A reusable perforator-preserving gluteal artery-based rotation fasciocutaneous flap for pressure sore reconstruction

A REUSABLE PERFORATOR-PRESERVING GLUTEALARTERY-BASED ROTATION FASCIOCUTANEOUSFLAP FOR PRESSURE SORE RECONSTRUCTION

PAO-YUAN LIN, M.D.,* YUR-REN KUO, M.D., Ph.D., and YUN-TA TSAI, M.D.

Background: Perforator-based fasciocutaneous flaps for reconstructing pressure sores can achieve good functional results with acceptabledonor site complications in the short-term. Recurrence is a difficult issue and a major concern in plastic surgery. In this study, we introducea reusable perforator-preserving gluteal artery-based rotation flap for reconstruction of pressure sores, which can be also elevated fromthe same incision to accommodate pressure sore recurrence. Methods: The study included 23 men and 13 women with a mean age of59.3 (range 24–89) years. There were 24 sacral ulcers, 11 ischial ulcers, and one trochanteric ulcer. The defects ranged in size from 4 33 to 12 3 10 cm2. Thirty-six consecutive pressure sore patients underwent gluteal artery-based rotation flap reconstruction. An inferior glu-teal artery-based rotation fasciocutaneous flap was raised, and the superior gluteal artery perforator was preserved in sacral sores; alter-natively, a superior gluteal artery-based rotation fasciocutaneous flap was elevated, and the inferior gluteal artery perforator was identifiedand dissected in ischial ulcers. Results: The mean follow-up was 20.8 (range 0–30) months in this study. Complications included fourcases of tip necrosis, three wound dehiscences, two recurrences reusing the same flap for pressure sore reconstruction, one seroma, andone patient who died on the fourth postoperative day. The complication rate was 20.8% for sacral ulcers, 54.5% for ischial wounds, andnone for trochanteric ulcer. After secondary repair and reconstruction of the compromised wounds, all of the wounds healed uneventfully.Conclusions: The perforator-preserving gluteal artery-based rotation fasciocutaneous flap is a reliable, reusable flap that provides rich vas-cularity facilitating wound healing and accommodating the difficulties of pressure sore reconstruction. VVC 2012 Wiley Periodicals, Inc.Microsurgery 32:189–195, 2012.

Pressure sore reconstruction using a local flap next to

the lesion is a common procedure that has a high-early

success rate with acceptable complications. After Kosh-

ima et al.1 proposed the gluteal perforator-based flap in

1993, the perforator-based fasciocutaneous flap became

popular in pressure sore reconstruction, because it allows

the transfer of healthy tissue into the defect and mini-

mizes donor site morbidity. Flaps used to reconstruct

pressure sores based on the perforator-based concept

include the propeller,2 bilobed,3 free-style,4,5 gluteal per-

forator island,6–8 and inferior gluteal artery9 flaps. These

provide good functional and esthetic results in the short-

term. However, such perforator-based island flaps are not

reusable in the event of recurrence.

Ulcer recurrence in paraplegic or bedridden patients is

always a major concern and is difficult to overcome with

pressure sore reconstruction. Although the initial appro-

priate soft-tissue transfer of a fasciocutaneous or muscu-

locutaneous flap is satisfactory, the long-term results can

be variable and disappointing. Multiple reconstructive

procedures resulting from high-recurrence rates make it

difficult to elevate healthy tissue next to the ulcer

because of massive scar tissue formation over the previ-

ous operative wound. A combination of muscle and fas-

ciocutaneous flap harvested from a distant site or a free

flap transfer can be used as a salvage procedure in this

situation.10–15 However, such flaps are not reusable.

To address this problem, before reconstructing the

ulcer, one should consider the possibility of ulcer recur-

rence and the absence of an available skin paddle if the

recurrence occurs at the same location.4 If a reusable flap

with healthy tissue was available, we could accommodate

the difficulties of pressure sore recurrence. In this study,

we introduce a reusable perforator-preserving gluteal ar-

tery-based rotation flap for reconstruction of pressure

sores, which can be also elevated from the same incision

to accommodate pressure sore recurrence.

