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The American Journal of Surgery (2012) 203, 303–307

Midwest Surgical Association

Biplanar flap reconstruction for pressure ulcers:experience in patients with immobility from chronicspinal cord injuries

Anupama Mehta, M.D.a, Todd A. Baker, M.D.a, Margo Shoup, M.D., F.A.C.S.a,irstyn Brownson, M.D.a, Sewit Amde, M.D.a, Erin Doren, M.D.a, Samir Shah, M.D.a,aul Kuo, M.D., M.S., M.B.A., F.A.C.S.a, Juan Angelats, M.D., F.A.C.S.a,b,*

aDepartment of Surgery, Loyola University Chicago, Stritch School of Medicine, 2160 S. 1st Ave., Maywood, IL 60153,

USA; bEdward Hines Jr. VA Hospital, Hines, IL, USA

AbstractBACKGROUND: Surgical therapy for advanced-stage pressure ulcers recalcitrant to healing is a

widely accepted practice. The present study examined the incidence of wound recurrence afterreconstruction with fasciocutaneous versus combined (biplanar) muscle and fasciocutaneous flaps.

METHODS: A retrospective review identified 90 nonambulatory patients with spinal cord injury whounderwent reconstruction for persistent decubitus ulcers from 2002 to 2008. Electronic medical recordswere surveyed for patient comorbidities and postoperative complications. Statistical methods includedthe Fisher exact test and the Mann–Whitney U test with a 2-sided P value of less than .05.

RESULTS: Among 90 patients reviewed, 33% (n � 30) received fasciocutaneous flaps and 66%(n � 60) underwent biplanar reconstruction. Comorbidities were the same between cohorts with theexception of a greater prevalence of diabetes in the biplanar group (27% vs 50%; P � .05). Theincidence of recurrence for biplanar flaps (25%) was significantly lower than for fasciocutaneousreconstruction (53%; P � .01).

CONCLUSIONS: Biplanar flap reconstruction should be considered for chronically immobilizedpatients at high risk for recurrent decubitus ulceration.Published by Elsevier Inc.

KEYWORDS:Decubitus ulcer;Paraplegia;Quadriplegia;Myocutaneous flap;Fasciocutaneous flap;Reconstructionbiplanar flap;Biplanar flap;Rotational flap;Axial flap;Complication

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The management of pressure ulcers in patients with spi-nal cord injury is a complex problem. Paraplegic and quad-riplegic patients have cutaneous anesthesia, resulting in nosensory warning of excess pressure below the level of in-jury. Common sites are usually over bony prominencesbecause of prolonged continuous pressure.1 The neural sig-

* Corresponding author. Tel.: �1-708-327-2653; fax: �1-708-327-3463E-mail address: jangela@lumc.eduManuscript received August 7, 2011; revised manuscript October 27,

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002-9610/$ - see front matter Published by Elsevier Inc.oi:10.1016/j.amjsurg.2011.10.007

als originate in the nociceptive afferent fibers, and theseathways are interrupted, leading to ischemia and tissueestruction.2 There is a greater incidence of pressure ulcers

in the paraplegic and quadriplegic populations secondary toprolonged confinement seen in the paralyzed patient.3 Theack of mobility in the paraplegic and quadriplegic popula-ions also leads to decubitus ulcers.

Nonsurgical efforts to heal wounds by pressure offload-ng, local wound care, and nutritional optimizations arerst-line therapies; however, advanced pressure ulcers may

equire surgical intervention. The goals of surgery include

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304 The American Journal of Surgery, Vol 203, No 3, March 2012

the prevention of progressive osteomyelitis, elimination ofnecrotic soft tissues, and reconstruction using well-vascu-larized tissue. In addition to wound closure, flap reconstruc-tions eliminates dead space while providing additional bulk.Surgical treatment of pressure ulcers leads to the reductionof protein losses, enhanced quality of life, decreased reha-bilitation costs, and hygienic improvement.3 The use ofpressurized beds before and after surgery or a change ofposition every 2 hours are of paramount importance.

