双侧反向臀上动脉远侧穿支V-Y推进筋膜皮瓣修复骶部巨大褥疮

目的:笔者设计了一种双侧反向臀上动脉远侧穿支V-Y推进筋膜皮瓣,关闭巨大骶部溃疡,以增加皮瓣推进量,避免臀大肌功能性缺损。方法:清创后V-Y推进皮瓣标记于双侧臀部。在缺损近侧掀起筋膜皮瓣,在远侧臀大肌肌肉附件里保留臀上动脉远侧穿支,直至获得足够的皮瓣前移。结果:用此方法治疗15个直径7～15cm的骶部褥疮的患者,没有出现皮瓣坏死和溃疡复发,91%的皮瓣Ⅰ期愈合。结论:此技术使皮瓣推进量增加,皮瓣存活可靠,并保留了双侧臀部和臀大肌功能。     

Bilateral gluteus maximus myocutaneous advancement flaps: sacral coverage for ambulatory patients

The standard gluteus maximus myocutaneous flap, though an excellent procedure for coverage of sacral soft-tissue defects, has several disadvantages. It is usually quite bulky, and risks hip instability in the ambulatory patient. Bilateral gluteus maximus myocutaneous advancement flaps obviate these problems. The superior half of each gluteus maximus muscle, with overlying skin island, is released from its origin and insertion. The superior gluteal artery is identified and preserved. Each myocutaneous unit may be advanced to the midline. The line of cleavage between units preserves normal contour. Donor-site deformity is closed in the V-Y advancement fashion. Hip instability is thus avoided. This technique is useful in the management of sacral defects in the ambulatory patient.     

臀大肌远侧穿支V-Y皮瓣修复骶部褥疮

目的探讨应用臀大肌远侧穿支V-Y皮瓣修复骶部褥疮,简化手术操作。方法2002年3月~2005年3月,对11例骶部褥疮应用臀大肌远侧穿支V-Y皮瓣修复。褥疮范围:13 cm×11 cm~18 cm×14 cm,褥疮最大直径达18 cm。其中男7例,女4例。年龄21~69岁。病程8个月~3年。手术彻底清创后,设计以褥疮外侧创缘为底部,顶在股骨大转子处的V形皮瓣,皮瓣的内侧半在臀大肌的浅面掀起,皮瓣的外侧部从臀大肌深面掀起,形成一包含外侧穿支的V形皮瓣。将皮瓣向内侧推进修复骶部创面,供区创面作V-Y缝合。结果11例骶部褥疮修复后,皮瓣全部成活。术后随访5个月~3年,双臀部对称,外形满意,除1例因其他疾病死亡外,余无褥疮复发。结论臀大肌远侧穿支V-Y皮瓣手术操作简便、血运丰富、蒂部较长、向内侧推进的幅度较大、皮瓣大及供区损害小且可直接缝合,是修复骶部较大的软组织缺损可供选择的一种方法。     

The gluteus maximus muscle flap for reconstruction of sacral chordoma defects

Four patients diagnosed with sacral chordoma underwent reconstruction with the gluteus maximus flap using an approach based on available muscle remnants and their residual blood supply. The entire unilateral gluteus maximus muscle was turned over to fill the defect in 2 patients. The flap was based on 1 or 2 gluteal vessels, depending on vessel availability following tumor resection. When all 4 major pedicles had been ligated, bilateral advancement gluteal muscle flaps based on their distal blood supply were used (patient 3). A longitudinally split flap was used for secondary reconstruction of a partially obliterated defect (patient 4). Over a mean follow-up period of 8 months, there was no wound breakdown and all patients were ambulant.     

岛状臀大肌肌皮瓣在臀部软组织缺损修复中的应用

目的：探讨岛状臀大肌肌皮瓣在臀部软组织缺损尤其是骶尾部褥疮修复中的应用。方法：以臀大肌臀上动脉穿出点为旋转轴,利用臀上动脉和臀下动脉交通支所在的臀大肌外缘肌为蒂,以旋转点至缺损区最近点为肌皮瓣蒂长度,根据缺损部位及大小进行肌皮瓣设计,形成岛状肌皮瓣,肌皮瓣面积稍大于缺损区创面。蒂部仅含臀大肌外缘肌肉,宽度1.5～2.0cm。沿设计线切开皮肤找到臀大肌臀上动脉穿出点及臀大肌外缘,向远端解剖,在臀大肌下形成的岛状皮瓣,通过皮下隧道将肌皮瓣转移到缺损区,逐层缝合切口。供区视大小可行直接拉拢缝合或邻近皮瓣转移或植皮修复。结果：应用岛状臀大肌肌皮瓣修复臀部软组织缺损7例,术后肌皮瓣全部成活,被修复处色泽、厚度及外形均满意。结论：岛状臀大肌肌皮瓣血供丰富,血管恒定,抗感染能力强,切取及转移方便,是修复臀部软组织缺损尤其是骶尾部褥疮的理想肌皮瓣。     

The gluteal perforator-based flap in repair of pressure sores.

