RECONSTRUCTIVE

Anatomical Basis and Clinical Application of the Infragluteal Perforator Flap

Oliver Scheufler, M.D. Jian Farhadi, M.D. Steven J. Kovach, M.D. Sebastian Kukies, M.D. Gerhard Pierer, M.D., Ph.D. L. Scott Levin, M.D. Detlev Erdmann, M.D., Ph.D.
Basel and Nottwil, Switzerland; and Durham, N.C.

Background: When selecting flaps for coverage of pressure ulcers of the sacrum and perineal region in paraplegic patients, long-term high recurrence rates should be considered. Therefore, the authors developed an infragluteal perforator flap to avoid burning bridges for future reconstruction. Methods: Infragluteal perforator flaps were dissected in five fresh human cadavers to define the anatomy of the cutaneous branches of the descending branch of the inferior gluteal artery and cluneal nerves and define anatomical landmarks for clinical application. In a series of 13 paraplegic patients, the authors used perforator-based flaps (additional skin bridge) to cover four perineal ulcers and one sacral ulcer and perforator flaps to cover six perineal and two sacral ulcers. Donor sites were closed by direct approximation. Results: Twelve of 13 flaps healed uneventfully. In all cadaver and clinical dissections, one or two cutaneous branches of the descending branch of the inferior gluteal artery and one or two cluneal nerves were found at the lower border of the gluteus maximus muscle supplying the infragluteal perforator flap. These direct cutaneous branches allowed dissection of inferior gluteal perforator flaps with improved flap mobility compared with the perforator-based flaps. The descending branch of the inferior gluteal artery could always be spared for future flaps. Conclusions: The infragluteal perforator flap is a versatile and reliable flap for coverage of ischial and sacral pressure sores. It can be designed as a perforatorbased or perforator flap and could provide a sensate flap in ambulatory patients. Donor-site morbidity is minimal, and options for future flaps of the gluteal and posterior thigh region are preserved. (Plast. Reconstr. Surg. 118: 1389, 2006.)

ressure sores frequently occur in hospitalized patients, geriatric patients, and paraplegics.13 Currently, an estimated 500,000 patients are affected by pressure sores annually in the United States, amounting to a financial burden of up to $7 billion. In a statistical evaluation of 14 treatment centers in the United States, the global incidence of pressure ulcers in 3322 paraplegic patients was approximately 30 percent, ranging from 16 to 37 percent among the different centers.2 Immobility, incontinence, altered level of consciousness, and impaired nutritional status are major risk factors for pressure sores.3 External factors such as presFrom the Department of Plastic, Reconstructive, and Aesthetic Surgery, University Hospital of Basel; Swiss Paraplegic Center; and Division of Plastic, Reconstructive, Maxillofacial, and Oral Surgery, Duke University Medical Center. Received for publication May 31, 2005; accepted August 24, 2005. Copyright 2006 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000239533.39497.a9

sure, shearing forces (friction), and moisture (maceration), and intrinsic predisposing factors such as ischemia, anemia, hypoalbuminemia, diabetes mellitus, and peripheral arterial occlusive disease contribute to the pathogenesis of pressure sores.4 Geriatric patients and paraplegics are at significantly increased risk of developing pressure sores.5 In a large, prospective, crosssectional study, the prevalence of pressure sores in 10,222 postmortem examinations was found to be 11.2 percent.6 A multicenter study with participation of 116 facilities from 34 U.S. states investigating 17,560 patients from medicalsurgical or intensive care units reported a prevalence of pressure sores in 7 percent of cases during an average hospital stay of 5 days.7 Although in the geriatric population pressure ulcers most frequently affect the sacrum, the ischial tuberosity is the site of predilection in paraplegics, followed by the trochanteric region and the sacrum.8 Because of the high recurrence rate of pressure sores in paraplegic and tetraplegic patients,

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the possibility of future reconstructive procedures should be considered during flap selection. A multitude of local flaps from the posterior thigh and gluteal region have been described that include simple skin flaps,9 12 fasciocutaneous flaps based on distinct axial vessels,13 muscle flaps,14 and myocutaneous flaps.1519 Recently, perforator flaps have been introduced as a valuable option.20,21 The gluteal thigh flap was first described by Hurwitz in 1980.22 Its blood supply is based on the subfascial descending branch of the infragluteal artery and its sensory innervation is from the posterior cutaneous nerve of the thigh. The flap can be elevated as a sensate compound myocutaneous flap or a direct fasciocutaneous flap.23 It has been described as a rotation or transposition flap and an island pedicled flap for coverage of groin, perineal, sacral, trochanteric, and ischial defects2229 and as a free flap for coverage of distant defects.30,31 Until recently, the gluteal thigh flap has served as the flap of first choice for ischial pressure ulcers at the Swiss Paraplegic Center at Nottwil, where all patients enrolled in this study were treated. Some of its limitations have stimulated the evolution of the infragluteal perforator flap as described below. fascial plexus nourished by the inferior gluteal artery and the first and second perforators of the profunda femoris artery has been confirmed by other authors.12,3335 The inferior gluteal artery exits the pelvis through the infrapiriform aperture and supplies the lower two-thirds of the gluteus maximus muscle and the overlying skin by numerous musculocutaneous perforators.22,33,35 Its descending branch enters the posterior fascia of the thigh at a point midway between the greater trochanter and the ischium at the inferior border of the gluteus maximus muscle, where it sends off a cutaneous branch that courses around the inferior border of the gluteus maximus, perforates the fascia lata, and penetrates the subcutaneous tissue.22,36 The descending branch of the inferior gluteal artery accompanies the posterior femoral cutaneous nerve at the subfascial level in the groove between the semitendinosus and biceps femoris muscles.12,32 Branches of the circumflex femoral arteries and the obturator artery ultimately combine with musculocutaneous perforators of the inferior gluteal artery and the first and second profunda femoris arteries to complete the cruciate anastomosis.12,22,3234,37 Even if the descending branch of the inferior gluteal artery is absent, the confluence of these anastomoses in the fascial plexus of the posterior thigh will provide adequate perfusion of a proximally based gluteal thigh flap.12,32,38 The venous drainage of the gluteal thigh flap is also redundant and is provided by the venae comitantes of the descending branch of the inferior gluteal artery, the profunda femoris perforators, and a superficial subcutaneous venous system. In the proximal thigh, a subcutaneous vein may drain medially into the saphenous vein. Because of the abundant drainage, venous congestion rarely develops in peninsular flaps of the posterior thigh but may occur in island flaps when the descending inferior gluteal vascular pedicle is hypoplastic or absent.32

