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Year : 2018  |  Volume : 26  |  Issue : 3  |  Page : 110-115

Applicability of medial sural artery perforator flap in patients with diabetes with peripheral arterial disease for complex lower extremity defects

1 Department of Plastic and Reconstructive Surgery, Adnan Menderes University Faculty of Medicine, Aydin, Turkey
2 Private Practice, Izmir, Turkey
Date of Web Publication2-Jul-2018

Correspondence Address:
Heval Selman Ozkan
Department of Plastic and Reconstructive Surgery, Adnan Menderes University Faculty of Medicine 09100 Center, Aydin
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_20_18

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Background : The objective of this study was to determine the applicability and reliability of the medial sural artery perforator (MSAP) flap in patients with diabetes with peripheral arterial disease (PAD) for lower extremity defects and to assess the effects of sacrificing the MSA on distal circulation. Patients and Methods: A radiologic and clinical study has been utilized to assess safety and applicability of MSA perforator flap in diabetics. Five diabetic patients operated for complex lower extremity defects were analyzed and radiological findings from 43 lower limbs of patients with diabetes previously subjected to angiography for PAD were analyzed. Age, duration of diabetes, concomitant complications and occluded vessel type, the diameter of MSA at the popliteal junction, the branching pattern, and the number of sizeable perforators were documented. Results: One total flap loss occurred, one donor side dehiscence occurred. All other flaps survived, and defects were successfully closed. Radiologically MSA was present in unoccluded form in all 43 diabetic patients. At least one sizeable perforator was observed in all patients. There was a statistically significant, but negative, correlation between the size of MSA and the occlusion of the popliteal artery. Conclusions: Diabetes solely is not a contraindication of MSAP flap usage, as MSA is not affected by PAD. However, perigenicular collateral hypertrophy through arteriogenesis can be an issue in patients with severe occlusion at the level of the popliteal artery, since MSA enlarges. Cases of MSA hypertrophy in the presence of PAD constitute a high risk; therefore, selection of another flap is recommended.

Keywords: Complex lower extremity defects, medial sural artery, microsurgery, perforator flaps, reconstruction

How to cite this article:
Ozkan HS, Irkoren S, Aydin OE. Applicability of medial sural artery perforator flap in patients with diabetes with peripheral arterial disease for complex lower extremity defects . Turk J Plast Surg 2018;26:110-5

How to cite this URL:
Ozkan HS, Irkoren S, Aydin OE. Applicability of medial sural artery perforator flap in patients with diabetes with peripheral arterial disease for complex lower extremity defects . Turk J Plast Surg [serial online] 2018 [cited 2023 May 31];26:110-5. Available from: http://www.turkjplastsurg.org/text.asp?2018/26/3/110/235787

  Introduction Top

Different perforator flaps have been added to the armamentarium of reconstructive surgeons within the last two decades. The medial sural artery perforator (MSAP) flap is a relatively new approach derived from the modification of the medial gastrocnemius mucocutaneous flap. [1] The posterior medial calf region was first investigated as a possible free flap donor site by Taylor and Daniel in 1973. [2] Later, topographic anatomy of this region was described by Montegut and Allen, [3] and the first clinical cases were presented by Cavadas et al. [4] in 2001. Since then, radiological and anatomical studies have been performed to elucidate the characteristic features of the MSAP flap.

Both the radial forearm and the MSAP flaps have common benefits such as thinness and long pedicle and pliability; however, the MSAP flap has lower donor site morbidity. Thus, the MSAP flap gained popularity during the last decade. [5] However, the main drawbacks that prevented this flap from gaining further acceptance were the need for extensive intramuscular dissection and variations in the dimension of the MSA and its perforators. In the current literature, few reports addressed the intramuscular anatomy of MSA and its perforators, as there were limited clinical series and cadaveric and radiological studies. Concerning the lack of clearly described anatomy, microsurgeons have been avoiding using the MSAP flap. [6],[7]

The use of flaps in diabetic patients is a challenging process. Peripheral arterial disease (PAD) is frequently associated with diabetes, and endovascular procedures can be used for its treatment. [8] Despite being associated with high mortality and morbidity, PAD remains underdiagnosed and undertreated in certain cases. There is no study in the literature regarding either the reliability of the MSAP flap in the presence of PAD or the subsequent effects of sacrificing MSA in distal circulation. Therefore, we retrospectively analyzed the angiographic images of 43 patients with diabetes with regard to the applicability and reliability of MSA, through MR angiography with contrast, its anatomy, and the number and location of its perforators. Furthermore, five clinical cases have been retrospectively evaluated regarding flap survival and donor complications. We discussed the potential advantages and disadvantages of using this particular flap and discussed some drawbacks, such as the deterioration of limb vascularization and the predisposition of future ulcer formation, especially in patients with diabetes.

