ABSTRACT
BACKGROUND: Clinically, arteriovenous malformations in the buttocks (bAVMs) are extremely rare. Our study aimed to evaluate the efficacy and safety of ethanol embolotherapy in managing bAVMs. RESULTS: A total of 32 patients with bAVMs (14 females and 18 males) from 2012 to 2021 were included in this study. All patients underwent complete clinical and imaging examinations. Further, the AVMs lesions were analyzed according to Schöbinger staging and Yakes classification. Each patient had undergone a multistage ethanol embolization. The amelioration of clinical symptoms and devascularization on angiography were evaluated at regular follow-ups. In the present cohort, the 11-20 age group had the most patients (15/32; 46.88%). A total of 124 embolization procedures were performed (average 3.88 procedures per patient), and the average dose of absolute ethanol was 18.96 mL per procedure. Thirteen patients with dominant draining veins underwent additional coil deployment before ethanol embolization (13/32; 40.63%). During follow-ups, clinical improvement was found in 23 of 27 who presented with a pulsating mass (85.19%), 17 of 20 with abnormal local skin temperature (85%), 5 of 6 with bleeding (83.33%), and 5 of 5 patients treated for pain (100%). More than 75% angiographic devascularization was achieved in 18 patients (18/32; 56.25%). Finally, 12 out of 13 patients (92.31%) reduced from Schöbinger Stage III to a lower grade, and ten patients exhibited a complete response (10/32; 31.23%). There was a single serious complication of local necrosis, while neither paranesthesia nor infection was observed postoperatively. CONCLUSIONS: Ethanol embolization assisted with coils can treat bAVMs effectively and safely. The Yakes classification contributed to the optimal ethanol embolotherapy of bAVMs.
Subject(s)
Arteriovenous Malformations , Embolization, Therapeutic , Ethanol , Humans , Embolization, Therapeutic/methods , Female , Male , Ethanol/therapeutic use , Arteriovenous Malformations/therapy , Buttocks/blood supply , Adult , Young Adult , Adolescent , Child , Middle Aged , Treatment OutcomeABSTRACT
BACKGROUND: In the event of an advanced rectal carcinoma, an evisceration with rectal amputation may become necessary. The resulting defects, due to their extent, depth, or local tissue damage from previous surgeries and radiation, can in many cases only be closed through free microvascular tissue transfer. In this case series, we demonstrate the successful combination of a musculocutaneous musculus vastus lateralis flap (MVL) with a direct connection to the superior gluteal artery. MATERIALS AND METHODS: Over a 47-month period, we retrospectively examined 11 cases of patients with dorsal pelvic defects after evisceration and rectal amputation that could not be closed using local or regional means. In cases of extensive defects with deep pararectal wound cavities, all these patients underwent defect coverage through a free myocutaneous MVL flap with a direct vascular anastomosis to the superior gluteal vessels. RESULTS: The mean defect size was 290.0 cm² (SD: 131.2; range: 200-600 cm²). The mean defect depth was 10.5 cm, necessitating MVL flap reconstruction with an average size of 336.3 cm². Three operative revisions were required due to postoperative bleeding. There were no arterial or venous thromboses, and no flap loss occurred. Only one necrosis of a distal flap tip was observed, which could be corrected secondarily by direct suturing. The case-mix evaluation yielded an average value of 24.251 (SD: 21.699; range: 7.036-65.748) points, emphasizing the complexity of the cases. CONCLUSIONS: Our results indicate that a free microvascular MVL flap is a viable therapeutic option for pararectal defects that cannot be closed by local or regional methods. The superior gluteal artery proves to be a safe and sufficient vascular connection. In combination, even extensive defects can be successfully closed.
