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

0 1984 The Trustees of British Association of Plastic Surgeons

A classification of fascia-cutaneous flaps according to their

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

Summary-The anatomical principles underlying fascia-cutaneous flaps in general are outlined. On the
basis of their patterns of vascularisation such flaps are classified into four types. Examples are given of
each of these types and some new, untried, flaps designed along these principles are postulated.

Prior to the first description of fascia-cutaneous
flaps by PontCn in 1980, the existence of fascio-
cutaneous vessels had been neglected. Even now
the anatomical vascular principles underlying the
fascia-cutaneous flaps have not been fully eluci-
dated.
Two patterns of blood supply to the skin have
been recognised for many years. Firstly, the direct
area of skin, but anastomosing in the subcutis with
adjacent vascular perforations (Fig. 2).
By contrast the fascia-cutaneous system consists
of vessels which reach the skin by passing along the
fascial septa between adjacent muscle bellies and
then fan out al the level of the deep fascia to form a
plexus from which blood reaches the skin (Fig. 3).
The fact that this system has not been utilised

Fig 1
Figure l-The direct cutaneous system of vessels.

cutaneous system of vessels running in the sub-
cutaneousfat, parallel to the skin surface and often
extending for some considerable distance at speci-
fic sites thereby enabling the elevation of axial
cutaneous flaps with impressive length to breadth
characteristics (Fig. 1). Secondly, the musculo-
cutaneous system of perforators arising from the
artery of supply of a muscle and passing up
perpendicular to the skin surface to supply a small
80
until recently is remarkable. This is particularly the
case since both Esser (1917) and Gillies (1920)
suggested that it might be advantageous to include
the deep fascia in what we now recognise as
random-pattern skin flaps. Instead, delayed flaps
and tube pedicles continued to consist of skin and
fat alone and an opportunity to discover the
existence of fascia-cutaneous perforators was
missed. Perhaps this is not surprising in view of the
A CLASSIFICATION OF FASCIO-CUTANEOUS
fact that the possibilities of axial cutaneous flaps
were also passed over at that stage and these
constituted a much more concrete, definable entity
based on obvious anatomical evidence. By con-
trast, fascia-cutaneous flaps depend on less
Figure 2-The musculo-cutaneous system of perforators.
Figure 3-The fascia-cutaneous system of perforators.
immediately obvious anatomy and the concept is
one of potential underlying skin vascular terri-
tories rather than the well-circumscribed ana-
tomical territories of the axial-pattern cutaneous
flaps. The concept of vascular territories is worthy
of elaboration, particularly with regard to their
demonstration by experimental techniques.
Many descriptions of new skin flaps have made
FLAPS 81
reference to Manchot’s (1889) original work on the
blood supply of skin which purported to show
anatomic territories based on the evidence of whole
cadaver dissection studies. Dynamic territories
have been demonstrated by in vivo injection
techniques using fluorescein or prostaglandin EI
(Nakajima et al., 1981) and reflect the dynamic
pressure equilibrium existing in the blood vessels of
each territory along the boundary line between
territories. This concept of an equilibrium point or
“watershed” was elaborated by McGregor and
Morgan (1973) in their paper on axial and
random-pattern flaps in which it was further
82
shown that if one of a pair of abutting vessels was
occluded then the other vessel would “extend” its
territory into the area of decreased intravascular
pressure. Using fluorescent injection techniques
this ‘was demonstrated at the internal
mammary/thoraco-acromial boundary and also
across the midline of the chest-a line across which
virtually no flow normally takes place.
These dynamic territories are clearly relevant to
the raising of flaps but a clinically-raised flap may
extend even further than dynamic studies appear to
