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Mohamed AAS, Mai L, Mashrah MA, Fan S, Wang S, Lin Z, Pan C. Medial sural artery perforator free flap versus radial forearm free flap in oral cavity reconstruction and donor site morbidity. Clin Oral Investig 2024; 28:269. [PMID: 38656417 DOI: 10.1007/s00784-024-05618-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 03/12/2024] [Indexed: 04/26/2024]
Abstract
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.
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Affiliation(s)
- Abdo Ahmed Saleh Mohamed
- Department of Oral & Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang Road, Guangzhou, 510120, China
| | - Lianxi Mai
- Department of Oral & Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang Road, Guangzhou, 510120, China
| | - Mubarak Ahmed Mashrah
- Department of Oral Implant, Guangdong Engineering Research of Oral Restoration and Reconstruction, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Song Fan
- Department of Oral & Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang Road, Guangzhou, 510120, China
| | - Shuang Wang
- Department of Oral & Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang Road, Guangzhou, 510120, China
| | - Zhaoyu Lin
- Department of Oral & Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang Road, Guangzhou, 510120, China.
| | - Chaobin Pan
- Department of Oral & Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yanjiang Road, Guangzhou, 510120, China.
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Maier MA, Palines PA, Guidry RF, Stalder MW. Use of Flow-through Free Flaps in Head and Neck Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5588. [PMID: 38504941 PMCID: PMC10950194 DOI: 10.1097/gox.0000000000005588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 12/11/2023] [Indexed: 03/21/2024]
Abstract
Background Reconstructive obstacles in composite head and neck defects are compounded in reoperated, traumatized, irradiated, and vessel-depleted surgical fields. In cases that require multiple free flaps, recipient vessel accessibility and inset logistics become challenging. Strategic flow-through flap configurations mitigate these issues by supplying arterial inflow and venous outflow to a second flap in a contiguous fashion. This approach (1) permits the use of a singular native recipient vessel, (2) increases the reach of the vascular pedicle, avoiding the need for arteriovenous grafting, and (3) allows for a greater three-dimensional flexibility in configuring soft tissue and bony flap inset. Methods To demonstrate this technique, we conducted a retrospective review of all head and neck reconstruction patients presenting to us from March 2019 to April 2021. Results We present seven oncological and two traumatic patients (N = 9) who received flow-through free flaps for head and neck reconstruction. The most common flap used as the flow-through flap was the anterolateral thigh flap (N = 7), followed by the fibula flap (N = 2). Mean follow-up time was 507 days. No flap failures occurred. Conclusion In head and neck reconstruction, the use of the flow-through principle enables uninterrupted vascular flow for two distinct free flaps in single-stage reconstruction for patients with vessel-depleted, irradiated, and/or reoperated fields. We demonstrate that flow-through flaps in the head and neck may be used successfully for a variety of cases and flaps.
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Affiliation(s)
- Mark A. Maier
- From the School of Medicine, Louisiana State University Health Sciences Center, New Orleans, La
| | - Patrick A. Palines
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, La
| | - Richard F. Guidry
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, La
| | - Mark W. Stalder
- Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, La
- University Medical Center—LCMC Health, New Orleans, La
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Lee ZH, Canzi A, Yu J, Chang EI. Expanding the Armamentarium of Donor Sites in Microvascular Head and Neck Reconstruction. J Clin Med 2024; 13:1311. [PMID: 38592147 PMCID: PMC10932027 DOI: 10.3390/jcm13051311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/03/2024] [Accepted: 02/23/2024] [Indexed: 04/10/2024] Open
Abstract
The field of microsurgical head and neck reconstruction has witnessed tremendous advancements in recent years. While the historic goals of reconstruction were simply to maximize flap survival, optimizing both aesthetic and functional outcomes has now become the priority. With an increased understanding of perforator anatomy, improved technology in instruments and microscopes, and high flap success rates, the reconstructive microsurgeon can push the envelope in harvesting and designing the ideal flap to aid patients following tumor extirpation. Furthermore, with improvements in cancer treatment leading to improved patient survival and prognosis, it becomes increasingly important to have a broader repertoire of donor sites. The present review aims to provide a review of newly emerging soft tissue flap options in head and neck reconstruction. While certainly a number of bony flap options also exist, the present review will focus on soft tissue flaps that can be harvested reliably from a variety of alternate donor sites. From the upper extremity, the ulnar forearm as well as the lateral arm, and from the lower extremity, the profunda artery perforator, medial sural artery perforator, and superficial circumflex iliac perforator flaps will be discussed, and we will provide details to aid reconstructive microsurgeons in incorporating these alternative flaps into their armamentarium.
