British Journal qfP/ast~c Surgery ( I989 ). 42.6 16-6 I8 (cl 1989 The Trustees of British Association of Plastic Surgeons

Letters to the Editor Sir. The Joint Meeting of Surgical Colleges was recently informed of a letter that has been circulated to senior registrars in plastic surgery by the President of the British Association of Aesthetic Plastic Surgeons (BAAPS). The letter states “. the BAAPS has to be the standard bearer for cosmetic surgery in the UK and this means that the BAAPS must be seen to have a yardstick by which an acceptable standard of training in aesthetic plastic surgery can be measured. It is the opinion of the Council of the BAAPS that, in their present forms, neither Accreditation nor the FRCS (Plast) provide such a yardstick for aesthetic plastic surgery.”

The Presidents of the Surgical Royal Colleges of Great Britain and Ireland wish to emphasise through your Journal to consultants and trainees in the specialty that responsibility for maintaining standards of training lies with the Colleges and that they have well-established and entirely adequate arrangements for doing so in plastic surgery (including aesthetic) in collaboration with the British Association of Plastic Surgeons (BAPS).

An Intercollegiate Board in Plastic Surgery has been established with specialty representation from the four Surgical Colleges (one member each) and the BAPS (two members) and the membership also includes the Chair- man of the Specialist Advisory Committee. This Board, through its panel of examiners whose expertise encom- passes every aspect of plastic surgical practice, conducts rigorous Assessments of those in the later stage of higher specialist training. Presently these are voluntary but success in an Assessment will become a prerequisite for award of a Certificate of Accreditation for all trainees entering higher training from January 1991 onwards. In this way, the Surgical Royal Colleges will continue to ensure that consultant plastic surgeons, adequately trained across the range of the specialty, provide the highest possible standard of care for patients within the health service.

Yours faithfully, Craig Duncan, BA Secretary, Joint Meeting of Surgical Colleges, Royal College of Surgeons, 35-43 Lincoln’s Inn Fields, London WC?A 3PN

Classification of fasciocutaneous flaps

Sir. Since the first description of the fasciocutaneous flap by Ponten in 1981, many anatomical studies and clinical applications have been reported. Cormack and Lamberty (1984) have classified fasciocutaneous flaps according to their patterns of blood supply, into four types: A. B. C and D.

Many authors have used this classification in their published articles. Through my clinical practice in recent years. the term “fasciocutaneous flap” should, I think, refer to a pedicled flap with a blood supply mostly depending on the arterial plexus of the deep fascia. Thus it would be a local flap. not free and not containing any other tissue beneath the deep fascia (e.g. bone, muscle or tendon; if a flap contains them, it is a composite flap). Some flaps have an axial vessel in their pedicles, which we call axial-pattern fasciocutaneous flaps; others with no axial vessel we term random-pattern fasciocutaneous flaps. Because the fascial vascular plexus is so well perfused with blood, we can raise axial-pattern fasciocu- taneous flaps much larger than the traditional axial cutaneous flaps which do not include the deep fascia: also, we can raise random-pattern fasciocutaneous flaps which have length-to-width ratios of 335 to 1, more than the traditional flaps. In these two patterns of flap the deep fascia has an important contribution to the blood supply and to the flaps’ survival. No doubt they are truly fasciocutaneous flaps.

In the elevation of free flaps and vascular pedicled island flaps. e.g. the radial forearm (Chinese) flap and reverse forearm island flap for hand reconstruction, we usually include the deep fascia, but the purpose is to avoid damaging the sizeable vessels. There is very little bleeding from the dissected surfaces because the plane between the deep fascia and muscle is relatively avascular and is opened up with ease. Haertsch (1981) has named the subfascial plane the “surgical plane” in the leg, and elsewhere in the body this plane has also proved easy to dissect. The deep fascia has no important effect on the blood supply of these flaps which are therefore, in my opinion, not fasciocutaneous flaps.

Yours faithfully. Shi-Min Chang, MD Department of Orthopaedics, Zhong Shan Hospital, Shanghai Medical University, Shanghai. People’s Republic of China.

References Cormack, C. C. and Lamberty, B. G. H. (1984). A classification

of fasciocutaneous flaps according to their patterns of vasculamation. Briri.4 Journo/o/‘P/mric Surgery,. 37. 80.

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LETTERS TO THE EDITOR 617

Haertsch, P. (1981). The surgical plane in the leg. British Journal of’ Plastic Surger?. 34,464.

Pontb, B. (1981). The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Briti,ph Journal qf P/ask Surgery, 34, 215.

Reply from Mr Cormack

Sir, Thank you for the opportunity tocomment on Dr Chang’s letter, the general thrust of which I feel is most pertinent at this time. I will reply to the broader issues raised and take the opportunity, if I may, to disagree on two minor points.

