|Year : 2021 | Volume
| Issue : 5 | Page : 33-37
A novel technique for trochanteric region soft-tissue reconstruction: coxal region perforator flaps
Soysal Bas1, Mustafa Durgun2
1 Department of Plastic, Reconstructive and Aesthetic Surgery, University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
2 Department of Plastic, Reconstructive and Aesthetic Surgery, Private Clinic, Izmir, Turkey
|Date of Submission||23-Aug-2020|
|Date of Acceptance||10-Jun-2020|
|Date of Web Publication||17-Mar-2021|
Dr. Soysal Bas
Sisli Hamidiye Etfal Training and Research Hospital, Halaskargazi Road. Etfal Street. 34371 Sisli, Istanbul
Source of Support: None, Conflict of Interest: None
Aims: Due to the complex anatomical structure of the trochanteric region, the options for reconstruction are relatively limited. This study aims to present a unique reconstruction of trochanter defects using a coxal region perforator flap and geometric planning to standardize the flaps. Subjects and Methods: Twelve patients with trochanteric defects that had been repaired with coxal region perforator flap following tumor excision between June 2016 and January 2019 were included in this study. The patients were aged between 20 and 68 years. Patients were evaluated with regard to age, gender, etiology, defect side and size, flap size, number of perforators, and complications. Results: Two patients were operated on for squamous cell carcinoma, one for Marjolin's ulcer, two for malignant melanoma, two for malignant fibrous histiocytoma, and five for dermatofibrosarcoma. Defect sizes ranged between 8 cm × 7 cm and 12 × 10 cm. The smallest flap size was 13 cm × 7 cm and the largest flap size was 21 cm × 10 cm. Nine flaps were raised from the single perforator, and three flaps were raised from two perforators. Venous congestion was seen in one patient postoperatively. There was no flap loss, infection, hematoma, suture detachment, and limitation of hip and knee movements in the patients. Conclusions: The pedicled perforator flaps are elevated over the major perforators located close to the defect in many parts of the body. Thus, low surgical morbidity is achieved, and surgery time is decreased. Furthermore, as in this study, preserving the muscles and preventing the functional deficits in the movement hip joint the body's major joint of the body, reveal the importance of using coxal region perforator flaps for reconstruction in ambulatory patients.
Keywords: Coxal region, perforator flap, soft tissue reconstruction, trochanteric region
|How to cite this article:|
Bas S, Durgun M. A novel technique for trochanteric region soft-tissue reconstruction: coxal region perforator flaps. Turk J Plast Surg 2021;29, Suppl S1:33-7
|How to cite this URL:|
Bas S, Durgun M. A novel technique for trochanteric region soft-tissue reconstruction: coxal region perforator flaps. Turk J Plast Surg [serial online] 2021 [cited 2023 May 31];29, Suppl S1:33-7. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/5/33/311441
| Introduction|| |
Carl Manchot conducted the first study of skin vascular perfusion in 1880 and a century later, Taylor and Palmer introduced the angiosome concept in detail. In 1989, Koshima and Soeda introduced the perforator flap concept in relation to the inferior epigastric artery skin flap. In 2004, Mardini and Wei defined a free-style free flap. Subsequently, Saint-Cyr et al. introduced the perforasome theory to guide the design of the perforator flap in 2009. Following these historical developments, perforator flaps are now preferred by many surgeons who perform reconstructive surgery.,,,
Due to the complex anatomical structure of the trochanteric region, the options for reconstruction are relatively limited. In addition to transferring body weight to the lower extremity, the hip joint has specialized high mobility that facilitates the performance of daily functions and activities. Moreover, the muscles in the region both surround the hip joint and contribute to joint movements. This condition and the muscles' vascular pattern limit the options in terms of muscle flap use. The skin on the hip joint contains a strong fascial adhesion zone and due to the high joint movement, the regional skin flaps remain under tension. Furthermore, the limited number of recipient vessels in the region limits the possibility of reconstruction using free flaps.
This study's aim was to present a unique reconstruction of trochanter defects using a coxal region perforator flap and geometric planning to standardize the flaps.
| Subjects and Methods|| |
Twelve patients with trochanteric defects that had been repaired with coxal region pedicled perforator flap following tumor excision between June 2016 and January 2019 were included in this study. Patients were evaluated with regard to age, gender, etiology, defect side and size, flap size, number of perforators, and complications [Table 1].
