Medial sural artery perforator flap: a challenging free flap
Navid Mohamadpour Toyserkani
Jens Ahm Sørensen
Received: 9 April 2015 /Accepted: 12 May 2015 /Published online: 24 May 2015
Springer-Verlag Berlin Heidelberg 2015
Background Oral and extremity defect reconstruction can of-
ten require a flap that is thin, and traditionally, the radial fore-
arm free flap has been used, however, this has significant
donor site morbidity. Over the last decade, the medial sural
artery perforator (MSAP) flap has emerged as a possible al-
ternative with lower donor site morbidity. We present our ex-
periences and review the literature regarding this promising
but challenging flap.
Methods The study was a retrospective case series in a uni-
versity hospital setting. All patients who had a MSAP flap
performed at our institution were included until March 2015,
and their data was retrieved from electronic patient records.
Results In total, ten patients were reconstructed with a MSAP
flap for floor of mouth (eight) and lower extremity (two) de-
fect reconstruction. The median flap dimensions were as fol-
lows: 10 cm (range 7–14 cm), width 5 cm (range 3.5–8cm),
thickness 5 mm (range 4–8 mm), and pedicle length 10 cm
(range 8–12 cm). In one case, the procedure was abandoned
because of very small perforators and another flap was used.
In two cases, late onset of venous congestion occurred which
could not be salvaged. There were no donor site complaints.
flap is needed with lower donor site morbidity than alternative
solutions. There seems to be a higher rate of late onset of
venous thrombosis compared with more established flaps.
Therefore, this flap should be monitored more closely for
venous problems and we recommend performing two venous
anastomoses when using this flap.
Level of Evidence: Level IV, therapeutic study.
Keywords Medial sural artery perforator flap
Floor of mouth reconstruction
Reconstruction with free flaps is a necessity when defects
become too large for more simple reconstruction options such
as skin grafting and local flap options. Many different free
flaps have been described throughout the years each with their
own strengths and weaknesses.
Several free flap options are available for oral reconstruc-
tion (without mandible defects), and the dominant choices
today are the anterolateral thigh (ALT) flap and the radial free
forearm flap (RFFF). Since the anterolateral thigh flap was
first reported by Song et al. in 1984 , its popularity has
steadily increased and is now one of the most used flaps for
head and neck reconstructions. This is largely due to its reli-
ability, versatility, long vascular pedicle with optimal diameter
for anastomosis, and the possibility for harvesting a large skin
territory. Furthermore, the donor site morbidity is very low
. The downside of this flap is its bulkiness which for some
defects can be too much. The flap can be thinned but still with
limits, and often, it is most appropriate to wait for a secondary
debulking procedure [3, 4]. On the other hand, the radial fore-
arm flap is also very reliable but has much larger donor site
morbidity and the defect in many cases requires split skin
grafting . However, the flap is very thin which in some
reconstructions is a necessity. What has been missing in the
armamentarium of a microsurgeon is a flap that combines the
* Jens Ahm Sørensen
Department of Plastic and Reconstructive Surgery, Odense
University Hospital, Sdr. Boulevard 29, DK-5000 Odense
Eur J Plast Surg (2015) 38:391–396