REVIEW PAPER
A Systematic Review Comparing Outcomes of Local Flap Options
for Reconstruction of Pressure Sores
Madhubari Vathulya, MS, MCh (Plastic Surgery),a A.J. Praveen, MS (ENT), MCh,a
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Sitanshu Barik, DNB (Orthopedics),b
Manish Pradip Jagtap, MS (GENERAL SURGERY) MCh,a and Pankaj Kandwal, MS (Orthopedics)b
Introduction: Pressure sores are agonizing complications of chronically bedrid-
den patients. The management of these lesions particularly with respect to grades
III and IV lesions are chiefly surgical and involves a multidisciplinary approach.
Although there are a variety of local flap options, like fasciocutaneous flaps,
musculocutaneous flaps, perforator flaps, and combinations of these to choose
from, there is a paucity of literature regarding which flap is better among these
in terms of complication and recurrence rates.
Methods: The databases searched were as follows: Cochrane Central Register of
Controlled trials (January 2000 to July 2020), MEDLINE (January 2000 to July
2020), and EMBASE (January 2000 to August of 2020). Key words used were
“pressure ulcer,” “flaps,” “surgery,” “pressure sore” with limits, “human,” and
“English.” Primary outcomes were “overall complication rates” and “recurrence
rates.” Overall complication was further categorized as flap necrosis, flap dehis-
cence, infection, and others.
Results: Thirty-nine articles were included in the final analysis. There was a sta-
tistically significant difference among the various types of flaps for overall com-
plication, flap dehiscence, infection, flap necrosis, and recurrence rates.
Conclusions: Our study indicates that musculocutaneous flaps have lower recur-
rence rates, and combined flaps have lower complication rates. However, various
other factors, like donor site morbidity, initial defect size, operating time, intraop-
erative blood loss, salvage options in case of recurrence, should also be consid-
ered while choosing a flap to reconstruct a defect.
Key Words: pressure ulcer, flaps, surgery, pressure sore
(Ann Plast Surg 2022;88: 105–113)
P ressure sores are agonizing complications of chronically bedridden
patients. The causes of this pathology range from congenital spinal
defects to acquired ones, including trauma; infection; like Pott spine;
and so on.1 The management of these lesions particularly with respect
to grades III and IV lesions are chiefly surgical and involves a multidis-
ciplinary approach, including a plastic surgeon's expertise. Although
the choice of reconstruction is wide from the armamentarium of local
flap options and varies from fasciocutaneous flaps, musculocutaneous
flaps, perforator flaps and combinations of these, the choice of these lo-
cal flap options have not been systematically reviewed on the basis of
outcome and complications implied, as observed by the paucity in liter-
ature. The authors of the article have conducted this meta-analysis and
hence tried to decipher the ideal flap option for the reconstruction of
pressure sores, a condition that interferes with the quality of life of an
individual to significant proportions.
Received December 2, 2020, and accepted for publication, after revision April 24,
2021.
From the aDepartment of Burns and Plastic Surgery, and bDepartment of Orthopedics,
All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India.
Reprints: A.J. Praveen, MS (ENT), MCh, Department of Burns and Plastic Surgery,
All India Institute of Medical Sciences, Rishikesh, Uttarakhand, Veerbhadra
road, Rishikesh, Uttarakhand, India 249203. E-mail: viperpraveen@gmail.com.
Conflicts of interest and sources of funding: none declared.
Type of study: systemic review and meta-analysis
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0148-7043/22/8801–0105
DOI: 10.1097/SAP.0000000000002941
Annals of Plastic Surgery • Volume 88, Number 1, January 2022
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
MATERIALS AND METHODS
Literature Search
A thorough literature search was done with the help of a profes-
sional librarian across 3 databases. The databases used were as follows:
Cochrane Central Register of Controlled trials (January 2000 to July 2020),
MEDLINE (January 2000 to July 2020), and EMBASE (January 2000 to
August of 2020). The key words used were “pressure ulcer,” “flaps,” “sur-
gery,” “pressure sore” with limits, “human,” and “English.”
