British Journal of Plastic Surgery (1998), 51, 113-117 �9 1998 The British Association of Plastic Surgeons

BRITISH JOURNAL OF ~ PLASTIC SURGERY ]

The lateral thigh V-Y flap for the repair of ischial defects

A. Hayashi, Y. Maruyama, M. Saze and E. Okada

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

SUMMARY. The lateral thigh fasciocutaneous flap described by Maruyama et al in 1984 is a useful method for the repair of ischial and trochanteric defects. We clinically re-evaluated the potential vascular territory of the nutrient artery for this flap, i.e., the first profunda perforator, and have newly designed the postero-lateral thigh V-Y flap in the area including the proximal two-thirds of the posterior thigh. This flap was applied to five difficult or recurrent ischial defects, and satisfactory results were obtained in all cases. For the reconstruction of ischial defects, the postero-lateral thigh V-Y flap has the following advantages; the proximal and well-vascularised portion of the flap is inserted into the area of the previously excised pressure sore, and this flap can potentially be readvanced if a recurrent pressure sore should develop. A Z-plasty can be performed to prevent excessive tension on the skin closure at the junction of the V-Y advancement flap. The postero-lateral thigh V-Y flap can be considered one of the first-line options for both primary and recurrent ischial pressure sores.

The skin overlying the ischium is the most common location for pressure sores, especially in paraplegic patients who are able to get about in wheelchairs. Recurrence of ulceration often develops despite successful flap closure because of the continuous pressure on the ischial region in the course of the patients' daily activities. Patients may require several flaps during their lifetime for the closure of ischial pressure sores. It is important to adopt a surgical strategy in which vascular pedicles to future flaps are not injured when the initial procedure is performed?

The lateral thigh flap was first described by Maruyama et al 2 in 1984 as an island fasciocutaneous flap for the repair of ischial and trochanteric defects. This flap uses the first perforating artery of the profunda femoris artery, and was originally designed on the postero-lateral aspect of the thigh. Since in the case of deep ischial wounds there are occasions when the descending branch of the inferior gluteal artery might have been damaged or cut at the edge of the ischial defect, 2,3 we clinically re-evaluated the potential vascular territory of the first profunda perforator and have newly designed a postero-lateral thigh V-Y flap for the closure of difficult or recurrent ischial defects.

Patients and methods

We performed 5 postero-lateral thigh V-Y flaps in four male patients. The patients' ages ranged from 44 to 58 years. All four patients were paraplegic. One patient had schizophrenia and diabetes mellitus. Three patients had other pressure sores in sacral or trochanteric regions. The postoperative follow-up period ranged from 9 months to 2 years.

Operative technique

The first profunda perforator pierces the adductor magnus close to the femur and appears in the posterior compartment. Here it gives off branches which supply the insertion of the gluteus maximus and the infero- lateral portion of the muscle, and further branches become cutaneous where the gluteus maximus inserts into the iliotibial tract. The lateral thigh flap is based on this cutaneous perforator, which divides into two cutaneous vessels with internal diameters of about 1 mm. One of these vessels fans out anteriorly over the iliotibial tract and superiorly over the greater trochanter, and the other is directed posteriorly. Distally these vessels anastomose with the lateral cutaneous branches of the second perforator? The point where the first profunda perforator penetrates the fascia is detected using a Doppler flowmeter and is marked on the patient prior to raising the flap.

All patients were operated on in the prone position. The ischial sore is debrided, with special attention given to removing all necrotic tissue, the surrounding bursa, and the bony prominence of the ischium. Once the wound is adequately debrided, it is irrigated with saline solution.

A V-Y postero-lateral thigh flap is then designed (Fig. 1). A line is drawn beginning at the anterior portion where the gluteus maximus inserts into the iliotibial tract, and continues postero-inferiorly crossing the lateral intermuscular septum of the thigh. While the length of the flap will vary depending on the size of the ischial defect, most flaps extended to two-thirds of the length of the posterior thigh. A medial line is then drawn from the apex of the V to the medial rim of the ischial defect.

