Experience with the island inferior gluteal thigh flap compared with other local flaps for the reconstruction of the pelvic area

Reconstruction of large perineal defects after advanced malignant tumour resection: a simple gluteal thigh flap modification

Reconstruction of large defects in the perineal region, after resection of advanced malignant tumours is challenging because both coverage of the perineal skin defect and adequate filling of the pelvic space must be achieved simultaneously. This manuscript introduces a simple gluteal posterior thigh flap modification for the reconstruction of such defects. A trilobed flap, in the gluteal and posterior thigh regions, was designed to be of an adequate size to repair the dermal and pelvic floor defects. After the flap was elevated and rotated 90^°, the posterior thigh portion was denuded. The lateral portion of the deep gluteal fascia was incised to allow medial advancement. Thus, the flap could be easily moved to fill the defect, without tension. To evaluate the results, we reviewed 8 patients with large (>10 cm in diameter) advanced perineal carcinomas. For each patient, the defect was successfully reconstructed using the technique described. A secondary operation was required for one patient, due to atheromatosis that developed several months after the operation. Another patient developed donor site wound dehiscence and was treated with skin grafting. The described technique facilitates the effective reconstruction of large perineal defects.

A Systematic Review and Meta-Analysis of the Pressure-Induced Vasodilation Phenomenon and Its Role in the Pathophysiology of Ulcers

BACKGROUND

Physiologic studies show that tissue perfusion increases during moderate amounts of tissue compression. This is attributed to sensory nerves initiating a vasodilatory cascade referred to as pressure-induced vasodilation.

METHODS

PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched for studies investigating perfusion during pressure exposure longer than 10 minutes. Retrieved studies were assessed using the Office of Health Assessment and Translation Risk of Bias Rating Tool for Human and Animal Studies. Results were pooled with random effects models. The body of evidence was rated using the Office of Health Assessment and Translation approach.

RESULTS

Twenty-nine articles were included, of which 19 articles were included in meta-analyses. The evidence indicates that moderate amounts of tissue compression have the capacity to increase perfusion in healthy humans by 46 percent (95 percent CI, 30 to 62 percent). Using the Office of Health Assessment and Translation approach, the authors found a high level of confidence in the body of evidence. Pressure-induced vasodilation blockade was associated with increased pressure ulcer formation. Pressure-induced vasodilation was impaired by neuropathy and by the drugs diclofenac and amiloride.

CONCLUSIONS

This systematic review and meta-analysis indicates that healthy humans have the capacity to increase local perfusion in response to mechanical stress resulting from tissue compression. Because pressure-induced vasodilation is mediated by sensory nerves, pressure-induced vasodilation emphasizes the importance of sensory innervation for durable tissue integrity. Pressure-induced vasodilation impairment seems to provide a complementary explanation for the susceptibility of neuropathic tissues to pressure-induced lesions.

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.

Indications for immediate tissue transfer for soft tissue reconstruction in visceral pelvic surgery

BACKGROUND

Perineal wound complications may occur after visceral pelvic surgery. We reviewed our experience to determine indications for immediate tissue transfer (TT) to prevent complications.

METHODS

Hospital records and computerized data were reviewed on 175 perineal repairs in 156 patients treated at The University of Texas M.D. Anderson Cancer Center for tumors involving the alimentary tract (135 of 175), genitourinary tract (15 of 175), perineum (19 of 175), or sacrum (6 of 175). Patients had either resection of only the colorectum and anus (APR) (46 of 175) or multivisceral resection (MVR) (129 of 175), and the perineal wound was closed by using TT (108 of 175) or primary closure (PC) (67 of 175) on the basis of the surgeon's judgment. Complications were compared between PC and TT groups.

RESULTS

Complications occurred in 57% (100 of 175). There was no significant difference overall in PC and TT procedures or in the APR subgroup. There were significantly fewer complications for TT patients in the MVR subgroup (P =.0001). There were significantly fewer complications for TT patients with prior irradiation in both APR (P =.01) and MVR (P =.007) subgroups.

CONCLUSIONS

Immediate TT for perineal wound closure is associated with fewer healing complications than PC in a subset of patients with multivisceral resection or prior radiotherapy. Surgical planning in these cases should consider immediate soft tissue reconstruction.

Gluteal thigh flap used as a fascio-cutaneous free flap

The gluteal thigh flap is a myofascio-cutaneous flap receiving its blood supply from a descending branch of the inferior gluteal artery. The gluteal thigh flap was first described by Hurwitz in 1980; since then numerous articles have reported on the successful use of this flap, as a transposition or a pedicled island flap, to cover wounds in the sacrogluteal and perineal regions. In contrast to its widespread use as a pedicled flap, employment of the gluteal thigh flap as a free flap is almost unreported in the literature, despite its extremely low donor morbidity and numerous articles on successful (other) free flap reconstructions based on the (same) inferior gluteal artery (e.g., in breast reconstruction). In this article we report on the successful use of the gluteal thigh flap as a purely fascio-cutaneous free flap in limb reconstruction. The literature on the microvascular anatomy of the gluteal thigh flap is reviewed in detail, and a precise description is given of the preoperative measures and surgical manoeuvres required to increase the reliability of this free flap. From the anatomical data and the problems encountered in this case, it should be concluded that, despite the many advantages of this flap and an ultimately successful outcome, the gluteal thigh flap is not a first choice flap for microvascular transfer.

Anatomy of the Fasciocutaneous Branches of the First and Second Perforators Arteries in the Posterior Thigh Area

The anatomy of the fasciocutaneous branches of the first and second perforators were studied to help elaborate a flap for use in the reconstruction of the gluteal and perineal regions. After dissecting 40 thighs in fresh cadavers, it was found that the fasciocutaneous branches of the first and second perforators were 1.21 mm and 1.01 mm in diameter, respectively. The distances from the first and second perforators to the greater trochanter of the femur were 6.23 cm and 12.19 cm, respectively. The cutaneous area nourished by each one of the arteries was evaluated through the injection of dye.