Comparison of the Medial Sural Artery Perforator Flap with the Radial Forearm Flap for Head and Neck Reconstructions:

[Free medial sural artery perforator flap for reconstruction of hand defects]

OBJECTIVE

Defect reconstruction of the hand by means of the free medial sural artery perforator (MSAP) flap.

INDICATIONS

Reconstruction of full-thickness defects on the hand with a thin non-bulky flap in cases of exposure of functional structures or in combination with simultaneous osteosynthetic procedures.

CONTRAINDICATIONS

Prior surgery at the donor site or progressive peripheral artery occlusive disease. Defect size that exceeds the maximum width of the free MSAP flap for primary closure of the donor site. Lack of patient consent or compliance.

SURGICAL TECHNIQUE

Suitable perforators are identified through a medial incision on the calf. The vascular pedicle is then completely followed subfascially along the gastrocnemius muscle until its source vessel the medial sural artery is reached. Subsequently, the flap design is adapted to the perforator anatomy and the flap is completely elevated. Indocyanine green fluorescence angiography can be used to identify the size of the reliable angiosome.

POSTOPERATIVE MANAGEMENT

Close monitoring of the flap is required for the first 48 hours after surgery. Anticoagulation with low-molecular weight heparin should be administered for thrombosis prophylaxis. The hand can be mobilized on the first day after surgery.

RESULTS

Between May 2017 and March 2022 a total of 16 free MSAP flaps were carried out for hand defect reconstruction. All donor sites were primarily closed. The reconstruction was successful in all cases. In one patient venous thrombosis occurred postoperatively, which was successfully revised. In two flaps, surgical hematoma evacuation was necessary within 24 hours after surgery. Complications or wound healing disorders at the donor site were not observed.

Radial and Ulnar Forearm Free Flaps: A Critical Comparison of Donor-Site Morbidity and Its Impact on Quality of Life

BACKGROUND

A poor evidence basis exists regarding directly comparing objective and subjective donor-site morbidity associated with the forearm flap. The authors evaluated the postoperative donor-site complications and quality-of-life outcomes between the radial forearm free flap (RFFF) and the ulnar forearm free flap (UFFF).

METHODS

All patients undergoing RFFF or UFFF harvest were included. Grip strength, pinch strength, wrist range of movement, and testing of skin sensitivity were assessed with the appropriate scales at different time intervals. In addition, appearance and quality of life were assessed using the Patient and Observer Scar Assessment Scale and the Disabilities of Arm, Shoulder, and Hand instruments.

RESULTS

Eighty patients were enrolled (RFFF, n = 40; and UFFF, n = 40). A short-term reduction in grip strength, fine motor skills (tip pinch, key pinch, palmar pinch), and range of motion was observed for the RFFF group and improved over time. None of the patients in either group experienced functional disturbance in grip strength, wrist motion, fine motor skills, or sensation to light touch at 1 year. Nine patients experienced partial skin graft loss (RFFF, n = 6; UFFF, n = 3). There was a significantly higher incidence of temporary numbness in the RFFF group ( P = 0.040). Persistent numbness occurred in 3 cases in the RFFF group. Cold intolerance was significantly lower in the UFFF group (2.5%) than in RFFF group (22.5%). Moreover, the mean Patient and Observer Scar Assessment Scale and Disabilities of Arm, Shoulder, and Hand scores were reduced at 12 months compared with 6 months, significantly superior for UFFF.

CONCLUSIONS

Objective function limitations are reversible short-term effects after forearm flap and do not affect daily routines in the long term. In addition, UFFF appears to be preferred over RFFF for subjective outcomes, which emphasizes that UFFF should be considered as an alternative to RFFF for reconstructing soft-tissue defects.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Head and neck reconstruction with the superficial circumflex iliac artery perforator (SCIP) free flap: Lessons learned after 73 cases

BACKGROUND

Head and neck tissue defects after ablative surgery often require complex and composite reconstructions. The superficial circumflex iliac artery perforator (SCIP) flap is an extremely versatile perforator-based flap with minimal donor site morbidity, which may represent the optimal procedure in this setting. Over the last 5 years, we collected a large base of experience, including both simple and chimeric SCIP-based reconstruction, making this flap our first choice for head and neck reconstructions.

PATIENTS AND METHODS

Seventy-three patients undergoing ablative head and neck surgery for oncologic pathologies were treated by means of a SCIP flap reconstruction. Patients' mean age was 67 years old (range 37-89), 51 were males and 22 were females. Fifty-eight flaps were simple and 15 were chimeric reconstruction patterns. Indocyanine green perfusion imaging was performed in all cases.

