(1)
Yotsuya Medical Cube, Chiyoda-ku, Tokyo, Japan
Basic Principles
Surgical treatment methods for pressure sores have undergone a number of changes over the years, from the use of a local flap to a musculocutaneous flap, then to a fascial flap and perforator flap, with methods chosen today that minimize loss of muscle. The reason behind this is that there is no guarantee that the use of muscle in a musculocutaneous flap is useful in preventing recurrence, and that there is no difference in the recurrence rate whichever surgical method is used. Therefore, the first option is always conservative therapy, and when selecting surgery, the method with the least invasion is chosen wherever possible.
Selectable Flaps and Surgical Procedures
Lumbosacral back flapGluteal musculocutaneous flapPosterior thigh flapGluteal perforator flapDistal based latissimus dorsi musculocutaneous flapTensor fascia lata musculocutaneous flapThe difficulty level of each surgical procedure is shown subsequent to the procedure title (e.g., Level of Difficulty: 2). The levels range from 1 to 5, with level 1 indicating a preliminary level and level 5 indicating a very advanced level.
13.1 Lumbosacral Back Flap (Level of Difficulty: 2)
Information
Vascular pedicle Dorsolateral branches of 3 & 4 lumbar artery.
Size A skin flap elevated from the middle of the back that exceeds the contralateral side by 4–5 cm still has good circulation.
Indication Sacral region pressure sore, congenital spina bifida.
13.1.1 Operation Procedures
Case 1
Fig. 13.1
Case 1: Procedure 1: For a superficial but broad skin defect across the sacral region, a lumbosacral flap that extends 4–5 cm across the contralateral side of the middle of the back was designed
Fig. 13.2
Procedure 2: This picture indicates the design for covering the skin defect after transferring the skin flap. It is all detached from beneath the fascia and transferred as a fascial flap. The dorsolateral branch of the lumbar artery is automatically included in the skin flap
Fig. 13.3
Procedure 3: Final appearance immediately after surgery
Case 2
Fig. 13.4
Case 2: Procedure 1: Lumbosacral flap and rotation flap are designed for the spina bifida case
Fig. 13.5
Procedure 2: A flap raised as a fascia flap containing deep fascia is transferred, and the wound closed. A continuous suction drain is inserted
Fig. 13.6
Procedure 3: A high standard reconstruction with sensation and skin texture is achieved
Note
Photo is 1 month after surgery.
13.2 Posterior Thigh Flap (Level of Difficulty: 3)
Information
Vascular pedicle Interior gluteal vessels accompanying the posterior thigh cutaneous nerve or the perforator from the deep femoral artery.
Size When using the skin flap as an island flap and rotating, if intending to temporarily conduct reefing it is possible to elevate a skin flap of about 8 × 25 cm. If using as a V-Y advancement flap, it is possible to raise the entire posterior surface of the thigh as the skin flap. It is also possible to create a combined flap together with the gluteal perforator flap.
Advantage The major axis of the skin flap is located in the center of the posterior thigh, and when elevating as a fasciocutaneous flap it is easy to confirm the neuro vascular pedicle. However, when using as a V-Y advancement flap, if it is possible to confirm several perforators, there is no need to identify the inferior gluteal vessels.
