Chapter 3 INTRODUCTION Perforator-based flaps nourished by musculocutaneous perforating vessels are becoming more popular, being used by surgeons around the world.1 One of the main advantages of these flaps is less donor site morbidity and muscle sparing; on the other hand, elevation of perforator flaps requires a long and difficult dissection, and above all, there is a great variability in the anatomy of perforators vessels.1 One of the last flap described is the medial sural artery perforator flap (MSAP flap) indicated primarily for reconstruction of the lower limb as a pedicled or free flap.2 We performed an anatomical study of this flap in order to improve our anatomical knowledge of the medial posterior calf region and to describe, according to the anatomical basis, a convenient surgical plan to make easier the flap sculpturing. MATERIALS AND METHODS We performed an anatomical study on 20 lower limbs of 10 fresh Caucasian corpses at the Ludwig-Maximilian University of Munchen. We used frozen and untreated corpses: 24 hours before dissection, they were positioned on the dissectory table to defrost; 12 hours before dissection, they were injected with a resin to allow a better observation above all of the perforator vessels. We used a mixture of an autopolymerizing resin (“Biodur®”) composed of 100 g. Biodur® E 20, 45 g. Biodur® E 2, 20 g. Biodur® Weichmacher AE 10 and 40 g. aceton. The resin had a hardening time of about 12 hours. In every leg, 30 ml of resin were injected at the origin of the popliteal artery, previously cannulated, before the emergence of sural vessels. Anatomical dissection Five corpses were positioned supine with extrarotated inferior limbs and flexed knees; five corpses were positioned prone. Medial sural artery perforator flaps were sculptured in the calf region according to the following anatomical markings: once the popliteal crease was drawn, a line perpendicular to this was traced between the medial and lateral heads of the gastrocnemius muscle; a parallel line was traced from the medial condyle. A last line parallel and equally distant between the previous ones was marked; this was considered the cutaneous projection of the perforators of the 33
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