OUTLINE

1) Definition
2) History
3) Timeline of Development of Flap Surgery
4) Classification of Flap in General
5) Principle of Flap Surgery
6) Blood Supply of Flap
7) Angiosome Concept
8) Arterial & Venous Territories
9) Flap Territories
10) Anatomic Concept
11) Delay Phenomenon
12) Classification of Flap

DEFINITION

Flap is a unit of tissue that is transferred from one site (donor site) to another (recipient site)
while maintaining its own blood supply or from a anastomised vessel.

The term "flap" originated in the 16th century from the Dutch word "flappe," meaning something
that hung broad and loose, fastened only by one side.

Graft is movement of tissue usually from a distant site, without an intact vascular network.

Graft Flap
Limited to tranplatation of skin Can carry other tissues
Depends on the recipient site for nutirtion Has own blood supply
Cosmetics- may discolor or contract Better color take, less likely to contract
Less adaptable to weight bearing More adaptable to weight bearing
Less able to survive on a bed with questionable Can be used on a bed with questionable
nutrition nutrition
Requires pressure dressing Requires no pressure dressing
Cannot bridge defect Cannot bridge defect

HISTORY

Basically divided in 3 phases:-

1) Before 1900 and early 1900 (from Shushrata to Sir Harrold Gillies)
2) 1950’s and 1960’s (McGregor, Bakamjian, Millard, Conley)
3) 1980’s (Aariyan, Mathes, Nahai, Taylor, O’Brien)
 Sushrata (1000-600 B.C.) - Forehead flap
 Sir Astley 1817 - Performed first successful human skin graft
 Manchot 1889 - Introduced concept that arteries have specific vascular territories
 Bakamjian’s 1965 - Deltopectoral flap
 McGregor 1960’s – Basic understanding of flap blood supply; found axial & random pattern
flap
 Baek, McGregor et al – Several flaps into axial & random pattern

HISTORY

• In the 16th century the word ‘flap’ was coined from the Dutch word ‘flappe’ meaning
something hanging broad and loose fastened onto one side.

• 600 BC in India, Sushruta described operations for reconstructions of the nose and
earlobes in his text the Sushruta Samhita

• 1440 AD in India, forehead rhinoplasty involving the use of pivotal flaps, which
involves transportation of skin to an adjacent area while rotating it about its pedicle

• 1442, Branca, Sicilian surgeon, performed nasal reconstruction using skin flap from face

• 1597, Tagliacozzi published a famous text in plastic surgery and wrote of the
reconstruction of the nose by borrowing tissue with a "flap" from the arm
• French surgeons were the first to describe advancement flap procedure, which involved
transfer of skin from an adjacent area without rotation.

• Italian literature during the Renaissance period described distant pedicle flaps, which
involves transfer of tissue to a remote site.

• 1793, the first reports of the midline forehead flap in the English-language literature

• 1837, the pedicle flap technique was first published in the United States in the Boston
Medical and Surgical Journal; William Horner of Virginia first demonstrated the value of
a Z-plasty in correcting an ectropion of the lower lid;

• Pietro Sabattini of Italy first reconstructed a missing section of the upper lip using a
full-thickness transposition flap from the lower lip, a procedure now known as an Abbe
flap

• January 17, 1864, Mr. Wood performed the first of a series of operations by dissecting
two broad flaps from the upper part of the groin

• 1893, the first recorded two-stage island pedicle flap with preservation of the transferred
blood supply was described by Theodore Dunham of New York
 • 1898, the one-stage island pedicle flap was first reported by Monks

• Subsequent surgical flap evolution occurred in phases. During the First and Second
World Wars, pedicled flaps were used extensively.

• The next period occurred in the 1950s and 1960s, when surgeons reported using axial
pattern flaps (flaps with named blood supplies).

• 1970s, a distinction was made between axial and random flaps (unnamed blood supply)
muscle and musculocutaneous.

