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Year : 2018  |  Volume : 14  |  Issue : 2  |  Page : 28-35

To evaluate effectiveness of flap surgery in patients of grades 3 and 4 pressure ulcers

Department of Burns and Plastic Surgery, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India

Date of Web Publication28-Nov-2018

Correspondence Address:
Dr. Sudhanshu Punia
41, Gautam Apartments, DDA, SFS, Flats, Gautam Nagar, New Delhi – 110049
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njps.njps_9_18

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OBJECTIVE: To evaluate the effectiveness of flap surgery for grades 3 and 4 pressure ulcers. DESIGN AND SETTING: Patients were included in this prospective study conducted in the Department of Burns and Plastic Surgery, Post Graduate Institute of Medical Sciences, Rohtak, along with the institute’s Paraplegia Unit. The outcome of flap surgery was assessed. PARTICIPANTS: The sample size was of 25 spinal cord injury patients with grades 3 and 4 pressure ulcers. INTERVENTION: After wound preparation, flaps were used to cover the resultant defect. OUTCOME MEASURES: The outcome was assessed on the parameters of wound dehiscence, flap necrosis, and recurrence. RESULTS: Points were allotted for the overall outcome assessed over the said parameters, 92% of the patients had excellent outcome and the remaining 8% had a good outcome, proving that flap surgery is extremely effective in management of patients with pressure ulcers. CONCLUSION: Pressure ulcers are a common sequalae of spinal cord injury. Irrespective of the cause, a patient of spinal cord injury would develop a pressure injury at some point of time. Pressure ulcers were best treated with flap surgery, after thorough debridement including dead or necrotic bone, along the special care to positioning.

Keywords: Effectiveness of flap surgery, flap surgery outcome, pressure ulcer, spinal cord injury

How to cite this article:
Punia S, Singh R B, Singh R. To evaluate effectiveness of flap surgery in patients of grades 3 and 4 pressure ulcers. Nigerian J Plast Surg 2018;14:28-35

How to cite this URL:
Punia S, Singh R B, Singh R. To evaluate effectiveness of flap surgery in patients of grades 3 and 4 pressure ulcers. Nigerian J Plast Surg [serial online] 2018 [cited 2023 Dec 10];14:28-35. Available from:

  Introduction Top

Pressure ulcers are as old as mankind itself. They were observed in autopsies of Egyptian mummies,[1] but very little attention was paid to their surgical treatment in early medical history. Pressure ulcers are defined as localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear.[2] They are also called bed sores and decubitus ulcers. The term pressure injury (PI) includes the entire spectrum of this disease.

Pressure is now viewed as the single most important etiologic factor in pressure ulcer formation. Prolonged immobilization, sensory deficit, circulatory disturbances, and poor nutrition have been identified as important risk factors in the development of pressure ulcer,[3],[4] all of which are seen in patients of spinal cord injury. Site of pressure ulcers depends on the position most commonly the patient is present in, most common sites tend to be the sacrum and ischium.[5] Surgical treatment is warranted in patients of grades 3 and 4 pressure ulcers as classified by the National Pressure Ulcer Advisory Panel.[6],[7]

In this study, we evaluated the outcome of flap surgery for such pressure ulcers in 25 patients.

  Design and methods Top

The study was conducted from October 2015 to October 2017. All consenting patients from 18 to 60 years of age, who presented to our clinic, were included. None of our patients had any comorbidities. The sample size of this study was 25 patients with grade 3 or 4 pressure ulcers. Preoperative treatment of patients included thorough evaluation of PIs, improvement of nutrition by high calorie, high protein diet with supplementation of micronutrients. Strict maintenance of hygiene by regular bathing and prompt cleaning in case of fecal or urinary soiling if an indwelling catheter was not placed or bladder drained by intermittent catheterization. Patients and caregivers were counseled about the nature of disease and management, to ensure cooperation and frequent position change. Debridement of ulcers was performed to promote healthy granulation.

Prior to surgery, patients were catheterized, placed on a low residue diet, and given enemas to reduce the risk of soiling. On the day of surgery, patients were bathed and parts were prepared accordingly.

Debridement was performed after staining the ulcer with a dye (methylene blue) to allow complete removal of unhealthy tissues. Pseudobursae, heterotrophic calcification, unhealthy bone were all debrided. After achievement of hemostasis, flaps were designed according to the site and size of the ulcers. Closure was performed over drains.