RESULTS

All the patients were successfully treated with no flap losses were encountered. Twelve patients encountered postoperative complications: in four cases revision surgery was required for venous congestion, while the remaining cases were managed conservatively (four wound dehiscence and three infections). No patients showed donor site complications. The mean follow-up period was 11 months (range 3-24).

CONCLUSIONS

Our case series demonstrates the reliability and versatility of the SCIP flap for different kinds of head and neck reconstructions. The chimeric options combined with bone, double skin paddle, and muscle offer a broad variety of functional reconstructive solutions for complex head and neck surgeries. Intraoperative indocyanine green perfusion examination provides a valuable tool to assess and ascertain proper vascularization and post-anastomosis vessel patency in complex microvascular flap-based reconstructions.

Characterization of the MSAP Flap in Head and Neck Surgical Oncology: A 3D Cadaveric Study

OBJECTIVES

The medial sural artery (MSA) perforator flap is a versatile free flap. However, the cutaneous perforators are not well characterized. The objectives of this pilot anatomical study were to: (1) visualize in three-dimensions, as in-situ, the origin, course, and distribution of the cutaneous perforators, (2) characterize the number and frequency of the perforators, and (3) quantify mean pedicle length.

METHODS

Thirteen cadaveric specimens were dissected, digitized, and modeled in 3D. Three-dimensional models and dissection photographs were used to determine the origin, course, number, distribution, and pedicle length of MSA perforators.

RESULTS

The most common pattern consisted of three perforators (39% of specimens). The maximum number of perforators identified was four (23%). The majority of specimens (92%) had a cutaneous perforator originating from the lateral branch of the MSA and coursed most frequently in the second (43%) and third (37%) quartiles of the length of the tibia. Mean pedicle length was 19.1 ± 6.9 cm. Perforators originating from the medial branch of the MSA were significantly (p < 0.05) shorter than those from the lateral branch and were found to course only in the first quartile.

CONCLUSION

The 3D models constructed in this study provide a comprehensive overview of the location and course of the perforators, enabling measurement of parameters in 3D-space. Anatomical characterization of the MSA perforator flap using 3D analysis can assist reconstructive surgeons in understanding the relevant anatomy and optimizing the surgical technique for flap harvest.

LEVEL OF EVIDENCE

N/A Laryngoscope, 2024.

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.

A Cadaveric Study on Perforator Anatomy of the Medial Sural Artery Perforator Flap

Background  The medial sural artery perforator (MSAP) flap was described by Cavadas et al in 2001. The aim of this study was to analyze the flap characteristics in the regional population and was planned as a cadaveric dissection study. Methods  Thirty-three legs of fresh cadavers were studied for perforator characteristics, length, and origin of pedicle and skin paddle thickness. Observations were documented and analyzed. Results  Seventeen right legs (51.5%) and sixteen left legs (48.5%) were studied. Twenty-five pedicles originated from popliteal artery (86.2%) and four (13.8%) from the common sural trunk. No perforators were seen in four legs. The mean number of perforators is 2 (0-6). The mean distance of perforator from midpoint of popliteal fossa was 10.7 cm (8-13 cm) and from posterior midline it was 3.2 cm. The mean size of the perforator was 1.1 ± 0.8 mm (0.8-1.5 mm). The mean pedicle length was 9.3 ± 1.3 cm. The mean flap thickness was 4.3 ± 0.7 mm (3.0-5.5 mm). There was no correlation for flap or perforator characteristics with side of leg. Conclusion  This study concludes that MSAP is a good flap in terms of perforator characteristics, pedicle length, and flap thickness, when a medium sized thin flap with long pedicle is needed. The location of perforator on calf varies in different population. Being a perforator flap, anatomical variability is common and should be thought of while choosing this flap.

Reconstruction of Head and Neck Defects Using Medial Sural Artery Perforator Free Flap

AIM

To study the use of medial sural artery perforator (MSAP) free flap in head and neck reconstruction.

MATERIAL AND METHOD

This was a prospective study. The patients with cancers of head and neck underwent excision of tumor along with neck dissection, and MSAP free flap was used for reconstruction.

RESULTS

The free MSAP flaps were used in 30 patients to reconstruct head and neck soft tissue defects. There were sixteen male and six female patients with the median age of 40 years. The most common site of tumor resection was the tongue (14 cases), followed by buccal mucosa (12 cases), neck skin(2 cases), skin over parotid(1 case) and lip(1 case). Average flap size was 56 cm2. Thickness of the flap ranged from 4 to 8 mm. The length of the vascular pedicle ranged from 8 to 14 cm (12 cm mean) which provides sufficient length during vessel anastomosis. Arterial diameter ranged from 1.0 to 1.5 mm(Average - 1.25 mm) and venous diameter of both veins in pedicle ranged from 1.5 to 2.5 mm(Average - 2 mm) in size. Most flaps were based on two perforators. Primary closure was attained in 11 cases whereas 19 patients required split thickness skin graft(STSG). The average flap harvesting time was 45 min. Flap was failed in two cases.

