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be present in a larger flap design. During the procedure, congestive insults, as a result, of this “over‑dissection”.
care was taken to ensure the incision was carried down As this plagues other types of flaps (such as propeller
to muscular or deep fascia in order to enhance mobility. flaps and free flaps), a case by case assessment should be
A deeper incision was not necessary. Although the series made, as always.
had high‑complication rate when all minor wound healing A minor point to consider is the length of operative time
issues were considered, the success rate was reported to required for the keystone flap procedure. The OR time
be 97%, with only one patient requiring reconstruction by in keystone flaps, as described in the literature, was less
an alternate method. [3]
than two hours. [3,7] This length of time is significantly
Additional reports of the use of the keystone flap for shorter than most microsurgical procedures, and it is one
lower limb reconstruction demonstrate that this flap of the advantages of the keystone‑design flap technique.
can be closed under relative tension, [4,5] since muscular Although not stated, it follows that the identification and
perforator arteries, which exit the surface of the muscle skeletonization of perforators would prolong OR time
to enter the subcutaneous tissue from directly beneath (as well as increase the rate of complications).
the flap, there is minimal risk of ischemic necrosis.
In conclusion, the keystone island flap is a useful
[6]
Moncrieff et al. published the largest series of flap technique to close both small and large defects of
reconstructions for melanoma of the leg, describing the the lower extremities. The advantage of preoperative
keystone flap as “the end of the skin graft.” The study identification of perforators may allow further flexibility
included 176 patients with primary melanomas of the in the utilization of the flap. We encourage the authors
lower limb. In some of the cases in this series, a modified to continue to share their experience with this technique,
technique was used, in which dermis was incised full in order to substantiate its role in lower limb defect
thickness, but not deeper, on the lateral border, and reconstruction, and expand the variety of defects it can
the subcutis was released with gentle blunt spreading be implemented for.
dissection. The average diameter of the excised specimen
was 2.6 cm. The reconstruction comprised 106 standard, REFERENCES
65 modified, and 5 double‑opposing type keystone
flaps performed from the proximal leg to the dorsum of 1. John JR, Balan JR, Tripathy S, Sharma RK, Jadhav C. The keystone-design
the foot. The modified technique of the keystone flap, perforator-based flap for leg defects: a synthesis of philosophies. Plast
with decreased tissue dissection, was associated with a Aesthet Res 2014;2:70-2.
significant decrease in major complication rate. [6] 2. Behan FC. The keystone design perforator island flap in reconstructive
surgery. ANZ J Surg 2003;73:112‑20.
Minimizing tissue dissection helps to minimize 3. Khouri JS, Egeland BM, Daily SD, Harake MS, Kwon S, Neligan PC,
Kuzon WM Jr. The keystone island flap: use in large defects of the
complications in this type of procedure. For larger defects, trunk and extremities in soft-tissue reconstruction. Plast Reconstr Surg
more extensive dissection may be warranted to facilitate 2011;127:1212‑21.
tissue movement, as described by Behan as keystone flaps 4. Martinez JC, Cook JL, Otley C. The keystone fasciocutaneous flap in the
type 3 or 4. Preoperative identification of the perforating reconstruction of lower extremity wounds. Dermatol Surg 2012;38:484‑9.
vessels may contribute to a more accurate flap design. 5. Hu M, Bordeaux JS. The keystone flap for lower extremity defects.
Dermatol Surg 2012;38:490‑3.
However it has not been demonstrated that it is essential 6. Moncrieff MD, Bowen F, Thompson JF, Saw RP, Shannon KF, Spillane AJ,
in order to perform a deeper dissection. The selection of Quinn MJ, Stretch JR. Keystone flap reconstruction of primary melanoma
limited defects in this work does not allow the authors excision defects of the leg-the end of the skin graft? Ann Surg Oncol
to conclude that identification of perforator vessels allows 7. 2008;15:2867‑73.
Chaput B, Herlin C, Espié A, Meresse T, Grolleau JL, Garrido I. The
better mobilization of the flap. However, we feel that it keystone flap alternative in posttraumatic lower-extremity reconstruction.
does facilitate safe elevation of a flap with the knowledge J Plast Reconstr Aesthet Surg 2014;67:130‑2.
that a perforator is present within the flap design. Having
said that, by dissecting out one or two main perforators, How to cite this article: Gofstein D, Bank J. Commentary. Plast
Aesthet Res 2014;1:72-3.
many other smaller vessels are transected. While it is
likely that the majority of the flap will survive, there Source of Support: Nil, Conflict of Interest: None declared.
is a potential for marginal necrosis from ischemic or Received: 05-07-2014; Accepted: 14-07-2014

Plast Aesthet Res || Vol 1 || Issue 2 || Sep 2014 73