The Medial Sural Artery Perforator - anatomic basis for a surgical plan because it enters the muscle in its proximal one-third, which is an area not usually involved by dissection. As reported in the literature, the sacrifice of the medial gastrocnemius muscle causes the loss of 10% of the jumping power; the morbidity of MSAP flap should be lower.12 In this study, 66% of perforators originated from the lateral branch of the medial sural artery; only 34% originated from the medial branch, located deeper in the muscular belly. In the four cases in which three perforatos were found, at least one of these originated from the medial branch of the medial sural artery. Venous perforators were not analized in this study but they always accompanied the arteries. The medial sural artery always originated from the medial aspect of the popliteal artery at the popliteal crease, as described in the literature. The average diameter of the medial sural artery and vein before bifurcation (artery: 2.2 mm; vein 2.6 mm) was of such dimensions to allow easy micro- anastomosis with most of the recipient vessels in the body. The medial sural artery division in medial and lateral branches deserves a consideration. Only in 15% of cases the bifurcation was extramuscular and near (1 cm to 1.5 cm) the medial sural artery origin. Dissection until the division, to obtain a satisfying pedicle length, is more difficult and risky. If a long vascular pedicle is needed, it is possible to reach the division and to ligate the medial sural artery. The risk of muscle ischemia is remote, because several secondary vascular pedicles have been described.7,13,14 The vascular pedicle of the MSAP flap varied in our study from 10 cm to 17 cm, depending on the position of perforators in the subcutaneous plane; however, in most cases it is possible to leave intact the bifurcation and to obtain a long enough pedicle, making this flap a good choice as a pedicled (the arc of rotation can reach the upper three-fourths of the tibia) or free transplant. CONCLUSIONS Perforator flaps are an important tool in reconstructive plastic surgery and represent the clinical counterpart of new and more detailed anatomical bases of cutaneous vasculature. Starting from this consideration, we performed an anatomical study that allowed us to improve the anatomical knowledge of the medial posterior calf region and to describe, according to the found anatomical basis, a convenient surgical plan to make flap sculpturing easier. 44
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