Plastic Surgery Volume 1 Principles 4th

342
CHAPTER 21 • Vascular territories
flap,59 profunda femoris artery perforator flap,60 and the
superior and inferior gluteal artery perforator flaps.61
The investigations initially involved an analysis of various
regions of the body to define possible donor sites for free skin
flap transfer.62 The studies subsequently focused on other
tissues and included the anatomic basis for the transfer of
bone,63 nerve,64 and certain muscles.21,65 Encouraged by the
success of some of the resulting clinical procedures, the
authors expanded the research to investigate composite units
of tissue, supplied by a single vascular system. Units of skin
and tendon,66 muscle with nerve,67 and skin, muscle, and
bone68–70 were analyzed. It was from this work that the angio­
some concept germinated. Various regions, including the
anterior abdominal wall,21,36,65,71 the anterior thorax,72,73 the
lower limb, and the upper limb, were studied. The results
added strength to the angiosome concept of the blood supply
and revealed the interconnections that exist at all levels
between adjacent vascular territories, a relationship that is
evident throughout the body.74
In cadaver vascular research, various techniques can be
used to identify and study the area of interest. In the past, the
integument (skin and subcutaneous tissue) was removed, and
the sites of emergence of the dominant cutaneous perforators
(0.5 mm diameter or more) were identified on the surface of
the deep fascia with lead beads. Currently, individual perfora­
tors are easily identified on CT angiography (CTA). Approxi­
mately 400 cutaneous perforators on average were identified
per body.40,47 The three-dimensional branching pattern of
main source vessels can be identified. Previous workers,
including Salmon, had made topographic boundary incisions
to remove areas of skin, particularly in the lines of the groins,
axillae, neck, and limb joints (Fig. 21.5
). These junctional
regions are of great clinical importance, and for this reason
the incisions were designed to retain their continuity wherever
possible. In our current techniques, using CTA, the incisions
utilized for dissection are not as crucial since the pathway and
branches of individual vessels are clearly documented prior
to dissection.
Fig. 21.5 appears online only.
In the original studies of the vascular supply of tissues of
the body, the integument was radiographed, and a montage
of the entire cutaneous circulation was constructed in “plan
view” (
Figs. 21.6, 21.7).47 Although Manchot and Salmon
described the origin and course of the cutaneous arteries, and
Salmon9 made a separate study of the individual muscles,
neither worker illustrated the course of the arteries between
the deep tissues and the skin. Therefore, the skin and subcu­
taneous tissues were cut into parallel strips and placed on
their side, and radiographs were taken to provide “elevation
views” of the vessels in different regions of the body
(Fig. 21.8). Current CTA techniques allow a far more detailed
three-dimensional appraisal of the vascular anatomy of tissues
(Fig. 21.9).
Fig. 21.6 appears online only.
All cutaneous perforators of diameter greater than 0.5 mm
were traced to their underlying source arteries. The results
were averaged from each cadaveric study and plotted on a
diagram of the body (Fig. 21.10). Subsequently, investigations
were expanded to map out the venous territories (venosomes)
of the body along with the neurovascular territories of the
skin and muscle.48 These results have led to an overall picture
of the vascular territories of the entire body. The remainder of
Fig. 21.7  Montage of the cutaneous arteries of the body. The skin has been
incised along the ulnar border in the upper extremities, and the integument has
been removed with the deep fascia on the left side and without it on the right. Note:
(1) the direction, size, and density of the perforators, which are large on the torso
and head and become progressively smaller and more numerous toward the
periphery of the limbs; and (2) the reduced-caliber (choke) anastomotic arteries,
which link the perforators into a continuous network. (From Taylor GI, Palmer JH.
The vascular territories [angiosomes] of the body: experimental study and clinical
applications. Br J Plast Surg. 1987;40:113.)
this section gives a brief overview of the arterial, venous, and
nervous territories of the body.
Arterial territories
The arterial network of the body forms a continuous interlock­
ing arcade of vessels throughout each tissue and throughout
the body, linked by reduced caliber choke anastomotic vessels
or true anastomoses. The course of the cutaneous perfora­
tors depends on the proximity of the source artery to the
undersurface of the deep fascia. As Michel Salmon noted
in 1936,8 arteries supply branches to each tissue that they
pass, including the intermuscular septae, fascia, nerves, and
tendons. Arteries generally fall into two groups, direct and
indirect (Fig. 21.11). In our anatomical dissections, it is clear
that there is great variability in the exact course and size
of individual perforators; however, the main source vessels
are relatively consistent. The direct cutaneous vessels pass

342.e1
Vascular anatomical research
Fig. 21.5  Cadaver with body landmarks and incision lines marked. (From Taylor GI,
Palmer JH. The vascular territories [angiosomes] of the body: experimental study
and clinical applications. Br J Plast Surg. 1987;40:113.)
Vascular anatomical research

342.e2
CHAPTER 21 • Vascular territories
Fig. 21.6  Lateral view of one female subject (A)
and anterior view of another (B). (A) The arm has
been removed. Note the network of large vessels
that sweep laterally from the ventral and dorsal
midlines, ascend from the groins, descend from
the shoulder girdle, and converge on the summits
of the scalp and the breasts. This demonstrates
the principle that vessels radiate from fixed
concave zones and radiate to mobile convex
areas. (B) A lower midline scar interrupts the
vessels with compensatory opening of a large
choke vessel above the umbilicus (arrow) to
re-establish the flow across the midline. (From
Taylor GI, Palmer JH. The vascular territories
[angiosomes] of the body: experimental study and
clinical applications. Br J Plast Surg.
1987;40:113.)
A
B

343
Vascular anatomical research
Fig. 21.9  Computed tomography angiography of a cadaver pelvis, showing bony,
vascular, and skin three-dimensional anatomy. Using MIMICS software, the various
anatomic structures can be included or removed. (From Morris SF, Tang M,
Almutairi K, et al. The anatomic basis of perforator flaps. Clin Plast Surg.
2010;37:553–570.)
Fig. 21.10  Map of the arterial perforators of 0.5 mm diameter or more, which are
color-coded to correspond to the underlying parent arteries and course with the
associated perforating veins. They provide the basis for perforator flaps. (From
Taylor GI, Palmer JH. The vascular territories [angiosomes] of the body:
experimental study and clinical applications. Br J Plast Surg. 1987;40:113.)
Fig. 21.8  Sectional strip radiographic studies of the
breast (A), thigh (B), sole of the foot (C), and buttock
(D). (D) includes the underlying gluteus maximus
muscle. The schematic diagram illustrates the dominant
horizontal axis of vessels that provides the primary
supply to the skin in each case and its relationship to
the deep fascia (arrow). (A) They predominate in the
subdermal plexus. Note from left to right the internal
thoracic perforator and lateral thoracic artery converging
on the nipple in the radiograph of the loose skin region
of the torso. (B) They are seen coursing on the surface
of the deep fascia in this relatively fixed skin area.
(C) The source artery itself is the dominant horizontal
vessel supplying the skin, coursing beneath the deep
fascia in this rigidly fixed skin region. (D) Small arrows
define the deep fascia, and the large arrow indicates the
large fasciocutaneous branch of the gluteal artery, which
descends with the posterior cutaneous nerve of the
thigh. (From Taylor GI, Palmer JH. The vascular territories
[angiosomes] of the body: experimental study and
clinical applications. Br J Plast Surg. 1987;40:113.)
B
C
D
A
between the deep tissues before piercing the outer layer of the
deep fascia. They are usually the primary cutaneous vessels
and their main destination is the skin. They tend to supply the
skin with larger-diameter vessels which have a large vascular
territory (e.g., circumflex scapular artery). The direct branches
include direct cutaneous vessels (sometimes called axial
vessels) and septocutaneous vessels. The indirect vessels can
be considered the secondary cutaneous supply. They emerge
from the deep fascia as terminal branches of arteries which
supply the muscles and other deep tissues. The majority of
indirect branches are musculocutaneous perforators which
emerge to supply the skin. In fact, there is usually significant
variability in the distribution of direct and indirect vessels
and their vascular territory from individual to individual.
There is a vast interconnected network of direct and indirect
arteries which supply the skin. The vascular territories of
individual perforators vary and tend to be reciprocal with
adjacent arterial vascular territories according to the so-called
law of equilibrium, described by Salmon and supported by
our work.
The direct cutaneous vessels arise from: (1) source arteries
just beneath the deep fascia (e.g., the superficial inferior epi­
gastric artery); (2) direct continuation of the source artery
(e.g., the cutaneous branches of the external carotid artery);
(3) deeply situated source artery or one of its branches to a
muscle; they follow the intermuscular septa to the surface
(e.g., septocutaneous branches of the lateral circumflex
femoral artery). Indirect cutaneous vessels generally emerge
from the main source artery as it courses on the undersurface

344
CHAPTER 21 • Vascular territories
from a plexus of smaller vessels. This plexus lies in loose
areolar tissue on the surface of the deep fascia. It is formed by
branches that arise from the direct perforators as they pierce
the deep fascia and the connections these branches make with
smaller indirect perforators. The large direct perforators then
pierce the subcutaneous layer. They ascend within the super­
ficial fascia (subcutaneous fat) to reach the rich subdermal
plexus, where they travel for considerable distances (see Fig.
21.8).
Within the deep tissue, whether muscle, tendon, nerve, or
bone, a pattern similar to that in the integument exists, with
a three-dimensional network of vessels interlinking between
vascular territories, the perimeters of which are linked by
choke arteries. Within the muscles, these choke vessels often
exhibit a characteristic corkscrew appearance on angiography.
Venous drainage
The cutaneous veins also form a three-dimensional plexus of
interconnecting channels throughout the body (Fig. 21.12).
There are valved segments in which valves direct flow in a
particular direction, and there are avalvular segments where
no valves are present. The avalvular or oscillating veins allow
bidirectional flow between adjacent venous territories. They
connect veins whose valves may be oriented in opposite direc­
tions, thus providing for the equilibration of flow and pres­
sure. Indeed, there are many veins whose valves direct flow
initially in a distal direction, away from the heart, before
joining veins whose flow is proximal. An example of this is
the superficial inferior epigastric vein that drains the lower
abdominal wall integument toward the groin. In some regions,
valved channels direct flow radially away from a plexus of
avalvular veins, for example, in the venous drainage of the
nipple–areola complex. In other areas, valved channels direct
flow toward a central focus, as seen in the stellate branches of
the cutaneous perforating veins of the limbs.
In general, venous anatomy parallels arterial anatomy (Fig.
21.13). From dermal and subdermal venous plexuses, the
veins collect either into horizontal large-caliber veins, where
they often relate to cutaneous nerves and a longitudinal
system of chain-linked arteries, or alternatively in centrifugal
or stellate fashion into a common channel that passes verti­
cally down in company with the cutaneous arteries to pierce
the deep fascia. Thereafter, the veins travel with the direct and
indirect cutaneous arteries, draining ultimately into the venae
comitantes of the source arteries in the deep tissue.
In general, the origin, course, and distribution of the deep
veins (vena comitantes) are a mirror image of the deep source
arteries, but they are larger and more plentiful. Although the
anatomy of the veins is subject to considerable variation
between sides in the same individual as well as between other
individuals, the pattern of venous arcades is evident through­
out. These arcades generally become smaller and more numer­
ous as the periphery of the region or the tissue is reached. The
superficial veins, however, are independent of the deep arter­
ies (e.g., greater saphenous vein, cephalic vein) and may have
a different area of drainage. For example, in the forearm there
are paired vena comitantes to the radial and ulnar arteries but
a separate system of large-caliber subcutaneous veins, includ­
ing cephalic, basilic, and antebrachial veins.
The site and density of the valves within the deep venous
network are variable. The deep veins follow the bony skeleton
Fig. 21.11  Schematic illustration of direct and indirect cutaneous vessels. D,
dermis; DC, direct cutaneous; DF, deep fascia; M, muscle; MC, musculocutaneous;
SA, source artery; SC, septocutaneous; SF, superficial dermis. (From Geddes CR.
MSc Thesis. Dalhousie University, Halifax, Nova Scotia, Canada.)
DC
SC
MC
M
M
DF
SF
D
SA
of a muscle and penetrate through the muscle; e.g., musculo­
cutaneous perforators of the deep inferior epigastric arteries
(DIEA). In the human body, there are approximately 400
perforators, about 40% of vessels are direct and 60% indirect
perforators.
The direct cutaneous perforators pierce the deep fascia
near where it is anchored to bone or the intermuscular and
intramuscular septa (see Fig. 21.10). These lines and zones of
fixation also correspond to the fixed skin areas of the body.
From these points, the vessels flow toward the convexities of
the body surface, branching within the integument. In general,
the wider the distance between the cavities and the higher the
summit, the longer the vessel (see Fig. 21.8). The size and
density of the direct perforators also vary in different regions.
For example, in the head, neck, torso, arm, and thigh, the
vessels are larger, longer, and less numerous. In the forearm,
leg, and dorsum of the hands and feet, the vessels tend to
be smaller, shorter, and more numerous. In the palms of the
hands and the soles of the feet, where the skin is fixed, there
is a high density of smaller perforators. Hence, the primary
supply of each cutaneous territory varies between source
arteries. Each of these territories also has indirect perforators.
The course of the cutaneous perforators between the deep
fascia and the skin also varies in different regions. Regardless
of their site, however, they follow the connective tissue frame­
work of the superficial fascia, interconnecting at all levels.
They ramify on the undersurface of the subcutaneous fat
adjacent to the deep fascia and then branch and course toward
the subdermal plexus, working their way between the fat
lobules. The smaller vessels tend to course vertically toward
the skin, whereas the larger vessels branch in all directions in
a stellate pattern or course in a particular axis, branching as
they pass parallel to the skin surface.
In the scalp and limbs, where the skin is relatively fixed to
the deep fascia, the larger vessels hug that surface. They
course on the deep fascia for a considerable distance in the
loose areolar layer that separates them from the subcutaneous
fat (see Fig. 21.8). This is especially true when a perforator
accompanies a cutaneous nerve.
In the loose skin areas of the body, the direct cutaneous
vessels course for a variable distance parallel to the deep
fascia. They are more intimately related to the undersurface
of the subcutaneous fat, however, being plastered to it by a
thin fascial sheet that separates them on their deep surface

345
Vascular anatomical research
is linked by a rich stepladder of venous channels that are
usually free of valves. These venae comitantes then reunite
to form single channels. In the lower limb, this occurs in
the popliteal fossa, but in the upper limb, the union is most
commonly in the proximal arm or even as high as the axilla.
In the torso, the pattern of arcades is conspicuous (see Fig.
21.13); the parent veins are oriented as longitudinal and
transverse arcades that match the pattern of the source artery.
Distinct territories are evident. Where choke arteries define
the arterial territories, they are matched by oscillating veins
in the venous network. The existence of venae comitantes is
variable.
Within the muscle, the intramuscular venous network
mirrors that of the arterial side. Where arterial territories are
linked by choke arteries or true anastomotic arteries without
changing caliber, the venous territories of the muscles, which
drain in opposite directions, are linked by avalvular oscillat­
ing veins. Broadly, the muscles can be classified into three
types on the basis of their venous architecture. Type I muscles
have a single venous territory that drains in one direction.
Type II muscles have two territories that drain from the oscil­
lating vein in opposite directions. Type III muscles consist of
three or more venous territories that drain in multiple direc­
tions (Fig. 21.14).
The extramuscular veins are of two types. The first group
consists of the efferent veins. They contain valves and drain
the muscles to their parent veins. The other group consists of
the afferent veins. They are derived from the overlying integu­
ment as musculocutaneous perforators or from adjacent
muscles (see Fig. 21.14).
Neurovascular territories
In our anatomical studies of neurovascular territories, fresh
human cadavers were injected with a radiopaque lead oxide
mixture, and the nerves were dissected and labeled with fine
computer wire.49 The nerves and vessels were then segregated
by subtraction angiography.
The most obvious feature seen throughout the skin and
muscle is the linear arrangement of the nerves and their
branches, compared with the looping arcades of the intercon­
necting vessel network, with the nerves taking the shortest
route between two points. In general, the orientation of cuta­
neous nerves is longitudinal in the limbs, transverse or oblique
in the torso, and radiating from loci in the head and neck. Of
particular note is that the cutaneous nerves, like the arteries,
pierce the deep fascia at fixed skin sites.
Each cutaneous nerve is accompanied by an artery, but the
relationship is variable. Some of the arrangements seen in the
integument are shown in Fig. 21.15. In each case, either a long
artery or a chain-linked system of arteries “hitchhikes” with
the nerve.
When the cutaneous nerve and artery appear at the
deep fascia together, their relationship is often established
early (e.g., the lateral intercostal neurovascular perforators
on the torso or the saphenous system in the lower limb).
However, the nerve sometimes pierces the deep fascia at a
point remote from the emergence of its associated artery (e.g.,
the lateral cutaneous nerve of the thigh and the superficial
circumflex iliac artery below the inguinal ligament; Fig. 21.16
). Alternatively, the nerve leaves one vascular system with
which it is traveling in parallel to cross the path of another
Fig. 21.12  The venous network of the integument of a female subject. This is a
montage of venograms from an injection study. (From Taylor GI, Caddy CM,
Watterson PA, et al. The venous territories [venosomes] of the human body:
experimental study and clinical implications. Plast Reconstr Surg. 1990;86:185.)
of the body or the intermuscular septa with their associated
arteries. In some regions, these veins are single; in others, they
are duplicated as venae comitantes. In the limbs, the veins
commence distally in the hands and feet as single channels
linked by venous arcades. These arcades become progres­
sively larger as they approach the wrist and ankle. The veins
are duplicated in the forearm and leg, and each pair of veins

346
CHAPTER 21 • Vascular territories
Fig. 21.13  (A) Arterial and (B) venous studies of the anterior torso. Note the “corkscrew” choke arteries that link adjacent territories in the arterial study and the mixture
that has extruded from the deep inferior epigastric veins as a result of the resistance of the valves. Radiographic lead beads identify the origin of the cutaneous perforators
from their source vessels in the arterial study. (From Taylor GI, Caddy CM, Watterson PA, et al. The venous territories [venosomes] of the human body: experimental study
and clinical implications. Plast Reconstr Surg. 1990;86:185.)
A
B
Fig. 21.14  Illustrations and radiographs of venous injection studies of the supraspinatus (A), gracilis (B), and sartorius (C) muscles. Note the oscillating veins that
separate them into type I, II, and III muscles and the efferent veins entering the supraspinatus and gracilis muscles (dashed arrows). (From Taylor GI, Caddy CM, Watterson
PA, et al. The venous territories [venosomes] of the human body: experimental study and clinical implications. Plast Reconstr Surg. 1990;86:185.)
2
2
2
3
4
5
1
1
1
B
C
A

