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Profunda femoris artery perforator-based fasciocutaneous flap (A) Schematic vascular diagram of profunda femoris artery perforator (*) flap. (B) This is an intraoperative image of Profunda femoris artery perforator flap and gracilis flap after dissection and before transposition. The yellow round dotted line is where the perforator is thought to be located. The existence of perforator was checked by an intraoperative Doppler flowmetry and perforator skeletonization was not performed because there was no problem in the transposition of the flap.
Source publication
Background
Reconstruction of ischial pressure sore defects is challenging due to extensive bursas and high recurrence rates. In this study, we simultaneously applied a muscle flap that covered the exposed ischium and large bursa with sufficient muscular volume and a profunda femoris artery perforator fasciocutaneous flap for the management of ischi...
Citations
... Having a good surgical procedure without longterm recurrences is difficult because of all of these considerations. 1 The pressure ulcers have been rebuilt using various techniques and flap covering. Examples include the posterior thigh flap, the V-Y fasciocutaneous flap, and the gluteus maximus island flap. ...
... Pressure ulcers are extremely common in individuals with spinal cord injuries (SCIs), and more than 80% of patients with SCIs who rely on wheelchairs for mobility will have a pressure ulcer at least once during their lifetime [1][2][3][4] . Ischial pressure ulcers are particularly difficult to treat due to the high rate of recurrence, especially because they are more common in highly active patients with SCIs than in other regions of the body 1,5) . Based on our experience of treating a patient with SCI with bilateral ischial defects due to surgical treatment of pressure ulcers, we report some points for consideration in the surgical treatment of ischial osteomyelitis. ...
Pressure ulcers are extremely common in individuals with spinal cord injuries, especially ischial pressure ulcers, which have a higher rate of recurrence and are more difficult to treat than those in other regions of the body. We report a case of a 69-year-old man with bilateral ischial defects due to surgical treatment of pressure ulcers. Previous reports have shown that when surgical resection of pressure ulcers extends beyond the ischial tuberosity to the pubic symphysis and acetabulum, the superior psoas and piriformis muscles are easily dislocated, and the pelvic ring can be unstable. Therefore, the region of resection must not extend beyond the acetabulum and pubic symphysis to achieve a stable sitting position. In this article, we discuss an anatomically safe ischial tuberosity resection.
... Having a good surgical procedure without longterm recurrences is difficult because of all of these considerations. 1 The pressure ulcers have been rebuilt using various techniques and flap covering. Examples include the posterior thigh flap, the V-Y fasciocutaneous flap, and the gluteus maximus island flap. ...
Background: Pressure ulcers frequently occur in the gluteal region, particularly in paraplegic patients with a high risk of recurrence. For this reason, future reconstructive treatments should be considered when choosing flaps for reconstructive surgery. Both the upper and superior gluteal artery perforator flaps (IGAP and SGAP) are examples of neural perforator flaps; first and second perforators from profundal femoris artery perforator (PFAP) are popular perforator flaps in the treatment of gluteal pressure sores. Objective: To assess the gluteal and para-gluteal regions by providing different sizes and designs of perforator propeller flaps to reconstruct gluteal pressure ulcers. Material and methods: A prospective study was conducted on forty patients at Al-Azhar University Hospitals between Dec. 2018 and Feb. 2023. Patients presented with different gluteal pressure ulcers reconstructed by free-style perforator propeller flaps. Flap size, source artery of the perforator, perforator site, flap survival, rotation angle, operative time, and complications were recorded. Result: The Mean hospital stay (days) was 37.85 ± 12.71, and the follow-up mean was 8.68 ± 1.95. The mean of propeller flap size was 183.64 ± 31.76, and the mean of Flap operation time was 158.50 ± 43.76. Conclusion: Reconstruction of pressure ulcers can benefit from the free-style perforator flap, which has the advantage of having little donor-site morbidity and preserving spare tissue for future reconstruction.
... Originally the PAP flap was described as a pedicled option for ischiatic pressure sores (Arquette et al., 2022;Homma et al., 2001;Kim et al., 2014;Lee et al., 2009;Sharp et al., 2021) and as a free flap for head and neck reconstruction, including tongue (Heredero et al., 2021;Riera et al., 2017;Scaglioni et al., 2015). A recent expanding use is for breast reconstruction (Ahmadzadeh et al., 2007;Allen et al., 2012Allen et al., , 2016Angrigiani et al., 2001;Atzeni et al., 2021;Cho et al., 2021;Jo et al., 2022;Martinez et al., 2021;Murphy et al., 2021;Saad et al., 2012;Song et al., 2020;Yano et al., 2020). ...
