A new technique of transferring island pedicled
Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 1060e1066anterolateral thigh and vastus lateralismyocutaneous flaps for reconstructionof recurrent ischial pressure sores
Jiunn-Tat Lee a,*, Li-Fu Cheng a, Chih-Ming Lin a, Chien-Hsing Wang a,Chieh-Chi Huang b, Sou-Hsin Chien b
a Division of Plastic Surgery, Department of Surgery, Buddhist Tzu Chi General Hospital,Tzu Chi University, Hualien, Taiwainb Division of Plastic Surgery, Department of Surgery, Buddhist Dalin Tzu Chi General Hospital, Chiayi, Taiwan
Received 10 May 2006; accepted 26 March 2007
KEYWORDSIsland pedicledanterolateralthigh flap;Vastus lateralismyocutaneous flap;Recurrent ischialpressure sore
Summary We describe island pedicled anterolateral thigh and vastus lateralis myocutaneousflaps for reconstruction of the difficult, recurrent ischial pressure sore. Rather than transferthrough a subcutaneous tunnel, the flap is transferred directly through the upper thigh tothe ischial defect. A total of 15 patients with 16 recurrent ischial pressure sores were treatedbetween May 2003 and April 2005. Eleven sores were treated with pedicled island anterolateralthigh flaps and five sores with vastus lateralis myocutaneous flaps. There was no difficulty intransferring the flap to reach the ischial defect in any patient. The length of the pedicle ran-ged from 8.5 to 14 cm. All donor sites were closed primarily. Fifteen of the 16 flaps survivedcompletely. Total necrosis occurred in one vastus lateralis myocutaneous flap, which waslocated at the distal third of the thigh. We conclude this flap can be added to the repertoirefor the treatment of recurrent, difficult ischial pressure sores. 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.
The free anterolateral thigh flap has been used extensively in* Corresponding author. Address: Division of Plastic Surgery,Department of Surgery, Buddhist Tzu Chi General Hospital, TzuChi University, 707, Section 3, Chung-Yang Road, Hualien 970,Taiwan. Tel./fax: 886 38222641.
E-mail address: email@example.com (J.-T. Lee).
1748-6815/$-seefrontmatter2007BritishAssociationofPlastic,Reconstrdoi:10.1016/j.bjps.2007.03.026the reconstruction of headandneckdefects following cancerablation since its introduction by Song et al. in 1984.1e3 Thepedicled anterolateral thigh flap has been recently used forcoverage of soft tissue defects over perineogenital, inguinal,and abdominal wall regions.4,5 This versatile perforator flapcan be harvested as a cutaneous and fasciocutaneous flapwith fascia lata, or as a myofasciocutaneous flap combined
Reconstruction of recurrent ischial pressure sore 1061with vastus lateralis muscle. This flap, which has a constantblood supply, canbeharvestedeasily and rapidlywithout donorsitemorbidity.With regard to the vastus lateralismuscle, it hasbeen used extensively as a local flap in the treatment of tro-chantericpressure soresandoccasionally for coverageof ischialpressure sores.6e11 The free flap of vastus lateralis can be usedfor soft tissue reconstruction or functionalmuscle transfer.12,13
In this paper, we describe a new technique of trans-ferring the island pedicled anterolateral thigh and vastuslateralis myocutaneous flaps to treat recurrent ischialpressure sores. The route of transferring this flap to reachthe ischial region is unique and innovative. The transfer isnot completed through a subcutaneous tunnel, but ratherthrough the substance of the upper thigh (Fig. 1). This flapwas found to be a valuable alternative for reconstruction ofa difficult and/or recurrent ischial pressure sore.
Patients and methods
Weperformed16 ischial pressure sore closures in 15patients,using either the island pedicled anterolateral thigh flap orvastus lateralis myocutaneous flap, at Buddhist Tzu ChiGeneral Hospital betweenMay 2003 and April 2005. Fourteenpatients were paraplegic, and one was ambulatory. All flapswere used for coverage of recurrent ischial sores. Thenumber of previous flap surgeries for the recurrent ischialsore ranged from three to nine (mean: 4.5). Patient follow upranged from 5 to 29months (mean: 14months). The detaileddata of the patients are listed in Table 1.
