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Quadrilobed superior gluteal artery perforator flap for
sacrococcygeal defects
HAI Heng-lin, SHEN Chuan-an, CHAI Jia-ke, LI Hua-tao, YU Yong-ming and LI
Da-wei
PLA Burn Center, The First Affiliated Hospital of PLA General Hospital, 51
Fucheng Road, Beijing 100048, China (Hai HL, Shen CA, Chai JK and Li DW)
Department of Burns and Plastic Surgery, The 98th Hospital of PLA, 9
Chezhan Road, Huzhou, Zhejiang 313000, China (Hai HL and Li HT)
Burn Unit, Department of Surgery, Massachusetts General Hospital and
Shriners Burns Hospital-Boston, 51 Blossom Street, Boston, MA 02114,
USA (Yu YM)
Correspondence to: Dr. SHEN Chuan-an, PLA Burn Center, The First
Affiliated Hospital of PLA General Hospital, 51 Fucheng Road, Beijing
100048, China (Tel: +86-13910595595. Fax: +86-10-68989181. Email:
[email protected])
This work was supported by a grant from the National Natural Science
Foundation of China (No. 30971128).
Keywords: quadrilobed superior gluteal artery perforator flap; sacrococcygeal
region; pressure sore; soft tissue defect
Background Perforator flaps are used extensively to repair soft tissue defects.
Superior gluteal artery perforator flaps are used to repair sacral defects, but
the tension required for direct closure of the donor area after harvesting of
relatively large flaps carries a risk of postoperative dehiscence. This paper
introduces a modified superior gluteal artery perforator flap for repairing
sacrococcygeal soft tissue defects.
Methods From June 2003 to April 2010, we used our newly designed superior
gluteal artery perforator flap to repair sacrococcygeal soft tissue defects in 10
patients. The wound and donor areas were measured, and the flaps were
designed accordingly. Wound healing was assessed over a follow-up period of
6 to 38 months.
Results After debridement, the soft tissue defects ranged from 12×10 cm2 to
26×22 cm2 (mean 16.3×13.5 cm2). Four patients were treated using right-sided
flaps, ranging from 15×11 cm2 to 25×20 cm2 (mean 18.2×14 cm2). Four
patients were treated using left-sided flaps, and two were treated using both
right- and left-sided flaps. Suction drains were removed on postoperative day
3–21 (mean 5.9) and sutures were removed on postoperative day 12–14. Each
flap included 1–2 perforators for each of the donor and recipient sites. Donor
sites were closed directly. All flaps survived. In eight patients, the wounds
healed after single-stage surgery. After further debridement, the wounds of the
remaining two patients were considered healed on postoperative days 26 and
33, respectively. Follow-up examinations found that the flaps had a soft texture,
without ulceration. In the two patients without paraplegia, the range of motion
of the hip joints was not affected.
Conclusions Use of the quadrilobed superior gluteal artery perforator flap can
overcome the disadvantages of traditional perforator flaps, and represents an
improved approach to repairing soft tissue defects in the sacrococcygeal
region.
Perforator flaps are similar to musculocutaneous flaps, but contain only skin
and subcutaneous fat. 1,2 In the early 1990s, Koshima et al and others3–12
reported the successful use of hip perforator flaps to repair pressure sores in
the sacrococcygeal region. Since then, gluteal artery perforator flaps have
become the primary choice for surgical repair of pressure sores in the
sacrococcygeal region, over the ischial tuberosity, and over the greater
trochanter of the femur. Currently, VY advancement flaps, oblong flaps, and
bilobed flaps are the most frequently used flaps based on perforator vessels of
the superior gluteal artery.13–15 Perforator flaps cannot be divided into too
many parts because of the limitations of their anatomical positions. A relatively
large flap may also result in difficulty with direct closure of the donor site
because of high tension, leading to a risk of postoperative dehiscence. Proper
design of the shape of the flap and separation of the pedicle parts are very
important for successful treatment. From June 2003 to April 2010, we
successfully treated 10 patients with relatively large soft tissue defects in the
sacrococcygeal region using quadrilobed superior gluteal artery perforator
flaps, including the use of bilateral flaps in two patients.
