RECONSTRUCTIVE SURGERY

Parasacral Perforator Flaps for Reconstruction of Sacral Pressure Sores Chin-Ta Lin, MD, Shih-Yi Chen, MD, Shyi-Gen Chen, MD, Yuan-Sheng Tzeng, MD, and Shun-Cheng Chang, MD Background: Despite advances in reconstruction techniques, pressure sores continue to present a challenge to the plastic surgeon. The parasacral perforator flap is a reliable flap that preserves the entire contralateral side as a future donor site. On the ipsilateral side, the gluteal muscle itself is preserved and all flaps based on the inferior gluteal artery are still possible. We present our experience of using parasacral perforator flaps in reconstructing sacral defects. Methods: Between August 2004 and January 2013, 19 patients with sacral defects were included in this study. All the patients had undergone surgical reconstruction of sacral defects with a parasacral perforator f lap. The patients’ sex, age, cause of sacral defect, flap size, flap type, numbers of perforators used, rotation angle, postoperative complications, and hospital stay were recorded. Results: There were 19 parasacral perforator f laps in this series. All f laps survived uneventfully except for 1 parasacral perforator f lap, which failed because of methicillin-resistant Staphylococcus aureus infection. The overall f lap survival rate was 95% (18/19). The mean follow-up period was 17.3 months (range, 2Y24 months). The average length of hospital stay was 20.7 days (range, 9Y48 days). No flap surgery-related mortality was found. Also, there was no recurrence of sacral pressure sores or infected pilonidal cysts during the follow-up period. Conclusions: Perforator-based f laps have become popular in modern reconstructive surgery because of low donor-site morbidity and good preservation of muscle. Parasacral perforator f laps are durable and reliable in reconstructing sacral defects. We recommend the parasacral perforator f lap as a good choice for reconstructing sacral defects. Key Words: parasacral perforator flap, sacral sore, reconstruction (Ann Plast Surg 2015;75: 62Y65)

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econstructing a sacral defect caused by pressure sores or infected pilonidal cysts is a common problem for reconstructive surgeons. It is still a challenge because there are limited local f laps available when ulcer recurs, especially in patients with a sacral pressure sore. Many surgical methods have been used to correct pressure sores, including primary closure, skin grafting, local random f laps, and muscle f laps. Myocutaneous f laps can provide well-vascularized tissue with good durability for covering a sacral defect.1 However, the disadvantages of myocutaneous f laps are that they sacrifice a functioning muscle; there is limited distance for f lap shifting and more blood loss than a fasciocutaneous f lap while splitting the muscle.1Y3 Gluteal muscle perforator-based f laps have been used for covering sacral defects for more than 10 years. This type has become more popular because of its versatility and low donor-site Received August 2, 2013, and accepted for publication, after revision, September 24, 2013. From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan. Conflicts of interest and sources of funding: none declared. Reprints: Shun-Cheng Chang, MD, Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Gung Rd, Taipei 11490, Taiwan. E-mail: [email protected]. Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7501-0062 DOI: 10.1097/SAP.0000000000000024

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complication.4,5 Koshima et al4 first described a gluteal flap based on parasacral perforators for repairing sacral pressure sores. The parasacral perforator f lap provides an ample amount of tissue, with good vascularity, to cover large sacral pressure sores in 1 stage and does not sacrifice the vascularity or innervation of the underlying gluteus maximus muscle. Here, we present our experience in successful reconstruction of sacral pressure sores using parasacral perforator f laps.