The boundaries of the coxal region consist of the tensor fascia latae (TFL) muscle in the anterior, the gluteus maximus muscle in the posterior and iliac crest in the superior. The superficial branch of the superior gluteal artery travels between the gluteus maximus and medius muscles, contributing to the supply of the gluteal muscles. Its deep branch is under the gluteus medius muscle. The deep branch subdivides into the superior and inferior divisions. The superior division anastomoses with the deep circumflex iliac artery and the ascending branch of the lateral circumflex femoral artery. Inferior subdivision anastomoses with the ascending branch of the lateral circumflex femoral artery. Perforators which was raised from these anastomoses, pierce the gluteus medius muscle and supply the muscles, subcutaneous fat, and skin in coxal region [Figure 1].
|Figure 1: Anatomical illustration showing the vascular network of the coxal region|
Click here to view
Surgical technique and geometry
All patients were operated on under general anesthesia and in the lateral decubitus position. Squamous cell carcinoma was excised with a surgical margin of 1 cm, and 2 cm for malignant melanoma, until the fascia, while dermatofibrosarcoma and malignant fibrous histiocytoma were excised with a surgical margin of 3–5 cm and included in the deep fascia.
In surgical planning, an inverted triangle was drawn with skin marker pen between the great trochanter, anterior iliac spine, and posterior iliac spine [Figure 2]a. The posterior border of the triangle forms the lateral border of the gluteus maximus muscle. The anterior border of the triangle corresponds to the septum between the gluteus medius muscle and the tensor facia latea muscle. Major perforators are located in the 2/3 inferior part of inverted triangle close to the great trochanter. After the perforators were detected by a hand-held Doppler, the flap was planned in the form of a quarter ellipse. The width and length of the defect constitute the base of the quarter ellipse and width of the defect constitutes the height of the quarter ellipse. In addition, to decrease the tension on the flap and avoid enlarging the defect, the base of the quarter ellipse was placed near the edge of the defect. Furthermore, flap-donor area was planned from the lower gluteal region, an area of loose skin, so that in no case did the flaps' rotation angle of the flaps exceed 90°. Depending on the defect structure and perforator localization, several centimeters' modification may be required in the drawings [Figure 2]b.
|Figure 2: Illustration of coxal perforator flap. (a) an inverted triangle is created by marking great trochanter, anterior and posterior iliac spine. Perforators are located in the 2/3 inferior part of the inverted triangle. (b) Geometric planning of the flap according to the surgical border. (c) Illustration of flap elevation. (d) Illustration of postoperative view|
Click here to view
The flaps were raised from medial to lateral in the subfascial plane using ×4.3 loupe magnification. Some soft tissue was left around the perforators. Attention was paid to perforator twisting in flaps that were raised from more than one perforator. In cases with suspicion of pedicle twisting, the weaker perforator was sacrificed. After bleeding control, vacuum drains were placed under the donor area and flap. The donor area and the defect area were closed in a tension-free manner [Figure 2]c and [Figure 2]d.
During the postoperative period, dressing was performed daily. The patients were followed up in the supine position or on the other side of the operation area. Patients were mobilized on the second postoperative day. Vacuum drains were withdrawn below 30 mL per 24 h. Intravenous (IV) cefazolin 2 × 1 1000 mg and IV paracetamol 3 × 1 500 mg were administered for 1 week for antibiotherapy and analgesia, respectively. In one patient, who experienced venous congestion in the flap, leech therapy was initiated and IV ceftriaxone 2 × 1 1000 mg was started as antibiotherapy. The patients were discharged in the 1st postoperative week and followed-up at the outpatient clinic with oral antibiotherapy. Sutures were removed at the third postoperative week. All patients were instructed to avoid lying on the operation area during this period.
| Results|| |
The patients were aged between 20 and 68 years (mean: 47.3 years). Five patients were female, and eight patients were male. No distant metastasis or pathological lymph nodes were detected in clinical examination or in whole-body computed tomography scans of the patients. Two patients were operated on for squamous cell carcinoma [Figure 3], one for Marjolin's ulcer, two for malignant melanoma, two for malignant fibrous histiocytoma, and five for dermatofibrosarcoma [Figure 4]. Tumoral masses were located in the right trochanteric region in eight patients and in the left trochanteric region in four patients. Defect sizes ranged between 8 cm × 7 cm and 12 cm × 10 cm (mean: 10.25 cm × 8.8 cm). The smallest flap size was 13 cm × 7 cm and the largest flap size was 21 cm × 10 cm (mean: 17.6 cm × 9.4 cm). Nine flaps were raised from the single perforator, and three flaps were raised from two perforators. Mean operative time was 84 min. Venous congestion was seen in one patient postoperatively. There was no flap loss, infection, hematoma, or suture detachment in the patient with venous congestion or in the other patients. Residual tumors, recurrence, or distant metastasis were not detected in any patients, and no limitation was observed in patients' hip and knee movements. The follow-up period was 29 months to 36 months (mean: 31.4 months).
