MANAGEMENT OF FACIAL CUTANEOUS

DEFECTS, PART I 0030-6665/01 $16.00 + .OO

SKIN ANATOMY AND

FLAP PHYSIOLOGY
Henri P. Gaboriau, MD, and Craig S. Murakami, MD

CUTANEOUS ANATOMY

General Characteristics

The skin is an important organ system necessary for all mammalian

life. It varies not only from one individual to another, but also from one
region of the body to another with respect to color, texture, thickness, and
adnexal structures (hair follicles, sebaceous glands, sweat glands, nerves
and vessels). It may be glabrous (smooth nonhair-bearing) or nonglabrous
(hair-bearing). The skin is classified into two layers: the epidermis (super-
ficial) and the dermis (deep) (Fig. 1).This article will review the anatomy
and characteristics of the skin that are of vital importance to surgeons per-
forming reconstructive surgery of the skin using flaps or grafts.
Careful inspection of a patient’s skin before surgery is essential. Hy-
pertrophic, hyper- or hypopigmented scars, and keloids should be noted, as
they may influence the choice of flap and, ultimately, the surgical outcome.
Aging also may affect the characteristics of the skin. Both exogenous and
endogenous processes cause aging. Exogenous changes mainly are caused
by chronic sun exposure, though smoking also is another contributing fac-
tor. The term photoaging has been used to describe these changes, encom-
passing coarse folds in the skin and a leathery appearance, solar lentigines,
actinic keratoses, and m ~ r e .Endogenous
~,~ changes include fine wrinkling,

From the Department of Otolaryngology-Head and Neck Surgery, Section of Facial Plastic
Surgery, University of Washington (HPG); and the Department of Facial Plastic Surgery,
Virginia Mason Medical Center (CSM), Seattle, Washington

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

VOLUME 34 NUMBER 3 JUNE 2001 555

556 GABORIAU & MURAKAMI

Figure 1. Cross section of skin showing skin appendages and nerve supply.

dermal atrophy, and a decrease in subdermal adipose tissue. Epidermal re-

generation also is decreased by 30% to 50%with aging and may account for
slower wound healing.13The skin’s natural collagen decreases in quantity
and quality with aging. Becoming more compact, it rearranges itself into
thick, coarse bundles or loosely woven straight fibers. In older skin, there
is a paucity of functional elastic fibers causing the skin to loosen. In the
elderly patient, the skin is less elastic but there is greater laxity because
there is quantitatively more skin present. Scars hide well in wrinkled skin
and there are also fewer tendencies to form hypertrophic scars in older pa-
tients. In the elderly, dermal blood vessels may be collapsed, disorganized,
or absent and because of this decrease in blood supply, these flaps may be
at a greater risk for necrosis than flaps performed on younger patients.*O

Epidermis

The epidermis is the top layer of the skin. It contains four distinct
cell types: keratinocytes (comprising 80% of the cells), melanocytes,
 SKIN ANATOMY AND FLAP PHYSIOLOGY 557

Langerhans' cells, and Merkel cells. The epidermis is made up of four

layers of keratinocytes in their various stages of differentiation. From the
deepest layer to the more superficial they are the basal cell (stratum basale),
prickle cell (stratum spinosum), granular cell (stratum granulosum), and
keratin (stratum corneum). The epidermis is a dynamic entity with cells
from the stratum basale constantly dividing and migrating superficially
toward the stratum corneum. The average turnover time of the epidermis
is 30 days. The epidermis is thin at birth, becomes thicker at puberty and
in early adulthood, and thins out again in the fifth to sixth decades of life.
Langerhans'cells are felt to be the mediators of immunologic responses
within the skin and are derived from the bone marrow. With its dendritic
processes, the Langerhans'cells capture and process antigens within the
skin and present them to the skin-specific lymphocyte^.^^, 26 With aging
and chronic sun exposure, the number of Langerhans' cells diminishs,2*
which has been shown to contribute, in part, to the increased number of
skin cancers seen in the elderly.
Melanocytes are of neural crest origin and are found in the basal layer.
These cells produce melanin, which protects the nuclei of the keratinocytes
from ultraviolet radiation. The number of melanocytes does not differ from
one race to another; however, in darkly pigmented skin the melanocytes are
more active than in less pigmented individuals. In albinism, melanocytes
are present but lack tyrosinase, an enzyme that is essential in the produc-
tion of melanin. In elderly people, the number of melanocytes is notably
diminished and may again explain the increase in skin carcinoma seen in
this population.'0,'5Merkel cells are found in the epidermis and the dermis.
They have an unclear origin and function.

