Chapter 1 vessels, which branch only to the skin and indirect vessels, supplying first of all deep structures as muscle and later on the skin. In 1889 Manchot9,10 published the first work on the arteries of the skin with a systematic analysis and 47 years later Salmon11,12,13 performed a more sophisticated study using a radiographic technique with the same purpose. Much of Salmon’s work remains accurate and applicable to modern flap design and his technique has served as a template for subsequent anatomic studies. Many of Salmon’s statements are still valid today. They are the logical consequence of the embryologic development of the human beeings: The muscle provides a vital anastomotic detour. Arteries link to form a continuous unbroken network. Intramuscular territories of the arteries and their veins match. The viability of a muscle flap depends on the size and number of its vascular territories. Vessels hitchhike with the nerves. Vessels follow the connective tissue framework. Vessels radiate from fixed to mobile areas. There is a direct relationship between muscle mobility and the size and density of the supplying vessels. Vessels tend to have a constant destination but may have a variable origin. The territory of the intramuscular arteries obeys the law of equilibrium. Vessel size and orientation are the product of tissue differentiation and growth in the area. Muscles are the prime movers of the venous return. THE ANGIOSOME CONCEPT Salmon described the cutaneous territories and the concept of arterial territories of the muscles. The angiosome concept introduced by Taylor and Palmer in 198714,15,16was an extension of this idea. It defines three-dimensional anatomic territories supplied by a source artery and its accompanying veins that span between the skin and the bone. The blood supply to the skin and underlying tissues was investigated by Taylor by ink injection studies, dissection, perforator mapping and radiographic analysis of fresh cadavers and isolated limbs. The blood supply was shown to be a continuous three-dimensional network of vessels not only in the skin but in all tissue layers. The anatomical territory of a source artery 9
5. lay-out phd DEFINITIEF_digitaal2
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