Inferior Gluteal Artery Perforator Flap for Sacral Pressure Ulcer Reconstruction: A Retrospective Case Study of 11 Patients
Despite advances in reconstruction techniques, sacral pressure ulcers continue to present a challenge to the plastic surgeon. 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. To incorporate the IGAP in the reconstruction of sacral pressure ulcers, a skin paddle over the gluteal crease was created and implemented by the authors.
Data from 11 patients (8 men, 3 women; mean age 67 [range 44–85] years old) whose sacral ulcers were closed with an IGAP flap between June 2006 and May 2012 were retrieved and reviewed. All patients were bedridden; 1 patient in a vegetative state with a diagnosis of carbon monoxide intoxication was referred from a local clinic, 2 patients had Parkinson’s disease, and 8 patients had a history of stroke. The average defect size was 120 cm2 (range 88–144 cm2). The average flap size was 85.8 cm2 (range 56–121 cm2). Only 1 flap failure occurred during surgery and was converted into V-Y advancement flap; 10 of the 11 flaps survived. 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. In this case series, flaps from the gluteal crease were successfully used for surgical closure of sacral pressure ulcers. This flap design should be used with caution in patients with hip contractures. Studies with larger sample sizes are needed to ascertain which type of flap is best suited to surgically manage extensive pressure ulcers in a variety of patient populations.
Managing sacral pressure ulcers is a common problem for reconstructive surgeons. Local flaps created from the gluteal region are preferred when wound closure is needed due to their reliability and short learning curve for surgeons. Gluteal muscle perforator-based flaps have been used to cover sacral defects for more than 10 years. This flap construct has become increasingly popular because of its versatility and low incidence of donor site complications.1-3
Three types of flaps involving the gluteal crease based on different terminal branches of the inferior gluteal artery have been described in the literature: the infragluteal flap,4 the inferior gluteal artery perforator (IGAP) flap,5,6 and the inferior gluteal artery myocutaneous flap.7 Many clinicians harvest free flaps from the gluteal crease region for breast reconstruction because of its fatty composition.4-6 Gluteal crease flaps also provide positive aesthetic results for both the breast reconstruction and donor site scar without sacrificing muscle at a donor site. According to the case studies of Scheufler et al8 (N = 13) and Higgins et al’s case report,9 gluteal crease flaps also may be harvested for ischial pressure ulcer coverage.8,9
Two mechanisms contribute to pressure ulcer development: external pressure that compresses blood vessels and friction and shearing forces that tear and injure blood vessels. The sacral pressure ulcer is susceptible to recurrence if the underlying mechanisms are not addressed.
In the authors’ facility, a local, unilateral, gluteus maximus myocutaneous advancement flap is the usual choice for sacral defects. Gluteus maximus myocutaneous flap surgery is technically easy to perform. However, the gluteus maximus muscle should be partially split to allow for advancement of the flap and tension-free closure, which introduces the potential for gait instability in an ambulatory patient. The derived flap seldom crosses the midline of the gluteal region; a bilateral gluteus maximus myocutaneous advancement flap is needed for larger defects.1
The purpose of this case study is to describe the outcomes of patients in whom a gluteal crease flap was used for reconstruction of sacral pressure ulcers.
Patients and Methods
The authors treated 350 sacral pressure ulcers in 289 total patients with 332 flaps from June 2006 to May 2012 in the Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan. From among these, they retrospectively analyzed the 11 patients (8 men, 3 women; mean age 67 [range 44–85] years old) whose sacral pressure ulcers had been reconstructed using IGAP flaps. The IRB committee of Tri-Service General Hospital approved all procedures for obtaining informed consent, reviewing records, and publishing data and photographs. All defects contained extensive destruction, tissue necrosis, and/or damage to muscle, bone, or supporting structures with or without full-thickness skin loss, a stage IV pressure ulcer according to the definition developed by Shea.10 All patients were bedridden; 1 patient was in a vegetative state following carbon monoxide poisoning, 2 patients had Parkinson’s disease, and the remaining 8 patients had a history of stroke. The patient summary is shown in Table 1.
Surgical procedure. Surgical repair of the defect was performed with the patient in a prone position under general anesthesia. The surgical field was sterilized, the sacral pressure ulcer was debrided, and the bony prominence of the sacral bone was removed using an osteotome. The wound then was covered with epinephrine-soaked gauze, and the defect size was measured. An elliptical flap was created from the gluteal crease region; the authors’ preference is to harvest the flap from the side closest to the sacral pressure ulcer if the ulcer is not centrally located, according to the recommendations of Scheufler et al8 and Higgins et al.9 The axis of the flap was fashioned along the natural gluteal crease, the length of the flap was determined according to the vertical length of the defect, and the width of the flap was 3–5 cm less than the horizontal width of the defect so as not to interfere with flap inset as well as to facilitate donor site closure (see Figures 1, 2). The incision was made along the inferior flap margin to identify the inferior border of the gluteus maximus muscle. The length of the dissected pedicle was determined by the arc of movement of the flap.
