10-01 Skin Grafts, Substitutes and Principles of Flaps-1

HISTORY OF SKIN GRAFTS
Ratner
1
and Hauben and colleagues
2
give excel-
lent overviews of the history of skin grafting. The
following highlights are excerpted from these two
sources.
Grafting of skin originated among the tilemaker
caste in India approximately 3000 years ago.
1
A
common practice then was to punish a thief or
adulterer by amputating the nose, and surgeons of
their day took free grafts from the gluteal area to
repair the deformity. From this modest beginning,
skin grafting evolved into one of the basic clinical
tools in plastic surgery.
In 1804 an Italian surgeon named Boronio suc-
cessfully autografted a full-thickness skin graft on a
sheep. Sir Astley Cooper grafted a full-thickness
piece of skin from a mans amputated thumb onto
the stump for coverage. Bunger in 1823 success-
fully reconstructed a nose with a skin graft. In 1869
Reverdin rekinkled worldwide interest in skin graft-
ing with his report of successful pinch grafts. Ollier
in 1872 pointed out the importance of the dermis
in skin grafts, and in 1886 Thiersch used thin split-
thickness skin to cover large wounds. To this day
the names Ollier and Thiersch are synonymous with
thin (0.0050.01-inch) split-thickness grafts.
Lawson, Le Fort, and Wolfe used full-thickness
grafts to successfully treat ectropion of the lower
eyelid; nevertheless, it is Wolfe whose name is
generally associated with the concept of full-
thickness skin grafting. Krause popularized the use
of full-thickness grafts in 1893, known today as
Wolfe-Krause grafts.
Brown and McDowell
3
reported using thick split-
thickness grafts (0.010.022-inch) for the treatment
of burns in 1942.
In 1964 Tanner, Vandeput, and Olley
4
gave us
the technology to expand skin grafts with a machine
that would cut the graft into a lattice pattern,
expanding it up to 12X its original surface area.
In 1975 epithelial skin culture technology was
published by Rheinwald and Green,
5
and in 1979
cultured human keratinocytes were grown to form
an epithelial layer adequate for grafting wounds.
6
ANATOMY
The character of the skin varies greatly among
individuals, and within each person it varies with
age, sun exposure, and area of the body. For the
first decade of life the skin is quite thin, but from
age 10 to 35 it thickens progressively. At some
point during the fourth decade the thickening stops
and the skin once again begins to decrease in sub-
stance. From that time until the person dies there is
gradual thinning of dermis, decreased skin elastic-
ity, and progressive loss of sebaceous gland con-
tent.
The skin also varies greatly with body area. Skin
from the eyelid, postauricular and supraclavicular
areas, medial thigh, and upper extremity is thin,
whereas skin from the back, buttocks, palms of the
hands and soles of the feet is much thicker.
Approximately 95% of the skin is dermis and the
other 5% is epidermis.
7
The dermis contains seba-
ceous glands and the subcutaneous fat beneath the
dermis contains sweat glands and hair follicles. The
skin vasculature is superficial to the superficial fas-
cia and parallels the skin surface. The cutaneous
vessels branch at right angles to penetrate subcuta-
neous tissue and arborize in the dermis. The final
destination of these blood vessels is a capillary tuft
that terminates between the dermal papillae.
TERMINOLOGY
An autograft is a graft taken from one part of an
individuals body that is transferred to a different
part of the body of that same individual. An isograft
is a graft from genetically identical donor and
recipient individuals, such as litter mates of inbred
rats or identical human twins. An allograft (previ-
ously homograft) is taken from another individual of
the same species. A xenograft (heterograft) is a
graft taken from an individual of one species that is
grafted onto an individual of a different species.
A split-thickness skin graft (STSG) contains epi-
dermis and a variable amount of dermis. A full-
thickness skin graft (FTSG) includes all of the der-
mis as well as the epidermis
8
(Fig 1). The donor site
SKIN GRAFTS AND SKIN SUBSTITUTES
James F Thornton MD
SRPS Volume 10, Number 1
2
of an FTSG must be closed by either direct suture
approximation or skin graft.
PROPERTIES OF SKIN GRAFTS
Skin grafts have been used for over a century to
resurface superficial defects of many kinds.
Whether intended for temporary or permanent
cover, the transplanted skin does not only protect
the host bed from further trauma, but also provides
an important barrier to infection.
Thin split-thickness skin grafts have the best take
and can be used under unfavorable conditions that
would spell failure for thicker split-skin grafts or full-
thickness grafts. Thin STSGs tend to shrink consid-
erably, pigment abnormally, and are susceptible to
trauma.
9
In contrast, full-thickness grafts require a
well-vascularized recipient bed
9
until graft perfu-
sion has been reestablished. FTSGs contract less
upon healing, resist trauma better, and generally
look more natural after healing than STSGs.
Rudolph and Klein
9
review the biologic events
that take place in a skin graft and its bed. An
ungrafted wound bed is essentially a healing wound
which, left alone, will undergo the typical processes
of granulation, contraction, and reepithelialization
to seal its surface. When a skin graft is placed on a
wound bed, these processes are altered by the pres-
ence of the graft.
10
Marckmann
11
studied biochemical changes in a
skin graft after placement on a wound bed and
noted similarities with normal skin in its response to
physical or chemical injury and aging. The changes
in wound healing brought about by the skin graft
can also be described as a general adaptation of
connective tissue to a diminished blood supply.
11
EPIDERMIS
In the mid-1940s Medawar studied the behavior
and fate of healing skin autografts.
1214
His findings
can be summarized as follows.
Histologic Aspects
During the first 4 days postgraft there is tremen-
dous activity in the graft epithelium, which doubles
in thickness and shows crusting and scaling of the
graft surface. Three cellular processes may explain
this thickening: 1) swelling of the nuclei and cyto-
plasm of epithelial cells; 2) epithelial cell migra-
tion toward the surface of the graft; and 3) accel-
erated mitosis of follicular and glandular cells.
10
By
the third day after grafting there is considerable
mitotic activity in the epidermis of a split-thickness
skin graft, whereas mitotic activity in full-thickness
skin grafts is much less common and may be totally
absenta reflection of their less-efficient early cir-
culation.
Between the fourth and eighth days after graft-
ing there is great proliferation and thickening of the
graft epithelium associated with obvious desqua-
mation. Epithelial thickness may increase up to
sevenfold, with rapid cellular turnover. At the same
time the surface layer of epithelium exfoliates and
is replaced by upwardly migrating cells of follicular
epithelium at an accelerated rate. This heightened
mitosis does not begin to regress until after the first
week postgrafting. By the end of the fourth week
Fig 1. Split-thickness skin grafts include a variable
amount of dermis. Full-thickness grafts are taken
with all the dermis. (Reprinted with permission
from Grabb WC: Basic Techniques of Plastic
Surgery. In: Grabb WC and Smith JW: Plastic
Surgery, 3rd Ed. Boston, Little Brown, 1979.)
3
postgraft the epidermal thickness has returned to its
normal, pregraft state.
Histochemical Aspects
The RNA content of graft epithelial cells changes
little in the first few days postgraft.
15
By the fourth
day postgraft RNA content increases greatly in the
basal layers of epithelium, paralleling the hyperac-
tivity of epithelial cells caused by acceleration of
protein synthesis during a period of rapid cellular
replication. By the 10th day postgraft the RNA
level returns to normal.
15
Over the first 2 to 3 days enzymatic activity pro-
gressively decreases in split-thickness skin grafts,
but as new blood vessels enter the dermisepidermis
junction, the enzyme levels rebound.
DERMIS
Cellular component
The source of fibroblasts in a skin graft remains
obscure.
16
Early investigators believed that these
cells came from large mononuclear cells in the blood,
while Grillo
17
theorized that they originated from
local perivascular mesenchymal cells. Whatever
their origin, most authors are convinced that active
fibroblasts in a healing skin graft do not come from
indigenous fibrocytes.
Converse and Ballantyne
18
studied cell viability in
rat skin grafts by assaying levels of diphosphopyri-
dine nucleotide diaphorase, an indicator of active
electron transport. The authors noted falling fibro-
cyte numbers in the first 3 days after grafting. The
remaining fibrocytes lay in two narrow layers, one
beneath the dermisepidermis junction and the other
just above the host bed. After day 3 fibroblast-like
cells began to appear, first in the graft bed and later
in the graft itself. By the seventh to eighth day
postgraft the fibroblast population and enzymatic
activity were greater than in normal skin. After this
early burst in fibroblastic activity, however, both
fibroblast numbers and enzyme levels resumed their
normal, pregraft states over the ensuing weeks.
Fibrous component
Medawar
12,13
stated that most of the collagen in
an autograft persists through the 40th day after graft-
ing. Hinshaw, Miller, and Cramer,
19,20
on the other
hand, concluded that split-thickness and full-
thickness skin autografts undergo considerable col-
lagen turnover. In their experiments the dermal
collagen became hyalinized by the third or fourth
day postgraft, and by the seventh day all of the
collagen was replaced by new small fibers. The
replacement continued through the 21st postgraft
day, and by the end of the sixth week postgraft all
the old dermal collagen had been completely
replaced. The rates of collagen turnover and epi-
thelial hyperplasia peaked simultaneously in the first
23 weeks postgraft.
Klein
21,22
and Peacock
23
used hydroxyproline to
determine the collagen content of grafted wounds.
Hydroxyproline is an amino acid found exclusively
in collagen at a constant proportion of 14%.
Changes in hydroxyproline and monosaccharide
content of grafted beds paralleled those of other
healing wounds.
24
Independent studies by Hilgert
25
and Marckmann
26
confirmed these findings and
documented plunging levels of hydroxyproline soon
after grafting. The hydroxyproline (collagen) level
eventually rebounded and finally returned to the
normal levels of unwounded skin. Although Hilgerts
cycle lasted 10 days and Marckmanns 1421 days,
it is now well established that most of the collagen
in a graft is ultimately replaced.
On the basis of studies involving tritiated pro-
line-labeled mature collagen, Udenfriend
27
and
Rudolph and Klein
28
agreed that 85% of the origi-
nal collagen in a graft is replaced within 5 months
postgraft. The collagen turnover rate of grafts is 3X
to 4X faster than that of unwounded skin.
29
In addi-
tion, although equal amounts of collagen are lost
from full- and split-thickness grafts, STSGs replace
only half as much of their original collagen as do
FTSGs of equal size.
Elastin fibers in the dermis account for the
resilience of skin. While the elastin content of
the dermis is small, the elastin turnover rate in a
healing graft is considerable, and most of the elas-
tin in a graft is replaced within a short time. Elas-
tin fiber integrity is maintained through the third
postgraft day, but by postgraft day 7 the fibers are
short, stubby, and have begun to fragment.
19
Elas-
tin degeneration continues through the third
postgraft week until new fibers can be seen
beginning to grow at 46 weeks postgraft. This
replacement process is the same in full- and split-
thickness skin grafts.
4
Extracellular Matrix
Far from simply supporting cells passively, the
extracellular matrix (ECM) plays a vital role in cell-
to-cell communication.
30
Through specific arrange-
ments of protein sequences within, the ECM influ-
ences cellular behavior in adjacent tissues with
regard to proliferation, differentiation, migration,
and attachment.
The extracellular matrix in the skin consists of
large insoluble proteins of fibroblast origin and
smaller soluble proteins produced by either
fibroblasts or keratinocytes. Both kinds of pro-
teins appear to be involved in directing the
behavior of keratinocytes and in promoting
appropriate communication between keratino-
cytes and fibroblasts.
Epithelial Appendages
The sweating capability of grafted skin is a func-
tion of the number of sweat glands transplanted
during grafting and of the extent of sympathetic
reinnervation to the graft. A skin graft will sweat
much like its recipient site due to ingrowing sym-
pathetic nerve fibers from the graft bed. Thus a
graft that is placed on the abdomen will sweat in
response to physical activity, whereas an identical
graft placed on the palm will sweat in response to
emotional stimuli.
Although both full- and split-thickness skin grafts
demonstrate sebaceous gland activity, thin split-
thickness grafts do not contain functional sebaceous
glands and typically appear dry and brittle after take.
Hair follicles are subjected to the same hyper-
plastic stimuli as the rest of the graft. On the fourth
day postgraft the original hair sloughs off and the
graft becomes hairless. Soon after the graft follicles
begin to produce new hair, and by the 14th postgraft
day very fine, baby-like hair is seen growing out of
the graft.
12
Full-thickness skin grafts produce hair while split-
thickness skin grafts produce little or no hair. Full-
thickness skin grafts that take well grow normal hair
in terms of orientation, pigmentation, and follicular
clustering.
13
Inadequate revascularization will dam-
age the graft hair follicles and result in decreased
hair density. Similarly, when graft take is inter-
rupted for any reason, subsequent hair growth will
be sparse, random, and lacking in pigment.
14
In summary, unlike STSGs, FTSGs contain sweat
glands, sebaceous glands, and hair follicles.
8
Only
full-thickness grafts, therefore, are capable of sweat-
ing, oil secretion, and hair growth.
GRAFT TAKE
The large array of physiologic events usually
seen in a healing skin wound are altered and modi-
fied by placement of a graft. The graft becomes
incorporated in the host bed through the process
of graft take. The success of a graft depends
primarily on the extent and speed at which vascu-
lar perfusion is restored to this parasitic, ischemic
tissue.
Given equal clinical and technical conditions,
two qualities of a skin graft influence its fate. The
first determinant is the blood supply of the skin
from which the graft was obtained. A graft har-
vested from a highly vascular donor site will pre-
dictably heal better than a graft taken from a poorly
perfused area. The second factor in graft take is the
metabolic activity of the skin graft at the time of
application, which will dictate its tolerance to the
inevitable period of ischemia.
Skin graft take occurs in three phases. The first
phase consists of plasmatic imbibition and lasts 24
48 hours. This is followed by an inosculatory phase
and a process of capillary ingrowth that occur
essentially simultaneously until generalized blood
flow has been established by the fifth or sixth
postgraft day.
Plasmatic Imbibition
The exact significance of plasmatic imbibition to
the healing of a skin graft is not clear. Hinshaw and
Miller
19
and Pepper
31
believed that plasmatic
imbibition is nutritionally important, while
Clemmesen,
32,33
Converse,
34,35
and Peer
36,37
thought
that it merely prevents the graft from drying out and
keeps the graft vessels patent in the early postgraft
period. Regardless of whose theory is correct, all
concur in the following:
The graft is ischemic for an undetermined period
of time that varies according to the wound bed:
24 hours for a graft placed on a bed that is already
proliferative; 48 hours for a graft covering a fresh
wound.
5
Grafts placed on poorly vascularized beds will
be ischemic for a longer time than those placed
on wounds with good blood supply. Exactly how
long a graft will tolerate this ischemic interval is
unclear, but thick FTSGs seem to tolerate
ischemia for up to 3 days while thin FTSGs sur-
vive for up to 5 days.
32,37
Split-thickness grafts
take well even after 4 days of ischemia.
37
Plasmatic imbibition allows a graft to survive this
immediate postgraft ischemic period until such
time as graft vasculature is reestablished.
9
Grafts gain weight during the phase of plasmatic
imbibition,
3335
adding as much as 40% to their
pregraft weight through fluid movement from
bed to graft.
35
The origin of graft edema is
believed to be the same as that of inflammatory
edemaie, from disaggregation and depolymer-
ization of proteoglycans, accumulation of osmoti-
cally active metabolites, and increased vascular
permeability.
3841
Inosculation and Capillary Ingrowth
At the end of 48 hours, a fine vascular network is
established in the fibrin layer between the graft and
its recipient bed. Capillary buds from the blood
vessels in the recipient bed make contact with the
graft vessels and open channels are formed. Blood
flow is established and the skin graft becomes pink.
Revascularization
Three theories have been put forth to explain
how a skin graft is revascularized.
Connection of graft and host vessels. The first
theory holds that after the inosculatory event, the
definitive vasculature of a graft consists of the blood
vessels originally present within the graft. Accord-
ing to this theory, circulation is restored in a graft
via the original skin graft vessels by anastomoses
formed between the recipient bed and the skin
graft through inosculation. Peer and Walker,
36
Clemmesen,
32,33
Haller and Billingham,
42
and Birch
and Branemark,
3840
among others, endorse this line
of thinking.
Clemmesen,
33
working on a porcine model,
injected India ink into the host vessels of the
autograft. No ink was seen within the graft on the
first postgraft day, but on day 2 a number of graft
vessels contained India ink, suggesting communi-
cation between the host and graft vessels. After
the second day many graft vessels contained India
ink, indicating patent connections between ves-
sels of the graft and its bed. Initially a fine fibrin
mesh linked the graft to the bed, but over the first
4 days this meshwork became lined with endo-
thelial cells and linked up with the vessels of the
graft.
Haller and Billingham
42
reached a similar con-
clusion in a study involving the hamster cheek pouch
model. They too noted that the pattern of vessels in
the healed graft was the same as the pattern before
grafting.
Formation of new vascular channels. The sec-
ond theory of graft revascularization holds that the
graft is perfused through new vessels going from
the recipient bed into the transplanted graft. Con-
verse,
18,35,4345
Zarem,
46
Ljungvist and Almgard,
47
and
Wolff and Schellander
48
espouse this theory.
Converse and Rapaport
43
studied skin grafts in
humans and noted an early connection of graft and
host vesselsthe inosculatory eventafter which
there was active invasion of the graft by host vessels
to produce the definitive vasculature of the graft.
On the basis of a later study in a rat model involv-
ing diaphorase,
18
Converse concluded that the final
vasculature of a graft stemmed from ingrown ves-
sels from the host bed. Degenerative changes in
the original graft vasculature were apparent in the
first 4 days postgraft, as evidenced by progressive
loss of diaphorase activity during this time. With
subsequent vessel ingrowth there was return of dia-
phorase activity.
Wolff and Schellander
48
measured cellular
enzymes to evaluate return of circulation in por-
cine skin grafts. ATP activity correlated well with
the pattern of new vessel ingrowth, leading the
authors to conclude that the new graft vasculature
consisted entirely of ingrown vessels.
Working on mice, Zarem et al
46
theorized that
preexisting graft vessels served only as nonviable
conduits through which the endothelium of the
ingrowing vessels progressed. The rate of vessel
ingrowth was measured at approximately 5 microns
per hour. The original graft vessels degenerated
concomitantly and at the same rate, leaving only
those vessels growing from the recipient bed as the
grafts definitive vasculature.
6
Combined old and new vessels. Smahel
10
and
Tsukada
49
proposed a third (and much less popular)
hypothesis of graft revascularization: a compro-
mise between the two above theories. The authors
speculated that circulation in a graft is reestablished
in various ways; that is, in any graft old vessels may
be recycled and new ones may grow to variable
degrees. These two pathways to restore circulation
to ischemic tissue may occur simultaneously or as
consecutive stages in the interaction between the
graft and its bed.
There are two methods of skin graft revas-
cularization: primary and secondary.
Primary revascularization. Under the scanning
electron microscope it can be seen that no real
circulation to the graft exists for the first 6 to 7 days
postgrafting. Whatever flow there is within the
graft is sluggish, shifting direction, and with atten-
dant pooling and pendulum-like movement.
50
Clini-
cally this manifests as cyanotic discoloration and is
particularly noticeable in full-thickness skin
grafts.
18,38,43
In the normal course of events circulation in a
skin graft is reestablished through vascular anasto-
moses between budding neovessels from the bed
and those already present in the graft (inoscula-
tion). Blood enters the graft via these newly formed
vascular connections and the graft turns pink. A
pink color is generally considered a sign of prob-
able graft survival, although the intensity of colora-
tion does not allow any conclusions regarding the
grafts circulatory status.
Inside the graft the hemodynamic situation is
complex. The old vessels of the graft are dilated
and denervated and some of the circulatory routes
are severed during graft harvest. Blood vessels from
the recipient bed attach to both arteries and veins
of the graft, yet all these connections are afferent
with respect to the graft. Blood and tissue fluids
moving into the graft are trapped there and unable
to return to the bed because of inadequate reverse
circulation.
Sometime between days 4 and 7 postgraft, the
newly formed vascular connections differentiate into
afferent and efferent vessels, and other vessels retain
their capillary-like character or simply disappear.
51
At this point the proper vascular system within the
graft is reestablished and blood flow is restored.
Secondary revascularization. When vascular con-
nections between the bed and the graft are delayed,
secondary revascularization occurs. Under normal
graft conditions, the vasoactive agent directing the
ingrowth of new blood vessels ceases to function
and capillary proliferation stops as good blood flow
is established by neovascularization. However, the
longer a graft remains ischemic, the longer the
vasoactive substance remains in the tissue. As a
result, great numbers of new capillaries grow into
the graft and granulation tissue accumulates under
the graft. This phenomenon is known as secondary
revascularization.
The mechanism of secondary revascularization
is as follows. Vascular connections between the
graft bed and the graft inhibit the formation of cap-
illary buds. If the graft is not well applied to the bed
and vascular connections are not established early
eg, in the periphery of large graftsthe inhibiting
effect does not take place. Within the graft itself
the vessels may be functionally deficient or the vas-
cular ingrowth may not reach the required level of
biologic activity for the inosculatory event. If anas-
tomoses fail to develop in time, the ischemic period
is extended and capillary proliferation in the bed
continues. Degenerative processes in the graft and
exuberant granulation tissue in the host bed go hand
in hand with prolonged ischemia. If blood vessels
reach the graft in time, the graft will survive; if not,
the graft will fail.
In the host bed, insufficient vascular proliferation
and wound contamination are the two common
causes of delayed inosculation. Anastomoses may
not form at the right time because of the increased
distance between the graft and its bed from inter-
posed necrotic material, a thick fibrin layer,
hematoma, seroma, or air bubbles.
Grafts that heal by secondary intention are
smooth, fibrotic, tight, and have a slick, silvery sheen
on the surface reflecting the large amount of cica-
trix within the graft. Large grafts often heal both by
primary and secondary revascularization, and cer-
tain areas show the typical appearance and desqua-
mation where the secondary process occurs.
Histologically the epidermis and papillary dermis
are destroyed by necrosis in the full-thickness graft
that heals by secondary revascularization. The pap-
illary dermis is replaced by a thin layer of connec-
tive tissue, which in turn is covered by a flattened
epidermis. The reticular dermis is normal histologi-
7
cally, but beneath the graft there is a layer of newly
formed connective tissue that infiltrates the dermis,
resulting in graft fibrosis. Hinshaw and Miller
19
noted
accelerated collagen turnover in pig autografts that
had healed by secondary revascularization.
SKIN GRAFTING TECHNIQUES
Donor Site Selection and Graft Harvest
The selection of a graft donor site is based on
three factors: 1) whether a full-thickness skin graft
or a split-thickness skin graft is to be used; 2) whether
the intended donor site matches the recipient bed
in color; and 3) potential morbidity of graft harvest
at that site.
An appropriate color match is particularly impor-
tant in head and neck reconstruction with skin grafts.
Any skin graft taken below the clavicles and applied
above the clavicle will result in a lifelong color mis-
match that is extremely difficult, if not impossible,
to correct.
52
Both full- and split-thickness skin grafts
can be harvested above the clavicle; STSGs obtained
from a shaved scalp, in particular, often yield very
good results. Figure 2 illustrates two patterns of skin
graft harvested from the submental, turkey gob-
bler area, which is another good source of graft
skin.
53
For large, full-thickness defects above the
clavicle, tissue expansion is recommended to recruit
an adequate volume of FTSG.
Graft reconstruction of the nasal tip requires spe-
cialized skin of similar thickness and pore size. The
glabella provides just such skin.
54
Historically, donor
sites for nasal tip grafting have included the concha,
nasolabial fold, pre- and postauricular skin, the neck,
and supraclavicular areas.
54
To minimize morbidity from graft harvest, donor
sites should be carefully chosen to avoid hair-bearing
skin and to camouflage the resulting scar.
52
Tiem
55
advocates a bilaminar harvest whereby an epithe-
lial flap is raised, a dermal graft is taken, and the
superficial layer is replaced in its original site. This
is known as the trapdoor or dermatome technique.
Tiem reports improved donor site management and
fewer pigmentary changes with this method than
with conventional harvest.
Beck and colleagues
56
compared the trapdoor
technique with standard elliptical excision in 52
patients (60 graft sites). Although both techniques
were successful and had minimal complications,
the elliptical method [was associated with] less dis-
comfort, texture change, numbness, and itching.
The scars were concealed better and less notice-
able.
56
Common full-thickness graft donor sites are the
groin, postauricular area, and clavicular region.
57
Yildirim and coworkers
57
also recommend the
preputium as a source of graft skin in children. Split-
skin grafts are usually harvested from the outer thigh
because surgeons prefer this site for its technical
ease and convenience of intraoperative position-
ing and postoperative dressings. The public, on the
Fig 2. The turkey gobbler deformity as a source of skin grafts. A
U-shaped excision results in dogears that may be visible laterally.
A triangular excision eliminates the dogear problem but yields
less skin. (With permission from Shiffman MA: Re: Cervicomental
turkey gobbler: a new source for full-thickness grafts (letter).
Dermatol Surg 28:1099, 2002.)
8
other hand, would prefer that grafts be taken from
their buttocks to avoid visible scars.
58
Graft Sizing and Expansion
Techniques for sizing skin grafts usually involve
preformed templates of easily available materials,
such as cardboard and latex.
59,60
A simple and
reproducible technique consists of placing card-
board in the wound to develop a blotter pattern
61
(Fig 3). The cutout is then applied over the donor
site, traced with a marking pen, and a graft of the
outlined area is resected.
61
A wound is reepithelialized from the edges
toward the center, therefore the perimeter of the
graft is the only part that contributes to the epithe-
lialization process. An expanded graft presents a
larger perimeter through which epithelial outgrowth
can proceed. With graft expansion, larger areas
can be covered with smaller sections of skin.
Various techniques to expand skin for grafting
have been described, including pinch grafts,
62
relay
transplantation,
63
meshing,
6467
Meek island grafts,
68
microskin grafts,
6974
and the Chinese technique of
intermingling autografts and allografts.
75,76
A pinch graft breaks up a whole graft of skin into
tiny pieces to increase the edge area. Pinch grafts
are reported to be effective in treating small- to
medium-size venous leg ulcers,
77,78
radiodermati-
tis, pressure sores, and small burns.
62
Relay transplantation consists of cutting a graft
into strips 36 mm wide and 510 mm apart. When
the epithelial growth becomes clinically obvious 5
to 7 days later, the original strips are removed and
transplanted, leaving the epithelial explants in place.
This process may be repeated up to 4 times.
63
Meshing is the term used for cutting slits into a
sheet graft and stretching it open prior to transplan-
tation. Meshed grafts have a number of advantages
over sheet grafts: (1) meshed grafts will cover a
larger area with less morbidity than non-meshed
grafts; (2) the contour of the meshed graft can be
adapted to fit in a regular recipient bed; (3) blood
and exudate can drain freely through the inter-
stices of a meshed graft; (4) in the event of local-
ized bacterial contamination, only a small area of
meshed graft will be jeopardized; (5) a meshed
graft offers multiple areas of potential reepi-
thelialization.
6466
The main disadvantages of
meshed grafts are the considerable surface area
Fig 3. A piece of cardboard is placed on the defect and the
moisture blot is traced. The cutout pattern is then placed on the
skin graft donor site and outlined. (With permission from
Putterman AM: Blotter technique to determine the size of skin
grafts (letter). Plast Reconstr Surg 112:335, 2003.)
9
that must heal by secondary intention and the less-
than-ideal cosmetic result. A small ratio of expan-
sion1:1.5and pulling the graft lengthwise to
narrow the skin perforations to slits before trans-
plantation lessens these problems.
65
Richard and colleagues
67
compared the Tanner
and Bioplasty skin graft meshing systems with respect
to their respective expansion ratios and predicted
versus actual expansion. Both systems delivered
approximately 50% of the anticipated skin expan-
sion, leading the authors to recommend harvesting
skin grafts larger than needed to compensate for
the eventual shortage.
Ingenious ways to mesh skin grafts when a mesher
is not available have been reported.
79,80
Kirsner
and associates conclude that meshed STSGs are
safe and effective therapy for recalcitrant leg ulcers.
81
The Meek technique involves a special der-
matome and prefolded gauzes for expanding small
pieces of split skin.
68
The expansion ratio obtained
with the Meek technique is almost 1:9. In contrast,
the expansion ratio of allograft meshed with the
Zimmer II dermatome set at 1:6 is actually 1:4.
Meek grafts are useful alternatives to meshed grafts
when donor sites are limited, and are particularly
well suited for grafting granulating wounds and
unstable beds.
Several authors report successful coverage of burn
wounds with microskin grafts.
6974
These are sheet
grafts that are minced with a Tanner-Vandeput der-
matome to achieve an expansion ratio of 1:10.
Graft take is said to be excellent even in difficult
beds.
Intermingled transplantation of autograft and
allograft has been practiced successfully in China
since at least 1973,
75,76
mostly in the treatment of
large burns. Yeh and colleagues
82
compared this
technique with the microskin method in a rat model,
and noted significantly less scar contracture with
the former. Other healing parameters were similar
between the two groups.
Graft Fixation
Adherence of the graft to its bed is essential for
skin graft take. A thin fibrin layer holds the graft to
the bed and forms a barrier against potential infec-
tion.
83
Factors such as bleeding, infection, and shear
force tend to work against graft take.
Two distinct phases of graft adherence occur.
Phase 1 begins immediately after grafting and lasts
about 72 hours.
84
During this time the graft remains
adherent to the bed through the bond formed by
the fibrin layer. Phase 2 coincides with the onset of
fibrovascular ingrowth and vascular anastomoses
between the graft and the host.
Novel methods of graft fixation abound. When
dealing with skin grafts to the penis and scrotum,
which are particularly difficult to immobilize and
dress, Netscher and associates
85
suggest wrapping
the graft area in nonadherent gauze mesh over
which Reston self-adhering foam is secured. The
foam maintains penile length and gently but firmly
compresses the skin graft during the crucial first
week. The authors cite ease of application and
removal, sterility, and effectiveness in wound cov-
erage as advantages of this method.
Saltz and Bowles
86
and Caldwell and col-
leagues
87
also advocate the use of Reston foam
applied over Xeroform gauze for securing skin
grafts to wounds on the shoulder and face,
respectively. Balakrishnan
88
prefers Lyofoam, a
semipermeable, nonwoven polyurethane foam
dressing. The foam is easy to apply directly on
the graft and is biologically inert. Its hydropho-
bic outer surface is said to retard bacterial colo-
nization.
Johnson, Fleming, and Avery
89
opt for a simple,
versatile, and rapid technique consisting of staples
and latex foam dressing to secure skin grafts. Wolf
and coworkers
90
confirmed the effectiveness of rub-
ber foam with staple fixation in various patterns to
provide even pressure distribution on skin grafts.
