Medial sural artery perforator (MSAP) flap: historical development, clinical indications, complications and current management in reconstructive surgery

Background: The medial sural artery perforator (MSAP) flap has emerged as a versatile and reliable option for soft tissue reconstruction requiring thin, pliable coverage and minimal donor-site morbidity. Since its first clinical description in the early twenty‑first century, its use has expanded to head and neck, extremity, and complex three‑dimensional reconstructions. To review the historical development, anatomical basis, clinical indications, surgical technique, reported complications, and current management strategies of the MSAP flap in reconstructive surgery. A narrative review of the literature was performed using PubMed, Scopus, and Google Scholar databases, including anatomical studies, clinical series, systematic reviews, and recent publications between 2001 and 2025 related to the MSAP flap. Flap characteristics, indications, outcomes, and complication rates were analyzed and synthesized. The MSAP flap is based on musculocutaneous perforators arising from the medial sural artery and provides a long, reliable pedicle with suitable vessel caliber for microvascular anastomosis. Recent studies demonstrate its wide application in head and neck reconstruction as an alternative to the radial forearm free flap, as well as in coverage of lower‑extremity and periarticular defects. Overall complication rates range between ten and fifteen percent, with venous congestion and partial flap necrosis being the most frequently reported adverse events. Advances in preoperative perforator mapping, anatomical algorithms, and refined microsurgical techniques have significantly improved flap survival and reduced donor‑site morbidity. The MSAP flap represents a valuable reconstructive resource. Detailed knowledge of its vascular anatomy, careful perforator selection, and early recognition and management of complications are essential to maximize flap survival and achieve optimal functional and aesthetic outcomes. Keywords: MSAP flap, Medial sural artery flap, Lower limb reconstruction.