COMPARISON OF OUTCOMES OF PRESSURE SORE RECONSTRUCTIONS AMONG PERFORATOR FLAPS, PERFORATOR-BASED ROTATION FASCIOCUTANEOUS FLAPS, AND MUSCULOCUTANEOUS FLAPS PAO-JEN KUO, M.D.,1 KHONG-YIK CHEW, M.B.B.S., M.R.C.S.,2 YUR-REN KUO, M.D., Ph.D.,1 and PAO-YUAN LIN, M.D.1*
Background: Pressure sore reconstruction remains a significant challenge for plastic surgeons due to its high postoperative complication and recurrence rates. Free-style perforator flap, fasciocutaeous flap, and musculocutaneous flap are the most common options in pressure sore reconstructions. Our study compared the postoperative complications among these three flaps at Kaohsiung Chang Gung Memorial Hospital. Methods: From 2003 to 2012, 99 patients (54 men and 45 women) with grade III or IV pressure sores received regional flap reconstruction, consisting of three cohorts: group A, 35 free-style perforator-based flaps; group B, 37 gluteal rotation fasciocutaneous flaps; and group C, 27 musculocutaneous or muscle combined with fasciocutaneous flap. Wound complications such as wound infection, dehiscence, seroma formation of the donor site, partial or complete flap loss, and recurrence were reviewed. Results: The mean followup period for group A was 24.2 months, 20.8 months in group B, and 19.0 months for group C. The overall complication rate was 22.9%, 32.4%, and 22.2% in groups A, B, and C, respectively. The flap necrosis rate was 11.4%, 13.5%, and 0% in groups A, B, and C, respectively. There was no statistical significance regarding complication rate and flap necrosis rate among different groups. Conclusions: In our study, the differences of complication rates and flap necrosis rate between these groups were not statistically significant. Further C 2014 Wiley Periodicals, Inc. Microsurgery 34:547–553, 2014. investigations should be conducted. V
The
problem of pressure sore reconstruction plagues reconstructive surgeons worldwide and has been an increasing problem, in part due to improvements in critical care and life support amid a rapidly ageing population. It is a bane for surgeons due to the high preponderance for complications and recurrence, in turn leading to diminishing options for reconstruction. Beginning in the 1970s, musculocutaneous flaps have been the mainstay of reconstruction in pressure sores.1,2 Further modifications continue to be reported, such as the use of V-Y advancement of a fasciocutaneous flap for sacral ulcers reported by Park and Park in 1988.3 With greater understanding of flap physiology and the perforator concepts, the perforator-based gluteal flaps were developed and first reported by Koshima et al. in 1993, and have gained popularity for reconstruction of pressure sores.4 Proponents of the different flap types argue about the superiority of one over the other, although evidence for it has been scarce. Sameem et al. conducted an extensive systematic review of pressure sore reconstruction in dif-
1 Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Kaohsiung, Taiwan 2 Department of Plastic, Reconstructive and Aesthetic Surgery, Kandang Kerbau Women’s and Children’s Hospital, Singapore *Correspondence to: Pao-Yuan Lin, MD, Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital, 123, Ta-Pei Road, Naio-Song District, Kaohsiung, Taiwan. E-mail: [email protected] Received 2 December 2013; Revision accepted 17 March 2014; Accepted 24 March 2014 Published online 5 April 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22257
Ó 2014 Wiley Periodicals, Inc.
ferent flaps and concluded that there were no statistically significant differences with respect to recurrence or complication rates among musculocutaneous, fasciocutaneous, or perforator-based flaps.5 They also called for more comparative studies on determining the ideal flap type for pressure sore reconstruction. This study is a review of our unit’s experience in treatment of this problem, with matched cohorts to compare the outcomes of the various flap types used. In this study, we compared the complication rates among three different flap types in pressure sore reconstructions: a) freestyle perforator-based gluteal flap, b) gluteal rotation fasciocutaneous flap, and c) musculocutaneous flap or a combination of muscle and fasciocutaneous flaps. PATIENTS AND METHODS
From February 2003 to December 2012, a total of 99 patients consisting of 54 males and 45 females with grade III or IV pressure sores received complete debridement, including bursectomy and partial ostectomy of the bony prominence where required, followed by immediate regional flap reconstruction. This study was divided into three cohorts according to the types of flaps used. During the period between 2003 and 2008, free-style perforator based flaps were widely used for reconstruction of pressure sores in our unit. During this period, 35 patients underwent freestyle perforator-based flaps (group A), consisting of 26 sacral, 5 ischial, and 4 trochanteric pressure ulcers.6 Between 2008 and 2010, the gluteal rotation fasciocutaneous flap was performed among 37 patients (group B), among them 25 cases were pressure sores involving the sacral region, 11 were ischial wounds, and
