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The role of medial gastrocnemius free flap in coverage of ischial pressure sore in paraplegic patients
International Journal of Surgery (2008) 6, e72ee76
w w w. t h e i j s . c o m
The role of medial gastrocnemius free flap in coverage of ischial pressure sore in paraplegic patients ´lez b, ´rez de la Fuente a,*, Isabel Gonza Teresa Pe ˜oz c ´n-Mun Francisco Caldero a
Department of Plastic and Reconstructive Surgery, Gregorio Maran˜o´n Hospital, Dr Esquerdo 46, Madrid 28007, Spain Department of Plastic and Reconstructive Surgery, Cruz Roja Hospital, Madrid, Spain c Department of Anesthesiology, National Paraplegic Hospital, Toledo, Spain b
Available online 18 March 2007
KEYWORDS Paraplegic; Free flap; Ischial pressure sore; Coverage
Abstract Pressure sores, and especially ischial pressure sores, are a serious concern in the life of paraplegic patients. The treatment of this pathology is obviously surgery, and several local flaps can be used for coverage. However, recurrent pressure sores in an active patient can be frustrating if all local flaps have been used. Free flaps are therefore the next option. In our experience, the free medial gastrocnemius musculocutaneous flap is the best option. This paper reports the closure of ischial pressure sores with a free medial gastrocnemius flap, the patient selection criteria used, and the postoperative care provided. ª 2007 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
In paraplegics, the appearance of ischial pressure sores due to the pressure points on the ischial tuberosities on the wheelchair is almost a rule and prevention is therefore the most important concern. There are several local flap options for sore reconstruction, but when all reasonable alternatives have been used and the patient continues to suffer ulceration, free flaps are the best option. In the first surgical operation, after bursectomy and a suitable bony prominence osteotomy, coverage is secured with musculocutaneous or fasciocutaneous flaps. The most
* Corresponding author. Tel.: þ34 6169 30532; fax: þ34 9130 47045. E-mail address: [email protected] (T.P. de la Fuente).
commonly used flap is the inferior gluteus maximus (as a turnover or sliding flap). Other locoregional muscle flaps are V-Y advancement of the hamstring muscles, gracilis and tensor fasciae latae. And as fasciocutaneous flaps we use the gluteal fasciocutaneous thigh flap and inferior gluteal artery perforator flap.1e3 When these flaps have already been used, the next alternatives are free flaps and the vertical rectus abdominis musculocutaneous (VRAM) flap.4,5 Several free flaps have been described for coverage of pressure sores, such as the latissimus dorsi, leg fillet flaps, sole foot flaps and medial gastrocnemius flap.6e11 In our opinion, the most appropriate free flap is the medial gastrocnemius musculocutaneous free flap, for several reasons: the type of skin is very similar to that of the
1743-9191/$ - see front matter ª 2007 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijsu.2007.03.005
Role of medial gastrocnemius free flap in paraplegic
e73
gluteal region, the amount of skin is sufficient, the donor zone exhibits low morbidity, we do not have to change the patient position, and two teams can work at the same time.
Patients and method Surgical procedure With the patient in the prone position under general anesthesia, and after sore debridement and ischial prominence osteotomy, we locate the inferior gluteal vessels. We next design a skin paddle over the medial gastrocnemius with the sore dimensions. Under tourniquet, we dissect the flap beginning with a medial curvilinear incision including the medial gastrocnemius, from distal to proximal, attempting to find the popliteal vessels. At the popliteal fossa, we identify the sural artery and vein beneath the upper margin of the medial gastrocnemius. After identifying the pedicle, we circumscribe the skin paddle around the entire lateral margin and remove the gastrocnemius from the soleus. A few stitches must be placed to fix the skin to the muscle. Finally, we divide the proximal gastrocnemius insertion. End-to-end anastomosis to the inferior gluteal vessels is carried out, and the flap is fitted to the defect. Suction drains are then placed in the gastrocnemius and gluteal area.