The PICO criteria were followed. Here, the participants/population
involved were patients with pressures sores. Interventions that were
compared were the different flap techniques. Primary outcome mea-
sures were the overall complication and recurrence rates. Overall com-
plication was further categorized as flap necrosis, flap dehiscence,
infection, and others.
Selection of Articles
Two reviewers (P.A.J. and S.B.) independently scanned all the re-
trieved articles and shortlisted the articles with relevance to this study. A
third reviewer (M.V.) guided the first 2 reviewers and also acted as an
arbitrator to settle any differences among the first 2 reviewers regarding
the relevance of any article. The fourth and fifth reviewers (P.K. and M.
P.J.) helped with the analysis of the data. The inclusion criteria for
selecting an article are as follows:
1. The study must have examined musculocutaneous, fasciocutaneous,
perforator flaps and/or or a combination of any of these 3 flaps in iso-
lation or as comparative groups.
2. The outcome of the flap was defined in terms of complication rate
and/or recurrence rates.
3. Location of the pressure sores was limited to ischium, sacrum, and
trochanter.
4. Types of studies/articles included were randomized controlled trials,
observational cohort and case-control studies, cross sectional stud-
ies, case series.
Exclusion criteria were as follows:
1. studies including free flaps,
2. case reports,
3. cadaver/animal studies,
4. articles in any language other than English,
5. experimental studies,
6. studies with sample size less than 10.
Outcome Measures
Our primary outcome measures were complication rates and re-
currence rates. The complication rates were further subdivided into cat-
egories like rate of flap dehiscence, flap necrosis, infections, and other
complications. Recurrence was defined as repeat occurrence of wound
breakdown after the surgical reconstruction. The duration of follow-up
was also noted.
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FIGURE 1. Prisma flow diagram.
Data Extraction
The selection process is shown in the PRISMA flow diagram
(Fig. 1). Of 125 articles that were found from the data search, 39 articles
were finally considered for the study. The following data were extracted
from each article. They included authors, journal, year of publication,
sample size, flaps used, location of pressure sores, follow-up period,
complication rate (overall, flap dehiscence, infection, flap necrosis,
and others), and recurrence rate. Although we tried to include operating
time and blood loss, only very few recent studies reported them and
hence could not be further evaluated.
Statistical Analysis
Descriptive analysis using means, standard deviation, and ranges
(minimum, maximum) of the pooled data across the included studies
was performed. Meta-analysis was performed using the Metafor package
in R statistical software v4.0.0 (R Core Team, Vienna, 2020). Analysis
was performed using a random-effects model using the DerSemonian
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Annals of Plastic Surgery • Volume 88, Number 1, January 2022
Laird method. Subgroup analysis was performed by grouping the studies
based on the type of flaps used (fasciocutaneous vs musculocutaneous vs
combined (FC + MC) vs perforator). Pooled data from the eligible studies
were evaluated for occurrence of complications. χ2 Test was used to as-
sess the statistical difference among the rates of various groups. The P
value for the overall heterogeneity (I2) was calculated to quantify het-
erogeneity among studies. Overall heterogeneity describes the propor-
tion of the variability in effect estimates that is due to heterogeneity
rather than chance. Funnel plot was constructed to assess the publica-
tion bias. A P value less than 0.05 was considered significant.
RESULTS
Study Details
The I2 for assessment of occurrence of any complications in the
included studies varied from 0% to 84.11% (Fig. 2). It was 84.11%
(P < 0.05) for fasciocutaneous flaps, 69.41% (P < 0.05) for
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 Annals of Plastic Surgery • Volume 88, Number 1, January 2022 Local Flap Options in Pressure Sore Reconstruction
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FIGURE 2. Forest plot showing overall complication rates.