347
Vascular anatomical research
(e.g., the lateral intercostal nerve, which courses initially
with its artery and then leaves it to meet the superficial
inferior epigastric vessel). In many of these cases, secondary
or tertiary branches of the artery often peel off to accom­
pany the nerve (see Fig. 21.16). Sunderland noted that each
peripheral nerve is abundantly vascularized by a “vascular
net” of a series of nutrient arteries entering the nerve at
different levels.75
Fig. 21.16 appears online only.
The vascular architecture of the intramuscular veins and
arteries is almost identical for each muscle. Therefore, to
simplify the description of the nervous supply to the muscles,
only the arterial relations of the nerves are discussed and
illustrated. The intramuscular branches of the nerves were
dissected to, but not within, the individual muscle bundles.
The following observations were made:
1. The nerves follow the connective tissue framework.
Dissection showed the motor nerves coursing in the
connective tissue sheath from its origin at the nerve
trunk to the neurovascular hilum of the muscle.
Thereafter, the nerve and its branches follow the
Fig. 21.15  The neurovascular patterns found in the integument. (A) A long artery
connected to its neighbor by a true anastomosis courses with the nerve. (B) A
chain-linked system of arteries hitchhikes with the nerve. (C) The nerve and artery
pierce the deep fascia at separate sites. Branches of the vessel peel off to
accompany the nerve as it crosses the main arterial trunk. (D) The nerve at first
courses parallel to an artery and then approaches the neighboring artery from its
periphery to descend along its branches toward the main trunk. (E) The nerve
crosses the primary and secondary arcades of the artery before coursing parallel to
the vascular network. (From Taylor GI, Gianoutsos MP, Morris SF. The neurovascular
territories of the skin and muscles: anatomic study and clinical implications. Plast
Reconstr Surg. 1994;94:1.)
A
B
C
D
E
intramuscular connective tissue to reach the muscle
bundles.
2. The nerves are economical. As in the integument, the
direct course of the motor nerves is in stark contrast to
the wandering pattern of the vessels. The nerves take
the shortest extramuscular and intramuscular routes
compatible with the function of each muscle.
3. Neurovascular relations vary with the muscle, the
extramuscular course, and the intramuscular branching
of the nerves and the vessels. Some muscles have a
single nerve supply; others receive multiple motor
branches. All receive multiple arterial pedicles.
However, despite the variables, certain observations can
be made:
• Each motor nerve is accompanied by a vascular
pedicle, but the reverse does not apply.
• The motor nerve is usually accompanied by the
dominant vascular pedicle. There are exceptions to
this, however. For example, the nerve supply to
sternocleidomastoid is usually accompanied by a
minor vascular pedicle.
• The nerve may enter the muscle before branching.
• Once within the muscle, the nerve divides early, and
its branches sweep rapidly into position, parallel to
the muscle fibers. The vessels, however, branch and
form primary and secondary arcades, often crossing
the muscle bundles and nerves before tertiary and
quaternary branches are provided to the muscle
fibers.
Ultimately, the terminal branches of the vessels and nerves
come into close contact and course together in the connective
tissue framework parallel to the muscle bundles.
Neurovascular anatomy of muscles of
the body
Several methods have been used to classify muscles on the
basis of morphology, function, blood supply, or nerve supply
(Table 21.1). We have classified muscles of the body according
to their most common pattern of innervation (Fig. 21.17). The
pattern of neurovascular anatomy of the muscles influences
the way a whole muscle or segment of muscle can be har­
vested as a functioning muscle microvascular transfer. It is
possible to subdivide certain muscles, based on the neurovas­
cular anatomy, into separate neurovascular units if each
segment has an individual vascular pedicle. Clinically, serra­
tus anterior, latissimus dorsi, gracilis, and rectus femoris are
often used in this way, taking a portion of the muscle with
their motor nerve and blood supply.55,56
■ Type I. The muscle is supplied by a single motor nerve
that divides after entering the muscle (Fig. 21.18).
Multiple vascular pedicles supply each muscle and form
a continuous network throughout the tissue. It is possible
in each case to remove a vascularized segment of muscle
with its nerve supply and yet leave viable muscle in situ.
■ Type II. A single motor nerve supplies each of the
muscles in this group, but the nerve divides before
entering the muscle. Muscles in this group include the
deltoid (see Fig. 21.18), gluteus maximus, trapezius,
vastus lateralis, serratus anterior, and flexor carpi ulnaris.

347.e1
Vascular anatomical research
Fig. 21.16  Arterial injection of the right upper limb
and torso. (A) Note the chain-linked systems of
arteries (arrows) that course with the cutaneous nerves
in the upper limb. (B) On the torso, the nerves are
marked on the arterial study. They course with the
cutaneous arteries, cross them at angles and collect
arterial branches, or approach the arteries from
opposite directions (arrows). (From Taylor GI, Palmer
JH. The vascular territories [angiosomes] of the body:
experimental study and clinical applications. Br J Plast
Surg. 1987;40:113; and Taylor GI, Gianoutsos MP,
Morris SF. The neurovascular territories of the skin and
muscles: anatomic study and clinical implications. Plast
Reconstr Surg. 1994;94:1.)
A
B
Vascular anatomical research

348
CHAPTER 21 • Vascular territories
Table 21.1  Classification of muscles based on their nerve supply
Type I
Type II
Type III
Type IV
Latissimus dorsi
Extensor indicis
Extensor pollicis longus
Abductor pollicis longus
Palmaris longus
Teres minor
Extensor hallucis longus
Plantaris
Popliteus
Deltoid
Gluteus maximus
Trapezius
Vastus lateralis
Serratus anterior
Flexor carpi ulnaris
Biceps brachii
Brachialis
Flexor pollicis longus
Flexor hallucis longus
Pectineus
Adductor longus
Adductor brevis
Gastrocnemius
Sartorius
Tibialis anterior
Flexor digitorum superficialis
Subscapularis
Teres major
Triceps
Extensor carpi ulnaris
Extensor digitorum longus
Gluteus medius
Gluteus minimus
Vastus medialis
Vastus intermedius
Peroneus longus
Soleus
Tibialis posterior
Rectus abdominis
Levator scapulae
Internal oblique
Digastric
Erector spinae
Fig. 21.17  Classification of muscle on the basis of nerve
supply. (From Taylor GI, Gianoutsos MP, Morris SF. The
neurovascular territories of the skin and muscles: anatomic
study and clinical implications. Plast Reconstr Surg.
1994;94:1.)
Type I
Single unbranched nerve
entering the muscle
Type II
Single branched nerve
entering the muscle
Type III
Multiple branches from
same nerve trunk
Type IV
Multiple branches from
different nerve trunks
■ Type III. Multiple motor nerve branches derive from the
same nerve trunk (see Fig. 21.18). Once again, it is
possible to subdivide each muscle into separate
functional units because of the multiple vascular pedicles
as well as the several nerve branches. Gastrocnemius is
often split in this way, taking one head for reconstruction,
leaving behind the other functional unit with its
neurovascular supply attached.
■ Type IV. Multiple motor nerves are derived from different
nerve trunks (see Fig. 21.18). It is apparent that each
muscle can be subdivided anatomically into several
functional units because of the multiple, often segmental
neurovascular pedicles. Indeed, several of these muscles
are formed developmentally by the fusion of adjacent
somites (e.g., rectus abdominis and internal oblique).
Access the Comparative Anatomy section, including
Figs. 21.19–21.21, online at

The angiosome concept
Following a review of the works by Manchot and Salmon,
along with the results of our total body studies of blood
supply to the skin and the underlying deep tissues, it has been
possible to divide the body anatomically into three-dimensional
vascular territories named angiosomes. Each of these three-
dimensional angiosomes is supplied by a source (segmental
or distributing) artery and its accompanying vein or veins
(Figs. 21.22–21.24). Each angiosome can be subdivided into

348.e1
Vascular anatomical research
Comparative anatomy
In the course of parallel investigations to describe animal
models for vascular studies, it was noted that there are close
similarities in vascular anatomy between animal species.
However, there are also important differences of which inves­
tigators should be aware. The purpose of this section is to
provide a more complete picture of the vascular territories. As
we shall see, the angiosome concept can be applied equally to
other members of the animal kingdom as well as to humans.53
In plastic surgical research, selection of various animals for
the study of flap physiology is based on cost, convenience,
availability, and/or ethical considerations rather than on a
profound knowledge of their vasculature. The pig, for
example, is a fixed-skin animal, and because human integu­
ment is also fixed in many areas, it has been assumed that this
animal is therefore most ideally suited for experiments on
skin flaps. It is important to understand the vascular basis of
the experimental animal model since results may not be
generalizable to humans.
Study of these animals also leads us to gain further insight
into the development and arrangement of the vascular system.
It may aid in identification of the ideal animal for other experi­
ments, such as investigation of the delay phenomenon, use of
tissue expansion, programming of vessels, and prefabrication
of flaps – whether they are skin, other tissues, or combinations
of tissues.
When the radiographs of four animals are reviewed
(Fig. 21.19), it is obvious there is a marked dissimilarity in the
vasculature of the integument between them and that of the
human (see Fig. 21.7). Surprisingly, however, this is in marked
contrast to the dramatic similarity of the radiographs of deep
tissue of the mammalian torsos (Fig. 21.20).
The pattern of the cutaneous vasculature of the integument
ranges from the fixed skin of the pig (supplied by a large
number of small vessels over most of the hemitorso) to the
mobile skin of the rabbit, in which four large vessels supply
the majority of this area. The duck, not surprisingly, shows
considerable diversity in the vasculature of its integument.
Nevertheless, basic patterns are evident, having been modi­
fied by the growth and functional demands of the species.
The similarity in vasculature of the deep tissue is not
confined to the anterior torso. Certain muscles between
species have a remarkably similar vascularity, as can be seen
in Fig. 21.21.
It appears that the vascular blueprint of the deep tissues of
the torso of mammals remains relatively constant. It is simply
enlarged from the fetus to the adult and from small to large
mammals. The reason for this may be that the functional
requirements of the torso are the same in each mammal, that
is, respiration, protection of the viscera, and aid in removal of
the contents. Beyond the deep tissues of the torso, it appears
that the vasculature of the overlying integument, the head
and the neck, and the limbs has been modified to meet the
functional demands of each species, as Hunter76 predicted
more than 200 years ago.
Similarities are also seen in comparing the torso studies of
mammals with those of other species, for example, the bird. In
each case, vascular arcades arise from three basic sites: cranially
from the subclavian and axillary vessels (aortic arch), laterally
Fig. 21.19  (A) Arteriogram of the skin of the pig. Note numerous small perforators on lateral torso, a superficial vein that has filled in the study (arrow), the larger
segmental vessels near the ventral and dorsal midline, and the large perforator of the deep circumflex iliac artery near the hip. (B) Angiogram of the dog. Note the large
perforator of the deep circumflex iliac artery and the thoracodorsal artery (arrows) near the hip and shoulder, respectively. (C) Arteriogram of the rabbit. Note the very large
perforators of the deep circumflex iliac artery and thoracodorsal arteries dorsally and the superficial inferior epigastric artery and lateral thoracic arteries ventrally. Note also
the large vessels supplying the ear. (D) Arteriogram of the duck. Note the discrete territories bounded by choke arteries and the long, stretched-out perforator of the
transverse cervical artery in the mobile skin area of the neck (arrow). (From Taylor GI, Minabe T. The angiosomes of the mammals and other vertebrates. Plast Reconstr Surg.
1992;89:181.)
A
B
C
D
Vascular anatomical research

348.e2
CHAPTER 21 • Vascular territories
Fig. 21.20  Injection studies of the anterior torso
with the integument removed and umbilicus located
(large dot). The studies of the human and dog (A
and C) are almost identical, with the deep inferior
epigastric artery larger than the deep superior
epigastric artery. In the pig and rabbit (B and D),
the reverse applies. (From Taylor GI, Minabe T. The
angiosomes of the mammals and other vertebrates.
Plast Reconstr Surg. 1992;89:181.)
A
B
C
D
from the aorta (descending part), and caudally from the iliac
and femoral vessels (terminal aorta). These three arcades form
the basic vascular loops in the body that are common through­
out the animal kingdom, including the human.
An underlying theme of the vascular architecture is that
of vascular loops and arcades. Comparison of the vascular
architecture in the human with that of other animals and
other species reveals a similar arrangement. In loose-skinned
animals, the arcades in the integument are stretched over long
distances (see Fig. 21.18). In the wings of insects and in the
leaves of plants, the “veins” assume a pattern of interconnect­
ing arcades similar to those of the intestinal mesentery.

348.e3
Vascular anatomical research
Fig. 21.21  Comparative study of the rectus abdominis
muscle from the various mammals studied. There is a
striking similarity between the studies. However, in all
animals except the pig, the muscle extends on to the
thorax more cranially than in the human, and this
region of the rectus receives additional branches from
the internal thoracic artery. The reciprocal size
relationship of the deep superior epigastric artery and
deep inferior epigastric artery between species is a
good example of the law of equilibrium. (From Taylor
GI, Minabe T. The angiosomes of the mammals and
other vertebrates. Plast Reconstr Surg. 1992;89:181.)
Vascular anatomical research

349
Vascular anatomical research
Fig. 21.18  Schematic diagram (left) of (A) type I (latissimus dorsi), (B) type II (deltoid), (C) type III (gastrocnemius), and (D) type IV (rectus abdominis) muscles to
match radiograph (right) of each muscle. Nerves and vessels are seen together in the radiographs. The nerves are straight, whereas the vessels are spiral. The nerves,
labeled with computer wire, appear black and the vessels pale and “ghost-like” in this subtraction study. (From Taylor GI, Gianoutsos MP, Morris SF. The neurovascular
territories of the skin and muscles: anatomic study and clinical implications. Plast Reconstr Surg. 1994;94:1.)
A
B
C
D

350
CHAPTER 21 • Vascular territories
Fig. 21.22  The technique by which the
angiosomes were defined. (A) The
cutaneous perforators with their choke
connections are depicted on the left. The
origin of the perforators from their
underlying source arteries and their
muscle branches is shown on the right.
(B) The vascular territories of each source
artery are illustrated in the integument
(left) and deep tissues (right) by lines
drawn through the choke connecting
vessels. Note that the territories
correspond in these two layers and how
they appear as sectors in the limbs. (From
Taylor GI, Palmer JH. The vascular
territories [angiosomes] of the body:
experimental study and clinical
applications. Br J Plast Surg.
1987;40:113.)
A
B
matching arteriosomes (arterial territories) and venosomes
(venous territories) or into further subunits based on indi­
vidual perforators to the skin. Forty of these territories were
initially described,73 but subsequent investigation has led to
many of these territories being subdivided further into smaller
composite units and revealed some that do not reach the skin
surface. In a later study, 61 vascular territories were identi­
fied.40 Recent work has illustrated no fewer than 13 angiosomes
of the head and neck, originally mapped as eight supplied by
branches of the external carotid, internal carotid, and subcla­
vian arteries.52 The angiosome concept indicates that the
three-dimensional block of tissue is supplied by a major
source artery and its accompanying vein(s), but it is important
to note that the angiosome itself may be divisible depending
on the branching pattern of the source vessel.
These composite blocks of skin, bone, muscle, and other
soft tissues fit together like the pieces of a jigsaw puzzle, to
make up the vascular supply of the body. In some of the
angiosomes, there is a large overlying cutaneous area and a
relatively small deep tissue region; in others, the reverse
pattern exists. Each angiosome is linked to its neighbor at
every tissue level, either by a true (simple) anastomotic arte­
rial connection without change in caliber of the vessel or by
a reduced-caliber choke anastomosis. A similar pattern with
avalvular (bidirectional or oscillating) veins on the venous
side links adjacent venosomes (see Fig. 21.24).
The angiosome concept has several important clinical
implications:
1. Each angiosome defines the safe anatomic boundary of
tissue in each layer that can be transferred separately or
combined on the underlying source vessels as a
composite flap (e.g., skin and muscle, muscle and bone,
etc). Also, the anatomic territory of each tissue in the
adjacent angiosome can usually be captured with safety
when it is included in the flap design based on one of
the source vessels.
2. Because the junctional zone between adjacent
angiosomes usually occurs within muscles of the deep
tissue, rather than between them, these muscles provide
an important anastomotic detour (bypass shunt) if the
main source artery or vein is obstructed.
3. Because most muscles span two or more angiosomes
and are supplied from each territory, one is able to
capture the skin island from one angiosome by muscle
supplied in the adjacent territory. As we shall see later,
this fact provides the basis for the design of many
musculocutaneous flaps.
The anatomical and clinical territory of a
cutaneous perforator
The angiosome concept provides a framework to understand
the vascular anatomy of the human body. Plastic surgeons
tend to focus on the vascular anatomy of skin but the angio­
some concept applies equally to all tissues. The main vascular
trunks which supply each angiosome are relatively consistent

351
Vascular anatomical research
in size and position, however the individual cutaneous per­
forators are highly variable in size and position. Each indi­
vidual cutaneous perforator territory fits together with its
neighboring territories like a giant jigsaw puzzle (Fig. 21.25).
The arterial connection between adjacent cutaneous perfora­
tors may be through reduced caliber choke anastomotic
vessels or through vessels which are not reduced in caliber
(true anastomoses).77 True anastomoses occur variably
throughout the body, most commonly along cutaneous nerves
or in areas where the skin is mobile.78
The importance of true anastomoses relates to the clinical
territory of an individual cutaneous perforator. Generally, it
has been found in experimental work on a series of animals
including pig, dog, guinea pig and rabbit that the limit of
viability of a skin flap is related to the anatomy of the pedicle
of the flap and the surrounding perforator angiosomes.78
Based on the flap perforator, it is possible to reliably capture
an adjacent cutaneous territory in any direction. In about 80%
of the animal studies, the limit of flap survival was at the
junction between second and third territory.
Fig. 21.23  The angiosomes of the source arteries of the body shaded to correspond to Fig. 21.10. The angiosomes are: (1) thyroid; (2) facial; (3) buccal (internal
maxillary); (4) ophthalmic; (5) superficial temporal; (6) occipital; (7) deep cervical; (8) transverse cervical; (9) acromiothoracic; (10) suprascapular; (11) posterior
circumflex humeral; (12) circumflex scapular; (13) profunda brachii; (14) brachial; (15) ulnar; (16) radial; (17) posterior intercostals; (18) lumbar; (19) superior gluteal;
(20) inferior gluteal; (21) profunda femoris; (22) popliteal; (22a) descending genicular (saphenous); (23) sural; (24) peroneal; (25) lateral plantar; (26) anterior tibial; (27)
lateral femoral circumflex; (28) adductor (profunda); (29) medial plantar; (30) posterior tibial; (31) superficial femoral; (32) common femoral; (33) deep circumflex iliac;
(34) deep inferior epigastric; (35) internal thoracic; (36) lateral thoracic; (37) thoracodorsal; (38) posterior interosseous; (39) anterior interosseous; and (40) internal
pudendal.
9
11
5
6
7
8
9
10
11
12
17
18
19
13
14
15
16
20
21
22
23
24
25
26
27
28
21
23
29
30
22a
22
31
40
32
33
34
35
36
37
12
11
13
14
15
16
38
39
4
3
2
1
However, if there are true anastomoses between vascular
territories, the third territory potentially could be captured
based on an individual perforator. This would be analogous
to a delay procedure (see Fig. 21.53) in which the choke
anastomotic vessels dilate between vascular territories,
increasing flap survival. Thus, it is the vascular anatomy of
individual perforators and the vascular connections between
perforators which govern the survival of flaps based on the
perforator. A novel technique using dynamic thermography
to preoperatively map cutaneous perforators and their inter­
connections has been reported which is non-invasive and
non-irradiating and shows promise as a tool to predict flap
survival.79
Access the Vascular Territories of the Body section,
including Figs. 21.26–21.38 and Tables 21.2–21.4,
online at