ANATOMY
The inferior gluteal artery varies considerably in size, and its descending branch has been reported to be inconsistent (Table 1). A poorly developed inferior gluteal artery may be inadequate as the sole blood supply for an island pedicled flap. In such instances, Walton et al.32 advised that the proximal perforating arteries of the femoral system be preserved. They assumed a dual blood supply of the posterior thigh skin with a subfascial plexus created by the descending branch of the inferior gluteal artery and a fascial plexus lying above the deep fascia that is fed by musculocutaneous perforators of the femoral and obturator arteries or the inferior gluteal artery. An extensive

Table 1. Prevalence of the Descending Branch of the Inferior Gluteal Artery

Authors Hurwitz et al. Cormack and Lamberty Frick et al. Paletta et al. Rubin et al. Walton et al. Windhofer et al.
IGA, inferior gluteal artery.

Year of Publication 1981 1985 1993 1993 1995 1998 2002

No. of Cadavers/Specimens 8/16 50/100 10/20 10/20 10/20 Not known 59/118

Prevalence of Descending Branch of the IGA (%) 100 25 100 100 0 66 91

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The posterior femoral cutaneous nerve supplies the skin of the inferior gluteal, perineal, and posterior thigh regions and is composed of several fascicles, where it exits the lower portion of the sciatic foramen with the inferior gluteal vessels. The fascicles converge to form a common trunk that joins the descending branch of the inferior gluteal artery and frequently lies medial to the artery.32 Cadaver dissection studies of Windhofer et al.36 revealed that the nerve joins the descending branch of the inferior gluteal artery in a common connective tissue sheath in 72 percent of specimens and loops around the artery in 29 percent of cases. Three or four sensate cutaneous branches of the posterior femoral cutaneous nerve, namely, the inferior cluneal nerves, course around the lower border of the gluteus maximus muscle.36 Walton et al.32 and Hurwitz39 reported absence of the descending branch of the inferior gluteal artery in 25 to 33 percent of cases. Although a pedicled flap would receive adequate blood supply from the cruciate anastomosis, a gluteal thigh free flap would be precluded. Therefore, Hurwitz39 cautioned against microsurgical transfer of the gluteal thigh flap, and Monstrey et al.31 discouraged its use even after a successful lower limb reconstruction with a large gluteal thigh free flap. However, in a cadaver dissection study, Windhofer et al.36 found a descending branch of the inferior gluteal artery in 108 of 118 specimens (91.5 percent) that constantly gave rise to a cutaneous branch coursing around the lower border of the gluteus maximus muscle. In 10 of 118 specimens (8.5 percent), the cutaneous branch derived from the medial or lateral circumflex femoral artery (n 5) or from a perforator of the profunda femoris artery (n 5). A single cutaneous branch was found in 37 cases (31.4 percent), two branches in 69 cases (58.5 percent), and three branches in 12 cases (10.1 percent). These data indicate that the descending branch of the inferior gluteal artery is present more often than previously assumed and that cutaneous branches supplying the distal gluteal and proximal posterior thigh skin are constantly identified.35,36 Based on these findings, Papp et al.40 used the infragluteal free flap for reconstruction of Achilles tendon defects in seven cases. Although they did not report the number of cutaneous branches, a flap survival rate of 100 percent supports the reliable nature of these branches. Similar to the flap design of Frick et al.35 and Papp et al.,40 we propose that an infragluteal perforator flap can be raised on these cutaneous branches for reconstruction of perineal and sacral defects, with minimal donor-site morbidity.

