The total gluteus maximus rotation and other gluteus maximus musculocutaneous flaps in the treatment of pressure ulcers

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<ul><li><p>British Journal of Plastic Surgery (1986) 39. 66-7 I ICI 1986 The Trustees of British Association of Plastic Surgeons </p><p>The total gluteus maximus rotation and other gluteus maximus musculocutaneous flaps in the treatment of pressure ulcers </p><p>S. PARKASH and S. BANERJEE </p><p>Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India </p><p>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. </p><p>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. </p><p>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. </p><p>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 </p><p>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. </p><p>Patients and methods </p><p>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 </p><p>Table 1 </p><p>Underlying condition No. Sensory deficit </p><p>Motor .spasf icitj </p><p>Bladder involvement </p><p>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 </p><p>66 </p></li><li><p>THE TOTAL GLUTEUS MAXIMUS ROTATION IN THE TREATMENT OF PRESSURE ULCERS </p><p>Table 2 Results </p><p>67 </p><p>I. Sup. Glu. Island 2. Inf. Glu. Island </p><p>3. Cruciate Island 4. Advancement </p><p>Dividing lateral attachment 5. Bilateral V-Y advancement </p><p>6. Total rotation </p><p>7. Extended total rotation </p><p>2 I 2 2 </p><p>I I 2 I </p><p>2 0 </p><p>3 2 </p><p>3 2 </p><p>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 </p><p>36 I Complete breakdown I8 months Residual Ulcer + </p><p>SaCrdl 216 Healed 24 months 36 48 </p><p>Sacral 120,25,60 Healed I2 months Trochanteric 80. 100.80 6 months &amp; </p><p>I month - </p><p>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. </p><p>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 </p><p>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- </p><p>Fig. 1 </p><p>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. </p></li><li><p>68 </p><p>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). </p><p>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 </p><p>BRITISH JOURNAL OF PLASTIC SURGERY </p><p>facilitates dissection. This procedure has never required more than one unit of blood (350ml). </p><p>Results </p><p>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. </p><p>Discussion </p><p>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. </p><p>Musculocutaneous flaps have the advantage of a </p><p>Fig. 2 </p><p>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. </p></li><li><p>THE. TOTAL GLUTEUS MAXIMUS ROTATION IN THE TREATMENT OF PRESSURE ULCERS 69 </p><p>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). </p><p>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. </p><p>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. </p><p>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. </p><p>The total rotation gluteus maximus musculo- cutaneous flap is a new and simple method for the cover of sacral pressure ulcers, especially extensive ulcers. The case illustrated in Figure 4 was a 20- year-old female who developed a sacral pressure ulcer after a prolonged comatose state due to corti- cal vein thrombosis. The ulcer had not healed after 2 months of conservative therapy. The Hb level was 9gm/dl, protein 52gm/l and albumin 26gm/l. There was extensive undermining and induration around the visible pressure ulcer (indicated by the arrows) which after excision produced a raw area of 216cm*. This was covered by a total rotation gluteus maximus flap as shown in Figure 4B. The cosmetic effect is satisfactory and there is no major functional disability. All three patients who under- went this type of flap closure in this study did well. </p><p>The addition of an inferior gluteal based fascio- cutaneous extension, similar to that described by </p><p>Fig. 3 </p><p>Figure 3-(A) Sacral pressure ulcer-preoperative. (B) Sacral pressure ulcer covered with a superior gluteal based gluteus ma island musculocutaneous flap. </p></li><li><p>70 BRITISH JOURNAL OF PLASTIC SURGERY </p><p>Figure 4 -(A) Sacral pressure ulcer-preoperative. Area enclosed by the arrows needed excision because of induration mining. 