A Retrospective Comparison of Perforator and Rotation Flaps for the Closure of Extensive Stage IV Sacral Pressure Ulcers

Wound coverage using a flap, most commonly a perforator or rotation flap, often is required for the closure of extensive sacral pressure ulcers. To assess the duration of wound healing and postsurgical complications following two types of surgical closure procedure, perforator and rotation flaps, a retrospective study was conducted among a convenience sample of 20 patients (10 men, 10 women) with Stage IV sacral pressure ulcers. All ulcers were repaired in 2011 and 2012 by the same surgical group and included nine perforator and 11 rotation flaps. Patient demographic and wound outcomes data were abstracted, and data were analyzed using Wilcoxon signed rank and chi-squared tests. No significant differences were noted in patient demographics between the two groups, although serum albumin level in the rotation flap group was significantly higher than in the perforator flap group (P = 0.01). The mean follow-up period was 18 (range 6–30) months. Mean time to healing was 34 ± 15.4 (range 10–58) days in patients with a perforator flap and 45.5 ± 24.0 (range 11–80) days in patients with a rotation flap (P = 0.03). Patients who underwent rotation flap surgery had a higher rate of postoperative complications and a significantly higher rate of postsurgical seroma (n = 9) compared to those who underwent perforator flap surgery (n= 2) (P = 0.05). The mean time to healing in both groups was 13.5 days in patients without and 48.5 days in patients who developed a seroma. (P <0.01). The results of this study show the proportion of patients who develop a seroma following surgical repair of a sacral pressure is lower following perforator than rotation flap surgery. Additional clinical studies are needed to confirm these findings.

When pressure ulcers become extensive enough to expose the sacral bone and are classified as Stage IV (according to National Pressure Ulcer Advisory Panel staging guidelines¹), wound coverage using a flap usually is required, because these deep wounds take a long time to heal and may cause serious infections such as osteomyelitis and sepsis.^1-4

Fasciocutaneous flaps are universally preferred for the resurfacing of sacral pressure ulcers because they facilitate the preservation of gluteal muscle integrity and muscle function, especially in nonparalyzed patients. They also are expected to provide better long-term results than a myocutaneous or muscle flap following the surgical reconstruction of pressure ulcers.⁵

On the other hand, the development of perforator flap surgery has increased the number of potential donor sites, because a flap can be supplied by any musculocutaneous perforator and donor site morbidity can be reduced. Perforator and fasciocutaneous rotation flaps avoid the sacrifice of underlying muscle and are commonly used. Literature is scant regarding which is the better procedure.   Seroma is described as serous fluid collection under a skin flap or in a dead space following debridement and/or flap dissection or the marked accumulation of exudate. Prolonged drainage is troublesome because it can cause wound dehiscence, leads to fistulae, and increases the risk for infection, which can significantly prolong wound healing.⁶ The frequency of seroma varies due to flap size, location, and type of flap; surgeons take precautions to avoid its occurrence, including providing drainage and adequate pressure.

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.

A retrospective review of the records of patients with wounds was conducted at the National Organization Nagasaki Medical Center from January 2011 to December 2012. The review established which patients had sacral pressure ulcers reconstructed using perforator or rotation flaps.

Surgical procedure. The same surgical team performed all surgeries, with no stated preconception regarding the choice of surgery. In cases of wound infection, patients underwent surgical debridement and wound bed preparation in advance of flap surgery. The surgical procedures are standard techniques and include thorough cleansing and debriding all necrotic tissues and removing the sacral bony prominence. Both perforator and rotation flaps are elevated above the gluteal muscle layer, and the donor site of the flap is sutured and closed directly without a free skin graft.^7,8 However, it is important to note that to resurface a round sacral pressure ulcer with a 7-cm diameter, the area to elevate a perforator flap is about 60 cm2 and approximately 120 cm² for a fasciocutaneous rotation flap — ie, a fasciocutaneous rotation flap requires twice the area of fascial dissection as a perforator flap.

Postoperatively, a negative pressure drain is placed under the flaps until the exudate decreases to <10 mL/day. Patients are provided a pressure redistribution mattress for 2 weeks, with gradual bed or wheelchair pressure on the flap permitted.

Data collection and analysis. Data on patient body weight, wound size, laboratory data including serum albumin (Alb) and hemoglobin (Hb), intraoperative bleeding, and the duration of the operation and anesthesia in patients who underwent sacral pressure ulcer resurfacing with perforator or rotation flaps were abstracted from patient charts (see Table 1).

Exudate quantity, wound separation, flap necrosis, and development of infection as recorded also were abstracted. Wound healing was determined when all sutures were removed without wound complications, such as seroma, fistulae, infection, flap necrosis, or wound dehiscence, usually 10 to 14 days after surgery. If 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 healed.

Data were analyzed using Wilcoxon signed rank and chi-squared tests.

Patient demographics and health status. Twenty patients (20) with Stage IV sacral pressure ulcers were found to have undergone surgical wound resurfacing with flaps. Of these, nine pressure ulcers were repaired using perforator flaps (perforator flap group) and 11 were covered with rotation flaps (rotation flap group). Mean patient age was 72.5 ± 10.1 (range 61–84) years in the perforator flap group (three men, six women) and 64.5 ± 15.7 (range 43 to 86) years in the rotation flap group (seven men, four women); no significant difference was noted (P >0.05, Wilcoxon signed rank test). The data revealed no significant differences between the groups in body weight, wound size, Hb A1c levels, intraoperative bleeding, and duration of the surgical flap procedure operation and (P >0.05, Wilcoxon signed rank test). Blood sugar levels were controlled in the four patients with diabetes mellitus before they underwent surgery. The patients’ wound size, the interval between resurfacing surgery to the healing of the wounds, and general and postsurgical wound complications in the perforator and rotation flap groups are shown in Tables 2 and 3. The mean follow-up period was 18 (range 6–30) months; there were no episodes of recurrence in either group.

