CME

Further Clarification of the Nomenclature for

Compound Flaps
Geoffrey G. Hallock, M.D.
Learning Objectives: After studying this article, the participant should be able to: 1.
Allentown, Pa. Understand the attributes and unique niche for compound flaps and their limitations.
2. Comprehend a proposed schema for further clarifying the classification of all types
of compound flaps that is differentiated on the basis of the distinct vascular supply to
each flap subtype. 3. Appreciate that minor technical modifications of known flaps of
any type in general do not necessarily create a new category of flap.
Background: A unique niche exists for compound flaps because of their extraor-
dinary capability to allow repair of massive defects where the simultaneous resto-
ration of multiple missing tissue components is demanded. The guidelines from the
previous “simplified” classification schema need to be updated to allow a more
complete clarification and further standardization of this concept.
Methods: Compound flaps can be partitioned into two major classes that in turn
are further differentiated into various subtypes according to their inherent pattern
of circulation.
Results: The subdivisions of compound flaps are those with a solitary source of
vascularization and those with combinations of sources of vascularization. Those
with a solitary source include composite flaps, defined as multiple tissue compo-
nents all served by the same single vascular supply, and thereby consisting of
dependent parts. Those flaps with combinations of sources of vascularization in-
clude (1) conjoined flaps, defined as multiple flap territories, dependent because
of some common physical junction, yet each retaining its independent vascular
supply; and (2) chimeric flaps, defined as multiple flap territories, each with an
independent vascular supply, and independent of any physical interconnection
except where linked by a common source vessel.
Conclusions: Although many technical modifications have improved and will im-
prove the reliability and versatility of compound flaps, these maneuvers alone
should not be confused with creating distinct flap types but rather acknowledged
to be only important variations. With this understanding, this revised nomenclature
system for compound flaps is intended to be a means of standardizing communi-
cation and to facilitate research agendas on a common ground, fully realizing its
primary role still only to serve as a convenient guideline. (Plast. Reconstr. Surg. 117:
151e, 2006.)

A
systematic nomenclature for flaps was a
relatively easy endeavor during most of
the last century because essentially all
known possibilities were just a variation of the
From the Division of Plastic Surgery, The Lehigh Valley Hospital.
Received for publication May 17, 2005; revised September 4, 2005.
Presented in part at the Inaugural Congress of the World Society
for Reconstructive Microsurgery, in Taipei, Taiwan, November
2, 2001; the 28th Annual Meeting of the Japanese Society of
Reconstructive Microsurgery, in Yamanashi, Japan, November
22, 2001; the Sixth International Course on Perforator Flaps,
in Taoyuan, Taiwan, October 24 through 26, 2002; and the
71st Annual Scientific Meeting of the American Society of Plas-
tic Surgeons, in San Antonio, Texas, November 5, 2002.
Copyright ©2006 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000219178.20541.7f
“random” cutaneous flap. 1 Such simplicity
abruptly ceased after Milton proved that the ar-
bitrary length-to-width ratio for flap construction
was an inaccurate and now archaic principle,
and that tissue viability instead depended on the
nuances of the circulation contained within the
given flap territory.2 Coincident with the subse-
quent and ongoing thorough analyses of the
anatomical bases for flap vascularization, there
has been an exponential growth of potential flap
choices but, concomitantly, a corresponding pot-
pourri of nomenclature that frequently can be
redundant, confusing, and at times even conflict-
ing.
A complete and standardized classification
schema for all types of flaps that would eliminate

