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Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps for reconstruction of sacral pressure sores Yen-Chou Chen a , Eng-Yen Huang b , Pao-Yuan Lin a, * a Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan b Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan Received 4 November 2013; accepted 20 December 2013 KEYWORDS Gluteal perforator flap; Gluteal fasciocutaneous rotation flap; Sacral pressure sore reconstruction Summary Background and aim: The gluteus maximus myocutaneous flap was considered the workhorse that reconstructed sacral pressure sores, but was gradually replaced by fasciocuta- neous flap because of several disadvantages. With the advent of the perforator flap technique, gluteal perforator (GP) flap has gained popularity nowadays. The aim of this study was to compare the complications and outcomes between GP flaps and gluteal fasciocutaneous rota- tion (FR) flaps in the treatment of sacral pressure sores. Methods: Between April 2007 and June 2012, 63 patients underwent sacral pressure sore re- constructions, with a GP flap used in 31 cases and an FR flap used in 32 cases. Data collected on the patients included patient age, gender, co-morbidity for being bedridden and follow-up time. Surgical details collected included the defect size, operative time and estimated blood loss. Complications recorded included re-operation, dehiscence, flap necrosis, wound infection, sinus formation, donor-site morbidity and recurrence. The complications and clinical outcomes were compared between these two groups. Results: We found that there was no significant difference in patient demographics, surgical complications and recurrence between these two groups. In gluteal FR flap group, all recurrent cases (five) were treated by reuse of previous flaps. Conclusions: Both methods are comparable, good and safe in treating sacral pressure sores. Gluteal FR flap can be performed without microsurgical dissection, and re-rotation is feasible in recurrent cases. The authors suggest using gluteal FR flaps in patients with a high risk of sore recurrence. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. * Corresponding author. E-mail address: [email protected] (P.-Y. Lin). + MODEL Please cite this article in press as: Chen Y-C, et al., Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps for reconstruction of sacral pressure sores, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2013.12.029 1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.12.029 Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx,1e6

Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps for reconstruction of sacral pressure sores

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Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e6

Comparison of gluteal perforator flaps andgluteal fasciocutaneous rotation flaps forreconstruction of sacral pressure sores

Yen-Chou Chen a, Eng-Yen Huang b, Pao-Yuan Lin a,*

a Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital andChang Gung University College of Medicine, Kaohsiung, Taiwanb Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang GungUniversity College of Medicine, Kaohsiung, Taiwan

Received 4 November 2013; accepted 20 December 2013

KEYWORDSGluteal perforatorflap;Glutealfasciocutaneousrotation flap;Sacral pressure sorereconstruction

* Corresponding author.E-mail address: chenrenslo@gmail

Please cite this article in press as: Chreconstruction of sacral pressure soj.bjps.2013.12.029

1748-6815/$-seefrontmatterª2013Brihttp://dx.doi.org/10.1016/j.bjps.2013.1

Summary Background and aim: The gluteus maximus myocutaneous flap was considered theworkhorse that reconstructed sacral pressure sores, but was gradually replaced by fasciocuta-neous flap because of several disadvantages. With the advent of the perforator flap technique,gluteal perforator (GP) flap has gained popularity nowadays. The aim of this study was tocompare the complications and outcomes between GP flaps and gluteal fasciocutaneous rota-tion (FR) flaps in the treatment of sacral pressure sores.Methods: Between April 2007 and June 2012, 63 patients underwent sacral pressure sore re-constructions, with a GP flap used in 31 cases and an FR flap used in 32 cases.

Data collected on the patients included patient age, gender, co-morbidity for beingbedridden and follow-up time. Surgical details collected included the defect size, operativetime and estimated blood loss. Complications recorded included re-operation, dehiscence,flap necrosis, wound infection, sinus formation, donor-site morbidity and recurrence. Thecomplications and clinical outcomes were compared between these two groups.Results: We found that there was no significant difference in patient demographics, surgicalcomplications and recurrence between these two groups. In gluteal FR flap group, all recurrentcases (five) were treated by reuse of previous flaps.Conclusions: Both methods are comparable, good and safe in treating sacral pressure sores.Gluteal FR flap can be performed without microsurgical dissection, and re-rotation is feasiblein recurrent cases. The authors suggest using gluteal FR flaps in patients with a high risk of sorerecurrence.ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

.com (P.-Y. Lin).

en Y-C, et al., Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps forres, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/

tishAssociationofPlastic,ReconstructiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.2.029

2 Y.-C. Chen et al.

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Pressure sores, especially in the sacral area, pose chal-

lenges for reconstructive surgeons. Patients with pressuresores are usually paraplegic or bedridden, making the soresreluctant to heal, prone to recurrence, and difficult toreconstruct.1e3

The gluteus maximus myocutaneous flap has beenconsidered the workhorse flap for reconstructing sacralpressure sores.4e7 However, disadvantages of using this flapare limited flap mobility, sacrifice of muscle and increasedblood loss. Yuhei et al.8,9 reported that the transferredmuscle portion of the flap showed remarkable atrophicchanges over the long term, and the recurrence rate wasnot significantly different from that with the fasciocuta-neous flap.