  Patients and Methods Top

Radiological data of 43 lower limbs obtained from the previous angiographic studies were analyzed. All patients were diabetic and had undergone angiography and endovascular procedures for PAD. All patients had undergone previous magnetic resonance angiography (MRA) before conventional angiography, which indicated some form of distal occlusion or narrowing of arteries in the lower extremity.

Age, duration of diabetes, concomitant complications and occluded vessel type, the diameter of MSA at the popliteal junction, the branching pattern, and the number of sizeable perforators were documented. The classification system proposed by Dusseldorp et al. [9] was used for evaluating intramuscular branching. According to the branching pattern, intramuscular anatomy was divided into groups. Type I exhibited a singular main branch; Type II demonstrated a double branching pattern with high take-off (IIA) occurring superior to the tibial plateau or low take-off (IIB) occurring inferior to the tibial plateau; and Type III consisted of three or more branches.

MSAP flaps were used in 5 patients for complex lower extremity reconstruction and results were retrospectively evaluated. Demographic data, flap failure, donor complications, and hospitalization were evaluated.

Statistical analysis

The measurements are reported as mean ± standard deviation (SD) whenever applicable. Compliance of the quantitative data with the normal distribution was analyzed by Kolmogorov-Smirnov test. An independent-sample t-test was used in the comparison of normally distributed data, and descriptive statistics are expressed as mean ± SD. The Mann-Whitney U-test was used in nonnormally distributed data, and descriptive statistics are shown in median format (25 th -75 th percentiles). P < 0.05 was considered as statistically significant. The level of agreement between the occluded vessel and the MSA diameter was analyzed using intraclass correlation.

  Results Top

[Table 1] shows the data obtained during the analysis. The 43 patients evaluated were 63.86 ± 9.61 years old (29 male; 14 female). The mean duration of the established diabetes was 15 years. All patients were on insulin treatment and four patients were also on hemodialysis for renal insufficiency. MSA was present in all 43 patients. The external diameter of the artery at the level of the popliteal junction was 2.41 ± 0.65 mm. At least one sizeable perforator was observed in every patient, as shown in [Figure 1]. The number of perforators was 2 ± 0.75. The angiography revealed posterior tibial artery occlusion in 27 patients, anterior tibial artery occlusion in 25, peroneal artery occlusion in 18, and popliteal artery occlusion in 9 patients. The vessels that obstructed more than 50% of the lumen diameter were considered, but smaller narrowing's or plaques, which did not require any intervention such as balloon angioplasty or stent placement, were excluded from the statistical analysis [Table 2]. The artery diameter was measured at 1.5 mm or less in seven patients and 3 mm or larger in 12 patients [Figure 2]. There was a statistically significant correlation between the occlusion of the popliteal artery and the size of MSA [Table 2]. According to the angiographic findings, Type I [Figure 3], a singular main branch in 44.2%, Type IIA in 27.9%, Type IIB in 16.3%, and Type III in 11.6% were observed [Table 3] for all patients. Preoperative angiographies have been done and patency of recipient vessels confirmed. MSA and perforators have also been evaluated and checked in the recipient extremity. One but all flaps survived. Flap loss was due to venous failure which cannot be salvaged with reoperation and leeching. Patient had negative pressure wound dressings, serial debridement, and final split thickness grafting. Wound dehiscence in one patient in the recipient area and in another patient in donor area was also grafted [Table 4] and [Figure 4], [Figure 5] [Figure 6]
Figure 1: Examples of medial sural artery and its perforator in conventional angiography. (a) Perforator emerging from the artery (arrow). (b) Medial sural artery (star) and sizeable perforator (arrow)

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Figure 2: Angiography on the left shows a small diameter medial sural artery (<1.5 mm). The right image shows marked hypertrophy of medial sural artery (>3 mm) due to total occlusion at the popliteal level. In patients with severely occluded distal vessels, hypertrophic medial sural artery can still serve as important collateral function

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Figure 3: Examples of different branching patterns of medial sural artery. Type I exhibits a singular main branch. Type II demonstrates a double branching pattern with high take.off (IIA) occurring superior to the tibial
plateau or low take.off (IIB) occurring inferior to the plateau. Type III consists of three or more branches