Smoot
91
uses a Xeroform sandwich filled with
molded cotton balls stapled in place, while Amir et
al
92
modify a cutoff disposable syringe to affix the
silk threads of their graft dressings. Cheng and col-
leagues
93
use a disk cut from the bottom of an IV
infusion bottle on which multiple radial slits are
made in the perimeter for tying the sutures holding
the graft.
Other suggested fixation methods for grafts
include silicone rubber dressings
94
and silicone
gel sheets,
95
rubber band stents,
96
transparent
gasbag tie-over dressings,
97
Coban self-adherent
wrap,
98
thin hydrocolloid dressings,
99
and assorted
Silastic and foam dressings for grafts to the neck or
hand.
100102
10
Dressings for specific applications include a dor-
sal and ventral sandwich bolster for grafts on the
tongue;
103
a cutout tie-over dressing of elastic tape
with silk threads on which a bolster is placed;
104
and malleable ear dressings constructed of silicone-
lined bandage with thin metal backing.
105
Modern bolster technologies of skin graft fixa-
tion replace sutures and staples with either fibrin
glue
106111
or octyl-2-cyanoacrylate (super glue)
on the edges of the graft.
112,113
Fibrin glue is strong,
transparent, hemostatic, does not interfere with
healing, and does not promote wound infection.
Proponents of fibrin glue say that it improves graft
survival, reduces blood loss, speeds reconstruc-
tion by allowing large sheet-graft coverage, and
produces better esthetic results.
111
Our experi-
ence at The University of Texas Southwestern
Medical Center bears out this assertion: A thin
layer of fibrin glue improves graft take consider-
ably, particularly in the head and neck and mobile
body parts.
Negative-pressure dressings (VAC device [KCI,
San Antonio, Texas]) also enhance graft adherence
and survival,
114117
and are a good option in diffi-
cult-to-bolster areas such as the hand and axilla.
The total time of bolster application can be reduced
from 5 to 3 days while the patient maintains mobil-
ity of the extremity.
Donor Site Management
Open Wound Technique
The open-wound technique of donor site man-
agement is associated with prolonged healing time,
more pain, and a higher risk of complications than
if the wound is covered. Most authors recommend
dressing the donor site of a skin graft to protect it
from trauma and infection.
Allen and coworkers
118
compared bacterial
counts of wounds left open to granulate and of
wounds covered by skin dressings. They found
12.5% of open wounds were sterile, but all the
dressed wounds showed some microbial flora.
When antibiotics were added, however, there was
a dramatic decrease in bacterial colonization, lead-
ing the authors to conclude that it was the antibi-
otic, not the dressing, that had a sterilizing influ-
ence. Skin grafts have no intrinsic bactericidal
properties.
119
Biologic Dressings
Autografts
Feldman
120
recommends returning unused skin
to the donor site as an autologous biologic dressing
on the grounds that this is logical in terms of wound
healing, tissue conservation, and expense. Wood
121
agrees that this is a good idea in immuno-
compromised or steroid-dependent patients, but
unnecessary in the general population. Careful plan-
ning before surgery to harvest only the required
amount of skin is the ultimate solution, in Woods
opinion.
Allografts
Traditionally cadaver allografts have been the
choice for resurfacing large denuded areas. Cadaver
skin serves as temporary wound cover, reduces pain
and fever, restores function, increases appetite,
controls fluid loss, and promotes wound healing. As
the grafts revascularize, they form a barrier against
bacterial invasion and prevent further loss of water,
electrolytes, and protein from the wound. Allografts
decrease bacterial counts of underlying tissues and
facilitate future grafting by promoting a sterile wound
bed.
122
Glycerol-treated cryopreserved allografts have a
number of applications such as in the treatment of
scald burns in children,
123,124
extensive burns in both
children and adults,
125
and deep burns down to
muscle fascia or fat (when combined with alloge-
neic cultured epithelial grafts).
126,127
The main draw-
back of glycerol-preserved allografts is their expense.
As discussed above, Chinese investigators have
successfully used combinations of allografts and
autografts for coverage of open wounds.
7577
The
autograft is cut into small pieces and placed in the
slits of meshed allografts, or is laid down in alternat-
ing strips of auto- and allograft. As rejection unfolds,
epidermal cells in the autograft gradually replace
the allograft.
128
Xenografts
Xenografts (collagenelastin prostheses) adhere
to a wound bed via fibrin bonding. The advantages
of xenografts are relatively low cost, ready availabil-
ity, easy storage, and easy sterilization. Disadvan-
tages are lack of antimicrobial activity, no proof that
they promote reepithelialization, potential for
absorption of toxic breakdown products, and poor
11
performance with respect to healing time and pain
when measured against other donor site dressings.
Synthetic Materials
Feldman
120
lists methods for dressing the donor
site of a skin graft (Table 1).
TABLE 1
Dressings for Skin Graft Donor Sites
(Annotated with permission from Feldman DL: Which dressing for
split-thickness skin graft donor sites? Ann Plast Surg 27:288,
1991.)
Synthetic wound dressings can be semiopen,
semiocclusive, or occlusive. Semiopen dressings
include Xeroform, Biobrane, and fine mesh gauze
impregnated with Scarlet Red or Vaseline.
Semiocclusive dressings include Op-Site, Tegaderm,
and DuoDERM. Semiocclusive dressings are
impermeable to bacteria and liquids, so fluid tends
to collect beneath the dressing and must be drained
frequently.
Feldman and colleagues
129
evaluated the effec-
tiveness of various donor site dressings in 30 patients
with respect to healing, pain, infection, and
expense. Xeroform had an average healing time of
10.46 days, no infections, and a low cost per patient
($1.16). The healing time for Biobrane was 19
days; for DuoDERM, it was 15.3 days. Biobrane
was more comfortable than Xeroform, but was
associated with 29% more infections and very high
cost ($102.50/patient).
In another study, donor site wounds dressed with
Op-Site and Tegaderm showed rapid, relatively
painless healing and low infection rates.
130
Brady
et al
131
compared Op-Site, Vaseline gauze, Jelonet,
Scarlet Red, and exposure in terms of healing time,
pain, infection, and cost. (Pig skin was initially
included in the study but was soon eliminated
because of Pseudomonas infection and hyper-
trophic scarring.) Wounds dressed with Jelonet
healed quickly, followed closely by Vaseline gauze.
The interval to healing was longest with the open
method. Op-Site was the most comfortable dress-
ing and the most expensive. Vaseline gauze was
second to exposure in low cost. Recommendations
from the authors were for Op-Site or Jelonet for
dressing small donor areas and for Vaseline gauze
to cover large wounds.
131
Barnett and coworkers
132
compared synthetic
adhesive, moisture-vapor-permeable and fine mesh
gauze dressings for STSG donor sites with respect
to pain, rate of healing, adherence, and infection.
Op-Site and Tegaderm promoted fast healing (mean
6.8 days) and were basically painless. Wounds cov-
ered with fine mesh gauze healed in 10.5 days but
were 3X as painful.
In a study comparing Op-Site with simple polyvi-
nyl film and tulle gauze, the authors note that Op-
Site was associated with low discomfort, but PVC
film was also well tolerated and was very inexpen-
sive.
133
Dressings that promote a moist wound environ-
ment are associated with faster healing. Zapata-
Sirvent
134
compared Biobrane and Scarlet Red and
found Biobrane to be better at controlling pain and
exudate accumulation, with shorter healing times.
Tavis et al
135
agree that Biobrane reduces pain,
limits infection and desiccation, and optimizes heal-
ing times, although its expense is considerable.
Poulsen and colleagues
136
found Jelonet superior
to Op-Site in the treatment of partial-thickness burns
both in terms of speed of healing (7 vs 10 days) and
residual scars (8% vs 21%). A large comparison
study of STSG donor site healing under Xeroform
and Jelonet dressings showed no difference in mean
time from harvest to healing, similar cost and ease
of use, and less discomfort with Xeroform, particu-
larly with movement.
137
Nemeth et al
138
note much
less discomfort and faster healing by nearly 4 days
of shave biopsy sites treated with DuoDERM over
12
conventional therapy consisting of cleansing, baci-
tracin, and band-aids.
Lawrence and Blake
139
and Porter
140
evaluated
Kaltostat, a calcium alginate dressing, in the healing
of STSG donor sites. The rate of epithelialization,
degree of pain, and convenience of use were mea-
sured and compared with the same parameters in
two other groups of patients treated with Scarlet Red
and DuoDERM. The Kaltostat-treated patients had
slower healing times (15.5 days) than other patients
(10 days). On the other hand, the alginate was easier
to apply and could be used on an outpatient basis.
The topical application of anesthetic agents
relieves the pain of skin donor sites. Goodacre et
al
141
studied the effectiveness of topical local anes-
thesia (EMLA) versus infiltrated anesthesia in an open
parallel group comparison in 80 patients. During
graft cutting and after harvest, patients who received
EMLA reported no discomfort. Owen and Dye
142
report that topical application of 2% lignocaine gel
to graft donor sites controlled discomfort during the
first week postgrafting and did not impair healing.
Azad and Sacks
143
recommend topical bupivacaine
on graft donor sites under calcium alginate dress-
ings to enhance comfort and improve hemostasis.
Others recommend honey-impregnated gauze
for dressing donor sites and report no significant
difference in time of reepithelialization or patient
comfort between this inexpensive material and the
more costly hydrocolloid dressings.
144
GRAFT HEALING
In his classic work on skin grafts in the mid-1940s,
Medawar
1214
described the appearance of healing
grafts as follows:
Immediately after removal from the donor area
the skin graft is white, but once applied to the
recipient area it becomes pink over the next few
days. There is blanching on pressure with prompt
capillary refill. At first the graft surface is depressed
below the level of the surrounding skin, but by the
14th to 21st postgraft day it becomes level with the
surrounding surface.
19
Collagen replacement begins by the seventh
postgraft day and is complete in about 6 weeks.
There is an abundance of polymorphonuclear lym-
phocytes and monocytes. The mononuclear infil-
trate persists in the dermis for an extended period
of time.
Vascular remodeling in the graft may take many
months.
145
Host vessel ingrowth is perpendicular to
the dermisepidermis junction and forms a charac-
teristic vascular pattern. The new vessels in the
graft are more numerous and show greater arboriza-
tion than those in normal skin.
Lymphatic drainage is present through connec-
tions between the graft and host lymphatics by the
fifth or sixth postgraft day, and subsequently the
graft loses weight until pregraft weight level is
attained by the ninth day.
146
GRAFT CONTRACTION
A skin graft begins to shrink immediately after
harvest. Primary contraction is passive and prob-
ably due to the recoil of the dermal elastic fibers. A
full-thickness graft loses about 40% of its original
area as a result of primary contraction; a medium-
thickness graft, about 20%; and a thin split-thickness
graft, about 10%. True Thiersch grafts do not
undergo primary contraction.
After transfer to a recipient site, the skin graft will
shrink as it healssecondary contraction. Full-
thickness grafts tend to remain the same size (after
primary contraction) and do not show secondary
contraction. Split-thickness grafts, on the other hand,
contract whenever circumstances allow. Unless split-
thickness skin grafts are fixed to underlying rigid
structures and cannot move, they will contract sec-
ondarily. Once wound contraction ends, full-
thickness grafts are able to grow, whereas split-
thickness grafts remain fixed, contracted, and grow
minimally, if at all.
147,148
Wound contraction is a critical part of wound
healing and is clinically useful because it reduces
wound size. A contracted wound is often tight and
immobile and there is distortion of surrounding nor-
mal tissue. The degree of graft contraction can be
manipulated somewhat by adjusting the thickness
and proportion of dermis in the graft. The contrac-
tion-inhibiting effect of dermis depends more on
the percentage of dermis included in the graft than
in overall thickness of the graft: the greater the
proportion of dermis, the greater the inhibition and
the less the graft will contract. FTSGs therefore
inhibit wound contraction better than STSGs;
147149
thin FTSGs inhibit wound contraction better than
thick STSGs, and thick STSGs contract less than thin
STSGs.
8,150,151
13
Brown, Garner, and Young
152
concluded that
the capacity of a skin graft to inhibit wound con-
traction is directly proportional to the amount of
structurally intact dermal collagen present in the
graft. The rate of wound contraction is not affected
by graft orientation, amount of epidermis, or
noncollagenous protein.
Various hypotheses have been proposed to
explain the mechanism of this inhibition, including
a mass effect, cellular interactions between graft
cells and host bed, epidermal interaction, mechani-
cal restriction, etc.
152
Rudolph
153,154
explains the
interaction between a graft and its bed in terms of
the lifecycle of a myofibroblast. In this hypothesis a
graft does not prevent the formation of myo-
fibroblasts, but rather speeds up completion of their
lifecycle and eventual disappearance.
155
Split-
thickness grafts cause a rapid decline in the num-
ber of myofibroblasts, and wounds contract less than
comparable nongrafted sites. Full-thickness grafts
trigger an even faster decrease in the myofibroblast
population, and wounds show minimal contraction.
Bertolami and Donoff
150,151
studied the effect of
dermis on the actinomycin content of granulating
wounds and suggest that the mechanism of wound
contraction is not simply the result of myofibroblast
activity;
155
the active role of collagen cannot be
ignored. Substances that inhibit wound contrac-
tion also inhibit prolyl hydroxylase activity (an indi-
cator of collagen synthesis). Lower levels of this
enzyme beneath a full-thickness graft may reflect
decreased collagen synthesis, which in turn may be
involved in preventing wound contraction.
150
Oliver and associates
156,157
highlight the impor-
tance of the collagen matrix in inhibiting wound
contraction. The matrix was prepared for grafting
by adding azide to destroy the cells and trypsin to
remove noncollagenous protein. These grafts, cell-
free and noncollagenous-protein-free, resist wound
contraction as well as full-thickness skin grafts, sug-
gesting that dermal cells and noncollagenous pro-
teins are not part of the inhibitory process. Grafts
free of dermal cells but possessing a collagen matrix
in fact behave much like FTSGs. It may be possible,
therefore, to store nonantigenic dermal substitutes
produced from banked cadaveric skin or xenoge-
neic sources by adding trypsin or azide to remove
noncollagenous protein and cells. This would
increase dramatically the clinical availability of sub-
stitute dermis as a potential source of grafts.
In a porcine study, Walden and coworkers
158
report minimal contraction at 14 days when epi-
dermal autografts were immediately placed over
acellular dermis, presumably by reducing early
inflammation. By day 30, however, these wounds
had contracted more than conventional autografts.
GRAFT REINNERVATION
Nerves grow into skin grafts from wound margins
and the graft bed.
159
The timing of neural invasion
and disposition of nerves within a skin graft vary
according to the graft thickness and recipient site.
Human skin grafts begin to show sensory recovery
at 45 weeks postgrafting, but occasionally sensa-
tion is delayed for up to 5 months. The return of
normal sensation is usually complete by 1224
months. The extent of reinnervation depends on
how accessible the neurilemmal sheaths are to the
invading nerve fibersie, most accessible in full-
thickness grafts and least accessible in thin split-
thickness grafts.
Skin grafts are initially hyperalgesic and slowly
regain normal sensation.
8
If skin graft healing is
uneventful, the results of two-point discrimination
testing will be very close to those of normal skin.
Other sensations do not recover so well. Waris
and associates
159
measured the thermal sensitivity
of 22 split skin grafts transplanted 14 years ear-
lier. Cold sensitivity was present in 14, warmth in
6, and heatpain in 8 grafts. If the warmth sensi-
bility had recovered, the threshold was lower than
for cold. Seven grafts showed no thermal sensibil-
ity at all.
Haro and colleagues
160
confirmed poor return of
sensitivity in grafts by means of immunohistochemi-
cal methods. Grafts less than 7 months old showed
no sensitivity whatsoever, and pain sensation had
developed only in the 15-month-old grafts. Although
deep and superficial nerve plexuses regenerated,
no sensory corpuscles were detected in grafted skin
at any time.
Stella et al
161
independently verified these find-
ings and speculate that the failure of regeneration
of sensory corpuscles may be related to the degen-
eration of periaxonal corpuscular elements.
Ponten
162
stated that grafts assume the sensory
pattern of the host tissue, but Adeymo and
Wyburn
163
and later Fitzgerald, Martin, and
Paletta
164
noted that nerves entering the graft fol-
14
low the evacuated neurilemmal sheaths and rees-
tablish the innervation pattern of the donor skin.
Weis-Becker and coworkers
165
note better rein-
nervation of split skin grafts placed on intact muscle
fascia than if the fascia had been removed. Sen-
sory functions on grafted skin were generally
reduced.
GRAFT PIGMENTATION
Immediately after harvesting, a skin graft
blanches from circulatory interruption. The con-
sequent loss of melanoblast content causes pro-
found alteration in the ratio of pigment-producing
to nonpigment-producing cells in the graft.
166
After
transplantation and graft revascularization there is
inflow of erythrocytes and the normal equilibrium
of the melanocyte population is restored. The
graft resumes a pink color which over time fades
to a normal skin tone. Mir y Mir
167
reviews mel-
anogenesis, its peripheral nervous system control,
the hyperpigmentation state that follows cutane-
ous grafting, and the effects of ultraviolet radiation
on the skin.
Skin grafts change color during healing.
10
Grafts
harvested from the abdomen, buttocks, and thigh
become darker as they heal, while grafts taken
from the palm tend to lighten. Grafts taken from
brunettes progressively darken, while those from
blondes usually lighten. Full-thickness grafts from
the eyelid, postauricular and supraclavicular areas
are usually good color match for the face, although
they may remain red for many months. In gen-
eral, grafts taken from below the clavicle assume
a yellowish-brown hue, while grafts taken from
above the clavicle provide a better color match
for facial skin. Thin split-thickness skin grafts from
the same donor site are usually darker than thick
ones.
162
The best treatment for hyperpigmented grafts is
dermabrasion. For dermabrasion to be effective,
however, it must be done at the appropriate time.
If it is performed too soon after skin graft, the
blanching will not last and the dark pigment will
reappear. The best results are seen when derm-
abrasion follows biologic reinnervation of the graft.
Generally, the later the dermabrasion is done after
grafting, the more effective it is in removing
unwanted pigment.
Skin depigmentation states and their treatment
are reviewed by Taki et al.
168
Vitiligo, senile leuko-
derma, dyschromatosis symmetrica hereditaria, and
second- or third-degree burns can produce signifi-
cant cosmetic deformity, particularly in dark-skinned
patients. Corticosteroids and oral psoralen may,
with exposure to sunlight, be successful in the treat-
ment of vitiligo provided that dopa-positive mel-
anocytes are present in the skin.
169
Burns that
invade the dermis (second- and third-degree)
decrease the number of dopa-positive melanocytes,
so that appropriate treatment consists of removing
the depigmented skin and replacing it with very
thin STSGs of normal color. This protocol is also
successful in treating leukoderma.
A number of authors report successful repig-
mentation in leukoderma or vitiligo after treatment
with ultra-thin, melanocyte-containing epidermal
sheet grafts
170177
or in-vitro cultured melanocytes.
178
Hosokawa and colleagues
179
report a novel method
of tattoo elimination in which the pigment-contain-
ing dermis is chemically removed and the epider-
mis is replaced. Wound healing time was much
shorter than for typical skin grafts.
OVERGRAFTING
Dermal overgrafting consists of applying a split-
thickness skin graft to a recipient bed or dermis or
denuded scar tissue.
180
Overgrafting preserves sub-
cutaneous tissues, is a relatively simple procedure,
and the tissue consequences of graft failure are
minimal. Rees and Casson
181
offer technical details
of skin removal and bed preparation and list the
best donor sites. Their indications for overgrafting
are as follows:
unstable, depressed, corrugated, or hypertrophic
scars
unstable or hyperpigmented skin grafts
large pigmented nevi
radiation damage
tattoos
Pigmented lesions should be excised deep
enough to remove all the pigment before the graft
is applied. A potential complication of the tech-
nique is the formation of cysts and granulomas from
retained epithelial remnants.
181
15
GRAFT FAILURE
A meticulous surgical technique contributes
greatly to the survival of a skin graft. Particular
attention should be paid to ensuring
atraumatic graft handling
a well-vascularized, scar-free bed
careful hemostasis and removal of accumulated
blood before dressing the wound
postoperative immobilization of the graft recipi-
ent site
use of a tourniquet during graft harvest and
transfer
no proximal constricting bandages
Flowers
182
reviews the usual complications asso-
ciated with graft failure and recommends steps to
avoid them. The graft bed should be as clean as
possible, free of dead tissue, and have an appropri-
ate substrate (eg, bone should have periosteum,
tendon should have peritenon). A clean area with
endothelium is all that is required in the bed of a
successful skin graft.
The most common cause of autologous skin graft
failure is hematoma. The clot isolates the
undersurface of the graft from the endothelial buds
of the recipient site so that revascularization cannot
take place.
182
The second most common cause of graft loss is
infection. Infection can be avoided by carefully
preparing the wound bed, using quilting sutures,
meshing or pie-crusting the graft surface to allow
free egress of subjacent fluids, and applying wet
saline dressings that are changed every 4 hours.
182
Fluid beneath the graft can also cause graft
necrosis. Areas rich in lymphatics such as the
supraclavicular, inguinal, and axillary regions are
particularly prone to develop seromas. Atraumatic
tissue handling, cauterization of lymphatic vessels,
limited use of electrocautery in the graft bed, and a
light pressure dressing or VAC technique minimizes
the risk of fluid accumulation under the graft.
182
Excessive pressure on a fresh graft may also cause
it to die. The applied pressure should never exceed
30 mmHg. Tie-over dressings immobilize the graft,
reduce dead space, and prevent hematoma forma-
tion, but exert no significant pressure on the
wound.
183
Other causes of graft failure include
gravitational dependency, movement of the area,
arterial insufficiency, venous congestion, lymphatic
stasis, and surgeon error.
Teh
184
studied 21 patients with stasis ulcers in an
attempt to pinpoint the causes of graft failure.
Wound exudates were assayed for fibrin degrada-
tion products, fibrinogen, available plasminogen,
and active plasmin. All wounds showed granulation
tissue and were classified as clean or dirty. Clean
wounds had low bacterial counts and showed no
detectable plasmin activity. Dirty wounds had high
bacterial counts and increased levels of active plas-
min. High plasmin and proteolytic enzyme activity
was generally seen in wounds contaminated with
beta-hemolytic streptococci and various species of
Pseudomonas. The presence of fibrin under
autografts was associated with success in 17 of 21
ulcers, and the absence of fibrin was associated
with graft failure. This finding suggested to the
author that dissolution of fibrin by plasmin and pro-
teolytic enzymes is the probable mechanism in graft
failure secondary to microorganisms.
184
In conclusion, a grafted wound is rendered ster-
ile through the blocking action of fibrin in the inter-
face between graft and bed. Fibrin plays a central
role in graft survival and is responsible for the anti-
bacterial character of adherent dressings and
autografts. This bacteriostatic effect of grafts has
proved invaluable in the management of large
burns.
184
Thourani and colleagues
185
assessed the effect of
various recipient beds on the success of STSGs in a
burn unit, and found it to be negligible at 14 days
postgrafting. The exception were patients under
18 years of age, in whom STSG success was higher
on granulation tissue than on fat.
Hill
186
recommends a number of measures to
enhance the survival of full-thickness grafts. Because
streptococci produce streptokinase and other
enzymes that break down the fibrin clot and
decrease adherence of the graft to its bed, he pro-
poses the administration of low-dose erythromycin
for the first 5 days after grafting to combat potential
strep and staph colonization. Patients should also
take vitamin C and zinc for a week to 10 days to
promote healing, and should abstain from using
alcohol for at least 2 days before and 5 days after
surgery. Ethanol in the bloodstream decreases the
initial phase of wound healing (the PMN clean-up
phase) and can result in infection and decreased
graft adherence.
186
16
Wolfort and colleagues,
187
working on rabbits,
found that epinephrine added to local anesthetic
solutions decreased inosculation in full-thickness
grafts but had no effect on ultimate survival of split-
thickness skin grafts. Subsequently Fazio and
Zitelli
188
assessed the clinical effects of epinephrine
in local anesthesia of the donor site. The authors
found an increased risk of graft complications at 1
week and no effect on the 6-week cosmetic out-
come. They do not recommend using plain
lidocaine for harvesting full-thickness grafts unless
the vascular supply of the donor area is compro-
mised.
Robson and Krizek
189
predict skin survival on the
basis of successful homograft take prior to
autografting. Perry
190
notes a direct correlation
between skin graft survival and bacterial counts of
<10
5
in the recipient bed.
SKIN SUBSTITUTES
Unlike temporary wound dressings, skin substi-
tutes are designed to be left in place for long peri-
ods of time. Fifteen years ago Pruitt and Levine
191
listed attributes of the ideal skin substitute which
are still current today:
little or no antigenicity
tissue compatibility
lack of toxicity, either local or systemic
permeability to water vapor just like normal skin
impenetrability to microorganisms
rapid and persistent adherence to a wound sur-
face
porosity for ingrowth of fibrovascular tissue from
the wound bed
malleability to conform to an irregular wound
surface
elasticity for motion of underlying tissues
structural stability to resist linear and shear stresses
a smooth surface to discourage bacterial prolif-
eration
sufficient tensile strength to resist fragmentation
biodegradability
low cost
ease of storage
indefinite shelf life
Classification
Skin substitutes may be classified according to
their originautologous, allogeneic, xenogeneic,
or recombinant
192
or whether they are used for
wound cover or wound closure.
193
Materials used
for wound cover are primarily indicated for
superficial burns, where they provide a barrier
against infection, control water loss, and create
an environment suitable for epidermal regenera-
tion. Examples of skin substitutes for wound cover
are Biobrane, Transcyte (formerly Dermagraft-
TC), cultured epidermal allogeneic keratinocytes,
Dermagraft, and Apligraf (Graftskin). Materials
intended for wound closure restore the epider-
mal barrier and become incorporated into the
healing wound. Skin substitutes for wound clo-
sure include Alloderm, Integra, cloned autolo-
gous keratinocytes (Epicel), and composites of
epi dermal dermal component s, al l ograf t
xenograft skin, or collagenglycosaminoglycan
matrix with a cultured epidermal autograft (CEA)
surface (Table 2).
Wound Cover
Biobrane
Biobrane is a bilaminar material consisting of nylon
mesh bonded to thin, semipermeable silicone mem-
brane. It provides a barrier function against fluid
loss as well as protection from environmental bac-
terial invasion. The product is often used as a tem-
porary skin replacement for superficial partial-
thickness burns as well as for skin graft donor sites.
When applied to clean wounds, Biobrane elimi-
nates the need for dressing changes and reduces
the length of inpatient treatment.
192,193
Transcyte
Transcyte is Biobrane with the addition of neo-
natal fibroblasts seeded to the collagen-coated
nylon mesh. The fibroblasts are nonviable at
application and the nylon mesh is not biodegrad-
able, so the material is designed for use as a tem-
porary cover. Transcyte for preliminary coverage
of partial thickness burns results in fewer dressing
changes and less hypertrophic scarring than con-
ventional treatment with topical silver sulfadiaz-
ine.
194
Transcyte is considerably more expensive
than Biobrane.
192,193
17
TABLE 2
A Guide to Biological Skin Substitutes
(Reprinted with permission from Jones I, Currie L, Martin R: A guide to biological skin substitutes. Br J Plast Surg 55:185, 2002.)
18
Cultured Allogeneic Keratinocytes
The delay in growing sheets of confluent autolo-
gous keratinocytes led to the deelopment of pregrown
allogeneic keratinocytes. Epidermal grafts are
obtained from neonatal foreskin or elective surgical
skin specimens and are cultured. Cultured alloge-
neic keratinocytes have been used to cover burn
wounds, chronic ulcers, and as donor site dressings
for split-thickness skin grafts. They will not in them-
selves achieve wound closure, but may survive for
up to 30 months. Allogeneic keratinocytes do pro-
duce growth factors that facilitate the proliferation
and differentiation of the host dermal and epidermal
cells. The main disadvantage is that the cultured
epithelial cell sheets are thin and fragile, requiring
meticulous wound care if they are to survive.
Apligraf/Dermagraft
These are multilaminar materials designed to
overcome the fragility of cultured allogeneic
keratinocytes by improved ease of handling and
healing characteristics. Apligraf is a type I bovine
collagen gel with living neonatal allogeneic fibro-
blasts overlaid by a cornified epidermal layer of
neonatal allogeneic keratinocytes. Apligraf is avail-
able in a ready-to-use form with a 5-day shelf life.
It has wide application in treating chronic ulcers as
well as in pediatric burn coverage, for coverage of
widespread skin defects such as epidermolysis
bullosa, and to cover full-thickness wounds result-
ing from Mohs micrographic surgery pending
definitive repair.
192,193,195199
Apligraf is the most
sophisticated tissue-engineered product available
for wound coverage, and is also the most expen-
sive.
193
Dermagraft is a cryopreserved dermal material
consisting of neonatal allogeneic fibroblasts on a
polymer (Dexon or Vicryl mesh) scaffold. Derma-
graft stimulates the ingrowth of fibrovascular tissue
from the wound bed and reepithelialization from
the wound edges, and as such promotes the heal-
ing of chronic lesions.
193
Dermagraft has been used
to replace lost dermal tissue beneath meshed split-
skin grafts on full-thickness wounds.
200
Wound Closure
Alloderm
Alloderm is processed human cadaveric skin from
which the epidermis has been removed and the
dermal cells extracted. Alloderm functions as a der-
mal graft, but has no barrier function because it has
no epidermal component. Alloderm is similar to
Dermagraft in many respects. A split-thickness skin
graft can be placed over Alloderm after tissue
ingrowth, or an ultra-thin graft can be placed at the
time of Alloderm application in a single-stage pro-
cedure. The indications for Alloderm are as dermal
replacement in full-thickness or deep partial-
thickness wounds.
193,201
Integra
Integra is a bilaminar skin substitute consisting of
a cross-linked bovine collagenglycosaminoglycan
matrix coated on one side with silicone elastomer
for a barrier function. Integra is applied in a two-
stage procedure much like a split- or full-thickness
skin graft. As the host tissue grows into the wound,
the silicone epidermis separates and sloughs off
in 34 weeks, after which the integrated matrix is
covered with a thin STSG.
Integra has widespread applications in burn and
full-thickness wound closure. Its reliability is good
on long clinical follow-up. Advantages of Integra
include off-the-shelf availability; improved elastic-
ity and cosmesis compared with thin STSG; and no
risk of cross infection. Disadvantages are a some-
what steep learning curve for application; the
necessity for a two-stage procedure, and its high
cost.
