Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 1339e1346

Management of recurrent ischial pressure sore withgracilis muscle flap and V-Y profunda femoris arteryperforator-based flap

Su-Shin Lee a,b,d,*, Shu-Hung Huang a,d, Meng-Chum Chen c,e,Kao-Ping Chang a,b,d, Chung-Sheng Lai a,b,d, Sin-Daw Lin a,b,d

a Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwanb Department of Surgery, Faculty of Medicine, Collage of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwanc Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung, Taiwand Plastic Surgical Association ROC, Taiwane Taiwan Nurses Association

Received 4 July 2007; accepted 24 December 2007

KEYWORDSIschial pressure sore;Recurrence;Perforator flap;Gracilis flap;Negative-pressuredressing

* Corresponding author. Address: DivTz-You 1st Road, Kaohsiung 807, Taiw

E-mail address: sushin@kmu.edu.t

1748-6815/$-seefrontmatterª2008Britdoi:10.1016/j.bjps.2007.12.092

Summary Background: Inappropriate seating has been implicated as a major contributingfactor in ischial pressure-sore recurrence. During their lifetime, paraplegic patients may re-quire several flaps for closure of the same or some other adjacent pressure sore. Despite a widevariety of flap reconstruction options being described, the ischium remains the most difficultpressure-sore site to treat.Methods: From June 1998 to July 2006, there were 253 pressure-sore patients operated uponat Kaohsiung Medical University Hospital. Ten patients (eight men and two women) sufferedfrom recurrent ischial pressure sores, and all of them received more than one flap reconstruc-tion for the ischial defect. For the treatment of the recurrent ischial pressure sore, gracilismuscle flap and readvancement of the VeY profunda femoris artery perforator-based flap wereused to fill the dead space as well as cover the defect.Results: Among these 10 recurrent ischial pressure-sore patients, six of them had sufferedbilateral ischial ulcers. Eight of them had previous sacral pressure sores. In all, 32 flap recon-struction procedures were performed on these 10 patients. Unfortunately, one patient hadrecurrent grade II bilateral ischial pressure sores after 11 months of ulcer-free period. Theother nine patients had no recurrence noted, and enjoyed their lives with an average 27.2months ulcer-free period (range 9e53 months).Conclusions: The fasciocutaneous flap provides a higher mechanical resistance than thedetached and transposed muscle. However, for the recurrent ischial ulcer patients, readvance-ment of the perforator-based fasciocutaneous flap alone cannot provide adequate bulk to

ision of Plastic Surgery, Chung-Ho Memorial Hospital, Kaohsiung Medical University, 19 Fl, No. 100,an. Tel.: þ886 7 3208176; fax: þ886 7 3111482.w (S.-S. Lee).

ishAssociationofPlastic,ReconstructiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

1340 S.-S. Lee et al.

obliterate the ‘dead space’ after debridement of the bursa and the surrounding necrotictissue. By combining the readvancement of V-Y profunda femoris artery perforator-basedfasciocutaneous flap and gracilis muscle flap, these recurrent ischial ulcers will heal withoutcomplication.

Recurrence of ulceration often develops despite successful flap closure. Patients and theirrelatives have to be educated regarding pressure relief, personal skin, and self-care. Surgeonsmust collaborate with the rehabilitation department, nursing staffs, and social workers toimprove long-term results.ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

Pressure ulcers are source of numerous complications,which result in long-term, frequent, and/or multiplehospital admissions. They constitute an important problemnot only in paraplegic but also in geriatric patients.Reconstructive surgery for pressure-sore defects presentsa difficult challenge because of the high rate of woundcomplications and recurrence.1 The incidence of pressureulceration among those with spinal cord injuries was re-ported up to 39%.2 Recurrence of ulceration often developsdespite successful flap closure, especially in paraplegic pa-tients who are able to move around in wheelchairs. Disaet al.,3 in their review of 66 cases of flap closure for pres-sure sores performed over 5.5 years, reported a 69% ulcerrecurrence in all patients. Tavakoli et al.4 reported thatthe male traumatic paraplegics had a recurrence rate of80%. During their lifetime, paraplegic patients may requireseveral flaps for closure of the same or some other adjacentpressure sore. Because of the high recurrence rate of pres-sure ulcers in these spinal cord injury patients, the possibil-ity of future reconstructive procedure should be consideredduring flap selection.