CONCLUSION

MSAP is good alternative to FRAFF in the reconstruction of defect after resection of head and neck cancer.

A 10-year experience in microsurgical reconstruction of the nose with a lower extremity flap

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.

Medial Sural Artery Perforator Flap: A Middle Ground Between Anterolateral Thigh and Radial Forearm Flaps

OBJECTIVE

The medial sural artery perforator (MSAP) flap has gained popularity in head and neck reconstruction primarily as a less morbid alternative to the radial forearm free flap (RFFF). However, no direct comparison of thickness exists among the MSAP, RFFF, and anterolateral thigh (ALT) flaps, which together represent the commonly utilized nonosseus-free flaps in head and neck reconstruction. Thus, this study aimed to compare these flap sites and identify predictors of thickness that will aid in reconstructive surgical planning.

STUDY DESIGN

Cross-sectional study.

SETTING

Tertiary referral hospital.

METHODS

The thickness of skin and subcutaneous tissue at the RFFF, MSAP, and ALT donor sites were measured in 54 adult patients using Doppler ultrasound. General linear models were generated to identify predictors of flap thickness.

RESULTS

The mean thickness of the RFFF, MSAP, and ALT flaps was 3.8 ± 2.2 mm, 7.4 ± 3.8 mm, and 9.6 ± 4.7 mm. Body mass index (BMI) was the only statistically significant contributing factor (p < .0001, coefficient: 0.15) for the RFFF. MSAP was affected by age (p = .006, coefficient = 0.06), female gender (p < .0001, coefficient = 3.2), and BMI (p < .001, coefficient = 0.25), while the ALT was affected by female gender (p = .0005, coefficient = 3.3) and BMI (p < .0001, coefficient = 0.35). Thus, the ratio of increase for flap thickness with respect to BMI is 3:5:7 for the RFFF, MSAP, and ALT flaps, respectively.

CONCLUSION

The MSAP is about twice the thickness of the RFFF and 2 mm thinner than the ALT; however, 22% of patients had thicker MSAP than ALT flaps. As the strongest predictors of flap thickness, female gender, and BMI may be taken into consideration during surgical planning for reconstruction.

The medial sural artery perforator flap for retromolar trigone reconstruction: A multicenter case series

BACKGROUND

Retromolar trigone (RMT) cancer is a rare malignancy, which develops in a narrow area of the oral cavity. Surgical intervention requires wide excision and appropriate reconstruction usually with a free tissue transfer. Little has been published regarding the ideal microvascular reconstruction, mainly focusing on radial forearm and anterolateral thigh free flap. The medial sural artery perforator flap (MSAP) is not new for head and neck reconstruction but its use for RMT reconstruction has not been previously explored. The purpose of the study is to present a multicentric case series investigating the reliability of MSAP flap for RMT reconstruction.

METHODS

The study is designed as a retrospective case series. All patients diagnosed with RMT cancer and undergone surgical resection and immediate reconstruction with a MSAP flap between February 2016 and March 2020 were identified. Patients' demographics and surgical details were collected. Functional results were evaluated using the Head and Neck Module of the European Organization for Research and Treatment of Cancer at 12 months of follow-up. A total of 34 patients with a mean age of 58 years were included in the study. An average defect size of 31.5 cm2 was observed after RMT tumor resection.

RESULTS

The MSAP flaps' average dimensions were 11 ± 3.1 cm in length and 4.7 ± 1.6 cm in width with a mean thickness of 1.4 ± 0.8 cm. No flap complications were observed in 28 cases; four patients developed an orocutaneous fistula. One patient needed surgical revision for venous congestion while only one case of flap failure was observed. At 12 months of follow-up, 87% of the patient cohort had normal, understandable speech. No patient experienced complete loss of swallowing. Results of the H&N35 module showed a significative postoperative improvement in mouth soreness, mouth opening and social (p < .05*). No patient complained difficulty in motility at the donor site.

CONCLUSIONS

The MSAP flap appears to be appropriate for RMT reconstruction and could be considered the workhorse for small to medium size defect of RTM region. It has a long pedicle of matching caliber and provides adequate tissue volume with minimal donor site morbidity.

