PART 1 — PRINCIPLES

Classification of Flaps
Geoffrey G. Hallock | Reza Ahmadzadeh | Steven F. Morris
2

INTRODUCTION

A BRIEF HISTORY OF FLAPS

The history of plastic surgery is in many ways a recapitula-
tion of the history and corresponding evolution of flaps
(Fig. 2.1). The earliest flaps were, as would be considered Random
today, random skin flaps, as the skin was raised without
regard to any known blood supply other than to maintain
the presence of the subdermal vascular plexus.1,2 The clas-
sification of flaps in the beginning was relatively easy, since
they could be distinguished from one another only accord-
ing to how they were constructed. This included how they
Muscle
were transposed (e.g., as an advancement, rotation, or trans-
position flap), their geometrical configuration (e.g., as a
tubed flap), or by their destination (e.g., as a local or distant Source
vessel Musculocutaneous
flap).3 Because of their limited blood supply, there was a
belief that random flaps had to be restricted to rigid length–
width ratios to ensure viability. Still, some flaps lived and
others died.
Such simplicity faded after Milton4 disproved flap length–
width ratios, and asserted instead that flap viability was Fascia
dependent on the vascular supply of the given flap territory.
This led to a renaissance in flap construction, based on an
improved understanding of the anatomic basis of the circu- Fasciocutaneous
lation to the skin, initiated by McGregor and Morgan,5 when
they discovered that some regions of the body had discrete
and relatively large subcutaneous vessels that had pierced
the deep fascia to follow a predictable course. Compara-
tively large cutaneous flaps, if oriented along the axis of that
vascular pathway, consistently maintained complete viability,
and appropriately were called axial flaps (e.g., deltopectoral
flap, groin flap).
Orticochea6 reported that the inclusion of muscle in the Perforator
flap could result in larger skin flap survival. McCraw et al.7
more precisely explained the reasoning behind this associa-
tion, and called the vessels coursing from the muscle to the
skin “musculocutaneous” arteries. Interestingly, Tanzini8 in
1906 had published the first report of such a musculocuta-
neous flap. Tanzini et al.,9,10 were well aware of the existence
of branches from the muscle necessary to form these com-
pound flaps. Nevertheless, it was not until the late 1970s that Subdermal vascular network
musculocutaneous flaps became a standard reconstructive Figure 2.1 The evolution of flaps has reflected a progression to
option. better ensure the adequacy of their intrinsic circulation, beginning
The zeal to adopt cutaneous flaps relying on musculocu- with the least reliable, nourished only via the subdermal plexus, and
taneous vessels perhaps delayed the recognition of other ultimately coming back again full circle to the subdermal vascular
important contributions to the “fascial plexus” that would network “supercharged” by retained perforators.

