Eur J Plast Surg (1990) 13:22-25 European 1 ~ 1 _ e Journal of IflStlC bur-gery © Springer-Verlag 1990

Reconstruction of ischial pressure sore using an inferior rectus abdominis myocutaneous flap

T. I n o u e , I. T a n a k a a n d T. H a r a s h i n a

Department of Plastic and Reconstructive Surgery, Saitama Medical Center, Saitama Medical School, 1981 Tsujido, Kamoda, Kawagoe 350, Japan

Summary. I n this ar t icle , a r e c o n s t r u c t i v e m e t h o d for i schia l p r e s su re sores u s i n g a n in fe r io r rec tus a b d o m i n i s m y o c u t a n e o u s f lap, is r epor t ed . Resu l t s o b t a i n e d wi th two p a r a p l e g i c p a t i e n t s w i th r e c u r r e n t ischial p ressure sores were excel lent , a n d they were free f r o m r ecu r r ence over two years af ter this o p e r a t i o n . Th i s t e c h n i q u e is o n e o f the m e t h o d s o f choice in cases o f r e c u r r e n t ischial p re s su re sore whe re c o n v e n t i o n a l m e t h o d s have b e e n tr ied.

Key words: R e c t u s a b d o m i n u s m y o c u t a n e o u s f lap - I s c h i u m - P res su re sore R e c o n s t r u c t i o n

T h e d e v e l o p m e n t o f p r e s su re sore is d i f f icul t to a v o i d in p a t i e n t s w i th pa rap leg ia . In p a r t i cu l a r , p re s su re sores in the ischia l r e g i o n l imi t the da i ly act ivi t ies o f p a t i e n t s c o n f i n e d to whee lcha i r s , a n d p r e v e n t the i r r e t u r n to soci- ety. P rev ious ly , local c u t a n e o u s f laps were u sed in r econ - s t ruc t ion , a n d in r ecen t years f a v o r a b l e resul ts have b e e n ach ieved wi th m y o c u t a n e o u s f laps, e.g. g lu teus m a x i m u s [1] o r b iceps f emor i s [2, 5, 9], w h i c h give a f a v o r a b l e c u s h i o n - l i k e effect. H o w e v e r , r e p e a t e d r ecu r r ences som e- t imes occur , a n d s o m e cases a re n o t su i t ab le for these t echn iques .

F o r such cases o f r e c u r r e n t i schia l p re s su re sore, fa- v o r a b l e resul t s have b e e n o b t a i n e d wi th r e c o n s t r u c t i o n u s i n g a n in fe r io r rec tus a b d o m i n i s m y o c u t a n e o u s f lap ( M - C flap).

Th i s m e t h o d is c o n s i d e r e d to be s u p e r i o r to o the r t e c h n i q u e s due to its t echn ica l s impl ic i ty , re l iab i l i ty a n d c o n s e q u e n t l y exce l len t resul ts .

Requests for reprints to. T. Inoue, MD, Department of Plastic and Reconstructive Surgery, Saitama Medical Center, Saitama Medical School, 1981 Tsujido, Kamoda, Kawagoe 350 Japan

Case 1

A 40-year-old man was rendered paraplegic following a thoraco- spinal injury sustained in an industrial accident 8 years previously. He underwent several reconstructive operations for sacral, trochan- teric and ischial pressure sores, including bilateral gluteus maxi- mum M-C flaps, lateral thigh flap and various local cutaneous flaps, but as he was confined to a wheelchair, the left ischial pres- sure sore recurred repeatedly. Because there were no suitable flaps available to give sufficient volume to prevent recurrence, recon- struction was performed using an inferior rectus abdominis M-C flap.

The operation was performed under general anesthesia in the thoracodorsal position. The inferior rectus abdominis M-C flap was designed as an island flap with a cutaneous area of 10 x 6 cm in a spindle shape, and the muscle pedicle was prepared using nearly the full length of the left rectus abdominis [3], without sepa- rating it from the pubis. The pressure sore was fully excised, and the ischium partly removed to make it flat. A subcutaneous tunnel, some 5 cm in diameter and 10 cm in length, was prepared from the left inguinal to the left ischial region. The inferior rectus abdo- minis M-C flap was then passed through the subcutaneous tunnel, and the left external oblique sutured to the right rectus abdominis muscle, and the abdominal wall was primary closed, to prevent post-operative herniation. The ischial deficit was filled with muscle, and the skin dosed, with drain tubes placed deep into the muscle for irrigation. The flap took extremely well, and drain tubes were removed 2 weeks postoperatively, although use of the wheelchair was banned for 2 months. Two years after surgery, there has been no recurrence, and no complications such as abdominal herniation.