351.e1
Vascular anatomical research
Vascular territories of the body
The angiosome concept has led to the segregation of the body
anatomically into three-dimensional vascular territories.
Further work has led to the investigation and detailing of
angiosomes in certain parts of the body. Some of these regions
are highlighted to expand and to clarify the concept. The
description of vascular territories is important to the design
of flaps throughout the body.
Vascular territories of the forearm
The forearm is an important flap donor site due to the high
incidence of hand and upper extremity injuries around the
world.50
Forearm skin
The cutaneous perforators arise directly from the source arter­
ies or from their muscular branches, and then they follow the
intermuscular septa distally. Proximally, perforators pierce
the muscle bellies near where the muscles are fixed at their
origins from bone or from the intermuscular septa. The per­
forators become more numerous but smaller distally, with the
maximum number of small perforators being seen in the
palm, where the skin is most rigidly fixed. The cutaneous
perforators on both the anterior and posterior surfaces of the
forearm emerge in rows along the course of the radial and
ulnar arteries (Fig. 21.26).
Muscles
In general, muscles are supplied by vascular pedicles from
each angiosome that they span. These can be divided into the
anterior group and the posterior group.
The anterior group of forearm muscles can be further sub­
divided into the superficial and deep muscles. The superficial
Fig. 21.26  The cutaneous perforators of the forearm,
color-coded to match the angiosomes. Large and small skin
perforators are indicated by size of the colored markers.
Compare with Fig. 21.22. ADM, abductor digiti minimi; ANC,
anconeus; APB, abductor pollicis brevis; APL, abductor
pollicis longus; BR, brachioradialis; ECRB, extensor carpi
radialis brevis; ECRL, extensor carpi radialis longus; ECU,
extensor carpi ulnaris; ED, extensor digitorum; EDM, extensor
digiti minimi; EPB, extensor pollicis brevis; EPL, extensor
pollicis longus; FCR, flexor carpi radialis; FCU, flexor carpi
ulnaris; FDM, flexor digiti minimi; FDS, flexor digitorum
sublimis; FPB, flexor pollicis brevis; PL, palmaris longus; PT,
pronator teres. (From Inoue Y, Taylor GI. The angiosomes of the
forearm: anatomic study and clinical applications. Plast
Reconstr Surg. 1996;98:195.)
ECRL
ANC
ECRB
APL
APB
ED
ECU
FCU
ADM
FDM
FCR
FDS
FCU
PL
PT
BR
FPB
EDM
EPB
EPL
BR
Brachial artery
Profunda brachii artery
Anterior interosseous artery
Posterior interosseous artery
Interosseous recurrent artery
Ulnar collateral artery
Ulnar recurrent artery
Posterior ulnar recurrent artery
Ulnar artery
Ulnar artery
Radial recurrent artery
Radial artery
Radial artery
Radial recurrent artery
muscles proximally receive branches from the brachial artery,
the ulnar artery, or the ulnar recurrent artery. Distally, they
receive branches from the radial artery or ulnar artery
(Fig. 21.27).
The deep anterior muscles are supplied by the radial artery,
the anterior interosseous artery, and the ulnar artery. Note in
Fig. 21.27 that the junctional zone between angiosomes occurs
primarily within the muscles and that most muscles span at
least two angiosomes.
The posterior group again can be divided into superficial
and deep muscles. The superficial muscles receive blood from
the radial recurrent artery, which supplies the proximal and
lateral halves of their muscle bellies. The distal and medial
halves of these muscles receive their blood supply from the
posterior interosseous and the interosseous recurrent arteries
(Fig. 21.28). The deep muscles receive their blood supply from
the radial recurrent artery, interosseous recurrent artery,
posterior interosseous artery, and anterior interosseous artery.
When cross-sectional studies of the forearm are reviewed,
it becomes clear that the angiosomes of each source artery
span between the skin and the bone (Fig. 21.29). It is notewor­
thy that the proportional representation of each source artery
varies between levels in the forearm. Although the angiosome
of the anterior interosseous artery does not reach the skin in
Fig. 21.29, it eventually surfaces in the distal forearm posteri­
orly or where the anterior interosseous artery provides a
dominant median branch. In the latter case, it supplies the
skin on the volar surface.
Forearm bones
The bones of the forearm also conform to the angiosome
concept. The radius is supplied mainly by the radial artery by
means of several large proximal branches and by very small
distal septoperiosteal and musculoperiosteal branches. In the
middle, it receives a nutrient branch from the anterior
Vascular anatomical research

351.e2
CHAPTER 21 • Vascular territories
Fig. 21.27  The vascular territories of the (A) superficial,
(B) middle, and (C) deep forearm flexor muscles. Note
that the junctional zone between angiosomes occurs
primarily within the muscles and that most muscles cross
at least two angiosomes. Compare with Figs. 21.23 and
21.24. ADM, abductor digiti minimi; APB, abductor
pollicis brevis; B, brachialis; BB, biceps brachii; BR,
brachioradialis; FCR, flexor carpi radialis; FCU, flexor carpi
ulnaris; FDM, flexor digiti minimi; FDP, flexor digitorum
profundus; FDS, flexor digitorum sublimis; FPB, flexor
pollicis brevis; FPL, flexor pollicis longus; PL, palmaris
longus; PQ, pronator quadratus; PT, pronator teres; S,
supinator. (From Inoue Y, Taylor GI. The angiosomes of the
forearm: anatomic study and clinical applications. Plast
Reconstr Surg. 1996;98:195.)
APB
FCR
FDS
FCU
PL
PT
BR
FPB
Radial artery
ADM
FDM
Radial recurrent artery
Profunda brachii artery
Ulnar collateral artery
Brachial artery
Ulnar artery
Ulnar recurrent artery
A
APB
ADM
FDM
FDS
FCU
BR
FPB
Median artery
Radial artery
Ulnar artery
Ulnar recurrent artery
B
S
B
BB
FDP
FPL
PQ
Profunda brachii artery
Ulnar collateral artery
Ulnar recurrent artery
Radial artery
Ulnar artery
Anterior interosseous artery
C
Fig. 21.28  The vascular territories of the (A) superficial and (B) deep
forearm extensor muscles, showing once again that the junctional zone
lies primarily within the muscles. ANC, anconeus; APL, abductor pollicis
longus; BR, brachioradialis; ECRB, extensor carpi radialis brevis; ECRL,
extensor carpi radialis longus; ECU, extensor carpi ulnaris; ED, extensor
digitorum; EDM, extensor digiti minimi; EI, extensor indicis; EPB,
extensor pollicis brevis; EPL, extensor pollicis longus; S, supinator. (From
Inoue Y, Taylor GI. The angiosomes of the forearm: anatomic study and
clinical applications. Plast Reconstr Surg. 1996;98:195.)
BR
ECRL
ECRB
ANC
ECU
ECU
EDM
EPB
ED
APL
EPL
Interosseous recurrent artery
Posterior interosseous artery
Radial artery
Profunda brachii artery
Radial recurrent artery
Anterior interosseous artery
A
ECRL
S
APL
EPB
EPL
EI
BR
Interosseous recurrent artery
Posterior interosseous artery
Anterior interosseous artery
B
interosseous artery. Distally, it also receives one or two small
septoperiosteal branches from the anterior interosseous artery,
and there is another blood supply from the posterior interos­
seous artery through the muscles that are attached to the bone.
The ulna is supplied predominantly by the ulnar artery,
again through several large proximal and several small distal
septoperiosteal branches. In the middle, it receives a nutrient
branch from the posterior interosseous artery. Again, as with
the radius, another blood supply enters through muscles
attached to the ulna, derived from branches of the anterior
interosseous artery.
Clinical implications
Donor site morbidity
From these data, it is evident that the radius and ulna, and
nearly every muscle in the forearm, receive a contribution
from at least two source arteries. Also, there are intramuscular

351.e3
Vascular anatomical research
and extramuscular anastomoses around the elbow that are
usually well developed, especially on the radial side. In addi­
tion to the connections within the muscles and skin, particu­
larly well-developed anastomoses occur between vessels that
travel on and within the deep and cutaneous nerves.
When the radial artery flap is harvested, the only muscles
that lie solely within this angiosome are the brachioradialis,
extensor carpi radialis longus, and extensor carpi radialis
brevis, supplied by its radial recurrent branch. However, this
branch has an excellent anastomosis with the profunda brachii
artery. Experience confirms this observation and has shown
that dissection of the radial forearm flap can proceed safely
right up to the origin of the radial artery from the brachial
artery, with either division of its recurrent branch or inclusion
of this vessel with one or more of “the mobile mass” muscles.
A proximal dissection of the ulnar artery to its origin from
the brachial artery, however, especially if the radial artery is
smaller than usual, may lead to problems.
The flexor digitorum profundus and flexor carpi ulnaris are
the only muscles supplied solely by the ulnar artery and its
anterior interosseous or recurrent interosseous branches (see
Fig. 21.27). If these branches (or the common interosseous
artery itself) are divided at their origin while a skin flap is
harvested on the ulnar artery, survival of part or all of the
flexor carpi ulnaris and flexor digitorum profundus will then
rely on: (1) the anastomosis between the ulnar recurrent and
the ulnar collateral vessels proximally, an anastomosis that
may not be so well developed in some; (2) the anastomosis
between branches of the radial artery and the anterior interos­
seous artery in the midforearm, especially within the flexor
pollicis longus; or (3) the connections between the anterior
interosseous and a reconstituted posterior interosseous artery
in the distal forearm.
In contrast to the flexor digitorum profundus, the flexor
digitorum superficialis is better protected because it has an
additional contribution from the radial artery angiosome.
Free-flap donor sites
From the angiosome concept, and applying the anatomic
knowledge in the previous sections, various tissues can be
Fig. 21.29  Cross-sectional studies of the forearm at the
level of (A) the head of the radius, (B) insertion of the
pronator teres, and (C) midforearm, showing the
angiosomes of the forearm: brachial (yellow), radial (blue),
ulnar (red), anterior interosseus (green), and posterior
interosseous (orange) arteries. Note that the junctions of
the angiosomes occur within the skin, within the muscles,
and within the bone. ANC, anconeus; APL, abductor pollicis
longus; B, brachialis; BR, brachioradialis; ECRB, extensor
carpi radialis brevis; ECRL, extensor carpi radialis longus;
ECU, extensor carpi ulnaris; ED, extensor digitorum; EDM,
extensor digiti minimi; EPL, extensor pollicis longus; FCR,
flexor carpi radialis; FCU, flexor carpi ulnaris; FDP, flexor
digitorum profundus; FDS, flexor digitorum sublimis; FPL,
flexor pollicis longus; PL, palmaris longus; PT, pronator
teres; S, supinator. (From Inoue Y, Taylor GI. The
angiosomes of the forearm: anatomic study and clinical
applications. Plast Reconstr Surg. 1996;98:195.)
BR
BR
BR
ECRL
ECRL
ECRL
ECRB
ECRB
ECRB
Head
Radius
Ulna
EDM
ANC
FDP
FDP
FDP
PT
FCU
ECU
FCU
S
ECU
ED
ED
FCU
APL
EPL
FCR
FCR
FCR
FDS
FDS
FDS
PL
PL
PL
FPL
FPL
PT
PT
B
S
EDM
B
A
C
ECRL
BR
PT
PL
FCR
FCU
FDS
ECRB
Common extensor
Deep extensor
Radial recurrent artery
Interosseous recurrent artery
Anterior interosseous artery
Posterior interosseous artery
Posterior interosseous artery
Ulnar artery
Radial artery
Brachial artery
Posterior branch of anterior
interosseous artery
Radial artery
Ulnar artery
Anterior
interosseous artery
Vascular anatomical research

351.e4
CHAPTER 21 • Vascular territories
combined or raised separately on the forearm on the various
source arteries and their accompanying veins. It has been
shown clinically that the dimensions of a flap designed in one
angiosome can be extended to include the anatomic territory
of the adjacent angiosome in each tissue layer.
In the proximal forearm, the cutaneous blood supply from
the radial and particularly the ulnar artery is often musculo­
cutaneous. This is seen especially where muscles are fixed to
bone or where they have a common fascial attachment, often
before the muscles separate. In these circumstances (e.g.,
where the muscles arise from the common flexor or common
extensor origin), the cutaneous vessels are derived usually
from muscle branches and emerge from the muscles near
these fixed attachments to bone or fascia.
Vascular territories of the lower leg
In the lower leg, the source arteries and their respective venae
comitantes travel adjacent to, but not within, the rigid fascial
envelopes of the leg.51 Here they are invested in loose connec­
tive tissue.
Lower leg skin
The cutaneous vessels in the lower leg, as in the forearm, arise
from the source arteries or their muscle branches. They pierce
the deep fascia in longitudinal rows in the vicinity of the
intermuscular septa or beside tendons. They supply branches
to each tissue they pass of the lower leg proximally, whether
bone, muscle, nerve, fat, tendon, or fascia. There tends to be
a line of cutaneous perforators over the anterior tibial, poste­
rior tibial and peroneal vessels. These perforators provide the
vascular basis of local perforator or “propeller” flaps for lower
leg reconstruction. On the anterior surface proximally, these
perforators usually emerge between the tibialis anterior and
extensor digitorum longus, where they are derived from the
anterior tibial artery, or between the flexor digitorum longus
and soleus muscles, where they arise from the posterior tibial
artery (Fig. 21.30). Branches are seen also emerging between
the tibia and tibialis anterior muscle and between the extensor
digitorum longus and the peroneal muscles, these being
derived from the anterior tibial artery. Distally, the vessels
appear between the muscle bellies or between the tendons of
the extensor digitorum longus, extensor hallucis longus, or
peronei, obtaining their supply from the anterior tibial artery.
Over the subcutaneous surface of the tibia where the skin is
fixed, the deep fascia is continuous with the periosteum of the
bone. In this area, branches of the anterior tibial and posterior
tibial arteries anastomose freely over the surface of the
periosteum.
In the posterior aspect of the leg, vessels pierce the deep
fascia around the perimeter of muscles and tendons or from
intramuscular septa. On occasion, they have a long intramus­
cular course and appear as terminal branches of a muscle
artery; this is seen especially in the proximal perforators of
the peroneal artery.
Lower leg muscles
In the lower leg, a picture similar to that in the forearm is seen,
with muscles being supplied by vascular pedicles from each
angiosome territory they span.
Anterior leg muscles
The muscles in this compartment are supplied exclusively
by the anterior tibial artery (Fig. 21.31). A common vessel
frequently passes through one muscle belly to supply the next
as well as providing a cutaneous perforator.
This group of muscles is particularly vulnerable to ische­
mia because they are housed in a compartment with rigid
walls across which vascular connections are sparse. This is
particularly so medially, where the tibia is subcutaneous. Here
the only connections between the anterior tibial and posterior
tibial arteries are by means of the periosteum of the bone and
Fig. 21.30  Vascular territories of the lower leg. The
colored circles represent cutaneous perforators emerging
from the deep fascia and depict relative size of the vessels.
EDL, extensor digitorum longus; EHL, extensor hallucis
longus; FDL, flexor digitorum longus; GAS, gastrocnemius;
PB, peroneus brevis; PL, peroneus longus; PT, peroneus
tertius; SO, soleus; TA, tibialis anterior. (From Taylor GI,
Pan WR. The angiosomes of the leg: anatomic study and
clinical applications. Plast Reconstr Surg. 1998;102:599.)

PB
PLEDL
TA
GAS
SO
PT
EHL
Anterior tibial
recurrent artery
Lateral sural artery
PB
FDL
Popliteal artery
Popliteal artery
Peroneal artery
Peroneal artery
Peroneal artery
Posterior tibial artery
Posterior tibial artery
Medial sural artery
Anterior tibial artery
Anterior tibial artery

351.e5
Vascular anatomical research
from within the cutaneous network. As can be seen from Table
21.2, all the muscles of this compartment lie in one territory.
Lateral leg muscles
The peroneus longus and peroneus brevis are supplied by the
anterior tibial and peroneal arteries, thus forming an impor­
tant, albeit tenuous, intramuscular connection between their
two source arteries (see Fig. 21.31). These muscles are situated
within a tight compartment bordered by the fibula, the ante­
rior and posterior intermuscular septa, and the deep fascia.
As with the anterior group muscles, the blood supply fre­
quently passes through one peroneal muscle to reach the next,
often hugging the fibula during its course.
Table 21.2  Leg muscle angiosomes
One territory
Tibialis anterior
Extensor digitorum longus
Extensor hallucis longus
Peroneus tertius
Two territories
Peroneus longus
Peroneus brevis
Flexor digitorum longus
Flexor hallucis longus
Three territories
Gastrocnemius
Soleus
Popliteus
Tibialis posterior
Fig. 21.31  Vascular territories of the lower leg. (A) Illustration of the anterior muscle group that lies totally within the anterior tibial angiosome (blue). This angiosome
extends to include part of the peroneal muscles. (B) Illustration of the lateral muscles and their supply from the anterior tibial (blue) and peroneal (green) angiosomes. EDL,
extensor digitorum longus; EHL, extensor hallucis longus; PB, peroneus brevis; PL, peroneus longus; PT, peroneus tertius; TA, tibialis anterior. (From Taylor GI, Pan WR. The
angiosomes of the leg: anatomic study and clinical applications. Plast Reconstr Surg. 1998;102:599.)
PB
PB
EDL
PL
PL
TA
EHL
PT
Popliteal artery
Popliteal artery
Peroneal artery
B
A
Anterior tibial artery
Anterior recurrent tibial artery
Posterior tibial artery
Anterior recurrent tibial artery
Inferior medial genicular artery
Inferior medial genicular artery
Anterior tibial artery
Anterior tibial artery
A
B
Vascular anatomical research

351.e6
CHAPTER 21 • Vascular territories
Posterior leg muscles
The muscles here can be divided into a superficial group,
comprising the gastrocnemius and soleus, and the deep
group, comprising the flexor hallucis longus, flexor digitorum
longus, tibialis posterior, and popliteus.
The superficial group lies superficial to and is supplied by
branches of the popliteal, posterior tibial, and peroneal arter­
ies. Of particular note, blood supply to the gastrocnemius
arises proximally in the popliteal fossa from the popliteal
artery by the medial and lateral sural arteries to each head of
gastrocnemius with little overlap between muscle bellies. This
is in marked contrast to soleus, where the blood supply is
provided by a large number of short vessels from the posterior
tibial, popliteal, and peroneal arteries, which anastomose
freely within the muscle, thus forming a vital anastomotic link
in the leg.
The deep muscles are supplied by the popliteal artery by
means of its inferior genicular branches, the posterior tibial
artery, the peroneal artery, and a contribution from the ante­
rior tibial artery (Fig. 21.32).
The junctions between angiosomes, and hence the anasto­
moses between adjacent source arteries, occur usually within
tissues, especially the muscles, rather than between them
(Fig. 21.33).
Leg skin vascular supply
Proximally in the leg, the cutaneous vessels often arise as
terminal branches of the muscle arteries and travel to the
surface nearby or adjacent to (not within) the intramuscular
or intermuscular septa.
In the middle of the leg, the vessels tend to have a more
direct course to the skin but again travel close to the septa,
either adjacent to or within muscles. As they travel, they
usually supply sizable branches to the bones, the muscles, and
other tissues.
In the distal part of the leg, the cutaneous vessels have an
even more direct course to the skin. However, they still
provide branches to the tendons (especially the Achilles
tendon), the bones, and the deep fat deposits during their
course, a point to be remembered in dissecting the skin paddle
of a fibula osteocutaneous flap.
The subcutaneous periosteal surface of the tibia contains
anastomoses between the posterior and anterior tibial arteries.
Most pretibial lacerations occur superficial to the periosteum
Fig. 21.32  Vascular territories of the
lower leg. (A) The superficial muscle
group with its supply from the arteries
of the popliteal (purple), sural
(orange), posterior tibial (yellow), and
peroneal (green) angiosomes. All
muscles cross at least two angiosomes
and receive branches from the source
arteries of each. (B) The deep muscles
and their supply form the source
arteries of each angiosome. FDL, flexor
digitorum longus; FHL, flexor hallucis
longus; GAS, gastrocnemius; PLA,
plantaris; POP, popliteal; SOL, soleus;
TP, tibialis posterior. (From Taylor GI,
Pan WR. The angiosomes of the leg:
anatomic study and clinical
applications. Plast Reconstr Surg.
1998;102:599.)
SOL
GAS
PLA
Inferior medial
genicular artery
Inferior lateral
genicular artery
FHL
TP
FDL
POP
Popliteal artery
Popliteal artery
Peroneal artery
Lateral sural artery
Medial sural artery
Peroneal artery
Posterior tibial artery
Posterior tibial artery
Anterior tibial artery
A
B

