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Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e6
Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps for reconstruction of sacral pressure sores Yen-Chou Chen a, Eng-Yen Huang b, Pao-Yuan Lin a,* a Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan b Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
Received 4 November 2013; accepted 20 December 2013
KEYWORDS Gluteal perforator flap; Gluteal fasciocutaneous rotation flap; Sacral pressure sore reconstruction
Summary Background and aim: The gluteus maximus myocutaneous flap was considered the workhorse that reconstructed sacral pressure sores, but was gradually replaced by fasciocutaneous flap because of several disadvantages. With the advent of the perforator flap technique, gluteal perforator (GP) flap has gained popularity nowadays. The aim of this study was to compare the complications and outcomes between GP flaps and gluteal fasciocutaneous rotation (FR) flaps in the treatment of sacral pressure sores. Methods: Between April 2007 and June 2012, 63 patients underwent sacral pressure sore reconstructions, with a GP flap used in 31 cases and an FR flap used in 32 cases. Data collected on the patients included patient age, gender, co-morbidity for being bedridden and follow-up time. Surgical details collected included the defect size, operative time and estimated blood loss. Complications recorded included re-operation, dehiscence, flap necrosis, wound infection, sinus formation, donor-site morbidity and recurrence. The complications and clinical outcomes were compared between these two groups. Results: We found that there was no significant difference in patient demographics, surgical complications and recurrence between these two groups. In gluteal FR flap group, all recurrent cases (five) were treated by reuse of previous flaps. Conclusions: Both methods are comparable, good and safe in treating sacral pressure sores. Gluteal FR flap can be performed without microsurgical dissection, and re-rotation is feasible in recurrent cases. The authors suggest using gluteal FR flaps in patients with a high risk of sore recurrence. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. E-mail address: [email protected] (P.-Y. Lin). 1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.12.029
Please cite this article in press as: Chen Y-C, et al., Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps for reconstruction of sacral pressure sores, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2013.12.029
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2 Pressure sores, especially in the sacral area, pose challenges for reconstructive surgeons. Patients with pressure sores are usually paraplegic or bedridden, making the sores reluctant to heal, prone to recurrence, and difficult to reconstruct.1e3 The gluteus maximus myocutaneous flap has been considered the workhorse flap for reconstructing sacral pressure sores.4e7 However, disadvantages of using this flap are limited flap mobility, sacrifice of muscle and increased blood loss. Yuhei et al.8,9 reported that the transferred muscle portion of the flap showed remarkable atrophic changes over the long term, and the recurrence rate was not significantly different from that with the fasciocutaneous flap. With the advent of the perforator flap technique described by Koshima et al.,10 gluteal perforator (GP) flaps have recently gained popularity for reconstruction of sacral pressure sores. These flaps can use perforators that emerge from either the superior or inferior gluteal vessels. By dissecting perforators and completely islanding the flap, healthy tissue with a robust blood supply can be transferred freely without sacrificing the underlying muscle. Although a systematic review11 showed that there was no statistically significant difference with regard to recurrence or complication rates among musculocutaneous, fasciocutaneous and perforator flaps for pressure sore reconstruction, comparisons of GP flaps and fasciocutaneous rotation (FR) flaps specifically focussing on sacral pressure sore reconstruction have rarely been discussed. The purpose of this study was to compare surgical complications and outcomes between these two techniques in a single institute.
Materials and methods Retrospective chart review of consecutive sacral pressure sore patients treated surgically using a GP flap (Figure 1) or
Y.-C. Chen et al. a gluteal FR flap (Figure 2) was performed at the Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital from April 2007 to June 2012. Those patients who were treated with secondary healing, primary closure, skin grafting, second flap reconstruction or other types of flap reconstruction were excluded. Data regarding the patient’s age, gender, co-morbidity for being bedridden and follow-up time interval were collected. Surgical details, including the defect size, operative time and estimated blood loss, were recorded. Complications, including re-operation, dehiscence, flap necrosis (partial and total necrosis), wound infection, sinus formation and donor-site morbidity, were also recorded. Recurrence was defined as a pressure sore that occurred at the site of flap reconstruction more than 3 months after reconstruction. An independent t-test was used to test the null hypothesis that the means of the two groups were equal. The chi-squared/Fisher’s exact test was used to analyse the differences in group complication rates and surgical outcomes. All statistical tests were two-sided, and a value of p < 0.05 was considered statistically significant. All statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) version 13.0 (SPSS, Inc., Chicago, Il, USA).
Results Of the 63 patients, a reconstruction using a GP flap (GP group) was done on 31 patients and a reconstruction using a fasciocutaneous rotation flap (FR group) was done on 32 patients. The demographic data for each group, including sex, age, co-morbidity, defect size, operative time, estimated blood loss and follow-up period, are outlined in Table 1. There were no significant differences between these two groups.
