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Weber et al. Pressure ulcer coverage with contralateral gracilis

every other day. The flap was monitored closely for any could be very devastating. Therefore, we often employ
signs of breakdown. He was discharged home when contralateral musculature to delay hip disarticulation
the 6 h maximum sitting time was reached without while continuing to provide durable wound coverage.
complication. Even in paraplegic patients with muscle atrophy,
the gracilis muscle provides sufficient bulk to fill the
DISCUSSION deepest portions of wound cavities. The anatomy of
the gracilis is well-suited for the coverage of posterior
Successful surgical treatment of stage IV pressure trochanteric, sacral, and ischial ulcers. The location of
ulcers requires the appropriate choice of a local tissue the vascular pedicle, which enters the deep surface of
flap or combination of flaps which provide muscle, the muscle proximally, allows rotation in all directions
subcutaneous tissue, and skin, as well as adherence without sacrificing length and the gracilis can easily
to a strict and lengthy postoperative protocol [7,8] . reach the contralateral ischium.
Despite this, many patients with spinal cord injury
will develop recurrent pressure ulcers. While there Aside from total thigh flaps and the gracilis muscle, other
are multiple gluteal and lower extremity muscle flap options for coverage of recalcitrant or recurrent
and fasciocutaneous flaps which can be utilized for pressure ulcers have been described. The posterior
pressure ulcer wound coverage, the challenge arises thigh fasciocutaneous flap is based off of the descending
when all local muscles have been previously used. branch of the inferior gluteal artery. By dissecting a long
fascial pedicle with the skin paddle at the distal thigh,

Durable, stage IV pressure ulcer coverage requires this flap can be taken from the contralateral leg and
[12]
not only soft tissue and skin but also muscle to fill the used to cover ischial pressure ulcers . Alternatively,
dead space. Closure of a stage IV ulcer with a skin an inferiorly-based rectus abdominis myocutaneous
or a fasciocutaneous flap alone often results in poor flap can be rotated inferiorly through the pelvis to treat
recalcitrant or recurrent ischial and perineal ulcers. The
apposition of the flap to the deepest portion of the flap can be harvested from ipsilateral or contralateral
ulcer. This inhibits optimal wound healing and can lead sides, depending on the location of the colostomy, and
to seroma or bursa formation and an increased risk did not affect the ability of spinal cord injury patients
of recurrent ulceration. Therefore, adequate closure of to sit upright [13] . In the closure of all pressure ulcers,
a stage IV ulcer typically requires both a muscle flap both initial and recurrent, it is important to remember
to obliterate the cavity and a fasciocutaneous flap for that adequate closure may also require the rotation or
replacement of soft tissue. In cases involving an ulcer re-advancement of multiple muscle, myocutaneous,
of small diameter, advancement of a myocutaneous or fasciocutaneous flaps in combination to achieve
flap, such as the gluteus maximus or biceps femoris sufficient bulk and area of coverage [13,14] .
may be sufficient and, in cases of shallow ulcers,
fasciocutaneous flaps or skin grafting alone may be Once a patient develops the first pressure ulcer,
adequate. However, in our spinal cord injury population, multiple recurrences are common. One reason for
the presence of small or shallow ulcers is rare. this is that, while flap surgery covers the wound with
additional soft tissue, the inciting event or events for
The patient presented here had had four prior pressure ulceration are not altered. In our practice, we
surgeries to close right-sided stage IV pressure ulcers. see a high degree of ischial and posterior trochanter
The ipsilateral gracilis, gluteus maximus, biceps ulcer recurrence. We believe this is due, in part, to
femoris, vastus lateralis, and tensor fascia lata had altered spinal and pelvic anatomy as a result of chronic
already been harvested and rotated to fill prior ulcers, spinal cord injury. Many of our patients develop
leaving very few options for coverage of a large ulcer. scoliosis and increased anterior pelvic tilt, causing
Hip disarticulation and a total thigh flap are often the increased pressure in the ischio perineum and other
last resort for recurrent pressure ulcers [9,10] . While non-anatomical regions. Similarly, over time, the femurs
some suggest that hip disarticulation improves patient rotate posteriorly such that the greater trochanter
quality of life and function, our patients are reluctant becomes a weight-bearing pressure point when sitting.
to accept lower extremity amputation and feel that the The Girdlestone procedure removes the proximal femur
positive benefits of ulcer coverage do not necessarily and is useful for the treatment of recurrent trochanteric
outweigh the social and psychological effects of limb ulcers [15,16] . For ischioperineal ulcers, postoperative
amputation [11] . Additionally, hip disarticulation, while physical therapy and careful adjustment of pressure-
providing necessary tissue for wound coverage, relieving devices are paramount to minimizing the
significantly alters pelvic mechanics when seated and recurrence rate.
patients must learn new techniques for positioning and
self-care to prevent future ulceration, a scenario which In summary, recurrent pressure ulceration is a

Plastic and Aesthetic Research ¦ Volume 4 ¦ October 31, 2017 193