The Versatility of Keystone Flap: Reconstructive Option in Ring Finger

We have read with interest the article entitled “Keystone Flap: Overcoming Paradigms” by Gómez et al.¹ Their article highlights the keystone flap (KF) versatility in different reconstructive procedures, and we come to the same conclusions about flexibility, reliability, and efficiency.

The keystone design perforator island flap, first described by Behan,² has been gaining popularity as a locoregional reconstructive option. Using angiotome and sympathectomy principles,³ the keystone is a robust flap with a design that can be adapted to fit defect and to reconstruct the defect with minimal tension distribution.

According to Gómez et al, we believe that KF is a very effective local flap that does not require identification and skeletonization of source vessel or specific perforator.

This eliminates the risks, complexity, and morbidity, reducing surgical time implied in perforator flap procedures. The current literature describes the keystone design perforator island flap in different anatomical location, such as trunk and extremities, but we did not find any description in finger of hands.

In our experience, we used KF in multiples cases; in 2011, we described the “freestyle technique” to enhance the mobility of the flap.⁴ This technique allows to harvest flaps in a freestyle manner; it consists of the association between the “microvascular freestyle technique” described by Wei in 2004 and tension-reducing modification of the KF by Rao et al., both in Monarca et al.⁴

We present our experience with the use of the modified “mouth fish” keystone designed perforator island flap. Thus, we raised the mouth fish KF variation to reconstruct the soft tissue of over the fourth finger joint of the hand (Fig. 1). Branch of digital artery usually looks very small during dissection but when the flap is raised in this region usually capture multiple perforators improving the reliability of the flap.⁵ We confirmed the effectiveness of this technique with a proper vascularization also in upper limb extremities, short surgical times and learning curve, superior tissue durability. Moreover, according to Gomez et al, KF provides similar tissues in terms of function, texture, color, and sensitivity.

Fig. 1.

The preoperative view is displayed.

The outcome at 4-month postoperative follow-up was aesthetically suitable without limitation of the joint mobility and pain free (See Video [online], which displays 4-month postoperative follow-up). If we consider the surgical reconstructive options for cutaneous dorsal finger loss of substance, the KF represents a useful and easy reproducible tool with optimal cost-effectiveness with better results when compared with other reconstructive procedures.

Video 1. Four-months post-operative follow-up

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