Gluteus Maximus Musculocutaneous Flap Research Articles

Single-session repair of multiple pressure ulcers in non-ambulatory patients

Pressure ulcers (PUs) are highly prevalent and challenging wounds. In this study, patients with either tetraplegia or paraplegia, all of whom had multiple grade 4 PUs and who underwent single-session surgical treatment were included. In order to increase the mobility of the musculocutaneous flap, the gluteus maximus muscle, which cannot be used by immobile patients, was detached and inserted into the flap. This was a retrospective case series and all PUs were reconstructed within the same surgical session. A total of nine patients participated in the study, all of whom were male. Mean age was 33 years (range: 20-42 years). Mean follow-up period was 14.3 months (range: 9-24 months). All patients had a successful single-session repair of all PUs. Total or partial flap losses were not observed. Mean and total number of reconstructed PUs were 2.55 and 23, respectively. The mean area of reconstructed open wounds per patient was 174.6cm2 and the mean operation duration was 253 minutes. The level of blood loss was acceptable as the decrease in haemoglobin levels was not more than 2g/dl for each patient. Multiple PUs can be repaired in one session using gluteus maximus musculocutaneous flaps in immobile patients. Based on the fact that the gluteus maximus is an essential muscle for ambulation, our approach can only be used in the treatment of patients with irreversible paraplegia or tetraplegia. When all prerequsities are met, the amount of blood loss and operation duration are acceptable, and returning the patient to a wound-free state can be achieved more quickly compared to multi-session repairs. Air-fluidised beds are vital tools for accomplishing single session repairs of multiple PUs. The data shows that the approach is safe and can be used in patients with multiple PUs.

Early rehabilitation after perineal reconstruction with musculocutaneous flaps

Background: Advanced colorectal cancer can lead to abdominoperineal resection (APR) which results in large loss of perineal tissue. The pelvic floor can be reconstructed by replacing the removed tissue with a musculocutaneous flap, which also facilitates the healing process. Several reconstructive options have been described included vertical rectus abdominis musculocutaneous (VRAM) and gluteus maximus musculocutaneous flap (GM).

Hatchet-type Gluteus Maximus Musculocutaneous Flap for Reconstruction of Sacral Pressure Sore

Hatchet-type Gluteus Maximus Musculocutaneous Flap for Reconstruction of Sacral Pressure Sore

Laparoscopic total pelvic exenteration with en bloc lateral lymph node dissection after neoadjuvant chemoradiotherapy for advanced primary rectal cancer

Total pelvic exenteration (TPE) may be the only procedure that can cure T4 rectal cancer that directly invades the urinary bladder or prostate. Here, we describe our experience of laparoscopic TPE with en bloc lateral lymph node dissection for advanced primary rectal cancer. A 62-year-old man diagnosed with advanced lower rectal cancer (T4bN0M0) underwent laparoscopic TPE with en bloc lateral lymph node dissection after neoadjuvant chemoradiotherapy. Ligation of the dorsal vein complex was performed under direct visualization through the perineal approach, and the large perineal defect was reconstructed using bilateral V-Y advancement of the gluteus maximus musculocutaneous flaps. The ileal conduit was constructed extracorporeally through an extended umbilical port that was extended to 4 cm. The total operative time was 831 min and estimated blood loss was 600 mL. Laparoscopic TPE appears to be safe and feasible in selected patients.

Closure of meningomyeloceles with the 4-flap compound technique according to Ramirez

Aims: Wound closure represents an important step in the surgical management of meningomyeloceles besides excision of the placode and subsequent reconstruction of the dural sac. Although numerous techniques and possibilities for the plastic repair of the defect are described, a comparison of these methods is missing. The aim of this study was to compare the 4-flap compound technique according to Ramirez with bilateral latissimus dorsi and gluteus maximus musculocutaneous flap advancements with other techniques.

