Use of the soleus musculocutaneous perforator for skin paddle salvage of the fibula osteoseptocutaneous flap: anatomical study and clinical confirmation.

BACKGROUND The skin paddle of the fibula osteoseptocutaneous flap is reliably vascularized by septocutaneous perforators from the peroneal artery. However, in 5 to 10 percent of lower limbs, these perforators are absent. This anatomical study evaluated use of the soleus musculocutaneous perforator for skin paddle salvage in such situations. METHODS Latex injection studies were performed on 20 cadaveric lower limbs. The presence, prevalence, and location of the musculocutaneous perforators in the distal leg were documented. The perforators were traced proximally to determine their origins. RESULTS Of the 20 cadaveric limbs, one or more musculocutaneous perforators of at least 0.5 mm in diameter were noted in 18 specimens (90 percent). They were located within 6 cm of the junction of the middle and lower thirds of the fibula. The soleus musculocutaneous perforators originated in the peroneal artery in 10 specimens (50 percent), the posterior tibial artery in seven (35 percent), and the tibioperoneal trunk in one (5 percent). This information was successfully used to salvage the skin paddle in two of our clinical cases. CONCLUSIONS Use of the soleus musculocutaneous perforator depends on its origin. When it arises from the peroneal artery, a single set of anastomoses is all that is necessary for flap revascularization, with the skin paddle serving as a monitor for the bone flap. When it originates from the posterior tibial artery or tibioperoneal trunk, a second set of anastomoses is needed and the skin paddle cannot monitor the bone flap. The authors propose that one or two soleus musculocutaneous perforators be preserved during harvest until existence of the septocutaneous perforator is confirmed.