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SUPERIOR GLUTEAL ARTERY PERFORATOR FLAP - A BETTER
ALTERNATIVE FOR SACRAL SORE RECONSTRUCTION
Dr N. A.
Gunasekaran
Assistant Professor, Department of Plastic Reconstructive & Facio-maxillary surgery,
Madras Medical College & RGGH, Chennai-03
Original Research Paper
Plastic Surgery
INTRODUCTION
As a result of continuous pressure applied to the skin and muscle in bed
ridden patients, blood supply to the tissue is decreased. This leads to
destruction of skin and underlying soft tissue following tissue necrosis.
And also thos e patients with exposed s acrum, thin skin, and
subcutaneous tissue had a higher rate of recurrence. Therefore,
reconstructing a sacral sore is still a difcult problem to surgeons.
Many traditional methods were applied to repair it, such as primary
closure, local random aps, and muscle aps. Gluteus maximus
myocutaneous ap has been a recent mainstream method to repair
sores because of providing excellent blood supply and tissue mass that
2
allow for better distribution of pressure. Simultaneously, the major
drawbacks such as limited shifting of ap, excessive blood loss, and
3
muscle, limit the range of application in some cases. After the concept
4
of perforator aps introduced by Koshima et al, the perforator aps
were widely used in the treatment of soft tissue defects. With the
thorough research on anatomy and clinical application of the SGAP
ap s, th ey be ca me we ll ac cepted as us eful alterna ti ves f or
reconstruction of sacral, ischial and trochanteric pressure sores.
Aim and objectives
To report the use of the pedicled superior gluteal artery perforator
(SGAP) fascio-cutaneous ap as a reliable surgical alernative for
sacral pressure sore reconstruction
Materials and methods
Clinical details
Between november 2017 and September 2018, we treated 20 patients
(14 males, 6 females) with sacral pressure sores, with unilateral
pedicled SGAP fascio-cutaneous aps. The average age was 48.85
years (range 38 - 61 years). All patients were non ambulant &
paraplegic. The cause of ulcer was spinal cord injury in 16 patients and
long-term hospitalisation in ICU in 4 patients. 14 patients had stage 4
sores while 6 had stage 3 sores (staging by NPUAP system).
The patient was placed in a prone position. A line drawn connecting the
posterior superior iliac spine (PSIS) to the apex of the greater
trochanter of the femur. The site where the SGA enters the buttock is
rd rd
identied by the medial 1/3 and lateral 2/3 junction of this line.
Another line is then drawn between the PSIS and the coccyx. The
position of the piriformis is located by joining the middle of the PSIS-
coccyx line to the superior edge of the greater trochanter. The SGA
supplies the gluteus maximus at its suprapiriform portion. Perforators
located superior to the piriformis and lateral to the SGA exit point, will
be considered. The position of the relevant perforators is identied and
marked on the skin, using a hand-held Doppler. The most lateral
perforator giving the highest Doppler signal is most important. The
sacral sore was then thoroughly debrided with complete removal of
bursa. According to the resultant sacral defect, the SGAP ap was
designed in an elliptical fashion of corresponding size over perforator .
The skin, subcutaneous tissue and deep fascia were incised over the
superior border of the ap. Flap elevated in the subfascial plane from
lateral to medial. Perforator was carefully dissected through the
gluteus maximus muscle. Any other suitable perforators encountered
may be dissected and included in the ap. Flap incision was completed
along medial and inferior borders. Pedicle was traced proximally until
the required length of pedicle was achieved. Adequate haemostasis
was achieved.. The SGAP ap was either advanced or transposed into
the defect, without causing any twisting, kinking, compression or
undue tension on the pedicle. The donor site was closed primarily.
Drains were kept,
Case 1
INDIAN JOURNAL OF APPLIED RESEARCH
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KEYWORDS : SGAP ap, gluteal ap, sacral sore reconsruction
Objective: To report the use of the pedicled superior gluteal artery perforator (SGAP) fascio-cutaneous ap as a reliable
surgical alternative for sacral pressure sore reconstruction.
Methods: A prospective study was conducted between November 2017 and September 2018 on 20 patients with stage 3 or 4 sacral pressure sores
treated with a unilateral pedicled SGAP ap.
Results: The size of the pedicled SGAP aps ranged from 6×10 cm to 8×14 cm. All aps survived completely without major complications. The
donor site was closed primarily in all cases. No recurrence of a bedsore occurred after an average follow-up of 12 months.
Conclusion: The SGAP ap is an excellent tool for coverage of loco-regional defects. It is particularly suited for reconstruction of midline sacral
sores. The SGAP ap is an excellent option due to preservation of an intact gluteus maximus muscle, so can be used as a muscle ap, if recurrence
occurs.
ABSTRACT
Dr Prince. H. P*
Post Graduate Resident, Department of Plastic Reconstructive & Facio-maxillary
surgery, Madras Medical College & RGGH, Chennai-03 *Corresponding Author
Dr M. Sridharan
Associate Professor, Department of Plastic Reconstructive & Facio-maxillary surgery,
Madras Medical College & RGGH, Chennai-03
Dr Badamutlang
Dympep
Post graduate resident, Department of Plastic Reconsructive & Facio-maxillary
surgery.
