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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 1  |  Page : 64-66

Reconstruction of a sacral defect with bilateral gluteus maximus V-Y advancement flap following resection of squamous cell carcinoma (Marjolin's ulcer)


1 Department of Plastic Surgery, Dr. B Borooah Cancer Institute, Guwahati, Assam; Dr. Bhubaneswar Borooah Cancer Institute, A Grant-in-Aid Institute of Department of Atomic Energy, Govt.of India and a unit of Tata Memorial Centre (Mumbai) Mumbai, Maharashtra, India
2 Dr. Bhubaneswar Borooah Cancer Institute, A Grant-in-Aid Institute of Department of Atomic Energy, Govt.of India and a unit of Tata Memorial Centre (Mumbai) Mumbai, Maharashtra; Department of Surgical Oncology, Dr. B Borooah Cancer Institute, Guwahati, Assam, India

Date of Submission11-May-2021
Date of Decision14-May-2021
Date of Acceptance17-May-2021
Date of Web Publication23-Jul-2021

Correspondence Address:
Dr. Anil Kareth Mathew
Department of Plastic Surgery, Dr. B Borooah Cancer Institute, Guwahati, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aort.aort_10_21

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  Abstract 


The incidence of squamous cell carcinoma arising from pressure ulcers has been reported to be as low as 0.5%. Malignant transformation arising from pressure ulcers is frequently overlooked as they often present with invasive infections. This results in wide defects post-excision which may not be amicable to reconstruction with conventional locoregional flaps. Through this case report, we discuss the versatility of using the bilateral gluteus maximus V-Y advancement flap following resection of sacral squamous cell carcinoma (Marjolin's ulcer).

Keywords: Marjolins ulcer, sacral defect reconstruction, V-Y advancement of gluteus maximus flap


How to cite this article:
Boro S, Kalita D, Kiling D, Mathew AK. Reconstruction of a sacral defect with bilateral gluteus maximus V-Y advancement flap following resection of squamous cell carcinoma (Marjolin's ulcer). Ann Oncol Res Ther 2021;1:64-6

How to cite this URL:
Boro S, Kalita D, Kiling D, Mathew AK. Reconstruction of a sacral defect with bilateral gluteus maximus V-Y advancement flap following resection of squamous cell carcinoma (Marjolin's ulcer). Ann Oncol Res Ther [serial online] 2021 [cited 2022 May 23];1:64-6. Available from: http://www.aort.com/text.asp?2021/1/1/64/322152




  Introduction Top


Malignant degeneration in any chronic wound is termed as Marjolin's ulcer (MU). The overall metastatic rate of MU is approximately 27.5%. However, the prognosis of MU specific to pressure sores is poor, with a reported metastatic rate of 61%.[1]

The gluteus maximus myocutaneous flap is considered as the workhorse in sacral as well as perineal defect reconstruction. The gluteus maximus (GLM) is a Type III muscle with two dominant pedicles, the inferior and superior gluteal arteries.[2]

The most significant advantages[3] of gluteus maximus myocutaneous flaps include:

  1. They have an excellent blood supply which allows greater versatility in flap design
  2. The surgical procedure can be performed in a relatively bloodless manner if dissection takes place in the avascular tissue plane between the gluteus maximus and medius
  3. This flap also provides muscle padding in the pressure area.


Defects in the sacral region can be a challenge to reconstruct as it is a pressure-bearing zone and also due to the paucity of redundant tissue in the proximity. The aggressive behavior of marjolins ulcer warrants resection with adequate margins. As we studied the literature, it was also noted that the instances of squamous cell carcinoma arising in the sacral region are a rare event.


  Case Report Top


A 75-year-old male patient was referred to the Department of plastic surgery from the Department of surgical oncology, for advice regarding the reconstruction of a sacral defect after excision.

He had a history of bedsore, following a road traffic accident 20 years back which later transformed into a small non-healing ulcer. There was multiple instances of healing and reappearance of the ulcer in this 20 years. But noticeably, for the past 2 years there has been a steady increase in the size of the ulcer. On clinical examination, the lesion appeared to be approximately 10 × 8 cm2, reddish-pink, and ulceroproliferative. The lesion was tender, fixed with indurated margins. The biopsy of the lesion was reported as well-differentiated squamous cell carcinoma. After assessing the various flaps possible, it was decided that the defect can be reconstructed with a V-Y gluteus maximus advancement flap.

Once the patient was anesthetized, he was placed in prone jack-knife position on a surgical frame and stabilized with pillows. The perforators, superior gluteal artery, and inferior gluteal artery were marked using Doppler. Wide excision of the lesion with adequate margins was done. Triangular flaps were marked bilaterally based on the defect size and centered over the perforators [Figure 1]. The size of the flap was approximately 12 cm × 10 cm. Skin incisions were made over the outline following which the plane between the gluteus medius and maximus was identified laterally. The origin of the gluteus maximus muscle is divided from the iliac crest, starting laterally and progressing medially. The flap dissection is performed with utmost care around the pedicle. Once the vascular pedicle is secured the reminder of the origin of the superior aspect of the muscle is detached followed by the medial attachment of the muscle. The inferior portion of the gluteus maximus muscle is left untouched to preserve hip stability. Similar steps are repeated on the opposite side following which the gluteus maximus myocutaneous is advanced to the midline. Hemostasis was verified and the donor defect was closed in a V-Y manner after placement of drains. Postoperatively, the patient was placed in the prone position for 2 weeks, and the drains were removed on the 8th day. The healing was uneventful [Figure 2].
Figure 1: (a) The image showing growth in the sacral region, (b) It shows the marking of the flap