• This was a breakthrough in the understanding of flap surgery that eventually led to the
birth of free tissue transfer

• 1980s, different tissue types used increased significantly with the development of
fasciocutaneous flaps (as it is less bulky than muscle flaps), osseous flaps, and
osseocutaneous flaps

• 1990s most recent advancement in flap surgery came in with the introduction of
perforator flaps. These flaps are supplied by small vessels.

• Future – flap prefabrication and flap prelamination

TIMELINE OF THE DEVELOPMENT OF FLAP SURGERY

600 BC Sushruta Samitha= pedicle flaps in face and forehead for nasal
Reconstruction
1597 Tagliacozzi – nasal reconstruction by tubed pedicle flap from arm ,
described ‘delay’ of pedicle flap.
1837 horner Z-plasty
1848 Stein Bilateral upper lip vascular pedicle flaps to the lower lip
1872 Estlanderr Repair of lateral defects of the lower lip using lateral upper lip and
corner of
the mouth on a labial artery pedicle
1889 Manchot Definition of vascular patterns of cutaneous circulation by
dissection
1898 Halsted “waltzing flap”
1898 Abbe Bilateral cleft lip reconstruction with cross lip flap
1906 Tansini Lattisimus dorsi musculocutanoues flap for breast reconstructuion
1912 Blair Osseocutaneous flap
1916 Filatov Tubed pedicled neck flap for lower eyelid reconstruction
1917 Gillies Tubed pedicled neck flap
1917 Aymand Tubed pedicle chest flap for nasal reconstruction
1917 ganzer Tubed pedicled flaps from the cheek, shoulder and back for nasal
reconstruction
1919 Davis First published observations on pedicle flap principles; reviewed
manchot’s work on vascular territories; described compound flaps
for mandibular reconstruction
1921 Blair Delay phenomenon in nonpedicle flap
1937 Webster Thoracoepigastric tubed pedicles
1942 Converse and Median forehead flap
Kazanjian
1946 Shaw and payne Hypogastric tubed pedicle flaps

1955 Owens Compound sternocledomastoid muscle skin-flap

1960 Littler Neurovascular flap
1965 Bakamjian Deltopectoral flap
1968 Ger Muscle flap
1972 Mcgregor and Jackson Groin flap
1973 Daniel, taylor, o’brien Microvascular free flap transfer
1975 Mccraw& furlow Dorsalis pedis flap
1976 Radovan Tissue expansion for breast reconstruction
1977 Mccraw Description of numerous independent musculocutaneous vascular
territories and musculocutaneous flaps
1977 Mathes Rectus abdominis flap
1981 Nakayama Arterialized venous flaps
1981 ponten Fasciocutanous flaps
1987 taylor and plamer Angiosomes
1989 Koshima and soeda Inferior epigastric perforator flap

TIMELINE OF THE DEVELOPMENT OF FLAP SURGERY

• Early years – Sushruta to the renaissance period.

• Phase I - WWI & II (pedicled skin flaps used extensively).
• Phase II – 1950s-60s (regional axial pattern flaps reported).
• Phase III – mainly 1970s, advances on axial, random, muscle & musculocutaneous flaps,
& free tissue transfer came into being.
• Phase IV – 1980s, development of fasciocutaneous flaps, osseous & osseocutaneous
flaps. Also specialized free flaps.
 THE EVOLUTION OF FLAP

Random

Musculocutaneous

Fasciocutaneous

Perforator

Subdermal vascular
network

The evolution of flaps has reflected a progression to better insure the adequacy of their
intrinsic circulation, beginning with the least reliable, nourished only via the subdermal
plexus, and ultimately coming back again full circle to the subdermal vascular network “
supercharged ” by retained perforators.
 CLASSIFICATION OF FLAP- 5C’s