The gluteal perforator-based flap is designed according to the localisation of sacral perforator vessels. These vessels penetrate the gluteus maximus muscle and reach the intrafascial and suprafascial planes, and the overlying skin forming a rich vascular plexus. The gluteal perforator-based flaps described in this paper are highly-vascularised, have minimal donor site morbidity, do not require the sacrifice of the gluteus maximus muscle and rarely lead to post-operative complications. We believe these easy-to-perform flaps might be considered as the first choice in the repair of gluteal pressure sores.     

Several types of gluteus maximus musculocutaneous flaps for closure of sacral decubitus ulcer — refinements in design

Summary The selection of gluteus maximus musculocutaneous flaps and the appropriate designs of such flaps are described. These flaps are based on either the superior gluteal pedicle or the inferior gluteal pedicle. Knowledge of the pedicle's position in relation to the skin surface is essential for correct design of the flap. We have treated 34 cases of sacral decubitus ulcer in which we have accomplished reconstruction with various types of gluteus maximus musculocutaneous flaps. Four representative cases are presented. Requests for reprints: A. Yanai, M.D.     

Perforator propeller flaps for sacral and ischial soft tissue reconstruction

The perforator-based flaps in the sacral and ischial region is designed according to the localization of perforators that penetrate the gluteus maximus muscle, reach the intra-fascial and supra-fascial planes with the overlying skin forming a rich vascular plexus. The perforator-based flaps described in this article are highly vascularized, have minimal donor site morbidity, and do not require the sacrifice of the gluteus maximus muscle. In a period between April 2008 and March 2009, six patients with sacral pressure sore were reconstructed with propeller flap method based on superior gluteal and parasacral artery perforators. One flap loss was noted. Three cases of ischial pressure sore were reconstructed with longitudinal propeller flap cover, based on inferior gluteal artery perforator. One flap suffered wound infection and dehiscence. Two cases of pilonidal sinus were reconstructed with propeller flap based on parasacral perforators. Both the flaps survived without any complications. Donor sites were closed primarily. In the light of this, they can be considered among the first surgical choices to re-surface soft tissue defects of the sacral and ischial regions. In the series of 11 patients, two patients (18%) suffered complications.     

The gluteus maximus muscle: experimental and clinical considerations relevant to reconstruction in ambulatory patients

The gluteus maximus muscle and other haemodynamically related structures have been used for the reconstruction of significant defects in the perineum, sacrum, lumbar area and hip in 35 patients. The preservation of muscle function was achieved in all of 20 ambulatory patients and documented by gait analysis, muscle strength testing and EMG studies. Dye injection studies of the first perforating artery, inferior gluteal artery and superior gluteal artery led to the design of new flaps based on this arterial system. They include: medial advancements with extension above the sacrum, lateral advancements, lower gluteus advancements, the tensor fasciae latae gluteal extension and modifications of the gluteal thigh flap. These findings significantly increase our ability to close difficult wounds within the perineal, sacral, lumbar and trochanteric regions.     

Gluteus maximus myocutaneous flap in the repair of sacral and gluteal decubitus ulcers]

16 cases of decubitus ulcers in the sacral, ischiadic and great trochanter regions were treated with rotating myocutaneous flap of the caudal portion of the gluteus maximus from 1983 to 1989. They were followed up for 3 to 68 months, with the exception of 4 patients. The results were excellent. 30 gluteus regions were studied in 15 cadavers. It was found that the caudal 3/4 of the gluteus maximus muscle was supplied by the inferior gluteal artery, and a flap measuring 12.9 x 9.7 cm could be formed therein with easy dissection. The flap tolerates pressure well. Unilateral flap is adequate to cover a decubitus ulcer within a diameter of 10cm, while bilateral flaps are necessary for a larger ulcer.     

