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J Reconstr Microsurg 2022; 38(09): 727-733
DOI: 10.1055/s-0042-1745744
Original Article

Outcomes of the Keystone Island Perforator Flap: A Systematic Review

Maxene Weinberg
1   Division of Plastic Surgery, Albany Medical College, Albany, New York
,
Adee J. Heiman 
1   Division of Plastic Surgery, Albany Medical College, Albany, New York
,
Rebecca DeSanti
2   Division of Plastic Surgery, University of Washington, Seattle, Washington
,
Michael A. Lanni
3   Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
,
Emily Van Kouwenberg
4   Division of Plastic Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
,
Ashit Patel 
1   Division of Plastic Surgery, Albany Medical College, Albany, New York
› Author Affiliations Funding None.
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Abstract

Background The Keystone Design Perforator Island Flap (KDPIF), first described by Behan in 2003, has been demonstrated as a versatile, safe, and straightforward reconstructive option for various soft tissue defects. The purpose of this systematic review is to evaluate the indications, variations, and overall complication profile of the keystone flap in reconstructive surgery.

Methods A literature review was conducted in accordance with PRISMA guidelines using MeSH term “surgical flaps” with the keyword “keystone flap.” Empirical studies with at least 15 patients who underwent keystone flap reconstruction were assessed for quantitative analysis. Outcomes of interest included patient demographics, indications, anatomic location, flap design, and complications.

Results Database search produced 135 articles, of which 25 were selected for full-text review. Out of 23 studies selected qualitative analysis and 22 met criteria for quantitative analysis. Overall success rate of this flap was 98%. Wound complications were highest in extremity flaps. Several modifications of this flap were described.

Conclusion Keystone reconstruction demonstrates excellent success rates and versatility. However, further studies with more standard reporting are needed to determine guidelines for patient specific surgical planning.

Keywords

keystone flap - perforator flap - reconstructive surgery

Previous Presentations

This work has not been previously presented.




Publication History

Received: 17 August 2021

Accepted: 20 February 2022

Article published online:
27 April 2022

© 2022. Thieme. All rights reserved.

