Volume 14 / Issue 1 / January-June 2018

Original Article

V–Y advancement gluteus maximus fasciocutaneous flap—A useful flap for sacral defects

Chetan Satish

Sapthagiri Medical College, Bangalore, Karnataka, India

Abstract

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Introduction: This study was done to evaluate the usefulness of V–Y advancement gluteus maximusfasciocutaneous flap in the management of sacral defects.Material and methods: A total of 15 patients with sacral defects either due to sacral pressure sores ordefects following excision of sacral soft tissue tumors were treated using this technique in a single stage.The size of the defect and postoperative complications in each patient were assessed. The follow-up periodwas a minimum of 1 year.Results: All wounds healed with no recurrence. During follow-up, two patients had wound healingproblems with wound discharge which healed with dressings within 2 months.Conclusion: The use of V–Yadvancement gluteus maximus fasciocutaneous flap offers an easy and safe flapin sacral defect reconstruction.

Keywords: Gluteus maximus, sacral defects, V–Y advancement

Address for correspondence: Dr. Chetan Satish, 67, 14th Cross, 1st Block, R.T. Nagar, Bangalore-560032, Karnataka, India.E-mail: drchetansatish5@gmail.com

INTRODUCTION

Sacral defect reconstruction is most commonly needed inthe treatment of sacral pressure sores.

Pressure sores are best defined as soft tissue injuriesresulting from unrelieved pressure over a bonyprominence.[1] Terms such as bedsore or decubitus ulcershould be avoided as they suggest all the sores are a resultof supine positioning.

The sacral region is one of the most frequent sites ofpressure sore development. Debridement of pressuresores in the sacral region often results in excessive softtissue defects that cannot be closed primarily and are

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DOI:10.4103/njps.njps_4_17

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further associated with increased risk of flap ischemia,wound dehiscence, and deep infection.[2]

Sacral defects can also result from tumor excisions mostcommonly sarcomas and rarely desmoid tumors.

Numerous surgical methods have been used to correctthese defects, including skin grafting, local flaps, muscleflaps, and free flaps. Local flaps in the sacral region are thefirst choice for reconstructions of sacral defects.

Overall, patients with pressure sores are important usersof medical resources. They require more nursing time,remain hospitalized for significantly longer periods and

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How to cite this article: Satish C. V–Y advancement gluteus maximusfasciocutaneous flap— A useful flap for sacral defects. Nigerian J Plast Surg2018;14:1-4.

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Satish: V–Y advancement gluteus maximus fasciocutaneous flap for sacral defects

incur higher hospital charges.[3] The aim of our treatmentis to reduce the morbidity of prolonged hospital stay.

PATIENTS AND METHODS

The study period was for 3 years from January 2012 toJanuary 2015. During this time, we managed 13 cases ofsacral pressure sores (eight males and five females) and twocases of sacral sarcomas postexcision defect (both females).

The age range of the patients was from 25 to 70 years.Eight of the cases of sacral pressure sores were inparaplegics secondary to spinal cord injury. In theother five patients who were not paraplegic, senilitywith diabetes was the reason for extended bedconfinement. In addition, two patients had Parkinson’sdisease. Two of the sacral soft tissue tumors weresarcomas in which a wide excision was done.

All the patients with pressure sores had stage IV pressuresores that extended to bone. The sores ranged from 7 to18-cm diameter in size. Seven sores that ranged from 7 to12 cmwere reconstructed with unilateral flap and six soresthat ranged from 12 to 18 cm were reconstructed withbilateral flaps.

The two cases of sacral tumors had a postexcisional defectof about 12-cm diameter and were managed withunilateral V–Y advancement flaps.

OPERATIVE TECHNIQUE

Patients were trained to get accustomed to prone positionat least 1 week prior to surgical procedure and should beon a liquid diet for at least 3 days before the procedure.Adequate bowel preparation is given the night before theprocedure.

Our operative technique was done either under generalanesthesia or spinal anesthesia with patient in proneposition. The first step in case of pressure sores was todebride the wound bed and excise all unhealthy tissueincluding any bursa and underlying bone. In case of thesarcomas, the procedure was done after wide excision oftumor by the oncosurgeon.

The V–Y advancement flap is planned to close the V intoa Y after closure of the defect. The length of the flapdepended on the size of the defect and can be extended upto the trochanters. The elasticity and redundancy ofgluteal region also determine the achievement ofoptimal wound closure.