indicate, by virtue of the area of skin appended
onto the end of the axial component. Thus the
potential vascular territory, which is to some extent
only learnt through clincial experience, is the
largest of all. Not only have fascia-cutaneous
vessels been inadequately investigated but
potential fascia-cutaneous territories have, until
recently, been ignored.
Potential territories cannot be demonstrated by
a single injection technique. What can, however,
be demonstrated is the vascular anatomy and on
the basis of these findings potential territories can
be postulated. In the final analysis the clinical
elevation of fascia-cutaneous flaps is the only
Figure 4-TYPE “A” fascia-cutaneous system flap. (Vessel diameters have been exaggerated by the artist.)
BRITISH JOURNAL OF PLASTIC SURGERY
proof and in some instances it has been possible to
verify our hypotheses by raising the flaps con-
cerned in clinical cases and these will be mentioned.
A series of injection studies (Lamberty and
Cormack, 1982 and 1983: Cormack and Lamberty,
1983, a, b) have enabled us to answer three
questions which any surgeon contemplating raising
a fascia-cutaneous flap should ask himself. These
are:
(i) Where are the fascia-cutaneous perforators
located?
(ii) Is there a fascial plexus present at that site?
(iii) Does the fascial plexus possess any predomi-
nating directional component or “axiality”?
Equipped with the answers to these questions we
have been able to apply our anatomical knowledge
to the design of new fascia-cutaneous flaps (Lam-
berty and Cormack, 1983). On the basis of these
clinical and experimental observations we feel that
it is appropriate to establish some of the principles
of the vascular anatomy of these fascia-cutaneous
flaps by means of a classification. We also present
here two theoretical fascia-cutaneous flaps which
are at present clinically untried.
A CLASSIFICATION OF FASCIO-CUTANEOUS
Classification
At present there would appear to be four types of
fascia-cutaneous flaps that we shall list as Types A,
B, C and D.
Type A
A pedicled fascia-cutaneous flap dependent on
multiple fascia-cutaneous perforators at the base
and orientated with the long axis of the flap in the
predominant direction of the arterial plexus at the
Figure 5-TYPE “B” fascia-cutaneous pedicled flap.
level of the deep fascia (Fig. 4). Good examples are
the “super-flap” in the lower leg (Ponttn, 1981),
the sartorius flap, without muscle (Cormack and
Lamberty, 1983) and upper arm flaps based on the
medial or lateral intermuscular septum.
Type B
A pedicled or a free flap depending on a single
sizeable and consistent fascia-cutaneous perfor-
ator feeding a plexus at the level of the deep fascia
(Fig. 5). Typical examples are the supraclavicular
flap (Lamberty, 1979), the medial arm flap (Daniel
et al., 1975), the antecubital forearm flap (Lam-
berty and Cormack, 1982), the saphenous artery
FLAPS 83
flap (Acland et al., 1981) and the parascapular flap
(Cormack and Lamberty* *983)+
A successful modification of a Type B ante-
cubital forearm flap has been reported (Lamberty
and Cormack, 1983) which has certain haemo-
dynamic advantages in a comparable way to the
Type C flaps but which depends on a single vessel
feeding the fascial plexus (Fig. 6). Such a flap may,
arguably, constitute a fifth type of fascio-
cutaneous flap but for simplicity is probably best
classified as Type B. The essential characteristic of
the flap is the T-junction on the single vessel
feeding the fascial plexus. In the forearm a flap
based on the inferior cubital artery but taking in
addition the radial artery, enables a long skin
paddle to be used together with a long arterial
pedicle thereby overcoming one of the constraints
of the present design of the forearm fascio-
cutaneous flap. It also, by virtue of the long
pedicle, allows greater versatility in flap orien-
tation at the recipient site. On purely anatomical
grounds there are two situations in which this flap
is not feasible. Firstly, in the absence of a signi-
ficantly sized inferior cubital artery and secondly
 BRITISH JOURNAL OF PLASTIC SURGERY

Fig 6
Figure 6-TYPE “B” MODIFIED fascia-cutaneous microvascular free flap.

