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The Gluteal Perforator-based Flap for Repair of Sacral Pressure Sores
Abstract
A gluteal perforator-based flap employing the gluteus maximus muscle perforators located around the sacrum is described. A cadaveric study disclosed the existence of several significant perforators all around the gluteal region. Among these, the parasacral perforators originating from the internal pudendal artery and lateral sacral artery have proven useful for the repair of sacral pressure sores. A total of eight decubitus in seven patients were treated with gluteal perforator-based flaps. There were no postoperative complications, such as flap necrosis and wound infection, with the exception of fistula formation in one case. This flap requires no transection or sacrifice of the gluteus maximus muscle, and elevation time for the flap is short. However, the perforators are located at various sites and thus require some careful dissection. (C)1993American Society of Plastic Surgeons
... The SGAP flap utilizes these perforators, ensuring a robust blood supply while preserving the underlying muscle. First described by Koshima et al. in 1993, the SGAP flap has since been employed across various fields of reconstructive surgery, ranging from autologous breast reconstruction to lower extremity reconstruction [10][11][12][13]. This flap offers several advantages that make it particularly suitable for perineal reconstruction. ...
... The SGAP flap utilizes these perforators, ensuring a robust blood supply while preserving the underlying muscle. First described by Koshima et al. in 1993, the SGAP flap has since been employed across various fields of reconstructive surgery, ranging from autologous breast reconstruction to lower extremity reconstruction [10][11][12][13]. This flap offers several advantages that make it particularly suitable for perineal reconstruction. ...
... Moreover, the preservation of abdominal wall integrity is a significant advantage of the SGAP flap, as it avoids the complications associated with muscle sacrifice and the opening of the abdominal cavity, which are common drawbacks of other reconstructive techniques such as the VRAM flap. The SGAP flap's ability to provide ample tissue volume while maintaining the structural integrity of the donor site underscores its utility in the restoration of perineal defects [10][11][12][13]. By leveraging the reliable vascular supply from the superior gluteal artery perforators, surgeons can achieve robust and sustained tissue viability, which is critical for successful reconstruction and optimal healing outcomes. ...
Background/Objectives: Perineal reconstruction after abdominoperineal excision often requires complex closures and is fraught with wound healing complications. Flap-based approaches introduce non-irradiated vascularized tissue to the area of resection to fill a large soft-tissue defect and dead space, reduce the risk of infection, and facilitate wound healing. Employing perforator flaps with their beneficial donor site properties, the authors have developed a concept of bilateral superior gluteal artery perforator (SGAP) flaps to restore extensive perineal defects. Methods: This retrospective case series was conducted between September 2015 and December 2019. We included three patients who received bilateral SGAP flap reconstruction after oncological resection. One deepithelialized SGAP flap was used for obliteration of dead space, combined with the contralateral SGAP flap for superficial defect reconstruction and wound closure. Results: Within this patient population, two male and one female patient, with a median age of 62 years (range, 52–76 years), were included. Six pedicled SGAP flaps were performed with average flap dimensions of 9 × 20 cm (range 7–9 × 19 × 21). No flap loss or no local recurrence were documented. In one case, partial tip necrosis with prolonged serous drainage was observed, which was managed by surgical debridement. No further complications were detected. Conclusions: The combination of two SGAP flaps provides maximal soft tissue for defect reconstruction and obliteration of dead space, while maintaining a very inconspicuous donor site, even with bilateral harvesting. Given these advantages, the authors recommend this promising approach for successful reconstruction of perineal defects.
... Many reports have introduced various options to reconstruct pressure injury in the sacrum and ischium. [11][12][13][14][15][16][17][18][19][20][21][22][23][24] Initially musculocutaneous flap was considered to be the best option since it had robust vascularization and bulkiness of muscle to fill the dead space and provide padding over the bony area of the sacrum and ischium. [11][12][13] Fasciocutaneous flap was later introduced and became widely used to reconstruct sacral pressure injury. ...
... 10,12,27 Lastly, perforator-based flaps have been gaining popularity for reconstruction of sacral and ischial defects using superior and inferior gluteal artery perforator flaps as well as free flaps. 14,[17][18][19][20][21][22][23] This technique, however, requires operator's experience and microsurgical technique of flap dissection to identify the perforator, thus longer operative time is expected. To date, no technique has been proven superior to others. ...
... Many flaps are available to reconstruct the defect of pressure injury. [11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26] In the 1970's and 1980's musculocutaneous flaps were the flap of choice to reconstruct sacral and ischial pressure injury. 11,12 Muculocutaneous flaps, however, had their disadvantages of sacrificing the function of the muscle, longer duration of operation and more bleeding intraoperatively, and muscles became atrophy over time. ...
Introduction: Reconstruction of sacral and ischial pressure injury offers great challenges due to its high complication and recurrence rate. Providing durable tissue coverage with minimal donor site morbidity is paramount while ensuring fast operative time for the patients who often possess multiple comorbidities. This study aims to present cases of sacral and ischial pressure injury reconstruction using a keystone flap. Method: A retrospective study was performed by reviewing data from fifteen patients with a sacral and ischial pressure injury who underwent reconstruction using various types of keystone flaps in our center between 2019 and 2020. Results: The patients’ age ranged from 10 to 83 years old (average, 40.5 years old). The average wound dimensions were 9.4 ± 3.1 cm x 6.5 ± 2.7 cm and the mean area of the defects was 52.3 ± 35.7 cm2, with the largest defect was 15 x 12 cm (141.3 cm2). Mean operative time was 140 ± 24.5 minutes with nine wounds were reconstructed using type IV keystone flap (60%) and six patients using type IIA (40%). Postoperative complications occurred in three patients (20%). Other patients resulted in uneventful complete healing. Conclusion: The keystone flap is reliable, simple, has a fast technique, and minimal donor site morbidity to cover the defects of sacral and ischial pressure injury. Performing thorough debridement, choosing the right type of keystone flap, elevating the flap adequately to allow mobilization, preserving perforator “hotspots”, and suturing of the flap without tension are keys to achieve satisfactory results.
... [1] Perforator flaps have gained popularity because they can be used to make a large flap and be reused for recurrent decubitus ulcers. [5][6][7][8] However, skeletonization of a proper perforator can be boring, and pedicle torsion or postoperative compression can lead to arterial ischemia and venous congestion. [2] Perforator-based flaps with the perforator placed close to the ulcer and stopped flap elevation at the surrounding selected perforator [9] have been performed to prevent vascular compromise and reduce the need for fastidious dissection. ...
... However, the optimization of flap design to ensure successful surgical outcomes requires much clinical experience; other methods are being tried to avoid wound dehiscence. [10,11] The sacrococcygeal area has many perforating vessels on which flaps may be raised, [5,12] and design changes depend on which perforating vessel is selected and defect shape. Here, we report our experiences selecting a perforator based on considerations of relaxed skin tension lines (RSTLs) that have provided efficient flap designs that enable primary closure. ...
... Various surgical options have been developed for the reconstruction of sacral defects, and since Koshima et al. first described perforator flaps in 1993, [5] several designs have been suggested to treat pressure ulcers. [3,4,6,12] The main advantage of perforator flaps is that they enable a longer pedicle and a greater arc of rotation while maintaining the gluteus maximus muscle, and coverage of large defect areas using remote flaps. ...
Many various types of operative techniques have been performed used to treat make-up for sacral defects. Perforator-based flaps with flap transposition, but achieving an optimal flap design and tension-free flap closure without skeletonizing the perforator requires a great deal of clinical experience. In this study, we demonstrate perforator selection based on considerations of the relaxed skin tension line (RSTL), which has proven to be a suitable method of achieving an efficient flap design that enables primary closure.
Twenty-five perforator-based flap procedures were performed on 25 patients at a single institution from February 2018 to January 2021. The medical records of patients were retrospectively reviewed.
Twenty-three flaps survived completely. Two flaps developed partial tip necrosis but recovered after secondary healing, and 1 patient developed temporary congestion, which resolved spontaneously. No recipient or donor site recurrence or dehiscence was identified during follow-up.
We report our clinical experiences of perforator-based flap use in the sacral region. When selecting an appropriate perforating vessel, 2 important points should be considered, that is, a flap long axis parallel to RSTLs and defect shape. According to the method presented in this paper, perforator-based flaps can be transposed safely and easily with few complications and serve as useful practice models to cover sacral defects.
