Medial Sural Artery V-Y Advancement Flap: Bridging a Learning Curve

It was interesting to read the article by Wong et al[1] on the medial sural artery perforator flap. Cadaveric dissection enabled the authors to chart the three-dimensional course of the largest perforator of the medial sural artery. They have utilized this knowledge to successfully perform the free medial sural artery perforator flap. As the authors rightly point out, it is not an easy flap to execute. The available literature is replete with flap failures and complications.[2] [3] [4]

Not everybody is so blessed as to have opportunity to test their dissection skills in the anatomy laboratory and then transfer their expertise to the clinical setting. We have found that the performance of the V-Y advancement variant of this flap helps in gaining vital operative experience. The advantages are many. The surgeon is able to identify all the perforators traversing the medial head of the gastrocnemius muscle. Because the movement of the flap is unidimensional and limited to several centimeters, multiple perforators along the line of advancement can be retained. This assures the surgeon that the flap in all likelihood would survive. One or two of the larger perforators can be judiciously dissected intramuscularly, to aid further advancement or to obviate tension on the flap inset. A case example is illustrated, in which a V-Y advancement flap was moved superiorly to cover a posttraumatic defect that exposed a fractured medial tibial condyle ([Fig. 1]). A literature search reveals only one article on the medial sural artery perforator flap that mentions the possibility of its elevation in a V-Y fashion.[5] Of course, this may be because such a flap is of limited mobility compared with the pedicled propeller variant.

Fig. 1 (Left) Upper leg defect with exposed fractured medial tibial condyle (ellipse). A medial sural artery V-Y flap was planned to advance superiorly. Two perforators were identified (marked with oblique lines), dissected and retained. (Right) Postoperative view.

The authors are to be complimented for conducting a meticulous anatomical-cum- clinical study on a flap that “requires proficient microsurgical skill.”[5] The experience gained through cadaveric dissection has no substitute. However, especially for a trainee in microsurgery, utilizing opportunities to raise this flap in either a V-Y or a perforator-plus design[6] would provide valuable practice in intramuscular perforator dissection.

• References

• 1 Wong MZ, Wong CH, Tan BK, Chew KY, Tay SC. Surgical anatomy of the medial sural artery perforator flap. J Reconstr Microsurg 2012; 28 (8) 555-560
• 2 Hallock GG. Sequential use of a true perforator flap and its corresponding muscle flap. Ann Plast Surg 2003; 51 (6) 617-620 , discussion 621–622
• 3 Park G, Kim H. Treatment of chronic osteomyelitis using the medial sural perforator flap. J Plast Reconstr Aesthet Surg 2010; 63 (1) 153-159
• 4 Xie RG, Gu JH, Gong YP, Tang JB. Medial sural artery perforator flap for repair of the hand. J Hand Surg Eur Vol 2007; 32 (5) 512-517
• 5 Xie XT, Chai YM. Medial sural artery perforator flap. Ann Plast Surg 2012; 68 (1) 105-110
• 6 Kim KS, Kim ES, Hwang JH, Lee SY. Medial sural perforator plus island flap: a modification of the medial sural perforator island flap for the reconstruction of postburn knee flexion contractures using burned calf skin. J Plast Reconstr Aesthet Surg 2012; 65 (6) 804-809