Vascular anatomy of the medial sural artery perforator flap: A new classification system of intra-muscular branching patterns

Vascular anatomy of the medial sural arteryperforator flap: A new classification systemof intra-muscular branching patterns

Joseph R. Dusseldorp a,*, Quy J. Pham b, Quan Ngo c,Mark Gianoutsos a, Pouria Moradi a

a Department of Plastic and Reconstructive Surgery, Prince of Wales Hospital, Sydney, Australiab University of Sydney, Sydney, Australiac Department of Plastic and Reconstructive Surgery, Liverpool Hospital, Sydney, Australia

Received 25 February 2014; accepted 7 May 2014

KEYWORDSMedial sural artery;CT angiography;Perforator;Intra-muscular;Free flap

Summary Background: Themedial sural artery perforator (MSAP) flap is a versatile fasciocuta-neous flap. The main difficulty encountered when raising the MSAP flap is in obtaining adequatepedicle length during intra-muscular dissection. The objective of this studywas to determine thepattern of intra-muscular course of the MSAP flap pedicle.Methods: 14 cadaveric specimens were dissected and CT angiograms of 84 legs were examined.The intra-muscular branching pattern and depths of the medial sural artery branches wereanalyzed. The number of perforators, position of the dominant perforator and both intra-muscular and total pedicle lengthwere also recorded and compared to existing anatomical data.Results: Three types of arterial branching pattern were identified within the medial gastrocne-mius, demonstrating one (31%), two (59%) or three or more (10%) main branches. A dominantperforator from the medial sural artery was present in 92% of anatomical specimens (13/14).Vertically, the location of the perforator from the popliteal crease was on average 13 cm(!2cm). Transversely, theperforator originated2.5 cm(!1cm) fromtheposteriormidline.UsingCT angiography it was possible in 10 consecutive patients to identify a more superficial intra-muscular branch and determine the leg with the optimal branching pattern type for flap harvest.Conclusions: This study is the first to describe the variability of the intra-muscular arterial anat-omy of the medial head of gastrocnemius muscle. Surgeons utilizing the MSAP flap option shouldbe aware of the possible branching pattern types and consequently the differing perforator dis-tribution and depths of intra-muscular branches. Routine use of pre-operative CTangiogrammayhelp determine which leg has the most favorable branching pattern type and intra-muscularcourse for flap harvest.

* Corresponding author. 1A Mount St, Redfern Sydney, NSW 2016, Australia. Tel.: "61 411 022 644.E-mail address: [email protected] (J.R. Dusseldorp).

+ MODEL

Please cite this article in press as: Dusseldorp JR, et al., Vascular anatomy of the medial sural artery perforator flap: A new classificationsystem of intra-muscular branching patterns, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/j.bjps.2014.05.016

http://dx.doi.org/10.1016/j.bjps.2014.05.0161748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e9

mailto:[email protected]

http://dx.doi.org/10.1016/j.bjps.2014.05.016



ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

Background

In their search for the ideal donor site in 1975, Taylor andDaniel1 were the first to propose the posterior calf as aversatile option for perforator-based free flap reconstruc-tion. Later, Montegut and Allen2 and then Hallock3

described the topographical anatomy of the posterior calflaying the foundation for Cavadas et al.4 to perform thefirst clinical series of six medial sural artery perforator(MSAP) flaps. The perforating vessels of the posterior calfhave since been thoroughly investigated.3e13 It is clearfrom these studies that there is a variable pattern ofperforating vessels to the skin of the posterior calf and thatthere is usually a dominant perforator contributing to thefascial plexus.3,7 It has also been recognized that themedial sural artery perforators are more commonly domi-nant3,7,14 whilst the lateral perforators are typically fewerand less reliable.3,4,7

There has been no previous reported study of thepattern of the intra-muscular course of the medial suralartery. References to the nature of the intra-musculardissection of the MSAP flap pedicle are inconsistent. Pre-vious authors have either described the intra-musculardissection as being tedious4,5,8,10,12,13,15 or superficial andsurprisingly straightforward.3,16 In our clinical experiencewe have found the nature of intra-muscular dissection to beroutinely deep and travel for a long distance within themuscle. See Figure 1. As a result of conflicting descriptionsin the literature and our clinical findings we sought to carryout an anatomical and radiological study to further delin-eate the true anatomy of the intra-muscular course of theMSAP flap pedicle.

