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British Journal of Plasm Surgery (1984) 37, 80-87

0 1984 The Trustees of British Association of Plastic Surgeons

A classification of fascia-cutaneous flaps according to their


patterns of vascularisation
G. C. CORMACK and B. G. H. LAMBERTY
Department of Anatomy, University of Cambridge and the Department of Plastic Surgery, Addenbrooke’s
Hospital, Cambridge

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

Figure 2-The musculo-cutaneous system of perforators.

Figure 3-The fascia-cutaneous system of perforators.

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

Classification flap (Acland et al., 1981) and the parascapular flap


At present there would appear to be four types of (Cormack and Lamberty* *983)+
fascia-cutaneous flaps that we shall list as Types A, A successful modification of a Type B ante-
B, C and D. cubital forearm flap has been reported (Lamberty
and Cormack, 1983) which has certain haemo-
Type A dynamic advantages in a comparable way to the
A pedicled fascia-cutaneous flap dependent on Type C flaps but which depends on a single vessel
multiple fascia-cutaneous perforators at the base feeding the fascial plexus (Fig. 6). Such a flap may,
and orientated with the long axis of the flap in the arguably, constitute a fifth type of fascio-
predominant direction of the arterial plexus at the cutaneous flap but for simplicity is probably best

Figure 5-TYPE “B” fascia-cutaneous pedicled flap.

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.

which reach it from a deep artery by passing along New flaps


the fascial septum between muscles. It is used as a
By analogy with the forearm it is possible to
free flap by taking the skin, fascia and supplying
imagine the peroneal artery as the basis of a Type C
artery in continuity (Fig. 7). Typical examples are
or D flap. Ten dissections have been carried out on
the radial (Chinese) forearm flap (Yang Guofan et
preserved cadavers to investigate the feasibility of
al., 1982; Mtihlbauer et al., 1982; Soutar et al.,
raising a 10x 10 cm fascia-cutaneous island flap
1983).
from the region overlying the upper fibula. The
Type D maximum number of perforators are incorporated
The osteo-myo-fascia-cutaneous free tissue trans- if the upper edge of the flap is sited 10 cm below the
fer. An extension of C, the fascial septum is taken upper end of the fibula (styloid process).
in continuity with adjacent muscle and bone which The arterial inflow of this flap could be by
derive their blood supply from the same artery reversed flow in the peroneal artery. The peroneal
86 BRITISH JOURNAL OF PLASTIC SURGERY

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

Figure IO-“Siamese” flaps.


