The Free Medial Sural Artery Perforator Flap for Microsurgical Reconstruction of Limbs: A Systematic Review and Meta-Analysis of Flap Characteristics and Outcomes

Kiron K Koshy MBBS, MRCS, BSc (Hons)¹* , Anish Naik MD, MRCS, MSc, BSc (Hons)²*,
Mohammad Mozaffor Hosain MBBS, MRCS, MSc, FRCS Plast³*
^{*Joint first author}
1. Department of Plastic and Reconstructive Surgery, Royal Victoria Infirmary, Newcastle, UK
2. Department of Plastic and Reconstructive Surgery, Royal Free Hospital, London, UK
3. Department of Plastic and Reconstructive Surgery, Wye Valley NHS Trust, Hereford, UK
Correspondence to: kironk7@gmail.com

DOI: https://doi.org/10.70389/PJS.100016

Additional information

• Ethical approval: N/a
• Consent: N/a
• Funding: No industry funding
• Conflicts of interest: N/a
• Author contribution: Kiron K Koshy, Anish Naik, Mohammad Mozaffor Hosain – Conceptualization, Writing – original draft, review and editing
• Guarantor: Kiron K Koshy
• Provenance and peer-review:
  Commissioned and externally peer-reviewed
• Data availability statement: N/a

Keywords: medial sural artery perforator flap, microsurgical limb reconstruction, donor site morbidity, flap characteristics, extremity defects.

Peer Review
Received: 25 August 2024
Revised: 26 September 2024
Accepted: 26 September 2024
Published: 14 October 2024

Introduction

The field of microsurgery has continued to grow since its experimental inception in the 1950s by Professor Sun Lee¹ and has become a vital tool for reconstructive surgeons.² Further work in 1987 introduced the angiosome concept by Taylor, which led to the use of perforator flaps.² Since then, further advancement has increased the popularity of perforator flaps, as they can be tailored to the reconstructive need of the patient, whilst also reducing donor site morbidity. When used in conjunction with the reconstructive elevator, microsurgical reconstruction can be the initial and correct reconstruction of choice in certain complex defects in extremities.³ Upper and lower limb reconstructions can prove difficult, as they require thin and pliable flaps. With this in mind, the radial forearm free flap (RFFF) became the workhorse for extremity reconstruction. Unfortunately, this often leads to significant morbidity to the patient’s donor site, with the frequent use of a split-thickness skin grafting being a considerable disadvantage. This is why reconstructive surgeons are continually searching for alternatives.

The medial sural artery perforator (MSAP) flap was first described by Cadavas in 2001 and showed many advantages. This included a pliable, thin flap, with a long consistent pedicle, low complications and morbidity as donor sites in most cases will allow for a direct closure, thus avoiding the need for a skin graft. Despite the MSAP flap increasing in popularity, the literature specifically looking at its use in extremities has been limited. Most studies are small case series, or articles illustrating cadaveric dissection and the anatomy of the flap itself. This systematic review was conducted to analyse/collate the current literature to help identify the indication, flap characteristics, technique used for harvest and ultimately, outcomes.

Flap Anatomy and Design

The following are the currently described measurements generally stated in textbooks:

Flap Anatomy

• Flap dimension: Average flap 12.9 × 7.9 cm
• Origin of perforators: Medial sural artery (66% from the lateral branch and 34% from the medial branch) arises from the popliteal artery
• Number of perforators: 1–3 (mean 1.9)
• Site of perforators: Area between 7 and 18 cm from the popliteal crease (90% were at 10 ± 2 cm from the crease), 13 ± 2 cm, from posterior midline 2.5 +/- 1 cm
• Diameter of perforators: 0.3–0.8 mm
• Pedicle length: 10–17 cm (11.75 cm)
• Pedicle diameter: Artery 1.7—3 mm (2.2 mm), Vein 2.3–3 mm (2.6 mm).

Flap Design: (Figure 1)

• Draw a long axis from mid popliteal crease to the prominence of the medial malleolus.
• Locate the perforators and mark using a handheld Doppler (usually 6–18 cm from the popliteal crease along the axis mostly at 10 ± 2 cm)

Draw a flap centred on the perforator using a template of the defect.

We have provided clinical pictures of a case carried out by the authors in Figures 2–6, with consent provided by the patient. In the present case, the injury was traumatic from a metal press, with no prospect of replantation as digits were lost at the scene.

Methods

This systematic review was performed in accordance with the preferred reporting items for systematic reviews and meta-analysis (PRISMA) system⁴ and AMSTAR 2 checklist.⁵ This research has also been registered through the research registry with ID: reviewregistry1891 https://researchregistry.knack.com/research-registry#registryofsystematicr
eviewsmeta-analyses/registryofsystematicreviewsmeta-analysesdetails
/66f592bdcaee7002cf0c730e/

The literary search was conducted in July 2020 and was performed using Medline, Google Scholar and the Cochrane library. The search looked at the outcome of free MSAP flap reconstructions to the extremities during the period of the last 10 years from January 2010 to July 2020. Relevant keywords were selected and combined. The results were formulated according to the best BETs technique (Table 1).

Table 1: Three-Part Question.

