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This chapter provides actual anatomical results of the human lymphatic system in regions of the head, neck, chest, and extremities. Most of the content was revealed and recorded for the first time. Presentation of photographs and radiographs combined with some schematic drawings enable readers to understand the detailed structure and distribution of the human lymphatic system in these regions. Content includes the lymph capillary plexus, precollecting and collecting lymph vessels, lymphatic trunk, lymphatic duct, and lymph node. In addition, details of the microanatomical morphology, unsymmetrical distribution pattern, and pathways of lymphatics, as well as the connection between lymph vessels and lymph nodes, have been presented and described. Furthermore, the latest findings of the lymphatic ampulla and diverticulum, transparent and degenerating lymph nodes, are explained in detail. This information upgrades the knowledge of the lymphatic anatomy, and results will be assisted for the clinical management of lymphoedema, cancer metastasis, and other lymphatic-related diseases.

Background The deep lymphatic anatomy of the hand still remains the least described in medical literature. Methods Eight hands were harvested from four nonembalmed human cadavers amputated above the wrist. A small amount of 6% hydrogen peroxide was employed to detect the lymphatic vessels around the superficial and deep palmar vascular arches, in webs from the index to little fingers, the thenar and hypothenar areas. A 30-gauge needle was inserted into the vessels and injected with a barium sulphate compound. Each specimen was dissected, photographed and radiographed to demonstrate deep lymphatic distribution of the hand. Results Five groups of deep collecting lymph vessels were found in the hand: superficial palmar arch lymph vessel (SPALV); deep palmar arch lymph vessel (DPALV); thenar lymph vessel (TLV); hypothenar lymph vessel (HTLV); deep finger web lymph vessel (DFWLV). Each group of vessels drained in different directions first, then all turned and ran towards the wrist in different layers. Conclusion The deep lymphatic drainage of the hand has been presented. The results will provide an anatomical basis for clinical management, educational reference and scientific research.

Background To determine the relationship between the perforating and deep lymphatic vessels in the knee region for clinical implications. Methods Four lower limbs from two unembalmed human cadavers were used. Under a surgical microscope, 6% hydrogen peroxide was employed to detect lymph vessels accompanying the small saphenous vein, anterior tibial, posterior tibial and fibular blood vessels all commencing from distal ends of specimens. Each lymphatic vessel was inserted by a 30-gauge needle and injected with a barium sulphate mixture. Each specimen was dissected, radiographed and photographed to determine the perforating and deep lymphatic vessels in the region. Results A perforating lymph vessel was observed in the popliteal fossa of each specimen. It arose from the superficial popliteal lymph node and terminated in the deep popliteal lymph node. The anterior tibial, posterior tibial and peroneal lymph vessels were discovered in the region travelling with the corresponding vascular bundles. After penetrating the vascular aperture of the interosseous membrane between the tibia and fibula, the anterior tibial lymph vessel entered directly into the deep popliteal lymph node or converged to either the posterior tibial or fibular lymph vessel, before entering the node. The posterior tibial and peroneal lymph vessels entered the deep popliteal lymph node. The efferent lymph vessel of the deep popliteal lymph node travelled with the femoral vascular bundle. Conclusion The perforating and deep lymphatic vessels in the knee region has been presented and discussed. The information advances our anatomical knowledge and the results will benefit clinical management.

To determine the radiologic manifestations of senile lymph nodes in the popliteal fossa for radiologic and clinical application.A total of six lower extremities from four unembalmed human cadavers were studied. Under a surgical microscope, 6% hydrogen peroxide was used to detect the lymphatic vessels commencing from the foot and leg. A 30-gauge needle was inserted into the vessels and injected with a radio-opaque lead oxide mixture. The specimens were radiographed and photographed to demonstrate the lymph nodes in the popliteal fossa. The final results were transferred to the computer for image analysis.An average of two lymph nodes (range 1 to 3) were found in the popliteal fossa of the lower extremity. They were divided into superficial and deep popliteal groups. The superficial group was located in the superficial layer of the popliteal fossa around the small saphenous vein (SSV). The deep group was close to the popliteal surface of the femur and always located next to the popliteal vein. All lymph nodes were transparent in appearance and contained coiled lymphatic tubules. The size and density of the tubules varied.The radiologic manifestations of senile lymph nodes in the popliteal fossa have been presented and discussed to upgrade our radiologic and anatomical knowledge. This will be of benefit for radiologic and clinical applications.

Background The deep and perforating lymphatic anatomy of the upper limb still remains the least described in medical literature. Materials and Methods Six upper limbs with the axillary tissue were harvested from three unembalmed human cadavers amputated at the shoulder joint. A small amount of 6% hydrogen peroxide was employed to detect the lymphatic vessels around the deep palmar arch, radial and ulnar neurovascular bundles. A 30-gauge needle was inserted into the vessels and they were injected with a barium sulphate compound. Each specimen was dissected, photographed and radiographed to demonstrate deep lymphatic distribution of the upper limb. Results Continuing from the deep lymph vessels of the hand, single or multiple deep collecting lymph vessels have been found along the radial, ulnar, anterior and posterior interosseous neurovascular bundles in the forearm, brachial and deep branchial neurovascular bundles in the upper arm. During their courses, lymph nodes were found setting in the trunk of the radial, ulnar and brachial lymph vessels near or in the cubital fossa, and in the axillar. Perforating lymph vessels have been found near the wrist and in the cubital fossa, which linked the superficial and deep lymph vessels. The direction of lymphatic drainage was from the deep to superficial or superficial to deep vessels. Conclusion The deep lymphatic anatomy of the upper limb has been described. The results will provide an anatomical basis for clinical management, educational reference and scientific research.

The lymphatic system consists of the lymphatic vessels (capillary plexus, precollecting and collecting lymph vessels including lymphatic ampullae and diverticulum and lymphatic trunks and ducts), organs (lymph nodes, spleen, thymus and tonsils), tissue (Peyer’s patch), etc. Relevant terminology regarding the components of the lymphatic system and newly discovered structures is listed and described in this chapter (Figs. 1.1 and 1.2).