Prevention of wound infection Two days before surgery, sore exudate culture is carried out, thus allowing for antibiotic coverage at the time of the operation. During surgery, we take bottom sore and bone biopsies for culturing. Based on the definitive results, we either change or maintain the antibiotic treatment during 7 days, or for 4e6 weeks in the event of bone infection.
Postoperative care During the postoperative period, the patient is in the prone position in an air-flushed bed for 6 weeks. During the first week, the patient is admitted to intensive care for monitoring. We consider it very useful to maintain patient analgesia with epidural block for 7 days, to avoid arterial spasm, which may produce autonomic hyperreflexia. In relation to postural changes, during the first three weeks the patient should remain in the prone position, and after the fourth week we change to the lateral and supine position. After 6 weeks, sitting of the patient can begin.
Figure 1 Patient 1, we can see the ischial pressure sore with multiple scars in gluteal region and posterior thigh.
free flap. The quality and amount of skin available were good (Figs. 2, 3). Lower leg arteriography showed the inferior and superior gluteal vessels to present suitable length and caliber. In relation to harvesting of the medial gastrocnemius, we found two major arterial pedicles arising from the popliteal artery. During the first 12 hours after surgery, the flap turned blue. We therefore reviewed it, and detected venous
Case 1 A 40-year-old man, with T12 level paraplegia, ASIA A, had been operated upon 6 times in the last 10 years due to a left recurrent ischial pressure sore. All local flaps had been used, leaving the buttock and posterior thigh full of scars (Fig. 1). We therefore decided to perform pressure sore closure by means of a free flap, and chose the medial gastrocnemius
Figure 2 Design of skin paddle over the medial gastrocnemius flap.
e74
T.P. de la Fuente et al.
Figure 3 Harvesting the medial gastrocnemius flap. In paraplegic patients we always found very important muscle atrophy.
Figure 5 Patient 2, recurrent ischial pressure sore surrounded by atrophic, scarred skin consequence of multiple local flaps.
thrombosis that was resolved successfully. On the fourth postoperative day we had to check the flap due to arterial ischemia. Important arterial spasm was observed, which was resolved with papaverine and lidocaine. From this moment onwards, flap evaluation was difficult due to the skin color changes, and the skin finally suffered necrosis, though the muscle survived; we therefore applied a skin graft over the muscle. The final result was good, with stable coverage. At present, 20 months after surgery, the patient is very satisfied, leading a very active life without recurrence (Fig. 4). As medical support we used prostaglandins during 7 days, while analgesia was limited to intravenous pyrazolones during 3 days. On the fourth day the patient suffered headache, nasal congestion and facial blush that we diagnosed as corresponding to autonomic hyperreflexia. In our case this could account for the arterial spasm crisis and variable flap appearance.
We attributed this phenomenon to the lack of guided analgesia. In this context, we used only minor analgesics during 3 days.
Figure 4 Postoperative appearance showing the skin graft 20 months following.
Case 2 A 32-year-old man, with T12 level paraplegia, ASIA A, had been operated upon 10 times in last 5 years due to a recurrent right ischial pressure sore (Fig. 5). The gluteal region and posterior thigh appeared full of scars from the previous operations, in which all local flaps had been used. Of particular note was the lack of tissue due to the previous operations, and the very thin body condition of the patient. Arteriography showed the inferior gluteal vessels to be of good length and caliber, so we chose a medial gastrocnemius free flap for coverage (Fig. 6). The operative procedure was the same as that described in the previous case. At this time, as medical support, we likewise used prostaglandins during 7 days. However, in contrast to the previous patient, we used an epidural catheter for a week with local anesthetic to secure
Figure 6
Grafted donor area of medial gastrocnemius flap.
Role of medial gastrocnemius free flap in paraplegic
Figure 7 Postoperative appearance of free flap showing replacement of ischial region skin. Scars are out of pressure points.
total analgesic control and prevent the development of autonomic hyperreflexia. There were no postoperative incidents (Fig. 7). The patient remained in bed during 6 weeks before being moved to a wheelchair. Twelve months after surgery, the patient is satisfied, with no recurrence and with a very active life.