www.plasreconsurg.org 151e

the aforementioned dilemma may be an unreal-
istic goal,3 and none certainly has yet been uni-
versally accepted. Nakajima et al.,4 as an example
of such an attempt, divided just skin flaps into
five distinct entities, whereas Nahai and Mathes
proposed five fundamental types of muscles as
flaps.5 Both these schema stratified their flaps
according to what was considered to be the most
crucial factor during flap dissection that would
ensure flap survival (i.e., the preservation of its
vascular supply).
However, an awareness of only the source of
circulation to a flap often provides an incom-
plete description. The identification of second-
ary characteristics is essential to create a more
accurate depiction, which is often necessary to
improve the efficacy of flap dissection and more
effective communication of results. To rectify
such an omission, Daniel and Kerrigan6 added
the “method of movement” in their description
of flaps. Tolhurst7,8 was even more elaborate with
his “atomic system,” but flap composition rather
than the origin of the circulation was his primary
focus or nucleus. Cormack and Lamberty,9,10 in
their anatomical system for complete flap classi-
fication, refined Tolhurst’s proposition by re-
placing the circulation as the crucial central fac-
tor. The other subordinate characteristics used
by them to describe any flap could be remem-
bered by the pneumonic of the “6 C’s” for flap
classification. In addition to the circulation, this
included constituents (composition or tissue
type), conformation (form or shape), contiguity
(destination), construction (type of pedicle),
and conditioning (preparation).9,10
The intent of this updated review is not to fur-
ther elaborate on how to completely classify any
flap but rather to concentrate on describing the
constituents or composition of a flap, and specifi-
cally only as regards the unique class of compound
flaps. A compound flap typically consists of multi-
ple tissue components linked together in a manner
that allows their simultaneous transfer and conse-
quently a more efficient reconstruction.11 This ap-
proach obviates the need to resort otherwise to
using many unrelated flaps from multiple donor
sites. Numerous variations of compound flaps have
been sporadically introduced over the years. This
also has created some confusion because minor
modifications often have been given different
names or eponyms. In reality, many of these ma-
neuvers have represented only a small change in
surgical technique, yet the basic flap composition
has remained unaltered.12 As Koshima has
stressed,13 a straightforward nomenclature system
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Plastic and Reconstructive Surgery • June 2006
for compound flaps would be valuable to enhance
worldwide communication in describing similar in-
novations and to further advance the reliable role
of these complex flaps not only as microsurgical
tissue transfers but also possibly their more simple
use as local flaps when applicable. A simplified
nomenclature schema has been previously intro-
duced in this Journal,11 and will be updated to
further clarify and standardize the terms used to
classify compound flaps.
BASIC SUBDIVISIONS OF COMPOUND
FLAPS
As stated previously, a compound flap incor-
porates many diverse tissue components into an
interrelated unit. These can be partitioned into
two major classes according to their most critical
element, their primary means of vascularization
(Fig. 1). The intense interest about this subject by
our Asian colleagues has led to an evolution of the
original simplified categorization,14 –17 which has
more closely adopted the ideas first promulgated
by Belousov et al.18 Some differences still exist, as
each of the two subdivisions can include individ-
ual, or “monoflaps,” as Belousov et al.18 termed
them, or multiple related flaps that they called
“polyflaps.” These polyflaps in turn can be further
differentiated by their inherent vascular pedicle,
which can be indigenous or surgically manipu-
lated to conjugate these flaps into advantageous
combinations.
Solitary Vascularization
Composite Flaps
From a conceptual standpoint, the simplest
form of compound flap is the composite flap that
contains en bloc multiple tissue components.19
The entire flap has a well-defined and solitary
source of vascular supply that is intertwined within
all parts. Thus, all the components are dependent
on each other and must all remain intact together
to sustain overall flap viability.20,21
The ubiquitous musculocutaneous and fascio-
cutaneous flaps would be common examples of a
composite flap, because these basically consist of
muscle or a fascial plexus, respectively, but in ad-
dition have a skin and subcutaneous tissue paddle
that depends on muscle or fascial perforators for
sustenance. Intuitively, it could even be construed
that all flaps are composite flaps, as all are also
composed of a discrete microvasculature plus con-
nective tissues plus intrinsic nerves plus fat, and so
forth, in addition to their basic building blocks.
However, this semantic technicality will hereafter
Volume 117, Number 7 • Nomenclature for Compound Flaps
Fig. 1. Compound flaps may be subdivided into either solitary
(above) or combined types (center and below) based on their pri-
mary source of vascularization. There are in turn two important
subtypes of combined flaps.
be intentionally overlooked in this proposed
schema, as this would confuse any further at-
tempts at simplification.
Composite flaps usually are monoflaps, follow-
ing the terminology of Belousov et al.,18 although
sometimes at their periphery they can be partially
divided along major branches of the solitary
source vessel into multiple parts that allow greater
freedom in insetting.22 Composite flaps are ade-
quate for uncomplicated defects where the defi-
cits are anatomically adjacent and require essen-
tially only a two-dimensional insetting.14
Combinations of Vascularization
All other compound flaps have multiple
sources of vascularization and their permutations
would form some type of combined flap. The two
major subtypes of combined flaps primarily differ
in the physical relationship of their component
flaps, yet are similar in that each anatomical flap
territory that is part of the combination always
retains its independent blood supply.
Conjoined Flaps
Harii et al.23,24 deserve the credit for introduc-
ing the concept of combined flaps, as they first
described a “combined myocutaneous flap and
microvascular free flap.” Their example captured
both the skin territory of the latissimus dorsi mus-
culocutaneous flap and the groin flap, which re-
mained connected together to essentially form a
bipedicled flap based at opposite ends on the tho-
racodorsal and superficial circumflex iliac vessels,
respectively.23 Either pedicle could be divided to
increase the arc of rotation or reach of the com-
bination in a caudal or cephalad direction, but an
auxiliary form of revascularization by means of
microanastomoses was then required for that ter-
ritory no longer nourished as a local pedicled flap.
Although theoretically still a single flap,
Belousov et al.18,25 called these exceedingly large
flaps that extended beyond the vascular territory
of a single vascular pedicle, not inappropriately,
“megaflaps.” In essence, these flaps are combina-
tions of at least two anatomically distinct territo-
ries, each retaining their independent vascular
supply but joined by means of some common phys-
ical boundary. The term “Siamese flap,” derived
from the congenital anomaly of the well-known
Siamese twins Chang and Eng (1811–1874),26 who
were born with their chests joined together, has
been often used as an apropos descriptive appel-
lation for this combination.16,19,21 Because those
Siamese twins were indeed conjoined twins, the
term conjoined flap would perhaps be a more
politically correct synonym.
Shibata et al.27 demonstrated another advantage
of this concept with a distal-pedicled posterior in-
terosseous (dorsal forearm) and lateral arm con-
joined flap for thin coverage of hand defects, that
proved that at least a venous anastomosis for the
detached pedicle can sometimes be avoided, as the
dorsal forearm veins proved sufficient to drain the
entire combination. Nassif et al.28 hypothesized that
conjoined flaps do not necessarily have to be just
cutaneous flaps, citing a combined latissimus dorsi
muscle and parascapular fasciocutaneous flap that
remained attached to each other by means of com-
mon musculocutaneous perforators as an example.
The latter has been clinically shown to enhance the
survival of either or both components,29 presumably
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 Plastic and Reconstructive Surgery • June 2006