"Pac Man" flap for closure of pressure sores

The purpose of this study was to modify the classic bilateral V-Y advancement flap procedure to decrease the tension in its closure and to break the midline vertical scar by interdigitating the flaps. After debridement of a pressure sore, the V-Y flaps were marked on both sides of the wound. Skin incisions were carried down to the muscle fascia along the sides of the flaps. The upper and lower limbs of the V-shaped flaps were elevated as triangular flaps but remained attached to the main flap. The tip of the upper limb of one of the flaps was transposed into the defect and sutured to the contralateral V-Y flap at the midpoint of its concave side facing the defect. The lower limb of the contralateral flap was then transposed into the defect and sutured to the first V-Y flap. To complete the interdigitated closure, the lower limb of the first flap was sutured below the contralateral flap, and the upper limb of the contralateral flap was sutured above the first flap. The final view of the flaps was similar to "Pac Man," so the authors decided to call this flap the Pac Man flap. The flaps healed well in all patients, and wound breakdown or recurrence of the pressure sore was not observed during the 3 to 14-month follow-up.     

Musculocutaneous island flap using the upper gluteus maximus muscle]

The authors report 24 cases treated with an gluteus maximus musculocutaneous flap. The gluteus maximus is generally used as a VY flap. Our technique uses the superior part of the muscle with the overlying skin as a rotation flap. The upper part of the muscle is supplied by the superior gluteal artery. A good knowledge of the anatomy makes this flap easy to perform. The skin part of the flap is drawn over the trochanter. It is generally a 8 cm diameter circle. We then create a subcutaneous tunnel to prepare the rotation. The muscle is then freed from its lateral origin. The separation from the gluteus medius is made by blunt dissection and the superior gluteal artery can then be seen. The myocutaneous flap can now be raised and transferred to the defect. This flap has, in our experience, many advantages especially in paraplegic patients: large skin defects can be covered with a single flap, the perisacral skin is free of any scar, the lower part of the muscle can still be used to cover ischial ulcers. Since 1987 we have treated 24 patients with good results. The reliability and the great technical simplicity makes us think that the superior gluteus maximus musculocutaneous island flap is optimal for the coverage of sacral pressure sores.     

The gluteus maximus musculocutaneous flap as bilateral V-Y sliding flap or as pendulum flap for closure of sacral and ischial pressure sores

Summary Eight V-Y and fourteen pendulum gluteus maximus myocutaneous flaps have been used in eighteen patients for closure of sacral and ischial pressure sores. The patients have been followed-up for between 3 and 36 months and there was only one recurrence in a patient who had had a bilateral pendulum flap. There has been no functional impairment in the ambulant patients.     

Perineal and posterior vaginal wall reconstruction with a superior gluteal artery dual perforator‐pedicled propeller flap

Gluteal artery perforator flaps are a good option to reconstruct perineal and posterior vaginal wall defects after abdominoperineal resection. The bulkiness of the folded flap may compromise the results by obliterating the introitus and vaginal cavity. In this report, we present a case of the use of a superior gluteal artery dual perforator‐pedicled propeller flap to reconstruct the posterior vaginal wall and perineum in a 60‐year‐old female who had an abdominoperineal resection of a locally progressive anal squamous cell carcinoma. Two perforators were completely skeletonized through gluteus maximus muscle fibers. The vascularization of the skin flap was based on the first perforator, whereas the aponeurotic flap was vascularized by the second perforator. The vaginal defect was reconstructed with a gluteus maximus aponeurotic flap, and the perineal reconstruction was based on a superior gluteal artery perforator skin flap. No postoperative infection or necrosis occurred. Skin healing was completed in 3 weeks. Vaginal opening was controlled using lubricant and graduated vaginal dilators during 6 weeks. The patient began sexual intercourse 2 months postoperatively. No revision was needed. Perineal and posterior vaginal wall defects may be reconstructed with a gluteal artery perforator flap. The thickness of the flap allows a complete filling of the full perineal cavity. The gluteus maximus aponeurosis may be suitable for the reconstruction of the posterior vaginal wall. © 2014 Wiley Periodicals, Inc. Microsurgery 35:64–67, 2015.     

The use of suture anchors in reconstruction of sacral pressure ulcers with gluteal fasciocutaneous advancement flaps

Suture anchors have already been successfully used for soft-tissue fixation to bone. In this study, suture anchors were used in sacral pressure ulcer reconstruction, aiming at secure midline attachment of gluteal fasciocutaneous flaps, obliteration of any dead space, and recreation of the natal cleft.Thirteen patients with sacral pressure ulcers were treated with bilateral gluteal fasciocutaneous V-Y advancement flaps. Suture anchors were used to invert and attach the flaps to the midline crest of the sacrum. All flaps healed well, no postoperative anchor failure or wound dehiscence was noticed, and the esthetic result was very pleasing.In conclusion, the use of suture anchors offers an easy, practical, and secure attachment of V-Y advancement gluteal fasciocutaneous flaps in sacral pressure ulcer reconstruction. Main advantages of the method suggested are reduction of suture-line tension, obliteration of any cavity at the midline, and recreation of the natal cleft.     

