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Reconstruction of trochanteric pressure sores with pedicled anterolateral thigh myocutaneous flaps
Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 671e676
Reconstruction of trochanteric pressure sores with pedicled anterolateral thigh myocutaneous flaps Chih-Hsin Wang, Shih-Yi Chen, Ju-Peng Fu, Niann-Tzyy Dai, Shao-Liang Chen, Tim-Mo Chen, Shyi-Gen Chen* Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China Received 26 May 2010; accepted 30 August 2010
KEYWORDS Anterolateral thigh flap; Trochanteric pressure sores; Tensor fasciae latae flap
Summary Background: To provide an alternative choice for covering trochanteric pressure sores, we report on a modified pedicle anterolateral thigh (ALT) myocutaneous flap based on the descending branch of the lateral circumflex femoral artery. Methods: From August 2007 to January 2010, 20 consecutive patients (10 men and 10 women) underwent 21 pedicled ALT myocutaneous flaps for reconstruction of trochanteric pressure sores. The flap was designed and elevated, resembling the ALT perforator flap including part of the vastus lateralis muscle but without skeletonisation of the perforators. Results: The mean age of patients was 79.4 years (range: 46e103). The mean follow-up period was 13.9 months (range: 3e32). The flaps were 8e21 cm long and 5e11 cm wide. All flaps healed without major complications. All donor sites were closed primarily without skin grafting and showed good aesthetic results. No recurrence was observed. Conclusions: This modified design of pedicled ALT myocutaneous flap without skeletonisation of perforators is a reliable and easily harvested flap for reconstruction of trochanteric pressure sores with limited morbidity. Crown Copyright ª 2010 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved.
Pressure sores are common conditions with an estimated prevalence of 3e10% among hospitalised patients, and up to 25e33% in nursing homes. The principles of treatment of
* Corresponding author. Division of Plastic Surgery, Department of Surgery , Tri-Service General Hospital, No. 325, Sec. 2, Cheng-Kung Road, Nei-Hu 114, Taipei, Taiwan, Republic of China. Tel.: þ886 2 87927195; fax: þ886 2 87927194. E-mail address: [email protected] (S.-G. Chen).
pressure ulcers include control of the underlying causes, reducing pressure, friction and shear forces, correcting nutritional deficits, managing bacterial contamination, optimising local wound care and surgical reconstruction. Trochanteric pressure sores develop in patients who lie in the lateral position, especially in those with significant flexion contracture. Kimata et al.1 first described the use of the anterolateral thigh (ALT) flap as a pedicled flap for perineal reconstruction. In our institute, Chen and Tzeng2 have applied the proximal pedicled ALT thigh flap in the
1748-6815/$ - see front matter Crown Copyright ª 2010 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved. doi:10.1016/j.bjps.2010.08.042
672
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Operative technique
reconstruction of trochanteric defects, including trauma and osteomyelitis. We found that it is a reliable and versatile flap but that the perforator dissection is tedious and time consuming. We now have modified and simplified the pedicled ALT perforator flap into a myocutaneous flap for covering trochanteric pressure sores. Myocutaneous flaps provide good blood supply and bulky padding, and are effective in treating infected wounds. It contains the cutaneous portion of ALT and part of the vastus lateralis muscle and does not require the skeletonisation of perforators. The advantage of this method is that it allows quick and easy harvesting of the ALT flap and maintains the tensor fasciae latae (TFL) as a reserve in case the pressure sore recurs.
The patient was placed in a supine position with a pad under the buttock ipsilateral to the pressure sore. The pressure sore was excised radically down to healthy tissue; the bony prominences of the greater trochanter were trimmed smoothly. A line was drawn between the anterosuperior iliac spine and the superolateral corner of the patella. The midpoint of this line was identified and was named point B.3 We marked two points approximately 5 cm above and below B and these were named points A (most proximal) and C (most distal). A 15-cm-long longitudinal incision, about 2 cm medial to the aforementioned line, was made down to the fascia over the rectus femoris muscle (Figure 1). The subfascial dissection proceeded laterally towards the intermuscular space between the rectus femoris and vastus lateralis muscles. Perforators distal to point B were then identified and adjacent tissue was preserved. The intermuscular septum of the rectus femoris and vastus lateralis muscles was dissected to explore the descending branch of the lateral circumflex femoris artery. The pedicle was dissected to the origin of the descending branch, proximally to distally, and then isolated around the anterior margins of the desired perforators. The desired size of the flap, based primarily on the extent of the trochanteric pressure sores, was then
Patients and methods Twenty-one pedicled ALT myocutaneous flaps were harvested for reconstructing trochanteric pressure sores in 20 consecutive patients (10 men and 10 women) between August 2007 and January 2010 in Tri-Service General Hospital, Taiwan. The mean age was 79.4 years (range: 46e103). The flaps ranged from 5 to 11 cm in width and 8 to 21 cm in length. The average follow-up period was 13.9 months (range 3e32 months). Detailed patient information is given in Table 1.
Table 1
Patient Data.
