Pressure sores are the wound the plastic surgeon gets consulted on after everything else has gone wrong — and the recurrence rate is brutal if you skip the basics. The lesson nobody teaches you in residency is that the surgery is the easy part.
In this episode of Plastics in Practice, we review the basics of pressure sore management: the pathophysiology of pressure-time injury, the six-stage NPUAP system, what you absolutely have to optimize preoperatively (albumin, A1c, spasm, contractures, osteomyelitis), how to choose between fasciocutaneous and musculocutaneous flaps for ischial, sacral, and trochanteric defects, and why the recurrence numbers stay high no matter what flap you pick.
Key takeaways:
- Tissue injury starts deep — muscle over bone fails first, the skin lesion is just the tip of the iceberg.
- Capillary perfusion fails above ~32 mm Hg; five minutes of off-loading every two hours is enough to prevent breakdown even at high pressures.
- Pressure x time is parabolic: 500 mm Hg for 2 hours or 100 mm Hg for 10 hours both kill muscle. Skin ulcerates last.
- Optimize before you operate: albumin >2.0 g/dL, A1c <6%, control spasm (baclofen, dantrolene, botulinum toxin), treat osteomyelitis surgically — not medically.
- Avoid primary closure and skin grafts — these wounds have a true tissue deficit. Use flaps.
- Fasciocutaneous vs. myocutaneous: in a 94-patient series there was no difference in recurrence, complications, or morbidity — pick the flap that preserves future options.
- Avoid radical ostectomy — total ischiectomy redistributes pressure and creates the next ulcer.
- Recurrence after flap closure runs ~39%; the most vulnerable window is the first 15–22 months.
- Watch for Marjolin ulcer in long-standing wounds — aggressive SCC with metastatic rates over 60%; wide excision is the answer.
This content is for educational purposes only and is not medical advice.
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