MATERIALS AND METHODS
Clinical data
The 10 patients in the study group were four males and six females aged 28
to 55 years (mean 41.4±9.3 years). All patients had large, deep, open wounds in
the sacrococcygeal region. Eight patients had pressure sores because of
paraplegia, one had undergone cervical carcinoma surgery, and one had chronic
ulceration after surgical resection of a sacral giant-cell tumor. The areas of the
soft tissue defects ranged from 10×8 cm2 to 18×16 cm2 (mean 13×11 cm2). After
debridement, the areas of the open wounds ranged from 12×10 cm 2 to 26×22
cm2 (mean 16.3×13.5 cm 2). The sizes of the quadrilobed flaps ranged from
15×11 cm2 to 25×20 cm2 (mean 18.2×14 cm2). Four patients were treated using
right-sided flaps, four using left-sided flaps, and two using both right- and
left-sided flaps. The demographic and clinical characteristics of the patients
are shown in the Table.
Preoperative evaluation and postoperative treatment
After
admission,
each
patient
underwent
physical
examination,
electrocardiography, chest X-ray, and routine blood count and blood
biochemistry tests. Wound exudates were sampled and cultured. Patients
underwent surgery at 3–17 days after hospital admission (mean 9.9 days). The
timing of surgery was decided based on the following criteria:
1) Resolution of swelling and redness of the skin around the wound.
2) Insignificant amount of wound exudate.
3) Routine blood cell count and blood biochemistry results within the normal
ranges on two consecutive analyses.
4) Successfully trained to rest in bed in the prone position, or lying only on the
non-donor side.
After surgery, patients were advised to rest in the prone position as much as
possible for 3 weeks. Appropriate rehabilitation therapy was performed with
patients lying in a lateral position. This positioning was necessary to prevent
compression of the flap. Sitting was not allowed, to prevent pulling on the
incision wound. The drain in the donor area was removed on postoperative
day 3. The sacrococcygeal drain was removed when the outer dressing
remained clean. Antibiotics were administered for 1 week after surgery. The
sutures were removed in stages on postoperative days 12 to 14.
Flap anatomy and design
The superior gluteal artery arises from the posterior branch of the internal iliac
artery, and passes through the suprapiriform foramen to the outside of the pelvis,
where it divides into a superficial branch and a deep branch. The superficial
branch lies deep to the gluteus maximus, through which its perforators pass to
supply the sacrococcygeal subcutaneous tissues, fascia, and skin. This artery is
therefore the main provider of the blood supply to these tissues. In the gluteal
region, the mean number of superficial cutaneous perforators with a diameter
≥0.5 mm is 5±2. All the superior gluteal artery perforators are musculocutaneous.
The mean internal diameter of the perforating arteries is (0.6±0.1) mm,16 and the
mean territory supplied by the cutaneous branches of the superior gluteal artery is
(69±56) cm2. The superior gluteal artery perforators are mainly distributed along
the medial two-thirds of a line drawn from the posterior superior iliac spine to the
greater trochanter.16 These vessels have definitive anatomical landmarks without
much variation, which makes them useful for designing flaps.
The quadrilobed superior gluteal artery perforator flap was designed as follows.
A superior gluteal artery perforator was located on one side of the
sacrococcygeal soft tissue defect using a portable auscultation-type Doppler
bloodstream detector (Lin Electric Corp., Japan). The quadrilobed flap was
then designed based on the location of the superior gluteal artery (Figure 1).
The inferior lobe was the main lobe of the flap, and consisted mostly of fatty
tissue, with the distal end not extending beyond the gluteal fold. After
pinching up the skin of the inferior lobe at the donor site to estimate the
tension between the skin edges during direct closure after harvesting of the
flap, we marked the proximal edge of the triangular-shaped defect resulting
from harvesting of the inferior lobe. The size of this triangular-shaped defect
was used to determine the size of the lateral lobe (lobe B in Figure 1). The
lateral edge of lobe B did not extend beyond the posterior edge of the greater
trochanter of the femur. The size of lobe B was used to determine the size of the
superior lobe (lobe C in Figure 1). The lateral edge of lobe C did not extend
beyond the posterior superior iliac spine. Finally, lobe D was designed, with one
edge extending to the sacrococcygeal defect. After the flap design was marked,
a paper draft was used to evaluate the result of rotating the flap over the
sacrococcygeal defect.
Surgical techniques
Preparation of the recipient site
The edges of the non-viable tissues were marked with methylene blue at 0.5
to 1 cm around the edge of the sacrococcygeal wound. After incising the skin
along the marked line, an electrotome was used to excise all necrotic and
scar tissues. Any protuberant bone in the sacrococcygeal region was chipped
off, and the open area was rinsed with 3% hydrogen peroxide, physiological
saline, and 0.1% bromogeramine solution. Hemostasis was achieved by
electrocoagulation. A gelatin form was applied to stop any residual
hemorrhage of the exposed bone. Pressure was then applied to the wound
using gauze soaked with gentamicin-saline (0.8 mg/ml).
