Operative Technique in Plastic Surgery – Kevin C.Chung

site at 3 months.
COMPLICATIONS
Penile Inversion Vaginoplasty
■ The most feared and serious complication is that of a rectovaginal fistula. We
assess for undetected rectal injury using a Betadine enema in the operating
room. If there is a tear in the rectum, it is repaired in two layers using 2-0
Vicryl. The patient is then left on a low-residue diet for several weeks.
■ If a rectovaginal fistula does develop, it is often managed with diverting
ostomy, continued dilation of the neovagina, and watchful waiting. Assistance
from a colorectal surgeon is necessary. A gracilis flap interposed between the
rectum and neovagina may be necessary.
■ Delayed bleeding from the corpus spongiosum deep to the urethral mucosa
may be managed with sutures and/or direct pressure. At time of inset of
urethra, attention must be paid to bury all erectile tissue under the mucosal
closure.
■ Delayed wound healing is relatively common, especially at the posterior
aspect of the labia majora and inside the neovagina. Most will heal
spontaneously without repeat intervention with meticulous hygiene and
continued dilation.
Phalloplasty
■ Venous congestion of the neophallus may be related to positioning the phallus
in the dependent position. It should be elevated continuously for the first
several postoperative days. If the phallus remains congested, venous outflow
can be augmented with creation of an AV fistula at the distal end of the phallus
between the ligated radial artery and vena comitans.
■ Urethral fistulas and strictures are common (greater than 50% in many case
series) and are difficult to manage. Involvement from a colleague from urology
is necessary. Urinary diversion with Foley catheter or suprapubic catheter for
an extended period may be necessary.
■ If a fistula remains after urinary diversion, superficial circumflex iliac
perforator or pudendal perforator flap for coverage may be necessary.
Cystoscopy may be required to assess and endoscopically treat urinary
strictures.

■ Risks of urinary complications should be discussed with the patient
preoperatively.
REFERENCES
1. Selvaggi G, Ceulemans P, De Cuypere G, et al. Gender identity disorder:
general overview and surgical treatment for vaginoplasty in male-to-female
transsexuals. Plast Reconstr Surg. 2005;116(6):
135e-145e.
2. Horbach SE, Bouman MB, Smit JM, et al. Outcome of vaginoplasty in male-
to-female transgenders: a systematic review of surgical techniques. J Sex Med.
2015;12(6):1499-1512.
3. Monstrey S, Hoebeke P, Selvaggi G, et al. Penile reconstruction: is the radial
forearm flap really the standard technique? Plast Reconstr Surg.
2009;124(2):510-518.
4. Monstrey SJ, Ceulemans P, Hoebeke P. Sex reassignment surgery in the
female-to-male transsexual. Semin Plast Surg. 2011;25(3):229-244.

29
CHAPTER
Section V: Reconstruction
of Pressure Injuries
Gluteal Flaps for Sacral
Pressure Injuries
Terri A. Zomerlei and Jeffrey E. Janis
DEFINITION
■ Sacral pressure injuries are common in chronically supine patients.
■ Patient populations most at risk include those in acute care settings, nursing
home patients, and paraplegic populations.
■ In addition to unrelieved pressure, the causes are multifactorial and may
include incontinence/moisture, friction/shear force, and altered sensory
perception.
■ Characteristically, the appearance of the overlying skin represents only a small
portion of the affected tissue (“the tip of the iceberg”).
ANATOMY
■ The sacrum is a large concave triangular bone at the base of the spine that is
the fusion of sacral vertebrae S1-S5.
■ A pressure injury develops as a result of unrelieved pressure between the
sacral bone and the sitting or lying surface.
■ The gluteus maximus muscle is a broad, thick, quadrangular muscle that forms
the prominence of the buttocks.
■ The gluteus maximus originates along the posterior gluteal line of the ilium
and the lateral aspect of the sacrum, coccyx, and sacral ligaments.
■ The superior portion of the muscle inserts along the iliotibial tract of the
fascia lata, and the inferior portion of the muscle inserts into the greater

trochanter of the femur.
■ It is a type III muscle with two dominant blood supplies, the superior and
inferior gluteal arteries.
• The vessels arise separately from the internal iliac artery.
• The arteries exit the pelvis with their respective venae comitantes and the
superior and inferior gluteal nerves.
■ The anatomic landmarks for locating the neurovascular pedicles are the
piriformis muscle, the posterior iliac spine, the greater trochanter, and the
ischial tuberosity.
■ The superior gluteal artery exits above the piriformis one-third the distance
from the posterior iliac spine along a tangent from the posterior iliac spine to
the greater trochanter.
■ The inferior gluteal artery exits below the piriformis just lateral to a point
half the distance between the posterior iliac spine and the ischial tuberosity
(FIG 1).
PATHOGENESIS
■ Primary mechanism of pressure injury is cellular ischemia.
■ Tissue pressure greater than the pressure of the microcirculation (32 mm Hg)
causes ischemia.
■ If the ischemic period is long enough and repeated frequently, the eventual
outcome is tissue necrosis.
■ Pressure injuries (decubitus ulcers) almost invariably occur in the tissue over
bony prominences in persons not able to change body position frequently.
■ Pressure injuries overlying the sacrum are common in chronically supine
patients.
■ In acutely ill patients, third-space fluid may mechanically compromise the
microvasculature.
■ Etiologic considerations can be divided in extrinsic and intrinsic factors.
■ Extrinsic factors: Primarily mechanical forces on the soft tissues
• Friction: Resistance that a surface encounters when moving over another;
most often occurs with patient transfers
• Moisture: Incontinence can lead to skin breakdown.
• Pressure: Mechanical force that is applied perpendicular to a plane (ie,
between a bony prominence and a chair or bed)
• Shear: Mechanical stress parallel to the plane results in stretching and

compression of the blood supply to the muscles and skin.
■ Intrinsic factors: Patient factors that affect the soft tissues
• Altered level of consciousness: Results in lack of voluntary movements and
protective reflexes that off-load pressure
• Anemia: Can contribute to fatigue and weakness which can perpetuate
immobility.
• Autonomic control: Decreased levels result in spasms, perspiration with
increased skin moisture, blood vessel engorgement with resulting tissue
edema, and problems with bowel and bladder control.
FIG 1 • Sacral anatomy.
• Age: Increasing age is associated with increased skin friability and
decreased tensile strength.
• Diabetes: Poorly controlled blood glucose levels are associated with early
recurrence of pressure injuries.
• Infection: Profoundly impairs wound healing abilities.
• Inflammation: Creates a hostile local milieu resulting in impaired healing,
especially in the setting of chronic wounds.

• Malnutrition: Results in wasting and decreased muscle bulk and impairs
wound healing abilities
• Sepsis: Can result in decreased tissue perfusion and ischemia
• Sensory loss: Patient is unable to experience the discomfort associated with
prolonged pressure over prominences.
NATURAL HISTORY
■ Pressure injuries are categorized according to the National Pressure Ulcer
Advisory Panel Stages.
■ Pressure injuries can progress through the following stages if extrinsic and
intrinsic insults are not remedied (FIG 2).
■ Stage I: Intact skin with nonblanching erythema
■ Stage II: Partial thickness skin loss with exposed dermis
• Presents as a blister, abrasion, or shallow open ulcer
■ Stage III: Full-thickness skin loss
• Subcutaneous fat may be exposed.
• Tunneling and undermining may be present.
■ Stage IV: Full-thickness skin and tissue loss
■ Unstageable: Full-thickness skin or soft tissue loss but depth is unknown
usually due to the presence of an overlying eschar
■ Suspected deep tissue injury: Blood-filled blister or deep purple
discoloration of intact skin may indicate deep tissue injury that needs to
evolve prior to staging.
HISTORY AND PHYSICAL FINDINGS
■ The preoperative evaluation of patients with any type of pressure injury
includes a detailed assessment of the patient’s medical history, social situation,
and baseline health status and a comprehensive wound evaluation.1
■ Patient history
■ How long has the pressure injury been present? Acute wounds may respond
to conservative treatment, whereas chronic wounds tend to be more
recalcitrant.
■ What is the current wound care treatment? Changing local wound care
regimens may help with improving the wound.
■ What surgical options have been tried in the past? Obtain any and all
operative reports as previous surgeries may limit surgical options.

