Bilateral Gluteal Fasciocutaneous Flap for Reconstruction of Large Sacral SCC Defect.
Bilateral Gluteal Fasciocutaneous Flap for Reconstruction of
Large Sacral SCC Defect
Elvida Christi*, I.B Suryawisesa**, I.B TjakraManuaba***
*Surgery Department, Faculty of Medicine Udayana University
**Oncology Surgery Department - Sanglah Hospital, Denpasar
Abstract
Introduction : Squamous Cell Carcinoma (SCC) is a malignant tumour that arises from the keratinizing
cells of the epidermis or its appendages. It is locally invasive and has the potential to metastase to other
organ of the body. The incidence of SCC is about 10,000 per year in England and Wales. We reported a
patient with a large SCC on the sacral region. The tumor was very large and the location was very risky to
tension while the patient sitting or binding. Therefore, it needs to be selective in choosing the flap to
close the defect. So, we decided to perform bilateral gluteal fasciocutaneuos flap.
Case report : Male patients 65 years of age, present with a lump on buttocks since 8 years ago. The lump
initially small, but gradually enlarged and when the patient comes, the tumor measuring 12 x 9 cm
accompanied by ulcers that smells and accompanied by pain in the area around the lump. Then we did a
wide excision and bilateral gluteal fasciocutaneous flap to close the defect.
Conclusion : The case reported a difficulty in reconstruction to the tumor location. Skin graft/flap was
not possible in this patient. Due to the anatomic site of the tumor, fasciocutaneous or myocutaneous
flap (e.g :advanceflap, propeller flap or rotational flap). Was preferred Bilateral gluteal fasciocutaneous
flap was performed in this patient. The patient showed adequate wound healing, well granulation and
patient has been mobile.
Keywords : Squamous Cell Carcinoma, Sacral defect, Bilateral gluteus fasciocutaneous flap.
Introduction
With a lifetime incidence of approximately
10% in the general population, cutaneous
squamous cell carcinoma (CSCC) is the second
most common type of nonmelanoma skin
cancer. Most CSCCs are benign and can be
completely eradicated by surgery procedure.
2. Major pedicles :
a. Superior gluteal arteries
b. Inferior gluteal arteries
c. From the internal iliac arteries
d. Pass superior and inferior to piriformis
Anatomy of gluteal flap
Nerve supply :
Gluteus Maximus :
1. Motor
1. Most superficial gluteal muscle
a. Inferior gluteal nerve
2. Origin
b. Enters with inferior gluteal artery
- Gluteal line of the posterior ileum and
sacrum
- Sacrotuberous ligament
3. Insertion
- Greater tuberosity of the femur
- Iliotibial band of fascia lata
2. Sensory
a. To skin S1-3 medially
b. L1-3 laterally
c. Posterior cutaneous nerve of the thigh (S12)
- Supplies the inferior buttocks and
posterior thigh
Vascular supply :
1. Type III vascular supply :
a.2 dominant pedicles
- Inferior gluteal arteries
- From the internal iliac artery
b. Both are deep to gluteus
c. Above and below inferior piriformis
d. 2 minor pedicles at area of insertion :
- First perforator or profundafemoris
- Two or three intermuscular branches of
the lateral femoral circumflex vessels
- This is can be included in the posterior
thigh flap (neurosensory flap)
Muscle function :
1. Essential in ambulatory patients
- Must preserve at least half
2. Extends hips
- Most powerful extensor of the hip
3. Rotates the thigh laterally
4. Important for running, jumping, climbing,
stabilizes the pelvis and hip
5. Largest muscle in the body
There is so many procedure used to
reconstruction the defect at sacral. Gluteal
perforator flaps and fasciocutaneous rotation
flaps are comparable for managing sacral
pressure sores. Both can be considered a firstline option. Gluteal FR flap reconstructions can
be performed without microsurgical dissection,
and re-rotation is feasible in the event of sore
recurrence. The authors suggest using gluteal
fasciocutaneous rotation flaps in patients with a
high risk of sore recurrence.
The gluteus muscle is an ideal flap for
reconstructing the dead space of large perineal
defects. Modification of this flap with a buttock
rotation flap based on the skin perforators
provides a versatile option for tension-free skin
closure of the perineal wound.
the reconstruction of sacral decubitus ulcers if
buttock sensation is intact, and may be best
designed to avoid extension beyond the gluteal
fold.