With the advent of the perforator flap techniquedescribed by Koshima et al.,10 gluteal perforator (GP) flapshave recently gained popularity for reconstruction of sacralpressure sores. These flaps can use perforators that emergefrom either the superior or inferior gluteal vessels. By dis-secting perforators and completely islanding the flap,healthy tissue with a robust blood supply can be transferredfreely without sacrificing the underlying muscle.

Although a systematic review11 showed that there wasno statistically significant difference with regard to recur-rence or complication rates among musculocutaneous,fasciocutaneous and perforator flaps for pressure sorereconstruction, comparisons of GP flaps and fasciocuta-neous rotation (FR) flaps specifically focussing on sacralpressure sore reconstruction have rarely been discussed.The purpose of this study was to compare surgical compli-cations and outcomes between these two techniques in asingle institute.

Materials and methods

Retrospective chart review of consecutive sacral pressuresore patients treated surgically using a GP flap (Figure 1) or

Figure 1 Gluteal perforator flaps can be transferred as advance (or propeller (below, right) fashion to reconstruct sacral pressure s

Please cite this article in press as: Chen Y-C, et al., Comparison of glureconstruction of sacral pressure sores, Journal of Plastic, Reconstj.bjps.2013.12.029

a gluteal FR flap (Figure 2) was performed at the Depart-ment of Plastic and Reconstructive Surgery, KaohsiungChang Gung Memorial Hospital from April 2007 to June2012. Those patients who were treated with secondaryhealing, primary closure, skin grafting, second flap recon-struction or other types of flap reconstruction wereexcluded.

Data regarding the patient’s age, gender, co-morbidityfor being bedridden and follow-up time interval werecollected. Surgical details, including the defect size,operative time and estimated blood loss, were recorded.Complications, including re-operation, dehiscence, flapnecrosis (partial and total necrosis), wound infection, sinusformation and donor-site morbidity, were also recorded.Recurrence was defined as a pressure sore that occurred atthe site of flap reconstruction more than 3 months afterreconstruction.

An independent t-test was used to test the null hy-pothesis that the means of the two groups were equal. Thechi-squared/Fisher’s exact test was used to analyse thedifferences in group complication rates and surgical out-comes. All statistical tests were two-sided, and a value ofp < 0.05 was considered statistically significant. All statis-tical analyses were performed using Statistical Package forthe Social Sciences (SPSS) version 13.0 (SPSS, Inc., Chicago,Il, USA).

Results

Of the 63 patients, a reconstruction using a GP flap (GPgroup) was done on 31 patients and a reconstruction using afasciocutaneous rotation flap (FR group) was done on 32patients. The demographic data for each group, includingsex, age, co-morbidity, defect size, operative time, esti-mated blood loss and follow-up period, are outlined inTable 1. There were no significant differences betweenthese two groups.

above, left), rotation (above, right), transposition (below, left)ores.

teal perforator flaps and gluteal fasciocutaneous rotation flaps forructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/

Figure 2 Sacral pressure sore (left). Conventional gluteal fasciocutaneous rotation flap for sacral pressure sore reconstruction(right).

Table 2 Comparison of surgical complications andoutcome.

Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps 3

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With regard to complications and outcomes, seven pa-tients (22.6%) from the GP group were taken back to theoperating room due to surgical complications. Flap necrosiswas noted in eight patients (25.8%), with two total necrosesand six partial necroses. Patients with total flap necrosisreceived secondary reconstruction using a FR flap from thecontralateral buttock. Wound infection occurred in fivepatients (16.1%). Two patients (6.5%) had sinus formation,and one patient (3.2%) had donor-site morbidity. In the FRgroup, nine patients (28.1%) had to be taken back to theoperating room to address complications. Six patientsdeveloped wound dehiscence (18.75%), which was higherthan that in the GP group but was not statistically signifi-cant (p Z 0.257). Flap necrosis occurred in eight patients.Although the flap necrosis rate (8/32 Z 25%) was similar tothe GP group, there was no total flap necrosis in the FRgroup. One patient (3.2%) had seroma, and four patients(12.5%) had donor-site morbidity.

