Gluteus maximus island musculocutaneous flap for closure of sacral and ischial ulcers

Anatomical Considerations and Plastic Surgery Reconstruction Options of Sacral Chordoma Resection

Introduction Chordomas are slow-growing malignant bone tumors arising from remnant embryonic notochord cells with predilection for the sacrum. They rarely metastasize, and early surgical resection with clear margins is the treatment of choice followed by plastic surgery reconstruction supplemented with adjuvant radiotherapy based on the local treatment protocol or in cases with a contaminated surgical field. Aim The aim of the present study is to present our experience in surgical management of sacral chordomas and propose a surgical reconstruction algorithm considering anatomical parameters after partial or total sacrectomy. Materials and methods  Twenty-seven patients with sacral chordomas were treated in our Orthopaedic Surgery Department between January 1997 and September 2022, and 10 of them had plastic surgery reconstruction. Patients were divided into groups based on the type of sacrectomy, sacrum anatomical vascular or neural variations, partial or total, and the type of soft tissue reconstruction. The postoperative complications and the functional outcomes in each patient were assessed. Results  Bilateral gluteal advancement flaps or gluteal perforator flaps are the first choice in patients with partial sacrectomy, intact gluteal vessels, and without preoperative radiotherapy followed by transpelvic vertical rectus abdominis myocutaneous flap or free flaps in those patients with near total sacrectomy and preoperative radiation therapy. Conclusion  There are four reliable options for patients after sacral chordoma resection: direct closure, bilateral gluteal advancement flaps, transpelvic vertical rectus abdominis myocutaneous flaps, and free flaps. Each time, tumor-free margins and a good reconstructive plan according to the defect and patient characteristics are mandatory.

A Dynamic Anatomic Study of Parasacral Perforators: Mapping, Perforasome, and Applications for Buttock Enhancement

BACKGROUND

Due to the lack of knowledge about parasacral artery perforators, flaps from this region cannot be used with complete confidence in their security and effectiveness. Knowledge of the clusters and perforasome of these perforators could help in the design of more reliable flaps and extend the range of applications.

OBJECTIVES

This study aimed to identify the location, number, and density of perforators, and to subsequently analyze the perfusion flow and linking vessel distribution.

METHODS

Five fresh cadavers were harvested and dissected. For the mapping, after injecting lateral sacral arteries with colored latex, perforators with a diameter of >0.5 cm were examined in 5 sacral regions. All data were collected on the suprafascial plane, with an orthonormal coordinate system placed on iliac crests and median lines. For perforasome analysis, 5 perforators and 3 three sacral flaps were injected with radiopaque dye. A dynamic (4-dimensional) computed tomographic angiography completed the analysis.

RESULTS

A mean [standard deviation] of 8.4 [1.36] perforators per corpse, with a mean diameter of 0.72 [0.14] mm, were identified. There was a higher density of parasacral perforators close to the median line and 7.6 cm above the iliac crests. This pattern was not a random distribution (P < 0.05). The perfusion area was preferentially in the superior gluteal region. Perfusion flow was permitted by the dominant direct-linking vessels towards adjacent lumbar perforators, oriented diagonally upward and outward to the midline.

CONCLUSIONS

Parasacral perforator flaps appear to be a useful procedure in reconstruction and in aesthetic surgery, especially in gluteal augmentation. Their reliability depends on sound anatomic knowledge, with accurate preoperative perforator mapping.

Pedicled Chimeric Perforator Flap Based on Inferior Gluteal Vessel Axis for the Reconstruction of Stage-Four Primary Ischial Pressure Sores-A New Design

Background  “Subfascial void reconstruction” in ischial pressure sores (IPSs) goes a long way in the amelioration of the common complications like persistent drainage, infection, wound dehiscence, and late recurrence. No locoregional flaps suffice this requirement. So we have designed a chimeric pedicled flap based on the inferior gluteal vessel axis (IGVA) perforators with two tissue components: (1) Pacman-style fasciocutaneous flap on a perforator and (2) gluteus maximus muscle (inferior portion) on another independent perforator.

Aim and Methods  After confirming the feasibility of novel design of chimeric pedicled IGVA perforator flap with cadaver study, we embarked on the clinical study with this chimeric flap. In this prospective cohort study, the study and the control existed in the same patient so that the biological factors affecting the wound healing would be the same.

Results  Twenty-one patients were included whose mean age was 39 years. Late recurrence occurred in one patient (4.8%) of chimeric flap while the control group (who had undergone conventional reconstruction) had recurrence in 11 patients (52.4%). On assessment with overall institutional score, grade A was observed in 18 patients of the chimeric IGVA flap group ( p < 0.045), and in only 3 patients of the control group.

Conclusions  This anatomically construed flap, a new addendum in the armamentarium of reconstruction of IPSs, with its potential to congruently fill the ischiogluteal subfascial void may provide a lasting solution for preventing recurrences.

[Dorsal skin defect: What solutions exist?]

Dorsal subcutaneous or cutaneous defects can be of multiple origin: tumor, congenital malformation, trauma, chronic radiodermitis ulceration, parting of sutures or spine surgery infection, pressure sore, etc. Wound healing of these defects can be really difficult to obtain with simple processes, such as direct sutures or skingrafts, and often implies skin flap surgery. The rarity of recipients vessels from the dorsal area makes free flaps surgery harduous. Various local or locoregional back cover solutions are available: muscular or musculocutaneous flaps (latissimus dorsi, trapezius muscle, spinal muscles, gluteus maximus), perforator flaps (DICAP, DLICAP, SCAP and IGAP…), random flaps. These flaps are really useful and must be mastered in order to propose the best-suited cover solution for each patient after a precise evaluation of their medical and clinical background. Our study, based on the Literature and some clinical cases, aims to draw up a complete table of local, locoregional and microsurgical coverage solutions by anatomical area for median and paramedian back wound defects and thus to produce a decisional algorithm facilitating our care.