Pilosebaceous Unit

This unit is comprised of hair bulb, hair follicle, hair shaft, sebaceous
gland, sensory end organ, and arrector pili muscle (see Fig. 1).The unit is
responsible for the formation of and the secretion of sebum. In the scalp,
the hair is thick and dense, while in the temple area the hair is thin and
dispersed. On the nose, the sebaceous portion of the pilosebaceous unit is
enlarged, which explains the oily character of nasal skin.

Dermoepidermal Junction

The epidermis is attached to the underlying dermis by means of a

complex structure called the basement membrane zone. It has three func-
tions: it attaches the epidermis to the dermis, provides mechanical support
to the epidermis, and also provides a barrier to chemicals or cells. The
558 GABORIAU & MURAKAMI

anchoring fibrils are responsible for the attachment of the epidermis and
the dermoepidermal junction to the dermis. The fibrils are made of collagen
Type VI122and these fibrils are degraded by collagenase. Ultraviolet light
may stimulate keratinocytes to produce interleuken-1 that, in time, may
stimulate collagenase. Topical tretinoin increases the density of anchoring
fibrils by possibly inhibiting ~ollagenase.~~,
32

Dermis

The dermis represents the inner layer of skin between the epidermis
and subcutaneous fat. It consists of two layers, a thin superficial papillary
dermis and a thicker reticular dermis that lies deeper. Collagen, elastic
tissue, and ground substance support the dermis. Blood vessels, nerves,
and cells are dispersed throughout the dermis.
The mechanical strength and extensibility of the skin greatly depends
on the dermal collagen fibers. The content of skin collagen decreases by 1%
per year throughout adulthood.24Topical tretinoin may affect aging skin
and wound healing by inhibition of dermal collagenase, thus slowing the
degradation rate of ~ o l l a g e n . ~ ~ , ~ ~
Elastic fibers in the dermis primarily are responsible for the recoil and
elastic properties of the skin. Elastic fibers tend to thicken and form clumps
in the papillary dermis in sun-damaged skin. These clumps may disappear
after chemical peel, dermabrasion, or laser resurfacing.I6
The cellular constituents of the dermis are embedded in ground sub-
stance. Ground substance is made of glycosaminoglycan, hyaluronic acid,
chondroitin-4-sulfate, fibronectin, and dermatan sulfate. These substances
play an important role in skin hydration and help to preserve the tensile
elasticity of the skin.I6
The main cell in the dermis is the fibroblast. This cell is important
for many functions of the skin and plays a major synthetic role in wound
healing and production of collagen, elastin, and ground substance. The
fibrocyte also may become a contractile cell during wound contraction.

Neurovascular Supply

The skin has a rich nerve supply (see Fig. 1).Sensory nerves for pain,
temperature, pressure, and proprioception are abundant. In the epider-
mis, the Merkel cell neural-cellular complex responds to touch. Meissner's
corpuscleslocated in the papillary dermal papillae, mediate fine touch sen-
sation. The Pacinian corpuscles mediate deep pressure and possibly vibra-
tion deeper in the subcutaneous tissue. Autonomic efferent nerves origi-
nating in the sympathetic system innervate blood vessels and appendageal
structures.'
 SKIN ANATOMY AND FLAP PHYSIOLOGY 559

The skin has two vascular plexuses: a deep vascular plexus and a su-
perficial vascular plexus (Fig. 2). The deep vascular plexus, also referred
to as the subdermal plexus, lies at the junction of the dermis and subcuta-
neous fat. The superficial vascular plexus, located in the superior aspect of
the reticular dermis, gives rise to the capillary loops in the dermal papillae.
Arterioles from the deep vascular plexus supply the pilosebaceous units.
Depending on their location in the face, there also may be a large network
of deep subcutaneous perforating vessels including the transverse facial,
submental, and posterior auricular arteries.29

FLAP PHYSIOLOGY

Introduction

Maintaining a comprehensive knowledge of skin vascular anatomy

and physiology is an essential part of local flap surgery. Vascular
supply to the skin serves two functions: nutritional support and thermoreg-
ulation. Largely the capillary network that is regulated by the precapil-
lary sphincters determines nutritional support. The precapillary sphinc-
ters vasodilate in response to local hypoxemia and increase in metabolic
byproducts.12Thermoregulation is controlled by the arteriovenous shunts.
The arteriovenous shunts and systemic blood pressure are regulated by the
prearteriovenous shunt sphincter^.^^,^^ This system is under postganglionic