Surgical treatment of pressure sores includes excision ofthe ulcer, underlying bony prominence and bursa if any,and closure of the defect with a flap.2,5,6 Various flap stud-ies have been performed to review the long-term result ofischial pressure sores. Foster et al.7 reviewed 139 ischialpressure sores and advised that proper flap selection andthe appropriate sequence of flap use significantly improvedsuccess rates for ischial pressure-sore coverage in both theshort and long term. He preferred the inferior gluteusmaximus island flap and gluteal thigh flap for ischial defectreconstruction with success rates of 94% and 93%, respec-tively. However, in clinical practice, a number of ‘frequentlyrecurrent’ ischial pressure-sore patients caused our opera-tion team much concern as to the next step/flap forreconstruction.

The treatment of recurrent ischial pressure sores usuallystarts with ulcer debridement and wound care. Topicalnegative-pressure dressings were used to treat the woundbase, depending on the surgeons’ preference.8 Since con-servative management for these ulcers is often ineffective,especially for grade III or grade IV ulcers,9 further read-vancement of the myocutaneous flap or other fasciocutane-ous flap was used to close the defect. However, there aresignificant changes in the tension exerted across ischialarea with different positioning of legs.7 Sometimes, thereadvanced flap lacks volume to fill the dead space and rel-atively high tension across the flap edge causes a breakdown

of the wound. Accordingly, we believe that the recurrent is-chial ulcer is the most difficult pressure ulcer to treat.10 Inthis study, patients with recurrent ischial pressure soresthat were treated at Kaohsiung Medical University Hospitalover the last nine years (1998e2006) were reviewed.

Patients and methods

From June 1998 to July 2006, there were 253 pressure-sorepatients operated upon at Kaohsiung Medical UniversityHospital. A retrospective survey was performed and 20ischial pressure-sore patients were identified. Further de-tailed chart reviews were developed to determine thepredisposing factors causing the pressure ulcer (like levelof spinal cord injury, cerebral vascular accident, major limbamputation), incidence of rehospitalisation, ischial pres-sure-sore condition at admission, wound pus culture re-ports, types and numbers of flap reconstruction associatedwith these lesions, and the final follow-up date and result.Ten patients (eight men and 2 women) had recurrent ischialpressure sores and all of them received more than one flapreconstruction for the ischial defect. The mean age ofthese patients at first treatment was 46.3 years (range 20e70 years).

All the pressure-sore patients were requested to prac-tice and get used to the prone position before the final flapsurgery. Before the definitive flap operation, routine socialwork and rehabilitation consultations were performed. Asfor the recurrent-pressure ulcer patients, we requestedextra help from social workers to make sure that thesepatients had at least some basic support from theirrelatives or the proper nursing care unit. Because theprone position maintained hip-joint extension and mini-mised skin tension at the ischial area, these recurrentischial pressure-sore patients were instructed to lie on theirstomach for the first postoperation week.

For the treatment of the recurrent ischial pressure sore,gracilis muscle flap and readvancement of the V-Y profundafemoris artery perforator-based flap were used to fill thedead space as well as to cover the defect. For theprocedure, each patient was put in the supine position.Then the ipsilateral gracilis muscle flap was elevated by thestandard method. The muscle could be felt when the legwas extended straight and externally rotated with abduc-tion of the hip. The full length of gracilis muscle washarvested (Figure 1). The dominant proximal pedicle of thismuscle was preserved. Then the patient was moved intothe prone position. The bursa of the recurrent ischial

Figure 2 One subcutaneous tunnel was created to pull thegracilis muscle into the ischial cavity.

Management of recurrent ischial pressure sore 1341

pressure ulcer was stained with methyl blue, which washelpful for complete excision of the bursa. Bony promi-nence was rasped, if any. One subcutaneous tunnel wascreated to pull the gracilis muscle into the ischial cavity(Figure 2). This V-Y flap was based on the perforators com-ing from the first branch (artery perforans prima) of theprofunda femoris artery. Ultrasound Doppler AudioScopewas helpful in detecting the location of these perforators(Figure 3). Then the readvancement of the V-Y profundafemoris artery perforator-based flap was done to seal thedefect.

In the recovery room, the patient was put in the supineposition until fully recovered from the anaesthesia and thenencouraged to keep the prone position to minimise thetension at the ischial area. Alternating air-therapy mattresswas used to reduce risks of further pressure sores. Patientswere allowed to sit but to keep off the operative site(s) for3e4 weeks after surgery.

