Masaki Fujioka, Department of Plastic and Reconstructive Surgery, National Hospital Organization Nagasaki Medical Center,
Japan, Tel: +81 0957-52-3121; Fax: +81 0957-54-0292; E-mail:
Keywords: Pressure ulcers; Perforator flap; Rotation flap; Postsurgical complications; Sacral pressure ulcer
In recent years, the development of perforator flap surgery has increased the number of potential donor sites, because this type of flap can be supplied by any cutaneous perforator and donor site morbidity can be reduced. The use of gluteal perforator flap from gluteal vessels is also spreading for the resurfacing sacral pressure ulcer. Now, we can use both perforator and rotation flaps; however, the literature is scant regarding which is the better procedure.
As a common complication a seroma is described as serous fluid collection under a skin flap or in a dead space following debridement and/or flap dissection and the marked accumulation of exudate [8]. Prolonged drainage is troublesome because it can cause wound dehiscence, lead to fistulae, and increase the risk of infection, which can significantly prolong wound healing [9].
The purpose of this retrospective study was to investigate differences in the duration of wound healing and the occurrence of postsurgical complications between perforator and rotation flaps to help determine which might be the better procedure to resurface pressure ulcers in the sacral region.
Hospitals: Thirty-one patients with Stage IV sacral pressure ulcers underwent surgical wound resurfacing with flaps in the National Organization Nagasaki Medical Center from 2012 through 2014. A retrospective review of their records was conducted.
Ethical Considerations: The procedures were in accordance with the Ethical Standards and Internal Review Board of our institutional committee (National Hospital Organization Nagasaki Medical Center) on human experimentation in 2015 (registration number 27020). All patients signed an informed consent of this study.
Participants: We treated all Stage IV pressure ulcers until they healed, and investigated them retrospectively. We included all patients in a consecutive sample.
Patients primary disease varied. We included all patients and no diseases were excluded in this study. Among these patients, 20 pressure ulcers were reconstructed using perforator flaps (perforator flap group, 9 men, 11 women), and 11 were reconstructed using rotation flaps (rotation flap group, 7 men, 4 women). Primary disease in perforator flap group was elderly 7, spinal cord injury 6, cerebral infarction 4, cerebral hemorrhage 3. All patients with spinal cord injury was classified into Grade A (complete neurological injury) categories in Frankel Classification grading system and those in rotation flap group were elderly 3, spinal cord injury 3, cerebral infarction 3, cerebral hemorrhage 1 (Tables 1,2). As the perforator flap surgery was newly developed technique, early 11 patients underwent conventional rotation flap resurfacing, and late 20 patients did perforator flap resurfacing during research period.
Surgical procedure: The same surgical team performed all surgeries. Patients underwent surgical debridement and wound bed preparation in advance of flap surgery. The surgical procedures are standard techniques and include the thorough cleansing and debridement of all necrotic and infectious tissues and removal of the sacral bony prominence. As fasciocutaneous flaps depend on the deep fascia, subcutaneous tissue and skin for its vascular supply, thus gluteal fasciocutaneous rotation flap could be designed freely [10,11]. In this study, the gluteal rotation flap was design at the first quarters to be large enough to cover the sacral defect by swinging in a wide arc. Both perforator and rotation flaps are elevated above the gluteal muscle layer [12-15]. Postoperatively, a negative pressure drain was placed under the flaps for drainage until the exudate decreased to < 10 ml/day. Penicillin (or cephalosporin) and anaerobic coverage (clindamycin) were used for 3 days.Patients were provided with a body pressure dispersion mattress (Bloom®, Cape Co. Ltd., Yokosuka, Japan) for 2 weeks. Two weeks after surgery, they were provided usual bed or wheelchair pressure gradually on the flap being permitted.
Data collection and analysis: Data on patient's body weight, wound size, laboratory data including serum Albumin (Alb) and Hemoglobin (Hb), intraoperative bleeding, and the duration of the operation and anesthesia in those who underwent sacral pressure ulcer resurfacing with perforator or rotation flaps were extracted from patient charts (Table 1). Patients' body weight, wound size, and laboratory data were examined as a pre-surgical check a few days before surgery. The exudate quantity, wound separation, flap necrosis, and development of infection were also extracted. Wound healing was determined when all sutures were removed without wound complications, such as a seroma, fistulae, infection, flap necrosis, or wound dehiscence [16,17].
If these complications were noted, they were managed using drainage, re-operation, or the administration of antibiotics. In such cases, once the problems were resolved and no further treatment was required, the wound was recorded as being healed.