Care was taken to identify the cutaneous branch from the descending branch of the inferior gluteal artery at the inferior margin of the gluteus maximus muscle. If the descending branch was of suitable size (>12 mm), the cutaneous branch was isolated and traced along the descending branch toward the origin of the inferior gluteal artery. If the cutaneous branch was absent or too small, the superior margin of the flap was incised. The incision was carried down to the subfascial level, and subfascial dissection was performed caudally to identify the myocutaneous perforator of the inferior gluteal artery. If the perforator was of adequate size (>1–2 mm), intramuscular dissection of the perforator was performed, and the vessel was traced proximally. The flap then was elevated and transferred to the defect either through a subcutaneous tunnel or by incising the skin between the flap and the sacral defect. The flap was set into the defect without tension or twisting on the pedicle. Usually, the flap is rotated 90˚ using the horizontal length of the flap to approximate the vertical length of the defect.
After surgery, vital signs were monitored every 4 hours in unstable patients and every 8 hours in stable patients. The incision and dressing were monitored for signs of infection, and the amount of drainage was noted. Wet gauze dressing changes were performed using sterile technique throughout the hospitalization, and patients’ positions were changed every 2 hours. Some patients were placed on air-fluidized beds to decrease the frequency of patient repositioning. Patients were instructed to lay in the supine position during the day and to remain prone at night for approximately 2 weeks until the flap healed, after which they were discharged to a nursing facility or returned home. Patients were instructed to transition to full supine bed rest 4 weeks after surgery and continue this until wound healing without dehiscence was achieved.
Patients were reexamined and the wound photographed every week in the outpatient department; alternatively, telephone interviews were conducted by the authors’ medical staff if the patients did not return for follow-up.
The average defect size was 120 cm2 (range 88–144 cm2). The average flap size was 85.8 cm2 (range 56–121 cm2). Seven (7) flaps were harvested from the left gluteal crease region and 4 from the right gluteal crease region. Although venous congestion commonly caused flaps to become purple and swollen immediately following surgery, 10 flaps survived completely and achieved wound healing without complications. One patient (patient 6) suffered a traction injury to the pedicle during the transfer of the flap through the subcutaneous tunnel; the flap was abandoned and immediately converted to a local gluteus maximus myocutaneous advancement flap. The skin between the sacral pressure ulcer and the donor site was incised for flap transfer in 3 patients; in 8 patients, the flaps were transferred through a subcutaneous tunnel. One wound dehiscence (patient 5) occurred over the donor site, requiring further wound reapproximation. No surgery-related mortality was noted. The longest follow-up was 24 months. No adverse outcomes were noted, but 1 pressure ulcer recurred (patient 2) 5 months after surgery (see Table 1).
Two case reports of the patients studied, exemplifying the use of IGAP flaps, are presented.
Patient 3. Mr. Q was an 85-year-old man who had been bedridden for 2 years due to a cerebrovascular accident. A grade IV sacral pressure ulcer developed 3 months before admission to the authors’ facility. Surgical debridement created an 11 cm x 10 cm defect, and a flap of corresponding size was designed from the left gluteal crease. During surgery, the cutaneous branch from the descending branch of inferior gluteal artery was identified, and the flap was harvested and transferred to the sacral region (see Figure 3). After surgery, the gauze dressing was changed daily to keep the wound clean; a single closed suction drain was used to monitor excessive bleeding from beneath the flap. Mr. Q was repositioned every 2 hours to prevent pressure ulcer development at other sites, pressure necrosis of the flap, or wound dehiscence. In addition, clinicians took steps to keep excess moisture and fecal contamination away from the wound by checking the wound dressings every 2 hours during repositioning. At 3 months post-surgery, the sacral defect was almost completely healed (ie, without wound dehiscence, discharge, and infection), and Mr. Q was left with an inconspicuous scar over the natural gluteal crease (see Figure 4).
Patient 10. Mr. K was a 69-year-old man who had been bedridden for 3 years before admission following an ischemic cerebrovascular accident. A grade IV pressure ulcer was present over his sacral region, resulting in a 10 cm x 10 cm defect after 2 debridements. A 10 cm x 7 cm flap was designed at the right gluteal crease to cover the defect (see Figures 5, 6, 7). After surgery, the gauze dressing was changed daily to keep the wound clean; a single closed suction drain was used to monitor excessive bleeding from beneath the flap. At his 5-month follow-up visit, both the sacral wound and gluteal wound were healing without ulcer recurrence.