Figure 1 Gluteal perforator flaps can be transferred as advance (above, left), rotation (above, right), transposition (below, left) or propeller (below, right) fashion to reconstruct sacral pressure sores.
Please cite this article in press as: Chen Y-C, et al., Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps for reconstruction of sacral pressure sores, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2013.12.029
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Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps
Figure 2 (right).
Sacral pressure sore (left). Conventional gluteal fasciocutaneous rotation flap for sacral pressure sore reconstruction
With regard to complications and outcomes, seven patients (22.6%) from the GP group were taken back to the operating room due to surgical complications. Flap necrosis was noted in eight patients (25.8%), with two total necroses and six partial necroses. Patients with total flap necrosis received secondary reconstruction using a FR flap from the contralateral buttock. Wound infection occurred in five patients (16.1%). Two patients (6.5%) had sinus formation, and one patient (3.2%) had donor-site morbidity. In the FR group, nine patients (28.1%) had to be taken back to the operating room to address complications. Six patients developed wound dehiscence (18.75%), which was higher than that in the GP group but was not statistically significant (p Z 0.257). Flap necrosis occurred in eight patients. Although the flap necrosis rate (8/32 Z 25%) was similar to the GP group, there was no total flap necrosis in the FR group. One patient (3.2%) had seroma, and four patients (12.5%) had donor-site morbidity. In this study, two patients from the GP group died 1 month after their operations because of pneumonia. In the FR group, one patient died 2 weeks postoperatively due to acute myocardial infarction, and another two died 3 weeks and 2 months after their operations, respectively. The above five cases with short postoperative life were excluded from long-term follow-up. Thus, the overall complication rate was 29.0% (9/31) in the GP group and 37.5% (12/32) in the FR group, which demonstrated no statistical significance between these two groups (p Z 0.663). The GP and FR groups had five patients each with sore recurrences, which was a 17.2% (5/29) recurrence rate. The surgical complications and outcomes for these two groups are presented in Table 2.
Table 1
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Patient demorgraphics.
Numbers Age Maleefemale ratio Defect size (cm2) Operative time (mins) Blood loss (mls) Follow-up (mos)
GP group
FR group
p Value
31 73.6 16:16 51.8 152.9 62.9 37.1
32 66.7 17:15 43.9 143.4 63.4 34.8
e 0.131 0.802 0.193 0.228 0.946
GP, gluteal perforator; FR, fasciocutaneous rotation.
Discussion Musculocutaneous flaps have been the mainstay for treating sacral pressure sores because of their rich blood supply.4 However, the arc of rotation is limited and may cause much blood loss during flap elevation. This technique also causes donor-site morbidity, especially in ambulatory patients. Additionally, the transferred muscle undergoes significant atrophic degeneration with time, usually 1 year postoperatively. In experimental studies, pressure-induced hypoxia can cause muscle necrosis without skin necrosis in musculocutaneous flaps.12 Although Thiessen et al.13 reported no differences in postoperative morbidity or recurrence between muscle and non-muscle flaps in univariate and multivariate analyses, Yamato et al.6 concluded that fasciocutaneous flaps have better long-term results than muscle or myocutaneous flaps when used for pressure sore reconstruction, and they suggested using fasciocutaneous flaps as a first choice for treating sacral pressure sores.7 Over the past few years, perforator flaps have gained popularity. By completely islanding the skin paddle based on one or more perforators, the flap can be transferred with maximal freedom in a tension-free manner. For the first time in 1988, Kroll et al.14 published the use of perforator flaps for coverage of low midline defects, and Koshima et al.15 repaired sacral pressure sores using GP flaps and confirmed the reliability of the blood supply by
Table 2 outcome.
Comparison of surgical complications and
Overall complication rate Re-operation Wound dehiscence Flap necrosis Infection Seroma or sinus formation Donor site morbidity Mortality Recurrence rate
GP group
FR group
p Value
n
%
n
%
9/31
29.0
12/32
37.5
0.663
7/31 2/31 8/31 5/31 1/31
22.6 6.5 25.8 16.1 3.2
9/32 6/32 8/32 6/32 1/32
28.1 18.8 25.0 18.8 3.2
0.836 0.257 0.941 0.784 0.999
2/31 2/31 5/29
6.5 6.5 17.2
4/32 3/32 5/29
12.5 9.4 17.2
0.999 1.000 1.000
GP, gluteal perforator; FR, fasciocutaneous rotation.
Please cite this article in press as: Chen Y-C, et al., Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps for reconstruction of sacral pressure sores, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2013.12.029
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Y.-C. Chen et al.
