Reply: The Versatility of the Pedicled Medial Sural Artery Perforator Flap: From Simple to Its Chimeric Pattern and Clinical Experience with 37 Cases.

Abstract

We read with great interest the reply to our article1 on the use of the pedicled medial sural artery perforator (MSAP) flap by our esteemed colleagues, Dr. Sadeghi and Dr. Pandey. We would like to offer our thoughts on their points of discussion. We thank our colleagues for highlighting the use of one MSAP skin paddle for donor-site closure as described in our article. As with other free flaps, donor-site closure plays an important role and can heavily influence the overall patient result. Utilizing MSAP free flaps can result in donor-site–specific complications, as outlined in the Discussion section of our article. In our experience, the majority of MSAP donor sites can be closed primarily without tension. However, in cases where primary donor-site closure is not possible, using a pedicled MSAP flap based on a second perforator can be an elegant solution to cover the donor site. In our reported cases, this has resulted in both functional and aesthetically pleasing results regarded as superior to a skin graft alternative. We recognize the importance of the medial sural artery branching pattern when using the MSAP flap, as mentioned by our colleagues. The vasculature pattern of the MSAP must be considered during dissection, and the classification introduced by Dusseldorp et al.2 can provide guidance for the operating surgeon. Indeed, the option to use the gastrocnemius muscle flap as a backup option after a failed MSAP flap is dependent on adequate vascular supply and, therefore, branching pattern. The recent report of two cases of gastrocnemius muscle flap necrosis by Tsou et al.3 underscores this issue. We agree with them that this is a rare complication of MSAP harvest, and careful dissection in combination with Doppler ultrasound can further minimize the risk.3 With regard to the synchronous harvest of functional tissue with the MSAP flap, we would like to thank our colleagues for raising another interesting topic. As described in our article, the chimeric form of the MSAP flap allows for harvest of (multiple) skin islands and independent muscular parts. While, to date, we have not harvested any other functional tissues with the flap, we recognize that the synchronous harvest of tendon, nerve, and vein grafts from the same donor site4 provides an additional range of reconstructive options. This increases the versatility of the donor site, providing a favorable single-stage reconstruction, and might even have applications beyond the described context of hand defects. Disclosure The authors have no financial interest to declare in relation to the content of this communication. No funding was received for this work. Timo Rodi, MD, MScMario F. Scaglioni, MDDepatment of Hand and Plastic Surgery Luzerner KantonsspitalLucerne, Switzerland