Patients and methods

Anatomical study

Using 14 fresh cadaveric lower limb specimens, the numberof perforators, position of the dominant perforator (definedas the single largest perforator with external diameter>0.5 mm), vessel caliber (at the level of the poplitealcrease) and both intra-muscular course and total pediclelength were recorded. A posterior midline incision wasmade and subfascial dissection performed to identify per-forators. See Figure 2. The dominant perforator was iden-tified and intra-muscular dissection was performed.

Radiological study

Radiological data of 84 lower limbs were obtained using aSiemens Definition Flash CT Scanner with Dual Sourcetechnology. The images were acquired using 100 kV andSn140 kV with 64 # 0.6 mm acquisition, a 0.33 s rotationtime and a pitch of 0.95. The contrast was Ultravist 370 at avolume of 80e120 mls at an injection rate of 4.5 ml/se5 ml/s. The start delay after injection was between 25 sand 35 s. In Phase 1 of the study we collected data retro-spectively from CT angiograms of 64 lower limbs. In Phase 2a further 10 CT angiograms (20 lower limbs) dedicated tothe calf region were collected and analyzed prospectively.Length and depth of the intra-muscular course of thebranches as well as total pedicle length and internaldiameter of the medial sural artery were measured usingSiemens Syngo Inspace software. See Figure 3.

Figure 1 Pictures of a single clinical case showing: (top row, left to right) A) pre-operative positioning and flap marking B) theextent of intra-muscular dissection required in a type IIB (low take-off) dual branching pattern C) flap raised after 10 cm intra-muscular dissection; (bottom row, left to right) D) the MSAP flap harvested E) recipient site at 6 months post-operatively (pos-terior view) F) recipient site at 6 months post-operatively (lateral view) and G) donor site at 6 months post-operatively.

2 J.R. Dusseldorp et al.+ MODEL


An independent CT angiography specialist analyzed thebranching pattern type of the medial sural artery usingmultiplanar and 3-dimensional (3D) reconstruction tech-niques. Independent statistical analysis using a paired-Ttest was performed to compare the depths of intra-muscular branches and to compare whether a significantlymore superficial branch could be identified in each of the10 cases. Internal diameter of the medial sural artery at thelevel of the tibial plateau was also measured.

Results

Anatomical study

In the cadaveric specimens the average age was 72 yearsand average height was 167 cm (male 173 cm, female

157 cm). A dominant medial sural artery perforator wasencountered in 86% (12/14) of cases and the averagenumber of medial perforators was 2 (one specimen had adominant lateral perforator and one specimen had nomedial perforator >0.5 mm). The average location of thedominant medial perforator was 13 cm (!2) from poplitealcrease and 2.5 cm (!1) from midline. The average length ofintra-muscular course was 9 cm (!3) and total pediclelength 14 cm (!3). See Figure 2. External diameter of themedial sural artery at the level of the popliteal crease was2.5 mm (!0.8).

Radiological study e phase 1

Three types of branching patterns of the intra-muscularcourse of the medial sural artery were found. See Figure 4.

Figure 2 Cadaveric dissection sequence showing: (left to right) A) posterior midline calf incision and location of the dominantmedial sural artery perforator B) measurement of the length of intra-muscular course of the MSAP flap pedicle in a type I (singlebranch) branching pattern.

Figure 3 3D CT images depicting the type IIA (high take-off) intra-muscular course of the MSAP flap pedicle (left to right) A)Lateral view of a subtraction 3D CT angiography image (Note that a deep and a superficial medial sural artery branch are visible inthe foreground whilst a lateral sural artery is visible in the background) B) Lateral view of a volume-rendered 3D CT angiographyimage showing the intra-muscular course C) Posterior view demonstrating the measurement of the intra-muscular pedicle lengthusing Siemens Syngo Inspace software.

Vascular anatomy of the medial sural artery perforator flap 3+ MODEL


Type I (31%) exhibited a singular main branch. Type II (59%)demonstrated a double branching pattern with either hightake-off occurring superior to the tibial plateau, type IIA(35%), or low take-off occurring inferior to the plateau,type IIB (24%). Type III was the least common branchingpattern (10%) and consisted of 3 or more branches. All typeIII branches also had high take-off points occurring superiorto the tibial plateau. The same branching pattern in bothlegs occurred in only 18% of cases. A median (superficial)sural artery was discovered in 9% of cases. The lateral suralartery had a singular intra-muscular branch in all cases. Theaverage length of intra-muscular course was 11 cm (!3) andtotal pedicle length 15 cm (!3). See Figure 2. Internaldiameter of the medial sural artery at the level of the tibialplateau was 2.3 mm (!0.4).

