Gluteal Rotation Flap Research Articles

VP3: Pelvic Reconstruction After Large Sacral Chordoma Resection Using Acellular Dermal Matrix and Double Pedicled Gracilis Muscle Flap Combined with Gluteal Fasciocutaneous Rotation Flap

INTRODUCTION: Sacral chordomas are rare, malignant primary bone tumors. Surgical resection with wide margins, combined or not with radiotherapy, is the only effective treatment with near 50% remission at 10 years. Surgery results in large three dimensional defects, as total or subtotal sacrectomy is often required. The treatment is challenging and requires a multidisciplinary approach. Several reconstructive approaches have been described, classically including rectus abdominis or gluteus musculocutaneus flap and omental flap. We aim at presenting an innovative method of pelvic floor reconstruction using acellular dermal matrix and double pedicled Gracilis muscle flap combined with gluteal fasciocutaneous rotation flap. MATERIALS AND METHODS: We report the case of a 70 yo patient affected by locally invasive sacral chordoma. The oncological treatment included neuronavigation-assisted subtotal sacrectomy with en bloc resection at the level of S1-S2 intervertebral disc and laparoscopic abdomino-perineal amputation with terminal colostomy. After the R0 resection was confirmed, pelvic floor was reconstructed with an acellular dermal matrix and a double-breasted pedicled muscle Gracilis flap to avoid herniation of the abdominal cavity organs. The overlying soft tissue defect was reconstructed with an unilateral gluteal fasciocutaneous rotation flap partially deepitelialized to fill the dead space. The donor sites were closed directly. RESULTS: No surgical complications were observed, with flaps and donor sites healing uneventfully. After 3 days in intermediate intensive care and 22 days in plastic surgery department, he was transferred to rehabilitation center. Walking was reassumed after 2 weeks, sitting after 4 weeks. Satisfying outcomes both functionally and cosmetically for both patient and surgeons were observed at 3 months follow-up. CONCLUSION: Large sacral defect can successfully be reconstructed with double pedicled muscle Gracilis flap combined with gluteal rotation flap. The association with acellular dermal matrix is recommended to avoid abdominal cavity organs herniation. The oncological, functional results at 3 months are satisfying with minimal donor site morbidity. Presentation Type

Coverage of sacral decubital ulcer with a gluteal rotation flap and anchored deepithelialized tip.

Coverage of sacral decubital ulcer with a gluteal rotation flap and anchored deepithelialized tip.

The Surgical Management of Pilonidal Disease is Uncertain Because of High Recurrence Rates.

BackgroundPilonidal disease is a common condition with no consensus for the best management of chronic disease or current practice in Australia and New Zealand.MethodsA survey was distributed among 190 colorectal and 592 general surgeons in Australia and New Zealand. Data was obtained regarding pilonidal surgery volume, procedures performed, non-operative management and recurrence rates. Three clinical scenarios were also presented.ResultsThe response rate was 58% among colorectal surgeons, 18% among general surgeons. Nineteen percent of surgeons were high-volume (>23 operations per year), 47% low-volume (<12 operations per year). The commonest procedure was the Karydakis procedure (77%), with many others performed including rhomboid flaps (36%), Bascom cleft lift (13%), Z-plasty (7%), and gluteal rotation flaps (5%). Fifty-five percent of high-volume surgeons offered more than one operation while only 16% of low-volume surgeons did. Nineteen percent operated on all patients with pilonidal disease, 89% believing off-midline closure to be superior to midline. Disease extent was the main driver for non-operative management; patient factors such as cosmesis and time-off work being the least important. Sixty-four percent reported recurrence rates above 5%, and 37% recurrence rates >10%. Six percent reported no recurrences ever. Five percent reported recurrence rates over 20%, but 24% stated that over one-fifth of their practice consists of recurrent disease.ConclusionsThis study reports higher recurrence rates than in published series, suggesting many surgeons do not see their own recurrences, with current treatment not as successful as previously thought. Combined with the widespread variation in practice, optimal management of this disease remains unclear.

