Archives of Plastic Surgery

Korean Society of Plastic and Reconstructive Surgeons (대한성형외과학회)
권호 표지
DOI QR코드

DOI QR Code

Comprehensive Outcomes of the Keystone Design Perforator Island Flap: A Prospective Study of 121 Consecutive Cases

  • Sofija Pejkova (University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius) ;
  • Gordana Georgieva (University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius) ;
  • Sofija Tusheva (University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius) ;
  • Katerina Jovanovska (University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius) ;
  • Stefania Azmanova Mladenovska (University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius) ;
  • Bisera Nikolovska (University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius) ;
  • Blagoja Srbov (University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius)
  • Received : 2024.11.08
  • Accepted : 2025.07.26
  • Published : 2025.11.15
Download PDF
⟨ Previous Next ⟩

Abstract

Background The Keystone Design Perforator Island Flap (KDPIF), developed by Behan in 2003, has significantly impacted reconstructive surgery. This technique utilizes angiotomes, which integrate vascular, dermatomal, neural, and lymphatic networks, providing various approaches for complex reconstructions. Methods This study enhances the initial PACE framework (Pain, Aesthetic appearance, Complication rates, Economic feasibility) by adding "S" for Sensibility, creating the PACES framework to include sensory improvements in the assessment. Our retrospective analysis included 121 patients over 51 months, primarily with defects from skin malignancies (66.9%) and chronic wounds (16.5%), mainly on the trunk (51.2%). The average age was 56.2 years, with males comprising 73.6% of the cohort. Results Outcome measures included pain, assessed using the Visual Analog Scale at 1 and 12 months postoperatively, revealing a significant reduction in pain. Aesthetic outcomes were evaluated through the Manchester Scar Scale, showing notable improvements in scar appearance. Complication rates were low, indicating the safety of the flap in this series. Economic efficiency was assessed by operative time and hospital stay, with shorter durations indicating cost-effectiveness. Sensory outcomes, measured with the Postoperative Flap Sensitivity Self-Assessment Questionnaire, showed substantial gains in sensory function, enhancing patients' quality of life. Conclusion The PACES framework facilitated a comprehensive evaluation of KDPIF, confirming its effectiveness across various defect types and patient populations. Our findings support the wider adoption of KDPIFs for reconstructive purposes, alongside ongoing efforts to optimize patient outcomes and functionality.

Keywords

Acknowledgement

The authors would like to thank Prof. Felix Behan for his involvement in guiding us to implement his technique as well as his invaluable contribution throughout the course of the study.

References

  1. Behan FC. The Keystone Design Perforator Island Flap in reconstructive surgery. ANZ J Surg 2003;73(03):112–120 https://doi.org/10.1046/j.1445-2197.2003.02638.x
  2. Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg 2009;124(05):1529–1544 https://doi.org/10.1097/PRS.0b013e3181b98a6c
  3. Pelissier P, Santoul M, Pinsolle V, Casoli V, Behan F. The keystone design perforator island flap. Part I: anatomic study. J Plast Reconstr Aesthet Surg 2007;60(08):883–887
  4. Gómez OJ, Barón OI, Peñarredonda ML. Keystone flap: overcoming paradigms. Plast Reconstr Surg Glob Open 2019;7(03): e2126 https://doi.org/10.1097/GOX.0000000000002126
  5. Weinberg M, Heiman AJ, DeSanti R, Lanni MA, Kouwenberg EV, Patel A. Outcomes of the Keystone island perforator flap: a systematic review. J Reconstr Microsurg 2022;38(09): 727–733 https://doi.org/10.1055/s-0042-1745744
  6. 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
  7. Blondeel PN, Van Landuyt KH, Monstrey SJ, et al. The "Gent" consensus on perforator flap terminology: preliminary definitions. Plast Reconstr Surg 2003;112(05):1378–1383, quiz 1383, 1516, discussion 1384–1387 https://doi.org/10.1097/01.PRS.0000081071.83805.B6
  8. Behan FC, Lo CH, Findlay M. Anatomical basis for the keystone island flap in the upper thigh. Plast Reconstr Surg 2010;125(01): 421–423 https://doi.org/10.1097/PRS.0b013e3181c2a66f
  9. Lo CH, Nottle T, Mills J. Keystone island flap: effects of islanding on vascularity. Plast Reconstr Surg Glob Open 2016;4(02):e617 https://doi.org/10.1097/GOX.0000000000000607
  10. McCreary DL, Dugarte AJ, Vang S, et al. Patient-level value analysis: an innovative approach to optimize care delivery. J Orthop Trauma 2019;33(Suppl 7):S49–S52 https://doi.org/10.1097/BOT.0000000000001624
  11. Ayhan Oral M, Zeynep Sevim K, Görgü M, Yücel Öztan H. Sensory recovery with innervated and noninnervated flaps after total lower lip reconstruction: a comparative study. Plast Surg Int 2013;2013:643061 https://doi.org/10.1155/2013/643061
  12. 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 https://doi.org/10.1097/SAP.0000000000000995
  13. Behan FC, Rozen WM, Lo CH, Findlay M. The omega - Ω - variant designs (types A and B) of the keystone perforator island flap. ANZ J Surg 2011;81(09):650–652 https://doi.org/10.1111/ans.2011.81.issue-9
  14. Myles PS, Myles DB, Galagher W, et al. Measuring acute postoperative pain using the visual analog scale: the minimal clinically important difference and patient acceptable symptom state. Br J Anaesth 2017;118(03):424–429 https://doi.org/10.1093/bja/aew466
  15. Lo Torto F, Frattaroli JM, Kaciulyte J, et al. The keystone flap: A multi-centric experience in elderly patients treatment. J Plast Reconstr Aesthet Surg 2022;75(01):226–239 https://doi.org/10.1016/j.bjps.2021.08.043
  16. 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 https://doi.org/10.1097/PRS.0b013e318205f36f
  17. Fearmonti R, Bond J, Erdmann D, Levinson H. A review of scar scales and scar measuring devices. Eplasty 2010;10:e43
  18. 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 https://doi.org/10.1097/PRS.0000000000002228
  19. Srivastav S, Gupta S, Sharma A. Keystone flap as a reconstructive option for selected areas; a prospective study. J Clin Orthop Trauma 2020;11(Suppl 5):S871–S875 https://doi.org/10.1016/j.jcot.2020.06.019
  20. 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 https://doi.org/10.1111/ans.2006.76.issue-5
  21. Jovic TH, Jessop ZM, Slade R, Dobbs T, Whitaker IS. The use of Keystone Flaps in periarticular wound closure: a case series. Front Surg 2017;4:68 https://doi.org/10.3389/fsurg.2017.00068
  22. Rao AL, Janna RK. Keystone flap: versatile flap for reconstruction of limb defects. J Clin Diagn Res 2015;9(03):PC05–PC07 https://doi.org/10.7860/JCDR/2015/12595.5631
  23. Yan M, Rose PS, Houdek MT, Moran SL. Outcomes of the keystone perforator island flap for oncologic reconstruction of the back. J Surg Oncol 2021;124(07):1002–1007 https://doi.org/10.1002/jso.v124.7
  24. 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 https://doi.org/10.1111/ans.2013.83.issue-12
  25. Bauer BA, Christen S, Spiegl MKF, Müller DA, Grünert JG. Keystone flap type IIIB: a new variation for coverage of defects at joint regions. Plast Reconstr Surg Glob Open 2021;9(03): e3450 https://doi.org/10.1097/GOX.0000000000003450