Flap dissection
The skin was incised along the marked line, down to the deep fascia. The
superior (C), medial (D), and lateral (B) lobes were dissected from the deeper
tissues along the deep fascia, followed by dissection of the inferior lobe (A).
During this dissection, the perforators were carefully located and protected,
and the main perforator was isolated before separation of the inferior lobe (A)
from the underlying tissues. If there were two or three perforators without an
obvious main perforator, the perforator closest to the center of the flap was
usually chosen for the pedicle, because multiple perforators in the pedicle
would have restricted rotation of the flap. If other perforators were retained, the
muscle tissues adjacent the vessels were carefully dissected to increase the
length of the pedicle, as inadequate pedicle length could cause compression
of the perforators after flap rotation, thereby interfering with the venous
drainage and even the arterial supply of the flap. After complete dissection
from the underlying tissues, the inferior flap (A) was rotated 90° medially, to
achieve maximal coverage of the recipient area. The sacrococcygeal wound
was closed in layers using interrupted sutures. To close the donor area, the
edges of the inferior part were pulled together, and the wound was closed
using a vertical row of interrupted sutures. The donor area of the lateral lobe (B)
was covered by the superior lobe (C) of the flap, and the donor area of the
superior lobe was covered by the medial lobe (D) (Figure 1). A drain was placed
below the sutured flap.
RESULTS
After surgical debridement, the soft tissue defects ranged from 12×10 cm 2 to
26×22 cm2 (mean 16.3×13.5 cm2). The areas of the quadrilobed superior
gluteal artery perforator flaps ranged from 15×11 cm 2 to 25×20 cm2 (mean
18.2×14 cm2). Eight patients were treated using single quadrilobed flaps, and
two were treated using bilateral quadrilobed flaps. All the sacrococcygeal
defects were covered and all donor sites were closed during the initial surgery.
All flaps survived. Drains were removed on postoperative day 3–21 (mean 5.9),
and sutures were removed on postoperative day 12–14. In eight patients,
wound healing was achieved with single-stage surgery. In one patient,
dehiscence occurred at the superior edge of the donor site on postoperative
day 6. The dehiscence was treated with frequent dressing changes, and the
wound was considered healed on postoperative day 26. In another patient, the
wound partially re-opened when the drainage tube was removed on
postoperative day 21. After minimal debridement, this wound was re-sutured
and was considered healed 12 days later. Patients were followed up for 6–38
months (mean 19.3±10.4 months). All flaps healed with a soft texture and
satisfactory appearance. In the two patients who did not have paraplegia, the
hip joints retained a normal range of motion.
Case reports
Case 2
A 49-year-old male patient had a fourth-degree pressure sore in the
sacrococcygeal region (Figure 2A). He had sustained fractures of the 1st and
2nd lumbar vertebrae in an injury caused by a crane bucket 5 years previously,
resulting in paraplegia. The pressure sore measured 14×13 cm 2, with tissue
necrosis down to the sacrum. Bacterial culture of the wound exudate grew
Staphylococcus aureus. The results of other investigations were unremarkable.
The patient received 5 days of intravenous norvancomycin before surgery.
Topical treatment included povidone-iodine gauze and frequent dressing
changes. Surgery was performed 10
days
after
admission.
After
debridement, the open wound measured 16×14 cm2. A 20×16 cm 2
quadrilobed left superior gluteal artery perforator flap was designed to cover
the debrided wound and donor site (Figure 2B). The drainage tube was
removed on postoperative day 7 (Figure 2C). The flap survived, and the
sutures were removed on postoperative day 14. All the wounds healed
uneventfully. The patient has been followed up for 12 months, and the
sacrococcygeal region remains covered by healthy skin and underlying soft
tissues, without ulceration (Figure 2D).
