British Journal of Plastic Surgery (1986) 39. 66-7 I ICI 1986 The Trustees of British Association of Plastic Surgeons
The total gluteus maximus rotation and other gluteus maximus musculocutaneous flaps in the treatment of pressure ulcers
S. PARKASH and S. BANERJEE
Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
Summary-The use of musculocutaneous flaps in the treatment of pressure ulcers has been widely accepted. This study presents the results of the use of various types of gluteus maximus musculocutaneous flaps such as island flaps, advancement flaps and new total gluteus maximus rotation flaps with or without an inferior gluteal fasciocutaneous extension, in the treatment of pressure ulcers.
Pressure ulcers are a difficult problem leading to chronic debility. After an initial florid phase of pro- gression the ulcers tend to get cleaner and contract. However, this process is slow and complete healing unusual. When it does occur many scars are un- stable and repeated breakdown is more often the rule.
In the past, large pressure ulcers were covered by local skin flaps (Croce and Beakes, 1947; Conway and Griffith, 1956). However, these procedures entailed considerable blood loss and an appreciable failure rate, sometimes resulting in a defect larger than the original ulcer (Constantin and Jackson, 1980). In contrast, musculocutaneous flaps provide more reliable cover and are easier to execute.
The gluteus maximus muscle, supplied by the superior and inferior gluteal arteries as well as branches from the cruciate anastomosis, provides the base for a number of versatile musculocu- taneous flaps for use in sacral, trochanteric and ischial pressure ulcers (Minami et al.. 1977). An in- ferior gluteal flap with a fasciocutaneous extension based on a branch of the inferior gluteal artery has
been described (Hurwitz, 1980); this idea was added as a refinement in 3 out of 6 cases of the new total gluteus rotation flap described in this study.
Patients and methods
Fifteen patients with pressure ulcers were studied. There were 11 male and 4 female patients with the age group ranging from 25 to 45 years. The under- lying condition responsible for the production of the pressure ulcers and associated neurological deficit are depicted in Table 1. The ulcers were measured using a piece of sterilised lint placed over the ulcer, cut out in the shape of the ulcer and placed over a graph paper. The area was then esti- mated. Serial measurements were taken until the time of surgical closure. After the conservative management of the pressure ulcers by slough exci- sion, antibiotics and topical therapy, musculo- cutaneous flap cover was carried out. Allowance was made where there was an extensive under- mining or bursa beyond the visible ulcer. Bone excision was limited to minor shaving, where it was
Underlying condition No. Sensory deficit
Motor .spasf icitj
Tuberculosis of the spine with paraplegia 2 2 Nil Nil Traumatic paraplegia 5 5 I 5 Prolonged comatose state e.g. encephalitis, meningitis, etc. 4 Nil Nil Nil Carcinomatous myopathy (carcinoma breast) 1 Nil Nil Nil Polyarticular rheumatoid arthritis 1 Nil Nil Nil Transverse myelitis with paraplegia I I Nil 1 Postoperative meningocoele repair I 1 Nil I
THE TOTAL GLUTEUS MAXIMUS ROTATION IN THE TREATMENT OF PRESSURE ULCERS
Table 2 Results
I. Sup. Glu. Island 2. Inf. Glu. Island
3. Cruciate Island 4. Advancement
Dividing lateral attachment 5. Bilateral V-Y advancement
6. Total rotation
7. Extended total rotation
2 I 2 2
I I 2 I
Sacral 80 Healed 24 months Sacral 30 Healed I?- I8 months Ischial 32 Trochanteric 63 Healed 24 months Sacral 20 Healed I8 months lshcial 63 1 Partial breakdown Healed Sacral 40 I Healed I2 months
36 I Complete breakdown I8 months Residual Ulcer +
SaCrdl 216 Healed 24 months 36 48
Sacral 120,25,60 Healed I2 months Trochanteric 80. 100.80 6 months &
I month -
exposed, or along with the overlying bursa when a plane could not be demonstrated. The types of gluteus maximus musculocutaneous flaps used are shown in Table 2.
