The keystone island perforator flap: An “ideal” local soft tissue flap for the lower extremity

Background

Lower extremity reconstruction best requires co-operation between orthopedic and plastic surgeons to preserve the musculoskeletal integrity while establishing essential skin coverage. Traditional dogma suggests microvascular tissue transfers alone would be preferable, but today inherent risks can be avoided by instead using mainly local perforator flaps.

Methods

Over a 5 year timeframe, 68 local flaps were used in 66 patients for non-specific lower extremity problems in all regions of the lower extremity in lieu of a free flap. These included both muscle and perforator flaps, the latter including peninsular, propeller, “true” island, and advancement variations. Particular emphasis on the choice of the keystone advancement flap alternative was here undertaken.

Results

All chosen lower extremity local flaps were successful without resorting to a second flap or skin graft to treat complications. Muscle flaps were used only on 4 occasions, whereas the remaining flaps were perforator flaps. Of these, the keystone island perforator flap was by far the most common choice, [27 (42.2 %)], even exceeding the combined use of propeller and peninsular flaps [26 (40.6 %)]. Keystone flap complications were virtually nil. Keystone flaps were most often used within the flexible tissues of the thigh, but could be used throughout the lower extremity.

Conclusion

Perforator flaps may be the optimal local flap choice for the lower extremity. Since no discrete perforator need be dissected, the simplest variation is the keystone flap. Harvest and insetting is facile, reliable, aesthetically acceptable, and often sensate. The keystone island perforator flap indeed is an “ideal” lower extremity local soft tissue flap.