Treatment of ischial pressure sores with an inferior gluteus maximus musculocutaneous island flap: an analysis of 31 flaps
Brmrh Journoi of Plusrrr Surgery (1994). 47. 431434 Treatment of ischial pressure sores with an inferior gluteus maximus musculocutaneous island flap : an analysis of 31 flaps N. Rajacic, R. K. Gang, I-I. Dashti and A. Behbehani Department of Surgery, Faculty of Medicine, Kuwait Unizlersity, Safat, Kuwait SUMMARY. We describe our experience with the use of an island gluteus maximus musculocutaneous flap (from its most inferior part) based on perforators from the inferior gluteal artery. The study is based on a series of 27 patients in whom treatment was carried out for 31 is&al pressure sores. Eight patients had postoperative complications in the form of dehiscence of the donor flap site and/or infection. Follow-up ranged from 6 to 32 months. During this period three patients developed recurrent sores which were treated with other flaps. We feel strongly that the use of this flap should be considered as a first choice in the treatment of the mild to moderate size ischial pressure sore. Its advantages include ease in elevation of the flap and the provision of a vascularized bulky flap which also spares the vascular pedicles of adjacent flaps for future use. The area overlying the ischium is one of the most common sites for pressure s0res.l The treatment of a pressure sore includes excision of undermined skin, abrasion or resection of the ischial tuberosity, removal of infected bursae and the closure of the defect by a flap.,3 Recurrence was quite common until musculo- cutaneous flaps were introduced for the management of such defects.1,*,5 The various types of musculo- and fasciocutaneous flaps used in such defects include hamstring,6 biceps femoris, tensor fasciae latae, gracilisg and posterior thigh flaps. lo During their lifetimes, paraplegic patients may require several flaps for closure of the same or some other adjacent pressure sore. Therefore it is necessary to adopt a forward looking surgical strategy in order to spare vascular pedicles for use with other flaps if they are needed in the future. The use of the inferior part of the gluteus maximus muscle with the island of overlying skin without disrupting the inferior gluteal artery was first reported in 1981 by Scheflan et al. l1 They used this part of the muscle and the overlying skin to close the defect after excision of an ischial pressure sore. Subsequently, in 1986 Stevenson et al. made a further modification of this by forming a true island flap and tunnelling it beneath the bridge of normai skin to cover the defect.r The purpose of this paper is to describe our experience in a series of 27 paraplegic patients with 3 1 ischial pressure sores of moderate size, all of which were treated by using an island gluteus maximus musculocutaneous flap from the most inferior part of the muscle based on branches of the inferior gluteal artery. Operative technique The anatomy of the gluteus maximus muscle is well known and thoroughly described.5s11 Recent vascular studies show that the blood supply to the skin and the subcutaneous tissue is derived from 20-25 perforating vessels mainly situated in the parasacral and central portions of the muscle but also found in its most infero-lateral part where it approaches the greater trochanter.13 In the absence of gross infection, excision and closure of an ischial pressure sore is accomplished in a single stage. The patient is positioned in the prone position, with hips flexed, and the outline of the flap is marked (Fig. 1). Following en bloc excision of the ulcer, the surrounding skin and infected bursa, the ischial tuberosity is conservatively reduced and rasped to a smooth contour (Fig. 2). A skin island of the flap, elliptically shaped and placed parallel to the skin creases in the infero-lateral part of the gluteal region, is incised down to the gluteus fascia and secured to the muscle with a few stitches in order to avoid inadvertent damage of the small perforating vessels during surgery. A wide undermining of the skin is carried out in the lateral, medial and inferior directions away from the skin island (Fig. 2). A skin bridge between the defect and the flap is usually incised for better visualization of the muscle pedicle and ease in positioning it during the transposition of the flap to the defect. The muscle is transected lateral to the skin flap and elevated in the bloodless areolar tissue plane deep to the muscle. After sufficient mobilization of the flap deeply in a medial direction, the superior and inferior borders of the muscle are also cut parallel to the muscle fibres half- way to the defect to form a pedicle, which is a little wider than the skin island. The flap is then transposed to the defect