Medial sural artery perforator flap: a challenging free flap

Abstract

BackgroundOral and extremity defect reconstruction can often require a flap that is thin, and traditionally, the radial forearm free flap has been used, however, this has significant donor site morbidity. Over the last decade, the medial sural artery perforator (MSAP) flap has emerged as a possible alternative with lower donor site morbidity. We present our experiences and review the literature regarding this promising but challenging flap.MethodsThe study was a retrospective case series in a university hospital setting. All patients who had a MSAP flap performed at our institution were included until March 2015, and their data was retrieved from electronic patient records.ResultsIn total, ten patients were reconstructed with a MSAP flap for floor of mouth (eight) and lower extremity (two) defect reconstruction. The median flap dimensions were as follows: 10 cm (range 7–14 cm), width 5 cm (range 3.5–8 cm), thickness 5 mm (range 4–8 mm), and pedicle length 10 cm (range 8–12 cm). In one case, the procedure was abandoned because of very small perforators and another flap was used. In two cases, late onset of venous congestion occurred which could not be salvaged. There were no donor site complaints.ConclusionsThe MSAP flap is an ideal flap when a thin free flap is needed with lower donor site morbidity than alternative solutions. There seems to be a higher rate of late onset of venous thrombosis compared with more established flaps. Therefore, this flap should be monitored more closely for venous problems and we recommend performing two venous anastomoses when using this flap.Level of Evidence: Level IV, therapeutic study.

The medial sural artery perforator flap: A better option in complex head and neck reconstruction?

“…Kao et al directly compared the MSAP and RFFF, demonstrating a 100% success rate in both flaps but with better subjective functional and cosmetic outcomes in the MSAP cohort. Although the RFFF risks tendon exposure, always requires coverage with a skin graft or other method, and is in a visible area of the forearm, we have shown the MSAP donor site can be well‐hidden in the medial leg (Fig. ).…”

“…The same surgical method was used in each case, similar to the surgical technique already reported in previous studies . A two‐team approach was used in each case.…”

“…In recent years, the radial forearm free flap (RFFF) and anterolateral thigh (ALT) flap have been the workhorses of head and neck reconstruction . RFFF is pliable and thin with a lengthy pedicle; however, it incurs significant donor site morbidity due to potential tendon exposure and excessive scarring, limitation in flap size and volume, and sacrifice of one of the two major arteries that supplies the distal upper extremity.…”

“…This flap has rarely been described in the otolaryngology literature, and the description and use of this flap is largely limited to plastic surgery and oral and maxillofacial literature . This may be in part due to the steep learning curve reported for this flap and the higher incidence of complications reported . However the paucity of otolaryngological literature suggests that this flap may be underutilized in this population.…”

Nose resurfacing with free fasciocutaneous flaps in burns patients

“…However, we preferred ulnar forearm flap due to its superior donor site cosmesis (Hsiao et al, 2016). Additionally, we found that MSAP flap can be another suitable choice, with its similar characteristics to the forearm flap, but less donor site morbidity (Ives & Mathur, 2015;Kao, Chang, Wei, & Cheng, 2009;Nugent, Endersby, Kennedy, & Burns, 2015;Toyserkani & Sørensen, 2015;Xie & Chai, 2012). With careful planning and meticulous dissection, we tend to gradually avoid the forearm flap and use this flap as a free flap in nose resurfacing.…”