Figure 3 Recurrent sacral pressure sore (above, left). The gluteal fasciocutaneous flap was re-elevated (above, right). Flap was re-rotated for sore reconstruction (below, left). View of the flap 1 year postoperatively (below, right).
describing details of perforator distribution based on cadaver dissection. Large flaps can be transferred based on one or several perforators due to their rich vasculature. Furthermore, the versatility of the flap design allows it to adapt to the defect. The preservation of blood supply and muscle results in minimal donor-site morbidity. Most important of all, long pedicles of GPs enable tissue mobilisation up to 12 cm in distance and achieve tension-free closure.16 Therefore, the use of perforator flaps can reduce the wound dehiscence rate. Although we observed a lower wound dehiscence rate in the GP group (6.45%) compared to the FR group (18.75%), the difference was not statistically significant. This outcome could be explained by the small number of cases in this study. Some drawbacks of using perforator flaps should be noted. First, due to varied perforator distribution and the unpredictable nature of perforator venae comitantes, more tendinous intramuscular dissection and surgical expertise are needed. Second, when a flap is designed in the propeller fashion based on a single perforator, although healthy and undamaged tissue can be transferred from a distant site, kinking of the perforator is possible and results in total flap failure, which rarely occurs with FR flaps. In our study, we found two cases of total flap necrosis in the GP group, whereas only partial flap necrosis was noted in the FR group. FR flaps are well known for sacral pressure sore reconstruction and have many advantages that are well described in the literature.8,9,17,18 Good blood supply via the fascial plexus allows this flap to be raised easily without major complications, such as total flap loss. The circumference of the flap should be approximately 5e8 times the width of the defect to achieve tension-free distribution. According to our experience, the greatest benefit of fasciocutaneous flaps is that they are reusable.19 By creating an incision through the previous operative wound, the flap can be elevated and advanced in the event of partial
necrosis or ulcer recurrence. Recently, Wong et al.20 and Lin et al.19 incorporated the concept of sparing the perforator in conventional FR flaps, which make them more reliable in vascularity and reusable for further reconstruction. However, reuse is generally not allowed for islandtype perforator flaps when flap necrosis or sore recurrence occurs, unless they are designed to be very large from the beginning. Feng et al.21 described the concept of free-style puzzle flaps to recycle a perforator flap. This innovative idea is valuable but has not yet been applied routinely to recurrent pressure sores. The recommended reconstructive options in this situation are perforator flaps or FR flaps from the contralateral buttock. The use of either perforator flaps or FR flaps in sacral pressure sore reconstruction remains controversial. A recent systematic review discussing complications and recurrence rates of musculocutaneous, fasciocutaneous and perforatorbased flaps for treatment of pressure sores revealed no significant differences among these flaps.11 In our study, variables such as operative time, defect size and blood loss were comparable in these two groups. There were also no significant differences between perforator and fasciocutaneous flaps with regard to re-operation, wound dehiscence, flap necrosis, infection, seroma, donor-site morbidity and overall complication rates. These results were similar to recent publications comparing perforator and fasciocutaneous flaps for pressure sore reconstruction.11,13 However, in our study, the overall complication rates for the perforator flap group (29%) and the fasciocutaneous flap group (37.5%) were higher than the complication rates (7e31%) reported in the literature.22e24 This elevated incidence could be explained by the advanced age of our patients and multiple comorbidities, which made postoperative care difficult. There was no significant difference in rates of recurrence between perforator and FR flaps in our study, which was comparable to other studies.22,25e27
Please cite this article in press as: Chen Y-C, et al., Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps for reconstruction of sacral pressure sores, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2013.12.029
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Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps In summary, we found that perforator flaps and FR flaps had comparable outcomes when used for reconstruction of sacral pressure sores. However, in cases of elderly patients with multiple co-morbidities, a high risk of sore recurrence should be kept in mind. When the first flap is selected, a future secondary reconstruction option should also be taken into consideration. In our study of the five cases of recurrence in the GP group, three cases were treated using an FR flap from the contralateral buttock, and the other two cases were managed using negative-pressure wound therapy. In the FR group, however, all recurrent cases could be treated using flap re-elevation and rotation (Figure 3). As a result, we suggest using gluteal FR flaps for patients with a high risk of sore recurrence. A limitation of the study is that this is a non-randomised, retrospective study with a small sample size. Selection bias and confounding factors are inevitable. Although the sample size was small, the number of GP flaps included in this study was comparable to the numbers reported in other published works in the literature.14e16,28e36 In addition, the design of the GP flaps was not uniform and varied, including advance, transposition, rotation and propeller fashion, due to the heterogeneity of perforator distribution and tissue laxity. Despite the above limitations, a strength of this study is that most of the published studies14e16,28e36 of GP flaps are case studies without comparisons, and defect locations also varied. Our study provided a comparison of the surgical complications and outcomes of these two techniques. Additionally, the defect location was specifically in the sacrum, making samples more homogeneous. A welldesigned comparative study with an adequate sample size is still recommended to elucidate differences in the future.