and the wound is closed in layers after the insertion of a suction drain. The donor area is closed primarily in two layers (Fig. 3). Patients and postoperative care Thirty-one consecutive ischial wound closures in 27 patients were achieved using this gluteus maximus 432 British Journal of Plastic Surgery Fig. Fig. 3 Figure l-Ischiat pressure sore with an island Rap outlined on the skin of the buttock. Figure 2-Elevation of flap completed. Figure 3-Wound healed 6 weeks postoperatively. island musc~locutaneous flap. There were 20 males and 7 females. The ages of the patients ranged from 15 to 47 with a mean of 35 years. All patients suffered from post-traumatic paraplegia and 4 of them had undergone earlier attempts at wound closure using direct approximation or local flaps elsewhere, after which they had been referred to us for management. The postoperative care regimen was similar for all patients. After operation the patients were maintained entirely non-weight bearing on the area for 2 weeks on air-flotation beds, and were then transferred to a regular mattress but kept off the operation site for a total of 5 weeks. After this period, a sitting protocol with gradual increase in pressure on the operation site was introduced. In cases with wound or donor site complications, a sitting protocol was delayed until the wound healed. Twenty-six patients were followed for an average period of 12 months (range 6-32 months). There was no perioperative mortality. However one patient died of sepsis later during the follow-up period. The sepsis was not related to the pressure sore and the flap remained intact. All patients treated by the inferior gluteus maximus island flap achieved complete healing of the pressure sore and the donor site at the time of hospital Treatment of ischial Pressure Sores with an inferior Gluteus Maximus Musculocutaneous island Flap 433 Table 1 Complications and outcome Na. ~a~~lieatio~s patients ~~teome Donor site dehiscence: femoris, hamstring), or have a poor blood supply to their distal third which makes them unreliable for soft tissue coverage (tensor fasciae latae. gracihs). a. superficial b. deep 3 healed by 2 intention 3 secondary sutures in 2 and flap in 1 case Wound dehiscence 2 healed spontaneously discharge. The mean hospitalization period after surgical closure of the wound was 40 days. Immediate complications occurred in 8 patients (Table 1). In two of them, complications were related to inadequate excision of the bed sore with minor infection and discharge, which healed spontaneously. In 6 cases we had partial dehiscence of the donor site due to an underlying seroma collection related to the early withdrawal of suction drains. Three healed spontaneously; in another 2, we performed secondary revision of the wound in order to accelerate healing, while in one case a local cutaneous flap was needed to obtain closure. All complications occurred during the hospital stay. On average the introduction of a sitting protocol was delayed for 3 weeks. Elevation of the inferior gluteus maximus island flap is easy and does not compromise blood supply to any of the flaps in surrounding areas. It requires only a minimal sacrifice of the most inferior part of the gluteal muscle and avoids any postoperative hindrance to walking in ambulatory patients. A rich vascular network and a large number of perforators to the skin, even in its most lateral part, obviate the need for a wide muscle pedicle and enable transposition of the flap into the defect without the necessity of including the inferior gluteal artery in the flap or detaching the origin of the muscle. Experience with our group of patients suggests that the inferior gluteus maximus island flap is a very useful method of providing soft tissue coverage for minor to moderate-sized ischial pressure sores. For major defects different designs of the inferior gluteus maximus or other flaps should be used. We had recurrence of the bed sore in three cases, which occurred between 6 and 13 months after the surgery. All three required another flap for closure (posterior thigh flaps were used). The number of donor site complications in our group indicates the need for tension-free closure with better obliteration of the secondary dead space and proper drainage. Contrary to the original description of the flap, we think that the bridge of skin between donor and pressure sites should be opened, not only for easier manipulation during dissection and trans- position of the flap but also to distribute equally the tension along the whole suture line during closure. Discussion Acknowledgement The clinical course of the paraplegic patient is often marked by recurrent breakdown of skin exposed to pressure at different sites in spite of skilled nursing care and surgical management. r* The