Reconstruction of Upper and Lower Limb Defects with Medial Sural Artery Perforator Flaps: Is Aesthetics Worth the Effort? A Retrospective Analysis

Background  One of the most essential goals in managing complex limb defects is obtaining adequate soft tissue coverage with excellent functional and aesthetic outcomes. Free perforator skin flaps represent an optimal option for such defects. Therefore, our intention was to reconstruct these kinds of defects with thin fasciocutaneous flaps without the need for debulking. Herein, we define the legitimate use of the medial sural artery perforator (MSAP) flaps for small-moderate size defect coverage of the hand and foot. Patients and Methods  Seven patients received MSAP flaps for reconstruction of different hand and foot defects, of which the majority were males (4/7). Age, sex, flap size, location, number of perforators, recipient vessel, type of anastomosis, technique of donor site closure, and postoperative morbidity were recorded. Patients' age ranged from 48 to 84 years. Results  Single-stage debridement followed by reconstruction was performed. Flap sizes ranged from 6 to 18 cm in length and 4 to 10 cm in width. The pedicles of 6 flaps were anastomosed to the tibial artery system (three posterior tibial artery, three dorsalis pedis artery) and one to the ulnar artery. Conclusion  MSAP flap can be a versatile option for single-stage reconstruction of small-moderate size defects of the extremities, where thin, soft tissue envelope is required. This flap has lower donor site morbidity, more tedious elevation process, and has a good reconstructive and aesthetic result without the need for debulking in the future.

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.

Cross-legged modification for medial sural artery perforator flap harvest

When thin and pliable free tissue is needed, the medial sural artery perforator (MSAP) flap provides an excellent option with minimal donor site morbidity. However, among its pitfalls include difficult patient positioning and surgeon ergonomics throughout the harvest. We describe a novel positioning technique that may significantly improve surgeon ergonomics and ease of MSAP flap harvest. A cross-legged modification may eliminate many of the issues associated with the classic frog-leg position. While the patient is cross-legged, the surgeon is afforded a normal field of view that is closer to their body, while simultaneously providing support to the lateral side of the gastrocnemius muscle. This pictorial essay describes this positioning technique and subsequent harvest. By incorporating a more ergonomic cross-legged position during flap elevation, many of thedrawbacks of the MSAP flap could be eliminated.

Tissue Transfer After Tongue Resection: Micro-Vascular Reconstruction Using Radial Artery Free Flap versus Reconstruction by Split Thickness Skin Graft in T2 Lesions of Tongue Carcinoma

To compare postoperative complications, functional rehabilitation, surgical outcomes of the radial artery forearm free flap (RAFFF) and split thickness skin graft (STSG) reconstruction of postsurgical defect in T2 lesions of cancer oral cavity. Observational Prospective comparative study. Academic tertiary referral centre. In our study of forty four patients, after tumour resection, half underwent reconstruction using RAFFF (Group I) and another half by STSG (Group II). All of the patients were followed postoperatively to determine and compare their functional outcomes related to donor site and recipient site complications, speech, deglutition and mouth opening. The speech intelligibility and deglutition were each assessed using Articulation Handicap Index and Vedio-fluoroscopy using the Functional oral intake scale. Operative time for STSG reconstruction was shorter at 2.2 ± 0.97 SD hours compared to 5.9 ± 1.24 SD hours for RAFFF reconstruction. Hospital stay was 8.3 ± 1.19 SD days for STSG patients and 12.6 ± 1.7 SD days for RAFFF patients. The functional outcomes of speech quality and swallowing were near comparable in both groups but the donor site complications were significant in the RAFFF group. Operative time, hospital stay and donor site complications are both significantly reduced with the STSG as opposed to RAFF. Functional and oncologic results of both methods are near comparable. To conclude, STSG can be used for reconstruction of the post-surgical defects in T2 lesions of the tongue.

The Medial Sural Artery Perforator Free Flap: A Novel, yet Challenging and Versatile Flap for Head and Neck Reconstruction

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.

Comparison of Current Free Flap Options for Intraoral Lining and Tongue Reconstruction

Free flaps have become the main alternative for intraoral reconstruction in current practice. However, controversy exists on pros and cons of different free flap options for this challenging area. Although there are various studies focusing on different free flap options, comparative studies are very few and there is not a single study comparing all 4 thin free flap options for intraoral reconstruction. Between 2018 and 2021, 30 patients underwent intraoral reconstruction. Four pliable and thin flaps, medial sural artery perforator flap, superficial circumflex iliac artery perforator flap, radial forearm free flap, and superthin anterolateral thigh flap were used for reconstructions and compared per functionality and patients' quality of life. One medial sural artery perforator flap and 1 superficial circumflex iliac artery perforator flap failed because of perfusion problems, and the remaining flaps survived. Harvest time and donor site closure were with significant difference ( P <0.05) between groups. Quality of life results were similar except one of the disease-specific questions. In authors' opinion, anterolateral thigh flap is the best option in normal-weight individuals because of its reliability, pliability, and constant reliable vascular structure. Although other options may be considered in overweighted patients, thinly elevated anterolateral thigh flap still seems to be the most reliable option.

