The keystone island perforator flap – expanding the toolbox for aesthetic nasal reconstruction
Reviewed by Shivanchan Rajmohan

The complexity of nasal reconstruction lies in its dual objective: restoring structural integrity while preserving subtle contours and symmetry that define facial aesthetics. This retrospective cohort study from a single centre in the United States evaluated the effectiveness of the keystone island perforator advancement flap as a reconstructive option for nasal soft tissue defects. Over a five-year period, 25 patients underwent 26 keystone flap reconstructions, primarily following excision of basal cell or squamous cell carcinomas. The study aimed to assess the flap’s versatility, reliability, aesthetic outcomes and limitations across different nasal subunits. The findings demonstrated that the keystone flap is a safe and effective technique for small nasal defects, especially those involving the dorsum, lateral side wall, alar and nasal tip. More than 50% of cases required incorporation of the underlying nasalis muscle creating a musculocutaneous variant that improved flap mobility while preserving vascularity. Notably, all flaps survived without necrosis or wound dehiscence. Alar trim retraction occurred in 20% of patients although this resolved spontaneously without further intervention. Hypertrophic, elevated or widened scars were noted in a small number, with one experiencing a trapdoor deformity. Hence careful patient selection and meticulous flap design are imperative to optimise cosmetic outcomes. As a local flap, the keystone island perforator flap offers excellent colour and texture matching, allowing scars to blend naturally within skin creases or nasal subunit boundaries. However, its application is largely limited to small nasal defects and not recommended for extensive contour deformities or reconstruction of the columella, soft triangle or larger multi-subunit defects. Can the keystone flap bridge the gap between surgical simplicity and aesthetic excellence, while expanding the reconstructive options for nasal soft tissue defects?

The keystone flap as an esthetic alternative for nasal soft tissue restoration.
Hallock G.
J PLAST RECONSTR AESTHET SURG
2026;118:59–65.