Subject(s)
Myocutaneous Flap , Rectal Neoplasms , Humans , Male , Female , Middle Aged , Aged , Myocutaneous Flap/surgery , Myocutaneous Flap/blood supply , Retrospective Studies , Rectal Neoplasms/surgery , Postoperative Complications/surgery , Postoperative Complications/etiology , Microsurgery/methods , Buttocks/surgery , Buttocks/blood supply , Free Tissue Flaps/surgery , Free Tissue Flaps/blood supply , Reoperation , Anastomosis, Surgical , Adult , Amputation, Surgical , Quadriceps Muscle/surgery , Quadriceps Muscle/blood supplyABSTRACT
BACKGROUND: In this study, we investigated the area that can be addressed with an approach in which the skin incision is made directly above the dorsal column with Thiel cadaveric specimens. METHODS: Six Thiel cadaveric specimens were prepared. A skin incision was made directly above the dorsal column. The accessible proximal end from the proximal part of the greater sciatic notch to the gluteal ridge and the accessible distal end of the ischium were marked with a flat chisel. A molded 8-hole reconstruction plate was placed from the base of the ischium toward the gluteal ridge and fixed with 3 screws proximally and 2 screws distally. The length of the skin incision and the distance from each reference point on the bone to the reachable markings were assessed after the muscles were removed. RESULTS: Mean skin incision length was 9.3 ± 0.7 (range, 8.0-10.0) cm. In 3 of 6 cases, proximal screws were inserted through different spaces between muscle fibers. In all cases, we were able to reach at least the greater sciatic notch, the gluteal ridge at the level of superior border of the acetabulum, and the base of the ischial tuberosity. In all cases, an 8-hole plate could be placed from the gluteal ridge to the base of the ischium. There were no superior gluteal artery or sciatic nerve injuries in any of the cases. CONCLUSION: We anatomically investigated the area that can be addressed with an approach in which the skin incision was made directly above the dorsal column. In all cases, we were able to access the areas needed to reduce the fracture and place the plates necessary to stabilize the fracture through a 9.3 ± 0.7 cm skin incision. This approach can be a useful minimally invasive posterior approach for acetabular fractures.
Subject(s)
Acetabulum , Bone Plates , Cadaver , Fracture Fixation, Internal , Fractures, Bone , Humans , Acetabulum/injuries , Acetabulum/surgery , Acetabulum/anatomy & histology , Buttocks/surgery , Buttocks/blood supply , Buttocks/injuries , Fracture Fixation, Internal/methods , Fractures, Bone/surgery , Bone Screws , Male , Female , Ischium/surgery , Ischium/anatomy & histology , AgedABSTRACT
AIM OF THE STUDY: This study investigated how the air-bladder offloading mode of the Orbiter by Kalogon wheelchair cushion (Orbiter) affected blood flow in the gluteal region of non-disabled subjects. The hypothesis was that the cushion's offloading mode would improve blood flow, resulting in reduced reactive hyperemia when compared to the static setting, or Loaded Control (LC). Furthermore, the study proposed a technique using a high-resolution image laser speckle contrast system to measure blood flow in the gluteal area. METHODS: Two procedures were carried out, one with the participant sitting on a cushion in LC, and the second, the cushion was set to offloading mode. Blood flow was measured through data imaging after each procedure. Three trials were performed, starting and ending in different cushion bladders. Customized algorithms were used to select regions of interest on the images for calculations. The Wilcoxon Signed-Rank Test was conducted to compare the offloads and loaded control values of each region of interest. Results were considered significant at α = 0.05. RESULTS: Ten healthy, non-disabled adults participated in the study, seven females and three males. There were no significant differences among the participants. However, results showed that seven subjects tended to decrease reactive hyperemia in the offload sequence of trial when the last two bladders offloaded were the sacrum followed by the right ischial tuberosity. CONCLUSIONS: The high-resolution imager showed that the Orbiter Offloads helped reduce reactive hyperemia in seven subjects, potentially improving blood flow. More research is necessary to comprehend the mechanisms of these effects fully.