... Surgery is often required for the definitive treatment of stage III and IV pressure ulcers, with many reconstructive options available for skin coverage and filling of the dead space over pressure ulcers, including regional musculocutaneous, fasciocutaneous, and perforator-based flaps. Musculocutaneous flaps have been the mainstay of surgical treatment for pressure ulcers since the late 1970s [4][5][6] ; however, fasciocutaneous flaps were first used to cover ischial and sacral ulcers in 1984 and 1988, respectively 7,8) , and perforator-based flaps have gained popularity since Koshima et al. reported their use in the reconstruction of pressure ulcers in 1993 9) . While the emergence of fasciocutaneous and perforator-based flaps caused much debate regarding optimal flap selection, a recent systematic review of 55 articles reported no statistically significant difference in ulcer complications and recurrence rates between musculocutaneous, fasciocutaneous, and perforator-based flaps 10) . ...
... While the emergence of fasciocutaneous and perforator-based flaps caused much debate regarding optimal flap selection, a recent systematic review of 55 articles reported no statistically significant difference in ulcer complications and recurrence rates between musculocutaneous, fasciocutaneous, and perforator-based flaps 10) . However, since perforator-based flaps preserve the blood supply and soft tissue for future reconstruction 11) , they are considered superior to other flaps as a first-line surgical option 12) , even though meticulous dissection is necessitated 9) . ...
... Sacral pressure ulcers are generally treated with either rotation or V-Y advancement flaps with or without gluteus maximus muscle grafting to preserve perforators 5,8,9,13,14) . Furthermore, primary closure can be achieved in small-and moderate-sized ulcers using simple techniques that reduce the tension of the skin over the muscle, or by advancement with a small incision. ...
Background: Pressure ulcers remain a challenge for plastic surgeons to effectively manage because of the patient's underlying physical condition, weakness, risk factors associated with the diagnosis, and resultant insufficient wound healing that results in incomplete treatment or recurrence after surgery. This review describes and analyzes the current literature regarding the management of pressure ulcers.
Methods: Risk factors primarily associated with wound dehiscence and recurrence were identified via a PubMed literature search using “ischial pressure ulcers, sacral pressure ulcers, and surgical coverage” as keywords. We analyzed and compared them to data from the Committee of the Japanese Society of Pressure Ulcers in 2016 and our facility.
Results: Many published reports contain pedagogical comments on the successful management of pressure ulcers that remain significant. Some reported risk factors associated with flap dehiscence and ulcer recurrence are age, low serum albumin levels, previous operative failures at the same site, and ischial ulcers. The prevalence of deep pressure ulcers at the sacrum was more than three times higher than that at any other site. At our facility, the most frequently performed surgeries were for ischial ulcers, and 86% of pressure ulcers healed after surgery.
Conclusions: Surgical site infection and surgical time were independent risk factors associated with wound dehiscence in the early phase after reconstruction. The effectiveness of closed wound management with negative-pressure wound therapy has been reported to be satisfactory for reconstructive surgeries with flaps for refractory pressure ulcers.
The distribution of ulcer locations in the analysis by the Committee of the Japanese Society of Pressure Ulcers in their fourth surveillance study in 2016. Fullsize Image
... Flaps can be classified based on several ways including their location, movement, blood supply and tissue composition. The primary classification relevant to pressure injury repair consists of local, regional, perforator and free flaps 31,33,34 . A comprehensive comparison of various aspects of flaps used in pressure injury reconstruction is provided in Table 1. ...
... Perforator flaps represent an advanced reconstructive option in moderate to large defects, sparing underlying muscle function by isolating skin and subcutaneous tissue supplied by specific perforator vessels that are identified through preoperative imaging (e.g., Doppler ultrasound or CT angiography) and are further divided into propeller and island flaps 33,39,40 . They have the advantages of reduced donor site morbidity due to the preservation of muscles and nerves, greater freedom in flap design and tailoring, minimal operative blood loss and postoperative pain with shorter hospital stays and reduced costs, improved cosmetic outcomes and robust durability and pressure relief, however they are technically demanding, require detailed anatomical knowledge and susceptible to venous congestion and partial flap necrosis in case the vascular supply is compromised [39][40][41] . ...
... Dạng đảo: sử dụng dạng đảo nhiều với vạt nhánh xuyên ĐMMT, kích thước vạt da dài nhất 17 cm, chiều rộng nhất 12 cm bởi vì sự linh hoạt của cuống mạch, độ rộng của góc xoay vạt có thể tới 180 độ, thích hợp che phủ được những tổn thương rộng và phù hợp với nghiên cứu của Koshima (1993) [6], Yuan ST (2007) [7] và Trần Vân Anh (2011) [8]. ...
... Dạng đảo: sử dụng dạng đảo nhiều với vạt nhánh xuyên ĐMMT, kích thước vạt da dài nhất 17 cm, chiều rộng nhất 12 cm bởi vì sự linh hoạt của cuống mạch, độ rộng của góc xoay vạt có thể tới 180 độ, thích hợp che phủ được những tổn thương rộng và phù hợp với nghiên cứu của Koshima (1993) [6], Yuan ST (2007) [7] và Trần Vân Anh (2011) [8]. ...
Mục tiêu: Nhận xét các đặc điểm lâm sàng của bệnh nhân loét tỳ đè vùng cùng cụt, đánh giá kết quả phẫu thuật che phủ loét độ III, IV vùng cùng cụt tại Bệnh viện Trưng Vương. Đối tượng và phương pháp nghiên cứu: Các bệnh nhân không giới hạn tuổi, giới tính được chẩn đoán loét độ III, IV, chỉ định phẫu thuật tại Khoa Bỏng – Tạo hình thẩm mỹ Bệnh viện Trưng Vương; phương pháp nghiên cứu tiến cứu theo dõi dọc. Kết quả: nhóm bệnh nhân trên 60 tuổi chiếm tỷ lệ 81,8%. Phần lớn các bệnh nhân có loét với kích thước 6-10 cm đường kính, chiếm 45,4%. Chủ yếu là các tổn thương loét độ IV chiếm 93,9%. Tỷ lệ vạt da sống tốt sau mổ là 78,8%. Vạt da cân phù hợp với những ổ loét có kích thước dưới 10 cm; vạt da cơ mông lớn với những khuyết hổng <6 cm sử dụng 1 vạt, ổ loét >6 cm cần dùng 2 vạt 2 bên mông; vạt nhánh xuyên động mạch mông trên (ĐMMT) phù hợp tạo hình cho những ổ loét to vùng cùng cụt.
... Smaller pressure ulcers may be closed primarily [2]. Larger pressure ulcers may be closed, by Inferiorly based skin flaps, Gluteal perforator-based flaps [3], Gluteus Maximus Musculocutaneous V-Y Advancement flaps [4,5], Transverse lumbar flaps [6], Superior gluteus myoplasty and Turnover gluteus myoplasty. The advantages of these muscle flaps are: (1) Volume, which fills up the residual dead space seen post debridement of devitalized tissue from the sore [2]. ...
... The advantages of these muscle flaps are: (1) Volume, which fills up the residual dead space seen post debridement of devitalized tissue from the sore [2]. Vascularity, which helps combat infection and promotes healing and [3] Skin coverage which acts as a cushion and prevents recurrence. A time tested alternative is the use one or more Limberg flaps. ...
Background: Sacral pressure sores have been treated with a variety of flaps, including the rhomboid flap by Limberg. This paper outlines the rationale for using this flap, while laying down the guidelines for the number required and the methods, depending upon the size, orientation and excursion of the defect.
... The major drawbacks are a limited arc of rotation or advancement, bleeding, and the need to sacrifice Gluteus Maximus muscle. 1 The superior glueal artery myocutaneous flap was first used in 1975. 2 Perforator flaps were described in 1993. 3 Superior gluteal artery perforator(SGAP) flap is now an established method of coverage for sacral pressure ulcers. Its advantages are that it spares the gluteus muscles for future use if required, decreasing donor site morbidity, has good vascularity, and its suture lines are placed far from areas of direct pressure. ...
... Detailed anatomy of this flap has been described previously. 3 The perforator length varies from 3 to 8 cm with diameter of 1 to 1.5 mm. A good-sized single perforator is adequate to nourish the flap, which in our series reached a maximum of 12 × 10 cm. ...
Study Design: Retrospective case study. Objective: To study the feasibility and ease of freestyle SGAP perforator flaps for sacral ulcers. Setting: This study was conducted in tertiary care hospital in India.
Sacral ulcers are commonly encountered in long-term bedridden patients. Various options to cover these ulcers include the gluteus muscle flaps (v-y, rotation and advancement), fascio-cutaneous flaps, superior and inferior gluteal artery perforator flaps. The superior gluteal artery perforator (SGAP) flap is a reliable option for sacral sore management. Using this flap, only one out of ten patients had partial flap necrosis. None had wound dehiscence nor seroma formation. No recurrence was seen at three months follow-up. This flap can safely be used as a ‘free style’ flap.
