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40 Medial Sural Artery Perforator Flap

tissue is required at the recipient site, such as the foot and ankle and dorsum of hand [37]. Leahy et al. have shown than the medial calf is associated with 47% less supra-fascial adipose tissue than the ALT region in both men and women [38].

40.3 Pre-operative Investigation

Routine pre-operative imaging is not required for MSAP ap harvest. However, CT angiography may be useful in patients with previous lower limb injury or surgery or patients with diabetes and atherosclerotic disease.

A standard hand-held Doppler ultrasound (8–10Hz) is routinely used to map perforators pre-operatively on the operating table [39]. These are most commonly found along the line marked from the midpoint of the popliteal fossa to the medial malleolus, in the region 6–18cm below the popliteal crease and 1–3cm lateral to the midline of the calf.

Colour duplex-Doppler has also been shown to be reliable for planning of sural artery perforator aps due to high precision in detecting location of dominant perforators and ability to assess ow more accurately than standard Doppler ultrasound [40].

For more accurate perforator mapping with assessment of the intra-muscular pedicle course, branching pattern type [32] or the site of fascial perforation, CT angiogram [41], with or without 3D visualization reconstruction [42], can also be used. While these are more time- and resourceintensive, it has been shown that routine use of pre-operative CT angiogram may help determine which leg has the most favorable branching pattern type and intra-muscular course for ap harvest [32].

40.4 Flap Design andMarkings

Flap Markings (Fig.40.2)

• Mark the midpoint of the popliteal fossa and the medial

malleolus.

– Draw a longitudinal line connecting the two

landmarks.

– Starting at roughly 12cm along and slightly posterior

to this line, use a hand-held Doppler to identify the perforators. Ensure these are proximal to the inferior border of the gastrocnemius.

– Mark the chosen perforator(s) using a clear ‘x’ and/or

number. – Mark the anterior border of the ap. – Adjust the ap markings to ensure the perforator in the

centre or upper edge of the ap depending on the laxity

387

Fig. 40.2 Pre-op markings of the MSAP ap. (1) Midpoint of the popliteal fossa. (2) Medial malleolus. (3) Longitudinal line between the midpoint of the popliteal fossa and the medial malleolus. (4) Inferior border of the gastrocnemius. (5) Chosen perforators marked using an ‘x’ and number. (6) Anterior border of the ap

of skin and ap design [4]. If pedicle length is a priority, the perforator can also be located towards the distal aspect of the ap to lengthen the pedicle as much as possible.

Flap Design: Key Points

• Design the skin island of the MSAP free ap in a slightly oblique but predominantly longitudinal direction, to capture interconnecting choke vessels between the perforasomes of the lower limb [43].

• Limit the ap width to less than 6cm width to enable primary closure [19].

– Some series have suggested a ap width of up to 8cm

can also routinely enable direct closure with generally mild risk of donor site wound dehiscence [2, 5].

• Wherever possible use ipsilateral donor and recipient sites to restrict the dressings, scarring, pain and rehabilitation to a single limb.

– This will still allow for a two-team approach if neces-

sary, for shortened operative time and the use of a single tourniquet [4]. However, if there has been high energy trauma with diffuse soft tissue damage, the medial calf may be within the zone of trauma and preclude this, requiring harvest from the contralateral leg in these cases.

40.5 Flap Raise/Elevation: AStep-by-Step

Guide

Positioning

• Position the patient supine with the thigh abducted, knee exed and lower leg externally rotated, so the medial aspect of the calf is easily accessed.

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Tourniquet

• Use of a mid-thigh tourniquet is recommended. – If used, exsanguinate the lower leg only by elevation for

1min, rather than using an eshmark, to maintain ll of venae comitantes and permit better visualization of the perforators.

Incision (Fig.40.3)

• Make the anterior incision rst.

• Be sure not to place this incision too posterior, as this

would risk missing or injuring the perforators immediately.

• Incise down to fascia overlying the medial gastrocnemius

muscle.

Identication of the Perforator(s)

• Identify and preserve any perforator passing through the

subcutaneous tissue, however small initially, as this may be your main perforator.

