Comparison of outcomes of pressure sore reconstructions among perforator flaps, perforator-based rotation fasciocutaneous flaps, and musculocutaneous flaps

COMPARISON OF OUTCOMES OF PRESSURE SORERECONSTRUCTIONS AMONG PERFORATOR FLAPS,PERFORATOR-BASED ROTATION FASCIOCUTANEOUSFLAPS, AND MUSCULOCUTANEOUS FLAPS

PAO-JEN KUO, M.D.,1 KHONG-YIK CHEW, M.B.B.S., M.R.C.S.,2 YUR-REN KUO, M.D., Ph.D.,1 and PAO-YUAN LIN, M.D.1*

Background: Pressure sore reconstruction remains a significant challenge for plastic surgeons due to its high postoperative complicationand recurrence rates. Free-style perforator flap, fasciocutaeous flap, and musculocutaneous flap are the most common options in pressuresore reconstructions. Our study compared the postoperative complications among these three flaps at Kaohsiung Chang Gung MemorialHospital. Methods: From 2003 to 2012, 99 patients (54 men and 45 women) with grade III or IV pressure sores received regional flapreconstruction, consisting of three cohorts: group A, 35 free-style perforator-based flaps; group B, 37 gluteal rotation fasciocutaneousflaps; and group C, 27 musculocutaneous or muscle combined with fasciocutaneous flap. Wound complications such as wound infection,dehiscence, seroma formation of the donor site, partial or complete flap loss, and recurrence were reviewed. Results: The mean follow-up period for group A was 24.2 months, 20.8 months in group B, and 19.0 months for group C. The overall complication rate was 22.9%,32.4%, and 22.2% in groups A, B, and C, respectively. The flap necrosis rate was 11.4%, 13.5%, and 0% in groups A, B, and C, respec-tively. There was no statistical significance regarding complication rate and flap necrosis rate among different groups. Conclusions: Inour study, the differences of complication rates and flap necrosis rate between these groups were not statistically significant. Furtherinvestigations should be conducted. VC 2014 Wiley Periodicals, Inc. Microsurgery 34:547–553, 2014.

The problem of pressure sore reconstruction plagues

reconstructive surgeons worldwide and has been an

increasing problem, in part due to improvements in criti-

cal care and life support amid a rapidly ageing popula-

tion. It is a bane for surgeons due to the high

preponderance for complications and recurrence, in turn

leading to diminishing options for reconstruction.

Beginning in the 1970s, musculocutaneous flaps have

been the mainstay of reconstruction in pressure sores.1,2

Further modifications continue to be reported, such as the

use of V-Y advancement of a fasciocutaneous flap for

sacral ulcers reported by Park and Park in 1988.3 With

greater understanding of flap physiology and the perfora-

tor concepts, the perforator-based gluteal flaps were

developed and first reported by Koshima et al. in 1993,

and have gained popularity for reconstruction of pressure

sores.4

Proponents of the different flap types argue about the

superiority of one over the other, although evidence for

it has been scarce. Sameem et al. conducted an extensive

systematic review of pressure sore reconstruction in dif-

ferent flaps and concluded that there were no statistically

significant differences with respect to recurrence or com-

plication rates among musculocutaneous, fasciocutaneous,

or perforator-based flaps.5 They also called for more

comparative studies on determining the ideal flap type

for pressure sore reconstruction.

This study is a review of our unit’s experience in

treatment of this problem, with matched cohorts to com-

pare the outcomes of the various flap types used. In this

study, we compared the complication rates among three

different flap types in pressure sore reconstructions: a)

freestyle perforator-based gluteal flap, b) gluteal rotation

fasciocutaneous flap, and c) musculocutaneous flap or a

combination of muscle and fasciocutaneous flaps.