As Dr Chang states, many authors have made reference to our classification of fasciocutaneous flaps and I am increasingly wishing that this would cease since it was never intended td convey the impression that these were in any way unalterable pronouncements. The original intention of the paper was two-fold, firstly to emphasise that the design of these flaps meant more than just the indiscriminate incorporation of the deep fascia in a skin flap, and secondly, we wished to initiate discussion on the topic of the fasciocutaneous flap. Our final sentence read. “We do not see this as a hard and fast classification but rather as an anatomical basis on which to elaborate.” I think that the key point here is that we were formulating an anatomical concept, namely. skin flaps supplied by vessels which pass along fascial intermuscular septa to a deep fascia1 plexus and then to skin (i.e. the fasciocuta- neous system of perforators), whereas what Dr Chang is elaborating is essentially a surgical concept. He is saying that he does not regard all the flaps he mentions in his letter as fasciocutaneous in surgical terms-nevertheless I maintain that ail these flaps do indeed depend for their blood supply on elements of the fasciocutaneous system. These two ways of seeing things are not mutually exclusive.

In our paper we pointed out that the “potential fasciocutaneous vascular territories” ( = flaps) could not be demonstrated by cadaver injection studies and that they could “only be learnt through clinical experience” which in 1983 was far from extensive. Since then much more has been learnt about the clinical behaviour and possibilities of these flaps, and while the underlying anatomy has not changed it has become apparent that many variations are possible, e.g. reverse-pedicled fascio- cutaneous flaps and fascia-only flaps to mention just two. As a result I now feel that while the classification was useful in 1984. a more surgical terminology would be of greater benefit at the present time and I welcome Dr Chang’s letter which I feel supports this view. Some will claim that we are already bedevilled with too much terminology and that we already have the anatomical classifications of Taylor and Palmer (1987), as well as the atomic system of Tolhurst (1987) which attempts to pull together the blood supply, geometry and various other characteristics of flaps. Nevertheless problems exist, particularly with the fasciocutaneous system. as Dr Chang demonstrates.

For example, Dr Chang refers to random-pattern fasciocutaneous flaps. I think that the use of the word “random”, widespread though it is, is unfortunate. It dates from the days when so little was known about the blood supply of skin that, firstly the subcutaneous vessel network was thought to be fairly random in the sense of haphazard and unschematic in orientation, and secondly, and probably as a consequence, the choice for the direction of the long axis of a flap was also often rather random in the sense of unselective and undiscerning. We are now in a position where firstly we know that in any area of skin or deep fascia the vessels are not random but tend to have a predominating directionality for example as a result of closely following alongside certain cutaneous nerves (Cormack and Lamberty, 1985), and secondly, if our planning of a flap is based on anatomical knowledge and careful consideration of the options then it certainly does not do it justice to describe it as random. Dr Chang mentions “random-pattern” fasciocutaneous flaps with a length-to-breadth ratio of 3-5 to 1 and these flaps, which may indeed reach 5 to 1. I would prefer to think of as /ink-pattern fasciocutaneous flaps since the territory of the flap is in fact made up of a series of interlinking anatomical territories of individual perforators whose anastomoses form a chain of vessels along the length of the flap.

Dr Chang’s final paragraph relates to the Type C flaps which he does not regard as fasciocutaneous. His problem could easily be resolved by adopting the term septocuta- neous to denote flaps such as the radial forearm flap raised in the manner he describes, whilst at the same time accepting that the anatomical basis of the flap lies in the system of fasciocutaneous perforators. Similarly, I do not find the term septocutaneous incompatible with the concept of a composite flap, as when the radial forearm flap is raised with a piece of bone.

I think that it is clear that after a decade of surgical development and evaluation the fasciocutaneous concept is ripe for reappraisal. Mr George Lamberty will be presenting an update paper on this topic at the European Meeting in Turkey in September 1989 and perhaps through the medium of these columns the subject could be opened for further discussion.

Yours faithfully, George Cormack, FRCSEd, Registrar in Plastic Surgery, Bangour Genera1 Hospital, Broxburn, West Lothian, EH52 6LR.

References

Cormack, G. C. and Lamberty, B. G. H. (1985). The blood supply of thigh skin. Plastic and Reconstructive Surger~~, 75, 342.

Taylor, G. I. and Palmer, J. H. (1987). The vascular territories (angiosomes) of the body: experimental study and clinical applications. British Journal ofPlastic Surgerv. 40, 113.

Tolhurst, D. E. (1987). A comprehensive classification of flaps: the atomic system. Plastic and Reconstructiw Surgery. 80,608.