ORIGINAL ARTICLE Efficacy of gluteus maximus fasciocutaneous v-y advancement flaps for coverage of sacral sore

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1 136 ORIGINAL ARTICLE Efficacy of gluteus maximus fasciocutaneous v-y advancement flaps for coverage of sacral sore Riaz Ahmed Afridi, Firdous Khan, Obaidullah Abstract Objective: To evaluate efficacy of gluteus maximus fasciocutaneous V-Y advancement flaps in the management of sacral sores in terms of flap survival, complications and recurrence. Methodology: This Prospective descriptive study was conducted at Plastic & Reconstructive Surgery Unit, Northwest General Hospital, Hayatabad, Peshawar from Jan 2010 to Dec Patients were admitted through out-patient department and detailed history, clinical examination and necessary investigations were carried out. Informed consent was taken. Patients with grade 3 and 4 sacral sores were included. Patients with concomitant trochanteric sores, immunocompromise patients or with terminal illness were excluded from the study. All patients were put on a standard regime postoperatively. Data was analyzed by using SPSS version 10 software. Follow-up period was 1 year. Results: A total number of 20 patients were included. Their ages ranged from yrs with mean age of ± 29.4 yrs. Males were 12 and females were 8. Causes of sacral sores were spinal cord injuries in 12 (60%), Cerebrovascular accidents (CVA) in 5 (25%) and other medical illnesses in 3 (15%) of patients. Grade 3 sores were found in 65% and grade 4 in 73% patients. Average defect size was 16 cm. Gluteus maximus V-Y fasciocutaneous flap was done unilaterally in 8 (40%) and bilaterally in 12 (60%) of patients. Complications were wound dehiscence in 10% and seroma formation in 5% of patients. Conclusion: Gluteul fasciocutaneous advancement flaps are a reliable and safe means for coverage of primary as well as recurrent sacral sores. Dissection is easy and defect as large as 20cm can be covered. Keywords: Pressure sore, gluteus maximus flap, sacral sore, wound dehiscence North West General Hospital, Hayatabad Peshawar. RA Afridi Obaidullah Hayatabad Medical Complex, Peshawar. F Khan Correspondence: Dr. Firdous Khan FCPS (Plastic Surgery), Senior Registrar, Plastic & Reconstructive Surgery Unit, Hayatabad Medical Complex, Peshawar firdous25@yahoo.com Introduction: Pressure ulcers, also known as decubitus ulcers or bed-sores, are defined as localized injuries to the skin and underlying tissue as a result of pressure, or pressure in combination with shear and friction 1. They are common in patients with spinal-cord injuries reaching to 39% incidence in these patients 2. Pressure sores can develop anywhere on the body but are mostly located on ischial (30%), trochanteric (20%), sacral (17%), and heel areas (9%). 3 Multiple classification systems have been described, but the one proposed by the National Pressure Sore Advisory Panel Consensus Development Conference (US-NOUAP) is the most commonly used. 4 It divides the lesions from Stage I to IV. Pressure sores are caused mainly by external unrelieved pressure that exceeds the capillary pressure (33 mmhg), leading to ischemic necrosis and shearing and friction 1. Predisposing factors for formation of pressure sores are moisture, neurological conditions, fecal and urinary incontinence, smoking, hypoalbuminemia, alcoholism, and diabetes mellitus. 5,6 The main treatment of pressure sores begins with prevention by optimizing nutrition status, preventing and eradicating infection and relieving pressure. 7 Pressure sores classified as stage I and II can be Pak J Surg 2014; 30(2):