The Medial Sural Artery Perforator Flap: A Historical Trek from Ignominious to “Workhorse”

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.

Superficial Circumflex Iliac Artery Perforator Flap in Advanced Head and Neck Reconstruction: From Simple to Its Chimeric Patterns and Clinical Experience with 22 Cases

BACKGROUND

Head and neck tissue defects after ablative head and neck surgery often require complex and composite reconstructions. The superficial circumflex iliac artery perforator (SCIP) flap is an extremely versatile perforator-based flap with minimal donor-site morbidity. The authors present their experience with both simple and chimeric SCIP flap reconstructions for complex defects in various head and neck regions.

METHODS

Twenty-two patients undergoing ablative head and neck surgery for oncologic abnormalities were treated by means of a SCIP flap reconstruction. Patients' mean age was 62 years; 21 were men and one was a woman. Seventeen flaps were simple and five were chimeric reconstruction patterns. Indocyanine green perfusion imaging was performed in all cases.

RESULTS

Twenty-one of 22 patients (95.5 percent) were successfully treated with good aesthetic and functional results. Two patients (9 percent) showed minor donor-site complications that were managed conservatively. The mean follow-up period was 5.3 months (range, 2 to 8 months).

CONCLUSIONS

This case series demonstrates the reliability and versatility of the SCIP flap for head and neck reconstruction. The chimeric options combined with bone, double-skin paddle, and muscle offer a broad variety of functional reconstructive solutions for complex head and neck surgery. Intraoperative indocyanine green perfusion examinations area valuable tool to assess and ascertain proper inset, vitality, and postanastomosis vessel patency in these complex microvascular flap reconstructions.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Case Report: Superficial Circumflex Iliac Artery Perforator Flap for Tongue Reconstruction Following the Hemiglossectomy

Objective: Therapeutic evaluation of applying superficial circumflex iliac artery perforator (SCIP) flap in tongue reconstruction after hemiglossectomy.

Methods: We retrospectively collected a total number of 14 patients who received SCIP flap reconstruction for tongue defects at the Fujian Medical University affiliated Union Hospital, between November 2016 and November 2020. We evaluated the clinical features of the flap, analyzed the postoperative functions and esthetic effects after 6 months of the tongue reconstruction.

Results: All the SCIP flaps survived successfully after the operation, the recipient site tongue bodies were well reconstructed 6 months after the surgery. Patient speech and swallowing functions were well recovered during the follow-up. The scars in the donor site were concealed with limited numbness.

Conclusions: With the advantages of the hidden donor site and aesthetic benefits, the SCIP flap is a reliable option for the reconstruction of the tongue defect after hemiglossectomy.

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.

Functional Outcomes of the Medial Sural Artery Perforator Flap in Oral Cavity Reconstruction

BACKGROUND

The medial sural artery perforator (MSAP) flap is an ideal option for reconstruction of oral cavity defects owing to its thin and pliable nature and favorable donor site. Our study presents an assessment of functional outcomes including speech and swallowing in patients with oral cavity tumors reconstructed with MSAP flaps.

METHODS

Patients undergoing MSAP reconstruction for oral cavity tumors between January 2014 and January 2018 were identified from our prospective head and neck cancer database. Functional outcomes were assessed in conjunction with the Speech and Language Team with a minimum follow-up of 6 months. Function (speech and swallowing) was recorded as a performance status scale set up by the assessing health care professional.

RESULTS

A total of 38 patients underwent reconstruction with the MSAP flap over the study period. The patient cohort included 10 female patients and 28 male patients. The age range was from 30 to 78 years, with a mean age of 56.8 years. Complications included 1 flap loss and 1 donor site wound dehiscence.Most patients (84.2%) had intelligible speech at 6-month follow-up and further improvement at 1 year (92.1%). All patients resumed feeding on postoperative day 4, and only 7.8% (n = 3) of the patients required assistance with feeding at 1-year follow-up.

CONCLUSIONS

The MSAP flap provides adequate small-volume replacement for oral cavity reconstructions. Our results indicate that most patients achieve a full diet with no restrictions by 1 year after reconstruction. Most of our patients demonstrated excellent speech with little or no need for repetition in conversation. Over the past few years, this has become the flap of choice for oral cavity reconstruction in our unit.

[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.