Our existing knowledge of the lymphatic system is mostly based on the early work that was done in the 19th century. This knowledge is often discordant with clinical experience. Also it does not explain clinical anomalies often seen in results of lymphoscinitgraphy and sentinel node biopsy for early stage cancer treatment of melanoma, breast cancer and other cancer patients. Importantly it is well known that cancers can spread to distant sites without involvement of regional lymph nodes, suggesting that disseminating cancer cells can access the circulation without traversing lymph nodes. Therefore it will be benefit for clinic management to understand accurate and detailed lymphatic anatomy.

Shoulder girdles of 20 cadavers (68–94yrs) were harvested. The anterior (ACHA) and posterior circumflex humeral arteries (PCHA) were injected with ink and the extra and intraosseous courses of the dyed vasculature dissected through the soft tissues and bone to the osteotendinous junctions of the rotator cuff. The ink injection and bone dissection method was newly developed for the study. Rates of cross-over at the osteotendinous juntion were 75% in the supraspinatus, 67% in subscapularis, 33% in infraspinatus and 20% in teres minor. The supraspinatus and subscapularis insertions were vascularised by the arcuate artery, a branch of the ACHA. The insertions of the infraspinatus and teres minor were supplied by an unnamed terminal branch of the PCHA. The insertions of the rotator cuff receive an arterial supply across their OTJ9s in 50% of cases. This may explain observed rates of AVN in comminuted proximal humeral fractures. The terminal branch of the PCHA supplying the infraspinatus and teres minor insertions was named the “Posterolateral Artery”. Finally, the new method employed for this study which allowed for direct visualisation of intraosseous vasculature, will enhance our understanding of skeletal vascular anatomy and have clinical applications in orthopaedic and reconstructive surgery.

Background The study of intraosseous vasculature has always been challenging due to the hard, calcified structure of bone. Techniques used to study intraosseous vasculature usually involve diaphanization with a Spalteholz technique, followed by X-ray imaging to display the radio contrast-injected blood vessels. These techniques produce results with fine detail when successfully executed. However, high failure rates and the extensive length of time required to perform these techniques are drawbacks. This paper describes a faster, alternative method for the study of intraosseous vasculature. Method Five embalmed and two fresh shoulder girdles were harvested from six cadavers. Cannulas were inserted into the origins of the anterior (ACHA) and posterior (PCHA) circumflex humeral arteries and injected with ink diluted in water or 6% hydrogen peroxide. The arteries and their branches were dissected until they entered their respective bony foraminae. A hammer, chisel, bone nibbler and mounted needles were used to follow the intraosseous course of these arteries and their branches. Results The intraosseous vasculature was seen in all specimens. The branches of the main nutrient artery to the proximal humerus were followed until they reached articular cartilage or crossed cortical bone again to enter the rotator cuff tendons. Discussion An innovative, new approach to the study of intraosseous vasculature with direct visualization of the intraosseous arteries of the proximal humerus is described.

Background: The route of lymphatic drainage from the heel to the inguinal lymph nodes is required to be accurately evaluated for clinical needs. Methods: Seven lower limbs from four unembalmed human cadavers were studied. Under a surgical microscope, 6% hydrogen peroxide was used to detect the lymphatic vessel on the lateral side of the heel. The vessel was then injected with a radio-opaque lead oxide mixture. The vessel was traced, photographed and radiographed to demonstrate the lymphatic pathways from the lateral heel to the inguinal lymph nodes. The final results were transferred to the computer for image analysis. Results: The lymph collecting vessel arising from the skin of the fossa between the lateral malleolus and the Achilles tendon ran along the posterolateral side of the leg, deep to the superficial fascia. From the popliteal fossa to the inguinal lymph nodes, three lymphatic routes were found: (i) via the superficial tissue of the medial side of the thigh; (ii) running with the superficial femoral blood vessels; (iii) running between the sciatic nerve and the profunda femoral vessels. The number and type of lymph nodes found in the popliteal fossa and femoral triangle were different from person to person. Conclusion: Actual and accurate lymphatic routes from the skin above the posterolateral heel to the inguinal lymph nodes have been described. This information upgrades our anatomical knowledge and the results will be of benefit for the clinical management of trauma and malignancies in the lower limb.

Zones of hypovascularity are thought to exist in several tendons of the shoulder, contributing to localized tendon weakness and subsequent rupture in clinical practice. Although these zones have been demonstrated in many frequently ruptured tendons, the existence of a similar area in the often ruptured long head of biceps (LHB) tendon is largely unknown. Twenty cadaveric upper limb specimens were dissected after injection with either a radio-opaque lead oxide/milk mixture or India ink, followed by histological sectioning of the tendons. The LHB tendon was consistently supplied via its osteotendinous and musculotendinous junctions by branches of the thoracoacromial and brachial arteries respectively. In two specimens, additional branches from the anterior circumflex humeral artery travelling in a mesotenon vascularized the midsection of tendon. These source arteries divided the LHB tendon into either two or three vascular territories, depending upon the presence of the mesotenon-derived vascular supply. A zone of hypovascularity was consistently found in the region of the LHB tendon most frequently prone to rupture. This zone covered an area 1.2-3 cm from the tendon origin, extending from midway through the glenohumeral joint to the proximal inter-tubercular groove. This hypovascular region occurred on the border of two adjacent vascular territories, where reduced caliber choke vessels provide limited arterial supply. While it is probable that the limited arterial supply contributes to the susceptibility of this area to rupture, similar to other tendons the true pathogenesis is likely to be a combination of both vascular and mechanical factors.

Previously little has been written about the morphology of the human lymphatic vessels since Sappey (Sappey [1874] Anatomie, Physiologie, Pathologie des Vaisseaux Lymphatiques, Paris: Adrien Delahaye) over 100 years ago. There needs to be an accurate re-evaluation of scientific observations to aid clinical management. Forty-nine combinations of tissue from the head and neck of 20 unembalmed human cadavers were studied. Six percent hydrogen peroxide was used to find the vessels. They were injected with radio-opaque mixture, dissected, photographed, and radiographed. Final results were transferred to the computer for analysis. Different sized lymphatic valves were found in the precollecting and collecting lymph vessels, the lymphatic trunks, and ducts. The intervals between the valves were of various lengths. Diverse lymphatic ampullae and diverticula were seen in precollecting and collecting lymph vessels. Initial lymph vessels arose from the dermis, the galea, and the mucosal membrane. The vasculature of the direct and indirect precollecting and collecting lymph vessels, lymphatic trunks, and ducts was recorded. The morphology of the human lymphatic vessels in the head and neck has been described and recorded using radiographs and photographs.