PATIENTS AND METHODS Between August 2004 and January 2013, 19 patients with sacral defects were included in this study. All of these patients underwent surgical reconstruction of sacral defects with a parasacral perforator f lap. This series included 10 men and 9 women. Their ages ranged from 22 to 89 years (mean, 62.2 years). There were 15 patients with the diagnosis of sacral pressure sores and 4 with infected pilonidal cysts. The average f lap size was 94.2 cm2, ranging from 42 to 168 cm2. All patients underwent wound debridement for sacral pressure sores or infected pilonidal cysts. Broad-spectrum antibiotics were prescribed, and the antibiotics were changed to specific ones if a specific organism were isolated from the wound culture. After debridement and adequate local wound care, reconstructive procedures were carried out when the wound base showed healthy granulation tissue. Perforators were identified and marked by acoustic Doppler with the patient in a prone position during operation.

Surgical Procedure With the patient in the prone position, the parasacral perforators were identified and marked on the sacrum using an acoustic Doppler technique. The border of the f lap was designed to include the wound edge and the lateral border of the f lap should be long enough to reach the contralateral wound edge after rotation. The upper border of the f lap was incised first to identify the chosen perforator. After the chosen perforator had been identified, the whole f lap was elevated and detached from the underlying muscle without doing intramuscular dissection. The emerging point of the perforator was designed as the rotation pivot point and then the f lap was transposed to the defect with a rotation angle of up to 180 degrees (Fig. 1). The donor sites were closed primarily. Closed suction drainage was placed in the donor site and under the f lap. The drainage amount was recorded once per day and the drain was removed when the amount was less than 10 mL/d. The patients’ sex, age, cause of sacral defect, f lap size, f lap type, numbers of perforators used, rotation angle, and postoperative complications were recorded.

RESULTS All f laps survived uneventfully except for 1 parasacral perforator f lap, which failed because of methicillin-resistant Staphylococcus aureus infection. The overall f lap survival rate was 95% (18/19). In the case with f lap necrosis, the patient was finally treated with contralateral V-Y advancement f lap coverage. There were 2 minor complications of partial dehiscence of the wound edge. The dehisced wounds were managed by delayed primary closure. All donor-site defects were closed primarily. The patients’ general data Annals of Plastic Surgery

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Parasacral Perforator Flaps for Sacral Sores

related mortality was found. Also, there was no recurrence of sacral pressure sores or infected pilonidal cysts during the follow-up period.

Case Report Case 6 This 68-year-old man sustained a sacral pressure sore and exposure of the sacrum. The parasacral perforator f lap was designed for reconstruction. One perforator was used and the rotation angle was 180 degrees. After reconstructive surgery, the sacral defect was well covered and the f lap showed good results at the follow-up visit 2 weeks later (Fig. 2).

Case 16 An 85-year-old woman had a 12  10-cm sacral defect caused by a pressure sore. A 14  12-cm parasacral perforator f lap was designed to reconstruct the defect. One perforator was included in the f lap and there was no intramuscular dissection. The f lap was transposed to the defect in a propeller fashion and the rotation angle was 180 degrees. The f lap demonstrated good survival 4 weeks later (Fig. 3).

DISCUSSION

FIGURE 1. The parasacral perforator f lap can be transposed with a rotation angle up to 180 degrees in a propeller fashion (P, perforator).

and characteristics are listed in Table 1. The mean follow-up period was 17.3 months (range, 2Y24 months). The average length of hospital stay was 20.7 days (range, 9Y48 days). No f lap surgery-

The common causes of sacral defects include pressure sores in paraplegic patients and infected pilonidal cysts in ambulatory patients. Delayed wound coverage of a sacral defect can cause progressive infections and wound pain. Therefore, surgical debridement and subsequent wound reconstruction remain the best treatments for most patients with a sacral defect.6,7 The gluteus maximus myocutaneous f lap has been the most popular technique for closure of a sacral defect, because of its reliability and short learning curve for surgeons. However, this f lap has several shortcomings. It requires the surgeon to sacrifice a functioning muscle and has potential risks of walking instability in an ambulatory patient. Other disadvantages

TABLE 1. Characteristics of Patients’ Age, Sex, Cause of Sacral Defect, Flap Size, Perforator Number, Rotation Angle, Outcome, and Hospital Stay Patient 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