Dual-Plane Gluteal Myocutaneous Flap for Reconstruction of Ischial Tuberosity Pressure Wounds

PURPOSE

Ischial tuberosity pressure wounds are the most common type of pressure wound and contribute to a large percentage of the total cost of surgical and nonsurgical management of pressure wounds. Gluteal myocutaneous and fascocutaneous flaps are well-documented methods of coverage for ischial pressure wounds. This study aimed to describe results using a novel dual-plane gluteal myocutaneous flap technique for reconstruction of ischial tuberosity pressure wounds.

METHODS

A retrospective chart review was performed of all patients who underwent dual-plane gluteus maximus myocutaneous flap reconstruction for ischial tuberosity pressure wounds performed by a single surgeon from 2012 to 2018. Patient demographic, clinical, and operative characteristics were reviewed. Outcomes were assessed by analyzing complication rates including recurrence, need for revision surgery, dehiscence, necrosis, wound infection, seroma, and hematoma.

RESULTS

Eight dual-plane gluteus maximus myocutaneous flaps were performed for reconstruction of ischial tuberosity pressure wounds in 7 male patients with a mean age of 49.1 ± 14.9 years (mean ± SD) and mean body mass index of 26.7 ± 6.4 kg/m. All patients were nonambulatory secondary to spinal cord injury or congenital neurological disease. Two patients (28.6%) were diabetic, and 1 patient (14.3%) was an active smoker. The mean defect size after debridement of ischial pressure wounds was 60.7 ± 29.4 cm. After a mean follow-up of 16.4 months, partial wound dehiscence occurred in 1 patient (14.3%) and was managed with local wound care only. Infection and recurrence occurred in another patient (14.3%) and required revision surgery.

CONCLUSIONS

The dual-plane gluteal myocutaneous flap is an effective method for reconstruction of ischial tuberosity pressure wounds. Partially elevating the cutaneous layer off the gluteus maximus muscle allows for greater mobility and rotation of the muscle flap into the ischial pressure wound defect and closure of the flap and donor site with the cutaneous layer.

Squamous cell carcinoma of the renal pelvis presenting as an integumentary neoplasm of the flank: A case report

RATIONALE

Although chronic pyelonephritis and urolithiasis are established risk factors for squamous cell carcinoma (SCC), only a minority of patients with chronic urolithiasis eventually develop SCC. It is believed that the chronic irritation leads to squamous cell metaplasia that may subsequently develop into SCC. Although studies show that SSC generally spreads locally with associated symptoms of lymphadenopathy, metastasis to the lungs and liver have also been reported. However, cases spreading to the flank have yet to be reported. Therefore, the use of reconstructive techniques for the repair of extensive soft tissue defects in the flank region after extended retroperitoneal resection, is unknown.

PATIENT CONCERNS

We report a 54-year-old man who presented with a 1-month history of an enlarged skin mass on the right flank.

DIAGNOSES

The patient was subsequently diagnosed with metastatic SCC involving the patient's integumentary system near the flank region proximal to the right kidney following percutaneous nephrostomy.

INTERVENTIONS

The skin mass and the surrounding muscle tissue of the right flank were excised with a wide resection margin including radial nephrectomy. The soft tissue defect after resection was reconstructed using a unilateral gluteus maximus myocutaneous V-Y advancement flap.

OUTCOMES

No recurrence of the SSC was found on follow-up CT performed 12 months postoperatively.

LESSONS

In patients with long-standing nephrolithiasis complicated by staghorn stone-related infections, biopsies from suspicious lesions detected during percutaneous nephrolithotomy may facilitate early diagnosis. The modified gluteus maximus V-Y advancement flap may be a useful technique for the reconstruction of extensive soft-tissue defects involving the flank region.

A New Option for the Reconstruction of Primary or Recurrent Ischial Pressure Sores: Hamstring-Adductor Magnus Muscle Advancement Flap and Direct Closure

BACKGROUND

Owing to the high recurrence rates of ischial pressure sores, surgeons should consider the possibility of future secondary flap surgery during flap selection. The purpose of this article is to present a new surgical option for the reconstruction of primary or recurrent ischial pressure sores using a simple hamstring-adductor magnus advancement flap and direct closure.

METHODS

After horizontal fusiform skin excision, complete bursa excision and ischiectomy were performed. The tenomuscular origin of the adductor magnus and the conjoined tenomuscular origin of the biceps femoris long head and semitendinosus were isolated and completely detached from the inferior border of the ischial tuberosity. They were then advanced in a cephalad direction without detachment of the distal tendon or muscle and securely affixed to the sacrotuberous ligament. The wound was directly closed without further incision or dissection.

RESULTS

Twelve ischial pressure sores (6 primary and 6 recurrent; 12 patients) were surgically corrected. The follow-up period was 12 to 65 months. All patients healed successfully without early postoperative complications, such as hematoma, seroma, infection, wound dehiscence, or partial necrosis. Late complications included wound disruption 5 weeks after surgery that spontaneously healed in 1 case and recurrence 3 years later in another case.

CONCLUSIONS

The new surgical option presented herein, which involves hamstring-adductor magnus advancement flap and direct closure, is a simple and reliable method for providing sufficient muscle bulk to fill the dead space and proper padding to the bone stump while preserving the main vascular perforators and pedicles as well as future surgical options.

