The operative treatment of pressure wounds: a 10‐year experience in flap selection

This study sought to both assist in the selection of flaps for ischial pressure wound reconstruction and evaluate the overall complication rates associated with reconstruction. A retrospective medical record review was conducted for 78 patients following the surgical reconstruction of an ischial pressure sore. Records were reviewed for demographics, location of sores, methods of reconstruction and flap selection, as well as any complications and recurrences. A total of 72 wounds were reconstructed with an average of 1·4 flaps used per wound. An ischial flap complication rate of 16% was observed in flap follow‐up, with a recurrence rate of 7% recorded. The vast majority of complications went on to heal with 15% of patients requiring a second reconstruction. Our relatively large sample of ischial flaps allowed for a close comparison with previously published work. Both flap selection and site of reconstruction significantly affected the success rates for pressure sore coverage. The overall complication rates by flap and reconstructive site in this review are lower than previously published reports. Our experience with ischial reconstruction was extensive enough to suggest a posterior medial thigh fasciocutaneous flap combined with a biceps femoris muscle flap as a first choice in ischial pressure wound reconstruction.     

The operative treatment of pressure wounds: a 10‐year experience in flap selection

This study sought to both assist in the selection of flaps for ischial pressure wound re‐construction and to evaluate the overall complication rates associated with re‐construction. A retrospective medical record review was conducted for 78 patients following the surgical re‐construction of an ischial pressure sore. Records were reviewed for demographics, location of sores, methods of re‐construction and flap selection, as well as any complications and recurrences. Seventy‐two wounds were re‐constructed with an average of 1·4 flaps used per wound. An ischial flap complication rate of 16% was observed in flap follow up, with a recurrence rate of 7% recorded. The vast majority of complications went on to heal with 15% of patients requiring a second re‐construction. Our relatively large sample of ischial flaps allowed for a close comparison with previously published work. Both flap selection and site of reconstruction significantly affected the success rates for pressure sore coverage. The overall complication rates by flap and re‐constructive site in this review are lower than previously published reports. Our experience with ischial re‐construction was extensive enough to suggest a posterior medial thigh fasciocutaneous flap combined with a biceps femoris muscle flap as a first choice in ischial pressure wound re‐construction.     

Covering of ischial pressure sores using a fasciocutaneous flap from the posterior surface of thigh (modified Griffith method) after mattressing with the biceps femoris. Apropos of 11 cases]

The ischial region is the commonest site for pressure sores in paraplegics capable of sitting. The choice of treatment must be guided by two imperatives: the need for a thick tissue cover (mattressing) and perfect trophicity, the risk of recurrence which always remains possible. The association of a modified Griffith fasciocutaneous flap from the posterior surface of the thigh and a hamstring muscle flap (preferably biceps femoris) providing mattressing of the ischial region, appears to satisfy these imperatives. The other repair procedures are discussed in order to ensure the best management of the paraplegic patient's cutaneous capital, due to the continual risk of a new pressure sore or a recurrence of the ischial pressure sore.     

Coverage of an ischial pressure ulcer with an interpolated contralateral posterior thigh fasciocutaneous flap.

The ipsilateral posterior thigh flap has become one of the workhorses for the closure of ischial pressure ulcers. We treated a 40-year-old paraplegic patient with a right ischial pressure ulcer, in whom all ipsilateral flap options had been expended or were precluded by scars. A contralateral left posterior thigh fasciocutaneous flap interpolated subcutaneously across the midline provided successful coverage.     