MATERIALS AND METHODS

Fresh human cadaver dissections were carried out in the Fresh Human Tissue Laboratory, Duke University Medical Center, Durham, North Carolina. All clinical cases were performed at the Swiss Paraplegic Center, Nottwil, by the first author (O.S.). Anatomical Study Bilateral dissections of a septocutaneous infragluteal perforator flap based on the cutaneous branch of the inferior gluteal artery were performed in three specimens. After identification of the inferior gluteal artery using a paramedian incision, the vessel was transected and cannulated. Sixty milliliters of colored liquid latex was injected into each main vessel. In one cadaver, the inferior gluteal artery of the right side was not available for study. In the remaining cadavers, the inferior gluteal artery latex injection was successful, with complete filling of the vascular territories. Latex was allowed to harden for 48 hours before flap dissection. The flap territory was outlined at the inferior margin of the gluteus maximus muscle, marked between the apex of the sacral bone and a point 8 to 10 cm below the greater trochanter, and centered over a point midway between the ischial tuberosity and the greater trochanter according to the expected position of the descending branch of the inferior gluteal artery (Fig. 1). Flap elevation started from the inferolateral flap margin with incision of skin, subcutaneous tissue, and deep fascia. Subfascial flap dissection proceeded in the superomedial direction guided by the inferior border of the gluteus maximus muscle. The descending branch of the inferior gluteal artery accompanied by the posterior femoral cutaneous nerve was identified, running in the groove between the biceps femoris and semitendinous muscles. The cutaneous branch of the descending branch of the inferior gluteal artery and adjacent inferior cluneal nerves were identified and isolated at the lower border of the gluteus maximus muscle near the midline of the posterior thigh, supplying the skin of the inferior gluteal and infragluteal region. Flap dissection continued from the superomedial flap margin, until the fasciocutaneous skin island was isolated on its neurovascular pedicle. Additional myocutaneous branches that could serve to supply the flap were marked (Fig. 2). Clinical Study Thirteen patients (11 men and two women) with pressure ulcers (nine primary and four re-

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Fig. 1. Anatomical basis and landmarks of the infragluteal perforator ap.

tuberosity (n 9), the sacrum (n 3), and the intertrochanteric region (n 1). The diameter of the ulcer at the time of closure ranged from 25 to 64 cm2 (mean, 44.6 14.2 cm2). All pressure ulcers were classified as grade 4A or 5A according to the classification of Daniels41 and Seiler42 (Tables 2 and 3), indicating clean granulated ulcers involving skin, subcutaneous tissue, fascia, and muscle, without or with involvement of the underlying periosteum and bone. Staged soft-tissue reconstruction was attempted after radical wound debridement and subsequent wound conditioning by wet gauze dressings or the VAC System (Kinetic Concepts, Inc., San Antonio, Texas). Thereby, ulcers were converted from necrotic and infected wounds (grades B and C) into clean and
Table 2. Daniels Surgical Classication of Decubitus Ulcers*
Fig. 2. Dissection of the infragluteal perforator ap on the left side in cadaver 1. The cutaneous branch (cb, blue loop) of the inferior gluteal artery, the inferior cluneal nerve (cn, yellow loop), and the myocutaneous perforators (mp) of the inferior gluteal artery (blue strips) are marked. Grade 1 2 3 4 5 Clinical Signs Fixed erythema Superficial skin ulceration (corresponding to second-degree burn) Infiltration of subcutaneous tissue Deep ulceration involving subcutaneous tissue, fascias, and muscle, sparing of periosteum and bone Deep ulceration involving bone and joints, infiltration into pelvic organs including urethra, rectum, and vagina

current) of the perineal and sacral regions underwent soft-tissue reconstruction using local flaps from the gluteal and infragluteal regions. The median patient age was 47 years (range, 33 to 68 years). Unilateral ulcer location was at the ischial

Data from Daniels, R. K., Hall, E. J., and MacLeod, M. K. Pressure sores: A reappraisal. Ann. Plast. Surg. 3: 53, 1979.

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Table 3. Seilers Classication of Decubitus Ulcers
Grade A B C Clinical Signs Clean, granulated wound without necrosis Necrotic wound without inflammation Necrotic wound with perifocal inflammation and septicemia

Data from Seiler, W. O., and Staehlin, H. B. Gefahren der Bettruhe unter spezieller Beru cksichtigung des Dekubitus. Schweiz. Rundsch. Med. Prax. 68: 505, 1979.

granulated wounds (grade A). Intravenous antibiotic prophylaxis was started 30 minutes before surgery and was continued for 7 days on a routine basis or for 2 to 3 months, when osteomyelitis was diagnosed by bone biopsy. After marginal ulcer excision, the defects were closed with perforatorbased flaps or perforator flaps that were raised on the gluteal vessels. In the early phase of the study, perforator-based flaps were used in five patients (group A). These fasciocutaneous flaps were based on distinct perforators of the gluteal vascular system that were identified and isolated but included a skin bridge on one side to preserve an additional venous drainage. Perforator-based flaps were designed as transposition flaps (n 2) or V-Y advancement flaps (n 3) and were easy to dissect but limited in their mobility (Fig. 3). After the cadaver dissection study, a true perforator flap design was chosen in the next eight flaps (group B). In these fasciocutaneous flaps, the skin island was completely isolated on its gluteal perforators, resulting in increased flap mobility. In all perforator flaps, the inferior gluteal artery served as the main source vessel. Identification of the inferior gluteal artery and its descending branch was attempted preoperatively in all patients by Doppler ultrasound.22,32 Although Doppler assessment of the inferior gluteal artery in its proximal position was easily performed, detection of the descending branch beyond the lower border of the gluteus maximus muscle was difficult, as has been reported by others.32 However, even with angiography, it is not always possible to visualize the descending branch in the clinical setting because of the cruciate anastomosis between the inferior gluteal artery and the circumflex femoral arteries or profunda femoris perforators.23 Duplex sonography has been advised by Windhofer et al.,36 Papp et al.,40 and Morrigl et al.43 for identification of the descending branch but requires more experience than simple Doppler ultrasound. Preoperative marking and dissection of the infragluteal perforator flap was performed as described in the cadaver study. Infragluteal perforator flaps were outlined in either a V-Y pattern (Fig.

