Keystone perforator island flap: a clinical summary of 28 melanoma cases

Main Article Content

Felix Behan


Islands, Perforator Flap, Hyperemia, Fascia, Pain


Background: The keystone perforator island flap (KPIF) and its design variations developed as a clinical necessity for reconstructing large surgical defects. This article focuses on melanoma management in 28 cases taken from a series of up to 3,000 established over 20+ years of clinical experience.

Method: The dermatome is the basis of the keystone success where vessels accompany nerves. Keystone perforator island flaps are fascial lined, supporting vascular integrity. The design resembles two conjoined VY island flaps facilitating closure under tension as the perforator zones (perforazones) are oriented vertically with a stronger hydrostatic supply than the horizontally aligned subdermal plexus. Tissue match is important and contributes to a sound aesthetic outcome.

Results: KPIF reconstructions are pain free even though tension is noted. KPIF reconstructions are almost anaesthetic for the complete dimension of the wound. This is explained by the simple fact that temporary interruption of somatic innervation in this design recovers over a few months in the same way as any longitudinal incision regains its nerve supply. Oedema in the KPIF is rarely observed and could possibly be a sympathetic affect. Reactive hyperaemia is evident in irradiated tissue, breaking another rule in plastic and reconstructive surgery in irradiated tissue where loco–regional reconstruction is contraindicated.

Conclusion: With an intact vascular system associated with autonomic and somatic support—including lymphatic drainage, the Gillies principles of replacing ‘like for like’ and the ‘next best tissue is the next best tissue’—reconstructive design principles are maintained.

Article Metrics Graph

Abstract 908 | PDF Downloads 123 HTML Downloads 132 Video Downloads 0


1. Morris SF, Tang M, Almutari K, Geddes C, Yang D. The Anatomic Basis of Perforator Flaps. Clinics in Plastic Surgery 2010; 37(4): 553-570.
2. Behan F, Wilson JSP. Vascular Basis of Laterally Based Forehead Island Flaps and their Clinical Applications. Transactions of the 2nd Congress of the European Section of the International Confederation of Plastic and Reconstructive Surgery. Madrid, 1973.
3. Mohan A, Saint-Cyr M, Behan F et al. Evolving concepts of Keystone Perforator Island Flaps (KPIF): principles of perforator anatomy, design modifications and extended clinical applications (Mayo Publication). Plast Reconstr Surg. 2016; 137(6): 1909-1920. PMid:26895582

1. Behan FC, Wilson JSP. The principles of the Angiotome: a system of linked axial pattern flaps. Sixth International Congress of Plastic and Reconstructive Surgery. Paris, 24-29 August 1975.
2. Behan FC. The keystone design perforator island flap in reconstructive surgery. ANZ J Surg. 2003; 73: 112-120. PMid:12608972
3. Behan FC, Findlay M, Lo CH. The Keystone Perforator Island Flap Concept. Sydney: Churchill Livingstone, 2012.
4. Behan FC, Lo CH, Shayan R. Perforator territory of the key-stone flap: use of the dermatomal roadmap. J Plast Reconstr Aesth Surg. 2009; 62: 551-553. PMid:19046659
5. Behan FC. Surgical Tips and Skills. Sydney: Churchill Livingstone, 2014.
6. Behan FC, Rozen WM, Azer S, Grant P. 'Perineal keystone design perforator island flap' for perineal and vulval reconstruction. ANZ J Surg. 2012; 82: 381-382. PMid:23305061
7. Behan FC. Evolution of the fasciocutaneous island flap leading to the keystone flap principle in lower limb reconstruction. ANZ J Surg. 2008; 78: 116-117. PMid:18269468
8. Behan FC. The fasciocutaneous island flap: an extension of the angiotome concept. Aust NZ J Surg. 1992; 62: 874-886.
9. Behan FC, Sizeland A, Porcedu S, Somia N, Wilson J. Keystone island flap: an alternative reconstructive option to free flaps in irradiated tissue. ANZ J Surg. 2006; 76: 407-413. PMid:16768705
10. Behan FC, Paddle A, Rozen WM et al. Quadriceps keystone island flap for radical inguinal lymphadenectomy: a reliable locoregional island flap for large groin defects. ANZ J Surg. 2013; 83: 942-947. PMid:22507632
11. Shayan R, Behan FC. Re the 'keystone concept': time for some science. ANZ J Surg. 2013; 83: 499-500. PMid:24049789
12. Pelissier P, Santoul M, Pinsolle V, Casoli V, Behan FC. The keystone design perforator island flap. Part I: anatomic study. J Plast Reconstr Aesthet Surg. 2007; 60: 883-887. PMid:17446152
13. Behan FC, Sizeland A, Gilmour F, Hui A, Seel M, Lo CH. Use of the keystone island flap for advanced head and neck cancer in the elderly: a principle of amelioration. J Plast Reconstr Aesthet Surg. 2010; 63: 739-745. PMid:19332401
14. Behan FC, Rozen WM, Tan S. Yin-yang flaps: the mathematics of two keystone island flaps for reconstructing increasingly large defects. ANZ J Surg. 2011; 81: 574-575. PMid:22295411
15. Behan FC, Rozen WM, Lo CH, Findlay M. The omega - ? - variant designs (types A and B) of the keystone perforator island flap. ANZ J Surg. 2011; 81: 650-652. PMid:22295410