Conclusion GP flaps and FR flaps are comparable for managing sacral pressure sores. Both can be considered a first-line option. Gluteal FR flap reconstructions can be performed without microsurgical dissection, and re-rotation is feasible in the event of sore recurrence. The authors suggest using gluteal FR flaps in patients with a high risk of sore recurrence.
Funding None.
Conflict of interest None.
References 1. Riggs A. Pressure ulcers lead to increased mortality, liability. Prevention, treatment require planning, team work. J Ark Med Soc 2003;100:160e1. 2. Reddy M, Keast D, Fowler E, Sibbald RG. Pain in pressure ulcers. Ostomy Wound Manage 2003;49:30e5. 3. Dharmarajan TS, Ahmed S. The growing problem of pressure ulcers. Evaluation and management for an aging population. Postgrad Med 2003;113:77e8. 81e84, 88e90.
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4. Ger R. The surgical management of decubitus ulcers by muscle transposition. Surgery 1971;69:106e10. 5. Minami RT, Mills R, Pardoe R. Gluteus maximus myocutaneous flaps for repair of pressure sores. Plast Reconstr Surg 1977;60: 242e9. 6. Yamamoto Y, Ohura T, Shintomi Y, et al. Superiority of the fasciocutaneous flap in reconstruction of sacral pressure sores. Ann Plast Surg 1993;30:116e21. 7. Yamamoto Y, Tsutsumida A, Murazumi M, et al. Longterm outcome of pressure sores treated with flap coverage. Plast Reconstr Surg 1997;100:1212e7. 8. Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989;42:645e8. 9. Yang CH, Kuo YR, Jeng SF, et al. An ideal method for pressure sore reconstruction: a freestyle perforator-based flap. Ann Plast Surg 2011;66:179e84. 10. Nola GT, Vistnes LM. Differential response of skin and muscle in the experimental production of pressure sores. Plast Reconstr Surg 1980;66:728e33. 11. Koshima I, Moriguchi T, Soeda S, et al. The gluteal perforator based flap for repair of sacral pressure sores. Plast Reconstr Surg 1993;91:678e83. 12. Sameem M, Au M, Wood T, et al. A systematic review of complication and recurrence rates of musculocutaneous, fasciocutaneous, and perforator-based flaps for treatment of pressure sores. Plast Reconstr Surg 2012;130:67e77. 13. Ger R, Levine SA. The management of decubitus ulcers by muscle transposition. An 8-year review. Plast Reconstr Surg 1976;58:419e28. 14. Baek SM, Williams GD, McElhinney AJ, et al. The gluteus maximus myocutaneous flap in the management of pressure sores. Ann Plast Surg 1980;5:471e6. 15. Stevenson TR, Pollock RA, Rohrich RJ, et al. The gluteus maximus musculocutaneous island flap: refinements in design and application. Plast Reconstr Surg 1987;79:761e8. 16. Wong TC, Ip FK. Comparison of gluteal fasciocutaneous rotational flaps and myocutaneous flaps for the treatment of sacral sores. Int Orthop 2006;30:64e7. 17. Ohjimi H, Ogata K, Setsu Y, et al. Modification of the gluteus maximus V-Y advancement flap for sacral ulcers: the gluteal fasciocutaneous flap method. Plast Reconstr Surg 1996;98: 1247e52. 18. Kroll SS, Rosenfield L. Perforator-based flaps for low posterior midline defects. Plast Reconstr Surg 1988;81:561. 19. Ao M, Mae O, Namba Y, et al. Perforator-based flap for coverage of lumbosacral defects. Plast Reconstr Surg 1998; 101:987e91. 20. Meltem C, Esra C, Hasan F, et al. The gluteal perforator based flap in repair of pressure sores. Br J Plast Surg 2004;57:342e7. 21. Coskunfirat OK, Ozgentas HE. Gluteal perforator flaps for coverage of pressure sores at various locations. Plast Reconstr Surg 2004;113:2012e7. 22. Seyhan T, Ertas N, Bahar T, et al. Simplified and versatile use of gluteal perforator flaps for pressure sores. Ann Plast Surg 2008; 60:673e8. 23. Prado A, Ocampo C, Danilla S, et al. A new technique of “double-A” bilateral flaps based on perforators for the treatment of sacral defects. Plast Reconstr Surg 2007;119:1481e90. 24. Verpaele AM, Blondeel PN, Van Landuyt K, et al. The superior gluteal artery perforator flap: an additional tool in the treatment of sacral pressure sores. Br J Plast Surg 1999;52: 385e91. 25. Tzeng Y, Chen S, Yu C, et al. Modification of superior gluteal artery perforator flap for reconstruction of sacral sores. J Med Sci 2007;27:253e8. 26. Ichioka S, Okabe K, Tsuji S, et al. Distal perforator-based fasciocutaneous V-Y flap for treatment of sacral pressure ulcers. Plast Reconstr Surg 2004;114:906e9.
