The Keystone Flap for Vulvar Reconstruction: A Case Series and BODY-Q Evaluation

Background: Vulvar carcinoma is a rare cancer that mainly affects women older than 60 years of age. The most common form is squamous cell carcinoma. The main treatment is vulvectomy, followed by reconstruction. Among reconstructive techniques, the keystone perforator island flap (KPIF) is a relatively novel solution, offering robust vascularity, minimal complications, and rapid recovery. This study analyzed the use of KPIF on 14 patients after vulvectomy, evaluating the aesthetic and functional results through the BODY-Q questionnaire, which has never been applied to evaluate this reconstruction before. Methods: Patients operated on at the authors' institution between 2016 and 2024 were retrospectively recruited and evaluated. The data collected included demographic and clinical characteristics, intraoperative parameters, and postoperative endpoints, including patient satisfaction assessed through the BODY-Q questionnaire. Results: The study analyzed 14 patients (mean age 74 y). Among them, 86% had vulvar squamous cell carcinoma. The average operating time was 278 minutes, and the mean hospital stay was 11.5 days. Complications were limited, and follow-up showed satisfactory oncological, aesthetic, and functional results. The BODY-Q evaluation showed a very high level of patient satisfaction. Conclusions: This study shows that KPIF is a safe, simple, and reproducible technique for vulvar reconstruction, providing favorable aesthetic and functional results. Compared with other flaps, it offers a more concealed donor site, with scars limited to the perineal area, fewer complications, and the possibility of further advancement in case of recurrence. KPIF is a safe and effective technique, which can therefore be included in the armamentarium of vulvar reconstruction surgery.