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Summary-The anatomical principles underlying fascia-cutaneous flaps in general are outlined. On the
basis of their patterns of vascularisation such flaps are classified into four types. Examples are given of
each of these types and some new, untried, flaps designed along these principles are postulated.
Prior to the first description of fascia-cutaneous area of skin, but anastomosing in the subcutis with
flaps by PontCn in 1980, the existence of fascio- adjacent vascular perforations (Fig. 2).
cutaneous vessels had been neglected. Even now By contrast the fascia-cutaneous system consists
the anatomical vascular principles underlying the of vessels which reach the skin by passing along the
fascia-cutaneous flaps have not been fully eluci- fascial septa between adjacent muscle bellies and
dated. then fan out al the level of the deep fascia to form a
Two patterns of blood supply to the skin have plexus from which blood reaches the skin (Fig. 3).
been recognised for many years. Firstly, the direct The fact that this system has not been utilised
Fig 1
Figure l-The direct cutaneous system of vessels.
cutaneous system of vessels running in the sub- until recently is remarkable. This is particularly the
cutaneousfat, parallel to the skin surface and often case since both Esser (1917) and Gillies (1920)
extending for some considerable distance at speci- suggested that it might be advantageous to include
fic sites thereby enabling the elevation of axial the deep fascia in what we now recognise as
cutaneous flaps with impressive length to breadth random-pattern skin flaps. Instead, delayed flaps
characteristics (Fig. 1). Secondly, the musculo- and tube pedicles continued to consist of skin and
cutaneous system of perforators arising from the fat alone and an opportunity to discover the
artery of supply of a muscle and passing up existence of fascia-cutaneous perforators was
perpendicular to the skin surface to supply a small missed. Perhaps this is not surprising in view of the
80
A CLASSIFICATION OF FASCIO-CUTANEOUS FLAPS 81
fact that the possibilities of axial cutaneous flaps reference to Manchot’s (1889) original work on the
were also passed over at that stage and these blood supply of skin which purported to show
constituted a much more concrete, definable entity anatomic territories based on the evidence of whole
based on obvious anatomical evidence. By con- cadaver dissection studies. Dynamic territories
trast, fascia-cutaneous flaps depend on less have been demonstrated by in vivo injection
immediately obvious anatomy and the concept is techniques using fluorescein or prostaglandin EI
one of potential underlying skin vascular terri- (Nakajima et al., 1981) and reflect the dynamic
tories rather than the well-circumscribed ana- pressure equilibrium existing in the blood vessels of
tomical territories of the axial-pattern cutaneous each territory along the boundary line between
flaps. The concept of vascular territories is worthy territories. This concept of an equilibrium point or
of elaboration, particularly with regard to their “watershed” was elaborated by McGregor and
demonstration by experimental techniques. Morgan (1973) in their paper on axial and
Many descriptions of new skin flaps have made random-pattern flaps in which it was further
82 BRITISH JOURNAL OF PLASTIC SURGERY
shown that if one of a pair of abutting vessels was proof and in some instances it has been possible to
occluded then the other vessel would “extend” its verify our hypotheses by raising the flaps con-
territory into the area of decreased intravascular cerned in clinical cases and these will be mentioned.
pressure. Using fluorescent injection techniques A series of injection studies (Lamberty and
this ‘was demonstrated at the internal Cormack, 1982 and 1983: Cormack and Lamberty,
mammary/thoraco-acromial boundary and also 1983, a, b) have enabled us to answer three
across the midline of the chest-a line across which questions which any surgeon contemplating raising
virtually no flow normally takes place. a fascia-cutaneous flap should ask himself. These
These dynamic territories are clearly relevant to are:
the raising of flaps but a clinically-raised flap may (i) Where are the fascia-cutaneous perforators
extend even further than dynamic studies appear to located?
indicate, by virtue of the area of skin appended
(ii) Is there a fascial plexus present at that site?
onto the end of the axial component. Thus the
potential vascular territory, which is to some extent (iii) Does the fascial plexus possess any predomi-
only learnt through clincial experience, is the nating directional component or “axiality”?
largest of all. Not only have fascia-cutaneous Equipped with the answers to these questions we
vessels been inadequately investigated but have been able to apply our anatomical knowledge
potential fascia-cutaneous territories have, until to the design of new fascia-cutaneous flaps (Lam-
recently, been ignored. berty and Cormack, 1983). On the basis of these
Potential territories cannot be demonstrated by clinical and experimental observations we feel that
a single injection technique. What can, however, it is appropriate to establish some of the principles
be demonstrated is the vascular anatomy and on of the vascular anatomy of these fascia-cutaneous
the basis of these findings potential territories can flaps by means of a classification. We also present
be postulated. In the final analysis the clinical here two theoretical fascia-cutaneous flaps which
elevation of fascia-cutaneous flaps is the only are at present clinically untried.
