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Perforator-based bilobed flaps in patients with a sacral sore: Application of a schematic design
Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 790e795
Perforator-based bilobed flaps in patients with a sacral sore: Application of a schematic design Hyuck-Jae Lee, Jai-Kyong Pyon*, So-Young Lim, Goo-Hyun Mun, Sa-Ik Bang, Kap-Sung Oh Samsung Medical Center, Department of Plastic Surgery, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea Received 23 March 2010; accepted 30 September 2010
KEYWORDS Sore; Bilobed flap; Recurrence; Pressure
Summary Background: Many procedures have been proposed for the treatment of sacral sores, and bilobed flaps are widely used to reconstruct defects of the lower third of the nose. This retrospective study was conducted to evaluate our experiences of bilobed flaps based on parasacral perforators, for the treatment of sacral sores. Methods: Twelve patients, six males and six females, aged 21e74 years (mean age: 51.08 years), with a sacral sore were treated with a bilobed flap at our institution from February 2007 to November 2009. Sacral sores were treated by en bloc excision and defects were closed using a bilobed flap in each case. Flaps were designed using parasacral perforators after considering pocket locations. The average postoperative follow-up duration was 16 months. Results: Primary wound healing was achieved in all patients. Large defects left after excision were easily closed using bilobed flaps, which provided tensionless wound closure. The postoperative courses were uneventful in all 12 cases, and no patient experienced recurrence. Conclusion: The use of a perforator-based bilobed flap enables regional reconstruction using well-vascularised tissues, and provides satisfactory and aesthetic results in sore patients. Furthermore, rerotation is possible in the event of sore recurrence. Accordingly, we consider the perforator-based bilobed flap to be a useful and additional tool for the treatment of pressure sores. ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Sacral sores are the result of ischaemic tissue formed due to prolonged pressure over bony prominences. The main treatment concept regarding the use of flaps is that they
* Corresponding author. Tel.: þ82 2 3410 2236; fax: þ82 2 3410 0036. E-mail address: [email protected] (J.-K. Pyon).
provide well-vascularised bulky tissue to cover sores over bony prominences. However, despite many efforts, no consensus has been reached regarding the definitive treatment of sacral sores.1 Furthermore, the rates of pressure sore recurrence are high. In particular, in spinalcord-injury patients, recurrence rates are around 50%.2 Recurrence impairs the success of all modalities used to
1748-6815/$ - see front matter ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.09.020
Perforator-based bilobed flaps in patients with a sacral sore treat sores, although the lowest rates have been reported for local flap reconstructions. Koshima et al. reported on the feasibility of using perforator flaps to cover sacral pressure sores.3 These flaps minimise donor-site morbidity by preserving underlying muscle, but all the designs described by Koshima et al. were island skin flaps, and this design limits the prospect of reusing a buttock flap for repeat surgery in cases of recurrence. To resolve the problem of recurrence, the rotation flap can be a useful option. Wong et al. described a reusable perforator-based rotational flap with enhanced vascularity.4 However, reconstruction with a rotation flap can produce dog-ear deformity and increase wound tension when defects are wide, and therefore, we used bilobed flaps to allow the wide defect coverage required for the treatment of pressure sores. The bilobed flap, first described by Esser and later detailed by Zimany, is widely used to reconstruct defects on the lower third of the nose.5 This flap produces aesthetically good results and provides tensionless reconstruction. We have achieved satisfying results using perforatorbased bilobed flaps for the treatment of sores, and we undertook this retrospective study to evaluate our experiences of bilobed flaps, based on parasacral perforators, for the treatment of sacral sores.
Patients and methods Twelve patients, six males and six females, aged 21e74 years (mean age: 51.08 years), with a sacral sore were treated with a bilobed fasciocutaneous flap at the Samsung Medical Center from February 2007 to November 2009. Six patients (50%) presented with a recurrent pressure sore after conventional surgery. Seven patients (58%) were paraplegic, one (8%) was quadriplegic and four (34%) were ambulatory. The causes of paralysis were spinal-cord injury from trauma in four patients, encephalitis in one, belowknee (B-K) amputation in one, multiple sclerosis in one and comatose state in one. Areas of defects, treatment methods, recurrence rates and complications were analysed using data obtained from medical records and clinical photographs.