192,199,201
Cultured Epithelial Autografts
Rheinwald and Green
5
pioneered a method to
clone human epidermal cells in vitro in 1975. In
1979, Green et al
6
perfected a technique for grow-
ing cultured epithelial keratinocytes into confluent
sheets suitable for grafting. Clinical experience with
epidermal cells grown in vitro include burns, chronic
leg ulcers, giant pigmented nevi, epidermolysis
bullosa, and large areas of skin necrosis. Like STSGs,
cultured epithelial autografts must be applied on a
wound bed with early granulation tissue or muscle
fascia for proper take.
193
Sheets of cultured epithelial cells (Epicel) are
expensive and require a fair degree of expertise
for application. These sheets are fragile, often
resulting in a friable, unstable epithelium that may
spontaneously blister, break down, and contract long
after application.
193
Cultured epithelial cells used
for grafting have an expansion capability of 10,000X
19
the original surface area.
202204
When cultured cells
and allografts are combined, they tend to be more
stable than either component alone, yet many pre-
fer to use CEAs alone on large burns.
205,206
Many burn centers continue to use cultured epi-
dermal autografts. The following conclusions
regarding grafts of cultured keratinocytes derive from
their combined experiences.
Tissue cultured grafts are commercially available.
CEAs are very expensive: a 2x2-inch graft cost
approximately $550 in 1996.
Sheets of cultured keratinocytes are very fragile
and must be handled with extreme care.
CEAs require well-vascularized beds.
Once the CEA takes, the cells will spread
peripherally to join other grafts or surrounding
skin.
CEAs are extremely sensitive to infection, toler-
ating maximum bacterial counts of 10
2
to 10
3
/
cm
3
(compared with 10
4
10
5
/cm
3
for standard
STSG).
207
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22
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23
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DEFINITIONS
A llap ls a unlt ol tlssuo that malntalns lts ovn
blood supply vhllo bolng translorrod lrom a donor
to a roclplont slto. ln contrast, gralts aro translorrod
unattachod to a vascular sourco and roly on tho
blood supply at tho roclplont slto lor tholr survlval.
llaps rango lrom slmplo advancomonts ol skln and
subcutanoous tlssuo to composlto llaps that may
contaln any comblnatlon ol skln, musclo, bono, lat,
or lascla.
HISTORY AND EVOLUTION
1ho orlgln ol tho torm llap orlglnatod lrom tho
16th contury Dutch vord llappo, moanlng somo-
thlng that hung broad and looso, lastonod only on
ono sldo.
1
1ho hlstory ol plastlc surglcal ropalr vlth
llaps can bo documontod as lar back as 600 C,
vhon Sushruta Samlta doscrlbod nasal roconstruc-
tlon uslng a chook llap. 1ho orlglns ol lorohoad
rhlnoplasty can bo tracod to lndla about 1440 AD,
but probably vas practlcod long boloro tho blrth ol
Chrlst.
2
1hoso surglcal procoduros lnvolvod tho
uso ol rotatlon llaps, vhlch transport skln to an
ad|acont aroa vhllo tvlstlng or rotatlng a podlclo.
1ho lronch aro crodltod vlth tho orlglnal doscrlp-
tlon ol slldlng or advancomont typo llaps, vhlch
translor skln lrom an ad|acont aroa vlthout torslon
ol tho baso. Dlstant podlclod llaps, vhlch translor
tlssuo to a romoto slto, voro lnltlally roportod ln tho
ltallan lltoraturo durlng tho konalssanco.
3
Subsoquont llap ovolutlon happonod ln phasos.
llrst thoro vas an oarly porlod durlng tho llrst and
Socond World Wars vhon podlclod skln llaps voro
usod oxtonslvoly. 1ho noxt porlod occurrod ln tho
1950s and 60s, vhon vhat vo nov rocognlzo as
roglonal axlal pattorn llaps voro roportod. A thlrd
porlod took placo malnly durlng tho 1970s, vhon a
dlstlnctlon vas mado botvoon axlal and random
llaps, musclo and musculocutanoous llaps voro
olovatod and translorrod, and lroo tlssuo translor
camo lnto bolng. 1ho 1980s sav tho dovolopmont
ol lasclocutanoous llaps, ossoous and ossoocutanoous
llaps, and spoclallzod lroo llaps.
1,4
ln 1984 Song ot al
5
lntroducod tho lroo thlgh llap
basod on porloratlng soptocutanoous artorlos ln
tho thlgh. 1hls vas tho llrst roportod doscrlptlon
ol tho nov vory popular antorolatoral thlgh llap.
loshlma and Sooda
6
colnod tho torm porlorator
llap ln 1989 vhllo roportlng on lnlorlor oplgas-
trlc artory llaps basod on a slnglo musculocutano-
ous porlorator vossol. 1ho orlglnal porlorator llaps
voro translors ol skln torrltorlos basod on a namod
vascular podlclo to a musclo vhllo prosorvlng tho
musclo and lts lnnorvatlon.
610
1ho porlorator con-
copt has ovolvod slnco tho dovolopmont ol
supormlcrosurgory.
11
Skln llaps aro nov succoss-
lully translorrod basod on tho small porloratlng vos-
sol alono, vlthout dlssoctlon ol tho namod vascu-
lar podlclo. Supormlcrosurglcal tochnlquos laclll-
tato tho anastomosls ol vossols 0.5 mm ln dlam-
otor.
1214
1ho rocont lnnovatlons ln porlorator llap surgory
roprosont a shllt tovard osthotlc lroo llap rollno-
monts and attompts to mlnlmlzo donor slto morbld-
lty. 1hln, supor-thln, and mlcro-thln porlorator llaps
havo lurthor advancod tho osthotlc roconstructlon
(llg 1) ol dolocts roqulrlng covorago vlth llno pll-
ablo tlssuo.
1519
1ho luturo ol porlorator llaps may
llo ln tho cllnlcal appllcatlon ol anglosomos
20
and
tho croatlon ol lroo-stylo lroo llaps ln vhlch a
porlorator locallzod by Dopplor slgnal can bo tho
basls lor a skln llap ln any anatomlc roglon.
2125
VASCULAR ANATOMY OF THE SKIN
Arterial Anatomy
ln 1889 Manchot
26
doscrlbod cutanoous vascu-
lar torrltorlos. 1n 1964 Soltchlk and lahn
27
stud-
lod tho anatomy ol tho lntrlnslc clrculatlon ol tho
skln and obsorvod that artorlal branchos ponotrato
tho suporllclal layor ol tho suporllclal lascla and
|oln a subdormal ploxus ol artorlos tormlnatlng ln
skln caplllarlos. 1ho vonous dralnago systom paral-
lolod tho artorlal systom. Spaltoholz
28
ln 1893 dom-
onstratod anatomlcally that tho clrculatlon to tho
skln vla subdormal and dormal ploxusos could bo
PRINCIPLES OF FLAPS
Amanda A Gosman MD
2
lod by olthor dlroct or lndlroct branchos lrom an
undorlylng sourco vossol
29
(llg 2).
1aylor and lalmor
20
proposo tvo thoorlos ol tho
blood supply to tlssuos. 1ho llrst dollnos tho
angiosome vhlch ls a composlto unlt ol skln and lts
undorlylng doop tlssuo suppllod by a sourco artory.
1ho socond dollnos tho routos by vhlch tho lntogu-
mont ls suppllod by that sourco artory. 1ho direct
routo oncompassos vossols that aro prlmarlly
dlroctod tovards tho skln, vhothor thoy lollov tho
lntormuscular soptum or plorco tho musclo. 1ho
indirect routo constltutos vossols vhoso maln sup-
ply ls olthor to musclo or anothor doop tlssuo and
only socondarlly supply tho skln. 1ho lollovlng
romarks aro basod on tho rosults ol tholr study.
1. 1ho blood supply ol tho body coursos vlthln
or ad|acont to tho connoctlvo tlssuo lramovork,
vhothor lt ls bono, sopta or lascla.
2. 1ho vossols courso lrom llxod locl to mobllo
aroas.
3. 1ho vascular outllov ls a contlnuous systom
ol artorlos llnkod prodomlnantly by roducod callbor
vossols, lo, tho choko artorlos and artorlolos.
4. 1ho body ls a throo-dlmonslonal |lgsav mado
up ol composlto blocks ol tlssuo suppllod by namod
sourco artorlos. 1ho artorlos supplylng thoso blocks
ol tlssuo aro rosponslblo lor tho supply ol tho skln
and tho undorlylng structuros. 1hoso composlto
unlts vo havo namod ANGIOSOMES.
1aylor and lalmor (1987)
1aylor and lalmor
20
doscrlbod 40 anglosomos
(llg 3) that aro llnkod to oach othor by truo anas-
tomotlc artorlos ol slmllar callbor or roducod call-
bor choko anastomotlc vossols.
30
1ho choko vos-
sols can potontlally dllato to tho callbor ol a truo
anastomosls altor surglcal dolay or vlth a docroaso
ln sympathotlc tono. 1ho anglosomo thoory has
moro rocontly boon appllod ln dotallod anatomlc
lnvostlgatlons ol tho loroarm, lovor oxtromlty, and
hoad and nock.
3133
Although many lmportant
Fig 1. 1ho ovolutlon ol tho ultrathln porlorator-basod llap.
(Reprinted with permission from Hallock GG: Discussion of A
microdissected thin tensor fasciae latae perforator flap by N
Kimura. Plast Reconstr Surg 109:78, 2002.)
Fig 2. 1ho cutanoous clrculatlon. (Reprinted with permission
from Daniel RK, Kerrigan CL: Principles and Physiology of Skin Flap
Surgery. In: McCarthy JG (ed), Plastic Surgery. Philadelphia,
Saunders, 1990. Vol 1, Ch 9.)
3
roglonal dllloroncos voro ldontlllod, tho authors
conllrmod that ln most casos connoctlons botvoon
ad|acont anglosomos occurrod vlthln tlssuos and
not botvoon thom.
McCrogor
34
acknovlodgos that 1aylor and
lalmors llndlngs havo practlcal appllcatlon ln tho
doslgn ol skln llaps, but stross tho llmltatlons ln tholr
concluslons duo to tho statlc naturo ol tho spocl-
mons usod. 1o dotormlno skln porluslon pattorns,
McCrogor porlormod lntraartorlal lluoroscoln
ln|octlon studlos on 23 patlonts undorgolng abdoml-
nal roductlon. ln 78.3 ol patlonts tho dlstrlbutlon
ol lluoroscoln vas ovor a much smallor roglon than
vould bo oxpoctod lrom 1aylor and lalmors study.
McCrogor notos that unllko tho 1aylor ln|octlons,
vhlch voro porlormod ln lrosh cadavors, hls study
vas porlormod ln llvlng patlonts vhoso vascular
roslstanco ls physlologlc rathor than anatomlc. Ho
also lound that tho vatorshod botvoon ad|acont
torrltorlos doos not corrospond to tho choko artor-
los doscrlbod at tho porlphory ol tho anglosomo,
and suggostod that tho torm choko artory bo aban-
donod.
Naka|lma
35
concoptuallzod tho vascular supply
to tho skln as an opllasclal vascular notvork vhlch
ls lod by dllloront conllguratlons ol lnllov vossols.
1ho notvork ls prosont throughout tho subcutan-
oous layor botvoon tho subdormal ploxus and tho
doop lascla. 1ho archltocturo ol thls notvork var-
los accordlng to anatomlc roglon but, llko tho sub-
dormal ploxus, lt oxtonds throughout tho body as a
contlnuous systom. 1hls opllasclal vascular notvork
ls prosont throughout tho suporllclal lascla and ls
callod tho lasclocutanoous ploxus.
Naka|lma
35
ldontlllod slx vossol typos that por-
lorato tho doop lascla to supply tho lasclocutanoous
ploxus. A) dlroct cutanoous, ) dlroct sopto-
cutanoous, C) dlroct cutanoous branch ol muscu-
lar vossol, D) porloratlng cutanoous branch ol mus-
cular vossol, L) soptocutanoous porlorator, l) mus-
culocutanoous porlorator (llg 4). 1ypos A and
arlso lrom tho sourco vossol and supply a largo
axlal torrltory abovo tho doop lascla. 1ypos C and
D arlso lrom tho muscular vossol and supply tho
lasclocutanoous ploxus and skln axlally ovor tho
musclo. 1ypos L and l arborlzo undor, ln, and
abovo tho doop lascla. 1hoso porlorators supply a
small vascular torrltory and cannot support axlal
skln pattorns.
Fig 3. 1ho anglosomos ol tho sourco artorlos ol tho body. 1hoy
aro. (1) thyrold, (2) laclal, (3) buccal, (4) ophthalmlc, (5)
suporllclal tomporal, (6) occlpltal, (7) doop corvlcal, (8) trans-
vorso corvlcal, (9) acromlothoraclc, (10) suprascapular, (11)
postorlor clrcumllox humoral, (12) clrcumllox scapular, (13)
prolunda brachll, (14) brachlal, (15) ulnar, (16) radlal, (17)
postorlor lntorcostals, (18) lumbar, (19) suporlor glutoal, (20)
lnlorlor glutoal, (21) prolunda lomorls, (22) poplltoal, (22a)
doscondln gonlculato (saphonous), (23) sural, (24) poronoal,
(25) latoral plantar, (26) antorlor tlblal, (27) latoral lomoral
clrcumllox, (28) adductor (prolunda), (29) modlal plantar, (30)
postorlor tlblal, (31) suporllclal lomoral, (32) common lomoral,
(33), doop clrcumllox lllac, (34) doop lnlorlor oplgastrlc, (35)
lntornal thoraclc, (36) latoral thoraclc, (37) thoracodorsal, (38)
postorlor lntorossoous, (39) antorlor lntorossoous, (40) lntornal
pudondal. (Reprinted with permission from Taylor GI, Palmer JH:
The vascular territories (angiosomes) of the body: experimental
study and clinical applications. Br J Plast Surg 40:113, 1987.)
4
Naka|lma and coauthors
36
studlod tho 3-
dlmonslonal structuro ol tho blood supply to tho
skln and subcutanoous tlssuo. Computor lmagos ol
anglograms porlormod on 28 sogmontal artorlos ol
tho body voro analyzod accordlng to tho tlssuo
layor ln vhlch thoy voro domlnant (vhothor dor-
mal, suporllclal, or doop adlpolasclal layors), tholr
axlallty, and tholr slzo. Altor porloratlng tho doop
lascla, tho artorlos voro asslgnod to ono ol slx dll-
loront typos (llg 5). 1ho artorlos voro locallzod on
a vholo body map and tho rolatlonshlp botvoon
tho typo ol artory and tho moblllty ol tho tlssuo lt
suppllod vas consldorod.
Naka|lmas slx typos ol artorlal conllguratlon
ovolvod lrom hls provlous porlorator classlllcatlon.
35
1ypos l and ll aro contlnuatlons ol dlroct cutanoous
and dlroct soptocutanoous porlorators (1ypos A and
), rospoctlvoly. 1ypos l and ll aro mobllo vascular
typos that shov axlallty and aro locatod ln tho doop
adlpolasclal layor. 1ypos lll and lV aro porlphoral
contlnuatlons ol olthor tho dlroct cutanoous branch
or porloratlng cutanoous branch ol a muscular vossol
(1ypos C and D). 1ypos ll and lV aro ol modlum slzo
and ol modorato axlallty, but havo dlvorglng branch
polnts. 1ypo lll ls domlnant ln tho doop adlpolasclal
layor and lV ls domlnant ln tho suporllclal layor,
rosultlng ln a roclprocal rolatlonshlp. 1ypos V and Vl
(1ypos L and l) aro llxod vascular typos ol llttlo axlal-
lty and aro contlnuatlons ol small soptocutanoous
and musculocutanoous porlorators, rospoctlvoly (llg
6). ln tho torso typos l, lll, and lV aro locallzod ln tho
Fig 4. Slx pattorns ol blood supply to tho lasclocutanoous ploxus. A, dlroct cutanoous vossol, , dlroct soptocutanoous vossol, C, dlroct
cutanoous branch ol muscular vossol, D, porloratlng cutanoous branch ol muscular vossol, L, soptocutanoous porlorator, l,
musculocutanoous porlorator. (Reprinted with permission from 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 16:1, 1986.)
Fig 5. Slx typos ol 3-dlmonslonal artorlal structuro. Soo toxt
lor dotalls. (Reprinted with permission from Nakajima H,
Minabe T, Imanishi N: Three-dimensional analysis and classi-
fication of arteries in the skin and subcutaneous adipofascial
tissue by computer graphics imaging. Plast Reconstr Surg
102:748, 1998.)
5
mobllo tlssuo at or around |olnts. 1ypo Vl vossols aro
moro common ln llxod skln aroas, such as tho contor
ol tho back. 1ypos ll, V, and Vl aro domlnant ln tho
oxtromltlos. 1ypo ll accompanlos cutanoous norvos
and volns that run ln tho doop adlpolasclal layor. lt ls
lmportant to knov tho subcutanoous dopth ol a
podlclos ploxus vhon olovatlng thln llaps and
adlpolasclal llaps.
Zhong and covorkors
38
classlllod tho vonous
archltocturo ol tho skln and subcutanoous tlssuo
lnto lour suporlmposod layors that aro dralnod by
tvo largo vonous trunks, a suporllclal and a doop
(llg 8). 1ho suporllclal vonous trunks aro locatod ln
tho subcutanoous tlssuo and do not accompany
artorlos. 1ho doop vonous trunks aro tho vonao
comltantos ol tho sourco artory. 1ho authors pro-
poso that tho maln vonous dralnago ol an anatomlc
roglon can bo prlmarlly vla tho doop vonous trunk,
tho suporllclal vonous trunk, or both.
lmanlshl and othors
3941
doscrlbod tho vonous
dralnago ol tho skln and subcutanoous tlssuo ol tho
loroarm, scapular roglon, and tomporal and parlotal
roglons. A slmllar pathvay ol vonous dralnago vas
ldontlllod ln oach anatomlc roglon. Small opldor-
mal and dormal branchos voro colloctod lnto a
suporllclal polygonal vonous notvork locatod ln tho
doop dormls or suporllclal adlpolaclal layor. Cstoal
valvos voro ldontlllod at tho anatomosls ol tho llrst
dralnlng dormal branchos and tho polygonal vonous
notvork to roslst rollux. Dormal blood can pool ln
tho polygonal notvork, vhlch has a varlablo dlstrl-
butlon ol valvos dopondlng on anatomlc roglon,
Fig 6. Classlllcatlon ol lasclocutanoous llaps. A, 1ypo l ls
suppllod by tho dlroct cutanoous vossol. , 1ypo ll ls suppllod
by tho dlroct soptocutanoous vossol. C, 1ypo lll ls suppllod by
tho dlroct cutanoous branch ol tho muscular vossol. D, 1ypo
lV ls suppllod by tho porloratlng cutanoous branch ol tho
muscular vossols. L, 1ypo V ls suppllod by tho soptocutanoous
porlorator. l, 1ypo Vl ls suppllod by tho musculocutanoous
porlorator. (Reprinted with permission from 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 16:1, 1986.)
Venous Anatomy
1horo aro tvo systoms ol vonous dralnago ol tho
skln and subcutanoous tlssuo. 1aylor and col-
loaguos
37
studlod tho vonous torrltorlos (vonosomos)
ol tho body and shovod that tho cutanoous vonous
ploxus ls composod ol valvular suporllclal and doop
cutanoous volns that parallol tho courso ol ad|acont
artorlos, and ol osclllatlng avalvular volns that por-
mlt bldlroctlonal llov botvoon ad|acont vonous tor-
rltorlos (llg 7).
Fig 7. Above, 1ho suporllclal (S) and doop (D) vonous systoms ln
an oxtromlty. A largo vona communlcans (C) connocts thoso
systoms, and tho altornatlvo pathvays ol lour vonao comltantos
aro shovn. Below, Cthor roglons vhoro tho prodomlnant
vonous dralnago ls by moans ol tho vonao comltantos. (Reprinted
with permission from Taylor GI, Caddy CM, Watterson PA, Crock
JG: The venous territories (venosomes) of the human body:
experimental study and clinical implications. Plast Reconstr Surg
86:185, 1990.)
6
and vhlch ovontually dralns lnto largo cutanoous
volns. 1ho authors dlstlngulsh botvoon a superfi-
cial vein that ls locatod abovo tho doop lascla and a
cutaneous vein that ls suporllclal and doos not
accompany an artory.
41
Cutanoous vonous trunks
aro tho prlmary dralnago ol tho dormls and aro
connoctod by varlous communlcatlng branchos to
tho vonao comltantos ol tho sourco artory (llg 9).
sourco artory (og, suporllclal tomporal artory and
voln), thoso parallol branchos may actually
bocomo tho vonao comtantos to tho sourco
artory
41
and to tho small artorlos that supply tho
cutanoous voln (og, lossor saphonous and copha-
llc).
39,42
1ho small artorlos corrospond to tho
Naka|lma typo ll and aro tho sourco ol vono-
cutanoous porlorators to tho skln. 1hoy aro an
lmportant bypass to tho unldlroctlonal valvos ol
tho cutanoous volns and pormlt rotrogrado llov
ln dlstally basod llaps.
42
llnal and 1aylor
43
doscrlbod macrovonous and
mlcrovonous systoms that bypass tho valvos ol tho
vonao comltantos and pormlt rovorsal ol llov.
Mul tl pl o vonous anastomotl c connoctl ons
adoquatoly draln most dormal roglons vla olthor
tho cutanoous voln or tho vonao comltantos ol tho
sourco artory.
FLAP CLASSIFICATION
llap classlllcatlons aro multlplo and vary
accordlng to tho organlzlng prlnclplo. Classlllca-
tlon schomos havo hlstorlcally boon vory conlus-
lng bocauso thoy voro basod on an lncomploto
undorstandlng ol llap vascularlty. As our knovl-
odgo ol tho vascular anatomy ol skln, subcutano-
ous tlssuo, and musclo lncroasod, nov llap typos
voro dovolopod and classlllcatlons voro proposod
that voro lroquontly lncongruont vlth provlous
systoms and vlth ono anothor. llaps usod to bo
classlllod accordlng to tholr mothod ol movo-
mont.
44
Local skln llaps aro stlll doscrlbod by thls
tormlnology. Whon dlstant podlclod llaps bocamo
commonplaco,
3
thoy voro labolod as local or dls-
tant dopondlng on tholr proxlmlty to tho donor
Fig 8. 1ho vonous archltocturo ol skln llaps.
(Reprinted with permission from Zhong SZ,
Wang GY, Yuan L, Xu DC: Anatomic basis of
venous drainage in donor flaps. Surg Radiol
Anat 16:349, 1994.)
Fig 9. lolygonal vonous notvork ol tho loroarm. (1) Largo
ascondlng voln. (2) Small ascondlng voln that anastomosod vlth
tho vonous notvork. (3) Small ascondlng voln that anastomosod
vlth ascondlng vossols lrom tho vonous notvork. (4) Anastomosls
ol tho long voln vlth tho cophallc voln. (5 and 6) ranchos that
anastomosod small ascondlng vossols lrom tho vonous notvork
and vonao comltantos ol tho radlal artory. ACV, accossory
cophallc voln, CV, cophallc voln, kV, radlal voln (vonao
comltantos). (Reprinted with permission from Imanishi N, Nakajima
H, Aiso S: Anatomical study of the venous drainage architecture
of the scapular skin and subcutaneous tissue. Plast Reconstr Surg
108:656, 2001.)
otvoon tho cutanoous volns and tho vonao
comltantos aro thln parallol branchos ol tho
cutanoous volns that play cllnlcally lmportant rolos.
ln aroas such as tho laco, vhoro tho courso ol tho
namod voln dlvorgos slgnlllcantly lrom tho namod
7
and roclplont sltos. Subsoquontly llaps voro cat-
ogorlzod by tholr tlssuo composltlon. musclo,
skl n, muscul ocut anoous, l ascl ocut anoous,
soptocutanous, and compound llaps. 1hls classl-
llcatlon systom can bo conluslng bocauso dlllor-
ont llaps basod on dllloront blood suppllos but ol
tho samo composltlon can bo harvostod lrom tho
samo roglon.
1ho lntrlnslc blood supply ol a llap ls tho most
crltlcal dotormlnant ol succosslul translor and ls
thoroloro tho most cllnlcally valld mothod ol clas-
slllcatlon. Numorous anatomlc studlos ol tho
blood supply to tho skln and lascla havo contrlb-
utod to our undorstandlng and lod to a slmplor
classlllcatlon ol cutanoous llaps.
15,20,25,3133,3542,45,46
Unlortunatoly, tho slmpllllod tormlnology doos
not oxtond to all llap typos. lor oxamplo, tho
lasclocutanoous llap that vas orlglnally dollnod
by tho prosonco ol doop lascla ls nov classlllod
accordlng to tho pattorn ol cutanoous vascularlty
through tho lasclocutanous ploxus, and lroquontly
doos not lncludo lascla. A lasclocutanoous llap
can bo any llap basod on tho lasclocutanoous
ploxus and composod ol any or all ol tho compo-
nont layors botvoon tho skln and doop lascla.
25
1ho nov tormlnology ol porlorator and vonous
llaps also rollocts tho trond tovard vascularlty-
basod nomonclaturo, and currontly a conluslng
comblnatlon ol old and nov llap tormlnology
cooxlsts.
Danlol and lorrlgan
29
groupod llaps lnto throo
catogorlos accordlng to tholr mothod ol movomont,
composltlon, and vascularlty. ln our dlscusslon ol
spoclllc llaps vo havo comblnod tho lattor tvo crl-
torla bocauso thoy ovorlap vlth oldor tormlnology
basod on composltlon tormlnology. Spoclllc classl-
llcatlons vlthln oach ol thoso llap typos vlll also bo
dlscussod.
Method of Movement
Skln llaps can bo groupod accordlng to tho
tochnlquo usod to translor tho tlssuo and tho dls-
tanco botvoon tho donor and roclplont sltos.
Local skln llaps aro usod to closo dolocts ad|acont
to tho donor slto, and aro ln turn classlllod basod
on tholr mothod ol movomont lnto llaps that
advanco lrom tho baso ln tho samo dlroctlon as
tho long axls ol tho llap (V-, -V, slnglo-podlclo,
and blpodlclo llaps) and llaps that plvot on a polnt
(rotatlon, transposltlon, and lntorpolatlon llaps).
Dlstant llaps uso donor tlssuo lrom sltos that aro
not ad|acont to tho roclplont bod, and can bo
groupod lnto dlroct llaps, tubo llaps, and lroo
llaps.
29,47,48
Advancement flaps aro slld dlroctly lorvard lnto
a doloct slmply by strotchlng tho skln, vlthout any
rotatlon or latoral movomont.
47
1ho slmplost
oxamplo ol thls typo ol movomont ls dlroct vound
closuro. Varlatlons aro tho slnglo- and doublo-
podlclo advancomont, V- advancomont (llg 10),
and lts opposlto, tho -V advancomont llap. Suzukl
and colloaguos
49
proposo a varlatlon ol tho tradl-
tlonal V--plasty ln vhlch tho urovs trlanglos aro
advancod rathor than oxclsod.
Fig 10. A, roctangular advancomont llap. , V- advancomont
llap. (Reprinted with permission from Smith JW, Aston SJ (eds),
Grabb and Smiths Plastic Surgery, 4th ed. Boston, Little Brown,
1991.)
Rotation flaps aro somlclrcular ln doslgn and
rotato about a plvot polnt lnto tho doloct to bo
closod (llg 11). 1ho donor slto can bo closod by a
skln gralt or by dlroct suturo ol tho vound. 1o
lacllltato rotatlon ol tho llap along lts arc, tho baso
can bo back-cut at tho plvot polnt or a trlanglo ol
skln (urovs trlanglo) can bo romovod oxtornal to
tho plvot polnt.
8
Fig 11. kotatlon llap. (Reprinted with permission from Smith JW,
Aston SJ (eds), Grabb and Smiths Plastic Surgery, 4th ed. Boston,
Little Brown, 1991.)
A transposition flap ls a (usually roctangular) llap
that ls rotatod (latorally) about a plvot polnt lnto an
lmmodlatoly ad|acont doloct. ocauso tho olloc-
tlvo longth ol tho llap bocomos shortor tho larthor
tho llap ls rotatod, tho llap must bo doslgnod longor
than tho doloct to bo covorod, othorvlso a back-
cut may bo nocossary (llg 12). 1ho llap donor slto
can bo closod by skln gralt, dlroct suturo, or soc-
ondary llapog, bllobod llap (llg 13).
A varlatlon ol tho transposltlon llap ls tho Z-plasty
tochnlquo ln vhlch tvo trlangular llaps aro rovorsod
and rotatod 90. 1ho throo llmbs ol tho Z must bo
ol oqual longth and tho latoral llmb to contral llmb
anglos should bo oqulvalont. 1ho galn ln longth ls
rolatod to tho anglo botvoon tho contral and latoral
llmbs (1ablo 1).
50
1ho 60 Z-plasty ls most olloctlvo
bocauso lt longthons tho contral llmb vlthout plac-
lng too much tonslon latorally (llg 14).
lurnas and llschor
51
ostlmato that tho actual galn
ln contral llmb longth ls 5584 ol prodlctod and
varlos vlth local skln tonslon. Soyhan
52
oxploros tho
goomotry ol Z-plastlos and romlnds us that a slnglo
largo Z-plasty ls moro olloctlvo than multlplo smallor
onos lor longthonlng tho skln ln a doslrod locatlon.
Fig 12. 1ransposltlon llap. 1ho llap bocomos shortor as lt plvots
and should bo doslgnod largor than tho doloct. A back-cut may
bo noodod to oaso tonslon at tho baso. (Reprinted with permission
from Smith JW, Aston SJ (eds), Grabb and Smiths Plastic Surgery,
4th ed. Boston, Little Brown, 1991; and Lamberty BGH, Healy
C: Flaps: physiology, principles of design, and pitfalls. In: Cohen
M (ed), Mastery of Plastic and Reconstructive Surgery. Boston,
Little Brown, 1994.)
Fig 13. 1ho bllobod llap. (Reprinted with permission from Jackson
IT: Local Flaps in Head and Neck Reconstruction. St Louis,
Mosby, 1985.)
9
1ho rhombold (Llmborg) llap ls anothor trans-
posltlon llap charactorlzod by lts goomotrlc pat-
torn. 1ho longltudlnal axls ol tho rhombold oxcl-
slon parallols tho llno ol mlnlmal skln tonslon.
lour dllloront rhombold llaps can bo doslgnod
vhon 60 anglos aro usod (llg 15). 1hls concopt
can bo oxpandod to croato a doublo or ovon a
trlplo rhombold llap, tho donor sltos ol tho llap
aro closod by dlroct suturo.