|Figure 3: Case 1, squamous cell carcinoma located in the right trochanteric region. (a) Preoperative planning. (b) View of the following tumor resection. (c) View of the elevated flap from two perforators. (d) Adaptation of the flap. (e) Early postoperative view|
Click here to view
|Figure 4: Case 7, dermatofibrosarcoma located in the right trochanteric region. (a) Preoperative planning. (b) View of the following tumor resection. (c) View of the elevated flap from one perforator. (d) Adaptation of the flap. (e) Postoperative third week view. (f) Postoperative 6th week view|
Click here to view
| Discussion|| |
In trochanteric defects, conventional muscle flaps, such as vastus lateralis, gluteus maximus, and TFL, can be used for wound space filling and covering bone protrusions.,, One of the major disadvantages of the use of muscle flaps is the scarification of the major muscle. This is not problematic in bedridden patients but creates functional deficits in ambulatory patients. Since the muscles are not sacrificed in the use of perforator flaps, no functional deficits are expected. In this study, no limitations were present in in the 12 patients' hip-and knee-joint movements.
As a result of joint movements in ambulatory patients, hip flexion contracture in bedridden patients, and strong fascial bands in the region, the flaps that turn into the trochanteric region remain under tension. Therefore, several skin modification techniques have been developed to reduce tension, especially in the TFL flap.,, In the perforator flaps, the complete release of the flap from the base, with the exception of the perforator vessels, allows the cutting of fibrous bands in the trochanteric region. The mobilization advantage of the perforator flap and the appropriate geometric planning of the flap in the adjacent of the defect with facilitated tension-free closure and no suture detachment was observed in the postoperative period.
Other advantages that perforator flaps have over muscle flaps include the short operation time required, the absence of need for excessive dissection and microsurgery, and the lower potential for associated complications, such as peroperative hemorrhage, postoperative hematoma, or seroma. Furthermore, perforator and fasciocutaneous flaps are as effective as muscle flaps against infection and osteomyelitis.,, In this study, no complications, such as hematoma, seroma, or wound infection, were observed.
Perforator flaps used in the reconstruction of the trochanteric region include the TFL perforator flap, gluteal perforator flap, anterolateral thigh flap, and the lateral thigh perforator flap.,,,, The source vessels of these flaps originate from the gluteal arteries or the lateral circumflex femoral artery system. The perforator flaps presented in this study can be raised from the deep branch of superior gluteal artery and lateral circumflex femoral artery systems, because both arteries anastomose in the coxal region. Furthermore, since it is raised from the area adjacent to the defect, less dissection is required than for other perforator flaps. Moreover, the procedure does not include maneuvers that may compromise the flap circulation, such as intramuscular dissection or pedicle tunneling, to increase pedicle length.
Postoperative venous congestion may be encountered in perforator flaps. There are three reasons for this situation: The first is that the veins accompanying the perforators remain inadequate, which can be overcome by perforator plus planning or by the addition of another venous system to the flap.,,, The second reason is the sacrificing of perforator veins due to excessive perforator dissection. To prevent this situation, it is recommended that some soft tissue be left around the perforator. The third reason is pedicle twisting. In this study, venous congestion was observed in a flap postoperatively and regressed with leech therapy.
Two important factors should be considered in the geometric planning of the flap: The first is the localization of the perforator adjacent to the defect, and the second is that the flap-donor area has sufficient laxity to allow primary closure. Considering these two factors, the optimal flap localization should be determined. Perforator flaps may be exposed to pedicle twisting due to propeller motion, causing arterial insufficiency or venous congestion. To prevent this, it is recommended that the rotation angle is maintained below 180°. Keles et al., in their experimental study evaluating the effect of single and double perforators on pedicle twisting, demonstrated that double perforators may cause pedicle twisting as the rotation angle increases. In this study, none of the flaps' rotation angles exceeded 90°, and no arterial insufficiency or venous congestion were detected in the flaps raised over the double perforator.
This study was conducted on a limited number of cases, but the aim was to present the optimal method to minimize surgical morbidity with coxal region perforator flaps and geometric planning. We believe that the method will ultimately be an acceptable option in trochanteric reconstruction, following more case studies.
| Conclusions|| |
The pedicled perforator flaps are elevated over the major perforators located close to the defect in many parts of the body. Thus, low surgical morbidity is achieved, and surgery time is decreased. Furthermore, as in this study, preserving the muscles and preventing the functional deficits in the movement hip joint, the body's major joint of the body, reveal the importance of using coxal region perforator flaps for reconstruction in ambulatory patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: Experimental study and clinical applications. Br J Plast Surg 1987;40:113-41.
Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989;42:645-8.
Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg 2004;114:910-6.
Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: Vascular anatomy and clinical implications. Plast Reconstr Surg 2009;124:1529-44.
Choi DH, Goh T, Cho JY, Hong JP. Thin superficial circumflex iliac artery perforator flap and supermicrosurgery technique for face reconstruction. J Craniofac Surg 2014;25:2130-3.
Ives M, Mathur B. Varied uses of the medial sural artery perforator flap. J Plast Reconstr Aesthet Surg 2015;68:853-8.