e1

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e2 PART 1 — PRINCIPLES
eventually allow cutaneous flaps to stand alone. Pontén11
deserves credit for reintroducing fasciocutaneous flaps,
although he was not quite sure why the inclusion of the
deep fascia with his “superflaps” resulted in a longer flap
survival length than could be predicted for random flaps of
comparable width. Note that Esser and Schwerer,12 and
Gillies13 in the early part of the last century, had already
suggested that it was advantageous to include the deep
fascia with skin flaps, so that perhaps all along, this, too, was
common knowledge.
The “fascial plexus” essential for survival of these fascio-
cutaneous flaps is not a discrete structure per se, but repre-
sents a confluence of subfascial, intrafascial, and suprafascial
vascular plexuses within the dermal, subdermal, superficial
adipofascial (above Scarpa’s fascia), and deep adipofascial
layers, where each is a component part of a magnificent
array of interconnected vessels.14–16 The medical student
Manchot,17 more than 100 years ago, was also well aware
that “larger cutaneous arteries … appear from the fissure
between … muscles …” as intermuscular or septocutaneous
perforators of the deep fascia. These, along with the direct
perforators of axial flaps and musculocutaneous perfora-
tors, are today the major contributors to the “fascial plexus”
from the underlying source vessels of a given angiosome.
As microsurgical tissue transfer became widely adopted,
there was an exponential growth in flap options. Virtually
every tissue could then be transferred including muscle,18
bone,19,20 nerve,21 viscera,22 etc. As well, modifications and
combinations such as perforator flaps,23,24 conjoined and
chimeric flaps25,26 were reported leading to an explosive
development in choices of flaps. The challenge was to clas-
sify all of these flaps into a system that allows teaching,
research, and communication regarding flaps.
SKIN FLAPS AND THEIR CLASSIFICATION
In the last few decades there have been many attempts to
provide a modern classification schema for skin flaps. The
simplest system is to describe all skin flaps as having direct
cutaneous, septocutaneous, or musculocutaneous perfora-
tors.27,28 However, many authors have published other con-
cepts of the vascular supply to skin flaps, which has led to
some degree of confusion about the terms. In this section,
we aim to clarify the terms used in the most well-known
classifications.
Nakajima et al.14 (1986) separated skin flaps into five
types: random pattern, fasciocutaneous, adipofascial, septo-
cutaneous, and musculocutaneous flaps.
Cormack and Lamberty29 (1984) emphasized that the
term “fasciocutaneous” implied retention of a system of
vascularization within the given flap, and does not refer to
any specific tissue constituents per se. Thus, even if the skin
(e.g., adipofascial flap) and/or deep fascia (e.g., subcutane-
ous flap) are excluded from a flap that is dependent on the
remaining “fascial plexus,” such a flap would still be a “fas-
ciocutaneous” flap.30 A fasciocutaneous flap can be com-
posed of any or all of the tissue layers found between the
skin and deep fascia.31 By this definition, Cormack and Lam-
berty29,32 were further able to contract all skin flaps into a
tripartite system that included direct cutaneous (sic. axial),
musculocutaneous, and fasciocutaneous flaps.
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CORMACK AND LAMBERTY CLASSIFICATION
Cormack and Lamberty29 classified fasciocutaneous flaps
into four major types (Fig. 2.2), differentiated by the origin
of the circulation to their “fascial plexus.” Their Type A flap
had multiple “fascial feeders”33 or perforators that did not
require specific identification, reminiscent of the random
skin flap. Type B flaps contained a large, solitary septocuta-
neous perforator. The Type C flap relied on multiple and
usually diminutive segmental septocutaneous branches, so
that elevation of these flaps almost always necessitated inclu-
sion of the source vessel with the flap, in order to maintain
their complete integrity. Type D is similar to Type C in that
it is based on multiple small perforators; however, it is raised
as an osteomyofasciocutaneous flap.
MATHES AND NAHAI CLASSIFICATION
Mathes and Nahai’s34 (1997) classification of fasciocutane-
ous flaps based on the type of deep fascial perforator (Fig.
2.3) is similar to Cormack and Lamberty’s classification of
flaps: their Type A is a direct cutaneous flap, in which the
vascular pedicle travels deep to the fascia for a variable dis-
tance then pierces the fascia to supply the skin (e.g., groin
flap, temporoparietal fascia flap). Type B is a septocutaneous
flap, which has a vascular pedicle that courses within an
intermuscular septum (e.g., lateral arm flap, radial forearm
flap). Type C is a musculocutaneous flap and is based on a
vascular pedicle that is traveling within the muscle substance
(e.g., DIEP flap).
NAKAJIMA CLASSIFICATION
Nakajima et al.14 expanded the subtypes of fasciocutaneous
flaps into six forms (Types I–VI, or A–F), each based on a
distinctly different perforator of the deep fascia (Fig. 2.4).
Most had been previously described, e.g., their Type I “direct
cutaneous flaps” were identical to the axial flaps of McGregor
and Morgan.5 The Type II “direct septocutaneous flaps”
were identical to Cormack and Lamberty’s type B fasciocu-
taneous flaps, and the type V “septocutaneous perforator
flaps” would be the same as the latter’s Type C.32,33 The Type
VI “musculocutaneous perforator flaps” resembled tradi-
tional myocutaneous flaps.
The remaining two types of flaps hypothesized by Naka-
jima et al.,14 based on a “direct cutaneous branch of muscu-
lar vessel” (IV) and “perforating cutaneous branch of a
muscular vessel” (III), were without question different and
that is their most important contribution. Later, using com-
puter graphics imaging, Nakajima et al .,16 in a 3-dimensional
view of the “fascial plexus,” demonstrated that the axiality,
vessel size, and suprafascial course of these vessels proved
that the function of these “muscular vessels” was to provide
nutrition to the skin, and only secondarily to the involved
muscle. The “direct cutaneous branch of muscular vessel”
remains an enigma due to its variable presence and has
been little described. However, the “perforating cutaneous
branch of muscular vessel” has become recognized as the
basis for the perforator flaps. Some have argued that these
are the only “true” perforator flaps.35
The fasciocutaneous flap classification schemas of
Cormack and Lamberty,29,32 Nakajima et al.,14 and then
 CHAPTER 2 — Classification of Flaps e3

Type A: multiple feeders Type B: solitary

Type C: segmental Type D: osteomyofascial

Figure 2.2 The subtypes of fasciocutaneous flaps in Cormack and Lamberty’s classification schema differ according to the means of vascu-
larization of the “fascial plexus.”

Type A: direct cutaneous Type B: septocutaneous Type C: musculocutaneous

Figure 2.3 Mathes and Nahai’s tripartite system of fasciocutaneous flaps is based on the three major types of deep fascial perforators.

Perforating cutaneous branch of

muscular vessel (III) Mathes and Nahai (see below)34 are very similar, as each uses
Septocutaneous subtle differences in circulation patterns to distinguish their
Direct cutaneous (I) perforator (V) flap subtypes. This is also a pragmatic approach, as the vas-
Direct Musculocutaneous Direct cular supply, if nothing else, must be correctly identified
septocutaneous (II) Muscle perforator (VI) cutaneous branch of and protected to ensure flap viability. Yet even further con-
muscular vessel (IV) solidation of cutaneous flap types is possible.
Skin
TAYLOR’S “ANGIOSOME” CONCEPT-BASED
CLASSIFICATION
Angiosomes refer to specific 3-dimensional blocks of tissue,
S including skin and deeper tissues layers that are supplied by
specific source arteries.27 In 1893, Spalteholz36 performed
F F injection studies using pigment mixed in gelatin to demon-
Figure 2.4 The six distinct deep fascia perforators according to strate a pure (intermuscular) or impure (i.e., primarily sup-
Nakajima et al.14 A different type of fasciocutaneous flap can be plied deeper tissues, mostly muscle) course of cutaneous
sustained by each discrete type of perforator. S, source or “mother” perforators. All arteries to the skin could most simply be
vessel; F, deep fascia. considered to be either “direct” or “indirect” branches from

