Utility of proximally based sural fasciocutaneous flap for. Medial sural artery perforator flap technique steven t. This descriptive case series was conducted at jinnah burn and reconstructive surgery center, lahore during october 2016 to. In the last decade, the medial sural artery perforator flap msap has emerged as one of the most popular reconstructive options for multiple body sites. A reverseflow sural artery flap is used to reconstruct a calcaneus wound. The sural artery flap is a type a fasciocutaneous flap based on the sural artery direct cutaneous branch of the popliteal artery. Two median sural artery perforators were identified and dissected on the lateral aspect of the flap. In summary, use of this pedicled perforator flap represents a reliable technique for softtissue reconstruction about the knee with an acceptable complication rate and optimal contour reconstruction without the need for a skin graft and secondary debulking procedures. A medial sural island fasciocutaneous flap, nourished by a posterior tibial artery perforator. Using an audible doppler probe to locate a distal perforator over the medial calf, a template of the defect was then centered about this point to create a 6. It is located between the popliteal fossa and the midposterior leg between the medial and lateral heads of the gastrocnemius muscle. After entering the undersurface of the muscle, most commonly the medial sural artery bifurcates to run superficial posterior or deep within the muscle surface 5. Distally based perforator sural flaps for foot and ankle. The rotation point is 5 cm above the lateral malleolus the limit for dissection of the pedicle.
To assess the outcome of medial sural artery perforator flap msap flap as an option for the soft tissue reconstruction of head and neck and limbs. The length of the pedicle is identical to the distance between the rotation point of the flap and the wound. For the middle tibia, the soleus flap is used, and distal to that a free flap is needed either the medial or lateral heads of the gastrocnemius can be used, though the proximity to the peroneal nerve and its shorter length make the lateral less desirable. Each head of the gastrocnemius muscle recevies its blood supply from a sural artery, medial and lateral respectively, which are branches off the popliteal artery. The medial sural artery perforator msap flap is a versatile fasciocutaneous flap. Gastrocnemius rotation flap technique orthopaedicsone. An defect on the posterior ankle exposing the tendoachilles and a fractured calcaneum covered with a sural artery flap. The flap was distally based, islanded and covered the. The medial gastrocnemius muscle flap is not usually harvested as a free flap.
It has tremendous potential for applications in a variety of softtissue defects. Soleus used for wounds over middle third of tibia supplied by b ranches of the popliteal artery trunk, the posterior tibial artery medial, and the peroneal artery proximal. Medial sural artery perforator msap flap is a relatively new flap which is a modification of medial gastrocnemius myocutaneous flap. Comparison between peroneus brevis flap and reverse sural. Medial sural artery perforator free flap msap a medial sural artery perforator free flap is also known as an msap flap. Popliteal fossa reconstruction with a medial sural artery. Medial gastroc flap used for medial and midline defects over proximal third of tibia pedicle supplied by medial sural artery. A sural artery flap was planned to reconstruct the defect with exposed tendons a,b. The medial sural artery perforator msap fasciocutaneous flap was first described by cavadas 2001 as a refinement of the medial gastrocnemius flap. The flap was designed as propeller flap, with large blade 10 cm. This report describes the authors experience and outcomes with this technique. Surgical anatomy of the medial sural artery perforator flap. The range of motion associated with the msapf in comparison to the range associated with the gastrocnemius. And in addition microsurgical techniques can greatly enhance the mobility and length of the flap when used locally.
The flap was rotated 180degrees to reach the wound. Lateral gastroc flap used for lateral defects over proximal third of tibia. Vascular anatomy of the medial sural artery perforator. Split median superficial sural artery perforator mssap. The gastrocnemius muscle is routinely used for soft tissue loss and bone coverage over the proximal onethird of the tibia. The sural arteries inferior muscular arteries are two large branches, lateral and medial, which are distributed to the gastrocnemius, soleus, and plantaris muscles. The donor site was opened and all sutures were removed at 2 weeks.
Medial sural artery perforator flap plastic surgery key. Reverse sural flap for ankle and heel soft tissues. A demonstration of anterolateral thigh flap markings and surgical technique karim bakri, md, brian t. Rather than a distant free flap, it can be used as a local free flap. Video shows the technique for a reverse sural artery flap used to cover a full thickness skin loss over the calcaneal tuberosity from delay in treatment of a severely reverse sural artery flap christopher finkemeier, md on vimeo. The proximally based lateral superficial sural artery flap. Parker peresko the medial sural artery perforator pedicled propellor flap for coverage of middlethird leg defects reference. The main perforators of the medial sural artery are located on a line drawn from the midpoint of the popliteal crease to the midpoint of the medial malleolus. Technique and cadaveric dissection of the scapular flap, including harvest of both soft tissue and bone.
