SLR - February 2020 - G. Parker Peresko

The Medial Sural Artery Perforator Pedicled Propellor Flap for Coverage of Middle-Third Leg Defects

Reference: Tee R, Jeng S, Chen C, Shih H. The Medial Sural Artery perforator Pedicled propeller Flap for Coverage of Middle-Third Leg Defects. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2019; 72;1971-1978.

Scientific Literature Review

Reviewed By: G. Parker Peresko, DPM
Residency Program: West Penn Hospital – Pittsburgh, PA

Podiatric Relevance: Coverage of wounds poses a constant threat to limb salvage. This article, coming out of E-Da Hospital in Kaohsiung, Taiwan, describes a successful flap technique with which the pedicled medial sural artery perforator (MSAP) flap is altered to extend its coverage for deficits located in the anterior middle-third of the lower leg, vs. its proximally-focused predecessor. The article also conveys the author’s experience with the MSAP flap designed in a retrograde-flow fashion, for which defects the anterograde-flow MSAP flaps could not reach. Insight and experience is provided with both of these flaps from the authors, as to show us viability and applicability of both methods.

Methods: The case series retrospectively reviewed outcomes in 14 patients undergoing anterograde or retrograde-flow pedicled MSAP flaps between October 2011 and August 2018 for coverage of lower extremity defects. The study revolved around outcomes of the novel flap method where the MSAP flap was used to cover deficits to the anterior middle-third of the leg via a “propeller” technique. A retrograde-flow MSAP flap was also fashioned; this was used when the prior-mentioned propeller MSAP flap was unable to reach the desired deficit. Normal techniques were utilized unless the defects were observed in the anterior middle-third of the leg, when this occurred the “pedicled propeller flap” variant was utilized to establish the extent of achievable coverage.

Results: Eleven anterograde MSAP flaps (one excluded for insufficient data) and three retrograde pedicle MSAP flaps were identified. As previously stated, these were constructed for deficit coverage of the lower leg. Of the 11 flaps in the anterograde-flow group, all survived within the 3.1 month follow-up, with only minor complications including infection of one flap and minor partial loss of one flap. Four of the 11 anterograde-flow flaps were used to cover the anterior middle-third deficits. Mean flap length and width were 11.1 centimeters and 5.3 centimeters, respectively, with mean pedicle length averaging 11.4 centimeters. In the flaps covering the anterior middle-third, the “propeller” design was applied, resulting in mean arc of rotation of 29 centimeters. The retrograde MSAP flap group showed mean values for flap length/width and pedicle length of 16.3 centimeters, 6 centimeters and 9.5 centimeters, respectively. This group showed all flaps suffering complication. Complications included partial flap loss, superficial epidermal loss and complete flap loss, secondary to venous congestion.

Conclusions: Much publication exists to support upper-third and knee coverage via the anterograde-flow MSAP flap; this study uncovered added utility, showing this flap was able to provide coverage of anterior middle-third defects up to 6 centimeters in width by means of “propeller” technique. The authors questioned multiple aspects of the retrograde-flow MSAP flap, relaying that it was indeed possible, but the extent of its usefulness in covering the same defects as the anterograde-flow MSAP flap and the exactness of the technique was still in question. The authors would go on to conclude that the latter flap would require further studies in ascertaining reliability but the “pedicled propeller flap” satisfactorily extended the reach of the already versatile MSAP flap. 

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