Case report
A male patients 65 years of age, present
with a lump on buttocks for 8 years. The lump
initially small, but gradually enlarged and when
the patient comes, the resultant sacral defect
measured 12 x 9 cm accompanied by ulcers that
smells and accompanied by pain in the area
around the lump. Incisional biopsy was
performed and the histological findings
confirmed the diagnosis of Well Differentiated
Squamous Cell Carcinoma. Then we did a wide
excision and reconstruction with bilateral
gluteal fasciocutaneous flap to close the defect.
The sensory lumbo-gluteal flap is useful for
A
C
C
B
D
E
E
F
Figure A. Patient. SCC of the sacrum in a 65-year-old male patient. B. Resultant sacral defectmeasuring 9 by 12 cm. C,D,E.
Bilateral Glutealfascio-cutaneous flap based on the inferior gluteal vessels. Arrow marks the perforator supplying the fasciocutaneous flap. F. Tension free closure of the sacral defect resulted in a well healed scar.
Discussion
Squamous-cell carcinoma or squamous cell cancer (SCC or SqCC) is a cancer of a kind of epithelial
cell, the squamous cell.1,2 These cells are the main part of the epidermis of the skin, and this cancer is
one of the major forms of skin cancer. However, squamous cells also occur in the lining of the digestive
tract, lungs, and other areas of the body, and SCC occurs as a form of cancer in diverse tissues, including
the lips, mouth, esophagus, urinary bladder, prostate, lung, vagina, and cervix, among others.1-3 Despite
sharing the name squamous cell carcinoma, the SCCs of different body sites can show tremendous
differences in their presenting symptoms, natural history, prognosis, and response to treatment.5
SCC is a histologically distinct form of cancer. It arises from the uncontrolled multiplication of cells of
epithelium, or cells showing particular cytological or tissue architectural characteristics of squamous cell
differentiation, such as the presence of keratin, tonofilament bundles, or
desmosomes, structures involved in cell-to-cell adhesion.1,2
SCC is still sometimes referred to as "epidermoid carcinoma" and "squamous cell epithelioma",
though the use of these terms has decreased. SCC typically initially occurs in the sixth decade of life (the
50s), but is most common in the eighth decade (the 70s).4,5 It is twice as prevalent in men as in women.
People with darker skin are less at risk to develop SCC. Populations with fair skin, light hair, and
blue/green/grey eyes are at highest risk of developing the disease. Frequent exposure to direct, strong
sunlight without adequate topical protection also increases risk.1
Pressure sores, especially in the sacral area, pose challenges for reconstructive surgeons. Patients
with pressure sores are usually paraplegic or bedridden, making the sores reluctant to heal, prone to
recurrence, and difficult to reconstruct.1-3 The gluteus maximusmyocutaneous flap has been considered
the workhorse flap for reconstructing sacral pressure sores.4-7
However, disadvantages of using this flap are limited flap mobility, sacrifice of muscle and
increased blood loss. Yuhei et al.8,9 reported that the transferred muscle portion of the flap showed
remarkable atrophic changes over the long term, and the recurrence rate was not significantly different
from that with the fasciocutaneous flap.
With the advent of the perforator flap technique described by Koshima et al.,10 gluteal perforator
(GP) flaps have recently gained popularity for reconstruction of sacral pressure sores. These flaps can
use perforators that emerge from either the superior or inferior gluteal vessels. By dissecting
perforators and completely islanding the flap, healthy tissue with a robust blood supply can be
transferred freely without sacrificing the underlying muscle.