Radiological study e phase 2

The depths of all intra-muscular branches were measured atthe tibial tuberosity, 2 cmabove and 2 cmbelow. SeeTable 1.Type IIA (dual branching with high take-off) was the mostcommon type and exhibited one superficial branch and onedeep branch: 0.5 cm (!0.2) versus 1.3 cm (!0.4). This dif-ference was highly statistically significant (p< 0.001). In themajority of type IIA cases the medial branch was more su-perficial than the lateral. Type 1 and type IIB were thedeepest branching pattern types with an average branchdepth of 1.2 cm (!0.3) and 1.1 cm (!0.4) respectively. Onetype III branching pattern was encountered with all threebranches undertaking a superficial course.

Discussion

Our findings are consistent with existing anatomical data onthe number and location of medial sural artery perfo-rators.3e13,16e18 See Table 2. A major medial sural arteryperforator was present in 98% of dissection specimens re-ported in the literature (162/166). However, its preciselocation was variable. The presence of multiple underlyingbranches makes transverse location of the perforatorsdependent on the underlying branching pattern type. Theperforator can be expected to arise along the axis frommid-popliteal crease to medial malleolus or 2.5 cm (!1)medial to the posterior midline. The vertical location of theperforator from the popliteal crease can reliably be ex-pected to arise between 10 and 12 cm when a singledominant perforator is present or 8e12 cm and 11e16 cmwhen 2 large perforators are present. See Table 2. A pediclelength of approximately 15 cm is routinely obtainable after,on average, 11 cm of intra-muscular dissection and theinternal diameter of the medial sural artery at the level ofthe tibial plateau is 2.3 mm (!0.4).

Three intra-muscular branching pattern types of themedial sural artery were encountered in our study: type I31%, type II 59%, type III 10%. See Figure 4. Within the type IIgroup there was a marked distinction between the point oftake-off of the dual-branching pattern with high take-off(type IIA 35%) occurring superior to the tibial plateau andlow take-off (type IIB 24%) inferior. After discovery of thisintra-muscular variability we undertook the second phase ofour radiological study. 10 patients were scanned and their

Figure 4 3D CT images and schematic representation of two patients demonstrating the 4 types of intra-muscular branchingpattern of the medial sural artery: (left to right) A) type I e single branch (31%) B) type IIA e dual branching pattern with high take-off point above tibial plateau (35%) C) type IIB e dual branching pattern with low take-off point below tibial plateau (24%) D) typeIII e 3 or more branches (10%). All cases demonstrated a single lateral sural artery (depicted in C and D by the dotted line).



medial sural artery anatomy was analyzed prospectively. Wewere able to correlate the branching pattern type with thedepth of the intra-muscular branches. Branching patterntype IIA yielded a significantly more superficial branch in allcases. Type IIB and type I yielded predominantly deeperbranches whereas type III was superficial. More importantlywe have showed that these findings can help guide pre-operative clinical decision-making. When comparing eachcase left to right it was found that in all 10 cases the pre-operative CT angiogram revealed a significantly more su-perficial branch in one leg or the other. See Figure 5. It wasalso possible to choose a leg with a superior branchingpattern, except where there was bilateral type IIA and bothsides had a superficial branch. In the studied cases, type IIAyielded the most favorable branching pattern with a super-ficial intra-muscular branch (usually the medial branch).Type III was preferable to type IIB which was in turn prefer-able to type I.

Using CT angiography, it can be difficult to accuratelydetermine the dominant medial sural artery perforator atthe level of the deep fascia. Once the optimal leg has beenchosen and a roadmap of the intra-muscular anatomy hasbeen determined pre-operatively we suggest that the usualflap harvest techniques should be employed. It is straight-forward to elevate and expose the perforators sub-fasciallyand on average two perforators will be present. If thedominant perforator arises from a superficial intra-muscular branch or equivalent perforators arise from botha superficial and a deep branch then the superficial branchshould be utilized. In the instance where a dominantperforator arises from a deep branch and a less dominantperforator arises from a superficial branch then the surgeonhas a choice. Many factors including surgeon preference,defect size and required pedicle length will influence thisdecision. If a small skin paddle and long pedicle arerequired it is possible that a less dominant perforator basedon a more superficial branch may in fact be a superiorreconstructive option than a large perforator based on adeep branch. For those surgeons without access to CTangiography our findings suggest that if 2 perforators areencountered in the medial sural artery territory, the medialperforator is more likely to arise from a superficial branchof the medial sural artery.