Case 4
A 42-year-old female patient had a fourth-degree pressure sore in the
sacrococcygeal region, involving the right ischial tuberosity and both greater
trochanters (Figure 3A). She had sustained fractures of the 2nd to 4th lumbar
vertebrae in a traffic accident 19 years previously, resulting in paraplegia. The
pressure ulcer measured 18×16 cm2, with necrosis of all the soft tissue layers
and partial exposure of the sacrum (Figure 3A). Bacterial culture of the wound
exudate grew Pseudomonas aeruginosa. Laboratory testing showed mild
anemia, hypoproteinemia, and renal dysfunction (blood urea nitrogen level 9.2
mmol/l, creatinine level 140.6 µmol/l). The patient received intravenous
cefoperazone-sulbactam
and
topical
wound
care
with
monolayer
povidone-iodine dressings and an infrared heating lamp for 7 days. She also
received whole blood and albumin infusions on alternating days, and oral
nutritional supplements for 17 days. Immediately prior to surgery, her
hemoglobin concentration was 127 g/l (red blood cells 4.24×10 12/l) and
protein
concentration
was
71.1
sacrococcygeal wound measured
g/l.
During
surgery,
the
open
26×22 cm2 (Figure 3B). Bilateral
quadrilobed superior gluteal artery perforator flaps were created (Figure 3C).
The left-sided flap measured 21×15 cm2, and the right-sided flap measured
20×14 cm2 (Figure 3B). The pressure ulcer over the right ischial tuberosity was
covered by a long head of the biceps femoris muscle flap and a posterior hip
fascia flap. The pressure ulcers over the bilateral greater trochanters were
covered with partial fascial flaps (Figure 3C). Two units of red blood cells and
350 ml of plasma were transfused during surgery. The drainage tube was
removed on postoperative day 5. All flaps survived. The sutures were partially
removed on postoperative day 12 and completely removed on postoperative
day 14. The patient was followed up by telephone for 21 months, and reported
that the sacrococcygeal flap remained intact. The appearance of the
sacrococcygeal area at 2 months after surgery is shown in Figure 3D.
Case 7
A 29-year-old female patient had a fourth-degree pressure sore in the
sacrococcygeal region 2 months after the onset of traumatic paraplegia. She
had been diagnosed with postnatal depression 12 months previously. The
pressure sore measured 12×9 cm2, with necrosis extending to the deep fascia.
Bacterial culture of the wound exudate grew S. aureus. Other findings were
unremarkable except for signs of postnatal depression. The patient received
intravenous norvancomycin for 5 days before surgery, and ongoing medical
treatment for postnatal depression. Povidone-iodine gauze was used for
topical wound care. Surgery was performed 8 days after admission. After
debridement, the wound measured 14×11 cm 2 (Figure 4A). A quadrilobed left
superior gluteal artery perforator flap measuring 16×13 cm 2 was created
(Figure 4B). The drainage tube was removed on postoperative day 4, and the
sutures were removed on postoperative day 12. The wound healed without
further surgery. After 6 months of follow-up, the flap and underlying soft
tissues remained intact (because of her depression, the patient refused
further photographs). The appearance of the wound at 2 weeks after surgery
is shown in Figure 4C.
DISCUSSION
Pressure sores with soft tissue defects in the sacrococcygeal region are
usually caused by long-term constant compression. This region is extremely
vulnerable to pressure sores because of its poor blood supply and the
relatively thin layer of soft tissues overlying the sacrum. Conventionally,
gluteus maximus flaps have been used to repair these tissue defects.
However, this approach may affect the stability of the hip joint, and may
cause restriction of hip extension in patients without paraplegia. Recently,
superior gluteal artery perforator flaps 3,5 have become the first choice of
treatment for surgical repair of soft tissue defects in the sacrococcygeal
region in patients with or without paraplegia. Perforator flaps differ from
myocutaneous flaps in that they only contain skin and subcutaneous fat, and
are therefore considered to be a development of the conventional
myocutaneous flap. The use of perforator flaps to treat deep tissue defects
represents a major advance in flap transplantation techniques.
Once a musculocutaneous perforator vessel adjacent to the area of the defect
has been detected by Doppler ultrasonography,17 it is theoretically possible to
design a suitable perforator flap to cover the defect. 11 Besides superior gluteal
artery-based perforator flaps, interior gluteal artery perforator flaps and tensor
fascia lata flaps have also been reported for the treatment of soft tissue defects
in gluteal/femoral region.4 A number of other perforator flaps have been
developed and named after their anatomical locations, blood supplies, and
perforated muscles. These flaps have been used to successfully treat skin and
soft tissue defects in various regions of the body.1–15,18-20 Compared with
traditional myocutaneous flaps, perforator flaps have unique advantages such
as reduced intraoperative blood loss and minimal muscle damage.