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Affiliation(s)
| | | | | | - Edward I. Chang
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX 77030, USA
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Suda S, Hayashida K. Crafting Contours: A Comprehensive Guide to Scrotal Reconstruction. Life (Basel) 2024; 14:223. [PMID: 38398732 PMCID: PMC10890180 DOI: 10.3390/life14020223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 01/29/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024] Open
Abstract
This review delves into reconstructive methods for scrotal defects arising from conditions like Fournier's gangrene, cancer, trauma, or hidradenitis suppurativa. The unique anatomy of the scrotum, vital for thermoregulation and spermatogenic function, necessitates reconstruction with thin and pliable tissue. When the scrotal defect area is less than half the scrotal surface area, scrotal advancement flap can be performed. However, for larger defects, some type of transplantation surgery is required. Various options are explored, including testicular transposition, tissue expanders, split-thickness skin grafts, local flaps, and free flaps, each with merits and demerits based on factors like tissue availability, defect size, and patient specifics. Also, physicians should consider how testicular transposition, despite its simplicity, often yields unsatisfactory outcomes and impairs spermatogenesis. This review underscores the individuality of aesthetic standards for scrotal reconstruction, urging surgeons to tailor techniques to patient needs, health, and defect size. Detailed preoperative counseling is crucial to inform patients about outcomes and limitations. Ongoing research focuses on advancing techniques, not only anatomically but also in enhancing post-reconstruction quality of life, emphasizing the commitment to continuous improvement in scrotal reconstruction.
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Affiliation(s)
| | - Kenji Hayashida
- Division of Plastic and Reconstructive Surgery, Faculty of Medicine, Shimane University, 89-1 Enya-cho, Izumo 693-8501, Japan;
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Wu RT, Lin CH, Hsu CC, Wei FC. Evolution of free flap reconstruction in the upper extremity: perspective from a tertiary plastic and reconstructive institution. J Hand Surg Eur Vol 2024; 49:8-16. [PMID: 37812517 DOI: 10.1177/17531934231181995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
Soft tissue reconstruction of the upper extremity requires consideration of wound bed status, varied anatomic composition, future function and tissue match, whether in thickness, pliability or involvement of other tissue components. Of the options available, microvascular free tissue flaps allow maximal customizability with the avoidance of long-term donor site morbidity. Free tissue transfers have evolved, given increased surgical proficiency, from direct vessel-based flaps to septocutaneous vessel-based flaps, to musculocutaneous perforator flaps, and most recently to free-style free flaps. With increases in technical complexity come limitless alternatives. We documented the progression of free flap upper extremity reconstruction in recreating form and function of the upper extremity. The foundations laid should allow surgeons the freedom and versatility to choose the most faithful restoration of the defect and produce the best functional and aesthetic results.
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Affiliation(s)
- Robin T Wu
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan
- Department of Reconstructive Microsurgery, Medical College, Chang Gung University, Taoyuan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Hospital, Stanford, CA, USA
| | - Chih-Hung Lin
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan
- Department of Reconstructive Microsurgery, Medical College, Chang Gung University, Taoyuan
| | - Chung-Chen Hsu
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan
- Department of Reconstructive Microsurgery, Medical College, Chang Gung University, Taoyuan
| | - Fu-Chan Wei
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan
- Department of Reconstructive Microsurgery, Medical College, Chang Gung University, Taoyuan
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Chen X, Fu K, Lai Y, Dong C, Chen Z, Huang Y, Li G, Jiang R, Wu H, Wang A, Huang S, Shen L, Gao W, Li S. Tetrahydropalmatine: Orchestrating survival - Regulating autophagy and apoptosis via the PI3K/AKT/mTOR pathway in perforator flaps. Biomed Pharmacother 2023; 169:115887. [PMID: 37984303 DOI: 10.1016/j.biopha.2023.115887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/07/2023] [Accepted: 11/13/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Introduced in clinical practice in 1989, perforator flaps are vital for tissue defect repair, but they are challenged by distal necrosis. Tetrahydropalmatine (THP) from celandine is renowned for its anti-inflammatory and analgesic effects. This study investigates THP's use in perforator flaps. METHODS Thirty rats were divided into a control group and four THP concentration groups, while seventy-eight rats were categorized as control, THP, THP combined with rapamycin (RAP), and RAP alone. We created 11 cm by 2.5 cm multi-regional perforator flaps on rat backs, assessing survival blood flow and extracting skin flap tissue for autophagy, oxidative stress, apoptosis, and angiogenesis markers. RESULTS The THP group exhibited significantly reduced distal necrosis, increased blood flow density, and survival area on the seventh day compared to controls. Immunohistochemistry and Western blot results demonstrated improved anti-oxidative stress and angiogenesis markers, along with decreased autophagy and apoptosis indicators. Combining THP with RAP diminished flap survival compared to THP alone. This was supported by protein expression changes in the PI3K-AKT-mTOR pathway. CONCLUSION THP enhances flap survival by modulating autophagy, reducing tissue edema, promoting angiogenesis, and mitigating apoptosis and oxidative stress. THP offers a potential strategy for enhancing multi-regional perforator flap survival through the PI3K/AKT/mTOR pathway. These findings highlight THP's promise in combatting perforator flap necrosis, uncovering a novel mechanism for its impact on flap survival.
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Affiliation(s)
- Xuankuai Chen
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325027, China; Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou 325027, China
| | - Kejian Fu
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325027, China; Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou 325027, China
| | - Yingying Lai
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325027, China; Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou 325027, China
| | - Chengji Dong
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325027, China; Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou 325027, China
| | - Zhuliu Chen
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325027, China; Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou 325027, China
| | - Yingying Huang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325027, China; Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou 325027, China
| | - Guangyao Li
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325027, China; Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou 325027, China
| | - Renhao Jiang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325027, China; Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou 325027, China
| | - Hongqiang Wu
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325027, China; Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou 325027, China
| | - Anyuan Wang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325027, China; Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou 325027, China
| | - Shaojie Huang
- Wenzhou Medical University School of Laboratory Medicine and Life Sciences, China
| | - Liyan Shen
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325027, China; Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou 325027, China
| | - Weiyang Gao
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325027, China; Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou 325027, China
| | - Shi Li
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou 325027, China; Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China; The Second School of Medicine, Wenzhou Medical University, Wenzhou 325027, China.