The partial gluteus maximus musculocutaneous turnover flap. An alternative concept for simultaneous reconstruction of combined defects of the posterior perineum/sacrum and the posterior vaginal wall.

Three cases with posterior perineo-sacral defects are presented. One is a 57-year-old white female following amputation of her rectum for carcinoma, radiation and chemotherapy with a significant residual sacral/perineal defect and loss of the posterior vaginal wall. The two other patients had radical pelvic exenteration after recurrent rectum carcinoma. A new myocutaneous turnover flap as a modification of the conventional gluteus maximus flap was designed to solve the particular reconstructive problems. The flap is based on branches of the inferior gluteal artery. The posterior cutaneous femoral nerve and the motor branches of the inferior gluteal nerve not leading into the muscle portion of the flap are left intact. The skin island can be used for vaginal reconstruction or can be de-epithelialised to fill perineal cavities. This new flap eventually enabled the successful reconstruction of the posterior vaginal wall and appropriate sacral/perineal soft tissue coverage in the first case. In the other patients the flap was used to achieve closure of the deep through-and-through defect acutely in one case, and after a 3-week interval in the other.     

Bilateral, extended V-Y advancement flap

A modification of the V-Y advancement flap for the closure of circular skin defects is presented to decrease the tension in the closure and to break the midline vertical scar. Bilateral, extended V-Y advancement flaps with additional limbs extending to the advancing edges of the standard flaps were marked on both sides of the wound. After advancement of the V-Y flaps on their subcutaneous pedicle, the upper and lower extensions were hinged downward as transposition flaps to close the middle portion of the circular defect, where maximum tension occurs. This procedure was applied to 10 patients with sacral and trochanteric pressure sores. No complications or recurrences were noted during the 2 to 10 months of follow-up. Bilateral, extended V-Y advancement flaps enable the reconstruction of large defects without midline tension. Also, the resulting scar where the flaps meet is a zigzag line, so a straight midline scar is avoided.     

Reconstruction of the natal cleft with a perforator-based flap.

Recurrent chronic conditions of the natal cleft, such as pilonidal sinuses, are difficult problems to treat. The deep natal cleft and the rolling effect of one buttock surface over the other contribute to the high recurrence rate. Wide excision of the affected area is the treatment of choice; to cover the defect many techniques have been described that flatten the natal cleft and shift the suture line away from the midline to try to reduce recurrence. These techniques include Z-plasties, rhomboid flaps, V-Y flaps, gluteus maximus myocutaneous flaps and others. Five patients with recurrent natal-cleft problems were operated on over a 1 year period. After wide excision of the natal cleft, the defect was reconstructed with a parasacral perforator-based flap. Preoperatively, a perforator situated superolaterally to the defect is identified with a Doppler probe; the flap is then designed horizontally around the perforator and, after elevation, is rotated 908 over the defect. The mean hospital stay was 5 days. Follow-up ranged from 3 months to 15 months, with no signs of recurrence. We believe this to be a simple and reliable technique, with the advantages of placing the scars away from the midline and flattening the natal cleft - factors that help to prevent recurrence.     

Comparison of fasciocutaneous V‐Y and rotational flaps for defect coverage of sacral pressure sores: a critical single‐centre appraisal

Pressure sore rates remain high in both nursing homes as well as in hospitals. Numerous surgical options are available for defect coverage in the sacral region. However, objective data is scarce as to whether a specific flap design is superior to another. Here, we aim to compare two fasciocutaneous flap designs for sacral defect coverage: the gluteal rotation flap and the gluteal V‐Y flap. All primary sacral pressure sores of grades III–IV that were being covered with gluteal fasciocutaneous rotational or V‐Y flaps between January 2008 and December 2014 at our institution were analysed. A total of 41 patients received a total of 52 flaps. Of these, 18 patients received 20 gluteal rotational flaps, and 23 patients received 32 V‐Y flaps. Both groups were comparable with regards to demographics, comorbidities and complications. Significantly more V‐Y flaps were needed to cover smaller defects. Mean length of hospital stay was significantly prolonged when surgical revision had to be carried out. Both flap designs have proven safe and reliable for defect coverage after sacral pressure sores. Gluteal rotational flaps appear to be more useful for larger defects. Both flap designs facilitate their reuse in case of pressure sore recurrence. Complication rates appear to be comparable in both designs and to the current literature.