Figure 2. Cutaneous vasculature. (From Connor CD, Fosko SW: Anatomy and physiology of
local skin flaps. Facial Plast Surg Clin North Am 468, 1996.)
560 GABORIAU & MURAKAMI

sympathetic control. When body temperature increases, the release of

norepinephrine decreases allowing for a greater flow of blood to the skin
that results in greater heat dispersion. Conversely, when body temperature
decreases, there is a release of norepinephrine that results in contraction of
the preshunt sphincters and diversion of blood away from the skin.7

Vascular Supply of Local Skin Flaps

A review of the literature on vascular supply to the face is comprised

of nomenclature and classification systems that are complex and confus-
ing. The skin of the face receives its blood supply through 14 main ar-
teries that can be divided into two types: (1) the musculocutaneous; and
(2) the direct cutaneous.29The musculocutaneous arteries vascularize the
skin by passing through the underlying muscle to provide nutritional sup-
port. Direct cutaneous arteries travel within the fascia septa between mus-
cles (Fig. 3h4,I4The direct cutaneous vessels also have been referred to as
fasciocutaneous or septocutaneous.” Blood from musculocutaneous and

Figure 3. Vascular supply to the skin showing the two types of artery: musculocutaneous
artery (MC) and the septocutaneous artery (SC). (From Goding GS, Horn DB: Skin flap
physiology. ln Baker SR (ed): Local Flaps in Facial Reconstruction. Philadelphia, Mosby,
1995, p 16; with permission.)
 SKIN ANATOMY AND FLAP PHYSIOLOGY 561

fasciocutaneous vessels reach the surface of the skin through perforating

vessels that run perpendicular to the skin.
In 1987, Taylor and Palmer coined the term of a n g i ~ s o m eto~refer
~ to
the block of tissue (muscle, fascia, subcutaneous fat and skin) supplied by
a named artery. In the head and neck region, some of the most preeminent
angiosomes are thyroid, facial, buccal (internal maxillary), ophthalmic, su-
perficial temporal and o c ~ i p i t a lMore
. ~ ~ recently, Whetzel and Mathes stud-
ied the 14 individual arteries of the face and scalp, along with the relation-
ship between the perforating system and the vascular territories that they
supplied.29The myocutaneous vessels have small perforators that supply
small areas of skin in the central face, while the fasciocutaneous vessels
have two types of perforators: one large and one small. The lateral face
has large perforators traversing through the subcutaneous tissue within a
vascular network of vessel forms that runs parallel to the skin and provides
nutrition to large areas of skin. This is the subcutaneous plexus and much
of the blood supply to the lateral face is supplied in this manner through
large perforators like the transverse facial artery and the submental artery.
Fasciocutaneous vessels that have small perforators in the subcutaneous
layer supplying smaller areas of skin supply the skin of the scalp. This infor-
mation regarding the size and location of the arterial perforators clinically
is significant and contributes to the explanation of why a flap’s vascularity
varies so dramatically in different regions of the face. It also reveals how
surgeons might improve the vascular supply of facial flaps. For example,
it explains why a cervical-facial flap elevated in a deep plane to SMAS
may have better vascularity, because it might preserve the large perforat-
ing branch of the fasciocutaneous transverse facial artery that supplies a
large portion of the lateral cheek.

Flap Designs

There are four types of flap designs based on their vascular supply:
random, axial flap (also called arterial cutaneous), fasciocutaneous, and
musculocutaneous (Fig. 4). In the head and neck region, flaps mainly are
random or axial.

Random Flaps
A random flap depends on vascular supply of the subdermal plexus
that is in turn supplied by unnamed musculocutaneous perforators at the
base of the flap.5 The plane of dissection of random flaps is through the
subcutaneous fat. Random flaps can be rotated, transposed, advanced, or
tubed. The survival of the flap may be unpredictable, related to the length-
to-width ratio. Originally it was believed that a ratio of 1:l was required,
562 GABORIAU & MURAKAMI

Figure 4. Classification of skin flaps based on vascular supply. A, Random. 6,Axial flap.
C, Fasciocutaneous. D, Musculocutaneous.

but clinical experience showed that a ratio of 3:l to 4:l gave viable flaps in
some areas of the face.4In many ways calculating random flap survival by
length-to-width ratios may be erroneous. It is better to think of the length
of the flap in relation to the capillary perfusion pressure of a given area
(see Biomechanics) (Fig. 5).