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one with trochanteric ulcer.7 From 2011 to 2012, the senior author (P.L.) employed the use of musculocutaneous flaps or combinations of muscle and fasciocutaneous flaps (group C) for treatment of 27 pressure ulcers. There were six sacral sores that were resurfaced with musculocutaneous flaps, two trochanteric ulcers were covered with pedicled anterolateral thigh musculocutaneous flaps, and 19 cases of ischial pressure sores resurfaced with a combination of biceps femoris muscle flaps and posterior thigh fasciocutaneous flaps. The recruitment of a muscle component for reconstruction was chosen for pressure sore reconstruction to allow cushioning of exposed bone as well as to decrease dead space using the additional soft tissue bulk. In the cases of ischial ulcers, a separate fasciocutaneous flap was raised during the same procedure when the significant cutaneous defects were encountered or when musculocutaneous flaps were unlikely to provide sufficient skin cover or where these were unavailable. Postoperatively, all patients were kept in supine or lateral decubitus position for a minimum of 3 weeks. In addition, all subjects were initiated on a sitting program consisting of graduated weight bearing over increments of time where possible. At the end of the study, sonography was undertaken at the location of pressure ulcer to evaluate the wound healing process.8 Medical records with regard to patient demographics, existing disorders such as spinal cord disease, medical co-morbidities, the surgical technique used, and wound complications and hospital stay were reviewed. Complications were documented individually, including wound infection, dehiscence, seroma formation, partial or complete flap loss, and recurrence. Chi-square test was used to compare statistical difference of proportion among different groups. A P-value of less than 0.05 indicated statistically significant results, and all confidence intervals are reported in the 95% range. All calculations were performed using SPSS for Windows, Version 14.0 (Chicago, IL). RESULTS
In this study, the age of patient population ranged 10–91 years with an average of 59.7 6 17.8 years. Divided into the separate groups, the average ages were 64 6 17, 58.7 6 18.6, and 55.4 6 16.9 years among groups A, B, and C. The defect sizes ranged from 4 3 3 cm2 to 27 3 13 cm2, with similar ranges among the three groups (group A: 7 3 2 cm2 to 27 3 13 cm2, group B: 4 3 3 cm2 to 12 3 10 cm2, and group C: 5 3 3 cm2 to 12 3 7 cm2 respectively). The mean follow-up period for group A was 24.2 months (ranging from 0 to 46 months), 20.8 months in group B (0 to 30 months), and 19.0 months for group C (14 to 26 months). Microsurgery DOI 10.1002/micr
Complications were common and affected 26.3% of all patients, excluding two mortality in the early postoperative period. For group A, eight patients or 22.9% of this cohort suffered from such complications, including one total flap loss, three partial flap necrosis, three wound dehiscence, and one recurrence (one mortality were not calculated). Among the group B cohort, five cases of partial flap necrosis, four wound dehiscence, one seroma formation, and two recurrences (one death which was not included in analysis) were reported, indicating a 32.4% complication rate (12 out of 37 cases). In group C, one case of wound dehiscence, two donor sites seroma formation, one infection, and two recurrences developed among 27 patients, or 22.2% of the cohort studied. The flap necrosis rate was 4/35 (11.4%, including one total loss) in group A, 5/37 (13.5%) in group B, and 0/27 (0%) in group C. The differences of complication rates and flap necrosis rate between these groups were not statistically significant (P 5 0.559 and 0.149, respectively). The recorded complications of these three groups are summarized in Table 1. CASE REPORTS
Case 1: A 69-year-old female patient with the history of end-stage renal disease presented with 6 cm 3 6 cm grade IV sacral pressure ulcer (Fig. 1) due to long-term bed ridden during hospitalization. She received adequate debridement and partial ostectomy of protruded sacral bone. Immediate gluteal perforator flap (Fig. 2) was elevated and reconstructed for the sacral defect. The flap was pink in color postoperatively (Fig. 3). However, the flap was necrosed gradually. No more flap was used for the wound reconstruction. After discharge, secondary healing with dressing was applied on the wound and this patient was followed at clinic regularly. However, the wound was still not healed at one-year follow-up. Case 2: A 58-year-old female patient presented with 6 cm 3 4 cm grade IV sacral pressure sore (Fig. 4) for 3 weeks at home. Debridement and partial ostectomy of sacral bone were undertaken. Left gluteal fasciocutaneous flap based on inferior gluteal artery (Fig. 5) was elevated and then rotated to repair the defect immediately. The wound was healed uneventfully at postoperative 3 weeks. At 8-month follow-up, the wound was healed without recurrence. Case 3: A 43-year-old male patient suffered from spinal cord injury due to traffic accident 5 years ago. He had 3 cm 3 3 cm grade IV left ischial pressure ulcer and received debridement and wound repair at first. The wound was dehiscent few days later. Adequate debridement and ostectomy of ischial bone were performed (Fig. 6). Due to huge defect (7 cm 3 7 cm 3 4 cm), left biceps femoris muscle (Fig. 7) was harvested and turned
55.4 6 16.9
58.7 6 18.6
64 6 17
Average age in years
Hip – 2
Sacrum – 6 Ischium – 19
Sacrum – 25 Ischium – 11 Hip – 1
Sacrum – 26 Ischium – 5 Hip – 4
Location and numbers of pressure sores
19 (14–26)
22.2%
b
0%
1 2 2 1
5 3 3–12 3 7
wound dehiscence donor site seroma recurrence wound infection
20.8 (0–30)
32.4%
13.5%
tip necrosisa wound dehiscence seroma diedb recurrence
5 4 1 1 2
4 3 3–12 3 10
24.2 (0–46)
22.9%
11.4%
flap total lossa partial flap necrosisa wound dehiscence diedb recurrence
1 3 3 1 1
7 3 2–27 3 13
Mean follow-up (range) in months
Complication rateb
Flap necrosis ratea
Postoperative complications
Defect size (cm2)
The case of total flap necrosis, partial flap necrosis and tip necrosis were included the calculation of flap necrosis rate Died cases were excluded from calculations of short-term complication.