791
Operative techniques Preoperatively, a portable Doppler assessment is conducted in the prone position, and the locations of gluteal perforators and of the planned bilobed flap are marked out using anatomical landmarks. To identify superior gluteal artery perforators, a line is drawn from the posterior inferior iliac spine to the coccyx, and from the posterior inferior iliac spine to the apex of the greater trochanter. At the midpoint of the line from the posterior inferior iliac spine to the coccyx, another line is drawn to the superior edge of the greater trochanter (this corresponds to the course of the piriformis muscle). A point is then marked at the proximal third of the line from the posterior inferior iliac spine to the greater trochanter. The major superior gluteal artery perforators are found lateral and distal to this point of exit and above the piriformis muscle. To identify the inferior gluteal artery perforator, a vertical line is drawn from the posterior inferior iliac spine to the ischial tuberosity. Along this line, the inferior border of the piriformis marks the point of exit of the inferior gluteal artery. Preferable perforators are found lateral to this line in the buttock region, extending from the piriformis muscle to the inferior gluteal crease (Figure 1).7e12 The dead space of the defect is then checked and the rotation axis direction decided. The axis point is located at the direction of the dead space, one semidiameter from the defect site. A bilobed flap is designed at a site adjacent to the defect with the first lobe (primary flap) at an angle of approximately 45 to the defect and the second lobe (secondary flap) perpendicular to the defect (the primary flap should be the same size and length as the skin defect, and the secondary flap should be narrower and longer than the primary flap) (Figure 2).5 Necrotic tissue and underlying bursa are excised down to healthy tissue. Osteotomy of any underlying bony prominences is then performed to even out any irregular bony surfaces, and the wound is massively irrigated. The primary flap, including the deep fascia of muscle, is then elevated with dissection, taking care to avoid damaging the musculocutaneous perforators present at the flap pedicle. The secondary flap dissection extends upwards at the same subfascial level, to allow complete coverage of the defect with tension-free closure.
Figure 1 Location of gluteal artery perforator. Shaded areas correspond to customary location of perforators. PSIS, posterior superior iliac spine; GT, greater trochanter; C, coccyx; I, ischium; P, midpoint of line posterior inferior iliac spine-coccyx; F, point at proximal third of line posterior inferior iliac spine-greater trochanter.
792
H.-J. Lee et al.
Figure 2
Perforator based bilobed flap design for each pocket direction (Rt. Lower, Lt. lower, Rt. Upper, Lt. upper).
The primary flap is then applied to the defect, while the secondary flap is turned sideways to the primary donor site, and the secondary donor site is closed. The two layers are closed using 2/0 or 3/0 Vicryl sutures for subcutaneous tissue and 4/0 Nylon sutures for skin.
Results Twelve patients were followed-up for an average of 16 months (range, 3e24 months). Primary wound healing was achieved in all patients. There were no early breakdowns or recurrences over follow-up. Large defects left after excision were easily closed using the bilobed flap, which provided tensionless wound closure. In 8 of the 12 patients, only a fasciocutaneous bilobed flap was used. In the other four patients, muscle was also needed to fill dead space at the base of defects. In these patients, fasciocutaneous bilobed flap rotation was performed independently of the muscle flap. We used the gluteus maximus muscle when the bony defect was wide and the dead space was too large to cover with a fasciocutaneous flap, though this procedure increased the operative time. We encountered four short-term complications. Two cases of seroma occurred among the patients in whom a muscle flap was used for defect coverage; these patients were treated by aspiration and compression. In addition, two patients with partial wound dehiscence responded to conservative treatment without recurrence. Aesthetic outcomes were satisfactory in all patients.
The average operation time for the 12 patients was 1.5 h, but for the four patients who required a muscle flap it was 2 h (Table 1).
Discussion The treatment of pressure sores involves surgical debridement with wide excision of necrotic tissues. Many surgical techniques are available for the coverage for wide defects after debridement, but high recurrence rates and the development of new sores make the management of pressure sores difficult. Furthermore, no definitive surgical technique has been devised, and thus, optimal defect closure remains debatable. Musculocutaneous flaps have become the method of choice for the surgical repair of pressure sores, but the indications for including muscle in transferred flaps remain poorly defined. There are many theoretical advantages of using muscle for the repair of pressure sores. Muscle flaps can be helpful to eliminate dead space, to supply reliable vasculature and for cushioning tissue over a pressurebearing area. However, it has been shown that the transferred muscle becomes atrophic, loses its dynamic function and, in time, loses its ability to cushion to absorb pressure. In a previous study on the differences between fasciocutaneous or perforator flaps and musculocutaneous flaps when used to cover pressure sores in terms of early and late complications, no significant differences were found in terms of postoperative morbidities or recurrences.14 Since the advent of the perforator flap, several
Patient data
No.