Reconstruction of thumb defects with medial sural artery perforator flap: case series

Background

Digital defect is one of the most common types of emergency hand injuries. Plastic surgeons continue to search for a better method to repair digital defects, especially those of the thumb. The medial sural artery perforator (MSAP) flap has been widely used as a popular method for limb and head reconstruction. Our findings have led us to advocate the use of free medial sural artery perforator flap to repair large thumb defects.

Methods

From July 2010 to July 2013, we used free MSAP flaps to resurface large defects of 9 thumbs in 9 clinical cases. There were 6 men and 3 women among the participants, aged 21–49 years (average age: 37.6 years). Flap sizes varied from 2 cm × 3 cm to 3 cm × 6 cm. Perforators of all flaps were accurately located by color Doppler detection.

Results

According to color Doppler detection, the distance from the popliteal crease to the points where first/second perforator pierced the deep fascia was 10.1±1.1/15.2±0.8 cm. The distance from the midline to the first/second perforator was 2.8±0.8/3.5±0.5 cm. A total of nine flaps fully survived. All defects of the nine thumbs were adequately resurfaced. Postoperative follow-up conducted at 12–24 months revealed satisfaction in both cosmetic and function results.

Conclusions

The MSAP flap, which can be easily harvested and well thinned, is an ideal choice to repair thumb defects. Accurate location of the perforator by Doppler detection ensures the surgical success, and minimizes injury to the donor site.

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.

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

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.

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.

Medial Sural Artery Musculocutaneous Perforator (MSAP) Flap for Reconstruction of Pharyngoesophageal Defects

We describe the use of the medial sural artery musculocutaneous perforator (MSAP) flap at our institution. It is a relatively new flap, originally described in 2001 for lower extremity defects, that has become increasingly popular for head and neck reconstruction due to its versatility, thinness, pliability, long pedicle, and particularly favorable donor site. It has been described for reconstruction of oral defects, but there is little published on its use in pharyngeal reconstruction. We suggest that the MSAP is an ideal flap for addressing defects caused by pharyngoesophageal stenosis, pharyngeal fistulas, or laryngopharyngectomies. We review 5 cases at our institution from June 2016 to November 2017.

The versatile free medial sural artery perforator flap: An institutional experience for reconstruction of the head and neck, upper and lower extremities

BACKGROUND

The medial sural artery perforator (MSAP) flap is an increasingly versatile and reliable flap for soft tissue reconstruction. This study investigates complication rates and long-term outcomes of the MSAP flap.

METHODS

A retrospective review was performed on consecutive patients undergoing MSAP flap reconstruction at Chang Gung Memorial Hospital from 2006 through 2017. Patient demographics were assessed. Flap failure and wound complications were the outcome measures.

RESULTS

In the cohort of 246 patients that underwent a total of 248 MSAP flap reconstructions were identified. The average age was 47.5 years (range 15-76). Of the 248 flaps, 170 were used for reconstruction of the head and neck, 48 for upper extremity reconstruction, and 30 for lower extremity reconstruction. The average MSAP flap size was 5.2 × 11.8 cm. 31 (12.5%) of the flaps developed arterial occlusion, venous insufficiency, or a hematoma postoperatively requiring re-exploration. Nineteen were successfully salvaged, yielding an overall failure rate of 4.8%. Minor complications included the need for flap debridement in 18 cases (7.3%) and need for donor site debridement in eight cases (3.2%).

CONCLUSIONS

The MSAP flap can be used in a versatile fashion to reconstruct defects of the head and neck, upper extremity, and lower extremity with minimal complication rates.

A Unifying Algorithm in Microvascular Reconstruction of Oral Cavity Defects Using the Trilaminar Concept

Although many algorithms exist to classify oral cavity defects, they are limited by either considering a single subsite or failing to provide a concise reconstructive algorithm for the breadth of defects. Based upon our experience as a tertiary referral center, a unifying algorithm is presented that guides free flap selection in this heterogenous population.

An early complication in the donor site of the medial sural artery perforator flap: necrosis of the medial head of gastrocnemius

The relatively new medial sural artery perforator flap is increasingly being used for reconstruction. However, muscle necrosis of the medial head of gastrocnemius after MSAP flap harvest is a previously unnoticed early complication of the donor site. We present two cases of MSAP flap reconstruction that developed this early complication.

Nose resurfacing with free fasciocutaneous flaps in burns patients

BACKGROUND

Nasal reconstruction after burn injury can be challenging due to limited availability of local flaps. We present our experience of free flap reconstruction for full-thickness nasal defect after severe facial burn injury.

