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39 Medial Femoral Condyle Flap
ab
377
c
Fig. 39.7 Illustrations of a medial femoral condyle structural bone
graft (a) and medial femoral trochlear graft (b) used for scaphoid reconstruction after insetting and microvascular anastomosis is shown.
Conversely, corticoperisoteal grafts are typically wrapped around the
recipient site, such as a clavicular nonunion undergoing revision open
reduction and internal xation (c). (Reproduced with permission of the
Mayo Foundation)
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A. L. Logli and A. Y. Shin
39.6 Core Surgical Techniques inFlap
Dissection
Under tourniquet control, a medial thigh incision starting at
the most palpable, distal edge of the femur and extending
proximally along the posterior border of the vastus medialis
is used (Step 1—Incision). A curved incision is used instead
when a component of articular cartilage is desired for the
graft. The incision should be extended as necessary, which
may be the case with more muscular patients. This should
be anterior to the SAB signal if a skin island is planned. In
all cases, the SAB is protected if identied during exposure.
Electrocautery and self-retaining retractors are used to dissect through subcutaneous tissue down to fascia and then to
make a small distal rent at the posterior border of the vastus
medialis fascia. Metzenbaum scissors are used to complete
the fascial divide proximally along the entire length of the
incision, and the vastus medialis is lifted from its compartment anteriorly. The MFC and overlying vascularity can
then be fully appreciated in the bed of the wound (Step 2—
Exposure). Posterior retraction of the sartorius muscle may
be needed for improved visualization. The DGA may be
visualized on the oor of the wound just anterior to the
adductor magnus tendon proximally and overlying the MFC
distally. If the DGA is large enough, the sMGA branch may
be ligated and divided. However, if the DGA is not large
enough, the sMGA should be used and DGA contribution
ligated instead. A green background is placed beneath the
chosen pedicle for ease of recognition. Once the supply vessel has been chosen (DGA or sMGA), the planned graft can
be outlined on the MFC periosteum using bipolar electrocautery (Step 3—Graft Planning). Planning a slightly larger
ap than measured is important to allow for later
customization.
Next, graft separation is dependent on graft composition.
For a structural graft, a small curved osteotome or microsagittal saw (9 mm wide blade) is used perpendicular to the
bone surface to vertically divide all but the proximal border
of the graft where the pedicle is travelling (Step 4—Graft
Separation). Identifying and avoiding the medial epicondyle
of the femur will prevent disturbing the MCL during this
step. Proximally, removal of the graft is done in three stages.
First, a vessel loupe should be used to gently lift the vascular pedicle out of harm’s way. Second, the small osteotome
is similarly used perpendicular to the bony surface to make
a vertical, proximal divide. Finally, the small osteotome is
used 1–2 cm proximally to the proximal border of the
planned graft at a 45° angle to undercut the graft (Step 5—
Graft Elevation). This prevents levering out an incomplete
or fragmented graft. The oor of the graft can then be lifted
out of the donor site without damage or tension to the vascular pedicle. Viability of the graft can be ascertained by
assessing for punctate bleeding from the periosteum. The
tourniquet may be deated if necessary, to visualize this.
Graft separation and elevation is performed similarly for
articular grafts, with exceptions being that the knee capsule
needs to be entered rst and that the last cut is made through
the cartilage to ensure an adequate amount is incorporated
(Step 5—Graft Separation and Step 6—Graft Elevation).
The process of graft separation differs in corticoperiosteal
grafts, where a curved osteotome is instead used running
almost parallel to the cortical surface and where gradual
separation occurs from the margins toward the center (Step
5—Graft Separation). Elevation is completed from distal to
proximal by prying the graft away from the underlying cancellous bone beneath the vascular pedicle (Step 6—Graft
Elevation).