Sex
Age
Diagnosis
1
F
21
2
M
42
3
M
65
4
F
32
5
M
55
6
F
67
Sacral sore Sacral sore Sacral sore Sacral sore Sacral sore Sacral sore
7
M
67
8
M
74
9
F
54
10
F
32
11
M
50
12
F
54
Sacral sore Sacral sore Sacral sore Sacral sore Sacral sore Sacral sore
Defect size (cm)
Bursa depth (cm)
Flap type
Flap size (cm)
Pocket direction
33
32
FC
95
7
32
6
FC
10 4
2
10 4.5
52
FC
12 8
11
10 6
43
FC
12 8
6
43
32
FC (M)
74
7
73
32
FC
10 5
12
54
53
FC
13 8
5
96
43
FC (M)
13 8
7
44
21
FC
55
6
65
41
FC (M)
10 7
12
64
53
FC
13 8
12
74
63
FC (M)
10 5
11
Status
Past history
Previous operation
Short term Cx.
Long term Cx
Operation time (h)
Follow up (month)
Normal (sensate) Paraplegia (insensate) Paraplegia (insensate) Paraplegia (insensate) Paraplegia (insensate) Lower extremity weaknees (sensate) Normal (sensate) Normal (sensate) Paraplegia (insensate) Paraplegia (insensate) Paraplegia (insensate) Quadriplegia (comatose)
Bipolar disorder Encephalitis
None
None
None
1
24
V-Y advancement 2 local flaps
None
None
1
23
Mild dehiscence Mild dehiscence None
None
1
21
None
2
20
None
2
19
None
None
1
19
B-K Amputation C-spine injury T10-spine injury Vasculitis
Several local flaps Several local flaps None
AMI
None
None
None
1
16
Urosepsis
None
None
None
2
16
Multiple sclerosis, DM T3 w T7 spine injury C-spine injury
None
None
None
1
14
Several local flaps STSG
Seroma
None
2
12
None
None
2
5
AMI
None
Seroma
None
2
3
Perforator-based bilobed flaps in patients with a sacral sore
Table 1
Cx, complication; FC, fasciocutaneous; (M), muscle flap using group; AMI, acute myocardiac infarction; DM, diabetes mellitus. Note that there was no case of long term complication. Six were recurrence cases from a previous conventional operation. After complete excision of the bursa, the dead space was filled with a muscle transposition flap, if dead space was not covered with fasciocutaneous flap.
793
794
Figure 3
H.-J. Lee et al.
(Case 6) F/67 Gr IV sacral sore, size 7 3 cm; intra-op.
Figure 4 (Case 6) F/67 Gr IV sacral sore, size 7 3 cm and post-op 8.5 months.
flap designs have been proposed for the coverage of sacral, ischial and trochanteric pressure sores. The major advantage of perforator flaps is that they help preserve the gluteus maximus muscle, which is particularly important for ambulatory patients, and therefore, the perforator flap should be considered a good option for the coverage of pressure sores. In the present study, we found no differences between patients treated with a muscle flap and those who were not, in terms of recurrences and complications. Furthermore, patients treated with a muscle flap exhibited the short-term complication of seroma. However, most previous designs of the island-type perforator flap described in the literature do not allow flap reuse. Disa et al. reported a 61% recurrence rate for 66 pressure sores after an average follow-up of only 9.3 months.1 More recently, Kierney et al. reported on 268 pressure sores managed using a standardised combination of plastic surgery and rehabilitative medicine, and found an overall recurrence rate of 19% after an average follow-up of 3.7 years.13 These two previous studies demonstrate that flap reusability must be viewed as an essential aspect of flap design for the treatment of pressure sores, to include
Figure 5 (Case 7) M/67 Gr IV sacral sore, size 5 4 cm; preop design.
Figure 6 (Case 7) M/67 Gr IV sacral sore, size 5 4 cm; postop 4 months.