Medial sural artery perforator free flap msap british. Nugent m, endersby s, kennedy m, burns a 2015 early experience with the medial sural artery perforator flap as an alternative to the radial forearm flap for reconstruction in the head and neck. The territory approximates to the medial half of the upper third of the posterior calf, an area of about 8x12 cm. Therefore, to facilitate easier free flap reconstruction of the popliteal fossa, we use a medial sural artery perforator msap free flap with a medial sural vessel as the recipient vessel, as it provides several advantages based on many reports. Medial sural artery perforator flap for head and neck.
Vy flap raised subfascially and advanced into defect. It is a useful alternative to radial forearm flap providing hairless tissue and less donorsite morbidity. Varied uses of the medial sural artery perforator flap. Except in cases of delayed healing, ambulation was started at 5 weeks using an 8mm mcr insole. The main difficulty encountered when raising the msap flap is in obtaining adequate pedicle length during intramuscular dissection. The medial sural artery perforator pedicled propeller flap for coverage of middlethird leg defects. The proximally based sural fasciocutaneous flap is an ideal alternative for reconstruction of soft tissue defects around the knee and on the proximal half of the lower leg.
More recently, the medial sural artery perforator msap flap has been described for such defects, although may necessitate skin grafting of the donor site. All arteries to these flaps are accompanied by venae comitantes. The sural arteries pass directly into the proximal portion of each head of the gastrocnemius muscle. The medial sural medial gastrocnemius perforator flap is a thin flap with a long pedicle.
We aimed to further clarify the vascular anatomy of the medial sural region and establish a safe approach for elevation of this flap. The objective of this study was to determine the pattern of intramuscular course of the msap flap pedicle. Heel coverage with medial plantar artery flap 90 p j m h s vol. The medial sural artery perforator flap is a reliable cutaneous flap that can be used for softtissue reconstruction in the extremities.
We did a retrospective study on 64 patients admitted between 2011 and 20 with posttraumatic moderate size defects of. The medial sural artery perforator msap flap is a fasciocutaneous flap and it was first described by cavadas et al. The skin over the pedicle is incised and split thickness skin grafted to reduce pressure on the nutrient vessels e,f. Supermicrosurgical reconstruction of knee defect using. Medial sural artery perforator flap msap harvesting for head and neck microsurgical reconstruction. We present an advantageous modification of the standard positioning. The success of the reverse sural flap is predicated on the ability to correctly incorporate its vascular supply which is based off the sural nerve and, to a greater extent, the sural artery which provides the true vascular network as it continues into the retromalleolar region and communicates with several anastomoses with the peroneal artery. Our modification leads to a favorable engorgement of the flap pedicle and perforators, without the need of a tourniquet and also improves the surgical field accessibility for the surgeon. Original article the proximally based lateral superficial. In the medial ankle, the primary example of this technique is the sural artery flap, which is based on the work of masquelet et al 6 on skin island flaps and the concept of the neuroskin flap. Sural versus perforator flaps for distal medial leg wounds. The purposes of this article are to fully document the. The medial sural artery perforator free flap was described in 2001 by cavadas et al. Supermicrosurgical reconstruction of knee defect using superior medial genicular perforator as a recipient vessel plastic and aesthetic research is an open acccess journal, which publishes articles on technical and clinical studies related to plastic and aesthetic surgery.
To best preserve the vascularity of this flap, the distal dissection of the pedicle should terminate where. Both radial forearm flap and msap has common benefits, such. Pedicled medial gastrocnemius flaps are the traditional reconstructive approach, but late contractures related to skin grafted muscle may affect knee function. Microsurgery medial sural artery perforator msap flap. After complete flap harvest, the skin island is transposed to the defect c,d. Its advantages include a thin sensate flap, good aesthetic outcomes, and reduced donor site morbidity. The medial sural artery is the source vessel to that muscle as it is to this flap. The reverse sural artery flap rsaf and distal peroneus brevis flap dpbf have gained popularity for lower third leg defects among surgeons. The medial sural artery perforator island flap as a.
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