The expansive gluteus maximus flap

The rich vascular network of the gluteal and posterior thigh region provides for a larger range of flaps for reconstructive surgery than previously described. Facility with these flaps requires an appreciation of relevant anatomy, embryology, and anthropology. Structural changes in the gluteus maximus muscle are critical to the evolutionary advance toward an upright stance during walking. The superficial and deep segmentation of the gluteus maximus are best appreciated by phylogenic and ontogenetic study. Femoral arterial and gluteal arterial anastomotic hemodynamics are affected by the relative involution of the gluteal system in late embryogenesis. The gluteal thigh flap should include contributions from the femoral system when the cutaneous branch of the inferior gluteal artery cannot be identified. Huge sacral wounds can be closed with gluteus maximus myocutaneous flaps with maintenance of muscular function by detaching the entire origin, sliding the muscle medially, and reconstructing these attachments. By dissection between the divergent inserting fibers of the gluteus maximus, a long, superficial portion of the muscle can be raised that forms the basis of the extended gluteus maximus flap. The pedicle of the flap is at the level of the piriformis muscle and the skin paddle can be placed over the midportion of the posterior thigh. Finally, the first deep femoral perforating artery forms the basis of a posterolateral fasciae latae flap that is well suited for coverage of defects over the trochanter.     

The nontypical gluteus maximus flap

Since 1984, 42 patients have been treated with gluteus maximus myocutaneous flaps. In 37 patients, a "classical" gluteus maximus myocutaneous flap was used to cover a sacral-gluteal defect. In 5 patients, a "nontypical" gluteus maximus myocutaneous flap was used: two flaps were advanced from caudal to cranial to close defects over the lumbar spinal area, two flaps were advanced from cranial to caudal to close defects in the perineal region, and one flap was advanced from medial to lateral to close a trochanteric defect. All defects could be closed. There was no flap necrosis. In 12 patients (out of 42) there were minor wound infections, and in 6 patients there were minor wound dehiscences. The average blood loss never exceeded 500 cc, the average time of hospitalization (postoperatively) was 17 days, and mobilization (walking) was started 3 to 4 days postoperatively. The average distance of flap advancement was 10 cm. The maximum defect closed by a bilateral V-Y gluteus maximus myocutaneous flap was 24 x 20 cm.     

The distally-based gluteus maximus muscle flap.

We describe a distally-based gluteus maximus muscle flap to cover trochanteric pressure sores. The results in 4 patients have been gratifying.     

The functional pectoralis major musculocutaneous island flap in head and neck reconstruction

We describe our experience with the true island pectoralis major musculocutaneous flap in patients with high-volume defects for whom free-tissue transfer is unsuitable. Our operative technique is presented. We have modified the method of making a true island of the pectoralis major musculocutaneous flap on a muscle-free pedicle as first described by Wei et al. in 1984. This maintains maximal donor-site muscle function and facilitates closure of the donor-site defect. We present our results in 24 patients, in whom the flap has proved to be robust and reliable. The flap's advantages in terms of increased pedicle length, wider arc of rotation, decreased pedicle bulk, and improved cosmesis of the reconstruction are discussed.     

Frontalis musculocutaneous island flap for coverage of forehead defect

The use of the frontalis musculocutaneous flap as a pedicle island flap offers some advantages in frontal reconstruction. It can be used for immediate reconstruction following the ablation of a small or moderate area, even after harvesting of the frontal flap for nasal reconstruction. Because of its intact lateral bundle, it has the potential to carry some sensory innervation, albeit minimal, to the reconstructed area. We have found the frontalis musculocutaneous flap, when used as a pedicle island flap, to be an adaptable and dependable alternative flap for repairs after small or moderate resections in the frontal region. This flap could be performed immediately and in one stage, have a low morbidity rate, and allow a rapid aesthetic restoration; and, it is easy to perform. In two cases, we have observed some degree of venous congestion in the island during the early postoperative period but with success in final healing. The experience demonstrates that this flap should be considered as another valuable tool in reconstructive efforts directed at the forehead. We propose a novel method for the forehead reconstruction using the frontalis musculocutaneous island flap. A case is presented that demonstrates the use of this flap for repair in a depressed frontal defect.     

A double-split gluteus maximus muscle flap for reconstruction of the rectal sphincter

A double-split gluteus maximus muscle flap has been described as a method for reconstructing difficult cases of rectal sphincter disruption secondary to trauma. Anatomic considerations and three case reports are documented. All three patients have derived nearly complete rectal continence after this procedure. The use of the inferior portion of only one gluteus maximus muscle preserves posterior hip stability and the proximal neurovascular supply to the portion of muscle that surrounds the anus. This procedure could potentially be used for rectal sphincter reconstruction in selected cases after ablative surgery in the anal region.     

The septal chondromucosal island pedicle flap: anatomic study and clinical application

A study was made of the facial regions of 10 fresh cadavers. The vascular anatomy of the perinasal region and the septum consistently confirmed the existence of a nasal alar basal artery and a nasal alar basal nerve to the septum. A new septal chondromucosal flap, supplied by the nasal alar basal artery and nerve, is proposed in this article. The composite flap can be used safely to restore partial or entire tarsoconjunctival defects of the upper or lower eyelid or combined defects of the upper and lower eyelid.     

Anatomical and functional specializations of the human gluteus maximus

Many anthropologists and anatomists have claimed that the human gluteus maximus is a functionally and structurally unique muscle, but there is not agreement on the actual characteristics of the muscle which do distinguish man from other primates. In this paper the superficial gluteus in a wide range of primates is discussed and those traits entirely unique to man are identified. The morphological specializations of the human gluteus maximus are confined to its cranial portion. This part is thicker in man than in any other primate; it has a new and firm origin, a modified ascending tendon of insertion, and an additional new insertion into the overlying fascia lata. Such changes improve the ability of the gluteus maximus to participate in controlling lateral stability of the trunk, and it suggested that this is the function which has been selected for in human evolution.     

The VY tensor fasciae latae musculocutaneous flap

When first introduced in 1978, the tensor fasciae latae flap was used both as a free-tissue transfer and as a local rotational flap. Its use as a free flap has diminished as other more appropriate flaps for free-tissue transfer have been described. The tensor fasciae latae flap has remained, however, an instrumental flap in the coverage of anterior and posterior soft-tissue defects around the hip region. The purpose of this paper is to present a new design of the tensor fasciae latae flap in the coverage of trochanteric pressure sores. By essentially creating a VY advancement flap into the trochanteric defect with the tensor fasciae latae, one can cover the trochanteric defect with the best-vascularized portion of the flap and avoid the dog-ear deformity.