The Emerging Role of the Direct Cutaneous Muscle Perforator Found Arising from the Muscle Vessel Hilum

Abstract

Perforator flaps based on either musculocutaneous or septocutaneous perforators are no longer a curiosity, but rather in the past decade have become "workhorse" soft tissue alternatives. Yet a keener understanding of their anatomy abetted by sophisticated imaging techniques has revealed other deep fascia perforators whose potential impact should not be overlooked. An important triad of these perforators can be found to arise ultimately from the source vessel to a muscle. This triumvirate includes the well-known, almost insignificant, capillary-like musculocutaneous perforator and the larger-caliber and often dominant musculocutaneous perforator that has become the basis of the conventional muscle perforator flap. An overlooked member of this tripartite system, though, is the direct cutaneous branch from the muscle hilum, which may be far more common than previously realized. The latter typically takes a paramuscular or extramuscular course to the skin, so that its corresponding perforator flap can be raised most simply while totally avoiding entering any muscle substance per se, and thus by definition will best ensure function preservation. Any surgeon considering a muscle perforator flap must be aware of the possibility of this tripartite system and the advantages as well as limitations of each component.