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

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

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

44 Citations (Scopus)


Background The medial sural artery perforator (MSAP) flap is a versatile fasciocutaneous flap. The main difficulty encountered when raising the MSAP flap is in obtaining adequate pedicle length during intra-muscular dissection. The objective of this study was to determine the pattern 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 were analyzed. The number of perforators, position of the dominant perforator and both intra-muscular and total pedicle length were also recorded and compared to existing anatomical data. Results Three types of arterial branching pattern were identified within the medial gastrocnemius, demonstrating one (31%), two (59%) or three or more (10%) main branches. A dominant perforator 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 (±2 cm). Transversely, the perforator originated 2.5 cm (±1 cm) from the posterior midline. Using CT 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 anatomy of the medial head of gastrocnemius muscle. Surgeons utilizing the MSAP flap option should be aware of the possible branching pattern types and consequently the differing perforator distribution and depths of intra-muscular branches. Routine use of pre-operative CT angiogram may help determine which leg has the most favorable branching pattern type and intra-muscular course for flap harvest.

Original languageEnglish
Pages (from-to)1267-1275
Number of pages9
JournalJournal of Plastic, Reconstructive and Aesthetic Surgery
Issue number9
Publication statusPublished - Sept 2014
Externally publishedYes


  • CT angiography
  • Free flap
  • Intra-muscular
  • Medial sural artery
  • Perforator


Dive into the research topics of 'Vascular anatomy of the medial sural artery perforator flap: A new classification system of intra-muscular branching patterns'. Together they form a unique fingerprint.

Cite this