Comparative study between fasciocutaneous and myocutaneous flaps in the surgical treatment of pressure ulcers of the sacral region

Introduction

Decubitus ulcers of the sacral region are common conditions in bedridden patients. Deep lesions (Stages III and IV) often require surgical treatment for closure. Flaps of the region are the first choice for treatment. We present our experience in the treatment of these lesions and compare two different approaches: local fasciocutaneous flap and gluteus maximus myocutaneous flap with V-Y advancement.

Method

From March 2009 to May 2014, 32 patients underwent closure of sacral pressure ulcers by flaps, 17 of them with rotational local fasciocutaneous flaps and 15 with myocutaneous flaps of the gluteus maximus muscle with V-Y advancement. Evolution regarding complications and rate of success after two months was compared between the groups.

Results

Out of the 32 operated patients we obtained resolution of lesions after two months in 23 (71.8%), 10 patients in the fasciocutaneous flap group (58.8%) and 13 cases in the myocutaneous flap group (86.6%). The most common complication was partial dehiscence of sutures in 12 patients (37.5%), 8 patients in the fasciocutaneous flap group (47%) and 4 patients in the myocutaneous flap group (26.6%). The group of patients reconstructed with local fasciocutaneous flaps presented 3 cases with seroma, one with hematoma and 6 with partial cutaneous necrosis; these patients also required more drainage time.

Conclusions

Both the local rotational fasciocutaneous flap and the myocutaneous flap of the gluteus maximus muscle in V-Y flap can be used in the surgical treatment of sacral ulcers. In our experience, a reduced success rate and more complications were found in the local fasciocutaneous reconstructive method.

Two-stage treatment of ischial pressure ulcers in spinal cord injury patients: Technique and outcomes over 8 years

BACKGROUND

Despite newly introduced techniques, reconstruction of ischial pressure ulcers remains a difficult problem with high-reported failure rates.

METHODS

A retrospective chart review was performed on all spinal cord injury patients who underwent ischial pressure ulcer reconstruction by the senior author (V.L.) between 2004 and 2012. The two-stage procedure consisted of debridement and bone biopsy, followed by bursectomy, partial ischiectomy, fascial release, and gluteus maximus and hamstring advancement flaps. Postoperative care included 2-week supine bed rest on an air-fluidized bed, sitting tolerance rehabilitation, and thorough behavioral training.

RESULTS

Sixty-five patients (74 flaps) were identified. A 45.9% had a previous attempt at reconstruction. The median follow-up period was 622 days. Overall, 67.6% of flaps were intact at the last follow-up. Superficial and deep dehiscence rates were 16.2 and 28.4%, respectively. Seven out of 35 flaps suffered late recurrence after being well healed for more than 1 year. History of previous reconstruction was found to be associated with increased odds of superficial (OR 6.02, 95% CI 1.55-23.3) and deep dehiscence (OR 12.3, 95% CI 1.99-76.9).

CONCLUSIONS

The evolution of the senior author's decades of practice has led to the development of a simpler repair, which relies on plane-by-plane release of scarred tissues to improve the mobility of muscle and skin flaps without large tissue movements, even in the setting of apparent extensive tissue loss. This technique is a reliable option, particularly for the primary ischial pressure ulcer.

Superior gluteal artery perforator flap: A reliable method for sacral pressure ulcer reconstruction

Objective:

To study the feasibility and reliability of the superior gluteal artery perforator (SGAP) flap for the reconstruction of sacral pressure ulcers.

Method:

A prospective study was conducted between 2009 and 2012 where a total of 15 patients with sacral pressure ulcers underwent reconstructive surgery with an islanded pedicled SGAP flap. Success of the flap reconstruction and primary healing were defined as a healed wound within 30 days of the procedure. Reconstructive failure was defined as those cases that resulted in a non-healed wound, thereafter.

Results:

Of the 15 patients in the evaluation, 12 were male and 3 were female. Eleven patients were paraplegic, 3 were ambulatory and one was quadriplegic. All reconstructed flaps survived completely with no mortality or major donor site complications. Three patients had a minor infection and wound dehiscence that healed spontaneously. All wounds healed within 30 days of surgery following local wound care and culture-sensitive antibiotics. No recurrence of the pressure ulcer occurred during follow-up. The non-paraplegic patients did not develop gait disturbances following the surgery.

Conclusion:

These observations suggest that the islanded pedicled SGAP fasciocutaneous flap is a relatively easy flap to raise, with good reliability and minimal complications, and is therefore highly recommended for the reconstruction of the sacral pressure ulcer.

Declaration of interest:

There were no external sources of funding for this study. The authors have no conflicts of interest to declare.

Salvage total pelvic exenteration with bilateral v-y advancement flap reconstruction for locally recurrent rectal cancer

Total pelvic exenteration for locally recurrent rectal cancer typically requires extensive excision of the pelvic floor with perineal skin. Due to the extensiveness of the procedure and its non-curative nature, it is controversial as purely palliative therapy. A 66-year-old male patient who had undergone abdominoperineal resection at another hospital 8 years prior was admitted to our hospital. During radiation and chemotherapy for 2 years, he complained of perineal pain, discharge, cacosmia and bleeding from a recurrent tumor. The 10 × 8 cm recurrent tumor was exposed on the perineum and the patient suffered from serious discomfort in his daily life during walking or sitting. We performed total pelvic exenteration with partial sacrectomy, after which the large perineal defect was reconstructed with a bilateral V-Y gluteus maximus advancement flap in approximately 120 min. The patient's postoperative course was satisfactory and his quality of life markedly improved.

