Modified inferior gluteal artery perforator-based hatchet-shaped flap for reconstruction of trochanteric pressure sores 改良下臀動脈穿通枝皮瓣 用於重建股骨大轉子褥瘡 陳俊宇 曾元生 三軍總醫院外科部 整形外科

Case report A 79-year-old man Type 2 diabetes mellitus End-stage renal disease Hypertension Parkinsonism Chronic obstructive pulmonary disease Inferior wall myocardial infarction after coronary artery bypass grafting

Recurrent stage IV left trochanteric pressure sore

After debridement, an 88 cm defect was created

Inferior Gluteal Artery Perforator-based hatchet-shaped flap

The flap was designed with a diameter 1 The flap was designed with a diameter 1.5–2 times the longitudinal diameter of the defect and included more than one perforator Subfascial flap dissection to explore the selected inferior gluteal artery perforators The vessel was dissected out to approximately 0.5 cm in length rather than by skeletonization of the perforator.

The IGAPs was detected by handle Doppler probe.

Discussion Treatment of trochanteric pressure sores Local flaps are the first choice Musculocutaneous, fasciocutaneous, or perforator flaps. Rotation, advancement, or island flaps The most commonly used flaps for trochanteric sores Tensor Fascia Lata (TFL) flaps Pedicled anterolateral thigh (ALT) flaps

Disadvantages of Traditional TFL flaps Wound coverage with the most distal and poorly vascularized portion of the flap Dog-ear deformity in the lateral thigh Primary repair of the donor area usually requires closure under extensive tension

Disadvantages of Pedicled ALT flaps Closure of the donor site generally requires skin grafting if the wound diameter is > 7 cm Lower recurrence rate, but needed a longer operative time than hatchet-shaped TFL flaps ALT flaps are not suitable for critically ill patients

Modified hatchet-shaped technique Combined the advantage of Fasciocutaneous flaps More durable and less susceptible to ischemia than myocutaneous flaps Perforator flaps Reliable wound coverage Without sacrificing muscle tissue

Obliterate the cavity without tension Skin flaps measuring about 1110 cm could be well vascularized by one perforator Major advantages over the V–Y advancement technique with less blood loss, shorter operating times, safer circulation

Insert the most proximal and well-vascularized portion of the flap into the bony defect area Decrease complication rates compared with true perforator flap techniques

Advantages of a flap derived from the gluteal region Minimizes donor site morbidity Sparing the gluteal muscle Primary closure of the donor site Avoids maximal pressure zones over bony prominences

Conclusion The modified IGAP flap procedure Simple and fast operation Avoids sacrificing muscle Improves the safety of circulation Closure of the donor site is simpler It serve as an acceptable alternative for the surgical repair of trochanteric pressure sores.