Bilateral Gluteus Maximus V-Y Advancement Musculocutaneous Flaps for the Coverage of Large Sacral Pressure Sores: Revisit and Refinement

Abstract

Surgical management of the sacral defect using the gluteal muscle or musculocutaneous flap has been well accepted over the years. In this study, refinements in the bilateral gluteus maximus V-Y advancement musculocutaneous flaps were made. These refinements include having sharper angle (60 degrees or less) at the donor sites of the flap, cutting the edges of the gluteal muscle of 3 cm beyond the skin flap, and cutting most parts of the gluteal muscle at a depth of only 2.5 cm (at the level of upper third portion). These improvements result in less tension closure of the donor site, easier closure of the advanced flaps in two planes without tension, and better preservation of most parts of the gluteal muscular insertions to the femur and their functions. The design of V-Y advancement has successfully maintained the superior and inferior gluteal vessels and inferior gluteal nerve. In this study, the average sacral defect was more than 12 cm in diameter, and each advanced flap was 15 x 12 x 3 cm in size. Of the 63 consecutive patients undergoing bilateral gluteus maximus V-Y advancement musculocutaneous flaps with refinements for coverage of large sacral pressure sores, 59 (93%) achieved complete healing after an average follow-up period of 28 months. Only 4 patients had recurrences of sacral sore. In this study, the duration of hospital stay for flap coverage averaged 38.5 days. Four patients (6%) had superficial dehiscences of the donor site requiring skin grafting. Ten patients (16%) developed stitch abscesses and 9 patients (14%) had wound infections, but no flap was lost. No significant functional impairment related to the flap procedure was noted. The operative technique described in this paper is not only simple and noninvasive, but with our refinements of flap design, the bilateral gluteus maximus V-Y advancement musculocutaneous flaps also provide reliable and durable coverage for large sacral pressure sores.