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CME Trunk, Abdomen, And Pressure Sore Reconstruction

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CME Trunk, Abdomen, and Pressure Sore Reconstruction Salah Rubayi, M.D. Bala S. Chandrasekhar, M.D. Downey and Los Angeles, Calif. Learning Objectives: After reading this article, the participant should be able to: 1. Describe the principles of wound closure, torso reconstruction, and pressure sore reconstruction. 2. Outline standard options to treat defects of the chest, abdomen, and back and pressure ulcers in all anatomical areas. 3. Manage and prevent pressure ulcers. Summary: Chest wall reconstruction is indicated following tumor resection, radi- ation wound breakdown, or intrathoracic sepsis. Principles of wound closure and chest wall stabilization, where indicated, are discussed. Principles of abdominal wall reconstruction continue to evolve with the introduction of newer bioprosthetics and the application of functional concepts for wound closure. The authors illustrate these principles using commonly encountered clinical scenarios and guidelines to achieve predictable results. Pressure ulcers continue to be devastating complica- tions to patients’ health and a functional hazard when they occur in the bedridden, in patients with spinal cord injuries, and in patients with neuromuscular disease. Management of pressure ulcers is also very expensive. The authors describe stan- dard options to treat defects of the chest, abdomen, and back and pressure ulcers in all anatomical areas. A comprehensive understanding of principles and tech- niques will allow practitioners to approach difficult issues of torso reconstruction and pressure sores with a rational confidence and an expectation of generally satisfactory outcomes. With pressure ulcers, prevention remains the primary goal. Patient education and compliance coupled with a multidisciplinary team approach can reduce their occurrence significantly. Surgical management includes appro- priate patient selection, adequate de ´bridement, soft-tissue coverage, and use of flaps that will not limit future reconstructions if needed. Postoperatively, a strict protocol should be adapted to ensure the success of the flap procedure. Several myocuta- neous flaps commonly used for the surgical management of pressure are discussed. Commonly used flaps in chest and abdominal wall reconstruction are discussed and these should be useful for the practicing plastic surgeon. (Plast. Reconstr. Surg. 128: 201e, 2011.) CHEST WALL RECONSTRUCTION A cquired chest wall defects result from trauma, tumor excision, radiation injury, complica- tion caused by cardiac bypass surgery (Fig. 1), or sepsis from intrathoracic disease, such as bron- chopleural fistulas. 1 Full-thickness lateral chest wall defects and those involving multiple rib resections may also cause a flail chest. 2,3 Reconstructive goals include eradication of infection, airtight pleural cav- ity seal, skeletal stabilization, and wound closure. (See Video 1, which contains case studies that dem- onstrate principles of chest and abdominal wall re- construction, available in the “Related Videos” sec- From the Department of Surgery, Rancho Los Amigos Na- tional Rehabilitation Center, and the Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California. Received for publication November 20, 2009; accepted Feb- ruary 17, 2011. Copyright ©2011 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e31822214c1 Disclosure: The authors have no financial interest to declare in relation to the content of this article. Related Video content is available for this ar- ticle. The videos can be found under the “Re- lated Videos” section of the full-text article, or, for Ovid users, using the URL citations printed in the article. www.PRSJournal.com 201e
Transcript
Page 1: CME Trunk, Abdomen, And Pressure Sore Reconstruction

CME

Trunk, Abdomen, and PressureSore Reconstruction

Salah Rubayi, M.D.Bala S. Chandrasekhar, M.D.

Downey and Los Angeles, Calif.

Learning Objectives: After reading this article, the participant should be ableto: 1. Describe the principles of wound closure, torso reconstruction, andpressure sore reconstruction. 2. Outline standard options to treat defects of thechest, abdomen, and back and pressure ulcers in all anatomical areas. 3. Manageand prevent pressure ulcers.Summary: Chest wall reconstruction is indicated following tumor resection, radi-ation wound breakdown, or intrathoracic sepsis. Principles of wound closure andchest wall stabilization, where indicated, are discussed. Principles of abdominal wallreconstruction continue to evolve with the introduction of newer bioprosthetics andthe application of functional concepts for wound closure. The authors illustratethese principles using commonly encountered clinical scenarios and guidelines toachieve predictable results. Pressure ulcers continue to be devastating complica-tions to patients’ health and a functional hazard when they occur in the bedridden,in patients with spinal cord injuries, and in patients with neuromuscular disease.Management of pressure ulcers is also very expensive. The authors describe stan-dard options to treat defects of the chest, abdomen, and back and pressure ulcersin all anatomical areas. A comprehensive understanding of principles and tech-niques will allow practitioners to approach difficult issues of torso reconstructionand pressure sores with a rational confidence and an expectation of generallysatisfactory outcomes. With pressure ulcers, prevention remains the primary goal.Patient education and compliance coupled with a multidisciplinary team approachcan reduce their occurrence significantly. Surgical management includes appro-priate patient selection, adequate debridement, soft-tissue coverage, and use of flapsthat will not limit future reconstructions if needed. Postoperatively, a strict protocolshould be adapted to ensure the success of the flap procedure. Several myocuta-neous flaps commonly used for the surgical management of pressure are discussed.Commonly used flaps in chest and abdominal wall reconstruction are discussed andthese should be useful for the practicing plastic surgeon. (Plast. Reconstr. Surg. 128:201e, 2011.)

