WORKUP	Section 5 of 9
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Lab Studies:

• Blood: Complete blood count and routine blood chemistry usually are required. In some specific situations, a complete metabolic profile, coagulation profile, and blood cultures may be indicated.

Imaging Studies:

• X-ray

• CT scan

• MRI

• Myelogram

	TREATMENT	Section 6 of 9
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Medical therapy: Conservative wound care and intravenous antibiotic therapy should be attempted initially to control the infection and improve the wound. Involve other ancillary services such as the physical therapy and nutritional departments.

Surgical therapy: Flap selection for back reconstruction is based on the size, location, and extent of the defect; previous radiation; previous incisions; and tissue availability. The following algorithm may be useful in providing the beginner with an overall idea of the available options.

Table 1. Algorithm

Defect	Technique
Cervical	Trapezius Latissimus dorsi
Thoracic	Trapezius Latissimus dorsi Serratus anterior
Lumbar	Latissimus dorsi Gluteus maximus Paraspinous muscle Reverse latissimus dorsi Perforator flaps
Sacral	Gluteus maximus Gluteal thigh flap Perforator flaps

All possible reconstructive options are discussed, beginning with the simplest skin graft and proceeding to complex free tissue transfers. Choose the most appropriate flap depending on the requirements of the defect and the availability of tissue.

Skin graft

Skin grafts can be used for repair of superficial wounds and burns. Skin grafts are unpredictable, especially in irradiated tissue. Furthermore, the long-term protection and durability of wounds repaired with skin grafts are questionable because of the effects of shearing and pressure forces. Therefore, skin graft may not be a viable option.

Skin flaps

• Limberg (rhomboid) flaps: These flaps can be used for small defects in the back and for small sacral pressure ulcers. This is a random pattern flap based on subdermal plexus.

• Skin rotation flap: Many small defects can be closed with skin flaps. However, in large defects, the area of poorest blood supply overlies the dural defects; hence breakdown may occur. The gluteal (buttock) rotation flap has remained the primary flap for the repair of sacral ulcers. It also can be used to repair sacral wounds caused by radiation injury or meningomyelocele. It is an inferiorly based flap consisting of skin and subcutaneous fat with a length-to-width ratio of 1:1. One tip is to make the flap as large as possible–bigger is certainly better and safer.

• Thoracolumbar sacral skin flap: This is a large, medially based flap that can be raised from the posterior thoracic, lumbar, and gluteal regions. This flap is based on the posterior perforating vessels of the intercostal and lumbar arteries. It can be used to cover sacral pressure ulcers.

• Transverse lumbosacral back flap: This flap provides a reasonable alternative for coverage of medium-to-large soft-tissue defects of the lower lumbar, sacral, and upper coccygeal areas. It is designed so that its vascular pedicle is preserved along the lateral aspect of the paraspinous muscles on either side. Extend it 2-3 cm lateral to the opposite paraspinous border. Advantages of the flap are that it is quick to raise, elevation is relatively bloodless, muscle is not sacrificed, and it can be re-elevated. Disadvantages include its lack of bulk, the unreliability of the flap tip's vascularity, its limited rotational arc, and the inability to close the donor site defect primarily.

• Intercostal neurovascular island skin flap: This flap can be used as a sensory flap for patients with paraplegia. Any intercostal vascular bundle on either side can be chosen, and the flap can reach from the nape of the neck to the sacrum. The cutaneous paddle may be located at any point along the course of the intercostal neurovascular bundle. The flap width is limited by ease of donor site closure. It is a durable, reliable, and sensate flap, particularly useful in children.

• Scapular and parascapular flaps: The dominant pedicle of these flaps is the circumflex scapular artery, which emerges from the triangular space bounded by the subscapularis and teres minor above, teres major below, and the long head of triceps laterally. The scapular flap has a horizontal skin paddle, and the parascapular flap has a vertical territory. Flap width may be increased to 10-12 cm depending on the skin laxity.