PATIENTS AND METHODS

From March of 2008 to September of 2009, 36

patients (23 men, 13 women) with pressure ulcers

underwent gluteal fasciocutaneous flap reconstruction per-

formed by a single surgeon (PL). At the time of surgery,

patient ages ranged from 24 to 89 years (average 59.3

years; men 54.5 years; women 65.5 years). There were

24 sacral sores, 11 ischial sores, and one trochanteric

ulcer.

SURGICAL TECHNIQUE

After inducing general anesthesia, the patient was

positioned prone, and the area from the lower back to the

upper thigh was disinfected and draped. A hand-held

Section of Plastic and Reconstructive Surgery, Department of Surgery,Kaohsiung Chang Gung Memorial Hospital, Chang Gung University Collegeof Medicine, Kaohsiung, Taiwan

*Correspondence to: Pao-Yuan Lin, M.D., Section of Plastic and Reconstruc-tive Surgery, Department of Surgery, Kaohsiung Chang Gung MemorialHospital, Chang Gung University College of Medicine, 123 Ta-Pei Road, Niao-Sung District, Kaohsiung 833, Taiwan. E-mail: paoyuan9219@gmail. com

Received 1 September 2011; Revision accepted 24 October 2011;Accepted 28 October 2011

Published online 20 January 2012 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/micr.20982

VVC 2012 Wiley Periodicals, Inc.

Doppler flow meter was used to establish the location of

perforators. The pedicle of the superior gluteal artery was

located one-third of the way between the posterior iliac

spine and the greater trochanter. The pedicle of the infe-

rior gluteal artery was located midway between the coc-

cyx and greater trochanter (Fig. 1). After detecting the

perforator, a large radius gluteal flap was marked on the

skin (Fig. 2). Methyl blue dye was injected into the

wound to facilitate adequate debridement. The ulcerated

area and underlying bursa were excised down to healthy

tissue. An ostectomy of any underlying bony prominences

was performed to smooth any irregular bony surfaces,

and the wound was washed with voluminous saline irri-

gation. After debridement, a perforator-preserving gluteal

artery-based fasciocutaneous flap was raised and rotated

to cover the defect.

Flap Harvest Procedure

The skin was incised along the marking, and the soft

tissues were dissected down to the fascia layer of the glu-

teus maximus muscle. The fascia was opened, and then

the fasciocutaneous flap was elevated. For sacral sores, a

flap based on the inferior gluteal artery perforator (IGAP)

was raised from the cranial side, preserving the superior

gluteal artery perforator (Fig. 3). Conversely, for ischial

ulcers, a flap based on the superior gluteal artery perfora-

tor was elevated from the caudal side, preserving the

IGAP (Fig. 4). Care should be taken during flap dissec-

tion close to the perforator(s). Because the perforator(s)

were identified and protected, sizable perforator(s) were

selected, and meticulous intramuscular dissection of the

perforator was performed down to the origin of the pedi-

cle (the superior or inferior gluteal artery) to facilitate

flap rotation (Fig. 5). In a patient with a sacral ulcer, the

flap was rotated upward and advanced medially, whereas

for an ischial wound the flap was rotated downward and

advanced medially (Fig. 1). A closed-suction drain was

inserted, and the wound was closed in layers without ten-

sion especially at the original ulcerated wound.

Figure 1. The location of the main pedicles of the superior and in-

ferior gluteal arteries. The pedicle of the superior gluteal artery is

located one-third of the distance between the posterior iliac spine

and greater trochanter, while that of the inferior gluteal artery is

located midway between the coccyx and greater trochanter. [Color

figure can be viewed in the online issue, which is available at

wileyonlinelibrary.com.]

Figure 2. Drawing of the incision for a gluteal artery-based fascio-

cutaneous perforator flap. For sacral sores, the flap was rotated

upward and advanced medially. For ischial sores, the flap was

rotated downward and advanced medially. [Color figure can be

viewed in the online issue, which is available at wileyonlinelibrary.

com.]

Figure 3. Inferior gluteal artery-based rotation fasciocutaneous per-

forator flap with superior gluteal artery perforator preservation for

the reconstruction of sacral sores. [Color figure can be viewed in

the online issue, which is available at wileyonlinelibrary.com.]