Discussion The indication for free flap coverage in a paraplegic patient must be rigorous. The required profile corresponds to a young paraplegic individual with low dorsal injury, where all local flap possibilities have been exhausted and good perspectives exist for prevention. The literature describes several free flaps options: latissimus dorsi,6 plantar fillet flap,12,13 and medial gastrocnemius flap.8,9 Regarding the latissimus dorsi flap, we tend to avoid using it, because this muscle is basic for maintaining trunk support in patients with cervical or dorsal spinal cord injury. Free flaps from the foot have been employed for pressure sore closure. They offer good skin quality, but are associated with donor-site disfigurement. The medial gastrocnemius flap is the most suitable option, because we can obtain a good amount of skin of good quality for pressure sore closure. This flap gastrocnemius flap was first described for local coverage in leg defects. However, only rarely has this donor site been used as a free flap,14,15 even though the artery (diameter 2e3 mm) and vein (2.5e5 mm) are of good caliber. The muscle is usually described as normally nourished by a single artery. However, in cadaver dissections, Potparic found 25% of medial gastrocnemius muscles to have two major arterial pedicles,16 as we found in one of our patients. In agreement with Hallock,10 we advocate preoperative arteriography for all free gastrocnemius flaps. As for the selection of recipient vessels in the ischial region, the inferior gluteal artery lies in closer proximity
e75 and has an advantage over the superior gluteal vessel. The gluteal vessels present deep location and a short pedicle length. However, intramuscular dissection of the perforating vessel provides a large caliber and an easier approach to the recipient vessel. Functional preservation of the gluteus maximus muscle can be achieved in outpatients by minimizing injury to the muscle fiber.17 During the operation, manipulation of the vessels should be minimized, since disturbance of the sympathetic system tends to give rise to intense arterial spasm. In our opinion, it is very important to block the pain routes, because they can trigger autonomic hyperreflexia. This phenomenon is characterized by the appearance of sympathetic hyperactivity below the level of spinal cord injury, particularly in patients with lesions at T8 level or lower. The syndrome can appear at any time after spinal cord shock, and can be triggered by any visceral or cutaneous stimulus below the injury. The patient presents severe arterial hypertension, bradycardia, excessive perspiration, facial blush (over the injury), nasal congestion, muscle spasm and headache. This is attributable to excessive sympathetic escape secondary to the loss of inhibitory descending fibers from the brain. The treatment consists of inducing anesthetic block by means of epidural or intradural anesthesia or deep general anesthesia and therefore, we consider that the patient management protocol should include epidural block for at least 7 days.18,19 This phenomenon was observed in our first patient, though damage was at T12 levelewhich can explain the arterial spasm and evolution to skin paddle loss. In the second patient we used epidural block, with no incidents.
Conflicts of interest: None declared.
References 1. Mathes SJ, Nahai F. Clinical applications for muscle and myocutaneous flaps. St. Louis: CV Mosby; 1982. 2. Angriniani C, Grillo D, Siebert j, Thorne C. A new musculocutaneous island flap from the distal thigh for recurrent ischial and perineal pressure sores. Plast Reconstr Surg 1995;96(4): 935e41. 3. 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. 4. Pena MM, Drew GS, Smith SJ, Given KS. The inferiorly based rectus abdominis myocutaneous flap for reconstruction of recurrent pressure sores. Plast Reconstr Surg 1992;92:90e5. 5. Lee MJ. Dumanian: The oblique rectus abdominis musculocutaneous flap: revisited clinical applications. Plast Reconstr Surg 2004;11(2):367e73. 6. Salibian AH, Tesoro VR, Word DI. Case report: staged transfer of a free microvascular latissimus dorsi myocutaneous flap using saphenous vein grafts. Plast Reconstr Surg 1983;71:543. 7. Ku ¨ntscher MV, Erdmann D, Levin LS, Germann G. Plantare neurovascula ¨re filetlappenplaastik. Der Chirurg 2003;74:734e8. 8. Yamamoto Y, Nohira K, Shintomi Y, Igawa H, Ohura T. Reconstruction of recurrent pressure sores using free flaps. J Reconstr Microsurg 1992;8:433.
