Dual Perforator Flap for Reconstruction of Large Sacral Defects: Superior Gluteal Artery Perforator Super-Flap with Parasacral Perforator

The superior gluteal artery perforator flap technique has increasingly been used for soft tissue defects in the sacral area following its introduction nearly 25 years ago. Advantages in covering sacral defects include muscle sparing, versatility in design, and low donor side morbidity. The bilateral superior gluteal artery perforator flap procedure is planned in cases of large sacral defects that cannot be covered with the unilateral superior gluteal artery perforator flap. Here, we report two cases of large sacral defects in which patient factors of poor general health, such as old age, pneumonia, and previous operation scar, led to use of a large unilateral superior gluteal artery perforator super-flap with parasacral perforator. The approach was utilized to reduce the operation time and prevent unpredictable flap failure due to the large flap size. Even though the parasacral perforator was included, the versatility of the large superior gluteal artery perforator flap was preserved because sufficient perforator length was acquired after adequate dissection.

Colgajo de perforantes de la arteria glútea superior para reconstrucción de defecto en región lumbosacra: reporte de un caso / Superior gluteal artery perforator (SGAP) flap for lumbosacral reconstruction

Los defectos de tejidos blandos a nivel de región lumbosacra son comunes en la cirugía reconstructiva. El colgajo de perforantes de la arteria glútea superior (SGAP) es una herramienta muy útil para el cubrimiento de este tipo de defectos y se asocia con un menor porcentaje de efectos funcionales secundarios al respetar el músculo glúteo mayor y su inervación. El objetivo de este artículo es realizar el reporte de un caso describiendo las indicaciones, la técnica quirúrgica y el resultado postoperatorio de esta intervención en un paciente con un defecto de cubrimiento a nivel lumbosacro secundario a una resección oncológica.

The soft tissue defects at the level of lumbosacral region are common in reconstructive surgery. Superior gluteal artery (SGAP) perforator flap is a very useful tool for covering such defects and is associated with a lower percentage of secondary functional effects as regards the gluteus maximus muscle and its innervation. The objective of this paper is report a case, describing the indications, surgical technique, and postoperative outcome of this intervention in a patient with a soft tissue defect in lumbosacral region secondary to an oncological resection.

Application of Perforator Flap for the Oral and Maxillofacial Reconstruction

The Gluteal Artery Perforator Sparing Gluteal Fasciocutaneous Rotation Advancement Flap with V-Y Closure

PURPOSE: The management of gluteal wound originated with burn is same as pressure sore. Pressure sores are managed surgically with two therapeutic components. One is a gross and sharp debridement and the other is a flap providing well-vascularized tissue to cover wounds. Central to the flap considerations is the tendency for recurrence mainly due to a poor blood supply, failure of tension-free closure and naive nursing care after operation, when reconstructive surgeons employ numerous surgical techniques in sores repair. The author used the gluteal artery perforator sparing and gluteal fasciocutaneous rotation advancement flap with V-Y closure to manage gluteal wound originated from burn. METHODS: Three cases of gluteal wound were treated with the gluteal artery perforator sparing gluteal fasciocutaneous rotation advancement flap with V-Y closure. The skin incision of conventional gluteal rotation flap is shortened to get a minimized flap size and adapts an advancement flap in a back cut pattern, supported laterally with V-Y closure for a tension-free closure. This superiorly (or inferiorly) based flap is elevated subfascially until one or two large musculocutaneous perforators of the inferior gluteal artery are encountered. The perforator down to its emergent point at the level of the piriformis muscle is dissected intramuscularly by splitting fibers of the gluteus maximus muscle in order to pivot freely. Then, the dead space is obliterated with a portion of the gluteus muscle transposed independently. The skin paddle is rotated to the defect area with the saved perforator(s) and closed the defect area. RESULTS: This technique encompasses the advantages of a perforator sparing flap, a fasciocutaneous rotation flap and an advancement flap with V-Y closure, providing a better vascularity, the flexibility of rerotation in the event of recurrence, preservation of the gluteus maximus muscle for ambulatory function, tension-free mobilization. Compared with other flaps which are previously used to manage pressure sores, one advantage is noted that the minimized operation wound is effective not only to improve the quality of patient's life in terms of position care but also to mitigate the associated wound- healing problems. CONCLUSION: This technique can be chosen primarily for management of various types of gluteal region wound including burn.

