Letters to the Editor 521
upper part of the flap beneath the chin was later defatted for better definition of the neck contour (Figs 3, 4).
In many patients, severe neck contractures following burns require flap reconstruction. The scapular flap has been used as a free flap but it provides a limited amount of tissue. Tissue expansion has been described in conjunction with free transfer of scapular, * and parascapular flaps.3 An extended free scapular flap has also been used to transfer more tissue for reconstruction of a neck contracture. Poole5 described a composite flap based on the thoracodorsal pedicle for reconstruction of the face. We have demonstrated that the pedicle of the scapular flap is sufficiently long to allow its direct transfer to the front of the neck, thus simplifying the procedure. The pedicle length of the scapular flap can be increased to 15 cm by dissecting the pedicle to the axillary vessels.G
We therefore suggest this as a reconstructive technique in
the treatment of the severely contracted neck. As with any flap, some thinning and adjustment may be required. Yours faithfully, M. Riaz, FRCSI, FRCS(Glas), FRCSEd Registrar R. Millar, FRCS Consultant Plastic Surgeon J. 0. Small, FRCS Consultant Plastic Surgeon Plastic Surgery and Burns Unit, Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6BA. UK.
1. Laitung JKG, Batchelor AG. Successful pre-expansion of a free scapular flap. Ann Plast Surg 1990; 25: 205-7.
2. Mayou BJ, Gault DT, Crock JG. Tissue expanded free flaps. Br J Plast Surg 1992; 45: 413-17.
3. Moghari A, Emami A, Sheen R, OBrien B McC. Lower limb reconstruction in children using expanded free flaps. Br J Plast Surg 1989; 42: 649-52.
4. Thoma A, Heddle S. The extended free scapular flap. Br J Plast Surg 1990; 43: 709912.
5. Poole MD. A composite flap for early treatment of hemifacial microsomia. Br J Plast Surg 1989; 42: 163-72.
6. Mayou BJ, Whitby D, Jones BM. The scapular flap-an anatomical and clinical study. Br J Plast Surg 1982; 35: 8-13.
Treatment of ischial pressure sores with an inferior gluteus maximus musculocutaneous island flap
Sir, We write in regard to the article by Rajacic and colleagues on the use of inferior gluteus maximus flaps for ischial
522 British Journal of Plastic Surgery
pressure sores. The authors showed their satisfactory results with this flap. They also stated that this flap should be considered the first choice of flap for the treatment of mild to moderate sized ischial pressure sores. We agree with the authors that the clinical course of paraplegics is marked by recurrent breakdown of their pressure sores and that an ideal flap should not only have sufficient bulk of vascularised tissue but also spare the vascular pedicles of other flaps in the region which may be required for the treatment of recurrent pressure sores.
Three of their cases developed recurrent pressure sores and the authors used posterior thigh flaps to close the defects. It is not clear what sort of posterior thigh flap was used. The gluteal thigh flap, supplied by muscular branches and direct cutaneous branches of the inferior gluteal artery, is often also named the posterior thigh flap. From their description of the operative technique for elevation of their inferior gluteus maximus island flaps, it seems that the descending cutaneous branch of the inferior gluteal artery which supplies the posterior thigh (gluteal thigh) flap could be divided during elevation of the inferior gluteus maximus island flaps. Were the three recurrent pressure sores treated with posterior thigh flaps, supplied by the terminal descending branch of the inferior gluteal artery, or with random pattern posterior thigh flaps?3
Rajacic and his colleagues consider that the inferior gluteus maximus island flap is the first choice of flap for minor and moderate sized pressure sores. We consider that the posterior thigh (gluteal thigh) flap is the first choice. Elevation of this flap only sacrifices the posterior thigh branch of the inferior gluteal artery. The more proximal branches of the inferior gluteal artery and the inferior gluteus maximus musculocutaneous unit are left intact and can be safely used for recurrent ischial pressure sores. To overcome the problem of excessive skin in the conventional posterior thigh (gluteal thigh) flap, we use the island flap modification43 5 of this flap.
Yours faithfully, Tai-Ju Cheng, MD, Yueh-Bih Tang, MD, PhD, Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Tapei, Taiwan.
1. Rajacic N, Gang RK, Dashti H, Behbehani A. Treatment of ischial pressure sores with an inferior gluteus maximus
musculocutaneous island flap: an analysis of 31 flaps. Br J Plast Surg 1994; 47: 4314.
2. Hurwitz DJ, Swartz WM, Mathes SJ. The gluteal thigh flap: a reliable, sensate flap for the closure of buttock and perineal wounds. Plast Reconstr Surg 1981; 68: 521-30.
3. Hallock GG. The random upper posterior thigh fascio- cutaneous flap. Ann Plast Surg 1994; 32: 367-71.
4. Walton RL. Inferior gluteal thigh flap. In: Mathes SJ, Nahai F. Clinical applications for muscle and musculocutaneous flaps. St. Louis: CV Mosby, 1982: 49&505.
5. Walton RL, Hurwitz DJ, Bunkis J. Gluteal thigh flap for reconstruction of perineal defects. In: Strauch B, Vasconez LO, Hall-Findlay EJ, eds. Grabbs Encyclopedia of flaps. Boston: Little Brown, 1990: 1455-61.
Treatment of ischial pressure sores with an inferior gluteus maximus musculocutaneous island flap-Reply
Sir, I would like to thank my colleagues from Taiwan for their comments on our paper on the inferior gluteus maximus island flap. We noted that the skin island of the inferior gluteus maximus island flaps was in the infero-lateral part of the gluteal region. As noted in the Discussion in our paper, the rich vascular network and 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. The muscle pedicle reaches the inferior gluteal artery but does not transect it.
We were therefore able to use the posterior thigh flap (also known as the gluteal thigh flap and the inferior gluteal thigh flap), based on the terminal branch of the inferior gluteal artery, for closure of the three recurrent pressure sores.
Cheng and Tang prefer the posterior thigh flap as the first choice of flap for ischial pressure sores. I disagree, for the reason given in their letter, which is that such defects need bulky flaps for coverage; the posterior island flap, par- ticularly the island flap version, does not have the necessary bulk.
Yours faithfully, N. Rajacic, MD, Department of Surgery, Faculty of Medicine, Kuwait University, P.O. Box 24923, Safat 13110, Kuwait