ARTICLE IN PRESS

DIAL SURAL ARTERY PERFORATOR FLAP

ME FORREPAIR OF THE HAND

R. G. XIE, J. H. GU, Y. P. GONG and J. B. TANG

From the Department of Hand Surgery, The Hand Surgery Research Center, Affiliated Hospital of Nantong University,Nantong, China

We report our experience of using the medial sural artery perforator flap in the reconstruction of

soft tissue defects in the hand in seven cases with 1 to 2 year follow-up. The flap is harvested fromthe posteromedial aspect of the leg, just below the knee and superficial to the medial head of thegastrocnemius muscle. It is based on the perforator arteries and veins supplied by the medial suralartery. The flaps ranged in size from 14� 10 cm to 8� 6 cm.The donor area was closed directly orby a skin graft. All but one flap survived. The cosmetic results were satisfactory and withoutapparent bulkiness. Similarity of colour and thickness of the donor and recipient sites areadvantages. We feel that this new flap is a satisfactory option for use in the hand, particularly forextended soft tissue defects on the dorsal hand.Journal of Hand Surgery (European Volume, 2007) 32E: 5: 512–517

Keywords: flap transfer, perforator flap, free tissue transfer, tissue defects in the hand

The medial sural artery perforator flap is arelatively new flap which has been used mainly toreconstruct soft tissue defects of the lower extremity(Cavadas et al., 2001; Chen et al., 2005a, b). It hasbeen used little to repair defects of the hand, althoughChen et al. (2005a) included four patients with softtissue defects of the hand in their report of 11 clinicalcases.

We report our experience of using of this new flap inthe reconstruction of defects of the soft tissues in thehand in seven cases.

MATERIALS AND METHODS

Between June 2004 and August 2005, we used freevascularised medial sural artery perforator flaps torepair soft tissue defects in eight cases, of which seveninvolved flap transfer to the hand. There were fivewomen and two men of mean age 40 (range 23–53)years.

The soft tissue defects were due to injury to the handby machines or in car accidents. The bones or tendonsover the dorsum of the hand and carpus, or in the palm,were exposed. In one case, the tissue defect extended tothe first web and the area over the dorsal aspect of themetacarpal bone of the thumb. In another case, thetissue defect extended to the distal part of the forearm(Table 1).

At the initial operation, the wounds were debrided,fractures were internally fixed and intravenous anti-biotics were started. The wounds were dressed daily andflap transfer was not performed until the wounds wereclean, without necrotic tissues and were free of signs ofinfection. The mean time from injury to flap surgery was7 (range 4–15) days.

512

Operative Technique

Surgery was carried out under continuous epiduralanaesthesia and tourniquet control. The patients wereplaced in a supine position. The ipsilateral leg was usedin all cases. This flap is located over the proximal half ofthe medial head of the gastrocnemius muscle and isharvested superficial to the medial head of the gastro-cnemius muscle (Fig 1). The flap is nourished by a totalof one to five perforator arteries, among which one ortwo are obviously dominant. In our series, we coulddetect two dominant perforator vascular pedicles in fivepatients and one dominant pedicle in two patients. Wekept only dominant vascular pedicles (of a diametergreater than about 1.0mm) when the flap beingharvested was relatively small, but kept the dominantpedicles together with two to three minor perforatorpedicles when the flap size was big (10� 8 cm or bigger).The minor perforators retained were usually of adiameter greater than about 0.5mm.