e76 9. Park Sanghoon. Muscle splinting approach to superior and inferior gluteal vessels: versatile source of recipient vessels for free tissue transfer to sacral, gluteal and ischial regions. Plast Reconstr Surg 2000;106(1):81e6. 10. Hallock GG. Closure o fan ischial pressure sore using a free gastrocnemius musculocutaneous flap with a long venous pedicle. Br J Plast Surg 1995;48:504e6. 11. Jones JW. Reinervated medial gastrocnemius free flan for closure of a recurrent ischial pressure sore: case report. J Reconstr Microsurg 2002;18(5):397e400. 12. Goldberg JA, Barwick WJ, Levin LS. Restoration of sensation in paraplegia by a sensory innervated plantar fillet free flap. Case report. Paraplegia 1995;33:397e400. 13. Ku ¨ntscher MV, Erdmann MD, Homann HH, Steinau HU, Levin SL, Germann G. The concept of fillet flaps: classification, indications and analysis of their clinical value. Plast Reconstr Surg 2001;15:885e95.
T.P. de la Fuente et al. 14. Xing-Yan L, Bao-Feng G, Yi-Min W, Hao J. Free medial gastrocnemius myocutaneous flap transfer with neurovascular anastomosis o treat Volkmann’s contracture of the forearm. Br J Plast Surg 1992;45:6e8. 15. Keller A, Allen R, Shaw W. The medial gastrocnemius muscle flap: a local free flap. Plast Reconstr Surg 1984;73: 302e7. 16. Potparic Z, Colen LB, Sucur D. The gastrocnemius muscle as a free-flap donor site. Plast Reconstr Surg 1995;95:1245e52. 17. Sanghoon P, Koh KS. Superior gluteal vessels as recipient for free flap reconstruction of lumbosacral defect. Plast Reconstr Surg 1998;101:1842e8. 18. Trop C, Bennett CJ. Autonomic dysreflexia and its urological implications: a review. J Urol 1991;146:1461. 19. Hunsaker R, Kimbell W. Clinical anaesthesia procedures of the Massachusetts general hospital. In: Hurford WE, editor. Lippincott, Williams & Wilkins. 5th ed.; 2000. p. 469e70.
w w w. t h e i j s . c o m
The role of medial gastrocnemius free flap in coverage of ischial pressure sore in paraplegic patients ´lez b, ´rez de la Fuente a,*, Isabel Gonza Teresa Pe ˜oz c ´n-Mun Francisco Caldero a
Department of Plastic and Reconstructive Surgery, Gregorio Maran˜o´n Hospital, Dr Esquerdo 46, Madrid 28007, Spain Department of Plastic and Reconstructive Surgery, Cruz Roja Hospital, Madrid, Spain c Department of Anesthesiology, National Paraplegic Hospital, Toledo, Spain b
Available online 18 March 2007
KEYWORDS Paraplegic; Free flap; Ischial pressure sore; Coverage
Abstract Pressure sores, and especially ischial pressure sores, are a serious concern in the life of paraplegic patients. The treatment of this pathology is obviously surgery, and several local flaps can be used for coverage. However, recurrent pressure sores in an active patient can be frustrating if all local flaps have been used. Free flaps are therefore the next option. In our experience, the free medial gastrocnemius musculocutaneous flap is the best option. This paper reports the closure of ischial pressure sores with a free medial gastrocnemius flap, the patient selection criteria used, and the postoperative care provided. ª 2007 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
In paraplegics, the appearance of ischial pressure sores due to the pressure points on the ischial tuberosities on the wheelchair is almost a rule and prevention is therefore the most important concern. There are several local flap options for sore reconstruction, but when all reasonable alternatives have been used and the patient continues to suffer ulceration, free flaps are the best option. In the first surgical operation, after bursectomy and a suitable bony prominence osteotomy, coverage is secured with musculocutaneous or fasciocutaneous flaps. The most
* Corresponding author. Tel.: þ34 6169 30532; fax: þ34 9130 47045. E-mail address: [email protected] (T.P. de la Fuente).