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Steel BJ, Mehta D, Nugent M, Wilson A, Burns A. Utility of preoperative colour flow Doppler assessment of perforator anatomy in medial sural artery perforator (MSAP) free flaps. Oral Maxillofac Surg 2023; 27:655-659. [PMID: 35982365 DOI: 10.1007/s10006-022-01108-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 08/02/2022] [Indexed: 10/15/2022]
Abstract
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.
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Affiliation(s)
- Ben J Steel
- Oral & Maxillofacial Surgery Department, Sunderland Royal Hospital, Kayll Road, Sunderland, SR4 7TP, UK.
| | - Darpan Mehta
- Oral & Maxillofacial Surgery Department, Sunderland Royal Hospital, Kayll Road, Sunderland, SR4 7TP, UK
| | - Michael Nugent
- Oral & Maxillofacial Surgery Department, Sunderland Royal Hospital, Kayll Road, Sunderland, SR4 7TP, UK
| | - Ajay Wilson
- Oral & Maxillofacial Surgery Department, Sunderland Royal Hospital, Kayll Road, Sunderland, SR4 7TP, UK
| | - Andrew Burns
- Oral & Maxillofacial Surgery Department, Sunderland Royal Hospital, Kayll Road, Sunderland, SR4 7TP, UK
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Yen CI, Lu YJ, Kao HK, Huang JJ, Wu CW, Chang CS, Chen HC, Hsiao YC. A 10-year experience in microsurgical reconstruction of the nose with a lower extremity flap. J Plast Reconstr Aesthet Surg 2023; 85:10-17. [PMID: 37453411 DOI: 10.1016/j.bjps.2023.06.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 05/29/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Traditionally, radial forearm free flaps are utilized for nasal lining reconstruction when local flaps cannot provide adequate coverage. However, according to our clinical observation, the skin of the forearm flap is relatively thin and prone to collapse. We present a series of nasal reconstructions using free flaps harvested from the lower extremities to determine if the thick flap could provide more support and decrease the tendency of airway collapse. METHODS From March 2011 to July 2021, we identified 15 patients who underwent total or subtotal nasal reconstruction with free flap from the lower extremities (10 anterolateral thigh flap, 4 medial sural artery perforator flap, and 1 profunda artery perforator flap). We included 15 patients who underwent free forearm flap reconstruction as controls. The Nasal Obstruction Symptoms Evaluation (NOSE) score was utilized to subjectively evaluate the degree of nasal obstruction symptoms. RESULTS The lower extremity group had a lower NOSE score than the forearm group (25.4 vs. 40). It took more time (6.5 vs. 4.2 months) and more surgeries (4.6 vs. 2.6) from the first free flap reconstruction till forehead flap reconstruction in the lower extremity group than in the forearm group, although the total number of surgeries was comparable between the 2 groups (7.2 vs. 8.1). CONCLUSIONS Utilizing free flaps from the lower extremities in total or subtotal reconstruction of the nasal lining may decrease the tendency of flap collapse and alleviate airway obstruction symptoms and may also allow reconstruction of surrounding defects simultaneously compared with using forearm flaps.
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Affiliation(s)
- Cheng-I Yen
- Department of Plastic and Reconstructive Surgery, Aesthetic Medical Center of Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yun-Jui Lu
- Department of Plastic and Reconstructive Surgery, Aesthetic Medical Center of Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Huang-Kai Kao
- Department of Plastic and Reconstructive Surgery, Aesthetic Medical Center of Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jung-Ju Huang
- Department of Plastic and Reconstructive Surgery, Aesthetic Medical Center of Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Wei Wu
- Vendome Private Practice Aesthetic Medical Center, Taipei, Taiwan
| | - Chun-Shin Chang
- Department of Plastic and Reconstructive Surgery, Aesthetic Medical Center of Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hung-Chang Chen
- Department of Plastic and Reconstructive Surgery, Aesthetic Medical Center of Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yen-Chang Hsiao
- Department of Plastic and Reconstructive Surgery, Aesthetic Medical Center of Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Muacevic A, Adler JR, Prakash G, Gupta M, Nagrajan N. The Medial Sural Artery Perforator Free Flap: A Novel, yet Challenging and Versatile Flap for Head and Neck Reconstruction. Cureus 2022; 14:e32572. [PMID: 36654627 PMCID: PMC9840734 DOI: 10.7759/cureus.32572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2022] [Indexed: 12/23/2022] Open
Abstract
Background In head and neck reconstruction, especially after cancer ablation, choosing the best flap is critical. Due to its thin, lengthy, and malleable vascular pedicle as well as low donor site morbidity, the medial sural artery perforator (MSAP) free flap is gaining popularity among reconstructive surgeons, particularly in oral soft-tissue reconstructions. The goal of this study was to record the clinical use of an MSAP flap in the repair of post-oncologic lesions in the head and neck region. Methodology Patients with oral cancer who came to our center after ablative surgery on the buccal mucosa, tongue, floor of the mouth, and hard palate were repaired utilizing the MSAP flap. Preoperatively, the perforators were discovered using an 8 MHz portable doppler and a computed tomography angiogram. Without the use of a tourniquet, the flaps were delineated and harvested. In all of our patients, a single venous anastomosis was sufficient. Results The MSAP flap was used to positively rebuild 14 cancer patients, with the flap design based on the amount of the resection site or defect. The buccal mucosa (n = 7) and tongue (n = 6) were the most common subsites of the ablative defect. The average flap size was 12 × 6 cm, with a thickness of 5-7 mm. In eight cases, the donor site defect was mostly closed, with the remaining patients receiving split-thickness grafts for subsequent healing. In 12 cases, the best cosmetic and functional results were obtained. One patient developed a postoperative wound infection, and the flap could not be saved. Another patient developed a neck hematoma which had to be debrided on the second postoperative day, with good results. In primary closure cases, patients were mobilized with full weight-bearing on the first postoperative day. Conclusions MSAP flap is an alternative to radial forearm free flap and anterolateral thigh flap in obese patients with medium-sized oral abnormalities. This flap stands out as an outstanding option for head and neck soft-tissue reconstruction due to its unique mix of flap thinness, greater skin region, and superior donor site cosmesis. Despite its importance, just a few case studies and reports have been published. A multicenter trial with a high sample size would demonstrate the use of this flap and its chimeric designs.