Three-Dimensional Arterial Anatomy of the Gluteus Maximus and the Proper Method of Muscle Splitting

Sir: The gluteus maximus muscle is a large muscle that is sometimes used as a split muscle flap in reconstructive surgery. Although several methods have been reported for splitting the gluteus maximus muscle,1–4 the proper method based on three-dimensional arterial anatomy has never been described. Using fresh cadavers, we performed systemic angiography. After dissecting the gluteus maximus muscle from the surrounding tissue, stereoscopic images were taken, and the three-dimensional arterial anatomy was reviewed (Fig. 1). Cadaveric studies demonstrated that the peripheral arteries inside the muscle are oriented in the direction of the muscle fibers, and the lower gluteal artery and the first perforating artery are strongly connected. From these observations, three methods can be used. The first is a superior gluteal artery pedicled flap using the superficial half of the gluteus maximus muscle where the skin is situated in the distal portion. The second is an inferior gluteal artery pedicled flap using the superficial half of the gluteus maximus muscle where the skin is situated in the distal portion. The third is a first perforating artery pedicled flap using the superficial half of the gluteus maximus muscle where the skin is situated medially. In all cases, the deeper part of the gluteus maximus muscle is preserved. Because the perforating branches in the muscle are difficult to identify, dissection of the muscle for the splitting should be performed with one-fifth of the muscle length around the pedicle untouched. Six patients with a total of seven skin defects underwent reconstruction with a split gluteus maximus musculocutaneous flap. In all cases, the flaps took well without any evidence of necrosis. The profiles of patients and results are listed in Table 1. A representative case (case 4) is shown in Figures 2 and 3. The application of the type of split gluteus maximus musculocutaneous flap depends on the sites of the skin defect. From our experience, the superior gluteal artery–based split gluteus maximus musculocutaneous flap is suitable for reconstructing the sacral and sciatic areas, the inferior gluteal artery–based split gluteus maximus musculocutaneous flap sciatic area, and the first perforating artery–based split gluteus maximus musculocutaneous flap greater trochanter area. The merits of using a split gluteus maximus muscle flap are as follows: (1) it is easy to perform; (2) there is less dead space and serous discharge from the drain becomes less after surgery; (3) the part of the function of the gluteus maximus is preserved; and (4) compared with the “perforator flap,” the surgeon does not need to worry about disturbing important perforating arteries. In contrast, the limits on how thin the muscle can be or how small the pedicle can be have not been delineated from the anatomical data. From our clinical cases, construction of a gluteus maximus musculocutaneous flap using half of the gluteus maximus muscle thickness with four-fifths of the muscle being dissected free was performed safely.Fig. 1.: A stereoscopic view of the gluteus maximus muscle demonstrates that the upper half of the gluteus maximus muscle is nourished by the superior gluteal artery (yellow arrow), and the lower half is nourished by the inferior gluteal artery (red arrow). The lateral portion is nourished by the first perforating artery of the deep femoral artery (blue arrow). Peripheral branches are inclined to the direction of the muscle fiber. The peripheral areas of the inferior gluteal artery and the first perforating artery communicate with one another (dotted line).Table 1: Profiles of the Patients and Clinical Results of the Split Gluteus Maximus Musculocutaneous FlapFig. 2.: A 40-year-old man with hidradenitis suppurativa on the right buttock underwent a split gluteus maximus musculocutaneous flap reconstruction based on the distribution of the superior gluteal artery (left). The dissection was performed at 50 percent thickness of the gluteus maximus, and three-fourths of the full length of the muscle was used (right).Fig. 3.: The patient immediately postoperatively.In conclusion, the gluteus maximus muscle can be safely split along the superficial and deep layers of its muscle fibers based on its blood supply. This technique represents an easier and safer method for reconstructing defects found in the gluteal region. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Kazuo Kishi, M.D., Ph.D. Hideo Nakajima, M.D., Ph.D. Department of Plastic and Reconstructive Surgery Nobuaki Imanishi, M.D., Ph.D. Department of Anatomy Tatsuo Nakajima, M.D., Ph.D. Department of Plastic and Reconstructive Surgery Keio University School of Medicine Tokyo, Japan