commonly used flap is the inferior gluteus maximus (as a turnover or sliding flap). Other locoregional muscle flaps are V-Y advancement of the hamstring muscles, gracilis and tensor fasciae latae. And as fasciocutaneous flaps we use the gluteal fasciocutaneous thigh flap and inferior gluteal artery perforator flap.1e3 When these flaps have already been used, the next alternatives are free flaps and the vertical rectus abdominis musculocutaneous (VRAM) flap.4,5 Several free flaps have been described for coverage of pressure sores, such as the latissimus dorsi, leg fillet flaps, sole foot flaps and medial gastrocnemius flap.6e11 In our opinion, the most appropriate free flap is the medial gastrocnemius musculocutaneous free flap, for several reasons: the type of skin is very similar to that of the
1743-9191/$ - see front matter ª 2007 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijsu.2007.03.005
Role of medial gastrocnemius free flap in paraplegic
e73
gluteal region, the amount of skin is sufficient, the donor zone exhibits low morbidity, we do not have to change the patient position, and two teams can work at the same time.
Patients and method Surgical procedure With the patient in the prone position under general anesthesia, and after sore debridement and ischial prominence osteotomy, we locate the inferior gluteal vessels. We next design a skin paddle over the medial gastrocnemius with the sore dimensions. Under tourniquet, we dissect the flap beginning with a medial curvilinear incision including the medial gastrocnemius, from distal to proximal, attempting to find the popliteal vessels. At the popliteal fossa, we identify the sural artery and vein beneath the upper margin of the medial gastrocnemius. After identifying the pedicle, we circumscribe the skin paddle around the entire lateral margin and remove the gastrocnemius from the soleus. A few stitches must be placed to fix the skin to the muscle. Finally, we divide the proximal gastrocnemius insertion. End-to-end anastomosis to the inferior gluteal vessels is carried out, and the flap is fitted to the defect. Suction drains are then placed in the gastrocnemius and gluteal area.
Prevention of wound infection Two days before surgery, sore exudate culture is carried out, thus allowing for antibiotic coverage at the time of the operation. During surgery, we take bottom sore and bone biopsies for culturing. Based on the definitive results, we either change or maintain the antibiotic treatment during 7 days, or for 4e6 weeks in the event of bone infection.
Postoperative care During the postoperative period, the patient is in the prone position in an air-flushed bed for 6 weeks. During the first week, the patient is admitted to intensive care for monitoring. We consider it very useful to maintain patient analgesia with epidural block for 7 days, to avoid arterial spasm, which may produce autonomic hyperreflexia. In relation to postural changes, during the first three weeks the patient should remain in the prone position, and after the fourth week we change to the lateral and supine position. After 6 weeks, sitting of the patient can begin.
Figure 1 Patient 1, we can see the ischial pressure sore with multiple scars in gluteal region and posterior thigh.
free flap. The quality and amount of skin available were good (Figs. 2, 3). Lower leg arteriography showed the inferior and superior gluteal vessels to present suitable length and caliber. In relation to harvesting of the medial gastrocnemius, we found two major arterial pedicles arising from the popliteal artery. During the first 12 hours after surgery, the flap turned blue. We therefore reviewed it, and detected venous
Case 1 A 40-year-old man, with T12 level paraplegia, ASIA A, had been operated upon 6 times in the last 10 years due to a left recurrent ischial pressure sore. All local flaps had been used, leaving the buttock and posterior thigh full of scars (Fig. 1). We therefore decided to perform pressure sore closure by means of a free flap, and chose the medial gastrocnemius
Figure 2 Design of skin paddle over the medial gastrocnemius flap.
e74
T.P. de la Fuente et al.
Figure 3 Harvesting the medial gastrocnemius flap. In paraplegic patients we always found very important muscle atrophy.
