Gluteal Flap
Transcript of Gluteal Flap
GLUTEAL FLAP
ARTCILES
1) Michigan – 472) Mathes – 157
ANATOMY
VASCULAR SUPPLY1) Type III vascular supply2) Major Pedicles:
a. Superior gluteal arteriesb. Inferior gluteal arteriesc. From the internal iliac arteriesd. Pass superior and inferior to piriformis
OPTIONS
1) can raise as a single flap2) can raise superior or inferior segments separately
a. this will preserve ambulation3) V-Y advancement flap4) Rotation flap
Gluteus Maximus / Posterior Thigh
ANATOMY
1) most superificial gluteal muscle2) ORIGIN
a. Gluteal line of the posterior ilium and sacrumb. [sacrotuberous ligament]
3) INSERTIONa. greater tuberosity of the femurb. iliotibial band of fascia lata
VASCULAR ANATOMY
1) type 3a. 2 dominant pedicles
ii. inferior gluteal arteriesiii. from the internal iliac artery
2) Both are deep to the gluteus3) above and below inferior piriformis4) 2 minor pedicles at area of insertion
a. first perforator of profunda femorisb. two or three intermuscular branches of the lateral femoral
circumflex vessels
NERVE SUPPLY
1) MOTOR
a. inferior gluteal nerveb. enters with inferior gluteal artery
2) SENSORYa. to skin S1-3 mediallyb. L1-3 laterallyc. posterior cutaneous nerve of the thigh (S1-2)
i. supplies the inferior buttocks and posterior thighii. this can be included in the posterior thigh flap (neurosensory flap)
MUSCLE FUNCTION
1) essential in ambulatory patientsa. must preserve at least half
2) extends hipsa. most powerful extensor of the hip
3) rotates the thigh laterally4) important for
a. runningb. jumpingc. climbingd. stabilizes the pelvis and hip
5) largest muscle in the body.
AREAS OF COVERAGE
STANDARD FLAP
1) PRESSURE SORE COVERGAEa. sacrumb. ipsilateral ischium
GLUTEAL THIGH FLAP (Considered Extended If Inferior Gluteal Muscle Included)
1) ischium2) sacrum3) perineum / vagina
REVERSE FLAP
1) based on perforators from profunda femoris2) posterior lateral thigh
SENORY / FUNCTIONAL TRANSFER
1) take inferior muscle with inferior gluteal nerve for sphincter reconstruction (vagina or anus)2) medially based V-Y advancement maintains sensation3) posterior thigh flap with posterior cutaneous nerve of the thigh maintains sensation4) If isolated on its vascular pedicle the flap can cross midline
TECHNIQUE STANDARD
1) MARKINGS a. mark the muscle boarders
i. sacrum (medial – origin ) ii. greater trochanter of the fermor (lateral - insertion) iii. PSIS (superior - aspect) iv. ischium (inferior – aspect )
2) superior skin island is just inferior to the PSIS3) inferior skin island is immediately superior to the ischial tuberosity
a. for patients at risk of recurrent ulcers it is important to design the skin island as large as possible for future re-advancements
4) incision through skin to identify the superficial fascia - this may be atrophic and hard to identify in patients who have lost gluteal function
5) with elevation of the muscle the insertion fibers are cut and the muscle elevated lateral to medial
6) identification of the piriformis is key to dissectiona. it helps ID siatic nerve and vascular pedicles
7) when standard superior / inferior gluteal flaps are elevated a lighted retractor to elevate gluteus from piriformis is helpful
V-Y ADVANCEMENT FOR SACRAL ULCERS
1) generally based only on superior gluteal vessel and superior half of the muscle2) allows continued ambulation if ambulatory patient3) For ambulatory patients Motor innervation is provided by the inferior gluteal nerve (L5 to
S1-2)a. From sciatic foramen deep surface of the gluteus maximus muscle at level of
piriformis4) ELEVATION – Key points:
a. Division of the entire fibers of insertion or of the superior or inferior half of these fibers is performed
b. fibers of origin are divided at the lateral edge of the sacrumc. piriformis muscle is key
i. to correct division of the muscle in its midportion for segmental elevation of either the superior or inferior half
ii. it is also a guide to the location of the point of entry of the superior and inferior gluteal vessels into the deep surface of the muscle
iii. Initial exposure of the pedicle will avoid injury during the muscle division into its superior and inferior halves
iv. Can be aided with a lighted retractor
INFERIOR GLUTEAL ISLAND FLAP
1) considered 1st choice for ischial ulcersa. can be re-advancedb. large skin paddlec. closed primarilyd. not put into tension with leg motion
2) MARKINGSa. Mid sacrum to greater tuberosity of the fermurb. Skin island centered over the gluteal creasec. Muscle identified at the lateral edge of the ischeal wound
3) SKIN ISLANDa. Medial edge = lateral edge of the ischeal soreb. Design the flap as large as possible without extending into superior gluteal flap or
beyond the greater trochanter of the femur 4) FLAP ELEVATION5) it is helpful to widely expose the anterior surface of the muscle first muscle is divided deep
distally, several centimeters beyond the skin island6) preserve the extension of the inferior gluteal artery and the sciatic nerve as they course onto
the thigh7) Division of the muscle continues laterally and then superiorly, mobilizing only the inferior half of
the gluteus muscle
POSTERIOR THIGH – Gluteal Thigh Flap
1) Based on descending terminal branch of the inferior gluteal artery2) posterior thigh skin flap based between ischial and greater trochanter3) axis of the flap
a. center of the thighb. inferior gluteal artery as it continues on to the posterior thighc. line drawn verticallyd. midway between the greater trochanter and the ischial tuberositye. perpendicular to the gluteal crease
4) if < 12 cm in width direct donor site closure5) distal tip to within 8 cm of the popliteal fossa6) key anatomic structures during the dissection
a. sciatic nerveb. posterior cutaneous nerve (S1-3) & inferior gluteal artery
i. travel together (medial to lateral) around the ischial tuberosity as they exit the gluteal space
ii. lies in the subcutaneous tissue, just below the fascia lata and superficial to the biceps femoris muscle
7) The skin incision over the distal third of the flap is made down through the deep fascia8) posterior femoral cutaneous nerve should be identified at the distal midline
a. descending branch of the inferior gluteal artery is ligated adjacent to the nerve
9) flap is elevated to the level of the gluteal crease (inferior edge of the gluteus maximus muscle) along the plane deep to the fascia
10) rotated into the ischial defect11) traction on the nerve confirms the flap is centered over the nerve which is adherent to the
descending branch of the inferior gluteal vessels12) to extend the flap length cut the inferior half of the gluteus lateral to the pedicle entrance13) Blood flow Doppler study can be used to trace the course of the descending branch of the inferior
gluteal artery during the flap design
MICROVASCULAR TRANPLANT
1) with microvascular transplant little muscle is taken and the skin flap is based on the superior
or inferior edge of the muscle2) superior skin flap centered between PSIS and superior sacrum3) dissect skin off muscle from lateral to medial until perforators are found4) dissect out the perforators
a. withb. or without splitting the superior portion of the muscle
5) inferior skin island centered over the gluteal crease lateral to the scarum6) intial incision at inferior aspect of gluteus to identify descending branch of inferior gluteal
artery7) trace this up to the inferior gluteal artery8) avoid injury to inferior gluteal of sciatic nerves
Below: superior gluteal island flap
Below: skin only flap in ambulatory patient, 2 different cases