■ Is the patient ambulatory, or wheelchair or bed bound? Some flap procedures
are not appropriate for ambulatory patients.
■ What type of mattress and turning regimen is currently being used? Airflow
mattresses offer the best protection, whereas normal mattresses offer little
defense against pressure.
■ Is fecal contamination a problem? A dressing or a temporary diverting
ostomy may be prudent.
■ Are there problems with urinary incontinence? A urinary diversion procedure
(ie, suprapubic tube) or indwelling Foley catheter may be indicated.
■ Does the patient have spasms? Optimize medications to control spasms.
■ Does the patient have any fixed contractures?
■ What is the baseline nutritional status of the patient?
■ Social history is crucial to obtain in order to understand possible postoperative
barriers to care and to thwart recurrence.
■ What is the social support/caregiver situation?
■ Do they have resources for obtaining durable medical equipment (low air loss
bed, seat cushion if bed bound or wheelchair bound)?
■ Is there smoking or substance abuse history?
• Active or prior nicotine use increases risk of poor wound healing.
• A urine toxicology screen or urine cotinine test may be useful.
■ Is there a history of psychiatric illness?
■ Does the patient follow a specific diet (cardiac, diabetic)?
■ What is their daily protein intake?
■ What is the patient’s compliance history?
■ Laboratory studies
■ Complete blood count to assess for anemia or active infection
■ Albumin, prealbumin, and total protein to assess protein stores
■ Coagulation panel to assess for coagulopathies
■ Cultures that should be obtained with tissue or bone biopsies as wound swabs
have little value due to chronic colonization. Cultures should be sent for
quantitative analysis, and if the organism count is greater than 105,
consideration should be given to systemic antibiotics and/or staged
debridement and reconstruction.
■ Urinalysis

FIG 2 • Pressure injury staging.
■ Physical exam
■ All wounds must be examined manually.
■ Visual wound assessment alone is not sufficient to obtain necessary
information about a wound.
■ Manually assess the size and depth of the wound, bony prominences, bursa,
proximity to the rectum, and presence of tunneling (may need to use long
cotton tip applicator to assess tunneling).
■ If an eschar is present, the wound cannot be accurately staged.
■ A limited bedside debridement may be useful, if the patient can tolerate this,
so that the wound can be staged and to facilitate local wound care
preoperatively.
■ From visual inspection, take note of any previous surgical scars as previous
surgeries may preclude the use of a flap secondary to compromised vascular
supply.
■ Muscle tone and bulk are assessed taking note of any spasticity or contraction
of the extremities.
■ Assess the patient’s sensation in the area of the wound.
IMAGING
■ MRI is recommended for all stage IV pressure injuries to evaluate for
osteomyelitis.
■ T2 hypersensitivity and low-intensity T1 is sensitive and specific for
osteomyelitis (97% and 89%, respectively).
■ If MRI is not available or the patient has conditions precluding its use, plain
films and CT scan may be used. This imaging can be confirmatory for
osteomyelitis but has low specificity.2
DIFFERENTIAL DIAGNOSIS

■ Marjolin ulcer
■ Burn
■ Pilonidal disease
■ Neoplasm with bony metastasis
■ Soft tissue neoplasm with ulceration
■ Chronic surgical wound
■ Traumatic wound
NONOPERATIVE MANAGEMENT
■ Relieve extrinsic pressure with frequent positional changes.
■ Turn every 2 hours when supine.
■ Lift for 10 seconds every 10 minutes when seated.
■ Use proper mattress (low air loss) and cushion for seating and wheelchair (seat
mapping).
■ Minimize head of the bed elevation (less than 45 degrees).
■ Optimize underlying medical status.
■ Address spasticity (baclofen, diazepam, dantrolene).
■ Optimize nutrition—protein intake of 1.5 to 3.0 g/kg/d.
■ Local wound care in those who are poor surgical candidates or while
optimizing a patient for surgery.
■ Dakin’s ¼ strength for a limited time period (days up to 1 week) can be
effective in decreasing wound colonization while preserving native tissues.3
■ Limited bedside debridement to remove any wet eschar to facilitate adequate
packing and wound care may be warranted.
■ Enzymatic debridement is helpful when the wound has heavy slough.
SURGICAL MANAGEMENT
Preoperative Planning4
■ The most crucial aspect of the surgical management of sacral pressure injuries
is the preoperative and postoperative care.
■ Do not operate on patients until their medical status is optimized and the
underlying etiology determined.
■ Obtain old operative reports to know what prior attempts at closure have been
tried.
■ Always consider future procedures in the operative planning so as to not “burn

bridges.”
■ Review with the patient and all caregivers the postoperative expectations and
restrictions to help ensure postoperative compliance.
Positioning
■ To minimize repositioning, have anesthesia induced while the patient is supine
on stretcher.
■ Ensure that anesthesia provider appropriately protects eyes, face, and
endotracheal tube.
■ Check OR table to ensure working properly (able to flex and extend at hips)
prior to patient transfer.
■ Position gel rolls for chest and hips onto OR table.
■ Patient gown should be removed.
■ With stretcher in locked position next to the OR table and with appropriate
resources and careful choreography, roll patient to prone position.
■ Pad all extremities with foam or gel pads; toes should be “floating” (consider a
Wilson frame).
■ Ensure that genitalia are free from compression.
■ Arms should be on arm boards in “Superman” position.
■ Check EKG pads, monitoring devices, grounding pads, and catheters to make
sure they are not placing pressure on the skin and are outside of the operative
field.
■ Take care that any ostomies, if present, are free from compression.
■ Ensure no traction on indwelling catheters.
■ Secure patient to bed at both the trunk and lower legs.
■ Apply warming blankets or forced air to the upper trunk.
■ If the GI tract is still in continuity, an adhesive drape can be applied as a “mud
flap” to exclude the rectum from the field.
■ OR table can be flexed at the patient’s hip level to improve exposure (FIG 3).

FIG 3 • Prone positioning.
Approach
■ Gluteal rotation flap
■ Can be taken from either left or right gluteal area
■ Able to be readvanced as needed in the future
■ Available as a fasciocutaneous or musculocutaneous flap
• Can be full or segmental (used in ambulators)
• Musculocutaneous flaps have the advantage of additional bulk and robust
blood supply
■ V-Y advancement flap
■ Ipsilateral for small wounds
■ Bilateral for larger sacral wounds
■ Sliding gluteal flap
■ A fasciocutaneous flap preferred for the ambulatory population
■ Can be unilateral or ipsilateral
T E C H N I Q U E S

■ Excisional Debridement
■ Failure to adequately debride can lead to recurrent disease and poor wound
healing.
■ Probe wounds prior to debridement so all tunneling is addressed.
■ Infiltration of the peribursal area with a wetting solution (1000 mL of normal
saline plus 30 mL of 1% lidocaine, plus 1 ampule of epinephrine 1:1000) can
assist with hydrodissection and decrease blood loss.5
■ Coating the cavity with methylene blue applied with a cotton applicator can
assist with bursa identification and verify the completeness of the
debridement.
■ Debridement removes necrotic tissue and biofilm and decreases bacterial
count.
■ Converts a chronic wound into an acute wound.
■ Quantitative wound cultures should be obtained following debridement so
that postoperative antibiotic coverage can be tailored appropriately.
■ If the completeness of the debridement is ever in question, or the wound is
severely contaminated, staged debridement and reconstruction can be
performed, although outcomes may be similar to immediate reconstruction.6
■ Ostectomy
■ Because most pressure injuries overlie bony prominences, and underlying
osteomyelitis and unhealthy bone are likely, the bony prominence should be
removed.
■ The ostectomy should be performed only to lessen the prominence as radical
removal may redistribute pressure points to adjacent tissue, result in
excessive bleeding, and affect the origin and/or insertion of skeletal muscle.
■ Gluteal Rotation Flap
■ Prep a wide field with Betadine and drape in the standard fashion (TECH
FIG 1A).
■ Mark key anatomic landmarks:
■ posterior superior iliac spine
■ Greater trochanter