The posterior thigh flap for defect coverage of ischial pressure sores – a critical single‐centre analysis

The development of pressure sores is still not only an enormous economical but also a medical burden. Especially in the ischial region, the local defect coverage remains demanding as it is the main weight‐bearing area in wheelchair‐mobilised patients and is prone to high mobility. The purpose of our study was to report our long‐time experience with the reconstruction of ischial pressure ulcers with the medially based posterior thigh flap. A retrospective analysis of all primary pressure sores grade III–IV in the ischial area, which were covered with a medially based posterior thigh flap between January 2008 and December 2014, at our department was conducted. A total of 28 patients underwent defect coverage of an ischial pressure sore with the aforementioned flap. The subgroup with complications showed a statistically significant longer hospital stay. A statistically significant correlation between age and the coincidence of comorbidities could be seen. Older patients showed significantly higher grades of pressure sores. The medially based posterior thigh flap is a safe and reliable flap design. Complication rates are comparable to other flaps. Nevertheless, in case of complications, a significantly longer duration of hospitalisation has to be taken into account.     

A reusable perforator-preserving gluteal artery-based rotation fasciocutaneous flap for pressure sore reconstruction

Background: Perforator‐based fasciocutaneous flaps for reconstructing pressure sores can achieve good functional results with acceptable donor site complications in the short‐term. Recurrence is a difficult issue and a major concern in plastic surgery. In this study, we introduce a reusable perforator‐preserving gluteal artery‐based rotation flap for reconstruction of pressure sores, which can be also elevated from the same incision to accommodate pressure sore recurrence. Methods: The study included 23 men and 13 women with a mean age of 59.3 (range 24–89) years. There were 24 sacral ulcers, 11 ischial ulcers, and one trochanteric ulcer. The defects ranged in size from 4 × 3 to 12 × 10 cm². Thirty‐six consecutive pressure sore patients underwent gluteal artery‐based rotation flap reconstruction. An inferior gluteal artery‐based rotation fasciocutaneous flap was raised, and the superior gluteal artery perforator was preserved in sacral sores; alternatively, a superior gluteal artery‐based rotation fasciocutaneous flap was elevated, and the inferior gluteal artery perforator was identified and dissected in ischial ulcers. Results: The mean follow‐up was 20.8 (range 0–30) months in this study. Complications included four cases of tip necrosis, three wound dehiscences, two recurrences reusing the same flap for pressure sore reconstruction, one seroma, and one patient who died on the fourth postoperative day. The complication rate was 20.8% for sacral ulcers, 54.5% for ischial wounds, and none for trochanteric ulcer. After secondary repair and reconstruction of the compromised wounds, all of the wounds healed uneventfully. Conclusions: The perforator‐preserving gluteal artery‐based rotation fasciocutaneous flap is a reliable, reusable flap that provides rich vascularity facilitating wound healing and accommodating the difficulties of pressure sore reconstruction. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

A new technique of transferring island pedicled anterolateral thigh and vastus lateralis myocutaneous flaps for reconstruction of recurrent ischial pressure sores.

We describe island pedicled anterolateral thigh and vastus lateralis myocutaneous flaps for reconstruction of the difficult, recurrent ischial pressure sore. Rather than transfer through a subcutaneous tunnel, the flap is transferred directly through the upper thigh to the ischial defect. A total of 15 patients with 16 recurrent ischial pressure sores were treated between May 2003 and April 2005. Eleven sores were treated with pedicled island anterolateral thigh flaps and five sores with vastus lateralis myocutaneous flaps. There was no difficulty in transferring the flap to reach the ischial defect in any patient. The length of the pedicle ranged from 8.5 to 14 cm. All donor sites were closed primarily. Fifteen of the 16 flaps survived completely. Total necrosis occurred in one vastus lateralis myocutaneous flap, which was located at the distal third of the thigh. We conclude this flap can be added to the repertoire for the treatment of recurrent, difficult ischial pressure sores.     

Reconstruction of recurrent pressure sores using free flaps.

The authors describe two successful reconstructions of recurrent pressure sores with free fasciocutaneous flaps. In Case 1, a free lateral thigh flap pedicled on the first and third direct cutaneous branches of the deep femoral vessels was used to cover a large recurrent sacral pressure sore. The vascular pedicle was dissected to the deep femoral trunk proximally and anastomosed to the inferior gluteal vessels. In Case 2, a free medial plantar flap was transferred to a recurrent ischial pressure sore. The vascular pedicle was dissected to the posterior tibial vessels proximally. The long vascular pedicle of the flap was passed through the femoral subcutaneous tunnel, and end-to-side microvascular anastomoses were performed to the superficial femoral trunk without any vein grafts. The authors advocate the use of free tissue transfer for recurrent pressure sore reconstruction.     

