The vascular territories (angiosomes) of the body: experimental study and clinical applications

doi:10.1016/0007-1226(87)90185-8

British Journal of Plastic Surgery

Volume 40, Issue 2, March 1987, Pages 113-141

https://doi.org/10.1016/0007-1226(87)90185-8 Get rights and content

Abstract

The blood supply to the skin and underlying tissues was investigated by ink injection studies, dissection, perforator mapping and radiographic analysis of fresh cadavers and isolated limbs. The results were correlated with previous regional studies done in this department.

The blood supply is shown to be a continuous three-dimensional network of vessels not only in the skin but in all tissue layers. The anatomical territory of a source artery in the skin and deep tissues was found to correspond in most cases, giving rise to the angiosome concept.

Arteries follow closely the connective tissue framework of the body. The primary supply to the skin is by direct cutaneous arteries which vary in calibre, length and density in different regions. This primary supply is reinforced by numerous small indirect vessels, which are “spent” terminal branches of arteries supplying the deep tissues.

An average of 374 major perforators was plotted in each subject, revealing that there are still many more potential skin flaps. Our arterial roadmap of the body provides the basis for the logical planning of incisions and flaps. The angiosomes defined the tissues available for composite transfer.

Reference (53)

CormackG.C. et al.
A classification of fascio-cutaneous flaps according to their patterns of vascularisation
British Journal of Plastic Surgery
(1984)
McCrawJ.B.
The recent history of myocutaneous flaps
Clinics in Plastic Surgery
(1980)
McGregorI.A. et al.
Axial and random pattern flaps
British Journal of Plastic Surgery
(1973)
PalmerJ.H. et al.
The vascular territories of the anterior chest wall
British Journal of Plastic Surgery
(1986)
Ponte´nB.
The fasciocutaneous flap: its use in soft tissue defects of the lower leg
British Journal of Plastic Surgery
(1981)
ReidC.D. et al.
The vascular territory of the acromiothoracic axis
British Journal of Plastic Surgery
(1984)
SongR. et al.
The forearm flap
Clinics in Plastic Surgery
(1982)
TaylorG.I. et al.
The versatile deep inferior epigastric (inferior rectus abdominis) flap
British Journal of Plastic Surgery
(1984)
TimmonsM.J.
Landmarks in the anatomical study of the blood supply of the skin
British Journal of Plastic Surgery
(1985)
AclandR.D. et al.
The saphenous neurovascular free flap
Plastic and Reconstructive Surgery
(1981)

BadranH.A. et al.

The lateral intercostal neurovascular free flap

Plastic and Reconstructive Surgery

(1984)

BakamjianV.Y.

A two stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap

Plastic and Reconstructive Surgery

(1965)

BlairV.P.

The delayed transfer of long pedicle flaps in plastic surgery

Surgery, Gynecology and Obstetrics

(1921)

BoydJ.B. et al.

The vascular territories of the superior epigastric and the deep inferior epigastric systems

Plastic and Reconstructive Surgery

(1984)

CarriquiryC. et al.

An anatomical study of the septocutaneous vessels of the leg

Plastic and Reconstructive Surgery

(1985)

CostaM.A.C. et al.

An anatomical study of the venous drainage of the transverse rectus abdominis musculocutaneous flap

Plastic and Reconstructive Surgery

(1987)

CrockH.I.

The Blood Supply of the Lower Limb Bones

(1967)

DanielR.K. et al.

Distant transfer of an island flap by microvascular anastomoses

Plastic and Reconstructive Surgery

(1973)

DanielR.K. et al.

The free transfer of skin flaps by microvascular anastomoses

Plastic and Reconstructive Surgery

(1973)

EsserJ.F.S.

Artery Flaps

(1929)

GilliesH.D. et al.

The Principles and Art of Plastic Surgery

(1957)

Grant's Atlas of Anatomy (1958). Ed. Anderson, J. E. 7th Edition. Baltimore: The Williams and Wilkins...

Gray's Anatomy. (1958). Ed. Johnston, T. B. Davies, I. E. S. and Davies, F. 32nd Edition. London:...

Gray's Anatomy. (1980). Ed. Williams, P. and Warwick, R. 36th Edition. Edinburgh: Churchill...

HunterJ.

A Treatise on the Blood, Inflammation and Gunshot wounds

(1794)

LastR.J. et al.

Corrosion casts of the blood vessels of stillborn babies

Acta Anatomica

(1962)