FLAP

CIRCULATION COMPOSITION CONTIGUITY CONTOUR CONDITIONING

RANDOM  CUTANEOUS  LOCAL  ADVANCEMENT

AXIAL
 FASCIOCUTANEOUS  REGIONAL  TRANSPOSITION
 DIRECT  FASCIAL  DISTANT  ROTATION
 INDIRECT  MUSCULOCATANEOUS  FREE  INTERPOLATION
 MUSCLE
 OSSEOCUTANEOUS
 OSSEOUS

PRINCIPLES OF FLAP SURGERY

Principle I: Replace Like With Like

• Ralph Millard once said, "When a part of one's person is lost, it should be replaced in
kind, bone for bone, muscle for muscle, hairless skin for hairless skin, an eye for an eye,
a tooth for a tooth "

• If this cannot be accomplished, use the next most similar tissue substitute.

• For example, scalp to replace a beard, skin from the forehead to cover a nose wound.
Principle II: Think of Reconstruction in Terms of Units

• As emphasized by Millard, "The most important aspects of a regional unit are its borders,
which are demarcated by creases, margins, angles and hair liners."

• Human beings may be divided into 7 main parts: the head, neck, body, and extremities.
• Each of these body parts can be further subdivided into units.
• The head, for example, is composed of several regional units: scalp, face, and ears.
• Consider that each of these units has its own unique features, and each feature has, in turn,
multiple subunits with their own special shapes.
• All of these different units and subunits must be considered and reproduced during
reconstruction
Principle III: Always Have a Pattern and a Back-up Plan

• The reconstructive ladder is a mental exercise that provides the surgeon with options
ranging from the simplest to most complex.
• A sound plan must provide restoration of function and aesthetic form.
• Once a plan has been determined, rehearse it. Trace the defect or cut a pattern to fit the
defect. Transpose the pattern and experiment with it to decide on the best donor area and
orientation.
• The surgeon should ask him or herself "what do I do next if this fails?"
Once in the operating room, keep an open mind and be ready to adjust the surgical plan as

the situation dictates

Principle IV: Steal From Peter to Pay Paul

 • Steal from Peter to pay Paul, but only when Peter can afford it.
• Do not make the naive mistake of merely advancing tissue to the deficient area unless this
can be accomplished completely without tension.
• Tension compromises the blood supply of the advanced tissue and, ultimately, results in flap
failure.

Principle V: Never Forget the Donor Area

• The significance of providing coverage of a defect with minimal deformity and disability is
one of the foremost principles on which the reconstructive surgery specialty is based.
• If reconstruction of the primary defect is too costly in terms of resultant deformity or
disability, re-evaluate and use another reconstructive option.
• Carelessness or overuse of a donor area eventually causes damage that may be far greater
than the original defect.
BLOOD SUPPLY OF FLAP

HISTORY OF CUTANEOUS CIRCULATION

Carl Manchot (1889 )

Performed the first examination of the vascular supply of the human integument.

Defined about 40 cutaneous territories on the basis of dissection of human integument.

His work “Die Hautarterien des menschlichen Körpers “ [The Cutaneous Arteries of the Human
Body], was initially published in German and later translated to English by Milton.

Spalteholz (1893)
Published paper on the origin, course and distribution of the cutaneous perforators in adult and
neonatal cadavers.

He performed arterial injections of gelatin and various pigments.

The soft tissues were fixed in alcohol and subtracted in xylol and the resulting vascular network
was embedded in Canada Balsam
.
Salmon (1930)
French anatomist and surgeon charted more than 80 cutaneous territories encompassing the
entire body .

Salmon dissected 15 human cadavers and took radiographs of integument which enabled him to
demonstrate much smaller vessel than Manchot.
 Manchot 40 cutaneous arteries Salmon 80 cutaneous arteris

The blood reaching the skin originates from deep vessels.