the eventuality of ulcer recurrence. Rotation flaps can be re-elevated using the same incisions, and can be advanced in the event of tip necrosis or ulcer recurrence. Furthermore, perforator flaps can also be elevated from the contralateral ‘virgin’ site, and, if a sore recurs, another flap can be prepared using another axis. However, when defects are wide, rotation flaps can produce dog-ears and increase tension at wound margins, which is one of the main reasons given for high recurrence rates. The bilobed flap can make use of the laxity or availability of tissues along two axes at right angles to each other and it compounds these available tissues into one flap.5 As a result, the bilobed flap-coverage technique can reduce tension at wound margins and lower recurrences. Furthermore, this technique can provide aesthetically excellent results (Figures 3e6). Blood supply is another important consideration. As pressure sores are the result of tissue ischaemia, the use of well-vascularised tissue is of considerable importance. In a cadaver study, Koshima et al. reported 20e25 perforators in the gluteal region.3 These perforators are 3e8 cm long with external diameters of 1e1.5 mm, and originate from the superior gluteal, interior gluteal, fourth lumbar, lateral sacral and internal pudendal arteries. Thus, we could design a bilobed flap based on parasacral
Perforator-based bilobed flaps in patients with a sacral sore musculocutaneous perforators. During the surgical reconstruction of sores, flap vascularity is critical. If the blood supply is inadequate, the flap margin becomes necrotic and wound problems follow. We preserved blood supply by observing perforators using Doppler sonography and by involving two to three perforators per flap.6 The perforatorpreserving bilobed flap offers advantages in cases of recurrence and produces flaps that are more resistant to pressure-induced ischaemia. Preoperatively, surgical incisions were designed after considering defect size and pocket direction, which considerably simplified the operative procedure. Because of the richness of perforators in this region, perforators can be easily found. Portable Doppler is used to check perforator status and ensure the safety of the reconstruction. These perforators were almost always at the flap axis, and thus, perforator dissection was not required, which simplified surgery. Furthermore, the design of the bilobed flap is straightforward, and flaps can be easily applied.
Conclusion Pressure sores often become personal, family, health and social problems, particularly in paraplegics, whose numbers continue to increase. Furthermore, preventive and conservative anti-decubital and pressure-relief measures are often inadequate in terms of preventing the appearance or the progress of pressure sores, which is why surgery must sometimes be considered. Many different operative options can be used to treat pressure sores. However, we advocate the use of a perforator-based bilobed flap when wide skin resection is required. This flap design allows aesthetic reconstruction and tension-free skin closure, which reduces the risk of local recurrence, and also enables regional reconstruction using well-vascularised tissues. In addition, surgery is easily performed and safe, and most importantly, in the event of sore recurrence, it allows rerotation. We recommend that the perforator-based bilobed flap be viewed as a useful additional tool for the treatment of pressure sores.
795
Acknowledgements Disclosure: The authors have no conflict of interest to declare.
References 1. Disa JJ, Carlton JM, Goldberg NH. Efficacy of operative cure in pressure sore patients. Plast Reconstr Surg 1992;89:272e8. 2. Conway H, Griffith BH. Plastic surgery for closure of decubitus ulcers in patients with paraplegia; based on experience with 1000 cases. Am J Surg 1956;91:946e75. 3. Koshima I, Moriguchi T, Soeda S, et al. The gluteal perforatorbased flap for repair of sacral pressure sores. Plast Reconstr Surg 1993;91:678e83. 4. Wong CH, Tan BK, Song C. The perforator-sparing buttock rotation flap for coverage of pressure sores. Plast Reconstr Surg 2007;119:1259e66. 5. Zimany A. The bi-lobed flap. Plast Reconstr Surg 1953;11:424e34. 6. Hallock GG. Doppler sonography and color duplex imaging for planning a perforator flap. Clin Plast Surg 2003;30:347e57. vevi. 7. Higgins JP, Orlando GS, Blondeel PN. Ischial pressure sore reconstruction using an inferior gluteal artery perforator (IGAP) flap. Br J Plast Surg 2002;55:83e5. 8. Coskunfirat OK, Ozgentas HE. Gluteal perforator flaps for coverage of pressure sores at various locations. Plast Reconstr Surg 2004;113:2012e7. discussion: 2018e2019. 9. Meltem C, Esra C, Hasan F, et al. The gluteal perforator-based flap in repair of pressure sores. Br J Plast Surg 2004;57:342e7. 10. Kim YS, Lew DH, Roh TS, et al. Inferior gluteal artery perforator flap: a viable alternative for ischial pressure sores. J Plast Reconstr Aesthet Surg 2009;62(10):1347e54. 11. Zogovska E, Novevski L, Agai L, et al. Our experience in treatment of pressure ulcers by using local cutaneous flaps. Prilozi 2008;29:199e210. 12. El-Khatib HA, Al-Basti HB. A perforator-based bilobed fasciocutaneous flap: an additional tool for primary reconstruction following wide excision of sacrococcygeal pilonidal disease. J Plast Reconstr Aesthet Surg 2009;62:494e8. 13. 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. 14. Thiessen Filip E, Andrades Patricio, Blondeel Philip N, et al. Flap surgery for pressure sores: should the underlying muscle be transferred or not? J Plast Reconstr Aesthet Surg; 2010 (Epub).