The profunda femoris artery perforator (PAP) flap has been recently popularized as an alternative option for microsurgical reconstruction. The use of PAP flap has never been reported and described for reconstruction of the upper extremities, in particular the forearm. The purpose of this case report is to describe a case suggesting the PAP flap as a further reconstructive option in the upper limb. A 16‐year‐old girl who sustained a traumatic injury to her right dominant forearm resulting in subtotal circumferential tissue loss following a road traffic accident was referred to the authors' department 2 years post‐trauma. The disabling fibrotic sequelae on her volar forearm (15 × 10 cm) resulted in a nonfunctional hand. She was unable to perform any active movement of her wrist or digits. Passive movements in the finger joints were preserved. Following debridement and reconstruction of nerves and tendons, soft tissues were resurfaced with a PAP flap. The transverse skin paddle, 12 × 7 cm, was placed distally with the adipofascial portion positioned proximally above the muscle bellies and anastomoses site. A small raw area (4 × 3 cm) was covered with an acellular dermal matrix (ADM). The postoperative course was uneventful. At 9 months postoperatively, the patient demonstrated active flexion and extension of the fingers with independent function. The patient reported satisfaction with the flap donor site and forearm resurfacing. The PAP flap can be a further option for areas requiring soft tissue coverage in patients refusing visible scars. This flap had both the advantage of reducing the morbidity and visibility of the donor site, as well as the ability to resurface a large recipient site with soft and pliable tissue, covering exposed nerves and tendons.
... The 70 mmHg of sustained pressure for 2 h can cause irreversible skin damage. 36,37 Continued pressure caused by local skin, soft tissue blood circulation disorders, ischemia and hypoxia can cause deep subcutaneous tissue, muscle, skin, and epidermal damage. Therefore, decompression is the most important factor in the prevention of a pressure ulcer. ...
To investigate the characteristics of pressure ulcer microcirculation in SCI patients with pressure ulcer, and to provide evidence for the treatment of pressure ulcer in patients with SCI. Group 1 ( n = 12) SCI patients with pressure ulcer, 23 pressure ulcers were included. Group 2 ( n = 15) SCI patients without pressure ulcer and the control group ( n = 16) healthy adults. The application of laser Doppler perfusion imaging system (Moor FLPI) detector to the microcirculation perfusion of the sacrum area of the control group, the observation group 2 and the pressure ulcer site of the observation group 1, record the microcirculation perfusion (PU), The data of microcirculation perfusion (PU) were compared and analyzed. The correlation between microcirculation perfusion and healing time of pressure ulcer was analyzed. (1) The microcirculation perfusion was highest in the pressure ulcer center. (2) SCI patients and healthy adults had no significant difference of microcirculation perfusion at sacrococcygeal skin. (3) The lower the microcirculation perfusion of the pressure ulcer center, the longer the healing time of pressure ulcer. The healing time and the microcirculation perfusion of pressure ulcer center was negatively correlated. Microcirculation perfusion detection is a noninvasive and effective method for the determination of the scope of pressure ulcer, detection and direction judgment of pressure ulcer sinus tract, monitoring and guidance of pressure ulcer treatment, and prediction of the healing time of pressure ulcer.
... The biceps femoris muscle flaps are an easily harvested muscle flap with a robust vascularity that could control residual bone infection and obliterate the ulcer dead space. [16,17] Moreover, the muscle bulk provides an even pressure distribution over the bony prominence in wheelchair pediatric patients. ...
... In addition, the incision lines of this flap design are positioned outside the area of weight-bearing besides possible frequent flap remobilizations if desired in recurrent sores. [9] Several authors [16][17][18][19][20][21][22] reported the use of a combined fasciocutaneous/muscle flap technique for reconstruction of ischial pressure ulcers. Ahluwalia et al. [18] and Bertheuil et al. [19] presented their experience by describing a medially based rotational posterior thigh flap with a biceps femoris muscle for ischial pressure wound reconstruction and recorded a relatively low recurrence rate. ...
... Few reports [17,21,22] described the use of perforatorbased flaps as profunda femoris artery perforator flaps along Fig. 3 a A 10-year-old male patient with a left side ischial pressure sore. b A posteromedial thigh flap was elevated. ...