Although a systematic review11 showed that there was no statistically significant difference with
regard to recurrence or complication rates among musculocutaneous, fasciocutaneous and perforator
flaps for pressure sore reconstruction, comparisons of GP flaps and fasciocutaneous rotation (FR) flaps
specifically focussing on sacral pressure sore reconstruction have rarely been discussed.6-8
10
Musculocutaneous flaps have been the mainstay for treating sacral pressure sores because of their
rich blood supply.4 However, the arc of rotation is limited and may cause much blood loss during flap
elevation. This technique also causes donor-site morbidity, especially in ambulatory
patients.Additionally, the transferred muscle undergoes significant atrophic degeneration with time,
usually 1 year postoperatively. In experimental studies, pressure-induced hypoxia can cause muscle
necrosis without skin necrosis in musculocutaneous flaps.12 Although Thiessenet al.13 reported no
differences in postoperative morbidity or recurrence between muscle and non-muscle flaps in univariate
and multivariate analyses, Yamato et al.6 concluded that fasciocutaneous flaps have better long-term
results than muscle or myocutaneous flaps when used for pressure sore reconstruction, and they
suggested using fasciocutaneous flaps as a first choice for treating sacral pressure sores.7
Over the past few years, perforator flaps have gaine popularity. By completely islanding the skin
paddle based on one or more perforators, the flap can be transferred with maximal freedom in a
tension-free manner.9,10 For the first time in 1988, Kroll et al.14 published the use of perforator flaps
for coverage of low midline defects, and Koshima et al.15 repaired sacral pressure sores using GP flaps
and confirmed the reliability of the blood supply by Sacral pressure sore.
Large flaps can be transferred based on one or several perforators due to their rich vasculature.
Furthermore, the versatility of the flap design allows it to adapt to the defect. The preservation of blood
supply and muscle results in minimal donor-site morbidity. Most important of all, long pedicles of GPs
enable tissue mobilization up to 12 cm in distance and achieve tension-free closure.16 Therefore, the
use of perforator flaps can reduce the wound dehiscence rate. Although we observed a lower wound
dehiscence rate in the GP group (6.45%) compared to the FR group (18.75%), the difference was not
statistically significant. This outcome could be explained by the small number of cases in this study.
Some drawbacks of using perforator flaps should be noted. First, due to varied perforator
distribution and the unpredictable nature of perforator venae comitantes, more tendinous
intramuscular dissection and surgical expertiseare needed. Second, when a flap is designed in the
propeller fashion based on a single perforator, although healthy and undamaged tissue can be
transferred from a distant site, kinking of the perforator is possible and results in total flap failure, which
rarely occurs with FR flaps.
In some study found good blood supply via the fascial plexus allows this flap to be raised easily
without major complications, such as total flap loss. The circumference of the flap should be
approximately 5-8 times the width of the defect to achieve tension-free distribution. According to many
experience, the greatest benefit of fasciocutaneous flaps is that they are reusable.9 By creating an
incision through the previous operative wound, the flap can be elevated and advanced in the event of
partial necrosis or ulcer recurrence. Recently, Wong et al.10 and Lin et al.9 incorporated the concept of
sparing the perforator in conventional FR flaps, which make them more reliable in vascularity and
reusable for further reconstruction. However, reuse is generally not allowed for islandtype perforator
flaps when flap necrosis or sore recurrence occurs, unless they are designed to be very large from the
beginning. Fenget al.21 described the concept of free-style puzzle flaps to recycle a perforator flap. This
innovative idea is valuable but has not yet been applied routinely to recurrent pressure sores. The
11
recommended reconstructive options in this situation are perforator flaps or FR flaps from the
contralateral buttock.
The use of either perforator flaps or FR flaps in sacral pressure sore reconstruction remains
controversial. A recent systematic review discussing complications and recurrence rates of
musculocutaneous, fasciocutaneous and perforatorbased flaps for treatment of pressure sores revealed
no significant differences among these flaps.11 In our study, variables such as operative time, defect size
and blood loss were comparable in these two groups. There were also no significant differences
between perforator and fasciocutaneous flaps with regard to re-operation, wound dehiscence, flap
necrosis, infection, seroma, donor-site morbidity and overall complication rates. These results were
similar to recent publications comparing perforator and fasciocutaneous flaps for pressure sore
reconstruction.11,17 However, in our study, the overall complication rates for the perforator flap group
(29%) and the fasciocutaneous flap group (37.5%) were higher than the complication rates (7e31%)
reported in the literature. 12-14 This elevated incidence could be explained by the advanced age of our
patients and multiple comorbidities, which made postoperative care difficult. There was no significant
difference in rates of recurrence between perforator and FR flaps in our study, which wascomparable to
other studies.12,15-17
Conclusion
The case reported a difficulty in reconstruction to the tumor location. Skin graft/flap was not
possible in this patient. Due to the anatomic site of the tumor, fasciocutaneous or myocutaneous flap
(e.g :advanceflap, propeller flap or rotational flap). Was preferred Bilateral gluteal fasciocutaneous flap
was performed in this patient. The patient showed adequate wound healing, well granulation and
patient has been mobile.