Perforator-based bilobed flaps in patients with a sacral sore: Application of a schematic design Hyuck-Jae Lee, Jai-Kyong Pyon*, So-Young Lim, Goo-Hyun Mun, Sa-Ik Bang, Kap-Sung Oh Samsung Medical Center, Department of Plastic Surgery, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea Received 23 March 2010; accepted 30 September 2010
KEYWORDS Sore; Bilobed flap; Recurrence; Pressure
Summary Background: Many procedures have been proposed for the treatment of sacral sores, and bilobed flaps are widely used to reconstruct defects of the lower third of the nose. This retrospective study was conducted to evaluate our experiences of bilobed flaps based on parasacral perforators, for the treatment of sacral sores. Methods: Twelve patients, six males and six females, aged 21e74 years (mean age: 51.08 years), with a sacral sore were treated with a bilobed flap at our institution from February 2007 to November 2009. Sacral sores were treated by en bloc excision and defects were closed using a bilobed flap in each case. Flaps were designed using parasacral perforators after considering pocket locations. The average postoperative follow-up duration was 16 months. Results: Primary wound healing was achieved in all patients. Large defects left after excision were easily closed using bilobed flaps, which provided tensionless wound closure. The postoperative courses were uneventful in all 12 cases, and no patient experienced recurrence. Conclusion: The use of a perforator-based bilobed flap enables regional reconstruction using well-vascularised tissues, and provides satisfactory and aesthetic results in sore patients. Furthermore, rerotation is possible in the event of sore recurrence. Accordingly, we consider the perforator-based bilobed flap to be a useful and additional tool for the treatment of pressure sores. ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Sacral sores are the result of ischaemic tissue formed due to prolonged pressure over bony prominences. The main treatment concept regarding the use of flaps is that they
* Corresponding author. Tel.: þ82 2 3410 2236; fax: þ82 2 3410 0036. E-mail address: [email protected] (J.-K. Pyon).
provide well-vascularised bulky tissue to cover sores over bony prominences. However, despite many efforts, no consensus has been reached regarding the definitive treatment of sacral sores.1 Furthermore, the rates of pressure sore recurrence are high. In particular, in spinalcord-injury patients, recurrence rates are around 50%.2 Recurrence impairs the success of all modalities used to
1748-6815/$ - see front matter ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.09.020
Perforator-based bilobed flaps in patients with a sacral sore treat sores, although the lowest rates have been reported for local flap reconstructions. Koshima et al. reported on the feasibility of using perforator flaps to cover sacral pressure sores.3 These flaps minimise donor-site morbidity by preserving underlying muscle, but all the designs described by Koshima et al. were island skin flaps, and this design limits the prospect of reusing a buttock flap for repeat surgery in cases of recurrence. To resolve the problem of recurrence, the rotation flap can be a useful option. Wong et al. described a reusable perforator-based rotational flap with enhanced vascularity.4 However, reconstruction with a rotation flap can produce dog-ear deformity and increase wound tension when defects are wide, and therefore, we used bilobed flaps to allow the wide defect coverage required for the treatment of pressure sores. The bilobed flap, first described by Esser and later detailed by Zimany, is widely used to reconstruct defects on the lower third of the nose.5 This flap produces aesthetically good results and provides tensionless reconstruction. We have achieved satisfying results using perforatorbased bilobed flaps for the treatment of sores, and we undertook this retrospective study to evaluate our experiences of bilobed flaps, based on parasacral perforators, for the treatment of sacral sores.
Patients and methods Twelve patients, six males and six females, aged 21e74 years (mean age: 51.08 years), with a sacral sore were treated with a bilobed fasciocutaneous flap at the Samsung Medical Center from February 2007 to November 2009. Six patients (50%) presented with a recurrent pressure sore after conventional surgery. Seven patients (58%) were paraplegic, one (8%) was quadriplegic and four (34%) were ambulatory. The causes of paralysis were spinal-cord injury from trauma in four patients, encephalitis in one, belowknee (B-K) amputation in one, multiple sclerosis in one and comatose state in one. Areas of defects, treatment methods, recurrence rates and complications were analysed using data obtained from medical records and clinical photographs.