The size and dimensions of the graft are then carefully
scrutinized. Additional cancellous bone can be harvested
from the donor site at this time. The pedicle is followed
proximally and dissected free to maximize pedicle length
before being clipped and sharply divided. The pedicle is
usually at least 6cm in length and close to the origin of the
donor vessel. One clip is placed on the artery and two clips
on any venae comitantes to facilitate ease of identication
during anastomosis (Step 6—Graft Preparation and
Division). Trimming and customization of the graft should
be performed after division of the pedicle. The donor site
wound is then copiously irrigated with sterile saline. The
bony defect is grafted with synthetic hydroxyapatite bone
ller of the surgeon’s choice. The donor site is closed in
layers using absorbable sutures (Step 7—Donor Site
Closure). Deep fascia and patellar retinacular tissues using
interrupted 0-Vicryl sutures in a gure-of-eight fashion.
Buried, interrupted 2–0 Monocryl is used to close subcutaneous tissue over a 10-French supra-fascial channel drain
set to bulb suction. A running 3–0 barbed suture followed
by an occlusive mesh and 2-octyl cyanoacrylate adhesive
dressing are used for skin. The knee is dressed in a soft and
bulky compressive dressing and a knee immobilizer is
applied. The drain is typically discontinued on postoperative day 1 for non-articular grafts and postoperative day 2
or 3 for articular grafts.
Structural grafts should be inset into the donor bed as an
interposition graft, while corticoperiosteal grafts are
wrapped around the recipient bone. In most instances, further stabilization is then necessary and is dependent on the
anatomic region of the donor site. Once satised with graft
39 Medial Femoral Condyle Flap
379
security, end-to-side arterial anastomosis followed by an
end-to-end microvenous repair is performed using an operative microscope and 8–0 or 9–0 nylon suture in an interrupted fashion (Step 8—Graft Inset and Anastomosis).
Patency of the vessels and perfusion of the graft are visually
conrmed prior to closure. Recipient site closure is performed in a layered fashion and is dependent on the anatomic site.
Postoperatively, the knee immobilizer is to be worn over
the rst few days for patient comfort as knee exion may be
uncomfortable. Immediate weight-bearing and range of
motion is permitted and is usually tolerated well. A cane is
supplied and may be used in the contralateral hand for support in the rst few days after surgery.
39.7 Clinical Scenario
A healthy, 19-year-old, right-hand-dominant college freshman injured his left wrist during a fall while playing soccer.
It initially was treated as a sprain. Due to ongoing pain, medical evaluation was sought 1year after injury, and he was
diagnosed with a scaphoid nonunion. Physical examination
revealed pain in the anatomic snuffbox and diminished active
wrist range of motion in all planes. Imaging demonstrated a
nonunion of the scaphoid waist with a large cystic area and
sclerosis of the proximal pole concerning for potential avascular necrosis (Fig. 39.8). A MFC vascularized bone graft
from the ipsilateral leg was recommended and performed.
The graft measured 10×10×10mm and was taken from the
posterior-distal aspect of the MFC off the DGA.Once inset,
the graft was pre-drilled and xed with a 24mm cannulated,
scaphoid-specic screw under uoroscopic guidance.
Standard reanastomosis and closure followed. Patient was
placed in a bulky, long-arm thumb spica splint and returned
for suture removal 2weeks later. He was transitioned into a
short arm cast for a period of 3months at which time plain
lms and a CT scan were obtained demonstrating healing at
the bone graft site (Fig.39.9). He was given a custom-fabricated splint to be weaned out of in 4–6weeks and initiated
gentle range of motion with a skilled hand therapist. He was
seen back 6months and 1year from surgery with excellent
pain-free range of motion of the wrist and knee with no complication (Fig.39.10).
