Chronic sacral ulcers, which develop as pressure ulcers and radiation ulcers, are a well-known clinical problem and usually require surgical treatment with gluteal fasciocutaneous (FC) flaps for closure.^1,2 Recently, the superiority of gluteal perforator-based flaps in the reconstruction of sacral pressure sores has been recognized. Gluteal FC rotation flaps can still be used, especially for older patients who cannot tolerate lengthy surgeries. A distressing problem with gluteal FC rotation flaps is that a large dog-ear (Burow’s triangle) may develop on the buttock (Figure 1). The authors present a new method of avoiding a dog-ear deformity while achieving adequate repair of pressure ulcers on the buttock by using a “pigeon head” modification of the rotation flap.

Materials and Methods

Seven patients were treated using modified rotation flaps in the authors’ facility between 2004 and 2005—6 had a sacral pressure ulcer and 1 had a sacral radiation ulcer. Ages ranged from 59 to 82 years (mean age, 69 years). The size of the soft tissue defects requiring coverage following debridement ranged from 5 cm x 4 cm to 14 cm x 10 cm.
Standard surgical techniques were performed leading up to the flap elevation and included thorough cleansing and debridement of all necrotic tissues, and removal of sacral bony prominence.
The gluteal FC flap was designed to be large enough to cover the sacral defect by swinging in a wide arc. A small triangular flap was also added to the base of the arc (Figure 2A). The length of the triangular flap base was roughly 20% of the gluteal FC flap. The elevated flap is a modified bilobed flap—the small lobe resembles a bird’s beak, and the entire design resembles a pigeon’s head. The gluteal FC flap is elevated above the gluteal muscle layer and includes the small triangular flap. After the FC flap is transposed to cover the skin defect, the point of the donor site of the small triangular flap (A–A’) are pulled to meet each other and sutured—consequently, the gluteal FC flap donor site is decreased in size. The triangular flap is small enough that it can usually be transposed and sutured without removal (Figure 2B).
The patients are permitted to lie on an extra-soft, urethane foam mattress devised to fractionate pressure against the body for 2 weeks. Afterward, normal pressure on the flap from a bed or wheelchair was permitted.

Results

The pigeon head modification of the rotation flap successfully covered all 7 sacral ulcers—6 were sacral pressure ulcers and 1 was a sacral radiation ulcer. The average follow-up time was 15 months. No flap complications were observed. Immediately after surgery in all cases, Burow’s triangles were unobtrusive.

Discussion