190 Lin et al.

Microsurgery DOI 10.1002/micr

Re-Elevating Flap Procedure

As recurrent pressure sore was occurring, debridement

of nonvitalized tissue was the first preformation. Skin

incision from the previous flap incisional wound and glu-

teal fasciocutaneous flap elevation at subfascial layer

were achieved. The flap that was based on superior or in-

ferior gluteal artery was elevated and rotated for repairing

the defect.

Postoperative Care

Postoperatively, we routinely used antibiotics such as

Cefamezine and Gentamicin for 3 days. The patient was

kept in the lateral or prone position for 3 weeks. The hip

and knee should be kept as straight as possible to avoid

tension over the wound. The suction drain could be

removed when the drainage was less than 30 mL/day for

3 days.

RESULTS

In this study, the defects ranged in size from 4 3 3

to 12 3 10 cm2. The mean follow-up period was 20.8

(range 0–30) months. Perioperative complications

included four cases of tip necrosis (one sacrum and three

ischium) receiving debridement and gluteal advance flap

reconstruction, three wound dehiscences (one sacrum and

two ischium) receiving further wound repair, two recur-

rences (both sacrum) reusing the same flap for pressure

sore reconstruction, one seroma (ischium), and one

patient who died on the fourth postoperative day (sac-

rum). The complication rate was 5/24 (20.8%) for sacral

ulcers, 6/11 (54.5%) for ischial wounds, and none for tro-

chanteric ulcer. After secondary repair and reconstruction

of the compromised wounds, all of the ulcers healed

uneventfully. The results are presented in Table 1.

Case Report

A 67-year-old woman had a grade IV sacral pressure

sore for 3 months (Fig. 6A). The sacral defect was 7 3 7

cm2 after debriding necrotic fascia and performing an ostec-

tomy of prominent bone. A left inferior gluteal artery-based

fasciocutaneous perforator flap was raised to cover the

defect (Fig. 6B). The patient was discharged in the third

postoperative week. Unfortunately, 4 months postopera-

tively, local recurrence of the sacral ulcer was noted as the

patient had been bedridden at home without appropriate

care (Fig. 6C). The defect measured 7 3 3 cm2 after the

second debridement (Fig. 6D). Again, a left inferior gluteal

artery-based fasciocutaneous perforator flap was elevated

from the previous surgical wound and covered the defect

without tension (Fig. 6E). The sacral wound was stable, and

the patient was discharged at the fourth postoperative week.

At her latest follow-up, 17 months later, the wound had

healed and no local recurrence was noted (Fig. 6F).

DISCUSSION

Pressure sores occur mostly over bony prominences,

such as the sacrum or trochanter in bedridden patients and

over the ischium in patients with spinal cord injury. The

position of the ulcer may suggest the most appropriate tis-

sue transfer. Acceptable conventional reconstructive strat-

egies include 1) for sacral pressure ulcers, even if the ulcer

is relatively small, large-radius buttock rotation flaps are

necessary to obtain good coverage, 2) trochanteric ulcers

are covered well with tensor fascia lata flaps, and 3) ischial

pressure ulcers can be closed with a posterior thigh flap or

a buttock rotation flap with or without muscle.16

Figure 5. A right gluteal fasciocutaneous flap based on the inferior

gluteal artery was elevated, and the superior gluteal artery perfora-

tor was preserved. [Color figure can be viewed in the online issue,

which is available at wileyonlinelibrary.com.]Figure 4. Superior gluteal artery-based rotation fasciocutaneous

perforator flap with IGAP preservation for the reconstruction of

ischial sores. [Color figure can be viewed in the online issue, which

is available at wileyonlinelibrary.com.]

Gluteal Flap for Pressure Sore Reconstruction 191


Table

1.Patie

ntList:Diagnosis,DonorFlap,Perioperative

Complication,andSecondProcedure

Patientno.