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  • References

  • 1 Canizares O, Mayo J, Soto E, Allen RJ, Sadeghi A. Optimizing Efficiency in Deep Inferior Epigastric Perforator Flap Breast Reconstruction. Ann Plast Surg 2015; 75 (02) 186-192
    CrossrefPubMedGoogle Scholar
  • 2 Lanni MA, Van Kouwenberg E, Yan A, Rezak KM, Patel A. Applying the Keystone Design Perforator Island Flap Concept in a Variety of Anatomic Locations: A Review of 60 Consecutive Cases by a Single Surgeon. Ann Plast Surg 2017; 79 (01) 60-67
    CrossrefPubMedGoogle Scholar
  • 3 Chao AH, Coriddi M. The Impact of Intraoperative Microvascular Compromise on Outcomes in Microsurgical Breast Reconstruction. J Reconstr Microsurg 2015; 31 (07) 493-499
    Article in Thieme ConnectPubMedGoogle Scholar
  • 4 Behan FC, Lo CH, Sizeland A, Pham T, Findlay M. Keystone island flap reconstruction of parotid defects. Plast Reconstr Surg 2012; 130 (01) 36e-41e
    CrossrefPubMedGoogle Scholar
  • 5 Stankiewicz M, Coyer F, Webster J, Osborne S. Incidence and Predictors of Lower Limb Split-Skin Graft Failure and Primary Closure Dehiscence in Day-Case Surgical Patients. Dermatol Surg 2015; 41 (07) 775-783
    CrossrefPubMedGoogle Scholar
  • 6 Choi JY, Kim SH, Oh GJ, Roh SG, Lee NH, Yang KM. Management of defects on lower extremities with the use of matriderm and skin graft. Arch Plast Surg 2014; 41 (04) 337-343
    Article in Thieme ConnectPubMedGoogle Scholar
  • 7 Reddy S, El-Haddawi F, Fancourt M. et al. The incidence and risk factors for lower limb skin graft failure. Dermatol Res Pract 2014; 2014: 582080
    CrossrefPubMedGoogle Scholar
  • 8 Thourani VH, Ingram WL, Feliciano DV. Factors affecting success of split-thickness skin grafts in the modern burn unit. J Trauma 2003; 54 (03) 562-568
    CrossrefPubMedGoogle Scholar
  • 9 Henderson NJ, Fancourt M, Gilkison W, Kyle S, Mosquera D. Skin grafts: a rural general surgical perspective. ANZ J Surg 2009; 79 (05) 362-366
    CrossrefPubMedGoogle Scholar
  • 10 Anderson JJ, Wallin KJ, Spencer L. Split thickness skin grafts for the treatment of non-healing foot and leg ulcers in patients with diabetes: a retrospective review. Diabet Foot Ankle 2012; 3: 3
    CrossrefPubMedGoogle Scholar
  • 11 Audrain H, Bray A, De Berker D. Full-thickness skin grafts for lower leg defects: an effective repair option. Dermatol Surg 2015; 41 (04) 493-498
    CrossrefPubMedGoogle Scholar
  • 12 Ebrahimi A, Ashayeri M, Rasouli HR. Comparison of Local Flaps and Skin Grafts to Repair Cheek Skin Defects. J Cutan Aesthet Surg 2015; 8 (02) 92-96
    CrossrefPubMedGoogle Scholar
  • 13 Moncrieff MD, Thompson JF, Stretch JR. Extended experience and modifications in the design and concepts of the keystone design island flap. J Plast Reconstr Aesthet Surg 2010; 63 (08) 1359-1363
    CrossrefPubMedGoogle Scholar
  • 14 Behan FC. The Keystone Design Perforator Island Flap in reconstructive surgery. ANZ J Surg 2003; 73 (03) 112-120
    CrossrefPubMedGoogle Scholar
  • 15 Mohan AT, Rammos CK, Akhavan AA. et al. Evolving Concepts of Keystone Perforator Island Flaps (KPIF): Principles of Perforator Anatomy, Design Modifications, and Extended Clinical Applications. Plast Reconstr Surg 2016; 137 (06) 1909-1920
    CrossrefPubMedGoogle Scholar
  • 16 Pelissier P, Gardet H, Pinsolle V, Santoul M, Behan FC. The keystone design perforator island flap. Part II: clinical applications. J Plast Reconstr Aesthet Surg 2007; 60 (08) 888-891
    CrossrefPubMedGoogle Scholar
  • 17 Rao AL, Janna RK. Keystone flap: versatile flap for reconstruction of limb defects. J Clin Diagn Res 2015; 9 (03) PC05-PC07
    PubMedGoogle Scholar
  • 18 Khouri JS, Egeland BM, Daily SD. et al. The keystone island flap: use in large defects of the trunk and extremities in soft-tissue reconstruction. Plast Reconstr Surg 2011; 127 (03) 1212-1221
    CrossrefPubMedGoogle Scholar
  • 19 Behan FC, Rozen WM, Wilson J, Kapila S, Sizeland A, Findlay MW. The cervico-submental keystone island flap for locoregional head and neck reconstruction. J Plast Reconstr Aesthet Surg 2013; 66 (01) 23-28
    CrossrefPubMedGoogle Scholar
