Gluteal thigh flap used as a fascio-cutaneous free flap

[Flap coverage using the posterior gluteal thigh flap]

OBJECTIVE

Defect coverage of the sacral, trochanteric or ischial region with durable tissue (gluteal thigh flap).

INDICATIONS

Decubital ulcers of the sacral, trochanteric or ischial region after exhaustion of conservative measures.

CONTRAINDICATIONS

Moribund or palliative patients who do not benefit from defect coverage and are likely to suffer a life-threatening complication. Noncompliant patients, who cannot follow the postoperative recommendations or protocols in regard to positioning or recurrence prevention. The presence of extensive scars after previous operations in the donor area or irradiation of the donor area can lead to flap necrosis.

SURGICAL TECHNIQUE

The posterior gluteal thigh flap can either be used as a fasciocutaneous flap or in combination with the gluteus muscle as myofasciocutaneous flap. Further microsurgical transfers have been described.

POSTOPERATIVE MANAGEMENT

Following surgery the patient needs to be positioned on the side or prone to prevent recurrence. Drains should be left for 5-7 days. Antibiotics are only needed in the case of persistent florid infection.

RESULTS

The posterior gluteal thigh flap is a well-known, reliable and versatile option for coverage of decubital ulcers in the sacral and ischial region with low recurrence rates described in the literature.

Reconstruction of acquired ischiatic and perineal defects: an anatomical and clinical comparison between gluteal thigh and inferior gluteal perforator flaps

BACKGROUND

Flap coverage is the gold standard in treating pressure sores, and due to the high recurrence rate, the possibility of multiple surgical procedures should be considered during flap selection. The gluteal thigh (GT) flap has become a workhorse for ischiatic pressure sore treatment at our hospital. Follow-up revealed a group of patients presenting recurrence of the pressure sore that needed a second flap. The inferior gluteal artery perforator (IGAP) flap was chosen in this series. The positive experience with both flaps raised the question of which flap should be the first option for the treatment of ischiatic and perineal pressure sores.

METHODS

IGAP and GT flaps were dissected in 21 fresh human cadavers to allow comparison of anatomical features. In a series of 60 patients, the authors used both the gluteal thigh and the IGAP flap to cover 76 ischiatic and perineal ulcers.

RESULTS

The IGAP flap was found to be wider and thicker than the gluteal thigh, but presented a shorter pedicle. All flaps healed uneventfully. Recurrent ulcers were treated successfully with both flaps.

CONCLUSIONS

Both flaps are suitable for coverage ischiatic and perineal sores. Due to its anatomical features, the IGAP flap should be considered the first choice of treatment for ischiatic ulcers. The gluteal thigh flap should be used in the recurrent sores.Level of Evidence: Level IV, therapeutic study.

[Oropharynx reconstruction. Use of free and pedicled flaps]

Oropharyngeal cancer surgery often does not allow primary wound closure; furthermore, surgery of tumors in the base of the tongue, the soft palate and the lateral pharyngeal wall often lead to swallowing disorders and nasal twang which severely impair quality of life. Secondary scarring may also result in fixation of the tongue or stenosis of the pharynx. Therefor reconstructive techniques with free or pedicled flaps are essential to reduce functional impairment. In addition, after trauma or due to malformations, reconstructive surgery using flap techniques is sometimes indicated.

Anatomical Basis and Clinical Application of the Infragluteal Perforator Flap

BACKGROUND

When selecting flaps for coverage of pressure ulcers of the sacrum and perineal region in paraplegic patients, long-term high recurrence rates should be considered. Therefore, the authors developed an infragluteal perforator flap to avoid "burning bridges" for future reconstruction.

METHODS

Infragluteal perforator flaps were dissected in five fresh human cadavers to define the anatomy of the cutaneous branches of the descending branch of the inferior gluteal artery and cluneal nerves and define anatomical landmarks for clinical application. In a series of 13 paraplegic patients, the authors used perforator-based flaps (additional skin bridge) to cover four perineal ulcers and one sacral ulcer and perforator flaps to cover six perineal and two sacral ulcers. Donor sites were closed by direct approximation.

RESULTS

Twelve of 13 flaps healed uneventfully. In all cadaver and clinical dissections, one or two cutaneous branches of the descending branch of the inferior gluteal artery and one or two cluneal nerves were found at the lower border of the gluteus maximus muscle supplying the infragluteal perforator flap. These direct cutaneous branches allowed dissection of inferior gluteal perforator flaps with improved flap mobility compared with the perforator-based flaps. The descending branch of the inferior gluteal artery could always be spared for future flaps.

CONCLUSIONS

The infragluteal perforator flap is a versatile and reliable flap for coverage of ischial and sacral pressure sores. It can be designed as a perforator-based or perforator flap and could provide a sensate flap in ambulatory patients. Donor-site morbidity is minimal, and options for future flaps of the gluteal and posterior thigh region are preserved.