Subject(s)
Wheelchairs , Humans , Buttocks/blood supply , Buttocks/physiology , Wheelchairs/standards , Male , Female , Adult , Equipment Design/standards , Equipment Design/methods , Regional Blood Flow/physiology , Laser Speckle Contrast Imaging/methods , Laser Speckle Contrast Imaging/standardsABSTRACT
INTRODUCTION: Knowledge of the vascular anatomy is critical to performing safe gluteal surgery. To date, only the course of the main blood vessels within the muscles has been outlined. These findings are based on MRI and CTA images that do not conform to a topographically standardized and normalized probability distribution. OBJECTIVES: The aim of this study was to develop a three-dimensional mapping of the gluteal zones of high vascular density in relation to anatomical landmarks. MATERIALS AND METHODS: This single-center retrospective cohort analysis comprised all consecutive patients who underwent cone-beam computed tomography (CBCT) scans between January 2016 and October 2021. The location of blood vessels in the gluteal region was allometrically normalized in relation to anatomical landmarks. Moreover, the caliber and area of the blood vessels were assessed. RESULTS: CBCT scans of 32 patients with an average age of 64 ± 12 years (range 34-87 years) were included. Fifty-three percent were female. The median [IQR] caliber of the intramuscular gluteal vessels was 1.47 [1.15-1.88] mm, significantly greater than that of the subcutaneous vessels 1.09 [0.72-1.44] mm (p < 0.001). Vascular density was higher intramuscularly, as 4.5% of the area of the muscle was occupied by blood vessels, as opposed to 0.3% in the adipose tissue. CONCLUSION: The analysis of the CBCT scans showed a higher vascular density and larger vessels intramuscularly. We, therefore, recommend the injection of autologous fat merely to the subcutaneous plane. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Subject(s)
Adipose Tissue , Cone-Beam Computed Tomography , Humans , Buttocks/blood supply , Buttocks/surgery , Buttocks/diagnostic imaging , Female , Middle Aged , Retrospective Studies , Male , Adult , Aged , Cone-Beam Computed Tomography/methods , Adipose Tissue/transplantation , Aged, 80 and over , Cohort Studies , Imaging, Three-Dimensional , Transplantation, Autologous/methods , Risk Assessment , Patient Safety , Body Contouring/methods , Body Contouring/adverse effectsABSTRACT
BACKGROUND: The lumbar artery perforator (LAP) flap is a valuable secondary option for autologous breast reconstruction when abdominal donor sites are not available. OBJECTIVES: The aim of this study was to determine how the LAP donor site affects waistline and gluteal proportions, and whether LAP flaps may produce potential secondary benefits concerning donor site aesthetics. METHODS: A retrospective review of 50 patients who underwent bilateral breast reconstruction with LAP flaps (100 flaps) between 2018 and 2022 was performed. Patient characteristics and postoperative complications were recorded. Pre- and postoperative standardized frontal and lateral patient photographs were analyzed to identify postoperative changes in waist-to-hip ratio (WHR) to assess waistline definition and buttock projection. The patients' individual perception of postoperative aesthetic changes to their waistline and buttocks was determined by an electronic survey. RESULTS: The patients had a mean age of 51 years (range, 24-63 years) and a mean BMI of 26.9â kg/m2 (range, 19.3-37.4â kg/m2). Postoperative donor site complications included seroma (n = 10), wound dehiscence (n = 5), hematoma (n = 4), and wound infection (n = 2). Flap loss rate was 2%. After reconstruction, patients were found to have a more defined waistline, indicated by a significantly decreased WHR on frontal images (mean [standard error of the mean], 0.85 [0.05] vs 0.80 [0.05], P < .005) and a more projected buttocks indicated by a significant reduction in WHR on lateral images (0.92 [0.07] vs 0.87 [0.07], P < .0001). Among the patients who responded to the survey, 73% indicated that their waistline had aesthetically improved, 6.7% felt it had not changed, and 20% felt that it had worsened. An aesthetic improvement of the buttocks was reported by 53%, 40% felt their buttocks had not changed, and 6.7% felt their buttocks appearance had worsened. CONCLUSIONS: Bilateral LAP flap breast reconstruction leads to improved waistline definition and buttock projection, bringing patients closer to ideal aesthetic proportions. This reconstructive approach is ideal for patients who are not candidates for abdominal free flaps, but who demonstrate excess flank tissue and seek a more defined waistline and projected buttocks.
