Versatility of the Medial Sural Artery Perforator Flap: Experience with 200 Consecutive Cases

Background:

The medial sural artery perforator (MSAP) flap was first described in 2001^1,2. Having constant anatomy, long pedicle, and pliable soft tissue, the flap was shown to be a good alternative option for soft-tissue reconstruction^3,4. The aim of this study was to report our experience with this flap for reconstruction throughout the body, highlighting its potentially increasing role as a workhorse flap for multi-purpose reconstruction.

Patients and methods:

Between March 2006 and July 2014, the MSAP flap was used for reconstruction in 200 cases. The flap was transplanted as free (n=189) and pedicled (n=11). The sites of reconstruction included head and neck (n=129), upper extremity (n=47), and lower extremity (n=24). Patients’ charts were reviewed retrospectively. Indications, flap design, flap survival, and complications were all analyzed. We further compared survival rate and complications between the three different reconstruction sites. The one-way ANOVA was utilized for this study.

RESULTS:

In head and neck group, flap survival rate was 95.3%. There were fifteen re-explorations (venous congestion: 14, arterial occlusion: 1) with 6 total failures due to unsalvageable congestion. The donor site was closed primarily in 85.3% of the cases.

In upper extremity group, flap survival rate was 95.7%. There were five re-explorations (venous congestion: 2, arterial occlusion: 2, both: 1) with 2 total failures. The donor site was closed primarily in 78.8% of the cases.

In lower extremity group, flap survival rate was 100% in free MSAP subgroup compared with 90.9% in pedicled MSAP subgroup. There was one re-exploration due to venous congestion salvaged successfully in free MSAP subgroup. Partial necrosis occurred in 2 pedicled MSAP flaps and managed by debridement and skin grafting. The donor site was closed primarily in 58.3% of the lower extremity cases.

Versatile designs of the flaps included chimeric flaps with the gastrocnemius muscle (n=11) and split flaps (n=2). The plantaris tendon was transferred with the flap in 15 cases for composite reconstruction.

CONCLUSION:

The MSAP flap is an alternative workhorse flap for reconstruction of the head/neck and extremities. The flap can be harvested as free or pedicled. Multiple tissue components can be included with the flap for multi-purpose reconstruction. A small-to-medium size flap should be harvested to ensure primary closure at the donor site, maximizing cosmesis and decreasing morbidity.