METHODS

Between August 1998 and September 2015, six patients underwent nasal reconstruction with seven free flaps after burn injury. Among them, flame burn occurred in two patients, chemical burn in two, explosive burn in one, and contact thermal burn in one patient. The percentage of total body surface area ranged from 4% to 48%, and the face and forehead were involved in all patients. Their clinical and photographic records were retrospectively reviewed to evaluate the aesthetic results.

RESULTS

Four ulnar forearm flaps, one radial forearm flap, one anterolateral thigh flap, and one medial sural artery perforator flap were used for nasal reconstruction. The nasal framework was constructed simultaneously using costal cartilage or conchal cartilage. The facial artery and vein were typically used as recipient vessels. One case each of partial necrosis and infection were noted during the average follow-up of 59 months (range, 16-126 months). Patients had satisfactory aesthetic and functional outcomes after 4.5 times (range, 2-7 times) refinement operation.

CONCLUSIONS

Free flap is an applicable alternative to restore nasal skin envelope, with rebuilding the nasal framework performed in the same stage after severe facial burn injury. Through thoughtful planning and sufficient refinement, satisfactory aesthetic, and functional results are achievable.

Medial Sural Artery Perforator Flap for Head and Neck Reconstruction

Aim:

The aim is to study the assessment of feasibility of medial sural artery perforator (MSAP) free flap for head and neck reconstruction at our center.

Materials and Methods:

Oral cancer patients with squamous cell carcinoma of the tongue, buccal mucosa, and floor of mouth cancer attending our center were reconstructed using MSAP flap after oncologic resection. Handheld 8 MHz Doppler was used to identify the perforator preoperatively.

Results:

We reconstructed 10 patients using MSAP flap. The flap was designed according to defect and donor site was primarily closed in all cases. Excellent results were seen in nine patients reconstructed with MSAP flap without any postoperative complication. Flap failure occurred in one patient due to venous thrombosis. The thickness of flap ranged from 4 to 8 mm. The vascular pedicle length ranged from 9 to 13 cm.

Conclusion:

The MSAP flap is appropriate for medium-sized oral defect reconstruction, with a long pedicle of matching caliber, adequate tissue volume, and minimal donor-site morbidity which makes it comparable to other microvascular free flaps such as radial artery free flap (RAFF) and anterolateral thigh flap.

[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.

Calf Perforator Flaps: A Freestyle Solution for Oral Cavity Reconstruction

BACKGROUND

Reconstruction of oral cavity defects requires a thin, pliable flap for optimal functional results. Traditional flap choices are imperfect: the anterolateral thigh flap is excessively thick, whereas the radial forearm flap has a poor donor site. The authors therefore favor calf perforator flaps such as the medial sural artery perforator flap to provide thin tissue with an acceptable donor site. This two-part study aims to demonstrate their suitability for intraoral reconstruction.

METHODS

In the radiologic part of the study, the authors compared thigh and calf tissue thickness by examining lower limb computed tomographic scans of 100 legs. For their clinical study, they collected data prospectively on 20 cases of oral cavity reconstruction using calf perforator flaps.

RESULTS

The mean thickness of the calf tissue envelope was significantly less than that of the thigh (8.4 mm compared with 17 mm) based on computed tomographic analysis. In the clinical study, a medial sural artery perforator was used in the majority of cases (17 of 20). The mean pedicle length was 10.2 cm and the mean time to raise a flap was 85 minutes. There were no flap losses. One patient was returned to the operating room for management of late hematoma and wound dehiscence.

CONCLUSIONS

Calf perforator flaps provide ideal tissue for intraoral reconstruction and are significantly thinner than anterolateral thigh flaps. In addition to medial sural artery perforator flaps, the authors raised both sural and soleal artery perforator flaps in this series. Opportunistic use of the calf donor site allows the harvest of thin tissue with minimal donor-site morbidity.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Suprafascial Anterolateral Thigh Flap Harvest: A Better Way to Minimize Donor-Site Morbidity in Head and Neck Reconstruction

BACKGROUND

The purpose of this study was to compare the clinical outcomes and donor-site morbidity between the suprafascial and subfascial harvesting of anterolateral thigh flaps.

METHODS

Sixty-one patients who underwent free flap reconstruction (30 suprafascial and 31 subfascial anterolateral thigh flaps) were included in this study. The patients assessed the subjective donor-site morbidity and satisfaction with the overall functional result using a self-reported questionnaire. The flap characteristics (i.e., perforator number, flap size, and harvest time) and outcomes (i.e., success rate, partial necrosis, infection, hematoma, and fistula) were compared.