because of a reversal of flow through the captured

perforators.30
Of course, any direct or indirect perforator
flap31 that has more than a single perforator could
theoretically also be considered to be a conjoined
flap. Indeed, each perforator has its own corre-
sponding skin territory, and yet otherwise all re-
main connected by common borders within the
flap, like the pieces of a puzzle. That portion based
on a single perforator of such a flap could still be
parceled out and transferred as a separate
monoflap. This actually has already been accom-
plished using multiple radial forearm free flaps
from a single forearm donor site,32 or by splitting
a flap into pieces that still remain pedicled to a
common source vessel, which would make this
new configuration a perforator-based chimeric
flap,33 as is discussed below.
For the sake of completeness, a cutaneous flap
with multiple perforators still intact, much like a
megaflap, would be considered a perforator-based
conjoined flap (Fig. 2). The flap originally intro-
duced by Harii et al.,23 because it is dependent on
large subfascial branches and not perforators spe-
cifically, could be called a branch-based (indepen-
dent) conjoined flap because the source vessel
branches to each territory were independent of
each other at opposite extremes of the flap. The
separate branches to the latissimus dorsi muscle
and parascapular combined flap proposed by Nas-
sif et al.,28 which could retain a common mother Fig. 2. Conjoined flaps can be further stratified into two sub-
vessel, the subscapular, would be called a branch- classes that are distinguished by their distinctly different source
based (common) conjoined flap. of vascularization; they can be either perforator-based (above) or
Chimeric Flaps branch-based (center and below). The larger caliber and often
The term “chimeric flap” was conceived origi- subfascial or axial branches of the branch-based form may have
nally to describe a combination of local flaps from completely unrelated origins from different angiosomes (the in-
the same anterolateral thigh angiosome.20 The chi- dependent type), or these branches may arise from a common
meric flap has probably been the most frequently source vessel (common type).
reported form of combined flap,17,34 –39 and use of
this term has become entrenched16,17,20,21 despite the
original attempt to name this type of combination chimeric flap would be considered a branch-based
the “conjoint” flap,11,40 which really is a more appro- type, with multiple relatively large subfascial
priate term to describe the Siamese combined flap. branches emanating from a common mother ves-
Also called polyflaps,18 the chimeric flap consists of sel. This type allows the simultaneous transfer of
multiple otherwise independent flaps that each have multiple and varied tissue components from a sin-
an independent vascular supply, but in turn all gle donor site. The subscapular system epitomizes
pedicles are linked to a larger common source this genre, where fascial (e.g., scapula, parascapu-
vessel.18,20 Because these combinations ultimately lar), muscle (e.g., serratus anterior, latissimus
have only a single source vessel, the microsurgical dorsi), and osseous (e.g., rib, scapula) flaps sup-
transfer of these combined multiple flaps can be plied by the thoracodorsal or circumflex scapular
accomplished while requiring only a single recipient branches can allow over five dozen known differ-
site, which is a major advantage (Table 1). ent flap permutations that permit near total free-
Huang et al.14 have further subdivided chi- dom in the independent insetting of each part.38
meric flaps into three subtypes, again based on As already mentioned, an intact perforator
their specific blood supply (Fig. 3). The classic flap with multiple perforators could be considered