Age/sex

Diagnosis

Defect(cm

2)

Flap

Follow-up

(months)

Perioperative

complication

Secondprocedure

133/M

Sacralpressure

sore,GrIV

113

7Leftglutealfasciocutaneousflap

30

No

No

231/M

Leftischialpressure

sore,GrIV

43


30

No

No

367/M

Sacralpressure

sore,GrIII

73


29

No

No

480/F

Sacralpressure

sore,GrIV

63


28

No

No

545/M

Sacralpressure

sore,GrIV

73

10

Rightglutealfasciocutaneousflap

26

No

No

682/F

Sacralpressure

sore,GrIV

63


27

No

No

763/M

Lefttrochantericpressure

sore,GrIII

63


19

No

No

884/M

Sacralpressure

sore,GrIII

63

5Rightglutealfasciocutaneousflap

26

No

No

984/M

Sacralpressure

sore,GrIII

83


24

No

No

10

76/F

Sacralpressure

sore,GrIII

73


0Dead

No

11

41/M

Sacralpressure

sore,GrIII

73


23

Recurrenceat

6th

month

Reusinggluteal

rotationflap

12

32/M

Sacralpressure

sore,GrIV

113


24

No

No

13

49/M

Rightischialpressure

sore,GrIV

83


24

Tip

necrosis

Adva

nceglutealflap

14

58/F

Sacralpressure

sore,GrIV

123

10

Leftglutealfasciocutaneousflap

24

No

No

15

53/M


sore,GrIII

53


23

Wounddehisce

nce

Woundrepair

16

79/F

Sacralpressure

sore,GrIV

63


23

No

No

17

78/F

Sacralpressure

sore,GrIII

93


22

Wounddehisce

nce

Woundrepair

18

67/F

Sacralpressure

sore,GrIV

73


20

Recurrenceat

4th

month

Reusinggluteal

rotationflap

19

77/M

Sacralpressure

sore,GrIV

83


20

No

No

20

80/F

Sacralpressure

sore,GrIV

73


19

No

No

21

65/M

Leftischialpressure

sore,GrIV

43


27

Wounddehisce

nce

Woundrepair

22

57/M

Sacralpressure

sore,GrIV

63


21

No

No

23

56/M

Leftischialpressure

sore,GrIV

63


20

Tip

necrosis

Adva

nceglutealflap

24

62/M

Leftischialpressure

sore,GrIV

103


21

Seromaat

4th

month

Debridement

andrepair

25

24/M

Sacralpressure

sore,GrIII

73


19

No

No

26

32/M

Recurrentrightischialpressure

sore,GrIV

53


19

No

No

27

89/M

Sacralpressure

sore,GrIV

53


17

Tip

necrosis

Adva

nceglutealflap

28

51/F

Recurrentleftischialpressure

sore,GrIV

83


18

No

No

29

67/M

Leftischialpressure

sore

73


18

Tip

necrosis

Adva

nceglutealflap

30

45/F

Sacralpressure

sore,GrIV

83


16

No

No

31

62/F

Sacralpressure

sore,GrIV

53


17

No

No

32

64/M

Sacralpressure

sore,GrIV

73


14

No

No

33

27/M

Sacralpressure

sore,GrIV

93


14

No

No

34

51/M


sore,GrIV

63


15

No

No

35

66/F

Sacralpressure

sore,GrIV

103


15

No

No

36

28/F


sore,GrIV

83


15

No

No

192 Lin et al.


With the advent of the perforator flap, reconstruction

of a pressure ulcer using a local fasciocutaneous flap can

readily achieve good short-term functional and esthetic

results with acceptable complications. Perforator-based

flaps allow reconstruction of the ulcer using healthy tis-

sue and minimize donor site morbidity. According to

Yang et al.,4 a free-style perforator local flap has advan-

tages, such as ease of design and harvest, and preserving

the gluteus maximus muscle can reduce blood loss during

the operation and prevent the sacrifice of its function.

Although it preserves options for future reconstruction, if

the ulcer recurs there is the potential for scar tissue under

the new flap making reuse of the same flap difficult. The

propeller flap, introduced by Jakubietz et al.,2 has the

benefit of transferring tissue from a distant site, but it is

possible to twist the pedicle and cause torsion and venous

obstruction if the pedicle is dissected too short to turn

the flap around. The bilobed flap described by Lee et al.3

enables regional reconstruction using well-vascularized

tissues and provides satisfactory, esthetic results in pres-

sure sore patients. However, rerotation is difficult in

recurrence due to scar tissue under the flap. The gluteal

perforator flaps introduced by Cos�kunfirat and

Ozgentas�17 can cover pressure sores in various locations.