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e4 PART 1 — PRINCIPLES
Direct perforators
Indirect perforators
S FLAP CLASSIFICATION
Figure 2.5 The deep fascia perforators of Nakajima et al.14 (see Fig.
2.4) can be more simply considered to be either “direct” or “indirect”
perforators. All perforators arise from the same source vessel (S) but
only “indirect” perforators (dotted lines) first pass through another
tissue intermediary (here depicted as muscle) before piercing the
deep fascia.
an underlying source vessel. Taylor has repeatedly argued
that the direct vessels are the primary cutaneous supply, and
it is irrelevant if they have first traversed intermuscular or
intramuscular septa, as their main destination always is to
the skin.27,28,37,38 The indirect vessels emerge above the deep
fascia as terminal, spent branches whose main purpose was
to supply the deeper tissues, so they are in reality only a sec-
ondary means of cutaneous blood supply.39 It can be further
argued that all deep fascia perforators would be “direct” if
they coursed from the source vessel to perforate the fascia
without first passing through some other tissue intermediary,
or otherwise they would be “indirect” perforators (Fig. 2.5).28,40
All corresponding cutaneous flaps would then be either
direct perforator flaps or indirect perforator flaps.
Because the perforator supplying a muscle perforator
flap, by definition,35 must have first traveled through the
substance of that muscle, in this classification system, these
would be indirect perforator flaps. Neurocutaneous flaps
would be an excellent example of indirect non-muscle per-
forator flaps. These flaps rely on an intrinsic and extrinsic
neurocutaneous or venocutaneous vascular supply that
accompanies a peripheral cutaneous nerve.41–44 The extrin-
sic vascular supply can often be a true artery, and, depend-
ing on the nerve, both structures can simultaneously pierce
the deep fascia before proceeding within the subcutaneous
tissues.41–44 The major purpose of this accompanying vascu-
lar system is to provide circulation to the nerve, and only
secondarily (or indirectly) are cutaneous branches given off
that will support an overlying cutaneous flap. Niranjan
et al.33 pointed out that perforators similar to those accom-
panying the cutaneous nerves can also arise independently
from fascioperiosteal or tenosynovial branches, which in
turn also can supply indirect non-muscle perforator flaps.
Thus, indirect perforator flaps, more than any other cutane-
ous flap, deserve a separate categorization to ensure the
appropriate dissection of whatever are the intermediary
structures, while protecting the requisite vascular supply.
MUSCLE FLAPS
In the 1980s, muscle flaps became very popular, since it was
a reliable method to transfer large skin flaps. Over the
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decades, the use of muscle flaps has evolved so that muscle
function is rarely sacrificed simply to supply skin blood
supply but rather, muscle flaps are used when a large volume
of flap is required to fill dead space or muscle function is
required, as, for example, with facial reanimation. It remains
important that the pattern of vascularity of muscles will
determine muscle flap survival and must be respected.
MATHES AND NAHAI MUSCLE
Mathes and Nahai45 (1981) categorized muscles into Types
I–V, based on their vascular supply (Fig. 2.6). On the other
hand, it is not just a coincidence that the majority of mus-
culocutaneous perforators arise near where the dominant
pedicle enters the hilum of that muscle. The astute student
of muscle perforator flaps must be fully aware of the most
reliable muscle types, which pedicle is dominant, and where
they are typically located to better predict the presence of
musculocutaneous perforators. This is essential for skilful
elevation of these flaps, even though the muscle itself is not
to be included.
TAYLOR CLASSIFICATION
Taylor et al.46 have also divided muscles into four groups
(Types I–IV) that differ by their mode of motor innervation
(Fig. 2.7). This classification becomes important when a
dynamic muscle transfer is considered, to ensure capture of
an appropriately functioning muscle unit.
OTHER FLAPS
Vascularized bone flaps are used less frequently than soft
tissue flaps. Again, as for all other flaps, a good system would
categorize these primarily on the basis of their circulatory
patterns.
SERAFIN CLASSIFICATION
Serafin has divided osseous flaps according to whether the
flap has a direct (endosteal) or indirect (periosteal) circula-
tion (Fig. 2.8).47 Vascularized joint transfers could similarly
be subclassified according to the source of vascularization
of their bony constituents.
COMBINED FLAPS
In extraordinary circumstances, the creative combination of
flaps from a single donor site is used to repair challenging
defects where multiple tissue islands are required. The spo-
radic introduction of variations of combined flaps has
created much confusion in terminology, since minor modi-
fications of technique often have been called different
names or given eponyms, but the basic flap composition
has remained unaltered. There are two major subtypes
of combined flaps that are distinctly different in regards
to the physical relationship of their component parts, yet
both are similar in that each anatomic territory that is part
of that combination always retains an independent blood
supply.
 CHAPTER 2 — Classification of Flaps e5

Type I Type II Type III Type IV Type V

D
M D1

D SS
D2 S
M
S
SS
S
SS
S
M
S

M
D

Gastrocnemius Trapezius Serratus anterior Tibialis anterior Internal oblique

Figure 2.6 The classic classification schema for muscle flaps by Mathes and Nahai is divided into five types, according to the predominant
45

vascular pattern for that type muscle. D, dominant pedicle; M, minor; SS, secondary segmental; S, segmental.