CHEST WALL RECONSTRUCTION

Acquired chest wall defects result from trauma,tumor excision, radiation injury, complica-tion caused by cardiac bypass surgery (Fig. 1),

or sepsis from intrathoracic disease, such as bron-chopleural fistulas.1 Full-thickness lateral chest walldefects and those involving multiple rib resectionsmay also cause a flail chest.2,3 Reconstructive goalsinclude eradication of infection, airtight pleural cav-

ity seal, skeletal stabilization, and wound closure.(See Video 1, which contains case studies that dem-onstrate principles of chest and abdominal wall re-construction, available in the “Related Videos” sec-

From the Department of Surgery, Rancho Los Amigos Na-tional Rehabilitation Center, and the Division of Plastic andReconstructive Surgery, Keck School of Medicine, Universityof Southern California.Received for publication November 20, 2009; accepted Feb-ruary 17, 2011.Copyright ©2011 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e31822214c1

Disclosure: The authors have no financial interestto declare in relation to the content of this article.

Related Video content is available for this ar-ticle. The videos can be found under the “Re-lated Videos” section of the full-text article, or,for Ovid users, using the URL citationsprinted in the article.

www.PRSJournal.com 201e

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tion of the full-text article on PRSJournal.com or, forOvid users, at http://links.lww.com/PRS/A373.)

Preoperative EvaluationPulmonary function tests, bronchoscopy, and

computed tomographic scans are often indicatedto delineate and characterize specific problems.Tumor size and invasion of surrounding struc-tures, presence of intrathoracic infection, and ribcage abnormality are identified. Important co-morbidities such as diabetes, history of irradiation,smoking history, and nutritional status are notedand optimized. Angiography is unnecessary unlessthere is a question about the vascular supply ofproposed muscle flaps. Culture-specific antibioticsare used where indicated.

Principles of ReconstructionThe primary pathologic findings will often dic-

tate reconstructive goals. Infected and devitalizedtissue is excised initially. Irradiated wounds ofteninvolve bone and cartilage under the necrotic softtissue, and a full-thickness chest wall resection maybe indicated as a first step in wound closure.1 Oncethe defect is identified, the goals become clearer.

Chest wall stability, if needed, is restored sim-ply with prosthetic mesh or human acellular der-mal matrix sutured to the edges of the defect.1–4

The visceral pleura will adhere to and create anairtight seal. Stabilization is indicated in lateralfull-thickness wounds, especially if more than sixribs are resected. Smaller defects generally do notneed this, as scar formation beneath the soft-tissuecover will provide sufficient rigidity. Sternal andcostal cartilage resection for osteomyelitis gener-ally does not need stabilization.

Large soft-tissue defects are closed with pecto-ralis major or latissimus dorsi flaps. Serratus flapswork well for closure of bronchopleural fistulas, asthey are small and can be moved into the thoraxeasily either through a previous thoracotomy inci-sion, creating a window in the intercostal space, orby rib resection and creation of a new passage.2,5

The approach depends on the fistula locationand available local muscle flap. Less commonare superiorly based transverse rectus abdo-minis musculocutaneous flaps, pedicled greateromental flaps, and rectus abdominis flaps. Thepedicled greater omentum can close extremelylarge defects well1,6,7 and can be harvestedlaparoscopically.8 (See Video 1, which containscase studies that demonstrate principles of chestand abdominal wall reconstruction, available inthe “Related Videos” section of the full-text ar-

Fig. 1. Irradiated chest wall following mastectomy, with underly-ing chondritis and osteomyelitis.

Video 1. Video 1, which contains case studies that demonstrateprinciplesofchestandabdominalwall reconstruction, isavailable inthe “Related Videos” section of the full-text article on PRSJournal-.com or, for Ovid users, at http://links.lww.com/PRS/A373.

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ticle on PRSJournal.com or, for Ovid users, athttp://links.lww.com/PRS/A373.)

The irradiated chest wall wound presents uniqueproblems. The borders of the damaged tissue areindistinct and adequacy of the resection is, at best, aneducated guess. This wound is prone to infection,and use of prosthetic mesh is relatively contraindi-cated. Generous wound debridement including un-derlying ribs followed by healthy muscle flap rota-tion offers the best chance for healing.