References
1. Ramirez CC, Federman DG, Kirsner RS. Skin cancer as an occupational disease: the effect of ultraviolet
and other forms of radiation. Int J Dermatol. 2005;44:95---100.
2. de Vries E, de Poll-Franse LV, Louwman WJ, de Gruijl FR, Coebergh JW. Predictions of skin cancer
incidence in the Netherlands up to 2015.Brit J Dermatol. 2005;152: 481---8.
3. Kwa RE, Campana K, Moy RL. Biology of cutaneous squamous cell carcinoma. J Am AcadDermatol.
1992;26: 1---26.
4. Johnson TM, Rowe DE, Nelson BR, Swanson NA. Squamous cell carcinoma of the skin (excluding lip
and oral mucosa). J Am AcadDermatol. 1992;26:467---84.
12
5. Riggs A. Pressure ulcers lead to increased mortality, liability. Prevention, treatment require planning,
team work. J Ark Med Soc 2003;100:160-1.
6. Dharmarajan TS, Ahmed S. The growing problem of pressure ulcers.Evaluation and management for
an aging population. Postgrad Med 2003;113:77-8. 81-84, 88-90.
7. Ger R. The surgical management of decubitus ulcers by muscle transposition. Surgery 1971;69:106-10.
8. Minami RT, Mills R, Pardoe R. Gluteus maximusmyocutaneous flaps for repair of pressure sores.
PlastReconstrSurg 1977;60: 242-9.
9. Yamamoto Y, Ohura T, Shintomi Y, et al. Superiority of the fasciocutaneous flap in reconstruction of
sacral pressure sores. Ann PlastSurg 1993;30:116-21.
10. Yamamoto Y, Tsutsumida A, Murazumi M, et al. Longterm outcome of pressure sores treated with
flap coverage. PlastReconstrSurg 1997;100:1212-7.
11. Yang CH, Kuo YR, Jeng SF, et al. An ideal method for pressure sore reconstruction: a freestyle
perforator-based flap. Ann PlastSurg 2011;66:179-84.
12. Nola GT, Vistnes LM. Differential response of skin and muscle in the experimental production of
pressure sores. PlastReconstrSurg 1980;66:728-33.
13. Koshima I, Moriguchi T, Soeda S, et al. The gluteal perforator based flap for repair of sacral pressure
sores. PlastReconstrSurg 1993;91:678-83.
14. Sameem M, Au M, Wood T, et al. A systematic review of complication and recurrence rates of
musculocutaneous, fasciocutaneous, and perforator-based flaps for treatment of pressure sores.
PlastReconstrSurg 2012;130:67-77.
15. Baek SM, Williams GD, McElhinney AJ, et al. The gluteus maximusmyocutaneous flap in the
management of pressure sores. Ann PlastSurg 1980;5:471-6.
16. Stevenson TR, Pollock RA, Rohrich RJ, et al. The gluteus maximusmusculocutaneous island flap:
refinements in design and application. PlastReconstrSurg 1987;79:761e8.
17. Wong TC, Ip FK. Comparison of gluteal fasciocutaneous rotational flaps and myocutaneous flaps for
the treatment of sacral sores. IntOrthop 2006;30:64e7.
13
Large Sacral SCC Defect
Elvida Christi*, I.B Suryawisesa**, I.B TjakraManuaba***
*Surgery Department, Faculty of Medicine Udayana University
**Oncology Surgery Department - Sanglah Hospital, Denpasar
Abstract
Introduction : Squamous Cell Carcinoma (SCC) is a malignant tumour that arises from the keratinizing
cells of the epidermis or its appendages. It is locally invasive and has the potential to metastase to other
organ of the body. The incidence of SCC is about 10,000 per year in England and Wales. We reported a
patient with a large SCC on the sacral region. The tumor was very large and the location was very risky to
tension while the patient sitting or binding. Therefore, it needs to be selective in choosing the flap to
close the defect. So, we decided to perform bilateral gluteal fasciocutaneuos flap.