PATIENTS AND METHODS

From February 2003 to December 2012, a total of 99

patients consisting of 54 males and 45 females with

grade III or IV pressure sores received complete debride-

ment, including bursectomy and partial ostectomy of the

bony prominence where required, followed by immediate

regional flap reconstruction. This study was divided into

three cohorts according to the types of flaps used. During

the period between 2003 and 2008, free-style perforator

based flaps were widely used for reconstruction of pres-

sure sores in our unit. During this period, 35 patients

underwent freestyle perforator-based flaps (group A),

consisting of 26 sacral, 5 ischial, and 4 trochanteric pres-

sure ulcers.6 Between 2008 and 2010, the gluteal rotation

fasciocutaneous flap was performed among 37 patients

(group B), among them 25 cases were pressure sores

involving the sacral region, 11 were ischial wounds, and

1Department of Plastic and Reconstructive Surgery, Kaohsiung ChangGung Memorial Hospital and Chang Gung University, College of Medicine,Kaohsiung, Taiwan2Department of Plastic, Reconstructive and Aesthetic Surgery, KandangKerbau Women’s and Children’s Hospital, Singapore

*Correspondence to: Pao-Yuan Lin, MD, Department of Plastic and Recon-structive Surgery, Kaohsiung Chang Gung Memorial Hospital, 123, Ta-PeiRoad, Naio-Song District, Kaohsiung, Taiwan.E-mail: [email protected]

Received 2 December 2013; Revision accepted 17 March 2014; Accepted24 March 2014

Published online 5 April 2014 in Wiley Online Library (wileyonlinelibrary.com).DOI: 10.1002/micr.22257

� 2014 Wiley Periodicals, Inc.

one with trochanteric ulcer.7 From 2011 to 2012, the

senior author (P.L.) employed the use of musculocutane-

ous flaps or combinations of muscle and fasciocutaneous

flaps (group C) for treatment of 27 pressure ulcers.

There were six sacral sores that were resurfaced with

musculocutaneous flaps, two trochanteric ulcers were

covered with pedicled anterolateral thigh musculocutane-

ous flaps, and 19 cases of ischial pressure sores resur-

faced with a combination of biceps femoris muscle flaps

and posterior thigh fasciocutaneous flaps. The recruit-

ment of a muscle component for reconstruction was cho-

sen for pressure sore reconstruction to allow cushioning

of exposed bone as well as to decrease dead space using

the additional soft tissue bulk. In the cases of ischial

ulcers, a separate fasciocutaneous flap was raised during

the same procedure when the significant cutaneous

defects were encountered or when musculocutaneous

flaps were unlikely to provide sufficient skin cover or

where these were unavailable. Postoperatively, all

patients were kept in supine or lateral decubitus position

for a minimum of 3 weeks. In addition, all subjects

were initiated on a sitting program consisting of grad-

uated weight bearing over increments of time where

possible. At the end of the study, sonography was

undertaken at the location of pressure ulcer to evaluate

the wound healing process.8

Medical records with regard to patient demographics,

existing disorders such as spinal cord disease, medical

co-morbidities, the surgical technique used, and wound

complications and hospital stay were reviewed. Compli-

cations were documented individually, including wound

infection, dehiscence, seroma formation, partial or com-

plete flap loss, and recurrence.

Chi-square test was used to compare statistical differ-

ence of proportion among different groups. A P-value of

less than 0.05 indicated statistically significant results,

and all confidence intervals are reported in the 95%

range. All calculations were performed using SPSS for

Windows, Version 14.0 (Chicago, IL).

RESULTS

In this study, the age of patient population ranged

10–91 years with an average of 59.7 6 17.8 years.

Divided into the separate groups, the average ages were

64 6 17, 58.7 6 18.6, and 55.4 6 16.9 years among

groups A, B, and C. The defect sizes ranged from 4 3 3

cm2 to 27 3 13 cm2, with similar ranges among the

three groups (group A: 7 3 2 cm2 to 27 3 13 cm2,

group B: 4 3 3 cm2 to 12 3 10 cm2, and group C: 5 3

3 cm2 to 12 3 7 cm2 respectively). The mean follow-up

period for group A was 24.2 months (ranging from 0 to

46 months), 20.8 months in group B (0 to 30 months),

and 19.0 months for group C (14 to 26 months).

Complications were common and affected 26.3% of

all patients, excluding two mortality in the early postop-

erative period. For group A, eight patients or 22.9% of

this cohort suffered from such complications, including

one total flap loss, three partial flap necrosis, three

wound dehiscence, and one recurrence (one mortality

were not calculated). Among the group B cohort, five

cases of partial flap necrosis, four wound dehiscence, one

seroma formation, and two recurrences (one death which

was not included in analysis) were reported, indicating a

32.4% complication rate (12 out of 37 cases). In group

C, one case of wound dehiscence, two donor sites seroma

formation, one infection, and two recurrences developed

among 27 patients, or 22.2% of the cohort studied. The

flap necrosis rate was 4/35 (11.4%, including one total

loss) in group A, 5/37 (13.5%) in group B, and 0/27

(0%) in group C. The differences of complication rates

and flap necrosis rate between these groups were not stat-

istically significant (P 5 0.559 and 0.149, respectively).

