On "Rare Variant of the Intrasoleus Musculocutaneous Perforator: Clinical Considerations in Raising a Free Peroneal Osteocutaneous Flap" (Journal of Reconstructive Microsurgery 2001;17:225-228)

We read the article ``Rare variant of the intrasoleus musculocutaneous perforator: clinical considerations in raising a free peroneal osteocutaneous flap'' in the Journal of Reconstructive Microsurgery [1] (2001;17) with interest. We had a similar experience while raising a free fibular osteocutaneous flap, with some differences we would like to share.

A 50-year-old male underwent a planned bilateral neck dissection and resection of the floor of the mouth with anterior segment of the mandible. Preoperatively, the patient had had bilateral lower extremity angiograms, which were unremarkable. The skin defect was 4x9 cm and the mandible defect was10 cm in length, so we intended to harvest an appropriate flap of skin and bone. We Dopplered both extremities and found single perforators on both sides in the middle third of the leg. We elected to use the right leg for harvest of the flap and, under tourniquet control, the skin paddle was dissected. In the course of dissection, a large vessel lateral to the fibula in an intermuscular fascial septum was divided, and a myriad of vessels were located in the soleus, with no visible perforators to the skin paddle.

Unable to clearly demonstrate a septal perforator in the right leg, we elected to use the left leg. The skin paddle was marked in the middle third of the leg including the previously identified Dopplered vessel. The anterior dissection failed to reveal any septal perforator. Further proximal dissection showed a large vessel in the intramuscular septum of the upper third of the leg. Incorporating this vessel in our flap, the fibula was harvested, making both proximal and distal osteotomies. Proximal dissection revealed large intramuscular branches not only from the peroneal artery, but also from the perforator, which were ligated. Further dissection up to the tibio-peroneal decussation did not result in confluence of the perforator with the posterior tibial or peroneal artery. Both the peroneal artery and the perforator had their separate veins, and thus were harvested separately, maintaining the fascial septal connection with each other. They were anastomosed to the facial artery and a branch of the external jugular vein using a Y-venous graft in both cases. Postoperatively, there was 100 percent survival of the fascial flap and the fibula.

Previous studies by Weber and Pederson[2] and Winters and Jongh[3] mention the possibility of musculocutaneous perforators and the need for separate anastomosis. We want to bring attention to the fact that, at times, there may be a single perforator audible on the Doppler, having multiple branches of its own. Careful dissection with wide exposure of the intramuscular septum[4] should allow recognition of this vascular pattern. The surgeon may then proceed to consider elevation of the skin and bone as individual flaps Also, this anomaly may occur simultaneously in both the legs and may not be recognized on the angiogram.

REFERENCES

• 1 Yokoo S, Komori T, Furudoi S. Rare variant of the intrasoleus musculocutaneous perforator: clinical considerations in raising a free peroneal osteocutaneous flap.  J Reconst Microsurg . 2001;  17 225
• 2 Weber R A, Pederson W C. Skin paddle salvage in the fibular osteocutaneous free flap with secondary skin paddle vascular anastomoses.  J Reconstr Microsurg . 1995;  11 242
• 3 Winters H AH, De Jongh J G. Rehabilitation of the proximal skin paddle of the osteocutaneous free fibula flap: a prospective clinical study.  Plast Reconstr Surg . 1999;  103 846
• 4 Anthony J, Ritter F, Young D, Singer M. Enhancing fibula free flap skin island reliability and versatility for mandibular reconstruction.  Ann Plast Surg . 1993;  31 106