A CLASSIFICATION OF FASCIO-CUTANEOUS FLAPS 87

comitantes of the peroneal artery contain Acknowledgements


numerous valves and, therefore, would probably We are very grateful to Mr R. Overhill, AIMI, for the execution
not permit reversal of blood flow in a manner of the line diagrams and to Mr R. LiIes for the photographic
similar to the artery. The proximal end of the prints thereof. We are grateful to Mrs P. Morley and Miss C.
peroneal vein would, therefore, have to be anasto- Hunt for the preparation of the manuscript.
mosed to a vein in the recipient area, such as the References
long or short saphenous vein when transferring the
Acland, R. D., Schusterman, M., Godina, M., Eder, E.,
flap into the ankle region. Clearly, there is also
Taylor, G. I. and Carlisle, I. (1981). The saphenous
potential for a Type D free tissue transfer from this neurovascular free flap. Plastic and Reconstructive Surgery,
area with peroneal artery supporting bone as well 67,763.
as overlying skin via fascia-cutaneous perforators. Cormack, G. C. and Lamberty, B. G. H. (1983 a). The
A further new Type C flap suggests itself on the anatomical vascular basis of the axillary fascia-cutaneous
flap. British Journal of Plastic Surgery, 36,4.
radial side of the upper arm, The profunda brachii Cormack, G. C. and Lamberty, B. G. H. (1983 b). The blood
artery divides into a posterior descending or middle supply of thigh skin. Plastic and Reconstructive Surgery (in
collateral artery (A. collateralis media) and an press).
anterior descending or radial collateral artery (A. Daniel, R. K., Terzis, J. and Scbwarz, G. (1975). Neurovascular
collateralis radialis). The middle collateral artery free flaps. Plastic and Reconstructive Surgery, 56, 13.
Esser, J. F. S. (1917). Studies in Plastic Surgery of the Face.
lies directly in relation to the lateral intermuscular Leipzig: F. C. W. Vogel.
septum and sends on average five fascia-cutaneous Gillies, H. D. (1920). Plastic Surgery of the Face. London:
perforators to the overlying skin. This artery Oxford University Press.
appears very promising as the basis for a Type C Lamberty, B. G. H. (1979). The supraclavicular axial patterned
flap. British Journal of Plastic Surgery, 32,207.
flap. Although in diameter it is considerably Lamberty, B. G. H. and Cormack, G. C. (1982). The forearm
smaller than the radial artery it does have the angiotomes. British Journal of Plastic Surgery, 35.420.
advantage of being comparatively less essential Lamberly, B. G. H. and Cormack, G. C. (1983). Misconcep-
and certainly would not require replacement with a tions regarding the cervico-humeral flap. British Journal of
vein graft. Venous drainage of such a flap would Plastic Surgery, 36,60.
Lamberty, B. G. H. and Cormack, G. C. (1983). The
be by the cephalic vein. antecubital fascia-cutaneous flap. British Journal of Plastic
A theoretical advantage of the modified Type B Surgery, 36,4.
flap and also of the Type C flap (or any other flap Manchot, C. (1889). Die Hautarterien des Menschlichen
with a “through-flow” situation) is that a second Kijrpers. Leipzig: F. C. W. Vogel.
McGregor, I. A. and Morgan, G. (1973). Axial and random-
flap can be attached onto the end of it. The two pattern flaps. British Journal of Plastic Surgery, 26, 202.
flaps would constitute sister or “Siamese” flaps. Miihlbauer. W.. Herndl. E. and Stock. W. (1982). The forearm
We cannot recall ever seeing a case report of such flap. Plastic and Rec&structive Surgery,. 70, j36.
an application (Fig. 10). Nakajima, H., Maruyama, Y. and Koda, E. (1981). The
definition of vascular skin territories with prostaglandin
El--the anterior chest, abdomen and thigh-inguinal regions.
Conclusion
British Journal of Plastic Surgery, 34,258.
The fascia-cutaneous flap is a relatively new con- PontCn, B. (1981). The fascia-cutaneous flap: its use in soft
cept and although its impact upon plastic surgery tissue defects of the lower leg. British Journal of Plastic
Surgery, 34,215.
has not been as dramatic as that of muscle and Soutar, D. S., Scheker, L. R., Tanner, N. S. B. and McGregor,
musculo-cutaneous flaps we are nevertheless con- 1. A. (1983). The radial forearm flap: a versatile method for
vinced that these flaps have specific advantages intra-oral reconstruction. British Journal of Plastic Surgery,
and will gain an increasing and permanent 36, 1.
Yang Guofan and Gao Yuzhi, (1981). Forearm free skin flap
foothold amongst the more commonly used flaps. transplantation. Journalof the ChineseMedical Association,
We hope that this simple classification based on 61, 139.
the patterns of vascularisation will act as the basis
for continuing elaboration of the fascia-cutaneous The Authors
flap concept. We do not see this as a hard and fast G. C. Cormack, FRCS(Ed), Department of Anatomy,
classification but rather as an anatomical basis on Downing Street, Tennis Court Road, Cambridge.
which to elaborate. B. G. H. Lamberty, MA, FRCS, Consultant Plastic Surgeon,
Addenbrooke’s Hospital, Trumpington Street, Cambridge.
Note:
Requests for reprints to: Mr G. C. Cormack, FRCS(Ed),
This paper was presented at the Summer Meeting of the British Department of Anatomy, University of Cambridge, Downing
Association of Plastic Surgeons in Bradford in July 1983. Street, Cambridge CB2 3DY.