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Anatomical basis of the medial sural

artery perforator flap in Asians
Authors: Hideki Okamoto a; Isato Sekiya a; Jun Mizutani a;
Takanobu Otsuka a
Affiliation:a Department of Orthopaedic Surgery, Nagoya City University
Medical School, Nagoya City, Aichi, Japan

DOI: 10.1080/02844310601159972
Publication Frequency: 6 issues per year
Published in: Scandinavian Journal of Plastic and
Reconstructive Surgery and Hand Surgery, Volume 41,
Issue 3 2007 , pages 125 - 129
First Published: 2007

Abstract
Forty-four lower limbs preserved in formaldehyde from cadavers of adult Asians were used.
In all specimens 1-5 perforating branches from the medial sural artery were found. No
perforators were found higher than 5 cm or lower than 17.5 cm from the popliteal crease. In
the most common place (16/44, 36%) in which 2 perforators were found, the proximal one
was a mean of 9.6 cm away from the popliteal crease, and the distant one 12.8 cm. All
perforators were in an area between 0.5 cm and 4.5 cm from the midline of the
gastrocnemius muscles. Because of the differences in the length of the muscle belly, the
distribution of perforators may differ between white people and Asians. It should be safe to
raise this flap in Asians, because the anatomical comparison of the perforators of the medial
sural artery between Asians and white people is now clear.
Keywords: Perforator flap; medial sural artery; Asian; anatomy

Introduction
Soft tissue coverage of the upper and lower leg has always been a challenge for the surgeon. The medial or lateral
gastrocnemius muscle or musculocutaneous flap has been the gold standard for more than 20 years.

The principle that the skin overlying certain muscles can be transferred reliably with that muscle as a
musculocutaneous flap is well recognised, and this is made possible by the presence of musculocutaneous
perforators. If those perforators were carefully separated from the muscle, all muscle could be excluded from the
skin flap and function would be preserved 1-3.

Recently, several perforator flaps have been described, and covering a tissue defect in a distal limb generally
requires a relatively thin flap to provide the reconstructive site with aesthetic and functional refinement in a single
stage. Thin perforator flaps from the extremity or back are useful for resurfacing shallow defects of distal limbs 4, 5.

The medial sural artery perforator flap was first described by Cavadas et al. in 2001 6. This flap uses a new concept
that involves a single musculocutaneous perforator to supply the whole skin flap, and is used for soft tissue

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coverage of the leg 6-8. However, there have been few anatomical studies of this flap in the west 6, 9, 10.

There are many differences in physique between white people and Asians. Asians tend to be shorter, and have a
lower skeletal muscle mass than white people 11, 12. Asian operations based upon white anatomical data may run
the risk of injury to important perforators, or the flap design may fail. The purpose of this investigation was to clarify
the anatomy of the perforator of medial sural artery and to facilitate the sculpturing of the flap in Asian patients.

Material and methods

Forty-four lower limbs preserved in formaldehyde from cadavers of adult Asians were used for the study. The skin,
subcutaneous fat, and deep fascia were incised along the posterior midline following the cleft between the medial
and lateral heads of the gastrocnemius muscles. Opposing skin flaps were then retracted in a subfascial plane that
essentially was traversed only by deep fascial perforators. The number and sites of perforating vessels were
recorded, expressed in cm, from the popliteal crease and from the posterior midline. Only perforating vessels that
were clearly coming from the medial and lateral sural arteries (not from the superficial sural arteries) were recorded.
The length of each pedicle and the diameter of each perforator were measured.

Results
Perforating branches from the medial sural artery were found in all 44 specimens, the mean being 2, range 1-5
(Table I). No perforators were found more than 5 cm above or 17.5 cm below the popliteal crease (Figure 1). The
musculocutaneous perforating branches were located a mean (SD) of 11.6 (2.7) cm from the popliteal crease.

Figure 1. . Distribution of perforators according to distance from popliteal crease.

Table I. Number (%) of perforators.

Number of perforators Number (%) of cases

1 10 (23)

2 16 (36)

3 10 (23)
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4 6 (14)

5 2 (5)

All perforators gathered in an area between 0.5 cm and 4.5 cm from the midline of the gastrocnemius muscles
(Figure 2), and 97 of 106 arose between 0.5 cm and 3 cm from the midline. However, several perforators that arose
near the midline traversed a variable distance toward the skin over the midline of the gastrocnemius muscles.

Figure 2. . Distribution of perforators according to distance from posterior midline

The external diameter of the vein in the perforating bundle was slightly larger (mean 0.9, range 0.2-2.0 mm) than the
artery (mean 0.8, range 0.2-2.0 mm).

The mean external diameter of the medial sural artery after it had separated from the popliteal artery was 2.5 mm
(range 2.0-3.5). The mean length of pedicle from the bifurcation of the medial sural artery to the skin was 14.6 cm
(range 7.7-20.7).

