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CC BY 4.0 · Arch Plast Surg 2023; 50(03): 264-273
DOI: 10.1055/a-2059-4009
Pediatric/Craniomilofacial/Head & Neck
Review Article

The Medial Sural Artery Perforator Flap versus Other Free Flaps in Head and Neck Reconstruction: A Systematic Review

Yasser Al Omran 
1   Department of Plastic Surgery, Royal Free National Health Service Foundation Trust, London, United Kingdom
,
Ellie Evans 
1   Department of Plastic Surgery, Royal Free National Health Service Foundation Trust, London, United Kingdom
,
Chloe Jordan 
2   Department of Plastic Surgery, Barts and The London School of Medicine and Dentistry, London, United Kingdom
,
Tiffanie-Marie Borg 
3   Academic Plastic Surgery Group, Barts and The London School of Medicine and Dentistry, London, United Kingdom
,
Samar AlOmran 
4   Department of ENT, Salmaniya Medical Complex, Kingdom of Bahrain
,
Sarvnaz Sepehripour 
1   Department of Plastic Surgery, Royal Free National Health Service Foundation Trust, London, United Kingdom
,
Mohammed Ali Akhavani 
1   Department of Plastic Surgery, Royal Free National Health Service Foundation Trust, London, United Kingdom
› Author Affiliations Funding None.
› Further Information
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Abstract

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.

Keywords

microsurgery - reconstruction - head and neck

Authors' Contributions

Y.A.L. and M.A. developed the concept and study design. E.E., C.J., T.M.B., S.A., and S.S. were involved in data acquisition. Y.A.L. analyzed and interpreted the data. All authors reviewed the final version of the manuscript and agreed to its submission.


Ethical Approval

This study is in line with guidance issued jointly by INVOLVE and the National Research Ethics Service [NRES], ethical approval is not needed for systematic reviews, even ones which involve patients and members of the public in a planning and advisory capacity.




Publication History

Received: 28 September 2022

Accepted: 07 March 2023

Accepted Manuscript online:
21 March 2023

Article published online:
29 May 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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  • References