351.e7
Vascular anatomical research
and “shear off” the cutaneous arteries that emerge from this
plexus, thus explaining the high incidence of traumatic skin
flap necrosis.
Connective tissue framework
The source arteries and their venae comitantes travel adjacent
to, but not within, the rigid fascial envelopes that make up
the compartments of the leg. They travel in loose connective
tissue, usually adjacent to one side of the fascial sheet. This is
important surgically, for example, to approach these vessels
to dissect the pedicles of local or free flaps, to use the vessels
as recipient sites for transplantation or replantation, or to
avoid them in decompressing the leg of a patient with a
compartment syndrome.
Compartment syndromes
It seems more than a coincidence that the compartment whose
blood supply is anatomically most vulnerable to ischemia, the
anterior tibial compartment, is the one most often affected by
exercise to give the painful condition of “shin splints”. The
Fig. 21.33  (A–C) Vascular territories of the lower leg. Anterior view of the leg with cross-sections at three levels, viewed distally. The figures show angiosomes of the
anterior tibial (blue), posterior tibial (yellow), peroneal (green), and sural (orange) arteries. Note in each case that the angiosome territories extend from the skin to the bone
and that their borders, defined by anastomotic vessels, meet usually within tissues, especially the muscles, rather than between them. EDL, extensor digitorum longus; EHL,
extensor hallucis longus; FDL, flexor digitorum longus; FHL, flexor hallucis longus; GAS, gastrocnemius; PB, peroneus brevis; PL, peroneus longus; PLA, plantaris; PT,
peroneus tertius; SOL, soleus; TA, tibialis anterior; TP, tibialis posterior. (From Taylor GI, Pan WR. The angiosomes of the leg: anatomic study and clinical applications. Plast
Reconstr Surg. 1998;102:599.)
B
A
C
PB
PL
EDL
TA
EHL
PT
Anterior tibial artery
PLA
FDL
PL
PL
PLA
PLA
FDL
FDL
TP
TP
TP
FHL
FHL
FHL
SOL
GAS
SOL
SOL
PB
PB
PB
PL
PT
TA
TA
TA
EHL
EHL
EHL
EDL
EDL
Posterior tibial artery
Branches of sural arteries
Peroneal artery
Anterior tibial
recurrent artery
Peroneal artery
Anterior tibial artery
Anterior tibial artery
Anterior tibial artery
Posterior tibial artery
Posterior tibial artery
Peroneal artery
GAS
GAS
Vascular anatomical research

351.e8
CHAPTER 21 • Vascular territories
only vessel supplying the muscles of this compartment is the
anterior tibial artery with its venous drainage paralleling the
arterial supply.
Flap donor sites
Following McGraw and Dibbell’s work on the musculocuta­
neous territories in the leg23,25 and Pontén’s work,28 which
drew attention to the vessels hugging the deep fascia and
septa in this region, a large number of flaps have been
described based proximally and distally in the leg. In most
cases, they have been designed after a review of the anatomy
of the leg vessels. Wei et al.80 have shown that a skin flap can
be included with the fibula as a free flap. On review of the
cutaneous perforators of the lateral aspect of the leg, it can be
seen that the skin paddle should be designed distally in the
leg to capture direct septocutaneous perforators from the
peroneal artery. Dissection of the distal septocutaneous per­
forators of the peroneal artery tends to be the most straight­
forward since the proximal branches tend to have long
intramuscular courses.
Vascular anastomoses around the knee
In the previous section on the forearm, emphasis was placed
on the anastomoses around the elbow joint. Here, the mass of
the brachioradialis, brachialis, and common flexor and exten­
sor muscles plays an important role in bypassing potential
obstruction of the brachial artery. The rich intramuscular
anastomoses within these muscles between the radial and
profunda brachii artery branch laterally, and between the
ulnar and ulnar collateral vessels medially, supplementing the
extramuscular anastomoses.
Around the knee, the story is very different. Few muscle
bellies actually cross the knee joint; most are represented by
tendons. The largest of these, the gastrocnemius, has a blood
supply that arises in the popliteal fossa, not above it, and has
a relatively poor connection with other vessels in the leg. The
main anastomoses between the thigh and leg are extramuscu­
lar (except for popliteus), represented by the geniculate
vessels. This helps explain the observation by Hunter and
Salmon8,9 that ligation of the popliteal artery, proximal to the
sural arteries, has a major effect on the blood supply to the
distal leg.
In the popliteal fossa distally, the soleus muscle receives
large branches from the popliteal artery, which link the
branches of the posterior tibial and peroneal vessels within
the muscle substance. This may explain why ligation of the
popliteal artery distal to the takeoff of its branches to the
soleus at the distal end of the popliteal fossa had little effect
on perfusion of the leg, as observed by Salmon.8,9
Vascular territories of the head and neck
The head and neck region is similar to the leg and forearm
region in that the angiosomes are connected usually within
the tissues, such as muscle, skin, specialized organs, or glands,
rather than between the tissues.52 The muscles usually have
vessels of two or more angiosomes supplying them and in
general can be classified into three major groups on the basis
of the similarity of their arterial supply (Tables 21.3–21.4).
In some areas, the midline anastomoses are rich, especially
in the integument of the scalp, forehead, and lips. In other
regions, such as the tongue and palate, the midline vascular
connections – those of the vertebral, lingual, and ascending
pharyngeal – are confined to the deep tissues without cutane­
ous representation.
Head and neck skin and superficial
musculoaponeurotic system
The blood supply to the skin of the face, scalp, and neck
follows the connective tissue framework. The main skin per­
forators pierce the deep fascia from fixed skin sites, especially
around the base of the skull, around the orbits, around the
nostrils, over the parotid gland, along the skin crease lines of
the face, and beside the muscles in the neck. They then radiate
into mobile skin areas and are intimately associated with the
superficial musculoaponeurotic system (SMAS) layer in the
face, the platysma in the neck, and the galea in the scalp
(Fig. 21.34).
Vascular arcades occur widely in the scalp between the
occipital, postauricular, and superficial temporal branches of
Table 21.3  Angiosome supply of the head and neck
Muscles of mastication
One territory
Lateral pterygoid
Medial pterygoid
Two territories
Buccinator
Temporalis
Masseter
Posterior neck muscles
One territory
Obliquus capitis superior
Two territories
Levator scapulae
Rectus capitis posterior major
Rectus capitis posterior minor
Three territories
Splenius capitis
Splenius cervicis
Semispinalis capitis
Semispinalis cervicis
Obliquus capitis inferior
Longissimus cervicis
Four territories
Trapezius
Five territories
Trapezius*
Longissimus capitis
Lateral neck muscles
Two territories
Scalene anterior
Scalene medius
Scalene posterior
Four territories
Sternocleidomastoid
Anterior neck muscles
One territory
Thyrohyoid
Two territories
Sternohyoid
Longus cervicis
Longus capitis
Three territories
Digastric
Omohyoid
*Note: Variation in number of angiosomes of trapezius is due to variability in
dorsal scapular artery origin.

351.e9
Vascular anatomical research
the external carotid system and the supraorbital, supratroch­
lear, and dorsal nasal branches of the internal carotid system.
The major veins and arteries in the head and neck often run
a different course and may be at a distance from each other.
In the neck, the blood supply is more sparse, with the main
perforators emerging from their source arteries where the skin
is attached (at the anterior border of the trapezius; along the
anterior and posterior borders of the sternocleidomastoid;
along the hyoid bone superiorly and the clavicle and sternum
inferiorly). They form a rich plexus within the platysma
muscle anteriorly (the counterpart to the SMAS in the neck)
en route to the skin. The external ear is supplied by two
angiosomes, the superficial temporal and the posterior auricu­
lar (Fig. 21.35).
The external nose has an abundant blood supply from the
ophthalmic branch of the internal carotid and the facial branch
of the external carotid artery. Classically, the external nasal
branch of each ophthalmic artery runs down the dorsum of
the nose to anastomose freely with the lateral nasal branch of
the facial artery on each side as well as its superior labial
branches. In summary, therefore, the external nose, like the
external ear, has two angiosomes supplying it on each side
Fig. 21.34  Fresh cadaver lead oxide arterial study of the lateral (A) and anterior (B) view of the composite skin
and superficial musculoaponeurotic system (SMAS) unit in the head and neck. The occipital (a), superficial
temporal (b), and ophthalmic (c) arteries have been labeled. Note that the facial vein (v) runs a more direct
course and at some distance to its arterial counterpart, the facial artery (d). (C) The skin layer alone reveals a
vast arterial “blush” zone of the skin and SMAS shown in sagittal view. Note: (1) the rich arterial anastomotic
“waves” formed between the branches of the occipital, superficial temporal, and ophthalmic arteries in the scalp;
(2) the cluster of small vessels supplying the fixed skin area over the parotid gland and masseter muscle
compared with the large branches of the facial artery that supply the mobile anterior face; and (3) the relative
paucity of large vessels in the neck except in the anterior triangle. The SMAS layer is seen only in (D) with the
muscles of facial expression outlined. They are: (1) frontalis; (2) procerus; (3) corrugator; (4) orbicularis oculi;
(5) levator labii superioris alaeque nasi; (6) nasalis; (7) levator labii superioris; (8) zygomaticus minor; (9)
zygomaticus major; (10) orbicularis oris; (11) depressor anguli oris; (12) depressor labii inferioris; (13)
mentalis; and (14) platysma. (From Houseman ND, Taylor GI, Pan WR. The angiosomes of the head and neck:
anatomic study and clinical applications. Plast Reconstr Surg. 2000;105:2287.)
A
B
C
D
Table 21.4  Angiosome supply of the aerodigestive system
Nose (bilateral)
Two territories
External nose
Three territories
Internal nose
Tongue and floor of mouth (bilateral)
Extrinsic
One territory
Geniohyoid
Styloglossus
Genioglossus
Hyoglossus
Two territories
Mylohyoid
Stylopharyngeus
Intrinsic
Two territories
Palate, pharynx, esophagus, and trachea (bilateral)
Five territories exist from hard palate to upper esophagus. There
is a paucity of vessels in the midline of the palate

351.e10
CHAPTER 21 • Vascular territories
and provides a major connection between the internal and
external carotid systems (Fig. 21.36; see Fig. 21.34).
The majority of the veins in the head and neck region are
avalvular, and most of the valved veins have ostial valves
sited at the entry of these bidirectional or oscillating veins into
the large collecting directional veins.
Head and neck muscles
The muscles of the head and neck may be grouped according
to the number of angiosomes they span and from which they
receive a vascular supply (see Table 21.3). These muscles are
subgrouped into regions. Together they form an important
vascular connection through their intramuscular anastomo­
ses, between branches of the internal carotid, external carotid,
and subclavian vessels.
Muscles of facial expression
These muscles lie within the mobile panniculus of the scalp,
face, and neck and the aponeurosis of the SMAS. They are
intimately related to, are supplied by, and contain within
themselves the major branches and cutaneous divisions of the
occipital, superficial temporal, ophthalmic, facial, superior
thyroid, and inferior thyroid arteries (see Figs. 21.34, 21.36).
This whole muscle aponeurotic layer tethered at various
points around the skull thus forms a rich continuous anasto­
motic layer extending from the occiput across the top of the
head and face to the root of the neck. Because of the mobility,
either the scalp or face, or a combination, can be involved in
degloving and scalping injuries. However, because of the rich
anastomosis between arteries both longitudinally and trans­
versely across the midline, combined with the poverty of
venous valves within their network, successful replantation
of the part without the need for large numbers of vascular
anastomoses has been performed.81
The platysma muscle forms a vascular link between the
external carotid and subclavian arteries through its branches
of the superior thyroid or submental branch of the facial
artery above and the transverse cervical and inferior thyroid
Fig. 21.35  (A) Lead oxide arterial study of the blood supply of the ear and adjacent tissues. Note the arcades formed between the
superficial temporal and posterior auricular arteries, highlighted with arrows. (B) Schematic picture shows the branches of the
superficial temporal (dark) and posterior auricular (light) supply to the front and back of the ear, respectively. Note also the true and
choke anastomoses between these two arteries in the scalp. (C, D) Close-up examination of the arterial anatomy of the external nose.
Note the arcades that occur around the alar dome between the columella branch of the superior labial artery and the facial artery. The
facial vein has also been partially filled with lead oxide and highlighted by the arrows. (From Houseman ND, Taylor GI, Pan WR. The
angiosomes of the head and neck: anatomic study and clinical applications. Plast Reconstr Surg. 2000;105:2287.)
A
B
2
1
C
D
Fig. 21.36  Angiosomes of the muscles of facial expression and mastication in the
face. (From Houseman ND, Taylor GI, Pan WR. The angiosomes of the head and
neck: anatomic study and clinical applications. Plast Reconstr Surg. 2000;105:
2287.)

351.e11
Vascular anatomical research
arteries below. As a result, the muscle can be raised on either
the superior or inferior pedicle.
The orbicularis oris muscle provides a vascular link
between the left and right sides of the face through the facial
artery and its superior and inferior labial artery branches. The
robustness of this blood supply has been used clinically for
more than 100 years in the Abbé flap1,82 lip reconstruction.
Ocular muscles
The six ocular muscles all lie within the territory of the oph­
thalmic artery angiosome. They are therefore potentially
vulnerable to ischemia. However, peripherally they are pro­
tected by rich anastomoses formed between branches of the
ophthalmic artery with (1) branches of the facial artery on
the face and (2) branches of the internal maxillary artery in
the temporal fossa and the nasal and cranial cavities.
Muscles of mastication
As a group, these muscles cross three angiosome territories,
forming a link between the superficial temporal, internal
Fig. 21.37  (A–D) The angiosomes of the head and neck colored and numbered to match Figs. 21.22 and 21.35.
Angiosomes: (1) internal maxillary; (2) facial; (3) ophthalmic; (4) superficial temporal; (5) posterior auricular; (6) occipital;
(7) transverse cervical; (8) deep cervical; (9) inferior thyroid; (10) superior thyroid. The sagittal section (B) shows the three
angiosomes: (11) vertebral; (12) ascending pharyngeal; (13) lingual, that do not reach the skin surface. (From Houseman
ND, Taylor GI, Pan WR. The angiosomes of the head and neck: anatomic study and clinical applications. Plast Reconstr
Surg. 2000;105:2287.)
8
7
6
5
4
3
4
1
6
11
12
7
8
9
10
13
2
1
3
1
1
2
1
10
9
A
B
10
1
1
6
3
4
2
8
9
7
C
4
6
2
5
10
8
7
D
maxillary, and facial arteries through intramuscular connec­
tions (see Fig. 21.36). Buccinator, temporalis, and masseter are
supplied by branches from two angiosomes and therefore can
be raised on either vascular pedicle.
Posterior neck muscles
As a group, these muscles span and are supplied by up to six
angiosome territories. There is thus a staircase of intramuscu­
lar vascular anastomoses, especially within the trapezius
muscle; between the intercostal branches of the aorta; the
suprascapular, transverse cervical, deep cervical, and verte­
bral branches of the subclavian artery; and the occipital branch
of the external carotid artery (Fig. 21.37).
With respect to the trapezius, there is a significant variation
in its vascular anatomy, depending on the origin of the dorsal
scapular artery.83 This may arise either as a branch of the
transverse cervical artery or as a separate branch from the
third part of the subclavian artery. As a result, the trapezius
has either four or five territories (see Table 21.3).
Vascular anatomical research

351.e12
CHAPTER 21 • Vascular territories
Fig. 21.38  Radiograph of the tongue; note the almost avascular midline. (From
Houseman ND, Taylor GI, Pan WR. The angiosomes of the head and neck: anatomic
study and clinical applications. Plast Reconstr Surg. 2000;105:2287.)
Lateral neck muscles
This group comprises the sternocleidomastoid muscle and the
deep scalene muscles. Each spans two or more angiosomes
and as a group through intramuscular links provides a
pathway between the transverse cervical and inferior thyroid
branches of the subclavian artery and the superior thyroid
and the occipital branches of the external carotid artery (see
Fig. 21.37).
Of note, the sternocleidomastoid has four angiosome ter­
ritories, the principal two being from the occipital and the
superior thyroid arteries. The lower two territories tend to be
less dominant, coming from the inferior thyroid and the
transverse cervical arteries. In head and neck reconstruction,
the sternocleidomastoid muscle has been used for many
years. It can be based either superiorly or inferiorly. However,
when it is based superiorly, the skin flap located at the lower
pole of the muscle has had a high incidence of loss of the skin
paddle because of its poor blood supply. This relates to the
number of vascular territories that blood from the superior
pole must cross to reach the skin paddle. The musculocutane­
ous flap may be unreliable depending on the vascular supply
to the flap and flap design.
Anterior neck muscles
Apart from the small thyrohyoid muscle, which occupies the
angiosome territory of the superior thyroid artery, the remain­
der of these muscles occupy at least two territories (see Table
21.3). These muscles form a link between the occipital, lingual,
and facial arteries (see Fig. 21.37).
Aerodigestive system
This system is supplied by no less than seven angiosome
territories (see Table 21.4 and Fig. 21.37).
Internal nose
This area is supplied by three primary sources from the
ophthalmic, maxillary, and facial artery angiosomes. There are
a large number of anastomoses with the blood supply to the
external nose (see Fig. 21.37).
Tongue and floor of mouth
The tongue can be divided into extrinsic and intrinsic muscu­
lature. The extrinsic muscles are either one-territory or two-
territory muscles. Of note, the mylohyoid is supplied on its
superficial surface by the submental branch of the facial artery
on each side; anastomosis in the midline forms an arterial
loop. On its deep surface, it is supplied by the lingual artery
and the mylohyoid branch of the internal maxillary artery.
The bulk of the intrinsic muscles are supplied by terminal
branches of the lingual artery as the vessel enters the pos­
terolateral portion of the tongue on each side. It also receives
a small supply from the facial artery. Of note, however, the
tongue has an obvious midline raphe, with a poor vascular
crossover between the right and left sides (Fig. 21.38). This
is of importance in resection of tongue tumors, raising the
possibility of tongue tip necrosis on the ipsilateral side if the
lingual artery is sacrificed.
Palate, pharynx, larynx, esophagus, and trachea
The region from the hard palate to the upper portion of the
esophagus spans and is supplied by five angiosomes. These
comprise the internal maxillary, facial, ascending pharyngeal,
superior thyroid, and inferior thyroid arteries. There is a
paucity of vessel crossover in the region of the hard palate,
and this appears to extend into the pharynx in a fashion
similar to the paucity in the midline of the tongue.
Glands
The salivary glands occupy one territory each. The parotid
gland receives its supply from the transverse facial branch of
the superficial temporal artery as well as a number of smaller
branches from the superficial temporal artery.
The submandibular gland is supplied by the facial artery
as it runs in the groove between the gland and the mandible.
The sublingual gland receives its supply by sublingual
branches of the lingual artery.
The thyroid gland spans two angiosome territories on each
side, being supplied by the superior and inferior thyroid
vessels. These vessels have a rich anastomotic network within
each lobe of the thyroid and form an important connection
between the subclavian and the external carotid systems on
each side and between each side.

