Sural perforator flap: Assessment of the posterior calf region as donor site for a free fasciocutaneous flap

Abstract

Three kinds of free fasciocutaneous flap from the posterior calf region have been described in the literature: the medial sural perforator flap, the lateral sural perforator flap, and the traditional posterior calf fasciocutaneous flap that is supplied by superficial cutaneous vessels. Moreover, it has been reported that superficial cutaneous vessels are of a suitable size for microanastomosis when deep musculocutaneous perforators are absent or relatively tiny. To establish a safe technique for free fasciocutaneous flap elevation from the posterior calf region, we examined the number and location of the musculocutaneous perforators and the size of superficial cutaneous vessels at their origin from the popliteal artery in six formalinized cadavers. We found that all legs had at least one perforator either from the medial sural artery or the lateral sural artery. By contrast, we failed to find superficial cutaneous vessels of suitable size for microanastomosis in three legs, and there was no significant inverse relationship between the diameter of the superficial cutaneous artery and the number of musculocutaneous perforators. Our results suggest that the medial sural perforator flap and the lateral sural perforator flap might be the surgeon's first and second choice, respectively. The traditional posterior calf fasciocutaneous flap should be the third choice because our study suggests that its availability is doubtful. Another site is recommended, when preoperative Doppler study suggests that the existence of musculocutaneous perforator is in doubt. Two clinical cases, with a medial sural perforator flap and a lateral sural perforator flap, respectively, are presented.

The vascularized sural nerve graft based on a peroneal artery perforator for reconstruction of the inferior alveolar nerve defect

“…It relies on the intrinsic and extrinsic neurocutaneous or venocutaneous vascular supply that accompanies the sural nerve. The blood supply of the flap comes from the superficial sural artery, perforators from the posterior tibial artery, and perforators from the peroneal artery . These perforators connect with each other in the subcutaneous plane, forming a longitudinal chain‐linked vascular plexus along the course of the sural nerve .…”

Superficial lateral sural artery free flap for intraoral reconstruction: Anatomic study and clinical implications

“…In this study, the diameter of the superficial lateral sural artery was found to be 0.5 mm on average, whereas the superficial median artery had a diameter of 1 mm. In a recent study by Shimizu et al11 superficial median and lateral sural arteries with diameters of 0.8 to 2.7 mm (median) and 0.4 to 2.5 mm (lateral) were found in 12 formalin‐ fixed legs, but in 3 specimens, no suitable superficial system was present at all. Walton et al7, 12 dissected 11 cadaver legs and described the superficial sural artery as a direct cutaneous branch developing from the popliteal artery in 50% and from the deep lateral sural artery in 45% of the specimens.…”

Free‐flap resurfacing of tissue defects in the foot due to large gouty tophi

“…Furthermore, the major perforator of the medial sural artery is easier to identify than the perforators of other flaps, thus enabling a rather safe and rapid dissection between the deep fascia and the medial gastrocnemius muscle. [14][15][16] Under these circumstances, the surgeon is not only required to cover an existing tissue defect but also to achieve a good-quality and natural-looking reconstructed site. Many factors affect the choice of the flap used for a particular patient, and the reconstructive procedure should be chosen depending on the characteristics of the defects.…”

“…12,[14][15][16][17] The ALT flap, first described by Song et al in 1984, is a perforator skin flap that leaves the muscle essentially intact, thereby minimizing donor site morbidity. The use of ALT flaps also allows simultaneous flap harvest and recipient site preparation, thus allowing a shorter surgical period, and enabling the patient to rest in a supine position during the procedure.…”