Ischial pressure sore reconstruction using an inferior gluteal artery perforator (IGAP) flap 83

British Journal of Plastic Surgery (2002) �9 2002 The British Association of Plastic Surgeons doi: 10.1054/bjps.2001.3713

Ischial pressure sore reconstruction using an inferior gluteal artery perforator (IGAP) flap

J. R Higgins, G. S. Orlando and P. N. Blondeel*

Division of Plastic Surgery, University of Rochester, Rochester, NY, USA; and *Department of Plastic and Reconstructive Surgery, University Hospital Gent, Belgium

SUMMARK Perforator-flap technique has revolutionised the practice of free tissue transfer with the goal of muscle sparing for function and strength. These concepts are being widely explored for breast reconstruction. The field of pressure-sore reconstruction presents a new application for this technique, preserving muscle for function in ambulatory patients and for future reconstruction in paraplegic patients. Just as the superior gluteal artery perforator flap holds promise for sacral and trochanteric reconstruction, the inferior gluteal artery perforator flap may provide a muscle- sparing alternative for ischial reconstruction. A case report of the successful use of an inferior gluteal artery perforator flap for ischial pressure-sore reconstruction is described, including the surgical technique employed for flap harvest, and 2 year's follow-up. �9 2002 The British Association of Plastic Surgeons

Keywords: perforator flap, pressure-sore reconstruction, inferior gluteal artery perforator flap.

The emergence of free tissue transfer as a reliable and re- producible means of soft-tissue reconstruction has ushered in a period of rapid advancement in the technology and techniques of reconstructive surgery. Perforator surgical technology is among these advances, providing reliable soft-tissue reconstruction with less donor-site morbidity.~-3

While perforator-flap techniques have primarily been applied in the field of breast reconstruction, 4,5 applications of this technique in pressure-sore recon- structive surgery have also been introduced. 6,7 The dissec- tion of parasacral perforators through the underlying gluteus maximus muscle bed to the superior gluteal artery pedicle has been described. The technique spares muscle by dissecting longitudinally between the fibres. An island fasciocutaneous flap is thus mobilised on a long pedicle for coverage of sacral and trochanteric pres- sure sores.

We present a case of a new perforator flap used to cover an ischial pressure sore. The dissection of a lateral perforator down to the origin of the inferior gluteal artery permits harvest of a well-vascularised fasciocutaneous perforator flap on a lengthy pedicle. This flap can be interpolated beneath the inferior margin of the intact glu- teus maximus muscle to provide hearty soft-tissue cover- age for the ischial region with minimal donor-site morbidity. This represents new donor and recipient sites for the application of this technique.

Case report

A 62-year-old retired industrial chemist suffered a fall 2 years ago that left him paralysed at the T6 level. After spending much of his time seated at a computer, he presented with a stage 4 left ischial pressure sore. After minor bedside and dressing debride- ment, his wound was ready for reconstruction.

Preoperatively, the patient underwent a unidirectional Doppler flowmetry examination of his inferolateral gluteal region to iden- tify and mark all perforators of the inferior gluteal artery. This provided us with 13 markings to guide our dissection (Fig. 1).

Intraoperatively, the dissection was diagrammed with the patient in the prone position. The landmarks of the posterior superior iliac spine, the greater trochanter and the ischial tuberosity were identified. The approximate locations of the superior gluteal artery and the inferior gluteal artery were marked. The inferior gluteal artery was located along a line connecting the posterior superior iliac spine and the ischial tuberosity, at approximately the inferior border of the piriformis muscle. A skin paddle was fashioned to incorporate many of the lateral perforators of the inferior gluteal artery in an elliptical fashion. This was done in a vertical orientation to permit pri- mary closure of the wound and to locate the healing incision away from the major pressure points of the gluteal region.

The flap was raised at the level of the gluteus maximus muscle fascia, and several viable perforators were encountered. The single largest of these was dissected carefully through the gluteus maximus muscle bed, taking care to split the muscle in the direction of the fibres, keeping them intact. All side branches of the perforator were clipped, allowing the dissection to con- tinue down to the passage of the inferior gluteal artery inferior to the piriformis muscle. The 7 cm pedicle permitted passage of the island flap under the intact inferior strip of gluteus maximus

Figure 1--Preoperative stage IV ischial pressure sore. PSIS: posterior superior iliac spine; SGA: superior gluteal artery; IGA: inferior gluteal artery; TROCH: greater trochanter.