Fig. 3. Perforator-based V-Y advancement ap for coverage of an ischial pressure ulcer of the left side. (Above) Superiorly based ap design with anticipated rotation-advancement. Flap dissection included identication and isolation of the perforator. (Below) Flap after inset and direct closure of the donor-site defect.

4) or an elliptical pattern (Fig. 5), permitting direct closure of the donor site. After identification of the cutaneous branch of the descending branch of the inferior gluteal artery and the inferior cluneal nerves at the lower border of the gluteus maximus muscle, the cutaneous branch was isolated, preserving the descending branch of the inferior gluteal artery. Superomedial flap dissection continued, leaving a skin bridge (perforatorbased flap) or completely isolating the skin island on the perforator vessel (perforator flap).

RESULTS
Anatomical Study A total of five gluteal regions in three fresh human cadavers were available for anatomical dissection. During dissection of the vasculature and nerves of the infragluteal region, a descending

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Fig. 4. Infragluteal perforator ap with V-Y pattern for closure of an ischial pressure sore on the right side. (Left) Excellent mobility of the ap facilitates its transfer into the ischial defect. (Right) The peripheral parts of the ap were deepithelialized to provide volume to the undermined wound margins.

Fig. 5. Infragluteal perforator ap with elliptical pattern for coverage of an ischial pressure sore on the right side. (Left) Flap isolated on its vascular pedicle. The course of the descending branch (db) of the inferior gluteal artery (IGA) is marked on the posterior thigh. (Right) Tension-free ap inset and direct closure of the donor-site defect in the gluteal fold. The position of the inferior gluteal artery was located before surgery by Doppler ultrasound.

branch of the inferior gluteal artery accompanied by the posterior femoral cutaneous nerve was a constant finding. In the course of the descending branch, a large direct cutaneous branch was found at the lower margin of the gluteus maximus muscle, coursing around the muscle. In cadaver 1, two direct cutaneous branches accompanied by inferior cluneal nerves were found on each side (Fig.

6). In addition, two large myocutaneous branches (1 mm) perforated the muscle 1.5 and 4 cm above the lower muscle border on the left side (Fig. 2). In cadavers 2 and 3, only one direct cutaneous branch accompanied by an inferior cluneal nerve was found, without any additional myocutaneous perforators. Therefore, a total of seven direct cutaneous branches and two myocutaneous

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Fig. 6. (Left) The course of the left cutaneous branch (cb, blue loop) and inferior cluneal nerve (cn, yellow loop) around the lower border of the gluteus maximus muscle in cadaver 1. (Right) Dissection of the infragluteal perforator ap on the right side. Two large cutaneous branches (cb, blue loops) and one inferior cluneal nerve (cn, yellow loop) winding around the right cutaneous branch were found. Myocutaneous perforators (mp) are marked with blue strips.

perforators were isolated in five unilateral cadaver dissections. The anatomy of the inferior cluneal nerves paralleled the course of the perforator vessels (Table 4). After distal transsection of the descending branch, dissection of the neurovascular bundle was continued to the origin of the inferior gluteal artery. In all cases, complete mobilization of the skin island on its main vascular axis enabled it to reach the sacrum or trochanter in all cases. Mobilization on its cutaneous branch alone, without transection of the descending branch, sufficed for unrestricted flap transposition to the ischial tuberosity. All flaps would have been appropriate for free flap transfer with the option of nerve coaptation. Clinical Study In group A, one of five perforator-based flaps was located in the gluteal region and four were in

the infragluteal region. In group B, three of eight perforator flaps were located in the gluteal region and five were in the infragluteal region. In a total of 13 flaps, nine flaps included one perforator and four flaps included two perforators. Comparing perforator-based flaps and perforator flaps, there were three flaps with one perforator and two flaps with two perforators in group A, and six flaps with one perforator and two flaps with two perforators in group B. Although three of four gluteal flaps included two perforators, all infragluteal flaps were on a single perforator. In all infragluteal perforator and perforator-based flaps, we found a direct cutaneous branch of the descending branch of the inferior gluteal artery and an adjacent inferior cluneal nerve at the lower border of the gluteus maximus muscle supplying the skin of the infragluteal region (Table 5). In three of three

Table 4. Anatomical Study: Number of Perforators and Nerves of the Infragluteal Perforator Flap*
Cadaver 1 1 2 3 3 Side Left Right Left Left Right Direct Cutaneous Branches 2 2 1 1 1 Myocutaneous Perforators 2 0 0 0 0 Nerves 2 2 1 1 1

*The term direct cutaneous branches refers to the perforators coursing around the lower border of the gluteus maximus muscle. The term myocutaneous perforators refers to the perforators piercing the gluteus maximus muscle that also served to supply the flap.