Please cite this article in press as: Chen Y-C, et al., Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps for reconstruction of sacral pressure sores, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2013.12.029
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6 27. Ahmadzadeh R, Bergeron L, Tang M, et al. The superior and inferior gluteal artery perforators. Plast Reconstr Surg 2006; 120:1551e6. 28. Thiessen FE, Andrades P, Blondeel PN, et al. Flap surgery for pressure sores: should the underlying muscle be transferred or not? J Plast Reconstr Aesthet Surg 2011;64:84e90. 29. Wong CH, Tan BK, Song C. The perforator-sparing buttock rotation flap for coverage of pressure sores. Plast Reconstr Surg 2007;119:1259e66. 30. Lin PY, Kuo YR, Tsai UT. A reusable perforator-preserving gluteal artery-based rotation fasciocutaneous flap for pressure sore reconstruction. Microsurgery 2012;32:189e95. 31. Feng KM, Hsieh CH, Jeng SF. Free-style puzzle flap: the concept of recycling a perforator flap. Plast Reconstr Surg 2013;131:258e63.
Y.-C. Chen et al. 32. Kierney PC, Engrav LH, Isik FF, et al. Results of 268 pressure sores in 158 patients managed jointly by plastic surgery and rehabilitation medicine. Plast Reconstr Surg 1998;102:765e72. 33. Schryvers OI, Stranc MF, Nance PW. Surgical treatment of pressure ulcers: 20-year experience. Arch Phys Med Rehabil 2000;81:1556e62. 34. Disa JJ, Carlton JM, Goldberg NH. Efficacy of operative cure in pressure sore patients. Plast Reconstr Surg 1992;89:272e8. 35. Mandrekas AD, Mastorakos DP. The management of decubitus ulcers by musculocutaneous flaps: a five-year experience. Ann Plast Surg 1992;28:167e74. 36. Relander M, Palmer B. Recurrence of surgically treated pressure sores. Scand J Plast Reconstr Surg Hand Surg 1988;22: 89e92.
Please cite this article in press as: Chen Y-C, et al., Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps for reconstruction of sacral pressure sores, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2013.12.029
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Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e6
Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps for reconstruction of sacral pressure sores Yen-Chou Chen a, Eng-Yen Huang b, Pao-Yuan Lin a,* a Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan b Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
Received 4 November 2013; accepted 20 December 2013
KEYWORDS Gluteal perforator flap; Gluteal fasciocutaneous rotation flap; Sacral pressure sore reconstruction
Summary Background and aim: The gluteus maximus myocutaneous flap was considered the workhorse that reconstructed sacral pressure sores, but was gradually replaced by fasciocutaneous flap because of several disadvantages. With the advent of the perforator flap technique, gluteal perforator (GP) flap has gained popularity nowadays. The aim of this study was to compare the complications and outcomes between GP flaps and gluteal fasciocutaneous rotation (FR) flaps in the treatment of sacral pressure sores. Methods: Between April 2007 and June 2012, 63 patients underwent sacral pressure sore reconstructions, with a GP flap used in 31 cases and an FR flap used in 32 cases. Data collected on the patients included patient age, gender, co-morbidity for being bedridden and follow-up time. Surgical details collected included the defect size, operative time and estimated blood loss. Complications recorded included re-operation, dehiscence, flap necrosis, wound infection, sinus formation, donor-site morbidity and recurrence. The complications and clinical outcomes were compared between these two groups. Results: We found that there was no significant difference in patient demographics, surgical complications and recurrence between these two groups. In gluteal FR flap group, all recurrent cases (five) were treated by reuse of previous flaps. Conclusions: Both methods are comparable, good and safe in treating sacral pressure sores. Gluteal FR flap can be performed without microsurgical dissection, and re-rotation is feasible in recurrent cases. The authors suggest using gluteal FR flaps in patients with a high risk of sore recurrence. ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. E-mail address: [email protected] (P.-Y. Lin). 1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.12.029
Please cite this article in press as: Chen Y-C, et al., Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps for reconstruction of sacral pressure sores, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2013.12.029
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2 Pressure sores, especially in the sacral area, pose challenges for reconstructive surgeons. Patients with pressure sores are usually paraplegic or bedridden, making the sores reluctant to heal, prone to recurrence, and difficult to reconstruct.1e3 The gluteus maximus myocutaneous flap has been considered the workhorse flap for reconstructing sacral pressure sores.4e7 However, disadvantages of using this flap are limited flap mobility, sacrifice of muscle and increased blood loss. Yuhei et al.8,9 reported that the transferred muscle portion of the flap showed remarkable atrophic changes over the long term, and the recurrence rate was not significantly different from that with the fasciocutaneous flap. With the advent of the perforator flap technique described by Koshima et al.,10 gluteal perforator (GP) flaps have recently gained popularity for reconstruction of sacral pressure sores. These flaps can use perforators that emerge from either the superior or inferior gluteal vessels. By dissecting perforators and completely islanding the flap, healthy tissue with a robust blood supply can be transferred freely without sacrificing the underlying muscle. Although a systematic review11 showed that there was no statistically significant difference with regard to recurrence or complication rates among musculocutaneous, fasciocutaneous and perforator flaps for pressure sore reconstruction, comparisons of GP flaps and fasciocutaneous rotation (FR) flaps specifically focussing on sacral pressure sore reconstruction have rarely been discussed. The purpose of this study was to compare surgical complications and outcomes between these two techniques in a single institute.
