Pressure sores are one of the most frustrating entities that a plastic surgeon is called on to treat. This is all the more true in patients with multiple bed sores because they require multiple procedures with multiple flaps. Sacral and ischial sores are the most common pressure sores in paraplegics. 1 Conventional methods of treatment have included using separate flaps for each site. This invariably leads to increased operating time and blood loss.
The gluteus maximus is one of the most reliable flaps for managing bed sores. It has been used successfully to manage both sacral and ischial sores. 2–5 Scheflan and colleagues 2 suggested that the gluteus maximus can be used to manage either sacral or ischial pressure sores. However, if both ischial and sacral pressure sores are present, one has to use more than one flap. I propose that the gluteus maximus can be used for concomitant closure of both these sores. It has been suggested that if only the upper or lower half of the gluteus maximus is used, there is no disability in an ambulatory patient. 6,7 On the contrary, use of the whole of gluteus muscle can be severely crippling in an ambulatory patient. However, in a paraplegic patient there is no such restriction, and the entire muscle can be used for this purpose. I present an innovation in the use of the gluteus maximus muscle in paraplegics in which only ipsilateral muscle is used for concomitant reconstruction of ischial and sacral pressure sores without unduly prolonging the operating time.
Anatomic Basis of the Technique
The gluteus maximus muscle can be divided arbitrarily into upper and lower halves by an imaginary line joining the midsacral point to the greater trochanter. The superior half is supplied by the superior gluteal artery (SGA) and the inferior half is supplied by the inferior gluteal artery (IGA). 8 These vessels arise above and below the piriformis. The musculocutaneous units are completely “islanded” and split into two halves, each supplied by their respective artery. Each of these halves can then be moved independently in different directions.
The pressure sores are adequately debrided and the bony prominences are removed as indicated. Surface marking of the SGA and IGA is performed. The SGA lies at the junction of the upper one third and the lower two thirds of a line joining the posterior-superior iliac spine to the top of the greater trochanter. The IGA is marked at a point halfway along a line drawn from the posterior-superior iliac spine to the ischial tuberosity (Figs A, C). The skin island is marked over the gluteus maximus, extending superiorly to the iliac crest, inferiorly to the gluteal fold, laterally to the greater trochanter, and medially to the paraspinal area. The skin incision is made along the marked flap and a deep cut is made down to the bone at the level of the greater trochanter. The insertion of the gluteus maximus is detached from this location using diathermy. The detached insertion is lifted, and a plane is developed deep to the muscle using finger dissection in this relatively bloodless area. The muscle is divided superiorly and inferiorly, and the dissection is continued deep to the gluteus maximus muscle. The SGA and IGA can be seen entering the muscle on the deeper aspect. The piriformis can also be visualized at this stage. The medial incision is now complete and the muscle is divided at its origin. There are numerous perforators that require careful dissection and cauterization. A line is marked joining the mid sacrum to the tip of the greater trochanter. The skin island is divided at this level into superior and inferior halves by incising along this line. Injury to the SGA and IGA can be avoided easily because they are clearly visible. The superior and inferior musculocutaneous units are now completely freed, attached only to the respective gluteal arteries (Figs D, E). The superior half is moved superomedially into the sacral defect and the inferior unit is moved inferomedially into the ischial defect. The donor area is closed primarily (Fig B).
The sacrum and ischium are the most common sites for pressure sores. 9 The treatment of pressure sores includes excision of the ulcer, underlying bony prominence, and bursae if any, and closure of the defect with a flap. 10,11 Recurrences were quite common until musculocutaneous flaps were introduced to treat such patients. 1,3
The gluteus maximus has been highly recommended for the management of both ischial and sacral bed sores. 2–5 However, previously described techniques allow closure of either one of these defects only. If both defects are to be managed, one has to use two flaps. It has been shown that the gluteus maximus can be used even in ambulatory patients because one “half” of the muscle is good enough for “function.”6,7 Paraplegic patients often have multiple bed sores, mainly ischial and sacral. In these patients, the entire gluteus maximus can be used for reconstruction. The muscle has enough bulk to obliterate the dead space and has a robust blood supply. I suggest that this muscle be used as two independent units, each with its own blood supply. Because these halves are completely islanded, they can be moved even in diametrically opposed directions (sacrum and ischium) easily. The donor area can be closed primarily in almost all patients. Because the vascular pedicles are left intact, they can again be “advanced” in case of recurrence of bed sores. The flaps could perhaps be extended beyond the muscle superiorly, above the iliac crest, because the dynamic territories of the SGA may extend well beyond the gluteus maximus, although I have yet to attempt this.
1. Disa JJ, Carlton JM, Goldberg NH. Efficacy of operative cure in pressure sore patients. Plast Reconstr Surg 1992; 89: 272–278
2. Scheflan M, Nahai F, Bostwick J. Gluteus maximus island musculocutaneous flap for closure of sacral and ischial ulcers. Plast Reconstr Surg 1981; 68: 533–538
3. Minami RT, Mills R, Pardoe R. Gluteus maximus myocutaneous flap repair of pressure sore. Plast Reconstr Surg 1977; 60: 242–247
4. Rajacic N, Gang RK, Dasti H, et al. Treatment of ischial pressure ulcer with an inferior gluteus maximus musculocutaneous island flap: an analysis of 31 flaps. Br J Plast Surg 1994; 47: 431–434
5. Prakash S, Banerjee S. The total gluteus maximus rotation and other gluteus maximus musculocutaneous flaps in treatment of pressure ulcer. Br J Plast Surg 1986; 39: 61–71
6. Ramirez OM, Hurwitz DJ, Futrell JW. The expansive gluteus maximus flap. Plast Reconstr Surg 1984; 74: 757–770
7. Ramirez OM, Orlando JC, Hurwitz DJ. The sliding gluteus maximus myocutaneous flap: its relevance in an ambulatory patient. Plast Reconstr Surg 1984; 74: 68–75
8. Cormack GC, Lamberty BG, eds. Arterial anatomy of skin flaps. Edinburgh: Churchill Livingstone, 1994: 336
9. Colen SR. Pressure sores. In: McCarthy JG, ed. Plastic surgery. Vol. 6. Philadelphia: WB Saunders, 1990: 3797–3838
10. Vasconez LO, Schneider WJ, Jurkiewicz MJ. Pressure sores. Curr Prob Surg 1977; 14: 1–5
11. Ger R, Levine SA. The management of decubitus ulcer by muscle transpositions: an eight year review. Plast Reconstr Surg 1976; 58: 419–424