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Santamaría-Córdoba N, Alejandro Déniz Martínez A, Guillermo Ayala Parra D. The antegrade flow pedicled medial sural artery perforator flap for knee soft-tissue reconstruction following high-voltage electrical burn injuries. BURNS OPEN 2022. [DOI: 10.1016/j.burnso.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Hallock GG. The Medial Sural Artery Perforator Flap: A Historical Trek from Ignominious to “Workhorse”. Arch Plast Surg 2022; 49:240-252. [PMID: 35832674 PMCID: PMC9045491 DOI: 10.1055/s-0042-1744425] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Rather than just another “review,” this is intended to be an “overview” of the entire subject of the medial sural artery perforator (MSAP) flap as has been presented in the reconstructive literature from its inception in 2001 until the present, with any exceptions not purposefully overlooked. Unfortunately, the pertinent anatomy of the MSAP flap is always anomalous like most other perforator flaps, and perhaps even more variable. No schematic exists to facilitate the identification of a dominant musculocutaneous perforator about which to design the flap, so some adjunctive technology may be highly valuable for this task. However, if a relatively thin free flap is desirable for a small or moderate sized defect that requires a long pedicle with larger caliber vessels, the MSAP flap deserves consideration. Indeed, for many, this has replaced the radial forearm flap such as for partial tongue reconstruction. Most consider the donor site deformity, even if only a conspicuous scar on the calf, to be a contraindication. Yet certainly if used as a local flap for the knee, popliteal fossa, or proximal leg, or as a free flap for the ipsilateral lower extremity where a significant recipient site deformity already exists, can anyone really object that this is not a legitimate indication? As with any perforator flap, advantages and disadvantages exist, which must be carefully perused before a decision to use the MSAP flap is made. Perhaps not a “workhorse” flap for general use throughout the body, the MSAP flap in general may often be a valuable alternative.
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Affiliation(s)
- Geoffrey G. Hallock
- Division of Plastic Surgery, St. Luke's Hospital, Sacred Heart Division, Allentown, Pennsylvania
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Perforator-based Adipofascial Flaps and ADM: A Novel Combined Approach to Distal Lower Extremity Defects. Plast Reconstr Surg Glob Open 2022; 10:e4131. [PMID: 35198355 PMCID: PMC8856593 DOI: 10.1097/gox.0000000000004131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/14/2021] [Indexed: 11/25/2022]
Abstract
Due to the wide spectrum of lower extremity defect presentation, various reconstructive techniques are available. Classic adipofascial flaps are still a second choice. The authors described a new multistage reconstructive approach with perforator-based pedicled adipofascial flap.
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13
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The Effect of Medial Sural Artery Perforator Flap on Reconstruction of Soft Tissue Defects: A Meta-Analysis With Multiple Free Soft Flaps. J Craniofac Surg 2021; 32:1689-1695. [PMID: 33273197 DOI: 10.1097/scs.0000000000007294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
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.
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Fritz C, Meroni M, Fritsche E, Rajan G, Scaglioni MF. Free double-paddle posterior tibial artery perforator flap for hypopharynx reconstruction: A case report and literature review. Microsurgery 2021; 41:660-665. [PMID: 34289177 DOI: 10.1002/micr.30790] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 06/30/2021] [Accepted: 07/09/2021] [Indexed: 01/09/2023]
Abstract
Microsurgical free tissue transfer is nowadays considered to be one of the main options for head and neck reconstruction. The free posterior tibial artery perforator (PTAP) flap is a well-known reconstructive technique for local defect coverage in the distal leg, and only recently has been employed for head and neck reconstructions. Being a very thin and pliable flap, with low donor site morbidity and constant anatomy, the PTA perforator-based flap could be a great alternative to the more commonly-employed radial forearm free flap (RFFF). The present case report shows a complex head and neck defect coverage by means of a free double-paddle PTA flap, with a concise literature review of previous PTA flap descriptions in this setting. A 59-year-old male patient presented with a hypopharynx leakage after radiotherapy due to hypopharynx carcinoma. Since the patient had an occluded ulnar artery on the left side and an arterial line in the radial artery on the right side, both a RFFF and an ulnar artery perforator (UAP) flap were contraindicated. Moreover, two different cutaneous flaps were needed to reconstruct a 6 × 8 cm2 defect, one for the reconstruction of the hypopharynx and one for the resurfacing of the neck, since previous surgeries and radiotherapy led to severe fibrosis of the neck. The patient had a BMI of 25.4 kg/m2, which led us to exclude the anterolateral thigh (ALT) flap because of its thickness. For the forementioned reasons, an unconventional double-paddle PTAP flap based on two perforator vessels was chosen. Based on two perforators, two skin islands were harvested, building a double-paddle PTA perforator-based flap. The proximal skin island was 6 × 7 cm2 and the distal one was 6 × 4 cm2 . The larger skin flap was set at the leakage of the hypopharynx. The smaller skin island was used to monitor the survival of the whole flap and for resurfacing the outer side of the neck. The postoperative course was uneventful and at 3 months follow up the reconstructive result was good with no functional drawback. In view of the obtained result, we can consider that the PTA flap might be a reliable alternative to the much widely used RFFF, with a minor donor site morbidity, for delicate head and neck reconstructions.