Case Age Underlying disease /Gender
Site
Ulcer size (cm)
Flap size Perforators Follow-up Complication (cm) (months)
1 2 3 4 5
87/M 78/F 78/F 88/M 82/F
Left Right Left Right Right
88 76 97 97 10 8
10 8 8 6.5 10 7 11 7 12 9
MC MC MC MC MC
32 29 28 27 2 weeks
6
67/M
Left
11 10
12 10
MC
2 weeks
7
82/M
Previous CVA with left hemiplegia Thoracic spine injury Alzheimer’s disease Senile dementia Hypertensive cardiovascular disease, coronary artery disease, Parkinsonism Rupture of the right vertebral artery aneurysm s/p VeP shunt with long-term immobilisation Previous CVA with right hemiplegia
Left
97
10 7
MC
17
8 9 10 11
46/M 52/F 83/F 89/F
Right Right Right Right
87 75 96 97
10 8 95 10 6 12 9
MC MC MC MC
14 14 12 11
12 13
97/M 81/M
Generalised encephalopathy Carcinoma of the lung Alzheimer’s disease Senile dementia and Alzheimer’s disease Senile dementia Previous CVA with left hemiplegia
14 15 16 17 18 19 20
87/F 73/M 64/F 76/F 88/M 103/F 87/M
Senile dementia Senile dementia Previous CVA with left hemiparesis Previous CVA with left hemiparesis Parkinson’s disease Senile dementia Previous CVA with left hemiparesis
Left Left Right Right Right Right Left Left Right Left
76 11 8 12 11 76 88 76 10 7 98 11 6; 7 5 10 7; 9 8
97 13 9 15 11 10 6 11 7 96 11 8 10 8 19 7 21 8
MC MC MC MC MC MC MC MC MC MC
11 10 10 10 9 9 8 7 4 3
CVA, cerebral vascular disease; MC, musculocutaneous; Bil, bilateral. a Died from aspiration pneumonia with septic shock. b Died from acute hemorrhagic gastritis with hemorrhagic shock.
None None None None Aspiration pneumoniaa Acute hemorrhagic gastritisb Haematoma (use of Plavix) None None None None None None None None None None None None None
Reconstruction of trochanteric pressure sores
Figure 1 Flap marking (Case 19) and schematic drawing of flap elevation. ASIS, anterosuperior iliac spine; P, superolateral corner of the patella; the midpoint between ASIS and P named point B; approximately 5 cm apart and named points A (most proximal) and C (most distal); DB, descending branch of the lateral circumflex femoral artery (LCF); TB, transverse branch; AB, ascending branch; FA, femoral artery; shaded zone, designed flap area.
marked, with the perforators kept distal to point B. The remainder of the flap was then incised. Cautery is recommended for flap harvest because it is time saving and causes less bleeding and also because there is no need for
673 intramuscular dissection of the perforators. To ensure primary closure of the donor site and fill out the ulcer space, the amount of vastus lateralis was harvested more than the width of the skin paddle (Figure 3C). In our series, the flap size measured 5e11 cm in width and 8e21 cm in length (always take at least 5 cm of muscle). The proximal cut of the muscle was about one to two proximal to perforators and the distal cut was bevelled to the distal portion of skin paddle. The flap was inset into the trochanteric defect through a subcutaneous tunnel in the lateral thigh or via a tunnel beneath the TFL. The pedicle was laid over the vastus lateralis muscle during transposition and a small portion of that muscle beneath the pedicle was excised, if needed, to avoid compression of the pedicle. Care was taken not to injure the ascending branch of the lateral circumflex femoris artery to preserve the TFL flap for subsequent reconstruction of any recurrence of the trochanteric pressure sores. After adequate haemostasis, the donor site was closed primarily with a drain placement.
Results There were one or two cutaneous perforators included in these 21 consecutive pedicled ALT myocutaneous flaps. All were located distal to point B and most were adjacent to point C. All of the perforators were musculocutaneous with small (<0.5 mm) vascular diameters. These perforators were identified and transferred with the vastus lateralis muscle without skeletonisation. The length of the pedicle ranged from 12 to 16 cm according to each patient’s height,
Figure 2 A. Preoperative appearance of the left trochanteric pressure sore. B. Preoperative appearance of the right trochanteric pressure sore. C. Appearance of the left hip and aesthetically inconspicuous scar of the donor site 16 months after surgery. D. Compared with the left trochanteric pressure sore, the right trochanteric pressure sore was reconstructed with a pedicled tensor fasciae lata flap. This showed an unsightly scar with a poor flap contour, and the patient could not extend the right knee.