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Table 5. Clinical Study: Number of Perforators and Nerves of the Infragluteal Perforator Flaps and the Infragluteal Perforator-Based Flaps
Patient IGP flaps 1 2 3 4 5 IGPb flaps 6 7 8 9 Side Right Left Right Left Right Left Right Left Right Direct Cutaneous Branches 1 1 1 1 1 1 1 1 1 Myocutaneous Perforators 1 0 0 0 0 1 0 1 0 Nerves 1 1 1 1 1 1 1 1 1

IGP flaps, infragluteal perforator flaps; IGPb flaps, infragluteal perforator-based flaps *The term direct cutaneous branches refers to the perforators coursing around the lower border of the gluteus maximus muscle. The term myocutaneous perforators refers to the perforators piercing the gluteus maximus muscle that also serve to supply the flap.

infragluteal perforator flaps, there was an additional myocutaneous branch approximately 1.5 to 2 cm above the lower margin of the muscle that also served to supply the flap. According to perforator flap terminology, a flap raised on a myocutaneous perforator of the inferior gluteal artery would correctly be termed an inferior gluteal artery perforator flap.44 In a single case of our study, an inferior gluteal artery perforator flap was elevated on a myocutaneous perforator, piercing the muscle immediately above its lower border. In this paraplegic patient, the perforator was released by transection of the thin muscle segment below the perforator (Fig. 7, above). However, in ambulatory patients, a more cumbersome dissection of the perforator through the muscle would be required to preserve muscle function. Therefore, the direct cutaneous branch of the inferior gluteal perforator flap offers a simpler and faster approach compared with the inferior gluteal artery perforator flap (Fig. 7, below). The mean operating time was 94.0 16.7 minutes (range, 80 to 120 minutes) in group A and 137.5 38.1 minutes (range, 90 to 200 minutes) in group B. There was one major flap complication, with total flap necrosis in a perforator flap caused by impaired venous drainage and congestion. This complication occurred in an elderly patient with multiple scars adjacent to the flap donor site following several operations for ischial pressure sore recurrence. All other flaps healed uneventfully (Table 6). Patients were mobilized according to a standardized protocol.45 Hip flexion of 90 degrees was usually attained after 4 to 5 weeks, and mobilization in the sitting position was initiated after 4 to 6 weeks under continuous observation of the wound. No recurrence occurred during the hos-

pitalization and all patients were followed on a regular basis.

DISCUSSION
Pressure ulcers remain a frequent complication in hospitalized patients, the geriatric population, and paraplegics. Despite high initial success rates of surgical closure, the incidence of early and late recurrence of pressure ulcers remains challenging. In 1000 ischial pressure sore patients reviewed by Conway and Griffith,10 the rate of recurrence reached 75 to 77 percent. Disa et al.46 reported a recurrence rate of 61 percent in 40 patients after a mean follow-up of just 9.3 months. Only recently, recurrence rates below 20 percent were published and attributed to the collaborative effort of plastic surgery and rehabilitation medicine with standardized management protocols, graduated patient mobilization, and skin care education.21,47 Some fundamental surgical principles should be followed. The first step involves radical debridement of the ulcer and underlying bursae and resection of bony prominences. In a second step, closure of the defect requires adequate flap selection and planning, and placing scars in non weight-bearing areas.10,45 Both steps can be performed in one operation or as staged procedures, depending on local wound conditions and surgeon preference. Flap selection should take into consideration the possibility of ulcer recurrence and the need for future reconstruction. Interruption of vascular sources of adjacent flap territories during flap dissection and undermining for donor-site closure should be avoided. Several studies suggest the superiority of fasciocutaneous flaps compared with muscle flaps for reconstruction of pressure sores.48,49 Recently, fas-

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Table 6. Comparison of Patients Treated with Perforator-Based Flaps (Group A) and Perforator Flaps (Group B)
Group A Patient age, years Pressure ulcer location Ischial tuberosity Sacrum Intertrochanteric crest Primary ulcers Recurrent ulcers Ulcer size, cm2 Flap location Gluteal Infragluteal Source vessel IGA SGA Operating time, minutes Complications 50.0 11.1 4 1 4 1 38.6 9.4 1 4 4 1 94.0 16.7 0 Group B 51.7 13.2 5 2 1 5 3 48.4 15.9 3 5 8 137.5 38.1 1

IGA, inferior gluteal artery; SGA, superior gluteal artery.

Fig. 7. Differences in ap dissection of the inferior gluteal artery perforator ap and the infragluteal perforator ap. (Above) Inferior gluteal artery perforator ap. A thin lower segment of gluteus maximus muscle was transected to release the myocutaneous perforator (mp arrow ) and allow passage of the ap into the ischial defect. The descending branch (db arrows) of the inferior gluteal artery was preserved. (Below) Infragluteal perforator ap. The gluteus maximus muscle and the descending branch of the inferior gluteal artery were spared during ap dissection without compromising ap mobility. The direct cutaneous branch (db) allows simple and fast elevation of the infragluteal perforator ap.

ciocutaneous perforator flaps of the gluteal region have been reported to be very reliable.21 The vascular anatomy of the posterior thigh and gluteal region has been investigated in detail.3236,5053 This led to the evolution of a multitude of myocutaneous and fasciocutaneous flaps of the gluteal region and posterior thigh.1113,1532,34,35,3740,43,45,5460 The fasciocutaneous gluteal thigh flap or posterior thigh flap is advocated for the closure of pressure sores of the perineal region. However, during dissection of a superior based flap, several large femoral perforators are

