Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 1060e1066

A new technique of transferring island pedicledanterolateral 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.ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

* 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: þ886 38222641.

E-mail address: ljt1225@ms43.hinet.net (J.-T. Lee).

1748-6815/$-seefrontmatterª2007BritishAssociationofPlastic,Reconstrdoi:10.1016/j.bjps.2007.03.026

The free anterolateral thigh flap has been used extensively inthe reconstruction of head and neck defects 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

uctiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Reconstruction of recurrent ischial pressure sore 1061

with vastus lateralis muscle. This flap, which has a constantblood supply, can be harvested easily and rapidly without donorsite morbidity. With regard to the vastus lateralis muscle, 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 functional muscle 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

We performed 16 ischial pressure sore closures in 15 patients,using either the island pedicled anterolateral thigh flap orvastus lateralis myocutaneous flap, at Buddhist Tzu ChiGeneral Hospital between May 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 29 months (mean: 14 months). The detaileddata of the patients are listed in Table 1.

Operative technique

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 the medial border of the flap. The incisionis made down to the deep fascia, which is included in the flap.The dissection then proceeds laterally towards the intermus-cular septum between 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

of flapd

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 m

a Case 4 and cab SCI: spinal cord taneous,m:months.

1062J.-T.

Lee

et

al.

t Data

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

(previous tensor fascia laProgressive spasticataxia (ambulatory)

M VLmc Middle third

SCI with paraplegia M ALT Middle third

SCI with paraplegia M VLmc Middle thirdSCI with paraplegia M ALT Middle thirdSCI with paraplegia M ALT Middle third

se 11 is the same patient with different sides of ischial sore at different time.injury, S: septocutaneous,M:musculocutaneous,ALT: anterolateral thigh,VLmc: vastus lateralismyocu

Reconstruction of recurrent ischial pressure sore 1063

Results

In our study, the island pedicled anterolateral thigh flapwas used for 11 sores and the vastus lateralis myocutaneousflap for five sores (Figs. 4 and 5). Twelve flaps were locatedat the middle third of the thigh. The flap was located in thedistal third of the thigh in four cases. The reasons for elect-ing this location include the distal location of the perfora-tor in one case and a decision to avoid the incorporationof a previous scar and flap (for example, a tensor fascialata VeY advancement flap with or without skin graft fora trochanteric sore) in three cases. No difficulty wasencountered in transferring the flap to reach the ischialdefect in any patient. The length of the pedicle rangedfrom 8.5 to 14 cm. Fifteen of the 16 flaps survived com-pletely. Total necrosis occurred in one vastus lateralis my-ocutaneous flap, which was located at the distal third ofthe thigh. Inadequate flap perfusion due to a relativelysmall perforator was thought to be the cause of failure. Bi-ceps femoris myocutaneous flap was then used to heal theischial wound in this patient. Slight wound edge dehiscencewas noted in two patients, and minor dehiscence of the do-nor site developed in one patient. All of these woundshealed by conservative treatment. There was no donorsite morbidity, and the linear scar on the donor site waswell accepted by all of the patients. Five sore recurrencesdeveloped in the follow-up period.

Figure 2 Anterior thigh. The asterisk (*) indicates the crea-tion of intermuscular space between the vastus medialis andvastus intermedius.

Discussion

We transferred the island pedicled anterolateral thigh flapand vastus lateralis myocutaneous flap directly through theintermuscular and intramuscular spaces of the upper thighto reach the ischial region. This manoeuvre, althoughunique, is simple and important. Through this passageway,the distance between the origin of the lateral circumflexfemoral artery from the deep femoral artery and the distalmargin of the ischial defect is in the range of 10 to 15 cm,which is 5 to 15 cm shorter than through a subcutaneousroute. The pedicle length of the descending branch of thelateral circumflex femoral artery measured between 8.5and 14 cm in our series. Adding the length of the skin island,it was easy for us to use the most reliable skin paddle, lo-cated in the middle third of the anterolateral thigh, toreach the ischial wound.

The vastus lateralis myocutaneous flap for reconstruc-tion of ischial pressure sores has been reported previouslyin one case by Drimmer and Krasna, two cases by Water-house and Healy, and eight cases by Schmidt et al.8e10 All ofthese authors elevated the whole vastus lateralis muscle asa vehicle of the skin island. In order to reach the ischialwound through a lateral subcutaneous tunnel, the skin pad-dle must be located at the distal third of the thigh. Their

Figure 3 The flap comes out through the gluteus maximusmuscle into the subcutaneous level. The asterisk (*) indicatesexit of the passageway.