Tissue expansion

Tissue expansion is a useful technique indicated in the reconstruction of various posterior trunk problems. It provides skin cover with similar color, texture, and thickness. It usually is indicated in the treatment of congenital giant nevi, burn scars, and posttraumatic unstable scars. While dealing with large lesions or scars, multiple expanders commonly are used.

Muscle and myocutaneous flaps

Muscle and myocutaneous flaps generally have a better blood supply and possess a superior ability to withstand infections and other adverse conditions. They facilitate wound healing by providing vascularized tissue for closure and antibiotic transport, by obliterating dead space, and possibly by improving leukocyte function. They are the best choices in patients with paraplegia or in situations in which the loss of muscle function is of no significance. They have been a valuable adjunct in treating complex back wounds.

• Trapezius: This is a Type II flap, with dominant blood supply coming from the transverse cervical artery. It receives minor pedicles from the dorsal scapular artery, branch of occipital artery, and perforating posterior intercostal arteries. Complete loss of the trapezius muscle results in shoulder droop, although adequate shoulder function is retained. Use a posterior trapezius advancement flap to provide coverage of small posterior midline defects. Free the muscle inferiorly but do not divide the fibers of insertion to the scapula. A reverse trapezius flap is based on segmental minor pedicles from the posterior intercostal vessels. The fibers of insertion from the scapula are turned over the vertebral column, and the superior fibers are preserved.

• Latissimus dorsi: This is a Type V flap, with thoracodorsal vessels forming the dominant source of blood supply. The secondary segmental pedicles arise from the posterior intercostal and lumbar vessels. Many flap options are possible using this excellent muscle.

• Bilateral advancement flaps based on their thoracodorsal vascular pedicles: These flaps can be used to cover midline defects without detaching their insertion.

• Bilateral bipedicle myocutaneous flaps: The lateral relaxing incisions extend from the posterior axillary line to the thigh, parallel to the free edge of the muscle. Carry the dissection deep to the muscle and raise a large bipedicled flap, including the thoracolumbar fascia. Divide the thoracolumbar perforators. Include the superficial gluteal fascia with the flap in distal defects. Cover the lateral secondary defects with skin grafts.

• Reverse latissimus dorsi muscle: Bostwick et al described the paraspinous perforating vessels that arise from the posterior intercostal arteries of the lower 7 intercostal spaces and the dorsal branches of the 4 lumbar arteries. In human cadaver dissections, Stevenson demonstrated that the main contributions of the perforator supply came from the 9th, 10th, and 11th intercostal vessels and that they arise approximately 5 cm from the mid line. The reverse latissimus dorsi muscle/myocutaneous flap is based on these perforators. The skin island is designed over the posterior axillary area, and the insertion of the muscle is divided to facilitate movement. One of the disadvantages of this flap is the questionable reliability of the distal (humeral insertion) portion.

• Latissimus dorsi triangular island advancement flaps: Thomas used 1-2 triangular advancement flaps based on the paraspinous perforators to cover spina bifida defects. In infants, these flaps move medially to great lengths. The latissimus fascia can be sutured separately in the mid line, thereby achieving a sound closure.

• Serratus anterior: This is a Type III flap receiving blood supply from the lateral thoracic artery and from branches of the thoracodorsal artery. It has a long arc of rotation that reaches the shoulder and upper back. Division of the lateral thoracic pedicle increases the posterior arc of rotation. The donor site can be closed directly. Harvesting the entire muscle results in winging of the scapula.

• Gluteus maximus: This is a Type III flap with 2 dominant vascular pedicles (superior, inferior gluteal) that provides reliable and durable coverage for sacral defects. It is used widely for reconstruction of these defects. Loss of gluteus function in an ambulatory patient results in significant hip instability. Harvesting the complete muscle is not advisable in ambulatory patients. In such circumstances, either the superior or inferior half of the muscle may be used. The entire muscle may be used in patients with paraplegia.