• Take care to identify whether the perforator travels supra-

fascially along the muscle fascia prior to perforating through the supercial fascia.

– This can necessitate raising a wide skin paddle to keep

the perforator central to the skin paddle, thus impacting donor site primary closure.

• Make an exploratory incision in the anterior aspect of the

gastrocnemius fascia.

• Visualize and conrm perforator location and adequacy

of size.

• Endoscope-assisted identication of the perforator(s) has

been described but is not common practice [44].

D. Reissis et al.

Fig. 40.3 Anterior incision and identication of perforators. (1) Anterior incision. (2) Main perforator arising from a larger deep musculocutaneous perforator. (3) Additional smaller and more proximal perforators, with predominantly supra-fascial course

Dissection

• Trace the course of the perforator through the medial gas-

trocnemius muscle by longitudinally splitting the supercial muscle bres (Fig.40.4).

• After a short supercial course, the vessel deepens down

into the belly of gastrocnemius muscle giving multiple branches in all directions.

• Use careful bipolar dissection with a ‘deroong’ tech-

nique with ‘ligaclipping’ and heat-sink diathermy of multiple side branches within the muscle.

– Meticulous ligation/clipping of these tiny intra-

muscular branches is mandatory to avoid intramuscular haematoma in the immediate post-operative period.

• Dissect the pedicle retrogradely to the medial sural artery

or until adequate pedicle length is achieved.

• Once the required length and calibre of pedicle vessel

have been dissected, the posterior border of the ap is incised and the ap islanded on the pedicle(s).

Fig. 40.4 Pedicle dissection. Main pedicle dissected free with longitudinal muscle-splitting dissection and ligaclipping of multiple side branches along its length. Two main perforators supply the skin paddle

• Once your pedicle dissection is complete and ap perfusion is conrmed, template the skin paddle to the defect and make the posterior incision, isolating the ap on the pedicle(s).

• Divide the pedicle proximally at the origin from the popliteal artery (Fig.40.5).

Additional Flap Considerations

• If it is felt an additional vein will be required, ensure the small saphenous vein, which is normally located 3 cm from the dominant perforator [45], is protected throughout and included in the ap.

40 Medial Sural Artery Perforator Flap

Fig. 40.5 Flap raised prior to division of the pedicle. The posterior skin incision has been made, after templating the ap to the recipient defect

Fig. 40.6 Donor site closed primarily with a low vacuum suction drain in place

– Likewise, if a chimeric ap is required, an additional bulk

of gastrocnemius muscle, plantaris tendon or sural nerve may be harvested as part of the ap too.

389

– Days 1–5: Elevation of the operated/recipient leg for

5days.

– Day 5: Begin dangling the limb for 5min within a 1h

period. Increase the period dangling by 5 min each hour, 10min in the second hour, 15min in the third hour, until the leg is down for 30min within the sixth hour.

• Laser Doppler perfusion imaging may be a valuable adjunct for post-operative ap monitoring if available, with the highest relative perfusion in the perforator zone of the ap between days 1 and 5 post-operatively [46].

40.6 Core Surgical Techniques inFlap

Dissection

• Position the patient on the operating table before mapping the perforators with the Doppler ultrasound.

• Use safe dissection technique for deroong the pedicle and using heatsink bipolar and ligaclipping of multiple muscular branches throughout.

• Reassess and modify the nal ap design after the perforator(s) are identied and dissected fully, with release of the prior to disconnecting the ap.

• Harvest a segment of the short saphenous vein to provide the option for additional venous drainage, for use as both a free and pedicled ap [47].

• Avoid using the MSAP ap if it is required to be greater than 6m width, to avoid the need for skin graft, which is unsightly and can result in tethered and poor quality scar [48].

40.7 Clinical Scenarios

Closure

• Close the donor site primarily in layers (Fig.40.6).

• Direct closure of the donor site is preferred as skin grafting to the calf compromises the aesthetics of the reconstruction.

• Place a low vacuum suction drain (to stay in place until draining <30mL/24h).