Results

Among these 10 recurrent ischial pressure-sore patients, sixof them were bilateral ischial-ulcer patients. Eight of themhad suffered previous sacral pressure sores. These patientsreceived at least two flap reconstructions (range from 2 to 8times flap surgery). During the follow-up period (mean 74.2months, range from 25 to 113 months), they were hospi-talised 6.9 times on an average (range from 1 to15 times)owing to different health problems. Four of these patientshad bacteria isolated from the wound pus culture.

A total of 32 flap reconstruction procedures wereperformed for these 10 patients (Table 1). The types offlap used included gluteus maximus myocutaneous flap(8 times), readvancement of gluteus maximus myocutane-ous flap (7 times), gluteus fasciocutaneous flap (2 times),profunda femoris artery perforator-based V-Y advancementflap (11 times), redone V-Y advancement flap (12 times),gracilis muscle flap (7 times), tensor fascia lata flap(1 time), and anterior thigh fillet flap (1 time) (Table 2).

Figure 1 Full length of the gracilis muscle was harvested.

All of the ischial defects healed successfully within 3 weeksafter the final flap surgery. They received regular outpa-tient clinical follow-up.

Unfortunately, one patient (no.1) had recurrent grade IIbilateral ischial pressure-sores again after an 11-monthulcer-free period (Figure 4). The other nine patients had norecurrence noted, and enjoyed their ulcer-free periodranging from 9 to 53 months (average 27.2 months)(Figure 5).

Figure 3 Location identified by Ultrasound DopplerAudioScope.

Table 1 Ischial pressure-sore patient data

No. Sex Age at 1sttreatment(years)

Predisposing factor Ischial lesion Hospitalisationduring follow-upperiod

Follow-up(months)

Ulcer-freefollow-up (months)

1 Male 20 L1 burst fracture Bilateral 15 times 113 11/BilateralGrade IIulcer recurrent

2 Male 31 L2 compression fracture Right side 14 times 107 193 Male 56 Old cerebral vascular accident Left side 2 times 99 244 Female 25 L1 and L3 compression

fracture soreBilateral 2 times 94 52

5 Male 59 T 12 spinal injury Bilateral 6 times 78 536 Female 56 Spinal cord injury, Left

below-knee amputationRight side 13 times 69 19

7 Male 37 T12 compression fracture Bilateral 2 times 54 388 Male 58 Apical bifida occulta post

laminectomyBilateral 7 times 52 22

9 Male 70 T4e5 spondylolisthesis Bilateral 7 times 51 910 Male 51 C-spine injury Right side 1 time 25 9

1342 S.-S. Lee et al.

Discussion

Many factors may affect the occurrence of pressure sores.They include immobility, incontinence, and poor nutritional

Table 2 Flap history of patients

No Other Pressure-sore history Flap reconstruction history

1 Sacral ulcer 1. Bilateral gluteal maximus m2. Readvancement of gluteal3. Bilateral gluteal fasciocuta4. Readvancement of bilatera5. V-Y profunda femoralis arte6. Readvancement of the V-Y7. Bilateral gracilis muscle fla

2 No 1. V-Y profunda femoralis arte2. Readvancement of the V-Y3. Gluteal maximus myocutan4. Readvancement of gluteal

3 Sacral ulcer 1. V-Y profunda femoralis arte2. Gracilis muscle flap þ read

4 Sacral ulcer 1. Bilateral V-Y profunda fem2. Gracilis muscle flap þ read

5 No 1. Right: gluteal maximus my2. Bilateral gluteal maximus m

6 Sacral ulcer 1. V-Y profunda femoralis arte2. Right gluteal fasciocutaneo3. Readvancement of gluteal4. Right gluteal maximus myo5. Gracilis muscle flap þ read

7 Sacral ulcer 1. Anterior thigh fillet flap2. Split thickness skin graft

8 Sacral ulcer 1. Right V-Y profunda femoral2. Left Gracilis muscle flapþ

9 Sacral ulcer 1. Bilateral V-Y profunda fem2. Right readvancement of V-

10 Sacral ulcer 1. Right V-Y profunda femoral2. Right Gracilis muscle flap þ

status and consciousness level changes.6 Recurrence ratesas high as 33e100% have been described, depending onthe different aetiology and age of patients.3 The overalllong-term follow-up recurrence rate of the pressure ulcer