■ Ischial tuberosity
■ Mark the locations of the vascular pedicles to the gluteus maximus.
■ Superior gluteal artery (SGA): Anticipated location is one-third the
distance between the posterior superior iliac spine and the greater
trochanter.
■ Inferior gluteal artery (IGA): Anticipated location is half the distance
between the posterior superior iliac spine and the ischial tuberosity.
■ A handheld Doppler can be used to confirm location.
■ Mark and elevate a larger flap than needed by 2 or 3 cm at least (TECH FIG
1B).
■ The flap design can incorporate the SGA and its perforators and/or the IGA
and perforators, depending on size needs (TECH FIG 1C–E).
■ For a myocutaneous rotation flap, the incision is made with a scalpel and
then deepened through the skin and subcutaneous tissues and muscle
insertion with electrocautery.
■ Take care to dissect straight down and not to undermine any of the
subcutaneous tissue off of the muscle.
■ Disinsert the gluteus at the lateral and inferior borders.
■ Elevate the gluteus maximus in a superomedial direction in the areolar plane
above the gluteus medius.
■ Identify and protect the superior and/or inferior gluteal artery.
■ Detach the gluteus maximus from its origin at the posterior superior iliac
spine.
■ Rotate the flap over the sacral defect (TECH FIG 1F).
■ A back-cut (Burow triangle) can be made at the inferolateral aspect to
rotate tension-free (do not injure the IGA).
■ Irrigate and obtain hemostasis.
■ Suture the flap muscle to the contralateral gluteus maximus muscle without
tension using monofilament long-acting absorbable suture.
■ Insert drains into both donor and recipient site.
■ Close the skin in layers with suture or suture plus staples.
■ The flap can be rerotated at a later date should the need arise.
■ A unilateral rotation flap can be used in conjunction with a contralateral V-Y
advancement flap.

TECH FIG 1 • A. Sacral pressure injury prior to
debridement. B. Wound following debridement. A
right-sided gluteal rotation flap has been marked. C,D.
Design of the gluteal rotation flap. E. A
fasciocutaneous rotation flap based on the perforators
of the inferior gluteal artery has been raised. F. The
flap has been inset with absorbable suture. Note the
back-cut or Burow triangle.

■ V-Y Advancement Flap
■ Mark anatomic and vascular landmarks as described previously.
■ Design and mark a skin paddle overlying the gluteus maximus (mark a flap
larger than needed).
■ Flap is designed in a triangle shape and can be designed to incorporate the
SGA, the IGA, or both (TECH FIG 2A).
■ Incise the skin sharply, and use electrocautery to dissect down to the muscle
beveling out to capture soft tissue.
■ Do not undercut the skin paddle with dissection.
■ Dissect from lateral to medial in the submuscular space after dividing the
muscle laterally.
■ Divide the muscle from the origin at the sacrum. Take care not to injure SGA
or IGA.
■ Once the muscle is fully divided around the skin paddle, the tissue should
easily advance medially (TECH FIG 2B).
■ Place drains into the donor and recipient sites.
■ Suture the flap gluteus maximus to the contralateral muscle with absorbable
sutures.
■ Close the skin and subcutaneous tissues in layers with sutures or sutures and
staples (TECH FIG 2C).
■ The lateral donor site will close primarily (Y).
■ This flap can be unilateral or bilateral and can be used in conjunction with a
rotational flap.
TECH FIG 2 • A. A sacral wound has been debrided,
and bilateral myocutaneous V-Y flaps have been
designed. B. The flaps easily advance to the midline,
filling the defect. C. The flaps have been inset with

suture.
■ Sliding Gluteal Flap (Fasciocutaneous)
■ Mark anatomic and vascular landmarks as described previously (TECH FIG
3A,B).
■ Design and mark a triangular skin paddle overlying the gluteus maximus
(mark a flap larger than needed).
■ Cutaneous skin island can reach up to T12 if needed.
■ Incise the skin sharply and use electrocautery to dissect down to the muscle
by beveling out to capture maximal soft tissue and preserve perforators.
■ Do not undercut the skin paddle with dissection.
■ Once skin paddle is “islandized,” it should easily move medially.
■ Insert drains into donor and recipient sites.
■ Close donor and recipient sites with layered sutures or sutures and staples
(TECH FIG 3C).
TECH FIG 3 • A. This ambulatory patient suffered a
pressure injury during hospitalization for an acute
injury. She developed a chronic wound and
osteomyelitis. A fasciocutaneous flap based on the
inferior gluteal artery perforators is planned. B.
Following debridement, the wound is much larger than
anticipated. Therefore, bilateral flaps were designed.
The area of bone that will undergo ostectomy is
outlined in methylene blue. Based on anatomic
landmarks, “A” represents the “anticipated” location of
the inferior gluteal artery. “R” represents the “real”

location of the artery based on Doppler exam. C. The
flaps are closed in a V-Y fashion. (Courtesy of R.
Chandawarkar, MD.)
PEARLS AND PITFALLS
Preoperative
planning
■ Evaluate extrinsic and intrinsic factors to determine wound
etiology.
■ Ensure that the patient is medically optimized prior to their
operation.
■ Engage social work to ensure that the patient has adequate social
support and resources for the postoperative period.
■ Consult with appropriate consultants prior to reconstruction
(colorectal for diverting ostomy, ID if osteomyelitis).
Positioning
■ Attention to choreography and team communication is crucial to
position the patient safely in the prone position.
Operative
strategy
■ Autonomic dysfunction in the patient can create difficulties for the
anesthesia team, so communicate with your providers frequently.

■ Know the location of the blood supply to the flaps. Use a handheld
Doppler if in doubt.
Postoperative
care
■ Engage a multidisciplinary team including nursing, social work,
and other consulting services as appropriate to ensure a safe
discharge and to give the patient the “best chance” of preventing
reoccurrence.7
POSTOPERATIVE CARE
■ Patients are hospitalized for 1 to 2 weeks after surgery, and many patients will
discharge to a rehabilitation hospital or an extended care facility for several
weeks to receive a higher level of nursing care.
■ A low air loss mattress should be ordered prior to the surgery and should be
available to move the patient onto directly from the operating room table.
■ The patient should limit the HOB to less than 10 degrees for 1 week.
■ The patient should be repositioned every 2 hours, unless he or she is on an air-

fluidized bed.
■ The postoperative dressing should be left in place for 48 hours, after which
time a light dressing can be applied to protect against shear and moisture or the
wound can be left open to the air to allow for ease of wound monitoring.
■ Bladder and bowel function should be controlled to prevent urinary or fecal
contamination of the surgical site.
■ Spasticity should be prevented with pharmacologic measures.
■ Obtain a dietary consultation so that the patient can maintain a positive
nitrogen balance.
■ Meticulous drain care should be performed in the hospital and taught to all
caregivers.
■ Obtain an infectious disease consultation for any positive operative cultures to
help guide antibiotic selection and duration of treatment.
■ Evaluate need for long-term intravenous access for antibiotics.
OUTCOMES
■ Recurrence rate is high.
■ Local wound/incision problems are common and should be treated with local
wound care.
■ Anticipate further reconstruction options with every surgical intervention.
■ Control for extrinsic and intrinsic factors that contributed to the initial pressure
injury formation.
COMPLICATIONS
■ Complications are not uncommon in those with significant preoperative
comorbidities.
■ Hematoma or seroma may occur.
■ If the patient is on anticoagulants, work closely with hematologist to
determine when these can be safely held and resumed in the perioperative
period.
■ One or more drains should be left under flaps for days to weeks to control for
fluid accumulation.
■ Small localized incisional breakdown should be treated with local wound care.
■ Persistent infection can be minimized with thorough debridement and long-
term antibiotics as deemed appropriate by infectious disease colleagues.
■ Unless underlying medical problems and extrinsic factors are controlled, the

recurrence rate is high.
REFERENCES
1. Marin J, Nixon J, Gorecki C. A systematic review of risk factors for the
development of and recurrence of pressure ulcers in people with spinal cord
injuries. Spinal Cord. 2013;51(7):522-527.
2. Huang AB, Schweitzer ME, Hume E, et al. Osteomyelitis of the hips/pelvis in
paralyzed patients, accuracy and clinical utility of MRI. J Comput Assist
Tomogr. 1998;22:437.
3. Heggers JP, Sazy JA, Stenberh BD, et al. Bactericidal and wound-healing
properties of sodium hypochlorite solutions: The 1991 Lindberg Award. J Burn
Care Rehabil. 1991;12:420.
4. Janis, JE, Kenkel, JM. Pressure Sores. Selected Readings in Plast Surg.
2003;9(39):1-42.
5. Han H, Fen J, Fine NA. Use of the tumescent technique in pressure ulcer
closure. Plast Reconstr Surg. 2002;110:711.
6. Larson DL, Hudak KA, Waring WP, et al. Protocol management of late stage
pressure ulcers: a 5-year retrospective study of 101 consecutive patients with
179 ulcers. Plast Reconstr Surg. 2012;129:897.
7. Bauer J, Phillips LG. Pressure sores. Plast Reconstr Surg. 2008;121:1-10.