Latissimus dorsi Vastus lateralis Sartorius Rectus abdominis

A B C D
Figure 2.7 Taylor’s46 alternative schema classified muscles according to the increasing complexity of their innervation, and concomitant
diminished suitability for use as a dynamic muscle transfer. (A) Type I: single unbranched nerve entering muscle. (B) Type II: single nerve that
branches just before entering muscle. (C) Type III: multiple branches from same nerve trunk. (D) Type IV: multiple branches from different nerve
trunks.

CONJOINED FLAPS
25,48
Harii et al. first introduced the concept of combined
flaps when they described a “combined myocutaneous flap
and microvascular free flap.” This captured the skin territo-
ries of the latissimus dorsi musculocutaneous flap and groin
flap, where both remained connected together to essentially
form a bipedicled flap with the thoracodorsal and superfi-
cial circumflex iliac vessels remaining as pedicles at opposite
ends, respectively.25 Such a conjoined flap or Siamese flap
(named after the conjoined Siamese twins, Chang and Eng,
1811–1874)49 will have multiple flap territories that remain
dependent due to some common physical junction, yet each
territory retains its intrinsic and independent vascular
supply (Fig. 2.9).
Any direct or indirect perforator flap40 that has more
than a single perforator could also be considered to be
a “conjoined” flap, as each perforator retains its specific
vascular territory that, for example, Tsai et al.50 have
used to advantage as the basis for “splitting” the flap. These
would be called “perforator-based conjoined flaps” in con-
tradistinction to Harii et al.’s25,48 flap that retained indepen-
dent branches of the source vessel to each territory, hence
being an example of a “branch-based (independent) con-
joined flap.” If the independent branches had a common
“mother” vessel, as in a conjoined parascapular and latissi-
mus dorsi muscle flap as theorized by Nassif et al.,51 this
would be an example of a “branch-based (common) con-
joined flap.”

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e6 PART 1 — PRINCIPLES
Endosteal Periosteal
Figure 2.8 Osseous flaps according to Serafin47 can be classified
as either endosteal, where the blood supply directly enters the bone,
usually via a nutrient foramen (left), or periosteal, which circumscribes
the bone within the periosteum to eventually reach the bone
indirectly.
CONJOINED
Perforator-based
Branch-based
Independent Common
Figure 2.9 Conjoined flaps have two subclasses distinguished by
the distinctly different caliber of their source of vascularization. The
larger caliber and often subfascial or axial branches of the branch-
based form may have completely unrelated origins from different
angiosomes (independent type), or these branches may arise from a
common source vessel (common type). The perforator-based form
usually has multiple deep fascia perforators arising from a common
source vessel.
CHIMERIC FLAPS
The chimeric flap, originally conceived as a combination of
local flaps from the same anterolateral thigh angiosome,26
has become entrenched in our vocabulary, despite the
obvious problem that a chimera generally refers to an
organism with a mixture of genetically different tissues. The
chimeric flap has two or more subunits, each with an inde-
pendent vascular supply, that are independent of any physi-
cal interconnection except where linked by a common
source or “mother” vessel. Huang et al.52 have further sub-
divided chimeric flaps into three subtypes, based on their
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CHIMERIC
Intrinsic
Perforator-based Branch-based
Fabricated
Sequential Internal
Figure 2.10 Chimeric flaps can be stratified into three subclasses
on the basis of either their intrinsic vasculature or whether prefabri-
cated via a microanastomosis. Perforator-based chimeric flaps are
nourished by perforators arising from a common source vessel.
Larger caliber and usually subfascial vessels to the branch-based
chimeric flap also ultimately are connected to a common “mother”
vessel. In the fabricated chimeric flap, the added component can be
attached to the terminus of the source vessel to create a “flow-
through” (sequential type) or to a branch indigenous within the flap
(internal type).
specific blood supply (Fig. 2.10). The more traditional chi-
meric flap or branch-based type will have multiple and rela-
tively large subfascial branches emanating from a common
“mother” vessel. The subscapular system epitomizes this
subtype, where fascial (dorsal thoracic), muscle (serratus
anterior, latissimus dorsi), and osseous (rib, scapula) flaps,
based on either the thoracodorsal or circumflex scapular
branches, can allow over 60 known different flap combina-
tions, which still permit independent insetting of each
part.53
If the common boundary of a “perforator-based con-
joined flap” is split apart, yet each part based on an indi-
vidual perforator still remains attached to the same source
vessel, these would become perforator-based chimeric
flaps.50 The anterolateral thigh flap is the prototypical donor
site for this variation, where it has been split into smaller
flaps to allow, for example, simultaneous intraoral and
cheek reconstruction without the need for flap infolding or
de-epithelialization.54
Koshima et al.,55 in their introduction to the chimeric flap
principle, prefabricated combinations by attaching other-
wise independent flaps to either side branches of the main
source vessel or to its distal continuation.48 This type of
fabricated chimeric flap always requires a microanastomo-
sis. If the added flap is connected to the terminus of the
source vessel, this would be a fabricated (sequential) chime-
ric flap as the circulation must proceed as a “flow-through”
across the first flap and then to that attached in sequence.
If a side branch of the first flap is used for this microanas-
tomosis, this would be a fabricated (internal) chimeric flap,
 CHAPTER 2 — Classification of Flaps e7