Koh K, Goh TLH, Song CT, Suh HS, Rovito PV, Hong JP, et al
. Free versus pedicled perforator flaps for lower extremity reconstruction: A multicenter comparison of institutional practices and outcomes. J Reconstr Microsurg 2018;34:572-80.
Durgun M, Bas S. Repair of sacral and ischial region defects with lateral sacral artery perforator flaps. Ann Plast Surg 2019;82:304-9.
Borley N, Healy J. True pelvis, pelvic floor and perineum. Standring S Gray's Anatomy: The Anatomical Basis of Clinical Practice. 40th
ed. London: Churchill Livingstone; 2008. p. 1083-98.
Nahai F. The tensor fascia lata flap. Clin Plast Surg 1980;7:51-6.
Bovet JL, Nassif TM, Guimberteau JC, Baudet J. The vastus lateralis musculocutaneous flap in the repair of trochanteric pressure sores: Technique and indications. Plast Reconstr Surg 1982;69:830-4.
Ramirez OM. The distal gluteus maximus advancement musculocutaneous flap for coverage of trochanteric pressure sores. Ann Plast Surg 1987;18:295-302.
Siddiqui A, Wiedrich T, Lewis JV. Tensor fascia lata VY retroposition myocutaneous flap: Clinical experience. Ann Plast Surg 1993;31:313-317.
Lynch SM. The bilobed tensor fascia lata myocutaneous flap. Plast Reconstr Surg 1981;67:796-8.
Aslan G, Tuncali D, Bingul F, Ates L, Yavuz N. The “duck” modification of the tensor fascia lata flap. Ann Plast Surg 2005;54:637-9.
Hong JP, Shin HW, Kim JJ, Wei FC, Chung YK. The use of anterolateral thigh perforator flaps in chronic osteomyelitis of the lower extremity. Plast Reconstr Surg 2005;115:142-7.
Yazar S, Lin CH, Lin YT, Ulusal AE, Wei FC. Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures. Plast Reconstr Surg 2006;117:2468-75.
Christy MR, Lipschitz A, Rodriguez E, Chopra K, Yuan N. Early postoperative outcomes associated with the anterolateral thigh flap in Gustilo IIIB fractures of the lower extremity. Ann Plast Surg 2014;72:80-3.
Tzeng YS, Yu CC, Chou TD, Chen TM, Chen SG. Proximal pedicled anterolateral thigh flap for reconstruction of trochanteric defect. Ann Plast Surg 2008;61:79-82.
Coşkunfirat OK, Ozgentaş HE. Gluteal perforator flaps for coverage of pressure sores at various locations. Plast Reconstr Surg 2004;113:2012-7.
Yang CH, Kuo YR, Jeng SF, Lin PY. An ideal method for pressure sore reconstruction: A freestyle perforator-based flap. Ann Plast Surg 2011;66:179-84.
Kim YH, Kim SW, Kim JT, Kim CY. Tensor fascia lata flap versus tensor fascia lata perforator-based island flap for the coverage of extensive trochanteric pressure sores. Ann Plast Surg 2013;70:684-90.
Grassetti L, Scalise A, Lazzeri D, Carle F, Agostini T, Gesuita R, et al
. Perforator flaps in late-stage pressure sore treatment: Outcome analysis of 11-year-long experience with 143 patients. Ann Plast Surg 2014;73:679-85.
Eom JS, Sun SH, Hong JP. Use of the upper medial thigh perforator flap (gracilis perforator flap) for lower extremity reconstruction. Plast Reconstr Surg 2011;127:731-7.
Coskunfirat OK, Uslu A, Cinpolat A, Bektas G. Superiority of medial circumflex femoral artery perforator flap in scrotal reconstruction. Ann Plast Surg 2011;67:526-30.
Sönmez E, Aksam E, Durgun M, Karaaslan O. Venous super-drained posterior interosseous artery flap for dorsal hand defects. Microsurgery 2018;38:876-81.
Wei JW, Ni JD, Dong ZG, Liu LH, Luo ZB, Zheng L. Distally based perforator-plus sural fasciocutaneous flap for soft-tissue reconstruction of the distal lower leg, ankle, and foot: Comparison between pediatric and adult patients. J Reconstr Microsurg 2014;30:249-54.
Durgun M, Baş S, Aslan C, Canbaz Y, Işık D. Use of dorsal intercostal artery perforator flap in the repair of back defects. J Plast Surg Hand Surg 2016;50:80-4.
Demir A, Acar M, Yldz L, Karacalar A. The effect of twisting on perforator flap viability: An experimental study in rats. Ann Plast Surg 2006;56:186-9.
Keleş MK, Demİr A, Küçüker I, Alici O. The effect of twisting on single and double based perforator flap viability: An experimental study in rats. Microsurgery 2014;34:464-9.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]