The venous anatomy of the MSAP flap pedicle consists ofpaired venae comitans traveling with the medial sural ar-tery back to the level of the popliteal crease (enabling anaverage pedicle length of 15 cm). It should be noted thatthe medial and lateral sural venae comitantes and thelesser saphenous vein may anastomose more proximallythan the arterial system but this is usually at or above thelevel of the popliteal crease. We do not recommendextending dissection for pedicle length above the level ofthe popliteal crease. Furthermore we consider venousvaricosities to be a relative contra-indication to MSAP flapharvest due to the prolonged duration of intra-musculardissection, risk of damage to the pedicle and abnormalvenous flow after flap harvest.

The relative advantages and disadvantages of the MSAPflap have been described extensively elsewhere and so willnot be addressed.15 Our findings support the use of pre-operative angiographic assessment of the intra-muscularanatomy. This allows surgeons to select the most favor-able branching pattern thereby preserving donor sitefunction and reducing operative time. It has been shownthat the medial gastrocnemius muscle is a Mathes and NahaiType II muscle with multiple anastomotic connections toadjacent source vessels.19,20 Therefore, the muscle shouldsurvive completely even after division of a type I pedicle.Utilization of type IIA or III (high take-off) branchingpattern types will leave the other intra-muscular branchesintact. Pre-operative CT also has the benefit of identifyingthose legs with a median (superficial) sural artery (9%),which may be utilized without sacrificing any muscle.

Knowledge of the branching pattern type may alsofacilitate the design and harvest of dual, metachronous orchimeric flaps, as either free flaps or pedicled re-constructions. In type IIA or III (high take-off) situations,after MSAP flap raise, the remaining medial gastrocnemiusmuscle could be raised as a muscle only flap based proxi-mally on the remaining medial sural pedicle. Where theknown branching pattern is low within the muscle sub-stance (as in type IIB), this may allow a fasciocutaneouspaddle and muscle flap to be raised as separate compo-nents of a chimeric flap on a long pedicle.21 The branchingpattern can thus be useful information for surgeons plan-ning to undertake pedicled reconstruction of the lower

Table 1 Intra-muscular Depths of Medial Sural Artery Branches in 10 Consecutive Patients (cm).



Table 2 Summary of Published Anatomical Data Regarding The Medial Sural Artery Perforator Flap.

Anatomical Radiological Clinical

Study Year Reference # n Treatment of Cadavers n Imaging modality n Site

Cavadas 2001 4 10 Preserved 6 Lower limbHallock 2001 3 10 FreshThione et al. 2004 13 20 Fresh (resin)Kim et al. 2006 12 40 Preserved 21 Distal extremitiesOkamoto et al. 2007 11 44 PreservedChen et al. 2008 10 12 Tongue/floor of mouthShimuzu et al. 2009 9 12 PreservedKao et al. 2010 16 26 Head and NeckAltaf 2011 8 10 Preserved (latex, lead) 10 X-ray (ex-vivo)Higueras et al. 2011 18 18 CT Angio 18 Lower limbLin et al. 2011 17 14 Upper limbKosutic et al. 2012 7 16 Preserved (latex) 32 DuplexWong et al. 2012 6 10 Fresh (latex) 5 Distal extremitiesWang et al. 2013 5 10 Fresh (lead oxide) 10 CT Angio (ex-vivo) 34 Distal extremitiesCurrent Study 2014 14 Fresh 84 CT Angio 5 Head and Neck

Study Year Reference# Absent medialperforator(cases/total)

Averageno ofmedialperforators

Transversedistancefromposteriormidline (cm)

Vertical distance from poplitealcrease (cm)

Pediclecaliber (mm)

Pediclelength (cm)

Dominant(or 1st)perforator

2ndperforator

Cavadas 2001 4 0/10 2.2 (1e4) 12 (8.5e15) 17 (15e19) 10 (8e17)Hallock 2001 3 1/10 2.3 ! 1.1

(1e5)3 ! 2 12 ! 3 15 ! 2

Thione et al. 2004 13 0/20 1.9 !1a 11 (8e13) 16 (12.5e18) 2.2 (1.7e3) 12 (10e17)Kim et al. 2006 12 1/40 1.7 ! 0.5 10 ! 1.1

(8e12)15 (11e18) 8 (5e12)