Patient characteristics	Patient with upper and lower extremity defects needing reconstruction
Intervention question	Reconstruction of defect with free medial sural artery perforator flap
Relevant outcome	Epidemiological, operative and functional outcomes

Keyword Search

Search keyword for lower limb reconstruction cohort:

(msap flap) OR (medial sural artery perforator flap)) OR (medial sural artery perforator free flap)) OR (free msap flap)) AND (lower limb reconstruction)) OR (lower extremity reconstruction))

Search keyword for upper limb reconstruction cohort:

((msap flap) OR (medial sural artery perforator flap)) OR (medial sural artery perforator free flap)) OR (free msap flap)) AND (upper limb reconstruction)) or upper extremity reconstruction or hand reconstruction))

Inclusion Criteria

• Studies involving the use of the MSAP free flap

Exclusion Criteria

• Non-human studies
• Studies where the recipient area was not in the upper or lower limbs
• Studies where full text is not available
• Studies which have not been translated into English

Search Outcome

The search results are highlighted in total in Figure 7 (PRISMA flow chart). These have been further divided into those pertaining to upper and lower limb reconstructions, respectively.

For the lower limb reconstruction cohort, 20,180 studies were found. Among them, 57 studies were shortlisted after screening the titles; 14 studies were then found to be more relevant to lower limb reconstruction after screening the abstracts. Following the search, three papers were excluded due to the lack of English translation and unavailability of full texts. Finally, 11 papers were selected for review. For the upper limb reconstruction cohort, 17,620 papers were found. After title screening, only 23 papers were shortlisted. Screening through the abstracts excluded another 13 papers due to the lack of relevance or no English translation. Three further studies were excluded because of the unavailability of full texts. Finally, seven studies were included in the present review. All articles were independently reviewed by two authors and extracted as per the PRISMA flowchart. There were no sources of funding for this study. The risk of bias was assessed and deemed to be low risk.

Results

Table 2: Abbreviated Results of Lower Limb MSAPs.

Author, Country, Journal, Year of Publication	Patient Group	Study Type (Level of Evidence)	Outcomes	Key Results	Study Weaknesses
Sarah Al-Himdani,	It is a hybrid	Combined	Limitation	Thin pliable flap	Not a RCT
Asmat Din, Thomas C	study	prospective	includes, long	good choice for	and small
wright, George	Comprised	and	intramuscular	lower limb	sample size
Wheble, Thomas WL	anatomical	retrospective	and tedious	reconstruction
Chapman, Umraz	and clinical	study.	dissection,	especially foot and
Khan	parts.		accidental	ankle. Less
United Kingdom	Anatomical		ligation of	donor site
Injury, Feb, 20006	study		muscular	morbidity with
	included,		branch. A 100%	most of the time
	raising of		flap survival	can closed
	MSAP flap on		rate with two	directly if flap
	10 cadaveric		partial flap	width <5.75 cm.
	fresh frozen		necrosis.	Thin walled,
	lower limb.			tortuous and
				wide calibre vein
				can cause
				congestion, so
				care should be
				taken to avoid
				pressure on it.
E. Fitzgerald	Total 15	Retrospective	The flap	All 15 patients	Case series
O’Connor, et al.	patients who	consecutive	survival rate	have defect at	with small
United Kingdom.	received the same	case series of	was 100%.	peri ankle area.	sample.
Foot and ankle	numbers of	a single	Only one flap	Eight of them were	Single
Surgery,	free MSAP	surgeon over	has partial	due to trauma	surgeons
20197	flap to	4 years	necrosis which	and remaining 7	experience
	reconstruct	from 2011 to	has managed	were from	and only
	the ankle and	2015. They	without the need	infection. The	included peri
	foot defects	were	for further free	mean flap length	ankle
	were	demonstrating	flap. All donor	was 6.5 cm with	reconstruction
	evaluated. Among them, 11	the use of	areas have	a range of 4–12	cohort.
	were	versality of	closed directly	cm. Flap width
	male and 4	The free MSAP	Without	was 3–8 cm with
	were female.	flaps at peri	complication.	a mean of 4.8 cm.
	The mean age of	ankle wound	Overall	Pedicle length
	patients was	reconstruction	outcome was	ranged from 6 to 10 cm
	47 years with	without the need	satisfactory.	(mean 8
	a range of 21–66 years.	for revision		cm). Seven were
		operation.		anastomosed
				with posterior
				tibial artery, 4
				with anterior
				tibial artery and 4
				with dorsalis
				pedis artery. All
				of them were end-
				to-end except
				one. Mean flap
				raising time was
				45 minutes.
Gloria R. Sue MD,	A total of 246	Retrospective	No flap failure	Average flap size	No clear
Huang-Kai Kao MD,	patients	study looking	in lower limb	was 11.8 × 5.8	outcome on
Mimi R. Borrelli	underwent	at the	reconstruction	Cm,	lower limb
MBBS, Ming-Huei	248 free	outcome and	cohort.	12.5% developed	reconstruction
Cheng MD	MSAP flap to	complications	Complications	arterial	cohort. Most
Taiwan,	head and	on	rate was	occlusion.	of the
Microsurgery,	neck and	consecutive	16.7%.	The majority of donor	outcomes
November 20198	extremities.	patients	Common	site could close	were
	Among them,	undergone	cause of	directly. An average	combined and
	30 patients	free MSAP	immediate	pedicle length	compared with
	had flap on	flap	threat to flap	was 11.3 cm.	H & N, upper
	lower limbs.	reconstruction	was due to	The mean flap	and lower
	The mean age of	from 2006 to	venous	ischemia time	extremity
	patients was	2017 in a	insufficiency	was 110	reconstruction