Summary Background The pudendal thigh fasciocutaneous (PTF) flap is a useful flap in perineal reconstruction, that is reliable when small but is traditionally unreliable when large flaps are raised. Large flaps in particular, are associated with an increased incidence of apical necrosis. Thorough descriptions of the vascular anatomy of this flap have been lacking from the literature, with the current study evaluating this anatomy, aiming to provide the anatomical basis for vascular problems and for techniques to maximise its survival. Methods Five unembalmed human cadaveric pelvis specimens were studied. Lead oxide injectant enabled radiographic and dissection analysis of the arterial anatomy of the integument of the perineum. Results A consistent pattern of vascular supply was found in all specimens. 1: the blood supply to the pelvic floor was supplied sequentially by the posterior labial/scrotal arteries, cutaneous branches from the anterior branch of the obturator artery, and branches from the external pudendal arteries. 2: these vessels ran close to the midline, medial to the PTF flap. 3: the posterior labial/scrotal arteries were deep to the Colles' fascia and the branches from the obturator artery and external pudendal arteries were located superficial to the Colles' fascia. Conclusion This study has demonstrated that the PTF flap is a three vascular territory flap and that the pedicle is situated close to the midline. This may explain why regions of the PTF flap may have a potentially precarious blood supply, and suggests that the PTF flap should be designed more medially. Given the third territory of supply to the apex of the flap, a delay procedure may help to avoid flap necrosis.

There are no reports or images of the blood supply to the lymphatic vessels. One lower limb of an unembalmed human cadaver was studied. Hydrogen peroxide (6%) was applied to find the lymphatic vessels by using a surgical microscope. The vessels were injected with a radio-opaque mixture and dissected. During the dissection, several sites of paralymphatics arteriole nutrient (PAN) vessels were found in close proximity to collecting lymphatic vessels in the medial aspect of the leg. The caliber of the lymphatic vessels was about 1 mm. The caliber of PAN vessels was

To understand the lymphatic drainage patterns of the tongue and the soft palate with radiographs and photographs. Tissues of the tongue, the laryngopharynx, the trachea, and the esophagus from six unembalmed human cadavers were studied. Six percent hydrogen peroxide was used to find the vessels. They were injected with a radio-opaque mixture, dissected, photographed, and radiographed. Final results were transferred to a computer for analysis. Four collecting lymphatic vessels were found. They are apical draining into the submandibular and/or submental nodes, anterolateral draining into the submandibular node, posterolateral draining into the submandibular and/or subdigastric nodes, and pharyngeal branches draining into the subdigastric node. The lymph vessels of the soft palate drained into the lateral pharyngeal and/or subdigastric nodes. The lymphatic drainage of the tongue and the soft palate was described and recorded using radiographs and photographs. It is a benefit for clinical management.

Radiographic contrast media have not been previously used in human lymphatic cadaver studies. As these will have further clinical applications, we sought to investigate their use in this role.Both lower legs from an unembalmed human cadaver were studied. We used hydrogen peroxide to identify the lymphatics of the dorsum of the foot, and a single lymphatic was microsurgically injected with 1 ml of 76% 'Urografin.' A series of radiographs were taken 1 min after injection and for 2.5 h until the Urografin vanished. Images were digitalized for analysis.The series of lymphangiograms generated showed the size, location, and course of the lymphatics in the leg. Over time, the density of the iodinated contrast in the lymphatic vessels reduced and disappeared completely after 2.5 hours postinjection. A 'digitally subtracted' image provided a clear and high-contrast lymphangiogram. The lymphatic network identified was shown to diverge and converge twice as it coursed proximally up the limb.Urografin, a clinical radiographic contrast medium, was shown to lose contrast density 2.5 h following cadaveric intralymphatic injection. The use of a new technique, that of 'digital subtraction lymphangiography,' was able to demonstrate the lymphatic vessel pathways clearly, and is a useful technique for cadaveric lymphatic studies.

Background: The previously described “perfusion zones” of the abdominal wall vasculature are based on filling of the deep inferior epigastric artery (DIEA) and all its branches simultaneously. With the advent of the DIEA perforator flap, only a single or several perforators are included in supply to the flap. As such, a new model for abdominal wall perfusion has become necessary. The concept of a “perforator angiosome” is thus explored. Methods: A clinical and cadaveric study of 155 abdominal walls was undertaken. This comprised the use of 10 whole, unembalmed cadaveric abdominal walls for angiographic studies, and 145 abdominal wall computed tomographic angiograms (CTAs) in patients undergoing preoperative imaging of the abdominal wall vasculature. The evaluation of the subcutaneous branching pattern and zone of perfusion of individual DIEA perforators was explored, particularly exploring differences between medial and lateral row perforators. Results: Fundamental differences exist between medial row and lateral row perforators, with medial row perforators larger (1.3 mm vs. 1 mm) and more likely to ramify in the subcutaneous fat toward the contralateral hemiabdomen (98% of cases vs. 2% of cases). A model for the perfusion of the abdominal wall based on a single perforator is presented. Conclusion: The “perforator angiosome” is dependent on perforator location, and can mapped individually with the use of preoperative imaging. © 2009 Wiley-Liss, Inc. Microsurgery, 2010.

Background: The lumbar region has been scarcely explored as a donor site for free tissue transfer or as a free flap recipient site. The lumbar integument provides a versatile prospective flap site, with a potentially well-concealed scar. Similarly, defects of this region can require recipient vessels that may be difficult to identify. Although lumbar artery perforators have been described, the reliability of perforators in this region remains questionable. Methods: An anatomical study was undertaken combining both cadaveric and in vivo analysis of the lumbar vessels. The cadaveric component comprised both dissection and angiographic studies in fresh and embalmed cadavers (36 lumbar regions in 18 cadavers), and the clinical study comprised a computed tomographic angiographic study (44 sides in 22 patients) and an operative case report. Results: Perforators were shown to arise from all eight lumbar arteries to enter the lumbar integument, with their size, location, and course described. Lower lumbar perforators were more often septocutaneous and of larger caliber. A case in which the fourth lumbar artery and concomitant vein were used as free flap recipient vessels is described, the first such reported case in the literature. Conclusions: Improving the incidence of identifying lumbar perforators of large caliber and with a septocutaneous course can be achieved by selecting lower lumbar vessels, or with the use of preoperative computed tomographic angiography. Computed tomographic angiography can successfully identify the location, size, and course of lumbar artery perforators and can aid flap design. Lumbar artery perforators are highly useful for both donor and recipient vessels in free flap surgery.

