Medial Sural Artery Perforator Flap Aided by Ultrasonic Perforator Localization for Reconstruction After Oral Carcinoma Resection

Evolution and Diversity of Medial Sural Artery Perforator Flap for Hand Reconstruction

The free medial sural artery perforator (MSAP) flap is a recently popularized flap. It has evolved from a composite myocutaneous flap to a pedicled perforator flap for lower limb reconstruction. It is also a versatile free perforator flap for extremity and head and neck reconstruction. The diversity of the flap designs with options for harvest of non-vascularized grafts enhances the versatility for hand and upper limb reconstruction. The adjunctive use of endoscopy and indocyanine green fluorescence imaging studies can assist and demystify the flap anatomy. The authors present their experience using free MSAP flaps for complex mutilated hand and upper extremity reconstruction.

Medial sural artery perforator free flap versus radial forearm free flap in oral cavity reconstruction and donor site morbidity

OBJECTIVE

Radial Forearm Free flap (RFFF) is widely used in head and neck reconstruction, yet its donor site defect remains a significant drawback. The Medial Sural Artery Perforator Free Flap (MSAPFF) is considered an alternative flap to RFFF. This study aims to comprehensively analyze their characteristics, outcomes, and their impact on patient quality of life.

METHODS

All patients who underwent oral cavity reconstruction using RFFF and MSAPFF between February 2017 and April 2023 were included in this study. Flap characteristics, outcomes and post-operative complications were recorded and compared. Subjective donor site morbidity, aesthetic and functional results, and quality of life were also analyzed.

RESULTS

The study included 76 patients: 37 underwent reconstruction with RFFF, and 39 with MSAPFF. There was no significance difference between the RFFF and MSAPFF regarding the success rate (97.2% vs 97.4%), flap size (4.8 × 8.8 cm2 vs 5 × 9.8 cm2), hospital of stay (15.5 days vs 13.5 days) and recipient site complications (P > 0.05). However, MSAPFF showed larger flap thickness (P = 0.001), smaller arterial caliber (P = 0.008), shorter pedicle length (P = 0.001), and longer harvesting time (P < 0.001). No significant difference was observed between the pre-and postoperative ranges of wrist and ankle movements or in recipient site complications. MSAPFF showed a significant difference in donor site morbidity (P < 0.05).

CONCLUSION

The MSAPFF is an excellent alternative to the RFFF for repairing oral cavity defects, with additional advantage of a well-hidden scar on the posterior calf, a larger flap thickness, accepted pedicle length and arterial caliber. However, one should consider the harvesting time and surgical skills required in comparison to the RFFF.

CLINICAL RELEVANCE

The study highlights the importance of the MSAPFF as an alternative option for RFFF with less donor site morbidity and high success rate in oral cavity reconstruction and improved patient Quality of life after ablative surgery.

Utility of preoperative colour flow Doppler assessment of perforator anatomy in medial sural artery perforator (MSAP) free flaps

PURPOSE

It is known that the vascular perforators upon which the medial sural artery perforator (MSAP) flap is based are subject to considerable variation. This study seeks to evaluate the use of colour flow Doppler (CFD) as an imaging technique to establish the presence of suitable vessels, the discriminatory findings from that imaging, the rate of flap abandonment and flap complications.

METHODS

All patients undergoing MSAP in our institution since 2015 had a pre-operative CFD using a standardised technique. A prior group of 22 patients not having CFD acted as a control group. Data were  collected prospectively.

RESULTS

Fourteen patients had CFD. In one patient, no suitable vessels were found. In 13 patients, vessels of suitable size and position were identified, which then correlated precisely with operative findings. Three had suitable vessels in one leg only. No flaps in the CFD group were abandoned. One flap in the CFD group was partially lost. One flap in the prior control group was abandoned.

CONCLUSIONS

CFD provided reliable discriminatory information to decide on flap suitability/which leg and correlated precisely with operative findings, with no flap abandonment. Flap survival rate was very high.