Figure 5 Patient 2, recurrent ischial pressure sore surrounded by atrophic, scarred skin consequence of multiple local flaps.
thrombosis that was resolved successfully. On the fourth postoperative day we had to check the flap due to arterial ischemia. Important arterial spasm was observed, which was resolved with papaverine and lidocaine. From this moment onwards, flap evaluation was difficult due to the skin color changes, and the skin finally suffered necrosis, though the muscle survived; we therefore applied a skin graft over the muscle. The final result was good, with stable coverage. At present, 20 months after surgery, the patient is very satisfied, leading a very active life without recurrence (Fig. 4). As medical support we used prostaglandins during 7 days, while analgesia was limited to intravenous pyrazolones during 3 days. On the fourth day the patient suffered headache, nasal congestion and facial blush that we diagnosed as corresponding to autonomic hyperreflexia. In our case this could account for the arterial spasm crisis and variable flap appearance.
We attributed this phenomenon to the lack of guided analgesia. In this context, we used only minor analgesics during 3 days.
Figure 4 Postoperative appearance showing the skin graft 20 months following.
Case 2 A 32-year-old man, with T12 level paraplegia, ASIA A, had been operated upon 10 times in last 5 years due to a recurrent right ischial pressure sore (Fig. 5). The gluteal region and posterior thigh appeared full of scars from the previous operations, in which all local flaps had been used. Of particular note was the lack of tissue due to the previous operations, and the very thin body condition of the patient. Arteriography showed the inferior gluteal vessels to be of good length and caliber, so we chose a medial gastrocnemius free flap for coverage (Fig. 6). The operative procedure was the same as that described in the previous case. At this time, as medical support, we likewise used prostaglandins during 7 days. However, in contrast to the previous patient, we used an epidural catheter for a week with local anesthetic to secure
Figure 6
Grafted donor area of medial gastrocnemius flap.
Role of medial gastrocnemius free flap in paraplegic
Figure 7 Postoperative appearance of free flap showing replacement of ischial region skin. Scars are out of pressure points.
total analgesic control and prevent the development of autonomic hyperreflexia. There were no postoperative incidents (Fig. 7). The patient remained in bed during 6 weeks before being moved to a wheelchair. Twelve months after surgery, the patient is satisfied, with no recurrence and with a very active life.
Discussion The indication for free flap coverage in a paraplegic patient must be rigorous. The required profile corresponds to a young paraplegic individual with low dorsal injury, where all local flap possibilities have been exhausted and good perspectives exist for prevention. The literature describes several free flaps options: latissimus dorsi,6 plantar fillet flap,12,13 and medial gastrocnemius flap.8,9 Regarding the latissimus dorsi flap, we tend to avoid using it, because this muscle is basic for maintaining trunk support in patients with cervical or dorsal spinal cord injury. Free flaps from the foot have been employed for pressure sore closure. They offer good skin quality, but are associated with donor-site disfigurement. The medial gastrocnemius flap is the most suitable option, because we can obtain a good amount of skin of good quality for pressure sore closure. This flap gastrocnemius flap was first described for local coverage in leg defects. However, only rarely has this donor site been used as a free flap,14,15 even though the artery (diameter 2e3 mm) and vein (2.5e5 mm) are of good caliber. The muscle is usually described as normally nourished by a single artery. However, in cadaver dissections, Potparic found 25% of medial gastrocnemius muscles to have two major arterial pedicles,16 as we found in one of our patients. In agreement with Hallock,10 we advocate preoperative arteriography for all free gastrocnemius flaps. As for the selection of recipient vessels in the ischial region, the inferior gluteal artery lies in closer proximity
e75 and has an advantage over the superior gluteal vessel. The gluteal vessels present deep location and a short pedicle length. However, intramuscular dissection of the perforating vessel provides a large caliber and an easier approach to the recipient vessel. Functional preservation of the gluteus maximus muscle can be achieved in outpatients by minimizing injury to the muscle fiber.17 During the operation, manipulation of the vessels should be minimized, since disturbance of the sympathetic system tends to give rise to intense arterial spasm. In our opinion, it is very important to block the pain routes, because they can trigger autonomic hyperreflexia. This phenomenon is characterized by the appearance of sympathetic hyperactivity below the level of spinal cord injury, particularly in patients with lesions at T8 level or lower. The syndrome can appear at any time after spinal cord shock, and can be triggered by any visceral or cutaneous stimulus below the injury. The patient presents severe arterial hypertension, bradycardia, excessive perspiration, facial blush (over the injury), nasal congestion, muscle spasm and headache. This is attributable to excessive sympathetic escape secondary to the loss of inhibitory descending fibers from the brain. The treatment consists of inducing anesthetic block by means of epidural or intradural anesthesia or deep general anesthesia and therefore, we consider that the patient management protocol should include epidural block for at least 7 days.18,19 This phenomenon was observed in our first patient, though damage was at T12 levelewhich can explain the arterial spasm and evolution to skin paddle loss. In the second patient we used epidural block, with no incidents.