  • 20 Behan FC, Paddle A, Rozen WM. et al. Quadriceps keystone island flap for radical inguinal lymphadenectomy: a reliable locoregional island flap for large groin defects. ANZ J Surg 2013; 83 (12) 942-947
    CrossrefPubMedGoogle Scholar
  • 21 Bhat SP. Keystone flaps in coloured skin: Flap technology for the masses?. Indian J Plast Surg 2013; 46 (01) 36-47
    CrossrefPubMedGoogle Scholar
  • 22 Kostopoulos E, Casoli V, Agiannidis C. et al. The Keystone Perforator Island Flap in Nasal Reconstruction: An Alternative Reconstructive Option for Soft Tissue Defects up to 2 cm. J Craniofac Surg 2015; 26 (04) 1374-1377
    CrossrefPubMedGoogle Scholar
  • 23 Stone JP, Webb C, McKinnon JG, Dawes JC, McKenzie CD, Temple-Oberle CF. Avoiding Skin Grafts: The Keystone Flap in Cutaneous Defects. Plast Reconstr Surg 2015; 136 (02) 404-408
    CrossrefPubMedGoogle Scholar
  • 24 Kostopoulos E, Agiannidis C, Konofaos P. et al. Keystone Perforator Island Flap as an Alternative Reconstructive Option for Partial Thickness Alar Defects Up to 1.5 Centimeters. J Craniofac Surg 2016; 27 (05) 1256-1260
    CrossrefPubMedGoogle Scholar
  • 25 Taleb M, Choi L, Kim S. Safety and efficacy of the keystone and rhomboid flaps for immediate reconstruction after wide local excision of non-head and neck melanomas. World J Surg Oncol 2016; 14 (01) 269
    CrossrefPubMedGoogle Scholar
  • 26 Kim H, Ryu WC, Yoon CS, Kim KN. Keystone-designed buried de-epithelialized flap: A novel technique for obliterating small to moderately sized dead spaces. Medicine (Baltimore) 2017; 96 (21) e7008
    CrossrefPubMedGoogle Scholar
  • 27 Aragón-Miguel R, Gutiérrez-Pascual M, Sánchez-Gilo A, Sanz-Bueno J, Vicente-Martin FJ. The Keystone Flap in Dermatology: Clinical Experience with 18 Patients. Actas Dermosifiliogr (Engl Ed) 2018; 109 (06) 515-520 (Engl Ed)
    PubMedGoogle Scholar
  • 28 Kostopoulos E, Agiannidis C, Konofaos P. et al. Changing the Paradigm in Medial Canthal Reconstruction: The Bridge Principle and the Croissant-Like Keystone Island Perforator Flap as An Alternative for Medium Size Soft Tissue Defects in Internal Canthus Reconstruction. J Craniofac Surg 2018; 29 (05) e455-e459
    CrossrefPubMedGoogle Scholar
  • 29 Lee JW, Kim CW, Park TH. Customized reconstruction with modified keystone flaps. J Dermatol 2018; 45 (07) 844-849
    CrossrefPubMedGoogle Scholar
  • 30 Darrach H, Kokosis G, Bridgham K, Stone JP, Lange JR, Sacks JM. Comparison of keystone flaps and skin grafts for oncologic reconstruction: A retrospective review. J Surg Oncol 2019; 119 (07) 843-849
    CrossrefPubMedGoogle Scholar
  • 31 Huang J, Kim CW, Wang X. et al. Successful application of modified keystone flaps following skin tumor ablation. Medicine (Baltimore) 2019; 98 (40) e17469
    CrossrefPubMedGoogle Scholar
  • 32 Yoon CS, Kim HB, Kim YK, Kim H, Kim KN. Relaxed skin tension line-oriented keystone-designed perforator island flaps considering the facial aesthetic unit concept for the coverage of small to moderate facial defects. Medicine (Baltimore) 2019; 98 (03) e14167
    CrossrefPubMedGoogle Scholar
  • 33 Yoon CS, Kim HB, Kim YK, Kim H, Kim KN. Keystone-design perforator island flaps for the management of complicated epidermoid cysts on the back. Sci Rep 2019; 9 (01) 14699
    CrossrefPubMedGoogle Scholar
  • 34 Fang S, Li Y, Tang W. et al. The use of modified keystone flap in periarticular or large superficial tumor resection surgery. J Surg Oncol 2020; 121 (07) 1090-1096
    CrossrefPubMedGoogle Scholar
  • 35 Behan F, Sizeland A, Porcedu S, Somia N, Wilson J. Keystone island flap: an alternative reconstructive option to free flaps in irradiated tissue. ANZ J Surg 2006; 76 (05) 407-413
    CrossrefPubMedGoogle Scholar
  • 36 Hong JP, Hur J, Kim HB, Park CJ, Suh HP. The Use of Color Duplex Ultrasound for Local Perforator Flaps in the Extremity. J Reconstr Microsurg 2021
    PubMedGoogle Scholar
  • 37 Pereira N, Hallock GG. Smartphone Thermography for Lower Extremity Local Flap Perforator Mapping. J Reconstr Microsurg 2021; 37 (01) 59-66
    Article in Thieme ConnectPubMedGoogle Scholar