Fig. 39.8 Left wrist demonstrating a scaphoid waist nonunion with cystic resorption and sclerosis of the proximal pole without fragmentation or
deformity (left—PA wrist; middle—coronal CT; right—scaphoid-axis, sagittal CT)
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A. L. Logli and A. Y. Shin
Fig. 39.9 Left wrist demonstrating proximal and distal incorporation of the vascularized MFC graft approximately 3months after surgery (left—
coronal CT; right—sagittal CT)
39 Medial Femoral Condyle Flap
381
Fig. 39.10 Patient returns 6months after surgery with a healed scaphoid, pain-free wrist, excellent motion, and no complication (top left—PA
wrist; top right—healed medial knee incision; bottom left—nal wrist exion; bottom right—nal wrist extension)
382
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39.8 Pearls andPitfalls 39.9 Selected Readings
• Sakai K, Doi K, Kawai S.Free vascularized thin cortico-
Pearls
• It is important to identify both the DGA and the
sMGA and choose the largest caliber vessel to serve
as the graft’s primary vascular supply. This is usually, but not always, the DGA.
• Thin corticoperiosteal grafts are much easier to
shape while large corticocancellous grafts will
serve more of a structural role. Functional expectations of the graft should be pre-determined to maximize its potential.
• To ensure graft viability after being raised, check
for bleeding edges of the periosteum, cortical, and
cancellous bone.
Pitfalls
• In addition to raising the graft according to preplanned dimensions, making an additional cut at a
45° angle just distal to the graft and elevating an
extra wedge of bone allows for easier removal of
the graft and decreases the risk of graft fracture or
corticoperisoteal separation.
• Particularly when considering large grafts, it is critical to identify and avoid important surrounding
anatomy. The adductor magnus tendon, supercial
femoral artery proper, supercial medial collateral
ligament and knee joint capsule are such
structures.
• While large, viable grafts can be obtained from
the MFC region [34], we recommend the proximal extent of the graft not pass the metaphyseal
are due to the risk of iatrogenic femur fracture as
has been observed before with femoral notching
[35].
• For interposition scaphoid reconstruction, insetting of the graft is the most difcult part. Correction
of DISI deformity and minimal bone resection of
the proximal and distal poles is necessary.
Overstufng has been suggested but is exceedingly difcult to accomplish. Normal anatomy is
restored, and the length of the scaphoid rarely is
“overstuffed” [37].
periosteal graft. Plastic and reconstructive surgery.
1991;87(2):290–8.
• Sakai et al. provide us with the rst description in the
American literature of the MFC graft used in a free fashion. All 6 patients had upper extremity nonunions that
previously failed one or more operations and went on to
union 2–3.5months after being treated with a free corticoperiosteal MFC graft.
• Larson AN, Bishop AT, Shin AY.Free medial femoral
condyle bone grafting for scaphoid nonunions with
humpback deformity and proximal pole avascular
necrosis. Tech Hand Up Extrem Surg. 2007;11(4):
246–58.
• One of the most common applications for a free MFC
graft has been scaphoid nonunions, particularly when
osteonecrosis of the proximal pole and/or deformity is
present. This article presents our original surgical technique, which has not changed considerably since.
• Hertel R, Masquelet AC.The reverse ow medial knee
osteoperiosteal ap for skeletal reconstruction of the leg.
Description and anatomical basis. Surg Radiol Anat.
1989;11(4):257–62.
• This article presents the rst description of the contempo-
rary MFC graft in the American literature. It was
described as a pedicled graft for treatment of local nonunions and osteonecrosis. More importantly, it describes
the vascular basis for the MFC graft in the context of relevant surrounding anatomy through the cadaveric prosection of 50 specimens.
• Hugon S, Koninckx A, Barbier O. Vascularized osteochondral graft from the medial femoral trochlea: anatomical study and clinical perspectives. Surg Radiol Anat.
2010;32(9):817–25.
• The MFC graft can be modied into an osteochondral
ap using cartilage from the medial femoral trochlea. In
these instances, it is typically referred to as an MFT graft.
This article offers the rst anatomic evaluation of the
MFT graft and suggests its feasibility for the treatment of
defects often seen in Kienböck’s disease or proximal pole
of the scaphoid pathology.