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Figure 4: Preoperative, intraoperative, and early-late postoperative views of a diabetic patient's dorsal foot defect due to motor vehicle accident

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Figure 5: Preoperative early and late postoperative views of a diabetic patient's heel defect due to diabetic ulcer

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Figure 6: Preoperative and early postoperative views of a diabetic patient's defect due to motor vehicle accident

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Table 1: Mean and standard deviations. Mean number of perforators and diameter of medial sural artery. Means compared with the paired samples t.tests (n=43)

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Table 2: Occluded vessels in relation to medial sural artery diameter. The occlusion of popliteal artery and diameter size of the medial sural artery are strongly correlated

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Table 3: Distribution of branching patterns of medial sural artery (n=43)

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Table 4: Demographic data, defect site, donor, and flap complications

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  Discussion Top

Perforator flaps are usually the first choice of treatment in modern free flap surgery with well-appreciated features such as reduced donor site morbidity and increased flap flexibility and versatility. Saint-Cyr et al. [10] described perforasome as a vascular territory supplied by a specific perforator that carries a highly variable and complex multidirectional flow pattern. Direct and indirect linking vessels play a critical part in perforator flap perfusion, and every clinically significant perforator has the potential to become either a pedicled or a free perforator flap. Through the efforts of several innovative contributors, many different flap sites have been added to the armamentarium of the reconstructive microsurgeon.

The MSAP flap was popularized in the last decade as a possible alternative free flap choice, especially in the head and neck and upper extremity reconstructions. This is a relatively new and promising perforator flap with many advantages: (1) it is pliable and has a thin skin island; (2) it has a long and reliable pedicle; (3) it does not sacrifice any major artery; and (4) it has a lower donor side morbidity. [11] Further, sural nerve and plantaris tendon grafts can also be harvested from the same incision. [12] Although it requires a tedious dissection or it may present anatomical variations, the overall success rate has been documented as 98%, which is comparable to the alternative anterolateral thigh and radial forearm flaps. [9]

There are studies in the literature regarding the anatomy of the source vessel and the perforator of the MSAP flap. [13] MSA originates from the popliteal artery. After running for a distance of 3-6 cm, the artery typically divides into two branches (medial and lateral) within the substance of the medial gastrocnemius muscle. Kim et al. [14] reported 10% of anatomical variations in MSA. In the present study, we observed MSA with consistent anatomical features in all 43 patients. Similar to the internal thoracic artery, the MSA is disease free in patients with arterial disease, which functions as an important collateral. [15],[16]

Perforator size and number have also been subject to many clinical and anatomic studies. Generally, the number of sizeable perforators ranges from one to four, with a mean of two. [5] In a study by Wong et al., [17] an average of 4.4 perforators was found to pierce the medial gastrocnemius muscle in each lower limb. In another report, a major MSAP was present in 98% of dissection specimens. [9] In the present study, we found at least one sizeable perforator branch in all 43 patients, but could not conclude whether the perforator was muscular or cutaneous, based on the radiologic views. Nevertheless, we determined the number of sizeable perforators as 2 ± 0.75. This finding suggests that there exists at least one usable perforator even in patients with diabetes with a high degree of PAD.

Intramuscular branching patterns were studied in an article by Dusseldorp et al. [9] They proposed a classification system and found 31% of Type I, 59% of Type II, and 10% of Type III. In our case, we identified Type I as more prevalent (44.2%) than the others (Type IIA 27.9, Type IIB 16.3%, and Type III 11.6%).

In the previous studies, the arterial diameter of the vascular pedicle was measured between 1 and 2 mm. Dusseldorp et al. [9] showed that the internal diameter of MSA at the level of the tibial plateau was 2.3 mm (±0.4). The diameter of the sural artery at the level of the popliteal entrance was measured as 2.41 ± 0.65 in this study. This result was in concordance not only with the current literature, but also, and more importantly, with patients with severe popliteal occlusion, as there was a statistically significant increase in the diameter of MSA. This may indicate that MSA may function as important perigenicular collateral in distal circulation. Therefore, it can be postulated that, in patients with severe distal occlusion, the sacrifice of important collateral may further deteriorate distal perfusion and may predispose the patient to future ulcer formation. Further, in the literature, there are a limited number of clinical series and case reports showing that MSA is a valuable option for distal bypass operations. [15],[16] On the basis of these reports, the preservation of MSA may have an important role in patients with diabetes with severe distal PAD for maintaining distal circulation and for possible bypass surgery.