Post-operative Care

• Each department may have a different post-operative regime based on personal experience.

• The protocol must be exible to the appearance and behaviour of the ap based on judicial clinical examination.

• An example of a post-operative regime for lower limb reconstruction may include:

40.7.1 Case 1

40.7.1.1 Partial Glossectomy Reconstruction

GeorgeOrfaniotis A 46-year-old female underwent left partial glossectomy for a T2N0M0 SCC from her left tongue. The resultant defect was reconstructed with a free MSAP ap, which was based on a single perforator and anastomosed to superior thyroid artery and a branch of the internal jugular vein. The tumor resection and ap inset were performed transorally, with no requirement for a mandibular split. At 1week post- operatively she was able to eat a soft diet and her speech was intelligible and easily understandable. At 4months post- operatively the patient was back to her job as a motivational speaker and was also able to run 10K (Fig.40.7).

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D. Reissis et al.

Fig. 40.7 Case 1. (a) Left glossectomy defect. (b) Free MSAP ap with single pedicle of sufcient length to anastomose to the ipsilateral trans- verse cervical vessels. (c) Result at 4months post-operatively, with natural contour and mucosalisation of the ap epithelium on the tongue

40.7.2 Case 2

musculocutaneous perforator. Pharyngeal reconstruction was achieved using an internal “patch” (6× 5 cm) MSAP

40.7.2.1 Pharyngeal Cancer Reconstruction

GeorgeOrfaniotis A 62-year-old male with an invasive T4N1M0 pharyngeal SCC underwent total laryngo-pharyngectomy and bilateral neck dissection levels II–VI.Reconstruction was with a chimeric free MSAP ap with two skin paddles and a segment of gastrocnemius muscle, each based on their own individual

skin paddle, with the segment of the gastrocnemius muscle secured on top of this as extra waterproong layer, also reducing the dead space. The second MSAP skin paddle was used to facilitate skin closure as well as to allow clinical ap monitoring. The ap was anastomosed to the right facial vessels, using a Cook-Schwartz Doppler probe to aid postoperative venous monitoring (Fig.40.8).

40 Medial Sural Artery Perforator Flap

391

Fig. 40.8 Case 2. (a) Chimeric free MSAP ap being raised with two separate skin paddles and a segment of gastrocnemius muscle, each based on their own individual musculocutaneous perforator. (b) Defect following pharyngectomy and bilateral neck dissection with the free MSAP ap anastomosed to the right facial vessels and inset for simul-

40.7.3 Case 3

taneous pharyngeal and soft tissue reconstruction. Note the CookSchwartz Doppler probe on one of the draining veins to aid post-operative venous monitoring. (c) Flap inset and closure, with tracheostomy, 2× low suction vacuum drains and the Doppler probe attached

medial malleolus and associated soft tissue defect. An MSAP ap was raised from the contralateral calf to provide soft tis-

40.7.3.1 Open Ankle Wound Post-septic

Arthritis

DariushNikkhah and BernardLuczak A 45-year-old man with diabetes developed septic arthritis of the ankle. After surgical debridement he had an exposed

sue coverage and tailored to the defect. This MSAP free ap was anastomosed to the anterior tibial artery and great saphenous vein, providing a stable reconstruction with minimal bulk and good contour to enable footwear. He had an uneventful post-operative recovery (Fig.40.9).

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a b

D. Reissis et al.

Fig. 40.9 Case 3. (a) Left medial ankle soft tissue defect with exposed medial malleolus resulting from surgical debridement following septic arthritis of the ankle. (b) Free MSAP ap raised on two perforators (P1 and P2), with inclusion of the short saphenous vein (V) in addition to

40.8 Pearls andPitfalls

Pearls

• Incise the anterior border of the ap, with single

incision in the fascia, to identify the perforator(s) before committing to your skin island.

• This ap can be raised with multiple very small size

perforators, therefore preserve all options until the anatomy is revealed. If one is not comfortable with small size intra-muscular perforator dissection then an alternative ap option should be considered.

• The course of the perforator is always intramuscu-

lar and will require careful, often tedious, dissection using careful techniques described above.