Gluteal artery perforator flap: a viable alternative for sacral radiation ulcer and osteoradionecrosis

Radiotherapy is a crucial part in the treatment of cancer; however, it may cause adverse effects to normal tissue such as radiation-induced ulcer and osteoradionecrosis. The few cases of conservative management that were reported had a limited value and unsatisfactory results. The most reliable method to treat sacral radiation ulcer and osteoradionecrosis is a wide excision of the affected tissue, followed by coverage with well-vascularised tissue. Musculocutaneous free flaps and local gluteus maximus musculocutaneous flaps have been used; however, there were many drawbacks such as dissection of recipient vessel in the previously radiated area and donor-site morbidity. During a 4-year time period at our institute, we found favourable clinical results using gluteal artery perforator procedure for radiation-induced ulcers and osteoradionecrosis of the sacral area. The 10 patients, who were treated with gluteal artery perforator flaps, had chronic non-healing radiation ulcers or bone exposure of the sacrum. Intra-operatively, massive debridement of bone and soft tissue was performed, while the well-vascularised skin with only a colour change was preserved. The flap was designed to include two or more perforators using Doppler flowmetry and the perforators were preserved with surrounding subcutaneous tissue during the flap elevation. The mean post-operative follow-up period was 25.7 months. As regards the surgery, there was one major complication (of partial flap loss) and three minor complications (of wound dehiscence). In the patient with partial flap loss due to infection and a floating flap, the contralateral superior gluteal artery perforator flap was used to treat complications. Other complications were conservatively treated and well healed. Gluteal perforator flaps are a valuable alternative in treating sacral radiation ulcers and osteoradionecrosis. Sufficient excision of devitalised tissue is a crucial procedure to achieve optimal results.

Extended split superior gluteus maximus musclocutaneous flap and reconstruction after resection of perianal and lower gluteal hidradenitis suppurativa

Various modifications of the gluteus maximus musculocutaneous flap have been reported. Among them, the split gluteus maximus musculocutaneous flap is easy to prepare and does not leave ambulatory insufficiency. However, the safety of extending the skin portion beyond the margin of the muscle has not yet been clarified. Angiography was performed systemically on 11 fresh cadavers, and the distance the margin of the gluteus maximus muscle could be extended was observed. Based on these anatomical data, reconstruction after total skin resection of perianal and lower gluteal hidradenitis suppurativa was performed with an extended split superior gluteal maximus musculocutaneous flap. Surgery was performed on three sides of two patients. From the anatomical results, we found that it is possible to extend the flap beyond the iliac crest several centimetres superiorly, and to the gluteal fold inferiorly, and several centimetres laterally. We designed the flap such that the extended area is situated in these areas. All flaps took well and did not show any congestion or necrosis. There were no recurrences at least 1 year after surgery. When reconstructing the lower part of the buttock, an extended split superior gluteus maximus musculocutaneous flap is easy to raise and leaves aesthetically satisfactory results. Thus it may be the first choice for reconstruction of the lower buttock.

