Purpose: Reconstruction of sacral defects remains challenging because of anatomical and patient characteristics. Although musculocutaneous flaps provide less postoperative complications, they have no further advantage due to muscle atrophy in long term. Superior gluteal artery perforator (SGAP) flap offers preservation of muscle integrity with the same perfusion pattern. Outcomes for SGAP flap and its superiority over fasciocutaneous flaps are discussed.

Materials and Methods: Between 2002 and 2004, 8 patients with sacral defects were treated with 9 SGAP (bilateral in one patient) flaps. Pressure sores, suppurative hydradenitis and pylonidal sinus constitute the etiology of 4 paraplegic and 4 ambulatory patients. Flaps were designed on the most laterally localized, single perforator so as to provide long pedicle. Perforator vessels were searched following superior incision and subfascial dissection. Once a suitable perforator was found muscle was splitted in order to free the pedicle off the perimysium. Flap was placed over the soft tissue defect when enough mobilization was provided. Seventeen other patients with sacral pressure sores were treated with fasciocutaneous rotation flaps.

Figure 1. Sacral pressure sore and flap design. (left) Elevation of the SGAP flap on a long, single perforator. (center) Tension free closure of the defect using SGAP flap. (right)

Results: Eight SGAP flaps healed uneventfully, 1 flap was lost due to total necrosis. No dehiscence, partial necrosis, infection or sinus formation were seen. All donor sites but one were closed primarily. Skin grafting was performed in one patient who had bilateral flap coverage. Mean hospitalization period was 7 days. No recurrence were detected after 11 months mean follow up and no limitation in muscle activity were seen in ambulatory patients. However, mean hospitalization time for fasciocutaneous flaps were 25 days. Dehiscence was seen in 7 of the patients and marginal necrosis was seen in 4 patients. Mean follow up period was 13 months and 3 patient had recurrency during this period. Postoperative complication rates and hospitalization time were significantly lower in SGAP flaps. (p<0,05)

Conclusion: SGAP flap can be elevated safely on a single long perforator which provides easy setting and tension free closure. Muscle integrity is preserved, so that postoperative activity is not impaired in ambulatory patients and future reconstruction alternatives are preserved in case of recurrency. With all these advantages SGAP flap provide a reliable and durable alternative among others.