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Affiliation(s)
- Caroline Fritz
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Matteo Meroni
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Elmar Fritsche
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Gunesh Rajan
- Department of Otolaryngology, Head and Neck Surgery, Luzerner Kantonsspital, Lucerne, Switzerland.,Otolaryngology, Head and Neck Surgery, Medical School, University of Western Australia, Perth, Australia
| | - Mario F Scaglioni
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
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15
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Fang J, Chen B, Wu Y, Tang Z, Ren F, Zhang W. [Research progress of clinical application of medial sural artery perforator flap]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:508-513. [PMID: 33855838 DOI: 10.7507/1002-1892.202011032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Jie Fang
- Department of Hand Surgery, Clinical Anatomy Laboratory, Xuzhou Ren Ci Hospital, Xuzhou Jiangsu, 221000, P.R.China
| | - Buguo Chen
- Department of Hand Surgery, Clinical Anatomy Laboratory, Xuzhou Ren Ci Hospital, Xuzhou Jiangsu, 221000, P.R.China
| | - Yao Wu
- Department of Hand Surgery, Clinical Anatomy Laboratory, Xuzhou Ren Ci Hospital, Xuzhou Jiangsu, 221000, P.R.China
| | - Zhaolin Tang
- Department of Hand Surgery, Clinical Anatomy Laboratory, Xuzhou Ren Ci Hospital, Xuzhou Jiangsu, 221000, P.R.China
| | - Fei Ren
- Department of Hand Surgery, Clinical Anatomy Laboratory, Xuzhou Ren Ci Hospital, Xuzhou Jiangsu, 221000, P.R.China
| | - Wenlong Zhang
- Department of Hand and Foot Surgery, Tianjin Union Medical Center, Tianjin, 300121, P.R.China
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16
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Ooi ASH, Ng MJM, Sudirman SRB, Chang D. The chimeric medial sural artery perforator flap as the ideal for partial tongue reconstruction: A case series and technical refinements. J Plast Reconstr Aesthet Surg 2021; 74:2613-2621. [PMID: 33972203 DOI: 10.1016/j.bjps.2021.03.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 01/29/2021] [Accepted: 03/11/2021] [Indexed: 01/21/2023]
Abstract
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.
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Affiliation(s)
- Adrian S H Ooi
- Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Singapore; SingHealth Duke-NUS Head and Neck Center, SingHealth, Singapore; Polaris Plastic & Reconstructive Surgery, Singapore.
| | - Marcus J M Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - David Chang
- Section of Plastic Surgery, The University of Chicago Medicine & Biological Sciences, Chicago, IL, USA
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17
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Bera RN, Tiwari P. Do medial sural artery perforator flaps have better clinical outcomes compared to the rectus abdominis perforator (DIEAP) flap in reconstruction of glossectomy defects? A Prisma guided meta-analysis. Ann Maxillofac Surg 2021; 11:121-128. [PMID: 34522666 PMCID: PMC8407617 DOI: 10.4103/ams.ams_339_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 02/16/2021] [Accepted: 02/24/2021] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND There is an increasing evidence for the use of thin flaps based on vascular perforators for reconstructive surgeries. The medial sural and deep inferior epigastric artery flaps offer versatility for the reconstruction of major defects of the head and neck. OBJECTIVES "Whether medial sural artery perforator (MSAP) flap or rectus abdominis perforator flap is better for the reconstruction of glossectomy defects in terms of functional outcome?" DATA SOURCES PubMed, Cochrane Library, clinicaltrials.gov and hand searches. PARTICIPANTS AND INTERVENTIONS Patients who underwent tongue reconstruction with either MSAP flap or deep inferior epigastric artery perforator (DIEAP) flap. STUDY APPRAISAL AND SYNTHESIS METHODS Based on defined study criteria 6 studies were selected according to Prisma Guidelines. The overall estimated effect was categorized as significant where P < 0.05. RESULTS There was no significant difference between both flaps in terms of receptor site complications (P = 0.223). Overall odds ratio (OR) for complications was 1.35 (95% confidence interval [CI]: 0.412-0.736) and the test for overall effect t value was 2.836, P < 0.05. Overall OR was 6.01 (95% CI 0.5-7.45) and the test for overall effect t value was 1.41, P < 0.05 indicating there was a statistical difference in the intelligibility of speech. LIMITATIONS Anatomical variations, under-reporting of studies and lack of universal tool for speech intelligibility. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Both the flaps are comparable in terms of functional outcome. Medium-sized defects can be reconstructed with MSAP and composite larger defects would benefit from DIEAP. In females, anterolateral thigh flap still remains the choice for composite reconstructions.
