Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 14  |  Issue : 1  |  Page : 1-4

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


Sapthagiri Medical College, Bangalore, Karnataka, India

Date of Web Publication10-Aug-2018

Correspondence Address:
Dr. Chetan Satish
67, 14th Cross, 1st Block, R.T. Nagar, Bangalore-560032, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njps.njps_4_17

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  Abstract 

Introduction: This study was done to evaluate the usefulness of V–Y advancement gluteus maximus fasciocutaneous flap in the management of sacral defects. Material and methods: A total of 15 patients with sacral defects either due to sacral pressure sores or defects 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 period was a minimum of 1 year. Results: All wounds healed with no recurrence. During follow-up, two patients had wound healing problems with wound discharge which healed with dressings within 2 months. Conclusion: The use of V–Y advancement gluteus maximus fasciocutaneous flap offers an easy and safe flap in sacral defect reconstruction.

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


How to cite this article:
Satish C. V–Y advancement gluteus maximus fasciocutaneous flap—A useful flap for sacral defects. Nigerian J Plast Surg 2018;14:1-4

How to cite this URL:
Satish C. V–Y advancement gluteus maximus fasciocutaneous flap—A useful flap for sacral defects. Nigerian J Plast Surg [serial online] 2018 [cited 2018 Oct 16];14:1-4. Available from: http://www.njps.org/text.asp?2018/14/1/1/238813


  Introduction Top


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

Pressure sores are best defined as soft tissue injuries resulting from unrelieved pressure over a bony prominence.[1] Terms such as bedsore or decubitus ulcer should be avoided as they suggest all the sores are a result of supine positioning.

The sacral region is one of the most frequent sites of pressure sore development. 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.[2]

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

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 pressure sores are important users of medical resources. They require more nursing time, remain hospitalized for significantly longer periods and incur higher hospital charges.[3] The aim of our treatment is to reduce the morbidity of prolonged hospital stay.


  Patients and methods Top


The study period was for 3 years from January 2012 to January 2015. During this time, we managed 13 cases of sacral pressure sores (eight males and five females) and two cases 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 in paraplegics secondary to spinal cord injury. In the other five patients who were not paraplegic, senility with diabetes was the reason for extended bed confinement. In addition, two patients had Parkinson’s disease. Two of the sacral soft tissue tumors were sarcomas in which a wide excision was done.

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

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


  Operative technique Top


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

Our operative technique was done either under general anesthesia or spinal anesthesia with patient in prone position. The first step in case of pressure sores was to debride the wound bed and excise all unhealthy tissue including any bursa and underlying bone. In case of the sarcomas, the procedure was done after wide excision of tumor by the oncosurgeon.

The V–Y advancement flap is planned to close the V into a Y after closure of the defect. The length of the flap depended on the size of the defect and can be extended up to the trochanters. The elasticity and redundancy of gluteal region also determine the achievement of optimal wound closure.

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

The flap is then closed initially on the defect side to reduce any tension over a suction drain. Closure of the tail of the flap or donor defect is done at the end as the elasticity of the gluteal region helps in easy mobilization and closure. The flap is snugly fit into defect, and closure is done in two layers one for subcutaneous tissue and another for skin. This is done to reduce the tension of single layer of skin sutures. The suction drains are usually kept for about 5 to 7 days and the patient is nursed in prone position for 2 weeks. The patient needs to be on liquid diet for at least 2 weeks after the procedure. The stitches are usually removed after 2 weeks.

The patient needs to be on a air bed after the procedure with frequent position changes, and the air bed needs to be continued in case of pressure sores even after wound healing to prevent recurrences.

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


  Results Top


The demographic data of the 15 patients including age, sex, size of ulcer, type, and complications are summarized in [Table 1].
Table 1: Table of patients

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The minimum follow-up period was 1 year.

All the flaps healed well, although in two cases, we had persistent discharge probably due to low-grade infection which healed conservatively with dressings within 2 months [[Figure 1],[Figure 2],[Figure 3],[Figure 4]].
Figure 1: Preoperative big sacral pressure sore

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

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Figure 3: Preoperative sacral sarcoma

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

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  Discussion Top


However, meticulous the conservative treatment of stage IV pressure ulcers might be, it is ineffective, especially in nonambulatory patients.[4]

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

As for sacral pressure ulcers, reconstruction can mainly be achieved with the use of local gluteal flaps, either fasciocutaneous or musculocutaneous. Both types of the flaps possess certain advantages and disadvantages.

