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Matiasek et al. Plast Aesthet Res 2018;5:36 I http://dx.doi.org/10.20517/2347-9264.2018.50 Page 5 of 11

Figure 1. Sacral pressure ulcer grad IV (EPUAP) after initial debridement and NPWTi. EPUAP: the European Pressure Ulcer Advisory
Panel; NPWTi: NPWT with instillation

wound irrigation solution for wound bed preparation. Gluteal/ischial PUs are at higher risk of infection. In
the following period 10 additional patients with various PU localizations were admitted to following hospitals:
St. Josef Hospital Vienna, Austria (2 sacral, 1 ischial/gluteal PU), St. Markus Hospital Frankfurt, Germany (2
sacral, 1 ischial/gluteal PU), Innsbruck Medical University, Austria (1 sacral, 1 trochanteric PU), Hospital St.
Gallen, Switzerland (1 sacral, 1 trochanteric PU).

Wound conditioning using NPWT
All patients underwent a surgical debridement of necrotic tissue as the first stage of treatment. This was
TM
undertaken to remove fluid, exudates and infectious material. NPWT (V.A.C.ulta ) was applied to the
TM
wound. A foam dressing (V.A.C. Granu-Foam , Kinetic Concepts Inc., San Antonio, TX, USA) was cut into a
shape which perfectly fitted the wound cavity. A transparent film was then used to seal the wound and a track
pad connected to an adjustable vacuum pump, was applied.

Continuous suction was used to maintain negative pressure at 125 mmHg. Every 12 h, wound rinsing was
performed for three minutes using octenilin® wound irrigation solution. To ensure that the ideal quantity of
irrigation solution was applied, it was instilled until the foam dressing was completely soaked (in presented
cases volumes ranged between 42 mL and 110 mL, depending on the size of defect.)

The treatment continued for 6 days, after which the wound bed was fully prepared for surgery and free from
visible signs of infection.

Flap coverage surgery
Following successful preparation with NPWT and octenilin instillation, wound closure was indicated in all 13
[24]
patients. According to the reconstructive ladder, wounds may be covered in ascending order of complexity .
Flaps in particular - which, unlike skin grafts, have their own blood supply - have shown good results in
[7]
treatment of complex defects . A major challenge in flap coverage is adequate flap selection which involves
considering several factors including the site of the pressure sore, flap design and the location of the flap
[7]
relative to the site of coverage . For covering large pressure sores in the gluteal/ischial region the posterior
[25]
thigh flap is often used due to its large reservoir of skin, fascia and muscle .
Local flap coverage was conducted in the first 3 patients, which all suffered from gluteal PU, by using the
posterior thigh flap. For the additional 10 patients following local flaps were used: 3 fasciocutaneous VY-flaps
[Figures 1 and 2] to cover 2 sacral [Figures 3 and 4] and 1 ischial PUs; 3 fasciocutaneous rotational flaps were
chosen to cover sacral PUs; 2 myocutaneous posterior thigh flaps covered ischial/gluteal lesions [Figures 5 and 6]
and 2 tensor fascia lata mycutaneous flaps were considered relating to trochanteric PUs.