Grabb’s Encyclopedia of Flaps Upper Extremities, Torso, Pelvis, and Lower Extremities

6. Jameson RM. Scrotal flap urethroplasty in the treatment of carcinoma of the penis. Trop Doct 1976;6:68.
7. Edgerton MT, Bull J. Surgical construction of the vagina and labia in male transsexuals. Plast Reconstr
Surg 1970;529.
8. Kaplan I. The scrotal flap in ischial decubitus. Br J Plast Surg 1972;25:22.
9. Kaplan I. The scrotal flap for ischial decubitus ulcers: a follow-up. Br J Plast Surg 1976;29:34.
10. Lanier VC Jr, Neale, HW. Necrosis of penis with decubitus ulcer: debridement and closure with scrotal
flap. Plast Reconstr Surg 1974;54:609.
11. Lich R Jr, Howerton LW. Anatomy and surgical approach to the urogenital tract in the male. In: Campbell
MF, ed. Urology Philadelphia: Saunders, 1963; Chap. 1, 37-38.
12. Masters FW, Robinson, DW. The treatment of avulsion of the male genitalia. J Trauma 1968;8:430.
13. Millard DR, Jr. Scrotal construction and reconstruction. Plast reconstr Surg 1966;38:10.
14. Tamai S. Microsurgical replantation of a completely amputated penis and scrotum. Plast Reconstr Surg
1977;60:287.
15. Altchek ED. A modification of the standard technique for repair of scrotal elephantiasis. Plast Reconstr
Surg 1977;60:284.

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Chapter 457
Medial Thigh Skin Flaps for Reconstruction of The Scrotum
B. HIRSHOWITZ
The bilateral superomedial thigh skin flap can be raised and transferred to reconstruct either the scrotum or the
vulva without recourse to delay procedures.
INDICATIONS
The main application so far has been in patients with large loss of scrotal skin in Fournier's gangrene or in a
patient with severe scrotal lymphedema (1, 2, 3, 4).
ANATOMY
See Chapter 330 for details.
OPERATIVE TECHNIQUE
See Chapter 438 for details of design, flap elevation, and donor-site closure.
With scrotal reconstruction, a saclike form of the new scrotum can be obtained by suturing together the distal
margins, as well as some of the lateral margins of the flaps, in the midline. This produces a tightening effect
distally, while leaving the central portion of the suture line loose (Fig. 457.1C).
SUMMARY
Fourteen patients with scrotal and vulvar defects have been reconstructed without flap failure using the
bilateral superomedial thigh flap.
FIGURE 457.1 A: Loss of most of the skin of the scrotum and perineum with exposure of both testes. The
proximal half of the ventral surface of the penis is also exposed. The outline of both flaps is shown on the
lax proximal thigh skin. B: The elevated flaps sutured together in the midline can readily be brought down to
cover both testes. (Continued)

FIGURE 457.1 (Continued) C: Both flaps in position before placement of the skin sutures. The skin of the
ventral surface of the penis also has been repaired. D: Appearance of the reconstructed scrotum 4 months
postoperatively.
References
1. Robinson DW, Stephenson KL, Padgett EC. Loss of coverage of penis, scrotum, and urethra. Plast
Reconstr Surg 1946;1:58.
2. Millard DR Jr. Scrotal construction and reconstruction. Plast Reconstr Surg 1966;38:10.
3. Altchek ED, Hoffman S. Scrotal reconstruction in Fournier's syndrome. Ann Plast Surg 1979;3:523.
4. Hirshowitz B, Moscona R, Kaufman T, Pnini A. One-stage reconstruction of scrotum following Fournier's
syndrome using a probable arterial flap. Plast Reconstr Surg 1980;66:608.

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Chapter 458
Medial Thigh Fasciocutaneous Flap for Total Scrotal
Reconstruction
G. G. HALLOCK
EDITORIAL COMMENT
This is a very acceptable flap that will serve to cover the testicles, as well as to reconstruct the scrotum.
The flap would be preferable to just burying the testicles in the medial aspect of the thighs.
The cutaneous territory of the medial thigh can sustain a long, narrow, fasciocutaneous flap. If the flap is
proximally based, a wide arc of rotation is possible, allowing transfer for total scrotal reconstruction (1, 2, 3, 4, 5)
and other debilitating groin or perineal wounds.
INDICATIONS
Most scrotal defects are acquired, frequently following trauma or iatrogenic sequelae. Coverage of the
testicles, without
resorting to orchiectomy or burying them in subcutaneous thigh pockets (6), is desirable, but such coverage
must also provide the best possible aesthetic result, to preserve male psychosexual identity. Frequently, the
redundant scrotum can be stretched to close small wounds, or a skin graft will suffice (7). However, an
unacceptable appearance often results from grafting, or the wound environment is not conducive to ensure
adequate graft inosculation. Under such conditions, the medial thigh fasciocutaneous flap may then be a
better alternative.
FIGURE 458.1 Diagram depicting the important landmarks for determining the boundaries of the medial
thigh fasciocutaneous flap. Although roughly centered over the gracilis muscle, the usual dimensions
exceed those of a conventional gracilis musculocutaneous flap. The proximal transverse dotted line must

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not be violated to preserve the depicted afferent perforators to the fascial plexus. A, subcutaneous branch
of deep external pudendal artery; B, gracilis musculocutaneous perforator; C, adductor magnus
musculocutaneous perforator. (From Hallock, ref. 4, with permission.)
This wide, sensate flap can be taken from a single thigh for single-stage total scrotal reconstruction, while
still permitting primary donor-site closure (4, 5). In addition, the underlying gracilis muscle always is exposed
during this dissection and can be utilized to broaden the potential area of coverage. The flap can also be
used for repair of concurrent penile injuries such as urethral fistula (6), where coverage would be
mandatory in any case.
ANATOMY
The fascial plexus of the medial thigh receives afferent inflow from direct branches such as the external pudendal
vessels or septocutaneous branches of the superficial femoral or medial circumflex femoral arteries, and indirect
branches from musculocutaneous perforators of the adductor compartment (1). Several such major perforators
are invariably found proximal to a line drawn 5 cm below a parallel line extending from the pubic tubercle to the
ischial ramus, which determine the most proximal point for rotation of the medial thigh fasciocutaneous flap (Fig.
458.1). The greater saphenous vein is found within this area, but can be excluded, as venous outflow paralleling
the perforating arteries will still be sufficient.
Since the ilioinguinal nerve accompanies the external pudendal artery to the proximal medial thigh, at least that
part of any flap will always be sensate. The distal two-thirds of the medial thigh is innervated by the medial
femoral cutaneous nerve, which must be dissected back to its origin from the femoral nerve, if distal flap
sensation is desired (2).
FLAP DESIGN AND DIMENSIONS AND OPERATIVE TECHNIQUE
Control of sepsis and adequate debridement must always precede scrotal reconstruction, as this body region is
notorious for contamination. Usually, all procedures are facilitated by placing the patient in a lithotomy position.
A line drawn from the pubic tubercle to the insertion of the semitendinous tendon represents the anterior border
of this pennant-shaped flap (Fig. 458.2). The posterior margin usually varies according to skin redundancy,
which is determined by squeezing the thigh to simulate primary closure. Often, a flap up to 9 cm in width is
possible. The wider the flap, the more likely that collateralization from multiple perforators will be captured, to
ensure the safety of a greater flap length. A sharp narrowing of the flap distally toward the knee simplifies donor-
site closure. Usually, when longer than 20 cm, this portion will not fluoresce, will be presumed non-viable, and
must be discarded.
Elevation begins distally with identification of the deep fascia of the thigh. The fascia is usually retained with the
flap, to ensure the integrity of the overlying fascial plexus. A rapid, proximal dissection in a relatively bloodless
plane is then possible, stopping 5 cm below the groin crease to preserve the vascular inflow to the flap (Fig.
458.3). Rotation of the flap
as a hammock to cover the testicles and thereby to recreate a scrotum must be accomplished with a tension-free
inset. Intravenous fluorescein is routinely administered, to ensure adequacy of circulation to the distal flap, if
capillary refill is ambiguous. If necessary, the donor leg is removed from the stirrups and adducted toward the
midline, to allow additional removal of distal portions of the flap and to minimize any risk of flap compromise.

FIGURE 458.2 A massive scrotal and perineal defect with exposed testicles, consequent to debridement for
Fournier's gangrene, is seen to the extreme right. A: Outline of a medial thigh fasciocutaneous flap after patient
was placed in lithotomy position. Cross-hatched area of the marked flap usually will be discarded, but inclusion
facilitates primary donor-site closure. B: Close-up of the same challenging scrotal defect.
FIGURE 458.3 Since the left groin was less violated by the debridement, the actual medial thigh fasciocutaneous
flap was taken from the left thigh. Flap seen here dangling from its proximally-based pedicle at the point of
clockwise rotation. The gracilis muscle has also been elevated on its own pedicle, is seen medial to the skin flap,
and was used to augment the width of the neoscrotum.