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Volume 117, Number 7 • Nomenclature for Compound Flaps

Table 1. Comparison of the Attributes of Compound Flap Subtypes

Conjoined Chimeric

Branch- Perforator- Branch- Perforator-

Characteristic Composite Based Based Based Based Fabricated
Circulation
Long pedicle ⫾ ⫾ – ⫹ – ⫹
Large caliber ⫾ ⫾ – ⫹ – ⫹
Single recipient site ⫹ – – ⫹ ⫹ ⫹
required
Composition
Multiple tissue types ⫹ ⫾ – ⫹ – ⫹
Independent inset of – – – ⫹ ⫹ ⫹
components
Anatomical consistency ⫹ ⫹ – ⫹ – ⫹
Conformation
Customized volume and – ⫾ ⫾ ⫹ ⫹ ⫹
contour
Contiguity
Local flap ⫹ – ⫹ ⫹ ⫹ –
Free flap ⫹ – ⫹ ⫹ ⫹ ⫹
Donor-site morbidity
Single site ⫹ – ⫹ ⫹ ⫹ –
Minimal residue ⫹ ⫾ ⫹ ⫾ ⫹ ⫾
Ease of dissection ⫹ ⫾ – ⫾ – –
⫹, positive attribute; –, negative or absent attribute.

Fig. 3. Chimeric flaps can be further stratified into three subclasses differentiated on the basis of either their intrinsic
vasculature (above) or whether they are prefabricated (below) (i.e., surgically joined together by means of a microa-
nastomosis). The fabricated component can be attached to the terminus of the source vessel to the combination
(sequential type) or to a branch indigenous within the flap (internal type).

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 Plastic and Reconstructive Surgery • June 2006

a form of conjoined flap, as each perforator has its

own independent territory. If their common
boundaries are split apart, yet each part based on
its individual perforator remains attached to the
same common source vessel, these would become
instead perforator-based chimeric flaps.33 The an-
terolateral thigh flap is the prototype donor site
for this variation and has been split into smaller
flaps especially useful for head and neck recon-
struction, epitomized by the simultaneous recon-
struction of intraoral and cheek defects while
avoiding flap infolding or deepithelialization.41 As
another advantage, Sano et al.42 have split the
medial sural gastrocnemius muscle perforator
free flap into very small chimeric flaps that, when
inset together, allow coverage of large defects, but
the overall original width is narrow enough to
permit direct closure of the donor site.
Koshima et al., in their introduction to the
chimeric flap principle, prefabricated combina-
tions, attaching otherwise independent flaps to
either side branches of the main source vessel or
to its distal continuation.43 This type of fabricated
chimeric flap thus always requires a microanasto-
mosis. If the added flap is directly connected to the
distal end of the source vessel supplying the orig-
inal flap, the resulting combined flap in the pre-
vious simplified nomenclature11 was called a se-
quential flap because circulation first had to
proceed by means of a “flow-through” across the
first flap or “bridge flap” to the attached one in
sequence. In reality, in this age of perforator flaps,
Fig. 4. A supercharged flap (above) receives vascular augmen-
such a fabricated flap is better considered as a
tation from an unrelated source vessel (arrow). A turbocharged
combination of independent flaps linked to a
flap (center and below) siphons off flow from a vessel already in-
common source vessel, which by definition can
trinsic to the flap territory, here demonstrated to be directly from
only be a true chimeric flap.
a branch of the flap source vessel (arrow) as in Koshima’s mosaic
flap principle19,44 or by means of an interposed vein graft (v.g.) if
CLARIFICATION OF TECHNICAL there is a lack of vessel contiguity as Core had proposed.12
MODIFICATIONS
As inferred by the previous definitions, many
specific variations of compound flaps are in reality Supercharging and Turbocharging
just minor modifications of the basic forms. Core Semple developed a compelling analogy of
correctly pointed out that many of these are pri- supercharging and turbocharging as related to
marily technical alterations of the basic com- automotive terms.50 If an external power source is
pound flaps; if given a separate name, this only used to boost an engine’s performance, this is
serves to cause obfuscation of this concept.12 Ko- supercharging50 (e.g., the use of an unrelated dis-
shima’s “mosaic” flap is a good case in point with tant vascular source by means of an anastomosis to
which to demonstrate this omnipresent dilemma a flap to augment either inflow or outflow) (Fig.
(Fig. 4).13,44 The confusing concepts of “turbo- 4).51 The superior unipedicled transverse rectus
charging” and “supercharging” must first be de- abdominis musculocutaneous (TRAM) flap sal-
fined. Unfortunately, even these terms have pre- vaged by an anastomosis of a thoracic or upper
viously been used interchangeably, even within extremity vascular source to the contralateral deep
the same report to imply the creation of new flap or superficial inferior epigastric vessels would be
types.16,45– 49 a classic example.45– 47