The Medial Sural Artery Perforator Flap versus Other Free Flaps in Head and Neck Reconstruction: A Systematic Review

The medial sural artery perforator (MSAP) flap is a versatile fasciocutaneous flap, and yet is less commonly utilized than other free flaps in microvascular reconstructions of the head and neck. The aim is to conduct a high-quality Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)- and Assessment of Multiple Systematic Reviews 2 (AMSTAR 2)-compliant systematic review comparing the use of the MSAP flap to other microvascular free flaps in the head and neck. Medline, Embase, and Web of Science databases were searched to identify all original comparative studies comparing patients undergoing head and neck reconstruction with an MSAP flap to the radial forearm free flap (RFFF) or anterolateral thigh (ALT) flap from inception to February 2021. Outcome studied were the recipient-site and donor-site morbidities as well as speech and swallow function. A total of 473 articles were identified from title and abstract review. Four studies met the inclusion criteria. Compared with the RFFF and the ALT flaps, the MSAP flap had more recipient-site complications (6.0 vs 10.4%) but less donor-site complications (20.2 vs 7.8%). The MSAP flap demonstrated better overall donor-site appearance and function than the RFFF and ALT flaps ( p  = 0.0006) but no statistical difference in speech and swallowing function following reconstruction ( p  = 0.28). Although higher quality studies reviewing the use of the MSAP flap to other free flaps are needed, the MSAP flap provides a viable and effective reconstructive option and should be strongly considered for reconstruction of head and neck defects.

The Versatility of the Pedicled Medial Sural Artery Perforator Flap: From Simple to Its Chimeric Pattern and Clinical Experience with 37 Cases

BACKGROUND

Defects in the knee area, popliteal fossa region, and upper third of the lower extremity can pose a challenge for reconstructive plastic surgeons. The purpose of this article is to report the authors' experience with the use of the pedicled medial sural artery perforator flap in its simple and chimeric form for reconstruction of defects in three different regions: knee, popliteal fossa, and proximal lower leg.

METHODS

From April of 2018 to April of 2019, 37 patients (29 men and eight women) with a mean age of 51 years (range, 18 to 78 years) underwent reconstruction with 37 pedicled medial sural artery perforator flaps. All flaps were harvested as pedicled perforator flaps in conventional or chimeric fashion and were based on one or two perforators. The defect locations included the knee (18 cases), popliteal fossa (seven cases), and proximal lower leg (12 cases). The cause of reconstruction was trauma in 22 patients (59 percent), tumor in 10 patients (27 percent), and donor-site closure of free medial sural artery perforator in five patients (14 percent).

RESULTS

The flap sizes varied from 3.5 × 5 cm to 5 × 10 cm. All but one flap, which showed distal tip necrosis, survived completely after surgery. The donor sites were all closed primarily. Minor complications included flap dehiscence (two cases) and minor wound infection delaying the healing process (four cases). All complications were treated conservatively. Follow-up observations were conducted for 3 to 12 months, and all patients had good functional recovery with satisfactory cosmetic results.

CONCLUSION

The pedicled medial sural artery perforator flap can be considered an optimal method of reconstruction for covering defects not only in the knee area but also in the popliteal fossa and upper lower leg.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

The Effect of Medial Sural Artery Perforator Flap on Reconstruction of Soft Tissue Defects: A Meta-Analysis With Multiple Free Soft Flaps

BACKGROUND

With the gradual popularity of relatively novel medial sural artery perforator flap (MSAPF), robust studies are needed to compare the surgical outcomes of MSAPF versus multiple free soft flaps (MFSFs) to verify the advantages and disadvantages of MSAPF.

METHODS

The authors searched PubMed, Web of Science, EMBASE, Cochrane Library, Chinese BioMedical Literature Database (CBM), and China National Knowledge Infrastructure (CNKI) until September, 2020, to identify studies that compared surgical outcomes of MSAPF and MFSFs. Two authors followed the PRISMA guidelines, individually extracted the data and performed the quality assessments. Survival rate of flaps, satisfaction degree of patients in recipient and donor site, skin grafting, and morbidity of recipient and donor site were evaluated.

RESULTS

A total of 441 cases from 7 studies were included in our analysis. No significant differences were found regarding survival rate of flaps, recipient morbidity, and recipient satisfaction degree between the 2 groups. However, MSAPF group was significantly superior to MFSFs group in terms of skin grafting, morbidity, and satisfaction degree of donor site.