• Flaps raised with a single small perforator may suf-

fer from venous congestion. If the VCs are too small

the venae commitantes. (c) Defect closure after MSAP ap inset with a low vacuum suction drain and separate Yates drain to reduce the risk of haematoma. Note the low prole of the ap to allow optimal contour of the medial malleolus and future footwear.

or damaged during dissection then the ap can be venous supercharged with the short saphenous vein (SSV). With careful dissection during the posterior incision, small branches of the SSV draining the ap can be preserved, and a good length of the SSV can be harvested proximally.

• Perform the dissection under tourniquet control without full exsanguination of the limb.

• Perform dissection under loupe magnication and preserve motor nerve branches to the gastrocnemius muscle. This can also be harvested as a nerve graft in a chimeric ap, if required.

• In cases of intra-oral reconstruction wait until the resection has nished before committing to the posterior incision. A template should be used with approximately the same thickness of the ap—such

40 Medial Sural Artery Perforator Flap

as sterile blue sponge. The template should be measured accurately from the defect taking into consideration the three-dimensional conguration of intra-oral defects, as well as the extra tissue required to create the lingual sulcus.

• The template then is transferred to the calf and centred on the marked skin perforator. The skin flap should exactly match the template whilst still attached to its pedicle. Attempts to remove additional tissue once the flap is inset should be avoided as the perforator can be accidentally damaged or cause bleeding. If the flap was made larger than needed, then the reconstruction will be bulkier compromising the functional outcome.

Pitfalls

• Committing to your skin paddle before visualizing and conrming your perforator(s).

• Placing the rst incision too posterior and missing or injuring the perforator from the outset.

• Damaging the pedicle during dissection of its long intramuscular course—good retraction, ligaclips, heat sink bipolar technique and deroong technique are vital to avoid perforator damage.

• Closing the fascia over the muscle—this may increase the risk of compartment syndrome in the case of haematoma post-operatively.

• Attempting to close the donor site directly if the width of the ap is more than 6cm—use an alternative ap if this is the case, to avoid an unacceptable donor site morbidity due to wound breakdown or use of a skin graft.

40.9 Selected Readings

• 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 ap. Plast Reconstr Surg. 2001;108(6):1609–17.

• Summary: This is the rst description of the free MSAP

ap in the literature, based on cadaveric studies and clinical case series and focused on its use for lower limb reconstruction. Based on 10 cadaveric leg dissections, a mean of 2.2 perforators (range, 1–4) from the medial sural artery were noted over the medial gastrocnemius muscle, clustered 9–18cm from the popliteal crease. A series of six successful clinical cases, including ve free

393

aps and one pedicled ap for ipsilateral lower-leg and foot reconstruction, demonstrated that while the dissection is somewhat tedious, the vascular pedicle can be considerably long and of suitable calibre with minimal donor-site morbidity.

• Dusseldorp JR, Pham QJ, Ngo W, Gianoutsos M, Moradi, P.Vascular anatomy of the medial sural artery perforator ap: a new classication system of intra-muscular branching patterns. J Plast Reconstr Aesthet Surg. 2014;67:1267–75.

• Summary: The objective of this study was to determine the

pattern of intra-muscular course of the MSAP ap pedicle. Fourteen cadaveric specimens were dissected and CT angiograms of 84 legs were examined. Three types of arterial branching pattern were identied within the medial gastrocnemius, demonstrating one (31%), two (59%) or three or more (10%) main branches. A dominant perforator from the medial sural artery was present in 92% of anatomical specimens (13/14). Vertically, the location of the perforator from the popliteal crease was on average 13cm (±2 cm). Transversely, the perforator originated 2.5 cm (±1 cm) from the posterior midline. Using CT angiography it was possible in ten consecutive patients to identify a more supercial intra-muscular branch and determine the leg with the optimal branching pattern type for ap harvest.

• Mughal M, Gabuniya N, Zoccali G, Roblin P, Townley W.Functional outcomes of the medial sural artery perforator ap in oral cavity reconstruction. Ann Plast Surg. 2020;85(3):256–9.

