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• W4200567944 abstract "What a true perforator is remains debatable. However, we continue to embrace the views of Fu Chan Wei, that a true perforator is the skin vessel that perforates the muscle, not the fascia, and requires intramuscular dissection.1 In our study,2 we have extended the application of this terminology to musculoseptocutaneous perforators, as they often required intramuscular and intrafat dissection. The term “septocutaneous perforator” used in our article was not in alignment with the definition set by Wei, but we chose it to minimize confusion for the reader. In our study, classification of perforators into septocutaneous perforator, musculoseptocutaneous perforator, and musculocutaneous perforator depended on the perforator exit point before it perforated the fascia, not the site at which the perforator first emerged from the source vessel and the course it then took.2 This is because our study is a clinical one, in which perforators were dissected in a retrograde manner, not in an antegrade manner, and so what appeared septal initially was often far from septal. “Musculoseptocutaneous perforator” is thus a broader term for all perforators that have an intramuscular and intraseptal course revealed by retrograde dissection, regardless of the distance these vessels traveled in the septum or the muscle, and the term described those we initially identified as septocutaneous perforator but turned out to require intramuscular dissection, taking the joy of such impression as some had long intramuscular courses. We have encountered a perforator that traveled 1.5 cm in the septum and then 10 cm intramuscularly to the oblique branch. As the term is a broad one, it covers those perforators described by Nakajima et al.3 and Hallock,4 but it should not be considered an alternative term. The anatomy is bigger than we are, and Kim et al.’s5 definition based on a computed tomography angiography finding—“a perforator with the intramuscular course less than 1 cm”—is a narrow one, for example. Our study serves two key purposes. One is to introduce and report on the musculoseptocutaneous perforators as an independent, broad category. This is helpful in clinical teaching of residents and fellows. So instead of misleading them with statements like “more than 80 percent of perforators are musculocutaneous perforators,” it is now more accurate to say, “More than 80 percent of perforators have an intramuscular course, and around 50 percent of perforators have a septum course, and the number reaches 85 percent at the proximal zone.”2 The second point down the line is that musculoseptocutaneous perforator dissection is not easier than musculocutaneous perforator dissection. When a musculoseptocutaneous perforator happens to be the type described by Nakajima et al.3 or Hallock,4 that is, a “direct cutaneous muscle vessel with no side branches but maybe a few wisps of muscle,” the dissection then becomes easier and these vessels become a real gift to the surgeon. Otherwise, it is not easy to judge intraoperatively, since the septal adipose tissue is sometimes dense and contains muscle and nerve fibers and injury could happen when opening the septum, as the perforator often sends nutrition branches to rectus femoris muscle and is adherent to septal adipose tissue. The message here is that competency in perforator dissection is required to elevate the flap safely. In conclusion, is the musculoseptocutaneous perforator a paramuscular perforator in disguise? Our answer is, the paramuscular perforators described by Hallock belong to musculoseptocutaneous perforators and represent one of the probably endless varieties a musculoseptocutaneous perforator could present with when the length of its septal course, branching pattern, and so on, are accounted for. DISCLOSURE None of the authors has a financial interest to declare in relation to the content of this communication." @default.
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• W4200567944 date "2021-12-02" @default.
• W4200567944 modified "2023-10-18" @default.
• W4200567944 title "Reply: Musculoseptocutaneous Perforator of Anterolateral Thigh Flap: A Clinical Study" @default.
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• W4200567944 doi "https://doi.org/10.1097/prs.0000000000008643" @default.
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