CONCLUSION

Our meta-analysis showed that the MSPAF and MFSFs groups were similar in terms of survival rate of flaps, recipient morbidity, and recipient satisfaction degree. Medial sural artery perforator flap group was superior to MFSFs group in terms of morbidity and satisfaction degree of donor site. The results may prove that MSAPF is gaining popularity for a reason and is a good choice for repairing soft tissue defects.

[Research progress of clinical application of medial sural artery perforator flap]

Objective

To review the research progress of the clinical application of the medial sural artery perforator flap (MSAPF).

Methods

The relevant domestic and abroad literature on the clinical application of MSAPF was extensively consulted, and the research progress were summarized and analyzed in aspect of its definition, anatomical characteristics, clinical application, surgical resection and improvement, and advantages and disadvantages of flaps, etc.

Results

MSAPF has the advantages of relatively constant anatomical position, thin flap texture, long vascular pedicle, large vessel diameter, no sacrifice of main blood vessels, concealed donor site, no hair, and fewer complications; it can carry nerves, tendons, and muscles to construct chimeric flaps to repair three-dimensional wounds; and can also repair wounds with high aesthetic and functional requirements such as hand, foot and ankle, head and neck, etc.

Conclusion

The MSAPF is a versatile, various forms, functional diversification, and three-dimensional flap donor site with various application forms and ideal repair effectiveness.

The chimeric medial sural artery perforator flap as the ideal for partial tongue reconstruction: A case series and technical refinements

BACKGROUND

The medial sural artery perforator free flap (MSAP) has gained increasing popularity in head and neck reconstruction. Its slightly bulkier nature than the radial forearm flap, combined with negligible donor site morbidity, makes it an ideal candidate for the reconstruction of partial glossectomy defects. The ability to harvest the MSAP as a chimeric flap with a portion of the medial gastrocnemius muscle gives it greater flexibility in soft tissue reconstruction.

METHODS

A retrospective study of patients with partial glossectomy defects reconstructed using the MSAP by a single surgeon was performed. Perioperative data, donor and recipient site characteristics, complications, and outcomes were analyzed. A video is included to show technical points for the harvest of the flap.

RESULTS

A total of 10 patients were included. The average age was 59.1 years, with a mean of 43.5% of the tongue resected. All flaps survived, with no major complications. At follow-up, the patients had regained an average of 86.5% of original speech, with none requiring NG feeding. The average MSAP skin flap thickness was 7.8 mm, with 6 flaps being harvested as chimeric fasciocutaneous muscle flaps. Five flaps incorporated 2 perforators. Two case examples are presented.

CONCLUSION

The chimeric MSAP perforator allows for more robust partial glossectomy reconstruction with improved postoperative functional outcomes. It should be considered as the workhorse flap for partial tongue reconstruction.

A Head-to-Head Comparison of the Medial Sural Artery Perforator versus Radial Forearm Flap for Tongue Reconstruction

BACKGROUND

 For tongue reconstruction, the radial forearm flap (RFF) is commonly used. In the last decade, the medial sural artery perforator (MSAP) flap has been successfully used with reportedly superior donor-site outcomes. Our study is the first to compare the RFF and MSAP for reconstruction of partial glossectomy defects (<50% of tongue).

METHODS

 We conducted a retrospective review of 20 patients with partial glossectomy defects reconstructed at a tertiary referral center. Patient demographics, perioperative data, and postoperative complications were analyzed. Objective measures of speech, swallowing, and subjective patient satisfaction with their donor site were recorded.

RESULTS

 Ten RFF and MSAP were each used, with a mean partial glossectomy defect size of 40.5 and 43.5%, respectively. The MSAP was significantly thicker (7.8 vs. 4.3 mm, p < 0.05) with a longer harvest time (122.5 vs. 75.0 minutes, p < 0.05). There were no cases of free flap failure. Donor-site healing times were comparable, but the MSAP group experienced significantly less donor-site complications (n = 1 vs. n = 7, p < 0.05). Functional outcomes were comparable with 13 patients achieving normal speech and diet after 3 months (MSAP = 6 vs. RFF = 7, p = 1.00). All patients were satisfied with their donor-site outcome with the MSAP group having a marginally higher score.

CONCLUSION

 Both flaps are good options for partial glossectomy reconstruction. Though more challenging to harvest, the MSAP gives comparable functional results and has become our first reconstructive option given its superior donor-site outcomes.