  • 1 Genden EM, Jacobson AS. The role of the anterolateral thigh flap for pharyngoesophageal reconstruction. Arch Otolaryngol Head Neck Surg 2005; 131 (09) 796-799
    CrossrefPubMedGoogle Scholar
  • 2 Toyserkani NM, Sørensen JA. Medial sural artery perforator flap: a challenging free flap. Eur J Plast Surg 2015; 38 (05) 391-396
    CrossrefPubMedGoogle Scholar
  • 3 Agrawal G, Gupta A, Chaudhary V, Qureshi F, Choraria A, Dubey H. Medial sural artery perforator flap for head and neck reconstruction. Ann Maxillofac Surg 2018; 8 (01) 61-65
    CrossrefPubMedGoogle Scholar
  • 4 Taufique ZM, Daar DA, Cohen LE, Thanik VD, Levine JP, Jacobson AS. The medial sural artery perforator flap: a better option in complex head and neck reconstruction?. Laryngoscope 2019; 129 (06) 1330-1336
    CrossrefPubMedGoogle Scholar
  • 5 Kruse ALD, Bredell MG, Lübbers HT, Jacobsen C, Grätz KW, Obwegeser JA. Clinical reliability of radial forearm free-flap procedure in reconstructive head and neck surgery. J Craniofac Surg 2011; 22 (03) 822-825
    CrossrefPubMedGoogle Scholar
  • 6 Daar DA, Abdou SA, Cohen JM. , et al. Is the medial sural artery perforator flap a new workhorse flap? A systematic review and meta-analysis. In: Plastic and Reconstructive Surgery. Lippincott Williams & Wilkins; 2019:393e-403e
  • 7 Cavadas PC, Sanz-Giménez-Rico JR, Gutierrez-de la Cámara A, Navarro-Monzonís A, Soler-Nomdedeu S, Martínez-Soriano F. The medial sural artery perforator free flap. Plast Reconstr Surg 2001; 108 (06) 1609-1615 , discussion 1616–1617
    CrossrefPubMedGoogle Scholar
  • 8 Wolff KD, Hölzle F, Kolk A, Hohlweg-Majert B, Kesting MR. Suitability of the anterolateral thigh perforator flap and the soleus perforator flap for intraoral reconstruction: a retrospective study. J Reconstr Microsurg 2011; 27 (04) 225-232
    Article in Thieme ConnectPubMedGoogle Scholar
  • 9 Achal KS, Farrell C, Smith AB, Mücke T, Mitchell DA, Kanatas AN. Anterolateral thigh skinfold thickness and the European head and neck cancer patient: a prospective study. J Craniomaxillofac Surg 2011; 39 (02) 111-112
    CrossrefPubMedGoogle Scholar
  • 10 Moher D, Liberati A, Tetzlaff J, Altman DG. PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6 (07) e1000097
    CrossrefPubMedGoogle Scholar
  • 11 Shea BJ, Reeves BC, Wells G. et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ 2017; 358: j4008
    CrossrefPubMedGoogle Scholar
  • 12 Higgins JPT, Sally GS. . Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0. (updated March 2011). Accessed November 16, 2020 at: http://www.cochrane-handbook.org
  • 13 CEBM. . Oxford Centre for Evidence-Based Medicine - Levels of Evidence (March 2009). Accessed November 30, 2018 at: https://www.cebm.net/2009/06/oxford-centre-evidence-based-medicine-levels-evidence-march-2009/
  • 14 Sterne JA, Hernán MA, Reeves BC. et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016; 355: i4919
    CrossrefPubMedGoogle Scholar
  • 15 Balk EM, Chung M, Chen ML, Chang LK, Trikalinos TA. Data extraction from machine-translated versus original language randomized trial reports: a comparative study. Syst Rev 2013; 2: 97
    CrossrefPubMedGoogle Scholar
  • 16 Kao HK, Chang KP, Wei FC, Cheng MH. Comparison of the medial sural artery perforator flap with the radial forearm flap for head and neck reconstructions. Plast Reconstr Surg 2009; 124 (04) 1125-1132
    CrossrefPubMedGoogle Scholar
  • 17 Song X, Wu H, Zhang W. et al. Medial sural artery perforator flap for postsurgical reconstruction of head and neck cancer. J Reconstr Microsurg 2015; 31 (04) 319-326
    Article in Thieme ConnectPubMedGoogle Scholar
  • 18 Zhao W, Li Z, Wu L, Zhu H, Liu J, Wang H. Medial sural artery perforator flap aided by ultrasonic perforator localization for reconstruction after oral carcinoma resection. J Oral Maxillofac Surg 2016; 74 (05) 1063-1071
    CrossrefPubMedGoogle Scholar
  • 19 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 2021; 37 (05) 445-452
    Article in Thieme ConnectPubMedGoogle Scholar
  • 20 Geddes CR, Morris SF, Neligan PC. Perforator flaps: evolution, classification, and applications. Ann Plast Surg 2003; 50 (01) 90-99
    CrossrefPubMedGoogle Scholar
  • 21 Xu Q, Yin SC, Su XZ, Wang SM, Liu YH, Xu ZF. 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 (05) 1689-1695