Measurements |
Median (Range) |
P value |
|
Age (years old) |
Perforator flap group |
60 (18-90) |
0.75 |
Rotation flap group |
58 (37-87) |
||
Body weight (Kg) |
Perforator flap group |
61 (33-80) |
0.31 |
Rotation flap group |
57 (20 -79) |
||
Wound size (cm2) |
Perforator flap group |
49 (6 - 140) |
0.15 |
Rotation flap group |
42 (9 - 80) |
||
Alb (g/dl) |
Perforator flap group |
2.7 (1.8 - 4.2) |
0.08 |
Rotation flap group |
3.3 (2.9 - 4.2) |
||
Hb (g/dl) |
Perforator flap group |
9.8 ( 6.3 - 14.0) |
0.08 |
Rotation flap group |
12.2 (7.6 - 17.6) |
||
Intraoperative bleeding (ml) |
Perforator flap group |
50 (20- 345) |
0.92 |
Rotation flap group |
72 (20 - 220) |
||
Operation time (minutes) |
Perforator flap group |
111 (30 - 145) |
0.64 |
Rotation flap group |
120 (49 - 166) |
||
Anesthesia time (minutes) |
Perforator flap group |
211(106 - 300) |
0.34 |
Rotation flap group |
235 (75 - 331) |
Primary disease |
Duration to heal (Days) |
Complication |
Seroma |
Wound infection |
Partial necrosis |
Wound separation |
Additional treatment |
Relapse |
|
1 |
elderly |
58 |
○ |
○ |
Free skin graft |
||||
2 |
elderly |
15 |
|||||||
3 |
spinal cord injury/paraplegic |
17 |
○ |
||||||
4 |
Cerebral infarction/ hemiplegic |
10 |
|||||||
5 |
spinal cord injury/paraplegic |
17 |
DM |
||||||
6 |
cerebral infarction/ hemiplegic |
10 |
|||||||
7 |
elderly |
10 |
|||||||
8 |
elderly |
30 |
RA |
○ |
Sclerotherapy |
||||
9 |
spinal cord injury/paraplegic |
17 |
|||||||
10 |
cerebral infarction/ hemiplegic |
14 |
|||||||
11 |
cerebral infarction/ hemiplegic |
20 |
|||||||
12 |
elderly |
35 |
○ |
re-suture |
|||||
13 |
elderly |
14 |
|||||||
14 |
cerebral hemorrhage/hemiplegic |
50 |
DM |
○ |
Free skin graft |
||||
15 |
cerebral hemorrhage/hemiplegic |
14 |
|||||||
16 |
spinal cord injury/paraplegic |
16 |
|||||||
17 |
elderly |
44 |
DM |
○ |
Sclerotherapy |
||||
18 |
cerebral hemorrhage/hemiplegic |
10 |
|||||||
19 |
spinal cord injury/paraplegic |
21 |
|||||||
20 |
spinal cord injury/paraplegic |
10 |
Primary disease |
Duration to heal (Days) |
Complication |
Seroma |
Wound infection |
Partial necrosis |
Wound separation |
Additional treatment |
Relapse |
|
1 |
elderly |
14 |
Malignant Lymphoma |
○ |
○ |
||||
2 |
elderly |
20 |
RA |
○ |
|||||
3 |
spinal cord injury/paraplegic |
35 |
RA,DM |
○ |
|||||
4 |
cerebral infarction/ hemiplegic |
34 |
○ |
||||||
5 |
spinal cord injury/paraplegic |
80 |
○ |
○ |
|||||
6 |
cerebral infarction/ hemiplegic |
23 |
○ |
○ |
|||||
7 |
elderly |
49 |
○ |
○ |
Perfolator flap |
||||
8 |
spinal cord injury/paraplegic |
55 |
○ |
Sclerotherapy |
○ |
||||
9 |
cerebral hemorrhage/hemiplegic |
70 |
DM |
○ |
○ |
||||
10 |
spinal cord injury/paraplegic |
11 |
|||||||
11 |
cerebral infarction/ hemiplegic |
12 |
|
Duration to heal (Days) |
Complication |
Seroma |
Wound infection |
Partial necrosis |
Wound separation |
Additional treatment |
Relapse |
1 |
14 |
Malignant Lymphoma |
○ |
|
○ |
|
|
|
2 |
20 |
RA |
○ |
|
|
|
|
|
3 |
35 |
RA,DM |
○ |
|
|
|
|
|
4 |
34 |
|
○ |
|
|
|
|
|
5 |
80 |
|
○ |
○ |
|
|
|
|
6 |
23 |
|
○ |
|
|
○ |
|
|
7 |
49 |
|
○ |
|
|
○ |
Perfolator flap |
|
8 |
55 |
|
○ |
|
|
|
Sclerotherapy |
○ |
9 |
70 |
DM |
○ |
|
|
○ |
|
|
10 |
11 |
|
|
|
|
|
|
|
11 |
12 |
|
|
|
|
|
|
|
The known advantages of using perforator flaps over traditional flaps include reduced bleeding, preservation of the muscle and its function, and versatility of the flap design that yields a better match to the defect [23]. To resurface a sacral round pressure ulcer with a 7-cm diameter, the area to elevate a perforator flap is about 60 cm2, on the other hand, that for a fasciocutaneous rotation flap is approximately 120 cm2. A perforator flap requires half the area of fascial dissection compared to a fasciocutaneous rotation flap (Figures 4,5). It is considered that a larger dissection causes both more bleeding and a larger dead space, consequently, resulting in a higher rate seroma development. The postoperative development of a seroma increased the time to healing.
