Outcomes for Reconstruction of Sacral Defects Using Superior Gluteal Artery Perforator Flaps: Comparison with Random Pattern Fasciocutaneous Flaps

Anatomic characteristics and premorbid patient conditions make the reconstruction of sacral defects challenging. Although musculocutaneous flaps provide fewer postoperative complications, they do not provide additional advantages due to muscle atrophy over the long-term. The superior gluteal artery perforator (SGAP) flap offers preservation of muscle integrity with the same perfusion amount. Outcomes for the SGAP flap and its superiority over fasciocutaneous flaps were discussed.

Between 2002 and 2004, 8 patients with sacral defects were treated with 9 SGAP (bilateral in one patient) flaps. Pressure sores, suppurative hydradenitis, and pylonidal sinus were the indications for surgery. Four patients were paraplegic and the others were ambulatory. Flaps were designed on the most laterally localized, single perforator which was detected with hand-held Doppler preoperatively, and vascular pedicles were dissected down to the superior gluteal artery so as to provide a long pedicle. Eighteen other patients with sacral pressure sores were treated with random pattern fasciocutaneous rotation flaps.

Seven SGAP flaps healed uneventfully, 1 flap was lost due to total necrosis. No dehiscence, partial necrosis, infection, or sinus formation were seen. All donor sites but one were closed primarily. The mean hospitalization period was 6.3 days. No recurrences were detected after 13 months mean follow-up, and no limitation in muscle activity was seen in the ambulatory patients. However, mean hospitalization time for the fasciocutaneous flaps was 25 days. Dehiscence was seen in 7 of the patients and marginal necrosis was seen in 4 patients. The mean follow-p period was 13 months, and 3 patients had recurrence during this period. Postoperative complication rates and hospitalization time were significantly lower with the SGAP flaps (p< 0.005).

These flaps can be elevated safely on a single long perforator which provides easy inset and tension-free closure. Muscle integrity is preserved, so that postoperative activity is not impaired in ambulatory patients, and future reconstruction alternatives are preserved in case of recurrence. However, the dissection technique needs a relatively long learning curve, and a tedious dissection can be time-consuming at the beginning. Total necrosis was due to technical problems within the learning curve of this series.

With the discussed advantages, the SGAP flap provides a reliable and durable alternative among others.