Pedicle Skin Blood supply

Fat
Fascia
Muscle
Cartilage
Skin Non-skin: Axial Random
Bone
blood vessels
subcutaneous tissue and
fascia
muscle Composite:
Unipedicle Bipedicle fasciocutaneous
musculocutaneous

Special preparation Form

Delay Tissue expansion Destination Rotation Transposition

Local Distant Special

Pedicled Free Bilobed Rhomboid, etc.

Figure 2.11 The “atomic system” that enumerates all known characteristics that are essential to fully describe any flap. (Reprinted with per-
mission from Tolhurst DE. A comprehensive classification of flaps: the atomic system. Plast Reconstr Surg 1987; 80:608–609).

as there would be flow only internally within the combina-
tion and no “flow-through.”
SECONDARY CHARACTERISTICS
There is no system that can perfectly categorize all types of
flaps,56 and most likely one never would be universally
accepted anyway. This is a Herculean task, just considering
the primary attributes of all flap types. To be absolutely
complete, other secondary characteristics must also be
accounted for. Tolhurst57,58 listed all possible distinguishing
characteristics that should be enumerated in his “atomic
system” but flap composition, rather than circulation was
his primary focus (Fig. 2.11). Cormack and Lamberty30,59
used a similar format with their anatomic system for com-
plete flap classification, but advocated using the source of
circulation as the nucleus or most critical factor in flap
selection. They also proposed a mnemonic of the “6 Cs” for
complete flap identification that, in addition to the circula-
tion, included constituents (composition), conformation
(form/shape), contiguity (destination), construction (type
of pedicle), and conditioning (preparation) (Table 2.1).32
PERFORATOR FLAPS
A perforator flap may be defined as a vascularized tissue
transfer based on a cutaneous perforator (direct, septocu-
taneous, or musculocutaneous). The individual perforators
are quite variable but the underlying source vessels and
regional vascular supply (angiosome) are quite consistent.
Therefore, a nomenclature system for describing perforator
flaps was reported, which identifies all skin flaps according
to the source vessel (e.g., lateral circumflex femoral, LCF);
artery perforator (AP, or septocutaneous S), and the muscle
penetrated by the perforator if required (e.g., tensor fascia
lata, tfl). Therefore, an upper anterolateral thigh flap would
be LCFAP-tfl.23,24
VASCULARIZED COMPOSITE
ALLOTRANSPLANTATION
CLASSIFICATION
In the continued quest for perfection, sources other than
autogenous tissues have shown promise for better results
with less donor site morbidity. Although tissue engineering
or regeneration may ultimately be the final answer, at the
present time, vascularized composite allotransplantation is
more pragmatic with stunning results, especially in face and
upper extremity reconstruction (see Chs 64 and 65). Other
body parts and organ systems such as the penis, abdominal
wall, and uterus have been transferred, but in comparably
smaller numbers (see Ch. 66). Successful transfer of flaps
such as muscle VCA has been reported,60 as has a DIEAP
(deep inferior epigastric artery perforator) free flap for
breast reconstruction61 and a temporoparietal scalp flap for
alopecia,62 with the latter two unique, in that they were
between identical twins, so no immunosuppression was
required. Since in all cases, VCA differs from autogenous
tissue transfers only in that the donor and recipient are not
the same individual, it would seem reasonable not to have

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e8 PART 1 — PRINCIPLES

Table 2.1 The complete classification of a flap

Primary Secondary
characteristics Pedicled flap Free flap characteristics Pedicled flap Free flap
Circulation Direct vessels Direct vessels Contiguity Local Free flap
(blood supply) (destination)
Axial Axial Regional
Septocutaneous Septocutaneous Distant
Endosteal Endosteal Construction Unipedicled Orthograde flow
(flow)
Indirect vessels Indirect vessels Bipedicled Retrograde flow
Myocutaneous Myocutaneous Orthograde flow Turbocharged
Periosteal Periosteal Retrograde flow Supercharged
Constituents Fasciocutaneous Fasciocutaneous Turbocharged
(composition)
Muscle/ Muscle/ Supercharged
myocutaneous myocutaneous
Visceral Visceral Conditioning Delay Delay
(preparation)
Nerve Nerve Tissue expansion Tissue expansion
Bone Bone Prefabrication Prefabrication
Cartilage Cartilage Conformation Special configurations Tubed
(geometry)
Other Other Tubed Combined flaps
Combined flaps

(Adapted from Cormack GC, Lamberty BGH. Alternative flap nomenclature and classification, the arterial anatomy of skin flaps, 2nd ed.
Edinburgh: Churchill Livingstone; 1994. p. 514–22.)