Sternal osteomyelitis following cardiac surgeryis fatal unless managed aggressively (Fig. 2, left).The infection can involve cardiac suture lines,prosthetic valves, and grafts (Fig. 2, right). Widedebridement of all infected bone, cartilage, andsoft-tissue and elimination of the mediastinal deadspace with vascularized tissue should be consid-ered as soon as the diagnosis is made. Bilateralpectoralis major flaps based on the thoracoacro-mial pedicle are excellent options for sternalreconstruction.9 A rectus abdominis muscle turn-over flap is used for lower sternal coverage ifneeded. For deep mediastinal wounds, omentalflaps may be the best choice.7

POSTERIOR TRUNK DEFECTSBack wounds are created by trauma, tumor

resection, or radiation therapy. Urgent closure isindicated for coverage of exposed hardware usedfor spinal stabilization. Reconstructive principlesof radical wound debridement, removal of hard-

ware when possible, and vascularized tissue cov-erage remain the keys for successful outcomes.Depending on the size and location of the defects,one may use latissimus, trapezius, gluteus maxi-mus, or paraspinal muscle flaps for wound closure.The superior gluteal artery perforator flap is analternate choice for lower lumbar or sacral defects.

CONGENITAL DEFORMITIESPectus Excavatum

Pectus excavatum is the most common congen-ital defect and is thought to be a result of overgrowthof rib cartilages, pushing the sternum toward thespine and causing the typical funnel-shaped chest.Cardiorespiratory dysfunction is common in severedeformities.

Mild deformations can be left alone or cam-ouflaged with custom silicone implants placedsubmuscularly.10 Sternal reconstruction is indicatedin children with functional problems such as dys-pnea, decreased exercise tolerance, or tachycardia.The Nuss procedure is designed to slip a convex steelbar under the sternum and stabilize it in an anteriorposition for 2 to 5 years. This procedure is bestperformed by experienced pediatric thoracic sur-geons. Teenagers or older patients will require re-section of the diseased costal cartilages, sternal os-teotomy, and rigid support.11,12

MeningomyeloceleMeningomyelocele is the most common vari-

ant of spina bifida, where the neural elements of

Fig. 2. (Left) Sternal osteomyelitis and mediastinitis following aortic arch replacement with a Da-cron graft. (Right) Exposed Dacron graft aortic arch replacement after sternal debridement.

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the spinal cord or cauda equina are exposed in thenewborn baby. Neurologic deficits include weak-ness in the lower extremities, bowel and bladderdysfunction, and hydrocephalus. Latex allergiesare also common in these infants.

Urgent coverage of the wound is indicated. Theneurosurgeon closes the dural defect and seals thecerebrospinal fluid leak. En bloc bilateral latissimusdorsi and gluteus myocutaneous flap advancementare good choices but place the wound closure scardirectly over the defect.13 Bilobed flaps of skin andsubcutaneous tissue avoid this problem.14 Smallerdefects can be simply closed by direct soft-tissue mo-bilization and advancement.

ABDOMINAL WALL RECONSTRUCTIONComplex abdominal wall defects result from

tumor resection, trauma, radiation injury, failedventral hernioplasties, or following the “open”technique to prevent abdominal compartmentsyndrome (Fig. 3). These wounds can be compli-cated by the presence of infected prosthetic mesh,enteral fistulas (Fig. 4), colostomies, or protrud-ing bowel, with the loss of abdominal domain.Partial losses of abdominal layers, and small andlateral defects are easier to reconstruct than large,midline, full-thickness losses. (See Video 1, whichcontains case studies that demonstrate principlesof chest and abdominal wall reconstruction, avail-able in the “Related Videos” section of the full-textarticle on PRSJournal.com or, for Ovid users, athttp://links.lww.com/PRS/A373.)

Goals of TreatmentWound closure needs to provide durable and

stable protection of the viscera and prevention ofrecurrent herniation, using the fewest procedurespossible, to decrease morbidity.15

Preoperative AssessmentAssessment and optimization of comorbidities

such as diabetes, smoking, and cardiovascular andnutritional problems is routinely performed. Com-puted tomographic scans will help to accurately as-sess the extent of myofascial loss, location of therectus muscles, and intraabdominal abscesses. Pul-monary function tests are indicated when there is ahistory of chronic obstructive pulmonary diseaseand for reducing huge ventral hernias.

SurgeryThere are several algorithms available with

which to classify and provide direction as to thebest approach to these difficult problems.15,16 Pre-operative evaluation will define the size, location,and nature of the defects and other considerationssuch as fistulas or continued intraabdominal sep-sis or bleeding. Immediate reconstruction is de-ferred until the intraabdominal catastrophe is re-solved. Soft-tissue cover is usually not an issue, butrelative or absolute fascial deficits need to be ad-dressed correctly.