The recorded complications of these three groups are

summarized in Table 1.

CASE REPORTS

Case 1: A 69-year-old female patient with the history

of end-stage renal disease presented with 6 cm 3 6 cm

grade IV sacral pressure ulcer (Fig. 1) due to long-term

bed ridden during hospitalization. She received adequate

debridement and partial ostectomy of protruded sacral

bone. Immediate gluteal perforator flap (Fig. 2) was ele-

vated and reconstructed for the sacral defect. The flap

was pink in color postoperatively (Fig. 3). However, the

flap was necrosed gradually. No more flap was used for

the wound reconstruction. After discharge, secondary

healing with dressing was applied on the wound and this

patient was followed at clinic regularly. However, the

wound was still not healed at one-year follow-up.

Case 2: A 58-year-old female patient presented with

6 cm 3 4 cm grade IV sacral pressure sore (Fig. 4) for

3 weeks at home. Debridement and partial ostectomy of

sacral bone were undertaken. Left gluteal fasciocutaneous

flap based on inferior gluteal artery (Fig. 5) was elevated

and then rotated to repair the defect immediately. The

wound was healed uneventfully at postoperative 3 weeks.

At 8-month follow-up, the wound was healed without

recurrence.

Case 3: A 43-year-old male patient suffered from spi-

nal cord injury due to traffic accident 5 years ago. He

had 3 cm 3 3 cm grade IV left ischial pressure ulcer

and received debridement and wound repair at first. The

wound was dehiscent few days later. Adequate debride-

ment and ostectomy of ischial bone were performed (Fig.

6). Due to huge defect (7 cm 3 7 cm 3 4 cm), left

biceps femoris muscle (Fig. 7) was harvested and turned

548 Kuo et al.

Microsurgery DOI 10.1002/micr

Tab

le1.

Patient

Dem

ogra

phic

s,P

osto

pera

tive

Com

plic

ation,

and

Com

plic

ation

Rate

Sex

(M/F

)

Ave

rage

age

inye

ars

Loca

tion

and

num

bers

of

pre

ssure

sore

s

Defe

ct

siz

e(c

m2)

Posto

pera

tive

com

plic

ations

Fla

pnecro

sis

rate

aC

om

plic

ation

rate

bM

ean

follo

w-u

p

(range)

inm

onth

s

Gro

up

A

Fre

esty

leperf

ora

tor

flaps

12/2

264

617

Sacru

m–

26

73

2–27

313

1flap

tota

llo

ss

a11.4

%22.9

%24.2

(0–46)

Ischiu

m–

53

part

ialflap

necro

sis

a

Hip

–4

3w

ound

dehis

cence

1die

db

1re

curr

ence

Gro

up

B

Fascio

cuta

neous

flaps

24/1

358.7

618.6

Sacru

m–

25

43

3–12

310

5tip

necro

sis

a13.5

%32.4

%20.8

(0–30)

Ischiu

m–

11

4w

ound

dehis

cence

Hip

–1

1sero

ma

1die

db

2re

curr

ence

Gro

up

C

Myo

cuta

neous

flaps

or

com

bin

ed

muscle

&fa

scio

-cuta

neous

flaps

18/9

55.4

616.9

Sacru

m–

65

33–12

37

1w

ound

dehis

cence

0%

22.2

%19

(14–26)

Ischiu

m–

19

2donor

site

sero

ma

2re

curr

ence

Hip

–2

1w

ound

infe

ction

aT

he

case

of

tota

lflap

necro

sis

,part

ialflap

necro

sis

and

tip

necro

sis

were

inclu

ded

the

calc

ula

tion

of

flap

necro

sis

rate

bD

ied

cases

were

exclu

ded

from

calc

ula

tions

of

short

-term

com

plic

ation.

Figure 1. Patient presented with grade IV sacral pressure ulcer.

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

at wileyonlinelibrary.com.]

Figure 2. Perforator flap was elevated during the operation. [Color

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

wileyonlinelibrary.com.]