FIGURE 458.4 Appearance 2 months postoperatively, with acceptable scrotal reconstruction, and a linear scar
along the medial left thigh the only residue of flap harvesting.
If desired, the now exposed gracilis muscle can be divided at its tendinous insertion and rotated to cover the
penis or augment potential scrotal coverage. Its proximal elevation will be restrained by the dominant pedicle
found entering its medial undersurface, about 8 to 10 cm below the inguinal ligament (8). The single medial thigh
donor site for both flaps should easily be closed by primary approximation. A scrotal support is used in the
postoperative period until dependent edema subsides.
CLINICAL RESULTS
Although a vascularized flap is not always mandatory for scrotal reconstruction (7), such a choice often
results in a superior cosmetic result (Fig. 458.4) and can better guarantee healing with a minimum of
surgical intervention, especially considering the contaminated wound. Bilateral gracilis muscles can be
utilized for total scrotal reconstruction, at the expense of violating the two extremities and muscle function,
although this is usually expendable (9).
The use of superior (10) or superomedial thigh (11, 12) flaps similarly requires bilateral flaps and requires a
skin graft for donor-site closure. The omentum (13) and rectus abdominis muscle (14) have also been used,
but with the obvious risks of laparotomy or abdominal-wall hernia, respectively. These potential deficits can
all be avoided by using a single flap from the medial thigh, based on the recently resurrected
fasciocutaneous flap principle (3). A conjoint flap, utilizing the underlying gracilis muscle for further penile (6,
8) or scrotal enhancement (4, 5), adds to the attributes of this donor region, which can still be closed
primarily, causing minimal morbidity.
SUMMARY

When vascularized tissue transfer is required for preservation of testicular function and appearance in total
scrotal reconstruction, a local proximally-based medial thigh fasciocutaneous flap is potentially sensate, can
be rapidly elevated from a single extremity in a single stage, and leaves virtually no donor-site deficit.
References
1. Cormack GC, Lamberty BGH. The blood supply of thigh skin. Plast Reconstr Surg 1985;75:342.
2. Wang N, Whetzel T, Mathes SJ, Vasconez LO. A fasciocutaneous flap for vaginal and perineal
reconstruction. Plast Reconstr Surg 1987;80:95.
3. Ponten B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Br J Plast Surg
1981;34:215.
4. Hallock GG. Scrotal reconstruction following Fournier's gangrene using the medial thigh fasciocutaneous
flap. Ann Plast Surg 1990;24:86.
5. Hallock GG. The chimera flap principle: conjoint flaps. In: Hallock GG, ed. Fasciocutaneous flaps. Boston:
Blackwell Scientific, 1992;172-180.
6. Heckler FR, Aldridge JE, Songcharoen S, Jabaley ME. Muscle flaps and musculocutaneous flaps in the
repair of urinary fistulas. Plast Reconstr Surg 1980;66:94.
7. Schaller P, Akcetin Z, Kuhn R, et al. Scrotal reconstruction after Fournier's gangrene with simple skin
grafting. Eur J Plast Surg 1994;17:261.
8. Heckler FR. Gracilis myocutaneous and muscle flaps. Clin Plast Surg 1980;7:27.
9. Westfall CT, Keller HB. Scrotal reconstruction utilizing bilateral gracilis myocutaneous flaps. Plast
Reconstr Surg 1981;68:945.
10. Tiwari IN, Seth HP, Mehdiratta KS. Reconstruction of the scrotum by thigh flaps. Plast Reconstr Surg
1980;66:605.
11. Hirshowitz B, Moscona R, Kaufman T, Pnini A. One-stage reconstruction of the scrotum following
Fournier's syndrome using a probable arterial flap. Plast Reconstr Surg 1980;66:608.
12. Hirshowitz B, Peretz BA. Bilateral superomedial thigh flaps for primary reconstruction of scrotum and
vulva. Ann Plast Surg 1982;8:390.
13. Kamei Y, Aoyama H, Yokoo K, et al. Composite gastric seromuscular and omental pedicle flap for
urethral and scrotal reconstruction after Fournier's gangrene. Ann Plast Surg 1994;33:565.
14. Young WA, Wright JK. Scrotal reconstruction with a rectus abdominis muscle flap. Br J Plast Surg

1988;41:190.

Chapter 459
Paired Inguinal Skin Flaps for Epispadias Exstrophy Repair
C. E. HORTON
C. J. DEVINE JR.
N. W. GARRIGUES
The constellation of defects presented by congenital epispadias with bladder exstrophy has been a problem for
reconstructive surgeons. Classically, closure of the abdominal defect and genital reconstruction were neglected,
while attention was focused on urinary diversion. As advancements in excretory control occurred, attention was
drawn to the puzzle of plastic repair of the lower abdomen and genitalia. During recent years, further surgical
advancements have offered improved function and better aesthetic appearance in this region. Developing a
urinary conduit can no longer be accepted as the single objective in the care of these complex cases.
INDICATIONS
Previous procedures for managing these patients presented numerous disadvantages (1, 2, 3, 4, 5). A
typical midline closure could divide the escutcheon with a wide hairless scar, frequently tethering the penis
to the abdominal wall. Multiple-staged procedures not only produced further morbidity, but often created
unaesthetic donor sites. While it may be acceptable to use any available closure in the difficult exstrophy
patient, it is in no way acceptable to allow the abnormal escutcheon or the bent penis to remain as
permanent, embarrassing results. With this in mind, we have developed a simple, reliable flap with hair-
bearing tissue to reconstruct the normal escutcheon, elongate the inferior abdominal wall, and allow penile
release.
A great advantage of this approach is the exposure provided for reconstruction of deeper structures. The
urethra, corporal bodies, pubic ramus, midline diastasis, and bladder are all made accessible to complete
systematic evaluation of the problem. The crura of the corporal bodies can easily be freed from the pubic
bone. Release of the chordee, which is particularly important in epispadic patients, is made convenient.
ANATOMY
The vascular supply of these superiorly based flaps is probably from the perforating vessels of both the muscular
and pubic branches of the inferior epigastric vessels.
FLAP DESIGN AND DIMENSIONS
Flap design allows excision of unattractive midline scarring. The tissue brought into the suprapubic region is hair-
bearing and produces an aesthetic escutcheon. Elongation of the lower abdominal midline mobilizes skin that, in
combination with procedures on the deeper structures mentioned above, significantly enhances penile length.
The donor defect is a well-hidden inguinal scar.
The paired inguinal skin flaps are W-shaped flaps with each apex extending to a point lateral and inferior to the
penis (Fig. 459.1). Markings are begun at a point inferiorly and laterally to the anterior superior iliac spine and
extended inferiorly in the groin crease to a point well below the penile base, usually at a low scrotal level. The
marking is then continued superiorly, including a small portion of the scrotum, to the superior penile border,
where it is joined by mirrored markings from the opposite groin.

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OPERATIVE TECHNIQUE
The flaps are elevated at the subcutaneous level, just superficial to the external oblique aponeurosis. Following
repair and release of chordee, corporal bodies, and urethra, the flaps are closed in a V-to-Y fashion. The groin-
crease donor site is easily closed without tension as the two flaps are sutured together in the midline (Fig.
459.2). The flaps may be further rotated to close in a Z configuration. However, this does leave a significant
suprapubic skin defect.
Since maximal penile lengthening is desirable, closure of the area must be tension-free. A full-thickness skin graft
may be used if the soft-tissue defect is limited to skin only. Typically, however, if a deficit exists, underlying
repairs to the deeper structures may necessitate vascularized flaps. We have used an island groin flap tunneled
subcutaneously or a rectus femoris musculocutaneous flap to close the created defect.
CLINICAL RESULTS
These simple random flaps have multiple inherent advantages. We have relied on them for reconstruction of
18 patients crippled by epispadias exstrophy. Figures 459.3 and 459.4 are characteristic of repair using the
paired inguinal skin flaps. Flap loss has not occurred. This may be due to an increased blood supply from
the inferior epigastric vessels, caused by the congenital midline diastasis.
SUMMARY
Paired inguinal flaps are reliable random flaps that can be used to great advantage in epispadias exstrophy
patients. They allow escutcheon reconstruction by bringing hair-bearing tissue into the congenitally
defective and frequently surgically scarred suprapubis. More important, phallic elongation by a single-stage
reconstruction is achieved. Excellent exposure for reconstruction of underlying malformed structures is also
offered.
FIGURE 459.1 Design of the paired inguinal skin flaps.

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FIGURE 459.2 Reconstructive closure of paired inguinal skin flaps.
FIGURE 459.3 A-D: An epispadias exstrophy patient with a previous urinary diversion and abdominal wall
closure demonstrates significant tethering of the penis within an abnormal escutcheon (A). The paired
inguinal skin flaps are designed (B) and transposed (C), allowing full approach to underlying pathology,
release of penile tether, enhancement of penile length, and reconstruction of an aesthetic escutcheon (D).

FIGURE 459.4 A-C: An adolescent reveals the typical features of epispadias exstrophy. D: Use of the
paired inguinal skin flaps allows reconstruction of ventral scarring and diastema, as well as penile release
and elongation.
References
1. Simon J. Ectopia vesicae. Lancet 1852;2:568.
2. Matthews D. Ectopia vesicae. Br J Plast Surg 1958;11:188.
3. Steffensen W, Ryan J, Sinclair E. A method of closure of the abdominal wall defect in exstrophy of the
bladder. Am J Surg 1956;92:9.
4. Erich J. Plastic repair of the female perineum in a case of exstrophy of the bladder. Mayo Clin Proc
1959;34:235.
5. Longacre J, deStefano G, Davidson D. Plastic repair of congenital defects of the ventral body wall with
particular reference to exstrophy of the bladder. Plast Reconstr Surg 1959;23:260.

Chapter 460
Rectus Abdominis Muscle Flap Incorporation Into Bladder Repair
F. R. HECKLER
Muscle and musculocutaneous flaps have assumed a central role in the reconstruction of difficult wounds in
almost all areas of the body. Reports of the use of such flaps within coelomic cavities as adjuncts to visceral
repair also have appeared, but to a much lesser extent (1, 2). In this context, the rectus abdominis muscle has
proven itself, in my practice, to have the potential to aid in successful salvage of difficult urinary bladder closure
problems.
INDICATIONS
Bladder defects and wounds, even when relatively extensive, can usually be managed by the standard
urologic techniques of debridement, mobilization of remaining healthy bladder wall, and suture closure in
multiple layers. Such techniques, combined with temporary bladder decompression using either a
transurethral or a suprapubic catheter, usually are followed by a successful outcome, albeit with the
accompaniment of a somewhat decreased bladder capacity. However, when additional factors that may
contribute to poor wound healing are present, such as prior therapeutic irradiation, severe local scarring, or
infection, the introduction of highly vascular, healthy muscle tissue may be an important adjunct to a
successful outcome.
ANATOMY
Details of the surgical anatomy of the rectus abdominis muscle are presented in Chapters 379 and 381 to 383
and will not be repeated here. Rather, I will concentrate on specific anatomic points pertinent to the transfer of
this unit to the urinary bladder.
The paired rectus abdominis muscles run from the pubis below to the costal margins above, enclosed within the
fascial rectus sheath. When used as an inferiorly based flap, the vascular pedicle consists of the inferior
epigastric artery and vein. These vessels originate from the external iliac artery and vein just prior to their
passage beneath the inguinal ligament. The inferior epigastric vessels pass obliquely upward in a preperitoneal
plane, penetrate the rectus sheath approximately 8 cm above the pubis, and then course in a cephalic direction
along the underside of the muscle. The entire rectus abdominis will survive based on this single arteriovenous
pedicle, although only about half this amount is needed for bladder repair.
FLAP DESIGN AND DIMENSIONS
Many of the traumatic defects and pathophysiologic entities in question involve the central suprapubic area,
including the pyramidalis muscles and the distal rectus abdominis. The oblique approach of the inferior epigastric
vessels and their entry into the rectus sheath at or near the arcuate line generally make the muscle unit available
for transfer from one or the other side, despite suprapubic pathology. If doubt about the persistence of an intact
inferior epigastric artery exists, a preliminary angiography study will clarify the picture. Alternatively, the vertical
midline lower abdominal incision usually used by the urologic member of the reconstructive team will allow
preliminary palpation or even direct visualization of the inferior epigastric pedicle, either in its retroperitoneal or
its retromuscular course.