musculocutaneous flaps, 64.71% (P < 0.05) for perforator flaps, and
0% (P > 0.05) for combined (FC + MC) flaps. The I2 for assessment
of recurrence rates in the included studies varied from 0% to 68.6%
(Fig. 3). There was a statistically significant difference among the vari-
ous types of flaps for overall complication, flap dehiscence, infection,
flap necrosis, and recurrence rates (P < 0.05) (Table 1).
Fasciocutaneous Flaps
A total of 13 studies were analyzed for complication rates in
fasciocutaneous flaps (Table 2). An overall complication rate of
21.3% (95% confidence interval [CI], 13.2–28.6%) was noted. Data
from the studies showing individual complication types showed flap

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FIGURE 3. Forest plot showing recurrence rates.

dehiscence rate of 6.6% (95% CI, 2.1–11.1%), infection rate of 2.7% Musculocutaneous Flaps
(95% CI, 1.6–3.9%), and flap necrosis rate of 7.5% (95% CI,
2.3–12.8%). A recurrence rate of 8% (95% CI, 4.7–13.3%) was noted Similarly, a total of 9 studies were analyzed for complication
for fasciocutaneous flaps. rates in musculocutaneous flaps (Table 3). An overall complication rate

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 Annals of Plastic Surgery • Volume 88, Number 1, January 2022 Local Flap Options in Pressure Sore Reconstruction

of 18.2% (95% CI, 10.3–27%) was noted. Data from the studies show-

7.5% (95% CI, 2.3–12.8%)

5.8% (95% CI, 2.7–7.8%)

5.7% (95% CI 0–10.1%)
ing individual complication types showed flap dehiscence rate of 4.5%

1.6% (95% CI, 0–2.6%)

(95% CI, 0.5–8.6%), infection rate of 4.6% (95% CI, 1.9–8.2%), and

Flap Necrosis
flap necrosis rate of 1.6% (95% CI 0–2.6%). A recurrence rate of 6.3%
(95% CI 2.1–9.4%) was noted for musculocutaneous flaps.
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Perforator Flaps
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<0.05
Twenty-two studies were evaluated for rates of complication in
perforator flaps (Table 4). Overall complication rate of 18.8% (95%
CI, 13.9–23.6%) was noted. Data from the studies showing individual
complication types showed flap dehiscence rate of 6.5% (95% CI,
4.6–8.4%), infection rate of 2.6% (95% CI, 1.6–3.6%), and flap necro-
4.6% (95% CI, 1.9–8.2%)
2.7% (95% CI, 1.6–3.9%)

2.6% (95% CI, 1.6–3.6%)

sis rate of 5.8% (95% CI, 2.7–7.8%). A recurrence rate of 7.5% (95%
4.9% (95% CI 0–9.8%)

CI, 3.8–10.1%) was noted for perforator flaps.

Infection

Combined (FC + MC) Flaps

Four studies were evaluated for rates of complication in perfora-
tor flaps (Table 5). Overall complication rate of 12.7% (95% CI,
<0.05

4.5–20.8%) was noted. Data from the studies showing individual com-
plication types showed flap dehiscence rate of 8% (95% CI,
1.8–15.2%), infection rate of 4.9% (95% CI, 0–9.8%,) and flap necrosis
rate of 5.7% (95% CI, 0–10.1%). A recurrence rate of 8% (95% CI,
1.8–15.2%) was noted for combined flaps.
6.6% (95% CI, 2.1–11.1%)
4.5% (95% CI, 0.5–8.6%)
6.5% (95% CI, 4.6–8.4%)

Individual anatomical regions like ischium, sacrum, trochanter,

5.5% (95% CI 0–11.3%)

and so on, were studied for the above parameters. Only in ischial region
Flap Dehiscence

we found a good number of studies in all 4 categories of flaps to perform

a meaningful statistical analysis. There were a total of 9 studies analyzing
the flaps of ischial regions (Table 6). Among them, musculocutaneous
TABLE 1. Table Comparing the Complication Rates and Recurrence Rates of Various Flap Types

flaps had the highest overall complication rates of 22.9% (95% CI,
0–63.2%), and perforator flaps had the lowest overall complication
<0.05

rates of 10.2% (95% CI, 2.6–19.6%). However, musculocutaneous

flaps had the lowest recurrence rates of 7.3% (95% CI, 0–19.4%),
and fasciocutaneous flaps had the highest recurrence rates of 13%
(95% CI, 2.7–23.3%)
8% (95% CI, 4.7–13.3%)

7.5% (95% CI, 3.8–10.1%)

8% (95% CI 1.8–15.2%)
6.3% (95% CI, 2.1–9.4%)