Perforator propeller flaps for sacral and ischial soft tissue reconstruction

The perforator-based flaps in the sacral and ischial region is designed according to the localization of perforators that penetrate the gluteus maximus muscle, reach the intra-fascial and supra-fascial planes with the overlying skin forming a rich vascular plexus. The perforator-based flaps described in this article are highly vascularized, have minimal donor site morbidity, and do not require the sacrifice of the gluteus maximus muscle. In a period between April 2008 and March 2009, six patients with sacral pressure sore were reconstructed with propeller flap method based on superior gluteal and parasacral artery perforators. One flap loss was noted. Three cases of ischial pressure sore were reconstructed with longitudinal propeller flap cover, based on inferior gluteal artery perforator. One flap suffered wound infection and dehiscence. Two cases of pilonidal sinus were reconstructed with propeller flap based on parasacral perforators. Both the flaps survived without any complications. Donor sites were closed primarily. In the light of this, they can be considered among the first surgical choices to re-surface soft tissue defects of the sacral and ischial regions. In the series of 11 patients, two patients (18%) suffered complications.

A New Technique of ???Double-A??? Bilateral Flaps Based on Perforators for the Treatment of Sacral Defects

BACKGROUND

Myocutaneous and fasciocutaneous flaps can provide stable coverage of sacral defects. For neurologically intact patients, sensate innervated gluteal artery perforator flaps are the ideal solution. For patients with spinal cord injury, soft-tissue coverage can be performed with a variety of noninnervated flaps.

METHODS

Between 1997 and 2004, the authors operated on 30 patients, 21 men and nine women, using bilateral gluteal distal fasciocutaneous and proximal musculocutaneous vertical vector rotation-advancement flaps, based on perforators with V-Y closures. The ages of the patients ranged from 32 to 74 years. Twenty-five patients had spinal cord injuries and all had sacral pressure sores extending to the bone. Three patients had low-grade malignant tumors (sacral chordomas); one had a sacral radiation-induced necrosis and two senile patients with large sacral defects had chronic renal failure and multiple sclerosis. No comorbidities were found in the sample.

RESULTS

All the lesions were closed successfully. After follow-up of 1 to 8 years, 27 patients never required repeated surgery after wound complications. Three patients had infection and partial dehiscence of the flaps that healed after reoperation with V-Y readvancement; three died as a result of their primary diseases.

CONCLUSIONS

This flap design has been used only in selected cases because, after its elevation, use of other gluteal-based flaps for future sacral reconstructions may not be possible. Five neurologically intact patients were found to have good sensitive protection of the flaps and adequate cushion contour after surgery because the authors conserved the gluteal arteries, perforators, and their corresponding sensory nerves.

The posterior thigh perforator flap or profunda femoris artery perforator flap

BACKGROUND

The thigh donor site has been used extensively for microsurgical tissue transfer; however, the posterior thigh has been neglected as a potential donor site. The perforators of the profunda femoris artery supply large cutaneous territories that could be useful for lower extremity coverage. The purpose of this article is to evaluate the anatomical basis of the posterior thigh perforator flap and to provide anatomical landmarks with which to facilitate flap dissection.

METHODS

Six fresh cadavers underwent a whole-body, intraarterial injection of a lead oxide and gelatin preparation. The integument of the posterior thigh was dissected (n = 11), and perforators of the profunda femoris artery were identified. Their type (septocutaneous versus musculocutaneous), course, size, and location were documented by angiography and photography. Surface areas were measured with Scion Image Beta 4.02. Results are reported as mean +/- SD.

RESULTS

The average number of profunda femoris cutaneous perforators in the posterior thigh was 5 +/- 2 (65 percent septocutaneous and 35 percent musculocutaneous), the average internal diameter was 0.8 +/- 0.3 mm, and the pedicle length was 29 +/- 14 mm from the deep fascia and 68 +/- 33 mm from the profunda femoris artery. The average profunda femoris cutaneous vascular territory was 229 +/- 72 cm, with a 46 +/- 13-cm perforator zone. Cutaneous perforators can be found on a line extending from the ischium to the lateral femoral condyle.

CONCLUSIONS

The profunda femoris provides cutaneous perforators of large caliber supporting a substantial cutaneous territory. This flap will likely be clinically useful in lower extremity reconstruction as a free or pedicled flap.

Anatomical Basis and Clinical Application of the Infragluteal Perforator Flap

BACKGROUND

When selecting flaps for coverage of pressure ulcers of the sacrum and perineal region in paraplegic patients, long-term high recurrence rates should be considered. Therefore, the authors developed an infragluteal perforator flap to avoid "burning bridges" for future reconstruction.

METHODS

Infragluteal perforator flaps were dissected in five fresh human cadavers to define the anatomy of the cutaneous branches of the descending branch of the inferior gluteal artery and cluneal nerves and define anatomical landmarks for clinical application. In a series of 13 paraplegic patients, the authors used perforator-based flaps (additional skin bridge) to cover four perineal ulcers and one sacral ulcer and perforator flaps to cover six perineal and two sacral ulcers. Donor sites were closed by direct approximation.

RESULTS

Twelve of 13 flaps healed uneventfully. In all cadaver and clinical dissections, one or two cutaneous branches of the descending branch of the inferior gluteal artery and one or two cluneal nerves were found at the lower border of the gluteus maximus muscle supplying the infragluteal perforator flap. These direct cutaneous branches allowed dissection of inferior gluteal perforator flaps with improved flap mobility compared with the perforator-based flaps. The descending branch of the inferior gluteal artery could always be spared for future flaps.

CONCLUSIONS

The infragluteal perforator flap is a versatile and reliable flap for coverage of ischial and sacral pressure sores. It can be designed as a perforator-based or perforator flap and could provide a sensate flap in ambulatory patients. Donor-site morbidity is minimal, and options for future flaps of the gluteal and posterior thigh region are preserved.