In this study, two patients from the GP group died 1month after their operations because of pneumonia. In theFR group, one patient died 2 weeks postoperatively due toacute myocardial infarction, and another two died 3 weeksand 2 months after their operations, respectively. Theabove five cases with short postoperative life wereexcluded from long-term follow-up. Thus, the overallcomplication rate was 29.0% (9/31) in the GP group and37.5% (12/32) in the FR group, which demonstrated nostatistical significance between these two groups(p Z 0.663). The GP and FR groups had five patients eachwith sore recurrences, which was a 17.2% (5/29) recurrencerate. The surgical complications and outcomes for thesetwo groups are presented in Table 2.

Table 1 Patient demorgraphics.

GP group FR group p Value

Numbers 31 32 e

Age 73.6 66.7 0.131Maleefemale ratio 16:16 17:15 0.802Defect size (cm2) 51.8 43.9 0.193Operative time (mins) 152.9 143.4 0.228Blood loss (mls) 62.9 63.4 0.946Follow-up (mos) 37.1 34.8

GP, gluteal perforator; FR, fasciocutaneous rotation.

Please cite this article in press as: Chen Y-C, et al., Comparison of glureconstruction of sacral pressure sores, Journal of Plastic, Reconstj.bjps.2013.12.029

Discussion

Musculocutaneous flaps have been the mainstay for treatingsacral pressure sores because of their rich blood supply.4

However, the arc of rotation is limited and may causemuch blood loss during flap elevation. This technique alsocauses donor-site morbidity, especially in ambulatory pa-tients. Additionally, the transferred muscle undergoes sig-nificant atrophic degeneration with time, usually 1 yearpostoperatively. In experimental studies, pressure-inducedhypoxia can cause muscle necrosis without skin necrosis inmusculocutaneous flaps.12 Although Thiessen et al.13 re-ported no differences in postoperative morbidity or recur-rence between muscle and non-muscle flaps in univariateand multivariate analyses, Yamato et al.6 concluded thatfasciocutaneous flaps have better long-term results thanmuscle or myocutaneous flaps when used for pressure sorereconstruction, and they suggested using fasciocutaneousflaps as a first choice for treating sacral pressure sores.7

Over the past few years, perforator flaps have gainedpopularity. By completely islanding the skin paddle basedon one or more perforators, the flap can be transferredwith maximal freedom in a tension-free manner. For thefirst time in 1988, Kroll et al.14 published the use ofperforator flaps for coverage of low midline defects, andKoshima et al.15 repaired sacral pressure sores using GPflaps and confirmed the reliability of the blood supply by

GP group FR group p Value

n % n %

Overall complicationrate

9/31 29.0 12/32 37.5 0.663

Re-operation 7/31 22.6 9/32 28.1 0.836Wound dehiscence 2/31 6.5 6/32 18.8 0.257Flap necrosis 8/31 25.8 8/32 25.0 0.941Infection 5/31 16.1 6/32 18.8 0.784Seroma or sinus

formation1/31 3.2 1/32 3.2 0.999

Donor site morbidity 2/31 6.5 4/32 12.5 0.999Mortality 2/31 6.5 3/32 9.4 1.000Recurrence rate 5/29 17.2 5/29 17.2 1.000

GP, gluteal perforator; FR, fasciocutaneous rotation.

teal perforator flaps and gluteal fasciocutaneous rotation flaps forructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/

Figure 3 Recurrent sacral pressure sore (above, left). The gluteal fasciocutaneous flap was re-elevated (above, right). Flap wasre-rotated for sore reconstruction (below, left). View of the flap 1 year postoperatively (below, right).

4 Y.-C. Chen et al.

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describing details of perforator distribution based oncadaver dissection. Large flaps can be transferred based onone or several perforators due to their rich vasculature.Furthermore, the versatility of the flap design allows it toadapt to the defect. The preservation of blood supply andmuscle results in minimal donor-site morbidity. Mostimportant of all, long pedicles of GPs enable tissue mobi-lisation up to 12 cm in distance and achieve tension-freeclosure.16 Therefore, the use of perforator flaps canreduce the wound dehiscence rate. Although we observed alower wound dehiscence rate in the GP group (6.45%)compared to the FR group (18.75%), the difference was notstatistically significant. This outcome could be explained bythe small number of cases in this study.

Some drawbacks of using perforator flaps should benoted. First, due to varied perforator distribution and theunpredictable nature of perforator venae comitantes, moretendinous intramuscular dissection and surgical expertiseare needed. Second, when a flap is designed in the propellerfashion based on a single perforator, although healthy andundamaged tissue can be transferred from a distant site,kinking of the perforator is possible and results in total flapfailure, which rarely occurs with FR flaps. In our study, wefound two cases of total flap necrosis in the GP group,whereas only partial flap necrosis was noted in the FR group.

