1. Perforator Flaps for Reconstruction of Sacral Defects
林進達 王志信 曾元生 戴念梓 陳錫根 陳天牧
三軍總醫院 外科部 整形外科
March 19th, 2017 外科醫學會

2. Introduction
A pressure ulcer is a localized area of damage to the skin and/or underly ing tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. 

3. Staging Stage I (nonblanchable erythema).
Stage II (breakdown of dermis).
Stage III (full- thickness skin breakdown).
Stage IV (bone, muscle, and supporting tissue involved).

4. Staging

5. Most cases: VY flap

6. Patients & Methods
Between April 2004 and March 2014, 60 patients with sacral wounds causing by pressure sores or infected pilonidal cysts underwent surgical reconstruction with perforator flaps.
We retrospectively analyzed: group1, 30 patients with superior gluteal artery perforator flaps; group 2, 19 patients with parasacral perforator flaps; group 3, 11 patients with inferior gluteal artery perforator flaps.

7. Group1, 30 patients with superior gluteal artery perforator flaps

8. Patient
Sex/ Age (year)
Cause of sacral defect
Flap size (cm2)
Ultilization
Outcome
Follow up period (m) 1
M/22
Infected pilonidal cyst
168
Rotation
Good 20 2
M/28
108
Wound edge dehiscence 22 3
M/48
Oral cancer, bed ridden 42
Tunnel 12 4
M/55
Laryngeal cancer, bed ridden 72 15 5
M/62
ICH, bed ridden 56 24 6
F/66 60 7
M/68
Stroke, bed ridden 45
Partial flap necrosis 8
F/72
Dementia, bed ridden 66 18 9
M/73 96 10
F/73 14 11
M/75 90 13
M/76
165
F/77
117
F/79 16
F/80 17
M/80 84
F/81 19
F/82
Parkinson’s disease, bed ridden 70
M/83
136 21
F/83 23
M/87
F/88 25
F/89 63 26
M/92
154 27
Leukemia, bed ridden 80 28
M/50 88 29
HIVD, bed ridden 30
M/78
120

10. Superior gluteal artery perforator flaps

11. Superior gluteal artery perforator flaps

12. Superior gluteal artery perforator flaps

13. Superior gluteal artery perforator flaps

14. Lin CT, Chang SC, Chen SG, Tzeng YS
Lin CT, Chang SC, Chen SG, Tzeng YS. Modification of the superior gluteal artery perforator flap for reconstruction of sacral sores. J Plast Reconstr Aesthet Surg Apr;67(4):

15. Group 2, 19 patients with parasacral perforator flaps

16. Rotation angle (degree)
Patient
Sex/ Age (year)
Cause of sacral defect
Flap size (cm2)
Rotation angle (degree)
Outcome
Follow up period (m) 1
F/22
Infected pilonidal cyst 42
180
Good 12 2
M/28 20 3
F/47
Stroke, bed ridden
192
MRSA infection, flap necrosis 18 4
M/56 48 90 5
F/58
Cerebral palsy, bed ridden 84 22 6
M/68 54 7
M/73
Parkinsonism, bed ridden
121
Dehiscence of wound edge 8
F/75
Dementia, bed ridden 70 9
M/76
Brain tumor, bed ridden
108 24 10
F/77 14 11
M/77
120
F/79
160 16 13
F/80 60 75
M/80
135 15
F/82
T spine fracture, paraplegia
156
F/85
168 17
M/89
M/78 19
M/30

17. Group 2, 19 patients with parasacral perforator flaps

18. Group 2, 19 patients with parasacral perforator flaps

19. Group 2, 19 patients with parasacral perforator flaps

20. Group 2, 19 patients with parasacral perforator flaps

21. Lin CT, Chen SY, Chen SG, Tzeng YS, Chang SC
Lin CT, Chen SY, Chen SG, Tzeng YS, Chang SC. Parasacral Perforator Flaps for Reconstruction of Sacral Pressure Sores. Ann Plast Surg Jul;75(1):62-5.

22. Group 3, 11 patients with inferior gluteal artery perforator flaps

23. Patient
Age/Sex (year)
Cause of sacral defect
Flap size(cm)
Ultilization
Outcome
Follow up period (m) 1
49/F
Old stroke
121
Tunnel
Good 12 2
82/M 91 18 3
85/M
110
Rotation 20 4
68/M
Parkinsonism 56 5
55/M 96
Donor site wound dehiscence 22 6
68/F 80
Total flap necrosis, converted to VY advancement flap 7
78/M 84 16 8
72/M 72 9
44/M
CO intoxication 24 10
69/M 70 11
67/F

24. Group 3, 11 patients with inferior gluteal artery perforator flaps

25. Group 3, 11 patients with inferior gluteal artery perforator flaps

26. Group 3, 11 patients with inferior gluteal artery perforator flaps

27. Group 3, 11 patients with inferior gluteal artery perforator flaps

28. Group 3, 11 patients with inferior gluteal artery perforator flaps

29. Lin CT, Ou KW, Chiao HY, Wang CY, Chou CY, Chen SG, Lee TP
Lin CT, Ou KW, Chiao HY, Wang CY, Chou CY, Chen SG, Lee TP. Inferior Gluteal Artery Perforator Flap for Sacral Pressure Ulcer Reconstruction: A Retrospective Case Study of 11 Patients. Ostomy Wound Manage Jan;62(1):34-9.

30. However………
Can we always trust the Doppler?

31. Modified incision

32. Indocyanine Green SPY® Fluorescence Imaging System
ICG is a water soluble dye, which binds to plasma proteins and is excreted into bile.
Tissue perfusion can be monitored intraoperatively via a imaging device that relies on indocyanine green (ICG) and infrared camera– computer system (SPY ®) 8X
ICG for cardiac output and liver function in US in 1959
ICG for ophthalmic angiography in 1975

33. SPY in cancer-related surgery
Sentinel lymph node (SLN) mapping
Intraoperative identification of solid tumors
Angiography during reconstructive surgery

34. ICG Preparation

35. For Reconstruction

36. Schematic drawing of stages of operation
(A) Draw the hypothetic line between PSIS and GT. (B) Locate point S with intraoperative ICGFA. Debride the wound and design the SGAP flap (C) Elevated the modified SGAP flap and rotate to cover the sacral defect, donor site closed primarily

38. Patients & Methods (2015~2016) Patient No. Sex/Age
Cause of bed-ridden status
Flap Size( cm2)
Major perforator detected
Quadrant of perforator
Rotation angle (degree)
Outcome 1
F/74
Dementia 90 3 70
Good 2
F/73
strorke
108
110
M/72
Spinal cord injury 96 4 60
M/75 80 5
M/91
Fracture of femoral intertrochanter
120 6
M/76
105
1,2
100 7
F/84
ICH 85 8
F/77
117 9
M/74 72
3,4 75 10
M/83
Parkinson's disease
125 11
M/80
136 12
M/92
124 13
150 14
M/50 88 95 16
Hypoxemic encephalopathy
104
Wound edge dehiscence
F/72
HIVD 17
M/84 18
M/78
115 19
F/85
135

39. Distribution of ICGFA detected major perforators

40. Patient 9

41. Patient 11

42. Thanks for your attention

43. Most cases: VY flap recurrence, design bigger VY flap