Conflicts of interest: None declared.
References 1. Mathes SJ, Nahai F. Clinical applications for muscle and myocutaneous flaps. St. Louis: CV Mosby; 1982. 2. Angriniani C, Grillo D, Siebert j, Thorne C. A new musculocutaneous island flap from the distal thigh for recurrent ischial and perineal pressure sores. Plast Reconstr Surg 1995;96(4): 935e41. 3. 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. 4. Pena MM, Drew GS, Smith SJ, Given KS. The inferiorly based rectus abdominis myocutaneous flap for reconstruction of recurrent pressure sores. Plast Reconstr Surg 1992;92:90e5. 5. Lee MJ. Dumanian: The oblique rectus abdominis musculocutaneous flap: revisited clinical applications. Plast Reconstr Surg 2004;11(2):367e73. 6. Salibian AH, Tesoro VR, Word DI. Case report: staged transfer of a free microvascular latissimus dorsi myocutaneous flap using saphenous vein grafts. Plast Reconstr Surg 1983;71:543. 7. Ku ¨ntscher MV, Erdmann D, Levin LS, Germann G. Plantare neurovascula ¨re filetlappenplaastik. Der Chirurg 2003;74:734e8. 8. Yamamoto Y, Nohira K, Shintomi Y, Igawa H, Ohura T. Reconstruction of recurrent pressure sores using free flaps. J Reconstr Microsurg 1992;8:433.
e76 9. Park Sanghoon. Muscle splinting approach to superior and inferior gluteal vessels: versatile source of recipient vessels for free tissue transfer to sacral, gluteal and ischial regions. Plast Reconstr Surg 2000;106(1):81e6. 10. Hallock GG. Closure o fan ischial pressure sore using a free gastrocnemius musculocutaneous flap with a long venous pedicle. Br J Plast Surg 1995;48:504e6. 11. Jones JW. Reinervated medial gastrocnemius free flan for closure of a recurrent ischial pressure sore: case report. J Reconstr Microsurg 2002;18(5):397e400. 12. Goldberg JA, Barwick WJ, Levin LS. Restoration of sensation in paraplegia by a sensory innervated plantar fillet free flap. Case report. Paraplegia 1995;33:397e400. 13. Ku ¨ntscher MV, Erdmann MD, Homann HH, Steinau HU, Levin SL, Germann G. The concept of fillet flaps: classification, indications and analysis of their clinical value. Plast Reconstr Surg 2001;15:885e95.
T.P. de la Fuente et al. 14. Xing-Yan L, Bao-Feng G, Yi-Min W, Hao J. Free medial gastrocnemius myocutaneous flap transfer with neurovascular anastomosis o treat Volkmann’s contracture of the forearm. Br J Plast Surg 1992;45:6e8. 15. Keller A, Allen R, Shaw W. The medial gastrocnemius muscle flap: a local free flap. Plast Reconstr Surg 1984;73: 302e7. 16. Potparic Z, Colen LB, Sucur D. The gastrocnemius muscle as a free-flap donor site. Plast Reconstr Surg 1995;95:1245e52. 17. Sanghoon P, Koh KS. Superior gluteal vessels as recipient for free flap reconstruction of lumbosacral defect. Plast Reconstr Surg 1998;101:1842e8. 18. Trop C, Bennett CJ. Autonomic dysreflexia and its urological implications: a review. J Urol 1991;146:1461. 19. Hunsaker R, Kimbell W. Clinical anaesthesia procedures of the Massachusetts general hospital. In: Hurford WE, editor. Lippincott, Williams & Wilkins. 5th ed.; 2000. p. 469e70.