The flap was harvested, starting with an incision alongthe medial border of the flap through the skin,subcutaneous tissue and deep fascia. The flap waselevated toward the midline of the posterior aspect ofthe lower leg. The flap can be detached from theunderlying muscle easily in the plane of the loose areolartissue lying between the deep fascia and the muscle. Thisplane is developed until the perforators are detected. Inmost cases, we found more than one perforator arterynourishing the flap. We used one, or two, dominantperforators as the feeding arteries of the flap and cutother, relatively small perforators which were in theoperative field when harvesting a small flap. Usually twodominant perforators and several small perforators tothe flap were seen when a flap of a greater size washarvested and we kept two dominant perforators

ARTICLE IN PRESS

Table

1—

Clinicaldetailsofthepatients

andtheirsurgery

Ca

seA

ge/

sex

Inju

ryS

ites

of

def

ects1

Tim

ing

of

fla

p

surg

ery

(d

ays

aft

erin

jury

)

Fla

psi

ze(

cm)

Len

gth

of

ped

icle

(cm

)

Ou

tco

me

Do

nor

site

ma

nag

emen

t

Oth

erin

juri

esa

nd

trea

tmen

ts

145years

female

Crush

R.Dorsum

of

hand

710�62

9Survived

Directclosure

Fracturesmetacarpals

K-w

irefixation

223years

male

Machine

R.Dorsum

of

handanddistal

forearm

5(after

skin

necrosis)

8�62

10

Survived

Directclosure

Fracture

distalradius

Plate

fixation

345years

male

Machine

R.Dorsum

of

hand

610�82

8Survived

Skin

graft

Fracture

index

phalanxK-w

ire

fixation,Dislocation

ringPIP

Reduction

438years

female

Machine

L.Palm

911�92

10

Survived

Skin

graft

–

534years

female

Caraccident

R.Dorsum

of

hand

514�10

9Survived

Skin

graft

Crush

interosseous

muscles,debridem

ent

653years

male

Machine

R.Dorsum

of

hand

413�7

10

Survived

Skin

graft

Fracturesmetacarpals

K-w

irefixation

744years

female

Caraccident

R.Palm

15

8�62

7Failed

Directclosure

–

1‘‘L’’and‘‘R’’in

thiscolumnrepresent‘‘left’’and‘‘right’’,respectively.

2Indicatestheflapsnourished

bytw

odistinct

perforatorvascularbundles.

MEDIAL SURAL ARTERY PERFORATOR FLAP 513

together with several other minor perforators as feedingarteries. Following identification of the perforator(s),the perforator(s) was dissected intramuscularly andmuscular branches were carefully cauterised with abipolar electrocautery. The perforator pedicle(s) wastraced along its oblique course through the muscle to thetrunk of the medial sural artery. This artery is about2mm in diameter and is accompanied by two venaecomitantes. A 10-cm long perforator pedicle could beobtained easily in all of our cases. Once an adequatelength and an appropriate diameter of the medial suralartery were reached, the lateral border of the flap wasincised and the flap completely detached from themuscle.

After appropriate preparation of the defect of thehand, the vascular pedicle, the medial sural artery itself,was divided and the flap revascularised on the hand byend-to-end arterial anastomosis to the radial artery. Thevenae comitantes were anastomosed to the cephalic veinor other subcutaneous veins of appropriate diameters.The venae comitantes of the medial sural artery hadmuch larger diameters than those of the radial or ulnararteries at the wrist level, so venae comitantes to venaecomitantes reconnection was never used.

RESULTS

The sizes of the flaps harvested ranged from 14� 10 cmto 8� 6 cm.The lengths of the pedicles ranged from 7 to10mm.The donor area was closed directly in three casesand resurfaced with split-thickness skin graft in fourcases. The details of the patients and the flap surgery aresummarised in Table 1.

All of the flaps survived except the last case. In the lastcase (Case 7), there was an obvious discrepancy indiameter of the donor and recipient arteries. Thetransferred flap failed 3 days after surgery and thewound was, subsequently, reconstructed with a split-skin graft after removal of necrotic superficial flaptissue. In one other case, the flap underwent a crisis of itscirculation and the vessels were re-anastomosed im-mediately. This flap survived after re-operation. Inanother case, the medial half of the gastrocnemiuspartially died after harvesting the flap. The necrotic partof the gastrocnemius was debrided, local and systemicantibiotics were given and later, the defect wasreconstructed with a split-thickness skin graft.