The venous anatomy has also been studied. The flap is drained by two vena comitantes of the source vessel, but inclusion of a superficial vein or vena saphena parva can be utilized to augment drainage. Further, encountering venous varicosities during dissection causes prolonged intramuscular dissection and an abnormal venous flow of the flap and may be accepted as a relative contraindication. Some authors have suggested that a large superficial vein encountered during dissection can be included in the flap to enhance venous outflow. [18] However, our clinical experience with 12 cases showed that all our cases had good-sized accompanying veins with good outflow, which were available for microanostomosis. [19] We believe that this maneuver would not be necessary, as adequate drainage may be possible through vena comitantes.

In diabetic patients, complex lower extremity and diabetic foot wound reconstruction with free flaps have certain difficulties. Major recipient vessels are mostly calcific and inappropriate for anastomosis. To overcome this obstacle, especially in the last period, small collateral branches and perforators with adequate flow which are generally disease free are used as recipients. Increased use of perforator flaps, super microsurgical techniques, and angiosome concept propose more predictable results in this highly challenging population. Traditional flaps such as latissimus dorsi, gracilis, tensor facia lata, and lateral arm are used. Anterolateral thigh flap, thoracodorsal perforator flap, and superficial circumflex iliac perforator flaps emerged as alternatives, especially in the last decade. [20] In this study; we showed that it is also possible to use MSAP as a new alternative to these options.

The median flap dimensions were between 6 cm × 4 cm and 8 cm × 10 cm. Pedicle length ranged from 8 to 14 cm. All of the donor sites closed primarily except one which was a large defect with 8 cm width. In this case, split-thickness skin graft was used for coverage.

The planning and execution of the perforator flaps can be facilitated by preoperative radiologic studies. The preoperative outlining of anatomical features of MSA and its perforators can avoid complications and shorten the operation time. For evaluating the anatomy and mapping of the perforator vessels, computed tomography angiography (CTA) has recently emerged as an excellent technique. The effectiveness of this modality for the preoperative identification of anterolateral thigh flap and deep inferior epigastric artery perforator flaps has been shown to significantly shorten the operation time. [21],[22],[23] Further, recently, CTA and MRA have been employed in MSAP planning and we routinely use it in our practice. We strongly recommend preoperative MRA or CTA, especially in diabetic patients, as it provides 3-fold benefits in this patient group: first, the location and reliability of the dominant perforator and the anatomy of the source vessel can be assessed; second, accompanying vascular disease and the condition of the perigenicular perforators can be examined; and third, a suitable extremity can be chosen.