1 (B) Sacral pressure ulcer covered by a total rotation gluteus maximus musculocutaneous flap based on the Delmas E approach. </p><p>Fig. 4 </p><p>and ur ider- Fiolle and </p><p>Fig. 5 </p><p>Figure 5-(A) Sacral and trochanteric ulcers preoperatively. (B) Extended total rotation flap to cover a sacral and a trochanteric ulcer in one stage. </p></li><li><p>THE TOTAL GLUTEUS MAXIMUS ROTATION IN THE TREATMENT OF PRESSURE ULCERS 71 </p><p>Hurwitz (1980). to the total rotation flap enables the closure of two pressure ulcers-one sacral and one trochanteric-at one stage. This can be com- bined with the closure of the opposite trochanteric pressure ulcer with a suitable flap such as the tensor fasciae latae musculocutaneous flap (Nahai, 1980). Thins achieves the difficult task of providing cover for three pressure ulcers at one stage and was car- ried out in three cases. One of these is illustrated in Figure 5. He was a 35year-old male with traumatic paraplegia and a sacral ulcer 60cm*, a right tro- chanteric ulcer 80cmZ and a left trochanteric ulcer 48cm. The Hb level was 8gm/dl, total proteins 66 em/l and albumin 22 gm/l. </p><p>These two new techniques can be added to the already existing methods of providing cover for pressure ulcers, which even today remain a for- midable surgical challenge. </p><p>Acknowledgements </p><p>We wish to thank the staff of the Department of Orthopedics and Medical Illustration Division for their help and co-opera- tion. and Miss Lesley Skeates. Royal Hospital for Sick Chil- dren, Edinburgh, for the drawings. </p><p>References </p><p>Conway, H. and Griffith, B. H. (1956). Plastic surgery for closure of decubitus ulcers in patients with paraplegia. American Journal q.SurgerJ. 91,946. </p><p>Croce. E. J. and Beakes, H. C. (1947). Operative treatment of decubitus ulcer. Nen. England Journal q/Medicine. 237. 141. </p><p>Ger, R. (1977). Surgical management of decubitus ulcers by muscle transpositi&amp;. Surgrry:63. 106. </p><p>Henrv. A. K. (1957). E.\lensile E.xoosure. 2nd Edition. Edin- hu;gh and London: E &amp;S Living&amp;one Ltd. </p><p>Hurwitz, D. J. (1980). Closure of a large defect of the pelvic cavity by an extended compound myocutaneous flap based on the inferior gluteal artery. British Journal c$ Plustic Surgery, 33, 256. </p><p>Maruyama, Y., Nakajima, H., Michitaka, W., Imai, T. and Fujino, T. (1980). A gluteus maximus myocutaneous island flap For the repair of a sacral decubitus ulcer. &amp;i/i.&amp; Journal of Plastic Surgery. 33. 150. </p><p>Minami, R. T., Mills, R. and Pardoe, R. (1977). Gluteus maxi- mus myocutaneous flaps for repair of pressure sores. Pkzstic and Reconstructive Surgery. 60.242. </p><p>Nahai. F. (1980). The tensor fascia lata flap. Chits in Plastic Surgery, I. 5 I. </p><p>Wesser, D. R. and Kahn, S. ( 1967). The reversed dermis graft in repair of decuhitus ulcers. Plusric and Reconstrwtive Surgery. 40. 252. </p><p>The Authors </p><p>Satya Parkash, FRCS(Eng), Professor of Surgery. Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry. </p><p>S. Banerjee, MS, Senior Resident, Department of Surgery, Jawaharlal Institue of Postgraduate Medical Education and Research. Pondicherrv. </p><p>Becker, H. (1979). The distally based gluteus maximus muscle flap. Phsric and Reconstructive Surgery, 63,653. Requests for reprints to: Dr S. Parkash, FRCS(Eng), Dean and </p><p>Constantin, M. B. and Jackson, H. S. (1980). Pressure ulcer.T. Professor of Surgery. Jawaharlal Institute of Postgraduate Boston: Little. Brown and Company. Medical Education and Research. Pondicherry-605006. India. </p></li></ul>

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