• Yamamoto H, Jones D Jr, Moran SL, Bishop AT, Shin
A. The arterial anatomy of the medial femoral condyle
and its clinical implications. J Hand Surg (European
Volume). 2010;35(7):569–74.
• These authors dene the microvascular anatomy of the
MFC graft while also reexploring the macrovascular
A. L. Logli and A. Y. Shin
39 Medial Femoral Condyle Flap
383
anatomy some 20years after its initial description. This
work signicantly contributed to our understanding of the
posterior-distal quadrant of the MFC to be the optimal
location for ap elevation as it reliably has the highest
density of perforating vessels.
• Oh C, Pulos N, Bishop AT, Shin AY.Intraoperative anatomy of the vascular supply to the medial femoral condyle.
J Plast Reconstr Aesthet Surg. 2019;72(9):1503–8.
• This work explores the intraoperative macrovascular
anatomy of the MFC graft in 113 patients. The major
limitation of all prior anatomic descriptions was a reliance on information gained from a limited number of
cadaveric specimens. It found the DGA to be present in
93% of patients and dominant 77% of the time with the
sMGA absent in 2% of cases.
• Mehio G, Morsy M, Cayci C, Sabbagh MD, Shin AY,
Bishop AT, etal. Donor-site morbidity and functional status following medial femoral condyle ap harvest. Plast
Reconstr Surg. 2018;142(5):734e–41e.
• This article thoroughly explores knee donor site morbid-
ity related to MFC graft harvest in 75 patients. These
authors found an overall complication rate of 18.6% with
the majority being saphenous nerve paresthesias with
increasing ap size as a signicant risk factor. Fifty-one
percent of patients had functional outcomes comparable
to a normal knee at 13months.
References
1. Acland R, Schusterman M, Godina M, Eder E, Taylor G, Carlisle
I. The saphenous neurovascular free ap. Plast Reconstr Surg.
1981;67(6):763–74.
2. Masquelet A, Nordin J, Guinot A. Vascularized transfer of the
adductor magnus tendon and its osseous insertion: a preliminary
report. J Reconstr Microsurg. 1985;1(3):169–74.
3. Sakai K.Free vascularized bone and periosteal graft for pseudarthrosis in the upper limb. J Jpn Soc Surg Hand. 1988;5:698–704.
4. Sakai K, Doi K, Kawai S.Free vascularized thin corticoperiosteal
graft. Plast Reconstr Surg. 1991;87(2):290–8.
5. Doi K, Sakai K.Vascularized periosteal bone graft from the supracondylar region of the femur. Microsurgery. 1994;15(5):305–15.
6. Fuchs B, Steinmann SP, Bishop AT.Free vascularized corticoperiosteal bone graft for the treatment of persistent nonunion of the
clavicle. J Shoulder Elb Surg. 2005;14(3):264–8.
7. Huang TC-T, Sabbagh MD, Lu C-K, Steinmann SP, Moran SL.The
vascularized medial femoral condyle free ap for reconstruction
of segmental recalcitrant nonunion of the clavicle. J Shoulder Elb
Surg. 2019;28(12):2364–70.
8. Aibinder W, Torchia M, Bishop A, Shin A.Vascularized medial
femoral condyle graft for manubrium nonunion: case report and
review of the literature. J Surg Orthop Adv. 2017;26(3):173–9.
9. Muramatsu K, Doi K, Ihara K, Shigetomi M, Kawai S.Recalcitrant
posttraumatic nonunion of the humerus: 23 patients reconstructed
with vascularized bone graft: 23 patients reconstructed with vascularized bone graft. Acta Orthop Scand. 2003;74(1):95–7.
10. Yajima H, Maegawa N, Ota H, Kisanuki O, Kawate K, Takakura
Y. Treatment of persistent non-union of the humerus using a vas-
cularized bone graft from the supracondylar region of the femur. J
Reconstr Microsurg. 2007;23(2):107–13.
11. Sammer DM, Bishop AT, Shin AY. Vascularized medial femoral
condyle graft for thumb metacarpal reconstruction: case report. J
Hand Surg Am. 2009;34(4):715–8.