Simultaneous coverage of ipsilateral ischial and trochanteric pressure sores--a case report

Multiple pressure sores represent recurrent problem in immobilized, mostly paretic patients. A lot of them undergo repeated surgeries and thus the positions of scars, directions of rotation or transposition of flaps limit other operations in the region. Then usually the length of hospital stay grows proportionally with the number of necessary operations and often exceeds 6 weeks. The authors present, in form of a case study, the simultaneous coverage of ipsilateral ischial and trochanteric pressure sores with V-Y advancement fasciocutaneous dorsal thigh flap supplied by perforators from the deep femoral artery, in a patient with multiple repeated decubiti.     

Sensate anterolateral thigh perforator flap for ischiatic sores reconstruction in meningomyelocele patients

Recidivating pressure sores are a frequent complication in meningomyelocele patients because of their limitation in motility and their scarce ability to monitor the pressure applied on insensate areas while seated. We report the utilization of the sensate pedicled anterolateral thigh perforator flap for reconstruction of ischiatic sores in meningomyelocele patients. Between May 2011 and September 2013, five patients underwent transfer of a sensate pedicled anterolateral thigh flap, by an intermuscular passageway through the upper thigh, to reach the ischial defect. Flap was properly harvested from the thigh after assessment of the lateral cutaneous femoral nerve sensitive area with the Pressure‐Specified Sensory Device. In all cases the flap reached the ischial defect harmlessly, healing was uneventful with no immediate nor late complications. Each patient showed persistence of sensitivity at the reconstructed area and no recurrent ischiatic sore was observed at mean follow‐up of 26.4 months. The sensate pedicled anterolateral thigh flap is a valuable solution for coverage of recurrent ischial sores in meningomyelocele patients, in which pressure consciousness is fundamental. The intermuscular passageway allows to reduce the distance between flap's vascular pedicle origin and the ischial defect, hence to use the more reliable skin from the middle third of the anterolateral thigh. © 2014 Wiley Periodicals, Inc. Microsurgery 35:279–283, 2015.     

The ��reading man flap�� for pressure sore reconstruction

Background:

The treatment of pressure sores represents a significant challenge to health care professionals. Although, pressure wound management demands a multidisciplinary approach, soft tissue defects requiring reconstruction are often considered for surgical management. Myocutaneous and fasciocutaneous flaps can provide stable coverage of pressure sores.

Purpose:

Here, we describe our experience using a recent fasciocutaneous flap, which is named ‘reading man’ flap, in sacral, ischial, and trochanteric pressure sores.

Materials and Methods:

During a period of 1 year the authors operated 16 patients, 11 men, and 5 women, using the reading man flap. The ages of the patients ranged from 24 to 78 years. The location of pressure sores was 8 sacral, 5 ischial, and 3 trochanteric pressure sores. The mean size of pressure sores was 8 cm × 9 cm.

Results:

All pressure sores covered bt the Reading Man flap healed asymptomatically. After follow-up of 2-8 months, no recurrences were encountered and no further surgical intervention was required.

Conclusion:

The reading man flap was found to be a useful technique for the closure of pressure sore in different anatomic locations. The advantage of tension-free closure and the minimal additional healthy skin excision made this flap a useful tool in pressure sore reconstructions.KEY WORDS: Local flap, pressure sore, ‘reading man’ flap     

Versatility of perforator sparing buttock rotation flap in repair of pressure sores