Materials and methods Retrospective chart review of consecutive sacral pressure sore patients treated surgically using a GP flap (Figure 1) or
Y.-C. Chen et al. a gluteal FR flap (Figure 2) was performed at the Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital from April 2007 to June 2012. Those patients who were treated with secondary healing, primary closure, skin grafting, second flap reconstruction or other types of flap reconstruction were excluded. Data regarding the patient’s age, gender, co-morbidity for being bedridden and follow-up time interval were collected. Surgical details, including the defect size, operative time and estimated blood loss, were recorded. Complications, including re-operation, dehiscence, flap necrosis (partial and total necrosis), wound infection, sinus formation and donor-site morbidity, were also recorded. Recurrence was defined as a pressure sore that occurred at the site of flap reconstruction more than 3 months after reconstruction. An independent t-test was used to test the null hypothesis that the means of the two groups were equal. The chi-squared/Fisher’s exact test was used to analyse the differences in group complication rates and surgical outcomes. All statistical tests were two-sided, and a value of p < 0.05 was considered statistically significant. All statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) version 13.0 (SPSS, Inc., Chicago, Il, USA).
Results Of the 63 patients, a reconstruction using a GP flap (GP group) was done on 31 patients and a reconstruction using a fasciocutaneous rotation flap (FR group) was done on 32 patients. The demographic data for each group, including sex, age, co-morbidity, defect size, operative time, estimated blood loss and follow-up period, are outlined in Table 1. There were no significant differences between these two groups.
Figure 1 Gluteal perforator flaps can be transferred as advance (above, left), rotation (above, right), transposition (below, left) or propeller (below, right) fashion to reconstruct sacral pressure sores.
Please cite this article in press as: Chen Y-C, et al., Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps for reconstruction of sacral pressure sores, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2013.12.029
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Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps
Figure 2 (right).
Sacral pressure sore (left). Conventional gluteal fasciocutaneous rotation flap for sacral pressure sore reconstruction
With regard to complications and outcomes, seven patients (22.6%) from the GP group were taken back to the operating room due to surgical complications. Flap necrosis was noted in eight patients (25.8%), with two total necroses and six partial necroses. Patients with total flap necrosis received secondary reconstruction using a FR flap from the contralateral buttock. Wound infection occurred in five patients (16.1%). Two patients (6.5%) had sinus formation, and one patient (3.2%) had donor-site morbidity. In the FR group, nine patients (28.1%) had to be taken back to the operating room to address complications. Six patients developed wound dehiscence (18.75%), which was higher than that in the GP group but was not statistically significant (p Z 0.257). Flap necrosis occurred in eight patients. Although the flap necrosis rate (8/32 Z 25%) was similar to the GP group, there was no total flap necrosis in the FR group. One patient (3.2%) had seroma, and four patients (12.5%) had donor-site morbidity. In this study, two patients from the GP group died 1 month after their operations because of pneumonia. In the FR group, one patient died 2 weeks postoperatively due to acute myocardial infarction, and another two died 3 weeks and 2 months after their operations, respectively. The above five cases with short postoperative life were excluded from long-term follow-up. Thus, the overall complication rate was 29.0% (9/31) in the GP group and 37.5% (12/32) in the FR group, which demonstrated no statistical significance between these two groups (p Z 0.663). The GP and FR groups had five patients each with sore recurrences, which was a 17.2% (5/29) recurrence rate. The surgical complications and outcomes for these two groups are presented in Table 2.
Table 1
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Patient demorgraphics.
Numbers Age Maleefemale ratio Defect size (cm2) Operative time (mins) Blood loss (mls) Follow-up (mos)
GP group
FR group
p Value
31 73.6 16:16 51.8 152.9 62.9 37.1
32 66.7 17:15 43.9 143.4 63.4 34.8
e 0.131 0.802 0.193 0.228 0.946
GP, gluteal perforator; FR, fasciocutaneous rotation.