Discussion
Although the medial gastrocnemius musculocutaneous flap has been used extensively as a pedicled flap for soft
tissue coverage of the proximal third of the tibia and anterior and medial aspect of the knee, it is bulky because of the
thickness of the muscle involved. This may sometimes be a disadvantage, and the removal of the medial
gastrocnemius muscle results in a weakening of the leg. The morbidity caused by sacrifice of the medial
gastrocnemius muscle has been reported to account for about a 10% loss of jumping power 6. The bulkiness and
donor-site morbidity often preclude its use as a free tissue transfer for resurfacing shallow defects in a distal limb.

The concept of perforator vasculature to circulation in flaps was first suggested by Fujino in the 1960s 13. McCraw
and Dibbell maintained that the skin, as a rule, is supplied by the perforating vessels that arise perpendicularly from
the subjacent muscle and that vessels branch in the perifascial layer to form the plexus around the fascial layer 14.
Perforator flaps were later developed and became more popular with Koshima et al. 1-3 and Kroll and Rosenfield
15.

The anatomy of the posterior calf region has been described previously 16, 17. The blood supply to its skin is

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derived from two sources, one the perforating artery that arises from the popliteal and posterior tibial arteries, and
the other the axial artery that originates from the popliteal, sural, and geniculate arteries that run either above or
below the deep fascia 17. However, less attention has been paid to the distribution of the musculocutaneous
perforating branches from the medial and lateral sural arteries. Cavadas et al. 6 first described the anatomical basis
of the perforators from the medial and lateral sural arteries, and a new type of thin skin flap from the medial aspect of
the upper calf: the medial sural artery perforator flap. Hallock did an anatomical study of the musculocutaneous
perforators from the gastrocnemius muscles into the posterior calf skin, and emphasised the potential for raising a
flap based on a gastrocnemius perforator without the need to lose any muscle 9. Thione et al. made an anatomical
study of the medial sural artery perforator flap on 20 lower limbs in white people 10. However, we know of scarcely
any anatomical study of the perforators of the medial sural artery in Asians. There are many differences of physique
between whites and Asians. Asians tend to have shorter and thicker legs 11, and the design of the flap and the place
of the perforator are important in the reconstruction. If Asians are operated on based on white anatomical data, there
is a possibility that important perforators may be injured or the design of the flap may fail.

With this anatomical study, we have tried to add information to simplify surgical treatment with this flap for Asian
patients. Perforators were found in the distal half of the medial gastrocnemius muscle, 5.5 to 17.2 cm (mean 11.6)
from the popliteal crease and 0.5 to 4.5 cm from the posterior midline (Figure 3). Cavadas et al. found them 8.5 to 19
cm (mean 14.2) from the popliteal crease 6. This obvious difference was solely because of the length of the leg and
muscle belly. The mean distance from the popliteal crease to the distal limit of the gastrocnemius medialis muscles
was 18.6 cm (15.0-22.2) and 22.8 cm (20-25) in our study of Asians and that of Cavadas et al., respectively, and the
ratio of the length of the gastrocnemius muscle to the length of the leg differed significantly between our study and
that of Cavadas et al. (p<0.01, data not shown). Because of these differences the distribution of perforators may be
different between white people and Asians. The mean external diameter of the perforator of the medial sural artery
was 0.8 mm (0.2-2.0) in our study, which was almost the same as the figure given by Cavadas et al. (<1.0) and
Thione et al. (0.5 mm; 0.3-0.8), respectively. The number of perforators ranged from 1 to 5 in our study, and 80% of
the specimens had 1 to 3, as described elsewhere 6, 9, 10.

Figure 3. . Photograph of distribution of perforators of medial sural artery. PC
=

popliteal crease.
If a long vascular pedicle is needed, it is possible to dissect near the division of medial sural artery. The length of
pedicle in our study was 14.6 cm (range 7.7-20.7), which was slightly longer than that of Cavadas et al. (10-17 cm)

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and Thione et al. (10-17 cm; mean 11.75). The risk of muscle ischaemia after the sacrifice of even an entire medial
sural artery should be remote, because several sources of secondary vascular pedicles have been described, a
proximal secondary pedicle 18 as shown in Figure 4, vascular connections with the lateral gastrocnemius muscle
19, and branches from the posterior tibial and peroneal arteries. The mean diameter of the medial sural artery after
the bifurcation (2.5 mm) was of such dimensions as to allow easy microanastomosis with most of the recipient
vessels in the body. The medial sural artery perforator flap is therefore useful for soft tissue coverage because it
maintains the function of the medial gastrocnemius muscle, with a thick enough and long enough pedicle.

Figure 4. . Two medial sural arteries, one proximal (*) and the other distal (**). Each
medial sural artery had perforators (***). +
=
superficial sural artery; +
+
=
lateral sural
artery; +
+
+
=
perforators of lateral sural artery.
Safe raising of this flap in Asians should now be feasible, because the anatomical comparison of the perforators of
the medial sural artery between Asians and white people have been clarified.