There are 2 main patterns of blood supply to the skin.The blood supply can come from the perforators, alsoknown as myocutaneous vessels, which travel directly to thedermis from underlying muscles or from cutaneous vesselsrunning parallel to the skin in the perifascial space. When amyocutaneous flap is harvested, it is composed of muscle,deep fascia, subcutaneous tissue, and overlying skin, all ofwhich are perfused by a dominant vascular pedicle that istransferred in one surgical step. A difference between afasciocutaneous flap and myocutaneous flap is that the fas-ciocutaneous flap does not have the same rich vascularsupply as the myocutaneous flap. It mainly depends on theoverlying skin, subcutaneous tissue, and deep fascia for itsblood supply.2 When part of a muscle is transferred forreconstruction, it provides a vascular supply to the overly-ing tissue.

In this study, biplanar flaps were used to treat pressuresores in which a transposed muscle flap provided bulk andpadding to the defect but more importantly sealed the ex-posed debrided bone, and a fasciocutaneous flap was rotatedto cover the rest of the wound. These types of flaps are notwell described or studied in the literature. The present studydirectly compares the incidence of postoperative complica-tions among fasciocutaneous and biplanar flaps consistingof fasciocutaneous reconstruction with a separate underly-ing muscle flaps.

Material and Methods

Patients wound characteristics

With approval from the Institutional Review Board at Ed-ward Hines Jr VA Hospital a retrospective review of a pro-spective database was conducted to identify a single surgeon’sexperience with the surgical management of recalcitrant de-cubitus ulcers. All patients had chronic spinal cord condi-tions and were receiving care at a center of excellenceknown for treatment for chronic deep-tissue decubitus ul-cers. Initial wound management involved debridement (sur-gical, mechanical, enzymatic), pressure relief, nutrition op-timization, infection control, and counseling/social support.Patients were identified as surgical candidates with nonheal-ing stage 3 and 4 pressure wounds. Subjects underwentcomplete ulcer excision, partial ostectomy of boney prom-

inence, and flap reconstruction. All instances of deep bone

biopsies and cultures consistent with infectious osteomyeli-tis were treated with 6 weeks of intravenous antibiotics.

Patients were stratified according to method of reconstruc-tion, with all subjects receiving either rotational fasciocutane-ous only or rotational fasciocutaneous flaps plus muscle flapsand had advanced ulcers with deep wounds. For the procedure,the patient was placed in the prone or lateral positions depend-ing on the location of the recurrent pressure sore. The woundswere cleaned and had partial ostectomies to create equalizedpressure over boney prominences.

To create the biplanar flap, a gluteal muscle flap waselevated and transposed to cover the exposed bone. Themuscle flap was sutured over the defect. A rotational fas-ciocutaneous flap then was created to cover the musculartransposition and the rest of the wound. Overall, the muscleflap plus the fasciocutaneous flap was placed without ten-sion. Postoperatively, patients were maintained on Clinitron(Hill-Rom, Batesville, IN) weight distribution beds for aminimum of 6 weeks. In addition, all subjects were initiatedon a sitting program consisting of graduated weight bearingover increments of time.

The surgeon performing the biplanar reconstruction waspreviously accustomed to using fasciocutaneous flaps as astandard method of repair for pressure ulcers as well de-scribed in the literature. The surgeon modified his techniquein the later half of the study so that all patients who under-went pressure sore reconstruction had the addition of mus-cle to the fasciocutaneous flap. The elevation, accessibility,and easy dissection of a well-vascularized portion of muscleallowed for the creation of a biplanar flap. This method ofreconstruction placed muscle over the exposed bone andgenerated enough bulk to decrease the dead space.