	47.5 years	single centre.	(74%). Free	minutes. No	.
	with a range		MSAP flap	significant
	of 15–76		shares many	correlation
	years. Among		qualities with	between flap
	them, 85.4%		free radial	failure rate with
	were male.		forearm flap	patient age,
			however had	gender or
			much less	recipient site.
			donor site	However, location
			morbidity	of reconstruction
			compared to	significantly
			RFFF.	affect the
			Versality of	complications.
			reconstruction
			from head to
			toe, with
			favourable
			outcome with
			high patient
			satisfaction
			and minimal
			donor site
			morbidity.
Farrukh Aslam	A total of 18	Retrospective	Only two free	Two free flaps both	Most of the
Khalid, Saif ur	patients had	study looking	MSAP flap	were to	outcomes
Rehman, Ata Ul Haq,	same number	for outcome	reconstruction	reconstruct	were
Ahsan Riaz,	of MSAP flap	of MSAP flap	to the lower	foot/ankle	combined with
Muhammad Saleem,	reconstruction	reconstruction	limb with no	defects. The	head and
Muhammad Jibran	. Among them,	in head and	flap failure or	causes of both	neck
Rabbani, Muhammad	only 5 patients	neck and	even partial	defects were	reconstruction
Amin, Abdul Malik	had MSAP	lower limb	loss. One of	traumatic. Flap	as well as
Mujahid, Hamid	flaps to	defects. All	the three pedicle	length ranged	some were
FazeelAlvi, Moazzam	reconstruct	cases have	flaps has	from 8 to 14	pedicle flaps.
Nazeer Tarar.	the lower limb	been done in	partial flap	cm with the mean of	Very little
Pakistan.	defects. Two of	a single	loss. One free	10.4 cm. Flap	sample for
J Ayub Med Coll	them were	centre	flap had post	mean width was	lower limb
Abbottabad, 2018	free flap.	between	operative	9.6 with a range of	cohort and
9	The mean age of	October 2016	venous	6–12 cm. The	outcome were
	the patients	and August	congestion	average pedicle	complicate by
	was 27.4	2017. Among	and one had	length was 8.4	including
	years with a	them less a	arterial	cm with a range of	pedicle flaps.
	range of 12–	third cases	occlusion both	8–9 cm. Both of	On title, they
s	36 years and	were lower	were salvaged	the free flaps has	said
	all were males.	limb cohort (5	but didn’t	anastomosed	reconstruction
	Cause of	out of 18).	mentioned the	using anterior	of head and
	defects were		site (H & N vs	tibial artery as	neck and
	Mostly		Lower limb)	recipient artery.	limbs.
	traumatic (3			Mean flap	However, it
	patients) 1			raising time was	only included
	was due to			84.6 minutes.	lower limb
	electric burn				cases and no
	and 1 was				upper limb
	from tumour				cases were
	excision.				included so
					using the
					terms limbs bit
					confusing.
Kyu Nam Kim, Sang	10 Patients	Retrospective	100% flap	All patients had	It is a small
Il Kim, Won Ha & Chi	aged from 30	case series,	survival noted	pre-operative CT	case series
Sun Yoon.	to 57 years	10 patients	with only one	Angiogram to	from a single
South Korea,	(mean 43.7	Received the	case had	assess the	unit. Only
Journal of Plastic	years)	same	partial flap	vascular status.	Showed
Surgery and Hand	received	numbers of	loss (10%). No	The defects were	outcome of
Surgery, January	FMSAP from	free MSAP	other obvious	mostly due to	popliteal fossa
201710	contralateral	flap to see the	complication	trauma except	reconstruction
	side to	outcome of	documented.	one, which was	. Some
	reconstruct	reconstruction		due to contact	operative data
	the popliteal	for popliteal		burn and all were	Specially
	defect mostly	defect		in popliteal fossa.	operative time
	from trauma.	anastomosing		The mean flap length	or ischemic
	All of the	end to end		was 15.2 cm with	time didn’t
	patients were	with medial		a range of 17.5–	mention.
	male.	sural		12 cm. The
		vessels.		average width of
		Those have		flap was 5.2 cm