12. Doi K, Oda T, Soo-Heong T, Nanda V. Free vascularized
bone graft for nonunion of the scaphoid. J Hand Surg Am.
2000;25(3):507–19.
13. Larson AN, Bishop AT, Shin AY. Free medial femoral condyle
bone grafting for scaphoid nonunions with humpback deformity
and proximal pole avascular necrosis. Tech Hand Up Extrem Surg.
2007;11(4):246–58.
14. Jones DB Jr, Bürger H, Bishop AT, Shin AY.Treatment of scaphoid
waist nonunions with an avascular proximal pole and carpal collapse. A comparison of two vascularized bone grafts. J Bone Joint
Surg Am. 2008;90(12):2616–25.
15. Choudry UH, Bakri K, Moran SL, Karacor Z, Shin AY.The vascularized medial femoral condyle periosteal bone ap for the treatment
of recalcitrant bony nonunions. Ann Plast Surg. 2008;60(2):174–80.
16. Higgins JP, Bürger HK.Osteochondral aps from the distal femur:
expanding applications, harvest sites, and indications. J Reconstr
Microsurg. 2014;30(7):483–90.
17. Kazmers NH, Rozell JC, Rumball KM, Kozin SH, Zlotolow DA,
Levin LS.Medial femoral condyle microvascular bone transfer as
a treatment for capitate avascular necrosis: surgical technique and
case report. J Hand Surg Am. 2017;42(10):841.e1–6.
18. Hachisuka H, Sunagawa T, Ochi M, Morrison WA.A vascularized
medial femoral condyle cortico-periosteal graft for total lunate
reconstruction. J Orthop Sci. 2020;25(2):354–8.
19. Hertel R, Masquelet AC.The reverse ow medial knee osteoperiosteal ap for skeletal reconstruction of the leg. Description and
anatomical basis. Surg Radiol Anat. 1989;11(4):257–62.
20. Cavadas PC, Landín L.Treatment of recalcitrant distal tibial nonunion using the descending genicular corticoperiosteal free ap. J
Trauma Acute Care Surg. 2008;64(1):144–50.
21. Doi K, Hattori Y.Vascularized bone graft from the supracondylar
region of the femur. Microsurgery. 2009;29(5):379–84.
22. Hsu C-C, Loh CYY, Lin C-H, Lin Y-T, Lin C-H, Wong J.The medial
femoral condyle ap to re-vitalise the femoral head for calcaneal
reconstruction. J Plast Reconstr Aesthet Surg. 2017;70(7):974–6.
23. Choi JW, Jeong WS, Kwon SM, Koh KS.Medial femoral condyle
free ap for premaxillary reconstruction in median facial dysplasia.
J Craniofac Surg. 2017;28(1):e57–60.
24. Taylor EM, Wu WW, Kamali P, Ferraro N, Upton J, Lin SJ,
et al. Medial femoral condyle ap reconstruction of a maxillary
defect with a 3D printing template. J Reconstr Microsurg Open.
2017;2(01):e63–8.
25. Banaszewski J, Gaggl A, Andruszko A. Medial femoral condyle
free ap for head and neck reconstruction. Curr Opin Otolaryngol
Head Neck Surg. 2019;27(2):130–5.
26. Martin D, Bitonti-Grillo C, De Biscop J, Schott H, Mondle J,
Baudet J, etal. Mandibular reconstruction using a free vascularised
osteocutaneous ap from the internal condyle of the femur. Br J
Plast Surg. 1991;44(6):397–402.
27. Pulikkottil BJ, Pezeshk RA, Ramanadham SR, Haddock NT.The
medial femoral condyle corticoperiosteal free ap for frontal sinus
reconstruction. J Craniofac Surg. 2017;28(3):813–6.