a
18/9
24/13
Group B Fasciocutaneous flaps
Group C Myocutaneous flaps or combined muscle & fascio-cutaneous flaps
12/22
Group A Freestyle perforator flaps
Sex (M/F)
Table 1. Patient Demographics, Postoperative Complication, and Complication Rate
Comparison of Outcomes of Pressure Sore Reconstructions 549
Figure 1. Patient presented with grade IV sacral pressure ulcer. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Figure 2. Perforator flap was elevated during the operation. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Figure 3. Immediately postoperative wound that was reconstructed by free-style perforator flap. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Microsurgery DOI 10.1002/micr
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Figure 4. Patient presented with grade IV sacral pressure sore. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Figure 7. Left biceps femoris muscle flap was elevated and this muscle was turned upwardly to obliterate the dead space at left ischium. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Figure 5. Left gluteal rotation fasciocutaneous flap was used to reconstruct sacral defect. Immediately postoperative wound. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
upwardly to obliterate the dead space at left ischium. Posterior thigh fasciocutaneous flap was elevated and then advanced to close the skin defect (Fig. 8). The wound seemed good postoperatively. However, wound was dehiscent due to poor postoperative care and patient compliance. Debridement was performed and negative pressure wound therapy was applied. Six weeks later, the wound was healed. However, left ischial pressure sore was recurred at 4-month follow-up. He received further debridement and negative pressure wound therapy was applied postoperatively. DISCUSSION
Figure 6. Left ischial pressure sore, Gr IV, post debridement. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Microsurgery DOI 10.1002/micr
Pressure sore reconstruction using regional flap is a standard surgical modality for reconstructive surgeon. The free-style perforator flap is supported by one or two perforators which mother vessel at gluteal region is not identified. This kind of flap could be advanced or rotated to achieve wound repair. The rotational gluteal flap is supported by the main trunk of superior or inferior gluteal artery and may have additional perforator to promote the vascularity of the flap.7 It could be rotated only to repair the wound.
Comparison of Outcomes of Pressure Sore Reconstructions
Figure 8. Immediately postoperative wound. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary. com.]
Comparing the different types of flap, the complication rate was 22.9% for free-style perforator flap, 32.4% for rotational gluteal fasciocutaneous flap, and 22.2% for musculocutaneous flap or muscle combined fasciocutaneous flap after long-term (at least 6 months) follow-up. Hence, this study only included small series of cases, which may be the reason for that the results of statistical analysis were negative. A systematic review by Sameem et al. reported overall complication rates of 19.6% for perforator based flaps, 11.7% for fasciocutaneous flaps, and 18.6% for musculocutaneous flaps, although the review similarly failed to demonstrate statistical significance between the different complication rates of these flaps.5 The reason, as pointed out by the authors, is that majority of research into pressure sore reconstruction are limited by small sample sizes, lack of control groups, population heterogeneity, and a large preponderance for case series, which tends to be susceptible to selection bias. In the first cohort of this study (group A), free-style perforator-based flaps were used as a standard method of repair for pressure ulcers.6 Wei and Mardini introduced the concept of free-style perforator flap surgery as a routine procedure and formed our basis for this flap choice in the first group studied.9 This technique allows for recruitment of healthy surrounding tissue with an axial vascular supply and has the added advantage of allowing
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for custom-designed flap shape and size to fit the defect. Perforator dissection allows for a long pedicle length and enhances its reach and facilitates inset and positioning of the flap. Moreover, the use of perforator flaps avoids damage to underlying muscle and underling structures such as sciatic nerves, preserving the ambulatory potential of these patients. Consequently, preservation of the underlying muscle allows for future use in the event of recurrence.10 However, total flap necrosis could happen in the case of perforator injury. Then we shifted free style perforator flap to perforator-based rotational gluteal flap reconstruction in our series. In 1997, Yamamoto and Tsutsumida reported the superiority of fasciocutaneous flaps and argued for its use as a first line treatment in pressure ulcer reconstruction,11 based on various experimental studies on muscle tolerance to pressure and anatomical studies on typical pressure points,12 as well as the significant muscle atrophy observed in the long-term.11 Our experience with gluteal rotation fasciocutaneous flaps reflects this sentiment,7 as these flaps have a broad-based cutaneous component, bestowing it with generous dermal blood supply complementing the superior or inferior gluteal vessels, but more importantly allows for adequate venous drainage.10,13 The use of this technique preserves many of the advantages of the perforator flaps, such as muscle preservation, excellent durability, minimal donor site morbidity, and in select cases the added ability for re-use in the event of recurrence. The main caveat for these flaps is the requirement of a large rotation arc for adequate tissue transfer and coverage. The idea of incorporating muscle for pressure sore reconstruction has been challenged as early as 1977 by Grabb.3 According to the study of Daniel and Faibisoff in 1982, the normal soft tissue coverage of various pressure points in cadavers and noted the absence of muscle over the sacrum and trochanter,14 for which Yamamoto et al. surmised that muscle coverage of pressure points “violates normal soft-tissue coverage of bony prominences.”15 However, a significant layer of muscle (5.0– 45 mm) has been shown to cover the ischium, although the muscle slides away on hip flexion in a sitting posture.14 By this rationale, we believe that muscle flaps remain necessary for anatomical replacement of deep ischial pressure ulcers. With experience and long-term analysis,11 however, even proponents of fasciocutaneous flaps (long-term outcome paper) concur that pressure sores with deep ulcer cavities are the main limitation for its use, especially with ischial ulcers. Yamamoto claimed against the use of musculocutaneous flaps, noting that muscles atrophy with loss of dynamic function, but in his review of 12 patients, a musculocutaneous flap was ultimately used for salvage of a failed fasciocutaneous flap with deep Microsurgery DOI 10.1002/micr
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wounds. In the latest cohort of patients of this series, we recruited the use of musculocutaneous flap, or in select cases, a muscle flap combined with a fasciocutaneous flap for pressure sore reconstruction. In this group, most patients suffered from spinal cord injury contributing to the formation of ischial sores, where fasciocutaneous flaps alone did not provide adequate bulk. Musculocutaneous flap has the effects of bacterial count reduction and blood flow increase. In a series of animal studies, Calderon et al. compared in great detail the hemodynamic features, histological changes, and bacteriology responses between the musculocutaneous and fasciocutaneous flaps.16 Detailed statistical analysis and control measurements revealed significantly increased blood flow to the undersurface of musclebearing flaps during the first 24 hours, which correlated with a significantly reduced bacterial count within the wound bed during this same period in musculocutaneous flaps. The effect of decreased bacterial count remains 30–60 times greater than fasciocutaneous flaps even at days 3–5. Besides demonstrating the superior suppression of bacterial proliferation, histological examination at day 6 showed enhanced fibrous tissue ingrowth and collagen deposition at the wound bed.16,17 The combination of greater pressure distribution, enhanced bacterial suppression, and higher tissue ingrowth represent significant factors in decreasing short-term complications, improving reconstructive success, thus making the musculocutaneous flap an ideal candidate for reconstruction for deep, potentially infected pressure sores typically seen in ischial ulcers. Even with complete muscle atrophy beyond 1–2 years, we speculate that the established tissue ingrowth combined with fibrotic change of the muscle likely serves to strengthen the subcutaneous tissue and confers increased resistance to shear. The major argument against using musculocutaneous flap as a first option is the sacrifice of muscle and should be considered carefully in ambulant patients. However, re-use of musculocutaneous flaps or the split muscle flap techniques have been documented.18,19 On the other hand, muscle atrophy is a significant long-term issue, results in loss of muscle padding function and may cause pressure ulcer recurrence. However, this phenomenon was not shown in our study, possibly owing to a shorter follow-up period. Ultimately, in case of huge lumbosacral defect or recurrent pressure sore without adequate or suitable soft tissue near the wound for reconstruction, free tissue transfer such as transverse rectus abdominis myocutaneous flap using superior gluteal artery perforator vessel should be considered.20 The limitations (weaknesses) of this study were small numbers for each group, different case numbers for each Microsurgery DOI 10.1002/micr
location of pressure sore, not long enough length of follow-up, and not all of cases being followed-up long enough, which made the real complication rate and outcomes could not compare among different flap reconstruction in our study. Further study with respect to more cases recruited and longer follow-up period should be conducted.
