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The Butterfly Design as an Alternative to the “Double-A” Bilateral Flaps for the Treatment of Large Sacral Defects


Prado, Arturo M.D.

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Plastic and Reconstructive Surgery: April 2008 - Volume 121 - Issue 4 - p 1514-1515
doi: 10.1097/01.prs.0000305368.14393.72
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I truly appreciate Weum and de Weerd’s communication. It is interesting that the authors add to Conway and Griffith’s 1956 principles for the management of pressure sores, that “whenever possible, protective sensibility should be provided as well”; this statement should be attributed to Kroll and Rosenfield for their article “perforator flap sensibility concept.”1

The butterfly design based on two lumbar perforator arteries was published in 2002 and is unique.2 The authors should then have at least a 5-year follow-up, a number of cases, and a rate of complications that we should be aware of before attempting this surgery, as I believe that this design should be used in selected cases (also shared with the double-A flap concept) with advance knowledge of the failure rates of a single perforator living flap.

The blood supply reliability of the double-A flaps is based on evidence,3 as each gluteal area originating from intact superior and inferior gluteal arteries will have 20 to 25 perforators for each side, as described by Koshima et al.4

Arturo Prado, M.D.

School of Medicine

Postgraduate School

Plastic Surgery

Hospital Jose Joaquin Aguirre

University of Chile

Santiago, Chile


1. Kroll, S. S., and Rosenfield, L. Perforator-based flaps for low posterior midline defects. Plast. Reconstr. Surg. 81: 561, 1988.
2. De Weerd, L., and Weum, S. The butterfly design: Coverage of a large sacral defect with two pedicled lumbar artery perforator flaps. Br. J. Plast. Surg. 55: 251, 2002.
3. Prado, A., Ocampo, C., Danilla, S., Valenzuela, G., Reyes, S., and Guridi, R. A new technique of “double-A” bilateral flaps based on perforators for the treatment of sacral defects. Plast. Reconstr. Surg. 119: 1481, 2007.
4. Koshima, I., Moriguchi, T., Soeda, S., Kawata, S., Ohta, S., and Ikeda, A. The gluteal perforator-based flap for repair of sacral pressure sores. Plast. Reconstr. Surg. 91: 678, 1993.

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