2 Efficacy of gluteus maximus fasciocutaneous v-y advancement flaps for coverage of sacral sore treated conservatively by using optimal nonsurgical ulcer treatment and by eliminating the local and general conditions that interfere with healing. However, if stage III or IV pressure ulcers are present, surgical management is normally required. 8 Debridement of pressure sores in the sacral region often results in excessive soft tissue defects that cannot be closed primarily and are further associated with increased risk of flap ischemia, wound dehiscence and deep infection. 9 Numerous surgical methods have been used to correct these defects, including skin grafting, local flaps, muscle flaps and free flaps. Local flaps in the sacral region are the first choice for reconstructions of sacral defects. Overall, patients with sores are important users of medical resources. They require more nursing time, remain hospitalized for significantly longer periods and incur higher hospital charges. 10 There are different types of gluteus flaps, which can be based on the method of transfer of the flap-such as island flaps, V-Y plasty, rotational flaps or they can be based on the types of tissue included, such as fasciocutaneous or myocutaneous flaps. Although their results are well evaluated in the literature 11, present study describes the efficacy of V-Y fasciocutaneous flap in terms of flap survival, complications and sacral sore recurrence. Patients and methods: This Prospective descriptive study was conducted at Plastic & Reconstructive Surgery Unit, Northwest General Hospital, Peshawar from January 2010 to December Patients were admitted through out-patient department and detailed history, clinical examination and necessary investigations were carried out. Informed consent was taken. A total number of 20 patients with grade 3 and 4 sacral sores were included in the study. Patients with concomitant trochanteric sores were excluded from this study because of risk of not utilizing the same side flap. Likewise patients with albumin level less than 3g/dl were deferred and put on high protein diet until the condition improved. Those patients with 137 severe immunocompromise or terminal illness were also excluded from this study. During the early phase of the treatment, debridement surgeries were performed; regular dressing and appropriate antibiotics coverage for all patients to control infection were prescribed. All patients were put on a standard post-operative regime including keeping suction drain for at least one week and low residue diet in the first week; regular turning of the patients and sitting out of bed to avoid pressure on the flap for two weeks were emphasized. Flaps were inspected daily to detect ischemia, congestion and starting infection. A minimum postoperative follow-up period of 1 year was chosen to provide time for detection of any complication or recurrence of the sore. Surgical Technique: After admission and necessary investigations, written informed consent was taken. The operations were performed under general anesthesia. The patient was put in prone position on operation table and wound thoroughly washed and debrided. The design of gluteus maximus fasciocutaneous advancement flap was marked in a V-Y fashion on either one or both sides of the defect. The incision was carried down to the fascia of the underlying gluteus maximus muscle. The upper and lower arms of the flaps were elevated and advanced on the gluteal muscle toward the midline. The overall result was a vertical midline suture. A suction drain was inserted at the end of procedure to facilitate drainage of blood and discharge in all patients. Statistical Analysis: The data were analyzed through SPSS version 10 and various descriptive statistics were used to calculate frequencies, percentages, means and standard deviation. The numerical data such as age and size of the wound was expressed as Mean ± Standard deviation while the categorical data such as the causes of ulcers, body area distribution, interventional procedures employed and complications observed were expressed as frequency and percentages.

3 138 RA Afridi, F Khan, Obaidullah Grade 4 sacral sore Results: A total of 20 patients were included in this study with age ranges from years of age with mean age ± 29.4 years. In this study 12 (60%) were males while 8 (40%) were females. Causes of sacral sores were spinal cord injury in 12 (60%) of patients, followed by CVA and other medical illnesses in 5 (25%), and 3 (15%) of patients respectively. Patients who were operated were having grade 3 sores in 13 (65%) of patients and grade 4 in 7 (35%) of patients. After debridement, the defect size was 12cm in 8 (40%) of patients, 16cm in 6 (30%) and 20cm in 4 (20%) of patients with average defect size of 16 cm. Gluteus maximus fasciocutaneous V-Y advancement flap was done unilaterally in 8 (40%) of patients and bilaterally in 12 (60%) of patients. All flaps survived without major problem except in 2 (10%) in whom wound dehiscence occurred, but the wound healed without necessitating a secondary operation, followed by seroma formation in 1(5%) of patients. Our results are shown in the figures. Discussion: The number of the patients with pressure ulcers is getting higher, as the percentage of Road traffic accidents (RTA), the elderly and the chronically Defect after wide debridement Spinal cord injuries Cerebrovascular accidents (CVA) Figure 2: Causes of sacral sores Other medical illnesses ill people continuously increases. However meticulous the conservative treatment of stage IV ulcers might be, it is ineffective, especially in non ambulatory patients. 12 Wide surgical debridement to healthy tissue, followed by coverage with well-vascularized tissues and tension-free closure is considered the treatment of choice. 13 Gluteal flaps remain one of the best reconstructive options for sacral defects because they result in a stable and well-vascularized closure. 14 After Minami and colleagues in 1977 reported the use of the gluteus maximus as a musculocutaneous flap for sacral pressure sore coverage, many different methods have been presented using the 15, 16 gluteus maximus muscle. Parry and Mathes introduced the bilateral gluteus maximus musculocutaneous advancement flap, and thereafter, the V-Y advancement method became an established technique for sacral defect closure. 17 Ohjimi and associates modified the musculocutaneous gluteal V-Y advancement method and used it as a fasciocutaneous flap. 18 This helps to close a circular defect by advancing subcutaneous, pedicled triangular flaps. The 19, 20 final midline closure is vertical and straight. Bilateral Flap dissection Final closure in V-Y manner Figure 1: Grade 4 sacral sore in a 35 years old male patient of CVA In this study, the loss of the soft tissue above the sacral bone was restored with a fasciocutaneous flap, taken from the great gluteal muscles in V-Y manner. Perfusion of this flap is optimal because it comes from two arteries- gluteal lower and upper. The flap innervations are provided by gluteal branches of the Ischial nerve. This technique did not result in loss of muscle function because muscle was actually not harvested and this was