CONCLUSIONS
The complications and flap necrosis rate showed no statistical significance among perforator flap, rotational gluteal fasciocutaneous flap, and musculocutaneous flap in pressure sore reconstruction in our study. The reliability of study is not strong enough based on above weaknesses. Further investigations are warranted.
REFERENCES 1. Ger R, Levine SA. The management of decubitus ulcers by muscle transposition. An 8-year review. Plast Reconstr Surg 1976;58:419– 428. 2. Minami RT, Mills R, Pardoe R. Gluteus maximus myocutaneous flaps for repair of pressure sores. Plast Reconstr Surg 1977;60:242– 249. 3. Park C, Park BY. Fasciocutaneous V-Y advancement flap for repair of sacral defects. Ann Plast Surg 1988;21:23–26. 4. Koshima I, Moriguchi T, Soeda S, Kawata S, Ohta S, Ikeda A. The gluteal perforator-based flap for repair of sacral pressure sores. Plast Reconstr Surg 1993;91:678–683. 5. Sameem M, Au M, Wood T, Farrokhyar F, Mahoney J. A systematic review of complication and recurrence rates of musculocutaneous, fasciocutaneous, and perforator-based flaps for treatment of pressure sores. Plast Reconstr Surg 2012;130:67e–77e. 6. Yang CH, Kuo YR, Jeng SF, Lin PY. An ideal method for pressure sore reconstruction. A freestyle perforator-based flap. Ann Plast Surg 2011;66:179–184. 7. Lin PY, Kuo YR, Tsai YT. A reusable perfator-preserving gluteal artery-based rotation fasciocutaneous flap for pressure sore rconstruction. Microsurgery 2012;32:189–195. 8. Aoi N, Yoshimura K, Kadono T, Nakagami G, Iizuka S, Higashino T, Araki J, Koshima I, Sanada H. Ultrasound assessment of deep tissue injury in pressure ulcers: Possible prediction of pressure ulcer progression. Plast Reconstr Surg 2009;124:540–550. 9. Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg 2004; 114:910–916. 10. Ahmadzadeh R, Bergeron L, Tang M. The superior and inferior gluteal artery perforator flaps. Plast Reconstr Surg 2007;120:1551– 1556. 11. Yamamoto Y, Tsutsumida A, Murazumi M, Sugihara T. Longterm outcome of pressure sores treated with flap coverage. Plast Reconstr Surg 1997;100:1212–1217. 12. Nola GT, Vistnes LM. Differential response of skin and muscle in the experimental production of pressure sores. Plast Reconstr Surg 1980;66:728–733. 13. Wong CH, Tan BK, Song C. The perforator-sparing buttock rotation flap for coverage of pressure sores. Plast Reconstr Surg 2007;119: 1259–1266. 14. Daniel RK, Faibisoff B. Muscle coverage of pressure points—The role of myocutaneous flaps. Ann Plast Surg 1982;8:446–452.
Comparison of Outcomes of Pressure Sore Reconstructions 15. Yamamoto Y, Ohura T, Shintomi Y, Sugihara T, Nohira K, Igawa H. Superiority of the fasciocutaneous flap in reconstruction of sacral pressure sores. Ann Plast Surg 1993;30:116–121. 16. Calderon W, Chang N, Mathes SJ. Comparison of the effect of bacterial inoculation in musculocutaneous and fasciocutaneous flaps. Plast Reconstr Surg 1986;77:785–792. 17. Gosain A, Chang N, Mathes S, Hunt TK, Vasconez L. A study of the relationship between blood flow and bacterial inoculation in musculocutaneous and fasciocutaneous flaps. Plast Reconstr Surg 1990;86:1152–1162.
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18. Yasser EH. The reusable V-Y advancement gluteus maximus fasciocutaneous flap in management of sacral pressure sores. Egypt J Plast Reconstr Surg 2013;37:125–129. 19. Baran CN, Celebio glu S, Civelek B, Sens€ oz O. Tangentially split gluteus maximus myocutaneous island flap based on perforator arteries for the reconstruction of pressure sores. Plast Reconstr Surg 1999;103:2071–2076. 20. Gaster RS, Bhatt KA, Shelton AA, Lee GK. Free transverse rectus abdominis myocutaneous flap reconstruction of a massive lumbosacral defect using superior gluteal artery perforator vessels. Microsurgery 2012;32:388–392.