... V-Y gluteus maximus advancement flap, gluteus maximus myocutaneous flap, free flaps, and perforator flaps have been used for gluteal region defects. (Kuo et al., 2014;Sameem et al., 2012) Recently, various perforator flaps have become popular due to minimal donor site comorbidity compared to myocutaneous or free flaps (Koshima et al., 1993). While gluteal artery perforator flaps are the foremost choice of a perforator flap, recurrent pressure ulcers damage the gluteal region. ...
... Gluteal artery perforator flaps are the gold standard for gluteal pressure sore reconstruction (Yoon et al., 2017). Koshima et al. (1993) introduced gluteal artery perforator flaps superiority over conventional methods for closing lumbosacral defects. It has reliable anatomy, well-vascularized tissue, adequate bulk, and minimal donor-side morbidity. ...
The reconstruction of the near-total or total gluteal defects is challenging. Reconstructive options were restricted when the gluteal flaps were sacrificed. The lumbar artery perforator flap (LAPF) has been recently popularized as an alternative option for sacral and gluteal pressure ulcers. Extension of flap size may be needed in extensive defects. We aim to use the delay phenomenon to increase lumbar artery perforator flap territory to reconstruct near total gluteal defect. A 36-year-old woman was referred to our clinic with defect sizes of 23 × 23 cm and 25 × 17 cm for the right and left gluteal regions. She had a history of multiple surgeries for her paraplegia-related sacrogluteal pressure sores. The reconstruction was started on the left side with delaying incisions to the flap borders. Seven days later, the left gluteal defect was reconstructed with 27 × 19 cm LAPF based on a second lumbar artery perforator. At the same session, the delaying incision was performed to the borders of the right LAPF. On day 14, the right gluteal defect was closed with a 25 × 25 cm-sized right LAPF. No flap loss and early complications were seen. The patient was discharged without complication after 10 days after the last operation. The patient was followed up for 1 year. A right ischial pressure ulcer due to wheelchair use was encountered, which was managed with conservative wound care in the 8th month. Giant-sized lumbar artery perforator flaps may be obtained by delay phenomenon to reconstruct near-total or total gluteal pressure sores.
... With this new technique, clinicians can obtain flaps of larger dimensions compared with conventional musculocutaneous flaps; therefore, the perforator flap has become a more popularized and favored method where perforators are present. Buttocks have redundant perforators from the lumbar, superior gluteal, lateral sacral, inferior gluteal, and internal pudendal arteries, as described by Koshima et al. [9]. There are numerous constant and reliable perforators along the lateral sacral border. ...
... There are numerous constant and reliable perforators along the lateral sacral border. Numerous cases have reported the successful use of gluteal artery perforator flaps for large lumbosacral defect reconstruction with primary closure of donor sites [9,10]. However, the thick fatty tissue of the buttocks cannot be rendered as thin as periscrotal tissues. ...
Fournier’s gangrene, a soft tissue infection which is aggressive and sometimes lethal, often passes through deep fascial planes of the penis, scrotum, perineum, and lower abdomen; however, it rarely extends upward into the high intermuscular plane. We managed a rare case of Fournier’s gangrene with a high intersphincteric abscess from a perianal infection that resulted in a large defect in the anus and inferior aspect of the scrotum. A perforator-based island flap for the post-debridement defect was performed successfully. The perforator was selected near the defect along the lateral sacral border; the border of the flap design was adjacent to the defect, thus providing a sufficient angle of rotation near the pedicle with minimal dissection. Remnant undissected tissues around the pedicle prevented postoperative vascular complications. Additionally, the distal part of the flap design was elongated to the gluteal sulcus to be harvested as a very thin flap. This study suggests a perforator-based island flap as a secure and convenient option for covering a large defect involving the perianal region and inferior aspect of the scrotum.
... These medial branches escape via the posterior foramina, perforates thick lumbar muscle, and vascularizes the skin on the dorsal surface. These artery perforators are called PSAPs 8,9 and are illustrated in Figure 1. ...
... Originally proposed in 2002 by Garrido et al, the PSAP flap was described in a series of 5 patients presenting recurrent pilonidal cyst disease with good results. 1 It should not be confused with the SGAP flap as suggested by Koshima et al. 9 Perforator flaps are an effective procedure, and have proved useful for covering and reconstructing a variety of sites with integumentary defects. Due to the advent of acoustic and color Doppler ultrasound, their reliability has increased, making it possible to safely identify a given perforator from a source artery and to vascularize a cutaneous, fasciocutaneous, or adipose flap of interest. ...
Background
Due to the lack of knowledge about parasacral artery perforators (PSAP), flaps from this region cannot be used with maximum security and efficiency. Knowledge of the clusters and perforasome of these perforators could help us to design more reliable flaps and extend the applications.
Objectives
This study aimed to identify the localization, number, and density, 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 more than 0.5cm were examined in five sacral regions. All data were collected on suprafascial plane, with an orthonormal coordinate system placed on iliac crests and median lines. For perforasome analysis, 5 perforators 3 three sacral flaps were injected with radiopaque dye. A dynamic (four-dimensional) computed tomographic angiography completed our analysis.
Results
An average 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 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 a useful procedure in reconstruction and in esthetic surgery, especially in gluteal augmentation. The reliability depends on sound anatomical knowledge, with accurate preoperative perforator mapping.
... Koshima 13 raised perforator flaps on a single perforator and achieved satisfactory outcomes. At the same time, Seyhan 12 suggests adding a backup perforator if the primary perforator is insufficient. ...
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.
... While the surgery was a technical success, the authors commented that due to the short pedicle length, the breast mound was superiorly displaced. In 1983, Shaw modified this flap with good aesthetic results and well-tolerated donor site morbidity [4] . However, the pedicle length remained short at 2-3 cm and 7 out of 10 patients required either vein grafts or anastomosis to other recipient veins. ...
Free flap autologous breast reconstruction is becoming more and more common for post-mastectomy reconstruction. Abdominally-based tissue flaps are the first choice for many reconstructive breast microsurgeons, but not all patients are candidates, whether due to their leaner habitus or a history of prior abdominal surgery. The gluteal donor site in many patients can provide adequate soft tissue for autologous breast reconstruction, even in lean patients, with a scar that remains well-hidden. This review presents an overview of the superior gluteal artery perforator (SGAP) flap as an invaluable tool for autologous breast reconstruction.
... Koshima 13 raised perforator flaps on a single perforator and achieved satisfactory outcomes. At the same time, Seyhan 12 suggests adding a backup perforator if the primary perforator is insufficient. ...
... Thus, to limit these sitting-associated forces on the wound, it would be best to choose a fascial, vertically oriented flap that has a stable blood flow and includes sufficient subcutaneous tissue. [27][28][29][30] In addition, paramedian wound closure using a transpositional flap minimizes wound tension and compression, thus avoiding prolonged dermal inflammation which results in less scarring than midline wound closure. 23 It would also be best to choose a flap whose donor site is not on the high pressure/shear-stress lower sacrum. ...
Background
Pilonidal sinus can be treated with excision and flap reconstruction, but treatment is often complicated by wound dehiscence, infection, and recurrence. Understanding the mechanical forces on the sacrococcygeal area during posture change could help guide optimal flap choice.
Methods
Sixteen volunteers underwent measurements of skin-stretching, pressure, and shear stress on the sacrum when sitting relative to standing. Skin-stretching was measured by drawing a 4 × 4 cm square on the sacrum and measuring the vertical, horizontal, and diagonal axes. Pressure and shear stress was measured at six sacral points with a device. The data analysis highlighted the potential of the superior gluteal artery perforator (SGAP) flap for dissipating mechanical forces. Ten pilonidal sinus cases treated with SGAP flaps were retrospectively reviewed for 6-month outcomes.
Results
Sitting is associated with high stretching tension in the horizontal direction [estimated marginal mean (95% confidence intervals) = 17.3% (15.4%–22.6%)]. The lower sacrum experienced the highest pressure [106.6 (96.6–116.5) mm Hg] and shear stress [11.6 (9.7–13.5) N] during sitting. The transposed SGAP flap was deemed to be optimal for releasing the horizontal tension and providing sufficient subcutaneous tissue for ameliorating pressure/shear stress during sitting. It also has high blood flow and can therefore be used with large lesions. Moreover, its donor site is above the high-pressure/stress lower sacrum. Retrospective analysis showed that no patients experienced complications.
Conclusions
Sitting is associated with high mechanical forces on the sacrococcygeal skin. The transposed SGAP flap may ameliorate these forces and thereby reduce the risk of complications of pilonidal sinus reconstruction for large defects.
... Thus, it is questionable whether this flap is consistently appropriate for pressure ulcers less than 12 cm in transverse width, recurrent ulcers or patients requiring sacro-gluteal sensation. Recently, the gluteal artery perforator (GAP) flap and its modifications are commonly used in sacral ulcers [12][13][14]. However, this technique also has several disadvantages: severance of gluteal cutaneous nerves resulting in considerable decrease of flap sensation, wide supra-muscular dissection for flap elevation and isolation of the main gluteal artery which may limit future flap selection for recurrent ulcer reconstruction, and gluteal donor site closure which can lead to gluteal disfiguration. ...