Daniel and Williams (1973)

Defined that the deep vessels supplying skin are fundamentally two type of arteries i.e. either
musculocutaneous or direct cutaneous arteries (septocutaneous arteries)

Both these type of vessels are present throughout the body but there exists appreciable
difference between them which is tabulated as following :
 Musculocutaneous arteries Septocutaneous arteries

Origin: Major vessel supplying the muscle Origin: Segmental or musculocutaneous

vessel

Are mainly over the torso Are mainly in the extremities

Passes parallel to the surface of skin and lie
superficial to the underlying muscle fascia

Receives their blood supply from segmental Receives blood supply from the segmental
vessels lying deep to the underlying muscle with vessels via perforators which penetrates the
a perforator vessel. muscle

Travel perpendicularly through underlying Pass directly within inermuscular fascial

muscle bellies into the overlying cutaneous septae to supple the overlying skin
circulation of skin
Ends in the subdermal plexus Ends in the dermal-subdermal plexus

Supply a small surface area of skin Supply greater areas of skin surface

Eg. Latissimus dorsi flap, Rectus abdominis Flap Eg. Radial forearm flap, Dorsalis pedis flap

WHY SO? WHY SO?

Well developed deep fascia covering the broad Deep fascia is more rigid, not only covering
muscles which is elastic permitting expansion of the muscles but also forms
abdominal muscles intercompartmental fascial septa between
muscles providing anchorage to the vessels.
BLOOD SUPPLY OF THE SKIN

1. Microcirculation:

• Involves terminal vessels of circulatory system (arterioles, terminal arterioles,

precapillary sphincters, capillaries, postcapillary venules, collecting venules,
muscular venules)

• The arterial and venous systems communicates and nutrient exchange

(subepidermal), waste removal, thermoregulation (dermal), and local regulation of
blood flow occurs.

2. Macrocirculation:
The vascular supply throughout the body exists at 3 levels:

a) Segmental vasculature:

• Consists of the body’s main distributing vessels which are in continuity with the
aorta in regard to the perfusion pressure and are identified anatomically. Example:
before it pierces the muscle or fascia

b) Perforators:

• Vessels connecting the segmental and cutaneous vasculature system

• Supply the muscles nutrients

c) Cutaneous system:
• Is considered the vasculature superficial to deep fascia
• The cutaneous vascular supply is composed of 3 main levels of vessels supplying the
fascia, subcutaneous tissue, and skin.
• Is made up of 6 recognizable vascular plexuses:-

1. subfascial ( minor cannot sustain fascial flap)

2. prefascial (dominant distribution system)
3. subcutaneous ( horizontal linear vascular plexus of arteries and veins)
4. subdermal (primary blood supply to the skin with wide meshwork)
5. dermal (close proximity & vast quantity to surface area ) - arteriole
6. subepidermal ( formed by capillaries )
1) Subfascial Plexus
• plexus lying on the under surface of the fascia
• relatively minor plexus .
• incapable of sustaining a fascial flap .
2) Prefascial Plexus : dominant distribution system
3) Subcutaneous Plexus
• Network of vessels which divide subcutaneous fat into deep (loose) and superficial
(dense) layers.
• More developed in torso than in extremities.
• Supplied by both septocutaneous and musculocutaneous arteries.
 Musculocutaneous arteries Septocutaneous arteries

Origin: Major vessel supplying the muscle Origin: Segmental or musculocutaneous

vessel

Are mainly over the torso Are mainly in the extremities

Passes parallel to the surface of skin and lie
superficial to the underlying muscle fascia

Receives their blood supply from segmental Receives blood supply from the segmental
vessels lying deep to the underlying muscle with vessels via perforators which penetrates the
a perforator vessel. muscle

Travel perpendicularly through underlying Pass directly within inermuscular fascial

muscle bellies into the overlying cutaneous septae to supple the overlying skin
circulation of skin
Ends in the subdermal plexus Ends in the dermal-subdermal plexus

Supply a small surface area of skin Supply greater areas of skin surface

Eg. Latissimus dorsi flap, Rectus abdominis Flap Eg. Radial forearm flap, Dorsalis pedis flap

WHY SO? WHY SO?