The putrefaction factor is one of the biggest problems when undertaking unembalmed cadaveric tissue dissections for lymphatic vessel mapping.One female bilateral breast and anterior upper torso from an unembalmed human cadaver was studied over an 8-week period. Multiple prefrozen domestic ice bricks were used to cover in turn and keep constantly cold or partially frozen, the contralateral side of the tissue during the dissections. Using hydrogen peroxide to identify the lymphatics under the surgical microscope, the vessels were injected with a lead oxide mixture, and then radiographed to demonstrate lymphatic vessels in both breasts. The final results transferred to the computer for analysis.Lymph collecting vessels were found in breasts, anterior upper torso, and the internal mammary vascular bundles. The lymphatics of the breast and the anterior upper torso drain radially into the axillary lymph nodes. Unexpectedly, the lymphatic vessel drainage patterns of each breast are asymmetrical in this specimen.This study provides a new method to slow down putrefaction of unembalmed cadaveric tissue, thus enabling lymphatic dissection of a bilateral breast and torso specimen.

BACKGROUND: The anterolateral thigh (ALT) flap has become increasingly popular due to its versatility and minimal donor site morbidity. Its major limitation has been uncertainty in predicting perforator anatomy, with the occasional absence of suitable perforators and high variability in their size and course. The variability of this anatomy has not been adequately explored previously. METHODS: A cadaveric study was undertaken, in which 19 thighs (from 10 fresh cadavers) underwent contrast injection and angiographic imaging. Anatomical variations of the vasculature were recorded. A clinical study of 44 patients undergoing ALT flap reconstruction was also undertaken. Perforator anatomy was described in the first 32 patients, and the subsequent 12 patients underwent computed tomography angiography with a view to predicting individual anatomy and improving operative outcome. RESULTS: Cadaver angiography was able to highlight and classify the variations in arterial anatomy, with four patterns observed and marked variability between cases. In 32 patients undergoing ALT flaps without preoperative CT angiography (CTA), five patients (16%) did not have any suitable perforators from the descending branch of the lateral circumflex femoral artery. By selecting the limb of choice with preoperative CTA, the incidence of flap unsuitability was reduced to 0%. Comparing CTA with Doppler, CTA was more accurate (sensitivity 100%) and provided more information. CONCLUSION: The perforators supplying the ALT flap show significant variability in location and course, with the potential for unsuitable perforators limiting flap success. Preoperative CTA can demonstrate the vascular anatomy and can aid perforator selection and operative success.

Background The angiosomes of the body were defined in 1987. The recent popularity of skin perforator and muscle flaps designed in the thigh, together with significant major vessel anomaly and disease, has necessitated a more detailed reevaluation of the blood supply to this region. Methods Eighteen new studies, combined with a review of 36 of the authors' archival studies of the buttock and the thigh, have been conducted in fresh human cadavers using arterial perfusion with a radiographic lead oxide mixture. Results The angiosome territories of the lumbar, deep circumflex iliac, sacral, gluteal, common femoral, superficial femoral, lateral femoral circumflex, medial femoral circumflex, profunda, descending genicular, and popliteal source vessels that contribute to the thigh and buttock were defined between the skin and the bone. The dominant cutaneous supply of perforators of 0.5 mm or greater emerged from the deep fascia predominantly in longitudinal rows from the intermuscular septa or from intramuscular septa, especially from the buttock muscles. Each muscle was supplied from two or more angiosomes, thereby constituting important bypass shunts for potential major vessel injury or disease, by means of their intramuscular anastomoses. Conclusions These results may help the surgeon in the design of skin perforator and refined muscle, musculocutaneous, and composite flaps in the thigh and the buttock. The study also provides for a better understanding of vessel anastomoses in the region.

Background. The lymphatic pathways of the nasal cavity are of enormous clinical importance. To date there has been no accurate radiographic record of these pathways. Methods. Four halves of the head and neck from 2 fresh human cadavers were studied. Results. The capillary network arises from the mucous membrane of the atrium, the turbinates, the floor of the nasal cavity, and the nasopharynx. They drain into the lateral pharyngeal and retropharyngeal lymph nodes. There is 1 lymphatic communication at the junction of the lateral posterior wall of the turbinates and the nasopharynx and another communication between 2 groups of lymph nodes situated between the origin of the facial artery and the bifurcation of the carotid artery. Conclusions. A rich avalvular lymph capillary network exists in the mucous membrane and 2 major lymph collecting vessels course through the parapharyngeal space to multiple first tier lymph nodes. © 2008 Wiley Periodicals, Inc. Head Neck, 2009

Background: Lymphoscintigraphy has become a routine examination for identifying the sentinel lymph node in various cancer patients. Despite increasing clinical information, the basic anatomy of the superficial lymphatic system of the upper torso has not been fully elucidated. Methods: Five female breasts, three anterior chest walls, and three forequarter specimens from fresh nine cadavers (two male and seven female) were used for this study. Our original radiographic method for delineating the lymphatics was applied. The course of the lymph vessels was traced from the x-ray films and color coded in accordance with their sentinel lymph node to define the lymph territories of the upper torso. In addition, cross-sectional studies were performed on the female breasts to demonstrate the three-dimensional pathway and connections of the lymphatic vessels. Results: The lymphatic territories of the upper torso were divided by the mid-axillary line. The anterior side drained into the external mammary or axillary vein lymph nodes and the posterior side drained into the scapular nodes. There was no significant difference between sexes. In most cases, one sentinel lymph node in the axilla notably covered a large lymph territory in both the upper arm and the upper torso. Conclusions: The authors have demonstrated by radiography and dissection the superficial lymphatics of the upper torso in male and female cadavers. The lymph vessels originating in the lower region of the upper torso have close spatial association with the breast tissue and seemed to play a key role in the breast lymph drainage.