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Affiliation(s)
- Rathindra Nath Bera
- Unit of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, Institute of Medical Sciences Trauma Centre BHU, Varanasi, Uttar Pradesh, India
| | - Preeti Tiwari
- Unit of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, Institute of Medical Sciences Trauma Centre BHU, Varanasi, Uttar Pradesh, India
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18
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Mashrah MA, Aldhohrah TA, Abdelrehem Moustafa A, Al-Sharani HM, Alrmali A, Wang L. Are hand biomechanics affected following radial forearm flap harvest? A systematic review and meta-analysis. Int J Oral Maxillofac Surg 2021; 50:21-31. [PMID: 32665139 DOI: 10.1016/j.ijom.2020.06.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 06/20/2020] [Accepted: 06/26/2020] [Indexed: 11/19/2022]
Abstract
Donor site morbidity following radial forearm flap (RFF) harvest remains a controversial issue. The aim of this meta-analysis was to answer the question "Are the range of wrist movements (range of motion, ROM) and hand strength affected after RFF harvesting?" The PubMed, Embase, Scopus, and Cochrane Library electronic databases were systematically searched (to December 2019). Self-controlled studies evaluating hand biomechanics after RFF harvest were included. Weighted mean differences with 95% confidence intervals were calculated using the random-effects model. The outcome variables were ROM, forearm movements, grip, and pinch strengths. Thirteen studies involving a total of 335 patients were included. With the exception of grip strength and supination, which showed statistically significant reductions of about 2.40 kg and 2.86° (P < 0.05), all other ROM, forearm movements, and pinch strengths showed an insignificant difference when the operated hand was compared to the non-operated hand (P > 0.05). Regression analysis showed that the method of donor site closure and size of the donor site defect had an insignificant impact on hand biomechanics. This study confirms the lack of discernible biomechanical morbidity after RFF transfer. The minimal reduction in hand biomechanics after RFF is considered to be clinically negligible.
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Affiliation(s)
- M A Mashrah
- Key Laboratory of Oral Medicine, Guangzhou Institute of Oral Disease, Stomatology Hospital of Guangzhou Medical University, Guangdong, Guangzhou, China.
| | - T A Aldhohrah
- Guanghua Stomatology Hospital, Sun Yat-Sen University, Guangdong, Guangzhou, China
| | - A Abdelrehem Moustafa
- Department of Craniomaxillofacial and Plastic Surgery, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
| | | | - A Alrmali
- Faculty of Dentistry, Tripoli University, Tripoli, Libya
| | - L Wang
- Key Laboratory of Oral Medicine, Guangzhou Institute of Oral Disease, Stomatology Hospital of Guangzhou Medical University, Guangdong, Guangzhou, China.
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Stocco C, Murphy DC, Gargiulo M, Marasca D, Figus A, Razzano S. Superficial peroneal nerve accessory artery (SPNAA) flap for head and neck reconstruction: A cadaveric anatomical study and retrospective case series review. J Plast Reconstr Aesthet Surg 2020; 74:1524-1533. [PMID: 33288472 DOI: 10.1016/j.bjps.2020.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 10/30/2020] [Accepted: 11/12/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Several different flaps can reconstruct intraoral defects or lower limb deficits after free fibula osteo-cutaneous flap harvesting for jaw reconstructions. However, commonly used options may not be available for various reasons and can be associated with significant morbidity. We hypothesized that flaps supplied by the superficial peroneal nerve accessory artery (SPNAA) could be a viable alternative reconstructive option. METHODS We describe the SPNAA's anatomy using 20 human cadaveric leg dissections and report eight cases involving SPNAA-based perforator flap reconstructions (six propeller flaps and two free flaps) in a retrospective case series. Patient-specific baseline variables and intraoperative and postoperative outcomes are described. RESULTS Cadaveric dissection suggests that the location of the SPNAA is reliable but its origin varies, with 40% (N = 8) of SPNAAs being of type I origin, 20% type II (N = 4), and 40% (N = 8) type III in our series. All reconstructions were successful. No intraoperative complications occurred during propeller or free-flap reconstructions. No flap failures occurred. One propeller reconstruction showed distal superficial skin necrosis and one donor site wound dehisced; both were successfully managed conservatively. No other short-term or long-term complications occurred. CONCLUSIONS Flaps based on SPNAA perforators appear effective, reliable, and safe reconstructive methods for covering fibula osteocutaneous donor site defects and for intraoral reconstructions. Controlled trials are required to compare its effectiveness and safety with other reconstructive methods.