The flap is raised beginning distally by incising the apex of the V through the deep fascia. The flap is

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Fig. 1

Figure 1--Schematic representation of the operative procedure. (Left) Design of the postero-lateral thigh V-Y flap for the repair of an ischial defect. The thin dotted line shows the additional skin incision when a Z-plasty is applied for closure of the donor site. (P, the point where the first profunda perforator penetrates the fascia.) (Centre) Rotation advancement of the flap to the defect, and V-Y closure of the donor site. (Right) Donor site closure in a V-Y fashion combined with a Z-plasty.

then separated from the hamstring muscles which lie underneath. Dissection continues supero-laterally to reach the junctional area where the inferior rim of the gluteus maximus muscle meets the posterior margin of the iliotibial tract. It is not necessary to actually identify and dissect the vascular pedicle itself. After dissection to the level of the first profunda perforator, the flap is rotated medially and superiorly to cover the ischial defect. The flap is then sutured in place over suction drains, and the donor site is closed primarily in a V-Y fashion. I f excessive tension is noted while closing the donor site at the junction of the V-Y advancement, a Z-plasty is added to release the tension of the donor area (Fig. 1).

with a physician and a psychologist, the patient's diabetes mellitus and schizophrenia were brought under control. The wound was then widely debrided and a 15 x 12 cm defect was left (Fig. 2A). A postero-lateral thigh V-Y flap was designed on the postero-lateral aspect of the thigh. The apex of the V extended beyond two-thirds of the length of the thigh (Fig. 2B). The flap was transferred to the defect, and the donor site was closed primarily in a V-Y fashion com- bined with a Z-plasty (Fig. 2C). VAM was administered intravenously for 5 days postoperatively. The flap survived completely and there was no evidence of infection (Fig. 2D).

Case 2

A 56-year-old man with post-traumatic paraplegia had chronic sacral and bilateral ischial pressure sores (Fig. 3A). He had had 8 previous operations including bilateral gluteus maximus musculocutaneous flaps, bilateral tensor fasciae latae musculocutaneous flaps, and bilateral gracilis musculo- cutaneous flaps, for repair of these ulcers. Despite these efforts, recurrences of the ulcers had developed. The patient was then transferred to our hospital.

At operation, the right ischial ulcer was excised down to healthy tissue producing a 8 x 5 cm defect over the ischium. A postero-lateral thigh V-Y flap was designed as a step advancement flap, and the apex of the flap extended distally to the lower third of the thigh (Fig. 3B). The flap was raised and then transferred easily to the ischial defect. The donor site was closed primarily in a V-Y fashion and combined with a Z-plasty (Fig. 3C). Partial ischial wound dehiscence developed at the 9th day postoperatively, but it healed without any problems after resuture of the wound.

The left ischial ulcer was simultaneously debrided and repaired using a postero-lateral thigh V-Y flap. One month after this operation, the sacral pressure sore was excised and reconstructed by a rectus abdominis musculocutaneous island flap. The patient has been followed-up for 12 months without any recurrence of pressure sores (Fig. 3D).

Discussion

Results

The postero-lateral thigh V-Y flap successfully covered all five ischial pressure sores. Skin grafts have not been required for closure of the donor wound. We have not encountered any cases of flap loss. One patient developed partial dehiscence in the ischial wound at the 9th day postoperatively but it healed after resuture of the wound. No recurrence of the ischial ulcers was observed during the follow-up period.

Case reports

Case 1

A 44-year-old diabetic man suffered sacral and left ischial pressure sores for 3 years. He had been paraplegic due to resection of a spinal tumour 20 years earlier. After bilateral gluteus maximus musculocutaneous flap transfers had been performed in another hospital for repair of the sacral decubitus the ischial pressure sore was left untreated because the patient became schizophrenic and difficult to deal with.