352
CHAPTER 21 • Vascular territories
Fig. 21.24  The venosomes of the body. Compare with Fig. 21.22. (From Taylor GI, Caddy CM, Watterson PA, et al. The venous territories (venosomes) of the human body:
experimental study and clinical implications. Plast Reconstr Surg. 1990;86:185.)
9
11
5
6
7
8
9
10
11
12
17
18
19
13
14
15
16
20
21
22
23
24
25
26
27
28
21
23
29
30
22a
22
31
40
32
33
34
35
36
37
12
11
13
14
15
16
38
39
4
3
2
1
Fig. 21.25  Individual perforator angiosome and relationship
between different perforators of a source artery.
Angiosome territory of
cutaneous perforator
Angiosome territory of
source artery

353
Vascular anatomical research
deep surface), tendons, bones, nerves, and deep fat deposits.
As the vessels divide and subdivide within the specialized
tissues, their branches again follow the connective tissue
framework to reflect the architecture of the tissue in question.
The arterial framework is beautifully illustrated in the corro­
sion cast studies of Last and Tompsett (see Fig. 21.2).2,85
The cutaneous perforators exhibit the same pattern. They
arise from their source artery (segmental or distributing
artery) or one of its muscle branches and follow the intermus­
cular or intramuscular septa toward the surface (see Fig. 21.8).
They pierce the deep fascia, branch, and ramify on its surface
and ascend in the connective tissue framework of the super­
ficial fascia, traveling between the fat locules to reach the
subdermal plexus. During their course, the cutaneous vessels
provide branches to the adjacent tissues, whether they are
muscle, nerve, bone, fascia, or fat.
The cutaneous perforating veins can be traced in a retro­
grade fashion by means of the intermuscular and intramus­
cular septa to the outer layer of the deep fascia, where they
usually form rich plexuses on either side of its surface. From
there, they can be followed along the connective tissue frame­
work of the superficial fascia, worming their way between the
fat locules until they meet and become continuous with the
horizontal plexus of large superficial veins near the dermis.
Arteries radiate from fixed to mobile areas and
veins converge from mobile to fixed areas
Few arteries cross mobile tissue planes. Instead, they cross
where tissues are anchored and radiate parallel to the plane
of mobility, often for long distances. The cutaneous vessels
pierce and emerge from the outer layer of the deep fascia near
where it is anchored, either to its deep septa or to bone. The
overlying integument is fixed also to the deep fascia at these
sites. The fixed skin regions are seen easily in a well-muscled
individual as grooves and valleys. They can be seen around
the perimeter of muscles, especially where they interdigitate;
over well-developed intermuscular septa; over the flexor
surface of joints; adjacent to the dorsal and ventral midline of
the body; around the base of the skull; and in the region of
some bone prominences (see Fig. 21.16).
From the grooves and valleys in the deep fascia, the arteries
flow toward the convexities of the body surface, branching
within the integument. The wider the distance between the
concavities and the higher the summit, the longer is the vessel.
This pattern is well demonstrated in the blood supply to the
integument of the scalp, nose, ears, breasts, and genitalia; the
extensor surface of the joints; and the bulging surface of
muscles (see Fig. 21.8).
Where the skin is relatively fixed to the deep fascia over a
wide area (e.g., in the scalp and many areas of the limbs), the
vessels remain close to the surface of the deep fascia for a
considerable distance. In the loose skin areas of the body,
especially over the pectoralis major muscle, the iliac fossa, and
the extensor surface of joints, the vessels course for a short
distance adjacent to the deep fascia. Soon they are plastered to
the undersurface of the subcutaneous layer by a thin glistening
sheet of fascia, and they then pierce the fat obliquely to reach
the subdermal plexus, where they travel for long distances.
The veins course parallel to the plane of mobility, often for
long distances, and cross where the tissues are anchored to
fascia or bone. This is seen at the same site as the arteries.
Anatomic concepts related to flap design
The following concepts provide an overview of the blood
supply to the integument and to the deep tissues (Box 21.1).
They are fundamental to the mapping of the vascular territo­
ries and to the planning of incisions and flaps. They help
explain the anatomic variations that exist between the vessels
of different regions of the body and allow better understand­
ing of the various classifications of the cutaneous blood supply
that have appeared in the literature. Finally, these anatomic
concepts provide the basis for interpreting many physiologic
and pathologic processes, including the delay phenomenon
and the necrosis line of flaps.
Vessels follow the connective tissue framework of
the body
This concept is fundamental to the design of flaps in general
and to fasciocutaneous and septocutaneous flaps in particular.
The connective tissue framework of the body is a continuous
syncytium, like the walls of a honeycomb, calcified in some
areas to form the bony skeleton, which houses, permeates,
and supports the specialized tissues. The vessels follow this
framework down to the microscopic level. Embryologically,
vessels develop with connective tissue in the mesoderm and,
through development, remain closely related. The clinical
application of this is the septocutaneous or fasciocutaneous
flap.
In general, if the connective tissue is rigid, such as inter­
muscular septa, periosteum, or deep fascia, the vessels travel
beside or on it. If the connective tissue is loose, they travel
within it. The vessels occasionally travel in a fibrous sheath
or a bony canal, but this tunnel always contains loose areolar
tissue, physiologically, to allow the veins to dilate and the
arteries to pulsate.84
The pattern is well illustrated if the arterial network is
traced from the heart to the periphery. The major arteries are
closely related to the bones of the axial skeleton (see Fig. 21.2).
Their branches at first follow the intermuscular septa. In the
deep tissues, they penetrate the muscles (usually on their
BOX 21.1  Anatomic concepts
Vessels follow the connective tissue framework of the body
Arteries radiate from fixed to mobile areas and veins converge from
mobile to fixed areas
Vessels “hitchhike” with nerves
Vessel size and orientation are the product of tissue growth and
differentiation
Vessels interconnect to form a continuous three-dimensional
network of vascular arcades
Vessels obey the law of equilibrium
Vessels have a relatively constant destination but may have a
variable origin
Venous networks consist of linked valvular and avalvular channels
that allow equilibrium of flow and pressure
Muscles are the prime movers of venous return

354
CHAPTER 21 • Vascular territories
the nerves are frequently large venous freeways, such as
the cephalic, basilic, long saphenous, and short saphenous
systems. The arteries either are long vessels (e.g., the supra­
orbital, lateral intercostal, or saphenous arteries) or exist
as a chain-linked system of cutaneous perforators, often
joined in series by true anastomoses without change in
caliber (see Fig. 21.16).
The nerves pierce the deep fascia together with the vessels,
they emerge separately and cross the vessels at an angle, or
they approach the vessels from opposite directions. The main
trunk of the vessel or some of its branches peels off to course
parallel (see Fig. 21.15) to the nerve. These vessels either
course in proximity to the nerve or travel nearby (see
Fig. 21.16B).
This neurovascular relationship presents another basis for
the design of long flaps with the added potential of providing
sensation at the repair site. Many of the current “axial” or
“fasciocutaneous” flaps are in fact neurovascular flaps. The
original long and short saphenous flaps described by Pontén
are examples.
Vessel growth and orientation are products of
tissue growth and differentiation
Two centuries ago, John Hunter76 suggested that at some stage
of fetal development, there are a fixed number of arteries in
the body. This has been the authors’ impression in comparing
the number of cutaneous perforators encountered while
raising the same flap in a child and in an adult. If this concept
is correct, it provides a plausible explanation for the density
and morphology of the cutaneous arteries in different regions
of the body. It explains why vessels radiate from concavities
and converge on convexities and why the vessels in some
areas are small and close together, whereas in others they are
large and spaced well apart (Fig. 21.39
).
Fig. 21.39 appears online only.
There are numerous examples to support this hypothesis.
The sternocleidomastoid and trapezius muscles split from the
same somite.86 The trapezius “drags” its supplying transverse
cervical artery (and nerve) across the root of the neck to the
back, together with a large band of skin that it nourishes.
Manchot4,5 suggested that the long course and the direction
of the superior and inferior epigastric arteries are brought
about by the extension of the fetal torso. If one remembers
that the cutaneous perforators pierce the deep fascia at fixed
points and that they all interconnect, this would explain why,
as the brain and skull expand, the scalp vessels hypertro­
phy and are stretched from the base of the calvaria toward
its vertex.
The primitive cutaneous perforators in the fetus branch in
all directions after piercing the deep fascia and have a stellate
appearance. This pattern is retained into adulthood in many
regions of the body. When a perforator departs from this
pattern and becomes oriented in one direction, it highlights
the differential increase in growth that has occurred along that
axis or the influence of a developing cutaneous nerve. Where
small perforators are clustered close together, this pattern
suggests that, by comparison, the growth and hypertrophy in
the area are less than at those sites where the perforators are
large and spaced well apart. This is well demonstrated by
comparing the perforators in the proximal and distal regions
of the limbs.
Within the subdermal plexus and in the subcutaneous
fat, the veins and arteries often travel nearby at a distance
and only come together when they pierce the outer layer
of the deep fascia. Veins leave the subcutaneous tissue and
pierce the deep fascia where the integument is anchored
to it. This occurs around the perimeter of muscles, in par­
ticular where they interdigitate, over well-developed inter­
muscular septa. This is especially true in the limbs, where
they are concentrated in longitudinal rows over the flexor
surfaces of joints (e.g., the cubital fossa, axilla, popliteal
fossa, and groin); adjacent to the dorsal and ventral mid­
lines of the body; around the base of the skull and orbital
margins where the galea is anchored; and where the deep
fascia is fixed to bone, such as the subcutaneous border of
the tibia (see Fig. 21.10).
In the deep tissues, veins leave muscles usually near their
attachments to bone or fascia, most commonly on their deep
surfaces. If a group of muscles has a common origin, for
example, where the flexor and extensor muscles arise from the
epicondyles of the humerus, the venous drainage of each is
frequently collected into a large venous arch that courses in
the muscle mass close to the bone.
It follows that, where a tissue is mobile over a long dis­
tance, whether muscle, skin, tendon, or nerve, large flaps
are available for transfer and should be based on the fixed
margin or end of that tissue. There are numerous situations
in which this observation is used in everyday clinical practice.
For example, the large axial skin flaps based on the fixed
area of the groin, the paraumbilical region, and the para­
sternal region use the mobile skin areas over the anterior
abdominal and chest walls. The commonly used muscle and
tendon transfers are also based on this principle. If mobil­
ity exists between tissue planes, this provides a relatively
avascular plane.
Vessels “hitchhike” with nerves
There is an intimate relationship between nerves and blood
vessels throughout the deep tissues and the skin and subcu­
taneous tissues of the body, especially where a cutaneous
nerve courses on the surface of the deep fascia. An artery may
accompany the nerve for a considerable distance, often con­
necting with its neighbor in chain-link fashion to provide the
basis for an axially oriented neurovascular flap. The cutane­
ous vessels and the nerve are occasionally in juxtaposition; in
other situations, they course parallel to each other but at a
distance. When the cutaneous nerve crosses a fixed skin site,
it frequently “picks up” its next vascular companion (see
Figs. 21.15, 21.16).
There are numerous instances throughout the body where
this pattern of distribution of nerves and vessels exists to
supply the integument. This includes the supraorbital, infra­
orbital, and occipital neurovascular bundles in the head; the
supraclavicular nerves collecting branches of the suprascapu­
lar and supraclavicular vessels as they cross the clavicle on to
the chest; the intercostal neurovascular bundles on the torso;
and the cutaneous nerves of the arm, forearm, thigh, leg, and
digits, which are accompanied by long named or unnamed
vessels or a chain-linked system of vessels.
The cutaneous nerves are accompanied by a longitudinal
system of arteries and veins that are often the dominant
blood supply to the region. The veins in company with

354.e1
Vascular anatomical research
Fig. 21.39  Diagram showing how the size and course of the direct cutaneous
perforators x and y, which emerge from fixed points in the deep fascia, could be
modified by growth either before or after birth. (A) The perforators, which are fixed
in number and position, form a major connecting network on the surface of the
deep fascia in the “resting state”. (B) They are stretched with the deep fascia by the
expansion of underlying tissues (e.g., the scalp vessels as the brain and skull
expand during fetal development). (C) As the breast develops within the
integument, the vessels are displaced toward the dermis and lengthened as they
converge on the nipple. (D) They are stretched apart in the limbs as the long bones
grow, but they still retain their original relationship to the deep fascia. (E) The
vessels are again stretched apart by growth, but the mobile relationship between the
undersurface of the integument and the deep fascia is responsible for their oblique
course. This pattern is characteristic of the loose skin areas of the torso. (From
Taylor GI, Palmer JH. The vascular territories [angiosomes] of the body:
experimental study and clinical applications. Br J Plast Surg. 1987;40:113.)
B
C
D
E
A
x
x
x
x
x
y
y
y
y
y
Vascular anatomical research

355
Vascular anatomical research
Vessels interconnect to form a continuous three-
dimensional network of vascular arcades
Arteries
Throughout the body, each vessel and its branches are con­
nected with adjacent vessels and branches of neighboring
vessels to form arches. The keystones in these arcades are
formed sometimes by true anastomoses without change in
caliber. More commonly, they are represented by reduced-
caliber choke arteries and arterioles. The perimeter of choke
or anastomotic vessels defines the anatomic territory of each
artery (Fig. 21.40
). Each vascular territory is surrounded by
reduced-caliber choke anastomotic vessels. Thus, each tissue
is supplied by a series of linked arterial territories, some small
and some large.
Fig. 21.40 appears online only.
The concept is three-dimensional and was documented by
Hunter in 1794.76 He cited the vascular arcades in the hands
and the feet as examples and stated that the arcades are
smaller and occur more frequently as the arteries become
more distal (Fig. 21.41
). Thus, like a Roman aqueduct, the
arterial framework consists of tiers of vascular arcades that
commence from the aorta and become progressively smaller
as the capillary bed is approached. In general, the large
arcades are formed by the segmental or distributing source
arteries (e.g., the intercostal, radial, ulnar, and deep epigastric
arteries) that course between the tissues. Successive tiers of
arcades are formed by the arteries, arterioles, and capillaries
that supply those tissues.
Figs. 21.41–21.43 appear online only.
Veins
Commencing at the capillary bed, the venous arcades have a
design similar to that of the arteries but in reverse, with the tiers
becoming larger and less numerous until the ultimate arcade is
reached – the arcade represented by the superior and inferior
venae cavae, with the heart situated at the keystone. These
arcades link adjacent venous territories in and between tissues.
Within this network, there is a basic venous module that is
repeated in the tiers of the venous network, modified in size
and shape by the structure and function of the tissue and the
embryologic growth and differentiation that have given rise to
its adult form (Fig. 21.44A). It is stellate or medusoid in form
and consists of a number of collecting veins that converge on
a pedicle. A good example of this arrangement is the cartwheel
of superficial veins that converge on the saphenous bulb in the
groin. In some areas, the tributaries are polarized from one
direction, like a tree that has been blown by the wind (Fig.
21.44B); this is true in the scalp, in muscles, and in the leg where
the short saphenous vein approaches the popliteal fossa.
The branches within each “venous tree” are linked by
channels, often free of valves, that are oriented like the rungs
of a ladder or the circumferential loops of a cobweb. These
arcades are well demonstrated in the hands, in the feet, in
the cubital fossa, and between the venae comitantes that
accompany the arteries. Peripherally, the radiating branches
of each venous tree are linked to those of its neighbor, again
by avalvular veins, to complete the network (Fig. 21.44C). In
the integument, large horizontal channels have developed
within this reticular framework to subserve the specialized
function of thermoregulation (Fig. 21.44D). Their connections
with the deep veins are retained as large channels, the venae
communicantes, or by means of the smaller venae comitantes
of the perforating cutaneous arteries (Fig. 21.45).
Vessels obey the law of equilibrium
This concept was described by Debreuil-Chambardel and is
mentioned in Salmon’s description of the cutaneous arteries.8,10
Basically, this concept states that “the anatomical territories of
Fig. 21.44  Schematic diagrams of (A) the basic venous module, (B) its modified
arrangement in different areas, and (C) how these modules interconnect to form a continuous
network. (D) In the integument, this network of venous perforators is reorganized in the
subdermal plexus to form longitudinal channels. The valved segments are solid blue, and the
avalvular oscillating veins are light blue. (From Taylor GI, Caddy CM, Watterson PA, et al. The
venous territories [venosomes] of the human body: experimental study and clinical implications.
Plast Reconstr Surg. 1990;86:185.)
A
B
C
D

355.e1
Vascular anatomical research
Fig. 21.40  Dotted line through choke connecting vessels of a large acromiothoracic
perforator to define its anatomic territory. Compare with Fig. 21.16, left side of chest.
(From Taylor GI, Palmer JH. The vascular territories [angiosomes] of the body:
experimental study and clinical applications. Br J Plast Surg. 1987;40:113.)
Vascular anatomical research
Fig. 21.41  Radiographs of the integument of the upper
limb and hand. (A) The skin has been incised along the
ulnar border. It has been removed (B) with the deep
fascia and (C) without it. (From Taylor GI, Palmer JH.
The vascular territories [angiosomes] of the body:
experimental study and clinical applications. Br J Plast
Surg. 1987;40:113.)
A
B
C

355.e2
CHAPTER 21 • Vascular territories
Comparison of the vascular architecture in humans with
that in other animals and other species reveals a similar
arrangement of arcades. In the wings of insects and in the
leaves of plants, the veins assume a pattern of interconnecting
arcades similar to those of the intestinal mesentery (Fig. 21.43).
Fig. 21.43  (A) The wing of a moth and (B) the leaf of
a tree, showing their interconnecting arcades of “veins”.
(From Taylor GI, Palmer JH. The vascular territories
[angiosomes] of the body: experimental study and
clinical applications. Br J Plast Surg. 1987;40:113.)
A
B
The arterial arcades in the bowel mesentery are a classic
example of vascular arcades in the body (Fig. 21.42). The
arteries are smaller and more numerous as they approach the
intestine. The basic pattern exists in all tissues and is modified
by the morphology and function of that tissue. Even during
tissue repair, the pattern of vascular arcades is reproduced in
granulation tissue. Undoubtedly there are many reasons for
the interconnections that exist between arteries, but almost
Fig. 21.42  The interconnecting arcades of the small intestine. (From Crosthwaite
GL, Taylor GI, Palmer JH. A new radio-opaque injection technique for tissue
preservation. Br J Plast Surg. 1987;40:497.)
certainly one of these is to allow the equilibration of pressure
across the arcades before the capillary bed is perfused.