791
Operative techniques Preoperatively, a portable Doppler assessment is conducted in the prone position, and the locations of gluteal perforators and of the planned bilobed flap are marked out using anatomical landmarks. To identify superior gluteal artery perforators, a line is drawn from the posterior inferior iliac spine to the coccyx, and from the posterior inferior iliac spine to the apex of the greater trochanter. At the midpoint of the line from the posterior inferior iliac spine to the coccyx, another line is drawn to the superior edge of the greater trochanter (this corresponds to the course of the piriformis muscle). A point is then marked at the proximal third of the line from the posterior inferior iliac spine to the greater trochanter. The major superior gluteal artery perforators are found lateral and distal to this point of exit and above the piriformis muscle. To identify the inferior gluteal artery perforator, a vertical line is drawn from the posterior inferior iliac spine to the ischial tuberosity. Along this line, the inferior border of the piriformis marks the point of exit of the inferior gluteal artery. Preferable perforators are found lateral to this line in the buttock region, extending from the piriformis muscle to the inferior gluteal crease (Figure 1).7e12 The dead space of the defect is then checked and the rotation axis direction decided. The axis point is located at the direction of the dead space, one semidiameter from the defect site. A bilobed flap is designed at a site adjacent to the defect with the first lobe (primary flap) at an angle of approximately 45 to the defect and the second lobe (secondary flap) perpendicular to the defect (the primary flap should be the same size and length as the skin defect, and the secondary flap should be narrower and longer than the primary flap) (Figure 2).5 Necrotic tissue and underlying bursa are excised down to healthy tissue. Osteotomy of any underlying bony prominences is then performed to even out any irregular bony surfaces, and the wound is massively irrigated. The primary flap, including the deep fascia of muscle, is then elevated with dissection, taking care to avoid damaging the musculocutaneous perforators present at the flap pedicle. The secondary flap dissection extends upwards at the same subfascial level, to allow complete coverage of the defect with tension-free closure.
Figure 1 Location of gluteal artery perforator. Shaded areas correspond to customary location of perforators. PSIS, posterior superior iliac spine; GT, greater trochanter; C, coccyx; I, ischium; P, midpoint of line posterior inferior iliac spine-coccyx; F, point at proximal third of line posterior inferior iliac spine-greater trochanter.
792
H.-J. Lee et al.
Figure 2
Perforator based bilobed flap design for each pocket direction (Rt. Lower, Lt. lower, Rt. Upper, Lt. upper).
The primary flap is then applied to the defect, while the secondary flap is turned sideways to the primary donor site, and the secondary donor site is closed. The two layers are closed using 2/0 or 3/0 Vicryl sutures for subcutaneous tissue and 4/0 Nylon sutures for skin.
Results Twelve patients were followed-up for an average of 16 months (range, 3e24 months). Primary wound healing was achieved in all patients. There were no early breakdowns or recurrences over follow-up. Large defects left after excision were easily closed using the bilobed flap, which provided tensionless wound closure. In 8 of the 12 patients, only a fasciocutaneous bilobed flap was used. In the other four patients, muscle was also needed to fill dead space at the base of defects. In these patients, fasciocutaneous bilobed flap rotation was performed independently of the muscle flap. We used the gluteus maximus muscle when the bony defect was wide and the dead space was too large to cover with a fasciocutaneous flap, though this procedure increased the operative time. We encountered four short-term complications. Two cases of seroma occurred among the patients in whom a muscle flap was used for defect coverage; these patients were treated by aspiration and compression. In addition, two patients with partial wound dehiscence responded to conservative treatment without recurrence. Aesthetic outcomes were satisfactory in all patients.
The average operation time for the 12 patients was 1.5 h, but for the four patients who required a muscle flap it was 2 h (Table 1).
Discussion The treatment of pressure sores involves surgical debridement with wide excision of necrotic tissues. Many surgical techniques are available for the coverage for wide defects after debridement, but high recurrence rates and the development of new sores make the management of pressure sores difficult. Furthermore, no definitive surgical technique has been devised, and thus, optimal defect closure remains debatable. Musculocutaneous flaps have become the method of choice for the surgical repair of pressure sores, but the indications for including muscle in transferred flaps remain poorly defined. There are many theoretical advantages of using muscle for the repair of pressure sores. Muscle flaps can be helpful to eliminate dead space, to supply reliable vasculature and for cushioning tissue over a pressurebearing area. However, it has been shown that the transferred muscle becomes atrophic, loses its dynamic function and, in time, loses its ability to cushion to absorb pressure. In a previous study on the differences between fasciocutaneous or perforator flaps and musculocutaneous flaps when used to cover pressure sores in terms of early and late complications, no significant differences were found in terms of postoperative morbidities or recurrences.14 Since the advent of the perforator flap, several
Patient data
No.