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Figure 3 A. Preoperative appearance of the left trochanteric pressure sore. B. Design of the 13 9 cm pedicled ALT mycutaneous flap based on musculocutaneous perforators distal to point B (see Figure 1). C. Elevation of the ALT myocutaneous flap. D. Appearance of the left hip 7 months after surgery.
which was sufficient to reach the trochanteric region without difficulty. With increasing experience, the operative time for flap harvesting was shortened to within 30 min. Nineteen of the 21 flaps survived, resulting in excellent functional and aesthetic results. The other two flaps healed well postoperatively, but these two patients died of aspiration pneumonia with septic shock and acute haemorrhagic gastritis with hemorrhagic shock, respectively. All donor-site wounds were closed primarily and healed uneventfully within 2 weeks without any signs of infection, wound dehiscence, delayed healing or seroma formation. There was only one haematoma caused by the use of an anticoagulation agent (Plavix, Sanofi-Aventis). This was found 2 h postoperatively and haemostasis was performed immediately. The postoperative course was uneventful. There was no donor-site morbidity and the linear scar on the donor site was well accepted by all of the patients. No recurrence was observed during the follow-up.
Patient 3 A 78-year-old woman, long bedridden with Alzheimer’s disease, presented with bilateral trochanteric pressure sores. After serial debridement, the left-side trochanteric pressure sore was reconstructed with a 9 7 cm pedicled ALT myocutaneous flap and primary closure of the donor site. Compared with the left trochanteric pressure sore, the right trochanteric pressure sore was reconstructed with a pedicled TFL flap and the donor site received a skin graft. This showed an unsightly scar with a poor flap contour, and the patient could not extend the right knee. Both trochanteric regions
and the donor sites had healed well at the 16-month followup (Figure 2). The left thigh showed a better aesthetic appearance.
Patient 13 An 81-year-old man with advanced cerebrovascular disease and left hemiplegia developed bilateral trochanteric pressure sores after prolonged bed stay. After serial debridement, the left-side trochanteric pressure sore was reconstructed with a 13 9 cm pedicled ALT myocutaneous flap, with primary closure of the donor site (Figure 3). One week later, the rightside trochanteric pressure sore was reconstructed with a 15 11 cm pedicled ALT myocutaneous flap, with primary closure of the donor site.
Discussion Trochanteric pressure sores are a common complication in long-term bedridden patients suffering from several medical diseases. Successful treatment requires a multidisciplinary approach and good surgical planning. Since first introduced by Nahai et al.,4 the TFL flap has become a standard approach for the management of trochanteric defects. However, the disadvantages of flap tip necrosis and dog-ear deformity from its original design led surgeons to look for new designs for this flap. Some modifications were proposed, such as the advancement VeY flap,5 the retroposition VeY flap6 and the bilobed flap.7 Despite these successful alternatives, the problems of prolonged
Reconstruction of trochanteric pressure sores operative time and unaesthetic scars remained. Recurrent rates of up to 80% have been observed with the treatment of trochanteric pressure sores using myocutaneous flaps based on the TFL.8 The primary consideration in the surgical treatment of trochanteric pressure sores is the need to fill skin and softtissue losses, and coverage of the greater trochanter with a durable, well-perfused musculocutaneous flap. The pedicled ALT myocutaneous flap is excellent for this purpose. The ALT flap has been used successfully as a pedicled flap, primarily for reconstructing the groin and abdominal wall.9,10 Luo et al. successfully reconstructed a large perineal wound with a pedicled flap measuring 20 8 cm. The vastus lateralis, rectus femoris and TFL muscles can also be combined to form compositae chimeric flaps if the volume or other attributes of the muscle are desirable.1,11 However, there are only a few reports in the literature about the use of the ALT for reconstructing the trochanteric region.2,12,13 We modified reported operative techniques3,11,14 to simplify flap elevation and shorten the learning curve among trainee surgeons. We found that this surgical method achieves easy harvesting, obviates the need for intramuscular dissection and offers a longer pedicle to both increase the arc of rotation and easily achieve primary closure of the donor site. The surgical approach was used to cover 21 trochanteric pressure sores in 20 successive patients. It provided good aesthetic coverage and durability while preserving the ascending branch of the lateral circumflex femoral artery. This method preserves the conventional TFL flap if a recurrent pressure sore should develop. In addition to a good cosmetic effect, the myocutaneous flap provides better vascularity and padding than does the conventional TFL flap, and can be used to fill up potential dead space in the trochanteric region. Good nursing care and proper patient instruction are critical to postoperative success. The patients are positioned in such a manner to avoid pressure on the operative site, with turning every 2 h. There was no recurrence during the follow-up period. The flap has a longer vascular pedicle and can reach the trochanteric region without difficulty. It can provide a larger skin paddle, which provides for the