Figure 3. Immediately postoperative wound that was reconstructed

by free-style perforator flap. [Color figure can be viewed in the

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

Comparison of Outcomes of Pressure Sore Reconstructions 549


http://wileyonlinelibrary.com



upwardly to obliterate the dead space at left ischium.

Posterior thigh fasciocutaneous flap was elevated and

then advanced to close the skin defect (Fig. 8). The

wound seemed good postoperatively. However, wound

was dehiscent due to poor postoperative care and patient

compliance. Debridement was performed and negative

pressure wound therapy was applied. Six weeks later, the

wound was healed. However, left ischial pressure sore

was recurred at 4-month follow-up. He received further

debridement and negative pressure wound therapy was

applied postoperatively.

DISCUSSION

Pressure sore reconstruction using regional flap is a

standard surgical modality for reconstructive surgeon.

The free-style perforator flap is supported by one or two

perforators which mother vessel at gluteal region is not

identified. This kind of flap could be advanced or rotated

to achieve wound repair. The rotational gluteal flap is

supported by the main trunk of superior or inferior glu-

teal artery and may have additional perforator to promote

the vascularity of the flap.7 It could be rotated only to

repair the wound.

Figure 4. Patient presented with grade IV sacral pressure sore.

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

at wileyonlinelibrary.com.]

Figure 5. Left gluteal rotation fasciocutaneous flap was used to

reconstruct sacral defect. Immediately postoperative wound. [Color



Figure 6. Left ischial pressure sore, Gr IV, post debridement. [Color



Figure 7. Left biceps femoris muscle flap was elevated and this

muscle was turned upwardly to obliterate the dead space at left

ischium. [Color figure can be viewed in the online issue, which is

available at wileyonlinelibrary.com.]

550 Kuo et al.






Comparing the different types of flap, the complication

rate was 22.9% for free-style perforator flap, 32.4% for

rotational gluteal fasciocutaneous flap, and 22.2% for mus-

culocutaneous flap or muscle combined fasciocutaneous

flap after long-term (at least 6 months) follow-up. Hence,

this study only included small series of cases, which may

be the reason for that the results of statistical analysis

were negative. A systematic review by Sameem et al.

reported overall complication rates of 19.6% for perforator

based flaps, 11.7% for fasciocutaneous flaps, and 18.6%

for musculocutaneous flaps, although the review similarly

failed to demonstrate statistical significance between the

different complication rates of these flaps.5 The reason, as

pointed out by the authors, is that majority of research

into pressure sore reconstruction are limited by small sam-

ple sizes, lack of control groups, population heterogeneity,

and a large preponderance for case series, which tends to

be susceptible to selection bias.

In the first cohort of this study (group A), free-style

perforator-based flaps were used as a standard method of

repair for pressure ulcers.6 Wei and Mardini introduced

the concept of free-style perforator flap surgery as a rou-

tine procedure and formed our basis for this flap choice

in the first group studied.9 This technique allows for

recruitment of healthy surrounding tissue with an axial

vascular supply and has the added advantage of allowing

for custom-designed flap shape and size to fit the defect.

Perforator dissection allows for a long pedicle length and

enhances its reach and facilitates inset and positioning of

the flap. Moreover, the use of perforator flaps avoids

damage to underlying muscle and underling structures

such as sciatic nerves, preserving the ambulatory poten-

tial of these patients. Consequently, preservation of the

underlying muscle allows for future use in the event of

recurrence.10 However, total flap necrosis could happen

in the case of perforator injury. Then we shifted free

style perforator flap to perforator-based rotational gluteal

flap reconstruction in our series.

In 1997, Yamamoto and Tsutsumida reported the

superiority of fasciocutaneous flaps and argued for its use

as a first line treatment in pressure ulcer reconstruction,11

based on various experimental studies on muscle toler-

ance to pressure and anatomical studies on typical pres-

sure points,12 as well as the significant muscle atrophy

observed in the long-term.11 Our experience with gluteal

rotation fasciocutaneous flaps reflects this sentiment,7 as

these flaps have a broad-based cutaneous component,

bestowing it with generous dermal blood supply comple-

menting the superior or inferior gluteal vessels, but more

importantly allows for adequate venous drainage.10,13

The use of this technique preserves many of the advan-

tages of the perforator flaps, such as muscle preservation,

excellent durability, minimal donor site morbidity, and in

select cases the added ability for re-use in the event of

recurrence. The main caveat for these flaps is the require-

ment of a large rotation arc for adequate tissue transfer

and coverage.