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Volume 117, Number 7 • Nomenclature for Compound Flaps
In contradistinction, vehicular turbocharging
relies on the engine’s own exhaust for additional
power.50 Thus, if the terminus or a branch of the
major pedicle to a flap were joined to another
minor pedicle, flow to the flap (the engine) could
be siphoned away (the exhaust) to augment an
ischemic portion (Fig. 4).51 Semple directly con-
nected the ipsilateral and contralateral deep in-
ferior epigastric vessels of a TRAM flap, after first
ensuring adequate retrograde pressures, specifi-
cally to improve transmidline blood flow of a su-
perior unipedicled TRAM flap50 (i.e., he turbo-
charged the flap).
Mosaic Flaps
Core turbocharged the notoriously unreliable
distal skin portion of a vertically oriented gracilis
musculocutaneous flap by connecting what oth-
erwise would be a perforator to a medial thigh flap
by means of a vein graft to a branch of the muscle’s
dominant medial circumflex femoral pedicle, be-
cause these vessels were not contiguous.52 Ko-
shima et al.44 similarly connected the source
pedicles of two adjacent thigh perforator flaps
directly to each other to augment flow but called
this variation a “mosaic” flap (Fig. 4). Both Core’s
salvage maneuver and Koshima et al.’s mosaic flap
really represent only the turbocharging of what
are conjoined flaps.
Chain-Link Flaps
The sequential fabrication of a chimeric flap
by the microsurgical attachment of another flap
that is perfused by a vascular flow-through across
the original flap has been called a “piggybacked
flap.”53,54 Because in this fashion multiple piggy-
backed flaps can be linked together sequentially
much as links on a chain, these have also been
called “chain-link” flaps55 but are no different
from fabricated (sequential) chimeric flaps. Ko-
shima’s “chain-circle” flaps piggybacked a second
flap to the terminus of a flow-through of the first,
but also attached the vascular terminus of the
pedicle of the second flap back to a branch of the
original flow-through, which could really be con-
sidered to be only a form of turbocharging.16,43 It
is no wonder these terms can be confusing, but
careful scrutiny as done here reveals that these are
all only technical modifications of defined com-
pound flaps, and not new entities.
Hybrid Compound Flaps
Despite the best efforts to fully clarify this issue,
permutations within and between the subdivisions of
compound flaps and even the subtypes of combined
flaps have also been described, which can become an
overwhelming task to precisely categorize. Single do-
nor sites chosen as the source of a combined flap can
be composed of identical (e.g., the latissimus dorsi
and serratus anterior chimeric muscle flap56 ), or
different tissue types (e.g., the subscapular-based
quadrifolate flap, consisting of bone, muscle, and
fasciocutaneous flaps34). A combined flap can also
be composed of a series of multiple composite flaps
(e.g., the anterolateral and anteromedial thigh con-
joined perforator flap44).
A perforator-based conjoined flap if divided
becomes a perforator-based chimeric flap, where
the difference is more than simply “hair splitting.”
Even the components of a musculocutaneous
composite flap can now be separated by the te-
dious intramuscular dissection of the musculocu-
taneous perforators into separate muscle and true
muscle perforator flaps.15 If the latter remain at-
tached to the same solitary vessel, this combina-
tion would then be a chimeric flap.
A final example of the potential confusion and
ambiguity still possible is represented by a case re-
port of a caudal-pedicled local latissimus dorsi–
groin flap [a classic conjoined flap (branch-based)]
used to cover a large thoracoabdominal defect
where the thoracodorsal pedicle was revascularized
by means of a flow-through radial forearm free flap.57
Because this was surgically prefabricated before in-
setting by means of a microanastomosis, this com-
bination then becomes a fabricated (sequential
type) chimeric flap according to this revised schema.
DISCUSSION
The touted advantage of compound flaps as a
group is their ability to simultaneously provide
multiple tissue types as building blocks of virtually
unlimited size to fill any volume deficit, restore any
absent underlying framework, and allow immedi-
ate coverage (Table 1).11,14 The ultimate shape and
contour can be independently customized and
then inset with impunity, especially with the chi-
meric type of combined flap.43 Ideally, all neces-
sary components can be obtained from a single
donor site that will then be closed primarily to
minimize overall morbidity. If multiple indepen-
dent flaps arise from a single mother major source
vessel, a compound free flap will require only a
single recipient site to revascularize the entire
complex, a major advantage when a paucity of
recipient vessels can otherwise be a significant lim-
iting factor. Intentional inclusion of a second
small yet independent flap as part of either a
branch-based or perforator-based chimeric free
157e