yocutaneous flapmaximus myocutaneous flapneous flapl gluteal fasciocutaneous flapry perforator-based fasciocutaneous flapflapp þ readvancement of V-Y flapsry perforator-based fasciocutaneous flapflapeous flapmaximus myocutaneous flapry perforator-based fasciocutaneous flapvancement of V-Y flapsoralis artery perforator-based fasciocutaneous flapvancement of V-Y flapsocutaneous flap, Left: tensor fascia lata fasciocutaneous flap

yocutaneous flapry perforator-based fasciocutaneous flapus flapfasciocutaneous flapcutaneous flapvancement of V-Y flaps

is artery perforator-based fasciocutaneous flapV-Y profunda femoralis artery perforator-based flapsoralis artery perforator-based fasciocutaneous flapY flaps; left gluteal maximus myocutaneous flapis artery perforator-based fasciocutaneous flapreadvancement of V-Y flaps

Figure 4 (Up) Two months post operation, complete healingof the ischial ulcer was noted. (Down) Bilateral recurrent gradeII ischial ulcer noted again at 11 months post operation.

Figure 5 (Up) Pre-operative view of patient No. 4.

Management of recurrent ischial pressure sore 1343

can exceed 50%.7 Disa et al.3 studied 40 patients with 68pressure sores over an 8-year period. He concluded thatthe operative therapy for pressure sores in traumatic para-plegics and elderly, debilitated patients is not always indi-cated. However, when considering that untreated ulcersand necrosis may spread widely and sores may cause seriouscomplications, including death,11 this conclusion raisesconcern. Furthermore, conservative management for theseulcers is often ineffective, especially for grade III or gradeIV ulcers9; therefore, surgeons should make every effortto improve this situation.

In clinical practice, we used the negative-pressuredressing technique to manage chronically difficult woundsincluding pressure sores, chronic diabetic mellitus foot andsternal osteomyelitis.12,13 The superficial ulceration over is-chial bony prominence demonstrates breakdown of the der-mis and necrosis of muscle fibre, and the injury is deeperand larger below the surface.14 Aggressive surgical debride-ment is often of critical importance in the treatment ofpressure sores; however, if the wound is inadequately de-brided before reconstruction, it will lend itself to failure.15

After removal of the devitalised tissue, there are likelyto be dead spaces under the surface of the skin, necessi-tating further flap reconstruction. However, in recurrent

ischial ulcer patients, the optimal flap has been used earlierand options of reconstruction sometimes are limited. Weuse topical negative-pressure therapy as a bridging pro-cedure before final flap surgery. The negative-pressuredressings are changed every other day for about one weekto inspect the wound condition. This method offers oppor-tunities for stabilising patients’ general conditions, re-ducing tissue oedema around the wound edges, waitingfor pus culture results, and improving the granulation tissueon the wound base.13,16 Also, patients are encouraged topractise the prone position during the topical negative-pressure treatment period. Negative-pressure therapy iswidely used for the pressure-sore patients in our institute.

A review of the relevant literature reveals that there are12 methods that have been reported for the reconstructionor treatment of ischial pressure sores. They are inferiorgluteus maximus island flap,5,7,17 VeY hamstring myocuta-neous flap,4,7,18 gluteal thigh fasciocutaneous flap,7 gracilismyocutaneous island/gracilis muscle flap,7,19e21 adipofas-cial turnover and fasciocutaneous flap,10 tensor fascialata flap,7 inferior gluteal artery perforator (IGAP)flap,1,11 lateral thigh V-Y fasciocutaneous flap,9,22 anteriorthigh flap,7 rectus abdominis myocutaneous flap,7 adductormuscle perforator flap,23 and sclerotherapy.24

1344 S.-S. Lee et al.

According to our estimates, inferior gluteus maximusisland flap was the most frequently used flap for re-construction of ischial pressure sores, followed by V-Yhamstring myocutaneous flap and gluteal thigh fasciocuta-neous flap (Table 3). However, the myocutaneous flaps of-ten leave readvancement of the flap as the only means ofaddressing recurrence.1 Also, the major disadvantage ofthese flaps is the sacrifice of a muscle and its function;this is especially important in ambulatory patients.11 In ad-dition, if the patients had suffered sacral pressure soresbefore, the gluteus maximus myocutaneous flaps wereoften selected to treat those defects previously. In thisseries, eight of 10 patients had histories of sacral pressuresores and six of 10 patients presented with bilateral ischialulcers e all difficult situations to deal with. The fasciocu-taneous flap is another option for reconstruction of thepressure sore. It provides a higher mechanical resistancethan the detached and transposed muscle.6,10 In the pastdecade, the concepts of perforator flaps have been widely