RESULTS

The success rates of suprafascial and subfascial anterolateral thigh flaps were 96.7 and 96.8 percent, respectively. There were no significant differences in flap size, harvest time, or overall complication rates. The suprafascial anterolateral thigh flap group experienced fewer abnormal sensations (p < 0.001) and better subjective satisfaction at the donor site than did the subfascial anterolateral thigh flap group (p = 0.03).

CONCLUSIONS

In terms of reducing donor-site morbidity, the suprafascial anterolateral thigh flap group showed fewer sensory disturbances in donor thighs and exhibited better patient satisfaction than did the subfascial anterolateral thigh flap group, but meticulous dissection of tiny perforators above the fascia is required for the former procedure.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Medial sural artery perforator free flap for the reconstruction of leg, foot and ankle defect: an excellent option

BACKGROUND

The defects over the leg, foot and ankle are best covered with a thin pliable flap. The use of muscle flap for the reconstruction of these defects leaves a grafted, aesthetically inferior result. The medial sural artery perforator (MSAP) free flap gives a thin pliable tissue for the reconstruction with better aesthesis.

METHODS

The study design was retrospective case analysis over a period of 2 years. All the patients who underwent flap for leg, foot and ankle defect reconstruction in the form of MSAP free flap were included in the study. The flap characteristics and aesthesis were assessed along with the patient satisfaction. The flap complication and donor site morbidity were also analysed.

RESULTS

A total of seven MSAP free flaps were done for leg, foot and ankle reconstruction. The mean flap size was 14.29 × 6.6 cm and mean pedicle length was 9.71 cm. One flap had venous congestion post-operatively resulting in marginal flap loss. All the flaps had acceptable aesthesis with good patient satisfaction. There was donor site morbidity in two patients, in the form of wound dehiscence.

CONCLUSION

MSAP free flap is a reliable choice for leg, foot and ankle defect reconstruction.

Coverage of Tendon Exposure after Radial Forearm Free Flap by the Dorsoulnar Artery Perforator Flap

Objective This study was designed to assess the effectiveness of an alternative technique using a perforator flap to manage secondary tendon exposure after a radial forearm free flap in head and neck oncologic surgery. Study Design Prospective cohort study. Setting Plastic Reconstructive Surgery Unit, Nice University Hospital, Pasteur 2 Hospital, France. Subjects and Methods Despite its numerous advantages, the radial forearm free flap is associated with significant donor site morbidity and the risk of secondary tendon exposure. Conventional skin grafts for secondary tendon exposure can lead to diminished wrist range of motion and grip strength, with residual pain and cold intolerance. Between 2012 and 2015, we prospectively studied 20 patients with secondary tendon exposure after a forearm radial free flap for head and neck reconstruction. Two techniques of secondary coverage were compared: a reference technique with a secondary full skin graft (10 patients) and a dorsoulnar artery perforator (DUAP) flap (10 patients). Results Maximum wrist extension (100%) was observed for the DUAP group compared with only 87% for the skin graft (SG) group ( P = .001). An improvement in grip strength (+14 kg) ( P = .028) and a decrease in pain or cold intolerance ( P = .002) were also observed in the DUAP group, in addition to a better aesthetic appearance. Conclusion The perforator flap procedure is an interesting tool in reconstructive surgery. The DUAP flap is a reliable, useful flap for secondary tendon exposure coverage after a radial forearm free flap. Level of Evidence III (case-control analytic studies of 1 center).

Assessing the suitability of medial sural artery perforator flaps in tongue reconstruction - An outcome study

Introduction

Oncological resection of the tongue can be reconstructed using a multitude of free flaps. The medial sural artery perforator (MSAP) flap has been well described in the literature in terms of its anatomy and harvest. However, functional outcome studies of post-reconstruction tongue defects using the MSAP flap have not been reported. This study represents the largest outcome study of patients with tongue reconstructions using MSAP flaps and a comprehensive review of its use.

Materials and methods

From December of 2010 to October of 2015, 579 patients with subtotal glossectomy and free flap reconstructions in Chang Gung Memorial Hospital were retrospectively reviewed. 27 patients were reconstructed with MSAP flap. The pre- and intra-operative factors, as well as flap-related factors were analyzed. Post-operative complications and functional outcomes were evaluated. Donor site assessment were also conducted.

Results

A 96.3% flap survival rate was found with an average total operating time of 6 hours and 18 minutes. 84.6% of patients had primary closure of the donor site with and the remaining either had skin grafts or delayed closure. Donor site closure can be achieved primarily with no functional deficit. Speech intelligibility remained for most patients. 100% of patients resumed normal oral feeding.

Conclusion

The MSAP flap is a small to medium sized flap most suited for subtotal glossectomy defects where optimal outcomes can be achieved in terms of speech clarity and restoration of oral intake.