30
CHAPTER
Posterior Thigh and
Hamstring Flaps for Ischial
Ulcers
John Hulsen and Jeffrey E. Janis
DEFINITION
■ A pressure injury is localized damage to the skin and soft tissue typically over
a bony prominence.
■ They occur as a result of prolonged pressure or pressure in combination with
shear.
■ National Pressure Ulcer Advisory Panel Stages1 are shown in FIG 2 in Chapter
32.
■ The ischial area is the most frequent site of development and recurrence of
pressure ulcers.2
■ Soft tissue overlying the bony prominence of the ischial tuberosity is
particularly vulnerable to pressure injury especially in the wheelchair-
bound/spinal cord injury patient.
ANATOMY
■ The posterior thigh is a region bordered by the inferior gluteal fold superiorly,
the iliotibial tract laterally, the thigh adductors medially, and the popliteal fossa
inferiorly.
■ The hamstring muscle group functions to flex, stabilize, and rotate the knee
and are not expendable as a group in the ambulatory patient (FIG 1).3
■ Biceps femoris
■ Semimembranosus
■ Semitendinosus
■ Blood supply of the posterior thigh skin:
■ The profunda femoris artery principally supplies the largest cutaneous area

on the posterior thigh.3
■ It originates laterally from the femoral artery, gives off both medial and
lateral circumflex femoral arteries, and then continues distally and traveling
behind the adductor longus.
• Medial branches enter into the adductor compartment.
• Lateral branches (four profunda femoris artery perforating vessels) pierce
the adductor magnus insertion and enter the posterior compartment of the
thigh.
• The fourth profunda femoris perforating artery is the termination of the
profunda femoris artery.
• Each profunda femoris perforating vessel perfuses musculocutaneous and/or
septocutaneous perforators that contribute to the well-developed fascial
plexus of the posterior thigh.
■ The inferior gluteal artery principally supplies the cutaneous vascular
territory of the lower gluteal region.
• It originates off the internal iliac artery and exits the pelvis to enter the
gluteal region inferior to the piriformis with the sciatic and posterior
cutaneous nerves. In 91% of patients, the inferior gluteal artery sends off a
descending fasciocutaneous branch.4
• The descending branch of the inferior gluteal artery travels in a common
sheath with the posterior cutaneous nerve in 72% of patients.
• Rather than singularly coursing down the thigh, the descending branch acts
as a “relay artery,” being reinforced along its length by myocutaneous and
fasciocutaneous branches from the profunda femoris perforating vessels.3
• Anastomotic branches from the descending branch of the inferior gluteal
artery join branches from the medial femoral circumflex artery, lateral
femoral circumflex artery, and the first profunda perforating artery to form
the cruciate anastomosis (FIG 2).5
• Each vessel that unites to form the cruciate anastomosis can provide
collateral circulation to the longitudinally directed fascial plexus of the
posterior thigh in the absence (or surgical ligation) of one of its
constituents.3,5
• This accounts for the clinical reliability of the multitude of fasciocutaneous
flap designs available from the posterior thigh.
PATHOGENESIS

■ Pressure ulcers are the result of numerous factors, both extrinsic and intrinsic
to the patient, that contribute to the development of a wound.
■ Pressure: Greatest areas found over bony prominences
• Can produce tissue ischemia if applied in excess of 32 mm Hg (skin end
capillary bed pressure)
• The ischial tuberosities are particularly vulnerable to ulceration and
recurrence as pressures over this region in the sitting position exceed 80 to
100 mm Hg.
• Shearing: Sliding deformation of tissue caused by oppositely directed
parallel forces
■ Friction: Contributes to abrasions and breakdown of the superficial skin
barrier
■ Moisture: Contributes to maceration of the skin
■ Limited mobility: Inability to adequately off-load pressure points, potentially
increasing friction and shearing forces
■ Altered sensation: Lack of protective sensory input
■ Spasticity: Interruption of supraspinal inhibitory pathways that may result in
contractures that create new or altered pressure points
■ Altered level of consciousness: Unrecognized prolonged pressure with skin
maceration/contamination from urine/fecal soilage

Inferior gluteal artery Descending branch of inferior gluteal artery Posterior cutaneous nerve of thigh Long head of biceps femoris Semitendinosis Semimembranosis Short head of biceps femoris Piriformis Sciatic nerve Medial circumflex femoral artery 1st perforating artery from profunda femoris 2nd perforating artery from profunda femoris Adductor magnus 3rd and 4th perforating artery from profunda femoris

FIG 1 • Key posterior thigh anatomy.
■ Tissue tolerance for pressure and shear forces is affected by microclimate,
nutrition, perfusion, comorbidities, and condition of the soft tissue.1
■ It is important to recognize, especially in the spinal cord injury patient, that
all phases of wound healing are impaired in denervated tissue.
NATURAL HISTORY
■ Skin hyperemia is seen within 30 minutes and is characterized by
nonblanching erythema that resolves within 1 hour after pressure is alleviated.
■ Tissue ischemia develops with sufficient continuous pressure for 2 to 6 hours,
causing erythema that requires at least 36 hours to resolve after pressure
cessation.
■ Deep tissue injury/tissue necrosis can develop after 6 hours of unrelieved
pressure and manifests as deep red, maroon, or purple skin discoloration with
induration.
■ Soft tissue ulceration over bony prominences occurs within 2 weeks after
tissue necrosis occurs.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patient age, general health/functional status, medical comorbidities, nutritional
intake, as well as the circumstances, etiology, chronology, and prior ulcer
management should be documented.
■ Note any medications or therapy that impairs wound healing such as
radiation and steroids.
■ Obtain reports from any previous surgical interventions that may influence
ulcer reconstructive options.
■ Social history including tobacco use and a clear picture of the patient’s
support system should be obtained.
• It is critical to identify the etiology that led to reconstructive failure when
treating a recurrent ulcer.
• Lack of compliance with postoperative care, lack of patient motivation, and
inadequate resources for home care will doom even the best executed
reconstruction and are critical to account for in determining whether a
patient is a reconstructive candidate.

FIG 2 • The cruciate anastomosis.
■ Physical examination
■ General appearance, BMI, assessment of nutrition status: Does the patient
appear well or fragile and emaciated?
■ Accurately assess location, dimensions (including tunneling), wound
condition/odor, and stage/depth of ulcer.
■ Presence of diverting ostomy or suprapubic catheter
■ Presence of lower extremity fixed posturing or uncontrolled spasticity
■ Evaluate the posterior trunk and lower extremities for surgical scars from
previous reconstructions while also assessing potential donor-site muscle bulk
(diminished in spinal cord injury).
IMAGING AND OTHER DIAGNOSTIC STUDIES
■ Preoperative laboratory studies
■ White blood cell count/differential and hemoglobin/hematocrit
■ Inflammatory markers: Erythrocyte sedimentation rate and C-reactive protein

(especially if suspect osteomyelitis)
■ Glucose and HgbA1c: Ideally, good long-term glucose control in diabetics
with a HgbA1c less than 6%6
■ Nutrition studies
■ Accurate assessment of the nutritional status of the pressure ulcer patient is
often compromised by proinflammatory factors that may preclude the use of
typical serum protein values.
■ Ideal, and potentially unattainable, preoperative serum protein levels:7
• Albumin: At least 3.5 g/dL with upward trend
• Prealbumin: At least 20 g/dL with upward trend
■ Unfortunately, there is little evidence that enteral or parenteral nutrition
supplementation has any effect on healing existing pressure sores or the
prevention of new ulcers.
■ Data suggest that anemia, serum protein alterations, and markers of
inflammation will actually normalize after surgical treatment of the ulcer.8
■ These deficient values are viewed as the result of the ulcer rather than
modifiable risk factors to optimize prior to surgery.
■ Imaging studies
■ Used to assess for any undrained fluid collection and as noninvasive modality
to detect osteomyelitis
■ MRI: 97% sensitive, 89% specific for diagnosis of osteomyelitis in the
pelvis9
■ Pathology/microbiology
■ Diagnostic standard for osteomyelitis is the pathology report of an aseptically
obtained bone biopsy.
DIFFERENTIAL DIAGNOSIS
■ Stage I to IV pressure ulcer, unstageable wound, or deep tissue injury
■ Wound infection
■ Acute or chronic osteomyelitis
■ Malnutrition
■ Muscle spasms
■ Fecal and/or urinary incontinence
■ Failed previous reconstruction
NONOPERATIVE MANAGEMENT