Laparoscopic and perineal approaches to perineal hernia repair

Perineal hernias after abdominoperineal resection (APER) of the rectum appear to be becoming more common, but there only a small number of reported cases, with very few reports discussing more than one or two. There is little consensus as to the optimal method of repair. We report the successful management of 7 cases of postoperative perineal hernia, including a hernia around a gluteal rotation flap that has not previously been reported, and discuss the operative approaches. We performed a single-centre hospital database review over 6years. Seven perineal hernias occurred after APER and were repaired. Six were treated with a transabdominal approach (5 laparoscopic and 1 laparoscopic converted to open) and one perineal approach. In 4 cases, a synthetic composite mesh was used, in 2 a biological mesh and in one direct suture repair. There have been no recurrences during a median follow-up of 25months. Laparoscopic mesh repair of symptomatic perineal hernia is the method of choice in most cases. Herniation may still occur despite inset of a gluteal rotation flap at initial APER and laparoscopic repair in that instance is difficult.

An Algorithmic Approach to Perineal Reconstruction After Cancer Resection—Experience From Two International Centers

This paper aims to simplify the approach to reconstruction of the perineum after resection of malignancies of the anal canal, lower rectum, vulva, and vagina. The data were collected from 2 centers, namely, Addenbrooke's Hospital, University of Cambridge, United Kingdom and Christchurch Hospital, University of Otago, New Zealand. All patients who underwent perineal reconstruction from 1997 to 2009 at Christchurch Hospital (13 years) and 2001 to 2009 at Addenbrooke's Hospital (9 years) were included. The diagnosis (indication), primary surgery, reconstructive surgery, complications, tumor outcomes (recurrence and survival), and follow-up were entered into a database (Microsoft Excel; Redmond, Wash). The incidence of previous radiotherapy, requirement for adjuvant radiotherapy, and length of inpatient stay were also recorded. Forty-six patients were identified for this study--13 in New Zealand and 33 in Cambridge. Indications for perineal reconstruction included resection of anal and rectal malignancies (24), vulval and vaginal malignancy (19), perineal sarcoma (1), and perineal squamous cell carcinoma arising in an enterocutaneous fistula (Table 1). The reconstructive strategies adopted included rectus abdominis myocutaneous flaps (26), gluteal fold flaps (9), gracilis V-Y or advancement flaps (7) and others (4), gluteal rotation flaps (1), local flap (2), and free latissimus dorsi flaps (1). Although various surgeons performed the reconstructive surgeries at 2 different centers, the essential approach remained the same. Smaller defects were best treated by local flaps, whereas the rectus abdominis flap remained the standard option for larger defects that additionally required closure of dead space. On the basis of our 2 center experience, we propose a simple algorithm to facilitate the planning of reconstructive surgery for the perineum.

Versatility of perforator sparing buttock rotation flap in repair of pressure sores

Eleven perforator-sparing gluteal fasciocutaneous rotation flaps were used for coverage of pressure sores in 10 patients with mean age 38.4 years. Nine patients were paraplegic, and one patient was ambulatory. All pressure ulcers were classified as grade 4. The pressure sores were sacral in five patients, unilateral ischial in five patients, and unilateral trochantric in one patient. Seven ulcers were recurrent and four were primary. The flap sizes ranged from 7 × 7 cm to 15 × 13 cm. In a total of 11 flaps, nine flaps included two perforators, one flap included three perforators, and one flap included single perforator. Skin incision is the same as that for the conventional gluteal rotation flap. The flap is elevated subfascially until at least two dominant musculocutaneous perforators of the superior or inferior gluteal arteries are encountered. In the recurrent ischial sores, the inferior part of gluteus maximus was used to fill dead space at the base of the ulcer as a separate muscle flap. Eight of 11 flaps healed uneventfully without complications. Mean follow-up period was 18.6 months (range 37–5 months). The recurrence rate in the same region was 0% during follow-up period. The appearances of pressure sores in other sites occurred in two patients that healed with conservative treatment. There was no major complication such as total flap necrosis. Only minor complications occurred which were treated without surgical intervention. The perforator-sparing gluteal rotation fasciocutaneous flap is a versatile and reliable flap for coverage of all gluteal pressure sores. This is an ideal flap for patients in whom the risk of ulcer recurrence is high as the rerotation is possible in case of recurrence.

