The Medial Sural Artery Perforator Free Flap

Abstract

The medial sural artery supplies the medial gastrocnemius muscle and sends perforating branches to the skin. The possible use of these musculocutaneous perforators as the source of a perforator-based free flap was investigated in cadavers. Ten legs were dissected, and the topography of significant perforating musculocutaneous vessels on both the medial and the lateral gastrocnemius muscles was recorded. A mean of 2.2 perforators (range, 1 to 4) was noted over the medial gastrocnemius muscle, whereas in only 20 percent of the specimens was a perforator of moderate size noted over the lateral gastrocnemius muscle. The perforating vessels from the medial sural artery clustered about 9 to 18 cm from the popliteal crease. When two perforators were present (the most frequent case), the perforators were located at a mean of 11.8 cm (range, 8.5 to 15 cm) and 17 cm (range, 15 to 19 cm) from the popliteal crease. A series of six successful clinical cases is reported, including five free flaps and one pedicled flap for ipsilateral lower-leg and foot reconstruction. The dissection is somewhat tedious, but the vascular pedicle can be considerably long and of suitable caliber. Donor-site morbidity was minimal because the muscle was not included in the flap. Although the present series is short, it seems that the medial sural artery perforator flap can be a useful flap for free and pedicled transfer in lower-limb reconstruction.

The free medial sural artery perforator flap: Versatile option for soft tissue reconstruction in small‐to‐moderate size defects of the foot and ankle

“…In contrast, the MSAP flap provides a thin and pliable skin island even in overweighed patients and the possibility for simultaneous harvesting of other tissue units (e.g., muscle, muscle/fascia) on the same pedicle, if needed (Hallock, ). Over the last decade MSAP flap reconstruction has displayed a reliable option for reconstruction of the oral cavity (Chen et al, ; Choi et al, ; He et al, ), head and neck (Kao et al, ; Mao et al, ; Nugent et al, ; Song et al, ), and the upper (Xie et al, ; Zheng et al, ) and lower (Cavadas et al, ; Chen et al, ; Kim et al, ) extremity including the foot and ankle (Chen et al, ; Kim et al, ; Wang et al, ; Hallock, ).…”

“…With the aid of a tourniquet (without exsanguination) and magnification loupes, the planned flap was first incised medially. Flap elevation can be done supra‐ or subfascial (Cavadas et al, ). We prefer the subfascial approach because of easier flap and pedicle dissection.…”

Free sural artery perforator flap: An occasional gift in oral cavity reconstruction

“…There are multiple source vessels nourishing the posterior calf skin, as deduced by previous studies; however, the MSAPs have been deemed the most reliable and predictable for use in free tissue transfer …”

“…The medial sural artery perforator (MSAP) flap is becoming increasingly popular in head and neck reconstruction because of its thin, pliable characteristics, reliable perforators of good caliber, and inconspicuous, low morbidity donor site . There is a long intramuscular dissection, which is more technical than a radial forearm flap or anterolateral thigh flap, and therefore can be challenging to the uninitiated.…”

Primary tumors of the hand: Functional and restorative management

“…This fasciocutaneous flap can be harvested simultaneously with a tendon and/or nerve graft through the same incision and in a single stage. However, the flap is difficult to dissect and appropriate perforators may not be present due to anatomic variability . In cases of malignant neural sheath tumors, simultaneous tendon transfers from the pronator teres, extensor carpi radialis brevis, and flexor carpi radialis brevis have been used …”