Partial DefectsDefects with just loss of skin and subcutaneous

fat with intact myofascial integrity can be closedeither by local tissue mobilization and advancement,or with skin grafts. Small fascial defects alone can bereconstructed with prosthetic mesh, fascia lata, or

Fig. 3. Delayed skin grafting over the bowel following abdom-inal compartment syndrome with loss of domain and lateral re-traction of the abdominal musculature.

Fig. 4. Central abdominal defect with multiple enterocutaneousfistulas after wound dehiscence.

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human acellular dermal matrix, placed in the pre-peritoneal layer whenever this is possible, as an inlay.Midline abdominal defects that cannot be closed bydirect approximation with minimal tension may war-rant component separation17 with or without theaddition of a mesh or bioprosthetic to accomplishthe closure.18,19 Release up to 18 cm can be obtainedusing this technique (at the level of the umbilicus).Bioprosthetic materials such as human acellular der-mal matrix have distinct advantages over syntheticmesh in abdominal wall reconstruction. These ma-terials are readily available and do not create donor-site concerns. Human acellular dermal matrix canbe used successfully in contaminated wounds, as itheals by regeneration and is ultimately replaced withnative tissue.4 There are also fewer adhesions tounderlying bowel.20 Exposure of human acellu-lar dermal matrix because of loss of soft-tissuecover does not necessitate removal. Human acel-lular dermal matrix is expensive and has a ten-dency to stretch over time.21,22 Other biopros-thetic materials are available in larger sizes,23 butlong-term outcome studies delineating theirrole in complex abdominal reconstruction arenot available. (See Video 1, which contains casestudies that demonstrate principles of chest andabdominal wall reconstruction, available in the“Related Videos” section of the full-text articleon PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A373.)

Full-Thickness DefectsThe principles of fascial closure are similar to

those indicated above. Frequently, the integu-ment can be closed by soft-tissue elevation andadvancement. Absolute loss of soft tissue may pre-clude this type of closure, and additional tissueflaps are indicated.24–26 The tensor fasciae lataemyocutaneous flap and the rectus femoris are use-ful for closing defects in the lower abdomen. Thelatissimus is useful for upper lateral defects. Oc-casionally, free flaps such as anterolateral thighflaps are used for large defects where regionalflaps, because of their limited size and arc of ro-tation, are inadequate.

The laparotomy wound that is deliberately leftopen for repeated debridements or preventionof compartment syndrome is a special challenge.Bowel edema, continued sepsis, and lateral abdom-inal wall retraction prevent easy fascial closure. Tem-porary use of a negative-pressure wound therapydevice over a polyethylene sheet that wraps aroundthe viscera allows for control of sepsis and preven-tion of adhesions between bowel and the inner sur-

face of the abdominal wall.27 The device keeps me-dial tension on the edges of the abdominal defectand gives better control of enteral fistulas. At thetime of definitive wound closure, this lack of lateralretraction allows easier component separation andsecure abdominal fascial closure.

ComplicationsPostoperative complications are common, es-

pecially after massive repairs. Wound dehiscence,enterocutaneous fistula, and recurrent ventralhernia are dreaded problems. Aggressive wounddebridement and control of fistulas and sepsis arethe first steps in managing the patient. Except inunusual cases, the infected prosthetic mesh is re-moved. Rupture of the wound repair is commonlycaused by excessive tension. Malnutrition, sepsis,uncontrolled diabetes, and smoking contribute topoor wound healing and need to be addressedbefore secondary reconstruction is attempted. Se-romas are common following the use of biopros-thetic materials. Repeated aspiration or ultra-sound-guided drainage may be necessary.

PRESSURE SORE RECONSTRUCTIONPressure Ulcer Management

Plastic surgeons in training or in practice maydeal with pressure ulcers on a frequent basis. Thisarticle discusses current knowledge concerningpressure ulcers from the point of view of cause,pathology, preoperative patient selection, prepa-ration for surgery, and postoperative manage-ment. Pressure ulcer development is devastatingto the patient, the health care provider, and so-ciety. Pressure ulcers can develop in the insensateand sensate patient when certain factors coexist.Here, we cover important issues of which everyplastic surgeon should be aware concerning pres-sure ulcers. Medicolegal and reimbursement is-sues from the health insurance providers to thesurgeon and hospital are common, and thereforedetailed documentation is essential. Details of op-erative surgery can be found in textbooks of plasticsurgery and the accompanying video. The plasticsurgeon should be the leader of the team respon-sible for the management of the pressure ulcer.

Goals for Treatment and Advantages andDisadvantages of the Methods

Advantages of early aggressive wound treat-ment include reduced spread of infection, im-proved quality of life, and decreased mortalityrates. In patients who develop pressure ulcers fol-lowing acute injury or illness, it is strongly recom-

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mended that surgical intervention be performedbefore the start of the rehabilitation program.Proper wound closure will allow for the patient toparticipate more actively in rehabilitation withoutthe burden of constant wound care and will helprestore quality of life. Despite the benefits of mus-cle flap closure of pressure ulcers, for some pa-tients, surgery may not be an option because theyare medically compromised.