Gluteal musculocutaneous flaps provide well-vascularized tissue, but gluteus muscle harvesting inflicts a serious functional deficit in ambulatory patients.[6],[7],[8]

Also, sacrifice of the muscle, either functional or not, deprives the patients from future use in case of pressure ulcer relapse. Gluteal fasciocutaneous flaps when compared with musculocutaneous flaps, except for being gluteal muscle sparing, seem to be more resistant to pressure and easier to harvest. They also seem to ensure longer pressure-ulcer-free survival rate.[7]

Unilateral V–Y advancement fasciocutaneous flaps can be used to close defect that required coverage of 10 cm in diameter. If the wound is larger or unilateral flap would have to be closed under tension, bilateral flaps are indicated.[8]

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

The largest defect that we closed with a unilateral advancement flap was 12 cm in diameter, and the largest one that we closed with bilateral flaps was 18 cm in diameter.

Several modifications of V–Y advancement gluteal fasciocutaneous flaps have been reported. Mithat-Akan et 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 and Maral,[6] was the gluteal fasciocutaneous rotation-advancement flap. Although all the aforementioned flaps minimized tension along the midline, they did not manage to obliterate dead space and also distorted or deleted the natal cleft.

If the subcutaneous tissue loss beyond the wound periphery is extensive, it is difficult to obliterate the dead space with a fasciocutaneous flap. A musculocutaneous flap may be more appropriate for longer and deep ulcer as other authors suggested. If the subcutaneous tissue loss is minimal, a fasciocutaneous flap will fill the ulcer defect well in most cases.[12]

In our series of 15 cases which also included two cases of sacral soft tissue sarcomas, we cut the gluteus maximus fascia which greatly helped in mobilization of the flaps. We also tend to close the recipient defect initially to avoid any tension on suture line. This is because the redundancy of tissues in gluteal region will easily allow closure of donor defect. These two steps differ from the series of El Hawary.[13]


  Conclusion Top


We find the V–Y advancement gluteus maximus fasciocutaneous flap to be very useful in reconstruction of sacral defects. It is simple and easy to perform with minimal blood loss, does not need any skin grafting, has minimal morbidity compared to muscle flaps in terms of functional deficit, can be reused in case of recurrences.

In our series, we used unilateral flap for defects of up to 12-cm diameter and bilateral flap for defects more than 12-cm diameter. Further the transverse dimension of flap was taken up to the trochanters in all cases.

However, we do stress the importance of good postoperative care in form of air mattresses, frequent position change, healthy nutrition, and compliance to liquid diet to avoid fecal soiling of the area in ensuring the success of this flap.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Park C, Park BY. Fasciocutaneous V-Y advancement flap for repair of sacral defects. Ann Plast Surg 1988;21:23-6.  Back to cited text no. 1
    
2.
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;35:492.  Back to cited text no. 2
    
3.
Yamamoto Y, Tsutsumida A, Murazumi M. Long-term outcome of pressure sores treated with flap coverage. Plast Reconstr Surg 1997;100:1212-7.  Back to cited text no. 3
    
4.
Gusenoff JA, Redett RJ, Nahabedian MY. Outcomes for surgical coverage of pressure sores in nonambulatory, nonparaplegic, elderly patients. Ann Plast Surg 2002;48:633-40.  Back to cited text no. 4
    
5.
Miles WK, Chang DW, Kroll SS. Reconstruction of large sacral defects following total sacrectomy. Plast Reconstr Surg 2000;105:2387.  Back to cited text no. 5
    
6.
Borman H, Maral T. The gluteal fasciocutaneous rotation advancement flap with V–Y closure in the management of sacral pressure sores. Plast Reconstr Surg 2002;109:2325-9.  Back to cited text no. 6
    
7.
Hung SJ, Chen HC, Wei FC. Free flaps for reconstruction of the lower back and sacral area. Microsurgery 2000;20:72.  Back to cited text no. 7
    
8.
Amamoto 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;30:116-21.  Back to cited text no. 8
    
9.
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;98:1247-52.  Back to cited text no. 9
    
10.
Mithat-Akan IM, Sungur NO, Zdemi R. “Pac Man” flap for closure of pressure sores. Ann Plast Surg 2001;46:421-5.  Back to cited text no. 10
    
11.
Ay A, Aytekin O, Aytekin A. Interdigitating fascio-cutaneous gluteal V-Y advancement flaps for reconstruction of sacral defects. Ann Plast Surg 2003;50:636-8.  Back to cited text no. 11
    
12.
Ulusoy MG, Akan IM, Sensoz O, Ozdemir R. Bilateral extended V-Y advancement flap. Ann Plast Surg 2001;46:5.  Back to cited text no. 12
    
13.
El Hawary Y. The reusable V–Y advancement gluteus maximus fasciocutaneous flap in management of sacral pressure sores. J Plast Reconstr Surg 2013;37:125-9.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]



 

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  In this article
Abstract
Introduction
Patients and methods
Operative technique
Results
Discussion
Conclusion
References
Article Figures
Article Tables

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