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Surgical

Management
for Pressure
Ulcer
Rani Septrina
2nd Update on Plastic Surgery
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Neligan, Chap. 16, Pressure ulcer

Suggested Guidelines of
Pressure Ulcer Wound

Ladin DA. Understanding dressings. Clin Plast Surg 1998;25:433.


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Neligan, Chap. 16, Pressure ulcer

Surgical Guidelines
(Conway and Griffith)
 Excision of the ulcer, surrounding scar, underlying bursa,
and soft-tissue calcifications, if any
 Radical removal of underlying bone and any
heterotopic ossification
 Padding of bone stumps and filling dead space
 Resurfacing with large regional pedicled flaps
 Grafting the donor site of the flap, if necessary.

Flap design:
1. Flap should be designed as large as possible, placing
the suture line away from the area of direct pressure.
2. The design should not violate adjacent flap territories
so as to preserve all options for coverage in the event
that
Neligan, Chap. 16, Pressure ulcer

Procedure Selection
Surgical coverage
 random skin flap
 myoplasty plus skin graft
 pedicled muscle
 Myocutaneous flap
 fasciocutaneous flap
 free flaps,
 tissue expansion.

Depends on many factors: location, level of spinal injury, history of


ulceration, history of surgery, ambulatory status, daily habits,
educational status, motivational level, other medical problems.
Neligan, Chap. 16, Pressure ulcer

Single- versus multiple-stage


reconstruction
Single stage reconstruction
 the hospital stay was decreased ( 9.5 weeks vs 19 weeks)
 cost savings per admission
 fewer anesthetic episodes
 earlier rehabilitation

Disadvantage Single Stage Recons:


 longer operative time
 higher intraoperative blood loss

Recommendation for multistage procedures:


 concurrent pressure sores on the anterior and posterior trunk
 difficult to address simultaneously.
Reconstructive Surgery ?
Neligan, Chap. 16, Pressure ulcer

Sacral Defects

Sacral Defects
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Gluteal Flap for Sacral Defects


Neligan, Chap. 16, Pressure ulcer

Outcome
 Nonsurgical treatment: 29%,
 split-skin grafts: 30%.
 Excision of bone + closure (large rotation
flap): 84%.
The Medial Thigh Flap in Ischial
Reconstruction, PRS, 1991

Ischial Defects
Neligan, Chap. 16, Pressure ulcer
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Ischial Defects
Neligan, Chap. 16, Pressure ulcer

Outcome
 Conservative therapy: 18%
 Skin graft: 17%, and
 Partial ischiectomy + primary suture: 46%
(54% recurrence).
 Total ischiectomy + muscle flap + regional
rotation: 22%
Neligan, Chap. 16, Pressure ulcer
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Trochanter Defects
Neligan, Chap. 16, Pressure ulcer

Outcome
 Non surgical: 41%
 split-thickness skin: 33%
 Excision ulcer + bursa + trochanter were
excised + primary suture: 83% (20%
reccured)
 Removal of trochanter + rotation flap: 92%
(6% recurred)
Flap Surgery to Cover Olecranon Pressure, Ulcers in Spinal Cord Injury Patients,
Salah Rubayi, M.D., and Yoshifami Kiyono, M.D., Ph.D., PLASTIC AND
RECONSTRUCTIVE SURGERY, May 2001

Olecranon
Defect
Take Home Message
 Debdidement
 Surgical management asessment
 Flap or Graft
 Bony Resection
 Rehabilitation
 Prevention of Recurrence