Immediate Reconstruction of Oncologic Hemipelvectomy Defects

Soft tissue and bony tumors of the pelvis are rare, but when they occur, treatment presents both an oncologic surgical and a reconstructive challenge. After reconstruction, soft tissue defects can be large and there is usually exposed bone and/or joint. A retroperitoneal abdominal wall defect may also be present. Flap mobilization is generally necessary to eliminate dead space and cover the exposed bone, viscera, and/or prosthetic orthopedic material. We performed immediate reconstruction on 11 patients after radical pelvic resections for tumor. Eleven cases of radical pelvic resection and immediate reconstruction were identified during the period from 1992 to 2002 at University Hospital, Newark, New Jersey. All patients were treated by both the orthopedic oncology and plastic surgery teams. A retrospective review of office charts and hospital records was performed. Data were gathered regarding the following: tumor type and oncologic history, extent of resection, reconstructive modality, complications, and outcome. All patients underwent radical resection of pelvic masses depending on the tumor type and location. Tumor types included chondrosarcoma (6), Paget osteosarcoma (1), giant cell tumor (1), metastatic uterine carcinoma (2), and invasive squamous cell carcinoma arising in a chronic decubitus ulcer (1). The reconstructive procedures performed were the following: rectus abdominus flaps (6), gluteus maximus musculocutaneous flaps (3), and thigh fillet flaps (2). The retroperitoneal defects were repaired with primary tissue approximation of the surrounding available musculature. Additionally, Gore-Tex mesh was used in 2 cases, tensor fascia lata was used in 2 cases, and acellular dermal matrix in 1 case. Blood loss for the combined procedures ranged from 400 mL to 1400 mL. The follow-up period in this series ranged from 24 to 114 months. Complications included skin flap loss with subsequent infection (1), local cellulitis controlled with antibiotics (1), regional recurrence (2). The postoperative course was uneventful for the remainder of the cases. Soft tissue reconstructions after extensive pelvic resections always present as complex reconstructive problems. Reconstruction is dictated by the size of the defects and by tissue availability. The extent and type of resections vary according to tumor size and location. In our experience, local pedicled muscle-based flaps, if available, usually provide adequate tissue mass to eliminate dead space, cover the extent of the wound, and close the retroperitoneal defect. Microvascular tissue transfer is always an option but was reserved in our series for cases with no suitable local alternative.

Choice of flaps for breast reconstruction

The optimal method for breast reconstruction should be safe, reliable, and accessible for every patient, and it should display little or no donor-site morbidity. After comparing mammary implants it has been found that autogenous breast reconstruction can create a ptotic, soft, symmetrical breast mound. The transverse rectus abdominis musculocutaneous flap (TRAM) remains the most popular method for autogenous reconstruction. Modern trends in breast reconstruction using the TRAM flap have promoted adequate blood supply to the flap while minimizing donor-site defects in the anterior abdominal wall. The pedicled TRAM flap remains one of the most frequently used flaps, but the indirect blood supply in this flap has required many modifications and refinements. Such modifications have included the bipedicled TRAM flap, the free TRAM flap, and the supercharged TRAM flap. To avoid donor-site morbidities, the muscle-sparing free TRAM, deep inferior epigastric perforator flap (DIEP), and superficial inferior epigastric artery (SIEA) flap were introduced. The DIEP perforator flap requires meticulous technique but offers proven reliability and a low rate of complications. As surgeons become more comfortable with harvesting DIEP flaps, the frequency of usage seems likely to increase. The latissimus dorsi musculocutaneous flap, gluteus maximus musculocutaneous flap, and others may be selected when these modifications of free TRAM flap are unavailable or unusable.

Clinical Experience With the Hatchet-Shaped Gluteus Maximus Musculocutaneous Flap

One of the most frequently used flaps for the coverage of sacral skin and soft-tissue defects (primarily decubiti) is the gluteus maximus musculocutaneous flap. The authors have developed a new, hatchet-shaped incision direction for the flap and have been using it for 6 years in the surgical treatment of various pelvic-area defects with good results. At the beginning, the gluteus maximus hatchet-shaped flap was used for treatment of pressure sores in the pelvic area: sacral decubitus on 31 patients, ischial pressure ulcer on 12 patients, and trochanteric ulcer on 1 patient. However, later the method was applied to nondecubitus defects, such as myelomeningocele on 4 patients, Crohn disease on 3 patients, pilonidal sinus on 2 patients, and traumatic defect on 1 patient, totaling 71 flaps on 54 patients. The seroma (4), hematoma (2), postoperative bleeding (1), and partial flap necrosis (1) healed following emptying and repeated surgery; recurrent ulcer was seen in 2 cases. Advantages of the method are the fewer incisions needed, the shorter operating time, and the smaller blood loss as compared with the methods known so far. The new incision direction improves the safety of circulation in the flap, the closure of the donor site is simpler, and no contour difference remains in the surgical area.

