J Plast Surg Hand Surg, 2013; Early Online: 1–5©2013 Informa HealthcareISSN: 2000-656X print / 2000-6764 onlineDOI: 10.3109/2000656X.2013.792269

ORIGINAL ARTICLE

Dual-dermal-barrier fashion flaps for the treatment of sacral pressure sores

Yen-Chang Hsiao & Shiow-Shuh Chuang

Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taipei,Taiwan

AbstractThe sacral region is one of the most vulnerable sites for the development of pressure sores. Even when surgical reconstruction is performed, there isa high chance of recurrence. Therefore, the concept of dual-dermal-barrier fashion flaps for sacral pressure sore reconstruction was proposed. FromSeptember 2007 to June 2010, nine patients with grade IV sacral pressures were enrolled. Four patients received bilateral myocutaneous V-Y flaps,four patients received bilateral fasciocutaneous V-Y flaps, and one patient received bilateral rotation-advanced flaps for sacral pressurereconstruction. The flaps were designed based on the perforators of the superior gluteal artery in one patient’s reconstructive procedure. Allflaps’ designs were based on dual-dermal-barrier fashion. The mean follow-up time was 16 months (range = 12–25). No recurrence was noted.Only one patient had a complication of mild dehiscence at the middle suture line, occurring 2 weeks after the reconstructive surgery. Thedual-dermal fashion flaps are easily duplicated and versatile. The study has shown minimal morbidity and a reasonable outcome.

Key Words: Pressure sore, flap

IntroductionThe disastrous progression from excessive pressure and sheerforce on the sacrum results in irreversible ischaemia and tissuenecrosis. Then a sacral pressure sore is developed. The sacralregion is one of the most vulnerable sites for the development ofpressure sores. Whether using conservative treatments or sur-gical interventions, cooperation among multiple disciplinarydepartments is crucial to treat pressure sores. Using either localflaps, myocutaneous flaps, or fasciocutaneous flaps for sacraldefect reconstruction has been documented and published whensurgical closure is needed once conservative treatments fail.However, even after surgical reconstruction, there is a 16%chance of recurrence.

Because pressure and sheer force after prolonged immobilisa-tion are the primary causes of pressure sores, it is very importantto have a strong tissue barrier to resist them. Therefore, dual-dermal-barrier flaps for sacral pressure sore reconstruction wereproposed. The application of this technique is duplicable andversatile. This technique is also easily applied to the bilateralfasciocutaneous V-Y flaps and bilateral musculocutaneousV-Y flaps. In addition, reasonable outcomes without recurrenceand long-lasting protection of the sacral area can be achieved.

Patients and methodsFrom September 2007 to June 2010, nine patients with sacralpressure sores were enrolled. Five patients were female. Allpatients sustained grade IV ulcers. Six cases were paraplegicafter traumatic injuries. Others experienced prolonged bed-ridden status due to various reasons including medical disease,strokes, etc.

Operative techniqueThe patients were placed in a prone position after receivinggeneral anaesthesia. All devitalised tissue and necrotic boneswere debrided until viable tissue was reached. The prominentportion of the sacrum were trimmed and smoothed. Contractiveand unhealthy wound margins were excised. Hence, relativelylarger lesions were created after debridement (Figure 1). Next,the sizes of the new wounds were measured again. All flaps’designs were based on the dual-dermal-barrier fashion. Inaddition, various designs of bilateral gluteal flaps wereperformed including bilateral myocutaneous V-Y flaps,bilateral fasciocutaneous V-Y flaps, and bilateral rotation-advancement flaps.