The result was evaluated on extent of wound dehiscence, flap necrosis, and recurrence.[8]


Inspection of flaps was performed daily till the flap has satisfactorily been incorporated and then patient was discharged. Patients were followed bi-weekly, initially for 2 months and later monthly till a total of 6 months [Figure 1],[Figure 2][Figure 3][Figure 4].
Figure 1: Rotation Flap for Sacral pressure ulcer

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Figure 2: Left TFL flap for trochanteric pressure ulcer

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Figure 3: Left Superior Gluteal Artery Flap (SGAF) for Sacral pressure ulcer

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Figure 4: Bilateral VY flap for large sacral Pressure ulcer

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  Results Top

The age of patients in this study ranged from 18 to 60 years, with the most common age group being 31 to 40 years [Chart 1]. All except one of the patients were male in the present series. Almost all patients were cases of spinal injury due to road traffic injuries—52%, followed by fall from height—40%. Nine patients had fractured D12 vertebra with spinal cord injury, resulting in paraplegia which was the most common type of vertebral injury, followed by four patients with C5-6 injury. Thirteen patients had sacral pressure ulcers, 10 had trochanteric, and two had ischial in this study [Chart 2]. Seventeen (68%) ulcers were of grade 4, rest eight (32%) were of grade 3. Flaps used for sacral ulcers included gluteus maximus VY advancement flap, random rotation flap, superior gluteal artery flap; trochanteric ulcers were managed by tensor fascia lata flap and ischial by inferior gluteal artery flap and VY hamstring flap. The interval between surgery and discharge was 20 to 40 days in 60.2% of patients [Chart 3]. The complications noted were surgical site infections, wound disruption, and recurrence [Chart 4].

Over all outcome of flap surgery was excellent in 23 (92%) patients and good in 2 (8%) [Chart 5].

During follow-up, all patients and caregivers reported peace of mind as they did not have to worry constantly about the wound dressing and soilage by fecal matter or urine. Furthermore, expenses incurred in dressing materials and doctor fees were negligible.

  Discussion Top

Pressure ulcers are a common, serious complication of bedridden patients. Most patients have been under ICU care at the time of development of the PIs. Paraplegic patients are especially vulnerable to the development of such injuries due to the loss of sensation, loss of muscle mass, inability to frequently change their position, frequently soiling themselves due to loss of bladder–bowel control. These injuries affect the physical, social, and psychological well being of the patient. They also result in drainage of financial resources and disruption of the lives of caregivers.

As patients of trauma, elderly patients have better longevity, and the risk of developing PUs is also increasing. Our study was undertaken to evaluate the effectiveness of flaps in successful management of such patients.

Treatment options for pressure ulcers are medical and surgical. Medical treatment consists of bedside debridement and dressing. Surgical part includes proper debridement of all unhealthy tissue, including bone followed by flap coverage. It is widely accepted that invasive type 3 or 4 pressure sores require surgical intervention, because the conservative nonsurgical therapy is extremely extended and increases the possibility of early recurrence.[9]

The advantages of using musculocutaneous flaps are that they can eliminate the dead space because they are bulky flaps; they provide a well-vascularized and cushioning tissue over the a pressure bearing area, and their vascularity helps in fighting infection at the local site.[10]

Improved vascularity enhances local oxygen tension, provides extended soft tissue penetration for antibiotics, and improves total lymphocyte function.[11] Flaps can also help in healing osteomyelitis and limiting the damage caused by shearing, friction, and pressure.[12],[13],[14]

Various authors have studied many flaps for such ulcers.[15],[16],[17],[18],[19] Gluteus maximus VY advancement flap was described as a procedure of choice,[18] as it could cover most defects easily and could also be advanced if recurrence occurred. Trochanteric ulcers were treated with tensor facia lata flaps,[20],[21] and fasciocutaneous or myocutaneous variants were described.[21] Ischial flaps were managed by inferior gluteal artery perforator flap,[22],[23] and these flaps provided more resistance to pressure-induced ischemia.

Surgery has shown improvement in patients of pressure sores, in terms of wound management.[4],[24],[25],[26],[27]

Patients also reported that they were less stressed, had a better state of mind as there were no wounds to worry about, positioning was easier, and perineal hygiene was easier to maintain as soiling of dressings was not a problem.

  Conclusion Top

The management of pressure ulcers requires a continuous and constant education about the nature of the disease and positioning to the patient and caregivers. Flaps also do well in the absence of excessive pressure, thereby reducing the risk of recurrence.

Flap surgeries provide a stable coverage, help in reducing nutrient loss from the wound, allow better maintenance of hygiene, prevent osteomyelitis, improve mental well-being, reduce economic costs of wound care, and promote early socioeconomic reintegration into society.

