| Summary: | **Background**: Palmar defects arising from surgical correction for Dupuytren’s disease can be surgically corrected using skin grafts. This article describes the applications of keystone principles as an alternative to John Hueston’s firebreak graft, popularised in the mid-1980s.
**Method**: In 2003, I introduced the principle of a fenestrated, full-thickness graft to optimise graft-take and expedite healing, offering an alternative for the management of palmar defects created by surgical release.
**Results**: The combination of reliable hypervascularity with a pain-free postoperative phase, characteristic of KPIF, ensures an easy recovery with early commencement of hand therapy. With minimal vascular complications (apart from clinical cases where diabetes and smoking are factors) the overall surgical outcome gives an aesthetic appearance matching surrounding tissues.
**Conclusion**: Island flaps based on the keystone principle improve vascularity resulting in minimal complications with healing. Recurrence of Dupuytren’s disease following this technique has not been observed to date.
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