Multidimensional Use of Pedicled Gluteal Artery Perforator Flaps in Perianal and Gluteal Regions

Introduction: Before the concept of the perforator flap, methods such as secondary intention, grafting, primary closure, random pattern transposition, and rotation flaps had been used to treat these wounds such as pilonidal sinus and hidradenitis suppurativa and pressure sores. In this report we have presented ten patients received operations because of wounds in the perianal and gluteal regions.

Methodology and Material: Patients with pilonidal sinus and hidradenitis who at our clinic with open wound mass in the gluteal regions between dates August 2011 and August 2013 were included in the study. One patient was operated on for neurofibroma. Before the operation, perforators around the wound were revealed during photography by using the manual 8 MHz Doppler. Postoperative comfort was increased by administering an enema one night prior. The procedure was performed under spinal anesthesia in all patients.

With the flap planned to be approximately the size of the area of the defect in the region where perforators were marked, local anesthesia was inducted at incision borders. The wound area was excised radically until healthy subcutaneous tissue was reached. An SGAP or IGAP flap was planned adjacent to the defect area to be formed by a rotational arc to the area of perforators. An incision was started at the near border of the wound area. The flap was elevated in the subfascial plane while preserving the perforators previously marked by the manual Doppler. The subfascial plane was a safe level for identifying the perforators, and to dissect them precisely. Localization of the perforators during dissection was made easier by translumination at set intervals while advancing parallel to muscle fibers. Perforators were skeletalized in the four operations. In the other operations, perforators were not skeletalized, allowing for a comfortable and tension free transposition to the wound. If the flap did not come into contact with subcutaneous tissues completely when the defect border was transposed, then dissection proceeded again. When the outflow was below 30 ml/day, the drainage was removed. During the postoperative period, clear diet and oral diphenoxylate and atropine were administered for 3 days to prevent fecal contamination. Patients received first generation cephalosporins intraoperatively and postoperatively, and the drug was stopped on the fifth postoperative day.

Consultations to recommend general surgery were conducted with two patients with perianal region excision.

Results: A total of 9 patients received operations because of wounds in the perianal and gluteal regions. All patients but one were males. The age of the patients ranged between 20 and 75 years (mean of 46 years). After the excision, lesion dimensions were between 5x6 cm and 18x27 cm (mean of 12x17 cm). A total of 14 flaps were performed on 9 patients; four of these were IGAP, 9 were SGAP and one was a biceps femoris muscle transposition flap.

Six patients were treated by double flaps. The mean duration of the procedure was 1.5 hours (the duration for the first two flaps was 2 hours), and mean duration of follow up was 18 months (12-24 months). All patients were operated on by the same surgeon. SGAP and biceps muscle advancement were performed on one patient, and primary repair was performed on one patient. Six patients had pressure ulcers; one patient had burn contracture repairment; one patient had nevus sebaceous; two patients had pilonidal sinus; and one patient had stage 3 sacral hidradenitis. Two flaps performed on one patient failed because of venous insufficiency, and a second SGAP was revised with a transposition flap and grafting. One patient stated that he was operated on 14 times in 5 years for pilonidal sinus; the SGAP did not adhere to the background, so inferior dehiscence developed. As he did not respond to primary repairs, the repair was completed without any problem by a second SGAP flap from the opposite side (Table 1).

Conclusions: Pedicled gluteal artery perforator flaps are quite useful in the repair of wounds in the gluteal region caused by any reason such as pressure ulcer, pilonidal sinus or hidradenitis. In particular, adequately large excision of pilonidal sinuses without any apprehension concerning closure will reduce the recurrence risk to a great extent. This contributes to the preservation of muscle flaps for later procedures to treat commonly encountered wounds in this region, such as pressure ulcers.