On admission to our clinic. Methicillin-resistant Staphylo- coccus aureus was cultured from the ischial wound, but it was sensitive to vancomycin (VAM). After a consultation

Ischial pressure sores often develop in paraplegic patients who can actively get about in wheelchairs. Despite successful flap closure, repeated recurrences of the sores sometimes occur, especially in patients who have complications or who are not cooperative. Furthermore, pressure sores may develop in other areas such as. the sacral and trochanteric regions. Patients may require several flaps during their lifetime for the closure of ischial and other pressure sores. 1

There are various alternatives for the closure of ischial pressure sores such as tensor fasciae latae musculocutaneous flap, 5,6 lateral thigh fasciocutaneous flap, ~ hamstring musculocutaneous flap,' gracilis musculocutaneous flap, 8 gluteal thigh flap, 9 gluteus maximus musculocutaneous flap, ~~ and rectus abdominis musculocutaneous flap. '2 To care for the patient who will potentially require multiple flap procedures during his or her lifetime, it is important to adopt a surgical strategy in which the vascular pedicles to future flaps are not injured when the initial procedure is performed. 1 It is also important to preserve options for the repair of ulcers which m a y develop in other regions.

Although the tensor fasciae latae flap is a versatile flap in resurfacing groin, perineal, trochanteric, and

The lateral thigh V-Y flap for the repair of ischial defects 115

A

Fig. 2

Figure 2~(A) Preoperative view of the ischial pressure sore, with the wide infected subcutaneous space shown by the dotted circular line. (B) Design of the postero-lateral thigh V-Y flap. (C) Immediate postoperative view. The donor site was easily closed in a V-Y fashion combined with a Z-plasty. (D) Postoperative view 2 months after the operation.

lower abdominal defects, 5'6 it is relatively far from the ischial defect, and the most distal portion of the flap is usually placed into the bed of the ischial pressure sore. Additionally, it may destroy vascular pedicles of the lateral thigh and gluteal thigh flaps. It is thus recom- mended that the tensor fasciae latae flap be preserved for further use or for the reconstruction of other regions. The gluteal thigh flap is a reliable sensate flap for the repair of buttock and perineal defects? However, in the case of deep ischial wounds, there are occasions when the descending branch of the inferior

gluteal artery might have been damaged or cut at the edge of the ischial defect. 2,3 V-Y advancement of a hamstring musculocutaneous flap is also a reliable method, 7 and it is thought to be a good choice in para- plegic patients because functional loss of hamstring muscles is not a problem. These options, in addition to the postero-lateral thigh flap, may be considered as the first-line procedures for the repair of ischial defects. In selecting options among these flaps, the above mentioned factors should be kept in mind as well as the patient's clinical history and complications.

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Fig. 3

Figure 3~(A) Preoperative view of Case 2, showing bilateral recurrent ischial pressure sores and a large sacral pressure sore. (B) The area to be excised and the design of the 'step advancement' postero-lateral thigh V-Y flap. (C) The ischial defect was covered by the first-step segment of the flap, and the donor site was closed primarily with a Z-plasty. (D) Postoperative view 10 months after the operation.

The nutrient artery of the lateral thigh flap is the first lateral perforating artery of the profunda femoris artery. Distally, it anastomoses with the second pro- funda perforator. Utilising these vascular linkages, Maruyama showed that the lateral thigh flap can be extended as far distally as the lower third of the postero-lateral thigh or more. 2 However, the possibility of extending the lateral thigh flap posteriorly into the territories of the posterior profunda perforators and the descending branch of the inferior gluteal artery has not been previously described.