Electronic medical records were reviewed for patientdemographics, comorbid spinal cord disease, surgical tech-nique, incidence of recurrent decubitus ulceration, woundcomplications, and the need for reoperation. Statistical anal-ysis was performed using GraphPad Prism 5 for Mac OSX(GraphPad Software, Inc., La Jolla, CA). Continuous vari-ables were described as medians with minimum and maxi-mum ranges. Normal distribution was assessed with theD’Agostino–Pearson omnibus K2 test; because not all datasets passed the normality test (á � .05), the Mann–WhitneyU test was used for continuous variables. The Fisher exacttest and the Pearson chi-square test were used for dichoto-mous categoric variables. A 1-tailed P value of less than .05

as considered significant.

Results

From 2002 through 2008, there were 90 chronicallyimmobilized patients with spinal cord pathology who wereidentified with stage 3 or stage 4 decubitus ulcers requiringsurgical management. Among this cohort, 64% were diag-nosed with ischial ulcers (n � 58), 42% suffered from sacral

decubitus ulcers (n � 26), and 29% had decubitus ulcers

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305A. Mehta et al. Biplanar flap reconstruction

overlying the greater trochanter of the femur (n � 26). Thesum of these percentages exceeds 100% because 42% of thepatients suffered from multiple areas of cutaneous break-down. Among all patients with decubitus ulceration, 33%(n � 30) received fasciocutaneous rotational flaps and 66%(n � 60) underwent reconstruction with a combined muscleand fasciocutaneous flap. There was no difference in inci-dence of pressure wounds by anatomic location and therewas a similar prevalence of paraplegia and quadriplegia ineach treatment group (Table 1).

The incidence of surgical complications was similar inboth groups. There was no significant difference in thefrequency of wound dehiscence, wound infection, seroma,or hematoma formation (Table 1, P � .05 for fasciocuta-neous vs muscle flap plus fasciocutaneous flap). The pa-tients in this study suffered from chronic immobility, result-ing in an overall 34% frequency of recurrent decubitusulceration. The incidence of recurrence in the fasciocutane-ous group (53%) was more than double the recurrenceamong patients with a biplanar flap (25%) (Fig. 1, P � .01for fasciocutaneous vs biplanar flaps).

The length of follow up evaluation between the groupswas similar. The patients who received fasciocutaneousflaps had a median follow up period of 38.5 months, and themedian follow up period in the biplanar group was 41months (P � .9352). The time until recurrence again wassimilar in both groups. In the group receiving fasciocutane-ous flaps, the median time until recurrence was 20.5 months,and in the biplanar group, the median time until recurrence

Table 1 Patient data

Fasciocutaneous Biplanar P value

DemographicsMedian age, y

(minimum–maximum) 60 (27–89) 58 (26–86) .92Sex, male:female ratio 29:1 60:1 .33

Wound characteristics, %Ischial decubitus ulcer 17 (57) 41 (68) .35Sacral decubitus ulcer 15 (50) 23 (38) .37Trochanteric decubitus

ulcer 8 (27) 18 (30) .81�1 Decubitus ulcer 13 (43) 25 (42) .99

Comorbid conditionsParaplegia, % 19 (63) 42 (70) .66Quadriplegia, % 10 (33) 17 (28) .63Spina bifida, % 1 (3) 1 (2) 1.00Diabetes mellitus 8 (27) 30 (50) .04Active smoker 13 (43) 17 (28) .16Peripheral vascular

disease 4 (13) 8 (13) 1.00Complications, %

Wound dehiscence 6 (20) 18 (30) .45Infection 3 (10) 3 (5) .40Seroma 1 (3) 1 (2) 1.00Hematoma 2 (7) 1 (2) .26

was 14 months (P � .9369).

Comments

This present study characterized technical aspects ofbiplanar flap reconstruction and its efficacy in the surgi-cal management of chronic decubitus ulceration. In ad-dition to describing a variant of the classic mycocutane-ous flap consisting of a separate underlying musclerotation with an overlying fasciocutaneous layer, thepresent study shows the efficacy of biplanar flap recon-structions among chronically immobilized patients withspinal cord pathology.