Background
Ischial pressure sores are mostly seen in wheelchair-bound pediatric patients, who are affected by a myelomeningocele, as a result of constant shearing force over the ischial region. The ischial sores are the most difficult to treat with high recurrence rates. Although there are various reconstructive modalities that are described for coverage of ischial pressure sores, there is still a long-term debate on an optimal method of reconstruction.Methods
Between April 2017 and June 2019, a total of 6 patients who were affected with a myelomeningocele anomalis were operated on for a total of 7 recurrent grade IV ischial ulcers. Data collection was done through analysis of medical records, which included the patients’ demography, operative details, and postoperative complications. A routine preoperative regimen including correction of the nutrition status and anemia should be ensured. We dissected a biceps femoris muscle turnover flap that obliterated the wound cavity and simultaneously applied a V-Y rotation advancement posterior thigh fasciocutaneous flap for coverage of ischial pressure sore surface.ResultsAll flaps survived without early complications except for one case (14.2%) where a minor wound dehiscence had occurred and managed by secondary stitches. Among all 7 cases, only one (14.2%) had a recurrence 9 months after surgery, which required further debridement and advancement of the same flap. The mean follow-up period was 12.3 months (range, 4–24 months).Conclusions
Although there is still no ideal flap for closure of ischial pressure sores, the rotation advancement V-Y posterior thigh fasciocutaneous flap combined with a biceps femoris muscle turnover flap is considered a reliable reconstructive technique in pediatric patients. The present technique integrates the benefits of well-vascularized muscle tissue with a durable skin coverage that can be reused in cases of recurrence.Level of evidence: Level V, therapeutic study.
... A wide range of techniques which have their own advantages and disadvantages was described for reconstruction of ischial pressure ulcers. Cutaneous [5], fasciocutaneous [1,3,6,7], musculocutaneous [8][9][10], adipofascial [11], combined [12][13][14][15], and free flaps [16] are some of the alternatives of reconstructive methods. In addition to this armamentarium, perforator flaps have gained popularity for pressure sore treatments in the last 10 years [1,[17][18][19][20][21][22][23]. ...
... Also, combined flaps have advantages of reutilizing in recurrent ulcers. These techniques however mandate large dissections and long operation times [8,12]. Fasciocutaneous and musculocutaneous flaps are used as separate [6,7,[27][28][29][30][31] or combined [14,15,25] flaps in treatment of ischial pressure sores. ...
Background
Ischial sores have higher risks of recurrence and considered the most difficult to treat. There are mainly 2 groups of techniques used in ischial pressure sore reconstruction which are as follows: (1) fasciocutaneous and/or myocutaneous flaps (Fc/Mc) and (2) perforator flaps. The aim of this study is to determine the advantages of perforator flaps over Fc and/or Mc flaps in reconstruction of ischial pressure ulcers.
Methods
All articles published before April 2018 were investigated and searched for eligibility using the databases PubMed and Google Scholar. Eligible studies were determined according to inclusion and exclusion criteria. Recurrence rates, complication rates, and time of recurrences were assessed.
Results
A total of 15 studies with 279 patients and 305 flaps were identified and included in the final analysis. The overall recurrence rate of flaps was 6.31 (95% CI, 5.86 to 6.78; p < 0.001); complication rate of flaps was 3.06 (95% CI, 2.91 to 3.23; p < 0.001); and recurrence time of flaps was 0.77 (95% CI, 0.66 to 0.90; p < 0.001). The mixed-effects analysis results have revealed that there was no statistically significant difference between the perforator and the Fc/Mc groups (between-level) in terms of recurrence rates (p > 0.05), complication rates (p > 0.05), and time of recurrences (p > 0.05).
Conclusions
Perforator flaps mandate thorough pre-operative preparations, meticulous dissections, and long surgery times. There seem no advantage in applying perforator flaps in ischial pressure sore reconstructions in terms of complications and recurrences. Surgeons may prefer to perform straightforward procedures, such as myocutaneous flaps.
Level of evidence: Level IV, risk/prognostic, therapeutic study.
... The gracilis is an easily attained muscle flap with a reliable blood supply and abundant flow, making it a robust reconstructive flap that may help to control residual infection and promote healing in ischial tuberosity wounds [9]. The mass of tissue provided by the gracilis flap effectively eliminates dead space and may allow for better distribution of pressure on return to seating [22]. As the gracilis is not essential for normal gait, it serves as a viable reconstructive option in patients with limited mobility. ...