		been done in		(range 4–7
		a single		cm). Pedicle
		centre over		length was 6–9
		the period of		cm with an
		5 years		average of 7.5
		between 2010		cm, 90% of
		and 2015.		donor side
				closed directly
				but one who
				needed SSG.
Jyoshid R. Balan,	Seven patients who	It is	All flaps have	Pre-operative	Small case
India	received 7	retrospective	survived with	perforator	series. The
ANZ J Surg, 2017	FMSAP flap	case series	only one has	marking was	operations
11	for lower limb	with FMSAP	partial loss	done using	were done in
	reconstruction	flap	due to venous	doppler US.	what years not
	. The mean	reconstruction	congestion.	Mean flap length	mentioned.
	age of patient	were done in	Two patients	was 14.2 cm with
	was 42 years	lower limb	have donor	a range of 9–21
	with a range of	traumatic	site	cm. Flap width
	19–72	wounds over	dehiscence.	was 4–8 cm
	years. All	2 years	Most of the	(mean 6.5 cm).
	patients were	periods in a	patient well	Pedicle length
	male. Six of the	single centre.	satisfied from	was 3–14 cm
	defects were		reconstruction.	with an average
	in foot and/or			of 9.7 cm. Only
	ankle and			one flap was
	one was leg.			anastomosed
	All defects			with anterior
	were			tibial vessel,
	secondary to			other 6 were
	trauma.			posterior tibial
				and dorsalis
				pedis 3 each. All
				anastomosis
				were end-to-end.
				Donor site had
				SSG in most
				cases (57%) and
				rest of 43%
				closed directly.
Zaher Jandali, Martin	In total, 22	Retrospective	Over all flap	Most of the	This is the
C. Lam, Kiomars	patients who	study	survival rate	patients were	only study we
Aganloo, Benedikt	were	comprised of	was 100%.	suffered for PVD	found with
Marwart, Jouke	undergone	22 FMSAP	Only one	with or without	unusual
Buissink, Klaus	FMSAP flap	flaps	patient had	DM. So cause of	cohort of
Muller, Lucian P. Jiga.	reconstruction	reconstruction	partial flap	most wounds	patient with
Germany.	for lower limb	on lower	failure	Those	PVD where as
Wiley Microsurgery,	defects. Mean	limbs of same	managed	reconstructed	most of the
August 201612	age of 59	number of	without further	were due to	studies
	years with	patients over	free flap. One	ischemia (16	showed the
	a range of 31–	the period of	patient had	patients). Rest of	indication of
	73 years.	2 years from	venous	six were indicated	reconstruction
	Among them,	2012 to 2014	congestion	for traumatic	was trauma.
	15 patients	in a single	needed return	wounds. All
	were male.	centre.	to theatre to	wounds were
			salvage the	involved foot and
			flap. Overall	ankle and all
			patient	patient had CT
			satisfaction	Angiogram
			was good for	preoperatively to
			all.	delineate the
				vascular status
				of their legs. The
				mean flap length
				was 9.5 cm
				(range 6–21 cm),
				flap width was
				4–9 cm with an
				average of 6 cm.
				Mean pedicle
				length was 7.2
				cm (range 6.3 to
				8.2 cm ) More
				than half of them
				(n = 12) were

				Anastomosed with DP vessels, 7 were with posterior tibial vessels and 3 were anterior tibial vessels. Nine of them were ETE and 13 were ETS anastomosis with recipient vessels. The average flap raising time was 139 minutes and the operative time was 293 minutes. A total of 14 donor sites were closed directly up to 9 cm wide gap. Eight of them needed skin graft. The mean hospital stay was 14 days. None of the flaps needed further adjustment.
Xin Wang, M.D. Jin Mei, M.D. Jiadong Pan, M.D. Hong Chen, M.D. Weiwen Zhang, M.D. Maolin Tang, M.D. China. PRSJ January 201313	A total of 34 patients received free MSAP flap. Among them, only nine patients have received the flaps for lower limb reconstruction at ankle and foot. Eight were male and one was female. The mean age was 35 years with a range of 23–48 years. An anatomical study was also performed on 10 cadaveric limbs to see the vascular anatomy of the MSAP flap.	Hybrid study which included an anatomical study on 10 cadaveric limbs and a retrospective clinical study of consecutive case series over the period of 3 years from 2007 to 2010 in a single centre. The study includes reconstruction of both upper and lower extremities. Among them, nine patients received FMSAP flap to reconstruct the lower limb defects.	In a clinical study, 100% flap survival with 2 partial flap loss. All patients were satisfied with the outcome.	The cause of all lower limb defects was from trauma. All patients had preoperative CT angiogram. All 9 patients received free flaps. The range of flap length was 5.5-12 cm with an average of 9.4 cm. The mean width of the flap was 5.3 cm with a range of 4.5 cm to 7 cm. Pedicle length was around 10 cm. Five of the donor sites were closed directly which were less than 5 cm wide. Four of them needed skin graft.	Complicated hybrid study which included anatomical study on cadavers as well as clinical study on patients. Only few of the patients had MSAP flap reconstruction to their lower limbs. It was difficult to extract the data about lower limb reconstruction cases. Small lower limb case sample.
Geoffrey G. Hallock, MD. United States of America. J of Reconstr Microsurgery, October 2013.14	A total of 14 patients who had FMSAP flap to reconstruct their defects on lower limbs. 12 were male and 2 were female.	Retrospective study of 14 consecutive patients who received FMSAP flap to reconstruct their lower limb defects.	One patient had total flap loss which was replaced by another free flap. One flap has a problem with venous congestion and one patient had donor site complication. All patients were satisfied	The indications for reconstruction were traumatic wounds for all, but one who has unstable scar at club foot. All patients had the reconstruction at the ankle or foot. All 14 patients have received free flaps average length of flaps was 10.3 cm with	Small case series.