Microsurgery DOI 10.1002/micr
Background: Pressure sore reconstruction remains a significant challenge for plastic surgeons due to its high postoperative complication and recurrence rates. Free-style perforator flap, fasciocutaeous flap, and musculocutaneous flap are the most common options in pressure sore reconstructions. Our study compared the postoperative complications among these three flaps at Kaohsiung Chang Gung Memorial Hospital. Methods: From 2003 to 2012, 99 patients (54 men and 45 women) with grade III or IV pressure sores received regional flap reconstruction, consisting of three cohorts: group A, 35 free-style perforator-based flaps; group B, 37 gluteal rotation fasciocutaneous flaps; and group C, 27 musculocutaneous or muscle combined with fasciocutaneous flap. Wound complications such as wound infection, dehiscence, seroma formation of the donor site, partial or complete flap loss, and recurrence were reviewed. Results: The mean followup period for group A was 24.2 months, 20.8 months in group B, and 19.0 months for group C. The overall complication rate was 22.9%, 32.4%, and 22.2% in groups A, B, and C, respectively. The flap necrosis rate was 11.4%, 13.5%, and 0% in groups A, B, and C, respectively. There was no statistical significance regarding complication rate and flap necrosis rate among different groups. Conclusions: In our study, the differences of complication rates and flap necrosis rate between these groups were not statistically significant. Further C 2014 Wiley Periodicals, Inc. Microsurgery 34:547–553, 2014. investigations should be conducted. V
The
problem of pressure sore reconstruction plagues reconstructive surgeons worldwide and has been an increasing problem, in part due to improvements in critical care and life support amid a rapidly ageing population. It is a bane for surgeons due to the high preponderance for complications and recurrence, in turn leading to diminishing options for reconstruction. Beginning in the 1970s, musculocutaneous flaps have been the mainstay of reconstruction in pressure sores.1,2 Further modifications continue to be reported, such as the use of V-Y advancement of a fasciocutaneous flap for sacral ulcers reported by Park and Park in 1988.3 With greater understanding of flap physiology and the perforator concepts, the perforator-based gluteal flaps were developed and first reported by Koshima et al. in 1993, and have gained popularity for reconstruction of pressure sores.4 Proponents of the different flap types argue about the superiority of one over the other, although evidence for it has been scarce. Sameem et al. conducted an extensive systematic review of pressure sore reconstruction in dif-
1 Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, College of Medicine, Kaohsiung, Taiwan 2 Department of Plastic, Reconstructive and Aesthetic Surgery, Kandang Kerbau Women’s and Children’s Hospital, Singapore *Correspondence to: Pao-Yuan Lin, MD, Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital, 123, Ta-Pei Road, Naio-Song District, Kaohsiung, Taiwan. E-mail: [email protected] Received 2 December 2013; Revision accepted 17 March 2014; Accepted 24 March 2014 Published online 5 April 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22257
Ó 2014 Wiley Periodicals, Inc.
ferent flaps and concluded that there were no statistically significant differences with respect to recurrence or complication rates among musculocutaneous, fasciocutaneous, or perforator-based flaps.5 They also called for more comparative studies on determining the ideal flap type for pressure sore reconstruction. This study is a review of our unit’s experience in treatment of this problem, with matched cohorts to compare the outcomes of the various flap types used. In this study, we compared the complication rates among three different flap types in pressure sore reconstructions: a) freestyle perforator-based gluteal flap, b) gluteal rotation fasciocutaneous flap, and c) musculocutaneous flap or a combination of muscle and fasciocutaneous flaps. PATIENTS AND METHODS
From February 2003 to December 2012, a total of 99 patients consisting of 54 males and 45 females with grade III or IV pressure sores received complete debridement, including bursectomy and partial ostectomy of the bony prominence where required, followed by immediate regional flap reconstruction. This study was divided into three cohorts according to the types of flaps used. During the period between 2003 and 2008, free-style perforator based flaps were widely used for reconstruction of pressure sores in our unit. During this period, 35 patients underwent freestyle perforator-based flaps (group A), consisting of 26 sacral, 5 ischial, and 4 trochanteric pressure ulcers.6 Between 2008 and 2010, the gluteal rotation fasciocutaneous flap was performed among 37 patients (group B), among them 25 cases were pressure sores involving the sacral region, 11 were ischial wounds, and
548
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one with trochanteric ulcer.7 From 2011 to 2012, the senior author (P.L.) employed the use of musculocutaneous flaps or combinations of muscle and fasciocutaneous flaps (group C) for treatment of 27 pressure ulcers. There were six sacral sores that were resurfaced with musculocutaneous flaps, two trochanteric ulcers were covered with pedicled anterolateral thigh musculocutaneous flaps, and 19 cases of ischial pressure sores resurfaced with a combination of biceps femoris muscle flaps and posterior thigh fasciocutaneous flaps. The recruitment of a muscle component for reconstruction was chosen for pressure sore reconstruction to allow cushioning of exposed bone as well as to decrease dead space using the additional soft tissue bulk. In the cases of ischial ulcers, a separate fasciocutaneous flap was raised during the same procedure when the significant cutaneous defects were encountered or when musculocutaneous flaps were unlikely to provide sufficient skin cover or where these were unavailable. Postoperatively, all patients were kept in supine or lateral decubitus position for a minimum of 3 weeks. In addition, all subjects were initiated on a sitting program consisting of graduated weight bearing over increments of time where possible. At the end of the study, sonography was undertaken at the location of pressure ulcer to evaluate the wound healing process.8 Medical records with regard to patient demographics, existing disorders such as spinal cord disease, medical co-morbidities, the surgical technique used, and wound complications and hospital stay were reviewed. Complications were documented individually, including wound infection, dehiscence, seroma formation, partial or complete flap loss, and recurrence. Chi-square test was used to compare statistical difference of proportion among different groups. A P-value of less than 0.05 indicated statistically significant results, and all confidence intervals are reported in the 95% range. All calculations were performed using SPSS for Windows, Version 14.0 (Chicago, IL). RESULTS