Clinical Experience With the Hatchet-Shaped Gluteus Maximus Musculocutaneous Flap

One of the most frequently used flaps for the coverage of sacral skin and soft-tissue defects (primarily decubiti) is the gluteus maximus musculocutaneous flap. The authors have developed a new, hatchet-shaped incision direction for the flap and have been using it for 6 years in the surgical treatment of various pelvic-area defects with good results. At the beginning, the gluteus maximus hatchet-shaped flap was used for treatment of pressure sores in the pelvic area: sacral decubitus on 31 patients, ischial pressure ulcer on 12 patients, and trochanteric ulcer on 1 patient. However, later the method was applied to nondecubitus defects, such as myelomeningocele on 4 patients, Crohn disease on 3 patients, pilonidal sinus on 2 patients, and traumatic defect on 1 patient, totaling 71 flaps on 54 patients. The seroma (4), hematoma (2), postoperative bleeding (1), and partial flap necrosis (1) healed following emptying and repeated surgery; recurrent ulcer was seen in 2 cases. Advantages of the method are the fewer incisions needed, the shorter operating time, and the smaller blood loss as compared with the methods known so far. The new incision direction improves the safety of circulation in the flap, the closure of the donor site is simpler, and no contour difference remains in the surgical area.

Autoprosthesis buttock augmentation during lower body lift

With the increasing popularity of bariatric surgery, patients with multiple body contour deformities have become more common in plastic surgery practice. Most of the deformities involving the abdomen, thighs, and buttocks can be effectively corrected with belt lipectomy and lower body lift. A common problem with this procedure is postoperative loss of gluteal projection and resulting flattened buttock contour, which is directly proportional to the extent of lower body lift achieved. The use of local myocutaneous flaps to provide coverage for the lumbosacral defects is a common plastic surgery procedure. The authors have used these techniques to create an autologous buttock implant for additional projection during a lower body lift. A local myocutaneous flap originating within the regularly excised supragluteal tissue is rotated caudally to function as an autologous buttock implant. This flap has reliable circulation, can be custom designed for each patient, requires minimal additional operating time, and allows the creation of more than one flap if necessary. This article describes the results of this procedure used for 20 consecutive women. There were no major complications, and the most common minor complications included delayed wound healing and local hardness in the area, suggesting fat necrosis, which resolved without intervention in a few months. High patient satisfaction combined with a low complication rate suggests that this reliable, versatile technique nicely complements the lower body lift procedure.

Triple Coverage of Ischial Ulcers with Adipofascial Turnover and Fasciocutaneous Flaps

Despite a wide variety of flap options, ischial ulcers remain the most difficult pressure ulcers to treat. This article describes the authors' successful surgical procedure for coverage of ischial ulcers using adipofascial turnover flaps combined with a local fasciocutaneous flap. After debridement, the adipofascial flaps are harvested both cephalad and caudal to the defect. The flaps are then turned over to cover the exposed bone in a manner so as to overlap the two flaps. A local fasciocutaneous flap (Limberg flap) is applied to the raw surface of the turnover flaps. Twenty-two patients with ischial ulcers were treated using this surgical procedure. Overall, 86.4 percent of the flaps (19 of 22) healed primarily. Triple coverage with the combination of double adipofascial turnover flaps and a local fasciocutaneous flap allows for an easily performed and minimally invasive procedure, preservation of future flap options, and a soft-tissue supply sufficient for covering the prominence and bony prominence and filling dead space. This technique provides successful soft-tissue reconstruction for minor to moderate-size ischial pressure ulcers.

Distal Perforator???Based Fasciocutaneous V-Y Flap for Treatment of Sacral Pressure Ulcers

Although the gluteal V-Y advancement flap has been recognized as the most reliable method for management of sacral pressure ulcers, its limited mobility has been a challenging problem. The authors present a new modification of the V-Y advancement flap to overcome the problem. After débridement, a large triangle is designed to create a V-Yadvancement flap on the unilateral buttock and the medial half is elevated as a fasciocutaneous flap, preserving the distal perforators in the muscular attachment. Then an arc-shaped incision is made in the gluteus maximus muscle along with the lateral edge of the triangular flap. The split muscle is elevated at a depth above the deeper fascia until sufficient advancement of the flap is obtained. This full-thickness elevation of the gluteus maximus muscle from the distal (lateral) side avoids the impairment of perforators or their mother vessels and achieves great advancement. Thirty-one patients with sacral pressure defects larger than 8 cm in diameter were treated using this surgical procedure. Overall, 93.5 percent of the flaps (29 of 31) healed primarily. The largest defect that was closed with a unilateral flap was 16 cm in diameter. The present technique accomplishes remarkable excursion of the unilateral V-Y fasciocutaneous flap, with high flap reliability and preservation of the contralateral buttock as well as gluteus maximus muscle function.

Gluteal Perforator Flaps for Coverage of Pressure Sores at Various Locations

Flap coverage is essential for successful treatment of pressure sores, and musculocutaneous flaps have been preferred universally. Development of perforator flaps supplied by musculocutaneous perforators has allowed reconstructive surgeons to harvest flaps without including muscles. Perforator flaps have enhanced the possibility of donor sites because a flap can be supplied by any musculocutaneous perforator, and donor-site morbidity is also reduced. Between November of 1998 and June of 2002, the authors used 35 gluteal perforator flaps in 32 consecutive patients for coverage of pressure sores located at sacral (n = 22), ischial (n = 7), and trochanteric (n = 6) regions. The mean age of the patients was 53.1 years (range, 5 to 87 years), and there were 16 male and 16 female patients. All flaps in this series were supplied by musculocutaneous arteries arising from gluteal muscles. Patients were followed up for a mean period of 13.6 months. Wound dehiscence was observed in two patients and treated by secondary closure. Three patients died during the follow-up period. All flaps survived except one that had undergone total necrosis, and only one recurrence was noted during the follow-up period. Gluteal perforator flaps are safe and reliable options for coverage of pressure sores located at different locations. Freedom in flap design and low donor-site morbidity make gluteal perforator flaps an excellent choice for pressure sore coverage.