The idea of incorporating muscle for pressure sore

reconstruction has been challenged as early as 1977 by

Grabb.3 According to the study of Daniel and Faibisoff

in 1982, the normal soft tissue coverage of various pres-

sure points in cadavers and noted the absence of muscle

over the sacrum and trochanter,14 for which Yamamoto

et al. surmised that muscle coverage of pressure points

“violates normal soft-tissue coverage of bony prom-

inences.”15 However, a significant layer of muscle (5.0–

45 mm) has been shown to cover the ischium, although

the muscle slides away on hip flexion in a sitting pos-

ture.14 By this rationale, we believe that muscle flaps

remain necessary for anatomical replacement of deep

ischial pressure ulcers.

With experience and long-term analysis,11 however,

even proponents of fasciocutaneous flaps (long-term out-

come paper) concur that pressure sores with deep ulcer

cavities are the main limitation for its use, especially

with ischial ulcers. Yamamoto claimed against the use of

musculocutaneous flaps, noting that muscles atrophy with

loss of dynamic function, but in his review of 12

patients, a musculocutaneous flap was ultimately used for

salvage of a failed fasciocutaneous flap with deep

Figure 8. Immediately postoperative wound. [Color figure can be

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

com.]





wounds. In the latest cohort of patients of this series, we

recruited the use of musculocutaneous flap, or in select

cases, a muscle flap combined with a fasciocutaneous

flap for pressure sore reconstruction. In this group, most

patients suffered from spinal cord injury contributing to

the formation of ischial sores, where fasciocutaneous

flaps alone did not provide adequate bulk.

Musculocutaneous flap has the effects of bacterial

count reduction and blood flow increase. In a series of

animal studies, Calderon et al. compared in great detail

the hemodynamic features, histological changes, and

bacteriology responses between the musculocutaneous

and fasciocutaneous flaps.16 Detailed statistical analysis

and control measurements revealed significantly

increased blood flow to the undersurface of muscle-

bearing flaps during the first 24 hours, which correlated

with a significantly reduced bacterial count within the

wound bed during this same period in musculocutane-

ous flaps. The effect of decreased bacterial count

remains 30–60 times greater than fasciocutaneous flaps

even at days 3–5. Besides demonstrating the superior

suppression of bacterial proliferation, histological

examination at day 6 showed enhanced fibrous tissue

ingrowth and collagen deposition at the wound bed.16,17

The combination of greater pressure distribution,

enhanced bacterial suppression, and higher tissue

ingrowth represent significant factors in decreasing

short-term complications, improving reconstructive suc-

cess, thus making the musculocutaneous flap an ideal

candidate for reconstruction for deep, potentially

infected pressure sores typically seen in ischial ulcers.

Even with complete muscle atrophy beyond 1–2 years,

we speculate that the established tissue ingrowth com-

bined with fibrotic change of the muscle likely serves

to strengthen the subcutaneous tissue and confers

increased resistance to shear.

The major argument against using musculocutaneous

flap as a first option is the sacrifice of muscle and should

be considered carefully in ambulant patients. However,

re-use of musculocutaneous flaps or the split muscle flap

techniques have been documented.18,19 On the other

hand, muscle atrophy is a significant long-term issue,

results in loss of muscle padding function and may cause

pressure ulcer recurrence. However, this phenomenon

was not shown in our study, possibly owing to a shorter

follow-up period.

Ultimately, in case of huge lumbosacral defect or

recurrent pressure sore without adequate or suitable soft

tissue near the wound for reconstruction, free tissue

transfer such as transverse rectus abdominis myocutane-

ous flap using superior gluteal artery perforator vessel

should be considered.20

The limitations (weaknesses) of this study were small

numbers for each group, different case numbers for each

location of pressure sore, not long enough length of

follow-up, and not all of cases being followed-up long

enough, which made the real complication rate and out-

comes could not compare among different flap recon-

struction in our study. Further study with respect to more

cases recruited and longer follow-up period should be

conducted.

CONCLUSIONS

The complications and flap necrosis rate showed no

statistical significance among perforator flap, rotational

gluteal fasciocutaneous flap, and musculocutaneous flap

in pressure sore reconstruction in our study. The reliabil-

ity of study is not strong enough based on above weak-

nesses. Further investigations are warranted.