356
CHAPTER 21 • Vascular territories
have consistent valves and numerous venous channels, large
and small, that are free of valves and allow flow within their
lumens in either direction. Conversely, there are many small
veins that have valves at or near their ostia (sentinel valves)
as they enter large channels (see Fig. 21.44).
Directional veins
Directional veins are valved veins which exist either as longi­
tudinal channels, well developed in the subcutaneous and
deep tissues of the limbs, or as a stellate pattern of collecting
veins, which converge on a pedicle. The cutaneous perforators
and the pedicle draining muscles are good examples of the
latter arrangement. Because many of their tributaries have
valves oriented distally as they converge on the pedicle, they
provide the anatomic basis for distally based flaps (see
Fig. 21.44).
Oscillating avalvular veins
Oscillating avalvular veins are avalvular vessels which are
numerous and may reach large dimensions. They connect
and allow free flow between the valved channels of adjacent
venous territories, territories whose valves are oriented in
the opposite direction (see Figs. 21.44, 21.45). They are also
found between the valved channels of the same system;
they match and accompany the choke arteries of the arterial
framework. In the same way that the choke arteries define
the arterial territories, oscillating veins define the perimeter of
the venous territories (see Fig. 21.45). This is well illustrated
in the study of the muscles (see Fig. 21.14) and in some areas
of the integument, especially the torso, head, and neck. In the
skin of the limbs, this pattern is overshadowed by the large
superficial channels in the subdermal plexus but is appar­
ent in cross-sectional studies. If one mentally subtracts the
long, large venous channels from the picture in the limbs, the
remaining stellate pattern of the perforating veins matches
that of the perforating arteries. It is noteworthy that there is
a rich network of large oscillating veins in the anterior thigh.
This may provide an explanation for arterialized venous
free flaps.
Muscles are prime movers of venous return
Most surgeons have been preoccupied with the arterial supply
of the various muscles used for transfer. The efferent veins
that accompany the arteries and drain the muscles have been
noted and assumed, quite correctly, to be sufficient to provide
an adequate venous return.
However, this is but half the picture. There are afferent
veins entering almost every muscle in the body that arise from
the overlying integument, adjacent muscles, and underlying
bone where muscles are attached. When the muscles contract,
valves in the efferent veins direct flow toward the heart.
During “diastole”, valves direct flow into the muscles by
means of their afferent veins. If the valves in the muscles in
the leg become incompetent (e.g., as the late result of deep
venous thrombosis), it would not be difficult to envision the
back-pressure effect on the afferent cutaneous veins entering
the muscle and their role in the pathogenesis of varicose veins
and venous ulceration.
Many veins connect muscle pairs or groups of muscles as
arcades. It is noteworthy that the muscles with the richest
afferent supply were those that filled most readily with our
adjacent arteries bear an inverse relationship to each other yet
combine to supply the same region”. If one vessel is small,
its partner is large to compensate, and vice versa. This is well
illustrated by the relative size of the superficial epigastric
artery and the perforators of the deep inferior epigastric
artery (DIEA). When the superficial inferior epigastric artery
territory is noted to be large, the DIEA territory is relatively
smaller, and vice versa (see Fig. 21.7). This is an important
observation since, if a large superficial inferior epigastric vein
is noted, the drainage of the inferior portion of the DIEAP flap
may be dependent on the superficial venous drainage system.
Vessels have a relatively constant destination but
may have a variable origin
This is typical of the vessels that emanate from the groin to
supply the skin of the lower abdomen and upper thigh. The
superficial inferior epigastric and the superficial circumflex
iliac arteries, for example, may arise either separately from the
common femoral artery or as a combined trunk from that
vessel or from one of its branches. Whatever the case, their
destination is constant to supply the integument of the lower
abdomen and the hip (see Figs. 21.7, 21.16).
Venous networks consist of linked valvular and
avalvular channels that allow equilibrium of flow
and pressure
The venous network of the body is relatively poorly studied,
compared to the arterial system. It consists of segments which
Fig. 21.45  Top: Schematic diagram of the integument and underlying muscle
(shaded) in a limb illustrating the superficial (S) and deep (D) venous systems with
their interconnecting network. A large vena communicans (C) connects these
systems, and the alternative pathways of four venae comitantes are shown. The
valved veins are dark blue, and the oscillating veins are light blue. Bottom: Similar
diagram representing other regions where the predominant venous drainage is by
means of the venae comitantes. Note in each diagram that oscillating veins link
adjacent territories in the integument and deep tissues. (From Taylor GI, Caddy CM,
Watterson PA, et al. The venous territories [venosomes] of the human body:
experimental study and clinical implications. Plast Reconstr Surg. 1990;86:185.)
S
C
D
D
D
D

357
Applications of the angiosome concept
injection studies. Notable examples are the gastrocnemius–
soleus complex, the quadriceps muscles, the triceps, and the
shoulder girdle muscles, especially the deltoid.
Superficial veins follow nerves and deep veins
follow arteries
The venous drainage of the skin following investigation has
been found to consist of two parts:
1. A subdermal horizontal network tends to follow the
cutaneous nerves. This is seen in the limbs in particular,
with named cutaneous nerves following named
superficial veins (Fig. 21.46).
2. Where perforating veins pass through the deep fascia in
a perpendicular fashion, this occurs with accompanying
arteries. As stated in previous concepts, this usually
occurs at fixed sites (see Fig. 21.39).
Applications of the angiosome concept
The vascular anatomical information contained in this chapter
is an overview to provide the reader with general information
important for the design of flaps. From our extensive anatomi­
cal studies, we have determined that the general vascular
architecture of the body is consistent but variation between
different individuals and from side to side in the same indi­
vidual is the rule. As our understanding of the vascular
anatomy of the human body improves, our ability to design
and transfer flaps successfully is also improving. Although
much is now known about the arterial framework of the body,
the venous framework, and the nervous network, there are
still gaps in our knowledge. Although knowledge of vascular
Fig. 21.46  (A) Arterial and (B) venous studies of the integument of the upper
limb with: (1) the axillary; (2) lower lateral brachial; (3) supraclavicular; (4)
intercostobrachial; (5) posterior antebrachial; (6) medial antebrachial; (7) medial
brachial; (8) lateral antebrachial; (9) dorsal branch of ulnar; (10) superficial radial;
(11) median; and (12) ulnar nerves labeled. (From Taylor GI, Gianoutsos MP, Morris
SF. The neurovascular territories of the skin and muscles: anatomic study and
clinical implications. Plast Reconstr Surg. 1994;94:1.)
A
B
anatomy can be applied to all aspects of surgery, the primary
focus in plastic and reconstructive surgery is often directed
towards successful flap design. Therefore, the clinical appli­
cability of this chapter pertains primarily to the identification
of cutaneous perforators, their inclusion in flap design, and
augmenting the blood flow of the vessels supplying the flap
when necessary.
Preoperative assessment of the cutaneous
vascular supply
Flap design
It has been determined clinically and experimentally that flaps
can be safely designed by identifying a cutaneous perforator
and an adjacent perforator; a line drawn between the two
perforators should represent the axis of a viable flap.87–89 In
the simplest situations, this approach can work well; however,
the technique depends on a very accurate assessment of the
cutaneous perforators.
Dopplers
A variety of Doppler ultrasound devices have been utilized
to identify cutaneous vessels. The Doppler probe allows sur­
geons to locate cutaneous perforators with precision in
individual cases. Using the knowledge that most cutaneous
arteries emerge from fixed skin sites, as already outlined in
the section on anatomic concepts (see Fig. 21.10), their expected
origin can be anticipated and located rapidly. The simplest
Doppler devices are handheld pencil Doppler probes.87 These
are easy to use, inexpensive, portable, and provide limited
information (Fig. 21.47
). All Dopplers require insight into
their limitations. Dopplers may pick up background vessels
and may not determine the course of vessels accurately. There
is considerable inter-observer variability with the use of the
Doppler. Obese patients in particular may limit its efficiency
for two reasons. First, the thick cutaneous layer may preclude
detection of the perforator as it emerges from the deep fascia.
Second, as adipose tissue increases, the integument stretches
into folds, and the course and destination of the perforators
become distorted. However, a simple Doppler is a handy tool
to identify cutaneous vessels accurately.
Fig. 21.47 appears online only.
The use of the Doppler probe to locate the origin of cutane­
ous perforators is not new and has been used by many in the
past.87 It is not necessary in every case, for obvious reasons.
However, its application in free-flap transfer has been found
to be invaluable, especially in siting a small flap. A good
example of this is the osteocutaneous fibular flap, where just
a small skin paddle(s) may be required as a part of the recon­
struction. The Doppler probe is a quick, simple method for
defining the perforators.
Color duplex Doppler
The more sophisticated Doppler devices are color duplex
Dopplers which have greater resolution, cost, and inconve­
nience but provide much more detail on examination.90–92 The
color duplex ultrasound can accurately detect vessel diameter
and flow velocity.92 Color duplex Doppler has advantages
over CTA, including no intravenous contrast, lower cost, and

357.e1
Applications of the angiosome concept
Fig. 21.47  Doppler probe for the design of skin flaps. The handheld Doppler can
be used to identify cutaneous perforators for the design of skin flaps. In this case,
the Doppler is used to design a flap based on perforators of the deep inferior
epigastric vessels.
Applications of the angiosome concept

358
CHAPTER 21 • Vascular territories
Fig. 21.48  Use of computed tomography angiography (CTA) in the planning of
deep inferior epigastric artery perforator flaps. (A) Axial view of abdomen in patient
preoperatively before deep inferior epigastric artery flap reconstruction of the breast.
(B) Using CTA to plan surgery. Markings show perforators detected with handheld
Doppler. (C) Grid overlay with white dots reflects radiologist’s description of
cutaneous perforators based on CTA using coordinates: R/L, distance from midline
in millimeters, distance inferior to umbilicus, size of perforator in millimeters. (From
Al-Dhamin A, Berry R, Prasad MA, et al. Coding system for computed tomographic
angiography of inferior epigastric artery perforators in DIEAP flaps. Plast Reconstr
Surg. 2012;129:387e–388e.)
A
B
C
no radiation exposure.92 The color duplex Doppler is usually
already present in the radiology department of many hospitals
but it generally requires training of a technician to obtain
reliable and consistent results.
CT angiography
The most accurate method to determine the position, diameter,
and course of perforators to the skin is CTA. Masia et al. ini­
tially reported the use of a multidetector CT scanner to map
perforators prior to DIEAP flap harvest.93 The CTA technique
has become very popular and is now used around the world
to define preoperatively the size, course, and details of indi­
vidual perforators (Fig. 21.48). We have compared the accuracy
of Doppler versus CTA and found CTA to be more accurate
and more useful (see Fig. 21.48).94 The high-resolution images
of CTA provide extensive information for the surgeon regard­
ing individual perforators as small as 0.3 mm.95 In DIEAP flap
reconstruction of the breast, we have developed a system to
report individual perforators using a grid, thus enhancing
communication between radiologist and surgeon (see Fig.
21.48C). Also, in freestyle, perforator free-flap surgery,96
knowledge of the perforator course prior to flap harvest can
save a great deal of operating room time. The main disadvan­
tages of CTA include cost and radiation exposure. Proponents
of CTA highlight the savings gained by reducing operating
room time. Also, radiation can be minimized by targeted
examinations of the flap donor site. In addition, allergic reac­
tions to contrast dye and claustrophobia are potential patient
problems with CTA.92
Axes of skin flaps
The cutaneous arteries of the skin have provided the basis of
“axial” flaps used extensively in plastic and reconstructive
surgery. Fig. 21.49 shows details of the origin, course, size,
density, and interconnections of the cutaneous perforators.
It therefore provides for the logical planning of the base and
axis of a skin flap. Cross-sectional studies confirm the reason
for including the outer layer of the deep fascia with flaps

359
Applications of the angiosome concept
A
a
b
+
c
B
Fig. 21.50  Propeller flap. (A) The flap is likened
to the blades of a propeller. (B) The flap is
designed based on the largest adjacent uninjured
perforator to the wound; a = b + c + 1 cm.
(C) The flap is elevated based on the perforator.
(D) The portion of the flap b is used to cover the
donor site and the flap a is used to cover the
wound. (From Teo TW. The propeller flap concept.
Clin Plast Surg. 2010;37:615–626.)
C
D
Fig. 21.49  Some of the large axial cutaneous flaps that have been used or are
available based on specific perforating arteries and their accompanying perforating
veins, as defined by radiographic studies of the integument. In the scalp and the
limbs, they should include the deep fascia. Compare with Figs. 21.10 and 21.16.
(From Taylor GI, Palmer JH. The vascular territories [angiosomes] of the body:
experimental study and clinical applications. Br J Plast Surg. 1987;40:113.)
raised in the scalp and in the extremities; in these situations,
the vessels hug the fascia for considerable distances. If a flap
is designed along the course of the cutaneous nerve, such as
the saphenous or the sural nerve, long safe flaps can be and
have been elevated. Pontén’s28 original flaps were designed in
this way, and the saphenous neurovascular flap was planned
in a similar manner.97 In the loose skin areas of the torso, it
is unnecessary to include deep fascia because the cutane­
ous arteries course at an early stage within the integument.
They frequently correspond with the course of the cutaneous
nerve.98
Distally based skin flaps
Arterial perforators radiate in stellate patterns, and this
includes branches that course proximally. The accompanying
veins converge from the same directions. Hence, if a flap is
based distally over such a perforating system, it will contain
arterial branches that radiate proximally from it and valved
veins that return to that point. Therefore, it has been noted
that the presence of the perforator in the base of the flap is
important and allows distally based flaps.99–101 An extension
of this is the so-called propeller flap (Fig. 21.50), which is a
local island fasciocutaneous flap based on a single dissected
perforator.102 The propeller concept is an extension of the
perforator flap concept. Basically, the most crucial element to
the design of an adequately vascularized flap is the inclusion
of a sufficient cutaneous perforator and its corresponding
vein in the base of the flap. The flaps can be designed through­
out the body in a wide variety of orientations as long as the
vessel included as the flap vascular supply is not injured prior
to or during the flap elevation and is not kinked. Therefore,
gentle tissue handling and surgical technique are important
to the success of propeller flaps and other local perforator
flaps as well as releasing the deep fascia around the perforator
to prevent kinking as the flap is rotated.
Skin flap dimensions
Because the blood supply of the integument, both venous and
arterial, has been shown to be a continuous system of linked
vascular territories, the survival length of a skin flap must
depend on: (1) the caliber and length of the dominant vessels
on which the flap is based; (2) the caliber and span of the
adjacent captured artery or arteries, vein or veins; (3) the
caliber and length of the connecting choke vessels; and (4) an
anatomically favorable or unfavorable venous return; and the
volume of flap tissue.
Where the arterial perforators are large and widely sepa­
rated, the territory of each is large and a long flap can be
raised with safety. These flaps are characteristic of the loose
skin areas of the torso and the scalp. Conversely, if the perfo­
rators are small and located close together, the territory of

360
CHAPTER 21 • Vascular territories
pattern of supply usually exists where the muscles glide on
either side of the intermuscular septum.
However, if the muscles attach to either side of the
intermuscular septum, the cutaneous perforator may have
a variable course. This variability is seen in particular in the
lateral aspect of the upper calf. If a compound skin and bone
flap is designed at this site over the lateral intermuscular
septum based on the cutaneous perforators of the peroneal
vessels, either these skin vessels may course directly to the
surface, traveling in a favorable position, either adjacent to the
septum or within the substance of the soleus or flexor hallucis
longus muscles, close to their attachments to the fibula, or
alternatively, they may arise indirectly from branches to the
soleus or flexor hallucis muscles as terminal twigs of muscle
branches that have arisen from the peroneal vessels at con­
siderable distance from the lateral intermuscular septum. In
these cases, a long and laborious intramuscular dissection
of the cutaneous supply will be required to raise the flap
successfully.
Musculocutaneous flaps
The musculocutaneous flap initially became popular when it
was recognized that the large vessels supplying muscle were
more reliable than the much smaller cutaneous vessels, and
as a result the skin overlying the muscle was reliably
transferred.23–26 Musculocutaneous flaps remain preferable in
cases where large vascularized tissue bulk is required.
However, it is now understood that the musculocutaneous
perforators can be harvested without the bulk of the muscle
as perforator flaps. When skin and deep fascia are firmly
bound to the underlying muscle (e.g., the gluteus maximus
and latissimus dorsi), the blood supply to the overlying skin
is ensured. At each fixed site over the muscle, vessels emerge
to supply the integument. However, when the muscle is
mobile beneath the deep fascia (e.g., the gracilis muscle), the
cutaneous supply is at most tenuous.
In general, musculocutaneous flaps can be raised safely if
the skin paddle is placed over the perforators of the feeding
muscle artery or those in the adjacent muscle territory.
Attempts to capture territories beyond this, without previous
delay, frequently result in vascular insufficiency. This situa­
tion may prevail, for reasons already outlined, in the pectoralis
major and the pedicled TRAM flaps.
Depending on the muscle type and the site of the skin
paddle, the venous pathway once again may become ana­
tomically favorable or unfavorable. In each case, the venous
drainage is thrust on perforators that drain to the intramus­
cular plexus of veins. In type I muscles, the drainage is favor­
able regardless of the site of the skin paddle over the muscle
because the venous drainage is in one direction. If the skin
paddle is placed over the distal territory of type II and type
III muscles, the valves of this territory are oriented in the
opposite direction to those of the draining pedicle, and the
pathway is anatomically unfavorable. This problem was
highlighted by Costa et al.103 in their investigations of the
venous drainage of the pedicled TRAM flap.
Many of the musculocutaneous flaps are being replaced by
local or free microvascular perforator flaps based on the
musculocutaneous perforators. These musculocutaneous
perforators are variable in size and position and require a
flexible operative approach. These “perforator flaps” are used
each is small. The viable length of the flap is short unless the
supplying source vessel is included in the design. This is
evident in the fixed skin area of the sole of the foot.
If very large flaps are required or if vessels of a large caliber
are necessary for microvascular anastomoses, the require­
ments can be satisfied by dissecting the perforators through
the intermuscular septa or the intramuscular septa to include
the underlying source vessels. The intelligent use of a delay
also allows safe capture of adjacent vascular territories.
When we consider the venous drainage, the large longitu­
dinal veins in the subcutaneous tissue of the limbs offer
excellent venous drainage for proximally based flaps because
their valves are oriented in that direction. However, in the
lower abdomen, the drainage of proximally based flaps may
be anatomically unfavorable because the valves of the super­
ficial inferior epigastric veins are directed distally toward the
groin. The undermined flap of a transverse abdominal lipec­
tomy is a case in point, and perhaps fortuitously, the area of
the flap in question is resected in the procedure.
The scalp veins are mostly free of valves, and hence flaps
based in any direction will drain favorably. In many regions,
however, the venous network consists of territories of valved
veins oriented in different directions that are linked by oscil­
lating veins.
The precise mechanism of the necrosis line of a flap is
unknown, although the opening-up of arteriovenous shunts
provides a plausible theory. Whatever happens, it has been
shown that the choke vessels on the arterial side and some of
the valved territories of the venous return provide a potential
mechanical obstruction to flow.
Fasciocutaneous flaps
The deep fascia should be included in the design of the fas­
ciocutaneous flap in those sites where the skin is relatively
fixed to the deep fascia, for example, in the limbs or the scalp.
In these instances, the dominant cutaneous vessels course
on or lie adjacent to the deep fascia. Although they can be
dissected free in some cases, it may be simpler and safer
to include the deep fascia with the flap. However, where
the skin and subcutaneous tissues are mobile over the deep
fascia, for example, in the iliac fossae or the breast, it is
unnecessary to include this fascial layer because the major
cutaneous vessels have already left its surface. To some extent,
the initial enthusiasm for fasciocutaneous flaps has been tem­
pered by increased anatomical understanding and there are
relatively few indications for the inclusion of deep fascia in a
cutaneous flap.
The term “septocutaneous” is sometimes misleading,
especially when it is used to describe a surgically created
entity rather than a true anatomic structure. This may occur,
for example, where the cutaneous perforators of a radial or
ulnar flap are dissected within an envelope of loose areolar
tissue. Furthermore, the septocutaneous flap may provide
traps for the unwary surgeon. In some cases, the cutaneous
artery and its accompanying vein leave the underlying source
vessels and course toward the surface in a surgically favorable
position, adjacent to a true white fibrous intermuscular
septum. This is typical of the blood supply to the skin of the
lateral arm flap, where cutaneous perforators arise from
descending branches of the profunda brachii vessels and
follow the lateral intermuscular septum toward the skin. This