tension-free reconstruction of a larger trochanteric pressure sore compared with the TFL flap, and donor sites can be closed primarily even if the width of the flap is more than 8 cm.14 Kuo et al. have shown that functional impairment of the thigh donor site is minimal in cases in which a muscular part of the vastus lateralis is taken, as in the myocutaneous flap transfer.15 Because of these advantages, we consider that the ALT myocutaneous flap is suitable for reconstructing trochanteric pressure sores as it provides good coverage and durability. Although the perforators can exhibit considerable anatomical variation, the dissection technique required for the ALT flap has become well established. Variations occur in vascular anatomy, which include its course (musculocutaneous or septocutaneous) and origin (the descending branch of the lateral circumflex femoral or the profunda femoris artery). In reported literature,11,14,16,17 most perforators were musculocutaneous, ranging from 74% to 90% of flaps.The long vascular pedicle and lack of restriction to the arc of rotation are keys to the successful
675 transposition of the flap for reconstructing the trochanteric region. It is desirable to use the most distal one for obtaining the longest pedicle, as suggested by Kimata et al.17 Yu3 reported that the use of more distal perforators provided longer pedicles, but the majority of perforators were musculocutaneous and small. To attain longer pedicles and easy, fast and safe harvesting of the flap, we introduced a modified strategy to simplify flap elevation and shorten the learning curve among trainee surgeons (Figure 1). The flap can be raised in less than half an hour with substantial experience, and detection of the perforators using Doppler mapping might not be necessary. Wei et al.11 found the perforator to be absent in only 0.89% of hundreds of cases in the extensive experience in Taiwan. All our patients had musculocutaneous perforators distal to point B with small diameters (<0.5 mm) and flaps were raised successfully in all patients. In conclusion, our method for coverage of trochanteric pressure sores offers the following advantages. It offers a longer pedicle with no restriction of the arc of rotation. It gives easy, quick and safe surgical procedure as the tedious intramuscular dissection of the perforators for the cutaneous skin paddle can be avoided. Most patients requiring coverage do not, however, need the muscle function lost from sacrifice of a portion of the vastus lateralis muscle. It increases the possibility of primary closure of donor site to gain an aesthetically inconspicuous curvilinear scar. This flap preserves the TFL flap for subsequent reconstruction of any recurrence of trochanteric sores. This pedicled ALT myocutaneous flap provides a large cutaneous island, with versatile applications and a reliable blood supply. It is a good alternative for covering trochanteric pressure sores.
References 1. Kimata Y, Uchiyarna K, Ebihara S, et al. Anatomic variations and technical problems of the anterolateral thigh flap: A report of 74 cases. Plast Reconstr Surg. 1998;102:1517e23. 2. Tzeng YS, Yu CC, Chou TD, et al. Proximal pedicled anterolateral thigh flap for reconstruction of trochanteric defect. Ann Plast Surg 2008;61:79e82. 3. Yu P. Characteristics of the anterolateral thigh flap in a Western population and its application in head and neck reconstruction. Head Neck. 2004;26:759e69. 4. Nahai F, Silverton JS, Hill HL, et al. The tensor fasciae latae musculocutaneous flap. Ann Plast Surg 1978;1:372e9. 5. Paletta CE, Freedman B, Shehadi SI. The V-Y tensor fasciae latae musculocutaneous flap. Plast Reconstr Surg. 1989;83: 852e7. 6. Siddiqui A, Wiedrich T, Lewis V. Tensor fasciae latae VeY retroposition myocutaneous flap: clinical experience. Ann Plast Surg. 1993;31:313. 7. Lynch SM. The bilobed tensor fasciae latae myocutaneous flap. Plast Reconstr Surg. 1981;67:796. 8. Evans GR, Dufresne CR, Manson PN. Surgical correction of pressure ulcers in an urban center: is it efficacious? Adv Wound Care. 1994;7:40. 9. Luo S, Raffoul W, Piaget F, et al. Anterolateral thigh fasciocutaneous flap in the difficult perineogenital reconstruction. Plast Reconstr Surg. 2000;105:171e3. 10. Celik N, Wei FC, Lin CH, et al. Technique and strategy in anterolateral thigh perforator flap surgery, based on an analysis of 15 complete and partial failures in 439 cases. Plast Reconstr Surg 2002;109:2211e6.
676 11. Wei FC, Jain V, Celik N, et al. Have we found an ideal soft tissue flap? an experience with 672 anterolateral thigh flaps. Plast Reconstr Surg. 2002;109:2219e30. 12. Gravvanis AI, Tsoutsos DA, Karakitsos D, et al. Application of the pedicled anterolateral thigh flap to defects from the pelvis to the knee. Microsurgery 2006;26:432e8. 13. Hallock GG. The proximal pedicled anterolateral thigh flap for lower limb coverage. Ann Plast Surg. 2005;55:466e9. 14. Shieh SJ, Chiu HY, Yu JC, et al. Free anterolateral thigh flap for reconstruction of head and neck defects following cancer ablation. Plast Reconstr Surg 2000;105:2349e60.
C.-H. Wang et al. 15. Kuo YR, Jeng SF, Kuo MH, et al. Free anterolateral thigh flap for extremity reconstruction: clinical experience and functional assessment of donor site. Plast Reconstr Surg 2001;107: 1766e71. 16. Wolff KD, Grundmann A. The free vastus lateralis flap: an anatomic study with case reports. Plast Reconstr Surg. 1992; 89:469e75. 17. Kimata Y, Uchiyama K, Ebihara S, et al. Versatility of the free anterolateral thigh flap for reconstruction of head and neck defects. Arch Otolaryngol Head Neck Surg 1997;123: 1325e31.