■ Indications for nonoperative management include patients with stage I and II
pressure ulcers as well as some patients with stage III and IV ulcers who are
not candidates for reconstruction:7
■ Unmotivated patient
■ Inadequate home support or outpatient care
■ Comorbidities that place the patient at an unacceptable surgical or anesthesia
risk
■ Unreconstructable defect
■ In all pressure ulcer cases particular emphasis is placed on the prevention of
wound complications and infections, halting ulcer progression, and reducing
the risk of additional ulcers.
■ If possible, the highest goal is a closed stable wound.
■ A closed wound is not an attainable goal for all patients.
■ The patient’s social situation is just as important, if not more so, than any
medical or surgical therapy.7
■ General treatment strategies for nonoperative management mirror those used
in preoperative optimization of the pressure ulcer surgical candidate.
■ Offloading pressure points with specialty beds, seat mapping, and turning
protocols every 2 hours.
■ Local skin and wound care to promote moist wound healing without
maceration is essential.
• Many passive and sophisticated active dressings are available; however,
evidence is mixed regarding head-to-head superiority.
• Fever/sepsis usually has a urinary or pulmonary source, not the open
wound.
■ Negative-pressure wound therapy may be more comfortable to patients and
effective in ulcers that fail to progress or as a bridge to surgery.
■ NPWT functions to increase wound perfusion and formation of granulation
tissue while reducing bacterial load
■ A well-balanced diet is best to provide adequate nutrition for wound healing.
• Supplements are beneficial only if there is a nutritional deficiency.10
• Goal is 30 to 35 kcal/kg and 1.25 to 1.5 g protein/kg/d for adults with a
pressure ulcer who are at risk for malnutrition.
• Additional fluid should be provided to patients with heavily exudative
wounds to prevent dehydration.
■ Management of muscular spasms helps to prevent new pressure points and

reduces wound-shearing forces.
SURGICAL MANAGEMENT
■ The presence of stage III and IV pressure ulcers alone is not an indication for
surgical management.7
■ Optimization of medical comorbidities, modification of risk factors, assuring
adequate home support, availability of medical equipment, access to
outpatient care, assessment of patient compliance, and motivation to take an
active role in self-care are essential for consideration of surgical candidacy.
■ The technical intraoperative aspects of pressure ulcer surgery are often the
easiest facet of the patient’s care.
■ Goals of surgical management:7
■ Sharp debridement of all devitalized tissue (including complete excision of
pseudobursa) to create a healthy bleeding wound bed
■ Ostectomy of devitalized bone to clinically hard bone with pinpoint bleeding
and rasped smooth contour
■ Obtain soft tissue and bone biopsies following debridement under sterile
conditions when indicated.
■ Provide tension-free soft tissue wound closure and obliterate dead space with
judicious selection of large, well-vascularized flaps.
■ Avoid suture lines across pressure/seating surfaces.
■ Selection of myocutaneous, fasciocutaneous, and perforator flap
reconstruction is dependent on the location and dimensional characteristics of
the ulcer, donor-site availability from prior surgery, ambulatory status of
patient, and surgeon familiarity/preference.
Preoperative Planning
■ Proactive coordination of multidisciplinary postoperative care and clear
communication of expectations between the patient and team members prior to
surgical intervention.
■ Discuss temporary fecal diversion with the patient and general surgery (if
incontinent or not compliant with a standard bowel regimen) if wound hygiene
is a concern.
■ Consider a urology consultation if there is concern for an occult urinary tract
leak into the wound or uncontrolled urinary incontinence.
■ Communicate in advance to the operating room staff the need for separate
instruments for the contaminated debridement, sterile biopsy, and clean

reconstructive portions of the case.
Positioning
■ The patient is transferred to the operating room table in the prone position.
■ Place the table in a moderate jack-knife position during flap inset to ensure
adequate flap length while simulating tensile forces across the closure during
the postoperative hip flexion protocol.
■ Chest rolls are used to reduce breast and shoulder pressure.
■ Assure adequate protective padding over the knees, legs, and feet.
Approach
■ Ulcer excision is optimally approached after infiltration of epinephrine
containing wetting solution around the pseudobursa/ulcer-healthy tissue
interface and coating the cavity with dye.
■ This approach reduces blood loss and facilitates defining the ulcer for
debridement.
■ Despite attempts to standardize flap terminology, considerable variability
exists in published literature and standard textbooks (with limited consensus
even among practicing surgeons) regarding what is considered a “posterior
thigh flap.”
■ Numerous flaps (with common aliases), varying in type, anatomy, and
clinical use are described in Table 1.
■ Regardless of nomenclature, it is vital to approach ulcer reconstruction with a
sound understanding of the anatomical basis and constraints of each flap
design.
• Tailor flap choice to the patient’s reconstructive needs, available donor sites,
intact pedicles, and surgeon experience/preference.
• Clear communication of your operative plan to the patient, surgical team,
anesthesia staff, and rehabilitation team will allow for better coordination of
OR resources and postoperative care
Table 1 Posterior Thigh Flaps
Use in

Flap Type
Names and
Aliases
Muscles Sacrificed
Ambulatory
Patients?
Dom
Fasciocutaneous
Posterior thigh
flap
None
Yes
Desc
glutea
crucia
Posterior thigh
fasciocutaneous
flap
None
Yes
1st an
perfo
Gluteal thigh
flap
Inferior gluteal
thigh flap
None
Yes
1st an
perfo
of infe
Posterior thigh
flap
Posterior thigh
fasciocutaneous
flap
Posterior thigh
rotation flap
V-Y profunda
femoris flap
None
Yes
1st an
perfo
branc
(if pre
divide
Posterior thigh
flap
V-Y posterior
thigh flap
None
Yes
Deep
fascio
perfo
comp
Musculocutaneous
Posterior thigh
flap
V-Y hamstring
flap
Biceps femoris
flap
Semicircular
hamstring flap
Biceps femoris
Yes
(potentially)a
1st pe
profu
Posterior thigh
flap
V-Y hamstring
flap
Semicircular
hamstring flap
Biceps femoris
Semitendinosus
Semimembranosus
No
1st pe
profu

Perforator
Posterior thigh
flap
Posterior thigh
perforator flap
None
Yes
3rd p
profu
Posterior thigh
flap
Posterior thigh
perforator flap
Profunda artery
perforator Flap
PAP flap
Adductor flap
Adductor
magnus
perforator flap
None
Yes
1st m
femo
aAs an isolated muscle, it is expendable as a knee flexor except in certain athletic situations.
T E C H N I Q U E S
■ Ulcer and Pseudobursa Cavity Identification,
Excision, and Bone
■ The patient is prepped and draped with the ulcer cavity and flap donor sites
exposed.
■ Percutaneous access incisions are made within the rim of the planned ulcer
excision as needed (TECH FIG 1A,B).
■ Warmed wetting solution containing 30 mL of 1% plain lidocaine and 1 mL
of 1:1000 epinephrine in 1000 mL of normal saline is injected
circumferentially around the entire cavity with a blunt-tipped infiltration
cannula (TECH FIG 1C).
■ Endpoints of wetting solution infiltration are increased skin turgor and
adequate circumferential hydrodissection of the cavity from healthy tissue.
■ Estimation of fluid volume used is 10 mL per 10 cm3 of pseudobursa
cavity resection.11
■ The epinephrine is allowed adequate time to achieve full hemostatic effect
(no less than 7 minutes).

