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Year : 2019  |  Volume : 27  |  Issue : 4  |  Page : 193-198

Safe and easy way to reconstruct pressure ulcers: Gluteal artery perforator flaps

Department of Plastic, Aesthetic and Reconstructive Surgery, Ankara Numune Training and Research Hospital, Saglik Bilimleri University, Ankara, Turkey

Date of Submission29-Dec-2018
Date of Acceptance17-Feb-2019
Date of Web Publication26-Sep-2019

Correspondence Address:
Dr. Burak Yasar
Department of Plastic, Aesthetic and Reconstructive Surgery, Ankara Numune Training and Research Hospital, Saglik Bilimleri University, Talatpaşa Boulevard No: 5 Altındağ, Ankara
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_102_18

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Introduction: Pressure ulcers continue to be a reconstructive challenge due to the growing number of patients under risk. Frail nature of the affected patient makes this problem even more complicated. Commonly pressure ulcers are reconstructed with random pattern flaps or musculocutaneous flaps. With the emergence of the perforator concept and expanding knowledge in the vascularity of the gluteal integument, gluteal artery perforator flaps became popular in reconstructing pressure ulcers. In this study, we aimed to review the technical tips to improve clinical outcomes of superior gluteal artery perforator and ınferior gluteal artery perforator flaps in the light of our clinical experience. Materials and Methods: Between 2015 and 2018, nine patients with pressure ulcers in the sacral and ischial regions were reconstructed with gluteal artery perforator flaps. Anatomical landmarks were marked, and Doppler ultrasound was also used to identify individual perforators. The subfascial dissection was opted, and skin island was inseted resembling an advancement pattern to prevent peforator kinking and to include maximum number of perforators. Results: All flaps survived, seroma was seen in two patients, and two of the patients had wound dehiscence at donor site. Conclusions: In the era of perforator flaps, with their safe anatomical basis, less morbidity and versatility in design we offer gluteal artery perforator flaps as a reliable alternative in reconstructing pressure ulcers.

Keywords: Inferior gluteal artery, perforator flap, pressure ulcer, superior gluteal artery

How to cite this article:
Yasar B, Duru C, Ergani HM, Kaplan A, Igde M, Unlu RE. Safe and easy way to reconstruct pressure ulcers: Gluteal artery perforator flaps. Turk J Plast Surg 2019;27:193-8

How to cite this URL:
Yasar B, Duru C, Ergani HM, Kaplan A, Igde M, Unlu RE. Safe and easy way to reconstruct pressure ulcers: Gluteal artery perforator flaps. Turk J Plast Surg [serial online] 2019 [cited 2022 Oct 6];27:193-8. Available from: http://www.turkjplastsurg.org/text.asp?2019/27/4/193/267926

  Introduction Top

Pressure ulcers occur as a result of unrelieved high-pressure exposure to the skin and subcutaneous tissues usually over a bony prominence. High-risk features for developing pressure ulcers include intensive care unit (ICU) admission, spinal cord injuries, lower extremity fractures, cachexia, and being over 65.[1],[2],[3] Additional pathologies such as anemia, hypoalbuminemia, diabetes mellitus, and peripheral arterial disease are predisposing factors for pressure ulcers.[4] The prevalence of pressure ulcers has been reported to be 12.5% and 15% in two international multicenter studies.[5],[6] Considering numerous patients affected, the burden of the comorbidities and high recurrence rates, pressure injuries continues to be a major reconstructive problem.

Relief of pressure and adequate debridement is essential for initial care, and operative treatment includes, primary repair, skin grafts, local random pattern fasciocutaneous flaps, and muscle flaps.[3] Since the 1970s, the number of treatment options have increased by the introduction of musculocutaneous flaps and by the end of 1980s, a new era for reconstructive surgery was begun by the use of perforator-based flaps providing freedom and less morbidity when compared to the conventional musculocutaneous flap design.[7]

Pressure ulcers mostly occur in the sacral, ischial and heel regions.[8],[9] Superior gluteal artery perforator-based flap (SGAP) for sacral pressure injuries was reported by Koshima et al. and inferior gluteal artery perforator-based flap (IGAP) for ischial defects was introduced by Higgins et al.[10],[11] In this study, we aimed to review the technical tips to improve clinical outcomes of SGAP and IGAP flaps in light of our clinical experience.