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Affiliation(s)
- Chiara Stocco
- Department of Medical, Surgical and Health Sciences, Plastic and Reconstructive Surgery Unit, University of Trieste, Trieste, Italy
| | - Declan C Murphy
- Institute of Genetic Medicine, Newcastle University, Tyne and Wear, United Kingdom; Northumbria Healthcare NHS Foundation Trust, Tyne and Wear, United Kingdom.
| | - Maurizio Gargiulo
- Department of Maxillo-Facial Surgery, A. Cardarelli Hospital, Naples, Italy
| | - Dario Marasca
- Department of Odontostomatology, A. Cardarelli Hospital, Naples, Italy
| | - Andrea Figus
- Plastic Surgery and Microsurgery Unit, University Hospital, Duilio Casula, Cagliari, Italy; Department of Surgical Sciences, Faculty of Medicine, University of Cagliari, Italy
| | - Sergio Razzano
- Department of Plastic Surgery and Burns, A. Cardarelli Hospital, Naples, Italy
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20
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Ng MJM, Goh CSL, Tan NC, Song DH, Ooi ASH. A Head-to-Head Comparison of the Medial Sural Artery Perforator versus Radial Forearm Flap for Tongue Reconstruction. J Reconstr Microsurg 2020; 37:445-452. [PMID: 33032358 DOI: 10.1055/s-0040-1718551] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Marcus J M Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Cindy S L Goh
- Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Singapore
| | - Ngian Chye Tan
- SingHealth Duke-NUS Head and Neck Center, SingHealth, Singapore
| | - David H Song
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Adrian S H Ooi
- Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Singapore.,SingHealth Duke-NUS Head and Neck Center, SingHealth, Singapore
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21
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22
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The Medial Sural Artery Perforator Flap: Lessons Learned from 200 Consecutive Cases. Plast Reconstr Surg 2020; 146:630e-641e. [DOI: 10.1097/prs.0000000000007282] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Extended medial sural artery perforator free flap for groin and scrotal reconstruction. Arch Plast Surg 2020; 47:354-359. [PMID: 32252207 PMCID: PMC7398806 DOI: 10.5999/aps.2019.01921] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 02/05/2020] [Indexed: 11/30/2022] Open
Abstract
The medial sural artery perforator (MSAP) flap is a versatile fasciocutaneous flap that has been used successfully in the reconstruction of defects across the body. In specific cases, it may prove superior to more commonly used options (e.g., anterolateral thigh flap and radial forearm free flap). Historically, a disadvantage of the MSAP flap is the relatively small surface area it provides for reconstruction. We recently encountered a patient with extensive pelvic injuries from prior trauma resulting in significant scarring and contracture of the groin, tethering of the penis, and loss of the scrotum and one testicle. The patient was unable to achieve erection from tethering and his remaining testicle had been buried in the thigh. In considering the reconstructive options, he was not a suitable candidate for a thigh-based or forearmbased flap. An extended MSAP flap measuring 25 cm×10 cm was used for resurfacing of the groin and pelvis as well as for the formation of a neoscrotum. This report is the first to document an MSAP flap utilized for simultaneous groin resurfacing and scrotoplasty. Additionally, the dimensions of this flap make it the largest recorded MSAP flap to date.
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Al-Himdani S, Din A, Wright TC, Wheble G, Chapman TWL, Khan U. The medial sural artery perforator (MSAP) flap: A versatile flap for lower extremity reconstruction. Injury 2020; 51:1077-1085. [PMID: 32192717 DOI: 10.1016/j.injury.2020.02.060] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 02/02/2020] [Accepted: 02/10/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND The medial sural artery perforator (MSAP) flap provides a thin, pliable and durable soft tissue reconstruction with adequate pedicle length and low donor morbidity. It is an ideal choice for small-to-moderate defects of the lower extremity, although it does have limitations. We report our experience of the flap in a three-pronged anatomical, clinical and patient reported outcome-based study. METHODS Cadaveric fresh frozen lower limbs (n = 10) were used for anatomical dissections to assess pertinent and clinically relevant findings. Data relating to MSAP flaps was collected from a prospectively maintained database over a 2-year period. Both clinical data and modified Enneking scores were analysed. RESULTS Anatomical study: A mean of 2.1 ± 0.99 perforators arose from the medial sural artery, located 11.9 cm ± 2.07 along the line between the popliteal fossa and medial malleolus. The largest perforator was located 13.58 cm ± 2.01 from the popliteal artery. The distance from the dominant perforator to the first branching point within the gastrocnemius was 7.39 ± 1.50 (range 5-9.2 cm). The short saphenous vein was located on average 3.08 cm ± 0.77 from the dominant perforator. Clinical study: Twenty free and nine pedicled MSAPs were included (n = 29). Open lower limb fractures (n = 18, 62%) and infection (n = 10, 35%) were the most common aetiologies. Defects sites included: foot-and-ankle (n = 12, 55%), knee (n = 9, 31%) and anterior leg (n = 4, 14%). Four patients (14%) required SSG to for donor site coverage. Venous congestion was responsible for partial flap necrosis in 6.9%(n = 2) of patients. All wounds were healed at discharge. At 14 months, the mean Enneking score was 72.5%. All patients were ambulant, 96% returned to work and 87% were using pre-operative footwear. CONCLUSIONS The MSAP provides robust foot-and-ankle reconstruction, whilst permitting glide when over the knee. Patient satisfaction and functional outcomes are excellent with careful patient selection. Care should be taken to avoid compression or kinking of the large, thin walled veins as the most commonly observed complication was venous congestion. We advocate MSAP as a first choice flap for small-to-moderate foot, ankle or knee defects.