REFERENCES

1. Ger R, Levine SA. The management of decubitus ulcers by muscletransposition. An 8-year review. Plast Reconstr Surg 1976;58:419–428.

2. Minami RT, Mills R, Pardoe R. Gluteus maximus myocutaneousflaps for repair of pressure sores. Plast Reconstr Surg 1977;60:242–249.

3. Park C, Park BY. Fasciocutaneous V-Y advancement flap for repairof sacral defects. Ann Plast Surg 1988;21:23–26.

4. Koshima I, Moriguchi T, Soeda S, Kawata S, Ohta S, Ikeda A. Thegluteal perforator-based flap for repair of sacral pressure sores. PlastReconstr Surg 1993;91:678–683.

5. Sameem M, Au M, Wood T, Farrokhyar F, Mahoney J. A system-atic review of complication and recurrence rates of musculocutane-ous, fasciocutaneous, and perforator-based flaps for treatment ofpressure sores. Plast Reconstr Surg 2012;130:67e–77e.

6. Yang CH, Kuo YR, Jeng SF, Lin PY. An ideal method for pressuresore reconstruction. A freestyle perforator-based flap. Ann Plast Surg2011;66:179–184.

7. Lin PY, Kuo YR, Tsai YT. A reusable perfator-preserving glutealartery-based rotation fasciocutaneous flap for pressure sore rcon-struction. Microsurgery 2012;32:189–195.

8. Aoi N, Yoshimura K, Kadono T, Nakagami G, Iizuka S, HigashinoT, Araki J, Koshima I, Sanada H. Ultrasound assessment of deep tis-sue injury in pressure ulcers: Possible prediction of pressure ulcerprogression. Plast Reconstr Surg 2009;124:540–550.

9. Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg 2004;114:910–916.

10. Ahmadzadeh R, Bergeron L, Tang M. The superior and inferior glu-teal artery perforator flaps. Plast Reconstr Surg 2007;120:1551–1556.

11. Yamamoto Y, Tsutsumida A, Murazumi M, Sugihara T. Longtermoutcome of pressure sores treated with flap coverage. Plast ReconstrSurg 1997;100:1212–1217.

12. Nola GT, Vistnes LM. Differential response of skin and muscle inthe experimental production of pressure sores. Plast Reconstr Surg1980;66:728–733.

13. Wong CH, Tan BK, Song C. The perforator-sparing buttock rotationflap for coverage of pressure sores. Plast Reconstr Surg 2007;119:1259–1266.

14. Daniel RK, Faibisoff B. Muscle coverage of pressure points—Therole of myocutaneous flaps. Ann Plast Surg 1982;8:446–452.

552 Kuo et al.


15. Yamamoto Y, Ohura T, Shintomi Y, Sugihara T, Nohira K, IgawaH. Superiority of the fasciocutaneous flap in reconstruction of sacralpressure sores. Ann Plast Surg 1993;30:116–121.

16. Calderon W, Chang N, Mathes SJ. Comparison of the effect of bac-terial inoculation in musculocutaneous and fasciocutaneous flaps.Plast Reconstr Surg 1986;77:785–792.

17. Gosain A, Chang N, Mathes S, Hunt TK, Vasconez L. A study ofthe relationship between blood flow and bacterial inoculation inmusculocutaneous and fasciocutaneous flaps. Plast Reconstr Surg1990;86:1152–1162.

18. Yasser EH. The reusable V-Y advancement gluteus maximus fascio-cutaneous flap in management of sacral pressure sores. Egypt J PlastReconstr Surg 2013;37:125–129.

19. Baran CN, Celebio�glu S, Civelek B, Sens€oz O. Tangentially splitgluteus maximus myocutaneous island flap based on perforatorarteries for the reconstruction of pressure sores. Plast Reconstr Surg1999;103:2071–2076.

20. Gaster RS, Bhatt KA, Shelton AA, Lee GK. Free transverse rectusabdominis myocutaneous flap reconstruction of a massive lumbosac-ral defect using superior gluteal artery perforator vessels. Microsur-gery 2012;32:388–392.



Documents

Comparison of outcomes of pressure sore reconstructions among perforator flaps, perforator-based rotation fasciocutaneous flaps, and musculocutaneous flaps