Using the Gluteal Artery Perforator Flap to Reconstruct Sacral Sore

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Initial surgical management of sacral sores begins with debridement. This procedure is one of the key steps, as it removes infected, necrotic, desiccated bone/soft tissue, and prepares the wound for further reconstruction. In this video, we used surgical options such as wide excision and a hydroject debridement device (see video, Supplemental Digital Content 1, which shows important steps in using a gluteal artery perforator flap to reconstruct sacral sores. This video is available in the Related Videos section of the Full-Text article on or available at
Reconstruction can be performed immediately after debridement or may be done after staged debridement until relevant risk factors are improved. Flaps are usually the choice of reconstruction in deep ulcers, as the vascularized tissue will facilitate wound healing and provide padding to redistribute pressure over the sacrum. Common options for sacral pressure ulcers include musculocutaneous and fasciocutaneous flaps. They have advantages; but when the margin of the closure is in the midline of the defect, high rate of recurrence over the bony prominence may be seen.
The concept of perforators has allowed a new dimension in reconstructive surgery. A perforator flap has the vascular supply for the skin island from a single perforator penetrating the deep muscle fascia.1 The propeller flap is a local island skin flap based on a perforator and is intentionally rotated based on this single perforator, resulting in effective transposition.2 By designing with accuracy, this perforator-based propeller flap can be used locally to cover defects of the sacrum without sacrificing any muscle, providing sufficient bulk to pad the sacral bone while closing the donor site primarily. Because any perforator can be used as a flap, the free style flap leads to flexible design of propeller flaps, enhancing the chance for prompt reconstruction.3 A hand-held Doppler can be used to preoperatively identify possible perforators. After debridement, one should reassess the perforator and start to explore the perforator with an exploratory incision. Physically identifying the perforator with a strong pulse is a key step. Subfascial approach usually makes the identification easier compared with the other layers of elevation. After the identification, a final design of the flap as a freestyle flap is made.4 One can mark the hot zone of the flap around the perforator and rapidly elevate the outer cold zone on the subfascial layer. Once the hot zone is reached, a meticulous approach should be made to dissect the perforator. More dissection or a near-skeletonized perforator with longer pedicle will allow you to have a better rotation without kinking from surrounding tissues.
Using the propeller flaps to reconstruct the sacral region in a free style approach can achieve tension-free closure, padding over the bony prominence, primary closure of the donor site, minimal muscle sacrifice, and coverage with a well-vascularized tissue.
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