53
1ho Dulourmontol llap ls slmllar to tho rhombold
llap oxcopt that lt can bo dravn vlth anglos ol up to
90.
losor and colloaguos
54
doscrlbod a curvlllnoar
modlllcatlon ol tho classlcal transposltlon llap. 1holr
varlant has doublo opposlng somlclrcular llaps and
ls usod to closo clrcular dolocts (llg 16).
TABLE 1
Theoretical gain in length of the central limb
with various angles in Z-plasty.
(Reprinted with permission from Rohrich RJ, Zbar RIS: A simplified
algorithm for the use of Z-plasty. Plast Reconstr Surg 103:1513,
1999.)
Fig 14. Z-plasty. (Reprinted with permission from Smith JW,
Aston SJ (eds), Grabb and Smiths Plastic Surgery, 4th ed.
Boston, Little Brown, 1991.)
Fig 15. 1ho rhombold (Llmborg) llap. (Reprinted with permission
from Smith JW, Aston SJ (eds), Grabb and Smiths Plastic Surgery,
4th ed. Boston, Little Brown, 1991.)
Fig 16. Doublo opposlng somlclrcular llaps. Altor olovatlng
tho llaps and undormlnlng tho ad|acont tlssuo, llap A ls
transposod vlth llap and llap A vlth llap . 1ho anglos
ol A and A llaps aro suturod to tho marks at x and x, and
and llaps to D and D, rospoctlvoly. (Reprinted with
permission from Keser A, Sensoz O, Mengi AS: Double
opposing semicircular flap: a modification of opposing Z-
plasty for closing circular defects. Plast Reconstr Surg 102:1001,
1998.)
10
Interpolation flaps rotato on a plvot polnt lnto a
doloct that ls noar but not ad|acont to tho donor
slto, so that tho llap podlclo must pass ovor or undor
tho lntorvonlng tlssuo. Lxamplos ol lntorpolatlon
llaps aro tho doltopoctoral (akam|lan) llap, lsland
llaps such as tho Llttlor nourovascular dlgltal pulp
llap (llg 17), and subcutanoous-podlclo llaps.
Fig 17. 1ho nourovascular lsland llap (Llttlor). (Reprinted with
permission from Daniel RK, Kerrigan CL: Principles and physiology
of skin flap surgery. In: McCarthy JG (ed), Plastic Surgery.
Philadelphia, Saunders, 1990. Vol 1, Ch 9, p 305.)
Distant flaps lmply that tho donor and roclplont
sltos aro not ln closo proxlmlty to oach othor.
Lxamplos lncludo dlroct llaps (not to bo conlusod
vlth dlroct cutanoous) such as tho thonar, cross-log,
and groln llaps. Whon tho tvo sltos cannot bo
approxlmatod, tubo llaps
55
(llg 18) or mlcrovascu-
lar lroo tlssuo translors aro lndlcatod.
Free Tissue Transfer
ln 1963 Coldvyn and colloaguos
56
roportod tho
llrst succosslul lroo llap translor vhon thoy olovatod
an lsland podlclod llap lrom tho groln ol dogs and
subsoquontly dlvldod tho podlclo and roplacod tho
llap ln lts orlglnal slto vlth mlcrovascular anasto-
mosos. Sovoral roports ol lroo llap roconstructlon
lollovod ln short ordor. Cllnlcal mlcrosurgory has
oxporloncod a rapld oxpanslon slnco lts boglnnlng
ln tho oarly 1970s. Succoss ratos ol mlcrovascular
procoduros ls voll ovor 90 ln most sorlos.
57
lor a
dotallod ovorvlov ol mlcrosurgory and lroo tlssuo
translor, ploaso rolor to tho Selected Readings lssuo
on thls toplc.
Fig 18. 1ho clavlcular tubod llap. (Reprinted with permission
from Mendelson BC, Masson JK: Cervical and clavicular tubed skin
flaps. In: Strauch B, Vasconez LO, Hall-Findlay EJ (eds), Grabbs
Encyclopedia of Flaps. Boston, Little Brown, 1990. Vol 1, Ch 42.)
11
Tissue Composition and Vascularity
Cutaneous Flaps
McCrogor and Morgan
59
catogorlzod llaps as ran-
dom or axlal. kandom llaps aro basod on tho sub-
dormal ploxus vhlch ls suppllod by dlroct cutano-
ous, musculocutanoous, or lasclocutanoous vossols.
1
kandom llaps aro tradltlonally llmltod to 3.1 longth-
to-vldth ratlos, and may roqulro multlplo dolays to
bo translorrod to a dlstant slto. Mllton
60
challongod
tho rolovanco ol longth-to-vldth ratlos and accu-
ratoly arguod that tho survlval ol a skln llap doponds
ontlroly on lts moans ol vascularlzatlon.
Axlal pattorn llaps contaln a spoclllc dlroct cuta-
noous artory vlthln tho longltudlnal axls ol tho llap.
An lsland llap ls an axlal pattorn llap that ls ralsod on
a podlclo dovold ol skln to lacllltato dlstant translor.
61
Slnco tho vascular anatomy ol lasclocutanoous por-
lorators vas dotallod, a classlllcatlon systom that can
bo appllod to all cutanoous llaps has boon dovlsod.
35,62
Cormack and Lamborty
1,63
stato that skln llaps
can bo classlllod as dlroct cutanoous, musculocuta-
noous, or lasclocutanoous accordlng to tholr ana-
tomlc systom ol vascularlzatlon, not tholr tlssuo com-
pononts. All skln llaps aro basod on tho lasclo-
cutanoous ploxus, vhlch lncludos tho lntorcon-
noctod componont parts ol tho sublasclal,
lntralasclal, and supralaclal vascular ploxusos
oncompasslng tho dormal, subdormal, suporllclal,
and doop adlposlasclal layors.
35,36,64
1ho lasclo-
cutanoous ploxus ls suppllod lrom porloratlng vos-
sols that ponotrato tho doop lascla olthor dlroctly,
through musclo, or botvoon musclos. Hallock
25
dollnos a porlorator as any vossol that ontors tho
supralasclal plano through a lonostratlon ln tho doop
lascla, rogardloss ol orlgln. llaps basod on lsolatod
porlorator(s) aro dollnod as porlorator llaps.
65,66
Naka|lma
35
classlllod skln llaps lnto llvo typos
accordlng to tholr vascularlzatlon. cutanoous,
lasclocutanoous, adlpolasclal, soptocutanoous, and
musculocutanoous (1ablo 2). All skln llaps aro sup-
pllod by porloratlng vossols to tho lasclocutanoous
ploxus. lasclocutanoous llaps voro lurthor groupod
lnto slx typos basod on tho slx pattorns ol doop
lasclal porlorators (soo llg 6). Naka|lmas dollnltlon
ol a dlroct cutanoous porlorator ls oqulvalont to tho
axlal vossol ol McCrogor and Morgan.
59
Mathos
and Nahal
67
dollnod lasclocutanoous llaps as thoso
suppllod by a dlroct cutanoous podlclo, sopto-
cutanoous podlclo, or musculocutanoous podlclo.
Naka|lma
36
analyzod and classlllod tho 3-dlmon-
slonal structuro ol tho skln and adlpolasclal tlssuo
lnto slx typos and doscrlbod tholr corrospondlng
llap appllcatlons ln a study that ls bocomlng
lncroaslngly rolovant lrom a cllnlcal standpolnt.
1aylor and lalmor
20
stato that cutanoous artorlos
contrlbutlng to an anglosomo can arlso directly lrom
tho undorlylng sourco vossol to provldo tho prlmary
cutanoous supply, or indirectly lrom tho branchos
ol tho sourco artory to doopor structuros.
20,30
Hallock
25
dlllorontlatos dlroct and lndlroct porlora-
tors basod on tho structuros that thoy travorso prlor
to plorclng tho doop lascla. Direct perforators plorco
tho doop lascla vlthout havlng travorsod any doopor
structuros. Indirect perforators pass through doopor
tlssuos, usually musclo or soptum, boloro ontorlng
tho doop lascla. Hallock
25
appllod thls concopt to
tho classlllcatlon ol doop lasclal porlorators pro-
posod by Naka|lma
35
vhoroby all cutanoous llaps
could bo doslgnatod as olthor direct or indirect
porlorator llaps (llg 19).
Perforator Flaps
y tho oarly 1980s, mlcrosurglcal tochnlquos had
boon succosslully lntogratod lnto tho practlco ol
roconstructlvo surgory and thoro vas a quost to
dlscovor nov donor llaps that vould bo rollablo,
thln, tochnlcally oasy to ralso and translor, and that
vould produco mlnlmal donor slto morbldlty. lor-
lorator llaps and tho loss-succosslul artorlallzod
vonous llaps ovolvod lrom thoso ollorts.
23,68
ln Chlna
and }apan tho llrst porlorator llaps voro dovolopod
lor hoad and nock roconstructlon and burn scar
contracturos. ln 1984 Song ot al
5
roportod tho lroo
thlgh llap, vhlch lncludod a doscrlptlon ol tho
antorolatoral thlgh llap, tho andromoda thlgh llap,
and tho postorlor thlgh llap. Lach llap vas doslgnod
ovor a soptocutanoous porlorator ol tho sourco vos-
sol, vhlch vas dlssoctod rotrogrado. ln 1989
loshlma and Sooda
6
roportod tho succosslul trans-
lor ol an lnlorlor oplgastrlc artory skln llap basod on
a roctus abdomlnls porlorator to a groln vound
(lsland) and to tho lloor ol mouth. Allon and 1rooco
7
and londool
8
roportod tho ultlmato musclo-spar-
lng 1kAM llap vhon thoy publlshod tholr succosslul
sorlos ol broast roconstructlons vlth tho doop lnlo-
rlor oplgastrlc porlorator llap. Clutoal artory porlo-
rator llaps voro llrst ralsod as podlclod llaps by
12
loshlma
69
lor tho ropalr ol sacral vounds, and lator
by Allon and 1uckor
10
as lroo llaps lor broast rocon-
structlon. Angrlglanl ot al
9
dovolopod tho latlssl-
mus dorsl musculocutanoous llap vlthout tho
musclo, a llap ol skln and subcutanoous tlssuo basod
on a thoracodorsal artory porlorator.
1ho lntroductlon ol porlorator llaps ushorod ln an
ora ol sophlstlcatlon and rollnomont ln roconstruc-
tlvo mlcrosurgory. 1ho omphasls shlltod lrom trylng
to onsuro lroo llap survlval to prosorvlng musclo lunc-
tlon, produclng mlnlmal donor slto morbldlty, and
doslgnlng llaps that aro hlghly vorsatllo and can bo
tallorod to tho spoclllc doloct. Cur undorstandlng ol
cutanoous vascularlty and porlorator anatomy has
grovn tromondously ln tho past 10 yoars. lorlorator
llaps aro typlcally composod ol skln and subcutan-
oous tlssuo suppllod by a doop lasclal porloratlng
vossol. lorlorator llaps allov tho surgoon to rocon-
struct body parts vlth tho samo tlssuos that aro most
lroquontly mlsslng. skln and subcutanoous lat.
lotontlal llap donor sltos aro numorous, and many
also havo tho capaclty to lncorporato musclo, lat,
and bono lnto tho llap doslgn.
(Reprinted with permission from 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 16:1, 1986.)
TABLE 2
Classification of Skin Flaps
Fig 19. Modlllcatlon ol Naka|lmas pattorn ol doop lascla
porlorators. (Reprinted with permission from Hallock GG: Direct
and indirect perforator flaps: the history and the controversy. Plast
Reconstr Surg 111:855, 2003.)
13
1ho lllth (Cont, olglum, 2001) and Slxth lntor-
natlonal Courso on lorlorator llaps (1alpol, 1al-
van, 2002) voro hold ln rosponso to tho rapld
ovolutlon ol porlorator llaps and conluslon rogard-
lng tholr tormlnology.
65
1ho consonsus dollnltlon
ol a porlorator llap ln 2002 vas a llap conslstlng ol
skln or subcutanoous lat. 1ho vossols that supply
blood to tho llap aro lsolatod porlorator(s). 1hoso
porlorators may pass lrom tholr sourco vossol orlgln
olthor through or ln botvoon tho doop tlssuos
(mostly musclo).
65
1hroo dllloront klnds ol porlo-
rator vossols voro rocognlzod. 1) lndlroct musclo
porlorators, 2) lndlroct soptal porlorators, and 3)
dlroct cutanoous porlorators
65
(llg 20). 1ho lndl-
roct musclo and soptal porlorators glvo rlso to mus-
culocutanoous and soptocutanoous porlorator llaps,
rospoctlvoly.
Fig 20. Slmpllllod dollnltlons omorglng lrom tho 2002 Slxth
lntornatlonal Courso on lorlorator llaps. (1) lndlroct musclo or
musculocutanoous porlorators travorso musclo to plorco tho
outor layor ol tho doop lascla and supply tho skln. (2) lndlroct
soptal or soptocutanoous porlorators travorso through soptum
and supply tho skln altor plorclng tho outor layor ol tho doop
lascla. (3) Dlroct porlorators ponotrato tho doop lascla only.
(Reprinted with permission from Blondeel PN, Van Landuyt K,
Hamdi M, Monstrey SJ: Perforator flap terminology: update
2002. Clin Plast Surg 30:343, 2003.)
Wol
21
and othor purlsts
70,71
contlnuo to arguo
that a truo porlorator should only rolor to a mus-
cular porlorator, vhlch roqulros lntramuscular dls-
soctlon and vhlch should thoroloro havo a dlstlnct
ldontlty lrom tho moro oaslly dlssoctod soptal por-
lorator.
25,65,66
llaps such as tho groln llap that voro
provlously classlllod as olthor axlal, artorlal, or cuta-
noous aro nov moro accuratoly doscrlbod as dlroct
cutanoous porlorator llaps.
72
1o losson conluslon ovor spoclllc porlorator llap
nomonclaturo, a consonsus vas roachod at tho moot-
lng to namo oach porlorator llap altor tho nutrlont
vossol(s) and not tho undorlylng musclo.
65
ln aroas
vhoro multlplo porlorator llaps can bo ralsod lrom
a slnglo vossol, tho llap should bo namod altor lts
anatomlc roglon or musclo.
65
lor oxamplo, llaps
basod on tho latoral clrcumllox lomoral vossols aro
namod tho antorolatoral thlgh llap, tonsor lasclao
latao porlorator llap, and so on, accordlng to loca-
tlon or undorlylng musculaturo.
lorlorator llaps havo tho lollovlng advantagos.
73
prosorvo musclo lunctlon
produco mlnlmal donor slto morbldlty
roduco postoporatlvo rocovory tlmo and paln
modlcatlon roqulromonts
can bo doslgnod ol varylng slzos and thlcknossos
to lmprovo tho osthotlc rosult
Many studlos comparlng tho doop lnlorlor opl-
gastrlc (DlLl) llap and tho 1kAM llap lor broast
roconstructlon attost to tho postoporatlvo advan-
tagos ol musclo-sparlng llap harvost.
7480
lorlorator
llaps ovo tholr vorsatlllty to tho largo cutanoous
torrltorlos, long podlclos that pormlt convontlonal
and lroo translor, potontlal lor bolng harvostod as
compound or sonsato llaps, and ablllty to bo thlnnod
to tho subdormal ploxus.
14,16,18,19,71,8183
1hoso char-
actorlstlcs mako porlorator llaps ldoal solt-tlssuo unlts
lor roconstructlon ln aroas that roqulro thln, pllablo
tlssuo, such as tho hoad and nock and tho lovor
oxtromlty.
69,71,8287
1ho dlsadvantagos ol porlorator llaps aro 1) tho
tlmo-consumlng, motlculous dlssoctlon ol tho
podlclo, 2) varlatlon ln porlorator anatomy, slzo,
and locatlon, and 3) a hlghor rlsk ol lat nocrosls
comparod vlth musculocutanoous llaps.
80,82,83,8893
1hoorotlcally, a porlorator llap could bo doslgnod
ln oach ol tho cutanoous torrltorlos ol tho 374 porlo-
rators >0.5 mm ln dlamotor ldontlllod by 1aylor and
lalmor.
20,94
1ho most commonly usod porlorator
llaps aro tho doop lnlorlor oplgastrlc (DlLl) llap, tho
antorolatoral thlgh (AL1l) llap, tho suporlor glutoal
artory (SCAl) llap, and tho thoracodorsal artory (1Al)
llap. Many othor llaps havo boon doscrlbod but
havo not yot galnod tho popularlty ol tho DlLl and
tho AL1l llaps. 1o quallly as a potontlal donor sourco
ol porlorator llap, a slto must havo a rollablo blood
supply, ono or moro largo (>0.5 mm dlam) porlora-
tors, podlclos ol sulllclont longth, and (prolorably) bo
ablo to bo closod prlmarlly altor llap harvost.
1ho dovolopmont ol supormlcrosurglcal toch-
nlquos has lacllltatod tho harvost ol llaps basod on
smallor and shortor porlorators, such as tho paraum-
14
blllcal porlorator llap.
11,18
1ho lroo-stylo lroo llap
ls tho ultlmato appllcatlon ol tho anglosomo thoory
and supormlcrosurglcal tochnlquos.
2125
A cutan-
oous porlorator ls ldontlllod by Dopplor probo and
a llap ls doslgnod on tho skln torrltory. 1ho porlora-
tor ls usod lor tho anatomosls, vhlch ls porlormod
vlth supormlcrosurglcal tochnlquos that ollmlnato
tho nood lor todlous dlssoctlon ol tho sourco vossol.
1ho roador ls oncouragod to rovlov tho rolor-
oncos on porlorator llaps lndopondontly bocauso
an ln-dopth doscrlptlon ol spoclllc llaps ls boyond
tho scopo ol thls toxt.
Fasciocutaneous Flaps
ln 1981 lonton
95
doscrlbod a novol vay to ralso
a skln llap basod on tho vascular ploxus ol tho doop
lascla. Although lonton mado tho lnltlal cllnlcal
obsorvatlons, tho lnvostlgatlons ol tho anatomlcal
vascular basls lor tho succoss ol thoso suporllaps
vas subsoquontly accompllshod by Haortsch
96
ln
1981 and arclay ot al
97
ln 1982. 1olhurst and
colloaguos
98,99
conllrmod tho usolulnoss ol tho
lasclocutanoous llap and oxpandod tho concopt to
oncompass roconstructlon ln othor parts ol tho body.
Larly lnvostlgatlons lnto tho blood supply ol tho las-
cla
1,63,99103
roportod that tho lasclocutanoous sys-
tom conslsts ol porloratlng vossols that arlso lrom
roglonal artorlos and pass along tho llbrous sopta
botvoon musclo bolllos or musclo compartmonts.
1hls vascular ploxus ls locallzod to tho lovol ol tho
doop lascla, vhlch ln turn glvos oll branchos to tho
skln.
Cn tho basls ol anatomlc studlos, ln 1984
Cormack and Lamborty
63,100
classlllod lasclo-
cutanoous llaps accordlng to tholr vascular pattorns
(llg 21).
Type A ls a podlclod llap suppllod by multiple
lasclocutanoous porlorators at tho baso ol tho llap
and orlontod vlth tho long axls ol tho llap ln tho
prodomlnant dlroctlon ol tho artorlal ploxus at tho
lovol ol tho doop lascla. 1ho llap can bo proxlmally
or dlstally basod and tho skln can bo romovod to
croato an lsland llap. Lxamplo. lontons llap.
Type B ls basod on a single lasclocutanoous porlo-
rator ol modorato slzo vhlch ls conslstont ln both
lts prosonco and lts locatlon. lt may bo usod as
olthor a podlclod or lroo llap. Lxamplo. modlal arm
llap.
Type B modified ls stlll lod by a single porlorator
but dlllors ln that tho porlorator ls removed in con-
tinuity with the major vessel lrom vhlch lt arlsos.
lt ls lntondod lor uso as a lroo llap.
Type C llap supports lts skln by multiple small por-
lorators along lts longth ln a laddor typo conllgura-
tlon. 1hoso porlorators roach lt lrom a doop artory
by passlng along a lasclal soptum botvoon musclos.
lts maln uso ls as a lroo llap. Lxamplo. radlal
loroarm llap.
Type D conslsts ol an osteomusculofasciocutaneous
lroo tlssuo translor.
1ho lnvostlgatlon ol tho lasclal vascular anatomy
to dovolop llap classlllcatlon systoms contrlbutod
groatly to our undorstandlng ol porlorator and cuta-
noous blood supply. Lvontually lt bocamo ovldont
that lncluslon ol tho doop lascla vas not nocossary
lor tho survlval ol lasclocutanoous llaps,
20,98
although
somo authors advocatod lts prosorvatlon lor protoc-
tlon ol tho lasclal ploxus.
104
Naka|lma
35
doscrlbod
tho lasclocutanoous ploxus as a vascular notvork
that oxtondod lrom bolov tho doop lascla to tho
dormls and vas porlusod by doop lasclal porlorat-
lng vossols. Any llap basod on thls vascular notvork
rogardloss ol lts tlssuo compononts ls a lasclo-
cutanoous llap.
25
llaps that voro provlously con-
sldorod lasclocutanous and that aro basod on lso-
latod porloratlng vossols can nov bo accuratoly clas-
slllod as dlroct or lndlroct porlorator llaps.
25,35,36,65,72
ln 1992 Masquolot
105
doscrlbod tho concopt ol a
nouroskln llap basod on tho artorlos accompanylng
cutanoous norvos. Naka|lma and colloaguos
106
doscrlbod tho nourocutanoous and vonocutanoous
vascular systoms and throo typos ol podlclod
lasclocutanoous llap ln tho oxtromltlos. vono-
adlpolasclal (VAl), nouroadlpolasclal (NAl), and
vono-nouroadlpolasclal (V-NAl). 1hoso llaps aro
all basod on typo ll vossols, lo, nourocutanoous and
vonocutanoous porlorators runnlng long ln tho doop
adlpolasclal layor ol tho skln. 1ho llaps aro ralsod
on a podlclo ol adlpolasclal tlssuo and doslgnod ol
approprlato vldth to lncludo tho rolovant vascular
systom. Naka|lma
107
roportod 23 succosslul casos
ol lovor oxtromlty roconstructlon vlth VAl and V-
15
Fig 21. A classlllcatlon ol lasclocutanoous llaps. (Reprinted with permission from Cormack GC, Lamberty BGH: The Arterial Anatomy
of Skin Flaps. Edinburgh, Churchill Livingstone, 1986.)
16
NAl llaps basod on tho lossor saphonous voln and
sural norvo. lour dlstally basod and lour proxlmally
basod typos ol llap aro ldontlllod (llg 22). 1ho
lossor saphonous-sural V-NAl llap lncludos tho
norvo, tho voln, and tholr rospoctlvo vascular sys-
toms, and vas rocommondod as tho most rollablo
llap cholco.
lmanlshl
42
ovaluatod tho vonous dralnago ol tho
dlstally basod lossor saphonous-sural V-NAl podlclod
lasclocutanoous llap ln cadavors. Ho ldontlllod small,
long volns along tho courso ol tho lossor saphonous
voln that lntormlttonly anastomosod vlth tho largor
voln, and proposod that tho small volns bypass tho
valvos ln tho lossor saphonous voln and aro tho vonao
comltantos to tho artory that accompanlos tho largor
voln.
lraccalvlorl ot al
108
roportod a sorlos ol 18 patlonts
troatod vlth tho dlstally basod suporllclal sural
llap lor roconstructlon ol solt-tlssuo dolocts ol tho
lovor log and loot. 1ho authors roportod suporll-
clal nocrosls ln ono patlont vho roqulrod graltlng
and dolayod hoallng ln 2 patlonts. aumolstor and
assoclatos
109
publlshod a sorlos ol sural artory llap
roconstructlons ln 70 patlonts, 60 ol vhom had at
loast ono ma|or systomlc lllnoss. 1ho compllcatlon
rato vas 59, llap nocrosls occurrod ln 36. klsk
lactors lor compllcatlons voro comorbldlty, ostoo-
myolltls, and a tlght subcutanoous tunnol.
Cavadas
110
translorrod largo rovorso-llov nou-
rocutanoous saphonous lsland llaps lor lovor
oxtromlty roconstructlon ln 5 patlonts. ln a lollov-
up artlclo 6 yoars lator, Cavadas
111
roports translor-
rlng a postorlor tlblal porloratorsaphonous subcu-
tanoous llap ln 40 casos. 1ho llap modlllcatlon vas
a rosponso to dllllcult transposltlon, poor podlclo
covorago, and donor slto compllcatlons vlth tho
provlous llap tochnlquo.
Naka|lma
45
vas tho llrst to roport tho artorlal
supply to tho lossor saphonous voln and tho rolatod
llap. Chon
112
roportod a sorlos ol 21 patlonts vho
had lovor oxtromlty roconstructlon vlth tho dlstally
basod saphonous vonolasclocutanoous llap (llg
23).
46
Dlstal llap nocrosls vas troatod vlth skln
graltlng ln 2 patlonts. Although lt can bo ralsod as
an lnnorvatod llap lor covorago ol plantar hool
vounds, tho sural norvo ls usually prosorvod and
thoroloro tho donor morbldlty ls loss than that ol
tho nourocutanoous llap.
Venous Flaps
1ho lntroductlon ol vonous llaps ln tho 1980s
vas a rosult ol tho quost to dovolop tho ldoal lroo
llap. ono that vas oasy, rollablo, thln, and not
morbld. Nakayama ot al
113
and lator }ll and col-
loaguos
114
and Nlchtor and Halnos
115
roportod
artorlallzlng a llap through a vonous podlclo. A
vonous lsland llap vlth an AV llstula vas thus cro-
Fig 22. 1hoorotlcal llaps vlth a proxlmal baso. 1ypo A contalns
both tho lossor saphonous voln and sural norvo. 1ypo ls tho
samo as typo A oxcopt tho sural norvo has boon romovod lrom
tho uppor llap. 1ypo C ls tho samo as typo A oxcopt tho lossor
saphonous voln has boon romovod lrom tho uppor llap. 1ypo
D ls tho samo as typo A oxcopt tho sural norvo has boon
romovod. 1o tho rlght ol oach llap a dlagram shovs vhlch
porlorators aro rosponslblo lor tho blood supply ol oach llap.
1ho small N donotos voak vascularlty to tho skln. (Reprinted
with permission from Nakajima H, Imanishi N, Fukuzumi S, et
al: Accompanying arteries of the lesser saphenous vein and sural
nerve: anatomic study and its clinical applications. Plast
Reconstr Surg 103:104, 1999.)
17
atod and vas roportod to havo up to 95 llap
survlval and hlgh patoncy ratos. 1ho survlval ol
thoso llaps, hovovor, vas not conslstont. Cormann
and assoclatos
116
shovod that although blood llov
ln plg lsland llaps vas rovorsod, oxygon consump-
tlon romalnod bolov basollno, oarly thrombosls vas
a common occurronco, and no llap survlvod longor
than 48 hours.
1ho llov through vonous llap ln vhlch both tho
alloront and olloront podlclos aro suppllod by vonous
blood vas doscrlbod ln 1985 by aok ot al,
117
vho
usod tho saphonous voln ol a dog. aok
117
pro-
posos a to-and-lro osclllatlng mochanlsm ol llov
ln tho voln, vonulos, and vonous caplllarlos. 1vo
yoars lator, Chavoln
118
appllod thls ln a cllnlcal sot-
tlng. ln 1987 a slnglo-podlclod vonous lsland llap
uslng tho saphonous voln vas croatod ln a dog by
1hatto and 1hatto.
119
1hoso slnglo-podlclod lsland
llaps can bo lurthor classlllod lnto olthor proxlmally
basod or dlstally basod llaps. Amaranto and
covorkors
120
concludod that slnglo-podlclod vonous
llaps cannot survlvo vlthout llov-through, and
Lonoblo ot als
121
llov-through vonous llaps all dlod
dosplto blood llov vlthln tho vonous systom.
1hatto and 1hatto
122
classlly vonous llaps lnto
throo groups, rovlov tho oxporlmontal and cllnlcal
studlos on vonous llaps, and dlscuss tho varlous thoo-
rlos ol llap survlval. Accordlng to thls classlllcatlon,
typo l ls a unlpodlclod vonous llap, or puro vonous
llap vlth a slnglo cophalad voln as tho only vascular
condult. uan, Shan, and Zhu
123
doscrlbo tvo pat-
torns ol llov ln puro vonous llaps. a shaklng movo-
mont rolatod to hoart rato and a pondulum-llko
movomont that ls tho maln contrlbutor to llap por-
luslon. Also obsorvod vas ongolng rovascularlzatlon,
vhlch ultlmatoly suppllod tho llap and vhlch ls
ossontlal lor llap survlval.
124
Noroldln and othors
125
attrlbutod survlval to a porlvonous aroolar notvork
ol vossols arrangod longltudlnally along tho vholo
longth ol tho podlclo. Shalaby and Saad
126
ldontl-
llod an artorlal notvork ln tho porlvonous aroolar
tlssuo on hlstologlal study ol tho saphonous and
cophallc vonous lsland llaps.
Naka|lmas
45
anatomlc study and doscrlptlon ol
tho lntrlnslc and oxtrlnslc vonocutanoous vascular
systom conllrmod tho prosonco ol porlvonous art-
orlal llov ol tho slnglo-podlclod vonous llap. 1ho
typo l vonous llap vould bo classlllod by tho author
as a vonocutanoous adlpolasclal llap.
1hatto and 1hatto
122
typo ll vonous llaps aro
blpodlclod llov-through llaps vlth alloront and
olloront volns oxhlbltlng llov lrom caudal to coph-
alad. \lu and Chon
127
roportod that tho porlvonous
aroolar tlssuo ls ossontlal lor llov-through llap sur-
vlval and concludo that lt ls both protoctlvo and
nourlshlng. 1hoy dlvldo tho survlval procoss lnto
an oarly (up to 72 hours) vonous nourlshlng stago
and a socondary (day 4 to 6 vooks) stago ol
noovascularlzatlon charactorlzod by artorlal nour-
lshlng and vascular roconstructlon.
lnadas group
128
lsolatod tholr llaps lrom tho
roclplont tlssuo bod and concludod that llov-through
vonous llaps vlth only a slnglo voln cannot survlvo
ll largor than 12 cm. lor largor llaps to survlvo, a
donso vonous notvork ls ossontlal, vhlch suggosts
that moro than ono voln vould probably bo bonoll-
Fig 23. 1hoorotlcal llaps vlth a dlstal baso. 1ypos A, , C, and
D aro rovorso llaps ol tho proxlmally basod llaps. (Reprinted with
permission from Nakajima H, Imanishi N, Fukuzumi S, et al:
Accompanying arteries of the lesser saphenous vein and sural
nerve: anatomic study and its clinical applications. Plast Reconstr
Surg 103:104, 1999.)
18
clal.