The six patients whose flaps survived were followedup for the first 2 months after surgery and returned laterfor evaluation at a mean of 19 (range 12–25) monthsafter surgery. At this follow-up, the part of the handreconstructed had a satisfactory cosmetic appearancewithout apparent bulkiness in all six cases withsuccessful flap transfer (Figs 2 and 3). Excellent post-operative hand motion was observed at follow-up in allcases (Fig 4) and flap transfer extending over the carpalarea did not cause any loss of wrist movement.

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Fig 1 Harvest of the flap and flap transfer to cover defects in the hand. (A) Donor site of the flap, located on the posteromedial upper part of the

lower leg superficial to the medial head of the gastrocnemius muscle. (B) The soft tissue defect of the left palm in Case 4. The wound was

debrided thoroughly before flap coverage. (C) The flap was harvested on dominant perforator vascular pedicles emerging from the

underlying muscle. The perforator pedicles were traced back to the medial sural artery. (D) The flap was transferred with end-to-end

anastomosis of the medial sural artery to the ulnar artery and two sural venae comitantes to the subcutaneous veins of the hand.

THE JOURNAL OF HAND SURGERY VOL. 32E No. 5 OCTOBER 2007514

The donor sites, whether closed directly or reconstructedwith a skin graft, healed very well and scar formation inthe donor areas was very localised (Fig 5). The scarformation was acceptable in the female patients becausethey wear trousers most of the time.

DISCUSSION

The medial sural artery perforator flap has only beendeveloped during the last 5 years. Previous clinicalreports of the use of this flap have concentrated on itsuse in reconstruction of wounds of the lower extremitiesas a free flap (Cavadas et al., 2001; Chen et al., 2005a, b;Hallock, 2001). Chen et al. (2005a) included reconstruc-tion of two palmar and two index finger defects in aseries of 11 patients, but our series is the only report ofuse of this flap exclusively for repair of soft tissues in the

hand. The sites of hand trauma in our series were mostlythe dorsum of the hand (five of seven patients) and thepalm (the other two patients).

As with other perforator skin flaps, muscle as a carrierfor skin flap vascular supply is no longer necessary(Koshima et al., 1988; Koshima and Soeda, 1989),thereby avoiding unwanted muscle bulk in the flap andmaintaining donor-site muscle function. As a conse-quence, this flap is relatively thin. Its skin colour andthickness match the hand, particularly the dorsum of thehand. A number of flaps, such as reverse pedicle flapsfrom the forearm, the contralateral radial artery freeflap, the lateral arm free flap and the anterior lateralthigh flap, are used to reconstruct soft tissue defects onthe dorsum of the hand. In our clinic, we also use theanterior lateral thigh flap, another perforator flap, torepair wounds in the dorsum of the hand. However, wefeel that the medial sural artery perforator flap is

ARTICLE IN PRESS

Fig 2 Satisfactory cosmetic appearance of the transferred flap in Case

4, 2 years after surgery. The appearance of the reconstructed

hand was similar to the contralateral, normal hand (A), with no

obvious bulkiness of the flap (B).

Fig 3 Flap transfer extended over the carpal area did not cause any

loss of wrist movement (Case 4). Excellent postoperative hand

motion was observed at final follow-up.

MEDIAL SURAL ARTERY PERFORATOR FLAP 515

superior to the anterior lateral thigh flap in skin colourand thickness.

Anatomical dissection by Hallock (2001), Cavadaset al. (2001) and Thione et al. (2004) have shown thatthis flap is nourished by multiple perforators from themedial sural artery, the average number being 2 (range1–4). Our experience has been that flaps of the size wedissected had one or two principal perforators and wecould always find one vascular bundle of the medialsural artery and vein appropriate for anastomosis. Theflaps we used were generally larger in size than thosepreviously described, with the smallest being 8� 6 cmand the biggest 14� 10 cm. The largest flap, of size14� 10 cm (Case 5), was harvested on two dominantand two minor perforators connecting to the suralartery. This flap provides a very useful option toresurface the shallow but extensive soft tissue defectswhich are common on the dorsum and palm of thehand.