Well developed deep fascia covering the broad Deep fascia is more rigid, not only covering
muscles which is elastic permitting expansion of the muscles but also forms
abdominal muscles intercompartmental fascial septa between
muscles providing anchorage to the vessels.

4) Sub dermal Plexus

• Primary blood supply to the skin.
• Vessels have a continuous arterial muscular wall.
• Primarily distributor function.
• Located at junction between reticular dermis and subcutaneous fat.
 • Corresponds with “dermal bleeding” at the edge of the flap.
• Arterioles run upwards to the overlying dermal plexus and others run downwards
to supply adipose tissue and various glands .
5) Dermal Plexus
• Present at lower limits of dermal papillary ridge.
• The vessel in the plexus are arterioles and wall contains isolated muscular elements
.
6) Sub epidermal Plexus
• Located at dermoepidermal junction.
• Consists mostly of capillaries having no muscle in their wall
• Therefore they serve to have primarily nutritive function

ANGIOSOME CONCEPT
• Introduced by Ian Taylor in Melbourne. Australia
• Taylor and Palmer described the concept of angiosome and published in a landmark
paper in 1987

• Comprehensive three dimensional concept of the vascular anatomy of the body.

• An angiosome is a composite block of tissue that is supplied anatomically by source

(segmental or distributing) vessels that span between the skin and bone.

• Each angiosome can be subdivided into matching

1.Arteriosomes (arterial territories)
2.Venosomes (venous territories).

• In some regions the angiosome territory does not reach the skin and is confined to the
deep tissue e.g. salivary gland ( one territory for each parotid, submandibular, sublingual)
and thyroid (2 territories on each side)
.

· Clinical applications:
 Each angiosome defines the safe anatomic boundary of each tissue in each layer that can be
transferred separately or combined together on the underlying source vessels as composite
flap.
 The junctional zone between adjacent angiosomes usually occurs within the muscles of the
deep tissues. These muscles provide a vital anastomotic detour (bypass shunt) if a main
source artery or vein is obstructed.
 Most muscles span across 2 or more angiosomes and are supplied from each territory, one is
able to capture the skin island from one angiosome via muscles supply in the adjacent
territory.

This anatomic fact provides the basis for the design of many musculocutaneous flaps.
ARTERIAL AND VENOUS TERRITORIES

Arterial Territories

• Arteries form a continuous network of vessels linked together as arcades by a connection

(vessels often of reduced caliber to provide a constant pressure at the capillary bed)

• The connection between adjacent cutaneous arteries is by:

1) Choke anastomotic vessels (reduced in calibre of vessels)

Eg. Flaps with 2 choke vessels/ anatomic territories
The deltopectoral flap of Bakamjian, based medially on a perforator of the internal
mammary artery that is connected laterally to the perforator of the acromiothoracic axis

2) True anastomotic vessels (without change in calibre of vessels)

 • Taylor recalled that in injection studies in 1893, using pigment mixed in gelatin,
Spalteholz 29 had demonstrated a pure (intermuscu-lar) or impure (i.e. primarily supplied
deeper tissues, mostly muscle) course of cutaneous perforators.

• All arteries to the skin could most simply be considered to be either “direct” or “indirect”
branches from an underlying source vessel.

• The cutaneous perforators are divided into 2 groups:

a) Direct cutaneous vessels

• They form the primary cutaneous supply

• They pass between muscles and other deep structures in the intermuscular septa and
reach outer layer of deep fascia for the skin.

b) Indirect cutaneous vessels

• They form secondary cutaneous supply

• Arise from source arteries penetrate the deep tissue and deep fascia emerging as terminal
branches.
• Whose main purpose is to supply the muscles and other deeper tissues.
Direct cutaneous (I)
Direct septocutaneous (II)
Perforating cutaneous branch of muscular vessel (III)
Direct cutaneous branch of muscular vessel (IV)
Septocutaneous perforator (V)
Musculocutaneous perforator (VI)

Figure 2.4 The six distinct deep fascia perforators accord- ing to Nakajima et al. 14 A different
type of fasciocutaneous flap can be sustained by each discrete type of perforator. S, source or “
mother ” vessel; F, deep fascia

Figure 2.5 The deep fascia perforators of Nakajima et al 14 (see Figure 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.