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The flap is completely islanded and incision is deepenedup to the gluteus maximus fascia. We tend to cut the fasciaas it helps in the mobilization of flap significantly,although damage to some perforators of gluteusmaximus can occur.[4] Care is taken not to injure theunderlying gluteus maximus muscle.

The flap is then closed initially on the defect side toreduce any tension over a suction drain. Closure of thetail of the flap or donor defect is done at the end as theelasticity of the gluteal region helps in easy mobilizationand closure. The flap is snugly fit into defect, andclosure is done in two layers one for subcutaneoustissue and another for skin. This is done to reducethe tension of single layer of skin sutures. The suctiondrains are usually kept for about 5 to 7 days and thepatient is nursed in prone position for 2 weeks. Thepatient needs to be on liquid diet for at least 2 weeksafter the procedure. The stitches are usually removedafter 2 weeks.

The patient needs to be on a air bed after the procedurewith frequent position changes, and the air bed needs tobe continued in case of pressure sores even after woundhealing to prevent recurrences.

The patient can subsequently lie on the flap after 2 weeksor after wounds have healed.

RESULTS

The demographic data of the 15 patients including age,sex, size of ulcer, type, and complications are summarizedin Table 1.

The minimum follow-up period was 1 year.

All the flaps healed well, although in two cases, we hadpersistent discharge probably due to low-grade infectionwhich healed conservatively with dressings within 2months [Figures 1–4].

DISCUSSION

However, meticulous the conservative treatment of stageIV pressure ulcers might be, it is ineffective, especially innonambulatory patients.[4]

Wide surgical debridement to healthy tissue, followed bycoverage with well-vascularized tissues and tension-freeclosure, is considered the treatment of choice.[5]

igerian Journal of Plastic Surgery | Vol 14 | Issue 1 | January-June 2018

Table 1: Table of patients

Serial no. Age Sex Defect size (cm diameter) Cause Type Complications1 30 Male 11 Pressure sore Unilateral None2 40 Male 15 Pressure sore Bilateral Persistent discharge—2 months3 32 Female 10 Pressure sore Unilateral None4 60 Male 15 Pressure sore Bilateral None5 55 Female 9 Pressure sore Unilateral None6 25 Female 13 Pressure sore Bilateral None7 48 Male 11 Pressure sore Unilateral Persistent discharge—2 months8 45 Female 12 Sarcoma Unilateral None9 39 Male 14 Pressure sore Bilateral None10 51 Female 7 Pressure sore Unilateral None11 50 Female 12 Sarcoma Unilateral None12 70 Male 8 Pressure sore Unilateral None13 57 Female 15 Pressure sore Bilateral None14 37 Male 18 Pressure sore Bilateral None15 42 Male 10 Pressure sore Unilateral None

Figure 1: Preoperative big sacral pressure sore

Figure 2: Postoperative well-settled bilateral V–Y advancement flap

Figure 3: Preoperative sacral sarcoma

Figure 4: Postoperative result of unilateral V–Y advancement forsacral sarcoma

Satish: V–Y advancement gluteus maximus fasciocutaneous flap for sacral defects

As for sacral pressure ulcers, reconstruction can mainly beachieved with the use of local gluteal flaps, eitherfasciocutaneous or musculocutaneous. Both types ofthe flaps possess certain advantages and disadvantages.

Nigerian Journal of Plastic Surgery | Vol 14 | Issue 1 | January-June 2018

Gluteal musculocutaneous flaps provide well-vascularizedtissue, but gluteus muscle harvesting inflicts a seriousfunctional deficit in ambulatory patients.[6-8]

Also, sacrifice of the muscle, either functional or not,deprives the patients from future use in case of pressureulcer relapse. Gluteal fasciocutaneous flaps when

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Satish: V–Y advancement gluteus maximus fasciocutaneous flap for sacral defects

compared with musculocutaneous flaps, except for beinggluteal muscle sparing, seem to be more resistant topressure and easier to harvest. They also seem toensure longer pressure-ulcer-free survival rate.[7]

Unilateral V–Yadvancement fasciocutaneous flaps can beused to close defect that required coverage of 10 cm indiameter. If the wound is larger or unilateral flap wouldhave to be closed under tension, bilateral flaps areindicated.[8]

The largest defects that were closed with unilateral andbilateral gluteal fasciocutaneous V–Y advancement flapswere 10 to 11 cm and 15 to 21 cm, respectively, in theseries of Ohjimi et al.[9]

The largest defect that we closed with a unilateraladvancement flap was 12 cm in diameter, and the largestone thatweclosedwithbilateral flapswas18 cm indiameter.