Subject(s)
Breast Neoplasms , Mammaplasty , Perforator Flap , Humans , Middle Aged , Female , Perforator Flap/blood supply , Buttocks/surgery , Buttocks/blood supply , Mammaplasty/adverse effects , Mammaplasty/methods , Retrospective Studies , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Postoperative Complications/surgery , Arteries , Breast Neoplasms/surgerySubject(s)
Mammaplasty , Perforator Flap , Humans , Perforator Flap/blood supply , Buttocks/surgery , Buttocks/blood supply , ArteriesABSTRACT
PURPOSE: In this article, we report a case of an atypical inferior gluteal artery that passed through the piriformis muscle when it emerged from the pelvic cavity in an elderly Japanese female cadaver. We speculate that this atypical artery could be entrapped and compressed by the piriformis muscle and may therefore be associated with piriformis syndrome; however, the anatomical characteristics of such an atypical artery have not been previously reported. To assess this potential association, the atypical inferior gluteal artery was anatomically examined. METHODS: The cadaver examined in this report was a 97-year-old Japanese female who was donated to The Nippon Dental University for use in medical education and research. The atypical inferior gluteal artery and surrounding structures in half of the pelvis were examined macroscopically. RESULTS: The atypical inferior gluteal artery arose from the common arterial trunk, formed by itself and the superior gluteal artery, passed through the superior proximal part of the piriformis muscle, and left the pelvic cavity. It supplies branches to the lower half of the gluteus maximus and proximal part of the long head of the biceps femoris muscle. The piriformis muscle originates from the 2nd to 4th sacral vertebrae and attaches to the greater trochanter via a single short tendon. CONCLUSION: According to our findings, when the atypical inferior gluteal artery is entrapped and compressed, ischemic signs and symptoms may emerge in the lower buttocks and proximal posterior thigh. These results provide a new perspective for the diagnosis and treatment of piriformis syndrome.
Subject(s)
Piriformis Muscle Syndrome , Humans , Female , Aged , Aged, 80 and over , Thigh , Muscle, Skeletal , Arteries , Buttocks/blood supply , Pelvis , CadaverABSTRACT
BACKGROUND: The profunda artery perforator (PAP) flap has emerged as an excellent secondary option for autologous breast reconstruction. Despite the increased acceptance, potential secondary benefits concerning aesthetic proportions of proximal thigh and buttock at the donor site have never been systematically investigated. METHODS: A retrospective review of 151 patients who underwent breast reconstruction with horizontally designed PAP flaps (292 flaps) from 2012 to 2020 was performed. Patient characteristics, complications, and numbers of revision surgeries were collected. In bilateral reconstructions, pre- and postoperative standardized patient photographs were analyzed to identify postoperative changes in proximal thigh and buttock contour. The patients' own perception of postoperative aesthetic changes was determined by an electronic survey. RESULTS: The patients had a mean age of 51 and a mean body mass index of 26.3 kg/m2. The most common complications were minor and major wound complications affecting 35.1% of patients, followed by cellulitis (12.6%), seroma (7.9%), and hematoma (4.0%). A total of 38 patients (25.2%) underwent revision of the donor site. After reconstruction, patients were found to have aesthetically improved proximal thigh and buttock proportions, indicated by a wider thigh gap (thigh gap-hip ratio: 0.05 ± 0.04 vs. 0.13 ± 0.05, p < 0.0001) and reduction in lateral thigh-to-buttock ratio (0.85 ± 0.05 vs. 0.76 ± 0.05, p < 0.0001). Among the 85 patients who responded to the survey (56.3% response rate), 70.6% felt that PAP surgery had aesthetically either improved their thigh contour (54.12%) or not changed it (16.47%), whereas only 29.4% reported that the surgery negatively impacted their thigh contour. CONCLUSION: PAP flap breast reconstruction leads to improved aesthetic proportions of the proximal thigh and buttock. This approach is ideal for patients with ptotic tissue of the inferior buttocks and medial thigh, a poorly defined infragluteal fold, and inadequate anterior-posterior buttock projection.