Type A: multiple feeders Type B: solitary Type C: segmental

Figure 2.2 The subtypes of fasciocutaneous flaps in Cormack & Lamberty’s classification
schema differ according to the means of vascularization of the “ fascial plexus. ”
Type A: direct cutaneous Type B: septocutaneous Type C: musculocutaneous

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

In the human body, there are approximately 400 perforators, about 40% of vessels are direct and
60% indirect perforators.
• In the head, neck, torso, arm, and thigh - the vessels are larger, longer, and less
numerous.
• In the forearm, leg, and dorsum of the hands and feet - the vessels tend to be smaller,
shorter, and more numerous.
• In the palms of the hands and the soles of the feet, where the skin is fixed - there is a high
density of smaller perforators.

Venous Territories

• The cutaneous veins like arteries form a three-dimensional plexus of interconnecting

channel in the subdermis.

• Many of these veins have valves in a particular direction connected by avalvular

(oscillating) veins, which allow bidirectional flow between adjacent venous territories
to allow equilibrium of flow and pressure.

Eg. Superficial inferior epigastric drains the lower abdominal wall towards groin
Nipple areolar complex – flow radially away from a plexus of avalvular veins

• From dermal and subdermal venous plexuses, the veins collect into horizontal larger
caliber veins, or common channel that passes vertically down to pierce the deep
fascia, in company with the cutaneous arteries.

• Thereafter, the veins travel with the direct and indirect cutaneous arteries, draining
ultimately into the venae comitantes of the source arteries in the deep tissue.

• The superficial veins are independent of the deep arteries (e.g., greater saphenous
vein, cephalic vein)
 Fig. 23.43 Schematic diagrams
of (A) the basic venous module,
(B) its modified arrangement in
different areas, and (C) how
these modules interconnect to
form a continuous network. (D)
In the integument, this network
of venous perforators is
reorganized in the subdermal
plexus to form longitudinal
channels. The valved segments
are solid blue, and the
avalvular oscillating veins are
light blue. (From Taylor GI,
Caddy CM, Watterson PA, et
al. The venous territories
[venosomes] of the human
body: experimental study and
clinical implications. Plast
Reconstr Surg. 1990;86:185.)

• Where arterial territories are linked by choke arteries or true anastomotic arteries
without changing caliber, the venous territories of the muscles, which drain in
opposite directions, are linked by avalvular oscillating veins.

• Intramuscular veins can be classified into 3 types on the basis of their venous
architecture.

Type I - have a single venous territory that drains in one direction.

Type II - have two territories that drain from the oscillating vein in opposite
directions.
Type III - consist of three or more venous territories that drain in multiple directions
 Extramuscular veins- 2 types
1) Efferent vein- with valves and drain their muscles to parent vein
2) Afferent vein- derived from the overlying integument as musculocutaneous perforators
or from adjacent muscles
Neurovascular Territories

 Each cutaneous nerve is accompanied by an artery, but their relationship is variable.

The following observations were made:-

1) The nerves follow the connective tissue framework
2) The nerves are economical
3) Each motor nerve is accompanied by vascular pedicle, but reverse does not apply
4) The motor nerve is usually accompanied by the dominant vascular pedicle. There are
exceptions to this. Eg. nerve supply to sternomastoid is usually accompanied by a minor
vascular pedicle.
5) The nerve may enter the muscle before branching.
6) Once in the muscle, the nerve divides early, and its branches sweep rapidly into position,
parallel to the muscle fibres. However the vessels will branch and form primary and secondary
arcades. Often crossing the muscle bindles and nerves before tertiary and quaternary branches
are provided to muscle fibres.
TERRITORIES OF FLAP

