Pedicled Chimeric Perforator Flap Based on Inferior Gluteal Vessel Axis for the Reconstruction of Stage-Four Primary Ischial Pressure Sores-A New Design

Abstract

Background "Subfascial void reconstruction" in ischial pressure sores (IPSs) goes a long way in the amelioration of the common complications like persistent drainage, infection, wound dehiscence, and late recurrence. No locoregional flaps suffice this requirement. So we have designed a chimeric pedicled flap based on the inferior gluteal vessel axis (IGVA) perforators with two tissue components: (1) Pacman-style fasciocutaneous flap on a perforator and (2) gluteus maximus muscle (inferior portion) on another independent perforator. Aim and Methods After confirming the feasibility of novel design of chimeric pedicled IGVA perforator flap with cadaver study, we embarked on the clinical study with this chimeric flap. In this prospective cohort study, the study and the control existed in the same patient so that the biological factors affecting the wound healing would be the same. Results Twenty-one patients were included whose mean age was 39 years. Late recurrence occurred in one patient (4.8%) of chimeric flap while the control group (who had undergone conventional reconstruction) had recurrence in 11 patients (52.4%). On assessment with overall institutional score, grade A was observed in 18 patients of the chimeric IGVA flap group ( p < 0.045), and in only 3 patients of the control group. Conclusions This anatomically construed flap, a new addendum in the armamentarium of reconstruction of IPSs, with its potential to congruently fill the ischiogluteal subfascial void may provide a lasting solution for preventing recurrences.

Keywords: chimeric inferior gluteal artery perforator flap; ischial pressure ulcer; myelopathic patients; recurrent pressure ulcer.

Fig. 1

Gluteal triangle marked in the cadaver.

Fig. 2

Chimeric pedicled perforator flap based on inferior gluteal vessel axis (IGVA) harvested in the cadaver.

Fig. 3

The components of the chimeric flap showing cutaneous paddle on long septofasciocutaneous perforator and islanded muscle paddle on another independent musculocutaneous perforator (arrow showing the stem of inferior gluteal vessel axis [IGVA]).

Fig. 4

Preoperative X-ray showing osteomyelitic destruction of ischial tuberosity on either side with cystolithiasis and intramedullary nailing of right femur proximal third fracture.

Fig. 5

Intraoperative picture showing the Pacman flap marked in the territory of Dopplered perforator.

Fig. 6

The superior nondelineating incision with supraepimysial dissection showing the musculocutaneous perforator through the lower third oblique portion of the gluteus maximus.

Fig. 7

Intraoperative picture showing Pacman-style fasciocutaneous flap elevated on two perforators before the selection of single best perforator.

Fig. 8

Intraoperative picture showing islanded Pacman perforator flap.

Fig. 9

Intraoperative picture showing chimeric configuration of pedicled inferior gluteal vessel axis (IGVA) perforator flaps with muscle island and fasciocutaneous island on separate perforator of IGVA.

Fig. 10

Intraoperative picture showing IGVA dissected unto the greater sciatic foramen.

Fig. 11

Intraoperative picture showing inset of Pacman flap incorporating transposition and rotation of jaws of the Pacman and V-Y advancement of entire fasciocutaneous perforator flap.

Fig. 12

Case 1 illustrations. Above: intraoperative picture after debridement of ischial pressure sores (IPSs) on either side. Below: postoperative picture at 24 months follow-up.

Fig. 13

Case 2 illustrations. Upper left: preoperative picture. Upper middle: preoperative AP view of the X-ray pelvis showing bilateral ischial tuberosity sequestrations. Upper right: intraoperative picture showing limited ostectomy specimens. Lower right: intraoperative picture showing a skin paddle raised on a single best perforator from the pedicled inferior gluteal vessel axis (IGVA). Lower left: postoperative picture at 26 months follow-up.