2. Blood Supply of the Skin

3. Anatomy of Circulation The blood reaching the skin originates from deep vessels These then feed interconnecting perforator vessels which supply the vascular plexus Thus skin fundamentally perfused by musculocutaneous or septocutaneous perforators

4. Nahai-Mathes Classification

5. Anatomy of Circulation The vascular plexuses of the fascia, subcutaneous tissue and skin are divided into 6 layers

7. Anatomy of Circulation 1)Subfascial plexus small plexus lying on the undersurface of the fascia

8. Anatomy of Circulation 2) Prefascial plexus -a larger plexus -particularly prominent on the limbs -fasciocutaneous vessels

9. Anatomy of Circulation 3)Subcutaneous Plexus -lies at the level of superficial fascia -Predominant on the torso -musculocutaneous vessels

10. Anatomy of Circulation 4)Subdermal Plexus -receives blood from underlying plexus -the main plexus supplying blood to the skin -represents the dermal bleed observed in incised skin

11. Anatomy of Circulation 5) Dermal Plexus -mainly arterioles -important in thermoregulation

12. Anatomy of Circulation 6)Subepidermal Plexus -contains small vessels without muscle in the walls -nutritive and thermoregulatory function

13. Angiosomes Similar to a skin dermatome is a composite block of 3 dimensional tissue supplied by a named artery Entire skin surface of the body is therefore perfused by a multitude of angiosome units First studied by Marchot 1889, expanded by Salmon 1930 and more recently by Ian Taylor

14. Angiosomes Each angiosome is linked to its neighbour at every tissue level, either by – a true (simple) anastomotic arterial connection without change in caliber of the vessel – or by a reduced-caliber choke anastomosis.

15. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg. 1987;40:113. The sites of emergence of the direct and indirect cutaneous arterial perforators of 0.5 mm or greater averaged from all studies. Direct perforators are more common in the limbs, whereas indirect perforators predominate in the torso

17. Choke vessels. A: Schematic of choke anastomoses (A) and true anastomoses (B) between adjacent arteries. (Taylor GI, Minabe T. The angiosomes of the mammals and other vertebrates. Plast Reconstr Surg. 1992;89:181.

18. Choke Vessels Choke vessels play an important role in skin-flap survival, they provide an initial resistance to blood flow between the base and the tip of the flap. When a skin flap is delayed by the strategic division of cutaneous perforators along its length, these choke vessels dilate to the dimensions of true anastomoses thus enhancing the circulation to the distal flap

19. Delay Phenomenon Is a preliminary surgical intervention wherein a portion of the vascular supply to a flap is divided before definitive elevation and transfer of the flap Mechanism of this phenomenon is controversial

20. Delay Phenomenon Increased axiality of blood flow – Removal of blood flow from periphery of a random flap promotes development of axial flow Tolerance to ischaemia – Cells become accustomed to hypoxia Sympathectomy vasodilation theory – Thus leading to vasodilation Dilation of choke vessels Hyperadrenergic theory

21. The angiosome concept has 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. 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.

22. The angiosome concept has important clinical implications 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.