Sex
Age
Diagnosis
1
F
21
2
M
42
3
M
65
4
F
32
5
M
55
6
F
67
Sacral sore Sacral sore Sacral sore Sacral sore Sacral sore Sacral sore
7
M
67
8
M
74
9
F
54
10
F
32
11
M
50
12
F
54
Sacral sore Sacral sore Sacral sore Sacral sore Sacral sore Sacral sore
Defect size (cm)
Bursa depth (cm)
Flap type
Flap size (cm)
Pocket direction
33
32
FC
95
7
32
6
FC
10 4
2
10 4.5
52
FC
12 8
11
10 6
43
FC
12 8
6
43
32
FC (M)
74
7
73
32
FC
10 5
12
54
53
FC
13 8
5
96
43
FC (M)
13 8
7
44
21
FC
55
6
65
41
FC (M)
10 7
12
64
53
FC
13 8
12
74
63
FC (M)
10 5
11
Status
Past history
Previous operation
Short term Cx.
Long term Cx
Operation time (h)
Follow up (month)
Normal (sensate) Paraplegia (insensate) Paraplegia (insensate) Paraplegia (insensate) Paraplegia (insensate) Lower extremity weaknees (sensate) Normal (sensate) Normal (sensate) Paraplegia (insensate) Paraplegia (insensate) Paraplegia (insensate) Quadriplegia (comatose)
Bipolar disorder Encephalitis
None
None
None
1
24
V-Y advancement 2 local flaps
None
None
1
23
Mild dehiscence Mild dehiscence None
None
1
21
None
2
20
None
2
19
None
None
1
19
B-K Amputation C-spine injury T10-spine injury Vasculitis
Several local flaps Several local flaps None
AMI
None
None
None
1
16
Urosepsis
None
None
None
2
16
Multiple sclerosis, DM T3 w T7 spine injury C-spine injury
None
None
None
1
14
Several local flaps STSG
Seroma
None
2
12
None
None
2
5
AMI
None
Seroma
None
2
3
Perforator-based bilobed flaps in patients with a sacral sore
Table 1
Cx, complication; FC, fasciocutaneous; (M), muscle flap using group; AMI, acute myocardiac infarction; DM, diabetes mellitus. Note that there was no case of long term complication. Six were recurrence cases from a previous conventional operation. After complete excision of the bursa, the dead space was filled with a muscle transposition flap, if dead space was not covered with fasciocutaneous flap.
793
794
Figure 3
H.-J. Lee et al.
(Case 6) F/67 Gr IV sacral sore, size 7 3 cm; intra-op.
Figure 4 (Case 6) F/67 Gr IV sacral sore, size 7 3 cm and post-op 8.5 months.
flap designs have been proposed for the coverage of sacral, ischial and trochanteric pressure sores. The major advantage of perforator flaps is that they help preserve the gluteus maximus muscle, which is particularly important for ambulatory patients, and therefore, the perforator flap should be considered a good option for the coverage of pressure sores. In the present study, we found no differences between patients treated with a muscle flap and those who were not, in terms of recurrences and complications. Furthermore, patients treated with a muscle flap exhibited the short-term complication of seroma. However, most previous designs of the island-type perforator flap described in the literature do not allow flap reuse. Disa et al. reported a 61% recurrence rate for 66 pressure sores after an average follow-up of only 9.3 months.1 More recently, Kierney et al. reported on 268 pressure sores managed using a standardised combination of plastic surgery and rehabilitative medicine, and found an overall recurrence rate of 19% after an average follow-up of 3.7 years.13 These two previous studies demonstrate that flap reusability must be viewed as an essential aspect of flap design for the treatment of pressure sores, to include
Figure 5 (Case 7) M/67 Gr IV sacral sore, size 5 4 cm; preop design.
Figure 6 (Case 7) M/67 Gr IV sacral sore, size 5 4 cm; postop 4 months.