TECH FIG 1 • A. Stage III ischial pressure ulcer with
undermining present. B. Ulcer opening with
undermining and tunneling present. C. Infiltration of
wetting solution containing epinephrine, “tumescent
technique.” D. Methylene blue is applied to the
tunneling ulcer to identify all tissue to be excised. E.
Clean, hemostatic wound, free from all

ulcer/pseudobursa tissue. The true extent of the
defect is now known. F. Pseudobursa and ulcer
excised en bloc.
■ The entire pseudobursa cavity is then coated with methylene blue dye
(TECH FIG 1D).
■ Dye is loaded into a 10 mL syringe capped with a 14 g angiocath for clean
application into tunneled areas.
■ Borders of the ulcer, along a rim of any residual scar, are sharply incised.
■ The rim of ulcer is grasped with an Allis or Kocher clamp for
countertraction, and excision proceeds sharply through the hydrodissected
planes with scissors and/or electrocautery. Endpoints are healthy, soft,
bleeding tissue.
■ The ulcer and pseudobursa cavity is excised en bloc, defining the new, larger
defect (TECH FIG 1E,F).
■ Ostectomy of exposed bony cortex proceeds, if indicated, using a sharp
sterile osteotome.12 Endpoints are hard, healthy, bleeding bone.
■ A sterile rongeur is used to obtain a bone biopsy for culture.
■ Posterior Thigh Fasciocutaneous Rotation Flap
With V-Y Closure
■ Identify the midpoint between the ischial tuberosity and greater trochanter
within the gluteal fold.
■ A reference line is drawn from this point down the midaxis of the thigh to a
distal point approximately 10 cm superior to the popliteal fossa.5
■ The most distal perforators are located approximately 10 cm proximal to
the lateral femoral condyle.
■ Outline the planned incisions for the V cutaneous island (TECH FIG 2A).
■ Medially, a curved line is drawn from the medial border of the ischial ulcer
to the distal mark in the midaxis.
■ The lateral line curves cephalad from the distal mark toward the posterior
border of the tensor fasciae latae terminating no higher than 10 cm inferior
to the ischial tuberosity to preserve the first and second profunda
perforators, which supply the flap with or without the descending branch of

the inferior gluteal artery (if present) via the cruciate anastomosis.5
■ Primary closure of the donor site is possible with flap widths of 9 to 10 cm,
otherwise plan for skin grafting.
■ Carry incisions through marked outline into subcutaneous tissue and through
the deep fascia of the posterior compartment just above the hamstring
musculature.
■ Begin elevation of the fasciocutaneous flap distally to protect the sciatic
nerve, which, in this location, is deep to the biceps femoris.5
■ The posterior femoral cutaneous nerve arborizes distally and may not be a
reliable reference for initial pedicle orientation.13
■ The fasciocutaneous unit is easily and quickly raised off the posterior
compartment muscles proximally with electrocautery.
■ The fascia is secured to the dermis of the skin paddle with suture to prevent
shearing.13
■ Identify and protect the sciatic nerve as it courses lateral and deep to the long
head of the biceps femoris.5
■ The profunda femoris perforating vessels are encountered and usually
preserved lateral to the sciatic nerve, approximately 10 cm inferior to the
ischial tuberosity (TECH FIG 2B).
■ Perforators may be preserved or ligated and controlled with
hemeclips/cautery if greater length is required and the inferior gluteal
system/cruciate anastomosis is patent.
■ If the profunda perforating vessels are sacrificed, the dissection continues
cephalad but does not extend superiorly beyond the level of the ischial
tuberosity.
■ The posterior thigh flap is then rotated into the ulcer/bursa defect.
■ Redundant distal portion of the flap should be de-epithelialized and inset
into the ulcer dead space and closed in a tension-free manner with long-
acting absorbable monofilament suture over closed suction drains.
■ The donor site is closed in a V-Y fashion over a drain (TECH FIG 2C).

TECH FIG 2 • A. Clean ischial wound, all ulcer tissue
excised. Posterior thigh/hamstring V-Y flap outlined.
B. The profunda femoris perforating vessels are
encountered lateral to the sciatic nerve, approximately
10 cm inferior to the ischial tuberosity. C. The flap is
rotated into the defect, and the donor site is closed in
a V-Y fashion.
■ If primary closure is not possible, the donor site is closed with a meshed
split-thickness skin graft over the intact hamstrings muscle wound bed.
Alternate Techniques
■ Designing and raising the entire posterior thigh fasciocutaneous unit, with a
distal V or U apex, to the base of the inferior border of the gluteus maximus
has been shown to be reliable, as previously described (TECH FIG 3).13
■ This technique relies on the presence of the descending branch of the inferior
gluteal artery, and this system must be patent.5
■ The descending branch of the inferior gluteal artery will supply the entire
posterior thigh fascial plexus through the cruciate anastomosis.

TECH FIG 3 • The entire posterior thigh can be raised
as a fasciocutaneous unit, the gluteal thigh flap.
■ Hamstring V-Y Flap2
■ Identify the midpoint between the ischial tuberosity and greater trochanter
within the gluteal fold.
■ A reference line is drawn from this point down the midaxis of the thigh to a
distal point approximately 10 cm superior to the popliteal fossa.5
■ The most distal perforators are located approximately 10 cm proximal to
the lateral femoral condyle.
■ Outline the planned incisions for the V cutaneous island.
■ Medially, a curved line is drawn from the medial border of the ischial ulcer
to the distal mark in the midaxis.
■ The lateral line curves cephalad from the distal mark toward the lateral
border of the pseudobursa/ulcer excision defect or the posterior border or
the tensor fasciae latae.
■ A wide V design that encompasses the entire posterior thigh skin will
reliably capture the underlying musculocutaneous and septocutaneous
perforators without the concern of centering the skin paddle over the

atrophied musculature.
• Note: The posterior thigh muscles may be atrophied and difficult to
identify, particularly in the spinal cord injury patient.
■ Carry incisions through marked outline into subcutaneous tissue and through
the deep fascia of the posterior compartment just above the hamstring
musculature.
■ Proximally, the hamstring muscle group has often been released from the
ischial tuberosity during ulcer excision and limited ostectomy.
■ Separate any remaining attachments, in particular the deeper
semimembranosus, with cautery.
■ Laterally, identify the distal biceps femoris as it inserts onto the head of the
fibula.
■ Divide the long head and deeper short head of the muscle at its
musculotendinous junction just distal to the skin island with electrocautery.
■ Medially, identify the distal semitendinosus and semimembranosus as they
insert onto the medial condyle of the tibia.
■ The semitendinosus is the most posterior tendon of the pes anserinus, the
conjoined tendon of the sartorius, gracilis, and semitendinosus.
■ Divide the remaining hamstring muscles at their musculotendinous
junction, again just distal to the skin island, with electrocautery.
■ Limited blunt undermining is performed laterally and medially to free the
hamstrings from the posterior compartment; however, the profunda femoris
perforator pedicles need not be skeletonized (TECH FIG 4A,B).
■ The musculocutaneous unit is easily advanced 10 cm toward the defect.
■ Meticulous hemostasis is achieved within the ulcer cavity and around the
elevated flap with electrocautery.
■ Hamstring muscle bulk and redundant distal fasciocutaneous flap is de-
epithelialized and advanced into the ulcer dead space and inset over a drain in
layers with long-lasting monofilament suture.
■ The cutaneous donor site is closed in layers over a drain in a V-Y fashion
(TECH FIG 4C).
Alternate Techniques
■ Potential skin paddles include medial and laterally based semicircular
rotation flaps with primary closure or split-thickness skin grafting of the
donor site.

