Sliding Perforator Island Flap For Covering A Big Lumbosacral Defect

Abstract

The use of perforator island flaps to cover big skin defects is described by many authors. Flex C.Behan 1 described this flap in many publications and showed many cases of hands, face,leg, upper back and other areas. (1,2,3,4,5,7) Closure of big defects is commonly done by skin grafting or distant flap transfer which often gives bulky masses. Use of transposed local flaps is an excellent idea which can employ different shapes like V-Y and other forms. (1) CASE REPORT 36 years old Malay man who has a recurrent dermatofibrosarcoma protuberans on the back at the level of the lumbo-sacral region was subjected on 10th of July 2008 for excision of the lesion with a safety margin of 2 – 3 cm, as shown in fig (1) and (2) The defect measured 12 cm X 10 cm and was rhomboid shaped. The general surgeon asked to wait until histopathologist gave us the needed informations about the safety margin excised. When he confirmed that the margins are free of any neoplastic cells we proceeded to cover the defect. Figure 1 Figure 1: Defect after tumor excision of the tumor (dermatofibrosarcoma protuberans) Figure 2 Figure 2 The author designed and mapped the defect and surrounding possible skin flaps. He put the design as shown in figure (3 7) either to make (right thoraco-lumbar and left gluteal) or (left thoracolumbar and right gluteal) island flaps. TECHNIQUE Incisions were done around the marked areas in Fig (4 and 7) and release of the fasciocutaneous flaps from the surrounding skin and mobilizing these flaps to meet at the center (Fig 5). Mild dissection of proximal ends of these flaps was done to become more mobile. Incision of the deep fascia was also done on both flaps with securing the bleeding vessels. Sliding Perforator Island Flap For Covering A Big Lumbosacral Defect 2 of 6 When the flaps became mobile enough, and met easily to fill the defect, the author started to undermine the upper and lower edges of the wound. When the author became comfortable with the all flaps, he started to close the wound in layers with a suction drain below the flap Fig (8 and 9). The medial edges of the flaps are sutured to each other and fixed to the underlying tissue over the spine to close any possible dead space. Figure 3 Figure 3: The defect Figure 4 Figure 4: Mapping Figure 5 Figure 5: Flap dissection Figure 6 Figure 6: Closure complete Sliding Perforator Island Flap For Covering A Big Lumbosacral Defect 3 of 6 Figure 7 Figure 7: Defect and mapping POST OPERATIVE Elastoplast was used with the dressing to cover the wound. Intermittent suction in the 1st 24 hours was done. One session of hyperbaric oxygen was given on the second postoperative day. Suction vacuum was used until the 8th day, with Cibrofloxacillin injection for one week. Limitation of movement after surgery was requested and prone position or later position was allowed. No sleeping on the back was permitted. RESULTS Flaps are nicely healed and closure of the wound was complete Figure 8 Figure 8: One week after operation with a drain in place