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e superior gluteal artery perforator flap for
reconstruction of sacral sores
Weijian Chen, MS, Bo Jiang, MS, Jiaju Zhao, MS, Peiji Wang, MD.
ABSTRACT
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ÆW¹e−F« WŠdIK 5²UŠ rOdð …œUŽù SGAP ÍuKF« Íu_«
s mK³¹ i¹dË ÂUŽ 47 dLF« s mK³ð WC¹d UMðbŠË w UM'UŽ
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Æ≤rÝ 16×9 v≈ 20×7 s nK²¹ SGAP `z«dý rOLBð
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is report describes our experiences using the
superior gluteal artery perforator (SGAP) flaps for
reconstruction of 2 sacral sore cases. A 47-year-old
female patient and a 38-year-old man with sacral sores
were treated in our unit. e size of the defects were
approximately 5×6 cm2 and 8×9 cm2, the defects
were repaired by SGAP flaps. e size of designed was
SGAP flaps varied from 7×20 to 9×16 cm2. All flaps
survived and healed primary, the texture, functions,
and appearance of flaps were satisfactory, and also
without region dysfunction of donor and recipient
sites. e SGAP flap, which has reliable blood supply,
preserves the gluteus maximus muscle and could be
transferred simply and safely, is an ideal and reusable
method to reconstruct sacral sores with low rate of
postoperative recurrence and satisfactory appearance.
Saudi Med J 2016; Vol. 37 (10): 1140-1143
doi: 10.15537/smj.2016.10.15682
From the Department of Hand and Foot Surgery (Chen, Jiang,
Zhao, Wang), e Second Affiliated Hospital of Soochow University,
Suzhou, and the Department of Orthopedic Surgery (Chen), Affiliated
Provincial Hospital of Anhui Medical University, Hefei, China.
Received 31st May 2016. Accepted 17th June 2016.
Address correspondence and reprint request to: Dr. Peji Wang,
Department of Hand and Foot Surgery, e Second Affiliated Hospital
of Soochow University, Suzhou, China. E-mail: wangpeiji88@163.com
Case Reports
Pressure sores result from the destruction of skin
and underlying soft tissue due to continuous
pressure applied to the skin and muscle. As a result, the
blood supply to the tissue is decreased, which leads to
necrosis.1 And also, those patients with exposed sacrum,
thin skin, and subcutaneous tissue had a higher rate of
recurrence. erefore, reconstructing a sacral sore is
still a thorny problem to surgeons. Many traditional
methods were applied to repair it, such as primary
closure, local random flaps, and muscle flaps. Recently,
the gluteus maximus myocutaneous flap has been a
mainstream method to repair sores because of providing
excellent blood supply and mass of tissue that allow
for better distribution of pressure.2 Simultaneously,
the major drawbacks such as limited shifting capacity,
excessive blood loss, and muscle atrophy long-term
postoperation limit the range of application in some
cases.3 After the concept of a perforator flap was
introduced by Koshima et al,4 the perforator flaps were
extensively used in the treatment of soft tissue defects.
With the in-depth research of anatomy and application
of clinical of the SGAP flaps, they became well accepted
as useful alternatives for reconstruction of sacral, ischial,
and trochanteric pressure ulcers. e aim of our study
OPEN ACCESS
Disclosure. Authors have no conflict of interests, and the
work was not supported or funded by any drug company.
is study was funded by the Scientific and Technological
Development Planning Project, Suzhou, (No.
SYS201230), and the Preponderant Clinic Discipline
Group Project Funding of the Second Affiliated Hospital
of Soochow University (No.XKQ2015010), Soochow,
China.
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www.smj.org.sa Saudi Med J 2016; Vol. 37 (10)
e SGAP flap for sacral sores ... Chen et al
was to show the experiences obtained from using the
SGAP flaps for reconstruction of sacral sores.
Case Report. Patient 1. A 47-year-old female was
involved in a traffic accident with right femoral shaft
fracture, after an open reduction and internal fixation,
bedridden long-term and improper nurse lead directly
to a sacral sore at home. After debridement, the size
of the defect was approximately 5×6 cm2 (Figure 1A).