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Affiliation(s)
- Sarah Al-Himdani
- Southmead Hospital, North Bristol NHS Trust Westbury-on-Trym, Bristol, BS10 5NB, United Kingdom
| | - Asmat Din
- Southmead Hospital, North Bristol NHS Trust Westbury-on-Trym, Bristol, BS10 5NB, United Kingdom
| | - Thomas C Wright
- Southmead Hospital, North Bristol NHS Trust Westbury-on-Trym, Bristol, BS10 5NB, United Kingdom
| | - George Wheble
- Southmead Hospital, North Bristol NHS Trust Westbury-on-Trym, Bristol, BS10 5NB, United Kingdom
| | - Thomas W L Chapman
- Southmead Hospital, North Bristol NHS Trust Westbury-on-Trym, Bristol, BS10 5NB, United Kingdom
| | - Umraz Khan
- Southmead Hospital, North Bristol NHS Trust Westbury-on-Trym, Bristol, BS10 5NB, United Kingdom.
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25
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Al Deek NF. Amending the Algorithm for Free Perforator Flap Selection in Lower Extremity Reconstruction. Plast Reconstr Surg 2020; 145:881e-882e. [PMID: 32221259 DOI: 10.1097/prs.0000000000006669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Nidal F Al Deek
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taipei, Taiwan
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26
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Mazur N, Osinga R, Lo S. Split median superficial sural artery perforator (MSSAP) flap and medial sural artery perforator (MSAP) flap for posterior thigh sarcoma reconstruction. BMJ Case Rep 2020; 13:13/2/e233352. [PMID: 32029521 DOI: 10.1136/bcr-2019-233352] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Reconstruction of composite defects of the posterior thigh and knee is challenging. Pedicled medial gastrocnemius flaps are the traditional reconstructive approach, but late contractures related to skin grafted muscle may affect knee function. More recently, the medial sural artery perforator (MSAP) flap has been described for such defects, although may necessitate skin grafting of the donor site. To minimise the drawbacks with these options, we describe a combination of a median superficial sural artery perforator (MSSAP) flap and MSAP flap. This allows both tension free closure of the donor site without skin grafting, and facilitates coverage of a round defect by splitting the flap into two adjacent triangular flaps. This is the first report of posterior thigh defect reconstruction with a combination of MSSAP and MSAP flaps.
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Affiliation(s)
- Natalia Mazur
- Medical School, Medical University of Gdansk, Gdansk, Poland.,Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - Rik Osinga
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, Glasgow, UK .,Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland
| | - Steven Lo
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, Glasgow, UK.,Translational Research Center, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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27
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Mashrah MA, Mai L, Wan Q, Huang Z, Wang J, Lin Z, Fan S, Pan C. Posterior Tibial Artery Flap with an Adipofascial Extension. Plast Reconstr Surg 2020; 145:142e-152e. [DOI: 10.1097/prs.0000000000006396] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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28
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Azoury SC, Stranix JT, Piper M, Kovach SJ, Hallock GG. Attributes of Perforator Flaps for Prophylatic Soft Tissue Augmentation Prior to Definitive Total Knee Arthroplasty. J Reconstr Microsurg 2019; 37:51-58. [PMID: 31877565 DOI: 10.1055/s-0039-3401847] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND As our population ages, the demand for total knee arthroplasty (TKA) will dramatically increase to ensure an independent lifestyle with unimpeded and pain-free ambulation. Complications will be inevitable, especially in that patient with preexisting soft tissue deficits or extensive scarring in the knee region. Under these circumstances, prophylactic soft tissue augmentation should be strongly considered and be extremely beneficial. METHODS A retrospective review of all TKA procedures at our institutions over the past two decades revealed seven patients who specifically had soft tissue augmentation prior to their definitive TKA. Each had a single perforator flap used to achieve this. In no cases was a muscle flap used for this purpose. Excluded were all patients who had a flap of any kind for coverage of an exposed prosthesis or to accomplish wound healing after the TKA. RESULTS Seven perforator flaps were utilized in seven patients for soft tissue replacement prior to the ultimate TKA. For smaller defects in three patients, a local island medial sural artery perforator flap was used. For larger defects in four patients, an anterolateral thigh perforator free flap was necessary. All flaps were successful. The only complication was an implant infection after one anterolateral thigh free flap that required a revision arthroplasty that eventually allowed salvage. Unrestricted ambulation was possible in all patients except for one who had a preexisting contralateral below-knee amputation. CONCLUSION As the number of TKA procedures in the near future increases, prevention of the absolute number of complications becomes even more important. An awareness that any knee region suboptimal soft tissue base can lead to wound breakdown and then periprosthetic infection should alert all involved that prevention of this sequela can be best achieved by prior soft tissue augmentation. Preferably, this may be possible by capturing the assets of local and free perforator flaps.
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Affiliation(s)
- Saïd C Azoury
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania
| | - John T Stranix
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania
| | - Merisa Piper
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania
| | - Stephen J Kovach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania
| | - Geoffrey G Hallock
- Division of Plastic Surgery, St. Luke's Hospital, Sacred Heart Division, Allentown, Pennsylvania
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Anatomical study and clinical application of medial sural artery perforator flap for oral cavity reconstruction. Ann Anat 2019; 227:151418. [PMID: 31626903 DOI: 10.1016/j.aanat.2019.151418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 07/22/2019] [Accepted: 09/05/2019] [Indexed: 11/20/2022]
Abstract
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.
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