129
1hoy surmlsod that thoso llaps bohavo not
unllko a gralt vhoso survlval doponds largoly on tho
surroundlng clrculatlon.
1ypo lll vonous llaps aro artorlallzod through a
proxlmal artorlovonous anastomosls and dralnod by
dlstal volns. Loo
130
rovlovs tho concopt ol vonous
llaps and tho artorlallzatlon ol tho vonous systom
and lllustratos throo klnds ol artorlallzod vonous
llaps (llg 24). Ho polnts out that tho clrculatlon ol
blood ln vonous llaps ls basod on spoculatlon, and
crodlts a numbor ol authors lor varlous oxplana-
tlons. losslblo pattorns ol blood llov ln tho artorlal-
lzod vonous llap rango lrom puro rotrogrado (lrom
a vonous to a vonous systom), through rovorso shunt-
lng (lrom vonulos to artorlolos lollovod by normal
orthogrado llov), to puro shuntlng (vhoro no por-
luslon ol tho llap occurs but rathor blood llovs
dlroctly lrom tho alloront to tho olloront channols).
Fig 24. 1hroo typos ol artorlallzod vonous llaps. (Reprinted with
permission from Lee WPA: Discussion of Arterialized venous flap
for treating multiple skin defects of the hand, by G Inoue, K Suzuki.
Plast Reconstr Surg 91:303, 1993.)
llmaz ot al
131
doscrlbo tho lour optlons ln hook-
lng up tholr radlal loroarm vonous llap. 1hoso
lncludo orthogrado lnllov/orthogrado outllov, rot-
rogrado lnllov/rotrogrado outllov, orthogrado
lnllov/rotrogrado outllov, and rotrogrado lnllov/
orthogrado outllov. 1hoy choso tho lourth systom
bocauso tho valvos aro rondorod lncompotont by
tho hlgh prossuro ol tho artorlal lnllov. Moshammor
ot al
132
roportod ln an oxporlmontal study that tho
clrculatlon at tho porlphory ol tho artorlallzod vonous
llap can bo onhancod by rotrogrado artorlallzatlon.
1ho authors proposo that tho roslstanco to llov lrom
tho volns valvos lorcos blood lnto tho llaps porlph-
ory. lrlshnan
133
conllrmod thoso concluslons and
also roportod that accordlng to tholr oxporlmontal
modol, vonous llaps artorlallzod agalnst tho valvos
achlovod a largor porluslon aroa than llaps por-
lusod ln tho dlroctlon ol tho valvos. 1ho largost
aroa ol porluslon vas soon ln bldlroctlonally por-
lusod llaps.
1ho mochanlsm ol porluslon ol vonous llaps ls
stlll not complotoly undorstood and has boon attrlb-
utod to a numbor ol lactors such as plasmatlc lmbl-
bltlon, porluslon prossuro, sltos ol artorlovonous
anastomosls, porlvonous artorlal notvorks, voln-to-
voln lntorconnoctlons and othor vascular notvorks,
and tho clrcumvontlon ol vonous valvos. Sovoral
studlos havo domonstratod lmprovod survlval ol
vonous llaps vlth proartorlallzatlon and dolay pro-
coduros.
68,134137
Unlortunatoly, tho survlval ol
vonous llaps contlnuous to bo lnconslstont.
Chavoln ot al
118
doscrlbo a rovorso shunt lrom
vonulos to artorlolos lollovod by orthogrado llov
lrom artorlolos to caplllarlos and thon to normal
vonous channols. lmanlshl and colloaguos
138
pro-
poso tho prosonco ol artorlovonous shunts around
tho olloront voln ol tholr artorlallzod cophallc
vonous llaps. 1hoy doscrlbo tho routo ol llov as
bolng lrom voln to porlvonous notvork, to
porlvonous artorlal notvork, to tho artorlal systom,
and thon back to tho vonous systom and tho orlgl-
nal voln.
Studlos by Chov, Chon, and Cu
139
notod bottor
survlval ol truo artorlal llaps than artorlallzod vonous
llaps. 1ho quallty ol tho survlvlng llap lmprovod
vlth lncroasod porluslon prossuro and bottor oxy-
gonatod blood. Uoda ot al
140
notod lncroasod sur-
vlval ol llov-through vonous llaps vhon dolayod.
Uslng lnlrarod thormography, Wolll ot al
141
oxam-
lnod throo typos ol vonous llaps vlth rogard to tholr
porluslon and long-torm rosults. At 4 months tho
survlval rato lor artorlallzod vonous llaps vas 92.7,
19
lor llov-through vonous llaps, 62.4, and lor vonous
lsland llaps, about 31. 1hoy concludod that art-
orlallzod vonous llaps aro tho salost typo ol vonous
llaps.
1ho cllnlcal advantagos ol vonous llaps aro mlnl-
mal donor slto morbldlty roqulrlng only tho sacrlllco
ol a voln and no artory, a long and vory thln, ana-
tomlcally constant podlclo (og, tho saphonous voln),
and last and oxpodlont llap olovatlon.
130,132,142145
1ho
poorly undorstood physlology and unprodlctablo
survlval ol vonous llaps makos tho cllnlcal appllca-
tlon ol thoso llaps contovorslal. 1ho maln dlsadvan-
tagos ol vonous llaps aro llmltod slzo ol tho llap,
varlablo rato ol tlssuo nocrosls, dolayod hoallng,
vonous congostlon, suscoptlblllty to lnloctlon, po-
tontlal (though unllkoly) homodynamlc compllca-
tlons ol a surglcally croatod AV shunt, rostrlctod
locatlon ol donor sltos to maxlmlzo tho vonous
ploxus, and lroquont nood lor skln gralt covorago
ol donor sltos.
68,129,132,143145
Cllnlcal trlals ol pro-
artorlallzatlon and dolay procoduros roport lmprovod
llap survlval
68,137
vlth thoso moasuros.
Nlshl and colloaguos
146
and lnouo and Suzukl
142
roport uslng artorlallzod vonous skln llaps lor tho
troatmont ol skln dolocts ln tho hand. Noordholls
group
147
appllod vonous llaps ln 28 patlonts and
catogorlzod tholr oporatlons lnto lour typos. 1hoy
noto tho advantagos and dlsadvantagos ol oach typo
and concludo that vonous llaps aro not lntondod to
roplaco moro convontlonal llaps.
Chla and colloaguos
148
doscrlbo tho succosslul
rotransplantatlon ol a vonous-notvork-pattorn skln
llap uslng a 12 x 12 cm skln paddlo lrom tho modlal
aspoct ol tho rlght thlgh translorrod to tho dlstal
lovor oxtromlty. Calumbock and lrooman
144
por-
lormod human anatomlcal studlos tho rosults ol
vhlch suggostod that only tho vonous trlbutarlos ol
tho llap rocolvo blood. 1ho authors appllod an
artorlallzod saphonous voln lasclocutanoous gralt
to covor tlssuo dolocts on both tho uppor and lovor
oxtromltlos.
Stovart and luckott
149
rovlov tho saloty ol
rovorso vonous llov ln lroo llap translors, spoclll-
cally tho radlal loroarm llap. loshlma ot al
143
usod
tho saphonous voln and lncorporatod an ossoous
componont. 1hoy voro ablo to lncroaso tho lunc-
tlonal slzo ol tho llap to 7 x 11 cm lrom tho 3 x 8 cm
roportod by Nakashlma.
150
llmaz and colloguos
151
roportod succosslul lroo llap translor ol an artorlal-
lzod vonous llap moasurlng 8 x 12 cm lrom tho
loroarm to tho laco.
lloln ot at
152
roportod 4 casos ol partlal llap
nocrosls and 8 casos ol total llap nocrosls ln a sorlos
ol 29 lroo artorlallzod lorarm llaps lor lntraoral
roconstructlon.
lovacs
153
comparod tvo typos ol artorlallzod
loroarm llaps lor oral roconstructlon. 1ypo l vas a
slnglo voln artorlallzod llov-through llap. 1ypo ll
vas an artorlallzod llap vlth tvo parallol volns on
tho proxlmal llap. 1ho smallor voln vas lor artorlal
lnllov and tho largor lor vonous outllov, thoorotl-
cally to avold bypasslng tho llap tlssuo. lour ol tho
5 typo l llaps shovod total or subtotal succoss and
ono vas lost. Cl tho 5 typo ll llaps, 3 voro lost, ono
vas a partlal lalluro, and tho othor ono vas a total
succoss.
Do Loronzl and colloaguos
145
roportod 40 casos
ol dlgltal solt-tlssuo roconstructlon vlth artorlallzod
vonous lroo llaps. lostoporatlvo congostlon vas
prosont ln all llaps and rosolvod vlthln 14 days.
1horo vas total llap survlval ln 57.5, 17.5 had
suporllclal opldormolysls, 17.5 had lull-thlcknoss
nocrosls that roqulrod graltlng, and 7.5 had total
llap nocrosls.
Cho ot al
68
roportod a cllnlcal sorlos ol 13 dolayod
artorlallzod vonous llaps. 1ho survlvlng surlaco ol
tho llap vas 100 ln 10 patlonts, 70 ln ono
patlont, 50 ln ono patlont, and 0 (total nocrosls)
ln ono patlont.
Wungcharoon and othors
137
roportod tho ropalr
ol oxtromlty vounds vlth a proartorlallzod vonous
llap ln 8 patlonts. Artorlovonous shunts voro cro-
atod at tho donor slto 2 vooks boloro llap harvost.
llap survlval vas roportod to bo 93100 ol tho
surlaco aroa.
Muscle and Musculocutaneous Flaps
1ho lnltlal vork doscrlblng tho prlnclplos, opora-
tlvo procoduros, and cllnlcal appllcatlons ol musclo
llaps vas dono by Cor
154
ln tho lato 1960s. ln 1977
Cor
155
roportod succosslul closuro ol opon vounds
ln 43 casos. Musculocutanoous llaps aro compos-
ltos ol skln, subcutanoous tlssuo, and undorlylng
musclo and lascla suppllod by a domlnant vascular
podlclo. 1anslnl
156
vas tho llrst to mako uso ol
musculocutanoous llaps ln 1906 vhon ho rocon-
structod a broast vlth a comblnatlon ol skln and
latlsslmus dorsl musclo ralsod as ono unlt. lor tho
20
noxt 50 yoars no ono took notlco ol thls ovont untll
Cvons
157
ln 1955 roportod tho ropalr ol masslvo
laclal dolocts vlth tho stornocloldomastold llap, a
compound llap lrom tho nock.
1ho ldoa that llat musclos (og, poctoralls and latls-
slmus musclos) could carry tholr ovorlylng skln as
composlto llaps camo lndopondontly to Huoston
158
and Doslroz.
159
Crtlcochoa
160,161
subsoquontly
appllod thls concopt cllnlcally, uslng tho gracllls mus-
culocutanoous unlt ln ponllo roconstructlon and to
ropalr an anklo doloct.
ln 1977 McCrav, Dlbboll, and Carravay
162,163
doscrlbod tho vascular torrltorlos ol sovoral nov
musculocutanoous unlts and dollnod llap dlmon-
slons and usolul arcs ol rotatlon. 1ho authors
omphaslzod tho concopt ol a domlnant vascular
podlclo that suppllos blood to a musclo and lts ovor-
lylng skln torrltory through porloratlng vossols.
Although somo dotalls ol tho goomotry, rollablllty,
and appllcatlon ol spoclllc llaps voro subsoquontly
lound to bo lnaccurato, tholr papors aro stlll consld-
orod to bo classlcs ln tho hlstory ol roconstructlvo
plastlc surgory. ln lator artlclos McCrav
164,165
tracod
tho ovolutlon ol musculocutanoous llaps, cltod
sourcos ol orlglnal doscrlptlons ol yot moro such
llaps, and rovlovod tho baslc prlnclplos ol muscu-
locutanoous llap anatomy and physlology.
1ho prlmary advantagos ol musclo llaps aro tho
potontlal to ablato doad spaco vlth vascularlzod
tlssuo and an lncroasod roslstanco to lnloctlon.
166
y moans ol radlolabolod mlcrosphoros, Cosaln ot
al
167
notod a markod lncroaso ln blood llov to all
lovols ol tlssuo ln both musculocutanoous and
lasclocutanoous llaps altor olovatlon. lood llov
vas also slmllar botvoon oqulvalont tlssuo layors.
Musculocutanoous llaps shovod a rapld rlso ln blood
llov that lovolod by 24 hours. ln contrast,
lasclocutanoous llaps shovod a gradual but stoady
rlso ln llov. 1ho groatost docroaso ln bactorlal
concontratlon also occurrod ln tho llrst 24 hours,
but vas slgnlllcantly groator ln tho musculocutan-
oous vound spaco (dropplng by a lactor ol 10
4
)
than ln lasclocutanoous llaps, vhlch only docroasod
by 10
2
. 1ho authors concludod that blood llov ls
not alloctod by tho prosonco ol bactorla, but mus-
culocutanoous llaps shovod bottor tlssuo lngrovth
lnto an lnoculatod vound spaco than lasclo-
cutanoous llaps.
Caldoron, Chang, and Mathos
168
lound that
lasclocutanoous llaps voro loss roslstant to tho olloct
ol bactorlal lnoculatlon and oxhlbltod loss collagon
doposltlon than musculocutanoous llaps.
1ho cllnlcal appllcatlon ol musclo to lnloctod
vounds has boon succosslul ln ostoomyolltls,
155,169
postthoracotomy modlastlnltls,
170
and prosthotlc
gralts.
171,172
1ho bonollts ol musclo oxtond to lroo
llaps. Chon,
173
Hammond,
174
and lorklns
175
suc-
cosslully troatod chronlc lntrathoraclc sopsls vlth
lroo latlsslmus and 1kAM llaps contalnlng musclo,
lat, and skln.
1ho prlmary dlsadvantagos ol musclo and
musculocutanoous llaps aro tho lunctlonal dollclt at
tho donor slto and tho bulk ol tho llap. 1ho doslgn
ol a musculocutanoous llap roqulros anatomlc
knovlodgo ol tho vascular archltocturo ol tho musclo
and tho dlstrlbutlon ol cutanoous porlorators that
vlll supply tho skln paddlo. ln 1979 Mathos and
Nahal
67
dovolopod a usolul classlllcatlon ol tho
blood supply to lndlvldual musclos. 1ho authors
doscrlbod llvo typos ol musclo on tho basls ol tholr
clrculatory pattorns (llg 25 and 1ablo 3).
1ypo l slnglo vascular podlcloog, tonsor
lascla lata
1ypo ll domlnant podlclo(s) and mlnor
podlclo(s)og, gracllls
1ypo lll tvo domlnant podlclosog, glutous
maxlmus
1ypo lV sogmontal vascular podlclosog,
sartorlus
1ypo V slnglo domlnant podlclo and
socondary sogmontal podlclosog,
latlsslmus dorsl
Compound and Prefabricated Flaps
llaps can conslst ol any numbor ol tlssuos ln vlr-
tually any comblnatlon. Compound llaps aro dollnod
as dlvorso tlssuo compononts that aro lncorporatod
lnto an lntorrolatod unlt.
176
Composlto llaps aro a
typo ol compund llap that olton lncorporato skln,
lat, lascla, musclo, and bono basod on a solltary
vascular podlclo, vhlch allovs slnglo-stago rocon-
structlon ol complox dolocts. Spoclallzod llaps can
provldo sonsory and lunctlonal musclo to aroas
roqulrlng spoclal noods.
29
Craham and Dollon
177
rovlov spoclallzod llaps ln roconstructlon ol tho
hand, loot, oropharynx, broast, and gonltalla.
Hallock
176
proposod a usolul classlllcatlon ol com-
pound llaps basod on tholr vascularlzatlon. Com-
pound llaps aro dollnod as dlvorso tlssuo compo-
21
nonts such as bono, skln, lascla, and musclo that
lncorporatod lnto an lntorrolatod unlt. Hallock s
classlllcatlon placos thoso complox llaps lnto tvo
groups, thoso vlth solltary vascularlzatlon and thoso
vlth comblnatlons ol vascularlzatlon. 1ho com-
pound llap vlth solltary vascularlzatlon ls a com-
poslto llap that lncorporatos multlplo tlssuo compo-
nonts dopondont on a slnglo vascular supply. Com-
pound llaps ol mlxod vascularlzatlon aro lurthor
subdlvldod lnto Slamoso llaps, con|olnt llaps, and
soquontlal llaps (llg 26).
1ho concopt ol llap prolabrlcatlon (or, moro
accuratoly, prolamlnatlon
178
) vas lntroducod cllnl-
cally by Crtlcochoa
179
and Washlo
180
ln 1971. 1ho
Fig 25. llvo pattorns ol vascular anatomy ol musclo. (Reprinted with permission from Mathes SJ, Nahai F: Classification of the vascular
anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg 67:177, 1981.)
TABLE 3
Examples of Common Muscle Flaps by Type
(Reprinted with permission from Cormack GC, Lamberty BGH: The Arterial Anatomy of Skin Flaps. Edinburgh, Churchill Livingstone,
1986.)
22
tochnlquo allovs lor tho croatlon ol an unllmltod
array ol composlto lroo llaps
181
that vould othor-
vlso not bo avallablo vlth standard llaps. Com-
blnod vlth skln oxpanslon and a dolay procoduro,
prolabrlcatod llaps aro ovon moro vorsatllo.
lhourl, Upton, and Shav
182
rovlov tho prlnclplos
ol llap prolabrlcatlon and llst spoclllc advantagos to
tholr uso, lncludlng vascular lnductlon ol spoclllc
blocks ol tlssuo vhlch aro not naturally porlusod by
anatomlcally voll-dollnod axlal vossolslo,
prolamlnatlon,
178
croatlon ol a largor llap than vould
othorvlso bo posslblo, roducod donor slto morbld-
lty, and ovaluatlon ol lunctlonal status boloro tho
translor ol tho llap. 1ho authors doscrlbo pro-
translor graltlng, vhlch vas usod by arton
183
to
lncorporato skln and cartllago ln a lorohoad llap lor
nasal roconstructlon. Cthors havo usod lt to croato
a llap lncorporatlng a prolabrlcatod vascularlzod
porlostoal gralt vlth good ostoogonlc capaclty.
184
ln tho luturo, slmplo musclo llaps may bo trans-
lormod lnto moldod vascularlzod bono gralts through
prolabrlcatlon.
182
ln anothor artlclo, lhourl ot al
185
addross laclal
roconstructlon vlth an oxpandod prolabrlcatod llap.
1ho authors doscrlbo croatlon ol tho prolabrlcatod,
lnducod, oxpandod (llL) llap uslng both a podlclod
tomporoparlotal and lroo radlal loroarm lasclo-
cutanoous llaps. 1ho llaps voro placod undor an
oxpandor ln tho supraclavlcular roglon, vhlch sub-
soquontly producod a capsulolasclocutanoous llap
altor oxpanslon vas complotod. Although thls llap
ls not lntondod to roplaco tho lorohoad lor spoclllc
llaps ln laclal roconstructlon, lt doos provldo cor-
taln advantagos vhon noodod.
Homma ot al
186
concludod that oxpandod musclo-
vascularlzod prolabrlcatod llaps havo largor aroas
ol survlval than oxpandod lascla-vascularlzod llaps.
Maltz
187
obsorvod lncroasod survlval ol dolayod pro-
labrlcatod llaps, vhllo lomuro ot al
188
noto no slg-
nlllcant dllloronco ln survlval ol prolabrlcatod arto-
rlallzod vonous llaps comparod vlth controls. Cthor
authors suggost that bocauso noovascularlzatlon ls
nocossary lor a succosslul llap, a dolay ol at loast 4
vooks
189
and ovon up to 8 vooks
190
should bo
obsorvod. Maltz, lrlbaz, and Horgruotor
191
noto
docroasod survlval ol prolabrlcatod llaps sub|octod
to mochanlcal prossuros or rostralnts (og, loldlng or
klnklng) comparod vlth axlal-pattorn llaps.
FLAP PHYSIOLOGY
Regulation of Blood Flow to the Skin
llap physlology boglns at tho lovol ol tho mlcro-
clrculatlon. 1ho mlcroclrculatlon ls also vhoro thor-
morogulatlon ol blood llovtho sklns prlmary
lunctlonoccurs. A numbor ol lactors contrlbuto
to tho rogulatlon ol blood llov, such as dlstontlon,
ondothollum-modlatod vasoconstrlctlon, noural con-
trol, tomporaturo, local ln|ury, and vlscoslty.
1
Danlol and lorrlgan
62
llnd tvo klnds ol rogula-
tory lactors ol cutanoous blood llov, systomlc and
local. Systemic control ls lacllltatod ln ono ol tvo
vays.
Neural rogulatlon acts through sympathotlc
adronorglc llbors. Alpha-adronorglc rocoptors
lnduco vasoconstrlctlon and bota-adronorglc
rocoptors lnduco vasodllatlon. Comblnod, thoy
malntaln basal tono ol vascular smooth musclo
at tho artorlovonous anastomosos, artorlolos, and
artorlos. Slmultanoously chollnorglc llbors lnl-
tlato bradyklnln roloaso, vhlch contrlbutos to
vasodllatlon.
Humoral rogulatlon causos vasoconstrlctlon
through tho actlon ol oplnophrlno and noropl-
nophrlno on alpha-adronorglc rocoptors ln tho
cutanoous vossols. Sorotonln, thromboxano A
2
,
and prostaglandln l
2
-alpha may also produco
vasoconstrlctlon, vhllo bradyklnln, hlstamlno,
and prostaglandln-L
1
causo dlroct vasodllatlon
(llg 27).
Fig 26. Compound llaps may bo subdlvldod lnto olthor solltary
or comblnod typos basod on tholr sourco ol vascularlzatlon.
Comblnod llaps may bo Slamoso, con|olnt, or soquontlal. (Re-
printed with permission from Hallock GG: Simplified nomencla-
ture for compound flaps. Plast Reconstr Surg 105:1465, 2000.)
23
1ho ollocts ol local ln|ury to a part ol tho artorlal
vall can complotoly ovorrldo basal vascular tono
and causo spasm ovon ln tho absonco ol sympa-
thotlc lnnorvatlon.
1
lor lnstanco, a pln prlck ollclts
a porslstont lsolatod rlng contractlon locally, and
oxtonslvo crushlng or toarlng can lnduco a vldo-
sproad and prolongod spasm dlstantly (llg 28).
Fig 28. lochomlcal agonts alloctlng tho clrculatlon. (Reprinted
with permission from Cormack GC, Lamberty BGH: The Arterial
Anatomy of Skin Flaps, 2nd ed. Edinburgh, Churchill Livingstone,
1994.)
Local ollocts (autorogulatlon) aro modlatod by
motabollc and physlcal lactors.
Metabolic lactors act prlmarlly as vasodllators
and lncludo hyporcapnoa, hypoxla, acldosls, and
hyporkalomla. 1hoso lactors aro not as slgnlll-
cant ln tho skln as ln musclo, vhlch has hlghor
motabollc roqulromonts.
Physical lactors that lnlluonco blood llov lncludo
tho myogenic reflex, vhlch trlggors vasoconstrlc-
tlon ln rosponso to dlstontlon ol lsolatod cutano-
ous vossols and thoroby malntalns caplllary llov
at a constant lovol lndopondont ol artorlal pros-
suro. Local hypothormla (vhlch acts dlroctly on
tho smooth musclo ln vossol valls) and lncroasod
blood vlscoslty (homatocrlt >45) may also
docroaso llov. 1ho ollocts ol homatocrlt voro
quostlonod by llm ot al,
192
vho concludod that
normovolomlc anomla (hct 19) had no slgnlll-
cant olloct on tho survlval ol podlclod musculo-
cutanoous llaps.
1hoso samo concopts ol blood llov rogulatlon
can bo appllod to musclos. Wlth rogard to systomlc
control, although musclo has a much hlghor capll-
lary donslty than skln, artorlovonous shunts aro
absont. And bocauso tho motabollc domand ol
musclo ls groator than that ol tho skln, autorogula-
tlon plays a moro lmportant rolo. Nouronal controls
such as oxorclso and artorlal hypotonslon lnduco a
rolloxlvo vasoconstrlctlon, vhllo hyportonslon rosults
ln vasodllatlon. Humoral rogulatlon ls slmllar oxcopt
that oplnophorlno causos vasodllatlon, ln dlroct con-
trast to tho vasoconstrlctlon soon ln skln. ln tho
schomo ol local control, motabollc autorogulatlon ls
llmltod ln musclo but doos oxcood that ol skln, and
blood llov ls mlnlmally changod ln rosponso to tom-
poraturo lluctuatlons.
urnstock and kalovlc
193
rovlov nov lnslghts lnto
tho local rogulatlon ol blood llov. 1ho authors
dlscuss tho concopt ol co-transmlsslon, vhoroby
norvos synthoslzo, storo, and roloaso moro than
ono transmlttor, and tho lmportanco ol tho ondo-
thollum as a modlator ol vasodllatlon and constrlc-
tlon.
ln summary, tho mochanlsms ol blood llov rogu-
latlon aro dllloront ln skln and musclo. Myogonlc
tono ls lmportant ln musclo rogulatlon but has llttlo
olloct on cutanoous vossols, vhoroas sympathotlc
vasoconstrlctors aro tho prodomlnant moans ol rogu-
latlng blood llov to tho skln.
Flap Transfer
1ho olovatlon ol a skln llap rosults ln many pro-
lound changos that drastlcally dlsrupt tho llnoly bal-
Fig 27. lhyslologlc lactors that rogulato tho cutanoous mlcroclr-
culatlon. (Reprinted with permission from Daniel RK, Kerrigan CL:
Principles and physiology of skin flap surgery. In: McCarthy JG (ed),
Plastic Surgery. Philadelphia, Saunders, 1990. Vol 1, Ch 9.)
24
ancod oqulllbrlum ol homoostasls. lrlmary changos
lncludo tho loss ol sympathotlc lnnorvatlon and tho
lnsult ol lschomla.
Hoopos
194
glvos a dotallod account ol tho clrcu-
latory ovonts that tako placo ln a podlclod llap altor
lts blood supply ls partlally lntorruptod durlng ol-
ovatlon and translor.
024 hrs. roductlon ln artorlal blood supply, pro-
grosslvoly docroaslng clrculatory olllcloncy lor tho
llrst 6 hours, platoau at 612 hours, lncroaso ln
clrculatory olllcloncy boglnnlng at 12 hours, markod
congostlon and odoma durlng tho lnltlal 24 hours,
markod dllatatlon ol artorlolos and caplllarlos
13 days. lncroaslng lsotopo appoaranco, lmprovo-
mont ln pulso amplltudo, llttlo or no lmprovomont
ln clrculatlon durlng tho lnltlal 48 hours, lncroaso
ln numbor and callbor ol longltudlnal anastomosos,
lncroaso ln tho numbor ol small vossols ln tho podlclo
37 days. progrosslvo lncroaso ln clrculatory olll-
cloncy untll lt roachos a platoau at about day 7,
vascular anastomosos botvoon llap and roclplont
bod prosont at 23 days, bocomo lunctlonally slg-
nlllcant at 5 to 7 days, lncroaso ln slzo and numbor
ol lunctlonlng vossols, roorlontatlon ol vossols along
tho long axls ol tho llap
1 week. clrculatory lunctlon voll ostabllshod bo-
tvoon llap and roclplont bod, pulsatllo blood llov
approachos prooporatlvo lovols
714 days. no lurthor slgnlllcant lncroaso ln vas-
cularlzatlon, artorlal pattorn bocomos normal, ra-
dlolsotopo cloaranco lndlcatos clrculatory olllcloncy
surpasslng normal valuos at 1021 days, roturnlng
to normal altor 3 vooks
2 weeks. progrosslvo rogrosslon ol tho vascular
systom, contlnuous maturatlon ol anastomosos bo-
tvoon podlclod llap and roclplont slto
3 weeks. vascular pattorn approxlmatos proopora-
tlvo stato, llap achlovos 90 ol lts llnal clrculatlon,
vltal stalnlng occurs slmultanoously vlth roclplont
llmb, lully dovolopod vascular connoctlons botvoon
podlclo and roclplont slto
4 weeks. all vossols docroasod ln dlamotor, lov
romalnlng novly lormod vossols
Most lnvostlgators ondorso tho concopt ol venous
insufficiency as tho prlmary causo ol nocrosls ln
podlclod llap tlssuo.
194
As oarly as 1967, lu|lno
195
concludod that roductlon ln vonous outllov prob-
ably rosults ln llap nocrosls dosplto tho prosonco ol
adoquato artorlal lnllov. 1suzukl and colloaguos
196
lound that mlld vonous lnadoquacy dld not alloct
survlval ol an oxporlmontal llap vhon tho artorlal
lnllov vas malntalnod, but onco artorlal lnllov vas
lmpalrod, ovon mlld vonous lnadoquacy roducod
llap survlval.
Angol and covorkors
197
studlod socondary ls-
chomla tlmo ln a rodont modol, and notod that
vonous obstructlon vas moro dolotorlous to llap
survlval than socondary lschomla lrom comploto
podlclo obstructlon. ln contrast, lorrlgan lound
inadequate arterial inflow vas tho prlmary causo ol
llap lalluro,
198
and proposod a comblnatlon ol ls-
chomla, lnllammatlon, and sympathoctomy to ox-
plaln tho vascular collapso that undorllos tho lalllng
skln llap.
199
lurthormoro, damago to tho llap bo-
comos lrrovorslblo ll adoquato nutrlont clrculatlon
ls not provldod
May
200
studlod clrculatory changos ln lroo opl-
gastrlc llaps ln rabblts. 1hoy notod conslstont odoma
and svolllng ol tho vascular paronchymal colls vhon
lroo llaps voro sub|octod to a porlod ol lschomla.
1horo vas concomltant narrovlng ol tho caplllary
lumon and trapplng ol lorolgn blood olomonts as
voll as sludgo or thrombus lormatlon ln tho stag-
nant blood vlthln tho vascular troo ol tho lschomlc
tlssuo. All llaps survlvod up to 4 hours ol lschomla.
otvoon 4 and 8 hours ol lschomla, tho typlcal
homodynamlc and collular ovonts occurrlng ln llaps
as a rosponso to lschomla voro rovorslblo. As tho
porlod ol lschomla longthonod, tho clrculatory al-
toratlons gradually vorsonod and vascular obstruc-
tlon progrossod untll thoy bocamo lrrovorslblo, thls
occurs altor 12 hours. 1ho polnt at vhlch lt ls not
posslblo to roostabllsh nutrlont lnllov dosplto
roporluslon ls knovn as tho no-reflow phonom-
onon . 1ho no-rollov phonomonon ls tho rosult ol
lschomla-lnducod roporluslon ln|ury and procodos
llap doath.
