GLUTEAL FLAP

ARTCILES
1) 2) Michigan 47 Mathes 157

ANATOMY

VASCULAR SUPPLY
1) 2) Type III vascular supply Major Pedicles: a. Superior gluteal arteries b. Inferior gluteal arteries c. From the internal iliac arteries d. Pass superior and inferior to piriformis

OPTIONS
1) 2) 3) 4) can raise as a single flap can raise superior or inferior segments separately a. this will preserve ambulation V-Y advancement flap Rotation flap

Gluteus Maximus / Posterior Thigh

ANATOMY

1) 2) 3)

most superificial gluteal muscle ORIGIN a. Gluteal line of the posterior ilium and sacrum b. [sacrotuberous ligament] INSERTION a. greater tuberosity of the femur b. iliotibial band of fascia lata

VASCULAR ANATOMY

1)

type 3 a. 2 dominant pedicles ii. inferior gluteal arteries iii. from the internal iliac artery 2) Both are deep to the gluteus 3) above and below inferior piriformis 4) 2 minor pedicles at area of insertion

a. b.

first perforator of profunda femoris two or three intermuscular branches of the lateral femoral circumflex vessels

NERVE SUPPLY

MOTOR a. inferior gluteal nerve b. enters with inferior gluteal artery 2) SENSORY a. to skin S1-3 medially b. L1-3 laterally c. posterior cutaneous nerve of the thigh (S1-2) i. supplies the inferior buttocks and posterior thigh ii. this can be included in the posterior thigh flap (neurosensory flap)

1)

MUSCLE FUNCTION

1) 2) 3) 4)

5)

essential in ambulatory patients a. must preserve at least half extends hips a. most powerful extensor of the hip rotates the thigh laterally important for a. running b. jumping c. climbing d. stabilizes the pelvis and hip largest muscle in the body.

AREAS OF COVERAGE

STANDARD FLAP 1) PRESSURE SORE COVERGAE a. sacrum b. ipsilateral ischium

GLUTEAL THIGH FLAP (Considered Extended If Inferior Gluteal Muscle Included)

1) 2) 3)

ischium sacrum perineum / vagina

REVERSE FLAP 1) based on perforators from profunda femoris

2)

posterior lateral thigh

SENORY / FUNCTIONAL TRANSFER 1) 2) 3) 4) take inferior muscle with inferior gluteal nerve for sphincter reconstruction (vagina or anus) medially based V-Y advancement maintains sensation posterior thigh flap with posterior cutaneous nerve of the thigh maintains sensation If isolated on its vascular pedicle the flap can cross midline

TECHNIQUE STANDARD 1) MARKINGS a. mark the muscle boarders i. sacrum (medial origin ) greater trochanter of the fermor (lateral - insertion) PSIS (superior - aspect) iv. ischium (inferior aspect ) superior skin island is just inferior to the PSIS inferior skin island is immediately superior to the ischial tuberosity a. for patients at risk of recurrent ulcers it is important to design the skin island as large as possible for future re-advancements incision through skin to identify the superficial fascia - this may be atrophic and hard to identify in patients who have lost gluteal function with elevation of the muscle the insertion fibers are cut and the muscle elevated lateral to medial identification of the piriformis is key to dissection a. it helps ID siatic nerve and vascular pedicles when standard superior / inferior gluteal flaps are elevated a lighted retractor to elevate gluteus from piriformis is helpful ii. iii.

2) 3) 4) 5) 6) 7)

V-Y ADVANCEMENT FOR SACRAL ULCERS

1) 2) 3)

generally based only on superior gluteal vessel and superior half of the muscle allows continued ambulation if ambulatory patient For ambulatory patients Motor innervation is provided by the inferior gluteal nerve (L5 to S1-2) a. From sciatic foramen deep surface of the gluteus maximus muscle at level of piriformis 4) ELEVATION Key points: a. Division of the entire fibers of insertion or of the superior or inferior half of these fibers is performed b. fibers of origin are divided at the lateral edge of the sacrum c. piriformis muscle is key i. to correct division of the muscle in its midportion for segmental elevation of either the superior or inferior half ii. it is also a guide to the location of the point of entry of the superior and inferior gluteal vessels into the deep surface of the muscle iii. Initial exposure of the pedicle will avoid injury during the muscle division into its superior and inferior halves iv. Can be aided with a lighted retractor

INFERIOR GLUTEAL ISLAND FLAP

considered 1st choice for ischial ulcers a. can be re-advanced b. large skin paddle c. closed primarily d. not put into tension with leg motion 2) MARKINGS a. Mid sacrum to greater tuberosity of the fermur b. Skin island centered over the gluteal crease c. Muscle identified at the lateral edge of the ischeal wound 3) SKIN ISLAND a. Medial edge = lateral edge of the ischeal sore b. Design the flap as large as possible without extending into superior gluteal flap or beyond the greater trochanter of the femur 4) FLAP ELEVATION 1)

5)

it is helpful to widely expose the anterior surface of the muscle first muscle is divided deep distally, several centimeters beyond the skin island 6) preserve the extension of the inferior gluteal artery and the sciatic nerve as they course onto the thigh 7) Division of the muscle continues laterally and then superiorly, mobilizing only the inferior half of the gluteus muscle

POSTERIOR THIGH Gluteal Thigh Flap

1) 2) 3)

Based on descending terminal branch of the inferior gluteal artery posterior thigh skin flap based between ischial and greater trochanter

axis of the flap inferior gluteal artery as it continues on to the posterior thigh line drawn vertically midway between the greater trochanter and the ischial tuberosity perpendicular to the gluteal crease if < 12 cm in width direct donor site closure distal tip to within 8 cm of the popliteal fossa key anatomic structures during the dissection a. sciatic nerve b. posterior cutaneous nerve (S1-3) & inferior gluteal artery i. travel together (medial to lateral) around the ischial tuberosity as they exit the gluteal space
a. b. c. d. e. center of the thigh

4) 5) 6)

lies in the subcutaneous tissue, just below the fascia lata and superficial to the biceps femoris muscle 7) The skin incision over the distal third of the flap is made down through the deep fascia 8) posterior femoral cutaneous nerve should be identified at the distal midline a. descending branch of the inferior gluteal artery is ligated adjacent to the nerve 9) flap is elevated to the level of the gluteal crease (inferior edge of the gluteus maximus muscle) along the plane deep to the fascia 10) rotated into the ischial defect
11) traction on the nerve confirms the flap is centered over the nerve which is adherent to the descending branch of the inferior gluteal vessels 12) to extend the flap length cut the inferior half of the gluteus lateral to the pedicle entrance 13) Blood flow Doppler study can be used to trace the course of the descending branch of the inferior

ii.

gluteal artery during the flap design

MICROVASCULAR TRANPLANT

1) 2) 3) 4) 5) 6) 7) 8)

with microvascular transplant little muscle is taken and the skin flap is based on the superior or inferior edge of the muscle superior skin flap centered between PSIS and superior sacrum dissect skin off muscle from lateral to medial until perforators are found dissect out the perforators a. with b. or without splitting the superior portion of the muscle inferior skin island centered over the gluteal crease lateral to the scarum intial incision at inferior aspect of gluteus to identify descending branch of inferior gluteal artery trace this up to the inferior gluteal artery avoid injury to inferior gluteal of sciatic nerves

Below: superior gluteal island flap

Below: skin only flap in ambulatory patient, 2 different cases