Tip Anchor Flap in Decubital Surgery

Anchoring a flap remains a key procedure in decubital surgery because a flap needs to be stable against shearing forces. This allows an early mobilization and undisturbed primary wound healing. This study evaluated a uniform group of eight paraplegic patients with sacral decubital ulcers and covered the lesions using gluteal rotation flaps with a deepithelialized tip to anchor the flap subcutaneously on the contralateral ischial tuber. Initial wound healing and recurrence after one year were evaluated. All but one flap showed uneventful wound healing, and all the flaps presented without any signs of recurrence or instability. The authors suggest that sufficient anchoring using a deepithelialized part of the flap helps to integrate and stabilize sacral rotation flaps.

Preventing ischial pressure ulcers: III. clinical pilot study of chronic neuromuscular electrical stimulation

Objective: BIONs™ BIOnic Neurons are injectable, wireless microstimulators that make chronic BION Active Seating BAS possible for pressure ulcer prevention PUP. Neuromuscular electrical stimulation NMES produces skeletal motion and activates trophic factors, counteracting three major etiological mechanisms leading to pressure ulcers PUs: immobility, soft-tissue atrophy, and ischemia. Companion papers I and II reviewed prior experience with NMES for PUP, and analyzed the biomechanical considerations, respectively. This paper presents a treatment strategy derived from this analysis, and the clinical results of the first three cases. Methods: Two BIONs implanted one on inferior gluteal nerve to gluteus maximus GM, and other on sciatic nerve to hamstrings HS, in 3 spinal cord injured SCI subjects already undergoing gluteal rotation flaps for PUs. BAS using HS when seated, and BION Conditioning BC via GM+HS when non-weightbearing. Follow-up: 1 yr, including 6 mo. treatment window interface pressure mapping; muscle perfusion scans; MRI, X-ray volume assessments. Results: Successfully implanted and activated both desired muscle groups, selectively, in all. No PU recurrences or wound complications. Two subjects completed protocol. Mean results: Interface: contact pressure -10%; maximum pressure -20%; peak pressure area -15%. Vascularity: GM +20%, HS +110%. Perfusion: GM +70%, HS +440%. Muscle volume: GM +14%, HS +31%. Buttock soft-tissue padding: +49%. 1 BION failed; 1 BION rotated under GM. Conclusions: Promising proof-of-concept data supporting the feasibility of implanted microstimulators to achieve sufficiently strong and selective activation of target muscles for PUP. Ultimate goal is prophylactic deployment through bilateral, nonsurgical injection of BIONs in chronically immobile patients.

Preventing Ischial Pressure Ulcers: III. Clinical Pilot Study of Chronic Neuromuscular Electrical Stimulation