1ho motabollc ollocts ol lschomla durlng llap
olovatlon aro many. Wlth lnadoquato tlssuo oxy-
gonatlon thoro ls a chango lrom aoroblc to anaoro-
blc motabollsm, rosultlng ln hlghor lovols ol supor-
oxldo radlcals. Clucoso consumptlon and lactato
productlon both lncroaso, vlth concomltant doplo-
25
tlon ol glycogon. 1ho motabollc dorangomonts ol
tlssuo lschomla also alloct physlcal proportlos ol
blood such as vlscoslty and clottlng. Dlroct cyto-
toxlc ln|ury rosults lrom tho accumulatlon ol oxy-
gon-dorlvod lroo radlcals durlng llap lschomla.
lm ot al
201
ln 1985 and lator Manson and col-
loaguos
202,203
notod lncroasod productlon ol toxlc
suporoxldo radlcals durlng anaoroblc motabollsm.
1ho authors suggostod a rolo lor oxygon-dorlvod
lroo radlcals (CDlk) as modlators ol tlssuo nocrosls
ln tho lschomlc transltlon zono botvoon tho proxl-
mal, vlablo portlon ol a skln llap and lts dlstal, non-
vlablo sogmont. Wlth ronovod llov comos an abun-
dant supply ol calclum lons and a roloaso ol oxygon
lroo radlcal spoclostho so-callod rosplratory burst.
lroo radlcals aro not only dlroctly cytotoxlc but also
trlggor tho synthosls ol numorous prolnllammatory
llpld modlators (og, lAl and L1
4
) as voll as pop-
tldo modlators (og, C5a, 1Nl-, and lL-1).
204
Altor
roporluslon, tho lroo radlcals aro attackod by lroo
radlcal scavongors, causlng lurthor ln|ury to tho colls.
1hls phonomonon has como to bo knovn as
ischemia-induced reperfusion injury (llkl). 1ho tran-
sltlon lrom normal roporluslon and roporluslon ln|ury
dlllors accordlng to tlssuo typo.
205
Skln and bono
can usually tolorato lschomla lor up to 3 hours but
musclo and lntostlnal mucosa aro much loss tolor-
ant.
lorrlgan and Stotland
206
rovlov tho cllnlcal slg-
nlllcanco, otlology, pathophyslology, rosoarch
lnvostlgatlons, and curront managomont ol lschomla
and llkl. lochomlcal changos occurrlng durlng
lschomla actually prlmo tho tlssuo to rospond ln a
pathologlcal lashlon upon oxposuro to ro-ostabllshod
vascular supply. 1ho authors dlscuss tho xanthine
oxidase and NADPH oxidase systoms, vlth tholr
productlon ol tho toxlc radlcals suporoxldo anlon
(C
2
), hydrogon poroxldo (H
2
C
2
), and tho hydroxyl
radlcal (CH). 1hoso roactlvo oxygon lntormodlatos
load to a varloty ol mlcrovascular and lnllammatory
dorangomonts such as ondothollal coll svolllng and
lncroasod caplllary pormoablllty. Loukotrlonos
(L1
4
), thromboxanos (A
2
), and prostaglandlns play
a ma|or rolo ln thoso procossos. ln addltlon, nou-
trophlls contrlbuto to tho acuto lmllammatory ln|ury
ol roporluslon through tholr adhoslon, omlgratlon,
and protoolytlc onzymo dogradatlon.
Carroll and Lsclamado
205
rovlovod llap physlol-
ogy, lschomla/roporluslon ln|ury, and tho uso ol
pharmacothorapoutlc agonts ln mlcrovascular sur-
gory.
FLAP DELAY
Dolay ls tho surglcal lntorruptlon ol a portlon ol
tho blood supply to a llap at a prollmlnary stago
boloro translor. 1ho purposo ol dolay ls to lncroaso
tho survlvlng longth ol a llap or to lmprovo tho
clrculatlon ol a llap to dlmlnlsh tho lnsult ol translor.
Dosplto advancos ln our undorstandlng ol llap physl-
ology tho oxact mochanlsm ol dolay ls lncomplotoly
dollnod.
1vo schools ol thought oxlst rogardlng tho mocha-
nlsm ol tho dolay phonomonon. Cno thoory holds
that delay conditions tissue to ischemia, allovlng lt
to survlvo on loss nutrlont blood llov than normally
noodod. Cthors bollovo that delay improves or
increases vascularity. 1ho procoss by vhlch dolay
contrlbutos to llap survlval ls llkoly to bo a comblna-
tlon ol both mochanlsms actlng to a groator or lossor
oxtont at varlous tlmos durlng surglcal dolay ol a
llap. Dollnltlvo lnvostlgatlons lnto llap rosponso to
docroasod blood supply havo boon hamporod by
lnconslstont rosults obtalnod ln dllloront laboratory
modols and lack ol adoquato controls to ostabllsh
truo lncroaso ln survlvlng longth lollovlng dolay
procoduros.
Hoopos
194
llsts tho lollovlng llvo mochanlsms ol
dolay.
sympathoctomy
vascular roorganlzatlon
roactlvo hyporomla
accllmatlzatlon to hypoxla
nonspoclllc lnllammatory roactlon
A numbor ol anatomlc and physlologlc lnvostlga-
tlons lnto tho dolay ol llaps bogan durlng tho 1950s.
ralthvalto
207,208
proposod that tho llkoly mocha-
nlsm ol dolay conslsts ol vascular roorganlzatlon
and roactlvo hyporomla actlng through nonlothal
lschomla to condltlon tho tlssuo to survlvo on loss
blood llov, togothor vlth an lncroaso ln slzo ol tho
vossols ln tho dormovonous ploxus. Ho postulatod
that tho hyporomla obsorvod vhon a tubod podlclo
ls translorrod arlsos lrom a vascular dobt as a rosult
ol lncroasod roslstanco to vonous outllov. rovn
and McDovoll
209
statod that tho purposo ol dolay ls
26
to pormlt gradual hyportrophy ol tho blood vossols
ln tho podlclo and posslbly to accustom tho tlssuos
ln tho llap to a lovor oxygon tonslon or poor clrcu-
latlon. 1ho accllmatlzatlon to hypoxla lormod tho
basls lor Danlol and lorrlgans
29
bollol that dolayod
llaps havo adoquato blood llov to survlvo tho oarly
stago ol vasoconstrlctlon vhoroas acuto llaps do
not.
Hynos
210
usod a varlatlon ol tho svoat tost to
dotoct tho prosonco or absonco ol sympathotlc ac-
tlvlty ln tubod podlclos. ln hls study, sympathoc-
tomy vas tho mochanlsm ol dolay, and lts olloct
vas to onhanco vascularlty. }uroll
211
analyzod lov-
ols ol noroplnophrlno, A1l, and cycllc-AMl ln do-
layod and nondolayod skln llaps to |udgo tho ollocts
ol sympathotlc donorvatlon on tho dolay phonom-
onon. Noroplnophrlno causos vasoconstrlctlon and
motabollc stlmulatlon. Whon llaps aro dolayod,
blood vossols and adronorglc norvos aro sovorod,
causlng a spontanoous dlschargo ol nourotransmlt-
tors, so that by tho tlmo ol llap lnsot thoro ls llttlo
roloaso ol noroplnophrlno and consoquont dlml-
nutlon ln vasoconstrlctlon ol tho llap. 1ho author
conllrmod slgnlllcantly lovor lovols ol noroplnoph-
rlno ln llaps at tho socond oporatlon.
Soltchlk and lahn
27
rovlovod tho hlstologlc al-
toratlons assoclatod vlth dolay and conllrmod tho
llndlngs ol Cormann and assoclatos
212
lrom 1933.
1holr obsorvatlons can bo summarlzod as lollovs.
longltudlnal roorlontatlon ol small vossols paral-
lol vlth tho long axls ol tubod podlclos at 1 to 7
days postdolay
lncroaso ln slzo ol vossols
lncroaso ln numbor ol small artorlos ln tho sub-
dormal ploxus
lang and colloaguos
213
monltorod skln caplllary
blood llov and anglogonosls ln dolayod and
nondolayod random skln llaps ln tho plg. Caplllary
blood llov vas slgnlllcantly hlghor ln tho dolayod
skln llaps and camo lrom tho podlclo only, not as
noovascularlzatlon lrom tho vound bod or margln.
1ho lncroaso ln llov vas dotoctablo vlthln 2 days
ol surglcal dolay, lncroasod 100 by day 4, and
romalnod at thls platoau untll day 14. 1horo vas,
hovovor, no slgnlllcant lncroaso ln tho donslty ol
artorlos botvoon acuto and dolayod skln llaps. 1ho
authors concludo that tho dolay phonomonon ls not
dopondont on anglogonosls but probably modlatod
through locally roloasod nourohumoral substancos.
Hovovor, as roportod llrst by Soralln
214
and lator by
Carcla,
215
both an lncroaso ln tho numbor and slzo
and an lngrovth ol nov vossols lrom tho surround-
lng tlssuo occurrod about 4 to 5 days postopora-
tlvoly.
}onsson and colloaguos
216
notod that surglcal do-
lay lmprovod dollvory ol oxygon to tho llap. Altor
dolay, blood vossols voro soon to roorganlzo paral-
lol to tho lnclslon llno and blood llov vas lncroasod
llrst by vasodllatlon and socondly by anglogonosls
untll about day 14. koroutlng ol blood llov by
ln|ury, lnllammatlon, and anglogonosls causod by
tho ropalr sooms to account lor a slgnlllcant portlon
ol tho dolay phonomonon. Cthors
217,218
conllrm
thoso llndlngs and suggost that an lschomlc tlssuo
gradlont provldos tho lmpotus lor anglogonosls and
loads to groator vlablllty ol dolayod llaps.
1ho anglogonlc procoss ln acuto and dolayod
llaps vas lnvostlgatod by Lopoz ot al
219
by moans ol
lmmunohlstochomlcal mothods vlth monoclonal
antlbodlos to ovaluato vascular ondothollum. Do-
layod llaps oxhlblt an lncroaso ln caplllarlos lrom 48
hours, and thls contlnuos untll 7 days altor llap ol-
ovatlon. 1holr thoory ol dolay holds that hypoxla
accounts lor vasodllatlon and roloaso ol nourohu-
moral substancos. Macrophagos subsoquontly ml-
grato to tho skln and roloaso anglogonlc lactors that,
along vlth othor lactors by platolots, damagod on-
dothollum, and tho olastlc layor ol vossols, trlggor
caplllary prollloratlon at tho socond surglcal stago.
1ho porlod ol dolay ollorlng maxlmum survlval ls
about 1 vook, vhoroas tho mlnlmum olloctlvo tlmo
ls 2 to 3 days.
Callogarl and colloaguos
220
subsoquontly con-
ductod a numbor ol oxporlmonts to dollno tho ana-
tomlc changos ln llaps altor surglcal dolay. 1ho
authors roachod tho lollovlng concluslons.
tho survlval longth ol llaps ls rolatod to tho dls-
tanco botvoon porlorators
tho nocrosls llno ol a llap usually appoars ln tho
zono ol choko vossols connoctlng ad|acont tor-
rltorlos
a surglcal dolay rosults ln dllatatlon ol oxlstlng
vossols vlth maxlmal olloct ln tho zono ol choko
artorlos
tho most olloctlvo dolay ls obtalnod by olovatlng
tho llap ln stagos lrom tho baso and not dotach-
lng tho tlp untll last
27
tlssuo oxpanslon ls a lorm ol surglcal dolay, par-
tlcularly ln torms ol vossol hyportrophy
slmllar changos occur vhon a musclo ls dolayod.
(Appllcatlon ol tho dolay phonomonon ln musclo
ls lurthor dlscussod by arkor ot al.
221
)
Dhar and 1aylor
222
lnvostlgatod tho soquonco ol
anatomlc changos vlth dolay ln a dog musclo and
rabblt skln modol to support tholr provlous conclu-
slon that llap dolay rosults ln dllatlon ol oxlstlng
vossols, not lngrovth ol nov vossols. 1ho authors
concludod that tho anatomlc olloct ol dolay ls
locusod on tho choko anastomotlc vossols that llnk
ad|acont torrltorlos and that tho tlmo soquonco ol
dolay ls slmllar ln dllloront tlssuo typos and ln dll-
loront spoclos. 1holr dolay soquonco ls dlvldod
lnto lour phasos (llg 29).
Fig 29. 1ho dolay soquoncosummary ol rosults. (Reprinted
with permission from Dhar SC, Taylor GI: The delay phenomenon:
the story unfolds. Plast Reconstr Surg 104:2079, 1999.)
Phase 1. lnltlal spasm ol all llap vossols vhlch lasts
up to 3 hours and ls lollovod by gradual dllatlon ol
vossol up to 24 hours.
Phase 2. otvoon 24 and 72 hours, an accoloratod
lncroaso ln tho callbor ol llap artorlos, prlmarlly at
tho choko vossol lovol.
Phase 3. lrom 72 hours to 7 days, lurthor gradual
dllatlon ol vossol lumon assoclatod vlth vossol vall
thlckonlng.
Phase 4. lrom 7 days on, tho choko vossols romaln
pormanontly and lrrovorslbly dllatod.
klbullo and colloaguos
223
soloctlvoly dolayod tho
doop and suporllclal lnlorlor oplgastrlc artorlos dur-
lng 1kAM llap roconstructlons. 1ho authors lound
slgnlllcantly lncroasod callbor ol tho suporlor opl-
gastrlc artory and docroasod artorlal roslstanco lol-
lovlng dolay ol olthor vossol. kostllo ot al
224
com-
parod tho dlamotor and llov ol tho suporlor oplgas-
trlc artory altor a dolay porlod ol 1 or 2 vooks. 1ho
dolay procoduro conslstod ol dlvlslon ol tho supor-
llclal and doop lnlorlor oplgastrlc vossols bllatorally.
1ho authors dld not llnd a statlstlcally slgnlllcant
dllloronco botvoon dolay altor 1 vook vorsus 2
vooks.
ln vlov ol tho conlllctlng ovldonco rogardlng tho
anatomy and physlology ol dolay, tho only unquos-
tlonablo lact sooms to bo that surglcal dolay rosults
ln hyportrophy and roorganlzatlon ol vossols along
tho axls ol a llap
220
and somohov lmprovos llap
survlval. Curront thoorlos attompt to oxplaln tho
dolay phonomonon as
a dramatlc altoratlon ol blood llov socondary to
closuro ol AV shunts, transoctlon ol sympathotlc
norvos, and hyporsonsltlvlty to catocholamlnos,
a condltlonlng ol tlssuo to lschomla, or
an lmprovomont ln vascularlty and blood llov
brought about through vasodllatlon, anglogon-
osls, or both.
Timing of Flap Division
Much ol tho oxporlmontal and cllnlcal data
rogardlng approprlato tlmlng ol llap dlvlslon ls basod
on obsorvatlons ol tubod podlclo llaps, at loast somo
ol vhlch may not havo roqulrod an lnltlal dolay
procoduro. Corman and assoclatos
212
concludod
that clrculatlon ln llaps vas roostabllshod consldor-
ably oarllor than provlously thought. 1hoy bogan
dlvldlng tholr llaps at 14 days posttranslor, and sub-
soquontly shortonod tho lntorval to 10 days vlthout
dolotorlous ollocts on llap survlval.
Stark, Hong, and lutroll
225
studlod tho rolo ol
lschomla lrom lov porluslon as tho trlggor ol
noovascularlzatlon ln a rat modol. 1hoy lound that
noovascularlzatlon vas onhancod by a porluslon
gradlont across tho vound marglns. loorly por-
lusod tlssuo brought lnto a hoalthy roclplont bod
onhancod noovascularlzatlon, oxcoodlng tho nood
ol tho lschomlc tlssuo ltsoll to oncompass tho vholo
ad|acont llap. 1ho authors concludo that thls ls
oxporlmontal ovldonco lor tho bonollclal olloct ol
dolayod dlvlslon ol a dlstant llap.
1o summarlzo tho avallablo data,
194,214,226229
although llaps can bo dlvldod as oarly as tho thlrd
28
day ln anlmal modols, cllnlcally dolay should bo
longthonod to sult spoclllc anatomy, oxpoctod llap
vlablllty, and charactorlstlcs ol tho roclplont slto.
Accordlng to Hausor ot al,
230
tho tradltlonal 3 vooks
lor dlvlslon ol an lnsot llap ls probably accoptablo ln
85 ol patlonts, but ls promaturo ln somo and
oxcosslvoly long ln most. 1ho cumulatlvo oxporl-
onco ol many surgoons suggosts that most llaps can
bo dlvldod saloly at 10 days to 3 vooks.
FLAP SURVIVAL
Physical Factors
1ho physlcal onvlronmont ol a llap can bo
manlpulatod to try to lmprovo llap survlval. Sasakl
and colloaguos
231
koop tho llap odgos moist and
roport an lncroaso ln tho survlvlng portlon ol llaps.
McCrath
232
statos that a molst onvlronmont dlmln-
lshos tho dopth ol tlssuo loss and lncroasos llap sur-
vlval, prosumably by mlnlmlzlng doslccatlon ol
lschomlc tlssuo.
Avvad ot al
233
ostabllshod a dlroct rolatlonshlp
botvoon local temperature and blood llov ln lsland
and lroo llaps. Hypothormla lod to vasoconstrlctlon
and lncroasod blood vlscoslty, vlth rosultant
docroaso ln skln blood llov, varmlng ol tho llap
had tho opposlto olloct. Whon llaps voro coolod
to 20C, Hussl and colloaguos
234
lound a roductlon
ln blood llov to 65 ol basollno and ln oxygon
consumptlon to 25 ol basollno. At 14C, blood
llov coasod complotoly, probably as a rosult ol
lncroasod plasma vlscoslty.
Mounsoy, lang, and lorost
235
oxploro tho con-
copt ol preconditioning, ln vhlch tho protoctlon
lrom lschomlc damago lnducod ln cardlac musclo
by brlol porlods ol coronary artory occluslon ls trans-
latod to skolotal musclo. 1o onhanco musclo llap
survlval and sustaln normothormlc lschomla, tho
musclo llap ls sub|octod to lntormlttont porlods ol
global lschomla lollovod by roporluslon. Mounsoy
notod a 20 lncroaso ln llap survlval at 30-mlnuto
lntorvals.
lrocondltlonlng as a moans to onhanco llap sur-
vlval has boon trlod on both skln and podlclod mus-
culocutanoous llaps.
236
Musculocutanoous llaps larod
slgnlllcantly bottor altor procondltlonlng, but not so
skln llaps, and both llap typos shovod lmprovod
survlval vhon usod as lroo llaps. 1ho mochanlsm ol
actlon ln procondltlonlng ls unknovn. lroposod
thoorlos lncludo altoratlons ln blood llov, docroasod
tlssuo motabollsm, soloctlvo loss ol cortaln nonos-
sontlal collular lunctlons, docroasod lovols ol oxy-
gon-dorlvod-lroo radlcals, and tho roloaso ol
ondothollum-dorlvod rolaxlng lactors, vhlch may
causo vasodllatlon and lmprovod dlstal blood
llov.
235,237
1an and othors
238
and kamon ot al
239
roport
lncroasod survlval ln rat abdomlnal llaps troatod
vlth hyporbarlc alr (21 C
2
) and hyporbarlc 100
C
2
, but not hyporbarlc 8 C
2
. Nomlroll and col-
loaguos
240
also shovod a bonollclal olloct ol hyper-
baric oxygen (HC) on acuto skln llaps, and notod
that, to bo holplul, HC must bo glvon as soon as
posslblo altor surgory. 1hoso llndlngs aro slmllar to
thoso ol ulrlnla and Vlldlk
241
and Lsclamado ot
al,
242
vho llnd that HC thorapy doos lmprovo skln
llap vlablllty. laolln ot al
243
lound that prolongod
prooporatlvo and postoporatlvo hyporbarlc oxygon
troatmont lmprovod survlval ln a rat skln llap modol.
1ho bonollclal olloct ol HC thorapy vas thought
to bo duo to lncroasod suporoxldo dlsmutaso actlv-
lty.
Not all lnvostlgators havo had posltlvo rosults vlth
hyporbarlc oxygon. Stovart and assoclatos
244
ovalu-
atod tho ollocts ol HC vlth and vlthout lroo-
radlcal scavongors, and notod no slgnlllcant lncroaso
ln llap survlval vlth HC unloss lt vas comblnod
vlth olthor alpha-tocopherol or suporoxldo
dlsmutaso and catalaso (CA1). Alpha-tocophorol ls
ono ol lour tocophorols maklng up vltamln L, vhoso
actlon ls to tormlnato lroo-radlcal roactlons by com-
potlng lor poroxyradlcals, ospoclally at coll mom-
brano surlacos. Catalaso ls an H
2
C
2
scavongor.
Pharmacologic
lang, lorrost, and Morrls
245
prosont a conclso
ovorvlov ol tho pathophyslology ol skln llap nocro-
sls and tho pharmacologlc manlpulatlon ol skln llaps
to provont or rovorso thls procoss. Carroll and
Lsclamado
205
rovlov tho uso ol pharmacothorapou-
tlc agonts ln mlcrovascular surgory (1ablo 4).
A numbor ol oxporlmontal studlos havo lookod
lnto drugs to lncroaso llap survlval. As lorrlgan
29
polnts out, many ol thoso studlos contradlct ono
anothor, aro porlormod by only ono rosoarchor on
a numbor ol dllloront oxporlmontal modols, and
olton uso an lnadoquato cohort that procludos sta-
tlstlcal valldatlon ol tho rosults. 1hls soctlon vlll
29
locus only on thoso pharmacologlc agonts that aro
commonly usod ln cllnlcal practlco.
Anticoagulants
Dextran, orlglnally doslgnod as a volumo
oxpandor, has boon a tool ol tho mlcrovascular
surgoon lor many yoars. kothkopl ot al
246
clto a
rovlov ol tho ollocts ol doxtran, vhlch lncludo
docroaso ln platolot adhoslvonoss and procoagulant
actlvlty, lncroasod bloodlng tlmo, lnhlbltlon ol plato-
lot aggrogatlon, and docroaso ln blood vlscoslty.
Wlth doxtran 40 as a porlusato, tho patoncy ol arto-
rlal lnvorslon gralts (slmllar to thoso ol Wollorts
247
)
almost doublod ovor that ol controls.
Worklng on a vonous modol, Zhang and
Wloslandor
248
obsorvod lncroasod mlcroclrculatory
patoncy vhon uslng doxtran 70. 1ho mlcro-
porluslon vas lurthor onhancod vhon lov-
molocular-volght hoparln vas addod. Lator
Salomark, lnudson, and Dougan
249
notod lncroasod
patoncy ol mlcroclrculatlon vlth doxtran 40, but
only on a short term basis. Altor 1 vook ol uso,
Doxtran 40 shovod llttlo olloct rogardloss ol modol.
Dlsa ot al
250
conductod a prospoctlvo random-
lzod analysls ol tho morbldlty assoclatod vlth doxt-
ran and asplrln prophylaxls ln hoad and nock
mlcrosurgory patlonts. 1ho lncldonco ol systom
compllcatlons lor patlonts rocolvlng lov molocular
volght doxtran lor 120 hours vas 51, lor 48 hours,
lt vas 29, and lor asplrln, 7. 1ho authors havo
dlscontlnuod tho uso ol doxtran ln tholr patlonts.
Doxtran ls assoclatod vlth slgnlllcant systomlc
morbldlty lncludlng anaphylaxls, pulmonary odoma,
cardlac compllcatlons, adult rosplratory dlstross syn-
dromo, and ronal lalluro. 1ho routlno uso ol doxt-
ran ln lroo tlssuo translor ls nov dlscouragod.
251,252
Heparin ls an olloctlvo antlcogulant that acts ln
con|unctlon vlth antlthrombln lll to lnhlblt throm-
bosls by lnactlvatlon lactor \. Hoparln ls moro
olloctlvo at provontlng vonous thrombosls than
artorlal thrombosls. Savada, Hatayama, and Sono
253
roport lmprovod llap survlval vhon hoparln vas
contlnuously and toplcally admlnlstorod to spoclllc
roglons ol tholr llaps. 1hoy attrlbutod tho bonoll-
clal olloct to platolot dlsaggrogatlon and malnto-
nanco ol vascular patoncy by hoparln, not to
vasodllatatlon and lncroasod vascular llov. 1hoso
llndlngs corrospond vlth thoso ol tho Cox group,
254
vho notod a doso-rolatod lncroaso ln llap patoncy
vlth hoparln. 1ho olloct vas llrst notod at hoparln
concontratlons ol 100 U/mL, a doso tho rosoarch-
ors llnd to bo ldoal lrom a morbldlty standpolnt.
lnvostlgators lrom Duko Unlvorslty Modlcal Con-
tor
255
roport that both unlractlonatod and lov
molocular volght hoparln (LMWH) lmprovod
mlcroclrculatory porluslon, but only LMWH
lmprovod anastomotlc patoncy vhllo mlnlmlzlng
homorrhago. lroll ot al
256
rotrospoctlvoly rovlovod
517 lroo llaps and notod a lovor lncldonco ol llap
loss vhon hoparln vas admlnlstorod (olthor as bolus
or ln lov doso), but thls dllloronco vas not statlstl-
cally slgnlllcant. Hudson ot al
257
roportod tho
oxporlmontal and cllnlcal uso ol a cathotor placod
proxlmal to tho vonous anastomosls lor tho dlroct
lnluslon ol hoparln to provont voous thrombosls.
1ho local partlal thromboplastln tlmo vas olovatod
but tho systomlc valuo ramlnod normal, thoroloro
roduclng tho systomlc compllcatlons ol hoparln.
Thrombolytic agents act by tho stlmulatlon ol
plasmlnogon vhlch ls tho procursor ol plasmln
vhlch acts to cloavo llbrln vlthln a thrombus. Strop-
toklnaso and uroklnaso aro llrst-gonoratlon agonts
and tlssuo plasmlnogon actlvator (t-lA) and acylatod
TABLE 4
Classification of Common Pharmacotherapeutic
Agents Used in Microvascular Surgery
(Reprinted with permission from Carroll WR, Esclamado RM:
Ischemia/reperfusion injury in microvascular surgery. Head Neck
22:700, 2000.)
30
plasmlnogon-stroptoklnaso actlvator complox
(AlSAC) aro socond-gonoratlon agonts. 1hrombo-
lytlcs havo boon olloctlvo ln anlmal modols lor tho
salvago ol llaps altor mlcrovascular thrombosls.
258
Stroptoklnaso ls a nononzymatlc protoln dorlvod
lrom group C bota-homolytlc stroptococcl. ln llap
salvago lt ls ln|octod lnto tho artorlal sldo ol tho llap
and dralnod through tho vonous sldo, usually avold-
lng systomlc ollocts. Dosos ol 50,000 to 125,000
unlts havo boon usod cllnlcally.
205
ll ot al
259
roportod 6 lroo llaps that voro sal-
vagod and 2 that lallod altor tho cllnlcal uso ol
thrombolytlcs (uroklnaso and t-lA) lor podlclo throm-
bosls. Sorlottl ot al
260
roportod 5 casos ol vonous
thrombosls that voro salvagod by rovlslon ol tho
vonous anastomosls lollovod by lntraoporatlvo
lnluslon ol 250,000 unlts ol uroklnaso.
Leeches havo boon usod ln modlclno slnco
anclont tlmos lor tho troatmont ol varlous all-
monts.
261
kocontly thoro has boon ronovod lntor-
ost ln modlclnal loochos, Hirudo medicinalis, lor
tho rollol ol vonous congostlon altor lroo tlssuo trans-
lors and roplantatlons.
262,263
Loochos oxort tholr
olloct by ln|octlng hlrudln at tho slto ol blto. Hlru-
dln ls a naturally occurrlng antlcoagulant that lnhlb-
lts tho convorslon ol llbrln to llbrlnogon and that,
unllko hoparln, doos not roqulro antlthrombln-lll
lor actlvatlon. ln addltlon, loochos socroto hyalu-
ronldaso, vhlch lacllltatos sproad ol tho antlcoagu-
lant vlthln tho tlssuos, and a vasodllator, vhlch con-
trlbutos to prolongod bloodlng (up to 48 hrs).
261,264,265
Moroovor, loochos havo a mochanlcal actlon by
croatlng physlcal channols through vhlch vonous
dralnago can occur. Novortholoss, accordlng to
kodgors ot al,
264
no controllod study has provon
tho olllcacy ol loochlng.
1ho maln lndlcatlon lor tho uso ol loochos ls ln
casos ol vonous congostlon vhoro outllov ls lnsul-
llclont or vonous channols aro olthor absont or
unsultablo lor anastomosls. 1ho prlmary contraln-
dlcatlon to loochos ls artorlal lnsulllcloncy, ln vhlch
caso tho loochos vlll slmply not attach thomsolvos
to tho llap.
Looch thorapy ls not vlthout potontlal compllca-
tlons. 1ho most slgnlllcant rlsks aro bactorlal lnloc-
tlon lrom tho gram-nogatlvo rod Aeromonas
hydrophila (vhlch ls tho looch ontorlc organlsm
rosposlblo lor rod coll dlgostlon), anaphylaxls, por-
slstont bloodlng, and oxcosslvo scarrlng. Curront
rocommondatlons lor troatmont vlth modlclnal
loochos lncludo prophylaxls vlth an amlnoglycosldo
and a thlrd-gonoratlon cophalosporln and cautlon
vhon troatlng lmmunocompromlsod patlonts.
261,265
Vasodilators
Many studlos
266270
shov lncroasod llap survlval
ln rats troatod vlth calcium-channel blockersog,
dlltlazom, nllodlplno, nltrondlplno, vorapamll
vhlch act on tho vascular smooth musclos to causo
vasodllatlon and lmprovo clrculatlon ln tho llap.
1hoso agonts do not rostrlct tholr ollocts to smooth
musclo, hovovor. lor lnstanco, dlltlazom has boon
shovn to stlmulato tho roloaso ol prostacyclln (lCl
2
),
a potont vasodllator and antlplatolot aggrogator, lrom
vascular ondothollal colls.
266
}ornbock and Dalsgaard
271
doscrlbo tho cllnlcal
appllcatlon ol lntravonous calcitonin gene-related
peptide ln tho troatmont ol llaps vlth compromlsod
clrculatlon.