Subject(s)
Mammaplasty , Perforator Flap , Humans , Middle Aged , Thigh/surgery , Thigh/blood supply , Buttocks/surgery , Buttocks/blood supply , Perforator Flap/blood supply , Mammaplasty/adverse effects , Arteries/surgery , Retrospective Studies , EstheticsABSTRACT
BACKGROUND: The inferior gluteal artery (IGA) is a large terminal branch of the anterior division of the internal iliac artery (ADIIA). There is a significant lack of data regarding the variable anatomy of the IGA. MATERIALS AND METHODS: A retrospective study was conducted to establish anatomical variations, their prevalence and morphometrical data on IGA and its branches. The results of 75 consecutive patients who underwent pelvic computed tomography angiography were analysed. RESULTS: The origin variation of each IGA was deeply analysed. Four origin variations have been observed. The most common type O1 occurred in 86 of the studied cases (62.3%). The median IGA length was set to be 68.50 mm (lower quartile [LQ]: 54.29; higher quartile [HQ]: 86.06). The median distance from the origin of the ADIIA to the origin of the IGA was set to be 38.22 mm (LQ: 20.22; HQ: 55.97). The median origin diameter of the IGA was established at 4.69 mm (LQ: 4.13; HQ: 5.45). CONCLUSIONS: The present study thoroughly analysed the complete anatomy of the IGA and the branches of the ADIIA. A novel classification system for the origin of the IGA was created, where the most prevalent origin was from the ADIIA (type 1; 62.3%). Furthermore, the morphometric properties (such as the diameter and length) of the branches of the ADIIA were analysed. This data may be incredibly useful for physicians performing operations in the pelvis, such as interventional intraarterial procedures or various gynaecological surgeries.
Subject(s)
Surgery, Plastic , Humans , Retrospective Studies , Arteries/diagnostic imaging , Arteries/anatomy & histology , Pelvis/diagnostic imaging , Buttocks/diagnostic imaging , Buttocks/blood supply , Immunoglobulin AABSTRACT
The reconstruction of the near-total or total gluteal defects is challenging. Reconstructive options were restricted when the gluteal flaps were sacrificed. The lumbar artery perforator flap (LAPF) has been recently popularized as an alternative option for sacral and gluteal pressure ulcers. Extension of flap size may be needed in extensive defects. We aim to use the delay phenomenon to increase lumbar artery perforator flap territory to reconstruct near total gluteal defect. A 36-year-old woman was referred to our clinic with defect sizes of 23 × 23 cm and 25 × 17 cm for the right and left gluteal regions. She had a history of multiple surgeries for her paraplegia-related sacrogluteal pressure sores. The reconstruction was started on the left side with delaying incisions to the flap borders. Seven days later, the left gluteal defect was reconstructed with 27 × 19 cm LAPF based on a second lumbar artery perforator. At the same session, the delaying incision was performed to the borders of the right LAPF. On day 14, the right gluteal defect was closed with a 25 × 25 cm-sized right LAPF. No flap loss and early complications were seen. The patient was discharged without complication after 10 days after the last operation. The patient was followed up for 1 year. A right ischial pressure ulcer due to wheelchair use was encountered, which was managed with conservative wound care in the 8th month. Giant-sized lumbar artery perforator flaps may be obtained by delay phenomenon to reconstruct near-total or total gluteal pressure sores.