361
Applications of the angiosome concept
to provide large vessels for microvascular transfer; to elimi­
nate the bulk of muscle, when appropriate; and to preserve
muscle function, for example, in harvesting a lower transverse
abdominal skin flap on one or more perforators of the deep
inferior epigastric artery flap.38,39
However, all cutaneous flaps are based on cutaneous per­
forators, whether direct or indirect, and regardless of whether
they pass between or through the muscles to reach the overly­
ing integument. Hence, to confine the term “perforator flap”
to those instances in which the cutaneous vessel emerges
from muscle to perforate the overlying deep fascia is mislead­
ing. The term “perforator flap” therefore should include any
island skin flap, based on a cutaneous perforator, whether it
arises from a source vessel between or within a muscle or
other deep tissue. Some of the early free flaps, for example,
the groin flap, are true perforator flaps, in this instance based
on the superficial circumflex iliac or superficial inferior epi­
gastric artery.22
Perforator flaps
A perforator flap has been variously defined as a cutaneous flap
based on a musculocutaneous perforator or any cutaneous flap
based on any vessel supplying the skin.30,104–106 However, this is
a semantic discussion which is not as important as the concept
of perforator flaps, which represent the continuing evolution
of tissue transfers. Initial pioneering reports of perforator flaps
demonstrated that it was possible to harvest a skin flap reli­
ably based on musculocutaneous perforators.38,107,108 Perfora­
tor flaps have the advantage of the large vessel size of vessels
supplying muscles of the body without the disadvantages of
unnecessary muscle bulk and the loss of function of unneces­
sary muscle sacrifice. The popularity of perforator flaps has
increased exponentially, as evidenced by publications in the
world’s plastic surgery literature, since the initial reports of
this surgical technique.
Anatomical understanding has laid the groundwork for
the success of perforator flaps.47 Without detailed knowledge
of the underlying vasculature, perforator flap surgery would
be difficult. We have compiled an atlas of the perforators of
the human body and subdivided their distribution into 61
vascular territories (Fig. 21.51).39,40,109 There are approximately
400 cutaneous perforators to the skin, about 60% musculocu­
taneous and 40% septocutaneous.39,40,109 The field has opened
up significantly due to increased enthusiasm of surgeons
to learn the “perforator flap technique” and increased flap
options. Ultimately, perforator flaps have become more
popular because patient outcomes have improved. Moreover,
the emphasis on perforator flaps has focused attention on the
vascular anatomy of the skin. Many of the 400 perforators to
the skin can be used as a local or free-flap vascular supply,
thus expanding the possible flap options dramatically. The
use of the perforator flap technique allows clever and cus­
tomized reconstructions which can provide optimal patient
outcomes. However, perforator flaps are simply more flaps in
the armamentarium of the plastic surgeon and good clinical
judgment is still required to choose the best flap or technique
for a specific application.110
The early pioneers of perforator flaps named flaps in a
descriptive fashion which led to a wide array of terms to
describe the flaps.104,110 In some cases, several terms were used
for the same flap, which led to confusion and sometimes
delayed meaningful communication about the flaps.104,110 In
an effort to standardize descriptions of perforator flaps, we
introduced a nomenclature in which all perforator flaps are
named according to the source vessel supplying the flap.30 The
letters AP are added to indicate artery perforator and the
initials of the muscle through which the perforators travel are
added as a suffix (Fig. 21.52). Hence, in the case of a DIEAP
flap, DIEAP-ra (rectus abdominis). The suffix with muscle
initials is only necessary when the perforating vessels can
pass through different muscles. The suffix -s indicates that the
perforator flap is a septocutaneous flap.
The choice of a suitable perforator and the dissection of the
pedicle of a musculocutaneous perforator flap through a
muscle require training, expertise, and gentle operative skills.
Generally, the perforator flap is planned preoperatively using
a handheld Doppler, a color duplex Doppler, or CTA.92,111 The
largest perforator is usually chosen for the flap. As the flap
dissection begins, each perforator over 0.5 mm in diameter is
preserved until the pedicle is clearly visualized. As the dissec­
tion proceeds, gentle surgical technique is required, particu­
larly at the fascial level, to avoid traction injuries to the small
perforating vessels. Generally, the surgical technique is to
skeletonize the vascular pedicle and keep the field dry.111,112
Dozens of new perforator flaps have been described in the
past decade. However, there is a core group of very useful
perforator flaps which have become standard, including
DIEAP flap,38,107,108 anterolateral thigh flap (based on the
descending branch of the lateral circumflex femoral vessels
through vastus lateralis, LCFAP-vl),113 submental artery flap
(SMAP),114 posterior interosseous flap (PIOAP-s),115 thora­
codorsal artery perforator flap (TAP-ld),116 superior gluteal
artery (SGAP-gm),117 and inferior gluteal artery perforator
flap (IGAP-gm).118 Depending on surgeon experience and
preference, a number of these have replaced conventional
flaps. The anterolateral thigh flap, in particular, has been
called the ideal free flap, because of its usefulness in a wide
variety of clinical applications.119 The perforator flaps are
thoroughly described in a textbook on perforator flaps.39 More
recently, local perforator flaps have become increasingly uti­
lized as a method of wound closure to provide tissues with
good color match and contour and often avoid a free tissue
transfer.120,121
As Pribaz and Chan state, “The use of perforator flaps is a
new and exciting paradigm in reconstructive surgery.”122
The delay phenomenon
The only documented method to increase skin flap survival
is the delay procedure. A delay procedure can be done in a
variety of ways, from a partial incision around the margin of
a planned flap, ligation of non-pedicle vessels supplying the
flap, to partial or complete flap elevation (Fig. 21.53). The
delay can be done in one or many stages and can lead to
significantly improved skin flap survival. The physiologic
effect of delay is an enlargement of the existing arteries along
the axis of the flap, which has been well documented in
experimental animal models (Figs. 21.54, 21.55
).88,123,124 One
adjacent anatomic vascular territory can be captured with
safety on the cutaneous artery at the flap base. Anastomotic
vascular keystones, usually formed by reduced-caliber choke
arteries that link adjacent cutaneous perforators, play an
integral role in the delay phenomenon. When a flap is elevated,

361.e1
Applications of the angiosome concept
Applications of the
angiosome concept
Fig. 21.55  Arteriogram of control (left) and delayed (right) rectus abdominis
muscle of a dog 12 weeks after re-anastomosis of the previously ligated deep
inferior epigastric artery (arrow). Note that the choke vessels remain tortuous and
dilated, revealing that the effect of the delay is permanent and irreversible. (From
Dhar SC, Taylor GI. The delay phenomenon: the story unfolds. Plast Reconstr Surg.
1999;104:2079.)

362
CHAPTER 21 • Vascular territories
STA
OCA
OPA
STHA
ITA
LTA
BA
PRCA
RA
UA
RRA
DHEA
SEA
SCIA
EPA
SFA
MSGA
LIGA
ATA
DPA
MCFA
MSCLA
MICLA
ATA
DPA
BUCA
IOA
TFA
FA
MA
PAURA
TCT
TAA
PCHA
BA
POA
PRCA
RRA
PIA
SCA
LPIA
LAP
OCIA
SGA
IGA
LCFA
LSGA
PA
PTA
PHA
PFA
TDA
UA
RA
AJA
DPAA
SPA
DCA
PFA
DGA
PA
PTA
PMA
MCA
MPA
LPA
LCA
SPA
DCA
A
Fig. 21.51  Perforator vascular territories of the human body. The vascular territories of the body which correspond to regions of musculocutaneous and septocutaneous
perforators to the skin. AIA, anterior interosseous artery; ATA, anterior tibial artery; BA, brachial artery; CSA, circumflex scapular artery; DCA, dorsal carpal arch; DCIA, deep
circumflex iliac artery; DGA, descending genicular artery; DIEA, deep inferior epigastric artery; DPA, dorsal pedis artery; DPAA, deep palmar arch; DPIA, dorsal branch of
posterior intercostal artery; EPA, external pudendal artery; FA, facial artery; IGA, inferior gluteal artery; IOA, infraorbital artery; IPA, internal pudendal artery; ITA, internal
thoracic (mammary) artery; IUCA, inferior ulnar collateral artery; LA, lumbar arteries; LCA, lateral calcaneal artery; LCFA, lateral circumflex femoral artery; LIGA, lateral
inferior genicular artery; LPA, lateral plantar artery; LPIA, lateral branches of posterior intercostal artery; LSA, lateral sural artery; LSGA, lateral superior genicular artery; LTA,
lateral thoracic (mammary) artery; MA, mental artery; MCA, medial calcaneal artery; MCFA, medial circumflex femoral artery; MIGA, medial inferior genicular artery; MSA,
medial sural artery; MSGA, medial superior genicular artery; OCA, occipital artery; OPA, ophthalmic artery; PA, popliteal artery; PAURA, posterior auricular artery; PBA,
profunda brachial artery; PCHA, posterior circumflex humeral artery; PFA, profunda femoris artery; PIA, posterior interosseous artery; PNA, peroneal artery; PRCA, posterior
radial collateral artery; PTA, posterior tibial artery; RA, radial artery; RRA, radial recurrent artery; SCIA, superficial circumflex iliac artery; SEA, superior epigastric artery; SFA,
superficial femoral artery; SGA, superior gluteal artery; SIEA, superficial inferior epigastric artery; SMA, submental artery; SPA, superficial palmar arch; STA, superficial
temporal artery; STHA, superior thyroid artery; SUCA, superior ulnar collateral artery; TAA, thoracoacromial artery. (From Geddes CR. MSc thesis. Dalhousie University,
Halifax, Nova Scotia, Canada.)
STA
OCA
OPA
STHA
PRCA
RA
AIA
LIA
DCA
DPAA
SPA
RRA
PIA
MSGA
MCFA
SFA
ATA
LSGA
PFA
PCHA
CBA
TDA
PBA
LCFA
IGA
SGA
DCIA
LPIA
BA
DPA
TFA
FA
PAURA
LSA
LA
SGA
DPIA
IUCA
CSA
SUCA
BA
UA
RA
IUCA
IGA
IPA
PA
PTA
PTA
PHA
PFA
DPAA
SPA
DGA
PA
PMA
MCA
MPA
DPA
LPA
LCA
LCA
B
Fig. 21.52  Perforator flap nomenclature. (From Geddes CR, Morris SF, Neligan PC.
Perforator flaps – evolution, classification and applications. Ann Plast Surg.
2003;50:90–99.)
Deep inferior
epigastric artery
(P)
Perforator artery
Musculocutaneous perforator flap nomenclature
Rectus abdominis
muscle
DIEA
RA
P
Source artery
Perforator artery
Muscle
Perforator
Pass through

363
Applications of the angiosome concept
Fig. 21.54  Arteriogram of control (left) and delayed (right) rectus abdominis
muscles of a dog 7 days postoperatively. Note the dilated choke vessels in the
delayed flap by ligation of the deep inferior epigastric artery (arrow). (From Dhar
SC, Taylor GI. The delay phenomenon: the story unfolds. Plast Reconstr Surg.
1999;104:2079.)
Bonus images for this chapter can be found online at

Fig. 21.3 Carl Manchot’s vascular territories of the human integument. (A)
Cutaneous vascular territories, ventral surface. (B) Cutaneous vascular territories,
dorsal surface. (From Manchot C. Die Hautarterien des menschlichen Körpers.
Leipzig: FCW Vogel, 1889.)
Fig. 21.4 Michel Salmon’s vascular territories of the human integument, 1936.
Summary of the cutaneous arterial territories of the ventral surface of the body.
(From Salmon M. Artères de la peau. Paris: Masson, 1936.)
Fig. 21.5 Cadaver with body landmarks and incision lines marked. (From Taylor
GI, Palmer JH. The vascular territories [angiosomes] of the body: experimental
study and clinical applications. Br J Plast Surg. 1987;40:113.)
Fig. 21.6 Lateral view of one female subject (A) and anterior view of another (B).
(A) The arm has been removed. Note the network of large vessels that sweep
laterally from the ventral and dorsal midlines, ascend from the groins, descend
from the shoulder girdle, and converge on the summits of the scalp and the
breasts. This demonstrates the principle that vessels radiate from fixed concave
zones and radiate to mobile convex areas. (B) A lower midline scar interrupts the
vessels with compensatory opening of a large choke vessel above the umbilicus
(arrow) to re-establish the flow across the midline. (From Taylor GI, Palmer JH.
The vascular territories [angiosomes] of the body: experimental study and clinical
applications. Br J Plast Surg. 1987;40:113.)
Fig. 21.53  Diagrammatic representation of the same flap raised with and without a
surgical delay to illustrate the necrosis line and the changes in the choke vessels.
(A) The adjacent territory x is captured with safety, and the necrosis line occurs at
the choke–vessel interface with vessel y or the one beyond. (B) Vessel x had been
delayed. Note the effect on the choke vessels and the site of the necrosis line.
(C) Vessels x and y have been delayed in this bipedicled flap. Vessel z is divided
and the tip of the flap elevated at a second stage to provide the longest flap. (From
Callegari PR, Taylor GI, Caddy CM, et al. An anatomic review of the delay
phenomenon I: experimental studies. Plast Reconstr Surg. 1992;89:397–418.)
x
y
z
x
y
z
x
y
z
B
C
A
these choke vessels, which initially reduce flow from one
arterial territory to the next along the flap, enlarge to the
caliber of the cutaneous arteries they connect. However, this
process of vessel enlargement is an active event and takes
time. It is a permanent and irreversible process involving
multiplication and hypertrophy of the cells in each layer of
the vessel wall, with its maximal effect occurring between 48
and 72 hours after operation (Fig. 21.56
).123 It has been
observed that necrosis usually occurs at the level of the next
choke anastomosis in the arterial network or the one beyond.
Surgically, flap survival can be extended by the strategic divi­
sion of vascular pedicles at various time intervals along the
length of the proposed flap – the “flap delay” procedure.
Composite flaps
A knowledge of the vascular supply of all the tissues that
constitute each angiosome provides the basis for the transfer
of composite units of skin, muscle, nerve, tendon, and bone
supplied by a single arteriovenous system. This knowledge
has been applied extensively in free composite tissue trans­
fer. The vessels within the angiosome interconnect between
the various layers. This interconnection is well illustrated
with the transfer of composite tissue from the groin region.
The direct cutaneous perforators of the superficial circumflex
iliac artery interconnect with the indirect perforators of the
deep circumflex iliac artery. When a composite osteocu­
taneous flap is based on the deep system, the perforators
of the deep circumflex iliac artery capture the territory of
the superficial circumflex iliac artery to perfuse the skin.66
When the superficial system is used, the reverse applies to
perfuse the anterior segment of iliac crest and the attached
muscles.68
Angiosome concept and flap design
In this chapter, we have presented a variety of anatomical
information which supports the angiosome concept and
which provides a blueprint for successful flap design. As
always in the course of surgical evolution, the ideas and
concepts will gradually change to reflect new discoveries
and the pioneering efforts of creative surgeons. Surgical
advances move as the pendulum in an undulating course,
ever closer to the true course.

363.e1
Applications of the angiosome concept
Fig. 21.56  Time sequence of delay. Immediately after the surgical elevation of a
flap, the overall vascular diameter is reduced by vasoconstriction. Following this,
gradual dilation occurs during the first 48 hours, and then dramatic dilation occurs
from 48 to 72 hours. The rate of vessel enlargement then begins to plateau, and
gradually, vessels increase thereafter.
4h
48h
Time
72h
7d
Choke vessel diameter
Applications of the angiosome concept