Discussion Musculocutaneous flaps have been the mainstay for treating sacral pressure sores because of their rich blood supply.4 However, the arc of rotation is limited and may cause much blood loss during flap elevation. This technique also causes donor-site morbidity, especially in ambulatory patients. Additionally, the transferred muscle undergoes significant atrophic degeneration with time, usually 1 year postoperatively. In experimental studies, pressure-induced hypoxia can cause muscle necrosis without skin necrosis in musculocutaneous flaps.12 Although Thiessen et al.13 reported no differences in postoperative morbidity or recurrence between muscle and non-muscle flaps in univariate and multivariate analyses, Yamato et al.6 concluded that fasciocutaneous flaps have better long-term results than muscle or myocutaneous flaps when used for pressure sore reconstruction, and they suggested using fasciocutaneous flaps as a first choice for treating sacral pressure sores.7 Over the past few years, perforator flaps have gained popularity. By completely islanding the skin paddle based on one or more perforators, the flap can be transferred with maximal freedom in a tension-free manner. For the first time in 1988, Kroll et al.14 published the use of perforator flaps for coverage of low midline defects, and Koshima et al.15 repaired sacral pressure sores using GP flaps and confirmed the reliability of the blood supply by
Table 2 outcome.
Comparison of surgical complications and
Overall complication rate Re-operation Wound dehiscence Flap necrosis Infection Seroma or sinus formation Donor site morbidity Mortality Recurrence rate
GP group
FR group
p Value
n
%
n
%
9/31
29.0
12/32
37.5
0.663
7/31 2/31 8/31 5/31 1/31
22.6 6.5 25.8 16.1 3.2
9/32 6/32 8/32 6/32 1/32
28.1 18.8 25.0 18.8 3.2
0.836 0.257 0.941 0.784 0.999
2/31 2/31 5/29
6.5 6.5 17.2
4/32 3/32 5/29
12.5 9.4 17.2
0.999 1.000 1.000
GP, gluteal perforator; FR, fasciocutaneous rotation.
Please cite this article in press as: Chen Y-C, et al., Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps for reconstruction of sacral pressure sores, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2013.12.029
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Y.-C. Chen et al.
Figure 3 Recurrent sacral pressure sore (above, left). The gluteal fasciocutaneous flap was re-elevated (above, right). Flap was re-rotated for sore reconstruction (below, left). View of the flap 1 year postoperatively (below, right).
describing details of perforator distribution based on cadaver dissection. Large flaps can be transferred based on one or several perforators due to their rich vasculature. Furthermore, the versatility of the flap design allows it to adapt to the defect. The preservation of blood supply and muscle results in minimal donor-site morbidity. Most important of all, long pedicles of GPs enable tissue mobilisation up to 12 cm in distance and achieve tension-free closure.16 Therefore, the use of perforator flaps can reduce the wound dehiscence rate. Although we observed a lower wound dehiscence rate in the GP group (6.45%) compared to the FR group (18.75%), the difference was not statistically significant. This outcome could be explained by the small number of cases in this study. Some drawbacks of using perforator flaps should be noted. First, due to varied perforator distribution and the unpredictable nature of perforator venae comitantes, more tendinous intramuscular dissection and surgical expertise are needed. Second, when a flap is designed in the propeller fashion based on a single perforator, although healthy and undamaged tissue can be transferred from a distant site, kinking of the perforator is possible and results in total flap failure, which rarely occurs with FR flaps. In our study, we found two cases of total flap necrosis in the GP group, whereas only partial flap necrosis was noted in the FR group. FR flaps are well known for sacral pressure sore reconstruction and have many advantages that are well described in the literature.8,9,17,18 Good blood supply via the fascial plexus allows this flap to be raised easily without major complications, such as total flap loss. The circumference of the flap should be approximately 5e8 times the width of the defect to achieve tension-free distribution. According to our experience, the greatest benefit of fasciocutaneous flaps is that they are reusable.19 By creating an incision through the previous operative wound, the flap can be elevated and advanced in the event of partial
necrosis or ulcer recurrence. Recently, Wong et al.20 and Lin et al.19 incorporated the concept of sparing the perforator in conventional FR flaps, which make them more reliable in vascularity and reusable for further reconstruction. However, reuse is generally not allowed for islandtype perforator flaps when flap necrosis or sore recurrence occurs, unless they are designed to be very large from the beginning. Feng et al.21 described the concept of free-style puzzle flaps to recycle a perforator flap. This innovative idea is valuable but has not yet been applied routinely to recurrent pressure sores. The recommended reconstructive options in this situation are perforator flaps or FR flaps from the contralateral buttock. The use of either perforator flaps or FR flaps in sacral pressure sore reconstruction remains controversial. A recent systematic review discussing complications and recurrence rates of musculocutaneous, fasciocutaneous