Sex/Age, y

Cause of Sacral Defect

Flap Size, cm2

Perforator Number

Rotation Angle, degree

Outcome

Hospital Stay, d

F/22 M/28 F/47 M/56 F/58 M/68 M/73 F/75 M/76 F/77 M/77 F/79 F/80 M/80 F/82 F/85 M/89 M/78 M/30

Infected pilonidal cyst Infected pilonidal cyst Stroke, bed ridden Infected pilonidal cyst Cerebral palsy, bed ridden Stroke, bed ridden Parkinsonism, bed ridden Dementia, bed ridden Brain tumor, bed ridden Stroke, bed ridden Stroke, bed ridden Stroke, bed ridden Stroke, bed ridden Stroke, bed ridden T spine fracture, paraplegia Stroke, bed ridden Stroke, bed ridden Stroke, bed ridden Infected pilonidal cyst

42 42 192 48 84 54 121 70 108 48 120 54 60 135 156 168 60 108 120

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

180 180 180 90 180 180 90 180 90 180 90 160 75 180 180 160 120 180 180

Good Good MRSA infection, flap necrosis Good Good Good Dehiscence of wound edge Good Good Good Good Good Dehiscence of wound edge Good Good Good Good Good Good

9 10 48 12 22 16 32 20 24 14 18 16 36 23 20 24 18 21 11

MRSA indicates methicillin-resistant Staphylococcus aureus.

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FIGURE 2. A 68-year-old man (case 6) sustained a sacral pressure sore and exposure of the sacrum. A, A parasacral perforator (P) f lap was designed to cover the 5  5-cm sacral defect. B, One perforator was used without intramuscular dissection. C, In an immediate postoperative view, the rotation angle was 180 degrees. D, Two weeks later, the defect was well covered and the donor site was healing well.

include a bulky appearance, limited distance of f lap transposition, and unnecessary blood loss when splitting the muscle.1Y3 Koshima et al4 first described a gluteal f lap based on parasacral perforators for repairing sacral pressure sores. This perforator-based fasciocutaneous f lap has been widely used for covering sacral defects because of its advantages of reliability, preservation of muscle, low blood loss, and durability.5,7Y9 The parasacral perforators can arise from the lateral sacral artery or the internal pudendal artery and the diameter ranges from 0.8 to 1.5 mm.4,10 In our series, the average size of the parasacral perforator f laps was 94.2 cm2 (range, 42Y192 cm2) and the largest f lap nourished by 1 parasacral perforator measured 16  12 cm. Parasacral perforator f laps have benefits in repairing sacral defects. They can provide a durable fasciocutaneous coverage on the sacral area with gluteal muscle sparing. The circulation of the perforator-based f laps is good and the f laps are reliable.4,5,10Y12 It is always designed close to the sacral defects and can be elevated and transposed to the defects in a propeller fashion. However, meticulous dissection of the perforators is mandatory to achieve a good surgical result and this might need a significant learning curve for surgeons. Unlike the superior gluteal artery perforator f lap, it does not need intramuscular dissection, and the risk of incidental perforator injury during intramuscular dissection can be reduced. However, the parasacral perforator f lap has several limitations. Because the nearest perforator to the wound is chosen and the vascular pedicle is short, the parasacral perforator f lap cannot be transposed with as long an arc of movement as the superior gluteal artery perforator f lap. The second risk of the parasacral perforator f lap is 64

