The medial malleolar network: a constant vascular base of the distally based saphenous neurocutaneous island flap

Based on 30 fresh cadaver dissections a detailed anatomic study of the medial malleolar network is presented with particular attention to the anastomoses between the latter and the vascular axis that follows the saphenous nerve. The medial malleolar network is formed by the anterior medial malleolar artery, branches from the medial tarsal arteries, the posterior medial malleolar artery and branches from the medial plantar artery. A distinct anterior medial malleolar artery and posterior medial malleolar artery could be identified in 80 and 20%, respectively, as well as constant additional small branches arising from the anterior tibial or posterior tibial artery. A constant anastomosis was found between the arcade formed by the medial tarsal arteries and the medial plantar a. in 60%, and the medial branch of the medial plantar artery in 40%, respectively. This anastomosis always gave rise to branches to the medial malleolar network. In the perimalleolar area and with regard to the great saphenous v. a larger anterior and a smaller posterior branch of the saphenous nerve was found in 100 and 90%, respectively. In all dissections, for both branches of the saphenous nerve two to four small, but distinct anastomoses between the medial malleolar network and the perineural vascular axis were identified. These constant anastomoses represent a new and reliable vascular base for the distally-based saphenous neurocutaneous island flap. Thus, the pivotal point of the flap can be chosen in the area of the medial malleolus without respecting the most distal septocutaneous anastomosis between the perineural vascular axis and the posterior tibial artery. Additionally, an illustrative clinical case is presented.