Case report : Male patients 65 years of age, present with a lump on buttocks since 8 years ago. The lump
initially small, but gradually enlarged and when the patient comes, the tumor measuring 12 x 9 cm
accompanied by ulcers that smells and accompanied by pain in the area around the lump. Then we did a
wide excision and bilateral gluteal fasciocutaneous flap to close the defect.
Conclusion : The case reported a difficulty in reconstruction to the tumor location. Skin graft/flap was
not possible in this patient. Due to the anatomic site of the tumor, fasciocutaneous or myocutaneous
flap (e.g :advanceflap, propeller flap or rotational flap). Was preferred Bilateral gluteal fasciocutaneous
flap was performed in this patient. The patient showed adequate wound healing, well granulation and
patient has been mobile.
Keywords : Squamous Cell Carcinoma, Sacral defect, Bilateral gluteus fasciocutaneous flap.
Introduction
With a lifetime incidence of approximately
10% in the general population, cutaneous
squamous cell carcinoma (CSCC) is the second
most common type of nonmelanoma skin
cancer. Most CSCCs are benign and can be
completely eradicated by surgery procedure.
2. Major pedicles :
a. Superior gluteal arteries
b. Inferior gluteal arteries
c. From the internal iliac arteries
d. Pass superior and inferior to piriformis
Anatomy of gluteal flap
Nerve supply :
Gluteus Maximus :
1. Motor
1. Most superficial gluteal muscle
a. Inferior gluteal nerve
2. Origin
b. Enters with inferior gluteal artery
- Gluteal line of the posterior ileum and
sacrum
- Sacrotuberous ligament
3. Insertion
- Greater tuberosity of the femur
- Iliotibial band of fascia lata
2. Sensory
a. To skin S1-3 medially
b. L1-3 laterally
c. Posterior cutaneous nerve of the thigh (S12)
- Supplies the inferior buttocks and
posterior thigh
Vascular supply :
1. Type III vascular supply :
a.2 dominant pedicles
- Inferior gluteal arteries
- From the internal iliac artery
b. Both are deep to gluteus
c. Above and below inferior piriformis
d. 2 minor pedicles at area of insertion :
- First perforator or profundafemoris
- Two or three intermuscular branches of
the lateral femoral circumflex vessels
- This is can be included in the posterior
thigh flap (neurosensory flap)
Muscle function :
1. Essential in ambulatory patients
- Must preserve at least half
2. Extends hips
- Most powerful extensor of the hip
3. Rotates the thigh laterally
4. Important for running, jumping, climbing,
stabilizes the pelvis and hip
5. Largest muscle in the body
There is so many procedure used to
reconstruction the defect at sacral. Gluteal
perforator flaps and fasciocutaneous rotation
flaps are comparable for managing sacral
pressure sores. Both can be considered a firstline option. Gluteal FR flap reconstructions can
be performed without microsurgical dissection,
and re-rotation is feasible in the event of sore
recurrence. The authors suggest using gluteal
fasciocutaneous rotation flaps in patients with a
high risk of sore recurrence.
The gluteus muscle is an ideal flap for
reconstructing the dead space of large perineal
defects. Modification of this flap with a buttock
rotation flap based on the skin perforators
provides a versatile option for tension-free skin
closure of the perineal wound.
the reconstruction of sacral decubitus ulcers if
buttock sensation is intact, and may be best
designed to avoid extension beyond the gluteal
fold.
Case report
A male patients 65 years of age, present
with a lump on buttocks for 8 years. The lump
initially small, but gradually enlarged and when
the patient comes, the resultant sacral defect
measured 12 x 9 cm accompanied by ulcers that
smells and accompanied by pain in the area
around the lump. Incisional biopsy was
performed and the histological findings
confirmed the diagnosis of Well Differentiated
Squamous Cell Carcinoma. Then we did a wide
excision and reconstruction with bilateral
gluteal fasciocutaneous flap to close the defect.
The sensory lumbo-gluteal flap is useful for
A
C
C
B
D
E
E
F
Figure A. Patient. SCC of the sacrum in a 65-year-old male patient. B. Resultant sacral defectmeasuring 9 by 12 cm. C,D,E.
Bilateral Glutealfascio-cutaneous flap based on the inferior gluteal vessels. Arrow marks the perforator supplying the fasciocutaneous flap. F. Tension free closure of the sacral defect resulted in a well healed scar.