28. Kollitz KM, Pulos N, Bishop AT, Shin AY.Primary medial femoral condyle vascularized bone graft for scaphoid nonunions with
carpal collapse and proximal pole avascular necrosis. J Hand Surg
(European Volume). 2019;44(6):600–6.
29. Hugon S, Koninckx A, Barbier O.Vascularized osteochondral graft
from the medial femoral trochlea: anatomical study and clinical
perspectives. Surg Radiol Anat. 2010;32(9):817–25.
30. Houdek MT, Matsumoto JM, Morris JM, Bishop AT, Shin
AY. Technique for 3-Dimesional (3D) modeling of osteoarticu-
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A. L. Logli and A. Y. Shin
lar medial femoral condyle vascularized grafting to replace the
proximal pole of unsalvagable scaphoid nonunions. Tech Hand Up
Extrem Surg. 2016;20(3):117–24.
31. Yamamoto H, Jones D Jr, Moran SL, Bishop AT, Shin A.The arterial anatomy of the medial femoral condyle and its clinical implications. J Hand Surg (European Volume). 2010;35(7):569–74.
32. Oh C, Pulos N, Bishop AT, Shin AY.Intraoperative anatomy of the
vascular supply to the medial femoral condyle. J Plast Reconstr
Aesthet Surg. 2019;72(9):1503–8.
33. Iorio ML, Masden DL, Higgins JP.Cutaneous angiosome territory
of the medial femoral condyle osteocutaneous ap. J Hand Surg
Am. 2012;37(5):1033–41.
34. Iorio ML, Masden DL, Higgins JP. The limits of medial
femoral condyle corticoperiosteal aps. J Hand Surg Am.
2011;36(10):1592–6.
35. Lesh ML, Schneider DJ, Deol G, Davis B, Jacobs CR, Pelligrini
VD Jr. The consequences of anterior femoral notching in total knee
arthroplasty: a biomechanical study. JBJS. 2000;82(8):1096.
36. Kakar S, Duymaz A, Steinmann S, Shin AY, Moran
SL.Vascularized medial femoral condyle corticoperiosteal aps
for the treatment of recalcitrant humeral nonunions. Microsurgery.
2011;31(2):85–92.
37. Giusti G, Bishop AT, Shin AY.Overstufng of unstable scaphoid
nonunions: a radiographic analysis of carpal parameters. J Hand
Surg Am. 2019;44(5):423.e1–6.
Medial Sural Artery Perforator Flap
DimitrisReissis, DariushNikkhah, BernardLuczak,
andGeorgiosOrfaniotis
40
40.1 Introduction
First described by Pedro Cavadas in 2001 [1], the Medial
Sural Artery Perforator (MSAP) ap has quickly become a
workhorse ap for reconstruction of both the head and neck
and distal extremities [2, 3]. It is an evolution of the gastrocne-
mius muscle ap (Fig.40.1), based on the musculocutaneous
perforators arising through the medial gastrocnemius muscle.
Most commonly harvested as a free ap, the MSAP is
primarily used to reconstruct small- to medium-sized defects
where thin pliable tissue is required [4–6]. It is particularly
useful for intra-oral reconstruction [7–14], for example after
partial glossectomy. It is also used in reconstruction of lower
leg, foot and ankle defects [4, 15–17], as well as full thickness defects of the hand [18–21], where other traditional
aps such as the ALT may be too bulky.
It also has a role as a pedicled ap [22, 23], for defects
around the knee and upper leg, and can include a muscle
component if required to ll dead space. It is a particularly
versatile ap, with potential to tailor the ap design with
multiple skin paddles each based on their own musculocutaneous perforators. It can also be harvested as a chimeric ap
[24–26] including sections of plantaris tendon [18], sural
[27] or saphenous nerve [19] for composite reconstruction
tailored to the defect.
In view of its inconspicuous donor site and reduced donor
morbidity with preservation of major vessels, the MSAP has
D. Reissis (*) . D. Nikkhah
Royal Free Hospital, London, UK
e-mail: dreissis@nhs.net
B. Luczak
Royal Perth Hospital, Western Australia, Australia
G. Orfaniotis
Guy’s and St Thomas’ Hospital, London, UK
notable advantages over other free aps such as the radial
forearm free ap [28–31], for similar reconstructive
indications.