Reconstruction of trochanteric pressure sores with pedicled anterolateral thigh myocutaneous flaps Chih-Hsin Wang, Shih-Yi Chen, Ju-Peng Fu, Niann-Tzyy Dai, Shao-Liang Chen, Tim-Mo Chen, Shyi-Gen Chen* Division of Plastic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China Received 26 May 2010; accepted 30 August 2010
KEYWORDS Anterolateral thigh flap; Trochanteric pressure sores; Tensor fasciae latae flap
Summary Background: To provide an alternative choice for covering trochanteric pressure sores, we report on a modified pedicle anterolateral thigh (ALT) myocutaneous flap based on the descending branch of the lateral circumflex femoral artery. Methods: From August 2007 to January 2010, 20 consecutive patients (10 men and 10 women) underwent 21 pedicled ALT myocutaneous flaps for reconstruction of trochanteric pressure sores. The flap was designed and elevated, resembling the ALT perforator flap including part of the vastus lateralis muscle but without skeletonisation of the perforators. Results: The mean age of patients was 79.4 years (range: 46e103). The mean follow-up period was 13.9 months (range: 3e32). The flaps were 8e21 cm long and 5e11 cm wide. All flaps healed without major complications. All donor sites were closed primarily without skin grafting and showed good aesthetic results. No recurrence was observed. Conclusions: This modified design of pedicled ALT myocutaneous flap without skeletonisation of perforators is a reliable and easily harvested flap for reconstruction of trochanteric pressure sores with limited morbidity. Crown Copyright ª 2010 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved.
Pressure sores are common conditions with an estimated prevalence of 3e10% among hospitalised patients, and up to 25e33% in nursing homes. The principles of treatment of
* Corresponding author. Division of Plastic Surgery, Department of Surgery , Tri-Service General Hospital, No. 325, Sec. 2, Cheng-Kung Road, Nei-Hu 114, Taipei, Taiwan, Republic of China. Tel.: þ886 2 87927195; fax: þ886 2 87927194. E-mail address: [email protected] (S.-G. Chen).
pressure ulcers include control of the underlying causes, reducing pressure, friction and shear forces, correcting nutritional deficits, managing bacterial contamination, optimising local wound care and surgical reconstruction. Trochanteric pressure sores develop in patients who lie in the lateral position, especially in those with significant flexion contracture. Kimata et al.1 first described the use of the anterolateral thigh (ALT) flap as a pedicled flap for perineal reconstruction. In our institute, Chen and Tzeng2 have applied the proximal pedicled ALT thigh flap in the
1748-6815/$ - see front matter Crown Copyright ª 2010 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved. doi:10.1016/j.bjps.2010.08.042
672
C.-H. Wang et al.
Operative technique
reconstruction of trochanteric defects, including trauma and osteomyelitis. We found that it is a reliable and versatile flap but that the perforator dissection is tedious and time consuming. We now have modified and simplified the pedicled ALT perforator flap into a myocutaneous flap for covering trochanteric pressure sores. Myocutaneous flaps provide good blood supply and bulky padding, and are effective in treating infected wounds. It contains the cutaneous portion of ALT and part of the vastus lateralis muscle and does not require the skeletonisation of perforators. The advantage of this method is that it allows quick and easy harvesting of the ALT flap and maintains the tensor fasciae latae (TFL) as a reserve in case the pressure sore recurs.
The patient was placed in a supine position with a pad under the buttock ipsilateral to the pressure sore. The pressure sore was excised radically down to healthy tissue; the bony prominences of the greater trochanter were trimmed smoothly. A line was drawn between the anterosuperior iliac spine and the superolateral corner of the patella. The midpoint of this line was identified and was named point B.3 We marked two points approximately 5 cm above and below B and these were named points A (most proximal) and C (most distal). A 15-cm-long longitudinal incision, about 2 cm medial to the aforementioned line, was made down to the fascia over the rectus femoris muscle (Figure 1). The subfascial dissection proceeded laterally towards the intermuscular space between the rectus femoris and vastus lateralis muscles. Perforators distal to point B were then identified and adjacent tissue was preserved. The intermuscular septum of the rectus femoris and vastus lateralis muscles was dissected to explore the descending branch of the lateral circumflex femoris artery. The pedicle was dissected to the origin of the descending branch, proximally to distally, and then isolated around the anterior margins of the desired perforators. The desired size of the flap, based primarily on the extent of the trochanteric pressure sores, was then
Patients and methods Twenty-one pedicled ALT myocutaneous flaps were harvested for reconstructing trochanteric pressure sores in 20 consecutive patients (10 men and 10 women) between August 2007 and January 2010 in Tri-Service General Hospital, Taiwan. The mean age was 79.4 years (range: 46e103). The flaps ranged from 5 to 11 cm in width and 8 to 21 cm in length. The average follow-up period was 13.9 months (range 3e32 months). Detailed patient information is given in Table 1.
Table 1
Patient Data.