Eleven perforator-sparing gluteal fasciocutaneous rotation flaps were used for coverage of pressure sores in 10 patients with mean age 38.4 years. Nine patients were paraplegic, and one patient was ambulatory. All pressure ulcers were classified as grade 4. The pressure sores were sacral in five patients, unilateral ischial in five patients, and unilateral trochantric in one patient. Seven ulcers were recurrent and four were primary. The flap sizes ranged from 7 × 7 cm to 15 × 13 cm. In a total of 11 flaps, nine flaps included two perforators, one flap included three perforators, and one flap included single perforator. Skin incision is the same as that for the conventional gluteal rotation flap. The flap is elevated subfascially until at least two dominant musculocutaneous perforators of the superior or inferior gluteal arteries are encountered. In the recurrent ischial sores, the inferior part of gluteus maximus was used to fill dead space at the base of the ulcer as a separate muscle flap. Eight of 11 flaps healed uneventfully without complications. Mean follow-up period was 18.6 months (range 37–5 months). The recurrence rate in the same region was 0% during follow-up period. The appearances of pressure sores in other sites occurred in two patients that healed with conservative treatment. There was no major complication such as total flap necrosis. Only minor complications occurred which were treated without surgical intervention. The perforator-sparing gluteal rotation fasciocutaneous flap is a versatile and reliable flap for coverage of all gluteal pressure sores. This is an ideal flap for patients in whom the risk of ulcer recurrence is high as the rerotation is possible in case of recurrence.     

Medial circumflex femoral artery flap for ischial pressure sore

A new axial pattern flap based on the terminal branches of the medial circumflex femoral artery is described for coverage of ischial pressure sore. Based on the terminal branches of the transverse branch of medial circumflex femoral artery, which exit through the gap between the quadratus femoris muscle above and the upper border of adductor magnus muscle below, this fascio cutaneous flap is much smaller than the posterior thigh flap but extremely useful to cover ischeal pressure sores. The skin redundancy below the gluteal fold allows a primary closure of the donor defect. It can also be used in combination with biceps femoris muscle flap.     

Sacral pressure sores and their treatment]

INTRODUCTION: Sacral bed sores still present a serious problem in most surgery departments. They occur mainly in elderly patients of limited mobility. The treatment of such sores extends over long periods of time and therefore involves considerable costs. MATERIAL AND METHODS: The material consisted of 11 sacral pressure ulcers treated surgically. The sores occured in 4 severely disabled patients suffering from proximal third femur fractures, 4 patients with traumatic brain injury (treated in the Intensive Care Unit), and 3 patients suffering from bed sores after spinal cord injury. In 6 patients a fasciocutaneous flap was applied to the sores and in 5 cases a pedicled musculocutaneous gluteus maximus flap. The end results were assessed using Seiler's criteria. RESULTS: Complications of the "seroma" type were observed in 3 patients, and in 2 marginal necrosis. In all our patients complete healing was achieved within 2-4 weeks. CONCLUSIONS: On analysing our experience to date in surgical treatment of bed sores we are of the opinion that even extensive sacral sores can be covered with unilateral pedicled flaps provided that they are appropriately planned. Deep sores of the 4th degree sometimes with concomitant osteomyelitis require pedicled muscle flaps or in some cases musculocutaneous flaps to improve local curculation. The preparation of the patient for reconstruction surgery is just as important as the operation itself and therefore such preparation should never be neglected.     

岛状股前外侧皮瓣修复腹股沟及会阴部创面

目的探讨一种皮瓣修复会阴部及腹股沟创面的方法。方法设计以旋股外侧动脉降支为血管蒂的岛状股前外侧皮瓣,掀起皮瓣后经过皮下隧道将其转移至会阴部及腹股沟创面。结果临床治疗12例,皮瓣面积为8cm×11cm～18cm×20cm。除1例皮瓣靠近肛门处部分表皮坏死外,其余成活良好,外形恢复满意。结论以旋股外侧动脉降支为血管蒂的岛状股前外侧皮瓣是修复会阴部及腹股沟创面较好的方法。     

A proposed protocol for the surgical treatment of pressure sores based on a study of 337 cases