			at the end.	a range of 5–17 cm. The range of width was 3–6 cm with a mean of 4.1 cm. In case of 7 patients recipient vessel was posterior tibial vessel, 5 were anterior tibial vessel, 2 were dorsalis pedis vessel. Nine donor sites closed directly (<5 cm width) 5 needed skin graft.
Sun G, Nie K, Qi J, Annotations Jin W, Li S, Bulk Zhang submission download s Z, Wei Z, Wang D China. Chinese Journal of Reparative and Reconstructive Surgery, March 201615	In total, 16 patients who received FMSAP to reconstruct their foot defects; 12 of them were male and 4 were female. The mean age was 35 years with a range of 16–58 years; 11 patients had traumatic wounds whereas 4 of them had burn wounds around ankle necessitated reconstruction.	Retrospective study to look at the outcome of 16 patients who were underwent FMSAP flap over the period of 5 years from 2010 to 2015 in a single centre.	Overall outcome was satisfactory with no flap failure or even no partial flap loss. Both donor and recipient sites were healed without any noticeable complications.	All 16 flaps were free flaps. Flap length was ranged from 5 to 11 cm and width was 4–8 cm. All flaps have survived with no complications.	Small case series. Article has written in Chinese only the abstract has found in English where we couldn’t find all the information about the study.
M. Ives, B. Mathur, United Kingdom. Journal of Plastic, Reconstructive & Aesthetic Surgery, 201516	In total, 18 patients who have received free MSAP to reconstruct their head and neck and limb defects. 4/18 patients received FMSAP for lower limb reconstruction. Among these four patients, two were male and two were female. The mean age of the patients was 37.7 years. The youngest patient in this cohort was 11 years old and the oldest one was 56 years old. All patients had their reconstruction for their	It is a retrospective case series of 18 patients who received free MSAP flap for reconstruction of head and neck and limbs defects in a single centre, to see the outcome and complications.	All flaps in lower limbs have survived over 3 months follow-up period. Only one patient had donor site complication.	The mean flap length was 7.7 cm with a range from 4 to 12 cm. Flap width ranged from 3 to 6 cm with a mean width of 4.2 cm. An average pedicle length was 9.5 cm with a range from 7 to 12 cm. All patients had their donor sites closed primarily and none of them needed skin graft.	Small case series with a very small number of cases from lower limb cohort which was only four in number. Had multiple cohorts including reconstruction of head and neck and also limbs.

traumatic wounds of their lower limbs. Two patients had reconstruction to their legs and other 2 patients had reconstruction to their foot and ankles.

Table 3: Abbreviated Results for Upper Limb MSAPs.

Author, Country, Journal, Year of Publication	Patient Group	Study Type (Level of Evidence)	Outcomes	Key Results	Study Weaknesses
Gloria R. Sue	A total of 246	Retrospective	There were 2 flap	Average flap	No clear
MD, Huang-Kai	patients	study looking at	failure in upper limb	size was 11.8 ×	outcome on
Kao MD, Mimi	underwent 248	the outcome and	reconstruction cohort.	5.8 cm;	upper limb
R. Borrelli	free MSAP flap to	complications on	Among 48 flaps in	12.5%	reconstruction
MBBS, Ming-	head and neck	consecutive	upper extremities 10	developed	cohort. Most of
Huei Cheng MD	and extremities.	patients	have complications	arterial	the outcomes
Taiwan,	Among them, 48	undergone free	with a rate of 20.8%.	occlusion.	were combined
Microsurgery,	patients had flap	MSAP flap	Common cause of	The majority of	and compared
November 2019	on upper limbs.	reconstruction	immediate threat to	donor site could	with H & N,
8	The mean age of	from 2006 to	flap was due to	close directly.	upper and lower
	patients was 47.5	2017 in a single	venous insufficiency	An average	extremity
	years with a range	centre.	(74%). Free MSAP flap	pedicle length	reconstruction.
	of 15–76 years.		shares many qualities	was 11.3 cm.
	Among them,		with free radial	The mean flap
	85.4% were male.		forearm flap, however,	ischemia time
			had much less donor	was 110
			site morbidity	minutes. No
			compared to RFFF.	significant
			The versality of	correlation
			reconstruction from	between flap
			head to toe, with	failure rate with
			favourable outcome	patient age,
			with high patient	gender or
			satisfaction and	recipient site.
			minimal donor site	However,
			morbidity.	location of
				reconstruction
				significantly
				affect the
				complications.
J.A.	A 28-year-old man	Case report	Used palmaris longus	The size of the	Only case
Jeevaratnam, D.	had index finger		tendon graft. Showed	flap was 8 ×	report of a
Nikkhah, N.F.	reconstruction with		versality of flap use.	4 cm. Donor	Patient
Nugent, A.V.	FMSAPF following		No flap failure, no	site has closed
Blackburn	high voltage		complication and	primarily.
United Kingdom.	electric burn injury.		patient showed very
JPRAS			good functional and
June 201417			aesthetic results. No
			donor site morbidity.
Cheng-Hung	This study	It was a	One out of 14 flaps has	The length of	Small case
Lin, MD, Chih-	included 14	retrospective	failed. One patient had	the flap ranged	series. No
Hung Lin, MD,	patients who	case series with	wound related	from 7 to 17	information
Yu-Te Lin, MD,	underwent free	14 patients who	complication. All but	cm with a mean	about follow up
Chung-Chen	MSAP flap	have treated	one donor sites closed	length of 10.9	period and
Hsu, MD,	reconstruction to	with FMSAP	primarily and only one	cm. Flap width	duration.
Timothy W. Ng,	their upper limb.	Flap for their	has needed split skin	ranged from 2.5
BS, and Fu-	11 of them were	upper limb	graft. There were no	to 8 cm with
Chan Wei, MD.	males and 3 were	defect during the	donor site complication	an average of
Taiwan	females. The mean	period of 2006	noted.	5.3 cm. Pedicle
J of Trauma,	age of the patients	to 2008 in a		length was 6
March 201118	was 32.8 years.	single centre.		–12 cm