Subject(s)
Perforator Flap , Plastic Surgery Procedures , Pressure Ulcer , Surgical Wound , Humans , Female , Adult , Perforator Flap/surgery , Pressure Ulcer/etiology , Pressure Ulcer/surgery , Postoperative Complications/surgery , Arteries/surgery , Buttocks/surgery , Buttocks/blood supply , Surgical Wound/surgeryABSTRACT
BACKGROUND: Although the deep inferior epigastric artery perforator flap is the criterion standard for autologous breast reconstruction, lumbar artery perforator (LAP) and superior gluteal artery perforator (SGAP) flaps are recent trends as alternatives. The purpose of our study was to clarify differences of these flaps based on multislice CT findings of the same patient. METHODS: Retrospective study was conducted on 58 patients who underwent preoperative contrast-enhanced multislice CT for breast reconstruction using deep inferior epigastric artery perforator. Of these, 32 patients' data were evaluated excluding 26 patients' data either for the lumbar or gluteal fat being outside the imaging range or for nondepiction of the vascular pedicle origin of LAP or SGAP flap. Vascular pedicle diameter, pedicle length, and subcutaneous fat thickness were measured for LAP and SGAP flaps. RESULTS: The vascular pedicle diameter, pedicle length, and fat thickness were 2.1 (SD, 0.3) mm, 3.4 (SD, 0.4) cm, and 4.9 (SD, 1.0) cm, respectively, for LAP flaps; and 1.7 (SD, 0.2) mm, 5.6 (SD, 1.1) cm, and 2.7 (SD, 0.7) cm, respectively, for SGAP flaps. CONCLUSIONS: The LAP flaps had thicker subcutaneous fat and a larger vascular pedicle diameter, whereas the SGAP flaps had a longer vascular pedicle. As donor material for breast reconstruction, the LAP flap is indicated for cases where absolute volume is needed; otherwise, the SGAP flap is more advantageous as it facilitates vascular anastomosis with its longer vascular pedicle.
Subject(s)
Mammaplasty , Perforator Flap , Humans , Perforator Flap/blood supply , Retrospective Studies , Buttocks/diagnostic imaging , Buttocks/surgery , Buttocks/blood supply , Mammaplasty/methods , Arteries/diagnostic imaging , Tomography, X-Ray ComputedABSTRACT
The presence of osteal stenosis/occlusion or osteal exclusion by prior interventions poses a challenge to selective catheterization of the internal iliac artery. We describe a case where a retrograde access through the superior gluteal artery (SGA) was used to successfully treat an internal iliac artery pseudoaneurysm (PSA) in a patient when an antegrade catheterization was not feasible due to internal iliac osteal exclusion by an endograft.
Subject(s)
Aneurysm, False , Iliac Aneurysm , Aneurysm, False/diagnostic imaging , Aneurysm, False/therapy , Arteries , Buttocks/blood supply , Buttocks/diagnostic imaging , Humans , Iliac Aneurysm/diagnostic imaging , Iliac Aneurysm/therapy , Iliac Artery/diagnostic imagingABSTRACT
ABSTRACT: Modern interdisciplinary concepts with involvement of various surgical specialties can considerably reduce perioperative morbidity after sacroperineal resection of locally advanced primary or recurrent anorectal malignancies. Resultant defects can represent a major challenge for reconstruction particularly with chemoradiotherapy. The aim is to assess the long-term outcomes of sacroperineal reconstruction using inferior gluteal artery perforator flaps.We performed a retrospective data analysis on 31 patients who were treated with inferior gluteal artery perforator flaps (n = 61) over the period 2009-2021. The demographic data, comorbidities, operative details, and outcomes with special focus on wound infection and dehiscence were recorded.The median age was 42 year (range, 25-82 years) with preponderance of males (n = 21). The follow-up period ranged from 6 to 80 months. Early minor complications included superficial wound dehiscence (3), which was managed conservatively, whereas the major (2) included deep wound collection and infection (1), which required surgical drainage, and perineal hernia, which required repair. All flaps survived completely.Inferior gluteal artery perforator flaps are safe, robust, and reliable with less donor side morbidity and positive impact on quality of life. It should be considered as a valuable tool in the reconstructive armamentarium of sacroperineal defects within a multidisciplinary setting.
