22:55, 05/04/2022 Effect of Flap Selection on Postoperative Sacral Pressure Injuries

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ORIGINAL RESEARCH Sections

References

Effect of Flap Selection on the Abstract

Postoperative Success of Sacral
Pressure Injuries: A Retrospective
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Analysis Introduction

Materials and Methods

Serhat Şibar, Kemal Findikcioglu, Kirdar Guney, Serhan Tuncer, Keywords
Myocutaneous Flap
Suhan Ayhan
Perforator Flap
Pressure Ulcer
Surgical Flaps
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October 2021
ISSN 1044-7946
Index Wounds 2021;33(10):271–276. Epub 2021 September 17

Abstract
Introduction. Pressure injuries (PIs) continue to be a substantial problem and
burden for the present-day health care system and are the leading cause of
chronic wounds worldwide. There is no current consensus on the long-term
results of the use of flaps in sacral PI reconstruction and optimal flap choice.
Objective. This study aimed to evaluate whether flap selection influences
postoperative results in sacral PI reconstruction. Materials and Methods.
Patients who underwent surgery for PIs in the authors’ clinic between 2002
and 2016 were retrospectively analyzed. A total of 63 patients with stage
3/stage 4 sacral PIs and who underwent reconstruction with fasciocutaneous
(FC) flaps (group 1), musculocutaneous (MC) flaps (group 2), or perforator (P)
flaps (group 3) were included in the study. The mean duration of the follow-up
period was 14.4 months, and patients were evaluated in terms of their
demographic data, length of hospital stay, complications, and recurrence.
Results. The mean age, sex distribution, and ambulatory status were similar
between the groups. In group 2 (MC), the mean length of hospital stay and
mean drain removal time were significantly longer. The mean daily drainage
amount was significantly higher in group 2 (MC) than in the other groups, and
long-term relapses were less frequently observed in group 3 (P). A significant
difference was observed between groups 2 (FC) and 3 (MC) in terms of
wound dehiscence. The authors determined that P flaps were associated with
a reduced mean length of hospital stay and daily drainage. Conclusions. For
these patients, P flaps appear to be the optimal flap choice for sacral area
reconstruction. However, new prospective randomized studies are needed to
support these findings.

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Şibar S, Findikcioglu K, Guney K, Tuncer S, Ayhan S. Effect of flap selection on

the postoperative success of sacral pressure injuries: a retrospective analysis.
Wounds. 2021;33(10):271–276. doi:10.25270/wnds/091721.01

Introduction
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Pressure injuries (PIs) are defined as tissue injuries caused by unrelieved pressure
over a bony prominence.1,2 Treatment of patients with this wound type can be
challenging for medical professionals, nursing staff, and health care providers
worldwide. Treatment success is limited to the closure of defects and prevention of
long-term relapse. This wound type is commonly seen in the sacral area; anatomic
location, presence of additional comorbidities, bed confinement status, malnutrition,
immobility, lack of sensation, and inadequacy of social care services are factors that
can negatively affect reconstruction success. In the literature, various flap options
have been identified to reconstruct sacral PIs, but studies that compare these
options using postoperative results are limited.3-8

In this study, the authors conducted a retrospective evaluation of postoperative

complications, clinical outcomes, and PI recurrence during 14 months of follow-up
for patients who had received musculocutaneous (MC), fasciocutaneous (FC), or
perforator (P) flaps for a sacral PI.

Materials and Methods

The study protocol was arranged in accordance with the ethical rules of the 1975
Declaration of Helsinki.  During 2002 to 2016, patients who underwent surgery for
sacral PIs were retrospectively analyzed. Patients who had stage 3 and/or stage 4
PIs were included in the current study. Patients using immunosuppressive
medication or having poor family social support were excluded. A total of 63 patients
whose sacral PIs were reconstructed using FC (group 1), MC (group 2), and P (group
3) flaps were included in this study. Patients were analyzed in terms of their
demographic features, wound etiology, defect size, postoperative complications,
daily drainage volume, recurrence rate, hospital length of stay, and the statistical
differences between the groups.

Statistical analysis

Whether the distributions of continuous variables were normal was determined

using Kolmogorov–Smirnov test. Levene test was used for evaluating the
homogeneity in variances. Continuous variables are presented as mean ± standard
deviation or median (min–max), where applicable. The number of cases and
percentages were used for the categorical data, and the mean differences between
the groups were evaluated using one-way analysis of variance. The Kruskal–Wallis
test was applied for comparisons of data that were not normally distributed. When
the value of P from the one-way analysis of variance or Kruskal–Wallis test statistics
was found to be statistically significant, a post hoc Tukey honestly significant
difference or Conover multiple comparison tests were used to identify which
group(s) differed. When there were 2 independent groups, the comparisons
between the groups were performed using a Student’s t test or Mann–Whitney U
test, where appropriate. The categorical data were evaluated by a Pearson’s χ² test,
Fisher exact test, or likelihood ratio, where applicable. Data analysis was performed
using IBM SPSS Statistics 17.0 (IBM Corp) software. A value of P less than .05 was
considered to be statistically significant. However, for all possible multiple
comparisons, the Bonferroni adjustment was applied to control for a type 1 error.