Background: The en bloc sliding gluteus maximus myocutaneous flap was introduced to preserve the vasculature, muscular integrity, sensory innervation, and normal gluteal contour with a midline scar in sacrococcygeal pressure ulcer reconstruction. However, its critical disadvantages include incomplete detachment of the origin of the gluteus maximus and central tension of the closed wound due to round ulcer excision. Therefore, we reviewed the surgical anatomy and applied modifications to achieve sufficient flap mobilization and to decrease complications.Methods: After fusiform or rocket-shaped ulcer excision, submuscular flap elevation was initiated by completely detaching the origin of the gluteus maximus, including the posterior iliac crest, followed by comprehensive lateral submuscular dissection in the gluteal space while preserving the neurovascular pedicles. Bony protrusions were tangentially resected from the lower sacrum and upper coccyx. After en bloc medial advancement of the bilateral flaps, defects were closed in layers, with muscle ligament fixation at the midline.Results: Twenty-nine patients underwent surgery for sacrococcygeal pressure ulcers (primary, n=22; recurrent, n=7). Transverse width of the excised ulcers was 5–12 cm (final defect, 7–15 cm). During the follow-up period (6 months to 7 years), no early postoperative complications or late aesthetic or functional discomfort occurred; however, intermittent skin sloughing occurred in four cases and one coccygeal sore recurrence occurred. The recurrent ulcer was treated using the same surgical method, with no recurrence after 2 years.Conclusion: This modification can be successfully used for the reconstruction of primary and recurrent sacrococcygeal pressure ulcers.
... 16 Various flaps have been used for the repair of buttock pressure sores including fasciocutaneous, muscle, and myocutaneous flaps. [17][18][19][20] Since the introduction of perforator flaps by Koshima et al, 21 the widespread use of perforator flaps has improved reconstruction options and quality of life of patients with skin and soft tissue defects and revolutionized modern reconstructive surgery. 22 Perforator flaps offer several advantages over muscle, myocutaneous or fasciocutaneous flaps, including the preservation of muscle function, reduced donor site damage and complication, versatility, and a reliable blood supply. ...
Perforator flaps have been increasingly used to repair stage IV buttock pressure ulcers. However, no one has proposed an approach for stage IV buttock pressure ulcers repairing based on the subregion of buttock pressure ulcers. This study aims to evaluate the effect of perforator flaps in the repair of stage IV buttock pressure ulcers, and flap selection was based on the location of the pressure ulcers. Over the past 5 years, we evaluated 65 cases of stage IV buttock pressure ulcers repaired using perforator flaps. Flap selection was based on the subregion of each buttock pressure ulcer, following our approach. A total of 87 perforator flaps were used for 65 cases, including 42 superior gluteal artery perforator flaps, 19 fourth lumbar artery perforator flaps, and 26 descending inferior gluteal artery perforator flaps. All patients showed satisfactory reconstruction. The authors' approach can support surgeons in selecting the appropriate flaps to repair stage IV buttock pressure ulcers and achieve excellent reconstructive outcomes. This method makes the selection of flaps for pressure ulcer repair systematic, simple, and highly feasible and thus is worthy of promotion.
... Gluteal perforator flaps are a valuable alternative for treating sacral radiation-induced ulcers and osteoradionecrosis 34) . Unlike a musculocutaneous flap, a gluteal artery perforator flap can preserve intact musculature with minimal donor site morbidity and avoids the need for secondary procedures that involve the underlying muscles 34,35) . ...
Background: Osteoradionecrosis significantly reduces quality of life. In this study, we reviewed our experience of surgically managing complicated cases of osteonecrosis and discussed the perioperative problems encountered.
Methods: We retrospectively evaluated 15 patients with osteoradionecrosis of the craniofacial or trunk skeleton who underwent flap reconstruction surgery at our institution between January 2002 and December 2021. In all cases, the irradiated tissues were excised, followed by coverage with well-vascularized tissue. Surgical methods and postoperative complications were evaluated as outcomes.
Results: The 15 patients included six men and nine women, with a mean age of 67.8 ± 17.0 years (range 20–83 years). The affected bone was the skull in one case, mandible in five cases, clavicle in one case, ribs in five cases, sacrum in two cases, and pubic bone in one case. In seven cases, a postoperative fistula formed in the craniofacial or pelvic region. The fistulas in the craniofacial region were closed by the removal of the infected plate or excision of the sequestrum.
Conclusions: Surgical treatment of osteoradionecrosis should include excision of the irradiated tissues followed by coverage with well-vascularized tissue. Well-vascularized transplanted tissues can be effective for wound healing in complicated cases.
A 75-year-old man with osteoradionecrosis of the skull (case 1). Fullsize Image
(a) Preoperative photograph showing necrotic parietal bone. (b) Sagittal preoperative computed tomography (CT) showing epidural abscess and brain edema. (c) Sagittal T1-weighted image showing an area of low intensity in the parietal bone. (d) Fresh bleeding after wide excision of the devitalized tissue. (e) The latissimus dorsi musculocutaneous flap and serratus anterior muscle with the eighth and ninth ribs designed on the right chest wall. (f) Ribs fixed with absorbable stitches across the parietal bone defect and the serratus anterior muscle covering the central portion of the defect. (g) CT image taken 14 months after surgery with a red arrow denoting the progression of necrosis of the marginal bone. (h) Photograph taken 16 months after surgery showing closure of the fistula.
... The IGA perforator flap has been used in both reconstructions of the gluteal region, but also breast reconstructive procedures [1,11]. Because of the clinical significance of this vessel, its anatomy has been extensively researched in the past. ...
BACKGROUND: The inferior gluteal artery (IGA) is a large terminal branch of the anterior division of the internal iliac artery (ADIIA). There is a significant lack of data regarding the variable anatomy of the IGA. MATERIALS AND METHODS: A retrospective study was conducted to establish anatomical variations, their prevalence and morphometrical data on IGA and its branches. The results of 75 consecutive patients who underwent pelvic computed tomography angiography were analysed. RESULTS: The origin variation of each IGA was deeply analysed. Four origin variations have been observed. The most common type O1 occurred in 86 of the studied cases (62.3%). The median IGA length was set to be 68.50 mm (lower quartile [LQ]: 54.29; higher quartile [HQ]: 86.06). The median distance from the origin of the ADIIA to the origin of the IGA was set to be 38.22 mm (LQ: 20.22; HQ: 55.97). The median origin diameter of the IGA was established at 4.69 mm (LQ: 4.13; HQ: 5.45). CONCLUSIONS: The present study thoroughly analysed the complete anatomy of the IGA and the branches of the ADIIA. A novel classification system for the origin of the IGA was created, where the most prevalent origin was from the ADIIA (type 1; 62.3%). Furthermore, the morphometric properties (such as the diameter and length) of the branches of the ADIIA were analysed. This data may be incredibly useful for physicians performing operations in the pelvis, such as interventional intraarterial procedures or various gynaecological surgeries.
... The concept of perforator flaps, described by Kroll and Rosenfield and Koshima et al., affirmed that any flap could be created out of tissue with an adequate blood supply that could be successfully isolated. This avoids the need to rely solely on larger, named vessels [11,12]. Hamdi et al. described the use of the LICAP flap in breast reconstruction using vessels located over the anterior border of the latissimus dorsi to repair defects in the lateral quadrant of the breast. ...
Pure cutaneous recurrence after breast-conserving surgery is rare and presents a unique challenge to clinicians. Some carefully selected patients may be amenable to further breast-conserving therapy. We present the case of a 45-year-old female with a cutaneous recurrence of previously treated right breast cancer along the operative scar in the upper outer quadrant. The patient underwent a further wide local excision with lateral intercostal artery perforator flap with a skin paddle reconstruction. We achieved volume replacement with this technique, disease control, and a pleasing cosmetic result.
... Lumbar artery perforator (LAP) and superior gluteal artery perforator (SGAP) flaps are historically im-portant components of the second-choice flaps 4,5 and becoming increasingly popular because a substantial amount of fat tissue may be obtained even in slender patients. Although there have been numerous anatomical studies on LAP and SGAP flaps, most have examined only LAP flap 4,[6][7][8][9][10][11][12][13][14][15] or SGAP flap [16][17][18][19][20][21][22][23][24][25][26] independently of each other. A direct comparison of the two on the same patient is rare. ...
Background:
Although the deep inferior epigastric artery perforator flap is the criterion standard for autologous breast reconstruction, lumbar artery perforator (LAP) and superior gluteal artery perforator (SGAP) flaps are recent trends as alternatives. The purpose of our study was to clarify differences of these flaps based on multislice CT findings of the same patient.