Regional vascular anatomy

The terminal branches of the internal iliac artery, superior, and inferior gluteal arteries supply the gluteal region integument. Both arteries run through the major sciatic foramen and exit the pelvis.

While the superior gluteal artery passes superior to the piriformis muscle (PM), the inferior gluteal artery (IGA) travels inferior to the PM. The superior gluteal artery supplies the upper portion of gluteus maximus muscle with overlying skin and the IGA similarly supplies the inferior part of the muscle with overlying skin. Perforators originating from the lateral sacral arteries, internal pudendal arteries, and lateral circumflex arteries also contribute to the supply of the skin.[12]

Whereas 20–25 perforator branches were observed in the gluteal region by Koshima et al.,[10] 10–20 perforator branches were identified in another anatomical study by Kankaya et al.[13] Almost all perforator branches are musculocutaneous. Perforator diameters were found to vary between 0.7 and 1.5 mm in various anatomical and clinical studies.[10],[13],[14]

  Materials and Methods Top

Preoperative marking

Inferior gluteal artery perforator

When IGA flap is planned for pressure ulcers, inferior gluteal crease (IGC) is drawn in the standing position if the patient is mobile. The preoperative determination of IGC is important for concealment of the donor site scar in oval flaps where IGC being the equator. For flaps to be placed over IGC, it is important that inferior of the flap should not exceed 3 cm inferior of the IGC as scar would lie over IGC.[14]

After placing the patient in prone position, a line is drawn from posterior superior iliac spine (PSIS) to the lateral edge of ischial tuberosity, and the intersection of the lower third and mid-third of that line is the origin of IGA, accompanying sciatic nerve, and other vascular structures [Figure 1]a.
Figure 1: (a) The inferior gluteal artery is located at the intersection of the lower and mid 1/3 parts of the line drawn from the posterior superior iliac spine (p) to the ischial tuberosity. Perforators of inferior gluteal artery lies on the inferior of the piriformis muscle, indicated by thick dotted lines. (b) Superior gluteal artery is located at the intersection of the lateral and mid third of the line drawn from the posterior superior iliac spine (p) to the great trochanter. Perforators lie on superior of the piriformis muscle

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The line drawn from the midpoint of the line connecting PSIS and the coccyx (C) to the superior tip of the greater trochanter of the femur topographically shows the PM. As IGA perforators lie on the inferior of this line, preoperative drawing the line is crucial for identifying the perforators.

Superior gluteal artery perforator

The patient is placed in prone position, and the locations of PSIS, great trochanter, and coccyx are identified. A line is drawn from PSIS to the great trochanter. The landmark on the intersection of the upper third and mid-third of that line represents the location of superior gluteal artery. Almost all the time, perforator is found close to that landmark. Superior gluteal artery provides 3–4 skin perforators.

The location of the PM is identified with a similar process as in the planning of IGAP flap. SGAP are found above that line [Figure 1]b.

The skin island can be planned obliquely or transversely. It is important to conceal the scar inside the underwear area whenever possible, especially if the patient is mobile.

Following the initial markings, perforators are identified with Doppler ultrasound (USG). Since the perforators adjacent to the defect may be injured during debridement, other perforators should also be identified. After all markings, the flap should be outlined according to the defect size so that the planned maximum perforator can be included in the flap.

Flap Dissection

After the skin incision, the dissection can be continued with a monopolar cautery until the gluteus fascia. The gluteus muscle fascia is then included in the flap, and the blunt dissection is performed from lateral to the medial, parallel to the gluteal muscle fibers. A subfascial dissection should be performed for easy visualization of the perforators. We prefer to use × 3.5 magnification in during perforator dissection. This is especially useful in preventing injuries to the perforators as getting close to the ones marked with Doppler USG.

Severe fibrosis and scarring usually occur in the soft tissue around the wound and vascular structures. Consequently, during the dissection of the perforators close to the pressure ulcer, perforators can be confused with the fibrous strips due to perivascular fibrosis. Thus, extra attention is required. The flap must be manipulated gently. It should be noted that careless, rough manipulations might damage perforators.

Although flap can be elevated with a single perforator, we preserve all perforators found during the dissection before the intramuscular dissection. Perforators without concomitant veins and with arterial diameter <1 mm should be sacrificed. When one or more of the perforators are to be sacrificed, the perforator should be checked for adequate perfusion while others are clamped. In our practice, we always try to incorporate the second perforator in flaps as a life saver.