Reconstruction after extirpation of sacral malignancies.

Defects after extirpation of either sacral or rectal tumors often present a reconstructive challenge to plastics surgeons. Because of their relative infrequency, management guidelines, in the authors' opinion, have been overlooked. They think that successful, comprehensive treatment lends itself to an integrated team approach. They review their experience with immediate reconstruction after total sacrectomy for sacral malignancies performed between 1996 and 2001. Medical records were reviewed retrospectively for the surgical procedure, postoperative complications, and eventual outcome. A total of 9 patients underwent sacrectomy with a gluteus maximus flap for reconstruction. Six patients had a simultaneous omental flap for complete obliteration of the surgical defect. The authors' experience suggests that this combination of techniques is a reliable approach for reconstruction of these extensive surgical defects.

Split gluteus maximus island flaps for concomitant closure of ischial and sacral pressure sores.

The author presents an innovation in the use of the gluteus maximus musculocutaneous flap that allows one to repair both sacral and ischial pressure sores concomitantly in a paraplegic patient. The musculocutaneous unit is divided into superior and inferior halves, each of which is supplied by their respective gluteal arteries. The "islanded" flaps can be moved in different directions independent of one another to cover both the sacral and ischial regions at the same time. The donor area can be closed primarily. Three patients were operated using this method. The 1-year follow-up of 1 patient is presented.

The Transverse Lumbosacral Back Flap for Salvage of Sacral Pressure Sore after Gluteus Maximus Musculocutaneous Flap Failure

Reconstruction for the sacral pressure sore after failed gluteus maximus musculocutaneous flap transfer is challenging to the plastic surgeon. In the condition of no available gluteus maximus musculocutaneous flaps, the transverse lumbosacral back flap may be used for salvage. The study is designed to review the reliability and versatility of the transverse lumbosacral back flap based on 12 consecutive patients in the past 5 years. With an average follow-up of 18 months (6 to 25 months), complete wound healing was achieved in 10 patients (83.3%). Two flaps had distal necrosis, of which required reinsertion of the flap and skin grafting. All donor sites were closed with skin graft. Based on results of our clinical experience, this flap is recommended as an another option for salvage of failed gluteus maximus musculocutaneous flap coverage of sacral pressure sore.

Reconstruction of perianal skin defect using a V–Y advancement of bilateral gluteus maximus musculocutaneous flaps: reconstruction considering anal cleft and anal function

In order to preserve the anal function after ano-perianal skin excision for malignancy, we have reconstructed a deep, symmetrical natal cleft using a V–Y advancement of bilateral gluteus maximus musculocutaneous flaps thinned medially and sutured to the coccyx, anococcygeal ligament and the central tendon of the perineum.This technique was applied in three cases of Bowen’s disease and two cases of Paget’s disease. In all five cases, postoperative anal functions such as comfortable defecation and sensation, were well preserved, the perianal skin and underwear stayed clean, and there was no disturbance of walking or exercise.

Reconstruction after resection of a large sacral neoplasm

The gluteus maximus musculocutaneous flap is a useful flap for sacral reconstruction. Many variations have been described. The flap can be raised simply, quickly and with minimal blood loss. This flap was used for closure of a large defect of the sacrum in a 44-year-old woman with an advanced neoplasia of the sacrum. The surgery, performed in a third world country, required a procedure which was unlikely to fail. The technique and the results are presented.

Unilateral multilayered musculocutaneous V-Y advancement flap for the treatment of pressure sore.

We have devised a modified technique using the gluteus maximus musculocutaneous flap as multilayered sliding V-Y advancement to cover pressure sores on the sacral area. Nine patients with relatively large (average 7 x 7 cm) sacral grade IV pressure sores underwent unilateral multilayered V-Y advancement flap. All patients were followed for a minimum of 8 weeks. The mean postoperative follow-up was 32.3 months, with a range of 24 to 39 months. Using this technique, the success of surgery, i.e., the percentage of sores that healed, was 100 percent in our patients. The advantages of this technique include sufficient advancement of the flap, coverage of large ulcer defects using only a unilateral musculocutaneous flap, and preservation of the contralateral gluteus maximus muscle for future use.