FR flaps are well known for sacral pressure sore recon-struction and have many advantages that are welldescribed in the literature.8,9,17,18 Good blood supply viathe fascial plexus allows this flap to be raised easily withoutmajor complications, such as total flap loss. The circum-ference of the flap should be approximately 5e8 times thewidth of the defect to achieve tension-free distribution.According to our experience, the greatest benefit of fas-ciocutaneous flaps is that they are reusable.19 By creatingan incision through the previous operative wound, the flapcan be elevated and advanced in the event of partial

Please cite this article in press as: Chen Y-C, et al., Comparison of glureconstruction of sacral pressure sores, Journal of Plastic, Reconstj.bjps.2013.12.029

necrosis or ulcer recurrence. Recently, Wong et al.20 andLin et al.19 incorporated the concept of sparing the perfo-rator in conventional FR flaps, which make them morereliable in vascularity and reusable for further reconstruc-tion. However, reuse is generally not allowed for island-type perforator flaps when flap necrosis or sore recur-rence occurs, unless they are designed to be very largefrom the beginning. Feng et al.21 described the concept offree-style puzzle flaps to recycle a perforator flap. Thisinnovative idea is valuable but has not yet been appliedroutinely to recurrent pressure sores. The recommendedreconstructive options in this situation are perforator flapsor FR flaps from the contralateral buttock.

The use of either perforator flaps or FR flaps in sacralpressure sore reconstruction remains controversial. A recentsystematic review discussing complications and recurrencerates of musculocutaneous, fasciocutaneous and perforator-based flaps for treatment of pressure sores revealed no sig-nificant differences among these flaps.11 In our study, vari-ables such as operative time, defect size and blood loss werecomparable in these two groups. There were also no signifi-cant differences between perforator and fasciocutaneousflaps with regard to re-operation, wound dehiscence, flapnecrosis, infection, seroma, donor-sitemorbidity and overallcomplication rates. These results were similar to recentpublications comparing perforator and fasciocutaneous flapsfor pressure sore reconstruction.11,13 However, in our study,the overall complication rates for the perforator flap group(29%) and the fasciocutaneous flap group (37.5%)were higherthan the complication rates (7e31%) reported in the liter-ature.22e24 This elevated incidence could be explained bythe advanced age of our patients and multiple co-morbidities, which made postoperative care difficult.There was no significant difference in rates of recurrencebetween perforator and FR flaps in our study, which wascomparable to other studies.22,25e27

teal perforator flaps and gluteal fasciocutaneous rotation flaps forructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/

Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps 5

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In summary, we found that perforator flaps and FR flapshad comparable outcomes when used for reconstruction ofsacral pressure sores. However, in cases of elderly patientswith multiple co-morbidities, a high risk of sore recurrenceshould be kept in mind. When the first flap is selected, afuture secondary reconstruction option should also betaken into consideration. In our study of the five cases ofrecurrence in the GP group, three cases were treated usingan FR flap from the contralateral buttock, and the othertwo cases were managed using negative-pressure woundtherapy. In the FR group, however, all recurrent cases couldbe treated using flap re-elevation and rotation (Figure 3).As a result, we suggest using gluteal FR flaps for patientswith a high risk of sore recurrence.

A limitation of the study is that this is a non-randomised,retrospective study with a small sample size. Selection biasand confounding factors are inevitable. Although the sam-ple size was small, the number of GP flaps included in thisstudy was comparable to the numbers reported in otherpublished works in the literature.14e16,28e36 In addition, thedesign of the GP flaps was not uniform and varied, includingadvance, transposition, rotation and propeller fashion, dueto the heterogeneity of perforator distribution and tissuelaxity. Despite the above limitations, a strength of thisstudy is that most of the published studies14e16,28e36 of GPflaps are case studies without comparisons, and defect lo-cations also varied. Our study provided a comparison of thesurgical complications and outcomes of these two tech-niques. Additionally, the defect location was specifically inthe sacrum, making samples more homogeneous. A well-designed comparative study with an adequate sample sizeis still recommended to elucidate differences in the future.

Conclusion

GP flaps and FR flaps are comparable for managing sacralpressure sores. Both can be considered a first-line option.Gluteal FR flap reconstructions can be performed withoutmicrosurgical dissection, and re-rotation is feasible in theevent of sore recurrence. The authors suggest using glutealFR flaps in patients with a high risk of sore recurrence.

Funding

None.

Conflict of interest

None.

References

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teal perforator flaps and gluteal fasciocutaneous rotation flaps forructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/