The authors strongly believe that flap surgeries attain these aforementioned goals and advise surgical intervention for the management of pressure ulcers.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Rowling JT. Pathological changes in mummies. Proc R Soc Med 1961;54:409-12.  Back to cited text no. 1
European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: Quick reference guide. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.  Back to cited text no. 2
Edlich L, Winters KL, Woodart CR, Buschbacher RM, Long WB, Gebhart JH. Pressure ulcer prevention. J Long Term Eff Med Implants 2004;14:285-304.  Back to cited text no. 3
Marchi M, Battaglia S, Marchese S, Intagliata E, Spataro C, Vecchio R. Surgical reconstructive procedures for treatment of ischial, sacral and trochanteric pressure ulcers. G Chir 2015;36:112-6.  Back to cited text no. 4
Agris J, Spira M. Pressure ulcers: Prevention and treatment. Clin Symp 1979;1-31.  Back to cited text no. 5
National Pressure Ulcers Advisory Panel. New 2014 prevention and treatment of pressure ulcers: Clinical practice guideline. J Adv Nurs 2014. [email protected]  Back to cited text no. 7
Aggarwal A, Sangwan SS, Siwach RC. Gluteus maximus island flap for repair of sacral pressure sores. Spinal Cord 1996;34:346-50.  Back to cited text no. 8
Bauer J, Phillips LG. MOC-PSSM CME article: Pressure sores. Plast Reconstr Surg 2008;121:1-10.  Back to cited text no. 9
Thiessen FE, Andrades P, Blondeel P, Hamdi M, Roche N, Stillaert F et al. Flap surgery for pressure sores: Should the underlying muscle be transferred or not? J Plast Reconstr Aesthet Surg 2011;64:84-90.  Back to cited text no. 10
Anthony JP, Huntsman WT, Mathes SJ. Changing trends in the management of pelvic pressure ulcers: A 12-year review. Decubitus 1992;5:44-7, 50–1.  Back to cited text no. 11
Daniel RK, Hall EJ, MacLeod MK. Pressure sores—A reappraisal. Ann Plast Surg 1979;3:53-63.  Back to cited text no. 12
Mathes SJ, Feng LJ, Hunt TK. Coverage of the infected wound. Ann Surg 1983;198:420-9.  Back to cited text no. 13
Vasconez LO, Schneider WJ, Trukiewicz MJ. Pressure sores. Curr Probl Surg 1977;24:23.  Back to cited text no. 14
Conway H, Griffith H. Plastic surgery for closure of decubitus ulcers in patients of paraplegia. Am J Surg 1956;91:946-75.  Back to cited text no. 15
White JC, Hamm WG. Primary closure of bedsores by plastic surgery. Ann Surg 1946;124:1136.  Back to cited text no. 16
Minami RT, Mills R, Pardoe R. Gluteus maximus myocutaneous flap for repair of pressure sores. Plast Reconstr Surg 1977;60:242.  Back to cited text no. 17
Scheflan M, Nahai F, Bostwick J. Gluteus maximus island myocutaneous flap for closure of sacral and ischial ulcers. Plast Reconstr Surg 1981;68:533.  Back to cited text no. 18
Akan IM, Uluso MG, Bilen BT. Modified bilateral advancement flap: Slide in flap. Ann Plast Surg 1999;42:545-8.  Back to cited text no. 19
Schulman NH. Primary closure of trochanteric decubitus ulcers: The bipedicle tensor fascia lata flap. Plast Reconstr Surg 1980;66:740-4.  Back to cited text no. 20
Lemaire V, Boulanger K, Heymans O. Free flaps for pressure sore coverage. Ann Plast Surg 2008;60:631-4.  Back to cited text no. 21
Reis J, Amarante J, Costa-Ferreira A, Silva A, Malheiro E. Surgical treatment of pressure sores. Eur J Plast Surg 1999;22:318-21.  Back to cited text no. 22
Higgins JP, Orlando GS, Blondeel PN. Ischial pressure sore reconstruction using an inferior glutealartery perforator (IGAP) flap. Br J Plast Surg 2002;55:83-5.  Back to cited text no. 23
Sapountzis S, Park HJ, Kim JH, Chantes A, Beak RM, Heo CY. The “reading man flap” for pressure sore reconstruction. Indian J Plast Surg 2011;44:448-52.  Back to cited text no. 24
[PUBMED]  [Full text]  
Aggarwal A, Sangwan SS, Siwach RC. Gluteus maximus island flap for repair of sacral pressure sores. Spinal Cord 1996;34:346-50.  Back to cited text no. 25
Singh R, Singh R, Rohilla RK, Siwach R, Verma V, Kaur K. Surgery for pressure ulcers improves general health and quality of life in patients with spinal cord injury. J Spinal Cord Med 2010;33:396-400.  Back to cited text no. 26
McGregor JC, Buchan AC. Our clinical experience with tensor fasia lata myocutaneous flap. Br J Plast Surg 1980;33:270-6.  Back to cited text no. 27


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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