Case Age Underlying disease /Gender
Site
Ulcer size (cm)
Flap size Perforators Follow-up Complication (cm) (months)
1 2 3 4 5
87/M 78/F 78/F 88/M 82/F
Left Right Left Right Right
88 76 97 97 10 8
10 8 8 6.5 10 7 11 7 12 9
MC MC MC MC MC
32 29 28 27 2 weeks
6
67/M
Left
11 10
12 10
MC
2 weeks
7
82/M
Previous CVA with left hemiplegia Thoracic spine injury Alzheimer’s disease Senile dementia Hypertensive cardiovascular disease, coronary artery disease, Parkinsonism Rupture of the right vertebral artery aneurysm s/p VeP shunt with long-term immobilisation Previous CVA with right hemiplegia
Left
97
10 7
MC
17
8 9 10 11
46/M 52/F 83/F 89/F
Right Right Right Right
87 75 96 97
10 8 95 10 6 12 9
MC MC MC MC
14 14 12 11
12 13
97/M 81/M
Generalised encephalopathy Carcinoma of the lung Alzheimer’s disease Senile dementia and Alzheimer’s disease Senile dementia Previous CVA with left hemiplegia
14 15 16 17 18 19 20
87/F 73/M 64/F 76/F 88/M 103/F 87/M
Senile dementia Senile dementia Previous CVA with left hemiparesis Previous CVA with left hemiparesis Parkinson’s disease Senile dementia Previous CVA with left hemiparesis
Left Left Right Right Right Right Left Left Right Left
76 11 8 12 11 76 88 76 10 7 98 11 6; 7 5 10 7; 9 8
97 13 9 15 11 10 6 11 7 96 11 8 10 8 19 7 21 8
MC MC MC MC MC MC MC MC MC MC
11 10 10 10 9 9 8 7 4 3
CVA, cerebral vascular disease; MC, musculocutaneous; Bil, bilateral. a Died from aspiration pneumonia with septic shock. b Died from acute hemorrhagic gastritis with hemorrhagic shock.
None None None None Aspiration pneumoniaa Acute hemorrhagic gastritisb Haematoma (use of Plavix) None None None None None None None None None None None None None
Reconstruction of trochanteric pressure sores
Figure 1 Flap marking (Case 19) and schematic drawing of flap elevation. ASIS, anterosuperior iliac spine; P, superolateral corner of the patella; the midpoint between ASIS and P named point B; approximately 5 cm apart and named points A (most proximal) and C (most distal); DB, descending branch of the lateral circumflex femoral artery (LCF); TB, transverse branch; AB, ascending branch; FA, femoral artery; shaded zone, designed flap area.
marked, with the perforators kept distal to point B. The remainder of the flap was then incised. Cautery is recommended for flap harvest because it is time saving and causes less bleeding and also because there is no need for
673 intramuscular dissection of the perforators. To ensure primary closure of the donor site and fill out the ulcer space, the amount of vastus lateralis was harvested more than the width of the skin paddle (Figure 3C). In our series, the flap size measured 5e11 cm in width and 8e21 cm in length (always take at least 5 cm of muscle). The proximal cut of the muscle was about one to two proximal to perforators and the distal cut was bevelled to the distal portion of skin paddle. The flap was inset into the trochanteric defect through a subcutaneous tunnel in the lateral thigh or via a tunnel beneath the TFL. The pedicle was laid over the vastus lateralis muscle during transposition and a small portion of that muscle beneath the pedicle was excised, if needed, to avoid compression of the pedicle. Care was taken not to injure the ascending branch of the lateral circumflex femoris artery to preserve the TFL flap for subsequent reconstruction of any recurrence of the trochanteric pressure sores. After adequate haemostasis, the donor site was closed primarily with a drain placement.
Results There were one or two cutaneous perforators included in these 21 consecutive pedicled ALT myocutaneous flaps. All were located distal to point B and most were adjacent to point C. All of the perforators were musculocutaneous with small (<0.5 mm) vascular diameters. These perforators were identified and transferred with the vastus lateralis muscle without skeletonisation. The length of the pedicle ranged from 12 to 16 cm according to each patient’s height,
Figure 2 A. Preoperative appearance of the left trochanteric pressure sore. B. Preoperative appearance of the right trochanteric pressure sore. C. Appearance of the left hip and aesthetically inconspicuous scar of the donor site 16 months after surgery. D. Compared with the left trochanteric pressure sore, the right trochanteric pressure sore was reconstructed with a pedicled tensor fasciae lata flap. This showed an unsightly scar with a poor flap contour, and the patient could not extend the right knee.