In this study, the age of patient population ranged 10–91 years with an average of 59.7 6 17.8 years. Divided into the separate groups, the average ages were 64 6 17, 58.7 6 18.6, and 55.4 6 16.9 years among groups A, B, and C. The defect sizes ranged from 4 3 3 cm2 to 27 3 13 cm2, with similar ranges among the three groups (group A: 7 3 2 cm2 to 27 3 13 cm2, group B: 4 3 3 cm2 to 12 3 10 cm2, and group C: 5 3 3 cm2 to 12 3 7 cm2 respectively). The mean follow-up period for group A was 24.2 months (ranging from 0 to 46 months), 20.8 months in group B (0 to 30 months), and 19.0 months for group C (14 to 26 months). Microsurgery DOI 10.1002/micr
Complications were common and affected 26.3% of all patients, excluding two mortality in the early postoperative period. For group A, eight patients or 22.9% of this cohort suffered from such complications, including one total flap loss, three partial flap necrosis, three wound dehiscence, and one recurrence (one mortality were not calculated). Among the group B cohort, five cases of partial flap necrosis, four wound dehiscence, one seroma formation, and two recurrences (one death which was not included in analysis) were reported, indicating a 32.4% complication rate (12 out of 37 cases). In group C, one case of wound dehiscence, two donor sites seroma formation, one infection, and two recurrences developed among 27 patients, or 22.2% of the cohort studied. The flap necrosis rate was 4/35 (11.4%, including one total loss) in group A, 5/37 (13.5%) in group B, and 0/27 (0%) in group C. The differences of complication rates and flap necrosis rate between these groups were not statistically significant (P 5 0.559 and 0.149, respectively). The recorded complications of these three groups are summarized in Table 1. CASE REPORTS
Case 1: A 69-year-old female patient with the history of end-stage renal disease presented with 6 cm 3 6 cm grade IV sacral pressure ulcer (Fig. 1) due to long-term bed ridden during hospitalization. She received adequate debridement and partial ostectomy of protruded sacral bone. Immediate gluteal perforator flap (Fig. 2) was elevated and reconstructed for the sacral defect. The flap was pink in color postoperatively (Fig. 3). However, the flap was necrosed gradually. No more flap was used for the wound reconstruction. After discharge, secondary healing with dressing was applied on the wound and this patient was followed at clinic regularly. However, the wound was still not healed at one-year follow-up. Case 2: A 58-year-old female patient presented with 6 cm 3 4 cm grade IV sacral pressure sore (Fig. 4) for 3 weeks at home. Debridement and partial ostectomy of sacral bone were undertaken. Left gluteal fasciocutaneous flap based on inferior gluteal artery (Fig. 5) was elevated and then rotated to repair the defect immediately. The wound was healed uneventfully at postoperative 3 weeks. At 8-month follow-up, the wound was healed without recurrence. Case 3: A 43-year-old male patient suffered from spinal cord injury due to traffic accident 5 years ago. He had 3 cm 3 3 cm grade IV left ischial pressure ulcer and received debridement and wound repair at first. The wound was dehiscent few days later. Adequate debridement and ostectomy of ischial bone were performed (Fig. 6). Due to huge defect (7 cm 3 7 cm 3 4 cm), left biceps femoris muscle (Fig. 7) was harvested and turned
55.4 6 16.9
58.7 6 18.6
64 6 17
Average age in years
Hip – 2
Sacrum – 6 Ischium – 19
Sacrum – 25 Ischium – 11 Hip – 1
Sacrum – 26 Ischium – 5 Hip – 4
Location and numbers of pressure sores
19 (14–26)
22.2%
b
0%
1 2 2 1
5 3 3–12 3 7
wound dehiscence donor site seroma recurrence wound infection
20.8 (0–30)
32.4%
13.5%
tip necrosisa wound dehiscence seroma diedb recurrence
5 4 1 1 2
4 3 3–12 3 10
24.2 (0–46)
22.9%
11.4%
flap total lossa partial flap necrosisa wound dehiscence diedb recurrence
1 3 3 1 1
7 3 2–27 3 13
Mean follow-up (range) in months
Complication rateb
Flap necrosis ratea
Postoperative complications
Defect size (cm2)
The case of total flap necrosis, partial flap necrosis and tip necrosis were included the calculation of flap necrosis rate Died cases were excluded from calculations of short-term complication.
a
18/9
24/13
Group B Fasciocutaneous flaps
Group C Myocutaneous flaps or combined muscle & fascio-cutaneous flaps
12/22
Group A Freestyle perforator flaps
Sex (M/F)
Table 1. Patient Demographics, Postoperative Complication, and Complication Rate
Comparison of Outcomes of Pressure Sore Reconstructions 549
Figure 1. Patient presented with grade IV sacral pressure ulcer. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Figure 2. Perforator flap was elevated during the operation. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Figure 3. Immediately postoperative wound that was reconstructed by free-style perforator flap. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
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Figure 4. Patient presented with grade IV sacral pressure sore. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Figure 7. Left biceps femoris muscle flap was elevated and this muscle was turned upwardly to obliterate the dead space at left ischium. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Figure 5. Left gluteal rotation fasciocutaneous flap was used to reconstruct sacral defect. Immediately postoperative wound. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
upwardly to obliterate the dead space at left ischium. Posterior thigh fasciocutaneous flap was elevated and then advanced to close the skin defect (Fig. 8). The wound seemed good postoperatively. However, wound was dehiscent due to poor postoperative care and patient compliance. Debridement was performed and negative pressure wound therapy was applied. Six weeks later, the wound was healed. However, left ischial pressure sore was recurred at 4-month follow-up. He received further debridement and negative pressure wound therapy was applied postoperatively. DISCUSSION
Figure 6. Left ischial pressure sore, Gr IV, post debridement. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
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Pressure sore reconstruction using regional flap is a standard surgical modality for reconstructive surgeon. The free-style perforator flap is supported by one or two perforators which mother vessel at gluteal region is not identified. This kind of flap could be advanced or rotated to achieve wound repair. The rotational gluteal flap is supported by the main trunk of superior or inferior gluteal artery and may have additional perforator to promote the vascularity of the flap.7 It could be rotated only to repair the wound.
