Is the Medial Sural Artery Perforator Flap a New Workhorse Flap? A Systematic Review and Meta-Analysis

Abstract

Background: The medial sural artery perforator flap offers thin, pliable tissue with a relatively long pedicle and low donor-site morbidity. This study explores the characteristics and uses of the medial sural artery perforator flap along with postoperative outcomes and complications. Methods: A systematic literature review was performed using PubMed, Embase, and Cochrane Central Register of Controlled Trials to identify all cases of medial sural artery perforator flap reconstruction. Descriptive and meta-analyses were performed on pooled outcomes. Multivariate logistic regression identified factors associated with increased complication rates. Results: Thirty-five studies encompassing 526 medial sural artery perforator flaps were included for analysis. The most common reasons for surgery were oncologic (47.6 percent) and traumatic injuries (31.8 percent). The oral cavity was the most common recipient location (45.5 percent). Average flap dimensions were 6.0 ± 2.3 cm × 9.8 ± 3.6 cm, with an average pedicle length of 10.1 ± 6.6 cm. Meta-analysis revealed an overall complication rate of 14.3 percent (Q value = 22.16; p = 0.877; I 2= −39.9). Use of chimeric medial sural artery perforator flaps was associated with significantly higher rates of complications (OR, 3.92; p = 0.039; 95 percent CI, 1.10 to 13.89). The majority of flap donor sites were closed primarily (68 percent) versus 32 percent that were covered with split-thickness skin grafts. A flap width greater than 5.75 cm had an odds ratio of 5.3 (95 percent CI, 1.3 to 21.8; p = 0.014) of having a donor-site complication if closed primarily. Conclusions: The medial sural artery perforator flap offers thin, pliable tissue with a relatively long pedicle and has minimal donor-site morbidity when the donor site is managed appropriately. As such, it should be considered a workhorse flap for both head and neck and extremity reconstruction.

Extended medial sural artery perforator free flap for groin and scrotal reconstruction

“…The flap dimensions were 25 cm × 10 cm, which is the largest reported MSAP in the literature. In addition, the pedicle length was 16 cm, which, although not the longest reported, is significantly longer than the average pedicle length of 10.1 cm [4].…”

“…The most frequent recipient sites are the oral cavity and foot/ankle. Other common recipient sites include the head/ neck, hand/wrist, and lower extremity [4]. It may be used as a A left chimeric medial sural artery perforator flap measuring 25 cm × 10 cm and included three perforators, two veins, and the posterior femoral cutaneous nerve was harvested for resurfacing of the wounds and scrotal reconstruction.…”

“…In cases without favorable vessel anatomy, harvesting a large flap may significantly increase the risk of total or partial necrosis. A further limitation is anatomic variability of the perforators with respect to location and caliber noted by some authors [4]. The use of perioperative imaging in the form of Doppler ultrasonography and computed tomographic angiography can improve the accuracy of perforator assessment [14].…”

“…Several decades would pass, however, before Montegut and Allen [ 2 ], Cavadas et al [ 3 ], and others applied such flaps clinically, eventually refining them to perforator-based flaps that spared the underlying gastrocnemius muscle. Many authors would now consider the medial sural artery perforator (MSAP) flap an excellent option for numerous reconstructive challenges [ 4 ]. The MSAP flap is a relatively thin and pliable fasciocutaneous flap with a long vascular pedicle and vessels of adequate caliber for microsurgical anastomosis.…”

Split median superficial sural artery perforator (MSSAP) flap and medial sural artery perforator (MSAP) flap for posterior thigh sarcoma reconstruction

“…Yet it still encourages for innovation in the harvest of local, pedicled and free fasciocutaneous flaps. Pedicled perforator flap variability provides an alternative to free tissue transfer for local reconstructions for both oncological and trauma cases 4 5. Precise identification of suitable perforators requires increased attentiveness due to substantial individual variability in lower limb arterial anatomy.…”