encountered proximally and may have to be divided to allow flap transposition. If further pedicle length is needed, this can be achieved by splitting the gluteus maximus muscle medially and laterally to the neurovascular pedicle but requires further division of several large muscular branches. Skeletonization of the neurovascular pedicle when elevating a gluteal thigh island flap is possible to facilitate transposition but may be hazardous when the inferior gluteal artery is not palpable. In these situations, Walton et al.32 advised that the deep fascia proximal to the skin island should be preserved and that the deep fascia, the overlying subcutaneous tissue, and a portion of the gluteus maximus muscle should be incorporated as a composite pedicle. The gluteal or posterior thigh V-Y advancement flap has been our first choice for coverage of ischial ulcers.45,52 Similar to the superiorly based flap, several perforators from the deep femoral artery have to be divided during dissection of the V-Y advancement flap while preserving the descending branch of the inferior gluteal artery. Recently, Frick et al.35 described the inferior gluteal flap, a myocutaneous flap of the lower gluteal region based on the inferior gluteal artery and containing distal parts of the gluteus maximus muscle. They noticed the presence of a small branch from the descending branch of the inferior gluteal artery, coursing around the lower border of the gluteus maximus muscle into the subcutaneous tissue, and speculated about a fasciocutaneous flap of the lower gluteal region that could be elevated on this cutaneous branch. Based on these findings and extensive cadaver dissection studies on the vascular anatomy of this region, Papp et al.40 reported the first series of the

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fasciocutaneous infragluteal free flap for reconstruction of Achilles tendon defects. This flap also offers interesting features for reconstruction of perineal defects (i.e., pressure sores). Therefore, we investigated the anatomical basis and clinical application of the infragluteal perforator flap. After a series of cadaver dissections and promising clinical results with perforator-based flaps of the infragluteal region, we continued with our first series of infragluteal perforator flaps. Slightly longer operating times in the perforator flap series compared with the perforator-based flaps can be attributed to the learning curve. The only major complication in either group was one flap loss in the perforator group, caused by compromise of the vascular flap territory after multiple prior operations. However, improved flap mobility and inset and the ability to reach more distant sites are major advantages. Compared with the gluteal or posterior thigh flap, all adjacent vascular territories of the inferior gluteal artery can be spared. This preserves options for future flaps in the event of ulcer recurrence. Even when the inferior gluteal artery is included during pedicle dissection to improve flap mobility, it has been demonstrated that posterior thigh flaps can be based safely on the axial fascial plexus that is supplied by the cruciate anastomosis.12,32,36 Compared with myocutaneous flaps of the posterior thigh, the infragluteal perforator flap significantly reduces donor-site morbidity and is especially advantageous in ambulatory patients.1517,2224,32 Although not applicable to the paraplegic patients in our study, the inferior cluneal nerves could provide a sensate flap in ambulatory patients. In addition, the posterior femoral cutaneous nerve can be spared during flap elevation, preserving sensitivity of the posterior thigh in ambulatory patients.36 Compared with the cumbersome dissection of the myocutaneous perforators of gluteal perforator flaps, the direct cutaneous branch of the descending branch of the inferior gluteal artery facilitates dissection of the infragluteal perforator flap, offering a simpler and faster approach.20,21 flaps based on the superior or inferior gluteal vessels remain available for future reconstructions.
Oliver Scheufler, M.D. Department of Plastic, Reconstructive, and Aesthetic Surgery University Hospital of Basel Spitalstrasse 21 4031 Basel, Switzerland oscheufler@uhbs.ch

ACKNOWLEDGMENTS

The authors thank Clinton A. Leiweke, Director, Fresh Tissue Laboratory, Duke University Medical Center, for assistance, and Stanley M. Coffmann, for illustrations.
DISCLOSURE

None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article.
REFERENCES
1. Petersen, N. C., and Bittmann, S. The epidemiology of pressure sores. Scand. J. Plast. Surg. 5: 62, 1971. 2. Young, J. S., Burns, P. E., Bowen, A. M., and McCutchen, R. Spinal Cord Injury Statistics. Phoenix, Ariz.: Good Samaritan Medical Center, 1982. 3. Norton, D., McLaren, R., and Exton-Smith, A. N. An Investigation of Geriatric Nursing Problems in the Hospital. Edinburgh: Churchill Livingstone, 1975. Pp. 193238. 4. Colen, S. R. Pressure sores. In J. G. McCarthy (Ed.), Plastic Surgery. Philadelphia: Saunders, 1990. Pp. 37973838. 5. Versluysen, M. Pressure sores in elderly patients: The epidemiology related to hip operations. J. Bone Joint Surg. (Br.) 10: 67, 1985. 6. Heinemann, A., Lockemann, U., Matschke, J., Tsokos, M., and Puschel, K. Decubitus ulcer in terminal phase: Epidemiologic, medicolegal and ethical aspects. Dtsch. Med. Wochenschr. 125: 45, 2000. 7. Whittington, K., Patrick, M., and Roberts, J. L. A national study of pressure ulcer prevalence and incidence in acute care hospitals. J. Wound Ostomy Continence Nurs. 27: 209, 2000. 8. Dansereau, J. G., and Conway, H. Closure of decubiti in paraplegics: Report of 2000 cases. Plast. Reconstr. Surg. 33: 474, 1964. 9. Conway, H., Kraissl, C. J., and Clifford, R. H., III. The plastic surgical closure of decubitus ulcers in patients with paraplegia. Surg. Gynecol. Obstet. 85: 321, 1947. 10. Conway, H., and Griffith, B. H. Plastic surgery for closure of decubitus ulcers in patients with paraplegia. Am. J. Surg. 91: 946, 1956. 11. Griffith, B. H. Thigh transposition skin flap. In B. Strauch, L. O. Vasconez, and E. J. Hall-Findlay (Eds.), Grabbs Encyclopedia of Flaps, Vol. 3, 2nd Ed. Philadelphia: LippincottRaven, 1998. Pp. 16571659. 12. Geoffrey, G., and Hallock, G. G. The random upper posterior thigh fasciocutaneous flap. Ann. Plast. Surg. 32: 367, 1994. 13. Hallock, G. G. Cutaneous cover for cutaneous coverage. Contemp. Surg. 39: 26, 1991.