Furthermore, the diverse designs of these flaps provide flexibility for the
treatment of wounds of various shapes and sizes, while minimizing restriction
of mobility.
Since superior gluteal artery perforator flaps were first used by Koshima 3 to
successfully treat pressure ulcers in the sacrococcygeal region in the early
1990s, they have become the treatment of choice for pressure ulcers in the
sacrococcygeal, ischial tuberosity, and greater trochanter regions.4,5,7,9,12
Because of the connection between the donor and recipient areas, adequate
design of the shape and size, together with proper dissection of the pedicle
parts, are important for successful wound healing after single-stage treatment.
The most commonly used perforator flaps based on the superior gluteal artery
are VY advancement flaps, oblong flaps, and bilobed flaps. 13–15,21 Because of
the limitations caused by their anatomical location, these perforator flaps
cannot be divided into multiple pieces. Dehiscence caused by high tension on
the sutures used to close the donor site is a frequent problem. To overcome
the difficulties associated with direct closure of the donor site, a bilateral VY
advancement flap was developed for the repair of large soft tissue defects.
However, the junction of bilateral VY advancement flaps is often located at the
midline in the sacral region, which causes problems with healing of this
weight-bearing area, and increases the risk of late recurrence of pressure
sores. As recurrence of pressure sores in areas treated by bilateral VY
advancement flaps reduces future opportunities to use perforator flaps to
repair defects, it is necessary to design a larger unilateral perforator flap for
one-stage repair of soft tissue defects in the sacrococcygeal region, which has
better placement of the flap edges than with bilateral VY advancement flaps.
Compared with other types of perforator flaps, the leaf-shaped quadrilobed
flap has the advantage of reducing the tension on the donor site wounds after
rotation.22 The design of the superior gluteal artery perforator flap is therefore
more advanced than the designs of VY advancement or unilobed oval flaps.
Our surgical procedure is as follows:
1) The middle of one side of the soft tissue defect in the sacrococcygeal
region is used as the reference point to locate a nearby perforator
vessel.
2) The perforator is located using a portable auscultation-type Doppler
blood stream detector.
3) A quadrilobed superior gluteal artery perforator flap is designed, to
allow tissue rotation and avoid a long pedicle.
4) The flap is rotated to cover the defect with soft tissue.
5) The donor site of the inferior lobe is closed directly. Tension on the
proximal triangular area of the donor site is diffused by covering this
area with the lateral lobe of the flap, to improve healing and minimize
scar formation.
The unique advantages of repairing a relatively large defect in the
sacrococcygeal region with a quadrilobed superior gluteal artery perforator flap
can be summarized as follows:
1) A musculocutaneous flap based on the superior gluteal artery has a
predictable anatomy, reliable blood supply, and high survival rate.
2) The main lobe is taken from an area with little tissue tension, with its
distal end extending to the gluteal fold, allowing direct closure.
3) Use of the three auxiliary lobes (lateral, superior, and medial) results in
relatively low tension on the flap after the defect is covered, leading to
good healing and a satisfactory appearance. After the position of the
perforator is determined using the Doppler blood stream detector, the
flap is usually designed with the perforator at the intersection of the four
lobes. The perforator is easily separated from the surrounding tissues
down to the deep fascia. Vascular dissection is usually not needed, and
the flap has adequate maneuverability.
4) A one-sided flap can be used to repair large soft tissue defects. This
retains the contralateral potential donor area in case pressure ulcers
recur, which may happen in paraplegic patients.
5) The gluteus muscle is not damaged. In our patients without paraplegia,
the procedure did not affect hip joint extension or walking. It is therefore
possible to restore very large soft tissue defects in the sacrococcygeal
region using bilateral flaps.
The 10 patients in our treatment group all had soft tissue defects in the
sacrococcygeal region. All wounds healed after treatment with quadrilobed
superior gluteal artery perforator flaps. After our experience with these patients,
we have the following suggestions:
1)
Good nutritional status, constant wound cleaning, and systemic and
topical infection control are important for successful outcomes.23
2)
Complete debridement of the necrotic and scar tissues, and chipping
away of protruding sacral bone, are important for the prevention of
recurrence.
3)
The largest perforator of the superior gluteal artery should be used for
the pedicle. If there is no main perforator, the perforator adjacent to the
inferior lobe should be used for the pedicle, to ensure an adequate
blood supply to the main lobe. The perforator should generally be
located in the central area between the four leaves. Caution should be
taken to avoid separating this area into too many sections, to ensure
viability of the entire flap.
