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

The medial sural artery perforator (MSAP) continues to gain popularity. Providing a versatile, thin and pliable alternative for commonly used workhorse flaps, it can be used to reconstruct extremities, with reduced donor site morbidity. This meta-analysis was conducted to analyse the current literature to help identify flap characteristics and outcomes. A systematic review was performed following the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines and a literature search was conducted using Medline, Google Scholar and the Cochrane Library. The aim was to identify the outcomes of free MSAP flap reconstructions of upper and lower limb defects over a 10-year period from January 2010 to July 2020. The data was then tabulated and a meta-analysis was carried out. A total of 11 studies for lower limbs and 7 studies for upper limbs were reviewed and analysed with a total number of 257 patients. Limb reconstructions were primarily due to trauma. The most common site of reconstruction of the upper limb was the hand or wrist and the lower limb was the ankle or feet. The mean length of the flap was 9.6 cm. The mean width was 5.4 cm. The mean pedicle length was 9.7 cm. The mean flap thickness was noted as 5.9 mm. The number of perforators was an average of 1.5. The pedicle’s mean arterial diameter was 1.9 mm (mean) and the vein’s mean arterial diameter was 2.9 mm. 80% of donor sites were closed directly. Overall, the flap success rate was 98%. Our results find the MSAP flap to be a versatile, reliable, functionally and aesthetically good reconstructive option for both lower and upper limb defects with low donor site morbidity.