Modification of the superior gluteal artery perforator flap for reconstruction of sacral sores

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  • Modification ofperforator flapsores

    Chin-Ta Lin, Shun-ChYuan-Sheng Tzeng*



    KEYWORDSSuperior gluteal

    Summary Background: Despite advances in reconstruction techniques, the treatment ofsacral sores remains challenging to plastic surgeons. The superior gluteal artery perforator

    er, dissection of the perforator is tedious and may compromise the perforator vessels.fied flap-harvestingdissection to cover

    30 sacral defects. Patient characteristics including sex, age, cause of sacral defect, flap size,perforator number, use and postoperative complications were recorded.

    sis and were finallyllow-up period wasrecurrence of sacral

    onstructive surgeryThe advantages ofg and lesser pedicleverage.eons. Published by

    * Corresponding author. Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, NationalDefense Medical Center, No. 325, Section 2, Cheng-Gung Road, Taipei 11490, Taiwan. Tel.: 886 2 87927195; fax: 886 2 87927194.

    E-mail address: (Y.-S. Tzeng).

    1748-6815/$-seefrontmatter2013BritishAssociationofPlastic,ReconstructiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

    Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) 67, 526e532Results: All flaps survived except two, which developed partial flap necrotreated by contralateral VeY advancement flap coverage. The mean fo14.8 months (range, 3e24 months). No flap surgery-related mortality orpressure sores or infected pilonidal cysts were noted.Conclusions: Perforator-based flaps have become popular in modern recbecause of low donor-site morbidity and good preservation of muscle.our modification procedure include shorter operative time, lesser bleedintrauma, which make the SGAP flaps an excellent choice for sacral sore co 2013 British Association of Plastic, Reconstructive and Aesthetic SurgElsevier Ltd. All rights reserved.Sacral sore;Reconstruction Methods: Between April 2003 and March 2013, we performed two modi

    techniques: a rotational and a tunnel method, with only a short pedicleartery perforatorflap;

    (SGAP) flap is reliable and preserves the entire contralateral side as a future donor site. Theipsilateral gluteal muscle is preserved, and the inferior gluteal artery flaps are viable. Howev-Division of Plastic and RecoNational Defense Medical C

    Received 11 October 2013; athe superior gluteal arteryfor reconstruction of sacral

    eng Chang, Shyi-Gen Chen,

    tive Surgery, Department of Surgery, Tri-Service General Hospital,Taipei, Taiwan

    d 21 December 2013

  • rtee dller, as su

    SGAP flap for reconstruction of sacral sores 527Reconstructing a sacral defect caused by pressure sores orinfected pilonidal cysts is a common problem for surgeons.Many surgical methods have been used to correct sacralsores, including primary closure, skin grafting, local randomflaps and muscle flaps. Muscle and myocutaneous flaps havebeen used successfully for pressure sore coverage1 and arethe choice treatment for pressure sores because they pro-vide excellent blood supply and durable coverage.Conversely, limited shifting capacity, excessive blood loss

    Figure 1 Stages of the operation using the superior gluteal aemerges at the junction of the middle and medial thirds of a linlateral border of the greater trochanter. (B1) The defect is sma(C1) The flap is sutured into the defect by tunnelling the pediclethe SGAP flap is designed to just close the defect. (C2) The flap ias the pivot point, and the donor site is closed primarily.and sacrifice of the muscle are the major drawbacks of thisprocedure.1e3

    The superior gluteal artery perforator (SGAP) flap pro-vides a considerable amount of tissue with good vascularityto cover large sacral pressure sores in one stage and doesnot compromise the vascularity or innervation of the un-derlying gluteus maximus muscle.4 During SGAP flap har-vesting, meticulous dissection of the pedicle is required,which can be time consuming and tedious and requires goodtechnical skill. To shorten the learning curve and to makethe SGAP flap procedure simpler and faster to perform, wemade two modifications. First, we modified the flap designby using either a rotational or a tunnel method dependingon the size of the defect. Second, we performed a shortpedicle dissection without skeletonisation to prevent vesseltrauma and to shorten operative time. Here, we report ourexperience of the successful reconstruction of sacral pres-sure sores using this modified SGAP flap technique.

    Vascular anatomy

    The superior gluteal artery (SGA) arises from the internaliliac artery with a deep branch to the gluteus mediusmuscle, which then runs through the gluteus maximusmuscle and ends at the cutaneous arteries located mainly inthe superolateral gluteal region. The SGA can be marked onthe skin of the buttock at one-third of the way on a linedrawn from the posterior superior iliac spine to the top ofthe greater trochanter (Figure 1). The piriformis muscle islocated on the skin of the buttock at a line drawn betweenthe greater trochanter and a point half way to the sacrum.Perforators can be found in the area lateral to the SGA andabove the piriformis muscle.4 In 1993, Koshima describedthe anatomy of the SGA perforator.5 The length of the

    ry perforator (SGAP) flap. (A) Anatomical landmarks: the SGArawn between the posterior superior iliac spine (PSIS) and theand comprises a skin strip between the defect and SGAP flap.

    nd the donor site is closed primarily. (B2) The flap is larger, andtured into the defect by rotating the SGAP flap with the pediclevessels varies from 3 to 8 cm and their diameters rangefrom 1 to 1.5 mm. These flaps can be nourished even withonly one perforator. In the cases of this study, the largestSGAP flap with one perforator was 12 14 cm.