• Tangentially split gluteus maximus myocutaneous island flap: Baran et al described a new partial thickness myocutaneous flap based on perforating vessels from superior and inferior gluteal arteries. One of the main advantages of this flap is the preservation of most of the gluteus maximus function in an ambulatory patient.

• Sliding gluteus maximus musculocutaneous flap: This commonly is performed for coverage of sacral ulcers in patients without paraplegia when the structural integrity of the muscle is preserved. Create triangular skin islands overlying the corresponding muscles. Elevate the muscle and skin en bloc and advance them to the mid line. Close the donor site in a V-Y fashion.

• Segmental muscle flaps: The muscle can be split and only the superior or inferior half of the muscle elevated as a flap. This can be performed either by transposition or by V-Y advancement.
  • Superior gluteal muscle flap: This is used successfully in complex lumbosacral wounds in nonparalyzed patients. This flap is used to cover the fourth and fifth lumbar regions and the sacral region. Identify the superior gluteal artery with a Doppler probe. It is located approximately 3 cm lateral to the mid line and 5 cm inferior to the posterior superior iliac spine (PSIS).

  • Superior gluteus maximus myocutaneous turnover flap: Use a de-epithelialized turnover superior gluteal island flap to patch the dural defect and simultaneously reconstruct large lower midline defects.

• Bilateral latissimus dorsi and gluteus maximus musculocutaneous flaps: Ramirez and colleagues described a technique in which they used both latissimus muscles along with bilateral gluteus maximus muscles for large lumbosacral defects. The flaps are based on the thoracodorsal and superior gluteal vessels and the intervening thoracolumbar fascia. They performed en bloc advancement of these muscles without lateral relaxing incisions. This flap provides tension-free, durable, and viable soft-tissue coverage over the dural repair.

• Paraspinous muscle flaps: These are Type IV flaps with segmental blood supply from medial and lateral lumbar perforators. Locate the paraspinous muscles by incising the thoracolumbar fascia medially and then elevating underlying serratus posterior inferior muscles. Release the muscle from its origin on the spine and then bluntly elevate it from the multifidus muscle, transverse processes, intertransversarii muscles, and transversalis fascia from a medial to lateral direction. Mobilize the muscle flap and advance it medially while preserving the lateral perforators. This flap is technically simple, quick, and does not involve another incision for muscle dissection. The technique ideally is suited for lumbar defects.

• Rectus abdominus muscle flap: This is a Type III flap with vascular pedicles coming from superior and inferior epigastric arteries. The muscle can be used for various posterior trunk defects either as a muscle or as a myocutaneous flap. Obviously, the drawback is that a laparotomy has to be performed.

Fasciocutaneous flaps

• Paralumbar fasciocutaneous flaps: Bilateral paralumbar fasciocutaneous flaps were used to provide stable and durable coverage for large myelomeningocele defects. The parascapular and scapular fascial branches of the circumflex scapular artery supplied the upper lateral portion of these flaps. Prominent lateral extensions of the superficial circumflex iliac arterial system formed the dominant vasculature of the lower lateral flap. The level of dissection is immediately above the lumbodorsal aponeurosis of the paraspinal longitudinal muscle groups. Make relaxing lateral incisions immediately above the iliac crests if tension exists.

• Lateral thoracic fasciocutaneous flap: This flap usually is based on the cutaneous branch of the lateral thoracic artery, although 2 other vessels, the accessory lateral thoracic artery and the cutaneous branch of the thoracodorsal artery, also supply this area of skin. It is a superiorly based flap that reaches the shoulder area and upper lateral trunk. The flap extends from the axillary crease to the sixth intercostal space.

• Gluteal thigh flap: The posterior thigh skin is elevated as a fasciocutaneous flap based on the inferior gluteal artery. The maximum dimensions of this flap are 10 X 35 cm, and the flap easily can cover large sacral defects. The flap usually is elevated to the level of the gluteal crease at the deep fascial layer. Including the inferior half of gluteus maximus muscle with the flap significantly increases the flap's arc of rotation.