Okamoto et al. 2007 11 0/44 2 (1e5) (0.5e4.5) 12 ! 2.7 2.5 (2e3.5) 14.5 (8e21)Chen et al. 2008 10 4 ! 2 9 ! 1.4

(8e12)9.5 ! 1

Shimuzu et al. 2009 9 1/12 2.0 ! 1.2(0e4)

8 11

Kao et al. 2010 16 1.6 ! 0.7(1e3)

11 ! 2.7

Altaf 2011 8 0/10 2 ! 0.3(1e5)

5 10 ! 0.02(9e12)

16 (14 $17) 3 (2e4) 15 (10e18)

Higueras et al. 2011 18Lin et al. 2011 17 10 ! 1.7

(8e13)2 10 ! 2

Kosutic et al. 2012 7 Not recorded 14b

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limb. For complex defects of the upper third of the leg afasciocutaneous MSAP flap can be used to obtain soft-tissuecoverage and a separate muscle flap can also be utilized toobliterate any deep dead space. These flaps can be raisedon the same pedicle or on separate branches of the medialsural artery depending on the underlying intra-muscularbranching pattern.

The main limitations to the routine use of pre-operativeCT are safety and expense. The risks of allergic or othercomplication from the use of iodinated contrast haverepeatedly been found to be extremely low.18 Routine CTangiography has been shown to be cost-effective inabdominally-based perforator flap reconstruction tech-niques as it substantially reduces operative time and alsoimproves outcomes.22e24 Further research is needed todetermine whether pre-operative knowledge of the intra-muscular branching pattern of the MSAP flap will reduceoperative time or improve outcomes. However, we hy-pothesize that knowledge of the underlying branchingpattern of the medial sural artery will allow surgeons tocustomize their operative plan and choose the leg with themost favorable intra-muscular course and the most suitableintra-muscular branching pattern type for their desired flapreconstruction.

Conclusion

The medial head of gastrocnemius is a reliable donor sitefor musculocutaneous perforators. If long pedicle length isrequired, the medial sural artery can be dissected up to thelevel of the popliteal crease for a pedicle length of onaverage 15 cm. However, the intra-muscular branchingpattern of the medial sural artery is variable. Type II dualbranching type was the most frequently encounteredpattern. When the dual branches had a high point of takeoff (type IIA), we discovered a significantly more superficialbranch (usually medial) and a deeper branch. In a series of10 consecutive patients it was also possible to use CTangiography to pre-operatively determine the optimal legfor flap harvest and the intra-muscular branch that wouldyield the most favorable operative approach. Routine useof a pre-operative CT angiogram may help to predict thelength and depth of intra-muscular course of the MSAP flappedicle and determine which leg has the most favorablebranching pattern type for flap harvest.

Ethics approval

Human Research and Ethics Committee approval wasgranted for this study and cadavers were procured andtreated in accordance with State and Federal Laws.

Disclosures

The authors have no conflicts of interest, commercial disclo-suresorfinancial disclosures todeclare in relation to this study.

No funding was received by any of the authors for thisstudy.

The products mentioned in the study are the CT machineand CT angiography software which are routinely used for

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all CT angiograms in our institution: Siemens DefinitionFlash CT Scanner with Dual Source technology and SeimensSyngo Inspace Software. We have included this informationfor scientific purposes only.

Acknowledgment

The authors would like to acknowledge Eddy Rizk fromSuperscan, Parramatta. Without his assistance, thisresearch would not have been possible.

References

1. Taylor GI, Daniel RK. The anatomy of several free flap donorsites. Plast Reconstr Surg 1975;56:243e53.

2. Montegut WJ, Allen RJ. Sural artery perforator flap as analternative for the gastrocnemius myocutaneous flap. Balti-more, Md.. In: Proceedings from the 90th Annual ScientificAssembly of the Southern Medical Association; 1996

3. Hallock GG. Anatomic basis of the gastrocnemius perforator-based flap. Ann Plast Surg 2001;47:517e22.

4. Cavadas PC, Sanz-Gimenez-Rico JR, Gutierrez-de la Camara A,et al. The medial sural artery perforator free flap. PlastReconstr Surg 2001;108:1609e15 [discussion 1616e1607].

5. Wang X, Mei J, Pan J, Chen H, Zhang W, Tang M. Reconstructionof distal limb defects with the free medial sural artery perfo-rator flap. Plast Reconstr Surg 2013;131:95e105.