Based on dual-dermal-barrier fashion, de-epithelialisationof a strip of flap was undertaken (Figure 2). The width of thestrip depended on the width of the prominent sacrum. Theaverage was 2 cm. Then, the flap with a de-epithelialised stripwas pulled down underneath the opposite flap. Two flaps’dermal layers were placed overlapping, respectively, andsutured together tightly to form a dual-dermal-barrier(Figure 3). Above, dual-dermal-barrier tissue blocks wereplaced centrally just above the sacral bone after advancementor rotation of the bilateral flaps (Figure 4). If the flaps weredesigned as myocutaneous flaps, the muscular part of the flapswere used to fill the dead space inside the wounds. Thecirculation of flaps was checked after closing the wounds.Finally, two suction drains were inserted, respectively(Figure 5). Postoperatively, the size of the defects, size offlaps, characteristics of flaps, blood loss, operative time, com-plications, and admission days were documented carefully.

Correspondence: Shiow-Shuh Chuang, MD, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College ofMedicine, Chang Gung University, 5, Fu-Hsing Street, Kweishan, Taoyuan 333, Taiwan. Tel: +886 3 3281200 Ext. 3355. Fax: +886 3 3287260.E-mail: nosehsiao@gmail.com(Accepted 28 November 2012)

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ResultsNine patients were enrolled. The mean age of the patientswas 53 years (range = 28–70). The mean follow-up time was16 months (range = 12–25). The mean size of the lesion was6.3� 4.8 cm (range = 5� 4 cm–8� 6 cm). All flaps were basedon dual-dermal-barrier fashion. Four patients received bilateralmyocutaneous V-Y flaps, four patients received bilateral fas-ciocutaneous V-Y flaps, and one patient received bilateralrotation-advanced flaps for sacral pressure reconstruction.The flaps were designed based on the perforators of the superiorgluteal artery in one patient’s reconstructive procedure.

At the beginning, flaps of the same size were designed fortwo patients, with a mean size of 9 � 7.5 cm. It resulted in anuneven scar over the bilateral gluteal areas after doing a de-epithelialisation strip. A refinement design was done due to theabove bias. Two flaps were designed of different sizes in orderto preserve a strip of flap of 2 cm width for the following de-epithelialisation. The larger flap, with de-epithelialisation, waspulled under the opposite, smaller flap. As a result, symmetricalscars over the bilateral buttock could be achieved. After refinedadjustment, the mean size of the V-Y flaps was 9.9 � 7.6 cmand 8.7 � 7.6 cm, respectively (range 9 � 8 cm–12.5 � 8 cmand 7 � 8 cm–11 � 8 cm). Average operative time was220 minutes (range = 170–240). Blood loss was minimal.One patient had a complication of mild dehiscence at the middlesuture line 2 weeks after the reconstructive surgery. The meanadmission period at the ward was 13.2 days (range = 10–19). Norevision procedures were needed. The results were durable andsustainable.

Case reportsCase 1.A 52-year-old woman suffered from lower-limbs paralysis aftera tumour resection at the spinal cord. A 7 � 5 cm, grade IV

pressure sore was noted due to poor rehabilitation and ambu-lation. A new, healthy wound, 8 � 6 cm in size, was createdafter adequate debridement. Resection of the prominent part ofthe sacrum was undertaken. Two myocutaneous V-Y flapsbased on superior gluteal artery perforators were harvested.The left flap was 12.5 � 8 cm in size, and the right one was10 � 8 cm in size. A 2 � 6 cm strip of skin at the medial part ofleft flap was de-epithelialised. Then, it was pulled down under-neath the right one. The overlapping dermis was pulled togetherby Dexon 2-0 sutures, and the sturdy overlap area was movedjust above the sacrum bone. The flaps’muscular parts were usedto seal off the dead space. The flaps were fixed carefully afteradvancement. Finally, two suction drains were inserted(Figure 6). The circulation of the flaps was satisfactory afterclosing the wounds.

There was no recurrence of sacral pressure sores in thefollowing 16 months. The patient was satisfied with the smoothhealing process of the pressure sore and the symmetrical scarsover the bilateral buttocks. Even the cleavage of the buttockswas built.

