Soft tissue coverage of a total gluteal defect with a combination of perforator‐based flaps: A case report

Abstract

Soft tissue defects in the buttock area are often related to decubitus ulcers, which are usually small to medium-large size and can be regularly treated with local flaps. However, when the defects have bigger size, such as those involving the whole gluteal region, the coverage can become more challenging, since this specific area needs both a good resistance to pressure and an acceptable functional result. The most common solution for similar cases is the use of multiple local flaps, or, in extreme situations, a free flap. In particular, local flaps based on perforator vessels are, in selected cases, a consolidated alternative to free flap allowing an efficient reconstruction of soft tissue defects using adjacent similar tissues, providing the benefit of "like with like" coverage. Here we present a case of a large mycosis fungoides nidus of the gluteal region measuring 25 cm × 18 cm reconstructed using two large perforator flaps adjacent to the defect combined with a remote one for coverage of the donor site. The cranial flap was designed based on a perforator arising from the superior gluteal artery and transferred into the defect by means of a V-Y advancement, while the two caudal propeller flaps in the posterior thigh were both based on perforators of the profunda femoris artery and rotated 180 , respectively. To obtain a tension-free cover of the donor site defect we applied the concept of "sequential" propeller flaps. Post-operative course was uneventful and the patient was ambulatory with assistive devices after 1 week. At 6 months follow-up, wounds were completely healed without complications and a good functional result was obtained. This report showed the great coverage potential of multiple perforator-based local flaps when properly combined allowing primary closure of the donor site. In particular, we managed to reconstruct a total gluteal defect using just ipsilateral side tissue, reducing morbidity, and obtaining a stable result.

Combined versus Single Perforator Propeller Flaps for Reconstruction of Large Soft Tissue Defects: A Retrospective Clinical Study

“…Combined PPFs may allow reconstruction of extended defects and therefore, extent reconstructive possibilities [37]. For instance, Scaglioni and colleagues reported successful reconstruction of a large gluteal defect by a combination of two PPFs and a VY advancement flap [38]. This supports our experience as we could demonstrate sufficient reconstruction of the posterior trunk by a combination of two PPFs.…”

Bilateral gluteal reconstruction with deep inferior epigastric perforator flaps and saphenofemoral arteriovenous loops

“…Limited‐sized defects are commonly repaired with local flaps; however, total gluteal defects pose a difficult and unique challenge. Regional tissue coverage for large gluteal defects have previously been described using multiple combination perforator‐pedicled propeller flaps (Scaglioni et al, 2020), proximally based anterolateral thigh flaps, tensor fascia lata flaps, or an extended IGA perforator V‐Y advancement flap for a unilateral defect (Vathulya et al, 2019). However, when the size of the defect becomes substantial, closure with regional options becomes difficult due to the limited volume of local soft tissue and lack of skin laxity.…”

“…In cases of total gluteal defects, reconstruction remains challenging due to limited locoregional flap options and the functional demands of the buttocks. Pedicled flaps (e.g., proximally based anterolateral thigh flaps or tensor fascia lata flaps) or pre‐expanded lumbosacral flaps are among a number of options to consider that have been reported in the literature, but often, free tissue transfer is necessary (Aggarwal & Pennington, 2013; Gaster et al, 2012; Park & Koh, 1998; Scaglioni et al, 2020; Tomita et al, 2015; Vathulya et al, 2019).…”

Free Flap Reconstruction of Oncologic Gluteal Defects

“…Soft tissue defects found in the gluteal region after resection of malignant tumor are usually reconstructed using various regional flaps 1–5 . However, when the size of the defect becomes large, the wound cannot be closed comfortably using regional options because of the lack of skin laxity and soft tissue volume.…”