Bilateral Gluteal Fasiociocutaneous 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,
5
prognosis, and response to treatment.
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
4-7
reconstructing sacral pressure sores.
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
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 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 reoperation, 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.
10. Yamamoto Y, Tsutsumida A, Murazumi M, et
al. Longterm outcome of pressure sores
treated
with
flap
coverage.
PlastReconstrSurg 1997;100:1212-7.
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.
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.
3. Kwa RE, Campana K, Moy RL. Biology of
cutaneous squamous cell carcinoma. J Am
AcadDermatol. 1992;26: 1---26.
12. Nola GT, Vistnes LM. Differential response
of skin and muscle in the experimental
production
of
pressure
sores.
PlastReconstrSurg 1980;66:728-33.
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.
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.
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.
8. Minami RT, Mills R, Pardoe R. Gluteus
maximusmyocutaneous flaps for repair of
pressure sores. PlastReconstrSurg 1977;60:
242-9.
16. Stevenson TR, Pollock RA, Rohrich RJ, et al.
The gluteus maximusmusculocutaneous
island flap: refinements in design and
application.
PlastReconstrSurg
1987;79:761e8.
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.
17. Wong TC, Ip FK. Comparison of gluteal
fasciocutaneous rotational flaps and
myocutaneous flaps for the treatment of
sacral sores. IntOrthop 2006;30:64e7.
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,
5
prognosis, and response to treatment.
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
4-7
reconstructing sacral pressure sores.
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
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 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 reoperation, 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.
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