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The perforator flap has garnered significant interest since its inception due to its advantage of not needing a vascular network at the deep fascial level. Perforator flaps are commonly utilized in different flap transplant surgeries, and the thigh flap is presently the most widely used perforator flap. Is it possible for the calf to replace the thigh as a more suitable site for harvesting materials? Currently, there is a lack of relevant anatomical research. This study aims to address this question from an anatomical and imaging perspective.
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The perforators had three main branches: the vertical cutaneous branch, the oblique cutaneous branch, and the superficial fascial branch. The superficial fascial branch traveled in the superficial fascia and connected with the nearby perforators. The vertical and oblique cutaneous branches entered the subdermal layer and connected with each other to create the subdermal vascular network.
We observed an intact calf cutaneous branch chain between the cutaneous nerve and the perforator of the infrapopliteal main artery at the superficial vein site. Utilizing this anatomical structure, the calfskin branch has the potential to serve as a substitute for thigh skin flap transplantation and may be applied to perforator flap transplantation in more locations.
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Flaps have become an integral part of plastic and reconstructive surgery. The robust blood supply of such flaps is a prerequisite to reduce flap failure. Despite the reported versatility of the occipital flap, comprehensive anatomical studies on its perforators and perforasomes are lacking. Hence, we examined the perforators originating from the occipital artery and their associated perforasomes, aiming to fill this knowledge gap for reconstructive surgery techniques.
39 of 40 occipital arteries of 20 fresh anatomical head specimens were dissected. Perforators with a least an outer diameter of 0.50 mm were identified and injected with dye to color their respective perforasomes. Location and size of the colored skin areas were determined as well as the location of their perforators were documented and analyzed.
In total, 183 perforators were found and described. The mean diameter of these vessels was 0.88 ± 0.27 mm (0.5–2.1 mm). The mean area of the perforasomes was 1288.26 ± 662.51 mm² (144.60–3890.60 mm²). They were localized over the whole nuchal and occipital area. Lastly, perforator diameters were significantly associated with the size of their resulting perforasomes.
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« Couteau-suisse » de la chirurgie reconstructrice, le lambeau de grand dorsal est de plus en plus délaissé au profit des lambeaux fasciocutanés. L’objectif de cette étude était d’analyser les modalités de réalisation de ce lambeau ainsi que l’évolution de ses indications afin de définir sa place actuelle en traumatologie. Quarante-quatre cas ont été recensés rétrospectivement de janvier 2000 à décembre 2020 au sein de l’HIA Percy, dont 37 cas de lambeaux libres, principalement réalisés pour des reconstructions de pertes de substance étendues avec exposition osseuse et/ou articulaire. Il était également réalisé dans 10,8 % des cas en sauvetage après échec d’une autre solution de reconstruction. Cette analyse a permis de confirmer l’intérêt du lambeau de grand dorsal dans le cas de pertes de substances délabrantes du membre inférieur, mais également chez le grand brûlé, à des fins de réhabilitation fonctionnelle ou de couverture, afin de permettre une rééducation précoce.
Reconstructive surgery's workhorse, the latissimus dorsi flap is increasingly abandoned in favour of fasciocutaneous flaps. The purpose of this study was to analyse the methods used to perform this flap and the evolution of its indications in order to define its current place in traumatology. Forty-four cases were recorded retrospectively from January 2000 to December 2020 at HIA Percy, including 37 cases of free flaps, mainly performed for reconstruction of extensive loss of substance with bone and/or joint exposure. It was also performed in 10.8% of cases for salvage after failure of an alternative reconstruction solution. This analysis confirms the value of the latissimus dorsi flap in cases of significant substance loss in the lower limb, but also in burn patients for functional rehabilitation or to allow early rehabilitation.
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L’utilisation des lambeaux dorsaux pédiculé épargnant le muscle grand dorsal (TDAP et MSLD flap) est une méthode de reconstruction bien décrite en reconstruction mammaire après cancer du sein. Néanmoins, peu de données existent concernant la satisfaction des patientes après cette chirurgie. L’objectif principal de cette étude a été d’évaluer la satisfaction des patientes après reconstruction mammaire secondaire totale unilatérale par lambeau TDAP ou MSLD. Les objectifs secondaires correspondaient à l’évaluation des complications postopératoires suite à cette chirurgie, l’évaluation de la durée de la reconstruction et de la nature des interventions complémentaires, l’évaluation des séquelles fonctionnelles, et l’évaluation de la taille de bonnet obtenue une fois la reconstruction terminée.
Il s’agit d’une étude de cohorte monocentrique et rétrospective, incluant 22 patientes opérées d’une reconstruction mammaire secondaire totale unilatérale par lambeau TDAP ou MSLD entre le 1^er janvier 2018 et le 31 décembre 2022. La satisfaction des patientes a été évaluée à l’aide de trois questionnaires validés en reconstruction mammaire : le module Reconstruction du BREAST-Q, le MBROS-S et le MBROS-BI.
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The vascular territories (angiosomes) of the body: experimental study and clinical applications

Abstract

British Journal of Plastic Surgery

Clinics in Plastic Surgery

British Journal of Plastic Surgery

British Journal of Plastic Surgery

British Journal of Plastic Surgery

British Journal of Plastic Surgery

Clinics in Plastic Surgery

British Journal of Plastic Surgery

British Journal of Plastic Surgery

The saphenous neurovascular free flap

Plastic and Reconstructive Surgery

The lateral intercostal neurovascular free flap

Plastic and Reconstructive Surgery

A two stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap

Plastic and Reconstructive Surgery

The delayed transfer of long pedicle flaps in plastic surgery

Surgery, Gynecology and Obstetrics

The vascular territories of the superior epigastric and the deep inferior epigastric systems

Plastic and Reconstructive Surgery

An anatomical study of the septocutaneous vessels of the leg

Plastic and Reconstructive Surgery

An anatomical study of the venous drainage of the transverse rectus abdominis musculocutaneous flap

Plastic and Reconstructive Surgery

The Blood Supply of the Lower Limb Bones

Distant transfer of an island flap by microvascular anastomoses

Plastic and Reconstructive Surgery

The free transfer of skin flaps by microvascular anastomoses

Plastic and Reconstructive Surgery

Artery Flaps

The Principles and Art of Plastic Surgery

A Treatise on the Blood, Inflammation and Gunshot wounds

Corrosion casts of the blood vessels of stillborn babies

Acta Anatomica