    Patients and methods

    Between April 2003 and March 2013, 30 patients underwentsurgery for sacral sores using SGAP flaps, out of which 17were men and 13 were women, and their mean age was79.8 years (range, 22e92 years). The flap size ranged be-tween 7 6 cm and 12 14 cm. The length of the pedicledissection was determined by the arc of movement of theflap. For all operations, the length of the perforatordissection did not exceed 1 cm. All defects were grade III orIV pressure sores located over the sacral region classifiedaccording to Sheas classification6 and infected pilonidalcysts. A total of 30 SGAP flap procedures were performed.The mean follow-up period was 14.8 months. Patient dataare given in Table 1.

    Surgical procedure

    The patient was placed in the prone position, theanatomical landmarks were drawn, and the SGA and its

  • l defect, flap size, perforator number, utilisation, outcome, and

    ize (cm2) Perforatornumber

    Utilisation Outcome Follow-upperiod (m)

    1 Rotation Good 241 Rotation Wound edge


    1 Tunnel Good 121 Tunnel Good 181 Tunnel Good 242 Tunnel Good 121 Tunnel Partial flap


    1 Tunnel Good 181 Tunnel Good 121 Rotation Good 121 Tunnel Good 181 Rotation Good 241 Rotation Good 12

    528 C.-T. Lin et al.Table 1 Characteristics of patients age, sex, cause of sacrafollow-up period.

    Patient Sex/age(year)

    Cause of sacral defect Flap s

    1 M/22 Infected pilonidal cyst 1682 M/28 Infected pilonidal cyst 108

    3 M/48 Oral cancer, bed ridden 424 M/55 Laryngeal cancer, bed ridden 725 M/62 ICH, bed ridden 566 F/66 ICH, bed ridden 607 M/68 Stroke, bed ridden 45

    8 F/72 Dementia, bed ridden 609 M/73 Stroke, bed ridden 9610 F/73 Stroke, bed ridden 10811 M/75 Dementia, bed ridden 7212 M/75 Stroke, bed ridden 9013 M/76 Stroke, bed ridden 165perforators were identified using unidirectional Dopplerultrasound. The SGA perforators are situated mainly aroundthe junction of the middle and medial third of the linedrawn between the posterior superior iliac spine and thegreater trochanter.4 A template of the defect was drawn ona sterile, exposed radiograph, which helped ensure theaccurate size and shape of the recipient site and donortissue. The flap template was placed on the perforatormark; the skin paddle was designed with an extra 0.5 cmwidth around the margin of the template to ensure that theflap had sufficient skin to cover the defect without tension.To cover a smaller sacral sore (usually 8 cm in diameter), or when a bilateral conventionalVeY flap was considered, the SGAP flap was designed toclosely fit the defect. The defect was covered by a rota-tional SGAP flap (Figure 1). Figure 2 shows the algorithm forour surgical reconstructive plan.

    14 F/77 Stroke, bed ridden 117 1 Rotation Good 1215 F/79 Stroke, bed ridden 42 1 Tunnel Wound edge


    16 F/80 Stroke, bed ridden 42 2 Tunnel Good 1817 M/80 Stroke, bed ridden 84 1 Tunnel Good 1218 F/81 Stroke, bed ridden 42 1 Tunnel Good 2419 F/82 Parkinsons disease, bed ridden 70 2 Tunnel Good 1820 M/83 Parkinsons disease, bed ridden 136 1 Rotation Good 1221 F/83 Stroke, bed ridden 56 1 Tunnel Good 1822 M/83 Stroke, bed ridden 56 2 Tunnel Good 1223 M/87 Dementia, bed ridden 42 1 Tunnel Good 2424 F/88 Dementia, bed ridden 56 1 Tunnel Good 1225 F/89 Dementia, bed ridden 63 2 Tunnel Good 1226 M/92 Stroke, bed ridden 154 2 Rotation Good 627 F/83 Leukaemia, bed ridden 80 1 Tunnel Good 628 M/50 ICH, bed ridden 88 1 Rotation Wound edge


    29 F/72 HIVD, bed ridden 117 1 Rotation Partial flapnecrosis


    30 M/78 Dementia, bed ridden 120 2 Rotation Good 3

    ICH: intracranial haemorrhage, HIVD: herniated intervertebral disc.

    Figure 2 The algorithm for our surgical reconstructive plan.