Extended Use of Chimeric Medial Sural Artery Perforator Flap for 3-Dimensional Defect Reconstruction

BACKGROUND

The medial sural artery perforator (MSAP) flap has become increasingly popular because it is thin and pliable for small to moderate defect soft tissue reconstruction. Furthermore, chimeric MSAP flap, which includes a skin paddle and a separated piece of medial gastrocnemius muscle, allowed more freedom for flap insetting, especially in 3-dimensional defect reconstruction. Here we describe our experience regarding this clinical application.

PATIENTS AND METHODS

From 2007 to 2016, 14 male patients (average age, 46.9 ± 14.4 years) who received either a free or pedicled chimeric MSAP flap were included. Of these 14 patients, 7 received this flap for reconstruction in the head and neck, 2 in the upper extremities, and 5 in the lower extremities. Demographic data were collected and analyzed, and a literature review was performed.

RESULTS

Ten patients received free chimeric MSAP flap, and 4 received the pedicled type. Thirteen of the 14 flaps (92.6%) survived, and 1 failed 2 days later owing to venous insufficiency. Venous congestion-related partial loss occurred in another case.

CONCLUSIONS

The chimeric MSAP flap is a good alternative for deep space obliteration or reconstruction of adjacent but separate defects in both free and pedicled flap design. Donor site morbidity is limited. However, the perforator needs to be mobilized carefully to prevent postoperative venous compromise.

Anatomical study and clinical application of medial sural artery perforator flap for oral cavity reconstruction

The present study aims to provide anatomical evidence for clinical application of the medial sural artery perforator (MSAP) flap. The current study investigated the vascular anatomy of the flap, evaluated the postoperative appearance and function of the donor and recipient sites, and investigate the clinical value in reconstruction of oral cavity. Six lower limbs of Chinese adult cadavers were microsurgically dissected. The locations and courses of the medial sural artery perforators were identified and recorded, which provided an anatomical basis for clinical application. Then, 16 clinical cases employing this flap were evaluated, ranging from 3×4cm to 6×8cm, and were employed for defects in the oral cavity region. Sixteen clinical cases with intraoral soft tissue defects, which included four clinical cases with inner cheek defects, were successfully followed up for 10-47 months (24 months on average). The donor site function, contour of recipient site and oral function recovery were evaluated as acceptable or better in cases with intraoral soft tissue defect, which were further verifying the value of clinical application of MSAP in repairing oral cavity defects. Moreover, two typical clinical cases were described in detail. To conclude, the MSAP flap is a favorable choice for small- to medium-size defects based on minor donor site morbidity, satisfactory oral function recovery, perforator stability and adaptation of the pedicle for anastomosis in the oral cavity region.

[The sural medial perforator flap: Anatomical bases, surgical technique and indications in head and neck reconstruction]

INTRODUCTION

The medial sural artery perforator (MSAP) flap is defined as a thin cutaneo-adipose perforator flap harvested on the medial aspect of the leg. The aims of this study were to describe the anatomical basis as well as the surgical technique and discuss the indications in head and neck reconstructive surgery.

MATERIAL AND METHODS

We harvested 10 MSAP flap on 5 fresh cadavers. For each case, the number and the location of the perforators were recorded. For each flap, the length of pedicle, the diameter of source vessels and the thickness of the flap were studied. Finally, we performed a clinical application of a MSAP flap.

RESULTS

A total of 23 perforators with a diameter superior than 1mm were dissected on 10 legs. The medial sural artery provided between 1 and 4 musculocutaneous perforators. Perforators were located in average at 10.3cm±2cm from the popliteal fossa and at 3.6cm±1cm from the median line of the calf. The mean pedicle length was 12.1cm±2.5cm. At its origin, the source artery diameter was 1.8mm±0.25mm and source veins diameters were 2.45mm±0.9mm in average. There was no complication in our clinical application.

DISCUSSION

This study confirms the reliability of previous anatomical descriptions of the medial sural artery perforator flap. This flap was reported as thin and particularly adapted for oral cavity reconstruction and for facial or limb resurfacing. Sequelae might be reduced as compared to those of the radial forearm flap with comparable results.