DISCUSSION
Recurrence

Our meta-analysis shows that there were statistically significant

differences among fasciocutaneous, musculocutaneous, perforator,
and combined flaps in terms of overall complication rates, rate of flap
dehiscence, infection, recurrence rates, and rates of flap necrosis.
<0.05

Overall Complications
In terms of overall complication rates, the fasciocutaneous flaps
top the chart (21.3%), closely followed by perforator flaps (18.8%) and
musculocutaneous flaps (18.2%). There were some studies that reported
21.3% (95% CI, 13.2–28.6%)

18.8% (95% CI, 13.9–23.6%)

18.2% (95% CI, 10.3–27%)

12.7% (95% CI 4.5–20.8%)

the overall complication rates in musculocutaneous flaps as low as

Overall Complication

0%.1,6,23 However, 2 of these studies had sample size of 4 and one

had a meager sample size of 2 only. The low sample size in these studies
reduces their external validity. Most of the recent studies show the com-
plication rates in musculocutaneous flaps in the range of 1% to
7%.7,9,13,29,46 Only 1 study reported a complication rate greater than
20%.5 Studies on fasciocutaneous flaps for pressure sores have reported
<0.05

the overall complication rates as high as 40% and as low as 0%.5,14–17,47

The complication rates in the perforator flaps is consistent with the stud-
ies we had considered for this review, which showed complication rates
ranging from 1% to 21%.5,28,36 The combined flaps had the lowest over-
all complication rate of 12.7%. Although this number is lesser com-
Musculocutaneous

pared with the other types of flaps, it is a bit higher than the
Fasciocutaneous

complication rates shown in the studies that we have included in this re-
view where the highest reported overall complication rate was only
Combined
Perforator

3%.43,44 The result shown by our study where there is a statistically sig-
χ2 (P)

nificant difference among these flap types in terms of overall complica-

tion rates with combined flaps and perforator flaps having lower rates

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 Vathulya et al Annals of Plastic Surgery • Volume 88, Number 1, January 2022

TABLE 2. Fasciocutaneous Flaps

Study No. subjects (n) Complication (n) Flap dehiscence (n) Infection (n) Necrosis (n) Recurrence (n) Follow-Up
2
Montag et al, 2018 35 8 18 mo
Djedovic et al, 20173 41 16 8.3 mo
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Djedovic et al, 20174 28 8 16.8 mo

Chiu et al, 20175 86 40 55.4 ± 38.0 mo
Hsiao and Chuang, 20156 5 1 1 0 0 0 16 mo
Wettstein et al, 20157 121 25 17 6–38 mo
Chen et al, 20148 32 12 6 6 8 5
Kuo et al, 20149 37 13 4 0 5 2
Greco 201310 338 33 0 5 3 4 55.27 mo
Lin and Ma 201211 36 8 3 0 4 2 20.8 mo
Erba et al, 201012 10 1 1 0 0 2 12 mo
Ahluwalia et al, 200913 63 7
Wong et al, 200714 3 0 0 0 0 0 30 mo
Borman and Maral, 200215 15 0 0 0 0 0 1.5–35 mo
Thomson et al, 200116 4 0 0 0 0 0 13 y
Mithat et al, 200117 13 0 0 0 0 0 14 mo