  • dissection. Once the vessel was located, the inferior border

    SGAP flap for reconstruction of sacral sores 529Results

    A total of 23 flaps had one SGA perforator, whereas sevenflaps had two perforators. None of the patients requiredconversion to a myocutaneous rotation flap. All flaps sur-vived, although venous congestion was common immedi-ately following surgery. A total of 19 SGAP flaps (patients 3,4, 5, 6, 7, 8, 9, 11, 15, 16, 17, 18, 19, 21, 22, 23, 24, 25 and27) were sutured into the defect by tunnelling the pedicles,and the other flaps (patients 1, 2, 10, 12, 13, 14, 20, 26, 28,29 and 30) were sutured into the defect by rotating theflap. Because of short pedicle dissection, all SGAP flapswere elevated within 1 h. Two flaps developed partial ne-crosis and were treated by contralateral VeY advancementflap coverage. Three patients developed minor complica-tions of partial dehiscence of the wound edge, which weremanaged by delayed primary closure. All donor sites wereclosed primarily and healed without any complication. Norecurrence was observed during the follow-up period(mean, 14.8 months; range, 3e24 months).

    Case report

    Case 9

    A 73-year-old man with a history of stroke was referredwith a sacral grade IV pressure sore. After debridement, anSGAP flap measuring 8 12 cm with one perforator wasmoved into the defect beneath the skin strip and insetof the flap was incised, and the flap was detached from themuscle to form an island flap. This island flap was trans-posed into the defect by tunnelling the pedicle or byrotating the flap approximately 180, as shown in Figure 1.Regardless of the method used, the length of the pedicledissection never exceeded 1 cm because of the vascularanatomy of the SGAP, which lay adjacent to the sacral re-gion. All donor sites were closed primarily. We preferred tofirst close the donor site to reduce the tension between theflap and the defect. Suction drainage was applied under theflap and in the donor area until

  • Figure 3 (A) Planning of an 8 cm 12 cm SGAP flap for a 7 cm 11 cm sacral pressure sore coverage. (B) The SGAP flap wasraised on one perforator. Note that the pedicle was still encased in its fibrous septum and the pedicle length did not exceed 1 cm.(C) The flap was tunnelled into the defect from the flap donor site, and the thickness of subcutaneous fat provided ample length totunnel the flap to the defect without further pedicle dissection. (D) The postoperative result 8 weeks after surgery.

    Figure 4 (A) A large pressure sore located at the midline sacral region and planning of an 8.5 cm 16 cm SGAP flap for sacralpressure sore coverage. Note that the flap was designed to just close the defect to avoid injury to the SGAP perforator duringharvesting. (B) The flap was raised on one perforator, which was still encased in its fibrous septum. Note that only a very shortpedicle was dissected. (C) The flap was rotated to cover the defect. (D) Stable results one week after surgery.

    530 C.-T. Lin et al.

  • SGAP flap for reconstruction of sacral sores 531with a unilateral flap.4 A long pedicle can be raised if alateral perforator is chosen, providing the flap with a largearc of movement, which allows undamaged tissue to beused from a distant non-traumatised zone in certain cases.However, in some very large defects, the margins of thedefect need to be included in the flap. In our series, weplanned the flap to be 1 cm longer and wider than thedefect around the predetermined perforator vessels. Insmaller defects, we included the perforator vessels in thecentral portion of the flap design, and the flap wastunnelled into the defect from the flap donor site. In largedefects, we included the margin of the defect in the flapand the flap was inset by rotating it.

    In contrast to previous studies,4,7e17 we dissected onlyup to 1 cm of length of the pedicle. Dissection is timeconsuming and requires extreme care to prevent injury tothe perforator vessel; pedicle dissection is the rate-determining step of the SGAP flap for closure of a sacralsore. A flap that is slightly larger than the defect shortensthe length of the dissected pedicle and reduces operatingtime. The risk of perforator vessel injury would also bereduced. Verpaele et al.4 suggested that for SGAP flaps withmore than one perforator vessel, choosing a lateral perfo-rator would create the longest possible pedicle to raise theflap from the distant non-traumatised zone and allow thesurgeon to inset the flap with minimal torsion to thevascular pedicle.

    We chose the medial perforator vessel as a pivot point torotate the SGAP flap and did not skeletonise the perforator.Although rotating the SGAP flap applies torsion to thepedicle, failure because of a kink at the pedicle was notnoted in any of the 11 rotating SGAP flaps. Studies havefailed to describe SGAP flap death from pedicletorsion.4,7e17 Raising the SGAP flap adjacent to the defectdoes not delay wound healing after adequate wounddebridement. Multiple perforator vessels restrict flapmobility, and fewer perforators allow the flap to movemore easily and farther.9 Using only one perforator maypreserve the viability of the flap. The additional perforatorvessels do not increase the viability of the flap, but provideadditional stretch between the flap and defect.11 Ligationof the marginal perforators may release tension withoutcompromising the SGAP flap.

    SGAP flaps could cover the sacral sores without a longpedicle dissection because of the following: (1) because th...


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