the eventuality of ulcer recurrence. Rotation flaps can be re-elevated using the same incisions, and can be advanced in the event of tip necrosis or ulcer recurrence. Furthermore, perforator flaps can also be elevated from the contralateral ‘virgin’ site, and, if a sore recurs, another flap can be prepared using another axis. However, when defects are wide, rotation flaps can produce dog-ears and increase tension at wound margins, which is one of the main reasons given for high recurrence rates. The bilobed flap can make use of the laxity or availability of tissues along two axes at right angles to each other and it compounds these available tissues into one flap.5 As a result, the bilobed flap-coverage technique can reduce tension at wound margins and lower recurrences. Furthermore, this technique can provide aesthetically excellent results (Figures 3e6). Blood supply is another important consideration. As pressure sores are the result of tissue ischaemia, the use of well-vascularised tissue is of considerable importance. In a cadaver study, Koshima et al. reported 20e25 perforators in the gluteal region.3 These perforators are 3e8 cm long with external diameters of 1e1.5 mm, and originate from the superior gluteal, interior gluteal, fourth lumbar, lateral sacral and internal pudendal arteries. Thus, we could design a bilobed flap based on parasacral
Perforator-based bilobed flaps in patients with a sacral sore musculocutaneous perforators. During the surgical reconstruction of sores, flap vascularity is critical. If the blood supply is inadequate, the flap margin becomes necrotic and wound problems follow. We preserved blood supply by observing perforators using Doppler sonography and by involving two to three perforators per flap.6 The perforatorpreserving bilobed flap offers advantages in cases of recurrence and produces flaps that are more resistant to pressure-induced ischaemia. Preoperatively, surgical incisions were designed after considering defect size and pocket direction, which considerably simplified the operative procedure. Because of the richness of perforators in this region, perforators can be easily found. Portable Doppler is used to check perforator status and ensure the safety of the reconstruction. These perforators were almost always at the flap axis, and thus, perforator dissection was not required, which simplified surgery. Furthermore, the design of the bilobed flap is straightforward, and flaps can be easily applied.
Conclusion Pressure sores often become personal, family, health and social problems, particularly in paraplegics, whose numbers continue to increase. Furthermore, preventive and conservative anti-decubital and pressure-relief measures are often inadequate in terms of preventing the appearance or the progress of pressure sores, which is why surgery must sometimes be considered. Many different operative options can be used to treat pressure sores. However, we advocate the use of a perforator-based bilobed flap when wide skin resection is required. This flap design allows aesthetic reconstruction and tension-free skin closure, which reduces the risk of local recurrence, and also enables regional reconstruction using well-vascularised tissues. In addition, surgery is easily performed and safe, and most importantly, in the event of sore recurrence, it allows rerotation. We recommend that the perforator-based bilobed flap be viewed as a useful additional tool for the treatment of pressure sores.
795
Acknowledgements Disclosure: The authors have no conflict of interest to declare.
References 1. Disa JJ, Carlton JM, Goldberg NH. Efficacy of operative cure in pressure sore patients. Plast Reconstr Surg 1992;89:272e8. 2. Conway H, Griffith BH. Plastic surgery for closure of decubitus ulcers in patients with paraplegia; based on experience with 1000 cases. Am J Surg 1956;91:946e75. 3. Koshima I, Moriguchi T, Soeda S, et al. The gluteal perforatorbased flap for repair of sacral pressure sores. Plast Reconstr Surg 1993;91:678e83. 4. Wong CH, Tan BK, Song C. The perforator-sparing buttock rotation flap for coverage of pressure sores. Plast Reconstr Surg 2007;119:1259e66. 5. Zimany A. The bi-lobed flap. Plast Reconstr Surg 1953;11:424e34. 6. Hallock GG. Doppler sonography and color duplex imaging for planning a perforator flap. Clin Plast Surg 2003;30:347e57. vevi. 7. Higgins JP, Orlando GS, Blondeel PN. Ischial pressure sore reconstruction using an inferior gluteal artery perforator (IGAP) flap. Br J Plast Surg 2002;55:83e5. 8. Coskunfirat OK, Ozgentas HE. Gluteal perforator flaps for coverage of pressure sores at various locations. Plast Reconstr Surg 2004;113:2012e7. discussion: 2018e2019. 9. Meltem C, Esra C, Hasan F, et al. The gluteal perforator-based flap in repair of pressure sores. Br J Plast Surg 2004;57:342e7. 10. Kim YS, Lew DH, Roh TS, et al. Inferior gluteal artery perforator flap: a viable alternative for ischial pressure sores. J Plast Reconstr Aesthet Surg 2009;62(10):1347e54. 11. Zogovska E, Novevski L, Agai L, et al. Our experience in treatment of pressure ulcers by using local cutaneous flaps. Prilozi 2008;29:199e210. 12. El-Khatib HA, Al-Basti HB. A perforator-based bilobed fasciocutaneous flap: an additional tool for primary reconstruction following wide excision of sacrococcygeal pilonidal disease. J Plast Reconstr Aesthet Surg 2009;62:494e8. 13. 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. 14. Thiessen Filip E, Andrades Patricio, Blondeel Philip N, et al. Flap surgery for pressure sores: should the underlying muscle be transferred or not? J Plast Reconstr Aesthet Surg; 2010 (Epub).