Case 2.A 58-year-old man who had a history of heart failure wasbedridden for a long period due to a previous stroke attack.A grade IV, 4 � 3 cm sacral pressure sore was noted. Theprevious bilateral V-Y myocutaneous flaps had been done atanother hospital. However, recurrence was noted 1 month later.Devitalised tissue was removed and the unhealthy woundmargin was trimmed. Then a clear wound, 5 � 4 cm in size,was created after excising the margins of the ulcer. The bonyprominence of the sacral bone was flattened. Two rotation-advancement myocutaneous flaps from the bilateral buttockswere designed. A wedge shaped, 4 � 3 cm section of skin was

Figure 1. Contractive and unhealthy wound margins were excised, andrelatively larger and clear lesions were created after debridement.

Figure 2. De-epithelialisation of a strip of flap was done.

Figure 3. The flap with a de-epithelialised strip was pulled downunderneath the opposite flap. Two flaps’ dermal layers were placedoverlapped and sutured together tightly to form a dual-dermal-barrier.

Figure 4. Dual-dermal barrier tissue block was placed centrally justabove the sacral bone after advancement or rotation of the bilateralflaps.

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de-epithelialised at the right flap. The dual-dermal barrier fash-ion was also applied (Figure 7). The operative time was170 minutes. Unfortunately, the patient suffered from pulmo-nary oedema and respiratory failure after the operation due to a

flare up of the heart failure. The patient had intubation withmechanical ventilation support for 2 weeks. The patient’sambulation was restricted during that period because of theunstable cardiopulmonary situation. Superficial skin dehiscencewas later found. Dehiscence was intentionally left as secondaryhealing after the patient’s general condition became stable.There was no recurrence of sacral pressure noted after the minorcomplication.

DiscussionA pressure sore is an unpleasant result of the impact of externalsheer force and pressure on soft tissue with an underlying bonyprominence [1]. The principle of reconstruction of sacral

Figure 5. The circulation of flaps was checked after closing thewounds.

Figure 6. Bilateral myocutaneous V-Y flaps based on superior glutealartery perforators with the dual-dermal-barrier fashion were designedto treat the sacral pressure sore.

Figure 7. Bilateral rotation-advancement myocutaneous flaps with thedual-dermal-barrier fashion were designed for the treatment of therecurrent sacral pressure sore.

Dual-dermal-barrier fashion flaps 3

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pressure sores should be strictly based on the plastic recon-structive ladders. Local flaps over the gluteal region are the firstand most reliable choice for reconstructing sacral ulcers [2-7].

The recurrent rate of the sacral pressure sores after flapreconstruction is ~ 16%–20% [5]. Theoretically, the dermishas relatively higher mechanical resistance than muscle andfascia. Traditionally bilateral V-Y flaps or bilateral rotation-advancement flaps were used to close sacral defects with onlyone fragile dermal barrier. Therefore, it is difficult to resist thesheer force and pressure over the sacral bony part. As a result,high recurrence of the pressure sore was noted inevitably. Incontrast, the dual-dermal-barrier fashion offers flaps that arerelatively durable and sturdy barriers through its overlappingdermal layers. Therefore, the dual-dermal-barrier fashion hasstronger resistance to the sheer force and the friction of the skinthan the traditional single-dermal-barrier fashion. In addition,the central part of the flaps is very vulnerable, and it is usuallyjeopardised by the prominent sacral bone. This is usually a weakpoint that results in failure of treatment. To avoid the aboveproblem, the territory of dual-dermal-barrier fashion is designedat the central part of the bilateral flaps and is carefully settledover the sacral bone. Because of the above extremely sturdyprotection, none of the patients developed recurrence inour series.

