BACKGROUND The keystone design perforator island flap was first described in 2003. It is a local flap based on axial perforators from the underlying structures. It is designed as a curvilinear shaped trapezoidal design flap which is essentially two V-Y flaps end to end. Most reports are of the lower limbs, but it has been used successfully almost all over the body. METHODS We report our experience in 21 patients, who underwent excision of skin malignancies and reconstruction of the defect with a keystone flap (24 flaps in total). RESULTS Only few complications were seen. Two patients had signs of infection at the border of the flap and were treated with local and/or oral antibiotics. In two cases a small necrosis developed at the border of the flap. In both cases, it healed conservatively. CONCLUSIONS The keystone flap has proven to be very reliable with only few reported flap losses. Furthermore, it is technically easy to perform and thus may be performed by trainee surgeons as well as senior surgeons. The cosmetic result is excellent and far superior to the alternative skin grafting with its color differences and contour defect. In addition, many patients may be treated as day-only surgery or discharged from the hospital after only one day.