Intramuscular length of the perforators on the lateral and inferior side of the gluteus maximus muscle is relatively shorter than usual length as muscle thickness is less in that anatomic region. Therefore, if the perforators on the lateral side are used as the flap supply, the pedicle length will be longer.[15]

SGAP are vertical and travel shorter distance, whereas the IGAP are oblique and travel a longer distance.[12] Therefore the pedicle is longer for the latter; however, as a disadvantage, the dissection of IGAP is more challenging since they have a longer intramuscular travel distance. In addition, while dissecting IGA one should avoid damaging accompanying posterior femoral cutaneous nerve.[14]

Good exposure during the intramuscular dissection reduces the risk of possible vascular injury. The use of automatic retractors during intramuscular dissection after perforators are chosen will facilitate dissection. Intramuscular dissection should be continued until the flap covers the defect in a tension free manner.

  Results Top

Nine patients admitted with sacral and ischial decubitus ulcers to our clinic between 2015 and 2018 were included in the study. Six of these patients were operated for ischial, two for sacral, and one was operated for both sacral and ischial defects [Table 1].
Table 1: Summary of the patients

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Case reports

Case number 3

Diabetic patient admitted for Grade 4 pressure sore in the ischial region had become paraplegic due to a traffic accident. A 10 cm × 8 cm IGAP flap was planned. The tip of the flap adjacent to the defect was deepithelialized and used for the obliteration of the pouch. Seroma was seen postoperatively [Figure 2].
Figure 2: (a) The identification of the perforators with Doppler and marking of flap borders (b and c) the isolation of the perforators (d) postoperative view

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Case number 8

Three months before the admission, the patient had been injured by falling from height and had a long stay in the ICU. He was admitted for a Grade 4, 5 cm × 6 cm 2, pressure injury in the sacral region. A 10 cm × 8 cm SGAP flap was planned for the patient. No postoperative complication was observed [Figure 3], [Figure 4], [Figure 5].
Figure 3: (a) The sacral decubitus ulcer of the mobile patient with intensive care unit admission history (b) the intraoperative view following drawing and debridement

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Figure 4: (a) The isolation of the perforator on the lateral side of the flap (b) single origin of two perforators labeled with Doppler on the superior side of the flap (c) the superior side of the flap, closer view (d) the inset of the flap, postoperative view

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Figure 5: Postoperative 6th month

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Case number 9

A 9 cm × 7 cm IGAP flap was planned for the patient with left ischial Grade 4 pressure ulcer who had become paraplegic because of a fall from height. The flap was advanced to the defect area over two perforators. The tip of the flap was deepithelialized, and the pouch was obliterated. No postoperative complication was observed [Figure 6].
Figure 6: (a) Preoperative markings and the defect (b and c) The isolation of the perforators, intraoperative view (d) postoperative view

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  Discussion Top

The rationale for the use of conventional gluteus maximus musculocutaneous flap for pressure injuries includes involvement of adequate mass for dead space, resolution of pressure effect, and better elimination of the infection due to sufficient blood supply. However, studies have shown that the mass of the transposed muscle loses its ability to support, and atrophy occurs over time.[16] The limitation of rotational arc, bleeding during flap elevation, and morbidity due to muscle sacrifice, which cannot be accepted in mobile patients, are also seen as limitations of the use musculocutaneous flaps in pressure wound reconstruction.[17],[18]

With the emergence of the perforator concept, perforator flaps have gained popularity in recent years for the reconstruction of nearly any given anatomical region. The fact that perforator-based flaps can be freely designed according to the size and location of the defects, we see these flaps as the greatest advantage against conventional options. At the same time, the preservation of the muscle is an important donor site improvement, especially for the defects of mobile patients. In a systematic review, no significant difference was found between the complications and recurrence rates of musculocutaneous, perforator, and fasciocutaneous flaps in reconstruction of pressure ulcers.[19] Reproducibility of perforator flaps makes them advantageous against other options since we can easily redesign a flap based on another perforator in the region in case of a recurrence.