    CrossrefPubMedGoogle Scholar
  • 22 Médard de Chardon V, Balaguer T, Chignon-Sicard B. et al. The radial forearm free flap: a review of microsurgical options. J Plast Reconstr Aesthet Surg 2009; 62 (01) 5-10
    CrossrefPubMedGoogle Scholar
  • 23 Kuo YR, Seng-Feng J, Kuo FM, Liu YT, Lai PW. Versatility of the free anterolateral thigh flap for reconstruction of soft-tissue defects: review of 140 cases. Ann Plast Surg 2002; 48 (02) 161-166
    CrossrefPubMedGoogle Scholar
  • 24 Zhou G, Qiao Q, Chen GY, Ling YC, Swift R. Clinical experience and surgical anatomy of 32 free anterolateral thigh flap transplantations. Br J Plast Surg 1991; 44 (02) 91-96
    CrossrefPubMedGoogle Scholar
  • 25 He Y, Jin SF, Zhang ZY, Feng SQ, Zhang CP, Zhang YX. A prospective study of medial sural artery perforator flap with computed tomographic angiography-aided design in tongue reconstruction. J Oral Maxillofac Surg 2014; 72 (11) 2351-2365
    CrossrefPubMedGoogle Scholar
  • 26 Xie XT, Chai YM. Medial sural artery perforator flap. Ann Plast Surg 2012; 68 (01) 105-110
    CrossrefPubMedGoogle Scholar
  • 27 Dusseldorp JR, Pham QJ, Ngo Q, Gianoutsos M, Moradi P. Vascular anatomy of the medial sural artery perforator flap: a new classification system of intra-muscular branching patterns. J Plast Reconstr Aesthet Surg 2014; 67 (09) 1267-1275
    CrossrefPubMedGoogle Scholar
  • 28 Wong MZ, Wong CH, Tan BK, Chew KY, Tay SC. Surgical anatomy of the medial sural artery perforator flap. J Reconstr Microsurg 2012; 28 (08) 555-560
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Ives M, Mathur B. Varied uses of the medial sural artery perforator flap. J Plast Reconstr Aesthet Surg 2015; 68 (06) 853-858
    CrossrefPubMedGoogle Scholar
  • 30 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 (04) 1077-1085
    CrossrefPubMedGoogle Scholar
  • 31 Hallock GG. The medial sural artery perforator flap: a historical trek from ignominious to “workhorse”. Arch Plast Surg 2022; 49 (02) 240-252
    Article in Thieme ConnectPubMedGoogle Scholar
  • 32 Kosutic D, Pejkovic B, Anderhuber F. et al. Complete mapping of lateral and medial sural artery perforators: anatomical study with Duplex-Doppler ultrasound correlation. J Plast Reconstr Aesthet Surg 2012; 65 (11) 1530-1536
    CrossrefPubMedGoogle Scholar
  • 33 Fang T-Y, Wang P-C, Liu C-H, Su MC, Yeh SC. Evaluation of a haptics-based virtual reality temporal bone simulator for anatomy and surgery training. Comput Methods Programs Biomed 2014; 113 (02) 674-681
    CrossrefPubMedGoogle Scholar
  • 34 Richardson D, Fisher SE, Vaughan ED, Brown JS. Radial forearm flap donor-site complications and morbidity: a prospective study. Plast Reconstr Surg 1997; 99 (01) 109-115
    CrossrefPubMedGoogle Scholar
  • 35 Baas M, Duraku LS, Corten EML, Mureau MAM. A systematic review on the sensory reinnervation of free flaps for tongue reconstruction: does improved sensibility imply functional benefits?. J Plast Reconstr Aesthet Surg 2015; 68 (08) 1025-1035
    CrossrefPubMedGoogle Scholar
  • 36 Wang X, Mei J, Pan J, Chen H, Zhang W, Tang M. Reconstruction of distal limb defects with the free medial sural artery perforator flap. Plast Reconstr Surg 2013; 131 (01) 95-105
    CrossrefPubMedGoogle Scholar
  • 37 Choi JW, Nam SY, Choi SH, Roh JL, Kim SY, Hong JP. Applications of medial sural perforator free flap for head and neck reconstructions. J Reconstr Microsurg 2013; 29 (07) 437-442
    Article in Thieme ConnectPubMedGoogle Scholar
  • 38 Sharabi SE, Hatef DA, Koshy JC, Jain A, Cole PD, Hollier Jr LH. Is primary thinning of the anterolateral thigh flap recommended?. Ann Plast Surg 2010; 65 (06) 555-559
    CrossrefPubMedGoogle Scholar
  • 39 Agha RA, Borrelli MR, Farwana R, Koshy K, Fowler AJ, Orgill DP. PROCESS Group. The PROCESS 2018 statement: Updating Consensus Preferred Reporting Of CasE Series in Surgery (PROCESS) guidelines. Int J Surg 2018; 60: 279-282
    CrossrefPubMedGoogle Scholar
  • 40 Al Omran Y, Abdall-Razak A, Sohrabi C. et al. Use of augmented reality in reconstructive microsurgery: a systematic review and development of the augmented reality microsurgery score. J Reconstr Microsurg 2020; 36 (04) 261-270
    Article in Thieme ConnectPubMedGoogle Scholar