Figure 6. (A) Grade IV sacral pressure sore with central necrosis. (B) A left gluteal fasciocutaneous rotation flap was elevated to cover the

defect. (C) Recurrence occurred at 4 months. Erythematous skin change with bullae formation was noted. (D) A second debridement was

performed and the defect measured 7 3 3 cm2. (E) The left gluteal rotation flap was re-elevated and covered the defect. (F) At the 17-month

follow-up, no local recurrence was seen. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]



Advantages of this flap include freedom in flap design

and low donor site morbidity. It is also beneficial for am-

bulatory patients because of muscle preservation. How-

ever, it is also difficult to reuse the same flap or design a

new-perforator flap next to the ulcer if there is recur-

rence. Although there are many advantages, such as the

ability to preserve muscle, the variability of flap design,

relatively good durability, and minimal donor site

morbidity, the IGAP flap is only considered a viable

alternative for ischial pressure sore surgery because of its

perforator location. In addition, like the other types of

perforator-based flap, the IGAP flap is difficult to reuse

when recurrence occurs at the same place unless a very

large flap is designed initially. Summarizing these perfo-

rator flap techniques, the major advantage of the perfora-

tor flap is preservation of the gluteus maximus muscle,

and this is beneficial for ambulatory patients. However, it

is difficult to reuse the flap in the event of recurrence.

The recurrence of pressure ulcers is still a major con-

cern and is difficult to manage in plastic surgery even

when the patient has received appropriate soft-tissue

transfer and good perioperative care. With pressure sore

recurrence, a muscle or myocutaneous flap from distant

site or a free flap transfer can provide bulk and healthy

tissue to fill the cavity following adequate debridement

and the excision of fibrotic tissue. However, due to the

possibility of muscle atrophy, the muscle bulk of a myo-

cutaneous flap is not retained beyond 1–2 years. Thus,

the long-term value of myocutaneous flaps in reducing

the recurrence rate of pressure sores also requires careful

follow-up in a major series of cases.18 Furthermore, this

kind of flap is the last-line choice for pressure sore

reconstruction. Lee et al.10 proposed the gracilis muscle

flap and V-Y profunda femoris artery perforator-based

flap to provide muscle and skin tissue to obliterate the

dead space and wound coverage of the ischium simulta-

neously. A combination of these two flaps can provide

good clinical results without complications. However,

there is no chance of using the same flaps if the ulcer

recurs (there is only one gracilis muscle per leg). The

island pedicled anterolateral thigh and vastus lateralis

myocutaneous flaps introduced by Lee et al.11 include the

advantages of a constant blood supply, sufficient bulk,

and easy elevation. The major drawback of this procedure

is compromise of the vascular pedicle of the vastus later-

alis muscle flap in future trochanteric ulcer reconstruc-

tion. In addition, they are the flaps of choice for recur-

rence only when there is no available soft-tissue in the

proximity of the wound for reconstruction. In our opin-

ion, free soft-tissue transfer is really a salvage procedure

and last-line option for the reconstruction of pressure

sores. In the studies of Yamamoto, Wei, Lee, and Lin

et al., because there was no available local tissue, free

flap transfer was considered for huge precoccygeal defect,

recurrent ischial, and sacral pressure sores reconstruc-

tion.12–14,19 In their reports, a microvascular composite

tissue transfer was the final choice. Furthermore, an

adequate recipient vessel is imperative for success in free

flap transfer. Summarizing the techniques combining a

muscle flap and fasciocutaneous flap from a distant site

or free flap transfer, these flaps provide good dead space

obliteration and mechanical resistance. However, they are

not first-line flaps for the reconstruction of pressure sores.

In addition, muscle atrophy in the long-term may make a

muscle or myocutaneous flap less reliable.