1064 J.-T. Lee et al.

Figure 4 Case 3. (A) Recurrent right ischial sore after debridement. Nine flap surgeries have been performed previously forcoverage. (B) Flap designed on the middle third of the thigh. (C) Island pedicled anterolateral thigh flap elevated. The asterisk(*) indicates intermuscular space between the vastus intermedius and vastus medialis muscles. (D) Flap transferred. In thiscase, the required pedicle length using our method was 10 cm. The length would be 16 cm through the medial subcutaneous tun-nel, and 23 cm through the lateral subcutaneous tunnel. (E) Three weeks postoperatively.

procedures were very extensive, and could have resulted inmuch blood loss. Furthermore, unreliability of the distalportion of the flaps also might have existed. Comparatively,our island pedicled vastus lateralis myocutaneous flap con-tained only a small segment of muscle; the skin island couldbe located at the middle third of the thigh with more pro-fuse vascularity. Most of the flaps (12) were located at themiddle third of the thigh; the other four were located atthe distal third in our series. Classically, the anterior borderof the tensor fascia lata flap is a line connecting the ante-rior superior iliac crest and the lateral condyle of the knee.This line is almost the same as the axis of the anterolateralthigh flap. Previous tensor fascia lata flap did not precludethe use of the pedicled anterolateral thigh flap, but a moredistal location of the flap with careful preoperative identi-fication of a strong perforator was required (Fig. 5). All

three flaps in this condition survived well. However, an-other distally located flap failed as a result of insufficientflap perfusion due to a relatively small perforator. We arein agreement with Wolff’s opinion that myocutaneous flapsshould be raised from the middle third of the vastus later-alis muscle, since the skin vessel is the most constant andstrongest here.12,13 This statement is also valid for a fascio-cutaneous anterolateral thigh flap.3,12

The advantages of island pedicled anterolateral thigh andvastus lateralis myocutaneous flaps include constant bloodsupply, sufficient bulk, easy elevation, no sacrifice of muscleif a fasciocutaneous flap is raised and primary closure of thedonor site with no morbidity. Even after multiple previousattempts to treat pressure sores with various local flaps, thelateral circumflex femoral artery vasculature needed for thisflap is usually left undamaged as a result of the anatomical

Reconstruction of recurrent ischial pressure sore 1065

Figure 5 Case 11. (A) Recurrent left ischial sore. The asterisk (*) indicates a healed previous right anterolateral thigh flap. (B)The lateral view shows previous tensor fascia lata VeY advancement flap with skin graft for a trochanteric sore. (C) Vastus lateralismyocutaneous flap designed on the distal third of the left thigh after Doppler detection of the perforator. (D) Flap elevated. (E)Two months postoperatively. The (þ) indicates a healed left vastus lateralis myocutaneous flap, and (*) indicates a stable previousright anterolateral thigh flap.

location of the vastus lateralis muscle and its pedicle. Thereare two disadvantages of the flap we describe. One majordisadvantage is the sacrifice of the descending branch of thelateral circumflex femoral artery and compromise of thevascular pedicle of the vastus lateralis muscle flap for futuretrochanteric sore reconstruction. Another minor disadvan-tage is encroachment on the skin territory of a future tensorfascia lata VeY flap, especially when a larger skin flap israised. To avoid this drawback, the skin island of theanterolateral thigh flap can be centred more anteriorly tothe flap axis. With this modification, this flap will notpreclude future use of a tensor fascia lata flap. Understand-ably, this flap is not the first-line flap. Nonetheless, weconclude from the present study that this flap can be added

to the repertoire for the treatment of recurrent, difficultischial pressure sores when there is scarce local tissueavailable. Finally, it is emphasised that surgical treatmentof pressure sores is a last resort and generally unsuccessful ifpresssure relief is not optimised.

References

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2. Shieh SJ, Chiu HY, Yu JC, et al. Free anterolateral thigh flap forreconstruction of head and neck defects following cancer abla-tion. Plast Reconstr Surg 2000;105:2349e57.

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3. Wei FC, Jain V, Celik N, et al. Have we found an ideal soft-tis-sue flap? An experience with 672 anterolateral thigh flaps.Plast Reconstr Surg 2002;109:2219e26.

4. Luo S, Raffoul W, Piaget F, et al. Anterolateral thigh fasciocu-taneous flap in the difficult perineogenital reconstruction.Plast Reconstr Surg 2000;105:171e3.

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8. Drimmer MA, Krasna MJ. The vastus lateralis myocutaneousflap. Plast Reconstr Surg 1987;79:560e6.

9. Waterhouse N, Healy C. Vastus lateralis myocutaneous flap forreconstruction of defects around the groin and pelvis. Br J Surg1990;77:1275e7.

10. Schmidt AB, Fromberg G, Ruidisch MH. Applications of the ped-icled vastus lateralis flap for patients with complicated pres-sure sores. Spinal Cord 1997;35:437e42.

11. Abu Jamra FN, Afeiche N, Sumrani NB. The use of a vastus lat-eralis muscle flap to repair a gluteal defect. Br J Plast Surg1983;36:319e21.

12. Wolff KD, Grundmann A. The free vastus lateralis flap: An ana-tomic study with case reports. Plast Reconstr Surg 1992;89:469e75.

13. Wolff KD. Indications for the vastus lateralis flap in oral andmaxillofacial surgery. Br J Oral Maxillofac Surg 1998;36:358e64.