Pressure sores are very common complications following spinal cord injuries and other neurological problems. We present out 15 years' experience in treating pressure sores with myocutaneous flaps. Each anatomical site is considered, divided into those in which cover was successful and those with recurrences. Over the past 8 years careful preoperative planning has been used and specific flaps for each anatomical area. Our home care system is organized to cover both domestic and medical problems. Treatment is determined after examining the wound (anatomical site, staging, infection) and underlying medical, nutritional, and neurological problems. The first choice for ischial ulcers is the VY advancement hamstring myocutaneous flap, sacral ulcers a VY myocutaneous advancement flap of gluteus maximus muscle, and for trochanteric ulcers the myocutaneous rotation flap of tensor fascia lata muscle. Using this protocol the treatment outcome of sacral and ischial ulcers has been encouraging, but in trochanteric ulcers the results have been less satisfactory. This experience supports the use of these flaps in the treatment of pressure sores in para and tetraplegic patients.     

Reconstruction of ischial pressure sore using an inferior rectus abdominis myocutaneous flap

Summary In this article, a reconstructive method for ischial pressure sores using an inferior rectus abdominis myocutaneous flap, is reported. Results obtained with two paraplegic patients with recurrent ischial pressure sores were excellent, and they were free from recurrence over two years after this operation. This technique is one of the methods of choice in cases of recurrent ischial pressure sore where conventional methods have been tried.     

Myokutane Lappen als sichere Defektdeckung bei höhergradigen pelvinen Dekubitalulzera Einteilung, Therapiekonzept und Darstellung des eigenen Krankenguts aus 16 Jahren

Infected pelvic pressure sores of Campbell stages IV–VII require soft tissue reconstruction, which means stable, multi-layered filling cover of the defect and reliable prophylaxis of relapse. Myocutaneous flaps meet these conditions well. Depending on the extent and the area of the sore, with predilection for the sacrum, the ischial tuberosity and the femoral trochanter, the gluteus maximus, biceps femoris and tensor fasciae latae muscles are most often used for myocutaneous flaps. Primary sutures, split skin grafts or local fasciocutaneous flaps are often sufficient treatment for smaller, superficial defects. Between 1981 and 1996, 133 patients (average age 50 years) with 212 pelvic pressure sores of all stages were treated in our clinic. After radical decubitus excision with pseudotumor technique and resection of the osseous prominences, one-stage reconstruction of solitary as well as multiple defects was performed with myocutaneous flaps in 135 cases. The postoperative general complication rate for all treatments was about 10–30%. With regard to the muscle flaps, one third healed without any problems, partial flap necrosis occurred in 6% and there was total loss of flap in 2% of all myocutaneous flaps. According to present knowledge, myocutaneous flaps seem to be the most reliable method for definitive covering of deep pelvic pressure sores, independent of the cause of the ulcer.     

Decubital ulcer--causes,surgical therapy and prognosis

7.6 % (n = 134/1 769) of all inpatients in Leuven, but 30.1 % of risk patients suffer of pressure sores (Norton Scale 10.4 points). Predisposed are geriatric patients or those of intensive care units. While fasciocutaneous flap likewise the superior gluteal artery perforator flap are more resistant to mechanical forces, myocutaneous flaps are the working horse for pressure sores with deep-tissue pockets or osteitis (Campbell stage > IV). Partial resection of the median sacral crest or ischiectomy are obligatory. In analyzing a 16 years period only 33 percent of myocutaneous flaps healed uneventful, while due to multiple enumerations more than 50 percent presented complications. Partial flap and complete necrosis happened in 6 respectively in 2 percent. Rectus abdominis myocutaneous flap reconstruction as well as the free tissue transfer are useful alternatives to hip disarticulation with total thigh flap coverage or a complete fillet flap of the lower extremity. Independently of the selected closure 50 percent of all decubitus patients will develop recurrences in longterm follow up. Thus prevention is of utmost importance. In Europe the costs for the hospitalisation of a patient with concomitant decubital ulcers are 2.5-times higher than for an average, non-afflicted patient.