	The oldest patient was 62 years old and the youngest one was 16 years old. The indication for reconstruction was traumatic defect in 13 patients and burns for one. All patients had their reconstruction on hand or wrist.			(mean 10 cm). Most of the cases recipient artery was radial artery (n = 12). In case of one patient, ulnar artery has been used as recipient artery and further one had UDA as recipient artery.
Zheng H, Liu J, Dai X, Schilling AF. China JPRAS 201419	In total, five patients who received conjoint or chimeric FMSAP flaps to reconstruct the jumping hand defects. All patients were male and aged from 19 to 38 years with a mean of 28 years. Three of them were due to trauma, burn and infection were one of each.	Retrospective case series over a period of 1 year from 2009 to 2010 in a single centre. Only patients with two perforators were included in the study. The follow-up was 6–24 months with an average of 13 months.	All flaps have been taken without any loss. One patient has wound dehiscence which has been managed conservatively. Overall, all patients were satisfied with a single stage of reconstruction, although three of them needed further surgery for revision and adjustment.	Five free MSAP each of which either split into two parts or raised as chimeric with multiple perforators. The average length of the flap was 6.5 cm (range 3–8 cm ) and the width was 4.5 cm (range 2.5–6 cm) The pedicle size was 9–16 cm. The average thickness of the flap was 5 mm (4–8 mm). The mean arterial and venous diameters were 3 and 3.5 mm, respectively. Three out of five needed split skin graft.	Very small case series with modification of flap.
Xin Wang, M.D. Jin Mei, M.D. Jiadong Pan, M.D. Hong Chen, M.D. Weiwen Zhang, M.D. Maolin Tang, M.D. China. PRSJ January 201313	A total of 34 patients received free MSAP flap. Among them, 25 patients have received the flaps for upper limb reconstruction at wrist and hands. 11 were male and 14 were female. The mean age was 35 years with a range of 19–52 years. Anatomical study also performed on 10 cadaveric limbs to see the vascular anatomy of the MSAP flap.	This is a hybrid study which included an anatomical study on 10 cadaveric limbs and a retrospective clinical study of consecutive case series over the period of 3 years from 2007 to 2010 in a single centre. The study includes the reconstruction of both the upper and lower extremities. Among them, 25 patients have received FMSAP flap to the upper extremity defects. Follow-up period is 6–21 months.	In a clinical study, 100% flap survival with three partial flap loss. All patients were satisfied with the outcome.	The main cause of upper limb defects was from trauma (21 patients). The rest of them were burns (4 patients). All patients had preoperative CT angiograms. All 25 patients received free flaps. The range of flap length was 7–14 cm with an average of 8.8 cm. The mean width of the flap was 5.6 cm with a range of 4.5–9 cm. Pedicle length was around 10 cm. Thirteen of the donor sites were closed directly which were less than 5 cm wide. Twelve of them were	Complicated hybrid study which included anatomical study on cadavers as well as clinical study on patients. It was difficult to extract the data about lower limb reconstruction cases. There was less information about the operation.

				needed skin graft.
Eren F, Oksuz S, Karagöz H, Melikoğlu C, Ulkur E. Turkey. Hippokratia, 201520	Two patients received FMSAP flap for reconstruction of post-burn contracture release of multiple fingers. Both were males and the average age was 21.5 years with a range of 21–22 years.	Retrospective case reports of 2 cases to see the outcome of FMSAP flap on volar wounds of multiple fingers with flexor tendons exposed after PBC release.	Both flaps worked well with even no partial failure. After 3 months of physiotherapy, patient achieved complete contracture release and adequate finger movements.	Both flaps were 6.5 cm long and 4.5 cm wide. Pedicle lengths were 8.3 and 8.8 cm with a mean of 8.5 cm. Both flaps anastomosed with radial artery as recipient vessel at anatomical snuff box. Both of the donor sites needed split skin graft. The author had an impression that donor defects could close directly if it was 5 cm or less.	Case report of two patients only.
M. Ives, B. Mathur, United Kingdom. Journal of Plastic, Reconstructive & Aesthetic Surgery, 201516	A total of 18 patients reviewed those who had FMSAP for reconstruction of head and neck and limb defects. Among them, only one patient has had free MSAP for hand reconstruction. That was a 35-year-old female, who had traumatic skin loss to her hand and needed reconstruction with the FMSAP flap.	It is a retrospective case series of 18 patients with free MSAP flap reconstruction of head and neck and limbs in a single centre. Only one patient had the MSAP flap to her upper limb.	The flap has survived without any problem. However, donor sites have delayed healing issues over a 3-month follow-up period.	The size of the flap was 12 × 8 cm. The pedicle length was 7 cm. The donor site has closed primarily and does not need skin graft.	Only one patient from the upper limb cohort.

Grouped Upper and Lower Limb Analysis

From this 10-year review, we shortlisted a total of 15 papers to be reviewed and analysed. Among them, 11 papers for lower limbs and 7 papers for upper limb reconstructions (3 papers included both). Overall total number of patients was 257, 12 of these underwent pedicled flaps, while the remaining underwent free MSAP flaps. These studies were carried out internationally, with five from the UK and three from China.

Table 4. Publication Country of Origin.