An ideal flap for pressure sore reconstruction should

be simply designed, reliable, and reusable. In our study,

the perforator-preserving superior or inferior gluteal ar-

tery-based rotation fasciocutaneous perforator flap possess

both vascularity from the preserving perforator(s) and a

broad-based blood supply from the superior or inferior

gluteal artery, respectively, and the concept is similar to

that of the perforator-sparing buttock rotation flap for

covering pressure sores.20 This rotation flap design can

be re-elevated using the same incision and advanced in

the case of tip necrosis or ulcer recurrence. A large ra-

dius flap design is preferred so that if rerotation is

required in the case of recurrence, the same flap can be

reused. We preserved the superior gluteal artery perfora-

tor in sacral sore patients, in whom that the flap is based

primarily on the inferior gluteal artery, and preserved the

IGAP in ischial wounds, in which the flap is based on

the superior gluteal artery, during flap elevation. This

facilitates flap rotation without tension and vascular com-

promise when compared with conventional rotation flaps.

Furthermore, the soft tissues are always lax in bedridden

patients; thus, it is typically easy to rerotate the flap for re-

currence. It remains controversial as to whether to perform

muscle obliteration in recurrent ischial pressure sore recon-

struction. Thiessen et al.21 reported that fasciocutaneous

flaps attain the same postoperative outcome as musculocu-

taneous flaps in the reconstruction of pressure sores. In

our experience, de-epithelizing the distal skin and turning

the flap into the defect could solve this problem. Other-

wise, transposing a portion of the gluteus maximus muscle

into the defect is necessary to fill a large dead space.20

Although our series is similar to Wong et al.’s20

report, there are still two main differences between these

two studies. First, in Wong et al.’s study, rerotation of

the perforator-sparing buttock rotation flap was possible

in the event of ulcer recurrence. It was only a hypothesis.

In our study, however, our rotation fasciocutaneous flap

was really reusable while pressure ulcer recurred. Second,

we could de-epithelize the distal flap to obliterate the

dead space instead of gluteal muscle.

In this series, the rate of perioperative complications,

including tip necrosis and wound dehiscence, was higher

in the spinal cord injury patients with ischial pressure

194 Lin et al.


ulcers (54.5%) than those with sacral pressure sores

(20.8%). However, our result is comparable with pub-

lished reports.22,23 In patients with spinal cord injury,

lower extremity muscle spasticity and reflex contraction

of the hip and knee place tension on the wound, which

contributes to wound dehiscence.24 For these patients,

perioperative antispasticity medication and maintaining

the prone position will prevent these complications.

Another cause that contributed to the complications in

our study was inappropriate flap design. If the distal tip

of the flap is too sharp and narrow, it results in poor vas-

cularity and necrosis.

Nutrition status is an important factor of wound heal-

ing. Before operation, we are concerned about patients’

nutrition status as well as general condition such as liver

and renal functions. Then, we would check albumin level

preoperatively. If the albumin level was less than 3.0 g/

dL, we should correct this patient’s nutrition status to

improve wound healing process.

Even if the reconstruction is doing well, for good

long-term results, it is important to educate patients and

caregivers. Recurrence is usually not secondary to the

operation but to the poor compliance of patients at home

or the lack of appropriate wound care assistance.25

Patients and their family or caregivers have to be edu-

cated on pressure relief and skin care.17 In bedridden

patients (sacral or trochanteric pressure sores), frequently

changing the body position prevents ulcer recurrence,

while patients with ischial pressure sores should learn cy-

clical pressure-release maneuvers to relieve pressure over

the ischium. It is also important to check the patient’s

sacrum, hip, ischium, and heels everyday. Early recogni-

tion and management are required to prevent ulcer recur-

rence and accelerate the healing of pressure sores.26

CONCLUSIONS

Our perforator-preserving gluteal artery-based rotation

fasciocutaneous perforator flap not only has the advan-

tages of being a perforator-based flap but also can be

reused in patients with ulcer recurrence. Ultimately, in

addition to a successful flap reconstruction, good long-

term results of pressure sore management involve appro-

priate home care and patient compliance.

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Documents

A reusable perforator-preserving gluteal artery-based rotation fasciocutaneous flap for pressure sore reconstruction