- The National Pressure Ulcer Advisory Panel (NPUAP) serves as the authoritative voice for improved patient outcomes in pressure ulcer prevention and treatment through public policy, education and research. NPUAP Pressure Ulcer Stages/Categories.
- Black J, Baharestani M, Cuddigan J, Dorner B, Edsberg L, Langemo D, et al. National Pressure Ulcer Advisory Panel's updated pressure ulcer staging system. Dermatol Nurs. 2007; 19(4):343-9.
- Bluestein D, Javaheri A. Pressure ulcers: prevention, evaluation, and management. Am Fam Physician. 2008; 78(10):1186-94.
- Livesley NJ, Chow AW. Infected pressure ulcers in elderly individuals. Clin Infect Dis. 2002; 35(11):1390-6.
- Marriott R, Rubayi S. Successful truncated osteomyelitis treatment for chronic osteomyelitis secondary to pressure ulcers in spinal cord injury patients. Ann Plast Surg. 2008; 61(4):425-9. doi: 10.1097/ SAP.0b013e318162f257.
- International Guideline. Treatment of Pressure Ulcers: Quick Reference Guide. European Pressure Ulcer Advisory Panel &National Pressure Ulcer Advisory Panel 2009.
- Stevenson TR, Pollock RA, Rohrich RJ, VanderKolk CA. The gluteus maximus musculocutaneous island flap: refinements in design and application. Plast Reconstr Surg. 1987; 79(5):761-8.
- Bailey SH, Oni G, Guevara R, Wong C, Saint-Cyr M. Latissimus dorsi donor-site morbidity: the combination of quilting and fibrin sealant reduce length of drain placement and seroma rate. Ann Plast Surg. 2012; 68(6):555-8. doi: 10.1097/SAP.0b013e318216b65c
- Srivastava V, Basu S, Shukla VK. Seroma formation after breast cancer surgery: what we have learned in the last two decades. J Breast Cancer. 2012; 15(4):373-80. doi: 10.4048/jbc.2012.15.4.373.
- Diaz S, Li X, Rodríguez L, Salgado CJ. Update in the Surgical Management of Decubitus Ulcers. Anaplastology. 2013; 2(3):113. doi: 10.4172/2161-1173.1000113.
- Levine SM, Sinno S, Levine JP, Saadeh PB. Current Thoughts for the Prevention and Treatment of Pressure Ulcers Using the Evidence to Determine Fact or Fiction. Ann Surg. 2013; 257(4):603-8. doi: 10.1097/SLA.0b013e318285516a.
- Ahmadzadeh R, Bergeron L, Tang M, Morris SF. The superior and inferior gluteal artery perforator flaps. Plast Reconstr Surg. 2007; 120(6):1551-6.
- Masaki F, Shuhei Y, Riko K. A technique to avoid a dog-ear deformity on buttock using a "pigeon head" modification of the rotation flap. Wounds. 2007; 19(3):69-72.
- Windhofer Ch, Michlits W, Gruber S, Papp Ch. Reconstruction in the buttock region using the local fasciocutaneous infragluteal (FCI) flap. J Plast Reconstr Aesthet Surg. 2010; 63(1):126-32. doi: 10.1016/j. bjps.2008.08.050.
- 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(2):116-21.
- Käser SA, Zengaffinen R, Uhlmann M, Glaser C, Maurer CA. Primary wound closure with a Limberg flap vs. secondary wound healing after excision of a pilonidal sinus: a multicentre randomised controlled study. Int J Colorectal Dis. 2015; 30(1):97-103. doi: 10.1007/s00384- 014-2057-x.
- Weaver TS, Wester JL, Gleysteen JP, Peck JJ, Wax MK. Surgical outcomes in the elderly patient after osteocutaneous free flap transfer. Laryngoscope. 2014; 124(11):2484-8. doi: 10.1002/lary.24762.
- Yamamoto Y, Tsutsumida A, Murazumi M, Sugihara T. Long-term outcome of pressure sores treated with flap coverage. Plast Reconstr Surg. 1997; 100(5):1212-7.
- Fujioka M, Hayashida K, Morooka S, Saijo H. A retrospective comparison of perforator and rotation flaps for the closure of extensive Stage IV sacral pressure ulcers. Ostomy Wound Manage. 2014; 60(4):42-8.
- Koshima I, Moriguchi T, Soeda S, Kawata S, Ohta S, Ikeda A. The gluteal perforato-based flap for repair of sacral pressure sores. Plast Reconstr Surg. 1993; 91(4):678-83.
- Lin PY, Kuo YR, Tsai YT. A reusable perforator-preserving gluteal artery-based rotation fasciocutaneous flap for pressure sore reconstruction. Microsurgery. 2012; 32(3):189-95. doi: 10.1002/ micr.20982.
- Xu Y, Hai H, Liang Z, Feng S, Wang C. Pedicled fasciocutaneous flap of multi-island design for large sacral defects. Clin Orthop Relat Res. 2009; 467(8):2135-41. doi: 10.1007/s11999-008-0643-3.
- Leow M, Limm J, Lim TC. The superior gluteal artery perforator flap for the closure of sacral sores. Singapore Med J. 2004; 45(1):37-9.