Sequential use of a true perforator flap and its corresponding muscle flap.

A true perforator flap completely spares the underlying muscle that was previously required as essentially a passive carrier of that musculocutaneous unit. Thus, a perforator flap and its related muscle can now be simultaneously transferred as independent but conjoint flaps based on the same source pedicle, or sometimes also in a metachronous fashion if the requisite source vessels remain intact. The latter principle proved feasible after failure of 2 medial sural perforator flaps that were subsequently successfully replaced by a conventional medial gastrocnemius muscle flap. At least theoretically, depending on the extent of intramuscular dissection, another advantage that can be applied to all perforator flaps is that the muscle can be held in reserve for sequential use as necessary.