All 20 sacral pressure ulcers healed within 80 days after surgery. The mean healing time was 34 ± 15.4 (range 10–58) days in the perforator flap group and 45.5 ± 24.0 (range 11–80) days in the rotation flap group. The healing time in the perforator flap group was significantly shorter than in the rotation flap group (P = 0.03, Wilcoxon signed rank test) (see Figure 1).

In the rotation flap group, the serum albumin level was significantly higher than in the perforator flap group (P = 0.01, Wilcoxon signed rank test).

Complications. Postsurgical wound complications in the perforator flap group included seroma (two), postsurgical wound infection (one), and partial flap necrosis (four). One patient required an additional free skin graft for the treatment of a remaining wound due to infection, and another patient underwent additional sclerotherapy for the treatment of seroma. Complications in the rotation flap group included seroma (nine), postsurgical wound infection (one), partial flap necrosis (one), and dehiscence (three). One patient required another perforator flap transfer for the treatment of a remaining wound due to dehiscence, and another patient underwent additional sclerotherapy to treat the seroma. Patients who underwent rotation flap surgery were significantly more likely to develop postsurgical seroma than those who underwent perforator flap surgery (P <0.05, chi-square test). No significant differences were found in the development of other postsurgical complications such infection, flap necrosis, and dehiscence between the two groups (P >0.05, chi-squared test).

Healing. The mean healing time in patients was 34 ± 15.4 (range 10–58) days in the perforator flap group and 45.5 ± 24.0 (range 11–80) days in the rotation flap group. Postsurgical wound complications, especially seroma formation, significantly prolonged the healing time in both groups (P = 0.01, Wilcoxon signed rank test) (see Figure 1).

Sacral pressure ulcers are common chronic wounds in patients with limited mobility, such as those who have paraplegia.⁹ Usually, these wounds require surgical treatment, and several surgical techniques are employed, including gluteal fasciocutaneous and gluteal perforator-based flaps.^2-4,10 Sameem et al¹¹ reviewed complications of musculocutaneous, fasciocutaneous, and perforator flaps for the treatment of pressure ulcers and found no significant difference with regard to complication rates among these flaps. However, results of the current study show that sacral pressure ulcers healed significantly faster in patients receiving a perforator flap than in patients receiving a fasciocutaneous rotation flap, even though the patients’ nutritional condition was more favorable in the rotation flap group.

In any type of flap, the donor site requires closure, which is a common site for the development of postoperative seroma. The current study revealed postsurgical healing is influenced by seroma formation, which significantly prolonged healing time.

Several case studies reported the frequency of seroma formation following sacral pressure ulcer reconstruction using perforator flaps. Koshima et al¹² reported that in eight pressure ulcers treated with gluteal perforator flaps, one fistula occurred. Lin et al¹³ found one seroma in 46 gluteal perforator flaps; Xu et al¹⁴ found one seroma among six flaps. Leow et al¹⁵ reported on four successful gluteal perforator flap surgeries without seroma. These outcomes suggest perforator flaps are less likely to develop seroma, although the frequency of seroma formation after fasciocutaneous rotation flap use is unknown. In the current study, two out of nine patients receiving perforator flaps and nine out of 11 receiving fasciocutaneous rotation flaps developed postsurgical seroma; fasciocutaneous rotation flap use was significantly more likely to lead to seroma formation.

The current findings may be limited by the small series of patients and retrospective study design. However, although these surgeries were performed by the same surgical group and no preconception regarding the choice of surgery was documented, one of the causes of seroma was thought to be surgical factors, including rough surgical maneuvers, remaining dead space, and the extent of dissection needed to cover the wounds.

The known advantages of using perforator flap over the traditional flap include reduced bleeding, preservation of the muscle and its function, and versatility of the flap design that yields a better match to the defect.¹⁵ A retrospective study of 20 cases in which sacral ulcer repair involved either perforator or rotator flap approaches showed use of perforator flaps resulted in fewer complications and faster time to healing than when rotator flaps were provided, especially with regard to seroma development. The authors hypothesize the need to dissect a larger area in order to elevate a fasciocutaneous rotation flap may be a risk factor for seroma formation (see Figure 2 and Figure 3).

Additional clinical studies to help surgeons make evidence-based decisions related to surgical pressure ulcer closure are needed.

Dr. Fujioka is the clinical professor, Department of Plastic and Reconstructive Surgery, Nagasaki University; and Director, Department of Plastic and Reconstructive Surgery, Clinical Research Center, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan. Drs. Hayashida, Morooka, and Saijo are staff surgeons, Department of Plastic and Reconstructive Surgery, National Hospital Organization Nagasaki Medical Center.

Please address correspondence to: Prof. Masaki Fujioka, National Hospital Organization Nagasaki Medical Center, Plastic and Reconstructive Surgery, 1001-1 Kubara 2, Ohmura , Nagasaki 856-8562; email: mfujioka@nagasaki-mc.com.