Reconstruction of a Sacral Pressure Ulcer With an Inferior Gluteal Artery Perforator Flap After Failed Reconstruction Using Bilateral V-Y Advancement Flaps

Many types of flaps are available if surgical reconstruction of a pressure ulcer is indicated, including a gluteus maximus flap, V-Y advancement flap, and superior gluteal artery perforator flap. Regional flap failure can complicate treatment, requiring additional flap surgery. An 80-year old woman with a 2-year history of being unconscious following a cerebrovascular accident presented with a Stage 4 sacral pressure ulcer of 2 months’ duration with eschar and abscess formation.Because the wound measured 15 × 10 cm², bilateral V-Y advancement flaps were used for surgical closure. However, 1 week later, ischemic change of the wound edges and wound dehiscence were observed. The wound was subsequently closed with an artery perforator (IGAP) flap, an approach that took into consideration religious preference of keeping the body intact. The patient was discharged with a healed wound 6 weeks postoperatively; long-term postoperative surveillance was hindered by the patient’s distance from the care facility (she lived on an outlying island). This is the first case report to describe IGAP flap application in a patient with a sacral pressure ulcer after failed reconstruction using bilateral V-Y advancement flaps. 

In the United States, more than 2.5 million patients per year are estimated to develop pressure ulcers.¹ Several types of flaps have been described in retrospective studies^2-7 for coverage of wounds such as pressure ulcers in the sacral area, but the scenario remains complex if the sacral wound recurs or the flap fails. Flap types include the V-Y advancement flap² and the buttock rotation flap³; specific types of perforator flaps include the inferior gluteal artery perforator (IGAP) flap⁶ and the superior gluteal artery perforator (SGAP) flap.⁷ To document available treatment options, a case is described of a long-term bedridden patient with a sacral pressure ulcer who received an IGAP after failed reconstruction using bilateral V-Y advancement flaps. 

Ms. R, an 80-year-old woman with a history of a cerebrovascular accident, type 2 diabetes mellitus, and hypertension managed using angiotensin-converting enzyme inhibitors and biguinide, was unconscious and bedridden for 2 years. She received tube feeding for nutritional support and was cared for on an alternating pressure air mattress in a supine or lateral position. She did not have hip contracture. 

Ms. R presented to Tri-Service General Hospital with a Stage 4 (per the definition developed by Shea⁸) sacral pressure ulcer of 2 months’ duration with eschar and abscess formation (see Figure 1A) that occurred, according to her family, due to neglectful home care. She had not received prior surgical intervention; the wound had been treated with neomycin ointment. 

Initial laboratory results revealed a white blood cell count of 11.0 × 10³ cells/mm³. Her C-reactive protein level was 5 mg/dL, and her blood urea nitrogen and creatinine levels were 12 mg/dL and 1.0 mg/dL, respectively. Aspartate transaminase and alanine transaminase values were 23 and 14 U/L, respectively. Ms. R’s vital signs were stable with no signs of sepsis on admission. 

The soft tissue defect measured approximately 15 cm × 10 cm over the sacrum. After surgical debridement (see Figure 1B), bilateral V-Y advancement flaps were used simultaneously for reconstruction (see Figure 2A). One (1) week following surgery, the wound dehisced and partial skin necrosis occurred (see Figure 2B). After the failed bilateral V-Y advancement flap reconstruction, the sacral soft tissue defect measured approximately 10 cm × 10 cm (see Figure 3A). The wound could not be closed with primary closure and undermined dissection. Additionally, because the angiosome area of the bilateral SGAP flaps had been injured after the bilateral V-Y advancement flap reconstruction, the wound could not be salvaged using SGAP flap reconstruction. 

