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Good morning ladies and gentlemen! Its my honor to stand here, and spare my topic with you, my topic is The anatomy and clinic application of free medial sural artery perforator flapAs we all know , the need for thin flap coverage has increased, especially for covering shallow defects of distal limbs. This flap has emerged as a good technique to meet the need. Up to now, we have used this way to resurface the distal defects for 21 patients.Cavadas first used this flap in lower limb reconstruction in 2001.He exclude the muscle portion and to raise the cutaneous part only. Later , hallock ,shaoliang-chen,and Hyo Heon Kim also reported their studies and clinic applications of it .After anatomic study in 6 cadaveric specimens, we have made the following conclusion. There was at least one perforator over the medial gastrocnemius muscle. The proximal one was usually located in an area 6 to 12 cm away from the popliteal crease and about 4 cm from the posterior midline of the leg.
Between April 2007 and Septemper 2010, we used this free flap to reconstruct the shallow defects in the distal limbs for 21 patients. We dissected one or two proximal major perforators ,and used it or use secondary branch of medial sural artery as the vessel pedicle of flap.Preoperative design of the flap depended largely on the Doppler ultrasound. We can use it to mark the location of the perforator and medial sural artery.Now , lets have a look at the Doppler graph. The blue region is skin , the yellow region is subcutaneous tissue, the red is deep fascia, the pale blue is muscular tissue, and this is the graph of the perforator .After the design of the flap, we can place the patient in a supine or prone position according to the recipient cite. Wed like to dissect and preserve a superficial vein to improve the back flow of the flap. This is the superficial vein of the flap , this is the secondary branch of the medial sural artery ,and this is the perforator out of the muscle.When finding the ideal perforator, we dissect it carefully. After cauterizing the muscular branches, we can achieve adequate pedicle length. The donor site is closed directly or covered with a split-thickness skin graft.In our series, 20 free flaps survived successfully, and 1 got partial necrosis because of vein congestion. The size of the flap ranged from 7.04.5 cm to 128 cm. 17 flaps were raised with single perforator and 4 with 2 perforators. 16 flaps were anastomosed a superficial vein in addition to two accompanyingveins. Now , I shall brief you on some of our clinic cases . This defect is located on the radial dorsum of the right hand with bones and tendons exposed. This flap was raised with two perforators. Because the caliber of the vein of the pedicle was bigger than that of the recipient cite, we always reduced it before we anastomosed. This defect is located on the radial dorsum of the left hand, with bones exposure and tendons defect . The flap was raised with single perforator. In order to restore the flap sensation, we preserved the part of the medial sural nerve, and sutured it with the superficial radial nerve.
During the time of flap grafting, we reconstruct the tendons defect with allosome tendons. This is another skin defect of the back of the right hand.This is another defect on the foot, Just as we can see here, the flap was very thin and cosmetic.There was a special case in our series. When we used this way to reconstruct the foot with partial necrosis, we found the perforator did not emerge out of the muscle but from the direct cutaneous artery. This was just the same as Geoffrey G. Hallock had earlier reported, he called it median sural artery, which emerges in 10% lower limbs.These three pictures show the direct cutaneous perforator clearly. The direct cutaneous artery is just located under the deep fascia. If we happen to find it , we can detach the flap more easily.The vast majority of patients were followed-up. These flaps were very thin and cosmetic , and there remained only a linear scar in the donor sites with a width less than 5CM. This flap has many advantages. All of the medial gastrocnemius muscle and its motor nerve can be preserved, and there is no need to sacrifice major arteries of the leg, so it is of little damage to the donor site. The thin skin flap is very suitable for shallow defects of distal limbs, especially for the dorsum of foot or hand. We can achieve a vessel pedicle long enough for free grafting the flap. By preserving the part of medial sural nerve, we can reconstruct sensation of the flap easily. Therefore , We believe that this flap will be widely used in clinic application .Thats all, thank you for your attention.