British Journal of Plasfic Surgery (1984) 37, 103- 107 CE 1984 The Trustees of British Association of Plastic Surgeons

The lateral thigh fascia-cutaneous flap in the repair of ischial and trochanteric defects

Y. MARUYAMA, K. OHNISHI and S. TAKEUCHI

Departments of Surgery and Plastic and Reconstructive Surgery, Toho University Hospital, Tokyo, Japan

Summary-We have recently designed and developed a lateral thigh fascia-cutaneous flap based on the first perforating artery. This artery supplies the distal part of the gluteus maximus muscle and continues to supply the fascia, subcutaneous tissues and skin over the lateral aspect of the thigh. We describe the use of this fascia-cutaneous flap in the repair of ischial and trochanteric defects.

Local skin flaps, muscle flaps and, more recently, myocutaneous flaps, have been widely used to resurface ischial and trochanteric defects. The various myocutaneous flaps are usually based on the gracilis muscle (Wingate and Friedland, 1978), tensor fasciae latae (Nahai et al., 1978), gluteus maximus (Maruyama et al., 1980), vastus lateralis (Bovet et al., 1982), or compound thigh flaps based on the inferior gluteal artery (Hurwitz, 1980; Hurwitz et al., 1981).

Although these myocutaneous flaps contain muscle, the functional deficit is usually far less than might otherwise be expected. However, the biceps femoris myocutaneous flap (Mathes and Nahai, 1979) although extremely versatile in the repair of ischial pressure ulcers in the paraplegic patient, is not otherwise a popular flap because of its significant functional loss. The inferior gluteal thigh flap is a reliable sensate flap for the repair of buttock and perineal defects but in the case of deep ischial wounds, there are occasions when the inferior gluteal artery might have been damaged and be no longer patent.

We have reviewed the surgical anatomy of the postero-lateral aspect of the thigh in search of other possibilities.

Between the tensor fasciae latae flap and the inferior gluteal thigh flap, the first perforating vessels supply not only the distal part of the gluteus maximus muscle but continue distally to supply the fascia, subcutaneous tissues and skin over the postero-lateral region of the thigh (Fig. IA, B, C) (Lang and Waschsmuth, 1972).

PontCn (198 1) showed that the survival length of flaps in the lower leg can be increased if fascia is included with the skin flap in the lower leg. A similar advantage has also been shown by Tolhurst

and Haeseker (1982) in the repair of burn con- tractures in the axillary region.

Precisely the same advantages can be obtained with a lateral thigh fascia-cutaneous flap based on the first perforating vessels and as a bonus some sensory innervation of the flap can be provided by including cutaneous branches of the inferior glu- teal nerve.

As the flap is raised as a fascia-cutaneous flap without any muscular component there is no significant motor disability and the donor site of the flap can be closed primarily.

The flap we have described lies lateral to the inferior gluteal thigh flap, so there is less risk to the sciatic nerve in any proximal dissection (Fig. 1C).

In the repair of the trochanteric defects the rotational pivot point is closer than with the inferior gluteal thigh flap and the lateral thigh fascia-cutaneous flap can be easily transposed into the trochanteric area.

In our small series of repairs using the lateral thigh fascia-cutaneous flap we have raised flaps extending as far distally as the lower third of the thigh without any evidence of necrosis and its range of transfer could well be further.

Case 1

A 29-year-old man presented with dense scarring over the left ischial area as a result of a traffic accident. He complained of severe pain especially when sitting.

At operation, with the patient lying prone, the ischial scar was excised down to healthy tissue producing a 12 x 8 cm defect over the ischium. A lateral thigh fascia-cutaneous flap was designed 8 cm wide and 25 cm long centred on the course of the first perforating artery, which lies bktween the trochanter and ischial tuberosity (Fig. 2A).

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104 BRITISH JOURNAL OF PLASTIC SURGERY

Posterior femoral n

Fig. 1

Figure l-(A) Diagram to show the first perforating vessels supply the distal part of the gluteus maximus muscle and continue distally to the lateral aspect of the thigh. (B) Fresh cadaver dissection to show the perforating vessels entering the subcutaneous tissues and skin of the lateral aspect of the thigh. (C) Diagram to show the territorial area of the first perforating vessels located lateral to the territory supplied by the inferior gluteal vessels.

The distal skin incision was made and deepened to include the fascia of the thigh: the flap was then raised in a proximal direction leaving the underlying muscle intact.

At the level of the trochanter, the first perforating vessels were identified entering the flap between the biceps femoris muscle and gluteus maximus muscle (Fig. 2B).

The viability of the flap was checked by good marginal bleeding, capillary refill, and with fluorescein dye injection.

The flap was then transposed easily into the ischial defect and the donor site area was closed by primary suture. The flap took well without any complications (Fig. 2C).