1oplcal nitroglycerin ls a potont vasodllator vlth
a groator olloct on tho vonous clrculatlon than on
artorlal vossols. kohrlch and colloaguos
272
roportod
lmprovod survlval ol axlal llaps ln plgs and rats
troatod vlth nltroglycorln olntmont, as dld lrlco
and loarl,
273
vho appllod nltroglycorln trans-
dormally. Nlchtor,
274
on tho othor hand, lound no
lncroaso ln survlval ol random pattorn llaps ln rats
troatod vlth nltroglycorln pasto.
lchloka and othors
275
ovaluatod tho ollocts ol
amrlnono, a soloctlvo phosphodlostoraso lll lnhlbl-
tor, and lound onhancod mlcroclrculatory blood
llov lrom lts posltlvo lnotroplc and vasodllatlng prop-
ortlos, vlth a corrospondlng lncroaso ln vlablo aroa
ol llaps. ln a lator cllnlcal study, lchloka ot al
276
domonstratod an lncroaso ln mlcroclrculatory blood
llov ln llaps altor lntravonous admlnlstratlon and a
docroaso ln vasospasm altor toplcal appllcatlon ol
amrlnono to tho podlclo. 1ho rosults obtalnod vlth
amrlnono voro comparablo to tho rosults obtalnod
vlth prostaglandln L1 and lldocalno.
Crossman and assoclatos
277
roport lncroasod llap
survlval ln a rat modol vlth lntraporltonoal ln|oc-
tlon ol dimethyl sulfoxide (DMSC) or hyaluronldaso,
and postulato a docroaso ln tlssuo odoma vlth
rosultant lmprovod blood llov. Hallor, 1rachy, and
Cummlngs
278
noto lmprovod llap porluslon altor
lntraporltonoal ln|octlon ol DMSC as moasurod by
lasor Dopplor voloclmotry and porluslon llovmotry.
kand-Luby and covorkors
279
dotormlnod that topl-
31
cal appllcatlon ol DMSC lncroasod llap vlablllty ln
humans by controlllng skln lschomla through
vasodllatlon, roductlon ol platolot aggrogatlon, or
tho lroo-radlcal scavonglng proportlos ol DMSC.
1hoy llnd DMSC salo to uso ln a cllnlcal sottlng.
1ho ollocts ol toplcal lidocaine and pentobar-
bital, vhlch aro bollovod to lnhlblt ondothollum-
dopondont rolaxatlon on tho vascular smooth
musclo, voro studlod by Wadstrom and Cordln.
280
1hoy concludo that although thoro ls an olloctlvo
and prompt rosolutlon ol mochanlcally lnducod
vasospasm, tho ollocts aro clrcumvontod by
mlcrovascular thrombosls.
Prostacyclin (lCl
2
) ls a potont vasodllator vhlch
also docroasos platolot actlvatlon and lmpalrs tho
roloaso ol cytotoxlns lrom vhlto blood colls.
205
Lmorson and Sykos
281
shovod lmprovod survlval ol
random skln llaps ln rats altor troatmont vlth
prostacyclln. lCl
2
vas lound to bo olloctlvo only ll
glvon at tho tlmo ol llap olovatlon and contlnuod
postoporatlvoly. 1ho authors thoorlzo that porhaps
lCl
2
also stlmulatos nov vossol lormatlon ln
lschomlc tlssuo. Cthors
282,283
havo had slmllar
oxporloncos vlth oxogonously admlnlstorod lCl
2
ln laboratory anlmals, but cautlon that hlgh-doso
prostacyclln actually has a dotrlmontal olloct on skln
llap survlval.
283
Catoloy, McAnulty, and Martln
284
roport tvo lnstancos ol lntravonous lnluslon ol
prostacyclln lor lmpondlng lroo llap lalluro, vlth
subsoquont plnklng up ol tho llaps and a succosslul
outcomo to tho casos.
A lCl
2
analog, iloprost, vas ovaluatod by
Sondoroll ot al,
285
vho lound slgnlllcantly hlghor
llap survlval ratos ln tho study group comparod vlth
llaps porlusod vlth lactatod klngors or uroklnaso
solutlons. 1ho authors noto that lloprost has tho
samo actlon and potoncy as lCl
2,
but vlth groator
chomlcal stablllty and thorapoutlc potontlal. ln
addltlon, lloprost sooms to havo a cytoprotoctlvo
olloct that provonts lysosomal onzymo roloaso dur-
lng tlssuo hypoxla. konaud and assoclatos
286
roport
succosslul rosolutlon ol a lalllng lroo llap altor
lntraartorlal lnluslon ol lloprost ln tho acuto sottlng
and lntravonous admlnlstratlon postoporatlvoly.
Suzukl and colloaguos
287
doscrlbod tho uso ol
prostaglandin E
1
(lCL
1
). lts ollocts voro vory slml-
lar to prostacyclln ln causlng porlphoral vasodlla-
tlon and platolot dlsaggrogatlon. lCL
2
may bo avall-
ablo ln a moro stablo lorm and, llko lCl
1
, has boon
notod to havo a blphaslc rosponsolo, hlghor dosos
ol tho agont rosult ln hypotonslon and slgnlllcant
docroaso ln blood llov to tho vholo skln llap.
Free Radical Scavengers
A numbor ol lnvostlgators
288292
havo shovn
lncroasod llap survlval vlth allopurinol troatmont
ln a rat skln modol. Allopurlnol lnhlblts xanthlno
oxldaso and ln tho procoss loads to dlmlnlshod lroo
radlcal productlon and rotards tho loss ol purlno
substratos avallablo lor hlgh-onorgy motabollc syn-
thosls. llcard-Aml and colloaguos
293
noto that xan-
thlno oxldaso lovols ln human tlssuo aro 1/40th ol
thoso ln rats, castlng doubt on \C as a ma|or sourco
ol lroo radlcals rosponslblo lor tlssuo ln|ury and llap
nocrosls ln human skln.
1roatmont ol skln llaps vlth superoxide dismutase,
a scavongor ol lroo oxygon radlcals, has boon shovn
to lmprovo llap survlval.
201
Manson and col-
loaguos
203
roportod that a slnglo doso ol SCD
lmprovod llap survlval lrom 38 to 76 ln rats.
1lssuo lovols ol SCD voro hlghor ln tho survlvlng
portlons ol llaps. Suzukl and covorkors
294
con-
llrmod tho bonollclal ollocts ol SCD ln provontlng
llap nocrosls, and suggostod that roporluslon lol-
lovlng lschomla, not contlnuous lncomploto
lschomla, producos roactlvo oxygon spoclos and a
gradual lncroaso ln blood llov ln tho dlstal llap.
Havkos, oung, and Cloland
295
noto anaphylactlc
roactlons ln a plg modol assoclatod vlth tho uso ol
suporoxldo dlsmutaso.
Angol and colloaguos
296
also domonstratod
lmprovod llap survlval vlth deferoxamine, an lron
cholator and lroo radlcal scavongor. Doloroxamlno
has boon shovn to dlmlnlsh llap nocrosls causod by
undorlylng homatomas. lts bonollclal olloct on llaps
probably rolatos to lts ablllty to scavongo lroo radl-
cals, although Croon and assoclatos
297
stato that tho
loglc bohlnd uslng cholators such as doloroxamlno
ls to lnhlblt hydroxy radlcal lormatlon lrom supor-
oxldo radlcals.
Antiinflammatory Agents
1ho rolo ol storolds on llap survlval contlnuos to
bo hotly dobatod. Nancarrov
298
domonstratod a
25 lncroaso ln survlval ol groln lsland llaps ln rats
altor admlnlstratlon ol 1.5 mg/lg ol dexametha-
sone 12 hours prooporatlvoly. Nakatsuka and oth-
ors
299
studlod tho olloct ol methylprednisolone on
32
plg musculocutanoous, axlal, and random pattorn
llaps. 1hoy lound no lncroaso ln aroa ol llap sur-
vlval or lluoroscoln dyo ponotratlon. 1horo vas
no lncroaso ln skln caplllary blood llov as moa-
surod by ontrapmont ol radloactlvo mlcrosphoros.
ln summary, thoro vas no ovldonco to support tho
cllnlcal uso ol cortlcostorolds to onhanco llap
vlablllty. 1hoso llndlngs voro ln contrast vlth
thoso ol Lsclamado, Larraboo, and Zol,
242
vho
obsorvod that porloporatlvo storolds dld lmprovo
skln llap vlablllty.
lorrlgan and Stotland
295
rovlov tho accumulatod
data rogardlng attompts to modulato tho prolnllam-
matory mochanlsm lnvolvod ln roporluslon ln|ury.
Varlous studlos havo lnvolvod platolot actlvatlng lac-
tor antagonlsm, soloctlvo lnhlbltlon ol loukotrlono
synthosls to provont loukocytoondothollal coll
adhoslon and macromolocular loakago, lnhlbltlon
ol thromboxano and complomont, and antlbodlos
dlroctod agalnst noutrophll toxlclty.
1hromboxano A
2
(1xA
2
) ls a potont vasoconstrlc-
tor and platolot aggrogator roloasod by platolots.
lrostacyclln (lCl
2
) ls a potont vasodllator and
lnhlbltor ol platolot aggrogatlon producod by
ondothollal colls. oth aro products ol arachldonlc
acld motabollsm and havo strong ollocts at tho
ondothollal coll lovol
285
(llg 30).
Fig 30. 1ho motabollsm ol arachldonlc acld. (Reprinted with
permission from Senderoff DM, Israeli D, Zhang WX, et al: Iloprost
improves survival of ischemic experimental skin flaps. Ann Plast
Surg 32:490, 1994.)
Asplrln (ASA) acotylatos tho onzymo cyclo-
oxygonaso, thoroby docroaslng tho synthosls ol 1\A
2
ln platolots and lCl
2
ln tho vossol valls. At lov
dosos tho olloct ol asplrln ls soloctlvo and only tho
cyclooxygonaso systom ln platlots ls lnhlbltod and
tho lormatlon ol thromboxano ls blockod. ln tho
laboratory, prooporatlvo asplrln docroasos throm-
bus lormatlon at vonous anastomosls and lmprovos
caplllary porluslon ln tho mlcroclrculatlon.
300
Cthor
studlos domonstrato lncroasod oarly anastomotlc
patoncy but no dllloronco lrom controls altor 24
hour to a vook.
205
Salomark and assoclatos
301
studlod tho posslblo
rolo ol ASA as an antlthrombogonlc agont. 1holr
rosults voro dlssapolntlng ln that ASA shovod both
bonollclal and dotrlmontal ollocts dopondlng on
vhon tho ln|octod drug vas oxposod to tho subon-
dothollal layors ol tho damagod vossol vall.
1horo ls no omplrlc support ln tho lltoraturo lor
tho uso ol asplrln postoporatlvoly.
205
uckloy,
Davldson, and Das
302
oxplorod tho ollocts ol anothor
NSAlD, kotorolac tromothamlno (1oradol). Dosplto
slgnlllcantly prolongod moan bloodlng tlmos, mark-
odly roducod platolot aggrogatlon, and consldor-
ably hlghor patoncy ratos ln tho kotorolac group at
20 mln, all vossols thrombosod at 24 hours.
Nicotine
lorrost, lang, and Llndsay
303
doscrlbod tho ollocts
ol nicotine on caplllary blood llov ln random pat-
torn skln llaps olovatod ln rats. 1ho authors lound
that nlcotlno slgnlllcantly docroasod caplllary blood
llov, dlstal porluslon, and llap survlval ln a doso-
and tlmo-dopondont lashlon, and proposod sovoral
hypothosos to oxplaln tho mochanlsm ol actlon ol
tho drug. lack ot al
304
noto that acuto oxposuro ol
human skln vasculaturo to nlcotlno ls assoclatod
vlth ampllllcatlon ol noroplnophrlno-lnducod skln
vasoconstrlctlon and lmpalrmont ol ondothollum-
dopondont skln vasorolaxatlon.
MONITORING FLAP VASCULARITY
Dosplto tho cllnlcal succoss ol lroo llaps, strlct
ovaluatlon ol llap porluslon ls ossontlal to provont,
rocognlzo, and troat compllcatlons. 1ho lalluro rato
ol lroo tlssuo translor ls roportod to bo loss than 5,
hovovor, tho lncldonco ol podlclo thrombosls ls
hlghor than tho lalluro rato vould rolloct duo to a
33
salvago rato altor podlclo thrombosls that rangos
lrom 3670.
259
Sovoral tochnlquos havo boon
suggostod to assoss porluslon ol llap tlssuos ln an
attompt to prodlct llap survlval.
29,305,306
1hoso moth-
ods aro rovlovod by lurnas and koson,
307
1ruolson,
308
radlord,
309
and Capany.
310
rovn ot al
311
rotrospocltvoly rovlovod succoss-
lul lroo llap salvago at tholr lnstltutlon. Duo to
moro succosslul salvago vlthln tho llrst 24 hours
altor tho lnltlal surgory, thoy rocommondod hourly
monltorlng lor tho llrst 24 hours and thon ovory 4
hours lor 48 hours .
1ablo 5 lrom Danlol and lorrlgan
29
summarlzos
varlous monltorlng tools usod to assoss llap vlablllty.
Accordlng to tho authors, tho ldoal monltorlng
dovlco should
rolloct tho condltlon ol tho ontlro (burlod) llap
bo rollablo, roproduclblo, conslstont, and sonsl-
tlvo
provldo contlnuous monltorlng
bo usor-lrlondly and oaslly lntorprotod
bo allordablo
bo rolatlvoly unalloctod by tho oxtornal onvl-
ronmont
Subjective/Physical Criteria
Cllnlcal obsorvatlon romalns tho gold standard
agalnst vhlch monltorlng systoms aro gonorally
moasurod...and lt...lullllls many ol tho crltorla ol
tho ldoal monltorlng systom.
306
Cllmo
312
survoyod
varlous cllnlcal moasuromonts ol llap vascularlty as
ol 1951 and notod that tho color of the blood ooz-
ing from the dermis vas a rollablo lndlcator ol clr-
culatory status. luo dormal bloodlng vas tho bost
varnlng slgn ol lnadoquato porluslon. Hoopos,
194
hovovor, bollovos that lt ls a mlsconcoptlon to
oquato blood supply vlth vlablllty, tho cruclal tost
ol adoquacy ol clrculatlon ls survlval ol tho podlclod
llap tlssuo.
Danlol and lorrlgan
29
rovlov varlous tochnlquos
lor sub|octlvoly ovaluatlng llap vlablllty and noto
that color, caplllary blanchlng, and varmth aro
unrollablo and ol llmltod uso. Cl tho sub|octlvo
tosts, bloodlng lrom a stab vound ls probably tho
most accurato. 1ablo 6 outllnos tho cllnlcal slgns
that can bo usod to dlllorontlato vonous lrom art-
orlal maladlos ln llaps.
Temperature monltorlng ls a slmplo tochnlquo to
ovaluato llap vlablllty. lt can bo accompllshod ln a
numbor ol vays, lncludlng surlaco tomporaturo and
dlllorontlal thormomotry. ln gonoral, surlaco tom-
poraturo can bo takon oaslly, roqulros rolatlvoly
lnoxponslvo oqulpmont, and ls cllnlcally usolul ln
monltorlng lor oxtrlnslc compllcatlons. As an lndl-
cator ol lntrlnslc llap lalluro lt ls lnadoquato, hov-
ovor. Dlllorontlal thormomotry ls a usolul tool to
monltor vascular patoncy ln burlod lroo tlssuo trans-
lors ln vhlch a tomporaturo gradlont oxcoodlng
3C ls consldorod slgnlllcant.
29
}onos, Dunscombo, and Croonhalgh
313
took sorlal
tomporaturo moasuromonts ol llap skln and control
skln slmultanoously ln ordor to nogato onvlronmontal
and motabollc varlablos. 1hoy lound that skln tom-
poraturo rospondod slovly to vascular occluslon and
vas not a rollablo lndlcator ol llap lalluro ln tho
lmmodlato postoporatlvo porlod. 1omporaturo
roadlngs, hovovor, can bo usod olloctlvoly to track
tho courso ol roplantod dlglts.
lhourl and Shav
314
rovlov surlaco tomporaturo
rocordlngs ol 600 lroo llaps and concludo that vhon
proporly appllod and lntorprotod, lts sonsltlvlty and
prodlctlvo valuo approach 98 and 75, maklng lt
a slmplo, lnoxponslvo, and hlghly rollablo tochnlquo
ol lroo llap monltorlng.
Cho ot al
315
and Akln and asut
316
croatod small
monltorlng llaps that aro oxtorlorlzod to lacllltato
monltorlng ol burlod lroo llaps. 1ho monltorlng
llap ls basod on a porlorator lod by tho maln podlclo.
1ho authors voro ablo to prodlct podlclo compro-
mlso lrom tho appoaranco ol tho monltorlng llap.
Vital Dye Measurements
Fluorescein has boon usod lor ovor 40 yoars to
cllnlcally assoss llap vascularlty.
317
ln 1962 Myors
318
rovlovod tho hlstory ol lluoroscoln and usod lt to
dotormlno tho vlablllty ol skln llaps altor radlcal
mastoctomy. McCrav, Myors, and Shanklln
319
dollnoatod tho pharmacologlc charactorlstlcs ol lluo-
roscoln that onablod lt to bo an lndlcator ol blood
llov, omphaslzod lts morlts ln prodlctlng tho vlabll-
lty ol artorlal llaps, and suggostod cllnlcal appllca-
tlons. lluoroscoln ls bollovod to bo bottor than
70 accurato as an lndlcator ol tho clrculatory sta-
tus ol a llap.
lluoroscoln ls usually glvon ln a bolus ln|octlon
ol 500 to 1000 mg (15 mg/lg). Altor a valtlng
34
porlod ol 2030 mln, tho oxtont ol dyo stalnlng ln
thoso tlssuos vhlch aro adoquatoly porlusod can bo
soon vlth a Woods lamp. ll nocossary tho tost can
bo ropoatod ovory 8 hours,
29
although othors sug-
gost valtlng 24 hrs.
320
lang and othors
321
roport
that vhon tho lluoroscoln tost ls porlormod 1 hour
altor llap olovatlon, tho longth ol llap that ls vlablo ls
conslstontly undorostlmatod. Whon tho tost ls por-
lormod at 18 hours postoporatlvoly, tho longth ol
dyo stalnlng and skln vlablllty corrolatod vory voll.
1hoso rosults voro obtalnod ln random llaps, axlal
pattorn llaps, and musculocutanoous llaps.
TABLE 5
Techniques for Monitoring Flap Perfusion
(Reprinted with permission from Daniel RK, Kerrigan CL: Principles and physiology of skin flap surgery. In: McCarthy JG (ed), Plastic Surgery.
Philadelphia, Saunders, 1990. Vol 1, Ch 9.)
35
Myors and Donovan
322
noto that all tochnlquos
lor ovaluatlng llap porluslon vlth lluoroscoln aro
roasonably accurato, lncludlng tho tradltlonal
Woods lamp mothod vhlch vas as rollablo as novor
onos. ln tholr oplnlon, lnaccuraclos ln lluoroscoln
tostlng aro probably lnhoront and unavoldablo, ln
that lt only moasuros vascularlty at tho tlmo tho dyo
ls glvon and blood supply can chango. Moro spo-
clllcs aro glvon by Cdland ot al,
323
vho noto that
slnco lluoroscoln ls a dorlvatlvo ol phthaloln, a pH
lndlcator, and lschomlc tlssuos bocomo acldotlc,
tho acldosls mlght quonch tho oxpoctod lluoros-
conco ln tho dlstal skln llap.
Sllvorman, Norton, and roussoau
324
doscrlbod
tho uso ol perfusion fluorometry, a tochnlquo vhoro
tho admlttod lluorosconco ol tho tlssuo ls moasurod
uslng a llboroptlc llght guldo (dormolluoromotor)
and an ob|octlvo valuo ol dyo-lluorosconco unlts ls
obtalnod. Accurato roadlngs can bo mado as oarly
as 2 mlnutos altor ln|octlon, and sorlal ln|octlons
and moasuromonts aro posslblo bocauso tho dosos
ol dyo aro small (0.15 mg/lg). 1ho mothod vas
96 accurato ln prodlctlng ultlmato llap vlablllty at
lovor dosago and vlth lovor sldo-ollocts than lluo-
roscoln tostlng.
Dormolluoromotry has rocontly boon appllod to
vonous llaps. Suzukl ot al
325
comparod artorlallzod
to nonartorlallzod and random-pattorn llaps and
notod that tho lnstrumont ls a rollablo lndlcator ol
clrculatlon ln all typos ol llaps ovaluatod.
1homson and lorrlgan
326
doscrlbod tho lormula
lor calculatlng tho dyo lluorosconco lndox (Dll) and
documontod that lluorosconco varlos vlth blood
supply. 1ho authors conllrmod tho accuracy ol
dormolluoromotry ln prodlctlng skln llap survlval ln
plgs. Cllnlcally, a Dll ol 30 or moro ls consldorod
salo.
lsslng and Naumann
327
usod computor-aldod dlgl-
tal morphomotry (CADM) to comparo lluoroscoln
stalnlng, skln pH, and skln tomporaturo ln tho ovalu-
atlon ol skln llap porluslon. 1hoy concludo that
lluoroscoln stalnlng ls tho most accurato prodlctor
ol llap vlablllty.
lndocyanlno groon (lCC) ls a socond-gonora-
tlon dyo that can bo usod as a cllnlcal markor ol
cutanoous blood llov. 1ho prlnclplo ol monltor-
lng ls slmllar to that ol lluoroscoln, but tho choml-
cal proportlos ol lndocyanlno groon aro moro sult-
ablo to cllnlcal uso.
328
lCC has boon usod succoss-
lully ln oxporlmontal and cllnlcal modols.
328331
lntraoporatlvo lasor-lnducod lluorosconco ol lCC
shovod artorlal spasm, vonous congostlon, and
roglonal hypoporluslon ln mlcrovascular llaps and
corrolatod strongly vlth tho cllnlcal outcomo.
329
Photoelectric Assessment
1vo typos ol Dopplor lnstrumonts aro currontly
ln cllnlcal uso. 1ho llrst ls tho ultrasound Dopplor,
vhlch usos rolloctod sound to plck up pulsatllo vos-
sols. 1ho socond ls tho laser Dopplor, vhlch moa-
suros tho lroquoncy shllt ol llght and thoroloro has
llmltod ponotratlon (1.5 mm).
29
Amorhausor and assoclatos
332
ovaluatod color
flow ultrasound (ClUS) ln an oxporlmontal and cllnl-
cal sottlng and notod that lt vas sonsltlvo to vonous
and artolal lnsulllcloncy at llov ratos as lov as 3.0
mL/mln. 1hoy lound ClUS vas capablo ol dlllor-
ontlatlng blood llov and vas prollclont at vlsuallz-
lng lumlnal dlssoctlons, lntlmal llaps, thrombosos,
and artorlolar constrlctlons.
1ho laser Doppler flowmeter glvos an output volt-
ago proportlonal to tho total llux ol rod blood colls
ln tho volumo ol tlssuo samplod (approxlmatoly 1
mm
3
), and thus lncludos tho subcaplllary ploxus.
1ho tochnlquo ylolds tvo valuos.
333
a Dopplor llov
moasuromont, vhlch ls a rolloctlon ol tho numbor
and voloclty ol movlng rod blood colls and vhlch
docroasos to lov lovols ln rosponso to artorlal or
vonous occluslon, and a photomotry valuo, vhlch
ls a photoplothysmographlc roadlng ol tho lntonslty
ol tho back-scattorod llght. 1hls valuo doos not
chango vlth artorlal occluslon but docroasos ln
rosponso to vonous occluslon, holplng to dlstlngulsh
TABLE 6
Signs of Arterial Occlusion and Venous Congestion
(Reprinted with permission from Adams JF, Lassen LF: Leech
therapy for venous congestion following myocutaneous pectoralis
flap reconstruction. ORL-Head Neck Nurs 13:12, 1995.)
36
botvoon vonous and artorlal causos ol llap ombar-
rassmont.
Hallock
334
lnvostlgatod tho crltlcal throshold lor
tlssuo vlablllty as dotormlnod by lasor Dopplor
llovmotry, and lound that a basollno ol 30 ls gon-
orally sulllclont to prodlct llap survlval. Hodon and
assoclatos
335,336
lound that lasor Dopplor llovmotry
corrolatod voll vlth actual skln vlablllty and nocro-
sls ln tho lmmodlato postoporatlvo porlod. A sonsl-
tlvlty ol 93 and spoclllclty ol 94 voro rocordod
by tho Hovlus group.
337
lrchor ot al
338
provldo an ln-dopth ovorvlov ol
guldollnos lor tho moasuromont ol cutanoous blood
llov by lasor Dopplor llovmotry. Svonsson,
Holmborg, and Svodman
339
rovlov tho propor
lntorprotatlon ol lasor Dopplor rocordlngs lrom lroo
llaps and suggost tho lollovlng guldollnos to lmprovo
accuracy ol tho analysls.
a llxod probo
contlnuous rocordlngs
attontlon to physlologlc lluctuatlons and tronds
Many lactors alloct tho cllnlcal usolulnoss ol thoso
tochnlquos. Among thom aro oaso ol appllcatlon,
oqulpmont cost, and oxportlso roqulrod to oporato.
Sllvorman and covorkors
340
comparod tho lasor
Dopplor, porluslon lluoromotry, and transcutano-
ous oxygon assay mothods and concludod that lluo-
romotry ls moro proclso and can bo usod to monl-
tor sovoral aroas ln sorlal lashlon. 1ranscutanoous
oxygon and Dopplor problng voro bottor sultod lor
contlnuous monltorlng. Cummlngs and col-
loaguos
341
roachod slmllar concluslons but ompha-
slzo, as doos Marks,
342
that boglnnlng 24 hours post-
oporatlvoly tho lasor Dopplor tochnlquo ls tho most
sonsltlvo.
llaco, Wltt, and Hondrlcks
343
agroo that Dopplor
llovmotry ls a usolul tool lor assosslng llap vlablllty,
but stross that slnco postoporatlvo blood llov ls a
dynamlc procoss that poaks about 52 to 80 hours
and roturns to basollno somo 120 hours postopora-
tlvoly, no slnglo moasuromont ls lndlcatlvo ol any-
thlng oxcopt tho status at that ono tlmo.
uon and long
344
roportod a 5-yoar oxporlonco
vlth lasor Dopplor llovmotor monltorlng ol 232
mlcrovascular llaps. Vascular compromlso vas
dotoctod ln all casos, vlth no lalso posltlvos or noga-
tlvos. 1ho salvago rato vas 69 and tho ovorall
succoss rato vas 98.
Advantagos ol Dopplor problng aro hlgh rollabll-
lty (approachlng 100 24 hrs altor llap translor)
and tho ablllty to contlnuously monltor skln porlu-
slon by a nonlnvaslvo tochnlquo. Dlsadvantagos
aro that lt ls not quantltatlvo, lt obtalns lnlormatlon
only lrom a slnglo slto, ls sonsltlvo to movomont ol
tho sub|oct, and has llmltod accuracy bolov tho
crltlcal throshold at vhlch tlssuo nocrosls ls guaran-
tood.
345
1ho scannlng lasor Dopplor
346
and lasor
llovgraph
347
may glvo a moro global plcturo ol tho
llap than could bo obtalnod by Dopplor llovmotry.
ln lorrlgan and Danlols vlov, hovovor, no slnglo
tochnlquo ls unlvorsally appllcablo or suporlor to all
othors.
199
Metabolic
1sur and covorkors
348
moasurod transcutaneous
oxygen tension ln dolayod axlal and random pat-
torn skln llaps by moans ol an oxygon oloctrodo
appllod to tho skln. 1hoy lound oxygon partlal-
prossuro moasuromonts to bo an olloctlvo prodlc-
tor ol tho olloctlvonoss ol tho dolay procoduro.
Slmllarly, H|ortdal and colloaguos
349
lound moasuro-
mont ol subcutanoous and lntramuscular oxygon
tonslon ln plg lsland llaps to bo a sonsltlvo lndlcator
ol acuto lmpalrmont ol tho supplylng vossols.
lorrlgan and Danlol
350
ovaluatod caplllary blood
samplos ln plg lsland llaps and notod that vhllo PC
2
and PCC
2
moasuromonts voro hlghly varlablo,
changos ln homatocrlt and pH voro usolul prodlc-
tors ol llap vlablllty. Cthor loss popular mothods ol
ovaluatlng clrculatlon ln a llap lncludo moasuro-
mont ol tho llbrlllatlon potontlal ln skolotal musclo,
351
magnotlc rosonanco lmaglng,
352
and magnotlc roso-
nanco spoctroscopy.
353
Coldo and Mahonoy
354
doscrlbod an lmplant-
ablo optochomlcal oxygon-sonslng oloctrodo
dovlco or optode that allovs rapld and contlnuous
monltorlng ol tlssuo PC
2
and vhlch vas lolt to
rollably rolloct vascular occluslon. 1ho probo ls
small, oaslly lmplantablo, and lndopondont ol anas-
tomotlc proxlmlty, but tho authors dld not com-
mont on tho ablllty ol tho optodo to dlllorontlato
botvoon artorlal and vonous compromlso. 1ho
lmplantablo PC
2
sonsor ln Holors
355
sorlos accu-
ratoly lndlcatod llap lalluro ln all casos, yot tho
authors doclslon to rooxploro a lalllng lroo llap
vas stlll basod on cllnlcal obsorvatlon.
37
Photoplethysmography ls a tochnlquo that moa-
suros lluld volumo by dotoctlng varlatlons ln lnlra-
rod llght absorptlon by tho skln. lts curront uso ln
cllnlcal practlco has sovoral llmltatlons.
29,305,307
ln
addltlon to dlsplaylng tho vavolorms ol tho
photoplothysmograph, tho pulse oximeter also moa-
suros llght absorptlon to dorlvo oxygon saturatlon ol
artorlal homoglobln. 1ho dovlco ls commonly usod
ln anosthoslology and vas ovaluatod by Llndsoy ot
al,
356
vho domonstratod lts usolulnoss but rocom-
mondod lurthor study to dovolop spoclllc guldo-
llnos boloro lt vas unlvorsally accoptod ln cllnlcal
practlco.
lrvln ot al
357
ovaluatod a novor and nonlnvaslvo
tochnlquo lor assosslng llap clrculatlon that lnvolvos
contlnuous monltorlng ol changos ln tho oxy-,
dooxy-, and total homoglobln concontratlons ol llap
blood. ln addltlon to doopor ovaluatlon (up to 10
cm) ol llaps than ls posslblo vlth tho lasor Dopplor,
near infrared spectroscopy (NlkS) vas ablo to
dollnoato tho dllloronco botvoon artorlal, vonous,
and total vascular occluslon.
Cthor moans ol ovaluatlng llaps lncludo quantl-
tatlvo tosts, cloaranco tosts, radloactlvo mlcrosphoros,
and oloctromagnotlc llovmotry. 1hoso aro osson-
tlally rosorvod lor oxporlmontal puposos only, and
vlll not bo dlscussod horo.
