Reconstruction of the sacral region using the lumbo-gluteal sensory flap

Abstract

Local skin flaps are used for reconstruction of sacral decubitus ulcers because of their structural endurance against the patient's weight. However, a major concern is associated with decubitus recurrence after repair. Sensory flaps are one choice to prevent recurrence. Thus, we reconstructed sacral decubitus ulcers using Nakajima's lumbo-gluteal flap as a sensory flap. Two patients with unstable sacral scars caused by decubitus ulcers were treated operatively. Neither had spinal cord injury, and buttock sensation thus remained. The flap's proximal end was designed on the posterior iliac crest and included the lateral dorsal cutaneous branch of the fourth lumbar artery as examined preoperatively with a Doppler stethoscope. The distal end was beyond the gluteal fold in case 1, but not in case 2. We subcutaneously dissected the vascular pedicle and the superior cluneal nerve located at the proximal portion of the flap after resection of the unstable scar. We then elevated the flap beneath the fascia of the gluteus maximus of the right buttock, preserving the nerve, artery and subcutaneous tissue as one pedicle, and transferred the flap to the defect. In case 1, 2cm of the distal end of the flap was lost. The sensation of the proximal two-thirds of the flap was identical to that of the contralateral buttock. However, the distal one-third of the flap, which was elevated from the area caudal to the gluteal fold, had insufficient sensation. Case 2 had complete flap survival and sufficient sensation in all areas of the flap. Decubitus recurrence has not occurred in 7 years in case 1 and in 9 months in case 2. This flap is useful for reconstruction of sacral decubitus ulcers if sensory function of the buttock remains and may be best designed as not extending beyond the gluteal fold.