The Venous Territories (Venosomes) of the Human Body: Experimental Study and Clinical Implications G. Ian Taylor, F.R.C! F.R.A.CS., Christopher M. Caddy, F.R.C.S.(Ed.), F.C.S.(S.A.), Paul A. Watterson, M.D., and John G. Crock, M.B., B.S., Dip. Anat. The venous architecture of the integument and the underlying deep tissues was studied in six total-body hhuman fresh cadavers and a series of isolated regional studies of the limbs and torso. A radiopaque lead oxide mixture was injected, and the integument and deep tis- sues were dissected andl radiographed. The sites of the venous perforators were plotted and traced to their un- derlying parent veins that accompany the source (seg- mental) arteries. A series of cross-sectional studies were made in one subject co illustrate the course of the per- forators between the integument and the deep tissues. The veins were dissected under magrifcation to iden- tify the site and orientation of the valves. Results revealed a large number of valveless (oscillating) veins within the integument and deep tissues that link adjacent valved venous territories and allow equilibration of flow and pressure throughout the tissue. Where choke arteries define the arterial territories, they are matched by boundaries of oscillating veins in the venous studies. The venous architecture is a continuous network of arcades that follow the connectivecissue framework of the body. The veins converge from mobile to fixed areas, and they *hitchhike” with nerves. The venous drainage mirrors the arterial supply in the deep tissues and in most trea of the integuinent inthe head neck, and torso. In the limbs, the stellate pattern of the venous perforators is modified by longitudinal channels in the subdermal network. However, when an island flap is taised, these longitudinal channels are disconnected, and once again the arterial and venous patterns match, ‘Our venous studies add strength to the angiosome concept. Where source arteries supply a composite block of tissue, we have demonstrated radiologically and by ‘microdissection that the branches of these arteries are accompanied by veins that drain in the opposite direction and return to the same locus. Hence each angiosome Consists of matching arteriosomes and venosomes ‘The clinical implications of these results are discussed with particular reference to the design of flaps, the delay phenomenon, venous free flaps, the pathogenesis of flap necrosis, the "muscle pump,” varicose veins, and venous ulceration Until recently, the anatomy of the venous sys- tem has been neglected by plastic surgeons. Whenever a flap is raised, it has been assumed by many that if the arterial supply is adequate, then the venous drainage will suffice. However, the introduction of the free flap'“* has demanded a closer scrutiny of the venous side of the circu lation. The inherent problems associated with the vascular anastomoses have crystalized the difference between arterial and venous insuffi- ciency The time has come to liberate the role of the venous network and some of its anatomic and surgical complexities. Since Harvey’ first pub- lished his treatise on the veins in 1628, there have been many dissections of the venous system by anatomists!”!? However, as K. J. Franklin? observed, the difficulties of injecting the venous framework of the entire body have daunted many a clinical researcher owing to the problems posed by the valves. Hence most critical studies have been confined to isolated regions.!** In 1987, a series of total-body studies" re- vealed that anatomically, the arterial framework of the body is structured in such a way that From the Department of Plaic Surgery and Professorial Department of Surgery atthe Royal Melbourne Hosptil and the Departinent of Anatomy at the Univenty of Melbourne, Received for publication August 7, 1989, Presented atthe Annual Gene Scientific Meeting of the Royal Australasian College of Surgeons, in Melbourne, in May of 1989, ane st the Annual Meeting of the American Society of Piste and Reconstructive Surgeon, in San Francisco, Cali, in October of 1089. Winner of Fst Prize, Senior Category in the Plastic Surgery Education Foundation Scholarship Essay Competition 1989.186 PLASTIC AND RECONSTRUCTIVE SURGERY, August 1990 composite blocks of tissue are supplied by named source (segmental or distributing) arteries. We named these composite blocks of tissue angio somes. They span between the skin and bone and fit together like the interlocking pieces of an intricate jigsaw puzzle. Their perimeters are de- ined usually by zones of reduced-caliber choke arteries that link adjacent angiosomes. Any struc- ture, whether skin, muscle, tendon, nerve or bone, that spans.a number of angiosomes receives a segmental blood supply from each. ‘These findings have certain clinical implica- ons. They define the various tissues supplied by a single source artery that can be designed as an land flap for free transfer. Similarly, they pro- vide an explanation for the survival length of flaps in different regions of the body. When a flap is elevated, regardless of the tissue in ques- tion, a series of arterial territories, each linked by choke arteries, is captured in succession on the artery at the base of the flap. Since each choke zone provides an initial pressure gradient, there are a finite number of territories that can be captured in a series. If the arteries supplying each territory are long and spaced well apart, then one would expect that the survival length of the flap would be long. If they are placed close together, then the reverse should apply. Clini- cally, this explanation is substantiated when, for example, one compares the survival length of skin flaps on the torso with that of flaps raised on the sole of the foot. This explanation is based on the arterial net- work and does not take into account similar problems that may be evident on the venous side of the circulation. During these dissections, we noted that in each instance the veins accom- panied the supplying arteries. However, the veins were not displayed radiographically nor were the sites and orientations of the venous valves noted. This study therefore attempts to define the venous architecture of the integument and un- derlying deep tissues, to locate the sites and ori- entations of the valves, and to complete the pic- ture of the angiosome concept. It is anticipated that these anatomic data will provide the basis for the more accurate design of flaps and an explanation for various pathophysiologic pro- cesses such as the venous side of the delay phe- nomenon, the “muscle pump”, the pathogenesis of varicose veins and ulcers, the necrosis line of flaps, and the mystery associated with venous free flaps. Because of the inherent problems posed by the valves, which sometimes foiled our efforts to inject the venous network, the huge volumes of the radiopaque substance that were required, and the variability of the venous architecture, the total picture is incomplete. This is essentially a preliminary but nevertheless timely report of the basic anatomic patterns that have emerged. Anatomic STupies The investigation was conducted in a series of fresh human and animal cadavers in which the venous network of the subject was perfused with a radiopaque substance, dissected, and radio graphed. A pilot study was performed in 1 hu- man subject, 11 dogs, and 2 rabbits to establi a reproducible technique. The definitive studies were performed in six total human studies, each of which took 3 to 4 months to complete, and a series of regional studies that embraced six lower limbs and one study of the torso. In three of the total-body studies, a simultaneous injection of the arterial system was performed to compare the anatomy of the venous and arterial networks. In fone subject, cross sections were made at 5-cm intervals to define the origin and course of the veins between the integument and the deep tis- sues. Finally, a total of 530 muscles were removed from five human cadavers, noting the destina- tions of their individual pedicles. Additional sam- ples of other tissues were taken to compare their venous architecture. These included nerves and viscera. Each muscle was radiographed and com- pared with similar arterial studies from a pre- vious investigation." Then a meticulous dissec- tion of the intramuscular venous network was performed under magnification to identify the site and orientation of the valves. Four-hundred and twenty-five of these muscles are the subject of a previous publication.” However, important observations will be included in this paper be- cause they are relevant to our overview of the venous network of the body. Preliminary Investigations The human pilot study was performed in a male cadaver in which both internal jugular veins and the superficial and deep veins of the limbs were cannulated at the wrists and the ankles. A radiopaque mixture of lead oxide, chlorocresol, and gelatin, as described by Crosthwaite et al. Taylor,” was introduced. The integument was removed, and then the skin and the deep tissues were radiographed separately. This provided ex-