40.2 Anatomy
The MSAP ap is located along an axis drawn from the midpoint of the popliteal crease to the medial malleolus of the
ankle. Thus the skin paddle overlies the medial gastrocnemius muscle.
The arterial supply is based on musculocutaneous perforators originating from the supercial branch of the medial
sural artery, which itself is a branch of the popliteal artery at
the level of the knee joint [32–34].
The distribution of these musculocutaneous perforators
are variable, but almost universally present in all patients.
Cavadas originally described an average of 2.2 perforators
that can sustain the MSAP ap [1]. Further anatomical studies demonstrate a range of 2–8 perforators supplying the
medial sural artery perforator territory, usually with a dominant perforator present [11, 34]. The intra-muscular branching patterns of the medial sural artery perforators has been
classied as having single vessel perforators in 31%, two in
59% and three or more in 10% cases [32].
The perforators are most commonly located 12–17 cm
below the popliteal crease along the line drawn from the midpoint of the popliteal crease to the prominence of the medial
malleolus [32]. A dominant perforator is most often found 13
(±2) cm inferior and 2.5 (±1) cm lateral to the midpoint of the
popliteal crease [32]. No perforator is found either less than
6cm or more than 18cm below the popliteal crease [11, 34].
The course of the perforator is intra-muscular through the
medial head of gastrocnemius. The pedicle initially runs
proximally towards the popliteal crease in the supercial
muscle bres of medial gastrocnemius muscle. After a short
supercial course the vessel deepens down into the belly of
gastrocnemius muscle giving multiple branches around
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_40
385
386
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D. Reissis et al.
Fig.40.1 (a) Pre-op markings of the pedicled Gastrocnemius muscle
ap with the primary incision already made. The ap most often utilises
the medial head of the gastrocnemius muscle, which in this case will be
used to reconstruction a defect on the antero-lateral aspect of the knee.
(b) Dissection of the medial head of gastrocnemius muscle, prior to
division of the distal tendinous insertion. (c) Tension-free transfer of the
pedicled gastrocnemius muscle ap into the recipient site defect on the
antero-lateral knee. The muscle and distal tendon are secured in place
and a skin graft placed over the muscle. (d) Healed gastrocnemius muscle ap with overlying skin graft at 6months post-operatively. (Case
Courtesy of D Nikkhah)
360°. Occasionally, the perforator may initially travel suprafascially along the muscle fascia for some distance prior to
perforating through the supercial fascia, which must be
identied early during dissection to avoid pedicle injury [4].
The length of the pedicle can range from 8 to 16 cm,
depending on the location of the perforator and degree of
dissection towards its origin from the medial sural artery [35,
36]. The arterial diameter of the vascular pedicle taken up to
the medial sural artery is most commonly 1–2mm [11]. This
allows for tailoring of the pedicle length and vessel diameter
to the defect being reconstructed and recipient vessels available. In the case of trauma or prior radiation to the recipient
site, one can harvest a pedicle of adequate length to allow
microvascular anastomosis outside the zone of trauma or
radiation, with access to a choice of recipient vessels, for
either end-to-end or end-to side anastomosis.
Venous outow is via the venae comitantes which parallel
the course of the perforators and have a slightly larger diameter than the artery (3.5mm). If required, an additional vein
such as the short or long saphenous vein can be incorporated
into the MSAP to improve venous drainage.
No nerve is usually included in the ap meaning it is
insensate. However, harvesting the MSAP with a segment of
the sural, saphenous or motor nerve to the gastrocnemius
muscle as a nerve graft, may allow for functional reconstruction in the appropriate patient and setting [27].
The thickness of the aps usually is as thin as 5 mm
(range, 4–8mm), allowing for a smooth prole where thin
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