"Pac Man" flap for closure of pressure sores

The purpose of this study was to modify the classic bilateral V-Y advancement flap procedure to decrease the tension in its closure and to break the midline vertical scar by interdigitating the flaps. After debridement of a pressure sore, the V-Y flaps were marked on both sides of the wound. Skin incisions were carried down to the muscle fascia along the sides of the flaps. The upper and lower limbs of the V-shaped flaps were elevated as triangular flaps but remained attached to the main flap. The tip of the upper limb of one of the flaps was transposed into the defect and sutured to the contralateral V-Y flap at the midpoint of its concave side facing the defect. The lower limb of the contralateral flap was then transposed into the defect and sutured to the first V-Y flap. To complete the interdigitated closure, the lower limb of the first flap was sutured below the contralateral flap, and the upper limb of the contralateral flap was sutured above the first flap. The final view of the flaps was similar to "Pac Man," so the authors decided to call this flap the Pac Man flap. The flaps healed well in all patients, and wound breakdown or recurrence of the pressure sore was not observed during the 3 to 14-month follow-up.

Split gluteus maximus island flaps for concomitant closure of ischial and sacral pressure sores

The author presents an innovation in the use of the gluteus maximus musculocutaneous flap that allows one to repair both sacral and ischial pressure sores concomitantly in a paraplegic patient. The musculocutaneous unit is divided into superior and inferior halves, each of which is supplied by their respective gluteal arteries. The "islanded" flaps can be moved in different directions independent of one another to cover both the sacral and ischial regions at the same time. The donor area can be closed primarily. Three patients were operated using this method. The 1-year follow-up of 1 patient is presented.

Reconstruction of large sacral defects following total sacrectomy

Total sacrectomies for cancer ablation often result in extensive defects that are challenging to reconstruct. In an effort to elucidate the criteria to select the most effective reconstructive options, we reviewed our experience with the management of large sacral wound defects. All patients who had a sacral defect reconstruction after a total sacrectomy at our institution between January of 1993 and August of 1998 were reviewed. The size of the defect, the type of reconstruction, postoperative complications, and functional outcome in each patient were assessed. A total of 27 flaps were performed in 25 patients for sacral defect reconstruction after a total sacrectomy. Diagnoses consisted of chordoma (n = 13), giant cell carcinoma (n = 2), sarcoma (n = 5), rectal adenocarcinoma (n = 4), and radiation induced necrosis (n = 1). The size of sacral defects ranged from 18 to 450 cm2 (mean, 189.8 cm2). Ten patients, including five who had preoperative radiation therapy, underwent transpelvic vertical rectus abdominis myocutaneous (VRAM) flap reconstruction for sacral defects with a mean size of 203.3 cm2. Of these, five patients (50 percent) had complications (four minor wound dehiscences and one seroma). Eight patients, including one who had preoperative radiation therapy, underwent bilateral gluteal advancement flap reconstruction for sacral defects with a mean size of 198.0 cm2. They had no complications. Two patients, both of whom had preoperative radiation therapy, underwent gluteal rotation flap reconstruction for sacral defects of 120 cm2 and 144 cm2. Both patients had complications (one partial flap loss and one nonhealing wound requiring a free flap). Three patients, including one who had preoperative radiation therapy, underwent reconstruction with combined gluteal and posterior thigh flaps for sacral defects with a mean size of 246 cm2; two of these patients had partial necrosis of the posterior thigh flaps. Three patients, all of whom had preoperative radiation therapy, underwent free flap reconstruction for sacral defects with a mean size of 144.3 cm2. They had no complications. Our experience suggests that there are three reliable options for the reconstruction of large sacral wound defects: bilateral gluteal advancement flaps, transpelvic rectus myocutaneous flaps, and free flaps. In patients with no preoperative radiation therapy and intact gluteal vessels, the use of bilateral gluteal advancement flaps should be considered. In patients with a history of radiation to the sacral area and in patients whose gluteal vessels have been damaged, the use of the transpelvic VRAM flap should be considered. If the transpelvic VRAM flap cannot be used because of previous abdominal surgery, a free flap should be considered as a last option.

Reconstruction of perianal skin defect using a V-Y advancement of bilateral gluteus maximus musculocutaneous flaps: reconstruction considering anal cleft and anal function

In order to preserve the anal function after ano-perianal skin excision for malignancy, we have reconstructed a deep, symmetrical natal cleft using a V-Y advancement of bilateral gluteus maximus musculocutaneous flaps thinned medially and sutured to the ooccyx, anococcygeal ligament and the central tendon of the perineum. This technique was applied in three cases of Bowen's disease and two cases of Paget's disease. In all five cases, postoperative anal functions such as comfortable defecation and sensation, were well preserved, the perianal skin and underwear stayed clean, and there was no disturbance of walking or exercise.