Results

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A total of 63 patients with sacral PIs were included in the study. The mean age was
45 years (range, 3–83 years); 39 patients were male and 24 were female. Sacral area
reconstruction was performed with FC flaps (group 1) in 28 patients, MC flaps
(group 2) in 13 patients, and gluteal artery P flaps (group 3) in 22 patients. Pressure

injuries occurred because of paralysis in 35 patients and for other reasons in 28

patients. The statistical analysis of the demographic and clinical properties
accordingCURRENT
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of the groupsONLINE
is outlined in Table 1.VIDEOS
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There were no significant differences between the groups regarding mean age and
sex distribution (P >.05). In addition, there were no significant differences between
the groups according to the number of patients with paralysis, immobility, lack of
sensation, body mass index, nutritional status, nicotine-opioid use, and insurance
status (P >.05).

There was a statistically significant difference between the groups regarding mean
drain removal time (P <.001). Specifically, the drains in group 3 were removed earlier
than in groups 1 and 2 (P <.001 and P <.001, respectively). There was no statistically
significant difference between groups 1 and 2 (P >.05).

There was a significant difference between the groups regarding mean length of
hospital stay (P =.004). In group 2, the length of hospital stay was longer than that in
groups 1 and 3 (P =.047 and P <.001, respectively). Moreover, in group 1, the length of
hospital stay was longer than group 3 (P =.017).

The mean follow-up time was statistically similar between the 3 groups (P >.05).
There was a statistically significant difference between the groups regarding daily
drainage amount (P <.001). In group 2, the mean drainage amount was significantly
higher than in groups 1 and 3 (P <.001 and P <.001, respectively). Group 1 also had a
significantly higher mean drainage volume than group 3 (P =.0031; Figure 1).

There was a statistically significant difference between the groups regarding

incidence of recurrence, with groups 1 and 2 exhibiting a significantly higher
recurrence rate than group 3 (P =.025 and P =.050, respectively). No statistical
difference was detected between groups 1 and 2 (P >.05) (Figure 2).

No statistical difference was found between the groups regarding major necrosis,
Fournier's gangrene, infection, fat necrosis, or marginal necrosis (P >.05).

There was a statistically significant difference between the groups regarding wound
dehiscence (P =.02). Dehiscence was more frequently seen in group 2 than group 3
(P =.019). There was no significant difference between groups 1 and 2 and groups 1
and 3 (P >.05) (Figure 3).

No statistical difference was detected between the groups regarding major and
minor complications (P >.05). Similarly, with mean defect size and rate of exitus,
there was no statistical difference between the groups (P >.05).

In each group, among the patients younger than 50 years and older than 50 years,
there was no significant difference in dehiscence or minor, major, or total
complication incidence according to the Bonferroni adjustment (P >.05).

In each group, among the patients who had paralysis and those who did not, there
was no significant difference regarding dehiscence, minor, major, and total
complication incidences according to the Bonferroni adjustment (P >.05).

There was no statistical correlation between the mean drain removal time and
dehiscence, or minor, major and/or total complication incidence according to the
Bonferroni adjustment in each group (P >.05).

There was no statistical correlation between the mean length of hospital stay and
dehiscence, or minor, major, and/or the total complication incidence according to
the Bonferroni adjustment in each group (P >.05).

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Statistically, no correlation was present between the mean defect size and
dehiscence, or minor, major, and/or total complication incidence according to the
Bonferroni adjustment in each group (P >.05). However, the patients in group 2 (MC)
who had at least 1 complication had a significantly greater defect size than those

without complications (P =.008) (Table 2).

There was no correlation between the daily drainage amount and dehiscence in
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each group according to the Bonferroni adjustment (P >.05). No correlation was
detected between the daily drainage amount and minor and/or major complications
according to the Bonferroni adjustment (P >.05). The patients in group 3 with minor
and/or major complications had a significantly higher mean daily drainage than
those without complications (P =.002).