84 British Journal of Plastic Surgery

Figure 2--Intraoperative passage of the inferior gluteal artery perfora- tor flap under the inferior margin of the intact gluteus maximus muscle and into the defect.

Figure 3--View 23 months postoperatively, showing no breakdown or recurrence. Note the position of the scars away from the pressure points.

muscle and into the defect, while rotating it 30 ~ on its pedicle (Fig. 2). The total operative time was 4h. All dissection was performed under 3.5 x loupe magnification.

The patient underwent an uneventful postoperative course with no anticoagulation therapy but with a 10 day course of postoperative antibiotics. The postoperative photograph shows a well-healed wound without recurrence 23 months after recon- struction (Fig. 3).

Discussion

Reconstructive surgery for pressure-sore defects presents a difficult challenge because of the high rates of wound complications and recurrence. Myocutaneous advance- ment flaps have been considered the standard first-line treatment for pressure sores that fail conservative therapy. The addition of muscle to the fasciocutaneous closure is thought to make successful repair more likely because of the bulk of the flap and its inherently rich blood supply.

This assumption was challenged by Kroll and Rosenfield. 6 Confronted with low midline and sacral

wounds generally reconstructed using myocutaneous flaps, they used superiorly based fasciocutaneous flaps over preserved large parasacral perforators. Koshima et al further advanced this concept into the current era of per- forator surgery by dissecting these parasacral perforators down to the superior gluteal artery in a series of seven patients. 7 They dissected along muscle-sparing planes longitudinally. The lengthy pedicle enabled them to cover trochanteric and ischial pressure sores. They suspected that these new flaps carried as rich a blood supply as their myocutaneous counterparts because of the intact perforators. Anatomic studies have confirmed that these vessels supply a thick hearty flap of local tissue, with well-vascularised skin in a large angiosome/

This patient presented a challenge for the application of perforator techniques because the location of the defect was ischial. The superior gluteal artery perforator flap was described for sacral and trochanteric ulcers, and its pedicle is insufficient to reach the ischial region. The flap can be mobilised along the axis of the spared supe- rior gluteus maximus muscle fibres, which enables it to cover sacral and trochanteric wounds well. In order to address this ischial wound and to spare muscle for future use, we chose to design a flap based on the inferior gluteal artery perforators. This was elevated through the inferior gluteus maximus muscle, interpolated under the narrow strip of inferior border of the muscle and inset without tension into the wound. The application of perforator-flap techniques to pressure-sore reconstruction yields three major advantages: preservation of muscle, conservation of future reconstructive options and the placement of suture lines away from pressure-laden prominences.

Preservation of muscle for functional purposes is a consideration only in the ambulatory population. While the functional deficit from muscle harvest for other reconstructive procedures (i.e. TRAM flap harvest) has been well examined, 2-4 the impact of partial gluteus max- imus muscle sacrifice still requires investigation. Until this is further elucidated, muscle sparing should always be a goal in the ambulatory and sensate patient, as it may prevent some functional loss and potentially reduce post- operative pain. Muscle sparing should be considered in paraplegic patients as well. Sacrifice of underlying muscle is required in the inferior gluteal myocutaneous rotation flap, a commonly used means of ischial recon- struction in these patients. The donor-site dissection requires closure over the dead space created by the disin- serted muscle. We have observed that this site is a common site of postoperative wound breakdown after this recon- struction. The perforator counterpart permits tension-free donor-site closure over an intact muscle bed.

Myocutaneous flaps for ischial reconstruction often leave readvancement of the failed flap as the only means of addressing recurrence. The inferior gluteal artery per- forator flap spares all muscle and myocutaneous flaps for future use, if required.

The inferior gluteal artery perforator flap, like the superior gluteal artery perforator flap, is also superior to the standard ischial myocutaneous flaps in terms of the location of the skin island harvest and the placement of the suture line. The redundancy of the local tissue

Porcine dermal collagen graft in abdominal-wall reconstruction 85

permits primary tension-free closure. Furthermore, the inferior gluteal artery perforator flap creates a healing wound away from pressure points, its course tracking obliquely between the ischium and the trochanter. The common V-Y flap creates a healing scar on the offending pressure point, increasing the likelihood of breakdown.