• Summary: This study assessed functional outcomes in

patients with oral cavity tumors reconstructed with MSAP aps, including speech and swallowing. Of the 38 patients included, 84.2% had intelligible speech at 6-month follow- up and further improvement at 1 year (92.1%). All patients resumed feeding on postoperative day 4, and only 7.8% (n = 3) of the patients required assistance with feeding at 1-year follow-up. Thus the authors conclude that the MSAP ap provides adequate small-volume replacement for oral cavity reconstructions, with most patients achieving a full diet with no restrictions by 1year after reconstruction and excellent speech with little or no need for repetition in conversation.

• Fitzgerald O’Connor E, Ruston J, Loh CYY, Tare M.Technical renements of the free medial sural artery perforator (MSAP) ap in reconstruction of multifaceted ankle soft tissue defects. Foot Ankle Surg. 2020;26(2): 233–8.

• Summary: The authors present their retrospective review

of 15 peri-ankle reconstructions using the MSAP ap—4 dorsal foot, 4 medial malleolar, 4 lateral malleolar and 3 tendo-achilles defects. All aps in this series survived.

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D. Reissis et al.

There was one case of partial ap necrosis and no incidences of donor site dehiscence. All patients returned to full ambulation and none required subsequent ap revision. This study demonstrates the versatility of the free MSAP ap in reconstructing defects around the ankle area, by providing a thin, pliable, single stage and robust reconstruction, with a cosmetically ideal donor site.

References

1. Cavadas PC, Sanz-Giménez-Rico JR, Gutierrez-de la Cámara A, Navarro-Monzonís A, Soler-Nomdedeu S, MartínezSoriano F. The medial sural artery perforator free ap. Plast Reconstr Surg. 2001;108(6):1609–17. https://doi.

org/10.1097/00006534- 200111000- 00027.

2. Daar DA, Abdou SA, Cohen JM, Wilson SC, Levine JP. Is the medial sural artery perforator ap a new workhorse ap? A systematic review and meta-analysis. Plast Reconstr Surg. 2019;143(2):393e–403e.

https://doi.org/10.1097/PRS.0000000000005204.

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4. Fitzgerald O’Connor E, Ruston J, Loh CYY, Tare M. Technical renements of the free medial sural artery perforator (MSAP) ap in reconstruction of multifaceted ankle soft tissue defects. Foot Ankle Surg. 2020;26(2):233–8. https://doi.org/10.1016/j.fas.2019.02.003.

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org/10.1097/SAP.0000000000002352. PMID: 32205498.

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12. Choi JW, Nam SY, Choi SH, Roh JL, Kim SY, Hong JP.Applications of medial sural perforator free ap for head and neck reconstructions. J Reconstr Microsurg. 2013;29(7):437–42. https://doi.

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13. Chalmers RL, Rahman KM, Young S, etal. The medial sural artery perforator ap in intra-oral reconstruction: a northeast experience. J Plast Reconstr Aesthet Surg. 2016;69(5):687–93. https://doi.

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14. Sun QW, Gao PF, Wang CX, etal. Anatomical study and clinical application of medial sural artery perforator ap for oral cavity reconstruction. Ann Anat. 2020;227:151418. https://doi.

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15. Chen SL, Chen TM, Lee CH. Free medial sural artery perforator ap for resurfacing distal limb defects. J Trauma. 2005;58(2):323–7.

16. Chen SL, Chuang CJ, Chou TD, Chen TM, Wang HJ.Free medial sural artery perforator ap for ankle and foot reconstruction. Ann Plast Surg. 2005;54(1):39–43.

17. Kim ES, Hwang JH, Kim KS, Lee SY. Plantar reconstruction using the medial sural artery perforator free ap. Ann Plast Surg. 2009;62(6):679–84.

18. Jeevaratnam JA, Nikkhah D, Nugent NF, Blackburn AV.The medial sural artery perforator ap and its application in electrical injury to the hand. J Plast Reconstr Aesthet Surg. 2014;67(11):1591–4.