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that a propeller transposition of the f lap might induce pedicle twisting and potential f lap congestion and loss. Demir et al13 showed that the twisting angle must not exceed 180 degrees if perforator twisting is to be avoided. In the present study, the average rotation angle of the parasacral perforator f laps was 150 degrees (range, 75Y180 degrees) and the maximum rotation angle was 180 degrees. There was no f lap congestion or failure caused by pedicle twisting. Another restriction of the parasacral perforator f lap is that this perforator may be lacking in an extremely large sacral defect. In conclusion, sacral sore management is a difficult issue in plastic surgery, and f laps must be chosen carefully. The parasacral perforator f lap provides a large, bulky, and safe fasciocutaneous f lap to cover sacral pressure sores. The f lap also has advantages of minimal blood loss, mild donor-site morbidity, and preservation of muscle function. Like other perforator f laps, pedicle dissection needs a meticulous dissection technique to avoid damaging the perforator vessels, especially for inexperienced surgeons. We found that the parasacral perforator f lap elevation was easier, faster, and safer. Because raising the parasacral perforator f lap is no longer a technique that demands a steep learning curve, we recommend the parasacral perforator f lap as a good alternative choice in the management of sacral sores that could not be covered with primary closure or local fasciocutaneous f lap. ACKNOWLEDGMENTS The authors thank the Civilian Administration Division of TriService General Hospital, National Defense Medical Center, Taipei, Taiwan. * 2015 Wolters Kluwer Health, Inc. All rights reserved.

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Parasacral Perforator Flaps for Sacral Sores

FIGURE 3. An 85-year-old woman (case 16) had a 12  10-cm sacral defect caused by a pressure sore. A, A 14  12-cm parasacral perforator (P) f lap was designed. B, One parasacral perforator was identified without intramuscular dissection. C, In an immediate postoperative view, the rotation angle was 180 degrees. D, Flap survival and wound healing were excellent 4 weeks later. REFERENCES 1. Minami RT, Mills R, Pardoe R. Gluteus maximus myocutaneous flaps for repair of pressure sores. Plast Reconstr Surg. 1977;60:242Y249. 2. Parry SW, Mathes SJ. Bilateral gluteus maximus myocutaneous advancement flaps: sacral coverage for ambulatory patients. Ann Plast Surg. 1982;8: 443Y445. 3. Stevenson TR, Pollock RA, Rohrich RJ, et al. The gluteus maximus musculocutaneous island flap: refinements in design and application. Plast Reconstr Surg. 1987;79:761Y768. 4. Koshima I, Moriguchi T, Soeda S, et al. The gluteal perforator-based flap for repair of sacral pressure sores. Plast Reconstr Surg. 1993;91:678Y683. 5. 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;52:385Y391. 6. 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;102:765Y772.

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7. Acarturk TO, Parsak CK, Sakman G, et al. Superior gluteal artery perforator flap in the reconstruction of pilonidal sinus. J Plast Reconstr Aesthet Surg. 2010;63:133Y139. 8. Roche NA, Van Landuyt K, Blondeel PN, et al. The use of pedicled perforator flaps for reconstruction of lumbosacral defects. Ann Plast Surg. 2000;45:7Y14. 9. Meltem C, Esra C, Hasan F, et al. The gluteal perforator-based flap in repair of pressure sores. Br J Plast Surg. 2004;57:342Y347. 10. Ahmadzadeh R, Bergeron L, Tang M, et al. The superior and inferior gluteal artery perforator flaps. Plast Reconstr Surg. 2007;120:1551Y1556. 11. Coskunfirat OK, Ozgentas HE. Gluteal perforator flaps for coverage of pressure sores at various locations. Plast Reconstr Surg. 2004;113:2012Y2017; discussion 2018-9. 12. Lee JT, Hsiao HT, Tung KY, et al. Gluteal perforator flaps for coverage of pressure sores at various locations. Plast Reconstr Surg. 2006;117: 2507Y2508. 13. Demir A, Acar M, Yldz L, et al. The effect of twisting on perforator flap viability: an experimental study in rats. Ann Plast Surg. 2006;56:186Y189.

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Parasacral Perforator Flaps for Reconstruction of Sacral Pressure Sores.

Despite advances in reconstruction techniques, pressure sores continue to present a challenge to the plastic surgeon. The parasacral perforator flap i...
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