4)
Drains should routinely be placed in the donor and recipient areas of
the graft. In general, we removed drainage tubes on postoperative day
3–5. If the drainage tubes are removed too early, exudate may
accumulate beneath the flap, which might interfere with healing and
increase the risk of infection. However, prolonged retention of drainage
tubes might lead to formation of sinus tracts.
In conclusion, we have demonstrated that the quadrilobed superior gluteal
artery perforator flap has an adequate and reliable blood supply, allowing
coverage of large defects with a high graft survival rate. The unique
quadrilobed design has the advantage of reducing tension at the donor site,
which can be directly closed without skin grafting. In addition, the
sacrococcygeal region is soft and smooth after graft healing, with good
resistance to pressure. We have also shown that this flap does not damage the
muscles or major vessels in the donor area. This technique therefore
represents an improved surgical approach to repairing soft tissue defects in
the sacrococcygeal region.
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Table. Patient characteristics
Case
Age
NO.
(y)
Sex
Diagnosis
Bacterial culture of
wound secretion
Soft tissue
Preoperative
Post-debridement
defect area
treatment time
wound range
(cm2)
(d)
(cm2)
Three-degree pressure
1
55
M
Four-degree pressure
49
10×9
8
12×11
40
Staphylococcus
10
16×14
aureus
4
None
18
7
None
12
4
None
21
5
None
21
3
None
38
3
None
15
4
None
6
(left)
Streptococcus
F
1 5×1 1
10×8
sore, paraplegia
(month)
(sheet) (d)
20×16
14×13
Four-degree pressure
3
flap(cm2)
Follow-up
Surgical complications
(right)
M
sore, paraplegia
Storage period
15×13
enterococcus
sore, paraplegia
2
Size of
perforator of drainage tube
13
13×9
faecalis
(right)
21×15
Multi-part four-degree
4
42
F
pressure sore, renal
inadequacy, paraplegia
pseudomonas
(l e f t )
18×16
17
26×22
20×14
aeruginosa
(right)
Three-degree pressure
15×12
5
45
F
sore, type-2 diabetes,
enterococcus
10×8
9
12×10
(left)
paraplegia
Radiation ulceration,
1 5×1 1
6
53
F
postoperative cervical
uncultivated
10×8
3
13×10
(left)
carcinoma
Four-degree pressure
7
29
Staphylococcus
F
16×13
12×9
sore, postnatal depression
aureus
8
14×11
(left)
Chronic ulcer,
postoperative sacral
8
28
F
giant-cell tumors
Staphylococcus
Partial disruption of
epidermidis,
streptococcus
16×14
9
18×16
9
36
M
sore, paraplegia
5
(right)
faecalis
Three-degree pressure
25×20
32
and surrounding
crissum incision
streptococcus
faecalis
upper recipient site
13×10
8
15×12
16×13
3
None
24
(right)
Staphylococcus
20×15
Cut disruption at parts
10
37
M
(left)
Four-degree pressure
aureus,
sore, paraplegia
streptococcus
20×15
faecalis
(right)
17×15
14
24×20
21
for placing drainage
skin grate
6
FIGURE LEGENDS
Figure 1. Design and rotation of the quadrilobed superior gluteal artery
perforator flap. A: inferior (main) lobe; B: lateral lobe; C: superior lobe; D: medial
lobe. The shaded area shows the sacral soft tissue defect.
Figure2A. Sacral pressure sore, and positions of the superior gluteal artery
perforators.
Figure 2B. Design of the quadrilobed left superior gluteal artery perforator
flap.
Figure 2C. Quadrilobed left superior gluteal artery perforator flap at 7 days
after surgery.
Figure 2D. Appearance of the flap at 12 months after surgery.
Figure 3A. Design of bilateral quadrilobed superior gluteal artery perforator
flaps.
Figure 3B. Dissected bilateral quadrilobed superior gluteal artery perforator
flaps.
Figure 3C. Postoperative view of the bilateral quadrilobed superior gluteal
artery perforator flaps.
Figure 3D. Appearance of the flaps at 2 months after surgery.
Figure 4A. Fourth-degree sacrococcygeal pressure sore.
Figure 4B. Design and dissection of the quadrilobed left superior gluteal
artery perforator flap.
Figure 4C. Appearance of the flap at 2 weeks after surgery.