Objective:BIONs™ (BIOnic Neurons) are injectable, wireless microstimulators that make chronic BION Active Seating (BAS) possible for pressure ulcer prevention (PUP). Neuromuscular electrical stimulation (NMES) produces skeletal motion and activates trophic factors, counteracting three major etiological mechanisms leading to pressure ulcers (PUs): immobility, soft-tissue atrophy, and ischemia. Companion papers I and II reviewed prior experience with NMES for PUP, and analyzed the biomechanical considerations, respectively. This paper presents a treatment strategy derived from this analysis, and the clinical results of the first three cases.Methods:Two BIONs implanted (one on inferior gluteal nerve to gluteus maximus (GM), and other on sciatic nerve to hamstrings (HS)), in 3 spinal cord injured (SCI) subjects already undergoing gluteal rotation flaps for PUs. BAS using HS when seated, and BION Conditioning (BC) via GM+HS when non-weightbearing. Follow-up: 1 yr, including 6 mo. treatment window (interface pressure mapping; muscle perfusion scans; MRI, X-ray volume assessments).Results:Successfully implanted and activated both desired muscle groups, selectively, in all. No PU recurrences or wound complications. Two subjects completed protocol. Mean results: Interface: contact pressure −10%; maximum pressure −20%; peak pressure area −15%. Vascularity: GM +20%, HS +110%. Perfusion: GM +70%, HS +440%. Muscle volume: GM +14%, HS +31%. Buttock soft-tissue padding: +49%. 1 BION failed; 1 BION rotated under GM.Conclusions:Promising proof-of-concept data supporting the feasibility of implanted microstimulators to achieve sufficiently strong and selective activation of target muscles for PUP. Ultimate goal is prophylactic deployment through bilateral, nonsurgical injection of BIONs in chronically immobile patients.

CR22P PERINEAL FLAP RECONSTRUCTION FOLLOWING EXTENDED RESECTION FOR PELVIC MALIGNANCY

Purpose Extended resection for colorectal pelvic malignancy has shown good outcome but may involve extensive perineal resection necessitating plastic surgical reconstruction. The aim was to assess the indications, techniques, morbidity, and outcome of perineal flap reconstruction for extended pelvic resection.Methods Patients requiring perineal flap reconstruction following colorectal resection at a tertiary centre from 1994 to 2006 were identified from a prospective colorectal database. Details of the indication, procedure, morbidity, and outcome were obtained from the database and retrospective chart review.Results 21 patients (11 male, 10 female), median age 59 years (range 26–80) underwent perineal flap reconstruction. Indications for resection were advanced primary colorectal cancer (7), recurrent rectal carcinoma (8), recurrent anal carcinoma (3), and other pelvic malignancy (3). 18/21 patients had neoadjuvant radiotherapy. Reconstruction was by pedicled flap in 14 patients (5 gracilis flap, 7 vertical rectus abdominal muscle flap; 1 gluteal rotation flap) and latissimus dorsi free flap with microvascular anastomosis in 7 patients. Eighteen patients had immediate reconstruction and three were delayed. Five patients underwent vaginal reconstruction following posterior vaginectomy. There were four major flap complications (19%) requiring five unplanned reoperations. There were 2 minor complications (10%) requiring 1 unplanned reoperation. There were no donor site or longterm flap complications.Conclusion Perineal flap reconstruction by both pedicled and free flaps may be achieved with low morbidity following extended pelvic resection.

The Perforator-Sparing Buttock Rotation Flap for Coverage of Pressure Sores

The rotation fasciocutaneous flap for buttock pressure sore coverage has the distinct advantage of allowing rerotation in the event of ulcer recurrence. The authors describe their approach of preserving and incorporating musculocutaneous perforators into the conventional rotation design. The skin incision is the same as that for the conventional gluteal rotation flap. The flap is elevated subfascially until one or two large musculocutaneous perforators of the superior or inferior gluteal arteries are encountered. Intramuscular dissection by splitting fibers of the gluteus maximus muscle is then performed to free the perforator down to its emergent point at the level of the piriformis muscle to enable the perforator to pivot freely with the rotation of the skin flap. Further elevation of the flap beyond the location of the perforator is then performed as necessary to enable tension-free rotation of the skin flap into the defect. Muscle to fill dead space when needed is raised as a separate flap. Seven patients underwent closure of buttock pressure sores in the sacral, ischial, and trochanteric areas using this technique. All wounds healed, with no recurrence, at a mean follow-up of 30 months. This technique can be used to cover pressure sores over the sacral, trochanteric, and ischial regions. This modification of the conventional rotation flap affords the flexibility of rerotation in the event of ulcer recurrence while providing the flap with enhanced blood supply. This is an ideal flap for patients in whom the risk of ulcer recurrence is high.