Subject(s)
Perforator Flap , Plastic Surgery Procedures , Adult , Arteries/surgery , Buttocks/blood supply , Buttocks/surgery , Humans , Male , Neoplasm Recurrence, Local/surgery , Perforator Flap/blood supply , Quality of Life , Retrospective StudiesABSTRACT
BACKGROUND: Due to the lack of knowledge about parasacral artery perforators, flaps from this region cannot be used with complete confidence in their security and effectiveness. Knowledge of the clusters and perforasome of these perforators could help in the design of more reliable flaps and extend the range of applications. OBJECTIVES: This study aimed to identify the location, number, and density of perforators, and to subsequently analyze the perfusion flow and linking vessel distribution. METHODS: Five fresh cadavers were harvested and dissected. For the mapping, after injecting lateral sacral arteries with colored latex, perforators with a diameter of >0.5 cm were examined in 5 sacral regions. All data were collected on the suprafascial plane, with an orthonormal coordinate system placed on iliac crests and median lines. For perforasome analysis, 5 perforators and 3 three sacral flaps were injected with radiopaque dye. A dynamic (4-dimensional) computed tomographic angiography completed the analysis. RESULTS: A mean [standard deviation] of 8.4 [1.36] perforators per corpse, with a mean diameter of 0.72 [0.14] mm, were identified. There was a higher density of parasacral perforators close to the median line and 7.6 cm above the iliac crests. This pattern was not a random distribution (Pâ <â 0.05). The perfusion area was preferentially in the superior gluteal region. Perfusion flow was permitted by the dominant direct-linking vessels towards adjacent lumbar perforators, oriented diagonally upward and outward to the midline. CONCLUSIONS: Parasacral perforator flaps appear to be a useful procedure in reconstruction and in aesthetic surgery, especially in gluteal augmentation. Their reliability depends on sound anatomic knowledge, with accurate preoperative perforator mapping.
Subject(s)
Latex , Perforator Flap , Angiography/methods , Buttocks/blood supply , Buttocks/surgery , Cadaver , Humans , Perforator Flap/blood supply , Reproducibility of ResultsABSTRACT
The superior gluteal artery perforator (SGAP) flap is an option for the reconstruction of deep sacral defects. Since a conventional SGAP flap is not neurotized, covered ulcers have a risk of recurrence, especially when patients cannot ambulate by themselves. In ambulatory patients, the sensory presentation of reconstructed tissue assures its protection. Purpose of this report is to present a case of the use of a sensate SGAP flap for reconstruction of a sacrococcygeal large wound dehiscence in a patient and review of literature for sensate reconstruction of sacral defects. A 72-year old woman with a sacrococcygeal large wound dehiscence measuring 12 cm in length, 9.5 cm in width and 5 cm in depth was treated. The defect was caused by a wound dehiscence after abdomino-perineal resection for rectal cancer. A unilateral SGAP flap measuring 16 × 7 cm length and 5 cm width was designed in the right buttock and the cranial border of the flap was lined near the iliac crest. An SGAP flap was elevated including the superior cluneal nerve (SCN), turned clockwise 70°, and inset to the defect. The defect remained in the deep caudal part a parasacral adiposal flap measuring 7 × 10 cm was harvested from the contralateral side and filled the defect. The postoperative course was uneventful without any complication. Sensation was observed immediately after surgery. Postoperative Semmes-Weinstein monofilament test showed 3.22 at 9 months postoperatively. There was no recurrence during follow-up of 20 months. The sensate SGAP flap may be elevated with SCN and be considered for reconstructions of deep sacral defect.