Various Designs of Gluteal Artery Perforator Flap for Buttock Reconstruction

PURPOSE: The gluteal artery perforator flaps earned its popularity in buttock reconstruction due to the lower morbidity of the donor site and the flexibility in the design. Speedy and safe reconstruction is important for the success of buttock reconstruction. If a proper design is selected, satisfactory results can be obtained with more simple method of surgery. METHODS: Between April 2005 and April 2006, buttock reconstruction by using gluteal artery perforator flaps were performed on sacral sores(6 cases), ischial sores(2 cases) and malignant melanoma on buttock(1 case). Various designs depending on the location and the size of the defect was made. In those designs, perforator was used as an axis for the minimal dissection of the vessel. Donor site from which sufficient amount of soft tissue can be transferred was selected, and also not causing high tension against the recipient site during the donor site closure. In addition, postoperative aesthetics, and the possibility of another design of a second operation which can be necessary in the future, was considered. RESULTS: Patient follow up was for a mean period of 10.8 months. All flaps survived except for one that had undergone partial necrosis. Wound dehiscence was observed in one patient treated by secondary closure. Most patients presented with cosmetically and functionally satisfying results CONCLUSION: By designing the flap using the perforator as an axis, depending on the defect size and degree, reconstruction can be performed with only a small tension to the donor and the recipient site. And the minimal perforator dissection allowed easier and faster reconstruction. Selection of a proper design is the key procedure which greatly affects operation time and result success.

Ischial Pressure Sore Reconstruction Using Inferior Gluteal Artery Perforator Flap

PURPOSE: The ischial area is by far the most common site of pressure sores found in wheel chair bound paraplegic patients, because greatest pressure is exerted from the body on this area in a sitting position. Even after a series of successful pressure sore treatments, the site is very prone to relapse by the simplest ordinary tasks of everyday life. Therefore, it is crucial to preserve the main pedicle during primary surgery. Various surgical procedures employed to treat pressure sores such as myocutaneous flap and perforator flap have been introduced. After introduction of ischial sore treatment using the inferior gluteal artery perforator (IGAP) has been made, the authors experienced favorable clinical results of patients who have undergone IGAP flap procedure in a three year time period. METHODS: A total of 17 patients received IGAP flap surgery in our hospital from January 2003 to May 2006, among which 14 of them being males and 3 females. Surgery was performed on the same site again in 6(35%) patients who had originally relapsed after receiving the conventional method of pressure sore surgery. Patients' average age was 49.4(27-71) years old. Most of the patients were paraplegic(11 cases, 65%) and others were either quadriplegic(4 cases, 23%) or ambulatory(2 cases, 12%). Based on hospital records and clinical photographs, we have attempted to assess the feasibility and practicability of the IGAP flap procedure through comparative analysis of several parameters: size of defective area, treatment modalities, occurrence of relapses, complications, and postoperative treatments. RESULTS: The average follow-up duration of 17 subjects was 25.4 months(5-42 months). All flaps survived without any necrosis. Six cases were relapsed cases from conventional surgical procedures. All of them healed well during our follow-up study. Postoperative complications such as wound dehiscence and fistula developed in some subjects, but all were well healed through secondary treatment. A total of 2 cases relapsed after surgery. CONCLUSION: The inferior gluteal artery perforator flap is an effective method that can be primarily applied in replacement to the conventional ischial pressure sore reconstructive surgery owing to its many advantages: ability to preserve peripheral muscle tissue, numerous possible flap designs, relatively good durability, and the low donor site morbidity rate.