Compared to the fasciocutaneous rotation flaps commonly used in reconstruction of pressure injuries, perforator flaps have become more prominent since they are elevated over a safe axial pattern; tension-free inset is obtained easier and can be designed with much more freedom. It is also advised to plan the superior border of the flap as a part of an imaginary rotational flap so that in case of a pedicle injury the surgeon could continue with a rotation flap.[15]

Gluteal perforator flaps can be elevated from both subfascial and suprafascial planes. We prefer subfascial approach due to simpler dissection and shorter operation time. Furthermore, subfascial approach can reduce bleeding during flap elevation due to the preservation of the prefascial plexi. Moreover, the subfascial approach is more practical in the obliteration of the defect as full-thickness fasciocutaneous tissue is advanced.

The flap can be inseted as a advancement, rotation or propeller flap on the defective area.[20],[21] Provided that the flap is going to be planned as a propeller flap, more medial perforator, that is the one closer to the defect, is suggested to be used. However, rotation of the pedicle might cause venous congestion, and we cannot add extra perforators since they will prevent motion of the flap. Better outcomes would be obtained if flap is adapted as advancement flap to the defective area. However, it should be kept in mind that more intramuscular dissection can be required to ensure tension-free inset when it is planned as an advancement flap.

The disadvantages of the perforator flaps compared to other options include prolonged operation duration due to careful dissection, the possibility of encountering anatomical variations and high learning curve.

In our study, no venous congestion was encountered that required surgical exploration or bedside interventions. In their study regarding IGAP flaps, Bali et al. encountered a total flap loss due to venous insufficiency caused by hematoma around the pedicle and are advising the use of drains.[22] Verpaele et al. report partial necrosis in two and seroma in four of their patients.[15] Khurram et al. managed wound dehiscence in two patients by appropriate wound care and antibiotic regime. The defects were <1.5 cm 2 and were healed in 1 month.[23] In our study, we encountered wound dehiscence in two patients, and they were managed by delayed primary repair. Similarly, there are also reports of delayed repair in the literature.[24],[25] Seroma was seen in two of our patients, and it was managed by bedside aspiration only. Seroma was reported as a complication in several other studies, but there is a lack of information in regarding the management.[26],[27] Although we used subfascial dissection in our study, suprafascial dissection can reduce the possibility of seroma formation.