Country of Origin	Number of Studies	References
United Kingdom	4	6, 7, 16, 17
China	3	13, 15, 19
Taiwan	2	21, 18
USA	1	14
South Korea	1	10
Germany	1	12
India	1	11
Turkey	1	20
Pakistan	1	9

^{Note: Publication year ranged from 2011 to 2020.}

Demographics of Patients

The age range was 11–79 years, with a mean age of 45.1 years. Regarding the need for reconstruction, 104/151 (69%) reported cases were reconstructed for traumatic lower limb wounds. The next most common causes were burns and ischemia (13% and 11%, respectively). The most common site in the case of the lower limb was the foot and ankle (77%) and the upper limb was the hands and wrist (100%).

Flap Characteristics

Flap length ranged from 3 to 22 cm. Flap width ranged from 2.5 to 12 cm. Pedicle length ranged from 3 to 16 cm.

Operation Details

End-to-end microsurgical anastomosis was used 65% of the time, with end-to-side anastomosis 35%. The mean flap raise time was reported as ranging from 45 to 139 minutes and the total operative time ranged from 282 to 293 minutes.^6,12 Flap raising time was not recorded in the majority of articles. According to the five papers that did document this, the mean flap-raising time was 82 minutes. Four articles reported mean operative time, which was approximately 5 hours, and 80% of donor sites closed directly. Total flap failure occurred in 1.3% and partial flap failure in 5.8%. Congestion was reported in 3.2% with wound problems (4.5%) and donor site problems (2.6%). No patients reported being ‘unsatisfied’ with their results.

Additional Lower Limb Analysis

In this review, 11 studies were included with reference to MSAP reconstruction of the lower limbs. This included 161 patients, with the same number of MSAP flaps. Among them, 149 were free flaps and 12 were pedicle flaps. In total, 125 (78%) were males and 36 (22%) were females. The range of age was 11–79 years with a mean of 41.8 years. In terms of need for reconstruction (Figure 8), 88/131 (67%) cases were reconstructed for traumatic lower limb wounds. The next most common causes were burns and ischemia (13% and 12%).

The most common sites in lower limb reconstruction with a free MSAP flap were foot and ankle (77%). The average flap length was 10.5 cm, with a range from 3 to 22 cm. Flap width ranged from 2.5 to 12 cm with a mean of 5.6 cm. Most of the authors agreed that the donor site could close directly if it is less than 6 cm in width. The highest documented width has closed primarily is 9 cm. The pedicle of the flaps was found on average to be 8.8 cm; however, this was as high as 16 cm. The most common recipient arteries were the anterior tibial artery and posterior tibial artery. In 50% (n = 45/90) of cases, the recipient artery was anterior tibial or dorsalis pedis, 37% (n = 33/90) was posterior tibial and 13% of cases (n = 12/90) used other arteries (2 superior medial geniculate arteries and 10 medial sural arteries) (data available for 90 patients). Two-thirds (47/72) of the anastomoses were end-to-end and one-third were end to side (25/72). One study¹³ showed two perforators were used in four out of nine patients and one perforator was used in the remainder.

The mean flap raising time was 90 minutes^9,12,7 and mean ischemia time was 85 minutes.^21,6 Total operative time was on an average of 287 minutes.^12,6 In 76% (84/110) of cases, the donor site closed directly and 24% (26/110) cases required a split skin graft. The maximum size closed was 9 cm. The mean hospital day was 14 days.¹² Only one free flap failed in 149 free flaps, giving a 99% flap survival rate. Eight patients had partial flap necrosis, five patients had venous congestion and five patients had wound-related complications. Donor site problems were noted in four patients. From the documentation of the studies included, all patients were satisfied with the outcome, excluding one flap failure.

Additional Upper Limb Data

In this study, seven studies were included with reference to MSAP reconstruction of the upper limbs. Among these studies, which included 96 patients, all of them had free MSAP flaps to reconstruct hand and wrist defects. There were nearly twice as many males as female patients (M:F = 5:3). Patients were mostly young with a mean age of 32.5 years (range 15–76 years). In the majority of cases, the indication for reconstruction was trauma (80% cases) 38/48, 18% were burn and 2% were due to infection. This is represented in Figure 9.

CT angiogram was only described in one study,¹³ which was carried out in all 25 patients. The mean flap length was 9.2 cm with a range of 3–22 cm. Flap width was ranged from 2.5 to 12 cm (mean 5.3 cm). The pedicle length was on an average of 9.4 cm (range 6–16 cm). The mean thickness of flaps was 5 mm (4–8 mm).¹⁹ Most of the anastomosis has been carried out using the radial artery. In 87% of cases, the recipient artery was the radial artery²⁰ and in 13%¹ cases, this was the ulnar artery,¹ the mean flap ischemia time was 110 minutes.²¹ One study¹³ mentioned that one perforator was used in 18/25 (72%) and two perforators were used in the remaining seven patients (28%). Nearly two-thirds of donor sites closed directly in 30/48 cases (62%), and 38% of 18/48 cases needed split skin grafting. Notably, 98% of cases had no donor site problem. Overall flap success rate was 97% (n = 3 flap failure) and partial flap loss occurred in 3% of cases (n = 3). Wound healing issues were encountered in 12.5% (12/96). Donor site problem was encountered in 1% (1/96). Notably, 3% of patients needed further flap adjustment; however, all patients had satisfactory outcomes with reconstruction.^13,19

Discussion

Flap anatomy: Many anatomical studies have been carried out for the MSAP flap.^8,22,23 In this study, we found mean flap length was 9.6 cm and width 5.4 cm which correlated with the previous literature. The mean pedicle length was 9.7 cm. This compares to other studies citing this at 10.1 cm.² With regards to the number of perforators, our study showed a range of 1–5, however, anatomical studies have provided a range of 1–8.^8,23,24 The average thickness of the flap was only 5.9 mm which has given its thin and pliability character.