364
CHAPTER 21 • Vascular territories
Fig. 21.16 Arterial injection of the right upper limb and torso. (A) Note the
chain-linked systems of arteries (arrows) that course with the cutaneous nerves in
the upper limb. (B) On the torso, the nerves are marked on the arterial study.
They course with the cutaneous arteries, cross them at angles and collect arterial
branches, or approach the arteries from opposite directions (arrows). (From Taylor
GI, Palmer JH. The vascular territories [angiosomes] of the body: experimental
study and clinical applications. Br J Plast Surg. 1987;40:113; and Taylor GI,
Gianoutsos MP, Morris SF. The neurovascular territories of the skin and muscles:
anatomic study and clinical implications. Plast Reconstr Surg. 1994;94:1.)
Fig. 21.19 (A) Arteriogram of the skin of the pig. Note numerous small perforators
on lateral torso, a superficial vein that has filled in the study (arrow), the larger
segmental vessels near the ventral and dorsal midline, and the large perforator of
the deep circumflex iliac artery near the hip. (B) Angiogram of the dog. Note the
large perforator of the deep circumflex iliac artery and the thoracodorsal artery
(arrows) near the hip and shoulder, respectively. (C) Arteriogram of the rabbit.
Note the very large perforators of the deep circumflex iliac artery and thoracodorsal
arteries dorsally and the superficial inferior epigastric artery and lateral thoracic
arteries ventrally. Note also the large vessels supplying the ear. (D) Arteriogram of
the duck. Note the discrete territories bounded by choke arteries and the long,
stretched-out perforator of the transverse cervical artery in the mobile skin area of
the neck (arrow). (From Taylor GI, Minabe T. The angiosomes of the mammals and
other vertebrates. Plast Reconstr Surg. 1992;89:181.)
Fig. 21.20 Injection studies of the anterior torso with the integument removed
and umbilicus located (large dot). The studies of the human and dog (A and C)
are almost identical, with the deep inferior epigastric artery larger than the deep
superior epigastric artery. In the pig and rabbit (B and D), the reverse applies.
(From Taylor GI, Minabe T. The angiosomes of the mammals and other
vertebrates. Plast Reconstr Surg. 1992;89:181.)
Fig. 21.21 Comparative study of the rectus abdominis muscle from the various
mammals studied. There is a striking similarity between the studies. However, in
all animals except the pig, the muscle extends on to the thorax more cranially
than in the human, and this region of the rectus receives additional branches from
the internal thoracic artery. The reciprocal size relationship of the deep superior
epigastric artery and deep inferior epigastric artery between species is a good
example of the law of equilibrium. (From Taylor GI, Minabe T. The angiosomes of
the mammals and other vertebrates. Plast Reconstr Surg. 1992;89:181.)
Fig. 21.26 The cutaneous perforators of the forearm, color-coded to match the
angiosomes. Large and small skin perforators are indicated by size of the colored
markers. Compare with Fig. 21.22. (From Inoue Y, Taylor GI. The angiosomes of
the forearm: anatomic study and clinical applications. Plast Reconstr Surg.
1996;98:195.)
Fig. 21.27 The vascular territories of the (A) superficial, (B) middle, and (C)
deep forearm flexor muscles. Note that the junctional zone between angiosomes
occurs primarily within the muscles and that most muscles cross at least two
angiosomes. Compare with Figs. 21.23 and 21.24. (From Inoue Y, Taylor GI. The
angiosomes of the forearm: anatomic study and clinical applications. Plast
Reconstr Surg. 1996;98:195.)
Fig. 21.28 The vascular territories of the (A) superficial and (B) deep forearm
extensor muscles, showing once again that the junctional zone lies primarily
within the muscles. (From Inoue Y, Taylor GI. The angiosomes of the forearm:
anatomic study and clinical applications. Plast Reconstr Surg. 1996;98:195.)
Fig. 21.29 Cross-sectional studies of the forearm at the level of (A) the head of
the radius, (B) insertion of the pronator teres, and (C) midforearm, showing the
angiosomes of the forearm: brachial (yellow), radial (blue), ulnar (red), anterior
interosseus (green), and posterior interosseous (orange) arteries. Note that the
junctions of the angiosomes occur within the skin, within the muscles, and within
the bone. (From Inoue Y, Taylor GI. The angiosomes of the forearm: anatomic
study and clinical applications. Plast Reconstr Surg. 1996;98:195.)
Fig. 21.30 Vascular territories of the lower leg. The colored circles represent
cutaneous perforators emerging from the deep fascia and depict relative size of
the vessels. (From Taylor GI, Pan WR. The angiosomes of the leg: anatomic study
and clinical applications. Plast Reconstr Surg. 1998;102:599.)
Fig. 21.31 Vascular territories of the lower leg. (A) Illustration of the anterior
muscle group that lies totally within the anterior tibial angiosome (blue). This
angiosome extends to include part of the peroneal muscles. (B) Illustration of the
lateral muscles and their supply from the anterior tibial (blue) and peroneal
(green) angiosomes. (From Taylor GI, Pan WR. The angiosomes of the leg:
anatomic study and clinical applications. Plast Reconstr Surg. 1998;102:599.)
Fig. 21.32 Vascular territories of the lower leg. (A) The superficial muscle group
with its supply from the arteries of the popliteal (purple), sural (orange), posterior
tibial (yellow), and peroneal (green) angiosomes. All muscles cross at least two
angiosomes and receive branches from the source arteries of each. (B) The deep
muscles and their supply form the source arteries of each angiosome. (From
Taylor GI, Pan WR. The angiosomes of the leg: anatomic study and clinical
applications. Plast Reconstr Surg. 1998;102:599.)
Fig. 21.33 (A–C) Vascular territories of the lower leg. Anterior view of the leg
with cross-sections at three levels, viewed distally. The figures show angiosomes
of the anterior tibial (blue), posterior tibial (yellow), peroneal (green), and sural
(orange) arteries. Note in each case that the angiosome territories extend from the
skin to the bone and that their borders, defined by anastomotic vessels, meet
usually within tissues, especially the muscles, rather than between them. (From
Taylor GI, Pan WR. The angiosomes of the leg: anatomic study and clinical
applications. Plast Reconstr Surg. 1998;102:599.)
Fig. 21.34 Fresh cadaver lead oxide arterial study of the lateral (A) and anterior
(B) view of the composite skin and superficial musculoaponeurotic system
(SMAS) unit in the head and neck. The occipital (a), superficial temporal (b), and
ophthalmic (c) arteries have been labeled. Note that the facial vein (v) runs a
more direct course and at some distance to its arterial counterpart, the facial
artery (d). (C) The skin layer alone reveals a vast arterial “blush” zone of the skin
and SMAS shown in sagittal view. Note: (1) the rich arterial anastomotic “waves”
formed between the branches of the occipital, superficial temporal, and
ophthalmic arteries in the scalp; (2) the cluster of small vessels supplying the
fixed skin area over the parotid gland and masseter muscle compared with the
large branches of the facial artery that supply the mobile anterior face; and (3)  
the relative paucity of large vessels in the neck except in the anterior triangle.  
The SMAS layer is seen only in (D) with the muscles of facial expression
outlined. (From Houseman ND, Taylor GI, Pan WR. The angiosomes of the  
head and neck: anatomic study and clinical applications. Plast Reconstr Surg.
2000;105:2287.)
Fig. 21.35 (A) Lead oxide arterial study of the blood supply of the ear and
adjacent tissues. Note the arcades formed between the superficial temporal and
posterior auricular arteries, highlighted with arrows. (B) Schematic picture shows
the branches of the superficial temporal (dark) and posterior auricular (light)
supply to the front and back of the ear, respectively. Note also the true and choke
anastomoses between these two arteries in the scalp. (C, D) Close-up
examination of the arterial anatomy of the external nose. Note the arcades that
occur around the alar dome between the columella branch of the superior labial
artery and the facial artery. The facial vein has also been partially filled with lead
oxide and highlighted by the arrows. (From Houseman ND, Taylor GI, Pan WR.
The angiosomes of the head and neck: anatomic study and clinical applications.
Plast Reconstr Surg. 2000;105:2287.)
Fig. 21.36 Angiosomes of the muscles of facial expression and mastication in
the face. (From Houseman ND, Taylor GI, Pan WR. The angiosomes of the head
and neck: anatomic study and clinical applications. Plast Reconstr Surg.
2000;105:2287.)
Fig. 21.37 (A–D) The angiosomes of the head and neck colored and numbered
to match Figs. 21.22 and 21.35. (From Houseman ND, Taylor GI, Pan WR. The
angiosomes of the head and neck: anatomic study and clinical applications. Plast
Reconstr Surg. 2000;105:2287.)
Fig. 21.38 Radiograph of the tongue; note the almost avascular midline. (From
Houseman ND, Taylor GI, Pan WR. The angiosomes of the head and neck:
anatomic study and clinical applications. Plast Reconstr Surg. 2000;105:2287.)
Fig. 21.39 Diagram showing how the size and course of the direct cutaneous
perforators x and y, which emerge from fixed points in the deep fascia, could be
modified by growth either before or after birth. (A) The perforators, which are fixed
in number and position, form a major connecting network on the surface of the
deep fascia in the “resting state”. (B) They are stretched with the deep fascia by
the expansion of underlying tissues (e.g., the scalp vessels as the brain and skull
expand during fetal development). (C) As the breast develops within the
integument, the vessels are displaced toward the dermis and lengthened as they
converge on the nipple. (D) They are stretched apart in the limbs as the long
bones grow, but they still retain their original relationship to the deep fascia.  
(E) The vessels are again stretched apart by growth, but the mobile relationship
between the undersurface of the integument and the deep fascia is responsible for
their oblique course. This pattern is characteristic of the loose skin areas of the
torso. (From Taylor GI, Palmer JH. The vascular territories [angiosomes] of the
body: experimental study and clinical applications. Br J Plast Surg. 1987;40:113.)
Fig. 21.40 Dotted line through choke connecting vessels of a large
acromiothoracic perforator to define its anatomic territory. Compare with Fig.
21.16, left side of chest. (From Taylor GI, Palmer JH. The vascular territories

365
Applications of the angiosome concept
10. Taylor GI, Tempest M. Salmon’s Arteries of the Skin. Edinburgh:
Churchill Livingstone; 1988.
21. Taylor GI, Daniel RK. The free flap: composite tissue transfer by
vascular anastomosis. Aust N Z J Surg. 1973;43:1–3. This is the
authors’ first report of vascularized free tissue transfer. A free flap was
required for coverage of a lower-extremity wound unsuited to then-more-
common techniques.
26. Mathes SJ, Nahai F. Clinical Atlas of Muscle and Musculocutaneous
Flaps. St. Louis: Mosby; 1979. This landmark reference offers detailed
schematics of key flaps for reconstructive procedures. Vivid photos enhance
the text.
30. Geddes CR, Morris SF, Neligan PC. Perforator flaps – evolution,
classification and applications. Ann Plast Surg. 2003;50:90–99. The
authors provide a historical review of the evolution of perforator flaps, and
the advantages of these flaps are described. A system of perforator flap
nomenclature is offered.
31. Taylor GI, Corlett RJ, Dhar SC, et al. The anatomical (angiosome)
and clinical territories of cutaneous perforating arteries:
development of the concept and designing safe flaps. Plast Reconstr
Surg. 2011;127:1447–1459.
39. Blondeel PN, Morris SF, Hallock GG, et al. Perforator Flaps.
Anatomy, Technique and Clinical Applications. 2nd edition. St. Louis:
Quality Medical Publishing; 2013.
40. Morris SF, Tang M, Almutairi K, et al. The anatomic basis of
perforator flaps. Clin Plast Surg. 2010;37:553–570. This report stresses
the importance of understanding the cutaneous blood supply in designing
perforator flaps. While individual perforator anatomy may be variable,
source artery anatomy is relatively consistent.
47. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the
body: experimental study and clinical applications. Br J Plast Surg.
1987;40:113–141.
48. Taylor GI, Caddy CM, Watterson PA, et al. The venous territories
(venosomes) of the human body: experimental study and clinical
implications. Plast Reconstr Surg. 1990;86:185–213.
49. Taylor GI, Gianoutsos MP, Morris SF. The neurovascular territories
of the skin and muscles: anatomic study and clinical implications.
Plast Reconstr Surg. 1994;94:1–36. Extensive human and animal
cadaveric studies were performed to characterize the anatomy of
fasciocutaneous skin flaps. Cutaneous and motor nerves were found to be
accompanied by a vascular system which often provided the regions’
dominant blood supply.
Access the complete reference list online at

[angiosomes] of the body: experimental study and clinical applications. Br J Plast
Surg. 1987;40:113.)
Fig. 21.41 Radiographs of the integument of the upper limb and hand. (A) The
skin has been incised along the ulnar border. It has been removed (B) with the
deep fascia and (C) without it. (From Taylor GI, Palmer JH. The vascular
territories [angiosomes] of the body: experimental study and clinical
applications. Br J Plast Surg. 1987;40:113.)
Fig. 21.42 The interconnecting arcades of the small intestine. (From
Crosthwaite GL, Taylor GI, Palmer JH. A new radio-opaque injection technique
for tissue preservation. Br J Plast Surg. 1987;40:497.)
Fig. 21.43 (A) The wing of a moth and (B) the leaf of a tree, showing their
interconnecting arcades of “veins”. (From Taylor GI, Palmer JH. The vascular
territories [angiosomes] of the body: experimental study and clinical
applications. Br J Plast Surg. 1987;40:113.)
Fig. 21.47 Doppler probe for the design of skin flaps. The handheld Doppler
can be used to identify cutaneous perforators for the design of skin flaps. In this
case, the Doppler is used to design a flap based on perforators of the deep
inferior epigastric vessels.
Fig. 21.55 Arteriogram of control (left) and delayed (right) rectus abdominis
muscle of a dog 12 weeks after re-anastomosis of the previously ligated deep
inferior epigastric artery (arrow). Note that the choke vessels remain tortuous
and dilated, revealing that the effect of the delay is permanent and irreversible.
(From Dhar SC, Taylor GI. The delay phenomenon: the story unfolds. Plast
Reconstr Surg. 1999;104:2079.)
Fig. 21.56 Time sequence of delay. Immediately after the surgical elevation of
a flap, the overall vascular diameter is reduced by vasoconstriction. Following
this, gradual dilation occurs during the first 48 hours, and then dramatic dilation
occurs from 48 to 72 hours. The rate of vessel enlargement then begins to
plateau, and gradually, vessels increase thereafter.

365.e1
References
References
1. Converse JM, ed. Reconstructive Plastic Surgery. 2nd ed.
Philadelphia: WB Saunders; 1977:193.
2. Tompsett DH. Anatomical Techniques. 2nd ed. London: E & S
Livingstone; 1970.
3. Gillies HD, Millard DR. The Principles and Art of Plastic Surgery.
Boston: Little, Brown; 1957.
4. Manchot C. Die Hautarterien des menschlichen Körpers. Leipzig: FCW
Vogel; 1889.
5. Manchot C. The Cutaneous Arteries of the Human Body. Ristic J,
Morain WD (trans). New York: Springer-Verlag; 1983.
6. Spalteholz W. Die Vertheilung der Blutgefässe in der Haut. Arch
Anat Entwicklungsgesch (Leipz). 1893;1:54.
7. Timmons MJ. Landmarks in the anatomical study of the blood
supply of the skin. Br J Plast Surg. 1985;38:197–207.
8. Salmon M. Artères de la peau. Paris: Masson; 1936.
9. Salmon M. Artères des muscles des membres et du tronc. Paris:
Masson; 1936.
10. Taylor GI, Tempest M. Salmon’s Arteries of the Skin. Edinburgh:
Churchill Livingstone; 1988.
11. Schafer K. Das subcutane Gefäss-System (untere Extremität).
Mikropräparatorische Untersuchungen. Gegenbaurs Morphol Jahrb.
1975;121:492.
12. Tansini I. Sopra il mio nuovo processo di amputazione della
mammella. [Coverage of the anterior chest wall following
mastectomy.]. Gazz Med Ital. 1906;57:141.
13. Davis JS. Plastic Surgery, its Principles and Practice. Philadelphia:
Blakiston; 1919.
14. Blair VP. The delayed transfer of long pedicle flaps in plastic
surgery (face). Surg Gynecol Obstet. 1921;33:261.
15. Esser JFS. Artery Flaps. Antwerp: De Vos-van Kleef; 1929.
16. Webster JP. Thoraco-epigastric tubed pedicles. Surg Clin North Am.
1937;17:145.
17. Shaw DT, Payne RL Jr. One-stage tubed abdominal flaps; single
pedicle tubes. Surg Gynecol Obstet. 1946;83:205–209.
18. Bakamjian VY. A two stage method for pharyngoesophageal
reconstruction with a primary pectoral skin flap. Plast Reconstr
Surg. 1965;36:173–184.
19. McGregor IA, Morgan G. Axial and random pattern flaps. Br J
Plast Surg. 1973;26:202–213.
20. Daniel RK, Williams HB. The free transfer of skin flaps by
microvascular anastomoses. Plast Reconstr Surg. 1973;52:16–31.
21. Taylor GI, Daniel RK. The free flap: composite tissue transfer by
vascular anastomosis. Aust N Z J Surg. 1973;43:1–3. This is the
authors’ first report of vascularized free tissue transfer. A free flap was
required for coverage of a lower-extremity wound unsuited to then-more-
common techniques.
22. Daniel RK, Taylor GI. Distant transfer of an island flap by
microvascular anastomoses. Plast Reconstr Surg. 1973;52:111–117.
23. McCraw JB, Dibbell DG, Carraway JH. Clinical definition of
independent myocutaneous vascular territories. Plast Reconstr
Surg. 1977;60:341–352.
24. McCraw JB. The recent history of myocutaneous flaps. Clin Plast
Surg. 1980;7:3–7.
25. McCraw JB, Dibbell DG. Experimental definition of independent
myocutaneous vascular territories. Plast Reconstr Surg.
1977;60:212–220.
26. Mathes SJ, Nahai F. Clinical Atlas of Muscle and Musculocutaneous
Flaps. St. Louis: Mosby; 1979. This landmark reference offers detailed
schematics of key flaps for reconstructive procedures. Vivid photos
enhance the text.
27. McDowell F. Logs vs. harpsichords, blobby flaps vs. finished
results. Plast Reconstr Surg. 1979;64:249.
28. Pontén B. The fasciocutaneous flap: its use in soft tissue defects of
the lower leg. Br J Plast Surg. 1981;34:215–220.
29. Nakajima H, Fujino T, Adachi S. A new concept of vascular supply
to the skin and classification of skin flaps according to their
vascularization. Ann Plast Surg. 1986;16:1–19.
30. Geddes CR, Morris SF, Neligan PC. Perforator flaps – evolution,
classification and applications. Ann Plast Surg. 2003;50:90–99. The
authors provide a historical review of the evolution of perforator flaps,
and the advantages of these flaps are described. A system of perforator
flap nomenclature is offered.
31. Taylor GI, Corlett RJ, Dhar SC, et al. The anatomical (angiosome)
and clinical territories of cutaneous perforating arteries:
development of the concept and designing safe flaps. Plast
Reconstr Surg. 2011;127:1447–1459.
32. Cormack GC, Lamberty BGH. The Arterial Anatomy of Skin Flaps.
Edinburgh: Churchill Livingstone; 1986.
33. Cormack GC, Lamberty BGH. Measurement of geometric
parameters in plastic surgery research: use of the departmental
microcomputer. Br J Plast Surg. 1986;39:307–311.
34. Drever JM. The epigastric island flap. Plast Reconstr Surg.
1977;59:343–346.
35. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a
transverse abdominal island flap. Plast Reconstr Surg.
1982;69:216–225.
36. Boyd JB, Taylor GI, Corlett RJ. The vascular territories of the
superior epigastric and the deep inferior epigastric systems. Plast
Reconstr Surg. 1984;73:1–16.
37. Moon HK, Taylor GI. The vascular anatomy of rectus abdominis
musculocutaneous flaps based on the deep superior epigastric
system. Plast Reconstr Surg. 1988;82:815–829.
38. Allen RJ, Treece P. Deep inferior epigastric perforator flap for
breast reconstruction. Ann Plast Surg. 1994;32:32–38.
39. Blondeel PN, Morris SF, Hallock GG, et al. Perforator Flaps.
Anatomy, Technique and Clinical Applications. 2nd edition. St. Louis:
Quality Medical Publishing; 2013.
40. Morris SF, Tang M, Almutairi K, et al. The anatomic basis of
perforator flaps. Clin Plast Surg. 2010;37:553–570. This report stresses
the importance of understanding the cutaneous blood supply in designing
perforator flaps. While individual perforator anatomy may be variable,
source artery anatomy is relatively consistent.
41. Rees MJW, Taylor GI. A simplified lead oxide cadaver injection
technique. Plast Reconstr Surg. 1986;77:141–145.
42. Crosthwaite GL, Taylor GI, Palmer JH. A new radio-opaque
injection technique for tissue preservation. Br J Plast Surg.
1987;40:497–501.
43. Tang M, Yin Z, Morris SF. A pilot study of three-dimensional
visualization of perforator flaps by using angiography in cadavers.
Plast Reconstr Surg. 2008;122:429–437.
44. Bergeron L, Tang M, Morris SF. A review of vascular injection
techniques for the study of perforator flaps. Plast Reconstr Surg.
2006;117:2050–2057.
45. Rozen WM, Chubb D, Ashton MW, et al. Achieving high quality
3D computed tomographic angiography (CTA) images for
preoperative perforator imaging: now easily accessible using freely
available software. J Plast Reconstr Aesthet Surg. 2011;64:e84–e86.
46. Tang M, Mao Y, Almutairi K, et al. Three-dimensional analysis of
perforators of the posterior leg. Plast Reconstr Surg.
2009;123:1729–1738.
47. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the
body: experimental study and clinical applications. Br J Plast Surg.
1987;40:113–141.
48. Taylor GI, Caddy CM, Watterson PA, et al. The venous territories
(venosomes) of the human body: experimental study and clinical
implications. Plast Reconstr Surg. 1990;86:185–213.
49. Taylor GI, Gianoutsos MP, Morris SF. The neurovascular territories
of the skin and muscles: anatomic study and clinical implications.
Plast Reconstr Surg. 1994;94:1–36. Extensive human and animal
cadaveric studies were performed to characterize the anatomy of
fasciocutaneous skin flaps. Cutaneous and motor nerves were found to be
accompanied by a vascular system which often provided the regions’
dominant blood supply.