CONCLUSIONS
The infragluteal perforator flap is a versatile and reliable flap for coverage of perineal and sacral pressure sores in paraplegic and ambulatory patients. It minimizes donor-site morbidity by sparing the gluteal muscles and primary closure of the donor site, leaving a scar that avoids maximal pressure zones over bony prominences, and can be used as a sensate flap in selected patients. Local

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14. Baker, D. C., Barton, F. E., and Converse, J. M. A combined biceps and semitendinous muscle flap in the repair of ischial sores. Br. J. Plast. Surg. 31: 26, 1978. 15. James, J. H., and Moir, I. H. The biceps femoris musculocutaneous flap in the repair of pressure sores around the hip. Plast. Reconstr. Surg. 66: 736, 1980. 16. Hurteau, J. E., Bostwick, J., Nahai, F., Hester, R., and Jurkiewicz, M. J. V-Y advancement of hamstring musculocutaneous flap for coverage of ischial pressure sores. Plast. Reconstr. Surg. 68: 539, 1981. 17. Hagerty, R. F., Hagerty, R. C., and Hagerty, H. F. The hamstring myocutaneous flap in repair of ischial decubiti. Ann. Plast. Surg. 5: 227, 1980. 18. Minami, R. T., Mills, R., and Pardoe, R. Gluteus maximus myocutaneous flap for repair of pressure sores. Plast. Reconstr. Surg. 60: 242, 1977. 19. Scheflan, M., Nahai, F., and Bostwick, J., III. Gluteus maximus island musculocutaneous flap for closure of sacral and ischial ulcers. Plast. Reconstr. Surg. 68: 533, 1981. 20. Koshima, I., Moriguchi, T., Soeda, S., Kawata, S., Ohta, S., and Ikeda, A. The gluteal perforator-based flap for repair of sacral pressure sores. Plast. Reconstr. Surg. 91: 678, 1993. zgentas, H. E. Gluteal perforator 21. Cos kunfirat, O. K., and O flaps for coverage of pressure sores at various locations. Plast. Reconstr. Surg. 113: 2012, 2004. 22. Hurwitz, D. J. Closure of a large defect of the pelvic cavity by an extended compound myocutaneous flap based on the inferior gluteal artery. Br. J. Plast. Surg. 33: 256, 1980. 23. Hurwitz, D. J., Schwartz, W. M., and Mathes, S. J. The gluteal thigh flap: A reliable, sensate flap for the closure of buttock and perineal wounds. Plast. Reconstr. Surg. 68: 521, 1981. 24. Hurwitz, D. J., and Walton, R. L. Closure of chronic wounds of the perineal and sacral regions using the gluteal thigh flap. Ann. Plast. Surg. 8: 375, 1982. 25. Achauer, B. M., Turpin, I. M., and Furnas, D. W. Gluteal thigh flap in reconstruction of complex pelvic wounds. Arch. Surg. 118: 18, 1983. 26. Achauer, B. M., Braly, P., Berman, M. L., and DiSaia, P. J. Immediate vaginal reconstruction following resection for malignancy using the gluteal thigh flap. Gynecol. Oncol. 19: 79, 1984. 27. Hurwitz, D. J., and Zwiebel, P. C. Gluteal thigh flap repair of chronic perineal wounds. Am. J. Surg. 150: 386, 1985. 28. Rosen, J. M., Mo, S. T., and Liu, A. Experience with the island inferior gluteal thigh flap compared with other local flaps for the reconstruction of the pelvic area. Ann. Plast. Surg. 24: 498, 1990. 29. Yanai, A., Bandoh, Y., and Tsuzuki, K. Bilateral gluteal thigh flaps for closure of large defects in the lumbosacral region and perineal region. Plast. Reconstr. Surg. 88: 703, 1991. 30. Le Quang, C. Two new free flaps developed from aesthetic surgery: II. The inferior gluteal thigh flap. Aesthetic Plast. Surg. 4: 159, 1980. 31. Monstrey, S., Van Landuyt, K., Blondeel, P., Tonnard, P., and Matton, G. Gluteal thigh flap used as a fascio-cutaneous free flap. Microsurgery 17: 386, 1996. 32. Walton, R. L., Hurwitz, D. J., and Bunkis, J. Gluteal thigh flap for reconstruction of perineal defects. In B. Strauch, L. O. Vasconez, and E. J. Hall-Findlay (Eds.), Grabbs Encyclopedia of Flaps, Vol. 3, 2nd Ed. Philadelphia: Lippincott-Raven, 1998. Pp. 14991504. 33. Cormack, G. C., and Lamberty, B. G. H. The blood supply of thigh skin. Plast. Reconstr. Surg. 75: 342, 1985. 34. Rubin, J. A., Whetzel, T. P., and Stevenson, T. R. The posterior thigh fasciocutaneous flap: Vascular anatomy and clinical application. Plast. Reconstr. Surg. 95: 1228, 1995. 35. Frick, A., Baumeister, R. G. H., and Wiebecke, B. Microvasculature of the inferior gluteal flap. Eur. J. Plast. Surg. 16: 30, 1993. 36. Windhofer, C., Brenner, E., Moriggl, B., and Papp, C. Relationship between the descending branch of the inferior gluteal artery and the posterior femoral cutaneous nerve applicable to flap surgery. Surg. Radiol. Anat. 24: 253, 2002. 