a special classification nomenclature just for VCA tissues
as the tissues themselves are no different from one person
to another. Composite tissues would be named according to
the region transferred, with VCA written as a suffix just to
clarify the source, e.g., “face composite VCA” or “face VCA”
for short. Individual flaps or combinations would follow the
same schema as outlined earlier in this chapter. Thus, a
DIEAP flap transferred from one individual to another
would simply be a DIEAP VCA free flap, again to differenti-
ate appropriately the tissue source.
CONCLUSION
Although there are a bewildering array of classification
schemes, some, such as the muscle flap classification of
Mathes and Nahai,45 have become well established. It would
be just as convenient to categorize all cutaneous flaps as
either direct or indirect perforator flaps,40 which also alerts
the surgeon to anticipate differences in the requisite dissec-
tion techniques to preserve the blood supply to the flap.
However, the terms axial, fasciocutaneous, and musculocutane-
ous are so entrenched that this will be unlikely. Some other
uncommonly used types of flaps have not even been dis-
cussed in this context but venous flaps, for example, could
be considered to be indirect perforator flaps, since all super-
ficial veins at some point pierce the deep fascia with their
intrinsic and/or extrinsic arterial supply.41 Visceral flaps
could be distinguished by the anatomic origin of the flap,
e.g., colon, jejunum, appendix, etc. To compound this
dilemma, so many other potential permutations or combi-
nations exist that it is just not possible to clearly stratify all
possibilities. A complete classification of flaps will always be
an elusive goal,56 but it is important to use surgical princi-
ples and a keen awareness of vascular anatomy to try to
simplify classifications rather than make them unusable due
to complexity. Muscle perforator flaps are the prototypical
example of this controversy, in which several classifications
have been proposed.23,63–65 The overall goal of classifications
should be to aid in communication between surgeons in the
quest to continually improve our results and try to use the
best flap for each reconstructive challenge.