Methods:
Retrospective study was conducted on 58 patients who underwent preoperative contrast-enhanced multislice CT for breast reconstruction using deep inferior epigastric artery perforator. Of these, 32 patients' data were evaluated excluding 26 patients' data either for the lumbar or gluteal fat being outside the imaging range or for nondepiction of the vascular pedicle origin of LAP or SGAP flap. Vascular pedicle diameter, pedicle length, and subcutaneous fat thickness were measured for LAP and SGAP flaps.
Results:
The vascular pedicle diameter, pedicle length, and fat thickness were 2.1 (SD, 0.3) mm, 3.4 (SD, 0.4) cm, and 4.9 (SD, 1.0) cm, respectively, for LAP flaps; and 1.7 (SD, 0.2) mm, 5.6 (SD, 1.1) cm, and 2.7 (SD, 0.7) cm, respectively, for SGAP flaps.
Conclusions:
The LAP flaps had thicker subcutaneous fat and a larger vascular pedicle diameter, whereas the SGAP flaps had a longer vascular pedicle. As donor material for breast reconstruction, the LAP flap is indicated for cases where absolute volume is needed; otherwise, the SGAP flap is more advantageous as it facilitates vascular anastomosis with its longer vascular pedicle.
... [4][5][6] This method of skin flap movement is also employed in the perforator flap on the gluteus maximus, which has a thick adipose tissue on the muscle. 11,12 In cases of adipose tissue dissection for rotational movement Fig. 5. case 1 is of a male patient with an ischial pressure sore undergoing transplantation of a perforator flap from his thigh. Flap design (6 × 15 cm) and X marks of the arterial sounds heard by a Doppler flow meter on the ischiorectal fossa can be observed (a). the ischial tuberosity is exposed in the debrided ulcer. ...
Perforator flaps based on the ischiorectal fossa (IRF) (ie, internal pudendal artery perforator flaps) are useful for perineal reconstruction. The three-dimensional characterization of perforator arteries in the IRF remains unclear, as the IRF contains thick adipose tissue as well as organs, such as the rectum, vagina, and urethra. This study aimed to evaluate perforators in the IRF to guide the safe elevation of skin flaps designed based on the IRF.
Methods:
IRF vessels were examined in 200 bilateral computed tomography angiography scans performed in 100 patients. We examined branching patterns arising from the internal iliac artery and the origins of the skin perforators in the IRF.
Results:
The branching patterns of the internal iliac artery were divided into three groups: perforators derived exclusively from the internal pudendal artery (78%), perforators derived from the internal pudendal artery and the inferior gluteal artery (18%), and perforators derived exclusively from the inferior gluteal artery (4%). The average number of perforators in the IRF was 1.5 ± 0.7. The number of perforators was significantly higher in women than in men. The perforator arteries were found exclusively around the medial and dorsal sides of the ischial tuberosity.
Conclusions:
We found that perforators in the IRF were stable. All cases had more than one skin perforator, which was mainly derived from the internal pudendal artery. Although perforators cannot be identified during flap elevation because the fatty tissue in the IRF is very thick, physicians must focus on preserving the perforator-containing fatty tissue around the ischial tuberosity.
... Since the recommended flaps are transposition or advancement flaps, the tissue around the injury zone becomes the tip of the flap that carries the higher tension, which has the possibility of dehiscence at the wound site. After understanding of perforator anatomy of the region, the preference has shifted gradually to perforator flap reconstruction (Koshima et al., 1993). Perforator flaps replaced conventional flaps in our department with advantages such as muscle preservation and lower donor site for over a decade. ...
Background:
Sacral pressure ulcer reconstruction is frequently applied in plastic surgery practice. Although perforator flaps are frequently used, recurrence is not uncommon in patients. For this reason, using the as little area as possible during the reconstruction is vital. Therefore, we aimed to describe a mathematically standardized bilobed perforator flap design for sacral pressure ulcer reconstruction with a certain proportion and angle relation between limbs.
Methods:
A total of 17 patients (5 female/12 male)were included in this report. The mean age of the patients was 50.4 years (Ranging from 32 to 79 years). The patients with grade 3-4 sacral pressure ulcers were included in the report. The patients have grade 1-2 sacral ulcers or the other areas of pressure ulcer excluded. The size of the defects ranged from 8 × 14 cm to 5 x 16 cm. For ulcers in the sacral region, we used bilobed flaps that we mathematically standardized. The length of the first limb of the flap was planned 90° vertically oriented according to the distance between the perforator zone to the distal lateral border of the defect. The width of the first limb was kept equal to the length of the defect. The orientation of the second limb of the flap was designed 90 degrees horizontally according to the first limb. Therefore, the lengths of second limbs were calculated as half of the first limb's width, and the widths of second limbs were calculated as ¾ width of the first limb's width.
Results:
A total of 10 flaps were elevated based on superior gluteal artery perforators, and seven flaps were nourished by inferior gluteal artery perforators. The mean size of the first limb of the flaps was 14.7 × 7.2 cm (Ranging from 8 to 20 × 6 to 13 cm). The mean size of the second limb of the flaps was 6.7 × 5.3 cm (Ranging from 5 to 12 × 4 to 8 cm). The mean size of defects was 10.5 × 7.3 cm (Ranging from 8 to 14 × 5 to 16). The mean rotation angle was 91.7° (ranging from 90 to 100). In the early postoperative period, the hematoma was detected in three patients and evacuated in one patient, resulting in wound separation. Tip necrosis was seen in a patient that was healed by wound care. No total flap loss was encountered. No late-term recurrence was seen during the follow-up. The mean follow-up time was 13.1 months (Ranging from 4 to 24 months).
Conclusion:
Unilateral standardized bilobed perforator can reliably be preferred in medium to large size sacral pressure ulcer defects.
... Many surgical methods have been used to reconstruct sacral defect, including local random flaps, and muscle flaps. In the recent years, the concept of perforator-based flaps has been used for covering sacral defects [4] . ...
... Perforator flaps are popular because they allow reconstruction of wide defects requiring long pedicles and large rotating arcs while preserving underlying muscles. However, meticulous perforator dissection is required, and for less experienced surgeons, skeletonization requires much effort [6][7][8][9][10]. In addition, pedicle twisting or postoperative compression can cause venous ischemia and congestion. ...
Background: Several surgical options are available for covering soft tissue defects. Perforator-based flaps can be utilized without skeletonization of the perforator, and surgery is usually straightforward, albeit with limited arcs of rotation. To overcome this limitation, we present our experience of the push technique, whereby the flap is manually pushed to release soft tissue attachments, allowing circumvention of the meticulous dissection required to enhance arc rotation. This technique allows faster flap elevation with minimal complications.Methods: The records of 37 patients that underwent perforator-based flap surgery using the push technique from September 2020 to June 2021 at our institution were retrospectively reviewed.Results: All 38 flaps survived completely though one flap developed congestion resulting in partial necrosis and revision. Mean operation time was less than 80 minutes. No dehiscence or recurrence was encountered at any donor or recipient site during follow-up.Conclusion: We present the “push technique” used during perforator-based flap surgery. This method allows for efficient, minimal, and rapid flap elevation without meticulous dissection and helps the operator determine which parts of soft tissue attachments require further release. The push technique can be performed safely and easily without jeopardizing flap survival due to venous ischemic or congestive change. It serves as a good practice model for inexperienced surgeons wishing to cover moderate-to large-sized defects.
... Pontén 4) reported the use of a fasciocutaneous (FC) flap. Koshima et al. 5) described the concept of a perforator-based FC flap, which has become the mainstream reconstruction technique for pressure ulcers. ...
Introduction: In sacral pressure ulcers, wound healing is poor and closure is difficult, resulting in complications, such as dissection. Skin flap utilization is the mainstay of treatment for ulcers with concerns regarding dissection and recurrence, intractable pockets, and bone exposure. We selected a perforator-preserving gluteal artery-based fasciocutaneous (FC) rotation flap as the first choice for sacral ulcer reconstruction. In addition to the commonly used back cut and typical Burow's triangle for rotation flaps, we have placed modified Burow's triangles to reduce the size of the second defect and used the deepithelialization technique for suturing ulcers to prevent dissection and recurrence.
In this study, we aimed to describe the usefulness and our ingenuity of the perforator-preserving gluteal artery-based rotation FC flap.
Materials and methods: We evaluated 14 patients with sacral pressure ulcers who underwent surgery. In all patients, the perforator-preserving gluteal artery-based rotation FC flap was used and had good wound bed preparation. The method (unilateral or bilateral, back cut, Burow's triangle, and deepithelialization technique) as well as the postoperative wound dehiscence, infection, epidermal necrosis, small fistula, and recurrence were retrospectively evaluated as outcomes.