Case 2

A 19-year-old man had been paraplegic for 2 years following a road accident. He developed bilateral trochanteric ulcers that were excised and repaired at the same operation with bilateral thigh fascia-cutaneous flaps (Fig. 3A, B).

He has been followed-up for 6 months without any recurrence (Fig. 3C).

Case 3

A 57-year-old man with paraplegia following a brain haemorrhage developed a chronic trochanteric pressure sore. After excision of the scar, bursa and the bony

Fig. 2

Figure-(A) A lateral thigh fascia-cutaneous flap based on the extension of the first perforating vessels to close an ischial defect. The flap was designed as an island. (B) The flap has been raised along with the fascia leaving the underlying muscles intact. (C) The donor site was closed primarily and the transposed flap has settled in nicely without any complications (Case 1).

Fig. 3

Figure 3--(A) Recurrent bilateral ischial pressure ulcers. A left gluteal thigh flap has been used previously to provide sacral cover. (B) As the flap was elevated leaving the underlying muscles intact the nutrient vessels can be clearly seen. (C) Through subcutaneous tunnels both flaps were introduced as “island” flaps to close the ischial defects (Case 2).

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Fig. 4

Figure 4-(A) Right trochanteric pressure ulcer to show its anatomical relationship to the territories of the lateral thigh flap (F.P.), the tensor fasciae latae flap (T.F.L.) and the inferior gluteal thigh flap (I.G.). (B) Close-up view to show the nutrient vessels entering the lateral thigh fascia-cutaneous flap. (C) Final result after the flap has settled (Case 3).

prominence, a lateral thigh fascia-cutaneous pedicle flap The ulcer was radically excised down to healthy tissue was raised and transferred to close the trochanteric and closed with a lateral thigh fascia-cutaneous island defect. flap measuring 7x23 cm. The wound healed well

The post-operative course was uneventful (Fig. 4A, B, without any complication. 9

Case 4

A 42-year-old woman with paraplegia following an References operation on a meningocele at the age of 1 year, presented with a chronic right-sided ischial pressure

Bovet, J. L., Nassif, T. M., Guimberteau, J. C. and Baudet, J.

sore. This had been treated surgically on several oc- (1982). The vastus lateralis musculocutaneous flap in the repair of trochanteric pressure sores: technique and indi-

casions including the use of local flaps without success. cations. Plastic and Reconstructive Surgery, 69, 830.

LATERAL THIGH FASCIO-CUTANEOUS FLAP IN THE REPAIR OF ISCHIAL AND TROCHANTERIC DEFECTS 107

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 of Plastic Surgery, 33, 256.

Hurwitz, D. L., Swartz, W. M. and Mathes, S. J. (1981). The gluteal thigh flap: a reliable sensate flap for closure of buttock and perineal wounds. Plastic and Reconstructive Surgery, 68, 521.

Lang, J. and Wachsmuth, W. (1972). Praktische Anatomie Bein and Statik. Berlin, Heidelberg, New York: Springer- Verlag.

Maruyama, Y., Nakajima, H., Wada, M., Imai, T. and Fujino, T. (1980). A gluteus maximum myocutaneous island flap for the repair of a sacral decubitus ulcer. British Journal of PIasfic Surgery, 33, 150.

Mathes, S. J. and Nahai, F. (1979). Clinical Atlas of Muscle and Musculo-CutaneousFlaps. St. Louis: C. V. Mosby Company.

Nahai, F., Silverton, J. S., Hill, H. L. and Vasconez, L. 0. (1978). The tensor fascia lata musculocutaneous flap. Anna/s of Plastic Surgery, 1, 372.

Ponten, B. (1981). The fascia-cutaneous flap: its use in soft tissue defects of the lower leg. British Journal of Plastic Surgery, 34. 215.

Tothurst, D. E. and Haeseker, B. (1982). Fascia-cutaneous flaps in the axillary region. British Journal of Plastic Surgery, 35,430.

Wingate, G. B. and Friedland, J. A. (1978). Repair of ischial pressure ulcers with gracilis myocutaneous island flaps. Plastic and Reconstructive Surgery, 62, 245.

The Authors

Yu Maruyama, MD, Assistant Professor and Chief, Depart- ment of Plastic and Reconstructive Surgery, Toho University Hospital.

Kiyoshi Ohnishi, MD, Instructor, Department of Plastic and Reconstructive Surgery, Toho University Hospital.

Setsuo Takeuchi, MD, Professor and Director, Department of Surgery, Toho University Hospital.

Requests for reprints to: Yu Maruyama, MD, Department of Plastic and Reconstructive Surgery, Toho University School of Medicine, 6-l l-1, Ohmori-nishi Ohta-ku, Tokyo 143, Japan.

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