Comparison of Outcomes of Pressure Sore Reconstructions
Figure 8. Immediately postoperative wound. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary. com.]
Comparing the different types of flap, the complication rate was 22.9% for free-style perforator flap, 32.4% for rotational gluteal fasciocutaneous flap, and 22.2% for musculocutaneous flap or muscle combined fasciocutaneous flap after long-term (at least 6 months) follow-up. Hence, this study only included small series of cases, which may be the reason for that the results of statistical analysis were negative. A systematic review by Sameem et al. reported overall complication rates of 19.6% for perforator based flaps, 11.7% for fasciocutaneous flaps, and 18.6% for musculocutaneous flaps, although the review similarly failed to demonstrate statistical significance between the different complication rates of these flaps.5 The reason, as pointed out by the authors, is that majority of research into pressure sore reconstruction are limited by small sample sizes, lack of control groups, population heterogeneity, and a large preponderance for case series, which tends to be susceptible to selection bias. In the first cohort of this study (group A), free-style perforator-based flaps were used as a standard method of repair for pressure ulcers.6 Wei and Mardini introduced the concept of free-style perforator flap surgery as a routine procedure and formed our basis for this flap choice in the first group studied.9 This technique allows for recruitment of healthy surrounding tissue with an axial vascular supply and has the added advantage of allowing
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for custom-designed flap shape and size to fit the defect. Perforator dissection allows for a long pedicle length and enhances its reach and facilitates inset and positioning of the flap. Moreover, the use of perforator flaps avoids damage to underlying muscle and underling structures such as sciatic nerves, preserving the ambulatory potential of these patients. Consequently, preservation of the underlying muscle allows for future use in the event of recurrence.10 However, total flap necrosis could happen in the case of perforator injury. Then we shifted free style perforator flap to perforator-based rotational gluteal flap reconstruction in our series. In 1997, Yamamoto and Tsutsumida reported the superiority of fasciocutaneous flaps and argued for its use as a first line treatment in pressure ulcer reconstruction,11 based on various experimental studies on muscle tolerance to pressure and anatomical studies on typical pressure points,12 as well as the significant muscle atrophy observed in the long-term.11 Our experience with gluteal rotation fasciocutaneous flaps reflects this sentiment,7 as these flaps have a broad-based cutaneous component, bestowing it with generous dermal blood supply complementing the superior or inferior gluteal vessels, but more importantly allows for adequate venous drainage.10,13 The use of this technique preserves many of the advantages of the perforator flaps, such as muscle preservation, excellent durability, minimal donor site morbidity, and in select cases the added ability for re-use in the event of recurrence. The main caveat for these flaps is the requirement of a large rotation arc for adequate tissue transfer and coverage. The idea of incorporating muscle for pressure sore reconstruction has been challenged as early as 1977 by Grabb.3 According to the study of Daniel and Faibisoff in 1982, the normal soft tissue coverage of various pressure points in cadavers and noted the absence of muscle over the sacrum and trochanter,14 for which Yamamoto et al. surmised that muscle coverage of pressure points “violates normal soft-tissue coverage of bony prominences.”15 However, a significant layer of muscle (5.0– 45 mm) has been shown to cover the ischium, although the muscle slides away on hip flexion in a sitting posture.14 By this rationale, we believe that muscle flaps remain necessary for anatomical replacement of deep ischial pressure ulcers. With experience and long-term analysis,11 however, even proponents of fasciocutaneous flaps (long-term outcome paper) concur that pressure sores with deep ulcer cavities are the main limitation for its use, especially with ischial ulcers. Yamamoto claimed against the use of musculocutaneous flaps, noting that muscles atrophy with loss of dynamic function, but in his review of 12 patients, a musculocutaneous flap was ultimately used for salvage of a failed fasciocutaneous flap with deep Microsurgery DOI 10.1002/micr
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wounds. In the latest cohort of patients of this series, we recruited the use of musculocutaneous flap, or in select cases, a muscle flap combined with a fasciocutaneous flap for pressure sore reconstruction. In this group, most patients suffered from spinal cord injury contributing to the formation of ischial sores, where fasciocutaneous flaps alone did not provide adequate bulk. Musculocutaneous flap has the effects of bacterial count reduction and blood flow increase. In a series of animal studies, Calderon et al. compared in great detail the hemodynamic features, histological changes, and bacteriology responses between the musculocutaneous and fasciocutaneous flaps.16 Detailed statistical analysis and control measurements revealed significantly increased blood flow to the undersurface of musclebearing flaps during the first 24 hours, which correlated with a significantly reduced bacterial count within the wound bed during this same period in musculocutaneous flaps. The effect of decreased bacterial count remains 30–60 times greater than fasciocutaneous flaps even at days 3–5. Besides demonstrating the superior suppression of bacterial proliferation, histological examination at day 6 showed enhanced fibrous tissue ingrowth and collagen deposition at the wound bed.16,17 The combination of greater pressure distribution, enhanced bacterial suppression, and higher tissue ingrowth represent significant factors in decreasing short-term complications, improving reconstructive success, thus making the musculocutaneous flap an ideal candidate for reconstruction for deep, potentially infected pressure sores typically seen in ischial ulcers. Even with complete muscle atrophy beyond 1–2 years, we speculate that the established tissue ingrowth combined with fibrotic change of the muscle likely serves to strengthen the subcutaneous tissue and confers increased resistance to shear. The major argument against using musculocutaneous flap as a first option is the sacrifice of muscle and should be considered carefully in ambulant patients. However, re-use of musculocutaneous flaps or the split muscle flap techniques have been documented.18,19 On the other hand, muscle atrophy is a significant long-term issue, results in loss of muscle padding function and may cause pressure ulcer recurrence. However, this phenomenon was not shown in our study, possibly owing to a shorter follow-up period. Ultimately, in case of huge lumbosacral defect or recurrent pressure sore without adequate or suitable soft tissue near the wound for reconstruction, free tissue transfer such as transverse rectus abdominis myocutaneous flap using superior gluteal artery perforator vessel should be considered.20 The limitations (weaknesses) of this study were small numbers for each group, different case numbers for each Microsurgery DOI 10.1002/micr
location of pressure sore, not long enough length of follow-up, and not all of cases being followed-up long enough, which made the real complication rate and outcomes could not compare among different flap reconstruction in our study. Further study with respect to more cases recruited and longer follow-up period should be conducted.