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Expert Commentary
Michel Saint-Cyr, MD, FRCS (C)
Regardless of origin and distribution, any single perforator holds
a unique vascular territory (Perforasome) and if large enough,
can be used as either a pedicle, or free, perforator flap. With
over 350 clinically relevant perforators in the body, this allows
for a tremendous number of options in flap choices and design.
Knowledge of the location of the most dominant perforators is
critical and will help facilitate flap design and harvest. Most
perforators in the body are distributed within “cold spots” and
“hot spots,” with hot spots being high perforator–concentrated
locations and cold spots being relative poor areas of perforator
distribution. Most hot spots can be found adjacent to articula-
tions and mid-point between two articulations in the extremi-
ties, whereas in the trunk, perforators are clustered parallel to
the posterior and anterior midline as well as midaxillary regions.
Designing the skin paddle over the hot spots will ensure that
as many perforators are incorporated within the flap, and
this will help maximize interperforator flow via linking vessels
between each perforator. Interperforator flow is ensured by a
series of direct and indirect linking vessels as well as multiple
communicating branches between the former two. The flap’s
long axis should be parallel to the direction of these linking
vessels in order to maximize interperforator flow, and hence,
increase flap perfusion. Linking vessels are usually oriented
parallel to the extremities and perpendicular to the midline in
the trunk. A perforator flap based on a perforator that originates
from a source artery with multiple sequential perforators, will
have more of an axial pattern of vascularity, compared with a
single dominant perforator. Perforators from the same source
artery will fill preferentially first before adjacent source artery
perforators (e.g., perforators of the descending branch of the
LCFA, lateral circumflex femoral artery). Mass vascularity of a
perforator found close to an articulation will also be directed,
in general, away from that same articulation, whereas mid-point
perforators (perforators found between two articulations) will
have a multidirectional distribution. With a significant number
of clinically relevant perforators available in the body, custom-
ized ad-hoc, or freestyle, perforator flaps can be designed to
reconstruct a panoply of defects.
REFERENCES
1. Mathes SJ, Nahai F. The reconstructive triangle: a paradigm for
surgical decision making. In: Reconstructive surgery: principles,
anatomy, and technique. New York: Churchill Livingstone; 1997.
p. 9–36.
2. Pearl RM, Johnson D. The vascular supply to the skin: an anatomi-
cal and physiological reappraisal – Part II. Ann Plast Surg 1983;
11:196–205.
3. Daniel RK, Kerrigan CL. Principles and physiology of skin flap
surgery. In: McCarthy JG, editor. Plastic surgery, vol. 1. Philadel-
phia: WB Saunders; 1990. p. 275–328.
4. Milton SH. Pedicled skin-flaps: the fallacy of the length: width ratio.
Br J Surg 1970;57:502–8.
5. McGregor IA, Morgan G. Axial and random pattern flaps. Br J Plast
Surg 1973;26:202–13.
6. Orticochea M. The musculo-cutaneous flap method: an immediate
and heroic substitute for the method of delay. Br J Plast Surg
1972;25:106–10.
7. McCraw JB, Dibbell DG, Carraway JH. Clinical definition of inde-
pendent myocutaneous vascular territories. Plast Reconstr Surg
1977;60:341–52.
8. Tanzini I. Sopra il mio nuovo processo di amputazione della mam-
mella. Gaz Med Ital 1906;57:141.
9. Owens NA. Compound neck pedicle designed for the repair of
massive facial defects: formation, development and application.
Plast Reconstr Surg (1946) 1955;15:369–89.
Downloaded for David Sidhom (david.sidhom@health.qld.gov.au) at Queensland Health Clinical Knowledge Network from ClinicalKey.com.au by
Elsevier on November 29, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
CHAPTER 2 — Classification of Flaps e9
10. Hueston JT, McConchie IH. A compound pectoral flap. Aust N Z
J Surg 1968;38:61–3.
11. Pontén B. The fasciocutaneous flap: its use in soft tissue defects of
the lower leg. Br J Plast Surg 1981;34:215–20.
12. Esser JF, Schwerer S. Verschluss einer Brustwand perforation.
Berliner Klin Wochenschr 1918;55:1197.
13. Gillies HD. The tubed pedicle in plastic surgery. New York Med J
1920;3:1–12.
14. Nakajima H, Fujino T, Adachi SA. New concept of vascular supply
to the skin and classification of skin flaps according to their vascu-
larization. Ann Plast Surg 1986;16:1–19.
15. Batchelor JS, Moss AL. The relationship between fasciocutaneous
perforators and their fascial branches: an anatomical study in
human cadaver lower legs. Plast Reconstr Surg 1995;95:629–33.
16. Nakajima H, Minabe T, Imanishi N. Three-dimensional analysis
and classification of arteries in the skin and subcutaneous adipo-
fascial tissue by computer graphics imaging. Plast Reconstr Surg
1998;102:748–60.
17. Manchot C. The cutaneous arteries of the human body. New York:
Springer-Verlag; 1983. p. 136–7.
18. Ger R. The technique of muscle transposition in the operative
treatment of traumatic and ulcerative lesions of the leg. J Trauma
1971;11:502–10.
19. Taylor GI, Townsend P, Corlett R. Superiority of the deep circum-
flex iliac vessels as the supply for free groin flaps. Clinical work.
Plast Reconstr Surg 1979;64:745–59.
20. Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A
clinical extension of microvascular techniques. Plast Reconstr Surg
1975;55:533–44.
21. Taylor GI. Free vascularized nerve transfer in the upper extremity.
Hand Clin 1999;15:673–95.
22. Robinson DW, MacLeod A. Microvascular free jejunum transfer. Br
J Plast Surg 1982;35:258–67.
23. Geddes CR, Morris SF, Neligan PC. Perforator flaps: evolution,
classification, and applications. Ann Plast Surg 2003;50:90–9.
24. Blondeel PN, Hallock GG, Morris SF, et al. Perforator flaps:
anatomy, technique & clinical applications. St Louis: Quality
Medical Publishing; 2006.
25. Harii K. Microvascular free flaps for skin coverage. Indications and
selections of donor sites. Clin Plast Surg 1983;10:37–54.
26. Hallock GG. Simultaneous transposition of anterior thigh muscle
and fascia flaps: an introduction to the chimera flap principle. Ann
Plast Surg 1991;27:126–31.
27. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the
body: experimental study and clinical applications. Br J Plast Surg
1987;40:113–41.
28. Taylor GI. The “Gent” consensus on perforator flap terminology:
preliminary definitions. Plast Reconstr Surg 2003;112:1384–7.
29. Cormack GC, Lamberty BG. A classification of fascio-cutaneous
flaps according to their patterns of vascularisation. Br J Plast Surg
1984;37:80–7.
30. Cormack GC, Lamberty BG. The anatomical basis for fasciocu­
taneous flaps. In: Hallock GG, editor. Fasciocutaneous flaps.
Cambridge, MA: Blackwell Scientific Publications; 1992. p. 13–24.
31. Hallock GG. Principles of fascia and fasciocutaneous flaps. In:
Weinzweig J, editor. Plastic surgery secrets. Philadelphia: Hanley
and Belfus; 1999. p. 419–26.
32. Cormack GC, Lamberty BG. The arterial anatomy of skin flaps.
Edinburgh: Churchill Livingstone; 1994. p. 514–22.
33. Niranjan NS, Price RD. Govilkar P. Fascial feeder and perforator-
based V-Y advancement flaps in the reconstruction of lower limb
defects. Br J Plast Surg 2000;53:679–89.
34. Mathes SJ, Nahai F. Flap selection: analysis of features, modifica-
tions, and applications. Reconstructive surgery: principles, anatomy,
and technique. New York: Churchill Livingstone; 1997. p. 37–160.
35. Wei FC, Jain V, Suominen S, et al. Confusion among perforator
flaps: what is a true perforator flap? Plast Reconstr Surg 2001;
107:874–6.
36. Spalteholz W. Die Vertheilung der Blutgefasse in der Haut. Archive
für Anatomie und Physiologie (Anat Abtheil) 1893;1:54.
37. Taylor GI, Palmer JH. McManamny D. The vascular territories of
the body (angiosomes) and their clinical applications. In: McCar-
thy JG, editor. Plastic surgery, vol. 1. Philadelphia: WB Saunders;
1990. p. 329–78.
38. Taylor GI. Foreword. In: Manchot C, editor. The cutaneous arteries
of the human body. New York: Springer-Verlag; 1983. p. i–ixiv.
e10 PART 1 — PRINCIPLES
39. Taylor GI. The blood supply of the skin. In: Aston SJ, Beasley RW,
Thorne CHM, editors. Grabb and Smith’s plastic surgery. Philadel-
phia: Lippincott-Raven; 1997. p. 47–59.
40. Hallock GG. Direct and indirect perforator flaps: the history and
the controversy. Plast Reconstr Surg 2003;111:855–66.
41. Nakajima H, Imanishi N, Fukuzumi S, et al. Accompanying arteries
of the cutaneous veins and cutaneous nerves in the extremities:
anatomical study and a concept of the venoadipofascial and/or
neuroadipofascial pedicled fasciocutaneous flap. Plast Reconstr
Surg 1998;102:779–91.
42. Masquelet AC, Romana MC, Wolf G. Skin island flaps supplied by
the vascular axis of the sensitive superficial nerves: anatomic study
and clinical experience in the leg. Plast Reconstr Surg 1992;89:
1115–21.
43. Hallock GG. Microleaps in the progression of flaps and grafts. Clin
Plast Surg 1996;23:117–38.
44. Bertelli JA, Catarina S. Neurocutaneous island flaps in upper limb
coverage: experience with 44 clinical cases. J Hand Surg [Am]
1997;22:515–26.
45. Mathes SJ, Nahai F. Classification of the vascular anatomy of
muscles: experimental and clinical correlation. Plast Reconstr Surg
1981;67:177–87.
46. Taylor GI, Gianoutsos MP, Morris SF. The neurovascular territories
of the skin and muscles: anatomic study and clinical implications.
Plast Reconstr Surg 1994;94:1–36.
47. Serafin D. Atlas of microsurgical composite tissue transplantation.
Philadelphia: WB Saunders; 1996. p. 513–691.
48. Harii K, Iwaya T, Kawaguchi N. Combination myocutaneous flap
and microvascular free flap. Plast Reconstr Surg 1981;68:700–11.
49. Webster’s New World dictionary of the American language. New
York: World Publishing; 1960. p. 1353.
50. Tsai FC, Yang JY, Mardini S, et al. Free split-cutaneous perforator
flaps procured using a three-dimensional harvest technique for the
reconstruction of postburn contracture defects. Plast Reconstr
Surg 2004;113:185–94.
51. Nassif TM, Vidal L, Bovet JL, et al. The parascapular flap: a new
cutaneous microsurgical free flap. Plast Reconstr Surg 1982;69:
591–600.
Downloaded for David Sidhom (david.sidhom@health.qld.gov.au) at Queensland Health Clinical Knowledge Network from ClinicalKey.com.au by
Elsevier on November 29, 2023. For personal use only. No other uses without permission. Copyright ©2023. Elsevier Inc. All rights reserved.
52. Huang WC, Chen HC, Wei FC, et al. Chimeric flap in clinical use.
Clin Plast Surg 2003;30:457–67.
53. Hallock GG. Permutations of combined free flaps using the sub-
scapular system. J Reconstr Microsurg 1997;13:47–54.
54. Huang WC, Chen HC, Jain V, et al. Reconstruction of through-and-
through cheek defects involving the oral commissure, using chime-
ric flaps from the thigh lateral femoral circumflex system. Plast
Reconstr Surg 2002;109:433–43.
55. Koshima I, Yamamoto H, Hosoda M, et al. Free combined compos-
ite flaps using the lateral circumflex femoral system for repair of
massive defects of the head and neck regions: an introduction to
the chimeric flap principle. Plast Reconstr Surg 1993;92:411–20.
56. Hallock GG. The complete classification of flaps. Microsurgery
2004;24:157–61.
57. Tolhurst DE. Fasciocutaneous flaps and their use in reconstructive
surgery. Perspec Plast Surg 1990;4:129–45.
58. Tolhurst DE. A comprehensive classification of flaps: the atomic
system. Plast Reconstr Surg 1987;80:608–9.
59. Lamberty BG, Healy C. Flaps: physiology, principles of design, and
pitfalls. In: Cohen M, editor. Mastery of plastic and reconstructive
surgery. Boston: Little Brown; 1994. p. 56–70.
60. Jones TR, Humphrey PA, Brennan DC. Transplantation of vascular-
ized allogeneic skeletal muscle for scalp reconstruction in a renal
transplant patient. Transplantation 1998;65:1605–10.
61. Allen RJ Jr, LoTempio MM, Craigie JE, et al. Transplantation in
identical twins: another option for breast reconstruction. Plast
Reconstr Surg 2008;122:1019–23.
62. Valauri FA, Buncke HJ, Alpert BS, et al. Microvascular transplanta-
tion of expanded free scalp flaps between identical twins. Plast
Reconstr Surg 1990;85:432–6.
63. Blondeel PN, Van Landuyt KH, Monstrey SJ, et al. The “Gent”
consensus on perforator flap terminology: preliminary definitions.
Plast Reconstr Surg 2003;112:1378–84.
64. Kim JT. New nomenclature concept of perforator flap. Br J Plast
Surg 2005;58:431–40.
65. Hallock GG. Muscle perforator flaps: the name game. Ann Plast
Surg 2003;51:630–2.