flap can be specifically designed to protect or re-
lieve tension at a tenuous recipient site38 or serve
as a monitoring flap.58
However, there must always be a disclaimer. Ba-
sic principles in flap selection should always be fol-
lowed. If a single flap is sufficient,11,18 the temptation
to choose any compound flap requires that there be
unquestioned advantages.11 As previously reported
in our experience with over 1500 flaps over the past
25 years, only 14 percent of free flaps and fewer than
5 percent of all flaps that were used (excluding rou-
tine musculocutaneous and fasciocutaneous com-
posite flaps) were compound flaps,11 proving that by
far this concept has a minority role. The restricted
indications for compound flaps were directly related
to disadvantages distinct for each subtype. Compos-
ite flaps are often bulky, and immediate thinning
could jeopardize their overall vitality. Their individ-
ual parts for the same reason cannot be indepen-
dently inset, which can become cumbersome. Inde-
pendent branch-based conjoined flaps, unless
transposed as a local bipedicled flap,59 require a
recipient vessel conveniently located at the end of
the flap’s reach to provide the mandatory auxiliary
revascularization. This could become a logistical
nightmare in flap planning. Any perforator-based
conjoined or chimeric flap requires a more tedious
dissection, just like any muscle perforator flap.14,15
Anatomical anomalies of perforator flaps in partic-
ular and chimeric flaps in general are not infre-
quent, which could require the inconvenience of
additional microanastomoses or even complete
abandonment of that donor site.38,60,61 Postoperative
monitoring can also be problematic, as one flap of
a combination can remain totally viable while an-
other withers away undetected. A good example is a
case where loss of only the more distal flap in a
fabricated chimeric flap was reported, presumably
because of the increased thrombogenicity caused by
the more proximal anastomotic site.53
CONCLUSIONS
Compound flaps, just because of their greater
innate complexity, will have unique complications
that must be anticipated and circumvented. To
maximize their potential and justify their niche in
the reconstructive hierarchy,62 compound flaps
must always be chosen prudently and only when
appropriate. The similarities yet inherent differ-
ences in the subtypes of compound flaps have
been highlighted in this updated review. This re-
vised classification schema has itself undergone a
significant evolution as our knowledge of flaps has
advanced but possibly has further clarified the
158e
Plastic and Reconstructive Surgery • June 2006
nuances of the terminology used to describe this
important concept.
Geoffrey G. Hallock, M.D.
1230 South Cedar Crest Boulevard, Suite 306
Allentown, Pa. 18103
pbhallock@cs.com
ACKNOWLEDGMENTS
David C. Rice, B.S., physician extender, Sacred
Heart Hospital, Allentown, Pennsylvania, assisted with
all microsurgery advancements, and Carol Varma, med-
ical illustrator, The Lehigh Valley Hospital, Allentown,
Pennsylvania, provided the schematics.
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10. Cormack, G. C., and Lamberty, B. G. H.. The anatomical
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160e
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