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OPERATIVE TECHNIQUE
Mobilization of the rectus abdominis is quite straightforward and rapidly accomplished. Either a midline or
paramedian skin incision is used, depending on the surgeon's preference and the presence or absence of
previous surgical scars on the abdomen (Fig. 460.1).
The presence of previous low transverse surgical scars (such as Pfannenstiel) does not usually preclude the use
of the rectus abdominis, since these will normally not have been carried far enough laterally to interfere with the
deep inferior epigastric pedicle. Thus, even if the lower rectus has been transected by such an incision, the
muscle flap can still be used because the vascular pedicle enters the muscle several centimeters cephalic to the
insertion.
The anterior rectus sheath is linearly opened and the rectus muscle is sharply dissected out, care being taken
not to avulse it accidentally from the vascular pedicle running immediately deep to it. The muscle is mobilized to
the pubis, from which it may be detached, if required, although this is not usually necessary.
The defect in the bladder wall is repaired, and the rectus muscle is applied directly over the bladder suture line
with absorbable sutures. The anterior rectus sheath is securely closed, followed by standard wound closure of
subcutaneous tissue and skin (Fig. 460.2).
The need for the addition of pedicled muscular reinforcement of bladder wall repairs is clearly infrequent.
However, in certain highly selected patients, it can be the additional ingredient required for overall success. The
additional dissection and operating time are quite modest, and the donor-site functional morbidity is minimal.
FIGURE 460.1 Anatomic relationships for incorporation of rectus abdominis into bladder repair. A: Inferior rectus
sheath is opened either through the anterior or medial edge, with reflection of fascia. The rectus abdominis is
mobilized based on its inferior epigastric vascular pedicle. Bladder repair is carried out in standard fashion. B:

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The rectus abdominis is then rotated inferiorly and medially and sutured directly over the bladder suture line in
close apposition to it. (From Heckler et al., ref. 1, with permission.)
FIGURE 460.2 Rectus abdominis incorporation into a suprapubic vesicocutaneous fistula repair. A: Suprapubic
postirradiation ulcer with vesicocutaneous fistula in base. Note that the heavily irradiated area extends laterally
to involve both distal segments of the rectus abdominis. (Continued)
FIGURE 460.2 (Continued) B: Debridement and bladder mobilization and repair have been carried out. The
distal rectus abdominis muscle has been debrided away. Note that the inferior epigastric vascular pedicle (dotted
lines) approaches obliquely and therefore is still intact. The more cephalic end of the rectus abdominis muscle
will be transposed inferiorly and applied to the bladder repair. C: The muscle has been rotated inferiorly and is
being applied over the bladder repair. In this case, the anterior fascia also has been included to provide distal
fascial reconstruction.
CLINICAL RESULTS
I have used the rectus abdominis as an aid in bladder repair in six patients, all with success.
SUMMARY
The value of the introduction of healthy, highly vascularized tissues into the healing milieu of wounds whose

healing potential is otherwise compromised seems obvious and is a time-honored reconstructive principle
(3). In particular, the application of healthy muscle flaps has proved efficacious in obtaining primary healing
in a large variety of difficult situations. The incorporation of rectus abdominis muscle flaps into the repair of
difficult bladder defects is simply another extension of the principle.
References
1. Heckler F, Aldridge J, Songcharoen S, Jabaley M. Muscle flaps and musculocutaneous flaps in the repair
of urinary fistulas. Plast Reconstr Surg 1980;66:94.
2. Skef Z, Bellinger M, Blomain E, Ballantine T. Use of the inferior rectus myocutaneous flap for coverage of
bladder exstrophy defect. J Pediatr Surg 1982;17:720.
3. Brown JB, Fryer M, McDowell F. Permanent pedicle blood-carrying flaps for repairing defects in avascular
areas. Ann Surg 1951;134:486.

Chapter 461
Inferior Rectal Artery Spiral Skin Flap
D. R. MILLARD JR.
The inferior rectal artery spiral skin flap is an axial-pattern flap that is used to create a skin-lined anal canal. For
patients with imperforate anus, it can be used both to prevent and treat rectal mucosal exposure and prolapse
(1).
INDICATIONS
Low imperforate anus is a translevator lesion in which the rectum can be brought out to the skin in the anal
position without complication using the standard method. In high imperforate anus, the rectum
communicates with the bladder, urethra, or vagina above the puborectalis sling of the levator ani muscle
and has not descended through the levator sling. Even when the rectum is rerouted through the levator
sling (2), pulled through a preserved distal cuff of rectum (3), and simply sutured to a hole in the skin in the
anal area, there are complications.
The high percentage of postoperative complications of mucosal ectropion, rectal prolapse, wet bottom, and
anal stricture are due to the absence of a distal skin-lined anal canal. After the rectum has been pulled
through a hole in the skin in the anal area, skin tension will pull it into ectropion or prolapse, and mucosal
exposure promotes a flow of mucus. The circularity of the anal scar often contracts to produce a stricture.
Surgical attempts to prevent these complications have all been based on the principle of advancement of
local skin by flaps from the same axis. This does not alleviate the problem, because the shortage of skin
merely causes what has been pulled in to pull out again.
ANATOMY
The flap used to create a skin-lined anal canal is an axial-pattern flap based on the inferior rectal artery.
FLAP DESIGN AND DIMENSIONS
A 1.5 × 5 cm skin flap based at the side of the future anus is taken from the groove between the thigh and the
scrotum (Fig. 461.1B). This flap is taken out of one axis and transposed into a different axis to bring in new skin
without tension.
In primary cases, a trapdoor flap, based posteriorly, is elevated to be inset into the rectal release. In secondary
cases, a posterior transposition flap must be designed.
OPERATIVE TECHNIQUE
In primary cases, the usual trapdoor skin flap in the anal area is lifted with its base posterior (Fig. 461.1A). The
distal end of the rectum, rerouted through the levator sling, is brought down the anal canal but sutured short of
the external skin by 1.5 cm, thus leaving a raw cuff of the distal anal canal (Fig. 461.1B). The trapdoor flap is
interdigitated across the circular ring of the distal rectum to interrupt the circle (Fig. 461.1B, inset).
The spiral flap is coiled into the 1.5-cm raw distal anal canal to line it with skin (Fig. 461.1C). The flap donor area
is sutured without difficulty, and the scar soon becomes unnoticeable (Fig. 461.1D).
In secondary cases, the ectropion or prolapse is resected up 1.5 cm from the external skin, leaving the same raw

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distal anal canal. Since there is no trapdoor flap available, a midline transposition is used to interdigitate across
the distal circle of rectum (Fig. 461.2A, inset). Then the inferior rectal spiral flap is used, as in the primary cases,
to line the distal anal canal with skin under no tension (Fig. 461.2A-C).
CLINICAL RESULTS
By March of 1982 (1), this procedure had been performed in four primary patients and seven secondary
patients. The inferior rectal vessels were found to be robust in all 11 patients.
If the colostomy is closed after this anal construction so that the new anal canal will have regular dilatations,
there will be no recurrence of the previously common complications.
SUMMARY
The inferior rectal artery skin flap has provided a solution to the problems of constructing an anus in both
primary and secondary cases of imperforate anus.
FIGURE 461.1 A: In primary correction of high imperforate anus, the anal dimple is lifted in a trapdoor flap.
(From Millard et al., ref. 1, with permission.) B: The distal rectum has been brought down and released by
an incision posteriorly. The spiral flap with the inferior rectal vessels has been marked. Inset: Trapdoor flap
let into rectal release. C: Spiral flap donor area closed and flap let into defect between perineal skin and
distal end of rectum to create a skinlined distal anal canal. D: Completed result.

FIGURE 461.2 A: In secondary correction of high imperforate anus, a trapdoor flap cannot be created;
therefore, a small posterior transposition flap is designed. The spiral flap is marked, and the distal rectum is
released by posterior incision. Inset: Posterior flap transposed 180 degrees into rectal release. B: Spiral
flap being inserted and donor area closed. C: Completion of skin-lined distal anal canal.
References
1. Millard DR Jr, Rowe MI. Plastic surgical principles in high imperforate anus. Plast Reconstr Surg
1982;69:399.
2. Stevens FD, Smith ED, eds. Ano-rectal malformations in children. Chicago: Year Book Medical
Publishers, 1971;255.
3. Rehbein F. Imperforate anus: experience with abdominoperineal and abdominosacroperineal pull-through
procedures. J Pediatr Surg 1967; 2:99.