CONCLUSIONS
The complications and flap necrosis rate showed no statistical significance among perforator flap, rotational gluteal fasciocutaneous flap, and musculocutaneous flap in pressure sore reconstruction in our study. The reliability of study is not strong enough based on above weaknesses. Further investigations are warranted.
REFERENCES 1. Ger R, Levine SA. The management of decubitus ulcers by muscle transposition. An 8-year review. Plast Reconstr Surg 1976;58:419– 428. 2. Minami RT, Mills R, Pardoe R. Gluteus maximus myocutaneous flaps for repair of pressure sores. Plast Reconstr Surg 1977;60:242– 249. 3. Park C, Park BY. Fasciocutaneous V-Y advancement flap for repair of sacral defects. Ann Plast Surg 1988;21:23–26. 4. Koshima I, Moriguchi T, Soeda S, Kawata S, Ohta S, Ikeda A. The gluteal perforator-based flap for repair of sacral pressure sores. Plast Reconstr Surg 1993;91:678–683. 5. Sameem M, Au M, Wood T, Farrokhyar F, Mahoney J. A systematic review of complication and recurrence rates of musculocutaneous, fasciocutaneous, and perforator-based flaps for treatment of pressure sores. Plast Reconstr Surg 2012;130:67e–77e. 6. Yang CH, Kuo YR, Jeng SF, Lin PY. An ideal method for pressure sore reconstruction. A freestyle perforator-based flap. Ann Plast Surg 2011;66:179–184. 7. Lin PY, Kuo YR, Tsai YT. A reusable perfator-preserving gluteal artery-based rotation fasciocutaneous flap for pressure sore rconstruction. Microsurgery 2012;32:189–195. 8. Aoi N, Yoshimura K, Kadono T, Nakagami G, Iizuka S, Higashino T, Araki J, Koshima I, Sanada H. Ultrasound assessment of deep tissue injury in pressure ulcers: Possible prediction of pressure ulcer progression. Plast Reconstr Surg 2009;124:540–550. 9. Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg 2004; 114:910–916. 10. Ahmadzadeh R, Bergeron L, Tang M. The superior and inferior gluteal artery perforator flaps. Plast Reconstr Surg 2007;120:1551– 1556. 11. Yamamoto Y, Tsutsumida A, Murazumi M, Sugihara T. Longterm outcome of pressure sores treated with flap coverage. Plast Reconstr Surg 1997;100:1212–1217. 12. Nola GT, Vistnes LM. Differential response of skin and muscle in the experimental production of pressure sores. Plast Reconstr Surg 1980;66:728–733. 13. Wong CH, Tan BK, Song C. The perforator-sparing buttock rotation flap for coverage of pressure sores. Plast Reconstr Surg 2007;119: 1259–1266. 14. Daniel RK, Faibisoff B. Muscle coverage of pressure points—The role of myocutaneous flaps. Ann Plast Surg 1982;8:446–452.
Comparison of Outcomes of Pressure Sore Reconstructions 15. Yamamoto Y, Ohura T, Shintomi Y, Sugihara T, Nohira K, Igawa H. Superiority of the fasciocutaneous flap in reconstruction of sacral pressure sores. Ann Plast Surg 1993;30:116–121. 16. Calderon W, Chang N, Mathes SJ. Comparison of the effect of bacterial inoculation in musculocutaneous and fasciocutaneous flaps. Plast Reconstr Surg 1986;77:785–792. 17. Gosain A, Chang N, Mathes S, Hunt TK, Vasconez L. A study of the relationship between blood flow and bacterial inoculation in musculocutaneous and fasciocutaneous flaps. Plast Reconstr Surg 1990;86:1152–1162.
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18. Yasser EH. The reusable V-Y advancement gluteus maximus fasciocutaneous flap in management of sacral pressure sores. Egypt J Plast Reconstr Surg 2013;37:125–129. 19. Baran CN, Celebio glu S, Civelek B, Sens€ oz O. Tangentially split gluteus maximus myocutaneous island flap based on perforator arteries for the reconstruction of pressure sores. Plast Reconstr Surg 1999;103:2071–2076. 20. Gaster RS, Bhatt KA, Shelton AA, Lee GK. Free transverse rectus abdominis myocutaneous flap reconstruction of a massive lumbosacral defect using superior gluteal artery perforator vessels. Microsurgery 2012;32:388–392.
Microsurgery DOI 10.1002/micr