compared with the other 2 entities is in contrast to the results of previous
meta-analysis done by Sameem et al48 in 2011, where there were no sig-
nificant differences in terms of overall complication rates. This can be
explained by the fact that in our meta-analysis we have more number
of perforator flaps and combined flaps which have been added to the lit-
erature over the last decade. Also, the lower complication rates in these
techniques might be accounted to the refined surgical technique
and finesse that is used in these modern techniques. In majority of
the studies the authors give credit to the defined vascular supply in
the musculocutaneous and perforator flaps for the lower complication
rates whereas in case of combined flaps the credit is given to the robust-
ness of the flaps due to the rich blood supply and the added benefits of
both the fasciocutaneous flaps and musculocutaneous flaps when com-
bined together.39,42
Flap Dehiscence
Myocutaneous flaps had lowest amount of flap dehiscence rates
of 4.5% closely followed by combined flaps with a dehiscence rate of
5.5%. Certain studies showed that the flap dehiscence rates were as
low as 0% for both combined and myocutaneous flaps.22,43,45 The
highest reported incidence rate of flap dehiscence in myocutaneous
flaps was 5%.13 Whereas for combined flaps it was only 1%.42,44 The
rate of dehiscence in fasciocutaneous flaps came out to be 6.6%. This
was similar to the results of the previous studies which showed the flap
dehiscence rates as low as 0% and as high as 6%.8,14–17,47 Perforator
flaps also had a similar dehiscence rate of 6.5%. The dehiscence rates
of the myocutaneous flaps have reduced in the studies in past 2 decades
remarkably. Earlier studies had shown flap dehiscence rates as high as
29%.49 This can be attributed to the refinement of surgical techniques
over the years. Muscle flaps have reliable blood supply and adequate
durability for preventing osteomyelitis in the deep layer thus reducing
the dehiscence rates.42 Our review shows that musculocutaneous flaps
have lowest amount of flap dehiscence rates and perforator flaps and
fasciocutaneous flaps have highest flap dehiscence rates and these dif-
ferences were statistically significant. Fasciocutaneous flaps are less
bulky compared to myocutaneous flaps and at times cannot adequately
fill the dead space in large pressure ulcers which leads to formation of
collections and infections which may further lead to flap dehiscence.
Perforator flaps are more versatile. They have larger defined pedicle
lengths that provide option for both advancement as well as transposi-
tion.39 But at the same time there are problems like variations in the an-
atomical location of perforators, unpredictable nature of the venae
comitantes and risk of kinking of perforators (in propeller flaps) which

TABLE 3. Musculocutaneous Flaps

Study No. Subjects (n) Complication (n) Flap dehiscence (n) Infection (n) Necrosis (n) Recurrence (n) Follow-Up
5
Chiu et al, 2017 52 23 8 55.4 ± 38.0 mo
Tadiparthi et al, 201618 32 7 5 0 0 2 6–38 mo
Nisanci et al, 201519 7 1 1 0 0 0 20 mo
Wettstein et al, 20157 11 5 2 6–38 mo
Hsiao and Chuang, 20156 4 0 0 0 0 0 16 mo
Kim et al, 201420 14 27.9 mo
Kuo et al, 20149 27 4 1 1 0 2
Buck and Lewis, 200921 40 12 ± 10 mo
Ahluwalia et al, 200913 41 6
Stamate and Budurcă, 200522 95 14 0 11 0 2 12 mo
Demirseren et al, 200323 4 0 0 0 0 0 4–12 mo
Singh et al, 200224 23 1 1 0 0 1 63 mo

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 Annals of Plastic Surgery • Volume 88, Number 1, January 2022 Local Flap Options in Pressure Sore Reconstruction

TABLE 4. Perforator Flaps

Study No. Subjects (n) Complication (n) Flap Dehiscence (n) Infection (n) Necrosis (n) Recurrence (n) Follow-Up
25
Kyung et al, 2020 14 2 0 0 0 0 10.9 mo
Yoon et al, 201826 21 2 2 0 0 0 11.14 mo
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Legemate et al, 201827 34 6 6 0 0 3 38 mo

Park et al, 201828 12 1 0 0 1 0 6.7 mo
Montag et al, 20182 25 0 18 mo
Yoon et al, 201729 51 12 7 0 5 4 6 mo
Kelahmetoglu et al, 201730 33 6 1 0 2 0
Chiu et al, 20175 43 21 55.4 ± 38.0 mo
Kim et al, 201731 16
Chang et al, 201732 19 2 2 0 0 0 6 mo
Chih-Hsun and Ma, 201633 23 3 0 0 3 0 15 mo
Bonomi et al, 201634 37 4 1 0 3 0
Grassetti et al, 201435 143 10 6 2 2 32 24 mo
Kuo et al, 20149 35 8 3 0 4 1
Chen et al, 20148 31 9 2 5 8 5
Lin and Ma, 201211 26 5 1 1 2 1 14.42 mo
Hurbungs and Ramkalawan, 201236 10 1 0 0 0 0 14 mo
Unal et al, 201237 14 34.3 mo
Yang et al, 201138 37 9 3 0 4 1 23.35 mo
Kim et al, 200939 23 8 6 0 1 5 14.8 mo
Lee et al, 200740 16 4 3 0 1 6 14 mo
Coşkunfirat and Ozgentaş, 200441 35 3 2 0 1 1 13.4 mo