For the nonsurgical candidate with a stage IVpressure ulcer, standard wound treatment optionsinclude use of air fluidized pressure-relieving beds,nutritional support, control of bacterial wound col-onization through use of antibiotics, and localwound care. Given all of these conservative mea-sures, it is often observed in clinical practice thatstage IV pressure ulcers do not heal properly. Ifwound healing does take place, it usually requiresmore than 8 weeks to occur and results in an un-stable scar highly vulnerable to wound recurrence.Flap surgery provides excellent quality of soft-tissuecoverage to the underlying defect and bone andoffers long-term durability to the affected area.

Preoperative and Postoperative ManagementPressure ulcer surgery is elective, but a patient

that acquires a pressure ulcer always has medicalproblems that need to be optimized preopera-tively. General laboratory tests are important, es-pecially if there is infection or anemia. Prealbu-min, albumin, and radiographs of the pelvis andhips are very important and may uncover patho-logic conditions such as scoliosis, hip joint dislo-cation, fracture or subluxation, and heterotopicossification. Magnetic resonance imaging scansare indicated for suspected osteomyelitis. Bonescans are not very helpful in pressure sores, as theyare all positive. All abnormal laboratory test resultsshould be corrected before surgery. Deep woundculture and sensitivity should be performed be-fore surgery, and appropriate preoperative anti-biotic coverage is started at least 1 day beforesurgery and continued postoperatively, depend-ing on the severity of the ulcer. If results of deepbone culture and sensitivity and histopathologyare positive for acute osteomyelitis, antibiotics areadministered for 4 to 6 weeks after flap surgery.28

Muscle spasms should be dealt with before sur-gery, as they interfere with flap healing, resulting inwound dehiscence, seroma, or bursa formation.Common medications for spasms are baclofen, di-azepam, and dantrolene. Phenol nerve injections orbotulinum toxin may also be used effectively.

Bowel diversion by colostomy before flap sur-gery may be indicated if the ulcer or multiple

ulcers are in close proximity to the anus or lessthan 6 cm from the ulcer excision margin. Whenan ulcer involves the perineal urethra in men,temporary or permanent urinary diversion shouldbe performed. A patient with spinal cord injurymay manifest psychosocial conditions, and a psy-chosocial evaluation and treatment of any abnor-mality should be considered preoperatively. Re-habilitation after surgery consists of physicaltherapy and occupational therapy and addressesthe long period of immobilization of patients. Thetype of rehabilitation program depends on theprimary diagnosis. The sitting program is per-formed in a gradual fashion after flap surgery, asit is very important to build skin tolerance to pres-sure along with improved tensile strength of thewound. Our sitting program29 starts at 6 weeksafter flap surgery with 30 minutes on the first day,and increasing by 30 minutes each subsequentday. When the sitting program reaches 6 hours perday, the patient can be discharged to home, pro-vided that there is no skin breakdown. This pro-tocol can be modified according to (1) the pri-mary patient diagnosis, (2) the type and healing ofthe flap, (3) the extent of the operation, and (4)the appearance of the wound clinically. The sittingprogram may start at 4 or 5 weeks after surgerywhen wound healing is uncomplicated and thetensile strength of the wound is approximately 40to 50 percent of normal. At 6 weeks after flapsurgery, the tensile strength is approximately 80 to90 percent of normal.30,31

Basic Surgical Procedure for the UlcerThe unhealthy skin edge of the ulcer is

marked for excision, Methylene blue dye is used tocolor all the undermining and ulcer extensionand helps to visually confirm complete ulcer ex-cision. After excision of the ulcer, the prominentunderlying bone is shaved to the healthy bleedinglevel. If osteomyelitis is suspected, a biopsy spec-imen from the deep bone should be sent for his-topathologic evaluation and culture and sensitivityto establish diagnosis of osteomyelitis.28 Then, anavailable flap is designed according to the ana-tomical area of the ulcer for reconstruction of thedefect.

SACRAL COCCYGEAL ULCERFlap Selection and Choice

The main flap used is the gluteus maximusmuscle. It can be designed as a rotation flap,32,33

advancement island flap,34–42 or split flap.43 Thechoice depends on the size of the ulcer and

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whether the ulcer is primary. A first-time ulcer mayneed a simple flap, whereas a recurrent ulcer usu-ally requires a large and complex flap. In an am-bulatory patient, complete detachment of the glu-teus maximus inferiorly should be avoided toprevent a functional deficit, and the muscle is usedonly after exhausting other options. The othergluteus muscles (medius and minimus) will com-pensate for the function of the used gluteus max-imus muscle, and this can be identified by muscletesting. Fasciocutaneous flaps such as the superiorgluteal artery perforator flap are useful especiallyin the ambulatory patient.

