The medial sural artery perforator flap: translation from anatomic study to clinical application for lower extremity reconstruction

Background: Perforator flaps have become a popular option for soft tissue reconstruction due to their ability to provide pliable and durable coverage without the donor site morbidities of more traditional “workhorse” pedicled and free musculocutaneous flaps. Over the last several years, the medial sural artery perforator flap has been increasingly employed as a reconstructive option in both head and neck surgery and for coverage of extremity defects. The goal of this paper is to review the anatomy of the medial sural artery flap through cadaveric study and highlight the utility of this reconstructive option over other more traditional options including the anterolateral thigh flap and radial forearm free flap through the treatment of several extremity defects at our institution in both pedicled and free tissue transfer. Methods: Four cadaveric lower extremities were dissected and the pedicle of the medial sural artery flap evaluated. Three clinical cases involving lower extremity reconstruction with the medial sural artery perforator flap at our institution were reviewed. Results: Four cadaveric specimens with medial sural artery perforator (MSAP) flap dissected were evaluated for pedicle length (11–16.5 cm) and diameter (2–5 mm). Three clinical cases are described highlighting the utility of this reconstructive method. Conclusions: Through our clinical implementation and cadaveric dissection, the MSAP flap was demonstrated to be a thin and pliable perforator option for reconstruction of the lower extremity in both pedicled and free fashion without significant sacrifice of pedicle length or donor skin paddle diameter. Advantages over more traditional “workhorse” flaps are highlighted. Level of evidence: Level IV, therapeutic.