SKIN EXPANSION
James F Thornton MD
HISTORY
onnot and Hlrt
1
rovlov tho hlstory ol tlssuo
oxpanslon and noto that lts orlglns dato to Colsus (25
C50 AD), vho doscrlbod tho tochnlquo ol vound
closuro by croatlng, strotchlng, and approxlmatlng
skln llaps. ln 1957 Noumann
2
roportod tho llrst
cllnlcal uso ol controllod skln oxpanslon. Ho placod
a rubbor balloon subcutanoously bonoath tho tom-
poral scalp and postaurlcular skln. Cvor tho noxt 2
months tho balloon vas gradually oxpandod, lncroas-
lng tho skln aroa by approxlmatoly 50 or onough to
provldo sulllclont covor lor cartllago gralt roconstruc-
tlon ol a traumatlc oar doloct. Not untll 1976, vhon
kadovan
3
roportod hls vork vlth tlssuo oxpanslon
lor broast roconstructlon, dld tho potontlal usolul-
noss ol thls tochnlquo bocomo obvlous. Slnco thon,
controllod tlssuo oxpanslon has boon usod lor tho
roconstructlon ol all aroas ol tho body ln many dlvorso
probloms. akor
4
summarlzos tho hlstory and
dynamlcs ol tlssuo oxpanslon.
TECHNIQUE
Modorn oxpandors aro mado ol slllcon olastomors
and como ln sovoral shapos and slzos or aro cus-
tom-mado to llt lndlvldual noods. 1ho oxpandor ls
usually connoctod to a subcutanoous valvo through
vhlch lsotonlc sallno ls ln|octod lor lncromontal
oxpanslon. }ackson and colloaguos
5
doscrlbod uslng
an oxtornal rosorvolr that vas assoclatod vlth lov
compllcatlons, but tho authors do not rocommond
lt ln casos vhoro a pormanont prosthosls ls plannod,
such as lor broast roconstructlon.
1ho tlmo lntorval botvoon ln|octlons ol sallno
lor gradual oxpanslon doponds on tho naturo ol tho
doloct and lts anatomlc locatlon as voll as host tls-
suo charactorlstlcs. 1ho lntorval rangos lrom 3 to
10 days. Hallock and klco
6
advocato monltorlng
tho oxpanslon procoss vlth a comblnatlon ol trans-
cutanoous oloctrodos lor moasurlng oxygon lovols,
lmplant prossuro, and local porluslon to gaugo tho
ond-polnt ol oach oxpanslon sosslon. Comparlng
slmultanoous lasor Dopplor llovmotry and transcu-
tanoous oxygon monltorlng,
7
thoy noto that olthor
tochnlquo rocords dlmlnlshod clrculatlon ln
rosponso to lncroasod oxpanslon, but adoquato tls-
suo clrculatlon stlll oxlsts at tho throshold ol paln.
llotlla and colloaguos
8
rocommondod ovorlllllng
tho oxpandor to lncroaso tho amount ol oxpanslon at
oach sosslon and shorton tho total oxpanslon porlod,
but Van ook and Adson
9
cautlon that ll tho lntralu-
mlnal prossuro oxcoods 500 mmHg, loakago at tho
ln|octlon port ls llkoly, ospoclally vhon uslng largo-
callbor noodlos. Although rapld oxpanslon ls pos-
slblo ln somo clrcumstancos, prosorvlng tlssuo lntog-
rlty takos procodonco ovor spood ol oxpanslon.
Van kappard ot al
10
ovaluatod tho dllloroncos ln
surlaco aroa ol oxpandod tlssuo ln rolatlon to shapo
ol tho lndlvldual oxpandor. lor oxpandors vlth a
round baso, a roctangular baso, or a croscontlc baso,
tho rospoctlvo galns voro 25, 38, and 32.
1ho authors concludod that an oxpandor ol appro-
prlato slzo has a baso that ls 2.5 tlmos as largo as tho
doloct to bo closod.
Matton and assoclatos
11
doscrlbod a unlvorsal
lnclslon lor tlssuo oxpandor lnsortlon that has boon
shovn to mlnlmlzo tho compllcatlons soon vlth
38
othor lnclslons. Austad and koso
12
doscrlbod a soll-
lnllatlng oxpandor contalnlng hyportonlc sodlum
chlorldo crystals vlthln a sholl that gradually lllls
through osmosls. osldos tho protractod lnllatlon
tlmos ol 8 to 14 vooks, tho dovlco vas plaguod by
roports ol skln nocrosls and lmplant rupturo. 1ho
concopt ol a soll-lnllatlng oxpandor vas oxplorod
lurthor by Wloso,
13
vho lncorporatod a copolymor
ol mothylmothacrylato and N-vlnyl-2-pyrrolldono
ln a gol caslng capablo ol gonoratlng a maxlmum
prossuro ol 235 mmHg. 1ho author notos that thls
oxpandor ls blocompatlblo and holds promlso ln
tho aroa ol tlssuo oxpanslon vlthout tho dlsadvan-
tagos notod abovo.
org and colloaguos
14
roportod dlroct closuro
vlth Hydrogol tlssuo oxpandors ln 9 ol 10 patlonts.
1ho dolocts closod voro tho rosult ol radlal loroarm
llap harvost. At lmplantatlon tho lnltlal volumo ol
tho oxpandors vas 10 mm, and ovor 20 days thoy
voro lnllatod to 100 mm.
HISTOLOGY OF EXPANDED SKIN
}ohnson ot al
15
rovlov tho hlstology and physlol-
ogy ol tlssuo oxpanslon. Austad and colloaguos
16,17
studlod changos ln tho opldormls, dormls, and sub-
cutanoous tlssuo ol oxpandod gulnoa plg skln. Com-
parod vlth normal skln, oxpandod skln shovod a
slgnlllcantly thicker epidermisvhlch thoy attrlb-
utod olthor to lncroasod mltotlc rato or docroasod
rato ol coll turnovorand a thinner dermis and
pannlculus carnosus. 1horo vas mlnlmal lnllam-
matory roactlon to tho oxpandor. 1holr conclu-
slons slgnlllod that skln oxpanslon ls not slmply a
mattor ol strotchlng skln but tho actual lormatlon ol
addltlonal nov skln vlth all tho attrlbutos ol tho
orlglnal tlssuo.
Argonta and covorkors
18
summarlzo tho
hlstomorphologlc changos occurrlng ln oxpandod
skln. 1ho opldormls doos not chango ln thlcknoss,
although thoro ls an undulatlon ol tho basal lamlna
and a loss ol lntorcollular spacos. 1ho surroundlng
dormls docroasos ln thlcknoss consldorably, and
lncroasod numbors ol llbroblasts and myollbroblasts
aro soon ln tho oxpandor capsulo. 1ho llbrous
capsulo that lorms around tho lmplant conslsts ol
thlck bundlos ol collagon llbors and olongatod
llbroblasts and myollbroblasts. 1lssuo oxpanslon
also trlggors an lncroaso ln vasculaturo, prlmarlly at
tho |unctlon ol tho capsulo and host tlssuo and to a
lossor dogroo ln tho dormls. Musclo and lat both
dlmlnlsh ln mass ln rosponso to oxpanslon, and
vhllo thoro ls no loss ol musclo lunctlon, tho loss ol
lat appoars to bo pormanont.
Llko Austad, lasyk ot al
19
notod slgnlllcant thlck-
onlng ol tho opldormls altor 5 vooks ol oxpanslon,
as voll as slgnlllcant thlnnlng ol tho dormls and
subcutanoous tlssuos. Lolghton and assoclatos
20
lound dlllorontlal thlnnlng ol all tlssuo layors oxcopt
tho opldormls, vhlch vas unchangod. Clonlus and
}ohansson
21
also roport slgnlllcant lncroaso ln opl-
dormal thlcknoss, but 6 months altor tho ond ol
oxpanslon tho opldormls had roturnod to normal
thlcknoss. Clonlus, Dalsgaard, and Wlckman
22
stud-
lod tho mltotlc actlvlty ol human skln samplos altor
tlssuo oxpanslon and notod a statlstlcally slgnlllcant
rlso ln tho numbor ol labolod basal and suprabasal
koratlnocytos. 1hls conllrmod oarllor llndlngs ol
lncroasod mltosls
17
and suggostod a net gain ol tls-
suo, not only by strotchlng tho oxlstlng aroa but
through gonoratlon ol nov tlssuo.
1ho phonomonon ol tlssuo grovth ln rosponso to
mochanlcal oxpanslon has boon lnvostlgatod by 1akol
and colloaguos.
23
1ho authors stato. 1ho mocha-
nlsm by vhlch straln causos an onhancomont ol col-
lular grovth appoars to bo a notvork ol sovoral lnto-
gratod cascados, lmpllcatlng grovth lactors, cytos-
koloton, and tho protoln klnaso lamlly. . . . Addltlonal
ovldonco has accumulatod that mochanlcal straln
stlmulatos slgnal transductlon pathvays that could
trlggor a sorlos ol cascados ovontually loadlng to a
nov skln productlon.
23
Normal human skln ls contlnually undorgolng
strotchlng and rolaxatlon. Collagen llbors oxlst ln a
convolutod lorm and, unllko llbors mado ol elastin,
aro lncapablo ol roturnlng to tholr rolaxod stato
altor bolng strotchod. ll tho llmlts ol tho olastlc
llbors aro oxcoodod, pormanont dolormatlon ol
collagon may rosult.
24
Molls and colloaguos
25
lound
changos ln tho orlontatlon ol collagon llbors ln tho
dormls as a rosult ol skln strotchlng. Altor 15 mln-
utos ol strotchlng vlth a skln-strotchlng dovlco, tho
llbors bocamo allgnod ln tho dlroctlon ol tho strotch-
lng lorco, porpondlcular to tho vound margln. 1hls
dynamlc roallgnmont ol collagon llbors oxplalns tho
slgnlllcantly docroasod vound closlng tonslon
rosultlng lrom skln strotchlng and oxplalns hov skln
strotchos boyond lts lnhoront oxtonslblllty.
Chang ot al
26
lound that tlssuo oxpanslon ln tho
rat lnhlblts tho contractllo lunctlon ol dormal llbro-
39
blasts ln vltro. 1hls olloct vas moro pronouncod
altor 5 vooks than ln tho llrst 1 or 2 vooks ol
oxpanslon. Loo, Squlor, and ardach
27
had provl-
ously notod that antlcontractllo agonts lnstlllod lnto
tho tlssuos surroundlng an oxpandor onhancod tho
rato and oxtont ol skln oxpanslon, prosumably
through rolaxatlon or lnactlvatlon ol contractllo
llbroblasts ln tho porlprosthotlc capsulo.
oauchonno
28
dotoctod hlghor lovols ol hydro-
xyprollno and a not accumulatlon ol collagon ln
oxpandod skln comparod vlth normal skln. }ohnson,
lornahan, and auor
29
llkovlso notod lncroasod
total collagon contont ln oxpandod skln, vhlch
rosultod ln a thoorotlcal not galn ln tho dormal layor
as voll as ln tho opldormal layor. lnlght and
covorkors
30
conllrmod lncroasod collagon contont
ln oxpandod dormls ol plgs, and spoculatod that lt
could bo duo to tonsllo lactors durlng oxpanslon
vhlch stlmulatod blosynthotlc actlvlty or mltosls ol
llbroblasts.
1lmmonga and covorkors
31
notod thlckonod
dormal collagon bundlos and collagon llbrlls that
voro loosoly packod ln both oxpandod and sham-
oporatod skln. 1ho mochanlsm ol actlon vas thought
to bo tho normal procoss ol vound hoallng ln addl-
tlon to a dolay phonomonon. Wlckman, Hodon,
and }uroll
32
roport adronorglc suporsonsltlvlty ln
oxpandod plg skln, suggostlng sympathotlc donor-
vatlon as a rosult ol oxpanslon.
lasyk, Austad, and Chorry
33
noto lormatlon ol a
capsulo around ovory slllcono oxpandor. 1ho cap-
sulo has lour hlstologlcal zonos.
lnnor zonoad|acont to tho oxpandor. Con-
talns llbrln-llko lllamonts and a collular layor vlth
macrophagos.
Contral zononoxt to tho lnnor zono. Con-
talns olongatod llbroblasts and myollbroblasts orl-
ontod parallol to tho surlaco ol tho lmplant.
1ransltlonal zonoon tho outsldo ol tho contral
zono. Has looso bundlos ol collago llbors.
Cutor zonomost suporllclal layor. Has ostab-
llshod vossols loosoly lntorsporsod vlth collagon
llbors.
Cnco an oxpandor ls romovod, tho surroundlng
llbrous capsulo rapldly thlns. Matturrl and colloaguos
34
blopslod provlously oxpandod skln at loast 1 yoar
altor oxpandor romoval and lound normal-appoarlng
opldormls vlth normal mltotlc actlvlty. 1ho dormls
shovod only mlnlmal dogroo ol olastosls and zonal
lragmontatlon ol olastlc llbors, vhllo tho hypodor-
mls, vhlch vas ln contact vlth tho oxpandor cap-
sulo, dld not manllost accontuatod llbrosls.
Lxpanslon ol tho human scalp shortons tho
tologon phaso ol halr lolllclos by actlvatlng and
accoloratlng opldormal mltosls.
35
1ho hlstologlc olloct ol oxpanslon on musclo vas
oxamlnod durlng broast roconstructlon vlth tlssuo
oxpandors. 1ho undorlylng poctoralls ma|or musclo
shovod consldorablo ultrastructural damago undor
llght and oloctron mlcroscopy.
36
1lssuo oxpanslon ol lrradlatod plg skln shovs no
lurthor hlstopathologlcal changos boyond thoso
causod by lrradlatlon and ls lndlstlngulshablo lrom
nonoxpandod lrradlatod skln ln tho porclno
modol.
37,38
kadlatlon dld roduco tho ovorall aroa ol
oxpandod skln by 23 ln ono study.
38
Worklng on
a rabblt modol, Coodman and assoclatos
39
noto
lncroasod opldormal thlcknoss but no dormal or
capsular altoratlons ln lrradlatod skln postoxpanslon.
BLOOD SUPPLY OF EXPANDED SKIN
1ho hlstologlc changos ovldont ln oxpandod skln
lond support to tho concopt that skln oxpanslon ls a
lorm ol dolay. Chorry, lasyk and othors
40
com-
parod tho survlval ol oxpandod and dolayod llaps
vlth acutoly ralsod random-pattorn skln llaps ln plgs.
Lxpandod llaps shovod a 117 lncroaso ln survlv-
lng longth ovor unoxpandod skln llaps. Dolayod
llaps shovod a 73 lncroaso ovor tho controls. No
slgnlllcant dllloronco vas notod botvoon oxpandod
and dolayod skln llaps. Spoclmon anglograms ol
oxpandod skln shovod ovldonco ol lncroasod vas-
cularlty comparod vlth control skln. 1ho authors
rocommondod lncludlng tho oxpandor capsulo ln
tho llap at tho tlmo ol translor lor lts contrlbutlon to
tho blood supply, and postulatod that mochanlcal
lorcos aro ln somo vay rolatod to tho lncroasod
vascularlty.
ln a slmllar study, Sasakl and lang
41
locusod on
tho vlablllty and caplllary blood llov ol oxpandod
and dolayod skln llaps. Comparod vlth acutoly
ralsod random-pattorn llaps, both oxpandod and
dolayod skln oxhlbltod lncroasod total caplllary
blood llov, and thls lncroaso parallolod llap sur-
vlval. 1ho survlval longth ol random llaps ln skln
ovorlylng tlssuo oxpandors vas also lncroasod,
vhothor tho oxpandor vas lnllatod or not.
40
Saxby
42
also roportod 150 groator survlvlng
longths ol oxpandod llaps ovor acutoly ralsod,
nondolayod llaps and 50 groator survlvlng longths
than nonoxpandod, dolayod llaps. Anglograms ol
tho llap spoclmons rovoalod lncroasod callbor ol
tho axlal vossols ln tho oxpandod llaps.
Wlckman and assoclatos
32
lound ovldonco ol
lncroasod suporllclal blood llov ln oxpandod skln
by lasor Dopplor llovmotry and vonous outllov moa-
suromonts, but no slgnlllcant dllloronco ln total blood
llov botvoon llaps ralsod ln oxpandod and
nonoxpandod skln.
abovlc ot al
43
studlod tho ollocts ol tlssuo
oxpanslon on lschomla ln lroo llaps. Comparod vlth
tho control and sham groups, prooxpandod skln
llaps domonstratod a statlstlcally slgnlllcant lncroaso
(700) ln porluslon as moasurod by lluoroscoln.
1ho lncroaso ln llap clrculatlon lnducod by tho
oxpanslon lacllltatod an lncroaso ln llap toloranco
to socondary lschomla.
EXTENT OF EXPANSION
Sovoral authors havo lnvostlgatod tho orlgln ol tho
oxpandod tlssuo. Austad
12,16
documontod a truo tls-
suo dlvldond lrom oxpanslon that vas thought to
rosult lrom tho lncroasod mltotlc actlvlty ol tho strossod
tlssuos. Vandor lolk and othors
44
roportod a 32
lncroaso ln mldhorlzontal longth and 44 lncroaso
ln mldvortlcal longth ol oxpandod porclno skln. Altor
llap olovatlon and lnsot, tho ovorall lncroaso ln sur-
laco aroa avallablo lor covorago vas 30. 1hroo
months altor surgory thoro vas a sllght docroaso ln
aroa vhlch vas not statlstlcally slgnlllcant.
RATE OF EXPANSION
1radltlonally, tho oxpanslon procoss boglns 2 to 3
vooks altor lmplantatlon ol tho oxpandor and con-
tlnuos at vookly lntorvals untll tho doslrod lnllatlon ls
achlovod. 1ho skln adapts to stross ln tvo vays.
llrst, ln tho ovont ol lmmodlato tlssuo oxpanslon,
mochanlcal strotchlng changos tho olastlclty and allgn-
mont ol collagon by a procoss callod creep. Croop ls
tho tlmo-dopondont plastlc dolormatlon ol any
matorlal or tlssuo ln rosponso to constant stross.
45
Socond, tho procoss ol stress-relaxation occurs
vhoro, ovor a porlod ol tlmo vhon skln ls strotchod
to a glvon constant longth, tho lorco roqulrod to
malntaln lt ls gradually docroasod.
24
As summarlzod
by akor,
4
tho physlologlc changos ln skln durlng
croop lncludo tho lollovlng.
dohydratlon ol tlssuo
mlcrolragmontatlon ol olastlc llbors
lncroaslngly parallol allgnmont ol randomly
posltlonod collagon llbors
mlgratlon ol tlssuo ln tho dlroctlon ol tho lorco
voctor
akor
4
oxpands Clbsons dollnltlon ol cyclic load-
ing to moan strotchlng lollovod by rolaxatlon ol
oxpandod tlssuo, as opposod to contlnuous oxpan-
slon. lt appoars that cycllc loadlng ls tho most olloc-
tlvo mothod ol rocrultlng oxtra tlssuo. Skln croop
alono doos not account lor all tho oxtra skln durlng
sorlal oxpanslon, and lactors such as rocrultmont,
tlssuo comprosslon/thlnnlng, and nov grovth also
play a rolo.
ln 1987 Sasakl
46
doscrlbod lntraoporatlvo sus-
talnod llmltod oxpanslon (lSLL) lor lmmodlato
roconstructlon. 1ho author lator roportod lntraop-
oratlvo oxpanslon ln closuro ol small skln dolocts on
an omorgoncy basls.
47
Ho montlons dlsadvantagos
ol tho slov oxpanslon mothod, namoly gradual
lnllatlon ovor many vooks and months, tho rlsk ol
lnloctlon and lmplant oxposuro lrom tho protractod
prosonco ol tho oxpandor, partlcularly ln poorly
vascularlzod aroas, and tho cosmotlc and lunctlonal
dolormltlos ol burlod oxpandors and valvos. Sasakl
statos that thoso shortcomlngs ol slov oxpanslon
aro ollmlnatod by tho lntraoporatlvo oxpanslon toch-
nlquo.
Slogort ot al
45
ovaluatod lntormlttont lntraopora-
tlvo short-torm tlssuo oxpanslon ln dogs and ln 30
patlonts vlth sovoro mlcrotla. Cyclod oxpanslons
yloldod maxlmal lncroaso ln longth ol 15 to 20.
1ho authors montlon mochanlsms that load to an
lncroaso ln skln longth (llg 1)olastlclty, lntorstltlal
dlsplacomont ol llulds, croop, and gonulno grovth
yot lall to crodlt any ol thoso spoclllcally lor tholr
llndlngs. lnstoad, thoy attrlbuto tho mochanlsm ol
oxpanslon to anothor, undollnod lorm ol subcuta-
noous moblllzatlon.
Shaplro
48
comblnos acuto cyclod oxpanslons vlth
roctangular skln llaps and notos a docroaso ln vound
closlng tonslon comparod vlth slmplo llap undor-
mlnlng. Novortholoss, tho author statos that un-
dormlnlng must stlll bo consldorod tho most lmpor-
tant olomont ln roduclng vound closlng tonslon.
41
Woo, Logan, and Mustoo
49
doscrlbo a contlnu-
ous lnluslon dovlco that malntalns a constant
oxpandor prossuro and shortons tho tlmo to lull
oxpanslon by tvo-thlrds. 1ho authors comparod
tho olllcacy ol contlnuous vorsus lntraoporatlvo tls-
suo oxpanslon ln a plg modol, and llnd throo tlmos
moro tlssuo galn vlth tho lormor tochnlquo.
lutran
50
dlscussos tho cllnlcal appllcatlons ol tho
Suro-Closuro' skln-strotchlng dovlco orlglnally
lntroducod by Hlrshovltz and colloaguos.
51
1ho
dovlco ls sald to harnoss tho vlscoolastlc proportlos
ol tho skln by applylng lncromontal tractlon to allov
tho skln to rapldly strotch and oxtond vhllo mlnl-
mlzlng lts tondoncy to rocoll.
Wlckman and colloaguos
52
moasurod mochanlcal
proportlos ol tho skln durlng rapld and slov tlssuo
oxpanslon lor broast roconstructlon. Dlstonslblllty
lossonod durlng oxpanslon, lncroasod altor tho
oxpandor vas roplacod by a pormanont lmplant, and
docroasod thoroaltor. Llastlclty dld not chango slg-
nlllcantly and nolthor dld hystorosls (a moasuro ol
tho skln turgor and plastlclty). ln summary, thoro
voro mlnlmal dllloroncos ln skln proportlos botvoon
rapldly and slovly oxpandod patlonts.
APPLICATIONS OF EXPANDED SKIN
1ho maln advantagos ol tlssuo oxpanslon ln
roconstructlvo surgory aro good color and toxturo
match ol tho skln usod lor covorago, prosorvatlon
ol sonsatlon and halr, absonco ol a donor doloct,
slmpllclty, and rollablllty. 1o dato oxpandors havo
boon usod to good olloct ln tho hoad and nock, tho
oxtromltlos, tho trunk, and lor broast roconstruc-
tlon. Lxpandors aro gonorally contralndlcatod ln
aroas ol poorly vascularlzod tlssuo, vhoro thoro ls
locallzod lnloctlon, or ll thoro ls a hlghor-than-
avorago rlsk ol rocurront cancor. llshor and
Hammond
53
rovlov tho lltoraturo ol oxpandors
comblnod vlth llaps lor broast roconstructlon.
Most roports ol roconstructlon by tlssuo oxpan-
slon lmply movomont ol tlssuo as advancomont llaps.
}oss and covorkors
54
noto that advancomont llap
roconstructlon vastos tlssuo (ln dog-oars) at olthor
ond ol tho doloct, and lnstoad rocommond trans-
poslng tho oxpandod tlssuo lnto tho vound bod
along a 90 arc (llg 2). 1ho oxpandor can bo ol any
shapo but should bo tvlco as vldo as tho doloct to
bo covorod.
Wllmhurst and Sharpo
55
lnsort tlssuo oxpandors
lmmodlatoly altor rosoctlon ol mallgnant skln loslons
to comploto tho roconstructlon ln tvo oporatlons.
1ho oxclslonal bod ls tomporarlly covorod by a skln
gralt.
Austad
56
advocatos agalnst tlssuo oxpanslon ln
acuto ln|urlos bocauso ol tho rlsk ol contamlnatlon
and posslblo lnablllty to obtaln ratlonal lnlormod
consont on an omorgoncy basls. Ho romlnds us
that tlssuo oxpanslon rosults ln a dlstortlon ol body
lmago that somo patlonts aro unablo to tolorato.
COMPLICATIONS
lotontlal compllcatlons ol tlssuo oxpanslon lncludo
lnloctlon, homatoma, soroma, oxpandor oxtruslon,
lmplant lalluro, skln nocrosls, paln, and nourapraxla.
1hoso probloms undoubtodly dolay tho roconstruc-
Fig 2. Marklngs lor transposltlon llap
and oxpandor placod bonoath llap
and boyond. 1ho shapo ol tho ox-
pandor ls lrrolovant. (Reprinted with
permission from Joss GS, Zoltie N,
Chapman P: Tissue expansion tech-
nique and the transposition flap. Br J
Plast Surg 43:328, 1990.)
Fig 1. Skln oxpanslon mochanlsms. (Reprinted with permission
from Siegert R, Weerda H, Hoffmann S, Mohadjer C: Clinical and
experimental evaluation of intermittent intraoperative short-
term expansion. Plast Reconstr Surg 92:248, 1993.)
42
tlvo procoss and may nocossltato lmplant romoval,
but do not slgnal a catastropho vlth dlro conso-
quoncos to tho patlont. Austad
56
notos a romark-
ablo absonco ol dlsastors ln a survoy ol moro than
50,000 tlssuo oxpanslon procoduros, and polnts out
that tho ovorall lncldonco ol compllcatlons assocl-
atod vlth tlssuo oxpanslon has docroasod as sur-
goons havo bocomo moro knovlodgoablo and
oxporloncod ln tho routlno uso ol oxpandors. Austad
rocounts lour casos ol partlal llap nocrosls altor tho
oxpandor had boon romovod and tho llap advancod
ovor tho doloct, and attrlbutos tho cyanosls to opl-
nophrlno ln tho local anosthotlc solutlon knovn to
bo dotrlmontal to tho survlval ol dolayodhonco
oxpandodllaps.
57
Mandors and colloaguos
58
roport a 24 lncldonco
ol ma|or compllcatlons that dolayod or compro-
mlsod tho outcomo ol tholr casos ol tlssuo oxpan-
slon. Mlnor compllcatlons voro notod ln 17 and
lncludod paln on oxpanslon, soroma, and vldonlng
ol scars. Argonta and assoclatos
18
also notod a 24
compllcatlon rato oarly ln tholr sorlos, but thls sub-
soquontly loll to 7. lnloctlon ls usually roportod ln
1 ol casos, and only ln patlonts vlth prodlsposlng
lactors. 1ho most lroquont causo ol oxposuro ls an
lnsulllclont pockot at tho lnltlal procoduro that lorcos
tho prosthosls agalnst tho suturo llno. Sharp odgos
or lrrogular lolds ln tho prosthosls should also bo
smoothod out or rlsk thlnnlng ol tho sholl lrom lrlc-
tlon and porhaps lmplant oxposuro. Argonta roc-
ommonds valtlng lor 2 vooks altor lmplantatlon ol
tho oxpandor boloro boglnnlng lnllatlon.
Zoltlo and assoclatos
59
rovlov tholr oxporlonco
vlth non-scalp, non-broast tlssuo oxpanslon ln 56
patlonts, and roport an ovorall lalluro ol 12. lall-
uros voro most common ln tho arm (31) and
rarost ln tho log (0). 1hoy crodlt tholr lov lalluro
rato to an oxpandor slzo tvlco as vldo as tho doloct,
slov rato ol lnllatlon, aggrosslvo managomont ol
any compllcatlon, and uso ol transposltlon llaps.
oum and covorkors
60
rovlovod rotrospoctlvoly
34 tlssuo oxpandors placod ln 30 patlonts at a Nov
ork Clty publlc hospltal ovor a 7-yoar porlod. Com-
pllcatlons occurrod ln 22 ol 34 oxpandors (65),
nocossltatlng romoval ln 13 (38). Cnly 12 ol 34
oxpandors (35) voro lroo ol compllcatlons.
1ho paln assoclatod vlth tlssuo oxpanslon tonds
to bo mlld and ol short duratlon, although an occa-
slonal patlont may complaln ol dlsabllng paln.
lntralumlnal lnstlllatlon ol lldocalno has boon sug-
gostod to rollovo paln durlng oxpanslon,
61
but Slnov
and Cunnlngham
62
roport no dllloronco ln paln
altor oxpanslon botvoon patlonts rocolvlng
lldocalno analgosla and placobo.
McCulro and Calloo
63
noto that tho rato ol
dllluslon ol lldocalno through an oxpandor mom-
brano doponds on tho pH ol tho solutlon. Cnly
by addlng sodlum blcarbonato to commorclally
avallablo lldocalno to ralso lts pH to 8.0 vlll tho
anosthotlc dllluso at a sulllclont rato to provldo
analgosla durlng oxpanslon. Dorby and col-
loaguos
64
slmllarly concludo that thls tochnlquo
ol lldocalno dollvory by dllluslon across a tlssuo
oxpandor sholl ls unllkoly to provldo slgnlllcant
salutary bonollt, and advlso agalnst lt bocauso ol
tho potontlal lor progrosslvo lldocalno accumula-
tlon that could load to lldocalno ovordoso ln tho
ovont ol lmplant lalluro.
lnlroquont roports ol oroslon and dolormatlon ol
bono undorlylng an oxpandor havo appoarod ln
tho lltoraturo, spoclllcally rlb concavlty vlth tho-
raclc skln oxpanslon and calvarlal dolormlty and
romodollng vlth scalp oxpanslon ln chlldron.
65
lalotta
66
doscrlbos rupturo ol an oxpandor placod
ln tho scalp ol a chlld causod by oroslon ol tho
outor tablo ol tho skull and bono spur lormatlon
lrom prossuro by tho oxpandor.
CONCLUSIONS
As summarlzod by akor,
4
tlssuo oxpanslon ls
assoclatod vlth
lmprovod llap survlval
lncroaso ln vascularlty to tho skln or capsulo
probablo onhancomont ol tho blood supply ol
rapldly oxpandod skln
croatlon ol addltlonal nov skln
thlnnlng ol tho dormls and subcutanoous tlssuo
and corrospondlng docroaso ln tonsllo strongth
largor surlaco aroa galns vlth prolongod oxpan-
slon
normallzatlon ol tho paramotors to tho proox-
pandod stato vhon tho oxpanslon procoss ls dls-
contlnuod
43
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10-01 Skin Grafts, Substitutes and Principles of Flaps-1

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HISTORY OF SKIN GRAFTS

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