Discussion
Sacral defects caused by PIs usually make reconstruction difficult because of
anatomic location and other patient-related factors. The flaps used in PI
reconstruction serve the same purpose, but the use of muscle remains
controversial.9-16 Additionally, data on the comparison of flap choice and the long-
term success rates are limited.17-20 All reconstructive techniques have particular
advantages and disadvantages. Furthermore, a clinical comparison of the success
rates of these techniques can serve as a guide to the surgeon. Although the current
study was retrospective in nature, the variables that could affect the results were
minimized as much as possible by including only sacral PIs.

Drain removal occurred later in patients who underwent reconstruction using the
MC flaps (group 2). It was considered that this finding might be due to the wide
dissection and dissection in the vascular tissue planes for flap elevation.

The mean length of hospital stay was found to be longer in the FC and MC groups
(group 1 and 2, respectively) when compared with the P group (group 3). This may
result from P flap dissection usually being performed in a limited area compared
with MC and FC counterparts. As a result, early drain removal in this group might
play a role in this observation.

Daily drainage volume was lowest in the P flap group (group 3). It was considered
that this finding might be due to the fine and delicate nature of the perforator
dissection and strict microhemostasis.

When recurrent cases were compared between each of the 3 groups, recurrence
was found to be lower in the P flap group (group 3). This may be because perforator
dissection is a time-consuming process and requires microsurgical techniques,
which lengthen the surgical time in most cases. Therefore, this reconstruction might
not be preferred in patients in poor condition. Although the 3 groups exhibited no
differences regarding the number of patients with paralysis, the lowest percentage
of patients with paralysis were found in the P flap group. This explains why a low
rate of recurrence can be accepted as a normal result in the P flap group.

Similar recurrence rates were observed in the FC (group 1) and MC (group 2)

groups, and this finding is consistent with data in the literature.21-24

In a study by Thiessen et al,9 the authors determined that PIs reconstructed with FC
or MC flaps exhibited no differences regarding the presence of hematoma, seroma,
wound dehiscence, or secondary procedures.

There were no differences found between the FC and MC groups regarding wound
dehiscence and necrosis, which is in line with other studies. However, wound
dehiscence was determined to be significantly lower in the P flap group (group 3)
when compared with the MC group (group 2). Therefore, the long pedicle length of
the P flap allows for a tension-free and easy adaptation of the flap to the defect and

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might have caused this difference. Additionally, the high rate of dehiscence in MC
flaps can be explained by the limited arc of rotation due to the muscular
components.

In the literature, MC flaps were accepted as a standard treatment modality for many

years due to their robust blood supply and resistance to infection.25-27 In some
studies, MC flaps were found to be superior to FC flaps in managing infected
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wounds25-27; other studies demonstrated no such superiority.28,29 In the current
study, no significant difference was found between the 3 groups.

From the authors’ experience, the main determining factor in infection rates is
related to the total bursectomy procedure rather than flap choice.

In the multivariate analysis, a significant relationship was found between the defect
size and rate of complications in the MC flap group (group 2). It was considered that
this might be due to the limited arc of rotation inherent to MC flaps when compared
with the FC and P flap groups.

The study performed by Thiessen et al⁹ is the most similar to the current study.
However, in this study, the P and FC flaps, which were used for the sacral area
reconstruction, were ranked within the same group.11 The P and FC flaps exhibit
significant differences regarding the blood supply, tension at the closure, and the
width of the dissection area.

In the authors’ opinion, because of the aforementioned differences, P and FC flaps

should be evaluated separately. Therefore, the current study differs from other
similar studies in the literature.

Limitations
The limitation of the study is that it is not a prospective randomized controlled study;
rather, it is retrospective. In addition, it is very difficult to standardize patients
according to groups in wound studies, and postoperative patient care conditions
may vary. This situation also makes it difficult to evaluate recurrence in these patient
groups.

Conclusions
Patient-, wound-, and surgeon-related factors are adequate for the flap choice in
sacral PI reconstruction. Per the authors’ clinical experience, P flaps are preferred as
the first choice in appropriate patients because they are associated with shorter
mean length of hospital stay, reduced daily drainage, and decreased recurrence rate.
The current study will be a guide for future randomized controlled studies.

Acknowledgments
Authors: Serhat Şibar, MD1; Kemal Findikcioglu, MD1; Kirdar Guney, MD2; Serhan
Tuncer, MD1; and Suhan Ayhan, MD1

Affiliations: 1Gazi University Hospital, Department of Plastic, Reconstructive and

Aesthetic Surgery, Ankara, Turkey; 2Renee Clinic, Istanbul, Turkey

Correspondence: Serhat Şibar, MD, Gazi University Hospital, Department of Plastic

Reconstructive and Aesthetic Surgery, 14th floor, Besevler, Ankara, Turkey;
serhatsibar@hotmail.com

Disclosure: The authors disclose no financial or other conflicts of interest.

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