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Open Access
CC BY 4.0 · Arch Plast Surg 2025; 52(06): 355-367
DOI: 10.1055/a-2668-4004
Reconstruction/Lymphedema
Original Article

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

Authors

  • Sofija Pejkova 

    1   University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius, Skopje, North Macedonia

  • Gordana Georgieva 

    1   University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius, Skopje, North Macedonia

  • Sofija Tusheva 

    1   University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius, Skopje, North Macedonia

  • Katerina Jovanovska 

    1   University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius, Skopje, North Macedonia

  • Stefania Azmanova Mladenovska 

    1   University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius, Skopje, North Macedonia

  • Bisera Nikolovska 

    1   University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius, Skopje, North Macedonia

  • Blagoja Srbov 

    1   University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Ss. Cyril and Methodius, Skopje, North Macedonia
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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

Keystone flap - reconstruction - KDPIF - perforator flap - sensibility

Authors' Contributions

Methodology: S.P., G.G., K.J., S.A.M., B.S.

Conceptualization: S.P., B.N.

Supervision: S.P., G.G., B.N.

Visualization: S.P., S.T.

Writing --original draft preparation: S.P., B.S.

Writing --review and editing: S.P., G.G., S.T., K.J., S.A.M., B.N.

Formal analysis: S.P., G.G., K.J., S.A.M., B.S.

Resources: S.P., G.G., B.N., B.S.

Data curation: G.G., K.J., S.A.M., B.S.

Project administration: G.G., S.T., B.N., B.S.

Validation: S.P., S.T., K.J., S.A.M.


Ethical Approval

The study was approved by the Institutional Review Board.


Patient Consent

All patients provided written informed consent for participation in the study, including permission for the use of anonymized clinical photographs in scientific publications.




Publication History

Received: 08 November 2024

Accepted: 26 July 2025

Accepted Manuscript online:
30 July 2025

Article published online:
20 November 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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