Results: A unilobar rotation flap or double-opposing unilobar rotation flap was selected in nine and five cases, respectively. The back cut technique (82.4%), Burow's triangle (42.1%), and deepithelialization technique (100%) were used to close the ulcer. The mean follow-up period was 9.8 ± 6.5 months with no observed cases of wound dehiscence (0%) or infection (0%). Although epidermal necrosis of the wound edge (28.7%) and small fistula (21.4%) were observed, wound closure was achieved conservatively and in a short period of time. No recurrence was observed.
Conclusion: The perforator-preserving gluteal artery-based rotation FC flap can be safely used in cases of sacral pressure ulcer reconstruction when using the back cut, Burow's triangle, and deepithelialization techniques appropriately under fine wound bed preparation.
... The real revolution emerged in the concept of cutaneous vascular supply in 1980s when Isao Koshima et al. introduced "perforasomes." [11][12][13][14][15][16][17][18] The perforasome is now defined as "a vaso-neuro-osteo-histo surgical unit supplied by the single perforator vessels (containing single perforator artery, and one or two venae commitantes and also sometimes a cutaneous nerve) arising from the source vessel." [1,2,19] arterial disease in the diabetic population attributing to increased limb loss. ...
Chronic limb-threatening ischemia in the diabetic foot is a spectrum disease characterized by the failure of wound healing and increased risk of amputation. The interspecialty consolidating services between the vascular and plastic surgeon with applied perforasome approaches both in the timely revascularization and early reconstruction culminate in the stable and shoeable foot or foot residuum.
... This design also provides a considerably larger flap than the fasciocutaneous V-Y advancement flap or the gluteal perforator-based flap. [9] Grabosch et al. carried out an electromyographic study on 11 patients who had undergone reconstructive surgery with gluteus maximus myocutaneous flaps in a period up to 7 months after surgery. The results showed signs of denervation, parallel re-innervation, and signs of functional integrity of the transposed muscle. ...
The incidence of squamous cell carcinoma arising from pressure ulcers has been reported to be as low as 0.5%. Malignant transformation arising from pressure ulcers is frequently overlooked as they often present with invasive infections. This results in wide defects post-excision which may not be amicable to reconstruction with conventional locoregional flaps. Through this case report, we discuss the versatility of using the bilateral gluteus maximus V-Y advancement flap following resection of sacral squamous cell carcinoma (Marjolin's ulcer).
... 52 The dissection of these flaps should be meticulous, and this is time consuming, leading to longer operating times and increased blood loss intraoperatively. 53 Newer studies have shed light on the fact that in chronically debilitated patients, there are increased chances of recurrence, which should be taken into consideration; hence, if fasciocutaneous flaps are used in the first surgery, it spares the muscle-based flap, which can be used in case if there is a recurrence. 54 An attempt was made to study these factors and to predict an algorithm for flap selection in specific anatomical locations. ...
Introduction:
Pressure sores are agonizing complications of chronically bedridden patients. The management of these lesions particularly with respect to grades III and IV lesions are chiefly surgical and involves a multidisciplinary approach. Although there are a variety of local flap options, like fasciocutaneous flaps, musculocutaneous flaps, perforator flaps, and combinations of these to choose from, there is a paucity of literature regarding which flap is better among these in terms of complication and recurrence rates.
Methods:
The databases searched were as follows: Cochrane Central Register of Controlled trials (January 2000 to July 2020), MEDLINE (January 2000 to July 2020), and EMBASE (January 2000 to August of 2020). Key words used were "pressure ulcer," "flaps," "surgery," "pressure sore" with limits, "human," and "English." Primary outcomes were "overall complication rates" and "recurrence rates." Overall complication was further categorized as flap necrosis, flap dehiscence, infection, and others.
Results:
Thirty-nine articles were included in the final analysis. There was a statistically significant difference among the various types of flaps for overall complication, flap dehiscence, infection, flap necrosis, and recurrence rates.
Conclusions:
Our study indicates that musculocutaneous flaps have lower recurrence rates, and combined flaps have lower complication rates. However, various other factors, like donor site morbidity, initial defect size, operating time, intraoperative blood loss, salvage options in case of recurrence, should also be considered while choosing a flap to reconstruct a defect.
This retrospective study evaluates the efficacy of the serratus anterior muscle (SAm) free flap combined with a split thickness skin graft (STSG) for thin resurfacing in reconstructive surgery, presenting an alternative to pure skin perforator flaps. It analyzes 14 SAm free flap procedures performed between January 2015 and December 2023. The study cohort comprised 5 women and 9 men, aged 31–80 years, addressing defects caused by infection, malignancy, burn, and trauma, located in various body parts.
The study involves harvesting the SAm flap while focusing on anatomical features such as the distinct direction of muscle fibers and the surface location of the vascular pedicle for efficient dissection. It emphasizes the anatomical advantages of the SAm flap, such as robust vascular supply, controlled flap thickness, and preservation of the long thoracic nerve, making it suitable for a range of surgical needs. Complications included STSG loss, partial necrosis, and infection, all managed effectively. Postoperative shoulder function assessment showed no significant impairment.
Results demonstrated the successful application of the SAm flap in all cases, with an average flap dimension of 38.21 cm ² and pedicle length of 7.3 cm. The average operation time was 122.1 minutes. The study underscores the SAm flap's adaptability, versatility, and minimal donor site morbidity.
It concludes that the SAm flap, in conjunction with STSG, is a viable alternative for thin resurfacing in reconstructive surgery. However, limitations such as the small sample size and procedural variability suggest the need for further research to fully establish the flap's potential in diverse surgical contexts.
Despite significant advances, treatment for chronic ulcers remains challenging to clinicians and surgeons and, in addition, they demand many healthcare resources. Chronic wounds include diabetic foot, venous or arterial vascular leg, and pressure ulcers. Due to their complex etiology, they frequently require a multidisciplinary approach. It is critical to provide individualized patient assessment and treatment, preventing complications. Pressure ulcers are classified as grades I–IV depending on the extent and severity of the wound. Grades I and II are generally managed conservatively; instead, grades III and IV may need surgical procedures, from debridement to complex reconstruction. Simple surgical procedures such as direct closure and skin grafting are useful in early-stage ulcers. However, for advanced chronic pressure injuries, soft tissue flap coverage such as musculocutaneous, fasciocutaneous, and perforator-based flaps may be required. The selection of a proper reconstructive surgery depends on multiple factors, including ulcer location and grade, vascularization of adjacent tissues, patient mobility, and surgeon preference.
This chapter provides an overview of the management and reconstructive modalities of complex chronic ulcers in various anatomical locations, including atypical location of pressure ulcers during the COVID-19 pandemic. Hence, particular emphasis has been given to current advances in reconstructive surgical procedures to achieve healing in such patients.
Background
Despite the increasing popularity of various materials for ischemia-reperfusion (I/R) injury mitigation, research on botulinum toxin type A (BoNTA) remains limited. This study assesses BoNTA’s efficacy in protecting flaps from I/R injury by inhibiting the nicotinamide adenine dinucleotide phosphate (NADPH) oxidase system and reducing reactive oxygen species (ROS) production.
Methods
Seventy-six Sprague-Dawley rats were studied. We examined the effects of BoNTA on superoxide production in four rats using a lucigenin-enhanced chemiluminescence assay (LECL). Another group of 60 rats had their superficial inferior epigastric artery (SIEA) flaps treated with either BoNTA or saline and clamped for 0, 1, and 4 hours before reperfusion. Flap survival and histological outcomes were assessed five days post-operation. ROS production in SIEA flaps and femoral vessels was analyzed in 12 additional rats, post-I/R injury.
Results
The LECL results showed that the BoNTA group had significantly lower superoxide production compared to controls, with notable reductions at 4 hours. While no significant differences were noted at the 0 and 1-hour marks, the 4-hour mark showed significant protective effects in BoNTA-treated groups. The survival rate was 90% for BoNTA-treated rats versus 60% for controls ( P = 0.028). Significant reductions in ROS were also observed in the 4-hour I/R group.
Conclusions
BoNTA effectively protects against I/R injury by inhibiting the NADPH oxidase system and reducing ROS levels. These results support further investigation into the specific mechanisms of NADPH oxidase inhibition by BoNTA and its potential clinical applications, given its safety profile
Clinical Relevance Statement
The findings from the present study are expected to provide a basis for clinical studies regarding this use of BoNTA.
