Surgical Anatomy of the Medial Sural Artery Perforator Flap

 

 Permissions and Reprints

Abstract

Background The medial sural (medial gastrocnemius) perforator flap is a thin flap with a long pedicle. It has tremendous potential for applications in a variety of soft-tissue defects. We aimed to further clarify the vascular anatomy of the medial sural region and establish a safe approach for elevation of this flap.

Methods Ten fresh cadaveric lower limbs were injected and used in this study. We identified the locations and courses of the medial sural artery perforators and correlated them to anatomic landmarks.

Results The medial sural artery divides into two branches, a medial and lateral branch. Correspondingly, musculocutaneous perforators supplying the overlying skin were oriented in two parallel vertical rows, along the course of the lateral or medial branch of the medial sural artery. Two to six perforators were located 6 cm to 22.5 cm from the popliteal crease. Perforators from the lateral row, nearer the posterior midline, were generally larger. In most cases, a large perforator with a superficial, straight intramuscular course could be identified a mean of 10 cm distal to the popliteal crease and an average of 2 cm from the posterior midline. Based on the above findings, we successfully used this flap in five clinical cases.

Conclusion Perforators of the medial sural artery were arranged in a medial and a lateral row. Use of perforators from the lateral row, nearer the posterior midline, is preferable as these are usually larger in size. A consistent major perforator could always be identified in all specimens. With increased safety and confidence in flap harvesting, the medial sural artery perforator flap may find wider clinical applications.

Clinical question: Therapeutic

Level of Evidence: IV

• References

• 1 Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast Reconstr Surg 1975; 56: 243-253
  CrossrefPubMedGoogle Scholar
• 2 Montegut WJ, Allen RJ. Sural artery perforator flap as an alternative for the gastrocnemius myocutaneous flap. Plast Reconstr Surg 1996; 89: 5113
  PubMedGoogle Scholar
• 3 Cavadas PC, Sanz-Giménez-Rico JR, Gutierrez-de la Cámara A, Navarro-Monzonís A, Soler-Nomdedeu S, Martínez-Soriano F. The medial sural artery perforator free flap. Plast Reconstr Surg 2001; 108: 1609-1615 , discussion 1616–1617
  CrossrefPubMedGoogle Scholar
• 4 Umemoto Y, Adachi Y, Ebisawa K. The sural artery perforator flap for coverage of defects of the knee and tibia. Scand J Plast Reconstr Surg Hand Surg 2005; 39: 209-212
  CrossrefPubMedGoogle Scholar
• 5 Shim JS, Kim HH. A novel reconstruction technique for the knee and upper one third of lower leg. J Plast Reconstr Aesthet Surg 2006; 59: 919-926, discussion 927
  CrossrefPubMedGoogle Scholar
• 6 Kim ES, Hwang JH, Kim KS, Lee SY. Plantar reconstruction using the medial sural artery perforator free flap. Ann Plast Surg 2009; 62: 679-684
  CrossrefPubMedGoogle Scholar
• 7 Chen SL, Chuang CJ, Chou TD, Chen TM, Wang HJ. Free medial sural artery perforator flap for ankle and foot reconstruction. Ann Plast Surg 2005; 54: 39-43
  CrossrefPubMedGoogle Scholar
• 8 Chen SL, Chen TM, Lee CH. Free medial sural artery perforator flap for resurfacing distal limb defects. J Trauma 2005; 58: 323-327 Erratum in: J Trauma 2005;58:763
  CrossrefPubMedGoogle Scholar
• 9 Chen SL, Yu CC, Chang MC, Deng SC, Wu YS, Chen TM. Medial sural artery perforator flap for intraoral reconstruction following cancer ablation. Ann Plast Surg 2008; 61: 274-279
  CrossrefPubMedGoogle Scholar
• 10 Chen SL, Chen TM, Dai NT, Hsia YJ, Lin YS. Medial sural artery perforator flap for tongue and floor of mouth reconstruction. Head Neck 2008; 30: 351-357
  CrossrefPubMedGoogle Scholar
• 11 Xie RG, Gu JH, Gong YP, Tang JB. Medial sural artery perforator flap for repair of the hand. J Hand Surg Eur Vol 2007; 32: 512-517
  CrossrefPubMedGoogle Scholar
• 12 Wong CH, Lin JY, Wei FC. The bottom-up approach to the suprafascial harvest of the radial forearm flap. Am J Surg 2008; 196: e60-e64
  CrossrefPubMedGoogle Scholar
• 13 Hallock GG. Anatomic basis of the gastrocnemius perforator-based flap. Ann Plast Surg 2001; 47: 517-522
  CrossrefPubMedGoogle Scholar
• 14 Kao HK, Chang KP, Chen YA, Wei FC, Cheng MH. Anatomical basis and versatile application of the free medial sural artery perforator flap for head and neck reconstruction. Plast Reconstr Surg 2010; 125: 1135-1145
  CrossrefPubMedGoogle Scholar
• 15 Sano K, Hallock GG, Hamazaki M, Daicyo Y. The perforator-based conjoint (chimeric) medial Sural (MEDIAL GASTROCNEMIUS) free flap. Ann Plast Surg 2004; 53: 588-592
  CrossrefPubMedGoogle Scholar
• 16 Hallock GG. Chimeric gastrocnemius muscle and sural artery perforator local flap. Ann Plast Surg 2008; 61: 306-309
  CrossrefPubMedGoogle Scholar
• 17 Hallock GG, Sano K. The medial gastrocnemius sural perforator free flap: an ‘ideal’ prone position skin flap. Ann Plast Surg 2004; 52: 184-187
  CrossrefPubMedGoogle Scholar
• 18 Thione A, Valdatta L, Buoro M, Tuinder S, Mortarino C, Putz R. The medial sural artery perforators: anatomic basis for a surgical plan. Ann Plast Surg 2004; 53: 250-255
  CrossrefPubMedGoogle Scholar
• 19 Okamoto H, Sekiya I, Mizutani J, Otsuka T. Anatomical basis of the medial sural artery perforator flap in Asians. Scand J Plast Reconstr Surg Hand Surg 2007; 41: 125-129
  CrossrefPubMedGoogle Scholar
• 20 Kim HH, Jeong JH, Seul JH, Cho BC. New design and identification of the medial sural perforator flap: an anatomical study and its clinical applications. Plast Reconstr Surg 2006; 117: 1609-1618
  CrossrefPubMedGoogle Scholar
• 21 Torres LR, Teixeira WGJ, Setani EO, Wei TH, Zumiotti A. Skin flap of medial gastrocnemius muscle's perforating arteries. An anatomical study. Acta Ortop Bras 2007; 15: 40-42
  PubMedGoogle Scholar
• 22 Hallock GG. A primer of schematics to facilitate the design of the preferred muscle perforator flaps. Plast Reconstr Surg 2009; 123: 1107-1115
  CrossrefPubMedGoogle Scholar
• 23 Higueras Suñé MC, López Ojeda A, Narváez García JA , et al. Use of angioscanning in the surgical planning of perforator flaps in the lower extremities. J Plast Reconstr Aesthet Surg 2011; 64: 1207-1213
  CrossrefPubMedGoogle Scholar
• 24 Wong CH, Wei FC. Anterolateral thigh flap. Head Neck 2010; 32: 529-540 Review
  PubMedGoogle Scholar