Chapter 462
Reconstruction of The Anoperineal Area With The V-Y
Advancement Triangular Island Flap
I. J. PELED
Y. ULLMANN
EDITORIAL COMMENT (Chapters 462 and 463)
These are other uses for bilateral V-Y sliding flaps. It is important to determine whether the internal
sphincter is working in the anal reconstruction.
The V-Y advancement triangular island flap is described for reconstruction after treatment of anal ectropion. It
can be applied after any ablative surgery of the anal area.
INDICATIONS
Tumors of the perianal area may extend into the anal canal, and their resection may leave a large, raw
surface in this area. Whitehead deformity or ectropion of the anal mucosa (Fig. 462.1A), following
hemorrhoidectomy, is infrequent but, when present, causes great discomfort, including wet anus, pruritus,
bleeding, pain, incontinence, and tenesmus. The treatment consists of excising the everted mucosa and the
adjacent skin, and the result, just as after tumor ablation, is a large, raw surface. Leaving this area open for
secondary healing, or resurfacing it with skin grafts, may lead to such unwanted consequences as strictures
and incontinence.
To avoid these complications and provide resumption of normal sensation in the anal area, it is desirable to
use local sensate flaps with intact skin for the reconstruction. Reported procedures have included sliding
skin flaps (leaving a raw surface for secondary healing), S-plasty, Limberg flaps (1, 2, 3), and muscle flaps
such as the gracilis and gluteus maximus (4). The usefulness and versatility of V-Y advancement flaps have
previously been reported (5), as well as their application for anal reconstruction (6, 7).
ANATOMY
The V-Y advancement gluteal island flap is a random flap that is subcutaneously based on the perforating
vessels emerging from the muscle. The gluteus maximus has a dual blood supply from the superior and inferior
gluteal arteries, which arise from the internal iliac vessels. Wide lateral undermining of triangular flaps between
the dermis and subcutaneous tissue allows medial and upward advancement without tension, and does not
jeopardize the blood supply to the flap.
FLAP DESIGN AND DIMENSIONS
One or two triangles are drawn on one or both sides of the created defect over the sphincter. The bases are the
right and left anal hemicircumference. The height of the triangle(s) is about 8 to 10 cm, so as to obtain an apex of
30 to 45 degrees (Fig. 462.1B).
OPERATIVE TECHNIQUE

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With the patient in the supine position and with elevation and flexion of the hips, the skin, subcutaneous tissue,
and fascia of the previously marked triangles are incised perpendicularly, in order to provide two deeply-based
island flaps. Undermining is performed lateral to the flaps, in order to free them without interfering with the blood
supply. The bases of the triangles are medially advanced and sutured to the mucosa, including the edge of the
sphincter, without tension. This medial flap advancement restores the mucocutaneous junction to its proper
position inside the anal canal. The donor sites are closed in a V-Y fashion. The mucosa/skin junction is sutured
with 3-0 buried absorbable suture, and the rest of the skin with 3-0 nylon (Fig. 462.1C and D). When the defect
involves only a part of the anal circumference, one flap is sufficient to close the defect.
CLINICAL RESULTS
The V-Y advancement principle, applied here to an island musculocutaneous flap, allows great mobility,
thus enabling
closure of the anal mucosa without tension at the suture line. No recurrences of prolapse or dehiscence
have been observed. Using the V-Y principle avoids dog-ears and involves a single- stage surgical
procedure. In addition, it is safe, simple, and successful.
FIGURE 462.1 A 43-year-old male patient with Whitehead deformity. A: Note everted mucosa. B:
Schematic representation of the triangular flap design. C: Following wide resection of the everted mucosa
seen in Figure 1A, the flap on the left side is proximally advanced and sutured to the remaining anal
mucosa. D: Both buttocks at 8 months postoperatively are separated, showing no outward retraction of the
anal mucosa after the procedure. (From Peled et al., ref. 6, with permission.)
SUMMARY
Reconstruction of perianal defects, using one or two medially- advanced triangular island flaps, is an easy

and reliable one-stage procedure for resurfacing the anal area with normal and sensate skin.
References
1. Rand AA. The sliding skin-flap graft operation for hemorrhoids: a modification of the Whitehead procedure.
Dis Colon Rectum 1969;12:265.
2. Ferguson JA. Whitehead deformity of the anus: S-plasty repair. Dis Colon Rectum 1979;22:286.
3. Kaplan HY, Freund H, Muggia-Sullam M, Wexler MR. Surgical correction of ectropion of the anal mucosa.
Surg Gynecol Obstet 1982;154:83.
4. Christiansen J. Advances in the surgical management of anal incontinence. Baillieres Clin Gastroenterol
1992;6:43.
5. Peled IJ, Wexler MR. The usefulness and versatility of V-Y advancement flaps. J Dermatol Surg Oncol
1983;9:1003.
6. Peled IJ, Manny J, Wexler MR, Luttwak EM. The triangular island skin flap for treatment of anal ectropion.
Dis Colon Rectum 1984;27:33.
7. Sagher U, Krausz MM, Peled IJ. V-Y plasty for perianal reconstruction after resection of tumor. Surg
Gynecol Obstet 1992;175:31.

Chapter 463
Island Flap Anoplasty for Anal Canal Stenosis and Mucosal
Ectropion
M. J. PIDALA
F. A. SLEZAK
J. A. PORTER
The island flap design has been demonstrated to have distinct advantages over older forms of anoplasty. The
operative procedure is presented for treatment of mucosal ectropion and anal canal stenosis.
INDICATIONS
Mucosal ectropion and anal canal stenosis are distinct anorectal abnormalities that have separate
etiologies, clinical features, and treatments. Ectropion is most commonly the result of an improperly
performed amputative hemorrhoidectomy in which the rectal mucosa has been sutured to the perianal skin.
Symptoms include mucous drainage (“wet anus”), pruritus, bleeding, pain, and tenesmus. Treatment is
directed toward resection of the prolapsing mucosa and reconstruction of the mucocutaneous junction at
the level of the original dentate line.
Anal canal stenosis is most commonly a result of prior hemorrhoidectomy. Other causes include laxative
abuse (especially mineral oil), chronic anal fissure, neoplasia, inflammatory bowel disease, and irradiation.
Patients often present with constipation, obstipation, pain, bleeding, and narrowed stools. In the more
severe forms of anal canal stenosis, the loss of tissue is the underlying pathology that must be addressed.
Anoplasty is a technique used to reconstruct the anal canal and recreate the mucocutaneous junction. It can
be used to replace descended mucosa, as seen in ectropion, or to replace fibrous scar tissue, as seen in
anal canal stenosis. Since its introduction (1), the island-flap anoplasty has become a popular choice for
repair of both (2, 3, 4, 5, 6, 7, 8, 9, 10). Compared with earlier forms of anoplasty (3, 4, 5, 6, 7, 11, 12, 13,
14, 15, 16, 17), the island-flap design is simpler, produces less morbidity, and provides an excellent
longterm outcome.
FLAP DESIGN AND DIMENSIONS
The shape and design of island flaps have varied among different reports (1, 2, 8, 9, 15). The diamond flap,
which is recommended, provides a very effective design for the treatment of patients with anal stenosis. A
modified V-Y advancement flap has been used for patients with mucosal ectropion. This is similar to the
previously described U-shaped flap (1, 15). The V-Y design offers more perianal skin to fill the larger defects
associated with ectropion, although any shaped flap may be used as long as sufficient skin to cover the anal
canal defect with minimal tension is provided. Undermining of the flap should be avoided to prevent destruction
of the blood supply and subsequent flap ischemia. The island advancement flap should allow for primary closure
of the donor site, to avoid the added discomfort of an open wound.
OPERATIVE TECHNIQUE
For anal canal stenosis, the patient receives a full mechanical bowel preparation including oral antibiotics
preoperatively. The morning of the procedure, one dose of an antibiotic is administered intravenously, usually a
cephalosporin. Spinal anesthesia is preferred, but local or general anesthesia may be utilized. The patient is

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placed in the prone jackknife position, with the buttocks taped apart.
A “diamond” flap design is used. A lateral internal sphincterotomy incision is made from the dentate line to the
anal verge. If there is a muscular component to the stenotic anal canal, an internal sphincterotomy is performed.
A medium- sized Hill-Ferguson retractor usually can be placed into the anal canal at this point, separating the
lateral incision and creating a defect to be filled by the advancement flap.
The diamond is outlined with the leading edges at least as long as the original lateral incision. The flap is incised
with a scalpel, and the sides are dissected down to the subcutaneous fat. The flap is not undermined. As the flap
is advanced into the anal canal, the subcutaneous bands holding the trailing end of the flap are carefully cut.
Once fully mobilized, the flap is easily advanced into the anal canal and sutured to the rectal mucosa. The
internal sphincter is included in the first sutures to anchor the flap. Suturing is continued around the perimeter of
the flap, and the remaining donor site is closed as a straight line.
A contralateral flap is created if there is persistent stenosis following completion of the first flap. The ability to
place a medium-sized Hill-Ferguson retractor is a good measure of the adequacy of anal-canal diameter.
For mucosal ectropion, the preoperative preparation, anesthesia, and patient position are similar to those
described above for anal stenosis. The initial step in the procedure is excision of the ectropion up to the level of
the original dentate line, creating the defect to be filled by the island flap. Bilateral triangular flaps are utilized, as
the ectropion is usually circumferential, and each flap provides enough skin to cover one-half the circumference
of the anal canal (Fig. 463.1).
The flaps are mobilized, similar to the above description. They are then advanced into the anal canal and
sutured to the rectal mucosa, creating a new mucocutaneous junction (Fig. 463.2). The internal sphincter is
included in this suture
line, to anchor the flap and the new dentate line in place. Interrupted 3-0 polyglycolic-acid sutures are continued
around the perimeter of the flap. The donor site is closed as a straight line, creating a Y-shaped closure (Fig.
463.3).
FIGURE 463.1 Bilateral triangular flaps outlined in ink prior to repair. (From Pidala et al., ref. 20, with
permission.)
Intravenous antibiotics are administered for 24 hours, followed by a 5-day course of oral metronidazole. The
bowels are generally not confined. A regular diet with fiber supplement is begun the morning of the first
postoperative day. Stool softeners are used as needed, but liquid stools are to be avoided. Aggressive hygiene

is encouraged with the use of a handheld shower head. Sitz baths are avoided for the first few postoperative
days to minimize suture-line tension and potential flap dehiscence that might be produced by squatting. The
patient is followed in the office until healing is complete (Fig. 463.4).
FIGURE 463.2 Bilateral triangular island flaps have been advanced into the anal canal and sutured to the rectal
mucosa, creating a new mucocutaneous junction. (From Pidala et al., ref. 20, with permission.)
FIGURE 463.3 Intraoperative appearance of anus following primary donor-site closure of bilateral triangular flap
anoplasty. (From Pidala et al., ref. 20, with permission.)
CLINICAL RESULTS
Island flap anoplasty was performed in a series of 20 patients with anal canal stenosis and 8 patients with
mucosal ectropion (18, 19, 20). Perioperative morbidity was minimal, and no flaps were lost to ischemia.
The average hospital stay was 3.5 days, and the average length of postoperative follow-up was 36 months.
Results were excellent in 91% of these patients who considered their condition to be significantly improved.
No patients believed that their condition had worsened. There were no recurrences of anal stenosis,
ectropion, or prolapse, and no patient required subsequent anorectal surgery.