ischial pressure sore is characterized by a relatively minor skin defect associated with a large, penetrating ischial tuberosity. Surgical treatment of an ischial pressure sore is aimed at debriding necrotic tissue, conservatively removing any bony prominence, and transferring viable and adequate soft tissue to the defect.2r3 A variety of surgical methods has been used for covering the post- excisional defect, including direct closure,15 local cutaneous flaps, musculocutaneous flaps based on adjacent muscles.. l1 and expanded skin flaps.17 An ideal flap for the coverage of an ischial pressure We are extremely thankful to Dr David L. Wright for helping us in the correction of the manuscript. References 1. Colen SR. Pressure sores. In: McCarthy JG. ed. Plastic surgery. Vol. 6. The trunk and lower extremity. Philadelphia: Saunders, 1990: 3797-838. 2. Conway H. Griffith BH. Plastic surgery for closure of decubitus ulcers in patients with paraplegia; based on experience with 1000 cases, Am J Surg 1956; 91: 94651. 3. Vasconez LO, Schneider WJ. Jurkiewicz MJ. Pressure sores. Curr Prob Surg 1977; 14: t-5. 4. Ger R, Levine SA. The management of decubitus ulcers by muscle transposition-an eight year review. Plast Reconstr Surg 1976; 58: 419-24. sore should be well vascularized, with sufficient bulk to obliterate any dead space and be easy to work with. It should also allow the sparing of potential vascular pedicles for other flaps which may be required in future reconstructions. 5. Minami RT, Mills R, Pardoe R. Gfuteus maximus myo- cutaneous flap for repair of pressure sores. Plast Reconstr Surg 1977 : 60 : 24227. 6. Hurteau LE, Bostwick J, Nahai F, Hester R. Jurkiewicz MJ. V-Y advancement of hamstring musculocutaneous flap for coverage of ischial pressure sores. Plast Reconstr Surg 198 I ; 68: 539114. In our opinion, skin and expanded skin flaps are of limited value as they lack bulk and adequate vascularization for combating infection. The use of gluteal thigh fasciocutaneous flaps, although com- monly used. should be reserved for those cases of ischial pressure sore with major skin defects or with multiple adjacent sores. A majority of the musculo- cutaneous flaps either transect the inferior gluteal artery extension to the posterior thigh, making the use of posterior thigh flap afterwards not feasible (biceps 7. Tobin GR, Pompi Sanders B, Man J, Weiner LJ. The biceps femoris myocutaneous advancement flap: a useful modifica- tion for ischial pressure ulcer reconstruction. Ann Plast Surg 1981; 6: 396401. 8. Nahai F, Hill HL, Hester TR. Experiences with the tensor fascia lata flap. Plast Reconstr Surg 1979; 63: 788-93. 9. Winaate GB. Friedland JA. Reoair of ischial uressure ulcers with gracilis myocutaneous island flaps. Plast Reconstr Surg 1978; 62: 241-50. 10. Hurwitz DJ, Swartz WM, Mathes SJ. The gluteal thigh Rap: a reliable sensate flap for the closure of buttock and perineal wounds. Plast Reconstr Surg 1981: 68: 521 -5. 434 British Journal of Plastic Surgery 11. 12. 13. 14. 15. 16. 17. Scheflan M, Nahai F, Bostwick J. Gluteus maximus island musculocutaneous flap for closure of sacral and ischial ulcers. Plast Reconstr Surg 1981; 68: 533-8. Stevenson TR, Pollock RA, Rohrich RJ, Craig AV. The gluteus maximus musculocutanebus island flap: refinements in design and application. Plast Reconstr Surg 1987; 79: 761-8. 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. Joseph JD, James MC, Nelson HG. Efficacy of operative care in pressure sore patients. Plast Reconstr Surg 1992; 89: 272-8. Arregui J, Cannon B, Murray JE, OLeary JJ Jr. Long-term evaluation of ischiectomy in the treatment of pressure ulcers. Plast Reconstr Surg 1965; 36: 583-7. Hill HL, Brown RG, Jurkiewicz MJ. The transverse lumbo- sacral back flap. Plast Reconstr Surg 1978 ; 62: 177-8 1. Gaetano E, Pasquale Z, Giovani Di Caprio, Nicolo S. Re- construction of ischial pressure ulcers by skin expansion. Stand J Plast Reconstr Hand Surg 1993; 27: 133-6. The Authors Nebojsa Rajacic, MD, FICS, Assistant Professor, Department of Surgery, Faculty of Medicine, Kuwait University, and Consultant Plastic Surgeon, Al Babtain Center for Burns, Plastic and Reconstructive Surgery. Raj Kumar Gang, MBBS, MS, FICS, FACS, Senior Registrar, Al Babtain Center for Burns, Plastic and Reconstructive Surgery. Hussain Dashti, MD, PhD, FICS, Associate Professor, Department of Surgery, Faculty of Medicine, Kuwait University. Abdulla Behbehani, MB, BCh, FRCS(I), PhD, FIGS, Associate Professor and Chairman. Department of Surgery, Faculty of Medicine, Kuwait University. Requests for reprints to: Dr N. Rajacic, Assistant Professor, Department of Surgery, Faculty of Medicine, Kuwait University, P.O. Box 24923, Safat 13110, Kuwait. Paper received 5 January 1994. Accepted 20 April 1994, after revision.