The first evidence of breast cancer dates back to the second millennium BC. Throughout the centuries, treatment was a challenge based on anecdotal concepts and theories. At the end of the 1800s, an inventive surgeon called Halsted standardised the radical mastectomy technique, achieving a 3-year or more survival rate of 38% to 42% (Halsted, Ann Surg 46:1-19, 1907). Halsted’s exclusive priority was controlling a regional affliction that could expand through the body and jeopardise patients’ lives. Therefore, he regarded breast reconstruction as a useless or even dangerous procedure. According to his rationale, breast reconstruction could interfere with adequate oncological safety and lead to recurrence. Besides that, some isolated attempts to perform breast reconstruction were reported in the literature. However, these techniques did not gain recognition until the mid-twentieth century.The development of breast reconstruction techniques followed the comprehension of breast cancer biology and behaviour. Currently, it has become an essential part of the standard of care offered to every patient facing this diagnosis. Techniques evolved from the simple repair of the thoracic wall to create a new breast shape and footprint, often preserving the nipple-areola complex. Eventually, natural results and symmetry became the goal for definitive surgical treatment of breast cancer, setting breast reconstruction as the final step of the surgical treatment. In this scenario, pedicled perforator flaps represent the latest descendant in a line of evolution for breast reconstruction that began with the random-pattern musculocutaneous and fasciocutaneous flaps.KeywordsHistory perforator flapPedicled perforator flapBreast cancerBreast reconstructionAutologous breast reconstruction
Objective:
Stage 3 and 4 pressure injuries (PIs) present an enormous societal burden with no clearly defined interventions for surgical reconstruction. The authors sought to assess, via literature review and a reflection/evaluation of their own clinical practice experience (where applicable), the current limitations to the surgical intervention of stage 3 or 4 PIs and propose an algorithm for surgical reconstruction.
Methods:
An interprofessional working group convened to review and assess the scientific literature and propose an algorithm for clinical practice. Data compiled from the literature and a comparison of institutional management were used to develop an algorithm for the surgical reconstruction of stage 3 and 4 PIs with adjunctive use of negative-pressure wound therapy and bioscaffolds.
Results:
Surgical reconstruction of PI has relatively high complication rates. The use of negative-pressure wound therapy as adjunctive therapy is beneficial and widespread, leading to reduced dressing change frequency. The evidence for the use of bioscaffolds both in standard wound care and as an adjunct to surgical reconstruction of PI is limited. The proposed algorithm aims to reduce complications typically seen with this patient cohort and improve patient outcomes from surgical intervention.
Conclusions:
The working group has proposed a surgical algorithm for stage 3 and 4 PI reconstruction. The algorithm will be validated and refined through additional clinical research.
The superior gluteal artery perforator (SGAP) flap has been used as a pedicled flap for lumbosacral, perineal defects or a free flap for breast reconstruction. We explored the history of the SGAP flap and its modifications over time. This was related to key anatomical principles in preoperative planning including investigations, flap harvesting and dissection technical tips based on the intended operation. We advocate the use of SGAP (unilateral or bilateral) to be the workhorse and robust flap for lower lumbosacral defects and the first choice in reconstruction.KeywordsSGAP flapPerforator torsionFlap de-epithelialisationBreast reconstructionSacral reconstruction
Despite advances in reconstruction techniques, sacral pressure ulcers continue to present a challenge to the plastic surgeon. Fasciocutaneous flaps are tissue flaps that include skin, subcutaneous tissue and the underlying fascia. Including the deep fascia with its prefascial and subfascial plexus enhances the circulation of these flaps. They can be raised without skin and are then referred to as fascial flaps. The present study was planned to evaluate the perforater Sparing Gluteal Fasciocutaneous flap for Sacral pressure sore. The rotation Gluteal Fasciocutaneous flap for sacral pressure sore coverage have distinct advantage of rotation in the event of ulcer recurrence. The flap from the gluteal crease derives blood supply from the inferior gluteal artery perforator (IGAP) and reliably preserves the entire contralateral side as a donor site. The author describe their approach of preserving and incorporating musculocutaneous perforators into the conventional rotation design.Data from 11 patients (8 men, 3 women; mean age [range 24-71] years old) whose sacral ulcers were closed with an IGAP flap between from Jan 2017 to Apr 2018 June were retrieved and reviewed. All patients were bedridden; 1 patient in a vegetative state with a diagnosis of Cerebro vascular accident was referred from a local clinic, 2 patients had pelvic bone fracture on long duration traction, and 2 patients had a history of Cervical injury leading to quadriplegia , and 6 patient have hemiplegia due to spinal injury . The average defect size was 110 cm(2) (range 78-134 cm(2)). The average flap size was 75.8 cm(2) (range 46-111 cm(2)). After surgery, the patients' position was changed every 2 hours; patients remained prone or on their side for approximately 2 weeks until the flap was healed. After healing was confirmed, patients were discharged. Complications were relatively minor and included 1 donor site wound dehiscence that required wound reapproximation. No surgery-related mortality was noted; the longest follow-up period was 24 months. The present study was planned in the Department of Plastic Surgery, Pulse Emergency Hospital, Patna, Bihar. Total 11 cases of the operated from Jan 2017 to Apr 2018 were included in the present study. All the patients were informed consents. The aim and the objective of the present study were conveyed to them. Approval of the institutional ethical committee was taken prior to conduct of this study. The data generated from the present study concludes that the modified method we proposed is relatively simple and easy for reconstructing sacral sores, provides sufficient padding, and has little donor-site morbidity. Once sufficient padding is established in cases like this, a takeaway from this report would be to study the recurrence rates compared with the classic fasciocutaneous flap. Keywords: Fasciocutaneous flaps, Sacral pressure, sore, etc.
Background:
There are several possible interventions for managing pressure ulcers (sometimes referred to as pressure injuries), ranging from pressure-relieving measures, such as repositioning, to reconstructive surgery. The surgical approach is usually reserved for recalcitrant wounds (where the healing process has stalled, or the wound is not responding to treatment) or wounds with full-thickness skin loss and exposure of deeper structures such as muscle fascia or bone. Reconstructive surgery commonly involves wound debridement followed by filling the wound with new tissue. Whilst this is an accepted means of ulcer management, the benefits and harms of different surgical approaches, compared with each other or with non-surgical treatments, are unclear. This is an update of a Cochrane Review published in 2016.
Objectives:
To assess the effects of different types of reconstructive surgery for treating pressure ulcers (category/stage II or above), compared with no surgery or alternative reconstructive surgical approaches, in any care setting.
Search methods:
We used standard, extensive Cochrane search methods. The latest search date was January 2022.
Selection criteria:
Published or unpublished randomised controlled trials (RCTs) that assessed reconstructive surgery in the treatment of pressure ulcers.
Data collection and analysis:
Two review authors independently selected the studies, extracted study data, assessed the risk of bias and undertook GRADE assessments. We would have involved a third review author in case of disagreement.
Main results:
We identified one RCT conducted in a hospital setting in the USA. It enrolled 20 participants aged between 20 and 70 years with stage IV ischial or sacral pressure ulcers (involving full-thickness skin and tissue loss). The study compared two reconstructive techniques for stage IV pressure ulcers: conventional flap surgery and cone of pressure flap surgery, in which a large portion of the flap tip is de-epithelialised and deeply inset to obliterate dead space. There were no clear data for any of our outcomes, although we extracted some information on complete wound healing, wound dehiscence, pressure ulcer recurrence and wound infection. We graded the evidence for these outcomes as very low-certainty. The study provided no data for any other outcomes.
Authors' conclusions:
Currently there is very little randomised evidence on the role of reconstructive surgery in pressure ulcer management, although it is considered a priority area. More rigorous and robust research is needed to explore this intervention.
Breast cancer is the most common cancer in women worldwide. There is enough evidence that mastectomy has an important impact on patient self-esteem and body image. For this reason, breast reconstruction is an integral part of breast cancer treatment that improves patients’ quality of life and psychosocial well-being. The goal of reconstructive breast surgery is to create a breast with a natural shape, volume, contour, and symmetry that evolve harmoniously with the patient over time. Currently, many effective options are available for breast reconstruction. These include implant-based and autologous tissue-based reconstructions that can be performed in the immediate or delayed setting. This chapter gives an overview of the different techniques available for breast reconstruction and the refinement procedures for the reconstructed breast.
Pressure injuries (PIs) represent a significant physical and financial burden for patients, families, healthcare systems, and funding agencies. National initiatives aimed at reducing the incidence of PIs have intensified in recent years, in large part due to the Centers for Medicare and Medicaid Services decision in 2008 to discontinue payments for the ancillary care of hospital-acquired PIs. As a result, early recognition, accurate diagnosis, and measures to prevent or arrest the progression of pressure injuries are of paramount importance. This chapter will outline recent changes in PI terminology and staging, as well as highlight advances in prevention strategies and their downstream effects on incidence, prevalence, and economic impact. The clinical management of pressure injury patients is discussed, including preoperative work-up and optimization, surgical planning, operative techniques for reconstruction, and postoperative care.