Various surgical techniques have been used for the man-agement of pressure sores. Davis’s report in 1938 docu-mented the successful use of a skin flap for closure.4 Con-way and Griffith4 detailed closure with reconstruction usingasciocutaneous flaps in 1956. In 1976, Ger3 was the first toescribe the concept of a myocutaneous flap for the treat-ent of pressure sores using the gluteus maximus, rectus

emoris, and sartorius muscles as flaps for grade 3 and gradepressure ulcer management. Recurrence rates are seen

ith resulting defects larger than the original ulcer.5 Mul-tiple surgeries have been proposed in the literature for theproper treatment of pressure ulcers while addressing theissues of durability, perfusion, flap versatility, and its reus-ability.6

Secondary to multifactorial reasons, postoperative com-plications including partial flap loss, wound dehiscence,hematoma, seroma, and long-term recurrence rates are high.The incidence of postoperative complications was similaramong both cohorts, suggesting that isolated wound com-plications did not contribute to flap failures. Reconstructionof decubitus breakdown has a wide range of recurrence ratesranging from 3% to 6%, or as high as 33%.7 Previousstudies have shown that the addition of muscle to fasciocu-taneous flaps has improved recurrence rates.2

In the present series, an overall decrease in the inci-dence of recurrence in those patients reconstructed withbiplanar flaps using muscle and fasciocutaneous flapswas noted without a difference in length of follow-up

Figure 1 Incidence of wound recurrence after fasciocutaneousreconstruction (light shaded) versus biplanar flap coverage (dark

shaded). Fasciocutaneous versus biplanar, P � .01.

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306 The American Journal of Surgery, Vol 203, No 3, March 2012

evaluation or time until recurrence. The variability seenmay in part be explained by the location of the ulcer,level of spinal cord injury, ambulatory status, and otherassociated medical problems. Both cohorts had a similarincidence of paraplegia and quadriplegia. There was nodifference in the distribution of decubitus ulceration byanatomic locations. In addition, there was similar preva-lence of chronic disease states that impair circulation andwound healing. The biplanar reconstructed group had agreater prevalence of diabetes mellitus despite superiorwound outcome, further substantiating the beneficial ef-fects of biplanar reconstruction.

When compared with the fasciocutaneous flaps, therewas a decrease in the incidence of recurrence in biplanarflaps. The addition of the muscle flap may allow for en-hanced nutrition provided by the additional blood supply,adequate padding over pressure points, limited blood loss,and a decrease in dead space.2 Some of the redundancyrovided by the local tissue permits primary tension-freelosure, which may decrease the overall incidence of recur-ence.8 The muscle has rich perforators that help penetratehrough the intrafascial and suprafascial planes, forming aich vascular plexus.9

A potential limitation of myocutaneous construction isthe loss of muscle bulk over time. A muscle flap can lose upto 30% of its bulk and may become less pliable and versa-tile.10 Part of the concern is that repeated pressure could bea reason for losing muscle bulk. Over time, the muscleportion in the transferred flap shows atrophic changes and,eventually, the skin, subcutaneous tissue, and fascia are theonly elements remaining that cover the defect.11 In addition,a disadvantage of the study is that it is not a randomizedcontrolled trial in which confounding is avoided, and thereis stronger evidence for cause and effect.

In summary, the addition of an underlying muscle layeris safe and results in a similar distribution of postoperativecomplications. Despite a greater frequency of diabetic mel-litus, the cohort receiving biplanar reconstruction had asignificantly lower incidence of recurrent decubitus break-down. The findings of the present study show that biplanarflap reconstruction should be considered for chronicallyimmobilized patients at high risk for recurrent decubitusulceration.

References

1. Becker H. The use of muscle flaps in the management of pressuresores. S Afr J Surg 1979;17:59–63.

2. Mandrekas AD, Mastorakos DP. The management of decubitus ulcersby musculocutaneous flaps: a five-year experience. Ann Plast Surg1992;28:167–74.

3. Aggarwal A, Sangwan SS, Siwach RC, et al. Gluteus maximusisland flap for the repair of sacral pressure sores. Spinal Cord1996;34:346 –50.