Gluteus Maximus as a MyocutaneousRotation Flap

Advantages of the gluteus maximus as a myo-cutaneous rotation flap include the fact that it isgood for covering large defects in nonambulatorypatients32,33 (Fig. 5). Disadvantages include exten-sive dissection, blood loss, and the part of the flapthat covers the defect is fasciocutaneous. This flapis not indicated in ambulatory patients. In a re-current or larger size ulcer, a bilateral gluteusmaximus muscle is used to cover the defect. (SeeVideo 2, which demonstrates comprehensivemanagement of pressure ulcers, available in the“Related Videos” section of the full-text articleon PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/A374.)

Gluteus Maximus Sliding Island FlapAdvantages of the gluteus maximus sliding is-

land flap include the fact that it is excellent forsmall and medium defects. Also, it involves lessextensive dissection and less blood loss and is idealfor ambulatory, sensory patients. The muscle bulkwill cover exposed bone34–41 (Fig. 6).

Disadvantages are that in larger defect it re-quires a bilateral flap. (See Video 2, which dem-

onstrates comprehensive management of pressureulcers, available in the “Related Videos” section ofthe full-text article on PRSJournal.com or, for Ovidusers, at http://links.lww.com/PRS/A374.)

Gluteus Maximus Splitting FlapAdvantages of the gluteus maximus splitting

flap are that it is a good flap for coccygeal ulcer,has less dissection and less blood loss, has themuscular bulk to cover the coccygeal bone, and isa good flap for the ambulatory patient43 (Fig. 7).

The disadvantage is that it is not suitable for alarger defect. (See Video 2, which demonstratescomprehensive management of pressure ulcers,available in the “Related Videos” section of thefull-text article on PRSJournal.com or, for Ovidusers, at http://links.lww.com/PRS/A374.)

Video 2. Video 2, which demonstrates comprehensive manage-ment of pressure ulcers, is available in the “Related Videos” sec-tion of the full-text article on PRSJournal.com or, for Ovid users, athttp://links.lww.com/PRS/A374.

Fig. 6. The design for the gluteus maximus sliding island flap.

Fig. 5. The design for the gluteus maximus rotation flap.

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Superior Gluteal Artery Perforator FlapThis fasciocutaneous flap has excellent vascu-

larity and is usually used for microsurgical breastreconstruction.44 It is also described as a flap forsacral and lumbar defects.45–47 The axis of the skinpaddle can be placed in many directions to coverthe adjacent defect. The perforators are located by

using a vascular Doppler over a triangular areabetween the iliac crest, the greater trochanter, andposterior superior iliac spine. The flap can beadvanced at least 2 to 3 cm in any direction to closesacral or lumbar ulcers.

Advantages include the fact that it is useful forclosing small defects and is indicated in ambulatorypatients. Disadvantages are that the flap requiresmeticulous dissection and cannot be revised in casesof wound complications or recurrent ulceration.

Recurrent Extensive Sacral Ulceration. When thegluteus maximus has been previously used andcannot be mobilized or readvanced, the followingsurgical options are used:

Distant fasciocutaneous flap. Posterior thigh flap orextended tensor fasciae latae flap.

Vastus lateralis muscle transfer. It can be tunneledunder the skin to the defect, and the musclesurface is covered with skin graft (Fig. 8). Oth-erwise, an island of skin may be carried with themuscle and tunneled to the defect.

Disarticulation and total thigh flap. With completeloss of both gluteus maximus muscles and ex-

Fig. 7. The design for the gluteus maximus splitting flap.

Fig. 8. Surgical photographs showing the use of vastus lateralismuscle tunneled to the sacral area.

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posure of the entire sacral bone and pelvicfloor, there may be no other flap option avail-able. This is an end-stage procedure. This isseen typically in insensate and nonambulatorypatients.

ISCHIAL ULCERThis ulcer is common in the insensate spinal

injury patient. The main cause is prolonged sittingwithout pressure relief or without a proper wheel-chair cushion.

Gluteus Maximus Myocutaneous Rotation FlapThe gluteus maximus myocutaneous rotation

flap is one flap used to close the ulcer48 (Fig. 9).An advantage of this flap is that it is indicated whenthe ulcer is undermined. On occasions, this flapalone is sufficient to cover the defect, but deeperwounds may need another layer of muscle to coverthe bone in addition to the gluteus maximus as afinal cover. This flap can be revised and read-vanced with recurrent ulceration.

A disadvantage is that it is not indicated inan ambulatory patient because of the functionaldeficit. Occasionally, the gluteus maximus flap

can be under tension even with the back cutwhen it is rotated medially, and this may lead toskin breakdown in the postoperative period.(See Video 2, which demonstrates comprehen-sive management of pressure ulcers, available inthe “Related Videos” section of the full-text ar-ticle on PRSJournal.com or, for Ovid users, athttp://links.lww.com/PRS/A374.)