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FIGURE 463.4 Appearance of the anus 6 weeks after diamond flap anoplasty. (From Pidala et al., ref. 20,
with permission.)
No patients treated for anal stenosis had further pain or bleeding. One-fourth of the patients had persistent
constipation. The patients treated for mucosal ectropion had no further mucous drainage or bleeding. One
patient who underwent a combined Delorme procedure and anoplasty for ectropion still complained of
leakage of stool. All other patients were fully continent.
Complications included five minor wound separations that healed with conservative management, one
urinary tract infection with subsequent Clostridium difficile enterocolitis, and one suture-line stricture in a
patient undergoing a combined anoplasty and Delorme procedure for mucosal ectropion. This last patient
was successfully treated with anal-canal dilatation. There was no flap necrosis in any patient.
SUMMARY
With its simplicity of construction, maintenance of maximal blood supply, and minimization of suture-line
tension, the island flap anoplasty offers a more satisfactory repair when compared to traditional pedicle skin
flaps.
References
1. Caplin DA, Kodner, IL Repair of anal stricture and mucosal ectropion by simple flap procedures. Dis Colon
Rectum 1986;29:92.
2. Christensen MA, Pitsch RM, Cali RL, et al. “House” advancement pedicle flap for anal stenosis. Dis Colon
Rectum 1992;35:201.
3. Corman ML, Veidenheimer MC, Coller JA. Anoplasty for anal stricture. Surg Clin North Am 1976;56:727.
4. Ferguson JA. Repair of “Whitehead deformity” of the anus. Surg Gynecol Obstet 1959;108:115.
5. Hudson AT. S-plasty repair of Whitehead deformity of the anus. Dis Colon Rectum 1967;10:57.
6. Kaplan HY, Freund H, Muggia-Sullam M, Wexler MR. Surgical correction of ectropion of the anal mucosa.
Surg Gynecol Obstet 1982;154:83.

7. Nickell WB, Woodward ER. Advancement flaps for treatment of anal stricture. Arch Surg 1972;104:223.
8. Rosen L. Anoplasty. Surg Clin North Am 1988;68:1441.
9. Rosen L. V-Y advancement for anal ectropion. Dis Colon Rectum 1986;29:596.
10. Sarver JB. Plastic relief of anal stenosis. Dis Colon Rectum 1969;12:277.
11. Gingold BS, Arvanitis M. Y-V anoplasty for treatment of anal stricture. Surg Gynecol Obstet
1986;162:241.
12. Milson JW, Mazier WP. Classification and management of postsurgical anal stenosis. Surg Gynecol
Obstet 1986;163:60.
13. Corman ML. Colon and rectal surgery, 2nd ed. Philadelphia: J.B. Lippincott, 1984;139-150.
14. Ferguson JA. Whitehead deformity of anus, S-plasty repair. Dis Colon Rectum 1979;22:286.
15. Pearl RK, Hooks VH, Abcarian H, et al. Island flap anoplasty for the treatment of anal stricture and
mucosal ectropion. Dis Colon Rectum 1990;33:581.
16. Oh C, Zinberg J. Anoplasty for anal stricture. Dis Colon Rectum 1982;25:809.
17. Khubchandani IT. Mucosal advancement flap anoplasty. Dis Colon Rectum 1985;28:194.
18. Pidala MJ, Slezak FA, Porter JA. Island flap anoplasty for anal canal stenosis and mucosal ectropion. Am
Surg 1994;60:194.
19. Pidala MJ, Slezak FA, Porter JA. Mucosal ectropion associated with complete rectal prolapse: treatment
with combined Delorme procedure and island flap anoplasty. Perspect Colon Rectal Surg 1994;7:71.
20. Pidala MJ, Slezak FA, Porter JA. Island flap anoplasty. Contemp Surg 1995;47:11.

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Chapter 464
Gluteus Maximus Transposition Flap for Sphincter Reconstruction
S. P. SEIDEL
K. E. GEORGESON
L. O. VASCONEZ
EDITORIAL COMMENT
The synergy of the gluteus maximus for anal sphincter control is superior to that of other muscles previously
used, such as the gracilis. The internal sphincter, of course, is the most important sphincter to prevent
incontinence but, in its absence, crossing the gluteus maximus and allowing contraction at will prevents
soiling, even in children without an internal sphincter.
The gluteus maximus flap uses the lower third of the muscle bilaterally to reconstruct an innervated, voluntary,
external sphincter. It is useful in cases of congenital, neurogenic, or traumatic incontinence, where direct
sphincter repair is impossible or has failed.
INDICATIONS
Three components are necessary to maintain fecal continence: a reservoir (the rectum), intact sensation
(including a sensate anal canal), and functioning internal and external sphincters. External sphincter
reconstruction can be successful only when the other components are in place. A patient with a severely
scarred and non-distensible rectum, or one that is insensate, will not benefit from reconstruction of the
external sphincter. Preoperative evaluation should include such tests as anorectal manometry, barium
enema, anorectal ultrasound, and video defecography, in order to optimize patient selection.
External sphincter incompetence can result from congenital anomalies such as imperforate anus, pelvic
trauma, birth trauma, and surgery. Ideally, repair is aimed at reconstruction of the native external sphincter
with a sphincteroplasty or related technique. However, when the sphincter is absent, hypoplastic, or
damaged beyond repair, another form of correction must be utilized.
External sphincter reconstruction has traditionally relied on the transposition of surrounding musculature
and encirclement of the anus to recreate a voluntary sphincter. The gracilis muscle sling has become the
standard against which other repairs are measured (1). The gluteus maximus has potential advantages over
the gracilis, which prompted its selection as a primary option for sphincter reconstruction.
ANATOMY
The paired gluteus maximus muscles are strong thigh extensors and lateral rotators of the hip. The muscle origin
is from the superomedial ilium, posterolateral sacrum, coccyx, and sacrotuberous ligament; it insets on the femur
and iliotibial tract. The blood supply is chiefly via the paired superior and inferior gluteal arteries, with
contributions from branches of the medial and lateral circumflex vessels. The muscle is innervated by the inferior
gluteal nerve, which originates from nerve roots of L-5, S-1, and S-2.

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FLAP DESIGN AND DIMENSIONS
The inferior third of the paired gluteus maximus muscles can be readily harvested without detriment to gait or
pelvic stability. The parallel fiber arrangement and large muscle mass lend themselves well to transposition and
reconstruction of a sphincter with adequate bulk. Perhaps most important, the gluteus maximus normally serves
as an accessory muscle of continence (2, 3, 4). After transposition, patients readily learn to contract their
buttocks and bring the new sphincter into action; this is, in fact, a normal response to the urge to defecate.
OPERATIVE TECHNIQUE
The technique is actually a modification of a previously reported rectal sphincter construction using the origin of
the gluteus maximus (2). Diverting colostomy is performed 2 to 3 weeks prior to sphincter reconstruction. The
patient is given a Fleet enema or Dulcolax suppository on the evening prior to surgery. Intravenous ampicillin,
gentamicin, and clindamycin are administered prior to making an incision. General endotracheal anesthesia is
utilized, and the patient is placed in the prone, jackknife position.
FIGURE 464.1 Two mirror-image incisions are drawn over each buttock. Care is taken to be at least 2 cm from
the anal canal.
Two mirror-image incisions are used (Figs. 464.1 and 464.2). Access to the gluteus muscles is gained via
bilateral incisions that parallel the caudal border of the muscle. They extend from the lateral sacral border to a
point just inferior and lateral to the ischial tuberosity. The caudal portion of the gluteus maximus is exposed. The
fibers are traced to their origin, and 4 cm of muscle are encircled and detached, along with a 6- to 10-mm rim of
sacral and coccygeal fascia, from its origin (Fig. 464.3). The muscle is then reflected laterally. Frequently, fibrous
attachments are identified, which must be divided to free the muscle sufficiently. Care must be taken to avoid
injuring the neurovascular bundle, which lies just deep to the plane of dissection. The dissection is continued
until the medial muscle edge will comfortably reach beyond the midline of the rectum (Figs. 464.4 and 464.5).
The initial incisions are extended inferiorly in a curvilinear fashion lateral to the anus (Fig. 464.2). They must
remain far enough outside the mucocutaneous junction to avoid scarring of the anal canal (at least 2 cm). A
capacious tunnel is created superiorly and inferiorly around the rectum, connecting
the two incisions. The dissected muscle is split lengthwise for 4 cm along the detached end and transposed
(Figs. 464.6 and 464.7). The superior portion is passed anteriorly, and the inferior portion posteriorly, around the
rectum. The cut ends are opposed to each other with 2-0 PDS mattress sutures, incorporating any attached
fascia to increase strength. A mirror-image procedure is performed on the contralateral side. This creates two,
opposing, muscle slings that completely encircle the rectum (Fig. 464.7). The anal canal is also effectively
lengthened by 2 cm. Incisions are closed in the usual manner (Fig. 464.8).

FIGURE 464.2 Skin incised and inferior edge of gluteus maximus muscle exposed.
FIGURE 464.3 Lower third of muscle isolated and encircled.
Patients are given a high-fiber diet, as tolerated. Activity is ad libitum, with sitting prohibited for 14 days or until all
incisions are well-healed. No attempts are made to delay a bowel movement. At 14 days, patients are instructed
to begin “sphincter training.” This consists of squeezing the buttocks, and thereby the neosphincter, with a digit
placed in the anus, thus simulating the sensation of stool in the rectal vault. The scissoring action provided by
contraction of the gluteus muscles effectively bars the passage of stool, additionally allowing for rectal distension
and consequent sensation (3, 4). With time, this response becomes nearly instinctive. Colostomy takedown is
performed in a standard fashion after 3 months. No adjunctive tests or training are necessary.
FIGURE 464.4 Fascial attachments are divided and the muscle split longitudinally.