References

1. Blondeel PN, Boeckx WD, Vanderstraeten GG, et al. The fate of the oblique abdominal muscles after free TRAM flap surgery. Br J Plast Surg 1997; 50: 315-21.

2. Blondeel PhN, Vanderstraeten GG, Monstrey S J, et al. The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg 1997; 50: 322-30.

3. Feller A-M. Free TRAM: results of abdominal wail function. Clin Plast Surg 1994; 21: 223-32.

4. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 1994; 32: 32-8.

5. Allen RJ, Tucker C Jr. Superior gluteal artery perforator free flap for breast reconstruction. Plast Reconstr Surg 1995; 95: 1207-12.

6. Kroll SS, Rosenfield L. Perforator-based flaps for low posterior midline defects. Plast Reconstr Surg 1988; 81: 561-6.

7. Koshima I, Moriguchi T, Soeda S, Kawata S, Ohta S, Ikeda A. The gluteal perforator-based flap for repair of sacral pressure sores. Plast Reconstr Surg 1993; 91: 678-83.

8. Salmon M. The lower limb. In Taylor GI, Tempest M, ed. Arteries of the Skin. London: Churchill Livingstone, 1988: 35.

The Authors

James P. Higgins MD Greg S. Orlando MD, Assistant Professor

Division of Plastic Surgery, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642, USA.

Phiilip N. Blondeel MD, Associate Professor

Department of Plastic and Reconstructive Surgery, University Hospital Gent, De Pintelaan 185, B-9000 Gent, Belgium.

Correspondence to James Higgins MD, 4816 Clairelee Drive, Owings Mills, Maryland 21117, USA.

Paper received 9 May 2001. Accepted 21 September 2001, after revision.

British Journal of Plastic Surgery (2002) �9 2002 The British Association of Plastic Surgeons doi: 10.1054/bjps,2001.3711

Porcine dermal collagen graft in abdominal-wall reconstruction

O. A. Adedeji, C. A. Bailey and J. S. Varma

Coloproctology Unit, Department of Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, UK

SUMMARY. We describe the use of a porcine dermal collagen graft in the reconstruction of a large abdominal-wall defect in a woman. The graft was not rejected and, after 1 year, was not associated with incisional hernia. This graft may become an alternative to synthetic-mesh and flap reconstructions because, despite being of a similar tensile strength, it promotes less adhesion, is incorporated into the host tissue and is less prone to infection. �9 2002 The British Association of Plastic Surgeons

Keywords: porcine dermal collagen graft, abdominal-wall reconstruction.

Synthetic materials and myocutaneous flaps are well doc- umented for the reconstruction of large defects of the abdominal wall? ,2 Wound infection and chronic sinus for- mation are particular problems of synthetic materials, 2 and flap necrosis is a problem of myocutaneous flaps. I Experimental studies in animals have shown that xenogenic collagen implants can be used instead of the traditional methods, without the associated specific com- plications. 3.4 We report the case of a patient who under- went anterior abdominal-wall reconstruction using a porcine dermal collagen graft (Permacol, Tissue Science Laboratories, Hampshire, UK), for the treatment of a large abdominal-wall defect secondary to sepsis and abdominal wound dehiscence.

Case report

A 69-year-old woman with a body mass index of 30 kg m -2 was admitted with large bowel obstruction secondary to

rectosigmoid diverticular stricture. At emergency laparotomy, a Hartman's procedure was performed, after bowel decompres- sion through a caecostomy, which was closed. She developed a colocutaneous fistula through her wound 5 days later, and the wound dehisced on the ninth postoperative day. At her second laparotomy, a patent caecostomy was found, and this was closed around a Foley catheter and brought out through the lower end of her abdominal wound. Oedema and her body habitus precluded bringing out the tube caecostomy through a separate wound. Unfortunately, her wound dehisced again, with the breakdown of the tube caecostomy, a few days later. At the third laparotomy, the caecostomy was sutured, and, because of a marked deficiency in the abdominal wall, a temporary polypropylene mesh containing an Ethizip was sutured to the edge of the abdominal wall.

The temporary wound cover was removed 8 days after the third laparotomy. The caecostomy remained closed, and defini- tive wound closure was undertaken. The abdominal-wall defect was closed using a porcine dermal collagen graft, suturing eight