Discussion
Squamous-cell carcinoma or squamous cell cancer (SCC or SqCC) is a cancer of a kind of epithelial
cell, the squamous cell.1,2 These cells are the main part of the epidermis of the skin, and this cancer is
one of the major forms of skin cancer. However, squamous cells also occur in the lining of the digestive
tract, lungs, and other areas of the body, and SCC occurs as a form of cancer in diverse tissues, including
the lips, mouth, esophagus, urinary bladder, prostate, lung, vagina, and cervix, among others.1-3 Despite
sharing the name squamous cell carcinoma, the SCCs of different body sites can show tremendous
differences in their presenting symptoms, natural history, prognosis, and response to treatment.5
SCC is a histologically distinct form of cancer. It arises from the uncontrolled multiplication of cells of
epithelium, or cells showing particular cytological or tissue architectural characteristics of squamous cell
differentiation, such as the presence of keratin, tonofilament bundles, or
desmosomes, structures involved in cell-to-cell adhesion.1,2
SCC is still sometimes referred to as "epidermoid carcinoma" and "squamous cell epithelioma",
though the use of these terms has decreased. SCC typically initially occurs in the sixth decade of life (the
50s), but is most common in the eighth decade (the 70s).4,5 It is twice as prevalent in men as in women.
People with darker skin are less at risk to develop SCC. Populations with fair skin, light hair, and
blue/green/grey eyes are at highest risk of developing the disease. Frequent exposure to direct, strong
sunlight without adequate topical protection also increases risk.1
Pressure sores, especially in the sacral area, pose challenges for reconstructive surgeons. Patients
with pressure sores are usually paraplegic or bedridden, making the sores reluctant to heal, prone to
recurrence, and difficult to reconstruct.1-3 The gluteus maximusmyocutaneous flap has been considered
the workhorse flap for reconstructing sacral pressure sores.4-7
However, disadvantages of using this flap are limited flap mobility, sacrifice of muscle and
increased blood loss. Yuhei et al.8,9 reported that the transferred muscle portion of the flap showed
remarkable atrophic changes over the long term, and the recurrence rate was not significantly different
from that with the fasciocutaneous flap.
With the advent of the perforator flap technique described by Koshima et al.,10 gluteal perforator
(GP) flaps have recently gained popularity for reconstruction of sacral pressure sores. These flaps can
use perforators that emerge from either the superior or inferior gluteal vessels. By dissecting
perforators and completely islanding the flap, healthy tissue with a robust blood supply can be
transferred freely without sacrificing the underlying muscle.
Although a systematic review11 showed that there was no statistically significant difference with
regard to recurrence or complication rates among musculocutaneous, fasciocutaneous and perforator
flaps for pressure sore reconstruction, comparisons of GP flaps and fasciocutaneous rotation (FR) flaps
specifically focussing on sacral pressure sore reconstruction have rarely been discussed.6-8
10
Musculocutaneous flaps have been the mainstay for treating sacral pressure sores because of their
rich blood supply.4 However, the arc of rotation is limited and may cause much blood loss during flap
elevation. This technique also causes donor-site morbidity, especially in ambulatory
patients.Additionally, the transferred muscle undergoes significant atrophic degeneration with time,
usually 1 year postoperatively. In experimental studies, pressure-induced hypoxia can cause muscle
necrosis without skin necrosis in musculocutaneous flaps.12 Although Thiessenet al.13 reported no
differences in postoperative morbidity or recurrence between muscle and non-muscle flaps in univariate
and multivariate analyses, Yamato et al.6 concluded that fasciocutaneous flaps have better long-term
results than muscle or myocutaneous flaps when used for pressure sore reconstruction, and they
suggested using fasciocutaneous flaps as a first choice for treating sacral pressure sores.7
Over the past few years, perforator flaps have gaine popularity. By completely islanding the skin
paddle based on one or more perforators, the flap can be transferred with maximal freedom in a
tension-free manner.9,10 For the first time in 1988, Kroll et al.14 published the use of perforator flaps
for coverage of low midline defects, and Koshima et al.15 repaired sacral pressure sores using GP flaps
and confirmed the reliability of the blood supply by Sacral pressure sore.
Large flaps can be transferred based on one or several perforators due to their rich vasculature.