Background Classic anatomical lymphatic mapping in humans is represented by four territories in the torso divided by the midline and horizontal line at the L2 level. Each territory drains into the ipsilateral axillary or inguinal lymph nodes. Recently, preoperative lymphoscintigraphy for staging breast cancer and malignant melanoma has become common in the clinical arena. It reveals an undescribed direct pathway from the skin of the loin to intraabdominal lymph nodes. The authors investigated the presence of such a lymphatic route using a dog model. Methods The authors used seven greyhound dogs for this study. The caliber of their lymph vessels was similar to those of humans, and because of a lack of fat tissue under the integument, the vessels were identified easily. The authors applied their original radiographic technique using hydrogen peroxide and lead oxide for delineating the superficial lymphatic system. Results Lymphatic territories of the torso were classified with relation to their regional lymph nodes. The authors found perforating lymph vessels in the lumbar and gluteal regions. They originated from the skin, penetrated the abdominal wall, and then drained into paraaortic lymph nodes instead of the axillary and inguinal lymph nodes. They were always accompanied by blood vessels, especially perforating veins. Conclusions The authors found perforating lymph vessels in a canine torso. They seem to be equivalent to the unexpected lymph pathways found in humans using lymphoscintigraphy.

Current understanding of the pattern of lymph channels is largely dependent on the anatomical studies of Sappey performed in the nineteenth century, when mercury was injected into human cadavers and the lymphatics were dissected. These studies have not been repeated because the use of mercury is now prohibited as a result of its toxicity. The aim of this study was to reappraise the gross lymphatic anatomy and lymph node connections using a radiologic technique. A period of 3 years was required for development of a new method.The definitive technique used hydrogen peroxide to identify lymphatic vessels and to inflate them. The individual channels were injected with a radiopaque lead oxide mixture and recorded on x-ray film. Each channel was dissected meticulously under the surgical microscope and its course examined in relation to the regional lymph nodes. This method was then applied to 14 human cadaver upper limbs obtained from 10 different cadavers.The authors found that the superficial lymphatic vessels course within the subcutaneous fat in close proximity to the main subcutaneous veins. Communication between the superficial and the deep lymphatic systems was not identified in these studies.Most lymph vessels were seen to flow into one main (sentry) lymph node in the axillary region; however, some of the lymph vessels ran along the posterior forearm, bypassing the "sentry" node to reach other smaller nodes.

To make a lymphatic specimen of the dorsum of the hand for educational and clinical purposes.A total of four hands from two unembalmed human cadavers were used. Under a surgical microscope, 6% hydrogen peroxide was employed to detect the lymphatic vessels commencing from fingers. A 30-gauge needle was inserted into vessels and injected with a barium sulphate mixture. Each specimen was radiographed, photographed, and dissected to demonstrate the lymphatic vessels on the dorsum of the hand. After being embalmed in 4% formalin for 3 months, specimen was then sealed in a plexiglass container for display.An average of sixteen lymph collecting vessels were found in the subcutaneous tissue of the dorsum of the hand. The diameter of the vessels varied from 0.2 mm to 0.6 mm. Vessels were the continuation of lymph vessels arising from fingers. They travelled meanderingly in the subcutaneous tissue and traversed over or under the veins when they met.Actual and accurate lymphatic distributions of the dorsum of the hand have been described and displayed. The information upgrades our anatomical knowledge and the results will be of benefit for the lymphatic education and clinical application.

Studies of the gross anatomy of the lymphatic system are few and far between when compared with those of other vascular systems. Our knowledge of the anatomy of the lymphatic system is so limited that it seems vastly inadequate in explaining the clinical manifestations caused by its disorder. This study has developed an effective method to identify the lymphatics using hydrogen peroxide, to demonstrate the lymphatic vessels radiographically using a lead oxide suspension, and to dissect them out in adult human cadavers.

This anatomical study involved the meticulous dissection of three fresh cadaveric specimens to characterize the vascular supply of the nerves of the lower limb. The findings demonstrated that the nerves were supplied segmentally by source vessels, which were color-coded to match the corresponding angiosomes. The segments were then classified into five categories according to whether the nerves and source vessels were branched or unbranched, which has clinical relevance for harvesting of nerves for vascularized nerve transfers.

To determine routes of lymphatic drainage from the heel to the inguinal lymph nodes to assist in the clinical management of lower limb lymphatic disorders.Six lower limbs from three unembalmed human cadavers were studied. Under a surgical microscope, 6% hydrogen peroxide was used to detect lymphatic vessels on the medial and lateral sides of the heel. The lymphatic vessel on either side was then injected with a radio-opaque mixture. The lymphatic vessels were traced, photographed, and radiographed to demonstrate the lymphatic pathways from the heel to the inguinal lymph nodes. The final results were transferred to computer for digital image analysis.Two groups of lymph collecting vessels were identified. The medial group, arising from the skin between the medial malleolus and the Achilles tendon, coursed along the medial side of the leg and thigh to the inguinal lymph nodes. The lateral group, arising from the skin between the lateral malleolus and the Achilles tendon, coursed along the postero-lateral side of the leg to the popliteal fossa. Alternative routes were then identified from the popliteal fossa to the inguinal lymph nodes. The number, size, type, and distribution of lymph vessels and nodes were variable from person to person.Two different lymphatic routes from the heel to the inguinal lymph nodes have been described. This information upgrades current anatomical knowledge and the results will be of benefit for the clinical management of lower limb trauma and malignancy.

Background Knowledge of the lymphatic anatomy in the lower extremity is inadequate. A reevaluation is needed to assist in guiding clinical management. Methods A total of five lower extremities from three unembalmed human cadavers were studied. Under a surgical microscope, 6% hydrogen peroxide was used to detect the lymphatic vessels commencing from the foot, the leg, and the thigh. A 30-gauge needle was inserted into the vessels and injected with a radiopaque lead oxide mixture. The vessels were traced, photographed, and radiographed to demonstrate the superficial lymphatic pathways of the lower extremity. The final results were transferred to the computer for image analysis. Results Numerous lymph collecting vessels were identified in the subcutaneous tissue and the superficial femoral vascular bundle of the lower extremity. They originated beneath the dermis of each side of the toes, the foot, and the lateral side of the thigh. The diameters of the vessels varied from 0.2 to 2.2 mm. The vessels traveled in the subcutaneous tissue of the lower limb toward the popliteal, femoral, superficial, and deep inguinal lymph nodes. During their tortuous course, some vessels branched, diverged, and converged; sometimes, they anastomosed with neighboring vessels or crossed them. Most vessels converged to form larger collectors and then diverged into small branches before entering the lymph nodes. Conclusions Accurate lymphatic distribution within the lower extremity has been described. This information upgrades our anatomical knowledge, and the results will be of benefit for clinical management.