Perforator flaps

Perforator flaps enable the transfer of a large amount of healthy, well-vascularized tissue without sacrificing important underlying muscles. The preservation of muscle integrity and muscle function is one of the great assets of the perforator flap principle, especially in patients without paraplegia. The arc of rotation also is larger than in traditional flaps. Flaps can be custom designed based on unnamed perforators in any location after mapping the vessels with Doppler ultrasonic probe. When addressing pressure ulcers, always consider the possible need for repeated surgery in the event of recurrence. Therefore, use a perforator-based flap as the method of first choice because of minimal morbidity at the donor site.

Perforator-based flaps have been used extensively for lumbosacral defects.

Kroll and Rosenfield described a perforator-based flap for paraspinal and parasacral defects. In the mid back, they include a small segment of latissimus dorsi muscle around the perforators. They stress meticulous dissection of the subcutaneous tissues from the underlying muscles with identification and preservation of perforators.

• Superior gluteal artery perforator (SGAP) flap: Large amounts of well-vascularized skin and subcutaneous tissue are transferred easily on one perforator to reconstruct sacral defects. The superior gluteal artery can be marked on the skin of the buttock on one third of a line drawn from the PSIS to the top of the greater trochanter. Only the perforators located above the piriformis muscle are used. These are located superiorly to a line drawn between the greater trochanter and a point halfway between the PSIS and the coccyx. The flap has a good reach, and the donor defect always is closed directly.

  Design the flap around the most lateral perforator to create the longest pedicle possible. A pedicle length of 8-10 cm is obtained easily, giving the flap an impressive mobility and the possibility of covering large defects with a unilateral flap. Dissection of the pedicle may take more time when first learning this procedure. The integrity of the gluteus maximus muscle is preserved, which is particularly important in nonparalyzed patients. All flaps based on the inferior gluteal artery also are preserved, and no significant donor site morbidity occurs. The SGAP flap has become a valuable flap for the reconstruction of sacral ulcers.

• Lumbar artery perforator flap: Four pairs of lumbar arteries arise on each side of the spine emerging through the lumbar fascia. They are given off just lateral to the erector spinae muscle, 5-9 cm from the mid line. Perforators of the second and fourth lumbar arteries are more prominent than the others. The skin territory supplied by the second lumbar artery extends from the posterior mid line to the lateral border of the ipsilateral rectus abdominus muscle and approximately 10 cm above the anterosuperior iliac spine. Choose the most suitable perforator according to the location of the ulcer.

  Design the flap transversely or obliquely from the posterior mid line down to the anterosuperior iliac spine. The distal edge of the flap can be placed as far anteriorly as the midaxillary line. The pivot point usually is placed where the perforator emerges through the lumbar fascia. Dissection proceeds from a lateral to medial direction, including the lumbar fascia. A relatively large flap (maximum 8 X 27 cm) with the distal margin extending to the midaxillary line has been elevated safely. The donor defect usually is closed directly. Its large arc of rotation enables it to be used for lower back, thoracic, and posterior costal regions.

• Intercostal artery perforator flap: The intercostal perforators are given off at the level of midaxillary line. The skin island usually is planned to overlay the 9th or 10th intercostal space. The largest flap reported measures 18 X 12.5 cm; size is limited by the possibility of secondary defect closure.

• Latissimus dorsi "perforator" flap: Angrigiani et al described a new flap that raised only the cutaneous component of the latissimus dorsi muscle flap without muscle, based on perforators. They found with cadaver studies that the thoracodorsal artery gave off 2-3 cutaneous perforators. A flap with dimensions reaching 25 X 15 cm oriented in any direction can be designed and raised safely. Donor sites can be closed primarily without tension.

