that supply and drain such flaps of skin, though huge compared with capillary networks, are still vessels of tiny caliber, and connecting them demanded a level of surgical precision previously unknown. With the naked eye, no one could cut and stitch vessels whose diameter might be little more than a millimeter. For this they would need a new but familiar tool.
By the 1970s, microsurgery was an established technique. The skin, whose anatomy had been so well explored by histologists with microscopes, could now be manipulated surgically using the same tool. In time the use of optical aids to magnify the view of the surgeon became as essential to the art of plastic surgery as McIndoeâs scissors or scalpel. The ability to operate under a greatly magnified field of view made finer procedures, including the connection of blood vessels and nerves, a reality. For the first time flaps of skin, muscle, and bone could be moved en bloc from one location to another in a single boundâthe so-called free flap.
This development massively expanded the plastic surgeonâs repertoire and gave rise to a plethora of important and exciting new techniques. But the selection of flaps that could be used was still relatively narrow. Though the grafts made available by this method could be moved quickly and could cover much larger areas, the aesthetic result was sometimes less than satisfactory. Authorities of the time referred to these early, free-flap grafts as âhamburgers of tissueâ or âglobs and blobs.â
To be of genuine value in aesthetic reconstruction, the library of skin and tissue flaps that plastic surgeons could draw upon needed to be greatly expanded. But knowledge of the vascular anatomy of skinâits relationship to the core circulationâwasnât yet at a point where this was possible.
In the 1980s, Australian plastic surgeon Ian Taylor recognized this and undertook a massive remapping of the circulation of the skin. In so doing, he reconceptualized the anatomy of human skin and its relationship to the circulation.
Prior to this work, understanding of the connection between the core identifiable vessels of the circulation and the supply of more peripheral structures was poor. The body has a network of named arteries and veins that are reproducible from one individual to the next with little variation. These divide ultimately to form more variable, less distinguishable vessels. By the time they arrive at the planes of tissue underpinning the skin, the network has degenerated into a complex weave of small and largely nameless tributaries.
This was fine if you were a surgeon operating on, say, the heart or the liver, where the principal vessels are generally constant in appearance, well mapped by anatomists and immediately recognizable. But for surgeons interested in moving units of flesh and skin around, it was like having an atlas of Great Britain that included only its highways and then trying to navigate a route to a remote farm in the Scottish Highlands.
Taylor injected radiopaque dyes into the skin of countless cadavers and took X-ray images. He generated stunning images of the network of small but remarkably consistent vessels that connected the core circulation to the skin and tissues above.
Understanding these connections and the routes that vessels took as they rose up from deeper structures, weaving between planes of muscle and fat, allowed him to deconstruct the body into a three-dimensional jigsaw puzzle. Taylor called the pieces of the jigsaw angiosomes, and together the pieces constituted a library from which units of tissue, skin, and bone could be drawn and reliably transferred to almost anywhere on the human body. But the battle between blood supply and beauty was far from over.
â
T HE FACE DERIVES ITS BLOOD SUPPLY from a branch of the carotid artery. This divides low in the neck into a deep internal branch and one that runs more superficially. It is from the superficial
By the 1970s, microsurgery was an established technique. The skin, whose anatomy had been so well explored by histologists with microscopes, could now be manipulated surgically using the same tool. In time the use of optical aids to magnify the view of the surgeon became as essential to the art of plastic surgery as McIndoeâs scissors or scalpel. The ability to operate under a greatly magnified field of view made finer procedures, including the connection of blood vessels and nerves, a reality. For the first time flaps of skin, muscle, and bone could be moved en bloc from one location to another in a single boundâthe so-called free flap.
This development massively expanded the plastic surgeonâs repertoire and gave rise to a plethora of important and exciting new techniques. But the selection of flaps that could be used was still relatively narrow. Though the grafts made available by this method could be moved quickly and could cover much larger areas, the aesthetic result was sometimes less than satisfactory. Authorities of the time referred to these early, free-flap grafts as âhamburgers of tissueâ or âglobs and blobs.â
To be of genuine value in aesthetic reconstruction, the library of skin and tissue flaps that plastic surgeons could draw upon needed to be greatly expanded. But knowledge of the vascular anatomy of skinâits relationship to the core circulationâwasnât yet at a point where this was possible.
In the 1980s, Australian plastic surgeon Ian Taylor recognized this and undertook a massive remapping of the circulation of the skin. In so doing, he reconceptualized the anatomy of human skin and its relationship to the circulation.
Prior to this work, understanding of the connection between the core identifiable vessels of the circulation and the supply of more peripheral structures was poor. The body has a network of named arteries and veins that are reproducible from one individual to the next with little variation. These divide ultimately to form more variable, less distinguishable vessels. By the time they arrive at the planes of tissue underpinning the skin, the network has degenerated into a complex weave of small and largely nameless tributaries.
This was fine if you were a surgeon operating on, say, the heart or the liver, where the principal vessels are generally constant in appearance, well mapped by anatomists and immediately recognizable. But for surgeons interested in moving units of flesh and skin around, it was like having an atlas of Great Britain that included only its highways and then trying to navigate a route to a remote farm in the Scottish Highlands.
Taylor injected radiopaque dyes into the skin of countless cadavers and took X-ray images. He generated stunning images of the network of small but remarkably consistent vessels that connected the core circulation to the skin and tissues above.
Understanding these connections and the routes that vessels took as they rose up from deeper structures, weaving between planes of muscle and fat, allowed him to deconstruct the body into a three-dimensional jigsaw puzzle. Taylor called the pieces of the jigsaw angiosomes, and together the pieces constituted a library from which units of tissue, skin, and bone could be drawn and reliably transferred to almost anywhere on the human body. But the battle between blood supply and beauty was far from over.
â
T HE FACE DERIVES ITS BLOOD SUPPLY from a branch of the carotid artery. This divides low in the neck into a deep internal branch and one that runs more superficially. It is from the superficial
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