Sacral defect reconstruction using a sensate superior gluteal artery perforator flap based on the superior cluneal nerves: A report of two cases

Abstract

The superior gluteal artery perforator (SGAP) flap is a widely used flap for sacral reconstruction. However, it is non‐sensate flap and sensory loss is one of the most important risk factors for pressure ulcer development and recurrence; therefore, a sensate SGAP flap would be ideal for the reconstruction. Because the upper buttock is innervated by the superior cluneal nerves (SCNs) which originate from Th11 to L4, a sensate SGAP flap based on SCNs is anatomically possible. Herein, we present a novel sensate SGAP flap based on SCNs for reconstruction of sacral defects. Two patients with a sacral defect underwent reconstruction using a sensate SGAP flap (53 and 56 years old, both men). Diagnoses were sacral spindle cell sarcoma and sacral pressure ulcer. The defect sizes were 16 × 13 and 12 × 11 cm. The flap was designed based on the locations of SCNs which are commonly located at 6–8 cm lateral from the midline at the iliac crest. Flap sizes were 16 × 9 and 15 × 13 cm, respectively. The flaps survived completely in both cases. Flap sensation was observed immediately after surgery except in flap margins. However, sensory recovery occurred in these areas as well several months postoperatively. None of the patients developed postoperative pressure ulcers during the follow‐up period of 37 and 13 months. This method may preserve flap sensation and therefore can contribute to reducing the risk of postoperative pressure ulcers and could be a useful option for sacral reconstruction.

A Guide to Perforator Flap Selection for Buttock Pressure Sore Reconstruction

“…The superior gluteal artery shows fixed anatomical marks, low variation, convenient location, and rich blood supply, which provides an anatomical basis for the wide clinical application of the perforator flap 6 . Therefore, the superior gluteal artery perforator flap has been used in various forms to repair ischial and sacral pressure ulcers 24,28–30 …”

“…6 Therefore, the superior gluteal artery perforator flap has been used in various forms to repair ischial and sacral pressure ulcers. 24,[28][29][30] In our study, a superior gluteal artery perforator flap was recommended to repair pressure ulcers in the central region, which could be in the form of island clockwise or counterclockwise rotation or V-Y advancement, and the donor site was sutured directly. In some cases, when a single perforator flap is insufficient because of excessive tension at the donor site, 2 or even multiple perforator flaps can be used and assembled, effectively distributing the tension among multiple flaps for repair.…”

Reconstruction of recalcitrant pressure ulcers with latissimus dorsi muscle‐splitting free flaps

“…The posterior divisions of the lateral cutaneous branches of the intercostal nerves can be included in thoracodorsal artery perforator flaps and used for neural coaptations (Lin et al, 2009). Harvested nerves can have coaptation with the superior cluneal (Iida et al, 2021) or sacral nerves (Cheong et al, 2005), also known as sensory nerves that innervate the buttock area. However, considering that most of the recalcitrant sore patients are paraplegia due to cord injury, sensory innervation should be restored through microsurgical coaptation between a flap and a sensory nerve located cranial to the level of injury (Zwanenburg et al, 2021).…”

“…In addition to the above advantages, the LD musculocutaneous flap can also be used as a sensate flap. It is well known that the sensate flap for sacral sore is very useful surgical option to prevent pressure ulcer recurrence and delayed wound healing (Iida et al, 2021). The posterior divisions of the lateral cutaneous branches of the intercostal nerves can be included in thoracodorsal artery perforator flaps and used for neural coaptations (Lin et al, 2009).…”

Sensate superior gluteal artery perforator flap for reconstruction of sacrococcygeal large wound dehiscence: A case report and literature review

“…Although the free SCN‐innervated SGAP flap has been already reported for breast reconstruction (Blondeel, 1999), there is few previous report on the pedicled SCN‐innervated SGAP flap for sacral ulcer reconstruction. Iida et al reported SGAP flap based on SCNs (Iida et al, 2021). Their concept is the same as ours; however, there are some differences.…”