Fig 7
Figure 7-TYPE “C” fascia-cutaneous flap.
A CLASSIFICATION OF FASCIO-CUTANEOUS FLAPS
in the presence of such an artery when it arises
from a radial recurrent which has its point of origin
from the brachial artery rather than the radial
artery (which is rare) (Lamberty and Cormack,
1982).
Type C
The ladder type. The support of the skin is
dependent upon the fascial plexus that is supplied
by multiple small perforators along its length
Fig 8
Figure I-TYPE “D” myo-osteo-fascia-cutaneous tissue transfer.
which reach it from a deep artery by passing along
the fascial septum between muscles. It is used as a
free flap by taking the skin, fascia and supplying
artery in continuity (Fig. 7). Typical examples are
the radial (Chinese) forearm flap (Yang Guofan et
al., 1982; Mtihlbauer et al., 1982; Soutar et al.,
1983).
Type D
The osteo-myo-fascia-cutaneous free tissue trans-
fer. An extension of C, the fascial septum is taken
in continuity with adjacent muscle and bone which
derive their blood supply from the same artery
85
(Fig. 8). Good examples are the Chinese forearm
flap with half the diameter of the radius
(Mtihlbauer et al., 1982, Soutar et al., 1983). The
Chinese flap, that may include half the diameter of
the radius, is the only flap thus far proven to fall
into this category. We have shown (Fig. 9) that the
bone is supplied by direct periosteal branches from
the radial artery and by branches which supply the
flexor pollicis longus muscle and thereby the radius
via the origin of the muscle from the bone.
New flaps
By analogy with the forearm it is possible to
imagine the peroneal artery as the basis of a Type C
or D flap. Ten dissections have been carried out on
preserved cadavers to investigate the feasibility of
raising a 10x 10 cm fascia-cutaneous island flap
from the region overlying the upper fibula. The
maximum number of perforators are incorporated
if the upper edge of the flap is sited 10 cm below the
upper end of the fibula (styloid process).
The arterial inflow of this flap could be by
reversed flow in the peroneal artery. The peroneal
86 BRITISH JOURNAL OF PLASTIC SURGERY

Fig 9
Figure 9-Distal radial artery, resin injected, viewed from the lateral side. The blood supply of the radius by direct periosteal
branches and via muscular branches of flexor pollicis longus can be seen. (PT= insertion of pronator teres.)

artery, at its distal end has three principal anasto-
moses, with the posterior tibia1 via a transverse
communicating branch, with the anterior tibia1 by
a perforating branch which pierces the inter-
osseous septum to communicate with the anterior
malleolar branch of the anterior tibial, and ter-
minal malleolar and calcaneal branches which
communicate with the lateral tarsal branches of the
dorsalis pedis and the calcaneal branches of the
posterior tibia1 artery respectively.
Our anatomical studies of preserved cadavers
have shown that the anterior perforating branch
lies approximately 5 cm and the transverse com-
municating branch 6.5 cm above the tip of the
lateral malleolus.
We suggest that a skin flap based on fascio-
cutaneous perforators and pedicled on the pero-
neal artery could be turned downward and used for
reconstruction around the ankle without the neces-
sity for an arterial anastomosis. The venae

SIAMESE FLAPS

Type 6 flap

Type B fasciocutaneous or

Type C flap

Fig 10

Figure IO-“Siamese” flaps.