Several modifications of V–Y advancement glutealfasciocutaneous flaps have been reported. Mithat-Akanet al.[10] introduced the “Pac Man” flap, and Ay et al.[11]

described the interdigitating technique. In both techniques,the midline vertical scar was broken in a Z-plasty pattern.Another modification, introduced by Borman andMaral,[6] was the gluteal fasciocutaneous rotation-advancement flap. Although all the aforementioned flapsminimized tension along the midline, they did not manageto obliterate dead space and also distorted or deleted thenatal cleft.

If the subcutaneous tissue loss beyond thewoundperipheryis extensive, it is difficult to obliterate the dead spacewith a fasciocutaneous flap. A musculocutaneous flapmay be more appropriate for longer and deep ulcer asother authors suggested. If the subcutaneous tissue loss isminimal, a fasciocutaneous flap will fill the ulcer defectwell in most cases.[12]

In our series of 15 cases which also included two cases ofsacral soft tissue sarcomas,we cut the gluteusmaximus fasciawhich greatly helped in mobilization of the flaps. We alsotend to close the recipient defect initially to avoid any tensionon suture line. This is because the redundancy of tissuesin gluteal region will easily allow closure of donor defect.These two steps differ from the series of El Hawary.[13]

CONCLUSION

We find the V–Y advancement gluteus maximusfasciocutaneous flap to be very useful in reconstruction

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of sacral defects. It is simple and easy to perform withminimal blood loss, does not need any skin grafting, hasminimal morbidity compared to muscle flaps in terms offunctional deficit, can be reused in case of recurrences.

In our series, we used unilateral flap for defects of up to12-cm diameter and bilateral flap for defects more than12-cm diameter. Further the transverse dimension of flapwas taken up to the trochanters in all cases.

However, we do stress the importance of goodpostoperative care in form of air mattresses, frequentposition change, healthy nutrition, and compliance toliquid diet to avoid fecal soiling of the area in ensuringthe success of this flap.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

REFERENCES

1. Park C, Park BY. Fasciocutaneous V-Y advancement flap for repair ofsacral defects. Ann Plast Surg 1988;21:23-6.

2. Chen TH. Bilateral gluteus maximus V-Y advancementmusculocutaneous flaps for the coverage of large sacral pressuresores: Revisit and refinement. Ann Plast Surg 1995;35:492.

3. Yamamoto Y, Tsutsumida A, Murazumi M. Long-term outcome ofpressure sores treated with flap coverage. Plast Reconstr Surg1997;100:1212-7.

4. Gusenoff JA, Redett RJ, Nahabedian MY. Outcomes for surgicalcoverage of pressure sores in nonambulatory, nonparaplegic, elderlypatients. Ann Plast Surg 2002;48:633-40.

5. Miles WK, Chang DW, Kroll SS. Reconstruction of large sacraldefects following total sacrectomy. Plast Reconstr Surg 2000;105:2387.

6. Borman H, Maral T. The gluteal fasciocutaneous rotationadvancement flap with V–Y closure in the management of sacralpressure sores. Plast Reconstr Surg 2002;109:2325-9.

7. Hung SJ, Chen HC,Wei FC. Free flaps for reconstruction of the lowerback and sacral area. Microsurgery 2000;20:72.

8. Amamoto Y, Ohura T, Shintomi Y, Sugihara T, Nohira K, Igawa H.Superiority of the fasciocutaneous flap in reconstruction of sacralpressure sores. Ann Plast Surg 1993;30:116-21.

9. Ohjimi H, Ogata K, Setsu Y, Haraga I. Modification of the gluteusmaximus V–Y advancement flap for sacral ulcers: The glutealfasciocutaneous flap method. Plast Reconstr Surg 1996;98:1247-52.

10. Mithat-Akan IM, Sungur NO, Zdemi R. “Pac Man” flap for closure ofpressure sores. Ann Plast Surg 2001;46:421-5.

11. Ay A, Aytekin O, Aytekin A. Interdigitating fascio-cutaneous glutealV-Y advancement flaps for reconstruction of sacral defects. Ann PlastSurg 2003;50:636-8.

12. Ulusoy MG, Akan IM, Sensoz O, Ozdemir R. Bilateral extended V-Yadvancement flap. Ann Plast Surg 2001;46:5.

13. El Hawary Y. The reusable V–Y advancement gluteus maximusfasciocutaneous flap in management of sacral pressure sores. JPlast Reconstr Surg 2013;37:125-9.

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