and perforatorbased flaps for treatment of pressure sores revealed no significant differences among these flaps.11 In our study, variables such as operative time, defect size and blood loss were comparable in these two groups. There were also no significant differences between perforator and fasciocutaneous flaps with regard to re-operation, wound dehiscence, flap necrosis, infection, seroma, donor-site morbidity and overall complication rates. These results were similar to recent publications comparing perforator and fasciocutaneous flaps for pressure sore reconstruction.11,13 However, in our study, the overall complication rates for the perforator flap group (29%) and the fasciocutaneous flap group (37.5%) were higher than the complication rates (7e31%) reported in the literature.22e24 This elevated incidence could be explained by the advanced age of our patients and multiple comorbidities, which made postoperative care difficult. There was no significant difference in rates of recurrence between perforator and FR flaps in our study, which was comparable to other studies.22,25e27
Please cite this article in press as: Chen Y-C, et al., Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps for reconstruction of sacral pressure sores, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2013.12.029
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Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps In summary, we found that perforator flaps and FR flaps had comparable outcomes when used for reconstruction of sacral pressure sores. However, in cases of elderly patients with multiple co-morbidities, a high risk of sore recurrence should be kept in mind. When the first flap is selected, a future secondary reconstruction option should also be taken into consideration. In our study of the five cases of recurrence in the GP group, three cases were treated using an FR flap from the contralateral buttock, and the other two cases were managed using negative-pressure wound therapy. In the FR group, however, all recurrent cases could be treated using flap re-elevation and rotation (Figure 3). As a result, we suggest using gluteal FR flaps for patients with a high risk of sore recurrence. A limitation of the study is that this is a non-randomised, retrospective study with a small sample size. Selection bias and confounding factors are inevitable. Although the sample size was small, the number of GP flaps included in this study was comparable to the numbers reported in other published works in the literature.14e16,28e36 In addition, the design of the GP flaps was not uniform and varied, including advance, transposition, rotation and propeller fashion, due to the heterogeneity of perforator distribution and tissue laxity. Despite the above limitations, a strength of this study is that most of the published studies14e16,28e36 of GP flaps are case studies without comparisons, and defect locations also varied. Our study provided a comparison of the surgical complications and outcomes of these two techniques. Additionally, the defect location was specifically in the sacrum, making samples more homogeneous. A welldesigned comparative study with an adequate sample size is still recommended to elucidate differences in the future.
Conclusion GP flaps and FR flaps are comparable for managing sacral pressure sores. Both can be considered a first-line option. Gluteal FR flap reconstructions can be performed without microsurgical dissection, and re-rotation is feasible in the event of sore recurrence. The authors suggest using gluteal FR flaps in patients with a high risk of sore recurrence.
Funding None.
Conflict of interest None.
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6 27. Ahmadzadeh R, Bergeron L, Tang M, et al. The superior and inferior gluteal artery perforators. Plast Reconstr Surg 2006; 120:1551e6. 28. Thiessen FE, Andrades P, Blondeel PN, et al. Flap surgery for pressure sores: should the underlying muscle be transferred or not? J Plast Reconstr Aesthet Surg 2011;64:84e90. 29. Wong CH, Tan BK, Song C. The perforator-sparing buttock rotation flap for coverage of pressure sores. Plast Reconstr Surg 2007;119:1259e66. 30. Lin PY, Kuo YR, Tsai UT. A reusable perforator-preserving gluteal artery-based rotation fasciocutaneous flap for pressure sore reconstruction. Microsurgery 2012;32:189e95. 31. Feng KM, Hsieh CH, Jeng SF. Free-style puzzle flap: the concept of recycling a perforator flap. Plast Reconstr Surg 2013;131:258e63.
Y.-C. Chen et al. 32. Kierney PC, Engrav LH, Isik FF, et al. Results of 268 pressure sores in 158 patients managed jointly by plastic surgery and rehabilitation medicine. Plast Reconstr Surg 1998;102:765e72. 33. Schryvers OI, Stranc MF, Nance PW. Surgical treatment of pressure ulcers: 20-year experience. Arch Phys Med Rehabil 2000;81:1556e62. 34. Disa JJ, Carlton JM, Goldberg NH. Efficacy of operative cure in pressure sore patients. Plast Reconstr Surg 1992;89:272e8. 35. Mandrekas AD, Mastorakos DP. The management of decubitus ulcers by musculocutaneous flaps: a five-year experience. Ann Plast Surg 1992;28:167e74. 36. Relander M, Palmer B. Recurrence of surgically treated pressure sores. Scand J Plast Reconstr Surg Hand Surg 1988;22: 89e92.
Please cite this article in press as: Chen Y-C, et al., Comparison of gluteal perforator flaps and gluteal fasciocutaneous rotation flaps for reconstruction of sacral pressure sores, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2013.12.029