37. Maruyama, Y., Ohnishi, K., and Takeuchi, S. The lateral thigh fasciocutaneous flap in the repair of ischial and trochanteric defects. Br. J. Plast. Surg. 37: 103, 1984. 38. Paletta, C., Bartell, T., and Shehadi, S. Applications of the posterior thigh flap. Ann. Plast. Surg. 30: 41, 1993. 39. Hurwitz, D. J. Microvasculature of the inferior gluteal flap (Discussion). Eur. J. Plast. Surg. 16: 32, 1993. 40. Papp, C., Todoroff, B. P., Windhofer, C., and Gruber, S. Partial and complete reconstruction of Achilles tendon defects with the fasciocutaneous infragluteal free flap. Plast. Reconstr. Surg. 112: 777, 2003. 41. Daniels, R. K., Hall, E. J., and MacLeod, M. K. Pressure sores: A reappraisal. Ann. Plast. Surg. 3: 53, 1979. 42. Seiler, W. O., and Staehlin, H. B. Gefahren der Bettruhe unter spezieller Beru cksichtigung des Dekubitus. Schweiz. Rundsch. Med. Prax. 68: 505, 1979. 43. Morrigl, B. F., Brenner, E. R. A., Stadler, F. N., and Kovacs, P. Anatomic study on the (extrapelvic) inferior gluteal artery and sciatic nerve: Basics for and first experience with ultrasound evaluation. Clin. Anat. 12: 206, 1999. 44. Geddes, C. R., Morris, S. F., and Neligan, P. C. Perforator flaps: Evolution, classification, and applications. Ann. Plast. Surg. 50: 90, 2003. 45. Lu scher, N. J. Decubitus Ulcers of the Pelvic Region: Diagnosis and Surgical Therapy. Seattle: Hogrefe & Huber, 1992. Pp. 117 119. 46. Disa, J. J., Carlton, J. M., and Goldberg, N. H. Efficacy of operative cure in pressure sore patients. Plast. Reconstr. Surg. 89: 272, 1992. 47. Kierney, P. C., Engrav, L. H., Isik, F. F., Esselman, P. C., Cardenas, D. D., and Rand, R. P. Results of 268 pressure sores in 158 patients managed by plastic surgery and rehabilitation medicine. Plast. Reconstr. Surg. 102: 765, 1998. 48. Yamamoto, Y., Ohura, T., Shintomi, Y., Sugihara, T., Nohira, K., and Igawa, H. Superiority of the fasciocutaneous flap in reconstruction of sacral pressure sores. Ann. Plast. Surg. 30: 116, 1993. 49. Nola, G. T., and Vistnes, L. M. Differential response of skin and muscle in the experimental production of pressure sores. Plast. Reconstr. Surg. 66: 728, 1980. 50. Taylor, G. I., and Palmer, J. H. The vascular territories (angiosomes) of the body: Experimental study and clinical applications. Br. J. Plast. Surg. 40: 113, 1987. 51. Taylor, G. I., Caddy, C. M., Waterson, P. A., and Crock, J. G. The venous territories (venosomes) of the human body: Experimental study and clinical applications. Plast. Reconstr. Surg. 86: 185, 1990. 52. Calil, J. A., Ferreira, L. M., and Laredo Filho, J. Anatomy of the fasciocutaneous branches of the first and second perforator arteries in the posterior thigh area. Can. J. Plast. Surg. 6: 155, 1998. 53. Suami, H., Taylor, I., and Pan, W. R. Angiosome territories of the nerves of the lower limbs. Plast. Reconstr. Surg. 112: 1790, 2003. 54. Calil, J. A., Ferreira, L. M., Neto, M. S., De Castilho, H. T., and Garcia, E. B. Clinical application of the V-Y posterior thigh fasciocutaneous flap. Rev. Assoc. Med. Brasil 47: 311, 2001. 55. Georgiade, G. S., Riefkohl, R., and Georgiade, N. G. Total thigh flaps. In B. Strauch, L. O. Vasconez, and E. J. HallFindlay (Eds.), Grabbs Encyclopedia of Flaps, Vol. 3, 2nd Ed. Philadelphia: Lippincott-Raven, 1998. Pp. 16841686.

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56. Erk, Y., Spira, M., Don Parsa, F., and Stal, S. A modified gluteus maximus musculocutaneous free flap based on the inferior gluteal vessels. Ann. Plast. Surg. 11: 344, 1983. 57. Paletta, C. E., Bostwick, J., and Nahai, F. The inferior gluteal free flap in breast reconstruction. Plast. Reconstr. Surg. 86: 875, 1989. 58. Hashimoto, I., Nakanishi, H., Nagai, H., Harada, H., and Sedo, H. The gluteal-fold flap for vulvar and buttock reconstruction: Anatomic study and adjustment of flap volume. Plast. Reconstr. Surg. 108: 1998, 2001. 59. Angrigiani, C., Grilli, D., and Thorne, C. H. The adductor flap: A new method for transferring posterior and medial thigh skin. Plast. Reconstr. Surg. 107: 1725, 2001. 60. Homma, K., Murakami, G., Fujioka, H., Fujita, T., Imai, A., and Ezoe, K. Treatment of ischial pressure ulcers with a posteromedial thigh fasciocutaneous flap. Plast. Reconstr. Surg. 108: 1990, 2001.

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