Cormack and Lamberty conceptualized three types of cutaneous vascular territories of

progressively larger size:

a) Anatomical Territories
 Anatomical territory is the extent to which the vessel branches out and anastomizes with
adjacent vessels.

b) Dynamic Territories
 The dynamic territory is also known as the physiological territory; corresponding territory of
cutaneous artery under physiological condition
 In reality, it is smaller than the anatomical territory because the existence of peripheral
pressure due to neighbouring vessels limits, in effect , the territory of the artery.

c) Potential Territories / Surgical territory

 It is greater than the anatomical and dynamic territories of the nutrient artery; potential
territory, result of 2 factors:
1. Basic geometry derived from the blood flow in the flap which is increased by the
suppression of peripheral pressure
2. An element of territorial extension made possible by the microanastomosis that do not
offer resistance to the vascular supply obtained from the main flap pedicle.
 This is usually accomplished by a delay procedure whereby a potential territory develops
during the period between delay and flap elevation
ANATOMIC CONCEPT

1) Vessels follow the connective tissue framework of the body

• The fascia of muscular compartments and septa, connect the skin to underlying body and
fascial structures. Separates the body into a honeycomb-like structure. The vessels follow
the fascial and septal planes, and supply branches to underlying structure
• Achieves special significance when the surgeon raises a cutaneous flap that includes the
outer layer of the deep fascia (termed fasciocutaneous flap) or when the design is
extended to include the intermuscular septa (the septocutaneous flaps).
• In those sites where the skin is relatively fixed to the deep fascia, for example, in the
limbs or the scalp (Fig. 4.10B), deep fascia should be included.
• In these instances the dominant cutaneous vessels course on, or lie adjacent to, the deep
fascia.
• Although they can be dissected free in some cases, it is safer and more expedient to
include the deep fascia with the flap.
• However, where the skin and subcutaneous tissues are mobile over the deep fascia, for
example, in the iliac fossae or the breast, it is unnecessary to include this fascial layer
as the major cutaneous vessels have already left its surface (Fig. 4.10A)

Fig. 23.8 Sectional strip radiographic studies of the breast (A), thigh (B), sole of the foot (C), and buttock (D). (D) includes the
underlying gluteus maximus muscle. The schematic diagram illustrates the dominant horizontal axis of vessels that provides
the primary supply to the skin in each case and its relationship to the deep fascia (arrow). (A) They predominate in the
subdermal plexus. Note from left to right the internal thoracic perforator and lateral thoracic artery converging on the nipple
in the radiograph of the loose skin region of the torso. (B) They are seen coursing on the surface of the deep fascia in this
relatively fixed skin area. (C) The source artery itself is the dominant horizontal vessel supplying the skin, coursing beneath
the deep fascia in this rigidly fixed skin region. (D) Small arrows define the deep fascia, and the large arrow indicates the
large fasciocutaneous branch of the gluteal artery, which descends with the posterior cutaneous nerve of the thigh. (From
Taylor GI, Palmer JH. The vascular territories [angiosomes] of the body: experimental study and clinical applications. Br J
Plast Surg. 1987;40:113.)
2) Vessel radiate from fixed to mobile area

• Generally there are many smaller vascular branches to the overlying skin in areas where
the skin is fixed to underlying structure. Long cutaneous vessels are seen where the skin
is mobile.

3) Vessels hitchhike with nerves

• There is often a chain-link system of vessels that accompanies cutaneous vein. This
combination vessels and nerves has been used by surgeons for the harvest of pedicled and
free innervated neurocutaneous flap

4) Vessels interconnected by choke anatomotic vessel to form a three-dimentional network

of vascular arcades

The outer limits of each vascular territory is defined by the position of the choke
anastomotic vessel relative to adjacent vascular territories

5) Vessel size and orientation are the product of tissue growth and differentiation

• Eg.SCM and trapezius- split from the same somite. The trapezius “drags” the transverse
cervical artery across the root of neck to the back along with the skin
6) Vessels obey the law of equilibrium
If one vessel is small, its partner is large to compensate and vice versa
Eg. in between each of the parasternal perforators of internal mammary origin