Axial Flaps
Axial flaps derive their blood supply directly from a fasciocutaneous
artery that runs beneath the longitudinal axis of the flap. Beyond the
 SKIN ANATOMY AND FLAP PHYSIOLOGY 563

Flap survival Flap necrosis

rnm Hg

Critical closing pressure

Low
1
Proximal b Distal
Location along flap

Figure 5. The distal part of the flap necroses when the capillary perfusion pressure falls
below the critical closing pressure of the arterioles in the deep vascular plexus. (From Goding
GS, Hom DB: Skin flap physiology. ln Baker SR (ed): Local Flaps in Facial Reconstruction.
Philadelphia, Mosby, 1995, p 19; with permission.)

territory of the artery the survival of the flap is based on the deep vascular
and superficial vascular plexus. In essence, the distal margin may have a
vascular supply similar to the random flap. The length-to-width ratio typi-
cally is greater than random flaps. The plane of dissection needs to include
the fasciocutaneous vessel within the subcutaneous fat. Commonly used
564 GABORlAU & MURAKAMI

axial flaps are the midforehead flap based on the supratrochlear artery and
the forehead (converse)flap based on the superficial temporal artery.

Fasciocutaneous Flaps
Fasciocutaneous flaps are composed of skin, subcutaneous and deep
fascia. The radial forearm flap is an example.

Musculocutaneous Flaps
These flaps incorporate skin, subcutaneous tissue, fascia and the un-
derlying muscle. Examples of such flaps are latissimus dorsi, pectoralis
major, temporalis muscle, and trapezius muscle.

FLAP BIOMECHANICS

Flap Tension

The survival of a local skin flap depends on blood supply that is re-
lated to the amount of wound tension present at the time of closure. It is
important to understand the concepts of stress and stvain that describe the
mechanical properties of the skin. Stress is a force applied per unit of orig-
inal cross section and strain is the change in length divided by the original
length of the tissue to which the force is applied (Fig. 6).17When small
amounts of stress are applied to skin, the stress-strain curve (Section I) is
flat, meaning that considerable extension occurs with little force. Under

- I- I I-- ( Ill-*

‘Aged Skin

Strain (Length)

Figure 6. Stress-strain curve for isolated skin

 SKIN ANATOMY AND FLAP PHYSIOLOGY 565

higher degrees of stress, the stress-strain curve demonstrates a rapid tran-

sition where little length is gained with increased force (Section 11).At very
high stress levels, minimal length is gained despite great increases in ap-
plied force (Section 111). At the microscopic level, the initial deformation
(Section I) corresponds to the stretching of collagen and elastic fibers in the
direction of the applied force and there is little resistance to initial defor-
mation. Additional collagen and elastic fibers are recruited and resistance
increases rapidly as the applied force increases (Section11).In Section 111,all
collagen and elastic fibers are recruited and aligned in the direction of the
applied force and no further deformation is possible. Aging skin behaves
differently: there is a progressive loss of elastic fibers and a loss of elastic
recovery. In Section I and 11, less force is needed to obtain the same increase
in length than with younger skin. Clinically, this results in less wound clo-
sure tension in elderly patients. When comparing older skin with younger
skin, the stress-strain curves are similar in Section I11 suggesting that the
stiffness of collagen fibers does not change with age. The probability of flap
necrosis is directly related to both length of the flap and tension applied.
At equal closing tensions, longer flaps will have higher probabilities of
necrosis.'s

Creep and Stress-Relaxation

Creep and stress-relaxation are two skin properties that are time-
dependent. Creep refers to the increase in strain seen when skin is placed
under constant stress. When stress is applied to the skin, the collagen fibers
displace interstitial fluid from one area to another, which explains the time
dependence of the process.'l
Stress-relaxa tion is a decrease in stress that occurs when skin is held
under tension at constant strain for a given time. Serial excision is based
on the principle that if a flap is closed under tension, a certain amount of
stress-relaxation and creep occurs over time.
The stress-strain curve varies depending on the region of the body
where the flap is raised. The thickness of the skin, the topography, and the
amount of movement, age, sex, body habitus, and more, affect the curve.

