WORLD JOURNAL OF PLASTIC SURGERY
Thu, Oct 15, 2026
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Volume 15, Issue 2 (2026)
WJPS 2026, 15(2): 3-12 |
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Alli T A, Mandal A. Keystone Flap Reconstruction in Skin Cancer and Soft Tissue Defects: A Scoping Review of Versatility, Safety and Outcomes. WJPS 2026; 15 (2) :3-12
URL: http://wjps.ir/article-1-1679-en.html
URL: http://wjps.ir/article-1-1679-en.html
1- Emergency Department, Arrowe Park Hospital, Wirral University Teaching Hospital NHS Foundation Trust, Wirral, UK
2- Department of Plastic Surgery, Whiston Hospital, Mersey and West Lancashire NHS Foundation Trust, Prescot, UK
2- Department of Plastic Surgery, Whiston Hospital, Mersey and West Lancashire NHS Foundation Trust, Prescot, UK
Abstract: (487 Views)
Background: We aimed to evaluate the versatility, safety and wide clinical applications of the keystone flap in reconstruction following skin cancer excision and in soft tissue defects of varying sizes across the head, neck, limbs and trunk, with respect to aesthetic and functional outcomes.
Methods: A scoping review of published literature was undertaken in accordance with PRISMA-ScR guidelines. PubMed, ScienceDirect and Google Scholar were searched. The initial focus was on keystone flap reconstruction following melanoma excision. However, due to limited melanoma-specific data, the inclusion criteria were expanded to include studies involving all skin cancers, including squamous cell carcinoma and basal cell carcinoma, as well as broader reconstructive applications of the keystone flap in soft tissue defects to enable a more comprehensive evaluation of outcomes.
Results: Seventeen studies published between 2003 and 2024 were included. Keystone flaps were most utilised in lower limb reconstruction following oncological excision and soft tissue defect reconstruction across multiple anatomical sites. Complication rates ranged from 0% to 38.8%, with the majority classified as minor and managed conservatively. Reported outcomes demonstrated high success rates and favourable cosmetic and functional results. No standardised patient-reported outcome measures were employed across the included studies.
Conclusion: The keystone flap appears to be a versatile and reliable reconstructive option with broad applications across defects of varying sizes and anatomical sites. The available evidence suggests it may serve as an effective alternative to conventional flaps and grafts in skin cancer and soft tissue reconstruction. However, findings are derived predominantly from retrospective case series and thus should be interpreted accordingly, with prospective comparative studies warranted to further validate these outcomes.
Methods: A scoping review of published literature was undertaken in accordance with PRISMA-ScR guidelines. PubMed, ScienceDirect and Google Scholar were searched. The initial focus was on keystone flap reconstruction following melanoma excision. However, due to limited melanoma-specific data, the inclusion criteria were expanded to include studies involving all skin cancers, including squamous cell carcinoma and basal cell carcinoma, as well as broader reconstructive applications of the keystone flap in soft tissue defects to enable a more comprehensive evaluation of outcomes.
Results: Seventeen studies published between 2003 and 2024 were included. Keystone flaps were most utilised in lower limb reconstruction following oncological excision and soft tissue defect reconstruction across multiple anatomical sites. Complication rates ranged from 0% to 38.8%, with the majority classified as minor and managed conservatively. Reported outcomes demonstrated high success rates and favourable cosmetic and functional results. No standardised patient-reported outcome measures were employed across the included studies.
Conclusion: The keystone flap appears to be a versatile and reliable reconstructive option with broad applications across defects of varying sizes and anatomical sites. The available evidence suggests it may serve as an effective alternative to conventional flaps and grafts in skin cancer and soft tissue reconstruction. However, findings are derived predominantly from retrospective case series and thus should be interpreted accordingly, with prospective comparative studies warranted to further validate these outcomes.
Keywords: Keystone flap, Perforator flap, Skin neoplasm, Melanoma, Soft tissue injuries, Reconstructive surgical procedures
References
1. Wang M, Gao X, Zhang L. Recent global patterns in skin cancer incidence, mortality, and prevalence. Chinese Med J 2025;138(2):185-192. doi:10.1097/CM9.0000000000003416. [DOI:10.1097/CM9.0000000000003416]
2. Asuku M, Yu TC, Yan Q, et al. Split-thickness skin graft donor-site morbidity: a systematic literature review. Burns 2021;47(7):1525-1546. doi:10.1016/j.burns.2021.02.014. [DOI:10.1016/j.burns.2021.02.014]
3. Moncrieff MD, Bowen F, Thompson JF, Saw RPM, Shannon KF, Spillane AJ, et al. Keystone flap reconstruction of primary melanoma excision defects of the leg - the end of the skin graft? Ann Surg Oncol 2008;15(10):2867-2873. doi:10.1245/s10434-008-0018-8. [DOI:10.1245/s10434-008-0018-8]
4. Behan FC. The Keystone Design Perforator Island Flap in reconstructive surgery. ANZ J Surg 2003;73(3):112-120. doi:10.1046/j.1445-2197.2003.02638.x. [DOI:10.1046/j.1445-2197.2003.02638.x]
5. 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(5):407-413. doi:10.1111/j.1445-2197.2006.03708.x. [DOI:10.1111/j.1445-2197.2006.03708.x]
6. 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. doi:10.3389/fsurg.2017.00068. [DOI:10.3389/fsurg.2017.00068]
7. Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Int Med 2018;169(7):467-473. doi:10.7326/M18-0850. [DOI:10.7326/M18-0850]
8. National Institutes of Health. Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. National Heart, Lung, and Blood Institute; 2014. Available from: https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools. Accessed 22 July 2026.
