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Keystone Flaps

Physiology, Types, and Clinical Applications

Riccio, Charles Alexander MD, MS*; Chang, Jeremy MS*; Henderson, Joshua Thomas MS*†; Hassouba, Mahmoud MD*; Ashfaq, Faisal MD*; Kostopoulos, Epameinondas MD, PhD; Konofaos, Petros MD, PhD*

doi: 10.1097/SAP.0000000000001854
Review Paper

The keystone perforator flap (KPF) was first introduced in 2003 by Behan et al for use in reconstruction after skin cancer excision. Since its initial description, KPF use has been expanded to complex defects of various etiologies and disorders throughout the body. At its most basic, the KPF is a perforator-type flap designed with a 1:1 flap-to-defect width ratio. Keystone perforator flaps are specifically raised on pedicles arising from musculocutaneous or fasciocutaneous perforator vessels. Major advantages of the KPF derive from the maintenance of perforator vascular territories, perforosomes, permitting increased flap viability. In turn, this allows for more aggressive undermining in sites away from perforators when greater skin mobilization is necessary. Furthermore, the KPF is relatively easy to perform leading to shorter operative times and no postoperative monitoring period. There are basically 4 different types of keystone flaps in order of increasing undermining and disturbance of underlying fascia. These different classifications of KPFs may be used in different anatomical locations over the entire body based on skin laxity and defect size/depth. Numerous advancements and modifications have been documented adapting the KPF to specific conditions, including myelomeningoceles, and scrotal and lower eyelid defects. The purpose of this article is to provide an organized review of the KPF with emphasis on different classifications, applications, and limitations as well as an overview of the surgical technique. We have additionally included a discussion on KPF physiology and review of current literature.

From the *Department of Plastic Surgery, University of Tennessee Health Science Center, Memphis, TN;

University of Louisville College of Medicine, Louisville, KY; and

Department of Plastic Surgery, ‘METAXA’ Hospital, Piraeus, Greece.

Received July 7, 2018, and accepted for publication, after revision December 29, 2018.

Conflict of interest and sources of funding: none declared.

Reprints: Petros Konofaos, MD, PhD, 1068 Cresthaven Rd, Suite 500 Memphis, TN 38119. E-mail:

Online date: May 23, 2019

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