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Series 1: The Skin · Episode 4

Blood Supply

Why Your Flap Lives or Dies

30 minutes. 17 references, each checked at source.

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Widening the base of a flap does not buy you length. It was proved in pigs in 1970, in a paper with the word "fallacy" in the title, and the length-to-breadth ratio you were taught has never recovered from it.

Episode 4 of The Anatomy Purist. Dev breaks down the blood supply to skin: the plexus system from deep fascia to papillary dermis, random versus axial flap supply, and the work of Taylor and Palmer in 1987 that gave us the angiosome concept and changed reconstructive surgery permanently.

Covering perforator classification, the DIEP flap, and the clinical failure that anatomy could have predicted.

Themes from this episode

Practice what you just heard

Two questions on the themes of this episode, free, marked as you go. Then one from the Vault on the same ground.

Question 1 · Applied

Under the Gent consensus terminology, what distinguishes a muscle perforator from a septal perforator, and why does it matter surgically?

Answer to see the explanation and the source.

Question 2 · Foundation

How does the epidermis receive its nutrition?

Answer to see the explanation and the source.

From the Vault, on the same theme

General Principles: Vascular, Lymphatic & Metameric Organisation · Purist Locked

A surgeon raises a pedicled flap on a single source artery and extends it well past that artery’s own anatomical territory. The flap survives across the territory of the adjacent source vessel but dies beyond it, along a line that proves remarkably consistent from patient to patient. What sets this limit?

  • AReduced-calibre linking vessels open across the first boundary, but pressure fails at a second
  • BVenous territories do not match arterial ones, and congestion sets the limit beyond one territory
  • CSympathetic section at flap elevation constricts the vessels progressively towards the tip
  • DThe subdermal plexus is interrupted at the boundary of each neighbouring territory
  • ELymphatic division causes oedema whose interstitial pressure throttles the distal microcirculation first

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References

  1. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg. 1987;40(2):113-141. PMID: 3567445.
  2. Milton SH. Pedicled skin-flaps: the fallacy of the length:width ratio. Br J Surg. 1970;57(7):502-508. PMID: 4913490.
  3. Blondeel PN, Van Landuyt KHI, Monstrey SJM, Hamdi M, Matton GE, Allen RJ, et al. The "Gent" consensus on perforator flap terminology: preliminary definitions. Plast Reconstr Surg. 2003;112(5):1378-1383. PMID: 14504524.
  4. Dhar SC, Taylor GI. The delay phenomenon: the story unfolds. Plast Reconstr Surg. 1999;104(7):2079-2091. PMID: 11149772.
  5. Taylor GI, Pan WR. Angiosomes of the leg: anatomic study and clinical implications. Plast Reconstr Surg. 1998;102(3):599-616. PMID: 9727424.
  6. Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg. 1989;42(6):645-648. PMID: 2605399.
  7. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg. 1994;32(1):32-38. PMID: 8141534.
  8. Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg. 2009;124(5):1529-1544. PMID: 20009839.
  9. Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg. 2007;119(7):2092-2100. PMID: 17519706.
  10. Geddes CR, Morris SF, Neligan PC. Perforator flaps: evolution, classification, and applications. Ann Plast Surg. 2003;50(1):90-99. PMID: 12545116.
  11. Mathes SJ, Nahai F. Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg. 1981;67(2):177-187. PMID: 7465666.
  12. Nakajima H, Fujino T, Adachi S. A new concept of vascular supply to the skin and classification of skin flaps according to their vascularization. Ann Plast Surg. 1986;16(1):1-19. PMID: 3273007.
  13. Nakajima H, Imanishi N, Fukuzumi S, Minabe T, Aiso S, Fujino T. 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(3):779-791. PMID: 9727444.
  14. Pignatti M, Ogawa R, Hallock GG, Mateev M, Georgescu AV, Balakrishnan G, et al. The "Tokyo" consensus on propeller flaps. Plast Reconstr Surg. 2011;127(2):716-722. PMID: 21285776.
  15. Bakamjian VY. A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap. Plast Reconstr Surg. 1965;36:173-184. PMID: 14339173.
  16. Cormack GC, Lamberty BGH. The Arterial Anatomy of Skin Flaps. 2nd ed. Churchill Livingstone; 1994.
  17. Standring S, editor. Gray's Anatomy: The Anatomical Basis of Clinical Practice. 42nd ed. Elsevier; 2020.
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