Acknowledgements
We thank the Furoukai (Nagoya, Japan) for providing the 44 cadavers for this study.

References
1. Koshima, I. and Soeda, S. (1989) Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast
Surg 42 , pp. 645-648. [ crossref ]
2. Koshima, I., Moriguchi, T., Soeda, S., Kawata, S., Ohta, S. and Ikeda, A. (1993) The gluteal perforator-based flap
for repair of sacral pressure sores. Plast Reconstr Surg 91 , pp. 678-683.
3. Koshima, I., Inagawa, K., Urushibara, K. and Moriguchi, T. (1998) Paraumbilical perforator flap without deep
inferior epigastric vessels. Plast Reconstr Surg 102 , pp. 1052-1057. [ crossref ]
4. Angrigiani, C., Grilli, D. and Siebert, J. (1995) Latissimus dorsi musculocutaneous flap without muscle. Plast
Reconstr Surg 96 , pp. 1608-1614.
5. Wei, FC, Jain, V., Celik, N., Chen, H., Chuang, DC and Lin, C. (2002) Have we found an ideal soft tissue flap? An
125.17.162.198:2096/smpp/section?co… 5/8
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experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 109 , pp. 2219-2230. [ crossref ]
6. Cavadas, PC, Sanz-Gimenez-Rico, JR, Camara, AG, Navarro-Monzonis, A., Soler-Nomdedeu, S. and Martinez-
Soriano, F. (2001) The medial sural artery perforator free flap. Plast Reconstr Surg 108 , pp. 1609-1615. [ crossref ]
7. Chen, SL, Chen, TM and Lee, CH. (2005) Free medial sural artery perforator flap resurfacing distal limb defects. J
Trauma 58 , pp. 323-327.
8. Umemoto, Y., Adachi, Y. and Ebisawa, K. (2005) The sural artery perforator flap for coverage of defects of the
knee and tibia. Scand J Plast Reconstr Surg Hand Surg 39 , pp. 209-212. [informaworld]
9. Hallock, GG. (2001) Anatomic basis of the gastrocnemius perforator-based flap. Ann Plast Surg 47 , pp. 517-522. [
crossref ]
10. Thione, A., Valdatta, L., Buoro, M., Tuinder, S., Mortarino, C. and Putz, R. (2004) The medial sural artery
perforators: anatomic basis for a surgical plan. Ann Plast Surg 53 , pp. 250-255. [ crossref ]
11. Kim, IG, Hwang, SH, Lew, JM and Lee, HY. (2000) Endoscope-assisted calf reduction in Orientals. Plast
Reconstr Surg 106 , pp. 713-718. [ crossref ]
12. Rush, E., Plank, L. and Chandu, V. (2004) Body size, body composition, and fat distribution: a comparison of
young New Zealand men of European, Pacific Island, and Asian Indian ethnicities. N Z Med J 117 , p. U1203.
13. Fujino, T. (1967) Contribution of the axial and perforator vasculature to circulation in flaps. Plast Reconstr Surg 39
, pp. 125-137. [ crossref ]
14. McCraw, JB and Dibbell, DG. (1977) Experimental definition of independent myocutaneous vascular territories.
Plast Reconstr Surg 60 , pp. 212-220.
15. Kroll, SS and Rosenfield, L. (1988) Perforator-based flaps for low posterior midline defects. Plast Reconstr Surg
81 , pp. 561-566.
16. Taylor, GI and Pan, WR. (1998) Angiosomes of the leg: anatomic study and clinical implications. Plast Reconstr
Surg 102 , pp. 599-616. [ crossref ]
17. Walton, RL and Bunkis, J. (1984) The posterior calf fasciocutaneous free flap. Plast Reconstr Surg 74 , pp. 76-85.
[ crossref ]
18. Potparic, Z., Colen, LB, Sucur, D., Carwell, GR and Carraway, JH. (1995) The gastrocnemius muscle as a free-
flap donor site. Plast Reconstr Surg 95 , pp. 1245-1252.
19. Tsetsonis, CH, Kaxira, OS, Laoulakos, DH, Spiliopoulou, CA and Koutselinis, AS. (2000) The arterial
communication between the gastrocnemius muscle heads: a fresh cadaveric study and clinical implications. Plast
Reconstr Surg 105 , pp. 94-98. [ crossref ]

List of Figures

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Figure 1. . Distribution of perforators according to distance from popliteal crease.

Figure 2. . Distribution of perforators according to distance from posterior midline

Figure 3. . Photograph of distribution of perforators of medial sural artery. PC
=

popliteal crease.

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Figure 4. . Two medial sural arteries, one proximal (*) and the other distal (**). Each
medial sural artery had perforators (***). +
=
superficial sural artery; +
+
=
lateral sural
artery; +
+
+
=
perforators of lateral sural artery.

List of Tables
Table I. Number (%) of perforators.

Number of perforators Number (%) of cases

1 10 (23)

2 16 (36)

3 10 (23)

4 6 (14)

5 2 (5)

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