Dominance between Angiosome and Perforator Territories: A New Anatomical Model for the Design of Perforator Flaps

ABSTRACT

An understanding of the angiosome of a source vessel in supply to a perforator flap is essential to flap design. With substantial interindividual variability in the size and reliability of such territories, preoperative awareness of factors that affect the number or size of perforators in a given territory can aid operative planning. Body weight and scarring are known to modify a given territory, and anecdotally so too can the “dominance” of adjacent vascular territories. A clinical study of 300 patients (600 body sides) was undertaken, using computed tomographic angiography, to map the vessels of six vascular territories. The effect of interplay between vascular territories was assessed by establishing whether a dominant territory was associated with a diminutive adjacent territory. For every vascular territory investigated, the effect of “dominance” was evident, with a statistically significant effect shown between the deep inferior epigastric artery and superficial inferior epigastric artery territories (p < 0.01), and the anteromedial thigh and anterolateral thigh perforator territories (p = 0.01). The size or dominance of perforators in a given vascular territory is influenced by the dominance of adjacent vascular territories. This concept of perforator or angiosome dominance is an important factor in the design of perforator flaps.

KEYWORDS

Superficial inferior epigastric artery - DIEA perforator flap - anterolateral thigh flap - computed tomographic angiography - preoperative imaging

REFERENCES

• 1 Saint-Cyr M, Schaverien M V, Rohrich R J. Perforator flaps: history, controversies, physiology, anatomy, and use in reconstruction.  Plast Reconstr Surg. 2009;  123 132e-145e
• 2 Wei F C, Celik N. Perforator flap entity.  Clin Plast Surg. 2003;  30 325-329
• 3 Geddes C R, Morris S F, Neligan P C. Perforator flaps: evolution, classification, and applications.  Ann Plast Surg. 2003;  50 90-99
• 4 Taylor G I. The angiosomes of the body and their supply to perforator flaps.  Clin Plast Surg. 2003;  30 331-342, v
• 5 Taylor G I, Palmer J H. The vascular territories (angiosomes) of the body: experimental study and clinical applications.  Br J Plast Surg. 1987;  40 113-141
• 6 Rozen W M, Ashton M W, Le Roux C M, Pan W R, Corlett R J. The perforator angiosome: a new concept in the design of deep inferior epigastric artery perforator flaps for breast reconstruction.  Microsurgery. 2010;  30 1-7
• 7 Rozen W M, Ashton M W, Pan W R et al.. Anatomical variations in the harvest of anterolateral thigh flap perforators: a cadaveric and clinical study.  Microsurgery. 2009;  29 16-23
• 8 Koshima I, Fukuda H, Utunomiya R, Soeda S. The anterolateral thigh flap; variations in its vascular pedicle.  Br J Plast Surg. 1989;  42 260-262
• 9 Rozen W M, Chubb D, Grinsell D, Ashton M W. The SIEA angiosome: interindividual variability predicted preoperatively.  Plast Reconstr Surg. 2009;  124 327-328 author reply 328-330
• 10 Koshima I. Short pedicle superficial inferior epigastric artery adiposal flap: new anatomical findings and the use of this flap for reconstruction of facial contour.  Plast Reconstr Surg. 2005;  116 1091-1097
• 11 Morris S, Tang M, Geddes C R. Vascular anatomical basis of perforator skin flaps.  Cir Plást Iberlatinamer. 2006;  32 225-236
• 12 Sutera S P, Skalak R. The history of Poiseuille's law.  Annu Rev Fluid Mech. 1993;  25 1-19
• 13 Rozen W M, Ashton M W, Le Roux C M, Pan W R, Corlett R J. The perforator angiosome: a new concept in the design of deep inferior epigastric artery perforator flaps for breast reconstruction.  Microsurgery. 2010;  30 1-7
• 14 Rozen W M, Chubb D, Grinsell D et al.. The variability of the superficial inferior epigastric artery (SIEA) and its angiosome: a clinical anatomical study.  Microsurgery. 2010;  , January 7 (Epub ahead of print)
• 15 Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich R J. The perforasome theory: vascular anatomy and clinical implications.  Plast Reconstr Surg. 2009;  124 1529-1544
• 16 Van Belle G, Heagerty PJ, Fisher LD, Lumley TS Biostatistics: A Methodology for the Health Sciences. Hoboken, NJ; Wiley-Interscience 2004
• 17 Rozen W M, Ashton M W, Stella D L, Phillips T J, Grinsell D, Taylor G I. The accuracy of computed tomographic angiography for mapping the perforators of the deep inferior epigastric artery: a blinded, prospective cohort study.  Plast Reconstr Surg. 2008;  122 1003-1009
• 18 Rozen W M, Garcia-Tutor E, Alonso-Burgos A, Corlett R J, Taylor G I, Ashton M W. The effect of anterior abdominal wall scars on the vascular anatomy of the abdominal wall: a cadaveric and clinical study with clinical implications.  Clin Anat. 2009;  22 815-822
• 19 Shayan R, Rozen W M, Bernard S, Corlett R J, Ashton M W, Taylor G I. Perforator dilatation induced by body weight gain is not reversed by subsequent weight loss: implications for perforator flaps.  Plast Reconstr Surg. 2008;  122 1765-1772