may increase the chances of complications like dehiscence.8 On the
other hand robust blood supply in myocutaneous and combined flaps
reduces the rates of flap dehiscence.42
Infection
Perforator flaps and fasciocutaneous flaps had lowest rates of in-
fection with each having infection rates of 2.6 and 2.7% respectively. In
the majority of studies where fasciocutaneous flaps were used, the infec-
tion rates were ranging from 0 to 1% except for 2 studies, which showed
infection rates of 5% and 6%.10 Similarly, in perforator flaps, only one
study showed infection rates above 2%.8 Whereas musculocutaneous
and combined flaps had high infection rates of 4.6 and 4.9% respec-
tively. The high infection rates in these flaps can be attributed to the fact
that these flaps are used in defects with larger dimension associated
with deep tissue infections, like osteomyelitis.8,22
Flap Necrosis
Our review showed that the infection rates were higher among
combined flaps and myocutaneous flaps (4.6% and 4.9%, respectively)
whereas it was significantly lower in perforator and fasciocutaneous
flaps (2.6% and 2.7%, respectively. This goes against the conventional
concept that says muscle-based flaps are more resistant to infections
compared with fasciocutaneous flaps because of the larger bulk and
more reliable blood supply. One reason that can be considered is that
musculocutaneous and combined flaps are used in larger defects with
osteomyelitis, which may lead to increased complications. However,
this could not be further explored in detail because very few studies
had mentioned the defect size.
Recurrence
In terms of recurrence rates, our review found statistically signif-
icant difference among the different approaches with musculocutaneous
flaps having the lowest recurrence rates of 6.3%. Both fasciocutaneous
flaps and combined flaps had higher recurrence rate of 8%. Perforator
flaps had a recurrence rate of 7.5%. These results were different compared
with the review by Sameem et al,48 which showed no difference in terms of
recurrence rates among different techniques. Musculocutaneous flaps are
the perfect options for deeper tissue defects, studies have shown that al-
though they undergo significant atrophy over time, they provide a reliable
padding over the bony prominences and prevent osteomyelitis.50,51 Studies
have shown that although fasciocutaneous flaps can be an excellent candi-
date for closure of smaller defects associated with pressure sores, it is often
insufficient in larger defects, requiring bilateral flap elevation and small re-
laxation incisions in flap to reduce tension in the center, which possibly
affects its viability. These flaps need extensive detachment, with higher

TABLE 5. Combined Flaps

Study
42
Ku et al, 2019
Han et al, 201643
Borgognone et al, 201044
Lee et al, 200945
Wong et al, 200714
No. subjects (n) Complication (n) Flap dehiscence (n) Infection (n) Necrosis (n) Recurrence (n) Follow-Up
15 2 1 0 0 1 12.9 mo
13 3 0 0 0 1 13.6 mo
12 3 1 0 2 1 45 mo
10 0 0 0 0 1 27.2 mo
4 0 0 0 0 0 30 mo