A CLASSIFICATION OF FASCIO-CUTANEOUS FLAPS
comitantes of the peroneal artery contain
numerous valves and, therefore, would probably
not permit reversal of blood flow in a manner
similar to the artery. The proximal end of the
peroneal vein would, therefore, have to be anasto-
mosed to a vein in the recipient area, such as the
long or short saphenous vein when transferring the
flap into the ankle region. Clearly, there is also
potential for a Type D free tissue transfer from this
area with peroneal artery supporting bone as well
as overlying skin via fascia-cutaneous perforators.
A further new Type C flap suggests itself on the
radial side of the upper arm, The profunda brachii
artery divides into a posterior descending or middle
collateral artery (A. collateralis media) and an
anterior descending or radial collateral artery (A.
collateralis radialis). The middle collateral artery
lies directly in relation to the lateral intermuscular
septum and sends on average five fascia-cutaneous
perforators to the overlying skin. This artery
appears very promising as the basis for a Type C
flap. Although in diameter it is considerably
smaller than the radial artery it does have the
advantage of being comparatively less essential
and certainly would not require replacement with a
vein graft. Venous drainage of such a flap would
be by the cephalic vein.
A theoretical advantage of the modified Type B
flap and also of the Type C flap (or any other flap
with a “through-flow” situation) is that a second
flap can be attached onto the end of it. The two
flaps would constitute sister or “Siamese” flaps.
We cannot recall ever seeing a case report of such
an application (Fig. 10).
Conclusion
The fascia-cutaneous flap is a relatively new con-
cept and although its impact upon plastic surgery
has not been as dramatic as that of muscle and
musculo-cutaneous flaps we are nevertheless con-
vinced that these flaps have specific advantages
and will gain an increasing and permanent
foothold amongst the more commonly used flaps.
We hope that this simple classification based on
the patterns of vascularisation will act as the basis
for continuing elaboration of the fascia-cutaneous
flap concept. We do not see this as a hard and fast
classification but rather as an anatomical basis on
which to elaborate.
Note:
This paper was presented at the Summer Meeting of the British
Association of Plastic Surgeons in Bradford in July 1983.
87
Acknowledgements
We are very grateful to Mr R. Overhill, AIMI, for the execution
of the line diagrams and to Mr R. LiIes for the photographic
prints thereof. We are grateful to Mrs P. Morley and Miss C.
Hunt for the preparation of the manuscript.
References
Acland, R. D., Schusterman, M., Godina, M., Eder, E.,
Taylor, G. I. and Carlisle, I. (1981). The saphenous
neurovascular free flap. Plastic and Reconstructive Surgery,
67,763.
Cormack, G. C. and Lamberty, B. G. H. (1983 a). The
anatomical vascular basis of the axillary fascia-cutaneous
flap. British Journal of Plastic Surgery, 36,4.
Cormack, G. C. and Lamberty, B. G. H. (1983 b). The blood
supply of thigh skin. Plastic and Reconstructive Surgery (in
press).
Daniel, R. K., Terzis, J. and Scbwarz, G. (1975). Neurovascular
free flaps. Plastic and Reconstructive Surgery, 56, 13.
Esser, J. F. S. (1917). Studies in Plastic Surgery of the Face.
Leipzig: F. C. W. Vogel.
Gillies, H. D. (1920). Plastic Surgery of the Face. London:
Oxford University Press.
Lamberty, B. G. H. (1979). The supraclavicular axial patterned
flap. British Journal of Plastic Surgery, 32,207.
Lamberty, B. G. H. and Cormack, G. C. (1982). The forearm
angiotomes. British Journal of Plastic Surgery, 35.420.
Lamberly, B. G. H. and Cormack, G. C. (1983). Misconcep-
tions regarding the cervico-humeral flap. British Journal of
Plastic Surgery, 36,60.
Lamberty, B. G. H. and Cormack, G. C. (1983). The
antecubital fascia-cutaneous flap. British Journal of Plastic
Surgery, 36,4.
Manchot, C. (1889). Die Hautarterien des Menschlichen
Kijrpers. Leipzig: F. C. W. Vogel.
McGregor, I. A. and Morgan, G. (1973). Axial and random-
pattern flaps. British Journal of Plastic Surgery, 26, 202.
Miihlbauer. W.. Herndl. E. and Stock. W. (1982). The forearm
flap. Plastic and Rec&structive Surgery,. 70, j36.
Nakajima, H., Maruyama, Y. and Koda, E. (1981). The
definition of vascular skin territories with prostaglandin
El--the anterior chest, abdomen and thigh-inguinal regions.
British Journal of Plastic Surgery, 34,258.
PontCn, B. (1981). The fascia-cutaneous flap: its use in soft
tissue defects of the lower leg. British Journal of Plastic
Surgery, 34,215.
Soutar, D. S., Scheker, L. R., Tanner, N. S. B. and McGregor,
1. A. (1983). The radial forearm flap: a versatile method for
intra-oral reconstruction. British Journal of Plastic Surgery,
36, 1.
Yang Guofan and Gao Yuzhi, (1981). Forearm free skin flap
transplantation. Journalof the ChineseMedical Association,
61, 139.
The Authors
G. C. Cormack, FRCS(Ed), Department of Anatomy,
Downing Street, Tennis Court Road, Cambridge.
B. G. H. Lamberty, MA, FRCS, Consultant Plastic Surgeon,
Addenbrooke’s Hospital, Trumpington Street, Cambridge.
Requests for reprints to: Mr G. C. Cormack, FRCS(Ed),
Department of Anatomy, University of Cambridge, Downing
Street, Cambridge CB2 3DY.