7) Vessels have a relatively constant destination but may have variable origin
Eg. Superficial inferior epigastric and superficial circumflex iliac arise separately or combined
trunk from common femoral artery

8) Venous network consist of linked valvular and avalvular channels that allow equilibrium
of flow and pressure

9) Muscles are the prime movers of venous return

10) Superficial veins follow nerves, perforating veins follow perforating arteries

11) Nervous and vascular systems develop embryologically in harmony

FLAP DELAYED PROCEDURE

• Division of the vascular pedicles at various time intervals along the length of the
proposed flap

• Delay procedure has been used for several hundred years.

16th century: Tagliacozzi delayed his upper arm flaps by making parallel incisions
through the skin and subcutaneous tissue overlying the biceps muscle.

It was not until the early 1900s that the concept was recognized.

1921: Blair introduced the term “DELAYED TRANSFER “

1965: Milton using the pig model, investigated the effectiveness of four different
methods of delaying a flap .

• A delay procedure can be done in a variety of ways:

o Partial incision around the margin of a planned flap
o Ligation of nonpedicle vessels supplying the flap
o Partial or complete flap elevation
Objectives:-
• To condition a flap to be able to survive in a state of relative hypoxia after it is raised and
transfered
• To enhance flap circulation, ensuring flap survival after advancement, transposition, or
transplantation to a defect site
• To increase skin flap dimension

Potential mechanism:
Skin metabolism and blood supply
• Goetz showed that the average flow of blood through the skin and subcutaneous tissue
was approx 15 ml per minute per 100cc of tissue
• Skin can survive on as little as 2 ml of blood flow per minute per 100 cc of tissue.

Anatomical changes in delayed skin flap

• Reorientation in the direction of the small arteries of the flap to correspond to the long
axis of the pedicled tissue
• Increase in the number of macroscopically observe small arteries
• Venous channel of the flap shows reduced in overall number but corresponding increase
in size and vessel caliber

Physiological changes in delayed skin flap

• Maintaining the toxic product of anaerobic metabolism – tolerance to hypoxia

Sympathetic theory
• Hynes (1950) demonstrated the absence of sympathetic control on the distal portions of
pedicle flaps and reduced pressure in the blood flow in denervated vessel.
• Lutz et al – noted that certain fibers of sympathetic nervous system are vasodilating and
the denervation of local areas can result in vasoconstriction rather than vasodilatation

Metabolites of hypoxic tissue theory

• Braithwaite – proposed that a histamine-like substance was released in injured and
hypoxic tissue causing secondary vascular changes
• Increase in number of identifiable vessel and vasodilatation resulting in increase blood
supply to affected area.

The arteriovenous shunt concept – John Reinisch

• Due to sympathectomy theory – innervate the AV shunt
• Denervation – cause AV shunt dilatation up to 14 days
• After 14 days – gradual closure of shunt due to denervation hypersensitivity
 Fig. 23.53 Arteriogram of control (left) and
delayed (right) rectus abdominis muscles of
a dog 7 days postoperatively. Note the
dilated choke vessels in the delayed flap by
ligation of the deep inferior epigastric artery
(arrow). (From Dhar SC, Taylor GI. The
delay phenomenon: the story unfolds. Plast
Reconstr Surg. 1999;104:2079.)

Changes to flap when delay procedure done

• Priming/ conditioning of flap
tissue to ischaemia
• Realignment of vessels along axis of flap
• Increased neovascularization

Limitations of delayed flap

• Preliminary operation is required.
• Possibility of inadvertent injury to the desired pedicle for flap design. (to overcome:
knowledge of anatomical territories, proper technique)
• Resultant scar tissue at site of flap delay may impair subsequent manipulation and inset
of the flap at recipient site. (to overcome: larger flap dimension)
• Parallel blood supply is not sufficient.