SLR - November 2012 - Nicholas R. Schmerbach(2)
Reference: Kosutic, D., Pejkovic, B., Anderhuber, F., Vadnjal-Donlagic, S., Zic, R., Gulic, R., Krajnc, I., Solman, L., Kocbek, L. (2012) Complete mapping of lateral and medial sural artery perforators: Anatomical study with Duplex-Doppler ultrasound correlation. Journal of Plastic, Reconstructive & Aesthetic Surgery.
Scientific Literature Review
Reviewed by: Nicholas R. Schmerbach, DPM
Residency Program: Columbia St. Mary’s Hospital, Milwaukee, WI
Podiatric Relevance:
The use of rotational flaps for soft tissue coverage throughout the foot and ankle is an incredible resource for the coverage of soft tissue defects, both large and small. Podiatric surgeons throughout the world are using such flaps to help cover soft tissue defects on both the foot and ankle. This article helps to point out that there is a great amount of variability in the overall blood supply and perforators of the commonly used sural artery flap. Pointing out and confirming this variability helps to further reiterate the fact that such flaps should only be performed by podiatric surgeons with extensive training in plastic surgery techniques and great knowledge of the blood supply to the flap.
Methods:
This study included both an anatomical and duplex-doppler ultrasound study. The anatomical study was of 16 cadaveric lower limbs to assess the position and number of medial and lateral sural artery perforators in relation to five different anatomical landmarks, including the medial and lateral condyles, medial and lateral malleolus and calcaneus. This was done by anatomical dissection of the 16 limbs with color-latex injection into arterial vasculature to visualize the medial and lateral perforators. The perforators were then visualized, counted, measured in diameter and measurements made from each exit point in the fascia to the five anatomical landmarks. Results were then recorded and analyzed. The second aspect of the study included duplex-doppler examination of 32 lower extremities to assess the location of dominant medial and lateral sural artery perforators in relation to the same five anatomical landmarks. This was done on 16 healthy individuals for a total of 32 lower limbs. Each limb was examined for medial and lateral sural perforators with the use of colored Duplex-Doppler ultrasound. The threshold used for a dominant vessel was greater than five mm. All dominant perforator vessels, both medial and lateral, were identified and measurements to each of the five anatomical landmarks were performed.
Results:
The anatomical study showed a two-to-one ratio of males to females with an age range from 18 to 81; with nine right and seven left lower limbs. The study showed 134 musculocutaneous perforating branches of the medial and lateral sural artery with 64 being lateral and 70 being medial. There were a total of six dominant lateral perforators and 26 dominant medial perforators. There was a dominant lateral sural artery perforator in 9.4 percent of all dissected lateral sural artery perforators and dominant medial sural artery perforator in 37.2 percent of all dissected medial sural artery perforators. There was no significant difference between dominant medial and lateral sural artery perforators in relation to distances from the five anatomical landmarks. In the duplex-doppler ultrasound aspect of the study only dominant perforators of the lateral and medial sural artery were examined with the total number of perforators in the 32 limbs identified being 100. Of the 100 perforators identified, 49 were lateral and 51 medial. The difference in number of dominant medial and lateral sural artery perforators between the anatomic and duplex-doppler study were statistically significant.
Conclusions:
Overall, the study confirms that there is a great variability of the location and number of medial and lateral sural artery perforators and confirms the need for preoperative planning and mapping prior to any flap procedure. The study also confirms that duplex-doppler ultrasound continues to be a viable option for preoperative flap planning as a result of its accuracy and precision in locating dominant sural artery perforators, both medial and lateral.