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Oropharyngeal Reconstruction Using a Medial Sural Perforator Flap

Shin, Seung-Kyu M.D.; Lee, Jun-Ho M.D.; Kim, Yong-Ha M.D., Ph.D.; Kim, Tae-Gon M.D.

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Plastic and Reconstructive Surgery: September 2010 - Volume 126 - Issue 3 - p 144e-146e
doi: 10.1097/PRS.0b013e3181e3b623
  • Free

Sir:

In the head and neck, free tissue transfer is the first choice for many postablative defects resulting from cancer resection.1 The radial forearm flap is the most commonly used fasciocutaneous free flap for oropharyngeal reconstruction.2 This flap can be successfully used for intraoral lining restoration, but it commonly leads to a conspicuous donor-site scar and sacrifices a major artery to the hand. The medial sural perforator free flap3 provides suitable thickness and is able to reduce morbidity at the donor site. Its vascular pedicle is also long and provides multiple recipient vessel choices in the neck region. We used the medial sural perforator free flap to treat four patients.

Before the operation, each patient was placed in the supine position in 45 degrees of flexion with external rotation of the hip joint and 90 degrees of flexion of the knee joint, and the donor side of the thigh was wrapped with a tourniquet. The center of the flap was the arising point, distal half-circle, within a radius of 2 cm located 8 or 15 cm from the proximal part of an imaginary line connecting the midpoint of the popliteal crease and the midpoint of the medial malleolus, of the first or second perforator of the medial sural artery.4 Dissection began from the anterior aspect of the flap, and an incision was performed anteriorly through the medial gastrocnemius muscle of the deep fascia as the perforators were being confirmed along with their accompanying venae comitantes. Dissection into the gastrocnemius muscle was performed along the main pedicle until a sufficient pedicle length was obtained. After proper flap setting, microanastomosis was performed with the recipient vessels in the neck (Fig. 1).

Fig. 1.
Fig. 1.:
A 56-year-old man with hypopharyngeal cancer (stage IVa) underwent total laryngectomy with partial pharyngectomy. Immediate postoperative view.

Four patients with oropharyngeal defects after cancer resection were treated using a medial sural perforator free flap. All flaps were safely raised with a single perforator. The pedicle length was controllable, and a 5- to 13-cm section was readily obtained. The donor defects were resurfaced with split-thickness skin grafts in all patients. All patients healed without any particular complications. We performed reexploration in one patient for venous insufficiency on the first day after surgery, and we were able to salvage the flap with vein reanastomosis. Follow-up periods ranged from 13 to 30 months. There was no orocutaneous fistula formation. All patients achieved moderately dysarthric but intelligible speech and had useful swallowing function (Fig. 2).

Fig. 2.
Fig. 2.:
A 55-year-old man with mouth floor cancer (stage III) underwent mouth floor mass excision and reconstruction with a medial sural perforator free flap. Results 24 months after surgery. The reconstructed mouth functioned well.

The skin of the sural region is ultrathin and usually produces aesthetically pleasing results. Moreover, the location of the pedicle is relatively consistent, so flap elevation is performed with ease. Relatively long, large, reliable pedicles can be obtained from this area. Flaps from only the subcutaneous layer can be elevated without damaging the medial sural muscles, thus minimizing functional problems with the donor site. Furthermore, these flaps preserve the medial gastrocnemius muscle and the major arteries of the leg to minimize donor-site morbidity. We believe medial sural artery perforator free flaps will prove to be useful in the reconstruction of soft-tissue defects after oropharyngeal cancer ablation

Seung-Kyu Shin, M.D.

Jun-Ho Lee, M.D.

Yong-Ha Kim, M.D., Ph.D.

Tae-Gon Kim, M.D.

Department of Plastic and Reconstructive Surgery

Yeungnam University Hospital

Daegu, Korea

ACKNOWLEDGMENT

This research was supported by Yeungnam University research grants in 2009.

REFERENCES

1.Smith RB, Sniezek JC, Weed DT, Wax KW. Utilization of free tissue transfer in head and neck surgery. Otolaryngol Head Neck Surg. 2007;137:182–191.
2.Gonzáles-García R, Rodríquez-Campo FJ, Naval-Gías L, et al. Radial forearm free flap for reconstruction of the oral cavity: Clinical experience in 55 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;104:29–37.
3.Cavadas PC, Sanz-Giménez-Rico JR, Gutierrez-de la Cámara A, Navarro-Monzonís A, Solder-Nomdedeu S, Martínez-Soriano F. The medial sural artery perforator free flap. Plast Reconstr Surg. 2001;108:1609–1615; discussion 1616–1617.
4.Kim HH, Jeong JH, Seul JH, Cho BC. New design and identification of the medial sural perforator flap: An anatomical study and its clinical applications. Plast Reconstr Surg. 2006;117:1609–1618.

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