The patient is positioned in a lateral decubitus positionwith the hip elevated and flexed. The decubitus ulcer is
Figure 1 Cross section through the upper third of the rightthigh. Arrows denote the flap passageway. AB, adductor brevis;AL, adductor longus; AM, adductor magnus; BF, biceps femoris;G, gracilis; GM, gluteus maximus; M, semimembranosus; RF,rectus femoris; S, subcutaneous layer; ST, semitendinosus; VI,vastus intermedius; VL, vastus lateralis; VM, vastus medialis.aggressively debrided to remove all necrotic and infectedskin, soft tissue, and bone. A line between the anteriorsuperior iliac spine and the lateral border of the patella isdrawn on the thigh. The skin perforators are mapped withDoppler flowmeter near the midpoint of this line. Approx-imately 90% of the perforators can be detected withina 3 cm radius of a circle drawn from the midpoint ascentre.3,12 A flap of an appropriate shape and size is designedto include the marked perforators. Flap elevation is startedwith the incision of themedial border of theflap. The incisionismadedown to thedeep fascia,which is included in theflap.The dissection then proceeds laterally towards the intermus-cular septumbetween the rectus femoris and vastus lateralismuscles. The rectus femoris is retracted medially, and thedescending branch of the lateral femoral circumflex isexplored along with its cutaneous vessels. The flap can beharvested either as an anterolateral thigh fasciocutaneousflap or a vastus lateralis musculocutaneous flap, accordingto the dimensions of the ischial defect.
The skin vessels originating from the descending branchof the lateral circumflex femoral artery can be septocuta-neous vessels or musculocutaneous perforators.1e3 Eleva-tion of a septocutaneous-type flap is straightforward,quick and easy. Conversely, the elevation of a musculocuta-neous perforator flap with intramuscular dissection of themusculocutaneous perforator is somewhat more difficult.Care must be taken not to injure the musculocutaneousperforator. Generally, only one larger perforator is ade-quate for flap perfusion. Other smaller perforators can bedivided. During musculocutaneous flap elevation, there isno need for dissection of the septocutaneous vessel or mus-culocutaneous perforator. Instead, the portion of the vastuslateralis muscle that contains a skin vessel with its overly-ing skin is cut as needed. Afterwards, the flap pedicle is dis-sected free towards the origin of the lateral circumflexfemoral artery. The motor branch of the femoral nerve run-ning medial to the flap pedicle should be always preserved.The elevated island pedicled flap is then ready for transfer.
A flap passageway is created as follows (Fig. 1): The in-termuscular space between the vastus intermedius andvastus medialis muscles is widened (Fig. 2). The origin ofthe vastus medialis muscle from the medial lip of the lineaaspera of the femoral bone is then divided. Further dissec-tion is made to penetrate through the adductor brevis, ad-ductor magnus, and gluteus maximus muscles along themedial aspect of the femoral bone as close as possible(Figs. 1 and 3). A short subcutaneous tunnel is then madeto reach the ischial defect. This passageway should be ofa generous width to facilitate easy passage of the flapand to prevent pedicle constriction. Care should be takennot to injure perforator vessels inside the adductor magnusto prevent bleeding. The sciatica nerve under the long headof the biceps femoris should also be avoided. The elevatedflap is transposed through the passageway into the ischialwound and then sutured in two layers. In all cases, the do-nor site is closed primarily. Patients are placed prone on anair-fluidised bed for three weeks postoperatively. After suc-cessful flap reconstruction, we educate the patients andtheir caretakers regarding pressure-release manoeuvres,techniques of skin care and the patients are followedup routinely in collaboration with the rehabilitationdepartment.
Table 1 Patien
Case Age/Sex Size (cm) Complication Outcomeb
1 30/F 7 4 e Recurrence at 14 m2 48/M 7 4 e Recurrence at 18 m3 51/M 6 4 e Stable at 24 m
4a 31/Mta flap)
5 4 Small woundedge dehiscence
Stable at 24 m
5 30/M 8 4 e Recurrence at 12 m6 36/M
tor)6 3 Total necrosis
7 34/M 9 7 e Stable at 13 m8 55/F
ta flap)6 3 Small wound
edge dehiscenceStable at 12 m
9 40/M 9 5 e Recurrence at 10 m10 50/M 9 6 e Stable at 12 m11a 32/M
ta flap)6 4 e Stable at 12 m
12 75/M 6 4 e Recurrence at 8 m
13 28/M 7 5 Minor dehescienceof donor site
Stable at 9 m
14 45/M 7 5 e Stable at 9 m15 30/M 6 4 e Recurrence at 8 m16 60/M 12 6 e Stable at 5 ma Case 4 and cab SCI: spinal cord taneous,m:months.
Diseaseb Perforator Typeb Flap Typeb Location
SCI with paraplegia S ALT Middle thirdSCI with paraplegia M ALT Middle thirdTB transversemyelitis with T10 paraplegia
M ALT Middle third
SCI with paraplegia M Right ALT Distal third(previous tensor fascia la
SCI with paraplegia S ALT Middle thirdTB transversemyelitis with T3 paraplegia
S VLmc Distal third(distal location of perfora
SCI with paraplegia M ALT Middle thirdSCI with paraplegia M VLmc Distal third
(previous tensor fascia laSCI with paraplegia M ALT Middle thirdSCI with paraplegia S ALT Middle thirdSCI with paraplegia M Left VLmc Distal third