Soleal perforators: recipient options in lower extremity reconstruction
Evan Garfein, MD, Nicholas Haddock, MD, Christopher Derderian, MD, Jamie Levine, MD, Pierre Saadeh.
NYU School of Medicine, New York, NY, USA.
BACKGROUND: “Ideal” recipient vessels are defined as vessels that are of adequate caliber, have a consistent, protected location, are easy to dissect, and are expendable. When free tissue transfer is employed for distal lower extremity defects, recipient anastamoses are typically performed end-to-end or end-to-side to the major vessels of the extremity. Recent data suggest that soleus musculocutaneous perforators are of adequate size and consistency to support free tissue transfer. We undertook an anatomic evaluation of perforators located in the distal half of the lower extremity to provide free flap recipient options out of hypothetical zones of injury. A case of free tissue transfer to a soleal perforator is described.
METHODS: Six fresh cadavers (12 limbs) were dissected. Perforators of adequate size (1mm or greater artery) were documented as was location and ease of dissection. Based on these findings, free tissue transfer to a lower extremity perforator was performed.
RESULTS: Soleal perforators most reliably matched our recipient vessel requirements. Consistent with recent data, perforators were of adequate size to support free tissue transfer and were located at mid to distal fibula level. Moreover, we identified distal soleal perforators, largely posterior tibial system based, that were not included in prior reports since they did not contribute to described musculocutaneous flaps. A patient with a large open distal tibial wound and a single vessel (posterior tibial artery) providing perfusion to the foot underwent successful free flap reconstruction with anastamoses to soleal perforator vessels.
CONCLUSIONS: Residing in the superficial posterior compartment, the soleus muscle is easily exposed during lower extremity dissection, can be approached from both medial and lateral directions, contains relatively protected blood supply facing the deep posterior compartment, and is supplied distally by perforators from both the posterior tibial and peroneal artery systems. At this level, the perforating branches to the soleus are more superficial than either the peroneal or posterior tibial arteries, making both the exposure and the anastomosis technically easier and sparing potential iatrogenic injury to a major and often critical artery to the foot.