Besides, anti-infective treatment and local treatment for
one week preceded surgical reconstruction. en, a left
SGAP flap was harvested to cover the defect. e size
of the flap was 7×20 cm2 (Figure 1B). e procedure
of operation runs: the skin of the superior border of
the flap was incised firstly along the marked line down
through the subcutaneous tissue and deep fascia to the
muscle, until our chosen perforator was encounted. By
using a loup magnification, this vessel was dissected out
slowly by splitting the muscles fibres rather than cutting,
and carefully ligated the small muscular side branches.
It is no need to excessively dissect this vessel to the
origin of the superior gluteal artery to prevent injury to
the perforator vessel. Generally, the pedicle contained
one, at most 2 perforators in the flap we designed, we
thought that multiple perforators in the pedicle would
restrict the mobility of flap. After the inferior border of
the flap was then incised, the flap was detached from the
muscle, perforator vessel was chosen as the pivot point to
advance, or rotate the SGAP flap into the sacral defect,
took care to avoid twisting, kinking, compression, or
undue tension on the pedicle. e operative region was
closed primarily without tension, suction drainages
were applied under the flap and defect (Figure 1C). e
flap survived and healed primary without flap necrosis.
After 10 months of follow-up, the result remained stable,
there was no donor site morbidity, no recurrence, and
also the appearance of the surgical site was satisfactory
(Figure 1D).
Patient 2. A 38-year-old man became paraplegic
because of severe spinal cord injury and developed a
deep sacral and 2 trochanteric pressure sores, which
failed to heal with traditional methods at the other
hospital (Figure 2A). Necrectomy, local treatment,
anti-infective treatment and enhanced nutrition
were underwent before surgery, the defect measured
8×9 cm2 after completely debridement. Two weeks
Figure 1 - Photograph showing A) a 47-year-old female involved in a traffic accident with right femoral shaft
fracture, bedridden long-term lead to a sacral sore with the size of 5×6 cm2 after debridement.
B) e superior gluteal artery perforator (SGAP) flap with the size of 7×20 cm2 was harvested
to cover the defect. C) e operative region was closed primarily without tension, suction
drainages were applied under the flap and defect. D) e flap survived and healed primary. After
10 months of follow-up, there was no donor site morbidity, no recurrence, the texture, functions
and appearance of flaps were satisfactory.
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Saudi Med J 2016; Vol. 37 (10) www.smj.org.sa
later, a flap of 9×16 cm2 based on a superior gluteal
artery perforator was rotated into the defect, the wound
of trochanteric pressure sores was closed directly after
excised the necrotic tissue and granulation tissue
(Figure 2B). e flap survived and healed primary after
10 days, postoperatively (Figure 2C). With a follow-up
of 2 years, the original sacral sore region and ischial
pressure ulcers were uneventful (Figure 2D).
Discussion. Patients who are paraplegic, or
bedridden are prone to pressure sores due to long-term
constant compression, sacral region is usually happen
to pressure sores due to its relatively thin layer of soft
tissues overlying the sacrum and local poor blood
supply, which make the sores reluctant to heal, prone
to recurrence, and difficult to reconstruct. Traditional
methods such as the gluteus maximus myocutaneous
flaps with its major drawbacks such as limited shifting
capacity, excessive blood loss, sacrifice the function of
the normal muscle, and not reusable if sore recurrence
occurs at the same region, which may limit the range
of application in some cases. To address this problem,
we should consider the possibility of sore recurrence,
preserve other reconstructive flap options and minimize
the function damage to donor site before harvesting a
flap
In 1993, Koshima et al4 introduced the concept
of a perforator flap for treating pressure sores in the
sacrococcygeal region. With an evolution of work
by surgeons, such as big difference had brought to
this problem. According to an anatomical study by
Ahmadzadeh et al,5 a mean of 5 + 2 cutaneous perforators
can be found in the gluteal region arising from the
superior gluteal artery. All of the superior gluteal artery
perforators were musculocutaneous perforators passing
through the gluteal muscle. e average diameter of the
perforators arising from the superior ranged from 0.6 to
1.0 mm. Each perforator of the superior gluteal artery
supplies an mean area of 21±8 cm2. With the in-depth
research of anatomy and application of clinical of the
SGAP flap, it was well accepted as an reliable and
alternative method to reconstruct soft tissue defects in
sacrococcygeal, greater trochanter, and ischial tuberosity
regions.