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FIGURE 464.5 Dissection completed and muscle ends split.
CLINICAL RESULTS
Nine procedures have been completed to date; in seven cases, the colostomy has been taken down. All
patients have the ability to generate good tone with gluteal contraction. Five of these patients have
excellent results, with normal continence; the other two have poor continence. We believe this is due to
placement of the perianal incisions too close to the anal canal early in the series. This has led to scarring of
the canal, preventing adequate sphincter contraction, despite a functional muscular sling. We are now
carefully avoiding encroachment on the anal canal, by placing the incisions 2 cm from the mucosal border.
SUMMARY
The inferior gluteus maximus muscle, split to encircle the rectum, is the anal encirclement procedure that
best restores voluntary extenal sphincter tone. It provides an excellent option for reconstruction of the
external rectal sphincter, with little donor-site morbidity.
FIGURE 464.6 Split muscle flap is transposed toward the rectum prior to creation of a sling.

FIGURE 464.7 Sling created by suturing opposing split muscles to each other about the rectum.
FIGURE 464.8 Wound closed.
References
1. Pickrell KL, Broadbent TR, Masters FW, et al. Construction of a rectal sphincter and restoration of anal
continence by transplanting the gracilis muscle. Ann Surg 1952;135:853.
2. Hentz VR. Construction of a rectal sphincter using the origin of the gluteus maximus muscle. Plast
Reconstr Surg 1982;70:82.
3. Pearl RK, Prasad ML, Nelson RL, et al. Bilateral gluteus maximus transposition for anal incontinence. Dis
Colon Rectum 1991;34:478.
4. Skef J, Radhakrishnana J, Reyes HM. Anorectal continence following sphincter reconstruction utilizing the
gluteus maximus muscle: a case report. J Ped Surg 1983;18:779.

Chapter 465
Limberg Skin Flaps
J. G. HOEHN
Even in the era of muscle and musculocutaneous flap reconstructions, the Limberg flap (1, 2, 3, 4, 5, 6), because
of its versatility of design and simplicity of surgical execution, continues to be my choice of treatment for small
pressure ulcers (7).
INDICATIONS
There are four basic principles of pressure ulcer surgery that have been established in the last 40 years.
They bear restatement:
1. Excision of the ulcer with the surrounding scar (removal of devitalized tissue and infection)
2. Ostectomy to remove the offending pressure point and the infected bone (removal of devitalized tissue
and infection)
3. Muscle-flap transfer (obliteration of dead space, restoration of contour)
4. Reconstruction with flap transfer (replacement with like tissue, restoration of durable tissue)
Use of Limberg flaps for reconstruction satisfies principle 4 and permits achievement of principles 1 to 3
when each or all are required.
ANATOMY
The arterial supply of the Limberg flap arrives by means of the subdermal plexus. This random-pattern supply
permits flap layout in any configuration (see Figs. 465.1 and 465.3A).
FLAP DESIGN AND DIMENSIONS
The geometric principles on which the flap is based must be understood. An equilateral parallelogram is
geometrically termed a rhombus (Fig. 465.1). Rhomboid figures have several characteristics that lead to the
conclusion that the minor angle should be 60 degrees for optimal Limberg flap transfers (3). Although 60 degrees
is the angle that allows for exact satisfaction of the defect, skin elasticity permits variation in design, and surgical
undermining will facilitate further adjustments in closure (3).
Knowledge of the patterns of skin elasticity and the position of the relaxed skin tension lines (RSTL) and their
counterparts, the lines of maximum extensibility (LME), is paramount in planning Limberg flaps (6). Donor-site
closure is facilitated by arranging the layout of the flap so that the donor-site scar coincides with the LME. This
minimizes tension at the point of closure (Fig. 465.1, point cf, and see Fig. 465.2B).
When these two principles of flap design are understood, a variety of Limberg flaps can be planned for most
defects (5) (Fig. 465.1). Excision of the defect is planned in a rhombic fashion, and the flap is then oriented so
that the donor-site scar will fall in the LME (see Fig. 465.2A). Flap design is marked on the skin and followed
throughout the operation. After the ulcer has been removed, the elasticity of the surrounding skin will produce an
enlargement of the defect. The temptation to enlarge the flap size must be resisted. As wound closure is
achieved, normal skin tension is restored (see Fig. 465.2B).
The inherent geometric design defines a length-width ratio of 1:1 (Fig. 465.1). This ratio relates to the adequacy

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of circulation in random flaps and establishes the safety factor of the flap. The high safety factor of Limberg flaps
has been confirmed by their use in diverse sites under all conditions. The universal application and design
potential of the Limberg flap should obviate any functional deficit.
The Dufourmentel flap (8) has proved a useful extension of the Limberg flap for irregular defects (2, 3, 4, 6).
Geometrically, the Dufourmentel flap is more complicated to design, but once planned, it is as technically easy to
execute as the Limberg flap (Fig. 465.1).
Postoperative effects of muscle spasm are considered in flap planning to reduce tension on the repair. The
RSTL and LME are assessed after final positioning, and the optimal location of the flap is noted. The rhombic
excision is planned and oriented to be placed in the LME in the ultimate donor-site closure (see Figs. 465.2A and
465.3A).
OPERATIVE TECHNIQUE
Excision of the ulcer, intact when possible, includes skin margins, contaminated periulcer tissue, and the ulcer
base (Fig. 465.2B). Osteophytes that are frequently a distinct part of the sacral pressure ulcer are removed with
a broad chisel to restore a smooth surface (9, 10, 11, 12).
Inspection of the defect for completeness of ulcer resection is pertinent at this time. Retention of “rind” will
inevitably lead to delayed wound healing. As noted earlier, the size of the surgical defect may alarm the
unfamiliar surgeon, but no change should be made in the original flap design.
The flap is elevated in the same plane as the excision and is transferred to the defect (Figs. 465.2B and 465.3B).
If significant dead space exists, an adjacent muscle flap can be used to obliterate the dead space and offer
additional soft tissue for padding.
Flap inset and closure are facilitated by prior closure of the donor site. Heavy retention sutures tied over gauze
or cotton bolsters may aid in the closure of the donor site (Fig. 465.2B), but care must be taken to avoid
strangulation of tissue.

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FIGURE 465.1 Basic geometric principles of Limberg flap design.
FIGURE 465.2 A 44-year-old bedridden patient with multiple sclerosis required closure of a sacral pressure ulcer
for hygienic reasons. The wound had been meticulously cared for at home and thus was small on presentation.
A: Intraoperative photographs demonstrating the degree of undermining (dotted line), anticipated surgical
resection designed in a rhomboid pattern, and Limberg flap design. Note location of rhomboid design and flap
choice. Compare with Figure 465.1. Three other Limberg flaps could be designed for this rhombus and an infinite
number of rhombus figure designs could be planned, allowing maximum flexibility in design. B: Postoperative
photograph at 7 days demonstrating flap closure. Note bolster stitches placed across point of maximum tension
at apex of donor-site closure. (From Hoehn et al., ref. 7, with permission.)

FIGURE 465.3 A 24-year-old quadriplegic man of markedly asthenic habitus who presented with a recurrent
sacral pressure ulcer. Fourteen months prior, a Limberg flap had been used to close a similar defect. The scar
from the previous donor site and flap transfer can be seen on the right side of the wound. A: The old Limberg
flap scars are on the right side. The rhombic excision is planned, and the new Limberg flap is designed on the
contralateral side. B: The Limberg flap of uniform thickness is being rotated into position.
Although postoperative morbidity is minimal, the positional and nursing care requirements prolong the hospital
stay. Hospital discharge is planned for 17 to 21 days.
CLINICAL RESULTS
In 20 years, 64 Limberg flaps were performed on 55 patients for reconstruction of small sacral decubitus
ulcer defects. Review of 1- to 16-year follow-ups reveals that there were 14 recurrent sacral ulcers in the
area of previous sacral ulcer repair by Limberg flaps. Two cases were reconstructed by transferring a
contralateral Limberg flap (Fig. 465.3); the remainder required a larger flap. I do not think that ulcer
recurrence and flap breakdown are related to flap design. Rather, various patient factors (spasticity,
motivation, and/or job requirements) contribute to the recidivism rate (11, 12).
SUMMARY
The Limberg flap and its variations can be satisfactorily used to close small sacral pressure ulcers.
References
1. Limberg AA. Design of local flaps. In: Gibson TA, ed. Modern trends in plastic surgery. London:
Butterworth, 1966;38-61.
2. Lister GD, Gibson T. Closure of rhomboid skin defects: the flaps of Limberg and Dufourmentel. Br J Plast
Surg 1972;25:300.
3. Koss N, Bullock JD. A mathematical analysis of the rhomboid flap. Surg Gynecol Obstet 1975;141:439.
4. Koss N. The mathematics of flaps. In: Basic science in plastic surgery: an educational foundation
symposium. St. Louis: Mosby, 1979; 274-283.

5. Jervis W, Salyer KE, Busquets HA, Atkins RW. Further application of the Limberg and Dufourmental flaps.
Plast Reconstr Surg 1974;54:335.
6. Borges AF. The rhombic flap. Plast Reconstr Surg 1981;67:458.
7. Hoehn JG, Elliott RA, Stayman JW. The use of Limberg flaps for repairing small decubitus ulcers. Plast
Reconstr Surg 1977;60:548.
8. Dufourmentel C. La fermeture des pertes de substance cutanée limitées: le lambeau de rotation en L pour
losange dit “LLL.” Ann Chir Plast 1962;7:61.
9. Conway H, Griffith BH. Plastic surgical closure of decubitus ulcers in patients with paraplegia based on
experience with 1000 cases. Am J Surg 1956;91:946.
10. Dansereau JG, Conway H. Closure of decubitus in paraplegics: report of 200 cases. Plast Reconstr Surg
1964;33:474.
11. Rogers J, Wilson LF. Preventing recurrent tissue breakdown after pressure sore closure. Plast Reconstr
Surg 1975;56:419.
12. Constantian MB, ed. Pressure ulcers: principles and techniques of management. Boston: Little, Brown,
1980;173.