4 Efficacy of gluteus maximus fasciocutaneous v-y advancement flaps for coverage of sacral sore Grade 4 sacral sore Final wound closure Figure 3: Grade 3 sacral sore in a 40 years female with spinal cord injury really advantageous in ambulatory patients. Most patients suffering from pressure sores use to be paralyzed or non ambulatory and despite prophylaxis and good wound care, relapses are usually common. Therefore the principle is that when planning a flap for closure, a possibility of collecting another flap with good perfusion must be taken into consideration. However this doesn t seem to be a great problem while utilizing the fasciocutaneous advancement flaps because the flaps can be re elevated and advanced to cover the recurred sacral sore. In current study, unilateral V-Y advancement fasciocutaneous flap was used to close defect as large as 12cm in diameter. For larger than 12 cm wounds, bilateral flaps were then utilized. 21 In our study, the largest defect which we have covered with bilateral V-Y fasciocutaneous gluteal flaps was 20cm in diameter, and the smallest, which was about 12cm in diameter with unilateral fasciocutaneous flap. This is well consistent with the results of Ohjimi et al who covered the defects with unilateral and bilateral gluteal fasciocutaneous V-Y advancement flaps as large as 10-11cm and 15-21cm respectively in their series. 18 The most common complication which occurred in our study was wound dehiscence, which occurred in 10% of patients and seroma formation which occurred in 5% of patients which closely matched with the result of the study done by Edward et al, who showed it to be 17% for dehiscence and infection. 22 Seroma formation was successfully treated with repeated aspiration and dehiscence with regular dressing 2 0 Wound dehiscence Figure 4: Complications encountered and secondary stitching. Seroma formation Conclusion: Gluteul fasciocutaneous advancement flaps are a reliable and safe means of coverage for sacral sore. The dissection is easy and defect as large as 20cm can be covered. Moreover, the flaps are reusable in case of recurrence of sacral sore which is very common in non ambulatory patients. References: 1. Aggrawal A, Sangwan SS, Siwach RC, Batra KM. Gluteus maximus island flap for the repair of sacral pressure sores. Spinal Cord 1996; 34: Giuglea C, Marrinescu S, Florescu IP, Jecon C. Pressure sores- a constant problem for plegic patients and a permanent challenge for plastic surgery. J Med Life 2010; 3: Brem H, Lyder C. Protocol for the successful treatment of pressure ulcers. Am J Surg 2004; 188: Bauer J, Phillips LG. MOC-PSSM CME article: Pressure sores. Plast Reconstr Surg 2008; 121: Bass MJ, Phillips LG. Pressure sores. Curr Probl Surg 2007; 44: Cakmak SK, Gui U, Ozer S, Yigit Z, Gonu M. Risk factors for pressure ulcers. Adv Skin Wound Care 2009; 22: Thoroddsen A. Pressure sore prevalance: a national survey. J Clin Nurs 1999; 8: Sorensen JL, Jorgensen B, Gottrup F. Surgical treatment of pressure ulcers. Am J Surg 2004; 188: Chen TH. Bilateral gluteus maximus V-Y advancement musculocutaneous flaps for the coverage of large sacral pressure sores: Revisit and Refinement. Ann Plast Surg 1995; 35: Yamamoto Y, Tsutsmida A, Murazumi M. Long-term Outcome of pressure sores treated with flap coverage. Plast Reconstr. Surg 1997; 100: Yamamoto Y, Ohura T, Shintomi Y, Sugihara T, Nohira K, Igawa H. Superiority of the Fasciocutaneous flap in reconstruction of sacral pressure sores. Ann Plast Surg 1993; 30: Gusenoff JA, Redett RJ, Nahabedian MY. Outcome for surgical coverage of pressure sores in non-ambulatory, non-paraplegic, elderly patients. Ann. Plast Surg 2002; 48: Miles WK, Chang DW, Kroll SS. Reconstruction of large sacral defects following total sacrectomy. Plast Reconstr 2000; 105(7): Aggarwal A, Sangwan SS, Siwach RC, Batra KM. Gluteus maximus island flap for the repair of sacral pressure sores. Spinal cord 1996; 34:

5 140 RA Afridi, F Khan, Obaidullah 15. Maruyama Y, Nakajima H, Wada M, A gluteus maximus myocutaneous island flap for repair of sacral decubitus ulcer. Br J Plast Surg 1980; 33: Fisher J, Arnold PG, Waldorf J, Woods JE. The gluteus maximus musculocutaneous V-Y advancement flap for large sacral defects. Ann Plast Surg 1983; 11: Parry SW, Mathes SJ. (1982): Bilateral gluteus maximus myocutaneous advancement flaps: sacral coverage for ambulatory patients. Ann Plast Surg 1982; 8: Ohjimi H, Ogata K, Setsu Y, Haraga I. Modification of the gluteus maximus V-Y advancement flap for sacral ulcers: the gluteal fasciocutaneous flap method. Plast Reconstr Surg 1996; 98: Stamate T, Budurca AR. The treatment of the sacral pressure sores in patients with spinal lesions. Acta Neurochir (supply) 2005; 93: Seyhan T, Ertas NM, Bahar T, Borman H. Simplified and versatile use of gluteal perforator flaps for pressure sores. Ann Plast Surg 2008; 60: Amamoto Y, Ohura T, Shintomi Y, Sugihara T, Nohira K, And Igawa H. Superiority Of The Fasciocutaneous Flap In Reconstruction Of Sacral Pressure Sores. Ann Plast Surg 1993; 30: Lewandowicz E, Witmanowski H, Sobieszek D. Selection of surgical technique in treatment of Pressure Sores. Advances in Dermatology and Allergology 2011; 1: 23-9.