Volume-9 | Issue-3 | March-2019 | PRINT ISSN - 2249-555X
Figure 2. A 45-year-old man became paraplegicbecause of spinal
cord injury and developed a sacral sore, which failed to heal with
traditional methods at the other hospital A)The defect of sacral region
measured 8×9 cm2. B) defect size 9×10 cm2 after debridement, along
with incised flap from right gluteal region C) A flap elevated on the
superior gluteal artery perforator D) The flap settled well, 1 month
postoperative photo.
one under the ap and one in the donor area. The patient was
maintained in prone position for initial 2 weeks, after which suture
removal was done and gradual mobilisation was allowed.
Results
The size of the pedicled SGAP aps ranged from 6×10 cm to 8×14 cm.
All aps survived without major complications. The donor site was
closed primarily in all cases. Two cases developed postoperative
hematoma, underneath ap. drainage of the hematoma was done,
followed by an uneventful recovery. No recurrence of a bedsore
occurred for an average follow up period of 12 months (range 4 - 20
months).
Conclusion.
The SGAP ap is an excellent tool for coverage of loco-regional
defects. It is particularly suited for reconstruction of midline sacral
sores. The SGAP ap is an excellent option due to preservation of an
intact gluteus maximus muscle, so can be used as a muscle ap, if
recurrence occurs.
CASE 2
Figure 3 A 47-year-old male was involved in a traffic accident with left
femoral shaft fracture, after an open reduction and internal fixation, he
was bedridden..A)The defect of sacral region measured 8×9 cm2 after
debridement. B) A flap based on superior gluteal artery perforator
was elevated to reconstruct the defect. C) The flap survived and healed
primary after 10 days postoperative.
Discussion.
Bedridden patients are prone for pressure sores due to long term
constant compression. Sacral region is especially prone, due to its
relatively thin layer of soft tissues overlying the sacrum and poor blood
supply, which make the sores difcult to heal, prone to recurrence.
Traditional methods such as the gluteus maximus myocutaneous aps
has the major drawbacks, such as limited shifting capacity, excessive
blood loss, it sacrices the function of normal muscle, and not
reusable if sore recurrence occurs at the same region, which may limit
the range of application in some cases.
4
In 1993, Koshima et al introduced the concept of a perforator ap for
treating pressure sores in the sacro-coccygeal region. According to an
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anatomical study by Ahmadzadeh et al, a mean of 5 + 2 cutaneous
perforators can be found in the gluteal region arising from the superior
gluteal artery, of which all were musculocutaneous perforators passing
through the gluteal muscle. The average diameter of the perforators
ranged from 0.6 to 1.0 mm. Each perforator supplies a mean area of
2
21± 8 cm . With the in depth research on anatomy and clinical
application of SGAP ap, it was well accepted as a reliable and
alternative method for reconstructing soft tissue defects in sacro-
coccygeal, greater trochanter, and ischial tuberosity regions. For better
ap outcome, we have the following suggestions: 1)Good general
condition of the patient is the foremost of a successful reconstruction,
improve nutrition, and local infection control. 2) Completely debride
the ulcerated area and scar tissues with adequate bursectomy. Thus,
these nonviable tissues must be excised down to healthy tissue. 3)
Guided by a hand-held Doppler, we chose the most lateral perforator
which creates the longest pedicle possible to give a greater arc of
movement. 4) It is necessary to educate patients and caregivers on
pressure relief and skin care for good long-term results. Recurrence is
usually not secondary to the operation, but to the poor compliance of
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patients at home or the lack of appropriate wound care assistance.
Comparing to tra dit ion al methods, the SGAP a p has many
advantages. The perforator ap has a reliable blood supply that makes
its high survival rate. Perforator aps only contains skin and
subcutaneous fat, therefore the sacro-coccygeal region has ne
appearance and good texture. Furthermore, the SGAP ap preserves
the entire contra lateral side as a future donor site. On the ipsilateral
side, the gluteal muscle itself is preserved and all aps based on the
6
inferior gluteal artery are still available.
REFERENCE
1. Kim CM, Yun IS, Lee DW, Lew DH, Rah DK, Lee WJ.Treatment of ischial pressure
sores with both profundafemorisartery perforator aps and muscle ap. Arch PlastSurg
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2. Cushing CA, Phillips LG. Evidence-based medicine: pressure sores. PlastReconstrSurg
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3. Parry SW, Mathes SJ. Bilateral gluteus maximus myocutaneousadvancement aps:
sacral coverage for ambulatory patients.Ann PlastSurg1982; 8: 443-445.
4. Koshima I, Moriguchi T, Soeda S, Kawata S, Ohta S, Ikeda A.The gluteal perforator-
based ap for repair of sacral pressuresores. PlastReconstrSurg 1993; 91: 678-683.
5. Ahmadzadeh R1, Bergeron L, Tang M, Morris SF. The superiorand inferior gluteal
artery perforator aps. PlastReconstrSurg2007; 120: 1551-1556.
6. Lin CT, Chang SC, Chen SG, Tzeng YS. Modication of thesuperior gluteal artery
perforator ap for reconstruction ofsacral sores. J PlastReconstrAesthetSurg 2014; 67:
526-532.
7. Gusenoff JA, Redett RJ, Nahabedian MY. Outcomes for surgical coverage of pressure
sores in non ambulatory, non paraplegic, elderly patients. Ann PlastSurg 2002; 48: 633-
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INDIAN JOURNAL OF APPLIED RESEARCH
Volume-9 | Issue-3 | March-2019 | PRINT ISSN - 2249-555X