Background
Although general principles of pressure wound management begin with optimisation of patient and wound factors to promote healing, refractory cases may require surgical intervention. Compared with other areas, ischial tuberosity (IT) wounds tend to occur in wheelchair-bound patients and may respond well to surgical debridement and flap reconstruction where added tissue bulk is preventative for further pressure ulcer formation. IT ulcers may occur in patients with some degree of ambulatory potential or those who have a temporary impairment. While the most commonly used flap for typical IT ulcers is the musculocutaneous hamstring flap, for these patients, this is not suitable due to the sacrifice of muscle function. We designed a combined posterior thigh flap with pedicled gracilis to provide robust coverage and vascularised muscle bulk, while preserving hamstring function and potential for re-advancement in ulcer recurrence.
Methods
Patients were selected for their grade of ulcer, compliance with physiotherapy, and their need to preserve muscle function. Each underwent surgical debridement and reconstruction using the combination flap. End-points included wound coverage, post-operative mobility, and complications. Follow-up was 3 months post-surgery.
Results
All patients achieved complete coverage of their wound. In the follow-up period, there were no wound complications or ulcer recurrence.
Conclusion
We describe a novel reconstruction method for IT pressure ulcers that maintains patient mobility. This combination perforator-based fasciocutaneous and gracilis flap is a superior reconstructive option that has reduced donor site morbidity and relatively simple operative technique and can be reutilised in ulcer recurrence.
Level of Evidence: Level V, therapeutic study.
... There is a segmental arterial supply to the muscle by the external branches of femoral artery and branches of the deep artery of the thighmainly from the medial circumflex femoral artery. Vessels supplying this muscle make it a well pedunculated muscle flap [11,19,20,21,28,33]. ...
Ten human gracilis muscles obtained from adults and ten gracilis muscles collected from human foetuses between the 15th and 21st week of gestation were examined. The results of this preparatory study show that the gracilis muscle in adults is narrow and long — 482 mm on average. The distal tendon of gracilis muscle is long, 294 mm on average. It can be divided into two sections — external part, outside the muscle belly, and internal, intramuscular, part. The latter one is partially covered by muscle fibres and some of it is completely hidden inside the muscle belly, which is on average 76 mm long. Presence of an intramuscular part of the distal tendon was also demonstrated in the foetal material. Moreover, very strong correlations between particular muscle lengths were noted in foetuses. (Folia Morphol 2018; 77, 1: 138–143)
... Reis 11 later in his study described lesser recurrence with gluteus maximus flap as compared with fasciocutaneous flaps. Recurrence in our study is 12% compared with 11% recurrence rate described by Rajacic et al and 23% by Kim et al. 12,13 The similar study was done by koshima et al 14 regarding the importance of musculocutaneous perforators in the gluteal area. The main advantage of gluteus maximum island flap is that it not only preserves the blood supply of inferior gluteal thigh flap and other future flap like biceps and hamstrings flaps but also provides adequate bulk that obliterates the dead space. ...
p>Surgical management of ischial pressure sores has always been a challenge due to high recurrence rate. Ischial pressure sores develop due to unrelieved pressure over the Ischium. Inferior gluteus maximus island flap has been used effectively for coverage of ischial pressure sores.
Objective: To describe the efficacy of inferior gluteus maximus flap for reconstruction of ischial pressure sores.
Methods: A retrospective case series, consisted of sample of 17 cases. The study was conducted in the Department of Plastic and Reconstructive Surgery, Post Graduate Medical Institute, Lahore General Hospital Lahore, over a period of 8 years from March 2008 to March 2016. The case series included17 patients with grade 3 and grade 4 ischial pressure sores, comprising 12 male and 5 female, with age range of 28 to 64 (mean = 46 years).Follow-up ranged from 1 to 4 years with a mean of 2.5 years. Inferior gluteus maximus island flap was used for reconstruction of Ischial pressure sores.
Results: In thirteen (76%) of the seventeen patients, wound healed uneventfully without any complication. Partial wound dehiscence was observed in 2 patients (12%). Both of these healed with conservative wound management. Recurrence was seen in 2 patients (12%) after 8 months. These two patients underwent reoperation and gluteus maximus flap was readvanced that resulted in satisfactory wound coverage.
Conclusion: Inferior gluteus maximus island flap can be considered as a reliable option for reconstruction of ischial pressure sores.</p