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 Vathulya et al
TABLE 6. Complication and Recurrence Rates of Flaps in Ischial Region
Overall Complication
Fasciocutaneous 14.4% (95% CI, 0–28.7%)
Musculocutaneous 22.9% (95% CI, 0–63.2%)
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Perforator 10.2% (95% CI, 2.6–19.6%)
Combined 12.3% (95% CI, 3.8–22.4%)
χ2 (P) <0.05
chances of seromas, flap ischemias, and higher recurrence rates.1,12,50
Perforator flaps have their own vices. The unpredictable nature of the
perforator venae comitantes and increased chances of kinking of ve-
nous pedicle increases the risk of venous congestion in these flaps.52
The dissection of these flaps should be meticulous, and this is time con-
suming, leading to longer operating times and increased blood loss in-
traoperatively.53 Newer studies have shed light on the fact that in
chronically debilitated patients, there are increased chances of recurrence,
which should be taken into consideration; hence, if fasciocutaneous flaps
are used in the first surgery, it spares the muscle-based flap, which can be
used in case if there is a recurrence.54
An attempt was made to study these factors and to predict an al-
gorithm for flap selection in specific anatomical locations. However, we
could find good number of studies only in the ischial region to make a
meaningful statistical analysis. Musculocutaneous flaps had the highest
overall complication rates of 22.9%, and perforator flaps had the lowest
overall complication rates of 10.2%. However, musculocutaneous flaps
had the lowest recurrence rates of 7.3%, and fasciocutaneous flaps had
the highest recurrence rates of 13%. Studies have shown that ischial
pressures have high recurrence rates, ranging from 7% to 48%. The ad-
vantages of muscle flap are as follows: (1) it provides adequate bulk to
fill the dead space, (2) muscle flaps have more reliable blood supply, (3)
the tissue bulk allows for better distribution of pressure, and (4) the in-
fection control is superior when compared with other types of flaps. Al-
though our results suggest muscle-based flaps have lower recurrence
rates compared with other flap types, we feel that these flaps should
not be considered as the first choice in the reconstruction of ischial
pressure sores because even with muscle-based flaps the recurrence
rates are as high as 7.3%. Hence it is only wiser to choose other expend-
able options, like fasciocutaneous flaps/perforator flaps in first surgery
(unless the defect is too extensive) so that the muscle-based flaps re-
main as backup option in case there is a recurrence. The high complica-
tion rates in muscle-based flaps also support this argument. More
studies with taking into consideration the defect size have to be con-
ducted to validate this.
Limitations
Many of the studies had smaller sample sizes. The sample sizes
ranged from 2 to 338, with 5 studies having sample size less than 10; we
eliminated these 5 studies to increase the internal validity of these stud-
ies.6,14,16,19,23 We had excluded the case reports to increase the external
validity of our study. We also found that there were only a few studies
which included other details like intraoperative blood loss, anatomical
location, defect size, age of the patient, presence of comorbidities,
and operating time, thus making a meaningful statistical analysis of
these factors impossible. The wide variation in reported outcomes sug-
gests that patient-specific risk factors, like BMI, nutritional status, co-
morbidities, age, and so on, should be investigated further. The final
verdict on the optimal flap to be considered for reconstruction for a par-
ticular defect can be given by taking all these facts into consideration.
We recommend future studies to undertake well-designed comparative
112 www.annalsplasticsurgery.com
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Annals of Plastic Surgery • Volume 88, Number 1, January 2022
Recurrence
13% (95% CI, 2.7–23.3%)
7.3% (95% CI, 0–19.4%)
8.5% (95% CI, 1.8–14.1%)
8% (95% CI, 0–15.2%)
<0.05
designs taking all these factors into account with adequate sample size
to elucidate the difference, if any, among these flap techniques.
SUMMARY
According to the results of our study we can concur that
musculocutaneous flaps and combined flaps have lower complication
rates and recurrence rates. However, these are not the only parameters
that can guide in choosing a particular flap as the method of choice
for pressure sore reconstruction. Various other factors, like donor site
morbidity, initial defect size, operating time, intraoperative blood loss,
and salvage options in case of recurrence, should also be considered.
Newer techniques, like 3D scanning, have been reported to measure the
defect size, which can accurately aid in selecting the flap accurately based
on the defect size. One such study has shown that fasciocutaneous flaps
should be the first choice for reconstruction of pressure sores for the first
time as the depth of the defect had corresponded to the flap thickness.54
Multiple prospective clinical trials, including all these factors into consid-
eration, are required to gain a clear picture regarding which flap is to be
used as the first choice for a defect. We would like to conclude by saying
that there were very few studies that reported about the size of the defect.
This should be a major factor in guiding flap selection. We recommend
that for smaller defects, it is always better to consider more expendable
options, like fasciocutaneous or perforator flaps (even though they have
higher complication and recurrence rates), so that whenever there is a
recurrence, muscle flaps can be used as the second option for recon-
struction. However, if the initial defect is large, then it is better to go
with a musculocutaneous or a combined flap option.
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