Figure 4-TYPE “A” fascia-cutaneous system flap. (Vessel diameters have been exaggerated by the artist.)
A CLASSIFICATION OF FASCIO-CUTANEOUS FLAPS 83
level of the deep fascia (Fig. 4). Good examples are classified as Type B. The essential characteristic of
the “super-flap” in the lower leg (Ponttn, 1981), the flap is the T-junction on the single vessel
the sartorius flap, without muscle (Cormack and feeding the fascial plexus. In the forearm a flap
Lamberty, 1983) and upper arm flaps based on the based on the inferior cubital artery but taking in
medial or lateral intermuscular septum. addition the radial artery, enables a long skin
paddle to be used together with a long arterial
Type B pedicle thereby overcoming one of the constraints
A pedicled or a free flap depending on a single of the present design of the forearm fascio-
sizeable and consistent fascia-cutaneous perfor- cutaneous flap. It also, by virtue of the long
ator feeding a plexus at the level of the deep fascia pedicle, allows greater versatility in flap orien-
(Fig. 5). Typical examples are the supraclavicular tation at the recipient site. On purely anatomical
flap (Lamberty, 1979), the medial arm flap (Daniel grounds there are two situations in which this flap
et al., 1975), the antecubital forearm flap (Lam- is not feasible. Firstly, in the absence of a signi-
berty and Cormack, 1982), the saphenous artery ficantly sized inferior cubital artery and secondly
BRITISH JOURNAL OF PLASTIC SURGERY
Fig 6
Figure 6-TYPE “B” MODIFIED fascia-cutaneous microvascular free flap.
Fig 7
Figure 7-TYPE “C” fascia-cutaneous flap.
A CLASSIFICATION OF FASCIO-CUTANEOUS FLAPS 85
in the presence of such an artery when it arises (Fig. 8). Good examples are the Chinese forearm
from a radial recurrent which has its point of origin flap with half the diameter of the radius
from the brachial artery rather than the radial (Mtihlbauer et al., 1982, Soutar et al., 1983). The
artery (which is rare) (Lamberty and Cormack, Chinese flap, that may include half the diameter of
1982). the radius, is the only flap thus far proven to fall
into this category. We have shown (Fig. 9) that the
Type C bone is supplied by direct periosteal branches from
The ladder type. The support of the skin is the radial artery and by branches which supply the
dependent upon the fascial plexus that is supplied flexor pollicis longus muscle and thereby the radius
by multiple small perforators along its length via the origin of the muscle from the bone.
Fig 8
Figure I-TYPE “D” myo-osteo-fascia-cutaneous tissue transfer.
Fig 9
Figure 9-Distal radial artery, resin injected, viewed from the lateral side. The blood supply of the radius by direct periosteal
branches and via muscular branches of flexor pollicis longus can be seen. (PT= insertion of pronator teres.)
artery, at its distal end has three principal anasto- Our anatomical studies of preserved cadavers
moses, with the posterior tibia1 via a transverse have shown that the anterior perforating branch
communicating branch, with the anterior tibia1 by lies approximately 5 cm and the transverse com-
a perforating branch which pierces the inter- municating branch 6.5 cm above the tip of the
osseous septum to communicate with the anterior lateral malleolus.
malleolar branch of the anterior tibial, and ter- We suggest that a skin flap based on fascio-
minal malleolar and calcaneal branches which cutaneous perforators and pedicled on the pero-
communicate with the lateral tarsal branches of the neal artery could be turned downward and used for
dorsalis pedis and the calcaneal branches of the reconstruction around the ankle without the neces-
posterior tibia1 artery respectively. sity for an arterial anastomosis. The venae
SIAMESE FLAPS
Type 6 flap
Type B fasciocutaneous or
Type C flap
Fig 10