Subject(s)
Perforator Flap , Plastic Surgery Procedures , Aged , Aorta, Abdominal/surgery , Buttocks/blood supply , Buttocks/surgery , Female , Humans , Perforator Flap/blood supplyABSTRACT
BACKGROUND: The fasciocutaneous inferior gluteal artery perforator (IGAP) has been previously demonstrated to be a robust reconstructive choice after abdominoperineal excision (APE), with comparably low morbidity relative to other flaps. In patients who undergo concurrent vaginectomy, we demonstrate in this retrospective cohort study how IGAP modification allows simultaneous vaginal reconstruction with a favourable complication profile and long-term return to sexual activity. METHODS: Oncological resection was completed with the patient prone. Unilateral or bilateral IGAP flaps may be used based on vaginal defect size and surgeon preference. In this study, important features of flap design, mobilisation and inset are presented, together with a retrospective cohort study of all cases who underwent vaginal reconstruction. Clinical outcomes were determined by the length of stay, early to late complications, and quality of life assessment including a return to sexual function. RESULTS: Over a 10-year period, 207 patients underwent abdominoperineal resection (APE) in our cross-centre study (86% subject to neoadjuvant chemoradiotherapy), with 22/84 female patients electing for vaginal reconstruction (19 partial, 3 total vaginectomies). Minor complications were observed in 6/22 cases, with two patients progressing to healing after-theatre debridement (major). The median follow-up time was 410 days. Quality of life questionnaires reported high patient satisfaction, with 70% of patients returning to sexual activity. CONCLUSIONS: For patients undergoing APE with concurrent vaginectomy, the IGAP flap can be used alone for both perineal dead space management and neovaginal reconstruction, negating the need for an alternative second flap and avoiding significant donor morbidity. This study shows excellent long-term clinical outcomes, including a return to sexual activity.
Subject(s)
Perforator Flap , Plastic Surgery Procedures , Proctectomy , Arteries/surgery , Buttocks/blood supply , Buttocks/surgery , Female , Humans , Perforator Flap/blood supply , Perineum/surgery , Quality of Life , Retrospective StudiesABSTRACT
BACKGROUND: Large midline sacral defects are reconstructive challenges. Superior gluteal artery perforator (SGAP) flap provides enough tissue and versatility to cover large defects; however, a single flap may be insufficient. We present a technique to cover large defects using single SGAP flaps. METHODS: Large sacral defects (>100 cm2) reconstructed with single SGAP flaps were included. Angle of transposition (45°-60°) was determined based on the tissue laxity and mobility of gluteal area. Perforator identification, intramuscular dissection, or skeletonization was not performed. Outcomes were measured as achieving durable reconstruction, flap viability, and complications. RESULTS: There were 17 patients (12 male, 5 females; aged 25-72 years) with different etiologies. The mean flap surface area (136.1 ± 45.6 cm2, between 9 × 8 and 26 × 10 cm) was smaller than the mean defect surface area (211.1 ± 87.2 cm2, between 10 × 10 and 28 × 14 cm) (P < 0.001). All flaps survived with no partial or complete flap loss. Minor dehiscence in 4 patients (2 at donor site and 2 at recipient site) healed with dressing changes or using negative-pressure vacuum therapy. All patients had durable outcomes without any recurrence. CONCLUSION: Single unilateral SGAP flaps can be used to completely cover midline large sacral defects. It is important to design the flaps to have a joint side with the defect in the proximal part and use the intrinsic mobility of gluteal soft tissues for the closure. Flaps can be (1) planned to be smaller than the defects, (2) harvested with no intramuscular perforator dissection or pedicle skeletonization, and (3) transposed with an angle less than 60°.