Case 2

A 42-year-old paraplegic woman was confined to a wheelchair following a thoracospinal injury sustained in a traffic accident 10 years previously. She underwent resection, drainage and debride- ment of a right ischial pressure sore by the orthopedic surgeons, because it was a focus of infection. The resulting deficit was large, and she had several repair operations for sacral and trochanteric pressure sores using cutaneous flaps, so on this occasion recon- struction was performed using an inferior rectus abdominis M-C flap. As in case 1, the operation was performed under general anesthesia in the thoracodorsal position. The inferior rectus abdo- minis M-C flap was designed as a TRAM flap in her lower abdo- men with dimensions of 10 x 26 cm [4]. The muscle body was made

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Fig. 1. Preoperative view of recurrent left ischial pressure sore of case 1 (40-year-old man)

Fig. 2. a Left inferior rectus abdominis M-C flap was raised, b The flap was then passed through the inguinal subcutaneous tunnel to the ischial region, c The ischial deficit was filled with muscle and the cutaneous part of the flap was sutured to the margin, with drain tubes placed deep to the muscle for irrigation

Fig. 3 a, b. Two years following surgery the patient was free from both recurrent pressure sore; and any kind of complications such as post-operative abdominal herniation

some 5 cm longer than the cutaneous part, and it was completely removed from the pubis leaving only a vascular pedicle containing the inferior epigastric vessels. As in case 1, a subcutaneous tunnel was made from the right inguinal region to the right ischial region, the flap transferred through the tunnel, and the abdominal wall primarily closed to prevent herniation. The pressure sore was fully excised, the flap sutured in place after some trimming of the distal margin, and drain tubes inserted under the flap. The flap healed uneventfully and drain tubes were removed after 3 weeks of irriga- tion. A return to the wheelchair was allowed after 6 weeks, and

there has been no recurrence of complications more than 2 years after surgery.

Discussion

The most i m p o r t a n t considera t ions in surgery for pres- sure sores in paraplegic pat ients are adequate curettage, debr idement of p ro t rud ing bone, and the transfer of an adequate vo lume of tissue to wi ths tand pressure. Wi th these points in mind , m a n y types of flaps inc luding local cutaneous, myocu taneous and fasciocutaneous have been reported f rom m a n y years ago [1, 6, 7, 9]. Each of these methods is effective and can achieve good final results. However, repeated recurrences can sometimes occur, par t icular ly in the case of ischial pressure sore in pat ients using wheelchairs. The technique reported is indicated in cases of recurrent ischial pressure sore where conven t iona l methods have been tried, and there are no local dono r sites available for transfer. The biceps femoris M-C flap was still available in case 2, bu t it was no t sufficient for the ischial defect.

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Fig. 4. The large tissue defect in the right ischial region due to abscess formation of the pressure sore

Fig. 5. a Right inferior rectus abdominis M-C flap was raised, b The flap was then passed through the inguinal subcutaneous tunnel to the ischial region, c The flap was sutured in p/ace after some

trimming of the distal part, and drain tubes inserted under the flap

Fig. 6a, b. Final results two years following surgery, a The ischial region was free from recurrence, b There were no complications in the abdominal donor site

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Use o f the inferior rectus abdominis M-C flap has been described by a number o f authors [3, 8], and it has come to be used in various types o f reconstruct ion due to its high utility, with the advantages o f a safe vascular supply and a wide arc o f rotat ion. Moreover , it can be used no t only as a pedicled flap, but is very useful as a free flap, due to the width and length o f the vascular pedicle, and the ease o f elevation, making it the mos t often used myocu taneous flap a long with the latissimus dorsi.

I t is no t difficult to pass a large flap th rough the inguinal subcutaneous tunnel, if the tunnel is slightly nar rower than the flap, the latter is wrapped in a vinyl sheet and can be passed smoothly.

The biggest p rob lem with the use o f myocu taneous flaps is, o f course the loss o f function. There is said to be little funct ional loss when only one side o f the rectus abdominis is used, bu t the indications mus t be carefully considered. It is impor tan t to consider recon- struction using this and other methods , and select the method which gives the least loss o f function.

It is interesting that the two cases reported in this article have bo th now gone more than 2 years since sur- gery wi thout recurrence, despite the repeated recurrences following the use o f other methods. There is much need for further research into this question, but in the authors ' opinion the reason is tha t the thick abdominal adipose layer acts as a efficient cushion, preventing recurrence.

I f this conjecture is correct, then even though some func- tional loss m a y be incurred, this me thod is indicated in the reconstruct ion o f pressure sores in the ischial re- gion, and m a y be one o f the t reatments o f choice.

References

1. Baek SM (1981) Gluteus maximum myocutaneous flap for ischial ulcers. Ann Plast Surg 7:508

2. Brenner P, Berger A (1987) The longterm management of sacral, ischial and trochanteric pressure sores by myocutaneous island flaps and their postoperative course. Eur J Plast Surg 10:24

3. De la Plaza R, Arroyo JM (1984) The flag flap: a new musculo- taneous flap of the rectus abdominis muscle. Riv Ital Chir Plasti- ca 16:541

4. Hartrampf CR, Sheflan M, Black PW (1982) Breast reconstruc- tion with a transverse abdominal island flap. Plast Reconstr Surg 69:216

5. McGraw JB, Arnold PG (1986) Atlas of muscle and musculocu- taneous flaps. Hampton Press, Norfolk, Virginia

6. Maruyama Y, Ohnishi K, Takeuchi S (1984) The lateral high fascio-cutaneous flap in the repair of ischial and trochanteric defects. Br J Plast Surg 37:103

7. Mathes S J, Nahai F (1979) Clinical atlas of muscle and musculo- cutaneous flaps. Mosby, St Louis

8. Taylor GI, Corlett RJ, Boyd JB (1984) The versatile deep inferior epigastric (inferior rectus abdominis) flap. Br J Plast Surg 37 : 330

9. Tobin GR, Sanders BP, Weiner LJ (1981) The biceps femoris myocutaneous advancement flap: as useful modification for ischial pressure ulcer reconstruction. Ann Plast Surg 6 : 396