Because of the religious ethics in Taiwanese tradition that demand the maintenance (intactness) of the human body before death, including even just managing a pressure ulcer, Ms. R’s family demanded sacral ulcer reconstruction as soon as possible; letting it heal by secondary intention resulted in poor outcomes according to the authors’ experience. IGAP flap reconstruction was performed 2 weeks after the failed bilateral V-Y advancement flap reconstruction. After intraoperative Doppler assessment, an IGAP flap was harvested measuring approximately 12 cm × 10 cm with an ~10 cm pedicle from the right gluteal crease region. Transposition of the IGAP flap to the sacral defect was performed without complications or any adverse event in an open route as opposed to subcutaneous tunnel fashion to avoid possible pedicle compromise by compression (see Figure 3); hip joint flexion could create complications for the healing of the IGAP flap donor site. Therefore, to prevent wound dehiscence at the flap donor site, a modified ventral splint was applied from the lower leg to the flank with elastic bandage fixation over the knee and flank (see Figure 4) for 3 weeks, at which time the sacral wound and the flap donor site both were healed without complications (see Figure 5). Ms. R was discharged with a healed wound 6 weeks postoperatively. She was not followed-up long-term because she lived on an outlying island, making oversight difficult.

Many kinds of flaps, such as a gluteus maximus V-Y advancement flap,² rotation flap,³ transverse lumbar flap,⁴ IGAP flap,^5,6 and SGAP flap,⁷ have been described for coverage of a sacral wound. Although flaps are commonly created by reconstructive surgeons, the condition can become complicated if the sacral pressure ulcer recurs or the flap fails related to surgical skill, nutrition, circulation, and infection, among other factors.

In the present case, because the angiosome area of the superior gluteal artery was injured after the failed bilateral V-Y advancement flap reconstruction, the wound could not be salvaged using SGAP flap reconstruction and subsequently IGAP flap reconstruction was employed.

The vascular territory of the perforator flap remains controversial. Several clinical studies address the vascular territory of IGAP flap. In 1993, Koshima et al⁹ showed that a flap in the gluteal region could be nourished even by a single perforator. In 2007, Ahmadzadeh et al¹⁰ described a detailed dissection of the gluteal region and determined that the vascular area of a single perforator from the inferior gluteal artery measures ~24 cm². However, Nojima et al¹¹ demonstrated a mean vascular territory of 15 cm × 12 cm in an IGAP flap using a single perforator with the dye injection method. In Ms. R’s case, an IGAP flap of approximately 12 cm × 10 cm was harvested without any necrosis.

A flap from the gluteal crease has 2 advantages: 1) the flap is raised from an area different from the previous surgical region and can serve as a secondary option for salvage¹²; and 2) the primary closure of the donor site leaves a scar that avoids maximal pressure zones over bony prominences and is well hidden in the natural gluteal crease.¹³ A major disadvantage of this flap is that it creates a relatively tense donor site wound; in addition, compared to other flaps, it is much harder and time-consuming to harvest the IGAP flap. Owing to increased tension over the gluteal crease, a patient that is bedridden long-term with hip contracture is not a suitable candidate for IGAP flap reconstruction because hip joint flexion could worsen the healing of the IGAP flap donor site due to higher tension over wound edge. Therefore, the most important step for IGAP flap reconstruction is the selection of the patient. In the authors’ experience, a patient who is bedridden long-term and without hip contracture is preferred. In addition, to avoid wound dehiscence at the flap donor site in Ms. R’s case, the authors applied a modified ventral splint as a strong support for 3 weeks; the final donor site condition was satisfactory.

According to medical ethics, before the sacral ulcer reconstruction the authors discussed with the family potential adverse scenarios the patient might encounter through the procedure and postoperative period. However, because of the religious ethics in Taiwanese tradition, her family demanded reconstruction to keep the body intact, requiring surgery.

IGAP flap reconstruction appears to be an alternative technique for surgical closure of a sacral pressure ulcer after failed reconstruction using bilateral V-Y advancement flaps. Because the IGAP flap is raised from an area different from that of the previous operation site, it can serve as a flap for salvage reconstruction from an adequate donor site and avoid flap failure. Long-term follow-up to ensure full healing and functionality of the surgical sites is advisable.

Dr. Wang is a resident physician at the Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan; and at Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan. Dr. Wu, Dr. Chu, Dr. Chen, Dr. Chou, Dr. Chiao, and Dr. Chang are resident physicians; and Dr. Dai is an attending physician, Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center.

Please address correspondence to: Niann-Tzyy Dai, MD, Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Gung Road, Taipei, 11490, Taiwan; email: niantzyy@ms17.hinet.net.