Furthermore, the versatility of the flap design allows it to adapt to the defect. The preservation of blood
supply and muscle results in minimal donor-site morbidity. Most important of all, long pedicles of GPs
enable tissue mobilization up to 12 cm in distance and achieve tension-free closure.16 Therefore, the
use of perforator flaps can reduce the wound dehiscence rate. Although we observed a lower wound
dehiscence rate in the GP group (6.45%) compared to the FR group (18.75%), the difference was not
statistically significant. This outcome could be explained by the small number of cases in this study.
Some drawbacks of using perforator flaps should be noted. First, due to varied perforator
distribution and the unpredictable nature of perforator venae comitantes, more tendinous
intramuscular dissection and surgical expertiseare needed. Second, when a flap is designed in the
propeller fashion based on a single perforator, although healthy and undamaged tissue can be
transferred from a distant site, kinking of the perforator is possible and results in total flap failure, which
rarely occurs with FR flaps.
In some study found good blood supply via the fascial plexus allows this flap to be raised easily
without major complications, such as total flap loss. The circumference of the flap should be
approximately 5-8 times the width of the defect to achieve tension-free distribution. According to many
experience, the greatest benefit of fasciocutaneous flaps is that they are reusable.9 By creating an
incision through the previous operative wound, the flap can be elevated and advanced in the event of
partial necrosis or ulcer recurrence. Recently, Wong et al.10 and Lin et al.9 incorporated the concept of
sparing the perforator in conventional FR flaps, which make them more reliable in vascularity and
reusable for further reconstruction. However, reuse is generally not allowed for islandtype perforator
flaps when flap necrosis or sore recurrence occurs, unless they are designed to be very large from the
beginning. Fenget al.21 described the concept of free-style puzzle flaps to recycle a perforator flap. This
innovative idea is valuable but has not yet been applied routinely to recurrent pressure sores. The
11
recommended reconstructive options in this situation are perforator flaps or FR flaps from the
contralateral buttock.
The use of either perforator flaps or FR flaps in sacral pressure sore reconstruction remains
controversial. A recent systematic review discussing complications and recurrence rates of
musculocutaneous, fasciocutaneous and perforatorbased flaps for treatment of pressure sores revealed
no significant differences among these flaps.11 In our study, variables such as operative time, defect size
and blood loss were comparable in these two groups. There were also no significant differences
between perforator and fasciocutaneous flaps with regard to re-operation, wound dehiscence, flap
necrosis, infection, seroma, donor-site morbidity and overall complication rates. These results were
similar to recent publications comparing perforator and fasciocutaneous flaps for pressure sore
reconstruction.11,17 However, in our study, the overall complication rates for the perforator flap group
(29%) and the fasciocutaneous flap group (37.5%) were higher than the complication rates (7e31%)
reported in the literature. 12-14 This elevated incidence could be explained by the advanced age of our
patients and multiple comorbidities, which made postoperative care difficult. There was no significant
difference in rates of recurrence between perforator and FR flaps in our study, which wascomparable to
other studies.12,15-17
Conclusion
The case reported a difficulty in reconstruction to the tumor location. Skin graft/flap was not
possible in this patient. Due to the anatomic site of the tumor, fasciocutaneous or myocutaneous flap
(e.g :advanceflap, propeller flap or rotational flap). Was preferred Bilateral gluteal fasciocutaneous flap
was performed in this patient. The patient showed adequate wound healing, well granulation and
patient has been mobile.
References
1. Ramirez CC, Federman DG, Kirsner RS. Skin cancer as an occupational disease: the effect of ultraviolet
and other forms of radiation. Int J Dermatol. 2005;44:95---100.
2. de Vries E, de Poll-Franse LV, Louwman WJ, de Gruijl FR, Coebergh JW. Predictions of skin cancer
incidence in the Netherlands up to 2015.Brit J Dermatol. 2005;152: 481---8.
3. Kwa RE, Campana K, Moy RL. Biology of cutaneous squamous cell carcinoma. J Am AcadDermatol.
1992;26: 1---26.
4. Johnson TM, Rowe DE, Nelson BR, Swanson NA. Squamous cell carcinoma of the skin (excluding lip
and oral mucosa). J Am AcadDermatol. 1992;26:467---84.
12
5. Riggs A. Pressure ulcers lead to increased mortality, liability. Prevention, treatment require planning,
team work. J Ark Med Soc 2003;100:160-1.
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