Tangentially split gluteus maximus myocutaneous island flap based on perforator arteries for the reconstruction of pressure sores

From 1995 to 1997, the authors used tangentially split gluteus maximus myocutaneous island flaps based on the musculocutaneous perforator arteries for the reconstruction of pressure sores located in the trochanteric, sacral, and ischial regions of 30 ambulatory and paraplegic patients. The postoperative follow-up period was 18 months. Postoperative electromyograms were performed on the ambulatory patients to compare the function of the gluteus maximus muscles on each side. There were one major and two minor postoperative complications. There was no total flap loss. The major advantage of this technique is the preservation of most of the gluteus maximus for stair climbing and single-limb support in the ambulatory patient. The tangentially split gluteus maximus myocutaneous island flap is recommended as the procedure of choice for closure of sacral, ischial, and trochanteric ulcers in both the ambulatory and nonambulatory patient.

Surgical treatment for ischial pressure sores with gracilis myocutaneous flap

Surgical reconstruction of ischial pressure sores is technically complex and presents a significant problem. Although there is consensus about the use of muscle or myocutaneous flaps in the closure of these sores, there is still dispute about which muscle or myocutaneous flap to use. This evaluation describes the use of the gracilis myocutaneous flap for the treatment of wide and chronic ischial pressure sores. Details of 14 cases are presented and compared with those described in the literature.

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

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.

Unilateral multilayered musculocutaneous V-Y advancement flap for the treatment of pressure sore

We have devised a modified technique using the gluteus maximus musculocutaneous flap as multilayered sliding V-Y advancement to cover pressure sores on the sacral area. Nine patients with relatively large (average 7 x 7 cm) sacral grade IV pressure sores underwent unilateral multilayered V-Y advancement flap. All patients were followed for a minimum of 8 weeks. The mean postoperative follow-up was 32.3 months, with a range of 24 to 39 months. Using this technique, the success of surgery, i.e., the percentage of sores that healed, was 100 percent in our patients. The advantages of this technique include sufficient advancement of the flap, coverage of large ulcer defects using only a unilateral musculocutaneous flap, and preservation of the contralateral gluteus maximus muscle for future use.

Ischial pressure sore coverage: a rationale for flap selection

The role of wound debridement and flap coverage in treating pressure sores is clearly established. However, criteria and supportive clinical data for specific flap selection and the sequence of flaps for coverage of the ischium remain ill-defined. From 1979-1995, 114 consecutive patients underwent flap coverage of 139 ischial pressure sores. Preoperative risk factors, prior flap history, defect size, flap success, complication rates, and the length of hospitalization were retrospectively evaluated and compared for 112 flaps in 87 patients. Flap success was defined as a completely healed wound. Average follow-up was 10 months (range: 1 month-9 years). Overall, 83% (93/112) of the flaps healed. In the majority of cases (75%, 84/112), wound debridement and flap reconstruction was achieved in a single stage. However, there were significant differences in the healing rates among the various flaps used. The inferior gluteus maximus island flap and the inferior gluteal thigh flap had the highest success rates, 94% (32/34) and 93% (25/27), respectively, while the V-Y hamstring flap and the tensor fascia lata flap had the poorest healing rates, 58% (7/12) and 50% (6/12), respectively. Flap success was not significantly affected by the age of the patient or the prior number of flaps used and preoperative risk factors were equally distributed across all types of flaps. The overall complication rate was 37% (41/112), most commonly from a slight wound edge dehiscence (n = 16) that healed with local wound care within one month postoperatively. Results of this study show that proper flap selection and the appropriate sequence of flap use significantly improve success rates for ischial pressure sore coverage in both the short- and long-term. Based upon flap reliability (successful healing rates), reusability, and the need to preserve as many future flap options as possible, a rationale for flap selection is presented which can be individualized to any patient.

Modification of the gluteus maximus V-Y advancement flap for sacral ulcers: the gluteal fasciocutaneous flap method

We designed a modified gluteus maximus V-Y advancement flap method for closing a sacral ulcer. The purposes of our method were to simplify the surgical procedure and to avoid a functional deficit of the gluteus maximus muscle that was sacrificed by the conventional method. After excising the sacral ulcer, the V-Y advancement flap is marked on the bilateral buttock. Fascial incision of the gluteus maximus is made at the same incision in the skin. One-third of each medial flap is elevated as a fasciocutaneous flap by dissecting the layer between the fascia and the muscle at the parasacral region. The flaps are then moved medially and sutured. We operated on 24 patients with sacral ulcers using this technique. The patients included 19 with a sacral pressure sore and 5 with a radiation ulcer on the sacrum. Eighteen ambulatory patients also were included in this group. The results showed no flap necrosis in any patient. No functional deficit of the gluteus maximus muscle was observed postoperatively in the ambulatory patients. Average blood loss was 250 ml during the procedure. We conclude that the gluteus V-Y advancement flap as a fasciocutaneous flap is superior to the conventional musculocutaneous flap method.

Reconstruction with bilateral gluteus maximus myocutaneous rotation flap after wide local excision for perianal extramammary Paget's disease. Report of two cases

PURPOSE

Extramammary Paget's disease is a rare dermatosis. Wide local excision is recommended in patients with perianal extramammary Paget's disease. After wide local excision, it is necessary to do reconstruction, with preservation of bowel function. We present here two cases of perianal Paget's disease, in which the patients were treated by reconstruction with bilateral gluteus maximus myocutaneous rotation flap after wide local excision.

PATIENTS AND METHODS

A 55-year-old woman and 58-year-old man were admitted with anal pain and bleeding. Histologic examination of the perianal lesion revealed the presence of typical Paget's cells, and no underlying carcinoma and no distant metastasis was detected in either patient. Wide local excision, including the rectal mucosa, was performed, with reference to intraoperative frozen sections. Surgical defect was overlapped with bilateral gluteus maximus myocutaneous rotation flap, and the anus was reconstructed.