Fasciocutaneous flaps are less sensitive to ischaemia andhave more mechanical resistance to pressure than myocutaneousflaps [5]. In contrast, the mainstay of myocutaneous flaps is usedto seal off the dead space within the ulcers. Hence, they aresuitable for relatively deep and large ulcers, but show someatrophic degeneration [6,8,9]. Furthermore, even though muscleunder skin can diffuse pressure and lessen incidence of ulcer-ation, the extremely high incidence of muscle necrosis inresponse to pressure can still be found. As a result, muscle isan unsuitable coverage for a pressure-bearing area [10]. Theversatile application of the dual-dermal-barrier fashion can beused in various situations and the variations in flaps’ designsdepend on different conditions of ulceration at the sacrum. Themyocutaneous flaps were designed for the big dead space in thewounds and the shallow defects can be covered by the fascio-cutaneous flaps. The dual-dermal-barrier fashion can enhancethe effects of all flaps’ reconstruction. In addition, this fashioncan be converted to any kind of flaps including bilateralV-Y flaps, bilateral rotation advanced flaps, bilateral superiorgluteal artery perforator flaps, and inferior gluteal arteryperforator flaps [11]. Various flaps’ designs combined withthe dual-dermal-barrier fashion can be individualised andmodified according to various complicated wounds.

In terms of other advantages, because the dual-dermal-barrierfashion must combine with bilateral flaps from both the rightand left buttocks, the tension of wound closure is relatively lessthan the unilateral flap either from left or right buttocks. Thesurgical time of performing bilateral gluteal flaps based on thedual- dermal-barrier fashion was ~ 220 minutes in our study,with no obvious difference between the traditional bilateral localflaps from the gluteal area. It does not deteriorate or compromisepatients’ postoperative recovery and early rehabilitation.

The additional benefit of dual-dermal-barrier flaps is theaesthetic concerns. Even though the patients with pressure soreswere relatively older, we still had some patients with sacral

pressure sores due to temporarily poor ambulation and poorpostoperation wound care. Furthermore, surgical coverage totreat pressure sores in non-paralyzed persons helped to reducethe morbidity and mortality after surgery [12]. Because most ofthe patients were conscious, they were still concerned abouttheir body figure whenever they recovered from the illness. Thedual-dermal-barrier fashion offers better-looking buttocks byproviding a pleasing gluteal cleavage rather than the traditionalbilateral gluteal flaps (Figure 8). It is no longer a bizarre patch atthe sacrum. Instead, by using this fashion, the overlapping flapscan create a natural cleavage figure, leaving more symmetricalscars over the bilateral buttocks.

There are also some disadvantages of the above fashion. Inthe patients have large sacral pressure sores, there will be moretension on the wound margin in order to keep at least 2 cm dual-dermal strip whenever the dual-dermal fashion was applied. Insuch patients, shifting to use traditional bilateral V-Y flaps wasbetter in order to prevent complications. Therefore, precisepreoperative evaluation and selection of adequate surgicalprocedures are the keys to sacral pressure sore repair.

In conclusion, the dual-dermal fashion flaps are easilyduplicated and versatile. The study has shown minimalmorbidity and a reasonable outcome.

Declaration of interest: The authors report no conflicts ofinterest. The authors alone are responsible for the contentand writing of the paper.

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[4] Yamamoto Y, Ohura T, Shintomi Y, et al.et al. Superiority of thefasciocutaneous flap in reconstruction of sacral pressure sores.Ann Plast Surg 1993;30:116–21.

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[8] Thiessen FE, Andrades P, Blondeel PN, et al.et al. Flap surgeryfor pressure sores: should the underlying muscle be transferredor not? J Plast Reconstr Aesthet Surg 2011;64:84–90.

Figure 8. A gluteal cleavage was created.

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[10] Nola GT, Vistnes LM. Differential response of skin and musclein the experimental production of pressure sores. Plast ReconstrSurg 1980;66:728–33.

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[12] Gusenoff JA, Redett RJ, Nahabedian MY. Outcomes for surgicalcoverage of pressure sores in nonambulatory, nonparaplegic,elderly patients. Ann Plast Surg 2002;48:633–40.

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