Anatomical basis and versatile application of the free medial sural artery perforator flap for head and neck reconstruction

Background: The medial sural artery perforator flap is a thin and pliable flap. This study investigated the perforator topography of the medial sural artery perforator flap and its clinical application in head and neck reconstruction. Methods: From January of 2005 to April of 2009, 29 patients with 29 medial gastrocnemius territories were evaluated. Among them, 26 patients underwent head and neck reconstruction using 26 medial sural artery perforator flaps. The number, location, and topographic patterns of the perforators were measured. Results: Flap sizes ranged from 8 × 4 cm to 12 × 14 cm. The mean pedicle length was 12.7 cm, the mean flap thickness was 4.8 mm, the mean number of total perforators was 2.7 ± 1.5 (range, 1 to 5), and the mean number of sizable perforators was 1.6 ± 0.7 (range, 1 to 3). The mean distance from the perforator perpendicular to the popliteal crease was 11.4 ± 2.7 cm. No perforators were found less than 6 cm or more than 18 cm from the popliteal crease. Most sizable perforators (85.4 percent) entered the medial gastrocnemius muscle at a relative distance of one-fifth to one-third of the lower leg length measured from the popliteal crease. All flaps survived, with good functional and aesthetic outcomes, except for one failed case. Conclusion: The medial sural artery perforator flap is a good alternative for head and neck reconstruction, with the advantages of thin and pliable skin, a long and reliable vascular pedicle, straightforward intramuscular dissection, the possibility of chimeric flap design, and minimal donor-site morbidity.