6. Wong MZ, Wong CH, Tan BK, Chew KY, Tay SC. Surgical anatomyof the medial sural artery perforator flap. J Reconstr Microsurg2012;28:555e60.

7. Kosutic D, Pejkovic B, Anderhuber F, et al. Complete mappingof lateral and medial sural artery perforators: anatomicalstudy with Duplex-Doppler ultrasound correlation. J PlastReconstr Aesthet Surg JPRAS 2012;65:1530e6.

8. Altaf FM. The anatomical basis of the medial sural arteryperforator flaps. West Indian Med J 2011;60:622e7.

9. Shimizu F, Kato A, Sato H, Taneda H. Sural perforator flap:assessment of the posterior calf region as donor site for a freefasciocutaneous flap. Microsurgery 2009;29:253e8.

10. Chen SL, Chen TM, Dai NT, Hsia YJ, Lin YS. Medial sural arteryperforator flap for tongue and floor of mouth reconstruction.Head Neck 2008;30:351e7.

11. OkamotoH, Sekiya I,Mizutani J,OtsukaT. Anatomical basis of themedial sural artery perforator flap in Asians. Scand J of Plast andReconstr Surg and Hand Surge Nordisk plastikkirurgisk forening[and] Nordisk klubb for handkirurgi 2007;41:125e9.

12. KimHH, Jeong JH, Seul JH, Cho BC. Newdesign and identificationof the medial sural perforator flap: an anatomical study and itsclinical applications. Plast Reconstr Surg 2006;117:1609e18.

13. Thione A, Valdatta L, Buoro M, Tuinder S, Mortarino C, Putz R.The medial sural artery perforators: anatomic basis for a sur-gical plan. Ann Plast Surg 2004;53:250e5.

14. Manchot C. The cutaneous arteries of the human body. NewYork: Springer-Verlag; 1983.

15. Xie XT, Chai YM. Medial sural artery perforator flap. Ann PlastSurg 2012;68:105e10.

16. Kao HK, Chang KP, Chen YA, Wei FC, Cheng MH. Anatomicalbasis and versatile application of the free medial sural arteryperforator flap for head and neck reconstruction. PlastReconstr Surg 2010;125:1135e45.

17. Lin CH, Lin CH, Lin YT, Hsu CC, Ng TW, Wei FC. The medial suralartery perforator flap: a versatile donor site for hand recon-struction. J Trauma 2011;70:736e43.

Figure 5 Axial CT angiogram images depicting the depth of intra-muscular branches: (top row, left to right) Case 5: A) Left legtype IIA at tibial tuberosity e note lateral branch is more superficial than medial branch. B) Right leg type I at tibial tuberosityshowing deep intra-muscular course; (bottom row, left to right) Case 7: C) Left leg type IIA at tibial tuberosity e note medial branchis more superficial than lateral branch. D) Right leg type I at tibial tuberosity showing deep intra-muscular course.



http://refhub.elsevier.com/S1748-6815(14)00232-0/sref1



































































18. Higueras Sune MC, Lopez Ojeda A, Narvaez Garcia JA, et al.Use of angioscanning in the surgical planning of perforatorflaps in the lower extremities. J Plast Reconstr Aesthet SurgJPRAS 2011;64:1207e13.

19. Taylor GI, Pan WR. Angiosomes of the leg: anatomic study andclinical implications. Plast Reconstr Surg 1998;102:599e616[discussion 617e598].

20. Mathes SJ, Nahai F. Classification of the vascular anatomy ofmuscles: experimental and clinical correlation. Plast ReconstrSurg 1981;67:177e87.

21. Hallock GG. Chimeric gastrocnemius muscle and sural arteryperforator local flap. Ann Plast Surg 2008;61:306e9.

22. Smit JM, Dimopoulou A, Liss AG, et al. Preoperative CT angi-ography reduces surgery time in perforator flap reconstruction.J Plast Reconstr Aesthet Surg 2009;62:1112e7.

23. Rozen WM, Ashton MW, Whitaker IS, Wagstaff MJ, Acosta R. Thefinancial implications of computed tomographic angiography inDIEP flap surgery: a cost analysis. Microsurgery 2009;29:168e9.

24. Rozen WM, Anavekar NS, Ashton MW, et al. Does the preoper-ative imaging of perforators with CT angiography improveoperative outcomes in breast reconstruction? Microsurgery2008;28:516e23.

































Vascular anatomy of the medial sural artery perforator flap: A new classification system of intra-muscular branching patterns

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