The gluteal perforator-based flap in repair of pressure sores

The British Association of Plastic Surgeons (2004) 57, 342 347 CASE REPORTS The gluteal perforator-based flap in repair of pressure sores Çilingir Meltem*, Çelik Esra, Fındık Hasan, Duman Ali Department of Plastic and Reconstructive Surgery, Haydarpaşa Numune Teaching and Research Hospital, Üsküdar, İstanbul, Turkey Received 24 September 2003; accepted 23 December 2003 KEYWORDS Gluteal perforator-based flap; Pressure sore; Island flap; Transposition Summary The gluteal perforator-based flap is designed according to the localisation of sacral perforator vessels. These vessels penetrate the gluteus maximus muscle and reach the intrafascial and suprafascial planes, and the overlying skin forming a rich vascular plexus. The gluteal perforator-based flaps described in this paper are highlyvascularised, have minimal donor site morbidity, do not require the sacrifice of the gluteus maximus muscle and rarely lead to post-operative complications. We believe these easy-to-perform flaps might be considered as the first choice in the repair of gluteal pressure sores. Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. Despite advances in reconstruction techniques, pressure sores continue to present a challenge to the plastic surgeon. Numerous surgical techniques have been employed in their repair, each with its own advantages and disadvantages. We present 27 patients operated on for sacral, ischial and trochanteric pressure sores using gluteal perforator-based flaps. Materials and methods Clinical study Twenty seven patients, 17 male and 10 female, were operated upon between the years 2000 and *Corresponding author. Address: Tütüncü Mehmet Efendi Cad. Hattat Bahattin, Sok. Günen Apt. No: 19/17 Göztepe/İstanbul, Turkey. E-mail address: mgcilingir@yahoo.com 2003. The mean age of the group was 49.4 (age range: 20 90 years). Dimensions of the skin defects and operative details for all patients are shown in Table 1. Eighteen (66.7%) patients were paraplegic, eight (29.6%) were ambulatory and one (3.7%) patient was quadriplegic. The ambulatory patients presented with pressure sores resulting from prolonged immobilisation after orthopedic or cardiovascular surgery. Of those sores; 20 (71.4%) were sacral, five (17.9%) were trochanteric and three (10.7%) were ischial. One patient (patient no: 1 in Table 1) had two pressure sores, one sacral and one trochanteric. Flaps with dimensions of 5 8cm 2 10 20 cm 2 were designed. Flaps were mostly raised based on 5 6 perforators at least (Fig. 1). One flap was transposed based on only one perforator (Fig. 2). Twenty of the defects were repaired using transposition flaps and advancement perforator-based flaps for the remaining eight. S0007-1226/$ - see front matter Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2003.12.039

The gluteal perforator-based flap in repair of pressure sores 343 Table 1 Patient summaries Case Age Sex Ambulatory para-quadriplegic patient Localisation Flap Flap size (cm 2 ) 1 23 M Quadriplegic Sol trochanteric þ sacral Gluteal perforatör-based island flap a,b 8 15 10 20 2 90 F Ambulatory Sacral Gluteal perforator-based island flap b 8 18 3 56 F Ambulatory Sacral Gluteal perforator-based island flap b 8 18 4 20 M Paraplegic Sacral Gluteal perforator based island flap b 10 20 5 45 F Paraplegic Sacral Gluteal perforator based island flap b 6 14 6 58 M Paraplegic Sacral Gluteal perforator based island flap b 10 20 7 63 M Paraplegic Trochanteric Gluteal perforator based island flap b 5 8 8 28 M Paraplegic Sacral Gluteal perforator based island flap a 15 20 9 72 F Paraplegic İschial Gluteal perforator based island flap a 14 20 10 88 F Paraplegic Sacral Gluteal perforator based island flap b 10 16 11 26 M Paraplegic Sacral Gluteal perforator based island flap b 8 12 12 65 M Ambulatory Sacral Gluteal perforator based island flap a 10 20 13 60 F Ambulatory İschial Gluteal perforator based island flap b 8 10 14 21 M Paraplegic Trochanteric Gluteal perforator based island flap b 16 20 15 30 M Ambulatory Sacral Gluteal perforator based island flap a 12 16 16 57 M Paraplegic Sacral Gluteal perforator based island flap b 10 20 17 27 F Paraplegic Sacral Gluteal perforator based island flap a 8 12 18 34 M Paraplegic Sacral Gluteal perforator based island flap b 16 20 19 42 M Paraplegic Sacral Gluteal perforator based island flap b 5 8 20 80 M Paraplegic Sacral Gluteal perforator based island flap b 16 20 21 48 F Paraplegic İschial Gluteal perforator based island flap a 10 15 22 64 F Ambulatory Sacral Gluteal perforator based island flap a 15 20 23 62 M Paraplegic Trochanteric Gluteal perforator based island flap a 6 10 24 75 M Ambulatory Sacral Gluteal perforator based island flap b 10 20 25 25 M Paraplegic Sacral Gluteal perforator based island flap b 8 14 26 36 M Ambulatory Sacral Gluteal perforator based island flap b 6 12 27 39 F Paraplegic Sacral Gluteal perforator based island flap b 10 18 a Advancement flap. b Transposition flap. Operative technique The localisation of perforators around the sacrum was preoperatively determined by a USG Doppler. The borders of the skin flap were marked on the parasacral region of the gluteal muscle. The first incision was made through the superior border, then using scissors and flap retractors the skin and subcutaneous tissue were dissected delicately and separated from the underlying muscle until the perforators were seen. The outlines of the flap were modified when no perforators were available within the expected flap area. The flap was raised off the underlying muscle from distal to proximal. The donor site was closed primarily. Figure 1 Intra-operative view of the flap. Figure 2 Intra-operative view of the flap with only one perforator preserved.