Managing sacral pressure ulcers is a common task for reconstructive surgeons. Several types of flaps have been developed to cover sacral pressure ulcers.1,11-14 Coskunfirat et al13 presented the largest case series in the literature, with 32 gluteal artery perforator flaps for pressure ulcer reconstruction. The perforator flap provides a reliable fasciocutaneous flap for sacral pressure ulcer closure and spares the underlying muscle. However, according to Coskunfirat et al’s13 study, unlike other gluteal perforator flaps, the unpredictable perforator artery location often necessitates a change of flap design intraoperatively.
Harvesting the flap is technically demanding. Creating the IGAP flap involves a dissection of the perforator penetrating the gluteus maximus muscle underneath the piriformis muscle. By separating the dissected pedicle for an island flap, the defect site can be replaced without any tension on the flap. Using the flap from the gluteal crease has several advantages.5-9 First, the constant circulation always ensures successful flap harvesting from the gluteal crease despite having only tiny (<1–2 mm) perforators. Coskunfirat et al13 suggest this flap can be used as a primary choice in sacral pressure ulcer coverage; Doppler has been found to be unreliable in detecting perforators in the gluteal region, and the perforator is typically identified directly through subfascial dissection.13 Second, according to case-control studies,7,8 the infragluteal perforator flap minimizes donor-site morbidity by sparing the gluteal muscles and eliminating the need for primary closure of the donor site; the resulting scar avoids maximal pressure zones over bony prominences. This is beneficial for ambulatory patients for walking or sitting; however, most of the patients in the current study were bedridden. Third, the IGAP minimizes donor site morbidity by sparing the gluteal muscle and primary closure of the donor site, leaving a scar that avoids maximal pressure zones over bony prominences and allowing the scar to remain well hidden in the natural gluteal crease.8 Fourth, in the event of a recurrent ulcer or flap failure, the flap can be raised from an area other than the previous operative site; this technique provides a secondary option for salvage in such cases, as described in the case control study of Higgins et al.9
The major disadvantage of this flap is vascular variation. According to a large case series (N = 118),14 the descending branch of the inferior gluteal artery is present with variable prevalence.8,14 In the Windhofer et al14 study, the descending branch was present in 91.5% of patients. When the descending branch was absent, the cutaneous branch came from the medial or lateral circumflex femoral artery or as a perforator of the deep artery of the thigh.
Hip contracture occurs frequently in the long-term bedridden patient.15 This increases wound tension over the donor site and increases the chance of wound dehiscence. In the current patient series, wound dehiscence of 1 donor site occurred in a patient with hip contracture. In addition, hip flexion might cause undue tension on the flap pedicle, requiring caution in a patient with hip contracture. During the postoperative care period, the caregiver should prevent overflexion of the hip joint for at least 2 weeks. An added consideration is the relatively technical nature of flap creation owing to the demands of intramuscular dissection.
Using the gluteal perforator flap is controversial because published anatomical studies state the blood supply to the gluteal skin is inadequate. In their case control study, Ahmadzadeh et al16 performed a detailed dissection of the gluteal region and determined the vascular territory of a single perforator from the inferior gluteal artery is approximately 24 cm2. However, Koshima et al’s17 case-control study demonstrated a flap in the gluteal region can be nourished even by a single perforator; similarly, Nojima et al’s18 case-control study reported a vascular territory of mean size of 15 cm x 12 cm in the superior gluteal artery perforator flap can be nourished using single perforator with the dye injection method. Skin in the gluteal region also has been shown to be richly vascularized with perforators connected by long and voluminous subcutaneous anastomoses.18 In light of these factors, the authors of the current study concluded the determinant factor for flap size is whether the donor site can be primarily closed.
As with all case studies, the outcomes described cannot be generalized to other patient populations. Although the IGAP flaps were found to be reliable and provided a viable option for primary sacral pressure ulcer reconstruction, the flaps should be used with caution in patients who may be at risk for an ischial pressure ulcer (eg, wheelchair users).
Sacral pressure ulcer management is challenging in plastic surgery, and patients and flaps both must be carefully selected. In this case series, the IGAP flap was found to be reliable and provided a viable option for primary sacral pressure ulcer reconstruction. Other advantages included minimal blood loss, mild donor site morbidity, and preservation of muscle function. Similar to other perforator flaps, pedicle dissection must be meticulous to avoid damaging the perforator vessels. The flap is raised from an area different from the previous operation site and can serve as a secondary option in difficult cases, such as a recurrent ulcer or flap failure. Studies with larger sample sizes are needed to ascertain which type of flap is best suited to surgically manage extensive pressure ulcers in a variety of patient populations. n
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Potential Conflicts of Interest: none disclosed. The Civilian Administration Division of Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan funded the project.
Dr. Lin and Dr. Ou are attending physicians; Dr. Chiao, Dr. Wang, and Dr. Chou are resident physicians; and Dr. Chen and Dr. Lee are attending physicians, Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan. Please address correspondence to: Tzu-Peng Lee, MD, Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Gung Road, Taipei, 11490, Taiwan; email: firstname.lastname@example.org.