V-Y Hamstring Muscle Advancement FlapThe vascularity of the skin island of this myo-

cutaneous flap is based on the hamstring muscleperforators. This flap can be used for recurrentischial ulceration or primary ulcer. Advantages ofthis flap are that it requires less dissection andentails less blood loss than other options, it can berevised for recurrent ulceration, and it is quiterobust49–52 (Fig. 10).

Disadvantages are that it is not indicated inambulatory patients, as transection of the ham-string tendons distally will leave a functional def-icit. The proximal part of the flap is fasciocuta-neous, and the gracilis muscle is used to fill thedefect. If the gracilis muscle is not available, deepi-thelialization of the proximal part of the ham-

Fig. 9. The design for the gluteus maximus flap for ischial ulcers.

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string flap is performed and advanced into thedefect. If the ulcer is too proximal in the glutealarea, this flap cannot be advanced to cover thedefect without tension.

Combined Flaps of Gracilis Muscle Transfer toCover the Ischium and the Medial ThighRotation Fasciocutaneous Flap

We prefer a combination of these flaps as afirst choice for ambulatory patients and in re-current ulcerations where other options havebeen used before53–56 (Fig. 11). A disadvantageis that it is difficult to reuse or revise this flap.(See Video 2, which demonstrates comprehen-sive management of pressure ulcers, available inthe “Related Videos” section of the full-text ar-ticle on PRSJournal.com or, for Ovid users, athttp://links.lww.com/PRS/A374.)

Tunneled Gracilis Muscle Transfer to Cover theIschium with Direct Closure of the Skin andSubcutaneous Layer over the Muscle

Advantages are that it involves less dissection,is ideal for the ambulatory patient, and reservesthe other flaps for future use in patients with spi-nal cord injury. Also, it is an ideal option forsmaller ulcers. (See Video 2, which demonstratescomprehensive management of pressure ulcers,available in the “Related Videos” section of thefull-text article on PRSJournal.com or, for Ovidusers, at http://links.lww.com/PRS/A374.)

Inferior Gluteal Artery Perforator FlapThis is a fasciocutaneous flap has a skin paddle

island over the gluteal crease and lateral to theischium. The flap was described for free tissuebreast reconstruction but can be used to close

ischial or perineal ulcers. The vascularity of thisflap is based on the branches from the inferiorgluteal artery and vein. The flap can be advancedmedially to close an ischial defect.57

Fig. 10. The design for the hamstring muscle advancement flapfor ischial ulcers.

Fig. 11. Surgical photographs showing the use of the gracilismuscle and medial thigh rotation fasciocutaneous flap to closean ischial ulcer.

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An advantage is that it is a small flap, idealfor mobile patients, as it leaves no functionaldeficit. Disadvantages are that it is difficult torevise or reuse this flap in recurrent ulcerationand it does need meticulous dissection to isolatethe perforators.

Posterior Thigh Fasciocutaneous Flap as aRotation Flap

This flap is available if there is no prior ulcer-ation or scarring in the posterior thigh with deepand extensive ulceration; the posterior thigh fas-ciocutaneous flap may not be sufficient to elimi-nate the dead space58 (Fig. 12). The gracilis muscleis transferred under the proximal fasciocutaneouspart of the flap to cover the bone, and the poste-rior thigh fasciocutaneous flap is rotated to closethe skin defect.

Extensive Recurrent Ischioperineal Ulcer Seenin Patients with Spinal Cord Injury

As a last option, the vastus lateralis muscle maybe used as a transposition flap from the verticalanatomical position to a horizontal position tocover the defect. The vastus lateralis is an excellentmuscle because of its size and blood supply. It cancover bilateral ischial defects. The surface of themuscle can be covered by skin graft or a fascio-cutaneous flap such as the extended tensor fasciaelatae flap.

TROCHANTERIC ULCERThis ulcer is less common than ischial and

sacral ulcers. It can develop in insensate and sen-sate patients because of direct pressure from aprominent greater trochanter. Skin ulceration is

associated with extension into the anatomical tro-chanteric bursa. Extension into the hip joint cancause infection and destruction of this joint.

Options for RepairThe most common flap used to close the ulcer

is the tensor fasciae latae,59–63 which is used in bothambulatory and nonambulatory patients withoutany significant functional deficit.

Tensor Fasciae Latae as a V-Y AdvancementFlap

The indication for the use of this flap is forulcers that are small to medium in size and locatedover the greater trochanter62,63 (Fig. 13). The flapcan be revised and advanced in the event of re-current ulceration. (See Video 2, which demon-strates comprehensive management of pressureulcers, available in the “Related Videos” section ofthe full-text article on PRSJournal.com or, forOvid users, at http://links.lww.com/PRS/A374.)