A new technique of a total rotation flap. de- veloped on the basis of the Fiolle and Delmas approach to the hip and gluteal region (Henry, 1957) was used in six of these cases. Fiolle and
Delmas described an approach to the hip and gluteal region which consisted of mobilisation of the gluteus maximus by dividing its attachments from the posterior superior iliac spine along the iliac crest and then obliquely down to the midpoint of the greater trochanter and inferiorly along the femoral shaft to the gluteal fold (Fig. IA). To raise this flap, the surface marking of the gluteus maxi-
Figure l-(A) Diagrammatic representation of a sacral ulcer with the total rotation gluteus maximus flap based on the Fiolle and Delmas approach outlined. (B) Cover of sacral pressure ulcer using the total rotation gluteus maximus musculocutaneous flap.
mus is first mapped out. An incision is made at the midpoint of the greater trochanter and deepened. A finger is inserted to obtain the plane deep to the gluteal fascia and the muscle separated along its upper border towards the iliac crest medially. The attachment to the iliac crest is alsoerased and the dissection extended downwards to mobilise the muscle well below the level of the ulcer. The muscle with the overlying skin is raised and the blood supply identified. The incision is now extended from the region of the trochanter downwards along the gluteal fold. The superior gluteal vessels often need division but the inferior gluteals are carefully safeguarded. The entire flap is then rotated to cover a sacral ulcer (Fig. 1B).
Three of these cases incorporated an inferior glu- teal based fasciocutaneous extension from the pos- terior aspect of the thigh, which was used to cover a trochanteric ulcer at the same time as the sacral ulcer (Figs. 2A and 2B). This technique was com- bined with a tensor fasciae latae musculocutaneous flap for the opposite trochanteric ulcer and enabled cover of three pressure ulcers in one stage in all three patients. However, the extended area required skin grafting in one case. Although the total gluteus maximus rotation flaps appear exten- sive, they are not really so since there is generally a clear bloodless plane deep to the muscle which
BRITISH JOURNAL OF PLASTIC SURGERY
facilitates dissection. This procedure has never required more than one unit of blood (350ml).
The results of musculocutaneous flap cover in this study are summarised in Table 2. The largest area covered was a sacral ulcer 216cmL using a total rotation flap. Similar large areas were covered with the extended total rotation flap with a simul- taneous cover of a sacral and a trochanteric ulcer.
Various techniques have been used for the cover of pressure ulcers. These include split skin grafts, reversed dermal grafts (Wesser and Kahn, 1967) skin flaps (Croce and Beakes, 1947; Conway and Griffith, 1956; Constantin and Jackson, 1980), muscle flaps (Ger, 1977) and musculocutaneous flaps (Minami eta/., 1977; Constantin and Jackson, 1980). Skin flaps depend largely on perforators for their nutrition and thus are random flaps. As the flaps are large, necrosis is not uncommon (Con- stantin and Jackson, 1980) and the dissection involved often results in considerable blood loss.
Musculocutaneous flaps have the advantage of a
Figure 2-_(A) Diagrammatic representation of the total rotation flap with the inferior gluteal fasciocutaneous extension with sacral and trochanteric ulcers outlined. (B) Cover of a sacral and a trochanteric ulcer with the extended total rotation flap.
THE. TOTAL GLUTEUS MAXIMUS ROTATION IN THE TREATMENT OF PRESSURE ULCERS 69
predictable blood supply, adequate padding over pressure points, limited blood loss, and a better cosmetic effect without major functional disability. Paraplegics, especially with spasticity, are prone to recurrent pressure ulcers and even after musculocu- taneous flap closure recurrence is as common as after any other method of cover. This emphasises the fact that other factors such as the after care of paraplegic patients determine the recurrence rate (Constantin and Jackson, 1980).
The gluteus maximus, with its predominantly biaxial vascular supply, can be used in a variety of mu:jculocutaneous flaps. The superior gluteal based island or pedicled flap can be used for sacral pressure ulcers (Figs. 3A and 3B). The inferior glu- teal based island or pedicled flap can be used for sacral and ischial ulcers. However, both these flaps suffer the limitation of access as the vascular pedi- cle has to be maintained, and hence they can be used only for ulcers of limited size within the reach of the vascular pedicle.
The cruciate anastomosis based island flap (Becker. 1979) has been used successfully for tro- chanteric ulcers. emphasising the third important vascular supply to the muscle. However. its blood supply is perhaps not as predictable as that of the above-mentioned flaps.
For sacral ulcers of limited size, a bilateral V-Y advancement musculocutaneous flap (Maruyama et al., 1980) can be used. This is very ingenious and probably the simplest of all the flaps and has been used in two cases in this study. Similarly. an ad- vancement flap dividing the sacral attachment of the muscle provides adequate cover but it cannot be used for larger pressure ulcers.
The total rotation gluteus maximus musculo- cutaneous flap is a