Figure 2 - Photograph showing A) a 38-year-old paraplegic man with severe spinal cord injury and
developed a deep sacral and 2 trochanteric pressure sores. e defect of sacral region measured
8×9 cm2 after debridement. B) A flap of 9×16 cm2 based on a superior gluteal artery perforator
was harvest to reconstruct the defect, the wound of trochanteric pressure sores was closed directly
after excised the necrotic tissue and granulation tissue. C) e flap survived and healed primary
after 10 days postoperative. D) With a follow-up of 2 years, the original sacral sore region and
ischial pressure ulcers were uneventful.
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e SGAP flap for sacral sores ... Chen et al
Compare to traditional methods, the SGAP flaps
were found many prominent advantages run: the
perforator flap based on the superior gluteal artery has
detectable anatomy. erefore, it has reliable blood
supply that make it high graft survival rate, and also,
perforator flaps differ from myocutaneous flaps in that
they only contain skin and subcutaneous fat; therefore,
the sacrococcygeal region has fine appearance, good
texture, and no significant flap bloated, which largely
brought aesthetic results (Figure 1D). Furthermore,
the SGAP flap preserves the entire contralateral side
as a future donor site. On the ipsilateral side, the
gluteal muscle itself is preserved and all flaps which
based on the inferior gluteal artery are still available.6
As we all know, sacral sores were prone to recurrence
especially to paraplegic patients because of the local
anatomy, despite any successful surgery, the possibility
of ulcer recurrence and the absence of an available
skin paddle should be taken into consideration if the
recurrence occurs at the same location. Take the gluteus
maximus myocutaneous flaps for example, if they were
used initially, it was difficult to elevate healthy tissue
ipsilateral side next to the sore to reconstruct the defect
if the recurrence occurs. For this reason, it is significant
that preservation of the tissue structure and vascularity
in those cases in which secondary surgery is probably
required.7 Moreover, the SGAP flap minimizes blood
and donor site morbidity, preserves the intact gluteal
muscle and prevent the sacrifice of its function which
is crucial to those ambulatory parients.8 In our patients
without paraplegia, this method did not affect their hip
joints extension-flexion function, or walking.
Two patients in our treatment group with pressure
sores were all in sacral region, all flaps survived and
healed primary without significant postoperative
complications. To better reach this goal, we have the
following experiences and suggestions: 1) A good general
condition is the premise of a successful reconstruction,
notice to strengthen nutrition, compensatory albumen
and vitamin, improve microcirculation, systemic
and local infection control. 2) Completely debride
the ulcerated area and scar tissues with adequate
bursectomy, generally, the underlying bursa were
deeper and wider than the skin defect. us, these
nonviable tissues must be excised down to healthy
tissue. 3) Guided by a hand-held doppler, we chose
the most lateral perforator vessel as the pedicle, the
flap around which would create a longest pedicle
possible to give a greater arc of movement. Generally,
the pedicle contained one, at most 2 perforators in the
flap we designed, we thought that multiple perforators
in the pedicle would restrict the mobility of flap. 4)
Dissection was time consuming and required extreme
care to prevent injury to the perforator vessel, this vessel
should be dissected out slowly by splitting along the
muscles fibres rather than cutting, and carefully ligate
the small muscular side branches, and also no need to
excessively dissect it to the origin of the superior gluteal
artery. 5) We preferred to close the donor site firstly to
reduce the tension between the defect and flap, which
would help to reduce the risk of wound dehiscence. 6)
It is necessary to educate patients and caregivers learn to
pressure relief and skin care for good long-term results.
Recurrence is usually not secondary to the operation,
but to the poor compliance of patients at home or the
lack of appropriate wound care assistance.9
References
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