■ A standard (deep-based) fasciocutaneous V-Y advancement flap may be used
if limited advancement required.
■ Extend the lateral incision to the lateral base of the defect and dissecting
down through the deep fascia.
■ Release in the subfascial plane around the cutaneous island borders for no
more than 1 to 2 cm, leaving the hamstring musculature intact.
■ The fasciocutaneous unit is advanced into the defect and closed as above.
TECH FIG 4 • A. Hamstring complex is divided and
the flap is freed to advance proximally. B. V-Y
hamstring flap elevated laterally and medially following
muscle division. C. The donor site is closed in a V-Y
fashion, supporting the advanced skin island.
PEARLS AND PITFALLS
Patient selection
and optimization
■ Recognizing and addressing preoperative medical
comorbidities as well as extrinsic and intrinsic etiologic
factors in a compliant patient will improve chances of surgical
success.
■ In a young patient with recurrent ischial ulcers and multiple

risk factors, chances of successful wound closure are
essentially 0%.6
Technique
■ Ulcer preparation with tumescent technique and methylene
blue aids ulcer identification, dissection, excision, and
hemostasis.
■ Multiple flap options for reconstruction have been described;
however, none have been shown to be superior. Plan your
current flap design with future flaps in mind (including
rerotation and/or readvancement).
Nutrition/glucose
control
■ Albumin less than 3.5 is a predictor of early ulcer recurrence;
however, nutritional parameters may not improve until after
ulcer reconstruction despite adequate intake.
■ HgbA1c greater than 6 predictor of dehiscence and
recurrence.
Postoperative
care/rehabilitation
■ Monitor triggers for autonomic dysreflexia in spinal cord
injuries at T6 or higher.
■ Monitor sitting protocol closely for signs of undue pressure.
Halt progression when indicated.
■ Coach patient on proper pressure off-loading strategies on an
up-to-date seat-mapped chair cushion.
Outcomes
■ Despite medical and surgical advances, pressure ulcer
recidivism remains very high.
■ An engaged multidisciplinary team with a standard treatment
protocol can improve outcomes and reduce costs.
■ The social/psychological aspects of wound healing in the
pressure ulcer population are likely more important than
surgery.
POSTOPERATIVE CARE
■ The patient is transferred to a pressure off-loading bed in the supine or prone
position for a recovery period of flat bed rest.
■ There is little consensus on the ideal duration (2–8 weeks) of flat
immobilization or ideal setting of convalescence (inpatient hospitalization,
acute care rehabilitation, home).
■ Preoperative skin care, management of fecal/urinary incontinence, and
regiments to control moisture, glucose level, and spasticity are continued
throughout the postoperative course for the lifetime of the patient.
■ Mobilization is initiated sequentially, with progression to each phase

contingent upon tissue tolerance and uncomplicated wound healing.
■ Immediate range of motion therapy for the unaffected limb
■ Initiate range of motion therapy on the affected side at approximately week 5
(or nearing the initiation of planned sitting protocol)
■ Sitting protocol, ideally in a seat-mapped cushion, is initiated at week 6.
• Monitored sitting intervals beginning with 15-minute sessions 2 or 3 times a
day on day 1.
• Evaluate the closure for any flap or incision line erythema concerning for
undue pressure.
• Absent incision/flap concerns, may continually progress intervals by 15
minutes each day (day 2, 30-minute intervals; day 2, 45-minute intervals;
and so on) until able to tolerate 4 to 6 hours of sitting
■ It is essential to coach the patient on adequate repositioning maneuvers when
sitting to relieve pressure and maintain tissue perfusion.
■ Side-to-side shifting, lean forward, tilt backs
■ Culture-directed antibiotic therapy should be initiated based on results of bone
and deep tissue biopsies at the time of surgery.
■ There should be clear coordination of outpatient care and social services as
well as family member/caregiver education/instructions and follow-up prior to
discharge.
OUTCOMES
■ Wide variation exists in the reported outcomes for pressure ulcer
reconstruction, which is likely attributable to the design of many studies in
pressure ulcer literature, length of patient follow-up, and definitions of
outcomes.
■ Keys et al. assessed the predictors of pressure ulcer reconstructive failure in a
retrospective review of 135 patients.6
■ 39% recurrence and 16% dehiscence rates were observed; 48% of
recurrences occurred within the first year and 76% within the first 2 years.
■ Albumin less than 3.5, age less than 45, and previous same-site surgical
failure predicted early recurrence within 2 years.
■ Ischial ulcer, age less than 45, and previous same-site surgical failure
predicted late recurrence after 2 years.
■ Poor diabetes control (hemoglobin A1c greater than 6%) was a predictor of
return to operating room for dehiscence as well as ulcer recurrence.

■ Larson et al. described outcome of a single surgeon experience with a standard
protocol of ulcer debridement with immediate reconstruction followed by
inpatient hospital admission for 3 weeks in 101 patients.12
■ Ischial ulcers represented the most common ulcer at 49.7% of the series.
■ Recurrence rate of 16.8% and complication rate of 17.3% reported.
■ Primary closure was performed in 45.8% of ulcers, the remaining 54.2%
underwent flap reconstruction. 17.8% had a V-Y biceps femoris flap and one
patient had a hamstring myocutaneous flap.
■ Surgery was performed without preoperative consideration of nutritional
status or osteomyelitis.
■ Outcomes for specific technique of reconstruction (primary closure vs flap
reconstruction) or location of recurrence were not provided.
■ Sameem et al. reviewed 55 articles in the pressure ulcer reconstruction
literature covering each type of flap reconstruction and found no statistically
significant difference in complication or recurrence rates between
musculocutaneous, fasciocutaneous, and perforator-based flaps.14
■ With no technique superior, consider the advantages and limitations of each
approach rather than complication and recurrence rate.14
COMPLICATIONS
■ Cellulitis
■ Abscess
■ Hematoma
■ Seroma
■ Urethral injury/leak
■ Sciatic nerve injury
■ Wound dehiscence
■ Partial or total flap necrosis
■ Ulcer recurrence
REFERENCES
1. National Pressure Ulcer Advisory Panel (NPUAP). Pressure Injury Stages.
Available at:
resources/npuap-pressure-injury-stages/Published 2016.
2. Hurteau JE, Bostwick J, Nahai F, et al. V-Y advancement of hamstring
musculocuataneous flap for coverage of ischial pressure sores. Plast Reconstr
Surg. 1981;68(4):539-542.

3. Cormack GC, Lamberty BG. The blood supply of thigh skin. Plast Reconstr
Surg. 1985;75(3):342-354.
4. Windhofer C, Brenner E, Moriggl B, Papp C. Relationship between the
descending branch of the inferior gluteal artery and the posterior femoral
cutaneous nerve applicable to flap surgery. Surg Radiol Anat. 2002;24(5):253-
257.
5. Rubin J, Whetzel T, Stevenson T. The posterior thigh fasciocutaneous flap:
vascular anatomy and clinical application. Plast Reconstr Surg.
1995;95(7):1228-1239.
6. Keys KA, Daniali LN, Warner KJ, Mathes DW. Multivariate predictors of
failure after flap coverage of pressure ulcers. Plast Reconstr Surg.
2010;125(6):1725-1734.
7. Larson JD, Altman AM, Bentz ML, Larson DL. Pressure ulcers and perineal
reconstruction. Plast Reconstr Surg. 2014;133(1):39e-48e.
8. Scivoletto G, Fuoco U, Morganti B, et al. Pressure sores and blood and serum
dysmetabolism in spinal cord injury patients. Spinal Cord. 2004;42(8):473-
476.
9. Huang AB, Schweitzer ME, Hume E, Batte WG. Osteomyelitis of the
pelvis/hips in paralyzed patients: accuracy and clinical utility of MRI. J
Comput Assist Tomogr. 1998;22(3):437-443.
10. Harrison B, Khansa I, Janis JE. Evidence-based strategies to reduce
postoperative complications in plastic surgery. Plast Reconstr Surg.
2016;137(1):351-360.
11. Han H, Few J, Fine NA. Use of the tumescent technique in pressure ulcer
closure. Plast Reconstr Surg. 2002;110(2):711-712.
12. Larson DL, Hudak KA, Waring WP, et al. Protocol management of late-stage
pressure ulcers: a 5-year retrospective study of 101 consecutive patients with
179 ulcers. Plast Reconstr Surg. 2012;129(4):897-904.
13. Friedman JD, Reece GR, Eldor L. The utility of the posterior thigh flap for
complex pelvic and perineal reconstruction. Plast Reconstr Surg.
2010;126:146-155.
14. Sameem M, Au M, Wood T, et al. A systematic review of complication and
recurrence rates of musculocutaneous, fasciocutaneous, and perforator-based
flaps for treatment of pressure sores. Plast Reconstr Surg. 2012;130(1):67e-
77e.
SUGGESTED READING

Posthauer ME, Banks M, Dorner B, Schols JM. The role of nutrition for pressure
ulcer management: national pressure ulcer advisory panel, European pressure
ulcer advisory panel, and pan pacific pressure injury alliance white paper. Adv
Skin Wound Care. 2015;28(4):175-190.