Outcome measure: The donor site can close primarily in 80% of cases, which compares to other articles that have stated 76.2%.² The overall flap success rate is 96%, with a total loss of 1.3% and a partial loss of 5.8% compared to other literature that stated 3.1% and 3.1%.² Overall complications found in this study were 17%, whilst other studies found similar findings of 14.3%² and 16.7%. Donor complications: 2% compared to 1.9%.² The most common cause of flap failure was venous congestion, which was similarly stated by Daar et al.² The challenges associated with reconstructing lower and upper limb defects carry many similarities. Specifically, the scarcity of soft tissue bulk as well as, exposure of bone, tendons and neurovascular structures. Most of the cases were complex traumatic wounds with extensive zones of injury. The distant/distal blood supply and other vascular comorbidities can add further complicating factors that need to be considered when reconstructing extremities.

Keeping these concerns/challenges in mind, reconstructive surgeons should look for well vascularised, robust tissues that are durable enough to provide cover over the zone of trauma, as well as protection for infection-free bone healing, thus allowing for early mobilisation and recovery. Coverage needs to be thin and pliable enough to allow an easy gliding surface for tendons and sufficient movement of joints. Donor site morbidity is also important to reduce and enhance the recovery of patients. Furthermore, the functional, psychological, social, financial and aesthetic importance of the upper and lower limbs puts an extra burden on the reconstructive plan. Therefore, the end functional and aesthetic outcome can have a significant impact on the patient’s psychosocial and financial stability/well-being. Free tissue transfer has become the gold standard for reconstructive options for lower limb reconstruction, especially for traumatic wounds which are the most common indication which was also reflected/echoed by our review. The MSAP flap is one option that has already gained popularity in limb reconstruction. Survival of the flap is the most critical/vital factor, with our review demonstrating a 98% survival rate, indicating that the MSAP is a reliable flap.

Other advantages include its versatility, pliability, durability and long pedicle.^16,25,18 This is in addition to the reduced donor site morbidity, as the lower limb has less subcutaneous fat and the skin has additional slack, making it more amenable for direct closure compared to other donor sites which may require skin grafting.²⁶ The MSAP flap appears to have significant advantages when compared to other workhorse free tissue flaps. The RFFF has significant donor site morbidity, while the anterolateral thigh flap can be bulky and often requires thinning, which may lead to vascular compromise.^27,28 The MSAP is also easy to monitor due to its skin paddle, in comparison to muscle and fascia only free flaps. Recent research has suggested laser Doppler imaging can also be used to monitor MSAP-free flap perfusion postoperatively.²⁹

Our study does, however, have certain limitations. The sample size of the literature that was ultimately included was relatively small and additionally, all studies were retrospective in nature, potentially biasing the identification of predictors of flap complications. The majority of the studies were single-centre series, with small sample sizes, thus limiting the strength and quality of our results. Additionally, our review concentrated on the outcomes of the MSAP flap, rather than directly comparing it to other workhorse flaps. A larger, prospective and multicentre trial comparing multiple flaps used to reconstruct the upper and lower limbs would provide even more useful data and more precise outcomes. Nevertheless, it should be pointed out that the aim of our work was to review the literature on the MSAP flap alone and our results provide a summary of the characteristics of the MSAP flap and its outcomes.

Advantages and Disadvantages of the MSAP Flap

Advantages

• Flap is thin, pliable and versatile flap designing
• Long vascular pedicle helps to anastomosis away from the zone of injury and radiotherapy
• Reliable pedicle with a good number of perforators with satisfactory size
• Minimal donor site morbidity (2%), more than 80% of cases can be closed directly
• Can raise as chimeric, can harvest with vascularised fascia and can act as a gliding surface.³⁰
• Consistent anatomy
• Can raise as a sensate flap with the saphenous nerve or sural nerve
• Less need for flap thinning or adjustment operation
• No donor site functional limitation.

Disadvantages

• Variations in perforator anatomy
• Tedious intramuscular dissection
• Cannot be used for large area reconstruction (on an average flap size of 9.6 × 5.3 cm)
• Scar stretching or notching, skin graft can leave scar with poor cosmesis, which is an important drawback of this flap.

Conclusion

This meta-analysis has shown the MSAP flap to be a versatile, reliable, functionally and aesthetically acceptable flap for both lower and upper limb reconstructions with maximum patient satisfaction and minimal donor morbidity. The overall combined flap success rate was 98%. The MSAP is a useful flap, bearing in mind the thin, pliable skin paddle, good pedicle length and ability to carry out a two-team approach, with low donor site morbidity. Our evidence suggests that the increasing popularity of the MSAP flap is justified and this flap is an excellent option for soft tissue extremity defects.

Acknowledgements

We acknowledge Juyrah Ayeesa Hosain and Juhymah Aeera Hosain for their excellent drawings and illustrations and Mr. David Bell for helping in the conception of this article.

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Cite this article as:
Koshy KK, Naik A, Hosain MM. The Free Medial Sural Artery Perforator Flap for Microsurgical Reconstruction of Limbs: A Systematic Review and Meta-Analysis of Flap Characteristics and Outcomes. Premier Journal of Science 2024:2;100016.

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