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

Abstract

Background The medial sural artery perforator (MSAP) flap has become increasingly popular because it is thin and pliable for small to moderate defect soft tissue reconstruction. Furthermore, chimeric MSAP flap, which includes a skin paddle and a separated piece of medial gastrocnemius muscle, allowed more freedom for flap insetting, especially in 3-dimensional defect reconstruction. Here we describe our experience regarding this clinical application. Patients and Methods From 2007 to 2016, 14 male patients (average age, 46.9 ± 14.4 years) who received either a free or pedicled chimeric MSAP flap were included. Of these 14 patients, 7 received this flap for reconstruction in the head and neck, 2 in the upper extremities, and 5 in the lower extremities. Demographic data were collected and analyzed, and a literature review was performed. Results Ten patients received free chimeric MSAP flap, and 4 received the pedicled type. Thirteen of the 14 flaps (92.6%) survived, and 1 failed 2 days later owing to venous insufficiency. Venous congestion-related partial loss occurred in another case. Conclusions The chimeric MSAP flap is a good alternative for deep space obliteration or reconstruction of adjacent but separate defects in both free and pedicled flap design. Donor site morbidity is limited. However, the perforator needs to be mobilized carefully to prevent postoperative venous compromise.

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

“…The ubiquitous audible Doppler can be tediously dragged over the entire MGM, 17 55 56 57 58 but care must be taken as the audio heard from the usually very superficial course of the intramuscular branches may be enhanced, thereby obscuring differentiation from the perforators themselves. 59 Computed tomography (CT) angiography 32 60 61 62 63 and color duplex ultrasound 27 32 64 may be beneficial means to show the course and origin of potential perforators—if available. A cheaper alternative may be just smartphone thermography to find “hot spots” after a “cold challenge” ( Fig.…”

“…Two small subfascial incisions at the anterior border of the MGM will allow passage of retractors and a 4-mm endoscope with a 30-degree angle for actual visualization of the perforator. 48 59 62 71 As an alternative, a small subfascial exploratory incision along the proposed anterior border of the flap with upward traction on the flap might be sufficient to lead to accurate citing of the perforator where it enters the deep fascia. 55 Once confirmed, the flap design should be revised as necessary.…”

“…If the intramuscular branching pattern were type II or III ( Fig. 1 ), Lee et al 62 have shown that the MSAP flap could arise from the lateral branch while the medial branch independently supplies the muscle, or vice versa. Another option is to keep the continuation of the intramuscular branch distal to the perforator origin (or any other reasonably large muscle branch) to serve the muscle portion separately ( Fig.…”

The Use of a Tetraminos Chimeric Free Flap in Lower Limb Trauma

“…Some surgeons have advocated the use of chimeric latissimus dorsi-serratus anterior flap reconstruction to provide reliable soft tissue coverage, with greater flexibility of size and geometric pattern [ 1 ]. For smaller defects, a medial sural artery perforator flap with a separated piece of gastrocnemius muscle has been shown to provide good three-dimensional reconstructive capabilities in the lower limb [ 2 ]. Otherwise, chimeric reconstructions seem to be interspersed between mandibular and upper limb reconstructive surgery [ 3 - 5 ].…”

Versatile design of compound vastus lateralis muscle and anterolateral thigh musculocutaneous perforator free flaps for customized reconstruction of complex skin and soft tissue defects in the extremities

“…Many applications of traditional chimeric flaps have been reported for reconstructing three‐dimensional (3D) defects, in which the skin flap covers the superficial wound, and a separate, mobile muscle segment fills the dead space. While this is an improvement compared with traditional skin and musculocutaneous flaps, donor site morbidity, operative complexity, and size challenges are areas requiring improvement (Lee, Chang, Hsiao, et al, 2019; Sung, Jang, Kim, Kim, & Kim, 2018; Wang, Xu, Wen, & Chai, 2018).…”