The superior gluteal artery perforator (SGAP) flap is an option for the reconstruction of deep sacral defects. Since a conventional SGAP flap is not neurotized, covered ulcers have a risk of recurrence, especially when patients cannot ambulate by themselves. In ambulatory patients, the sensory presentation of reconstructed tissue assures its protection. Purpose of this report is to present a case of the use of a sensate SGAP flap for reconstruction of a sacrococcygeal large wound dehiscence in a patient and review of literature for sensate reconstruction of sacral defects. A 72-year old woman with a sacrococcygeal large wound dehiscence measuring 12 cm in length, 9.5 cm in width and 5 cm in depth was treated. The defect was caused by a wound dehiscence after abdomino-perineal resection for rectal cancer. A unilateral SGAP flap measuring 16 × 7 cm length and 5 cm width was designed in the right buttock and the cranial border of the flap was lined near the iliac crest. An SGAP flap was elevated including the superior cluneal nerve (SCN), turned clockwise 70°, and inset to the defect. The defect remained in the deep caudal part a parasacral adiposal flap measuring 7 × 10 cm was harvested from the contralateral side and filled the defect. The postoperative course was uneventful without any complication. Sensation was observed immediately after surgery. Postoperative Semmes-Weinstein monofilament test showed 3.22 at 9 months postoperatively. There was no recurrence during follow-up of 20 months. The sensate SGAP flap may be elevated with SCN and be considered for reconstructions of deep sacral defect.
Background:
Reconstruction of recalcitrant pressure ulcers is very challenging because all available local tissues have been exhausted. Although occasionally suggested as reconstructive options in some reports, free flaps are still not favored for pressure ulcers because of the less available recipient vessels in buttock area and the need for position change. Here, we describe our experience with latissimus dorsi muscle-splitting free flaps harvested in prone position for recalcitrant pressure ulcers.
Methods:
Between January 2012 and January 2020, 10 patients of recalcitrant pressure ulcers underwent reconstruction using latissimus dorsi muscle-splitting free flaps. To harvest flaps in the prone position, the curvilinear incision was made along the line connecting the lateral border of the scapula and the midaxillary line of the armpit and the latissimus dorsi muscle was split just below the skin incision. Only the required amount of muscle was harvested including the 5 × 3 cm sized muscle cuff around bifurcation points of the transverse and descending branches.
Results:
Flap size ranged from 16 × 9 to 24 × 14 cm and the gluteal vessels were mainly used as recipients. The mean operation time was 170 mins. All the flaps survived but two patients suffered wound disruption and partial flap loss, respectively. During the mean follow-up periods of 2.45 years, there were no recurrences at the reconstruction site, and no patient complained of donor site morbidity.
Conclusions:
Based on the results obtained from this consecutive series of patients, latissimus dorsi muscle-splitting free flaps are valuable option for recalcitrant pressure ulcer reconstruction.
Background:
Large midline sacral defects are reconstructive challenges. Superior gluteal artery perforator (SGAP) flap provides enough tissue and versatility to cover large defects; however, a single flap may be insufficient. We present a technique to cover large defects using single SGAP flaps.
Methods:
Large sacral defects (>100 cm2) reconstructed with single SGAP flaps were included. Angle of transposition (45°-60°) was determined based on the tissue laxity and mobility of gluteal area. Perforator identification, intramuscular dissection, or skeletonization was not performed. Outcomes were measured as achieving durable reconstruction, flap viability, and complications.
Results:
There were 17 patients (12 male, 5 females; aged 25-72 years) with different etiologies. The mean flap surface area (136.1 ± 45.6 cm2, between 9 × 8 and 26 × 10 cm) was smaller than the mean defect surface area (211.1 ± 87.2 cm2, between 10 × 10 and 28 × 14 cm) (P < 0.001). All flaps survived with no partial or complete flap loss. Minor dehiscence in 4 patients (2 at donor site and 2 at recipient site) healed with dressing changes or using negative-pressure vacuum therapy. All patients had durable outcomes without any recurrence.
Conclusion:
Single unilateral SGAP flaps can be used to completely cover midline large sacral defects. It is important to design the flaps to have a joint side with the defect in the proximal part and use the intrinsic mobility of gluteal soft tissues for the closure. Flaps can be (1) planned to be smaller than the defects, (2) harvested with no intramuscular perforator dissection or pedicle skeletonization, and (3) transposed with an angle less than 60°.
Résumé
Introduction
Les reprises chirurgicales multiples (exérèses et cicatrisations dirigées) des kystes pilonidaux récidivants sont sources de cicatrices instables. Il apparaît fréquemment des ulcérations chroniques associées ou non à une récidive authentique. Un lambeau local fascio-cutané perforant basé sur les artères para-sacrée permettraient d’apporter un tissu sain et d’éviter les désavantages des techniques classiques (musculo-cutanés ou au hasard).
Matériels et méthodes
Une série de 8 cas de couverture par un lambeau de transposition basé sur les perforantes para-sacrées, chez des patients multi-opérés. Les perforantes sont repérées par sonde doppler avant le geste, puis le lambeau est tracé obliquement selon la taille de la perte de substance. Le geste est court, peu morbide et accessible à tous par une technique qui exclut la dissection fine du pédicule. La durée d’hospitalisation est de 2 jours.
Résultats
Malgré deux complications mineures et résolutives (un hématome et une désunion du site donneur) la cicatrisation était complète et sans récidive chez tous les patients à 2 ans. Tous étaient satisfaits de la chirurgie.
Conclusion
Ce lambeau simple fiable et reproductible devient la technique de référence dans notre service pour les séquelles de kyste sacrococcygien récidivant.
The superior gluteal artery perforator (SGAP) flap is a widely used flap for sacral reconstruction. However, it is non-sensate flap and sensory loss is one of the most important risk factors for pressure ulcer development and recurrence; therefore, a sensate SGAP flap would be ideal for the reconstruction. Because the upper buttock is innervated by the superior cluneal nerves (SCNs) which originate from Th11 to L4, a sensate SGAP flap based on SCNs is anatomically possible. Herein, we present a novel sensate SGAP flap based on SCNs for reconstruction of sacral defects. Two patients with a sacral defect underwent reconstruction using a sensate SGAP flap (53 and 56 years old, both men). Diagnoses were sacral spindle cell sarcoma and sacral pressure ulcer. The defect sizes were 16 × 13 and 12 × 11 cm. The flap was designed based on the locations of SCNs which are commonly located at 6-8 cm lateral from the midline at the iliac crest. Flap sizes were 16 × 9 and 15 × 13 cm, respectively. The flaps survived completely in both cases. Flap sensation was observed immediately after surgery except in flap margins. However, sensory recovery occurred in these areas as well several months postoperatively. None of the patients developed postoperative pressure ulcers during the follow-up period of 37 and 13 months. This method may preserve flap sensation and therefore can contribute to reducing the risk of postoperative pressure ulcers and could be a useful option for sacral reconstruction.
The reconstruction of complex tissue defects in the lumbar and gluteal areas is a surgical challenge. The use of freestyle perforator-based flaps has gained popularity in the reconstruction of these defects due to several advantages: versatility, minimal donor-site morbidity, and tension-free closure. The present study reports the outcome of using a dual coverage of lumbar and gluteal defects with a gluteus maximus rotation flap as a deep layer and a freestyle propeller perforator-based flap as a superficial layer.
Methods:
A retrospective analysis of 18 patients who had a dual coverage of complex wounds of the lumbar and the gluteal areas was conducted. Different propeller flaps were used as superior gluteal artery perforator flap (SGAP), inferior gluteal artery perforator flap (IGAP), and posterior thigh perforator flap (PTP).
Results:
The study included 15 men and 3 women. The mean age was 26.3 years. The causes of the defects were: pressure ulcers in 14 patients and post-traumatic in 4 patients. A total of 28 freestyle flaps was used: 11 patients had 1 flap, 4 had 2 flaps, and 3 had 3 flaps. The mean postoperative follow-up was 12.2 months. The complications registered in the medical records were venous congestion in 2 patients, partial flap necrosis in 2 patients, and wound dehiscence in 1 patient.
Conclusions:
A freestyle propeller perforator-based flap combined with a gluteus maximus muscle flap is a solution that provides well-padding over bony prominence with a low complication rate. However, a long-term follow-up is needed to verify these results.
Posterior trunk defects have been a challenging anatomical area to cover in reconstructive surgery. The use of local myocutaneous flaps has been described extensively in the literature to cover these defects, but these techniques are associated with significant donor-site morbidity, including functional loss of muscle units. Freestyle perforator flaps enable local tissue recruitment with skin of a similar color and texture in diverse anatomic areas, but there is a shortage of case series on posterior trunk defects using propeller dorsal intercostal artery perforator (DICAP) flaps, particularly when the defects are extensive. In this report, the authors present a successful case of a DICAP propeller flap for an extensive defect on the upper back following a malignant peripheral nerve sheath tumor resection.
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