Flap Undermining

When elevating a local skin flap, some degree of undermining is re-

quired. The force required to advance a flap is the force used to counteract
the resistance between the dermis and underlying tissues (shearing force).6
Undermining releases the vertical attachments between the dermis and
underlying tissues that reduces the shearing force and allows the skin to
566 GABORIAU & MURAKAMI

slide over the subcutaneous tissue. Choosing the proper plane of dissection
is important in order to include the feeding vessels or vascular plexuses. It
also is important to decide how far one chooses to undermine a flap. Ani-
mal studies have demonstrated that undermining beyond 4 cm may have
little effect in reducing the flap tension and also may result in higher de-
grees of flap necrosis.'s,'9In humans, the amount of undermining depends
on the location and type of flap being used.
On the nose, undermining of the skin is limited by the innate inelastic-
ity of sebaceous skin and deep attachments of nasalis muscle. Undermining
in the subcutaneous plane put the skin at risk of vascular compromise and
subsequent necrosis. If undermining is carried out below fascia and muscle
the vascular supply is safe but no tension release is achieved.
At the level of the scalp and forehead, undermining in a subcutaneous
plane provides mobility by releasing the vertical attachments to the dermis
and underlying muscle; however, this puts vessels and sensory nerves at
risk of injury. Undermining at the galea level would provide an avascular
plane. Because of the inelastic nature of the galea, however, no release of
tension will be achieved. In order to achieve this goal a galeotomy needs
to be performed. In the forehead region mobility can be achieved by sub-
periosteal elevation and release of the periosteum at the level of the or-
bital region. In this case the supraorbital neurovascular bundle is at risk of
injury.
In the temple area, undermining may put the frontal branch of the
facial nerve at risk. If undermining is necessary it should be performed
superficially and cautiously.
The cheek is composed of two distinct regions. Laterally, the cheek has
a thick, deep layer of subcutaneous fat. Undermining within the subcuta-
neous fat is safe because the facial nerve branches are protected within the
parotid gland. Medially, the facial nerve branches ascend and undermining
deep to the muscle may put the branches at risks.
In the periocular region, the skin is very thin with almost no subcu-
taneous fat. Undermining may be performed with caution to avoid dam-
age and necrosis of the skin. Also in this region, undermining should be
performed above the plane of the orbicularis oculi muscle. In the perio-
ral region, undermining should be performed above the orbicularis oris
muscle.

Impairment of Vascular Supply

In random flaps, the perfusion pressure decreases with increasing dis-

tance from the base to the tip of the flap. The perfusion pressure is an
important parameter for the flap survival. If it drops below the critical
 SKIN ANATOMY AND FLAP PHYSIOLOGY 567

closing pressure of the arterioles in the deep vascular plexus the blood
flow ceases and necrosis of the flap is inevitable (see Fig. 5). Making a flap
wider may not result in longer flap survival, because it may not increase
the perfusion pressure of the critical closing pressure (Flap A versus Flap B,
see Fig. 5).

Relaxed Skin Tension Lines and Lines

of Maximum Extensibility

Skin tension exists in all directions but is greatest along the relaxed
skin tension lines (RSTLs) and is minimal along the lines of maximum
extensibility (LMEs)’ (Fig. 7). The LMEs run perpendicular to the RSTLs
and represent the direction that closure can be performed with the least
t e n ~ i o nTherefore,
.~ surgeons should place incisions parallel to the RSTLs
where tension will be minimized.

Figure 7. The facial relaxed skin tension lines (RSTLs). (From Miller PJ, Constantinides M:
Simple and serial excisions. Facial Plast Surg Clin North Am 6:142, 1998.)
568 GABORIAU & MURAKAh4I

SUMMARY

In the first part of this article, the authors reviewed the anatomy of the
skin. In-depth knowledge of the different components of the skin is crucial.
In the second part, the facial reconstructive surgeon should become familiar
with the different types of skin flaps and their vascular supply. Finally in
the third part, the authors reviewed several aspects of flap biomechanics
that should allow the surgeon to perform the most adequate reconstruction
in regard to location and size of defects.

ACKNOWLEDGMENT
The authors would like to acknowledge Ms Kate Keith for her help correcting and typing
the manuscript.

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Address reprint requests to

Craig S. Murakami, MD
Department of Facial Plastic Surgery
Virginia Mason Medical Center
XlO-ON
Seattle, WA 98111