe the keystone flap concept
Address for correspondence: Dr. Jonathan Bank, Department of in 2003. He described four subtypes of flaps: (1) type
[2]
Surgery, Division of Plastic Surgery, University of Pennsylvania one – the classical flap in which very little elevation from
Health Systems, 3400 Spruce Street, 10 Penn Tower,
Philadelphia, PA 19104, USA. the flap bed is performed; (2) type two – allows additional
E-mail: bank.yonni@gmail.com flap advancement by performing a dissection of the lateral
deep fascia margin; (3) type three – the use of two
John et al. describe five cases in which a keystone flap was keystone flaps in order to repair larger defects; and (4) type
[1]
performed for reconstruction of lower extremity defects. four – where subfascial undermining of up to 50% of the
In an attempt to address the difficulty of reconstruction of flap is required to allow flap movement. All four types of
these defects, that is, limited skin laxity, thick deep fascia, fasciocutaneous flaps do not require identification of the
and limited availability of perforating vessels, the authors perforators prior to elevation of the flap. Emphasis is made
propose identifying the perforating vessels to facilitate flap on performing a blunt dissection in order to preserve as
movement. Vessel locations were detected preoperatively many vessels as possible. In this paper, keystone flaps were
with a Doppler probe. Subfascial dissection of the flap was used to reconstruct trunk and limb defects.
performed in order to identify the perforators. However, Reconstruction of lower limb defects with the keystone
further skeletonization of the vessels was not performed. design island flap was subsequently reported by several
authors. Khouri et al. reported a case series of 28
[3]
Access this article online large defects of the trunk and extremities. Lack of local
Quick Response Code: tissue laxity was significant enough to make the patients
candidates for microvascular reconstruction. Preoperative
identification of the perforators by a Doppler probe was
Website: performed in the smaller reconstructions. According to the
www.parjournal.net
authors, this was deemed unnecessary in larger defects
because of the frequency of such vessels throughout the
body and the assumption that adequate perforators would

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