  Conclusion Top

Diabetes solely is not a contraindication of MSAP flap usage. In patients with severe occlusion at the level of the popliteal artery, an enlarged MSA may indicate perigenicular collateral hypertrophy. The role of MSA in these patients may be crucial and sacrifice may predispose the patient to the likelihood of future ulcer formation. A routine CTA is recommended before choosing this flap, especially in patients with diabetes with advanced age, as it may be beneficial in several ways. The condition of the peripheral arteries and the vascular disease can be determined. The diameter and availability of MSA can be assessed, if accepted as suitable, and a dominant perforator can be identified before flap elevation. In cases associated with PAD and the hypertrophy of MSA, clinicians are advised to choose another flap in this high-risk patient group.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Hallock GG. Anatomic basis of the gastrocnemius perforator-based flap. Ann Plast Surg 2001;47:517-22.  Back to cited text no. 1
Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast Reconstr Surg 1975;56:243-53.  Back to cited text no. 2
Montegut WJ, Allen RJ. Sural Artery Perforator Flap as an Alternative for the Gastrocnemius Myocutaneous Flap. Presented at: The 90 th Annual Scientific Assembly of the Southern Medical Association; November 20-24, 1996; Baltimore, MD; 1996.  Back to cited text no. 3
Cavadas PC, Sanz-Giménez-Rico JR, Gutierrez-de la Cámara A, Navarro-Monzonís A, Soler-Nomdedeu S, Martínez-Soriano F, et al. The medial sural artery perforator free flap. Plast Reconstr Surg 2001;108:1609-15.  Back to cited text no. 4
Kao HK, Chang KP, Chen YA, Wei FC, Cheng MH. Anatomical basis and versatile application of the free medial sural artery perforator flap for head and neck reconstruction. Plast Reconstr Surg 2010;125:1135-45.  Back to cited text no. 5
Kosutic D, Pejkovic B, Anderhuber F, Vadnjal-Donlagic S, Zic R, Gulic R, et al. Complete mapping of lateral and medial sural artery perforators: Anatomical study with duplex-Doppler ultrasound correlation. J Plast Reconstr Aesthet Surg 2012;65:1530-6.  Back to cited text no. 6
Altaf FM. The anatomical basis of the medial sural artery perforator flaps. West Indian Med J 2011;60:622-7.  Back to cited text no. 7
Hinchliffe RJ, Brownrigg JR, Apelqvist J, Boyko EJ, Fitridge R, Mills JL, et al. IWGDF guidance on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes. Diabetes Metab Res Rev 2016;32 Suppl 1:37-44.  Back to cited text no. 8
Dusseldorp JR, Pham QJ, Ngo Q, Gianoutsos M, Moradi P. Vascular anatomy of the medial sural artery perforator flap: A new classification system of intra-muscular branching patterns. J Plast Reconstr Aesthet Surg 2014;67:1267-75.  Back to cited text no. 9
Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: Vascular anatomy and clinical implications. Plast Reconstr Surg 2009;124:1529-44.  Back to cited text no. 10
Xie XT, Chai YM. Medial sural artery perforator flap. Ann Plast Surg 2012;68:105-10.  Back to cited text no. 11
Lin CH, Lin CH, Lin YT, Hsu CC, Ng TW, Wei FC, et al. The medial sural artery perforator flap: A versatile donor site for hand reconstruction. J Trauma 2011;70:736-43.  Back to cited text no. 12
Thione A, Valdatta L, Buoro M, Tuinder S, Mortarino C, Putz R, et al. The medial sural artery perforators: Anatomic basis for a surgical plan. Ann Plast Surg 2004;53:250-5.  Back to cited text no. 13
Kim HH, Jeong JH, Seul JH, Cho BC. New design and identification of the medial sural perforator flap: An anatomical study and its clinical applications. Plast Reconstr Surg 2006;117:1609-18.  Back to cited text no. 14
De Luccia N, Sassaki P, Durazzo A, Sandri G, Kikuchi M, Hirata C, et al. Limb salvage using bypass to the perigeniculate arteries. Eur J Vasc Endovasc Surg 2011;42:374-8.  Back to cited text no. 15
Matsumoto H, Yamamoto E, Kamiya C, Miura E, Kitaoka T, Suzuki J, et al. Sural artery bypass in Buerger's disease: Report of a case. Ann Vasc Dis 2012;5:199-203.  Back to cited text no. 16
Wong MZ, Wong CH, Tan BK, Chew KY, Tay SC. Surgical anatomy of the medial sural artery perforator flap. J Reconstr Microsurg 2012;28:555-60.  Back to cited text no. 17
Ranson J, Rosich-Medina A, Amin K, Kosutic D. Medial sural artery perforator flap: Using the superficial venous system to minimize flap congestion. Arch Plast Surg 2015;42:813-5.  Back to cited text no. 18
Özkan HS, Ýrkören S, Aydýn OE, Eryýlmaz A, Karaca H. Medial sural artery perforator flap in head and neck reconstruction. Eur Arch Otorhinolaryngol 2016;273:4431-6.  Back to cited text no. 19
Suh HS, Oh TS, Lee HS, Lee SH, Cho YP, Park JR, et al. A new approach for reconstruction of diabetic foot wounds using the angiosome and supermicrosurgery concept. Plast Reconstr Surg 2016;138:702e-9e.  Back to cited text no. 20
Rozen WM, Phillips TJ, Ashton MW, Stella DL, Gibson RN, Taylor GI, et al. Preoperative imaging for DIEA perforator flaps: A comparative study of computed tomographic angiography and Doppler ultrasound. Plast Reconstr Surg 2008;121:9-16.  Back to cited text no. 21
Chen SY, Lin WC, Deng SC, Chang SC, Fu JP, Dai NT, et al. Assessment of the perforators of anterolateral thigh flaps using 64-section multidetector computed tomographic angiography in head and neck cancer reconstruction. Eur J Surg Oncol 2010;36:1004-11.  Back to cited text no. 22
He Y, Jin SF, Zhang ZY, Feng SQ, Zhang CP, Zhang YX, et al. A prospective study of medial sural artery perforator flap with computed tomographic angiography-aided design in tongue reconstruction. J Oral Maxillofac Surg 2014;72:2351-65.  Back to cited text no. 23


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2], [Table 3], [Table 4]

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