The Medial Sural Artery Perforators

Abstract

We performed an anatomic study on 20 fresh lower limbs. Resin was injected in the popliteal artery. Medial sural artery perforator flaps were sculptured according to anatomic markings. On average, length of flaps was 12.9 cm, width was 7.9 cm; all 38 perforators were musculocutaneous: 1 perforator was always found (on average, 1.9 per flap). All perforators gathered between 7 and 18 cm from the popliteal crease; 34.2% of perforators arose on the midline of the medial head of gastrocnemius muscle; before entering the fascia, the perforator artery diameter was on average 0.5 mm. Two configurations of the intramuscular course of perforators were found. Sixty-six percent of perforators originated from the lateral branch of the medial sural artery, 34% from the medial one. These results improve the anatomic knowledge of the medial posterior calf region and allow us to describe a convenient plan to make flap sculpturing easier.

An early complication in the donor site of the medial sural artery perforator flap: necrosis of the medial head of gastrocnemius

“…However, the medial gastrocnemius muscle could survive even after division of medial sural artery pedicle, owing to adjacent angiosomes. Some studies suggest that the possibility of muscle ischaemia after sacrifice of even the entire medial sural artery should thus be remote [1,2,9].…”

The Medial Sural Artery Perforator Flap: A Historical Trek from Ignominious to “Workhorse”

“…The first efforts to determine the vascular anatomy of the MSAP flap specifically as a “perforator flap” initially by Cavadas et al 2 and Hallock 1 have been repeated by many others in an attempt to find any consistency that would better assure reliability. 27 28 29 30 31 32 33 34 35 Unfortunately, as is usually the outcome with investigations of perforator flaps, the pattern in an individual's contralateral side is rarely identical to that of the ipsilateral, 36 and often even less so when seeking comparisons with others—the MSAP flap is no exception to this rule! 28…”

“…9 Then proceeding posteriorly, the MSA enters the undersurface of the medial head of the gastrocnemius muscle at the level of the fibular head, which corresponds to the articulation of the knee joint. Before or after entering this muscle hilum, Manchot long ago knew that, sometimes the MSA will “divide into one or more deep muscular branches.” 9 More recently, Thione et al 31 described two such major branches, but others have rarely discovered the presence of three or more branches. 28 33 37 Dusseldorp et al 28 devised a classification schema for these various branching patterns ( Fig.…”

“…The importance of the MSA branching patterns should not be overlooked, as these ultimately give rise to the musculocutaneous perforators that must be included in the MSAP flap. Thione et al 31 stated that two-thirds of such perforators arose from the lateral branch, but 87% overall were within 1 cm of the midline of the medial gastrocnemius muscle (MGM) itself. When only two branches were present, according to Wong et al, 33 the lateral branch would be the larger with a typically straight and relatively superficial intramuscular course away from the muscle hilum.…”

“…To further complicate matters, sometimes MSAPs may not even exist, yet the number of dominant perforators (i.e., subfascial caliber ∼0.5 cm 28 31 ) could range even up to half a dozen! 25 28 29 32 34 In the absence of an MSAP, Dusseldorp et al 28 in 9% and Wang et al 38 in 10% of the time found instead a suitable median sural artery perforator as an alternative, so that although a “true” MSAP perforator flap would only be possible ∼90% of the time, almost always a satisfactory calf perforator flap was still possible.…”