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20. Wang X, Mei J, Pan J, Chen H, Zhang W, Tang M.Reconstruction of distal limb defects with the free medial sural artery perforator ap. Plast Reconstr Surg. 2013;131(1):95–105.

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24. Zheng H, Liu J, Dai X, Schilling AF.Free conjoined or chimeric medial sural artery perforator ap for the reconstruction of multiple defects in hand. J Plast Reconstr Aesthet Surg. 2015;68(4):565–70.

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25. Sano K, Hallock GG, Hamazaki M, Daicyo Y.The perforator-based conjoint (chimeric) medial sural MEDIAL GASTROCNEMIUS free ap. Ann Plast Surg. 2004;53:588–92.

26. Hallock GG.Chimeric gastrocnemius muscle and sural artery perforator local ap. Ann Plast Surg. 2008;61(3):306–9.

27. Deek NFA, Hsiao JC, Do NT, et al. The medial sural artery perforator ap: lessons learned from 200 consecutive cases [published online ahead of print, 2020 Aug 19]. Plast Reconstr Surg. 2020;146:630e. https://doi.org/10.1097/

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Peroneal Artery Flaps: The Free Fibula

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

Flap

AmitabhThacoor, DanielButler, DariushNikkhah, andJeremyRawlins

41.1 Introduction

The bula free ap (FFF) provides well-vascularised bone for the microsurgical reconstruction of defects following trauma or cancer. It was rst described in 1975 by Taylor [1] for the reconstruction of two large traumatic tibial defects. Its rst use in head and neck reconstruction occurred later in 1989 by Hidalgo [2] and it has since become the gold standard for the reconstruction of composite midface and oromandibular defects involving the intraoral mucosa (lining), mandibular bone and external skin (cover) [3].

Originally described as a purely osseous ap, the FFF can also be raised as an osteofasciocutaneous ap by including a skin paddle, which may also be sensate. It provides large calibre vessels with a long vascular pedicle and enough bone length (25cm) to reconstruct near-total mandibular defects and withstand irradiation, with minimal long-term donor site morbidity [2]. Furthermore, the endosteal and periosteal blood supply safely permits multiple osteotomies, and the donor site is far away from the head and neck area to allow a two-team surgical approach.

Supplementary Information The online version contains supplementary material available at [https://doi.

org/10.1007/978- 3- 031- 07678- 7_41].

41.2 Anatomy

41.2.1 Bony

The lower extremity long bones include the principal weightbearing tibia and the more slender bula. Proximally, the bular head articulates with the lateral condyle of the tibia while distally the bula forms the lateral component of the ankle mortice. The syndesmosis between the distal bula and tibia is essential in maintaining the stability of the ankle mortise and, thus, should be respected when planning ap harvest. At the bular neck, the common peroneal nerve passes from the popliteal fossa, lateral to bula and into the lateral compartment of the lower leg. Care should be taken when dissecting at this level.

41.2.2 Fascial

Four fascial compartments dene the lower leg: anterior, lateral, supercial posterior and deep posterior compartments (Fig. 41.1). The anterior and deep posterior compartments are separated by the interosseous membrane, while the anterior and posterior crural intermuscular septa separate the lateral compartment from the anterior and posterior compartments respectively.

A. Thacoor (*) Pan Thames Rotation, London, UK e-mail: amitabh.thacoor@doctors.org.uk

D. Butler Bay of Plenty District Health Board, Tauranga, New Zealand

D. Nikkhah Department of Plastic, Reconstructive and Aesthetic Surgery, Royal Free Hospital, London, UK

J. Rawlins Department of Plastic Surgery, Royal Perth Hospital, Perth, Australia

41.2.3 Vascular

The FFF is supplied by the peroneal artery (branching from the tibio-peroneal trunk) and its venae commitantes. The overlying skin is supplied by septocutaneous perforators, carried in the posterior crural intermuscular septum, which should be protected in osteofasciocutaneous aps. Musculocutaneous perforators through the exor hallucis longus and soleus muscles may also be additionally present. A skin paddle of 8×15cm may be based on these perforators.

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