BACKGROUND: Venous congestion leading to partial or total nipple necrosis is a relatively uncommon complication of breast reduction and mastopexy procedures but still occurs, particularly in larger reduction procedures. This is largely preventable if the surgeon has an understanding of the venous drainage to the nipple and carefully preserves it. METHODS: An anatomical study was undertaken on 16 fresh female cadaveric breast specimens. The venous drainage of the breast was explored through vascular injection, radiographic, and cross-sectional studies. RESULTS: The venous drainage of the breast consists of an extensive network of vessels. The nipple-areola complex is drained by a superficial subareolar ring of veins that drains by means of medial and lateral veins. Laterally, superolateral and inferolateral veins drain into the subclavian veins, whereas medially, two veins drain into the internal mammary veins. An inferior vein drains the inferior quadrant of the breast in the midmammary line. Medially, the veins have a superficial course, whereas laterally, the veins follow a deeper course. CONCLUSIONS: The breast contains an extensive venous network. To avoid necrosis of the nipple-areola complex, this venous network should be preserved. The superomedial/medial and inferior pedicles contain the most extensive and more reliable venous drainage patterns.

Background. Lymphoscintigraphy reveals incon- sistencies in our knowledge of the lymphatic anatomy of the external ear. Methods. Fifteen external ears from 9 unembalmed human cadavers were studied. Six percent hydrogen peroxide was used to find the lymphatic vessels using a surgical micro- scope. They were injected with a radio-opaque mixture, dis- sected, photographed, and radiographed to demonstrate lymphatic vessels in the tissue. Final results were transferred to the computer for analysis. Results. Four groups of lymph collecting vessels were found. The anterior branch, in all specimens, drained directly or indirectly (having merged with a vessel descending from the scalp) into the preauricular lymph nodes. The superior, middle, and inferior (lobule) branches drained to their multiple first tier lymph nodes. Conclusion. An accurate lymphatic map of the external ear is described to upgrade our anatomic knowledge. It will be of benefit for the clinical management of malignancies in this region. V C 2010 Wiley Periodicals, Inc. Head Neck 33: 60-64

Background Despite improving outcomes, venous problems in the harvest of deep inferior epigastric artery perforator (DIEP) flaps remain the more common vascular complications. However, it is apparent that the venous anatomy of the anterior abdominal wall has not been described to the same extent as the arterial anatomy. Previous anatomical studies have focused on cadaveric anatomy or excisional specimens. The current study uses in vivo computed tomographic angiography to evaluate this anatomy, in combination with a cadaveric radiographic study. Methods Both cadaveric and in vivo studies were undertaken using eight whole fresh cadaveric specimens (16 sides) and 100 patients undergoing DIEP flap breast reconstruction (200 sides). The cadaveric component used direct catheter venography and the in vivo studies were undertaken using preoperative computed tomographic angiography, mapping in vivo venous flow. Results : The location, caliber, course, and distribution of the superficial and deep inferior epigastric veins were recorded. The dominance of each system and their direction of drainage were described. Mechanisms for poor venous drainage were postulated, including perforator size, midline crossover of the superficial inferior epigastric vein, and the superficial and deep inferior epigastric vein communications. The incidence of each of these anatomical factors was evaluated. Conclusion The cause of venous compromise is multifactorial, with the current study showing that preoperative computed tomographic angiography may predict venous problems during flap harvest, by demonstrating perforator diameter, midline crossover, and deep-superficial venous communications.

The gross anatomy of the lymphatic system is one of the least studied areas of anatomy, primarily because of the technical difficulties encountered in demonstrating this almost invisible yet vast system. Similarly, there have been very few studies of the gross lymphatic anatomy of the adult human breast. Previous studies used young pregnant female cadavers. When mercury was injected into the lactiferous ducts or breast lymphatic channels, these cadavers enabled early anatomists to see the breast lymphatics. Both Cruikshank (1786) and Cooper (1840) located the axillary lymph pathway as well as accessory pathways directly from the breast. Sappey (1874) concluded that all lymphatics arising from the breast drained into the axilla via the subareolar plexus. Current descriptions of the breast lymphatics may be traced back to the diagram made by Poirier and Cuneo (1902). However, it is apparent that this diagram is a composite of adult breast studies by Sappey, their fetal studies and even clinical feedback. This study provides an historical perspective of the methods that have been previously used to study the lymphatics of the breast and introduces an update on current investigative approaches.

Background: There is an increasing clinical need for evaluation of the lymphatic anatomy of the breast. Because of tissue putrefaction, previous studies have not been able to achieve radiographic analyses of bilateral breasts in cadaver specimens. The use of improved preservation techniques with computed tomographic lymphangiography (CT; CTL) has now allowed this analysis to be undertaken. Materials and Methods: The bilateral breasts and anterior upper torso from a female unembalmed human cadaver was studied over an 8-week period. Using microsurgical techniques, lymphatic vessels were identified with hydrogen peroxide, injected with lead oxide mixture, and radiographed to demonstrate lymphatic vessels in both breasts. Multiple frozen domestic ice bricks were used to cover the contralateral side of tissues to keep them partially frozen during this lengthy process. The specimen was radiographed, CT scanned, cross-sectioned, and radiographed again, with images digitalized for analysis. Results: A three-dimensional analysis of lymph collecting vessels in the breasts, anterior upper torso and the internal mammary vascular bundles was achieved using both plain radiography and CTL. The lymphatics of the breast and anterior upper torso drain radially into the axillary lymph nodes. A predominance of superficial lymphatics are noted. Importantly, lymphatic vessel patterns of the breast are asymmetric between breasts of each side. Conclusion: Three-dimensional images of the lymphatic drainage of the breasts using advanced imaging technologies are described, with lymphangiography achieved in bilateral cadaveric breasts and anterior upper torso for the first time. This has significant future application for clinical practice.