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Figure 3 A. Preoperative appearance of the left trochanteric pressure sore. B. Design of the 13 9 cm pedicled ALT mycutaneous flap based on musculocutaneous perforators distal to point B (see Figure 1). C. Elevation of the ALT myocutaneous flap. D. Appearance of the left hip 7 months after surgery.
which was sufficient to reach the trochanteric region without difficulty. With increasing experience, the operative time for flap harvesting was shortened to within 30 min. Nineteen of the 21 flaps survived, resulting in excellent functional and aesthetic results. The other two flaps healed well postoperatively, but these two patients died of aspiration pneumonia with septic shock and acute haemorrhagic gastritis with hemorrhagic shock, respectively. All donor-site wounds were closed primarily and healed uneventfully within 2 weeks without any signs of infection, wound dehiscence, delayed healing or seroma formation. There was only one haematoma caused by the use of an anticoagulation agent (Plavix, Sanofi-Aventis). This was found 2 h postoperatively and haemostasis was performed immediately. The postoperative course was uneventful. There was no donor-site morbidity and the linear scar on the donor site was well accepted by all of the patients. No recurrence was observed during the follow-up.
Patient 3 A 78-year-old woman, long bedridden with Alzheimer’s disease, presented with bilateral trochanteric pressure sores. After serial debridement, the left-side trochanteric pressure sore was reconstructed with a 9 7 cm pedicled ALT myocutaneous flap and primary closure of the donor site. Compared with the left trochanteric pressure sore, the right trochanteric pressure sore was reconstructed with a pedicled TFL flap and the donor site received a skin graft. This showed an unsightly scar with a poor flap contour, and the patient could not extend the right knee. Both trochanteric regions
and the donor sites had healed well at the 16-month followup (Figure 2). The left thigh showed a better aesthetic appearance.
Patient 13 An 81-year-old man with advanced cerebrovascular disease and left hemiplegia developed bilateral trochanteric pressure sores after prolonged bed stay. After serial debridement, the left-side trochanteric pressure sore was reconstructed with a 13 9 cm pedicled ALT myocutaneous flap, with primary closure of the donor site (Figure 3). One week later, the rightside trochanteric pressure sore was reconstructed with a 15 11 cm pedicled ALT myocutaneous flap, with primary closure of the donor site.
Discussion Trochanteric pressure sores are a common complication in long-term bedridden patients suffering from several medical diseases. Successful treatment requires a multidisciplinary approach and good surgical planning. Since first introduced by Nahai et al.,4 the TFL flap has become a standard approach for the management of trochanteric defects. However, the disadvantages of flap tip necrosis and dog-ear deformity from its original design led surgeons to look for new designs for this flap. Some modifications were proposed, such as the advancement VeY flap,5 the retroposition VeY flap6 and the bilobed flap.7 Despite these successful alternatives, the problems of prolonged
Reconstruction of trochanteric pressure sores operative time and unaesthetic scars remained. Recurrent rates of up to 80% have been observed with the treatment of trochanteric pressure sores using myocutaneous flaps based on the TFL.8 The primary consideration in the surgical treatment of trochanteric pressure sores is the need to fill skin and softtissue losses, and coverage of the greater trochanter with a durable, well-perfused musculocutaneous flap. The pedicled ALT myocutaneous flap is excellent for this purpose. The ALT flap has been used successfully as a pedicled flap, primarily for reconstructing the groin and abdominal wall.9,10 Luo et al. successfully reconstructed a large perineal wound with a pedicled flap measuring 20 8 cm. The vastus lateralis, rectus femoris and TFL muscles can also be combined to form compositae chimeric flaps if the volume or other attributes of the muscle are desirable.1,11 However, there are only a few reports in the literature about the use of the ALT for reconstructing the trochanteric region.2,12,13 We modified reported operative techniques3,11,14 to simplify flap elevation and shorten the learning curve among trainee surgeons. We found that this surgical method achieves easy harvesting, obviates the need for intramuscular dissection and offers a longer pedicle to both increase the arc of rotation and easily achieve primary closure of the donor site. The surgical approach was used to cover 21 trochanteric pressure sores in 20 successive patients. It provided good aesthetic coverage and durability while preserving the ascending branch of the lateral circumflex femoral artery. This method preserves the conventional TFL flap if a recurrent pressure sore should develop. In addition to a good cosmetic effect, the myocutaneous flap provides better vascularity and padding than does the conventional TFL flap, and can be used to fill up potential dead space in the trochanteric region. Good nursing care and proper patient instruction are critical to postoperative success. The patients are positioned in such a manner to avoid pressure on the operative site, with turning every 2 h. There was no recurrence during the follow-up period. The flap has a longer vascular pedicle and can reach the trochanteric region without difficulty. It can provide a larger skin paddle, which provides for the