Dominance between angiosome and perforator territories: a new anatomical model for the design of perforator flaps

An understanding of the angiosome of a source vessel in supply to a perforator flap is essential to flap design. With substantial interindividual variability in the size and reliability of such territories, preoperative awareness of factors that affect the number or size of perforators in a given territory can aid operative planning. Body weight and scarring are known to modify a given territory, and anecdotally so too can the "dominance" of adjacent vascular territories. A clinical study of 300 patients (600 body sides) was undertaken, using computed tomographic angiography, to map the vessels of six vascular territories. The effect of interplay between vascular territories was assessed by establishing whether a dominant territory was associated with a diminutive adjacent territory. For every vascular territory investigated, the effect of "dominance" was evident, with a statistically significant effect shown between the deep inferior epigastric artery and superficial inferior epigastric artery territories (p < 0.01), and the anteromedial thigh and anterolateral thigh perforator territories (p = 0.01). The size or dominance of perforators in a given vascular territory is influenced by the dominance of adjacent vascular territories. This concept of perforator or angiosome dominance is an important factor in the design of perforator flaps.