There remains much confusion regarding the pathophysiology of pressure ulcers. Data indicate that the prevalence of pressure ulcers is increasing. The heel is unique in structure and well adapted to the task of shock absorption. However, it is often subject to prolonged pressure, which predisposes it to tissue breakdown, with attempts at reconstruction prone to failure. Four dissections were carried out of the heel region, which included removing each heel pad en bloc for histology. Seventeen arterial injection studies, 12 venous studies, and a combined arterial and venous study of the foot were performed. The results were correlated with clinical cases and previous research. The heel was found to be richly vascularized by a subdermal plexus and periosteal plexus with vessels traveling between the 2 within fibrous septa that connect the reticular dermis and periosteum of the calcaneus. These septa effectively create isolated compartments containing relatively avascular fat. A layer of panniculus carnosus muscle was observed in the subcutaneous tissue. It is likely that the metabolically active panniculus carnosus muscle is involved early in the course of pressure ulcers. Extensive pressure damage can be concealed by intact skin. Friction and shear are additional factors important in skin breakdown.

The Achilles tendon is the most frequently ruptured tendon in the lower limb and accounts for almost 20% of all large tendon injuries. Despite numerous published studies describing its blood supply, there has been no uniformity in describing its topography. The current study comprises a detailed anatomical study of both the intrinsic and extrinsic arterial supply of the Achilles tendon, providing the detail sought from studies calling for improved planning of surgical procedures where damage to the vascularity of the Achilles tendon is likely. A dissection, microdissection, histological, and angiographic study was undertaken on 20 cadaveric lower limbs from 16 fresh and four embalmed cadavers. The Achilles tendon is supplied by two arteries, the posterior tibial and peroneal arteries. Three vascular territories were identified, with the midsection supplied by the peroneal artery, and the proximal and distal sections supplied by the posterior tibial artery. The midsection of the Achilles tendon was markedly more hypovascular that the rest of the tendon. The Achilles tendon is at highest risk of rupture and surgical complications at its midsection. Individuals with particularly poor supply of the midsection may be at increased risk of tendon rupture, and approaches to the tendon operatively should consider the route of supply by the peroneal artery to this susceptible part of the tendon.

The middle-third of the patellar tendon (PT) is well-established as a potential graft for cruciate ligament reconstruction, but there is little anatomical basis for its use. Although studies on PT vascular anatomy have focused on the risk to tendon pedicles from surgical approaches and knee pathophysiology, the significance of its blood supply to grafting has not been adequately explored previously. This investigation explores both the intrinsic and extrinsic arterial anatomy of the PT, as relevant to the PT graft. Ten fresh cadaveric lower limbs underwent angiographic injection of the common femoral artery with radio-opaque lead oxide. Each tendon was carefully dissected, underwent plain radiography and subsequently schematically reconstructed. The PT demonstrated a well-developed and consistent vascularity from three main sources: antero-proximally, mainly by the inferior-lateral genicular artery; antero-distally via a choke-anastomotic arch between the anterior tibial recurrent and inferior medial genicular arteries; and posteriorly via the retro-patellar anastomotic arch in Hoffa's fat pad. Two patterns of pedicles formed this arch: inferior-lateral and descending genicular arteries (Type-I); superior-lateral, inferior-lateral, and superior-medial genicular arteries (Type-II). Both types supplied the posterior PT, with the majority of vessels descending to its middle-third. The middle-third PT has a richer intrinsic vascularity, which may enhance its ingrowth as a graft, and supports its conventional use in cruciate ligament reconstruction. The pedicles supplying the PT are endangered during procedures where Hoffa's fat pad is removed including certain techniques of PT harvest and total knee arthroplasty.

Detailed gross anatomical information about the lymphatic system is essential for predicting accurate distant metastatic sites in solid cancers. Current anatomical knowledge of the lymphatic drainage of the breast is derived from studies by Sappey, Poirier, and Cuneo one century ago. The authors have developed a new radiographic protocol for delineating the lymphatic system in human cadavers; firstly using hydrogen peroxide to identify lymphatic vessels in the soft tissues, then injecting a radioopaque lead oxide mixture directly into these vessels and recording their findings on radiographs. We found that the lymph vessel drainage patterns of the breast and upper torso showed no significant difference between male and female specimens. Some lymph vessels that originated at or below the costal margin of the chest, coursed through the breast tissue to reach the axilla. Other lymph vessels coursed beside the perforating branches of the internal mammary blood vessels to reach the internal mammary lymphatics. These findings are discordant with our basic knowledge of breast lymphatic drainage, thereby initiating our anatomical review of the lymphatics of this region.

Background: The degenerative process of lymph nodes is poorly documented. Methods: 161 lymph nodes of seven fresh and one embalmed human cadavers in the head and neck were studied. We used 6% hydrogen peroxide, lead oxide injectant, and radiographs to demonstrate lymphatic vessels, and found both solidified and transparent lymph nodes. They were removed, fixed in 10% formalin and sent for histopathology cross section. Results: Thirty-eight solidified and 123 transparent lymph nodes were found. A series of histopathological sections show the degenerative process is variable and continuous. Senile involution affects all elements of the lymph node including the cortex, the medulla, and the architecture. Conclusion: This study provides actual anatomical and histopathological images of lymph nodes in different degenerative stages in the head and neck region. It may help explain some clinical conditions in the elderly, especially their diminished immunological response to infection and cancer metastasis.

Background Current knowledge of the anatomy of the lymphatic system does not match or explain some of the unexpected clinical and lymphoscintigraphic findings seen in head and neck cancer patients. There is the need, therefore, to remap the lymphatic network of the superficial tissues of the head and neck region. Methods Eighteen halves of the superficial tissues of the head and neck from nine fresh human cadavers were studied over a 20-month period using a mixture of 6% hydrogen peroxide (Orion Laboratories, Balcatta, Australia) with and without India ink to detect the lymphatic vessels and then inject them with a radiopaque lead oxide mixture (AJAX Chemicals, Sydney, Australia). Results These unique studies showed (1) lymph capillaries arising from the skin and the galea layers draining sequentially into precollecting lymph vessels, collecting lymphatics, and the first-tier lymph nodes; (2) collecting vessels averaging 0.2 mm in diameter with unusual "lymphatic ampullae" structures and inactive lymph nodes observed often along their course; (3) different network patterns between subjects and between sides of the same subject; (4) similar relationships between lymphatic and venous systems; (5) a lymphaticovenous shunt in the occipital region; (6) lymphatics sometimes bypassing the expected nodes to reach sentinel nodes in the root of the neck; and (7) the lymphatics of the anterior neck lying above the platysma and coursing horizontally, obliquely, and upward toward the mandible. Conclusion A map of the head and neck lymphatics is presented to aid clinicians with the management of trauma and malignancies in the region.

