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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. REFERENCES 1. Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg. 1989;42:645-648. PMID: 2605399 2. Blondeel PN, Van Landuyt K, Hamdi M, Monstrey SJ. Perforator flap terminology: update 2002. Clin Plastic Surg, 2003, 30: 343-346. PMID: 12916591 3. Koshima I, Moriguchi T, Soeda S, Kawata S, Ohta S, Ikeda A. The gluteal perforator-based flap for repair of sacral pressure sores. Plast Reconstr Surg 1993;91:678-683. PMID: 8446721 4. Ao M, Mae O, Namba Y, Asagoe K. Perforator-based flap for coverage of lumbosacral defects. Plast Reconstr Surg 1998;101:987-991. PMID:9514331 5. 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 ;52:385-391. PMID:10618982 6. Higgins JP, Orlando GS, Bondeel PN. Ischial pressure sore reconstruction using an inferior gluteal artery perforator (IGAP) flap. Br J Plast Surg 2002;55:83-85. PMID: 11783978 7. Meltem C, Esra C, Hasan F, Ali D. The gluteal perforator-based flap in repair of pressure sores. Br J Plast Surg 2004;57:342-347. PMID: 15145738 8. Ishida LH, Munhoz AM, Montag E, Alves HR, Saito FL, Nakamoto HA, et al. Tensor fasciae latae perforator flap: minimizing donor-site morbidity in the treatment of trochanteric pressure sores. Plast Reconstr Surg 2005; 116:1346-1352. PMID:16217478 9. Lee JT, Hsiao HT, Tung KY, Ou SY. Gluteal perforator flaps for coverage of pressure sores at various locations. Plast Reconstr Surg 2006; 117: 2507-2508.PMID: 16772972 10. Prado A, Ocampo C, Danilla S, Valenzuela G, Reyes S, Guridi R. A new technique of "double-A" bilateral flaps based on perforators for the treatment of sacral defects. Plast Reconstr Surg. 2007; 119:1481-1490. PMID:17415242 11. Bravo FG, Schwarze HP. Free-style local perforator flaps: concept and classification system. J Plast Reconstr Aesthet Surg 2009;62:602-608. PMID: 19181580 12.Jakubietz RG, Jakubietz DF, Zahn R, Schmidt K, Meffert RH, Jakubietz MG.Reconstruction of pressure sores with perforator-based propeller flaps. J Reconstr Microsurg 2011;27:195-198. PMID: 21184385 13.Ichioka S, Okabe K, Tsuji S, Ohura N, Nakatsuka T. Distal perforator-based fasciocutaneous V-Y flap for treatment of sacral pressure ulcers. Plast Reconstr Surg 2004 ;114:906-909. PMID:15468397 14.Yildirim S, Taylan G, Aköz T. Freestyle perforator-based V-Y advancement flap for reconstruction of soft tissue defects at various anatomic regions. Ann Plast Surg 2007 ;58:501-506. PMID: 17452833 15. Lee HJ, Pyon JK, Lim SY, Mun GH, Bang SI, Oh KS. Perforator-based bilobed flaps in patients with a sacral sore: Application of a schematic design. J Plast Reconstr Aesthet Surg. 2011;64:790-795. PMID: 21144809 16. Ahmadzadeh R, Bergeron L, Tang M, Morris SF. The superior and inferior gluteal artery perforator flaps. Plast Reconstr Surg 2007;120:1551-1556. PMID: 18040187 17.Chen XH, Zhao HX, Fang JG, Yu ZK, Huang ZG.Use of preoperative ultrasound in designing the true pectoralis major myocutaneous island flap.Chin Med J 2012;125:667-70.PMID: 22490493 18.Yan XQ, Yang HY, Zhao YM, You L, Xu J. Deep inferior epigastric perforator flap for breast reconstruction: experience with 43 flaps. Chin Med J 2007;120:380-384. PMID: 17376307 19.Huang D, Wang HW, Wang HG, Wu WZ, Zhao CY. Reconstruction of soft tissue defect of the extremity with the perforator flap from inguinal region. Chin Med J 2009;122:2861-2864. PMID: 20092791 20.Cai PH, Liu SH, Chai YM, Wang HM, Ruan HJ, Fan CY. Free peroneal perforator-based sural neurofasciocutaneous flaps for reconstruction of hand and forearm. Chin Med J 2009;122:1621-1624. PMID: 19719961 21.Leow M, Lim J, Lim TC. The superior gluteal artery perforator flap for the closure of sacral sores. Singapore Med J. 2004;45:37-39. PMID: 14976580 22. Murakami M, Hyakusoku H, Ogawa R. The multilobed propeller flap method. Plast Reconstr Surg. 2005;116:599-604. PMID: 18040187 23.Hai HL, Dai HH, Xu YP,Hua YF, Bian LF,Wu SG, et al.Combined treatment of refractory decubitus ulcers.Chin J Repar Reconstr Surg(Chin) 2006;20:909-911. PMID: 17036979 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.