Tensor Fasciae Latae as a Rotation FlapThe use of tensor fasciae latae in this form is

indicated for larger ulcers and when the greatertrochanter is rotated posteriorly, secondary to hipsubluxation. This posterior trochanteric ulcer isseen frequently in patients with spinal cord injuryand severe muscle spasticity.

Anterior Lateral Thigh FlapThis flap is perfused by descending branches

of the lateral circumflex femoral artery. It is anisland flap but can be used as a rotation flap toclose small trochanteric ulcers.

Distal Gluteus Maximus MyocutaneousRotation Flap

This flap may be used when the trochantericulcer is small and posteriorly rotated.

Rectus Femoris Muscle FlapThis muscle has application for a deep exten-

sive trochanteric ulcer with wide exposure of thegreater trochanter. This muscle is used as the firstlayer of repair over the bone and is then coveredby the tensor fasciae latae flap in any form (e.g.,rotation or V-Y).

Hip Joint InfectionThe hip joint is vulnerable to secondary in-

fection when ulceration is close to the joint andmay result in joint destruction. The most commonulcers that can cause septic arthritis are trochan-teric and ischial ulcers. Hematogenous hip infec-tion is rare. The principles of management ofseptic hip arthritis are through debridement andwound closure with healthy tissues.

Fig. 12. The design of the posterior thigh fasciocutaneous flapto close an ischial ulcer.

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The first step is the Girdlestone procedure64–68

and debridement of all of the infected bone andheterotopic calcification. In the next step, the de-fect is closed with a muscle flap.65–68 The commonmuscle used is the vastus lateralis muscle (Fig. 14)

with direct skin closure over muscle. In a largewound, a tensor fasciae latae flap is designed as arotation flap to close the defect over the vastuslateralis muscle. Both procedures can be per-formed in one stage or two stages, depending onthe severity of the infection. If the hip cavity afterdebridement is small, the rectus femoris can beused to fill the defect, preserving the vastus late-ralis muscle for future use in the patient withspinal cord injury. (See Video 2, which demon-strates comprehensive management of pressureulcers, available in the “Related Videos” section ofthe full-text article on PRSJournal.com or, forOvid users, at http://links.lww.com/PRS/A374.)

End-Stage DiseaseSometimes, a patient presents with extensive

recurrent ulceration around the pelvis and ahistory of bilateral Girdlestone procedures andmultiple flaps having been performed previously;also, the patient may have a urinary diversionand colostomy. The only option available is dis-articulation and a total thigh flap.69 –72 The am-putation level is either above or below the knee

Fig. 13. The design of the tensor fasciae latae flap in V-Y fashionand rotation to close a trochanteric ulcer.

Fig. 14. Surgical photograph showing the use of a vastus late-ralis muscle flap to fill a hip defect following the Girdlestoneprocedure.

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to use the calf muscles to cover the sacral ulcer(Fig. 15). (See Video 2, which demonstratescomprehensive management of pressure ulcers,available in the “Related Videos” section of thefull-text article on PRSJournal.com or, for Ovidusers, at http://links.lww.com/PRS/A374.)

Closure of Multiple Ulcers by MultipleFlaps as a Single-Stage Procedure

It is very common to see multiple ulceration inpatients with spinal cord injury. We recommendclosing these ulcers as a one-stage procedure.72–74

It has the advantages of removing all septic fociand expedient wound closure, improving thehealth and quality of life of the patient. The dis-advantages are the need for an operating team,significant blood loss, and increased anesthesiaand operative time.

ComplicationsThe predisposing factors are the premorbid

medical conditions of patient age, primary diag-nosis, flap selection, preexisting skin condition,and the available reserve of muscles. Commoncomplications are wound dehiscence, skin necro-sis and hematoma under the flap, seroma, andbursa formation. The initial management is localwound care and debridement of necrotic tissueand negative-pressure wound therapy. If the woundshows no healing with all of these local measures, aflap revision or new flap is performed.

Closing a wound, especially in a functionalpart of the body, is very rewarding, as it improvesthe patient’s quality of life. Unfortunately, in theinsensate group of patients, the phenomenon ofrecurrent ulceration places the reconstructive sur-geon in a moral and ethical dilemma as to howlong to continue with repeated surgery. Educationof all health care providers on prevention of pres-sure ulcers in a hospital or nursing home envi-ronment is important and is mandated and legis-lated by federal and state laws. Collaborationbetween health care providers and at-risk patientsin preventive measures is warranted to reduce thechances of developing this unfortunate problemin the first place.

Salah Rubayi, M.D.Rancho Los Amigos National Rehabilitation Center

7601 East Imperial HighwayDowney, Calif. 90242

[email protected]

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