Periosteal flaps

• Lumbar periosteal turnover flaps: In meningomyelocele closure, these flaps reinforce the dural repair and help contain a potential cerebrospinal fluid leak from the primary repair of the cord. This technique essentially involves the development of bilateral thoracolumbar fascial flaps in conjunction with periosteal flaps, which are elevated from adjacent lumbar pedicles and transverse processes, thus forming a composite tissue flap. This technique provides an additional autologous tissue layer for a reliable and watertight closure.

Osteocutaneous

• Intercostal osseocutaneous flap: Rib can be harvested with the intercostal island skin flap to provide skeletal stability when needed.

Osteomuscular

• Paravertebral osteomuscular flap: This flap is developed by incising the paravertebral muscle mass and fracturing the transverse processes.

Osseomusculocutaneous

• Serratus osseomuscular flap: Serratus anterior muscle with portions of the ribs can be elevated as an osseomusculocutaneous flap.

Omental flaps

An omental flap provides the surgeon with neovascularized tissue for repairing complex wounds. It can cover wounds as large as 600 cm². Mobilize it as a vascular flap based either on left or right gastroepiploic vessels. Tunnel it retroperitoneally through a defect in the lumbar fascia to reach the posterior trunk. A disadvantage of this technique is the required laparotomy.

Free flaps

Free tissue transfer is effective in achieving primary healing and providing durable coverage for extensive defects of the back where local tissue is not available. Microsurgical reconstruction of the trunk is complicated by a paucity of recipient vessels and difficulties in postoperative care.

Latissimus dorsi, serratus anterior, tensor fascia lata, and lateral thigh usually are used for ease of harvesting, with the patient in the lateral or prone position. Recipient vessels are superficial or deep femoral vessels, inferior epigastric vessels, and superior and inferior gluteal vessels, lumbar vessels, intercostal vessels, and thoracodorsal vessels. Long vein grafts frequently are used.

Nahai and Hagerty report use of latissimus dorsi free muscle transfer with interposition grafts of 25 cm to extend the flap to the sacral area in one stage.

Innervated flaps

The advantage of using sensate or innervated flaps for pressure sore coverage in paraplegic patients is the hope that sensation will prevent behavior modifications by the patient to avoid pressure on these areas and thus prevent recurrent ulceration.

• Plantar flap: A plantar flap may be used as a free sensory flap.

• Intercostal flap: The extended intercostal flap based on T9 or T10 intercostal vessels and nerves provides a sensory flap.

Filleted leg tissue

In patients with paraplegia, filleted leg and/or thigh tissue provides large amounts of tissue to obliterate large cavities and resurface wounds. These are obviously operations of last resort for patients in whom all conventional choices have been exhausted and when the patients have intractable osteomyelitis and severe soft-tissue defects. Preserve the latissimus muscle in patients with paraplegia, because they depend on upper limb strength to mobilize themselves.

Preoperative details: Include a complete history and physical examination in the initial evaluation. Involve various other disciplines including neurosurgery, orthopedics, infectious disease, pulmonary medicine, and nutrition. Perform extensive debridement of all devitalized soft tissue, cartilage, and bone before flap coverage.

As part of preoperative planning, devise more than one reconstructive plan in the event the resected area is larger than anticipated. Consider each wound on an individual basis and consider the armamentarium of available techniques. Try to use 1-stage procedures that yield a totally healed wound in the shortest time.

Intraoperative details: Meticulous hemostasis and application of suction drainages are essential. Wound closure should be without tension. Employing 2 surgical teams in long operations can save operating time.

Postoperative details: Proper postoperative care is as important as the surgical procedure. The patient maintains a prone or lateral position for at least 3 weeks, avoiding compression on the flap or pedicle. Patients usually are treated in the intensive care unit for the first few days. They are nursed on low air-loss mattresses and are turned regularly to prevent recurrence of pressure ulcers. Incentive spirometry and breathing exercises are crucial to prevent pulmonary problems.