Reconstruction of large sacral defects following total sacrectomy.

Total sacrectomies for cancer ablation often result in extensive defects that are challenging to reconstruct. In an effort to elucidate the criteria to select the most effective reconstructive options, we reviewed our experience with the management of large sacral wound defects. All patients who had a sacral defect reconstruction after a total sacrectomy at our institution between January of 1993 and August of 1998 were reviewed. The size of the defect, the type of reconstruction, postoperative complications, and functional outcome in each patient were assessed. A total of 27 flaps were performed in 25 patients for sacral defect reconstruction after a total sacrectomy. Diagnoses consisted of chordoma (n = 13), giant cell carcinoma (n = 2), sarcoma (n = 5), rectal adenocarcinoma (n = 4), and radiation induced necrosis (n = 1). The size of sacral defects ranged from 18 to 450 cm2 (mean, 189.8 cm2). Ten patients, including five who had preoperative radiation therapy, underwent transpelvic vertical rectus abdominis myocutaneous (VRAM) flap reconstruction for sacral defects with a mean size of 203.3 cm2. Of these, five patients (50 percent) had complications (four minor wound dehiscences and one seroma). Eight patients, including one who had preoperative radiation therapy, underwent bilateral gluteal advancement flap reconstruction for sacral defects with a mean size of 198.0 cm2. They had no complications. Two patients, both of whom had preoperative radiation therapy, underwent gluteal rotation flap reconstruction for sacral defects of 120 cm2 and 144 cm2. Both patients had complications (one partial flap loss and one nonhealing wound requiring a free flap). Three patients, including one who had preoperative radiation therapy, underwent reconstruction with combined gluteal and posterior thigh flaps for sacral defects with a mean size of 246 cm2; two of these patients had partial necrosis of the posterior thigh flaps. Three patients, all of whom had preoperative radiation therapy, underwent free flap reconstruction for sacral defects with a mean size of 144.3 cm2. They had no complications. Our experience suggests that there are three reliable options for the reconstruction of large sacral wound defects: bilateral gluteal advancement flaps, transpelvic rectus myocutaneous flaps, and free flaps. In patients with no preoperative radiation therapy and intact gluteal vessels, the use of bilateral gluteal advancement flaps should be considered. In patients with a history of radiation to the sacral area and in patients whose gluteal vessels have been damaged, the use of the transpelvic VRAM flap should be considered. If the transpelvic VRAM flap cannot be used because of previous abdominal surgery, a free flap should be considered as a last option.

Surgical treatment of invasive malignancies of the vulva using CO2 laser

In a retrospective study, we analysed 26 CO2-laser vulvectomies within the observation period between 1982 and 1990. Indications for vulvectomies were invasive malignancies of the vulva, FIGO stage I to III. 91.7% were squamous cell carcinomas. The mean age of patients was 69.3% (43 to 87) years. Five radical local excisions, one modified radical vulvectomy and in all other cases radical vulvectomy was performed. Laser surgery of the vulva was combined with bilateral lymphadenectomy or radiotherapy of inguinal lymph nodes. If necessary, a gluteal rotation flap was built to achieve closure of the wound without tension. No serious intra- or postoperative complications were observed, wound breakdown with per secundam healing as the most common complication occurred in 29.1%. Functional and cosmetic results were examined in a detailed follow-up at least 12 months postoperatively, showing promising results (56.3% good, 37.5% satisfactory, 6.3% unsatisfactory). The surgical procedure, perioperative management, recurrence rate (3 patients, 12.5%), as well as functional and cosmetic results, are presented and discussed in detail. The use of CO2-laser in surgical treatment of vulvar malignancies improves cosmetic and functional results. This is important, particularly with regard to the increasing number of young women with vulvar neoplasia.