Clinical observations and anatomical studies have demonstrated that if a particular perforator is blocked, the adjacent perforator can supply this territory through the confluence of collateral anastomoses? ,m4 In a similar way, a single large perforator can irrigate more than one adjacent territory by preservation of the anastomotic plexus. Similarly, the first lateral profunda perforator may be able to irrigate the territories of the posterior profunda perforators and the descending branch of the inferior gluteal artery in some circum- stances. In the present small clinical series, the design

The lateral thigh V-Y flap for the repair of ischial defects 117

o f the lateral thigh V-Y flap included the p rox imal two- thirds o f the pos te r io r thigh, and the flaps survived comple te ly wi thou t any c i rcula tory problems. This indicates that the lateral thigh flap may be able to be extended pos tero-media l ly to some extent, par t icu la r ly when the b lood flow from the infer ior gluteal region has been d is turbed by a large ischial pressure sore. We have therefore t e rmed this flap a pos tero- la tera l th igh flap and within its potent ia l t e r r i to ry one will be able to design the flap freely depending on the shape and d imensions o f the defect, even in a s tep ladder advance- men t fashion 15 as demons t ra t ed in case 2.

A l t h o u g h the pos te ro- la te ra l th igh V-Y flap is no t a t rue V-Y advancement , the f lap design allows p r i m a r y donor -s i t e closure in a V-Y fashion. F o r the recon- s t ruct ion o f ischial defects, the pos te ro - la te ra l th igh V-Y flap has the fol lowing advantages. Because o f the design o f the flap, the p rox imal and wel l -vascular ised p o r t i o n o f the f lap is inser ted into the area o f the pre- viously excised pressure sore. In add i t ion , this f lap can poten t ia l ly be readvanced if a recurrent pressure sore should develop. A Z-p las ty can be pe r fo rmed to prevent excessive tens ion on the skin closure at the j u n c t i o n o f the V-Y advancement flap. This f lap also al lows the surgeon to utilise the under ly ing hams t r ing muscles to fill a very deep cavity.

The lateral th igh V-Y flap can thus be cons idered one o f the first- l ine op t ions for bo th p r ima ry and recurrent ischial pressure sores.

References

1. Colen SR. Pressure sores. In McCarthy JG. (Ed): Plastic Surgery. Vol 6. Philadelphia: WB Saunders Company, 1990.

2. Maruyama Y, Ohnishi K, Takeuchi S. The lateral thigh fascio- cutaneous flap in the repair of ischial and trochanteric defects. Br J Plast Surg 1984; 37: 103-7.

3. Jurkiewicz MJ. Discussion. Plast Reconstr Surg 1981; 68:531 2. 4. Cormack GC, Lamberty BGH. The arterial anatomy of skin

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5. Nahai F, Silverton JS, Hill HL, Vasconez LO. The tensor fascia lata musculocutaneous flap. Ann Plast Surg 1978; 1: 372-9.

6. Withers EH, Franklin JD, Madden JJ, Lynch JB. Further experience with the tensor fascia lata musculocutaneous flap. Ann Plast Surg 1980; 4: 31-6.

7. Hurteau JE, Bostwick J, Nahai F, Hester R, Jurkiewicz MJ. V-Y advancement of hamstring musculocutaneous flap for coverage of ischial pressure sores. Plast Reconstr Surg 1981; 68: 53942.

8. Wingate GB, Friedland IA. Repair of ischial pressure ulcers with gracilis myocutaneous island flaps. Plast Reconstr Surg 1978; 62:245 8.

9. 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.

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12. Inoue T, Tanaka I, Harashina T. Reconstruction of ischial pres- sure sore using an inferior rectus abdominis myocutaneous flap. Eur J Plast Surg 1990; 13: 22-25.

13. Ponten B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Br J Plast Surg 1981; 34: 215-20.

14. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 1987; 40:11341.

15. Hayashi A, Maruyama Y. Stepladder V-Y advancement flap for repair of postero-plantar heel ulcers. Br J Plast Surg 1997; 50: 657-61.

The Authors

Akiteru Hayashi MD, Assistant Professor Yu Maruyama MD, Professor and Chairman Michio Saze MD, Instructor Emi Okada MD, Staff Plastic Surgeon

Department of Plastic and Reconstructive Surgery, Toho University Hospital, 6-11-10hmorinishi, Ohta-ku, Tokyo 143, Japan.

Correspondence to Akiteru Hayashi.

Paper received 14 July 1997. Accepted 24 November 1997.