Table 3 Reported flap used for ischial pressure-sore reconstruc

Name of flap Reporte

Inferior gluteus maximus island myocutaneous flap 1. High2. Relia3. Provi4. Bulky

V-Y hamstring myocutaneous flap 1. Leg-b2. Limit

Gluteal thigh fasciocutaneous flap 1. High2. No m3. More

Gracilis myocutaneous island/gracilis muscle flap 1. Most2. Minim3. The c

reco4. Domi5. Dista

Adipofascial turnover and fasciocutaneous flap 1. Simp2. For m3. Need

Tensor fascia lata flap 1. Dista2. Not r

is criInferior gluteal artery perforator (IGAP) flap 1. Musc

2. One3. Suffic4. Vario

Lateral thigh V-Y fasciocutaneous flap 1. Proxiinto

2. PotenAnterior thigh flap 1. Othe

and tRectus abdominis myocutaneous flap 1. TunnAdductor muscle perforator flap 1. Adva

2. AllowSclerotherapy 1. Not a

expo2. Simp3. Low

discussed and applied to clinical practices.1,6,13,23 The per-forator-based fasciocutaneous flap is well vascularised. Itsterritory is compatible with the myocutaneous flap.25 Incomparison with the myocutaneous flap, the perforatorflap has less donor-site morbidity. Muscle is preserved forfurther reconstructive options and it possesses the versa-tility in design, to include as little or as much tissue as re-quired.26 These advantages lead us to treat ischialpressure sores with perforator-based flaps. However, forrecurrent ischial ulcer patients, readvancement of the per-forator-based fasciocutaneous flap alone cannot provideadequate bulk to obliterate the dead space after adequatedebridement of the bursa and the surrounding necrotic tis-sue. Tuncbilek et al.18 described partially de-epithelialisedand buried V-Y advancement flap technique and Ichiokaet al.10 used triple adipofascial turnover and fasciocutane-ous flaps to cover the ischial ulcers. However, all V-Y flapsare intrinsically limited in their advancement by the lengthof the supplying pedicle.7 Also, in the recurrent situation,

tion

d advantages and disadvantages

success rate7

ble vascularised7

de a large area of soft tissue for transposition7

enough to obliterate the dead space5

ased flap7

ed in advancement by the length of the pedicle7

success rate7

uscle provided7

shearing and tension force due to location on the leg7

extensively used muscle for free tissue transfer19

al donor-site morbidity and easily concealed donor scar19

hoice of gracilis flap does not preclude other future surgicalnstruction19

nant proximal blood supply21

l third of skin flap not always reliable5

le and safe procedure10

inor to moderately sized ischial pressure ulcers only10

drainage of subcutaneous effusion10

l third not always reliable5

eliable enough at distal 6e8 cm of the flap and this portiontical for ischial coverage7

le preserving1

perforator can supply a large skin flap11

ient endurance to resist pressure11

us flap designs are possible11

mal and well-vascularised portion of the flap is insertedthe cavity of pressure ulcer22

tially can be re-advanced22

r flap should be used prior to considering leg amputationhigh flap coverage7

elling through the groin needed7

ntages of fasciocutaneous flap23

simultaneous direct closure of the donor site23

ppropriate in acute inflammation pressure ulcer and bonesure under the skin24

licity and minimally invasive24

cost24

Management of recurrent ischial pressure sore 1345

the inflammation-induced fibrosis, shortage of subcutane-ous tissue, and one incision across the weight-bearingareas are the drawbacks. It provides soft tissue coverageonly for minor-to-moderately sized ischial pressure ul-cers.10 Additional flap is necessary to fill the cavity underthe skin.

The gracilis muscle flap is one of the most extensivelyused muscles for free-tissue transplantation. The use ofgracilis flaps for ischial sore has been reported, and it hasstood the test of time.19,20,21 The muscle is easily harvestedfrom the inner thigh without leaving any functional or aes-thetic deficit.27 The whole length of this muscle is used toobliterate the dead space after debridement. It has enoughbulk to obliterate the dead space and has a robust bloodsupply.4,21 However, the gracilis myocutaneous island flapis not favoured in this series because it concerns the distalthird circulation status of the skin island.7,17 By combiningthe readvancement of V-Y profunda femoris artery perfora-tor-based fasciocutaneous flap and gracilis muscle flap,these recurrent ischial ulcers were healed withoutcomplication.

