Reconstructive surgery for pressure ulcer defects presents a difficult challenge; an outcomes analysis12 showed patients with pressure ulcers often are bedridden, paraplegic, or quadriplegic. Ischial pressure ulcers are the most difficult pressure ulcers to treat because the ischial area is mobile and vulnerable to pressure when a person is in the sitting position.13 In addition, position changes involving flexion and extension of the lower extremities influence the tension on and size of the pressure ulcer. According to the report by Conway and Griffith14 on the basic tenets of surgical treatment of pressure ulcers, treatment should involve excision of the ulcer, surrounding scar, underlying bursa, and soft tissue calcifications, if any, as well as radical removal of underlying bone and any heterotopic ossification. Padding bone stumps and filling dead space also were suggested. Inadequate debridement can lead to treatment failure; tissue removal usually reveals dead spaces under the surface of the skin, necessitating further flap reconstruction.
Although different types of flaps (ie, muscle, myocutaneous, and fasciocutaneous) are available for the surgical closure of ischial pressure ulcers, the optimal treatment remains controversial.1,2,4-9 A systematic review3 revealed recurrence and complication rates of 8.9% and 18.6%, but differences with regard to recurrence or complication rates among musculocutaneous, fasciocutaneous, or perforator-based flaps for pressure ulcer coverage were not significant.
Many factors may affect the occurrence of pressure ulcers, including immobility, incontinence, poor nutritional status, and changes in consciousness.15 Retrospective chart reviews16,17 have shown the type of surgical flap should be selected according to its ability to provide the adequate bulk for soft tissue coverage, vascularization, and sensory recovery fundamental to the reconstruction of pressure ulcer, as well as the importance of educating the caregiver on pressure ulcer management, especially pressure redistribution.
Fasciocutaneous flaps based on the anterolateral thigh perforator flap, gluteal perforator flap, gracilis perforator flap, or profunda femoris perforator flap and their various modifications also have been used to treat ischial pressure ulcers.2,18 Flaps that provide inherent skin coverage and have good blood supply do not necessitate sacrifice of major vessels or nerves of the donor site; insufficient bulk and structural instability are disadvantages when reconstructing a wound with significant depth. Moreover, with the advent of reconstructive microsurgery, the use of free flaps has become the first choice of treatment to cover and reconstruct such defects.19 However, in the authors’ experience, the use of free flaps presents certain disadvantages, including donor-site morbidity, increased operation time, use of a major leg vessel, and the necessity of microsurgical expertise.
Myocutaneous flaps have sufficient bulk and robust vascularization and have been reported in chart review studies to be the method of choice for the surgical repair of pressure ulcers.20,21 The muscle part of flaps can be helpful in obliterating dead space and supplying reliable vasculature to cushion the tissue over a pressure-bearing area, and the skin paddle is durable in terms of gliding and tolerating the shearing force. This modified GMM flap also can retain the superior gluteal artery perforator flap should there be recurrence. However, myocutaneous flaps sacrifice muscular function that may destabilize walking and, as such, are not an ideal option in ambulatory patients.20
This retrospective study noted good outcomes in 21 cases (95.5%) during the average follow-up period of 20.3 months with 1 recurrence that was treated with a pedicled anterolateral thigh flap. A mild complication (wound dehiscence) occurred in 2 cases (9.1%), but the ulcers completely healed after resuturing. The average operating time was 80 minutes. In the authors’ experience, this operation time was shorter than other reconstructive methods such as traditional V-Y hamstring advancement flaps, profunda femoris arery perforator flaps, or pedicle anterolateral thigh flaps.