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Figure 2: (a) Flap after mobilization from superior and medial attachment, (b) The healed wound after 2 months of follow-up

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  Discussion Top


The gluteus maximus V-Y advancement flap was originally used as a myocutaneous flap to treat decubitus ulcers in the sacral, ischial and greater trochanter regions. Its robust blood supply and relatively larger size allow for the reconstruction of extensive skin defects in the sacral region.[4]

In 1981, Scheflan et al. reported using a gluteus maximus V-Y advancement flap to treat a decubitus ulcer in the sacral and ischial regions.[5] Ramirez also reported using a gluteus maximus V-Y advancement flap to reconstruct skin defects after the resection of a decubitus ulcer in the greater trochanter.[6] Di Mauro et al. in 2008 assessed the role of V-Y bilateral gluteus maximus myocutaneous flap (GLM) in the reconstruction of large perineal defects after resection of pelvic malignancies. The study involved 12 patients who underwent abdominoperineal resection with partial sacrectomy or total pelvic exenteration. After a mean follow-up of 31.2 months, no major functional impairment in daily activities was observed.[7] In our patient, after assessing the various reconstructive options, it was decided to go ahead with a bilateral V-Y advancement gluteus maximus myocutaneous flap.

The gluteus muscle has a significant role in hip stability. Hence, we should preserve either the superior half or inferior half of the muscle in ambulatory patients.[1] Preserving the inferior gluteal nerve and the gluteal muscular insertion helps in the rehabilitation program of the patient later. In paraplegic patients, when the defect size is large the origin, as well as insertion, can be incised which allows for the greater advancement of the flap.

Uing the V-Y advancement design, it makes it possible to perform the re-advancement of the flap. The time taken for the flap raise and in-setting was about 90 min. In a study done by Chen, the average operative time was 2 h and 45 min.[8] The operative technique is less complicated as well as less time consuming than bilateral gluteal thigh flaps, the expanded skin flaps, the expanded fascial flap, and the gluteus maximus flap.

The size of the flap was approximately 10 cm × 9 cm × 2.5 cm. This design also provides a considerably larger flap than the fasciocutaneous V-Y advancement flap or the gluteal perforator-based flap.[9]

Grabosch et al. carried out an electromyographic study on 11 patients who had undergone reconstructive surgery with gluteus maximus myocutaneous flaps in a period up to 7 months after surgery. The results showed signs of denervation, parallel re-innervation, and signs of functional integrity of the transposed muscle.[10] The gait and posture of our patient were satisfactory. The wound healing was exceptional, and this can also be due to minimal tension along the suture lines owing to the V-Y closure along with the donor site. Our patient was able to start his daily activities just after 2 weeks of surgery. The patient was advised to use a specialized cushion for 3 months whenever he assumes the sitting posture.


  Conclusion Top


As we have discussed, defects in the sacral region can be a challenge to reconstruct due to the paucity of adequate redundant tissue. This area being a pressure bearing zone needs a flap which has adequate thickness The instance of SCCa arising in the sacral region as we see in this patient by itself is a rare finding. The GLM advanced in a V-Y fashion not only provides reliable coverage of sacral defects but is also a dependable option for reconstruction for large sacral defects.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Khan K, Giannone AL, Mehrabi E, Khan A, Giannone RE. Marjolin's ulcer complicating a pressure sore: The clock is ticking. Am J Case Rep 2016;17:111-4.  Back to cited text no. 1
    
2.
Wei FC, Mardini S. Flaps and Reconstructive Surgery. 2nd ed, Oct 2016, Elsevier Publications, Netherlands.  Back to cited text no. 2
    
3.
Lee, Bernard T, Strauch, Berish, et al, Grabbs Encyclopedia of Flaps. 4th ed, Vol. 2, Dec 2015, Lippincott Williams and Wilkins publication.  Back to cited text no. 3
    
4.
Takanori G, Kenji K, Kanji K. Modified gluteus maximus V-Y advancement flap for reconstruction of perineal defects after resection of intrapelvic recurrent rectal cancer: Report of a case. Surg Today 2003;33:626-9.  Back to cited text no. 4
    
5.
Scheflan M, Nahai F, Bostwick J 3rd. Gluteus maximus island musculocutaneous flap for closure of sacral and ischial ulcers. Plast Reconstr Surg 1981;68:533-8.  Back to cited text no. 5
    
6.
Ramirez OM. The distal gluteus maximus advancement musculocutaneous flap for coverage of trochanteric pressure sores. Ann Plast Surg 1987;18:295-302.  Back to cited text no. 6
    
7.
Di Mauro D, D'Hoore A, Penninckx F, De Wever I, Vergote I, Hierner R. V-Y Bilateral gluteus maximus myocutaneous advancement flap in the reconstruction of large perineal defects after resection of pelvic malignancies. Colorectal Dis 2009;11:508-12.  Back to cited text no. 7
    
8.
Chen TH. Bilateral gluteus maximus V-Y advancement musculocutaneous flaps for the coverage of large sacral pressure sores: Revisit and refinement. Ann Plast Surg 1995;35:492-7.  Back to cited text no. 8
    
9.
Koshima I, Moriguchi T, Soeda S, Kawata S, Ohta S, Ikeda A. The gluteal perforator-based flap for repair of sacral pressure sores. Plast Reconstr Surg 1993;91:678-83.  Back to cited text no. 9
    
10.
Grabosch A, Gutjahr L, Gruhl L, Bruck JC. Electromyographic studies of myocutaneous sliding flaps for the covering of sacral decubitus ulcer. Handchir Mikrochir Plast Chir 1991;23:307-11.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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