title: Medial sural artery perforator flap: a challenging free flap.
abstract: BACKGROUND
  Oral and extremity defect reconstruction can often require a flap that is thin, and traditionally, the radial forearm free flap has been used, however, this has significant donor site morbidity. Over the last decade, the medial sural artery perforator (MSAP) flap has emerged as a possible alternative with lower donor site morbidity. We present our experiences and review the literature regarding this promising but challenging flap.
  
  
  METHODS
  The study was a retrospective case series in a university hospital setting. All patients who had a MSAP flap performed at our institution were included until March 2015, and their data was retrieved from electronic patient records.
  
  
  RESULTS
  In total, ten patients were reconstructed with a MSAP flap for floor of mouth (eight) and lower extremity (two) defect reconstruction. The median flap dimensions were as follows: 10 cm (range 7-14 cm), width 5 cm (range 3.5-8 cm), thickness 5 mm (range 4-8 mm), and pedicle length 10 cm (range 8-12 cm). In one case, the procedure was abandoned because of very small perforators and another flap was used. In two cases, late onset of venous congestion occurred which could not be salvaged. There were no donor site complaints.
  
  
  CONCLUSIONS
  The MSAP flap is an ideal flap when a thin free flap is needed with lower donor site morbidity than alternative solutions. There seems to be a higher rate of late onset of venous thrombosis compared with more established flaps. Therefore, this flap should be monitored more closely for venous problems and we recommend performing two venous anastomoses when using this flap. Level of Evidence: Level IV, therapeutic study.
authors.affiliation: Department of Plastic and Reconstructive Surgery, Odense University Hospital, Sdr. Boulevard 29, DK-5000 Odense C, Denmark.
authors.forename: Navid Mohamadpour
authors.initials: NM
authors.lastname: Toyserkani
authors.affiliation: Department of Plastic and Reconstructive Surgery, Odense University Hospital, Sdr. Boulevard 29, DK-5000 Odense C, Denmark.
authors.forename: Jens Ahm
authors.initials: JA
authors.lastname: Sørensen
keywords: Complication; Distal limb reconstruction; Floor of mouth reconstruction; Medial sural artery perforator flap; Microsurgery