RESULTS

Postoperative bowel function and quality of life were well preserved, and flaps healed satisfactorily. Patients have had no recurrence and have been able to return to work.

CONCLUSION

Bilateral gluteus maximus rotation flap may be useful after wide local excision of perianal extramammary Paget's disease without underlying invasive carcinoma.

Modifications of the paraspinous muscle flap: anatomy and clinical application

Soft-tissue defects of the back, particularly involving the paravertebral tissues, are generally covered with myocutaneous, muscle, or fasciocutaneous flaps. The case of a 64-year-old man with a paravertebral malignant fibrous histiocytoma is reported. To ensure adequately radical margins, the ipsilateral trapezius and latissimus dorsi muscles as well as the costal periosteum and the spinous processes were resected between T9 and T12. The resulting defect was covered with a pedicled latissimus dorsi flap and an island flap of the paravertebral muscles. Prompted by this case, we studied the blood supply of the paravertebral muscles in 10 cadavers. The vasculature was visualized after flushing with colored latex and microsurgical dissection. Another 4 specimens were subjected to angiography and tomography. In the majority of cases (8 of 10), three perforators emerging from the intercostal arteries were identified. These were found to communicate in a longitudinal and vertical direction. Before piercing the fascia, they ramified in three layers matching the layers of the paravertebral muscles. Since the intercostal arteries were shown to communicate through anastomoses of adequate caliber, the paravertebral muscles appear to be useful candidates for proximally or distally pedicled transposition or island flaps.

Treatment of ischial pressure sores with an inferior gluteus maximus musculocutaneous island flap: an analysis of 31 flaps

We describe our experience with the use of an island gluteus maximus musculocutaneous flap (from its most inferior part) based on perforators from the inferior gluteal artery. The study is based on a series of 27 patients in whom treatment was carried out for 31 ischial pressure sores. Eight patients had postoperative complications in the form of dehiscence of the donor flap site and/or infection. Follow-up ranged from 6 to 32 months. During this period three patients developed recurrent sores which were treated with other flaps. We feel strongly that the use of this flap should be considered as a first choice in the treatment of the mild to moderate size ischial pressure sore. Its advantages include ease in elevation of the flap and the provision of a vascularized bulky flap which also spares the vascular pedicles of adjacent flaps for future use.

Modified gluteus maximus V-Y advancement flaps

A modified method is presented for the closure of wounds using gluteus maximus V-Y advancement flaps. Extra tissue is included in each flap by extending the corners of its advancing edge. The extra tissue is utilised to aid closure by using a combination of rotation and transposition in addition to advancement. This modification is illustrated and examples of its clinical use described.

The contributions of plastic surgery to care of the spinal cord injured patient

Plastic surgeons have contributed to the understanding of pressure sore pathophysiology and prophylaxis. Increasingly sophisticated surgical techniques such as myocutaneous or innervated flaps add to the reliability and durability of repairs. The majority of quadriplegics may benefit from surgical restoration of active elbow extension, lateral pinch and grasp. Prolonged postoperative care in bed or immobilisation of the upper limb demands that patients should understand fully all that the reconstructive procedure involves. The nature and importance of subsequent rehabilitation must be appreciated by the patient so that he will be motivated to achieve the best possible result. Functional electrical stimulation may find an increasing role in the years to come.

The one-stage surgical treatment of multilocated pressure sores using various myocutaneous island flaps

Report on 32 patients suffering from chronical pressure sores (n = 18 solitary, n = 14 multilocated), Campbell stages IV-VI, overlaying sacral bone, ischial tuberosity and tuber femoris, which were treated by using various combinations of myocutaneous island flaps (uni- or bilaterally glutaeus maximus and/or biceps femoris flaps). Indications, operative procedures, perioperative management and follow-up results are presented. Superficial skin lesions (n = 2) and wound dehiscence (n = 1) appeared as temporary wound complications in the 14 patients with multilocated pressure sores. In all cases stable and durable coverage was achieved without any recurrence. The value of adequate rehabilitation in avoiding relapses is pointed out.

The gluteus maximus muscle: experimental and clinical considerations relevant to reconstruction in ambulatory patients

The gluteus maximus muscle and other haemodynamically related structures have been used for the reconstruction of significant defects in the perineum, sacrum, lumbar area and hip in 35 patients. The preservation of muscle function was achieved in all of 20 ambulatory patients and documented by gait analysis, muscle strength testing and EMG studies. Dye injection studies of the first perforating artery, inferior gluteal artery and superior gluteal artery led to the design of new flaps based on this arterial system. They include: medial advancements with extension above the sacrum, lateral advancements, lower gluteus advancements, the tensor fasciae latae gluteal extension and modifications of the gluteal thigh flap. These findings significantly increase our ability to close difficult wounds within the perineal, sacral, lumbar and trochanteric regions.

Anorectal continence following sphincter reconstruction utilizing the gluteus maximus muscle: a case report

Rectal incontinence following pull-through procedure for high imperforate anus remains a difficult problem. Based on recent knowledge of the segmental neurovascular supply of the gluteus maximus muscle, the inferior half of the muscle on both sides was used for anorectal sphincter reconstruction on a 10-year-old boy who was totally incontinent following a pull-through procedure for a high imperforate anus. The technique of constructing this sphincter is simple and utilizes principles of muscle tendon transfer without jeopardizing the function of gait. Furthermore, the gluteus maximus muscle, being an accessory muscle of anal continence, is an ideal structure for this reconstruction. Colostomy can be prevented with the use of good preoperative bowel preparation and a constipating program for 1 week postoperatively. The results are directly related to the success of the operative procedure, and the maturity and degree of motivation of the child to undergo bowel-control training.