ObjectThe angiosome concept has been the subject of extensive research by the senior author (G.I.T.), but its specific applicability to the spinal cord was hitherto unknown. The aim of this study was to see if the spinal cord vasculature followed the angiosome concept and to review the usefulness of preoperative spinal angiography in surgery for spinal disorders. Spinal cord infarction and permanent paraplegia may result from inadvertent interruption of the artery of Adamkiewicz. Spinal angiography, which may enable avoidance of this catastrophic complication, is still not commonly used.MethodsTwo fresh cadavers were injected with a gelatin–lead oxide mixture for detailed comparative study of spinal cord vasculature. One cadaver had insignificant vascular disease, whereas the other had extensive aortic atherosclerosis, presenting a unique opportunity for study. After removal from each cadaver, radiographs of the spinal cords were obtained, then photographed, and the vascular territories of the cords were defined.ResultsFour angiosome territories were defined: vertebral, subclavian, posterior intercostal, and lumbar. These vascular territories were joined longitudinally by true anastomotic channels along the anterior and posterior spinal cord. Anastomosis between the anterior and posterior vasculature was poor in the thoracolumbar region. The anterior cord relied on fewer feeder arteries than the posterior, and the anterior thoracolumbar cord depended on the artery of Adamkiewicz for its supply. In chronic aortic disease with intercostal artery occlusion at multiple levels, a rich collateral circulation supporting the spinal cord was found.ConclusionsThe arterial supply of the spinal cord follows the angiosome concept. The atherosclerotic specimen supports the suggestion that the blood supply is able to adapt to gradual vascular occlusion through development of a collateral circulation. Nevertheless, the spinal cord is susceptible to ischemia when faced with acute vascular occlusion. This includes inadvertent interruption of the artery of Adamkiewicz. The authors recommend the use of preoperative spinal angiography to prevent possible paraplegia in removal of thoracolumbar spinal tumors.

Background There have been very few anatomical reports on the changing lymph structure of the upper limb after axillary dissection despite its clinical significance for predicting skin cancer recurrence in the limb and secondary lymphedema. The authors used both upper limbs harvested from a fresh human cadaver that had undergone unilateral right radical mastectomy and radical axillary dissection for breast cancer. Methods Hydrogen peroxide was used to identify and inflate the lymphatic vessels. Individual channels were injected with a radiopaque lead oxide mixture and recorded on x-ray film. Results Results from the normal left upper limb were similar to results from the authors' previous studies. However, the right limb from the mastectomy side showed remarkable differences and revealed that the lymph node clearance in the axilla had been incomplete on that side. The major difference was the almost complete absence of the superficial lymphatic network in the right arm, proximal to the elbow, because of fibrosis and blockage of the lymphatic channels. A circuitous pathway was identified that bypassed the blocked lymphatics in the arm to reach the deep system. This was facilitated often by backflow through precollectors and avalvular lymph capillaries in the dermis of the forearm, to reach eventually the few remaining lymph nodes in the axilla. Conclusions Previously undetected lymph channels connecting the superficial and the deep lymphatic system had opened up because of the blockage of superficial lymphatic vessels caused by axillary dissection. It is presumed that these channels prevented lymphedema in this case.

Background Current understanding of the lymphatic system of the breast is derived mainly from the work of the anatomist Sappey in the 1850s, with many observations made during the development and introduction of breast lymphatic mapping and sentinel node biopsy contributing to our knowledge. Methods Twenty four breasts in 14 fresh human cadavers (5 male, 9 female) were studied. Lymph vessels were identified with hydrogen peroxide and injected with a lead oxide mixture and radiographed. The specimens were cross sectioned and radiographed to provide three dimensional images. Lymph (collecting) vessels were traced from the periphery to the first-tier lymph node. Results Lymph collecting vessels were found evenly spaced at the periphery of the anterior upper torso draining radially into the axillary lymph nodes. As they reached the breast some passed over and some through the breast parenchyma, as revealed in the cross-section studies. The pathways showed no significant difference between male and female specimens. We found also perforating lymph vessels that coursed beside the branches of the internal mammary vessels, draining into the ipsilateral internal mammary lymphatics. In some studies one sentinel node in the axilla drained almost the entire breast. In most more than one sentinel node was represented. Conclusion These anatomical findings are discordant with our current knowledge based on previous studies and demand closer examination by clinicians. These anatomical studies may help explain the percentage of false-negative sentinel node biopsy studies and suggest the peritumoral injection site for accurate sentinel lymph node detection.

Background: The authors previously reported a new technique with which to delineate the lymphatic vessels, using hydrogen peroxide to identify them and a lead oxide suspension to demonstrate them on radiographs. This technique provided excellent studies of the lymph vessels in human cadavers, but there was still room for improvement. Methods: Lymph collecting vessels run superficially in some regions, where they may be damaged while the surgeon is attempting to find them. Vessels smaller than 0.3 mm in diameter could not be cannulated with a 30-gauge needle, which was the smallest the authors had available, and the lead oxide suspension often blocked this cannula. The authors also encountered problems holding the cannula steady. Results: The authors solved these problems by using a mixture of hydrogen peroxide and ink to better identify the lymphatics, an extruded glass tube instead of a metal needle to cannulate them, an agate pestle and mortar to grind the lead oxide into finer particles, powdered milk to suspend the lead oxide, and a micromanipulator to facilitate accurate and steady cannulation of the vessels. Conclusion: This study developed these modifications to focus on tributaries of the collecting lymphatic channels that are smaller than 0.3 mm in diameter.

This anatomical study analyzed the neurovascular relationships of the brachial plexus. Ten fresh cadaveric brachial plexuses were examined after injection of the arterial system. The vascular anatomical features of the brachial plexus were documented with microdissection after lead oxide/gelatin injection. The specimens were analyzed by using radiography (including digital subtraction techniques) and light-microscopic, macroscopic, and digital photography. Four angiosomes, based on the subclavian, axillary, vertebral, and dorsal scapular arteries, were observed. As noted in previous angiosome studies, connections between angiosome territories lay within tissues, in this case, nerve trunks. Nutrient vessels penetrated nerve trunks at points of branching within the brachial plexus, with a Y-shaped mode of division on entry. The vascular supply was markedly rich, often with true anastomotic connections occurring within the nerves. There was much variation in supply, depending on the vascular anatomical features of the subclavian artery.