For long-term results of pressure-sore management, thebest surgical outcome can easily be jeopardised by the ill-informed or the noncompliant patient. Recurrence is notsecondary to operative technique, but to poor complianceat home or lack of proper wound-care assistance.9 Patients’personalities, social situation, and family network are im-portant factors for the recurrence of pressure sores.4 Sur-geons must collaborate with the rehabilitationdepartment, nursing staffs and social workers to improvelong-term results. Patients and their relatives have to beeducated regarding pressure relief, personal skin and self-care.9,11 The ischial pressure-sore patients must learn pres-sure-release manoeuvres that are then performed cyclicallywhile seated. Also, it is important to perform daily exami-nation of the trochanteric, ischial, sacral, and heel areasof the patients. Early recognition and treatment are man-datory to prevent progression and accelerate healing ofthese pressure ulcers.2 Kierney et al. collaborated in surgi-cal reconstruction, postoperative rehabilitation, and pa-tient education to achieve as low as 23% recurrence inpressure sores with trauma-induced spinal cord injurypatients.28

In conclusion, the inferior gluteus maximus island flapand the inferior gluteal thigh flap had high success rates forischial pressure-sore coverage.7 However, recurrent ischialpressure-sore management is a difficult issue in plastic sur-gery. It is mandatory that patients and caregivers learn theappropriate techniques to maintain skin integrity. For themanagement of recurrent ischial ulcers, we advocate ade-quate wound debridement and gracilis muscle flap in addi-tion to V-Y advancement of profunda femoris arteryperforator-based flap reconstruction in conjunction withcomprehensive pre- and postoperative rehabilitation. Thiscombination is worthy of consideration when dealing withdifficult, recurrent ischial pressure-sore patients.

References

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4. Tavakoli K, Rutkowski S, Cope C, et al. Recurrence rate ofischial sores in para- and tetraplegics treated with ham-string flaps: an 8-year study. Br J Plast Surg 1999;52:476e9.

5. Sharma RK. Split gluteus maximus island flaps for concomitantclosure of ischial and sacral pressure sores. Ann Plast Surg2001;46:52e4.

6. Scheufler O, Farhadi J, Kovach SJ, et al. Anatomical basis andclinical application of the infragluteal perforator flap. PlastReconstr Surg 2006;118:1389e400.

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10. Ichioka S, Okabe K, Tsuji S, et al. Triple coverage of ischialulcers with adipofascial turnover and fasciocutaneous flaps.Plast Reconstr Surg 2004;114:901e5.

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18. Tuncbilek G, Nasir S, Ozkan O, et al. Partially de-epithelialisedand buried V-Y advancement flap for reconstruction of sacro-coccygeal and ischial defects. Scand J Plast Reconstr SurgHand Surg 2004;38:94e9.

19. Cheong EC, Lim J, Lim TC. An atrophic, fat-infiltrated gracilismuscle for ischial reconstruction? Br J Plast Surg 2005;58:749e51.

20. Wingate GB, Friedland JA. Repair of ischial pressure ulcerswith gracilis myocutaneous island flaps. Plast Reconstr Surg1978;62:245e8.

21. Labandter HP. The gracilis muscle flap and musculocutaneousflap in the repair of perineal and ischial defects. Br J PlastSurg 1980;33:95e8.

22. Hayashi A, Maruyama Y, Saze M, et al. The lateral thigh V-Yflap for the repair of ischial defects. Br J Plast Surg 1998;51:113e7.

23. Hallock GG. The propeller flap version of the adductor muscleperforator flap for coverage of ischial or trochanteric pressuresores. Ann Plast Surg 2006;56:540e2.

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24. Haayashi T, Honda K, Kimura C, et al. Treatment of ischialpressure sores by means of sclerotherapy using absolute etha-nol. Ann Plast Surg 2004;53:554e9.

25. Koshima I, Moriguchi T, Socda S, et al. The gluteal perforator-based flap for repair of sacral pressure sores. Plast ReconstrSurg 1993;91:678e83.

26. Geddes CR, Morris SF, Neliqan PC. Perforator flaps: evolution,classification, and applications. Ann Plast Surg 2003;50:90e9.

27. Manktelow RT, Zuker RM. Free functioning muscle transfersin the upper limb. In: Mathes SJ, editor. Plastic surgery.2nd ed. vol. 8. Philadelphia: Elsevier Inc; 2006. p. P489e

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