Chapter 466
Gluteal Rotation Skin Flap
B. H. GRIFFITH
EDITORIAL COMMENT
The editors would like to point out that in using the skin rotation flap for closure of sacral detects, skin-
grafting is required for the donor site. Failure to do so limits the ability to rotate the flap. Additionally, modern
postoperative care includes the use of Clinitron and Ken Air beds with less postoperative turning of the
patient.
Since the early days of pressure sore closure in 1945, the gluteal rotation flap has been the workhorse for the
repair of ulcers in the sacral area (1). At first, closure was attempted by simple approximation of the edges of the
wound, but the tension was too great and the procedure was usually unsuccessful. The rotation of adjacent skin
and subcutaneous fat was a logical improvement in technique and has had a remarkably long and successful
track record (2, 3).
INDICATIONS
Coverage of the sacral area after excision of a sacral pressure ulcer is the chief use for this flap. However,
it also can be used to close a sacral wound due to radiation injury, a meningomyelocele, and others.
FIGURE 466.1 Gluteal rotation skin flap. The flap extends from the edge of the defect to just medial to the
posterior edge of the greater trochanter. A split-thickness skin graft is placed laterally over the gluteus
muscle to take tension off the medial suture line. The flap crosses the midline 2 to 3 cm. The flap is based
inferiorly to avoid a scar in an area subject to pressure from sitting. The length-to-width ratio is 1:1.
ANATOMY
The blood supply of this random flap is derived from the superficial branch of the superior gluteal artery and from
the inferior gluteal artery, which anastomose freely within the gluteus maximus and send perforating branches
through the muscle to form a rich network in the subcutaneous fat and the overlying dermis.

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FLAP DESIGN AND DIMENSIONS
The flap consists of the skin and subcutaneous fat of essentially the entire buttock. It is based inferiorly, i.e., over
the distal edge of the gluteus maximus muscle (Figs. 466.1 and 466.2). This ensures that the scar created by
rotating the flap
will not be in a position where it can be pressed on when the patient is sitting. If this rule is violated and the flap
is based superiorly, i.e., over the upper buttock, the scar is made more vulnerable to the trauma of sitting, and
recurrence of the ulcer is likely (Fig. 466.3).
FIGURE 466.2 Typical use of the gluteal rotation flap for closure of a sacral ulcer.
The flap size obviously varies with the size of the patient and the width of the buttock, but it should extend from
the edge of the defect over the sacrum to just medial to the posterior edge of the greater trochanter of the femur.
The flap may therefore be 15 to 25 cm wide. If the length of the flap from base to distal edge does not exceed the
width (a 1:1 ratio), there is no need for a delay; i.e., the flap may be raised and rotated in one stage. The pivot
point is in the medial third of the base, and the arc of rotation is 25 to 40 degrees.
The flap should be as large as possible within the limits described above. The larger the flap, the more
expandable it is, the farther away from the pressure of sitting its scar will be, and the more possible it will be to
rotate it a second or even a third time should this be necessary. A small flap usually cannot be successfully
rotated a second time because it is too narrow to reach and the old scar would be placed over an area of
pressure.
FIGURE 466.3 A: Sacral ulcer unsuccessfully closed with a gluteal flap incorrectly based superiorly, with
resultant loss of a portion of the flap and the scar in an area subject to trauma from sitting. (From Griffith et al.,
ref. 6, with permission.) B: Result after closure with a gluteal rotation flap as described.

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OPERATIVE TECHNIQUE
The gluteus maximus and its fascia are not raised with the flap. However, turnover flaps of gluteal fascia should
be used to cover the sacrum after the bone has been smoothed down and deprived of its bony prominences. It is
usually necessary to place a skin graft over the muscle laterally to close part of the flap donor area in order to
take tension off the important suture line over the sacrum (Fig. 466.1). Only when the buttock (and, therefore, the
flap) is very wide and the flap is under no tension when it is sutured into place can the skin graft be safely
omitted (Fig. 466.4).
Rotation of the flap across the midline is usually possible for a distance of 2 to 3 cm. In the case of a large sacral
defect that cannot be covered by one gluteal rotation flap, a second similar flap from the other buttock can be
added (Fig. 466.5).
When this is done, an inferior base should be used for the second flap for the same reasons that were given
above for this design.
FIGURE 466.4 Closure of a large sacral wound with a gluteal rotation flap in a patient with a wide pelvis. Skin
graft not needed laterally.
FIGURE 466.5 Closure of an extremely large sacral ulcer with two gluteal rotation flaps. Note that both are
based inferiorly to avoid a scar in the “sitting area.” (From Griffith et al., ref. 6, with permission.)
Postoperative hematoma is usually successfully prevented by the use of continuous suction by means of a
catheter left in place under the flap for 2 full weeks (4, 5, 6). The patient is best kept prone on a well-padded
Stryker frame or Circolectric bed for 1 to 2 days postoperatively and then turned prone to supine alternately
every 2 hours for 2 weeks. Sutures are left in place for 2 weeks as well.
CLINICAL RESULTS
This is a very durable flap, providing that the underlying sacral prominences are smoothed down and

pressure over the sacrum is avoided in the future. Based on an experience with 1000 patients (2), the
success rate was 95 percent, but there was an 11 percent recurrence rate of the ulcer in paraplegic
patients who did not avoid later prolonged pressure over the sacral area.
Necrosis of even a small portion of the distal edge of the flap is extremely rare if the rules mentioned above
are followed. Loss of the skin graft over the lateral muscle is an irritating, but rarely serious complication.
There is no significant functional deficit.
SUMMARY
The inferiorly based gluteal rotation flap is still the standard and well-proven technique for repair of sacral
defects.
References
1. Barker DEL Elkins CW, Poer DH. Methods of closure of decubitus ulcers in the paralyzed patient. Ann
Surg 1946;123:523.
2. Conway H, Griffith BH. Plastic surgical closure of decubitus ulcers in patients with paraplegia: based on
experience with 1000 cases. Am J Surg 1956;91:946.
3. Griffith BH, Schultz RC. The prevention and surgical treatment of recurrent decubitus ulcers in patients
with paraplegia. Plast Reconstr Surg 1961; 27:248.
4. Griffith BH. Advances in the treatment of decubitus ulcers. Surg North Am 1963;43:245.
5. Griffith BH. Pressure sores. In: Grabb WC, Smith JW, eds. Plastic surgery, 3rd ed. Boston: Little, Brown,
1979.
6. Griffith BH, Lewis VL, Jr. Pressure Sores. In: Goldwyn RM, ed. The unfavorable result in plastic surgery,
2nd ed. Boston: Little, Brown, 1984; 1073-1084.

Chapter 467
Gluteus Maximus Muscle and Musculocutaneous Flaps
S. W. PARRY
E. C. ALMAGUER
L. O. VASCONEZ
Gluteus maximus muscle and musculocutaneous flaps (1, 2, 3, 4, 5, 6, 7, 8, 9, 10) have provided more reliable
coverage of the sacral area than techniques used in the past.
INDICATIONS
These flaps have several advantages over the random flaps previously employed:
1. Their excellent blood supply permits more versatility in flap design with a greater assurance of primary
healing; this is especially useful in difficult secondary cases where random flaps are not available
because of previous scarring.
2. The procedure, which is not technically difficult, is relatively bloodless because most of the dissection
takes place in areolar tissue planes.
3. Since the continuity between the subcutaneous tissue and the muscle fascia is not disturbed, the natural
resistance to shearing forces is preserved; the problem of nonadherence of the skin flap to the underlying
structures is reduced.
4. These flaps also provide muscle padding in the pressure area.
5. The presence of well-vascularized muscle may promote healing in infected tissue (11).
The gluteus maximus muscle is not an expendable muscle. Loss of gluteus maximus function in an
ambulatory patient results in significant hip instability. Therefore, only the superior or inferior half of the
muscle may be used. In the paraplegic, the entire muscle may be employed for coverage (5).
FIGURE 467.1 Anatomy of the gluteus maximus muscle. It can be divided into halves based on either the
superior or inferior gluteal arteries. (From Parry et al., ref. 9, with permission.)
ANATOMY
The gluteus maximus muscle is the most superficial of the gluteus muscle group. It is a thick, broad muscle
originating from the posterior gluteal line of the ilium, as well as the lateral aspect of the sacrum and coccyx. The

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major portion of the muscle inserts into the iliotibial tract. The inferior deep portion inserts into the greater
tuberosity of the femur between the vastus lateralis and the adductor magnus (5, 7) (Fig. 467.1).
The gluteus maximus is a type III muscle with two dominant pedicles (10). The muscle is supplied by direct
branches of the hypogastric artery—the superior and inferior gluteal arteries, each with an accompanying vein.
These vessels arise separately from the hypogastric artery and exit the pelvis through the lateral border of the
sacrum.
The superior gluteal artery, the larger of the two vessels, leaves the pelvis above the piriformis muscle, supplying
the superior half of the gluteus maximus muscle. It then courses laterally to supply the gluteus medius and
gluteus minimus muscles.
The inferior gluteal artery passes posterior to the piriformis muscle as it exits from the sciatic foramen adjacent to
the sciatic nerve. The vessel supplies the inferior half of the gluteus maximus muscle and a portion of the
posterior thigh (7). Thus the gluteus maximus muscle may be divided into superior and inferior halves, each with
a distinct medially located vascular pedicle (Fig. 467.1). There are anastomotic channels between the superior
and inferior gluteal arteries, but it is not known whether these are consistent.
FIGURE 467.2 Vascular territories of the lower back and gluteal region: (1) from the sacrospinalis muscle, (2)
from the superior gluteal- supplied portion of the gluteus maximus muscle, and (3) from the inferior gluteal-
supplied portion of the gluteus maximus muscle. (From Parry et al., ref. 9, with permission.)
The blood supply of the skin and subcutaneous tissue of the buttock is derived from numerous
musculocutaneous perforators that exit on the superficial surface of the muscle. The skin over the lower buttock
and the upper posterior thigh is nourished by branches of (1) the descending branch of the inferior gluteal artery,
(2) the medial and lateral circumflex femoral arteries, and (3) the first perforating branch of the deep femoral
artery (5). Specific vascular territories for the gluteal region have been described (6) (Fig. 467.2).
The gluteus maximus muscle functions as extensor and lateral rotator of the thigh. Additionally, it serves to raise
the trunk from the stooping position by rotating the pelvis backward on the head of the femur (1). It is innervated
by the inferior gluteal nerve (L5, S2), a pure motor nerve.
FLAP DESIGN AND DIMENSIONS
Rotation Flap
The gluteus maximus musculocutaneous rotation flap has proved to be quite reliable. It is based inferiorly and
medially. Blood supply for sacral coverage is furnished by the superior gluteal artery. In designing the flap, the
posterior superior iliac spine and the greater trochanter are key anatomic landmarks (5). The superior gluteal