  Conclusions Top

With their safe anatomical basis and versatility in design, we offer gluteal artery perforator flaps as a reliable alternative in reconstructing pressure ulcers of the gluteal region.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Lindholm C, Sterner E, Romanelli M, Pina E, Torra y Bou J, Hietanen H, et al. Hip fracture and pressure ulcers – The Pan-European Pressure Ulcer Study – Intrinsic and extrinsic risk factors. Int Wound J 2008;5:315-28.  Back to cited text no. 1
Gélis A, Dupeyron A, Legros P, Benaïm C, Pelissier J, Fattal C, et al. Pressure ulcer risk factors in persons with spinal cord injury part 2: The chronic stage. Spinal Cord 2009;47:651-61.  Back to cited text no. 2
Ricci JA, Bayer LR, Orgill DP. Evidence-based medicine: The evaluation and treatment of pressure injuries. Plast Reconstr Surg 2017;139:275e-86e.  Back to cited text no. 3
Cakmak SK, Gül U, Ozer S, Yiğit Z, Gönü M. Risk factors for pressure ulcers. Adv Skin Wound Care 2009;22:412-5.  Back to cited text no. 4
VanGilder C, Amlung S, Harrison P, Meyer S. Results of the 2008-2009 international pressure ulcer prevalence survey and a 3-year, acute care, unit-specific analysis. Ostomy Wound Manage 2009;55:39-45.  Back to cited text no. 5
Whittington K, Patrick M, Roberts JL. A national study of pressure ulcer prevalence and incidence in acute care hospitals. J Wound Ostomy Continence Nurs 2000;27:209-15.  Back to cited text no. 6
Kroll SS, Rosenfield L. Perforator-based flaps for low posterior midline defects. Plast Reconstr Surg 1988;81:561-6.  Back to cited text no. 7
Dansereau JG, Conway H. Closure of decubiti in paraplegics. Report of 2000 cases. Plast Reconstr Surg 1964;33:474-80.  Back to cited text no. 8
Meehan M. National pressure ulcer prevalence survey. Adv Wound Care 1994;7:27-30, 34, 36-8.  Back to cited text no. 9
Koshima I, Moriguchi T, Soeda S, Kawata S, Ohta S, Ikeda A, et al. The gluteal perforator-based flap for repair of sacral pressure sores. Plast Reconstr Surg 1993;91:678-83.  Back to cited text no. 10
Higgins JP, Orlando GS, Blondeel PN. Ischial pressure sore reconstruction using an inferior gluteal artery perforator (IGAP) flap. Br J Plast Surg 2002;55:83-5.  Back to cited text no. 11
Ahmadzadeh R, Bergeron L, Tang M, Morris SF. The superior and inferior gluteal artery perforator flaps. Plast Reconstr Surg 2007;120:1551-6.  Back to cited text no. 12
Kankaya Y, Ulusoy MG, Oruç M, Yildiz K, Koçer U, Tüccar E, et al. Perforating arteries of the gluteal region: Anatomic study. Ann Plast Surg 2006;56:409-12.  Back to cited text no. 13
Scheufler O, Farhadi J, Kovach SJ, Kukies S, Pierer G, Levin LS, et al. Anatomical basis and clinical application of the infragluteal perforator flap. Plast Reconstr Surg 2006;118:1389-400.  Back to cited text no. 14
Verpaele AM, Blondeel PN, Van Landuyt K, Tonnard PL, Decordier B, Monstrey SJ, et al. The superior gluteal artery perforator flap: An additional tool in the treatment of sacral pressure sores. Br J Plast Surg 1999;52:385-91.  Back to cited text no. 15
Nola GT, Vistnes LM. Differential response of skin and muscle in the experimental production of pressure sores. Plast Reconstr Surg 1980;66:728-33.  Back to cited text no. 16
Thiessen FE, Andrades P, Blondeel PN, Hamdi M, Roche N, Stillaert F, et al. Flap surgery for pressure sores: Should the underlying muscle be transferred or not? J Plast Reconstr Aesthet Surg 2011;64:84-90.  Back to cited text no. 17
Hallock GG. In an era of perforator flaps, are muscle flaps passé? Plast Reconstr Surg 2009;123:1357-63.  Back to cited text no. 18
Sameem M, Au M, Wood T, Farrokhyar F, Mahoney J. A systematic review of complication and recurrence rates of musculocutaneous, fasciocutaneous, and perforator-based flaps for treatment of pressure sores. Plast Reconstr Surg 2012;130:67e-77e.  Back to cited text no. 19
Unal C, Ozdemir J, Yirmibesoglu O, Yucel E, Agir H. Use of inferior gluteal artery and posterior thigh perforators in management of ischial pressure sores with limited donor sites for flap coverage. Ann Plast Surg 2012;69:67-72.  Back to cited text no. 20
Seyhan T, Ertas NM, Bahar T, Borman H. Simplified and versatile use of gluteal perforator flaps for pressure sores. Ann Plast Surg 2008;60:673-8.  Back to cited text no. 21
Bali Z, Ahmedov A, Ozkan B, Mazican M, Kececi Y. Inferior gluteal artery perforator flap for closure of sacral defects after pilonidal sinus surgery. Turk J Plast Surg 2019;27:9-13.  Back to cited text no. 22
  [Full text]  
Khurram MF, Khan AH, Ahmad I, Nanda M, Masoodi Z. Superior gluteal artery perforator flap: A reliable method for sacral pressure ulcer reconstruction. J Wound Care 2013;22:699-702, 704-5.  Back to cited text no. 23
Lin CT, Chang SC, Chen SG, Tzeng YS. Modification of the superior gluteal artery perforator flap for reconstruction of sacral sores. J Plast Reconstr Aesthet Surg 2014;67:526-32.  Back to cited text no. 24
Lin CT, Chen SY, Chen SG, Tzeng YS, Chang SC. Parasacral perforator flaps for reconstruction of sacral pressure sores. Ann Plast Surg 2015;75:62-5.  Back to cited text no. 25
Tuinder S, Chen CM, Massey MF, Allen RJ Sr., Van der Huist R. Introducing the septocutaneous gluteal artery perforator flap: A simplified approach to microsurgical breast reconstruction. Plast Reconstr Surg 2011;127:489-95.  Back to cited text no. 26
Lin PY, Kuo YR, Tsai YT. A reusable perforator-preserving gluteal artery-based rotation fasciocuta neous flap for pressure sore reconstruction. Microsurgery 2012;32:189-95.  Back to cited text no. 27


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1]


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