Many kinds of flaps, such as a gluteus maximus V-Y advancement flap,2 rotation flap,3 transverse lumbar flap,4 IGAP flap,5,6 and SGAP flap,7 have been described for coverage of a sacral wound. Although flaps are commonly created by reconstructive surgeons, the condition can become complicated if the sacral pressure ulcer recurs or the flap fails related to surgical skill, nutrition, circulation, and infection, among other factors.
In the present case, because the angiosome area of the superior gluteal artery was injured after the failed bilateral V-Y advancement flap reconstruction, the wound could not be salvaged using SGAP flap reconstruction and subsequently IGAP flap reconstruction was employed.
The vascular territory of the perforator flap remains controversial. Several clinical studies address the vascular territory of IGAP flap. In 1993, Koshima et al9 showed that a flap in the gluteal region could be nourished even by a single perforator. In 2007, Ahmadzadeh et al10 described a detailed dissection of the gluteal region and determined that the vascular area of a single perforator from the inferior gluteal artery measures ~24 cm2. However, Nojima et al11 demonstrated a mean vascular territory of 15 cm × 12 cm in an IGAP flap using a single perforator with the dye injection method. In Ms. R’s case, an IGAP flap of approximately 12 cm × 10 cm was harvested without any necrosis.
A flap from the gluteal crease has 2 advantages: 1) the flap is raised from an area different from the previous surgical region and can serve as a secondary option for salvage12; and 2) the primary closure of the donor site leaves a scar that avoids maximal pressure zones over bony prominences and is well hidden in the natural gluteal crease.13 A major disadvantage of this flap is that it creates a relatively tense donor site wound; in addition, compared to other flaps, it is much harder and time-consuming to harvest the IGAP flap. Owing to increased tension over the gluteal crease, a patient that is bedridden long-term with hip contracture is not a suitable candidate for IGAP flap reconstruction because hip joint flexion could worsen the healing of the IGAP flap donor site due to higher tension over wound edge. Therefore, the most important step for IGAP flap reconstruction is the selection of the patient. In the authors’ experience, a patient who is bedridden long-term and without hip contracture is preferred. In addition, to avoid wound dehiscence at the flap donor site in Ms. R’s case, the authors applied a modified ventral splint as a strong support for 3 weeks; the final donor site condition was satisfactory.
According to medical ethics, before the sacral ulcer reconstruction the authors discussed with the family potential adverse scenarios the patient might encounter through the procedure and postoperative period. However, because of the religious ethics in Taiwanese tradition, her family demanded reconstruction to keep the body intact, requiring surgery.