The medial sural artery perforator free flap.

The medial sural artery supplies the medial gastrocnemius muscle and sends perforating branches to the skin. The possible use of these musculocutaneous perforators as the source of a perforator-based free flap was investigated in cadavers. Ten legs were dissected, and the topography of significant perforating musculocutaneous vessels on both the medial and the lateral gastrocnemius muscles was recorded. A mean of 2.2 perforators (range, 1 to 4) was noted over the medial gastrocnemius muscle, whereas in only 20 percent of the specimens was a perforator of moderate size noted over the lateral gastrocnemius muscle. The perforating vessels from the medial sural artery clustered about 9 to 18 cm from the popliteal crease. When two perforators were present (the most frequent case), the perforators were located at a mean of 11.8 cm (range, 8.5 to 15 cm) and 17 cm (range, 15 to 19 cm) from the popliteal crease. A series of six successful clinical cases is reported, including five free flaps and one pedicled flap for ipsilateral lower-leg and foot reconstruction. The dissection is somewhat tedious, but the vascular pedicle can be considerably long and of suitable caliber. Donor-site morbidity was minimal because the muscle was not included in the flap. Although the present series is short, it seems that the medial sural artery perforator flap can be a useful flap for free and pedicled transfer in lower-limb reconstruction.     

The preexpanded radial free flap

The experimental basis for free-flap preexpansion is briefly discussed. Two cases are reported in which the ankle/heel area was resurfaced and reinnervated with a preexpanded radial flap. The size of the first flap was half the surface area of the entire forearm. Direct closure of the secondary defect was possible with a single scar and without functional deficit in both cases. The flaps were well-vascularized and consisted of the sensory distribution of one peripheral nerve division, which was anastomosed in the recipient site. This preparation proved to be finer and to have better contouring capacity and skin quality than existing alternatives. It is clear that hydraulic tissue expansion facilitates great additional use of the radial flap as well as a range of other modified free flaps when there is time available for the flap to be developed prior to transfer.