tension-free reconstruction of a larger trochanteric pressure sore compared with the TFL flap, and donor sites can be closed primarily even if the width of the flap is more than 8 cm.14 Kuo et al. have shown that functional impairment of the thigh donor site is minimal in cases in which a muscular part of the vastus lateralis is taken, as in the myocutaneous flap transfer.15 Because of these advantages, we consider that the ALT myocutaneous flap is suitable for reconstructing trochanteric pressure sores as it provides good coverage and durability. Although the perforators can exhibit considerable anatomical variation, the dissection technique required for the ALT flap has become well established. Variations occur in vascular anatomy, which include its course (musculocutaneous or septocutaneous) and origin (the descending branch of the lateral circumflex femoral or the profunda femoris artery). In reported literature,11,14,16,17 most perforators were musculocutaneous, ranging from 74% to 90% of flaps.The long vascular pedicle and lack of restriction to the arc of rotation are keys to the successful
675 transposition of the flap for reconstructing the trochanteric region. It is desirable to use the most distal one for obtaining the longest pedicle, as suggested by Kimata et al.17 Yu3 reported that the use of more distal perforators provided longer pedicles, but the majority of perforators were musculocutaneous and small. To attain longer pedicles and easy, fast and safe harvesting of the flap, we introduced a modified strategy to simplify flap elevation and shorten the learning curve among trainee surgeons (Figure 1). The flap can be raised in less than half an hour with substantial experience, and detection of the perforators using Doppler mapping might not be necessary. Wei et al.11 found the perforator to be absent in only 0.89% of hundreds of cases in the extensive experience in Taiwan. All our patients had musculocutaneous perforators distal to point B with small diameters (<0.5 mm) and flaps were raised successfully in all patients. In conclusion, our method for coverage of trochanteric pressure sores offers the following advantages. It offers a longer pedicle with no restriction of the arc of rotation. It gives easy, quick and safe surgical procedure as the tedious intramuscular dissection of the perforators for the cutaneous skin paddle can be avoided. Most patients requiring coverage do not, however, need the muscle function lost from sacrifice of a portion of the vastus lateralis muscle. It increases the possibility of primary closure of donor site to gain an aesthetically inconspicuous curvilinear scar. This flap preserves the TFL flap for subsequent reconstruction of any recurrence of trochanteric sores. This pedicled ALT myocutaneous flap provides a large cutaneous island, with versatile applications and a reliable blood supply. It is a good alternative for covering trochanteric pressure sores.
References 1. Kimata Y, Uchiyarna K, Ebihara S, et al. Anatomic variations and technical problems of the anterolateral thigh flap: A report of 74 cases. Plast Reconstr Surg. 1998;102:1517e23. 2. Tzeng YS, Yu CC, Chou TD, et al. Proximal pedicled anterolateral thigh flap for reconstruction of trochanteric defect. Ann Plast Surg 2008;61:79e82. 3. Yu P. Characteristics of the anterolateral thigh flap in a Western population and its application in head and neck reconstruction. Head Neck. 2004;26:759e69. 4. Nahai F, Silverton JS, Hill HL, et al. The tensor fasciae latae musculocutaneous flap. Ann Plast Surg 1978;1:372e9. 5. Paletta CE, Freedman B, Shehadi SI. The V-Y tensor fasciae latae musculocutaneous flap. Plast Reconstr Surg. 1989;83: 852e7. 6. Siddiqui A, Wiedrich T, Lewis V. Tensor fasciae latae VeY retroposition myocutaneous flap: clinical experience. Ann Plast Surg. 1993;31:313. 7. Lynch SM. The bilobed tensor fasciae latae myocutaneous flap. Plast Reconstr Surg. 1981;67:796. 8. Evans GR, Dufresne CR, Manson PN. Surgical correction of pressure ulcers in an urban center: is it efficacious? Adv Wound Care. 1994;7:40. 9. Luo S, Raffoul W, Piaget F, et al. Anterolateral thigh fasciocutaneous flap in the difficult perineogenital reconstruction. Plast Reconstr Surg. 2000;105:171e3. 10. Celik N, Wei FC, Lin CH, et al. Technique and strategy in anterolateral thigh perforator flap surgery, based on an analysis of 15 complete and partial failures in 439 cases. Plast Reconstr Surg 2002;109:2211e6.
676 11. Wei FC, Jain V, Celik N, et al. Have we found an ideal soft tissue flap? an experience with 672 anterolateral thigh flaps. Plast Reconstr Surg. 2002;109:2219e30. 12. Gravvanis AI, Tsoutsos DA, Karakitsos D, et al. Application of the pedicled anterolateral thigh flap to defects from the pelvis to the knee. Microsurgery 2006;26:432e8. 13. Hallock GG. The proximal pedicled anterolateral thigh flap for lower limb coverage. Ann Plast Surg. 2005;55:466e9. 14. Shieh SJ, Chiu HY, Yu JC, et al. Free anterolateral thigh flap for reconstruction of head and neck defects following cancer ablation. Plast Reconstr Surg 2000;105:2349e60.
C.-H. Wang et al. 15. Kuo YR, Jeng SF, Kuo MH, et al. Free anterolateral thigh flap for extremity reconstruction: clinical experience and functional assessment of donor site. Plast Reconstr Surg 2001;107: 1766e71. 16. Wolff KD, Grundmann A. The free vastus lateralis flap: an anatomic study with case reports. Plast Reconstr Surg. 1992; 89:469e75. 17. Kimata Y, Uchiyama K, Ebihara S, et al. Versatility of the free anterolateral thigh flap for reconstruction of head and neck defects. Arch Otolaryngol Head Neck Surg 1997;123: 1325e31.