344 C. Meltem et al.c. Meltem et al. Figure 3 A 23-year-old male patient. (A) Pre-operative view of the trochanteric and sacral pressure sores. (B) Marking of the flap. (C) Gluteal perforator-based transposition and advancement flaps.

The gluteal perforator-based flap in repair of pressure sores 345 Figure 4 A 90-year-old female patient. (A) Pre-operative view of the pressure sore. (B) Gluteal perforatorbased transposition flap. Results There was no total flap necrosis seen in 27 cases. The most serious post-operative complication was necrosis of the distal quarter of flaps in two (7.4%) cases (patients no: 11, 16 in Table 1), which were repaired with rotation flaps. In four (14.8%) patients distal epidermolysis of the flap was seen which improved spontaneously. All other flaps healed after an uneventful follow-up period. Case reports Case 1 A 23-year-old quadriplegic male patient was referred with grade 3 left trochanteric and sacral pressure sores (Fig. 3(A)). The trochanteric defect was repaired using a gluteal perforator-based advancement flap (Fig. 3(B) and (C)). The sacral defect was reconstructed with a gluteal perforatorbased rotation flap (Fig. 3(C)). There were no postoperative complications. Figure 5 A 56-year-old female patient. (A) Pre-operative view of the pressure sore. (B) Marking of the flap. (C) Gluteal perforator-based transposition flap. After 6 months. Case 2 A 90-year-old ambulatory female patient presented with a sacral pressure sore after a prolonged hospitalisation because of cardiovascular insufficiency (Fig. 4(A)). Gluteal perforator-based transposition flap was used for reconstruction and the flap healed without any complication (Fig. 4(B)). Case 3 A 56-year-old ambulatory female patient who had a

346 Ç. Meltem et al.ç. Meltem et al. he fell from a height. A sacral pressure sore was closed with a 10 20 cm 2 gluteal perforator-based rotation flap (Fig. 6(A) and (B)). The flap recovery was uneventful (Fig. 6(C)). Discussion Figure 6 20-year-old male patient. (A) Pre-operative view of the pressure sore. (B) Marking of the flap. (C) After two weeks. right femur fracture presented with a sacral pressure sore (Fig. 5(A)). A gluteal perforatorbased transposition flap with dimensions of 8 18 cm 2 was used for reconstruction and no complication was observed (Fig. 5(B) and (C)). Case 4 A 20-year-old male patient became paraplegic after A gluteal perforator-based flap is outlined depending on the localisation of the sacral perforators that are penetrating the gluteus maximus muscle. According to anatomic and clinical studies by Koshima et al. the number of perforators in the gluteal region is 20 25. The length of these vessels varies between 3 and 8 cm with diameters of 1 1.5 cm. Large calibre perforators are found in the parasacral and central portions of the gluteal maximus muscle. 1 These perforators pass through the muscle and fascial portion of the muscle to reach the overlying skin. According to the localisation and grade of pressure sores, primary closure, skin grafts, fasciocutaneous or musculocutaneous flaps may be preferred for reconstruction. 2,3 More recently the gluteal perforator-based flaps have been used for pressure sore repair. They have proved to be safe, reliable flaps allowing closure of sacral, trochanteric and ischial pressure sores. Large calibre perforators that are found in the parasacral and central portions of the gluteal maximus muscle make these flaps reliable. Donor site can be closed directly. The requirement for skin grafting is minimal. Even using only one perforator, the viability of the flap may be preserved. 1 Ambulatory patients are thus spared from any difficulty in walking since the gluteus maximus muscle is not sacrificed. 4 In paraplegic patients preserving the gluteus maximus muscle provides an opportunity to repair recurrent pressure sores. 5 Random pattern fasciocutaneous flaps have the significant risk of failure due to poor perfusion. Axial pattern gluteus maximus gluteal perforator-based flaps are superior to random pattern local fasciocutaneous flaps for this particular reason. By planning the flap around predetermined and predictable perforator vessels the viability of the flap may be preserved whilst increasing the amount of movement. The technical problem of anatomic variations can be overcome by using Doppler USG to identify perforating vessels, which are then included in the flap design. We present the gluteal perforator-based flap as a useful means to reconstruct pressure sores of sacral, trochanteric and ischial areas.

The gluteal perforator-based flap in repair of pressure sores 347 References 1. Koshima I, Moriguchi T, Soeda S, et al. The gluteal perforatorbased flap for repair of sacral pressure sores. Plast Reconstr Surg 1993;91:678 83. 2. Mancoll JS, Philips LG. Chapter 90: pressure sores. In: Aston SJ, Beasly RW, Thorne CHM, editors. Grabb and Smith s plastic surgery, 5th ed. New York: Lippincott-Raven; 1997. p. 1083 97. 3. Mathes SJ, Nahai F. Reconstructive surgery: principles, anatomy, and technique. New York: Churchill Livingstone; 1997. p. 499 535. 4. Padubidri AN, Browne EZ, Lucas AR. Back reconstruction. Med J 2001;2(12). 5. Spyriounis PK. Perforator flaps the first choice in pressure sore reconstruction. Hellenic Plastic Surgery; November 2001.