4. Lee JT, Cheng LF, Lin CM, et al. A new technique of transferring

island pedicled anterolateral thigh and vastus lateralis myocutaneous

flaps for reconstruction of recurrent ischial pressure sores. J PlastReconstr Aesthet Surg 2007;60:1060–6.

5. Ahluwalia R, Martin D, Mahoney JL. The operative treatment ofpressure wounds: a 10 year experience in flap selection. Intern WoundJ 2010;7:103–6.

6. Daniel RK, Faibisoff B. Muscle coverage of pressure points—the roleof myocutaneous flaps. Ann Plast Surg 1982;8:446–52.

7. Rubabayi S, Doyle BS. The gluteus maximus muscle splitting myo-cutaneous flap for treatment of sacral and coccygeal pressure ulcers.Plast Reconstr Surg 1995;96:1366–71.

8. Meltem C, Esra C, Hasan F, et al. The gluteal perforator-based flap inrepair of pressure sores. Br Assoc Plast Surg 2004;57:342–7.

9. Thiessen FE, Andrades P, Blondeel PN, et al. Flap surgery for pressuresores: should the underlying muscle be transferred or not? J PlastReconstr Aesthet Surg 2011;64:84–90.

10. Hentz VR. Management of pressure sores in a specialty center. Areappraisal. Plast Reconstr Surg 1979;64:683–91.

11. Higgins JP, Orlando GS, Blondeel PN. Ischial pressure sore recon-struction using an inferior gluteal artery perforator (IGAP) flap. Br JPlast Surg 2002;55:83–5.

Discussion

Dr Jeffrey S. Bender (Oklahoma City, OK): Theseare the most inelegant of patients to take care of. They dohave a major and frequently life-limiting problem, and thiscorrect solution has alluded surgeons for years. I have a fewquestions. Perhaps I do not fully understand this techniquebut why 2 flaps; 1 muscle, 1 fasciocutaneous instead of just1 myofasciocutaneous flap? This is what I remember doingwhen I was a much younger man.

Second, it is not clear from the paper how it was decidedwhich flap was done on which patient. Was it due to alsolocation or was it done with increasing surgical surgeon expe-rience? In other words, as the surgeon got more experienced,did you do more of the biplanar flaps and these improvedresults were just due to increased surgeon experience?

Dr Samir Shah (Maywood, IL): To answer your firstquestion, why biplanar flaps versus a simple myocutaneousflaps, you are correct in that myocutaneous flaps haveshown that there is enhanced blood supply, decreased re-currence rate, however, our thought process was to come upwith a flap that not only allowed the advantage of adding amuscle flap but also doing it in two different planes. Thereasoning behind that was to close dead space in two dif-ferent planes, not in one plane.

Using a biplanar flap allowed for a tension free repair.The tension free component is more beneficial in the eventthat of reoperation because only a portion of the muscle isused. During a second operation, more muscle can be usedin addition to the advancement and rotation of a fasiocuta-neous flap. An important aspect of this repair is covering thebone without any dead space. In theory, this would allow forbetter blood supply to the bone and overall improved woundhealing. So that was the thought process behind that, and toanswer your second question as to how patients were de-cided which type of repair they got, with primary discussion

with this one surgeon who did it, there was no reasoning

307A. Mehta et al. Biplanar flap reconstruction

why one set got biplanars and the other ones got fasciocu-taneous. It was random. There was no bias from that stand-point from him.

Dr Raymond P. Onders (Cleveland, OH): I have onequestion on how long these patients were getting therapyprior to this, how long they were getting a back drain? Aswe all know, the costs in many institutions for these othernonoperative treatments can get quite expensive and go on

for months to years. Did you look at any aspect of that, how

long patients were undergoing other therapy before surgerywas chosen?

Dr Shah: So this was done—they were optimized interms of nutrition, and we made sure they were infectionfree. They were on the Clinitron air-pressurized beds forat least 6 weeks prior. And there is also a wound carenursing facility at the VA that we have that made surethey were on the Clinitron beds for at least 6 weeks

afterwards.