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artery exits from the pelvis approximately 5 cm inferior to the superior iliac spine and 5 cm lateral to the midline of
the sacrum, on the deep surface of the gluteus maximus muscle (Fig. 467.3). The skin and subcutaneous portion
of the flap may be designed as large as necessary to cover the sacral defect within the confines of the vascular
territory (Fig. 467.4A). The flap may be designed to cross the midline without delay (4).
FIGURE 467.3 Anatomic landmarks.
Muscle Transposition Flap
The muscle transposition flap or turnover flap is another reliable alternative for providing coverage for the
sacrum. The entire gluteus muscle or one-half of it may be used. Again, the entire muscle should not be used in
ambulatory patients.
The preferred incision for approaching this flap is the oblique incision across the buttock (Fig. 467.5B). A
curvilinear incision over the iliac crest may be alternately employed for patients who have previously undergone
gluteal rotation flaps (7) (Fig. 467.5C).
Island Musculocutaneous Flap
The gluteus maximus island musculocutaneous flap is another method of obtaining soft-tissue coverage of sacral
defects (8, 9, 10). When employing this method, it is technically simpler to elevate the superior half of the gluteus
maximus muscle and advance this to cover the sacral defect. In ambulatory patients, maintaining the inferior half
of the gluteus maximus muscle intact preserves function and restores normal buttock contour (9, 10).
When the sacral defect is less than 6 cm after debridement, a unilateral superior gluteal island
musculocutaneous flap is usually adequate for closure (8, 10). If the defect is larger, bilateral flaps may be
necessary for coverage (9, 10).
After the sacral prominence is excised and all the necrotic or chronically infected soft tissue is removed, the
musculocutaneous island is outlined (Fig. 467.6A). It is advisable to design the skin island 3 to 4 cm larger than
the defect to be covered to minimize tension.
OPERATIVE TECHNIQUES
Loss of tissue directly over the sacrum involves only subcutaneous tissue and skin. In the treatment of soft-tissue
defects of the sacrum, meticulous debridement of any devitalized soft
tissue or granulation tissue must be performed. In addition, removal of exostoses, the bony prominence of the
sacrum, and any infected sacral bone is mandatory. Coverage of the sacral soft-tissue defect may be obtained
by employing the gluteus maximus musculocutaneous flap in several ways.

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FIGURE 467.4 A,B: Gluteus maximus musculocutaneous rotation flap with the donor defect skin-grafted. (From
Parry et al., ref. 9, with permission.)
Rotation Flap
Once the flap is designed, the incision is made through the skin, subcutaneous tissues, and gluteus maximus
muscle insertion. The gluteus maximus muscle is incised along the inferior and lateral borders without
undermining the subcutaneous tissues. The muscle is then elevated in the plane overlying the gluteus medius
muscle.
FIGURE 467.5 A: Superior half of the gluteus maximus muscle used as a turnover flap. B,C: Either an oblique or
a curvilinear incision can be used for access to the muscle. A split-thickness skin graft is then applied to the
muscle. (From Parry et al., ref. 9, with permission.)
At this point, the key structure in dissecting this anatomic region is the piriformis muscle. The superior gluteal
artery and accompanying veins emerge from its superior edge about three fingerbreadths inferior to the iliac
crest—a variable danger point (5). The piriformis muscle is identified, and elevation of the gluteus maximus
muscle is continued in a superomedial direction. The superior gluteal artery with its accompanying

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vein is identified and preserved. Detachment of the gluteus maximus muscle from its origin is performed as
widely as necessary (starting from its superior border) to allow the musculocutaneous flap to rotate properly (5).
FIGURE 467.6 A: Design of an island gluteus maximus musculocutaneous flap. B: The flap is based on the
superior gluteal artery. C: The flap inset. (From Parry et al., ref. 9, with permission.)
For ambulatory patients, the entire gluteus maximus muscle should not be transected, for this may cause
debilitating hip instability. For these patients, the inferior half of the muscle should remain intact. It may be
necessary to backcut the flap, allowing the flap to rotate fully without tension, but caution must be exercised.
Once the flap is elevated, it is rotated over the sacral defect. Hemostasis is then achieved, and the gluteus
maximus muscle fibers are sutured to the contralateral gluteus maximus muscle without tension. The
subcutaneous tissue of the flap is inset into the sacral defect, and the skin is closed. Drains are placed within the
donor defect, which may be grafted with split-thickness skin if necessary (Fig. 467.4B).
Muscle Transposition Flap
The gluteus maximus muscle is exposed by incising the skin and subcutaneous tissue flaps. The insertion of the
muscle is detached from the greater trochanter and iliotibial tract. The
dissection proceeds bluntly as the gluteus maximus is elevated off the underlying gluteus medius and reflected
superiorly and medially (Fig. 467.5A).
The pivot point of the flap is the gluteal vessels when the whole muscle is transposed and the superior gluteal

artery when the superior half of the gluteus maximus muscle is transferred (Fig. 467.5A). The flap is based
superomedially and is turned over like the page of a book in a like direction, extending up to 5 cm past the
midline. The transposed muscle is sutured to the base of the defect without tension. A split-thickness skin graft is
then employed to cover the surface of the muscle. A drain is left to obliterate the dead space, and the incision is
closed (1, 2, 3) (Fig. 467.5B and C).
Island Musculocutaneous Flap
The island of skin and subcutaneous tissue is incised down to the gluteus maximus fascia. Care should be taken
not to undermine the island of skin and subcutaneous tissue from its attachment to the gluteus maximus muscle
fascia. It is advisable to secure the subcutaneous tissue to the fascia temporarily. At this point, the skin and
subcutaneous tissue surrounding the island flap are undermined, exposing the gluteus maximus muscle.
The superior half is detached from its insertion on the femur and iliotibial tract. The muscle with the island of skin
and subcutaneous tissue is elevated in a superomedial direction, exposing the piriformis muscle. The superior
gluteal artery and vein are exposed and preserved. Then the origin of the superior half of the gluteus muscle is
detached, leaving the whole muscle and skin paddle attached only by the superior gluteal vessels (Fig. 467.6B).
The flap is advanced to cover the sacral defect. It also may be rotated in an inferomedial direction to cover
ischial defects. The gluteus muscle origin is sutured to the contralateral border of the sacral defect, and the
cutaneous island is inset. Care must be exercised to prevent tension on the vascular pedicle. The donor site is
closed in V-to-Y advancement fashion, and drains are left in place (Fig. 467.6C).
Bilateral island musculocutaneous flaps may be employed when the sacral defect to be covered is larger than 6
cm. Once the flaps are dissected and advanced, the flaps are sutured to each other in the midline, recreating the
intergluteal fold. The donor defects are again closed in a V-to-Y advancement fashion, and drains are left in
place.
CLINICAL RESULTS
The muscle transposition flap is very durable, providing adequate muscle and subcutaneous tissue padding
over the sacral defect. In ambulatory patients, this flap has shown longterm stability, as well as improved
cosmetic appearance (9).
In using the muscle transposition flap, precautions to be taken while elevating the muscle are avoidance of
damage to the gluteal vessels or sciatic nerve and prevention of hematoma or seroma by meticulous
hemostasis. The complications of this flap are hematoma formation, skin-graft loss, loss of flap (full or
partial), sciatic nerve damage, and wound infection. Fortunately, the incidence of flap loss is small, owing to
the rich blood supply provided by the gluteal vessels. In Ger's experience (1), there were no instances of
muscle necrosis, one instance of partial skin-graft loss, and one hematoma due to accidental early removal
of the drain—a complication rate of 5.8 percent.
The possible complications of the island musculocutaneous flap are hemorrhage, hematoma formation, loss
of the skin and subcutaneous tissue paddle, loss of the entire musculocutaneous flap, and wound infection.
Virtually all these complications may be eliminated with meticulous and gentle technique and a thorough
understanding of the anatomy involved.
SUMMARY
The gluteus maximus muscle can be used as a muscle or musculocutaneous flap for coverage of sacral

defects.
References
1. Ger R. The surgical management of decubitus ulcers by muscle transposition. Surgery 1971;69:106.
2. Stallings JO, Delgado JP, Converse JM. Turnover island flap of gluteus maximus muscle for the repair of
sacral decubitus ulcer. Plast Reconstr Surg 1974;54:52.
3. Mathes SJ, Vasconez LO, Jurkiewicz MJ. Extension and further applications of muscle flap transpositions.
Plast Reconstr Surg 1977;60:6.
4. Vasconez LO, Schneider WJ, Jurkiewicz MJ. Pressure sores. Curr Probl Surg 1977;14:34.
5. Minami RT, Mills R, Pardoe R. Gluteus maximus myocutaneous flaps for repair of pressure sores. Plast
Reconstr Surg 1977;60:242.
6. McCraw JB, Dibbell DG, Carraway JH. Clinical definition of independent and myocutaneous vascular
territories. Plast Reconstr Surg 1977;60:341.
7. Mathes JM, Nahai F, eds. Clinical atlas of muscle and musculocutaneous flaps. St. Louis: Mosby,
1979;91-103.
8. Maruyama Y, Nakajima H, Wade M, et al. A gluteus maximus myocutaneous island flap for the repair of a
sacral decubitus ulcer. Br J Plast Surg 1980;33:150.
9. Parry SW, Mathes SJ. Bilateral gluteus maximus myocutaneous advancement flaps: Sacral coverage for
ambulatory patients. Ann Plast Surg 1980;8:443.
10. Mathes JM, Nahai F, eds. Clinical applications for muscle and musculocutaneous flaps. St. Louis:
Mosby, 1982;426-432.
11. Chang N, Mathes SJ. Comparison of the effect of bacterial inoculation in musculocutaneous and random-
pattern flaps. Plast Reconstr Surg 1982;70:1.