31
CHAPTER
Tensor Fascia Lata Flaps for
Trochanteric Ulcers
Terri A. Zomerlei and Jeffrey E. Janis
DEFINITION
■ Trochanteric ulcers are common in chronically bed-bound patients who lie in
the lateral position.
■ Patient populations most at risk include those in acute care settings, nursing
home patients, paraplegic populations and those with hip flexion contractures.
■ In addition to unrelieved pressure, other contributing factors include
incontinence/moisture, friction/shear force, and altered sensory perception.
■ Characteristically, the appearance of the overlying skin only represents a small
portion of the affected tissue (“the tip of the iceberg”).
ANATOMY
■ The tensor fascia lata (TFL) is a thin, bandlike muscle located in the lateral
thigh just distal to the greater trochanter. It functions as a lateral knee stabilizer
(FIG 1).
■ Rectus femoris borders anteriorly
■ Biceps femoris borders posteriorly
■ Size: The muscle is 5 cm wide, 12 cm long, and 2 cm thick.
■ Origin: Anterior 5 cm of the lateral lip of the iliac crest and the lateral aspect
of the anterosuperior iliac spine (ASIS). A small portion also originates from
the greater trochanter.

FIG 1 • Lateral leg anatomy.
■ Insertion: The fascia lata is an extension of the TFL and inserts into the
lateral condyle of the tibia.
■ The aponeurosis of the superficial potion of the gluteus muscle, the
aponeurosis of the TFL and the fascia lata are commonly referred to as the
iliotibial tract.
• When the iliotibial tract is taut, the knee is held in extension.
• When tense, the iliotibial tract also stabilizes the hip and knee while
standing.
• Harvest of the TFL flap is associated with minimal functional morbidity.
■ The TFL flap is a type I muscle with one dominant pedicle, the lateral
circumflex femoral artery (LCFA).
■ The LCFA is a branch of the profunda femoris.
■ The LCFA passes deep to the sartorius and rectus femoris.

■ It gives rise to three branches: the ascending, the transverse, and the
descending branches that supply the superior, mid, and inferior portions of the
TFL respectively.
■ Two venae comitantes travel with the LCFA and join the femoral vein.
■ The TFL receives its motor supply from the superior gluteal nerve, which has
contributions from L4, L5 and S1. It enters the muscle in the middle third on
the posterior aspect.
■ The TFL sensory nerve supply is from the lateral cutaneous branch of T12,
which provides sensory innervation to the most superior aspect of the muscle
and its overlying skin.
■ The lateral femoral cutaneous nerve with contributions from L2 and L3
innervates the remaining portion of the skin and muscle.
PATHOGENESIS
■ Primary mechanism of pressure ulceration is cellular ischemia.
■ Tissue pressure higher than the pressure of the microcirculation (32 mm Hg)
causes ischemia.
■ If the ischemic period is long enough and repeated frequently, the eventual
outcome is tissue necrosis.
■ Pressure sores (decubitus ulcers) almost invariably occur in the tissue over
bony prominences in persons not able to change body position frequently.
■ Pressure sores overlying the greater trochanter are common in those with hip
flexion contractures who lie in the lateral position.
■ In acutely ill patients, third-space fluid pressure may mechanically
compromise the microvasculature.
■ Etiologic considerations can be divided in extrinsic and intrinsic factors.
■ Extrinsic factors: Primarily mechanical forces of the soft tissues
• Friction: Resistance that a surface encounters when moving over another.
Most often occurs with patient transfers
• Moisture: Incontinence can lead to skin breakdown.
• Pressure: Mechanical force that is applied perpendicular to a plane (ie,
between a bony prominence and a chair or bed)
• Shear: Mechanical stress parallel to the plane results in stretching and
compression of the blood supply to the muscles and skin.
■ Intrinsic factors: Patient factors that affect the soft tissues.
• Altered level of consciousness: Results in lack of voluntary movements and

protective reflexes that off-load pressure
• Anemia: Can result in fatigue and weakness which can contribute to and
perpetuate immobility. Also affects wound healing capabilities.
• Autonomic control: Decreased levels result in spasms, perspiration with
increased skin moisture, blood vessel engorgement and resulting tissue
edema, and problems with bowel and bladder control.
• Age: Increasing age is associated with increased skin friability and
decreased tensile strength.
• Infection: Profoundly impairs wound healing abilities
• Inflammation: Creates a hostile local milieu resulting in impaired healing,
especially in the setting of chronic wounds
• Malnutrition: Results in wasting and decreased muscle bulk and impairs
wound healing abilities
• Sepsis: Can result in decreased tissue perfusion and ischemia
• Sensory loss: Patient is unable to experience the discomfort associated with
prolonged pressure over prominences
NATURAL HISTORY
■ Pressure sores are categorized according to the National Pressure Ulcer
Advisory Panel Stages (NPUAP 2016).
■ Pressure sore can progress through the following stages if extrinsic and
intrinsic insults are not remedied (see FIG 2 in Chapter 29).1
■ Stage I: Intact skin with nonblanching erythema
■ Stage II: Partial-thickness skin loss with exposed dermis
• Presents as blister, abrasion, or shallow open ulcer
■ Stage III: Full-thickness skin loss
• Subcutaneous fat may be exposed.
• Tunneling and undermining may be present.
■ Stage IV: Full-thickness skin and tissue loss
■ Unstageable: Full-thickness skin or soft tissues loss but depth is unknown
usually due to the presence of an overlying eschar
■ Suspected deep tissue injury: Persistent deep red, maroon, or purple
discoloration of intact skin may indicate deep tissue injury that needs to
evolve prior to staging.
PERTINENT HISTORY AND PHYSICAL FINDINGS

The preoperative evaluation of patients with pressure ulcers includes a detailed
assessment of the patient’s medical history, social situation, baseline health
status, and a comprehensive wound evaluation.2
■ Patient history
■ How long has the ulcer been present? Acute wounds may respond to
conservative treatment while chronic wounds tend to be more recalcitrant.
■ What is the current wound care treatment? Changing local wound care
regimens may help with improving the wound.
■ What surgical options have been tried in the past? Obtain any and all
operative reports as previous surgeries may limit surgical options.
■ Is the patient ambulatory, wheelchair bound or bed bound?
■ What type of mattress and turning regimen is currently being used? Airflow
mattresses offer the best protection while normal mattresses offer little
defense against pressure.
■ Is fecal contamination a problem? A dressing or a temporary diverting
ostomy may be prudent.
■ Are there problems with urinary incontinence? Does the patient require
temporary or permanent urinary diversion?
■ Does the patient have spasms? Are their medications optimized to control
spasms?
■ Does the patient have any fixed contractures?
■ What is the baseline nutritional status of the patient?
■ Social history is crucial to obtain in order to understand possible postoperative
barriers to care and to prevent recurrence.
■ Social support/caregiver situation
■ Resources for obtaining durable medical equipment (low air loss bed, seat
cushion if bed bound or wheelchair bound)
■ Smoking or substance abuse history
• Active or prior nicotine use increases risk of poor wound healing.
• Consider urine cotinine testing.
■ Psychiatric illness
■ Diet, specifically amount of protein intake
■ Compliance history
■ Laboratory studies
■ Complete blood count to assess for anemia or active infection
■ Albumin, prealbumin, and total protein to assess protein stores

■ Coagulation panel to assess for coagulopathies
■ Cultures that should be obtained with tissue or bone biopsies as wound swabs
have little value due to chronic colonization. Cultures should be sent for
quantitative analysis and if the organism count is greater than 105,
consideration should be given to systemic antibiotics and/or staged
debridement and reconstruction
■ Urinalysis
■ Physical examination
■ All wounds must be examined manually.
■ Visual wound assessment alone is not sufficient to obtain necessary
information about a wound.
■ Manually assess the size and depth of the wound, bony prominences, bursa,
and presence of tunneling (may need to use long cotton tip applicator to assess
tunneling).
• If an eschar is present, the wound cannot be accurately staged.
• A limited bedside debridement is useful to stage the wound and to facilitate
local wound care preoperatively.
■ From visual inspection, take note of any previous surgical scars because
previous surgeries may preclude the use of a flap secondary to compromised
vascular supply.
■ Muscle tone and bulk are assessed, taking note of any spasticity or contraction
of the extremities.
■ Assess the patient’s sensation in the area of the wound.
IMAGING
■ MRI is recommended for all stage IV pressure ulcers to evaluate for
osteomyelitis.
■ T2 hypersensitivity and low-intensity T1 are sensitive and specific for
osteomyelitis.
■ CT scan or plain films have lower sensitivity but can be used if MRI not
available or patient condition precludes its use.3
DIFFERENTIAL DIAGNOSIS
■ Marjolin ulcer arising in a chronic wound
■ Burn
■ Soft tissue neoplasm with ulceration