Gluteus maximus musculocutaneous flap for the treatment of recalcitrant pilonidal disease.

Although conservative surgery should be the initial approach to pilonidal disease, there remains a select group of patients with recalcitrant disease who fail repeated interventions and for whom a more aggressive approach is justified. Use of a large gluteus maximus musculocutaneous flap to facilitate wide excision, to allow for primary closure with well-vascularized tissue, and to alter the anatomy of the gluteal cleft has been used in 5 patients with chronic recurrent recalcitrant disease. The use of this large muscle unit in these otherwise healthy adults has achieved control over their pilonidal disease with acceptable morbidity and no demonstrable functional sequelae.

Treatment of ischial pressure sores with an inferior gluteus maximus musculocutaneous island flap: an analysis of 31 flaps

We describe our experience with the use of an island gluteus maximus musculocutaneous flap (from its most inferior part) based on perforators from the inferior gluteal artery. The study is based on a series of 27 patients in whom treatment was carried out for 31 ischial pressure sores. Eight patients had postoperative complications in the form of dehiscence of the donor flap site and/or infection. Follow-up ranged from 6 to 32 months. During this period three patients developed recurrent sores which were treated with other flaps. We feel strongly that the use of this flap should be considered as a first choice in the treatment of the mild to moderate size ischial pressure sore. Its advantages include ease in elevation of the flap and the provision of a vascularized bulky flap which also spares the vascular pedicles of adjacent flaps for future use.

症例経過報告 本学会誌で報告した後，経過観察中に転移をきたした血管肉腫と再発をきたした有きょく細胞癌

Report of Two Cases-A metastatic Angiosarcoma Case and A Case of Recurrent Squamous Cell CarcinomaCase 1: A 64-year-old woman was referred to us with multiple faint red masses on her scalp in June 1988. Wide excision including whole scalp and the periosteum beneath the affected area was done. The defect was covered with split thickness skin grafts. Postoperatively, the patient received radiotherapy and chemotherapy with rIL-2. One year and two months later she developed a subcutaneous tumor of left preauricular region. The patient accordingly received total parotidectomy combined with excision of the overlying skin and of temporal and zygomatic branches of facial nerve, and neck lymph node dissection. Pathologically, parotid lymph node metastasis was confirmed, but no neck lymph node metastasis was observed (0/32). The defect was reconstructed by pectoralis major musculocutaneous flap, followed by radiation therapy to the parotid area and neck. The patient is alive and well 4 years 7 months after the primary operation.Case 2: A 58-year-old man was first seen by us in March 1989 at Obihiro Kosei Hospital with multiple abscesses and suppurating sinuses involving the buttocks. In May 1989 excision of the skin and subcutaneous tissues including sinuses was performed. The defect was covered with split thickness skin grafts. The graft healed well. One month later, however, abscesses and sinuses of right buttock recurred, resulting elevated fungating tumor masses. Biopsy of the tumor showed squamous cell carcinoma. In January 1990, whole tumor was removed with rectum after a colostomy was made. The tissue defect was covered with gluteus maximus musculocutaneous flap and split thickness skin grafts, followed by radiation therapy and chemotherapy with Peplomycin and Carboquone. One year later, pus discharge was observed, and recurrence of S.C.C. was confirmed pathologically. CT and MRI findings demonstrated the tumor recurrence involved prostate, upper urethra, posterior wall of bladder, and sacrum. In May 1991, total pelvic exenteration combined with sacral resection was performed at Hokkaido University Hospital. The resultant tissue defect was reconstructed with free latissimus dorsi musculocutaneous flap, followed by chemotherapy with Bleomycin. The patient was alive and well 2 years 8 months after the total pelvic exenteration.