We noted a discrepancy between the diameter of thefeeding artery of this flap and the recipient artery inmost of our cases. Usually, this did not constitute aproblem for microsurgical end-to-end arterial anasto-mosis and the flaps survived. However, the differencewas particularly marked in one case and this flap faileddays after surgery, although the arterial anastomosisseemed satisfactory at the time of surgery. It is necessaryto be aware of the variation in the diameter of themedial sural artery over the part from which theperforators are given off and trace the artery proximallyto a segment of an appropriate size for arterialanastomosis.

We closed the donor wound primarily in threepatients but needed split-thickness skin grafts in fourpatients. Harvesting a flap of width over 6 cm usuallyneeds skin grafts. The scars of wounds closed primarilymay stretch. The upper medial aspect of the lower leg isan area exposed less frequently than many other flap

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Fig 4 The appearance of the dorsum of the hand of Case 5, 1 year after surgery.

Fig 5 The donor site of the flap showing scar formation at the donor wound closed directly (A) or with a skin graft (B).

THE JOURNAL OF HAND SURGERY VOL. 32E No. 5 OCTOBER 2007516

donor sites in our country and the patients in our seriesdid not have concerns about the appearance of theirdonor sites. In fact, the female patients in this series

wear trousers most of the time. In western countries,high skirts are worn more often and scar formation inthis area may be of a greater concern.

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MEDIAL SURAL ARTERY PERFORATOR FLAP 517

In conclusion, we have found transfer of the medialsural artery perforator flap to be a satisfactory optionfor treatment of soft tissue defects of the hand,particularly on the dorsum of the hand. This flap canbe used to resurface the entire dorsum of the hand.Similarity of colour and thickness of the donor area withthe recipient site and availability of this flap for use inextended wounds are the principal advantages to its use.

References

Cavadas PC, Sanz-Gimenez-Rico JR, Gutierrez-de la CA, Navarro-Monzonis A, Soler-Nomdedeu S, Martinex-Soriano F (2001). Themedial sural artery perforator free flap. Plastic and ReconstructiveSurgery, 108: 1609–1615.

Chen SL, Chung CJ, Chou TD, Chen TM, Wang HJ (2005a). Freemedial sural artery perforator flap for ankle and foot reconstruc-tion. Annals of Plastic Surgery, 54: 39–43.

Chen SL, Chen TM, Lee CH (2005b). Free medial sural arteryperforator flap for resurfacing distal limb defects. Journal ofTrauma, 58: 323–327.

Hallock GG (2001). Anatomic basis of the gastrocnemius perforator-based flap. Annals of Plastic Surgery, 47: 517–522.

Koshima I, Soeda S (1989). Inferior epigastic artery skin flaps withoutrectus abdominis muscle. British Journal of Plastic Surgery, 42:645–648.

Koshima I, Soeda S, Yamasaki M, Kyou J (1988). The free orpedicled anteromedial thigh flap. Annals of Plastic Surgery, 21:480–485.

Thione A, Valdatta L, Buoro M, Tuinder S, Mortarino C,Putz R (2004). The medial sural artery perforators: anatomicbasis for a surgical plan. Annals of Plastic Surgery, 53:250–255.

Received: 26 July 2006Accepted after revision: 23 May 2007Professor Jin Bo Tang, MD, Department of Hand Surgery,Affiliated Hospital of Nantong University, 20 West Temple Road,Nantong 226001, Jiangsu, China.Tel./fax: +86 513 85110966.E-mail: jinbotang@yahoo.com

r 2007 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rightsreserved.doi:10.1016/j.jhse.2007.05.010 available online at http://www.sciencedirect.com