9. Sterne JAC, Hernan MA, Reeves BC, Savovic J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016;355:i4919. doi:10.1136/bmj.i4919. [DOI:10.1136/bmj.i4919]
10. Pripotnev S, White C. The keystone flap - a case series demonstrating practical design, use, and applications. Plast Surg 2017;25(3):184-187. doi:10.1177/2292550317716121. [DOI:10.1177/2292550317716121]
11. Aragón-Miguel R, Gutierrez-Pascual M, Sanchez-Gilo A, Sanz-Bueno J, Vicente-Martin FJ. The keystone flap in dermatology: clinical experience with 18 patients. Actas Dermo-Sifiliograficas 2018. doi:10.1016/j.adengl.2018.05.011. [DOI:10.1016/j.adengl.2018.05.011]
12. Talev 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(1). doi:10.1186/s12957-016-1019-x. [DOI:10.1186/s12957-016-1019-x]
13. Singh A, Singh R, Chaturvedi G, Singh M, Singh RB. Utility of keystone flap in armory of dermatosurgeons. Indian J Dermatol 2024;69(6):432-441. doi:10.4103/ijd.ijd_953_23. [DOI:10.4103/ijd.ijd_953_23]
14. Gordon T, Golin AP, Anzarut A. Keystone flap for closure of skin cancer defects on the upper extremity. Plast Surg 2022. doi:10.1177/22925503221094106. [DOI:10.1177/22925503221094106]
15. 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(7):1002-1007. doi:10.1002/jso.26629. [DOI:10.1002/jso.26629]
16. Franco E, Bryzgalin L, Metanes I, Nae B, Segal M, Hasan S, et al. The keystone flap: our prospective clinical experience with a hundred consecutive cases. Eur J Plast Surg 2024;47(1). doi:10.1007/s00238-024-02202-4. [DOI:10.1007/s00238-024-02202-4]
17. Behan F. Keystone perforator island flap: a clinical summary of 28 melanoma cases. Aust J Plast Surg 2018;1(1):43-48. doi:10.34239/ajops.v1i1.66. [DOI:10.34239/ajops.v1i1.66]
18. Rini IS, Gunardi AJ, Marsaulina RP, Aryandono T, Dachlan I, Dwiprahasto I. A systematic review of the keystone design perforator island flap in the reconstruction of trunk defects. Arch Plast Surg 2020;47(06):535-541. doi:10.5999/aps.2020.00094. [DOI:10.5999/aps.2020.00094]
19. Hallock GG. The keystone island perforator flap: an 'ideal' local soft tissue flap for the lower extremity. Orthopl Surg 2024;17:23-29. doi:10.1016/j.orthop.2023.10.001. [DOI:10.1016/j.orthop.2023.10.001]
20. Pawlak N, De La Cruz Ku G, Chatterjee A, Persing S, Homsy C. The keystone perforator island flap: review of utility and versatile clinical applications. Plast Reconstr Surg 2024;12(2):e5556. doi:10.1097/GOX.0000000000005556. [DOI:10.1097/GOX.0000000000005556]
21. Huang J, Yu N, Long X, Wang X. A systematic review of the keystone design perforator island flap in lower extremity defects. Medicine 2017;96(21):e6842. doi:10.1097/MD.0000000000006842. [DOI:10.1097/MD.0000000000006842]
22. Kong YT, Kim J, Shin HW, Kim KN. Keystone flap with omega variation and Sydney melanoma unit modification to cover small- and moderate-sized defects in the anterior lower leg. J Wound Manag Res 2021;17(2):94-101. doi:10.22467/jwmr.2020.01452. [DOI:10.22467/jwmr.2020.01452]
23. Maurichi A, Barretta F, Patuzzo R, Sala L, Miceli R, Gallino G, et al. Association of excision margin size with local recurrence and survival in patients with T1a melanoma at critical structures. JAMA Dermatol 2023;159(6):587-595. doi:10.1001/jamadermatol.2023.0620. [DOI:10.1001/jamadermatol.2023.0620]
24. Huang J, Kim CW, Wang X, Zhao Y, Yu N, Zhao R, et al. Successful application of modified keystone flaps following skin tumor ablation. Medicine 2019;98(40):e17469. doi:10.1097/md.0000000000017469. [DOI:10.1097/MD.0000000000017469]
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