Pressure Ulcer (Decubitus) Treatment in Ankara, Turkey

Pressure ulcer (decubitus ulcer) reconstruction includes the surgical and supportive treatment of tissue loss that develops in the skin and underlying tissues due to prolonged bed rest or immobility. The goal is to control infection, promote wound healing, and prevent recurrence.

In early-stage wounds, conservative treatment is applied with pressure-relieving measures, wound care, and nutritional support. In advanced stages, surgical intervention is required. Non-viable tissues are removed, infected areas are debrided, and a transition to healthy tissue is ensured.

In extensive tissue losses, flap surgery is used to transfer durable, well-vascularized tissues to the wound area. The region is re-covered using gluteal, lumbar, or muscle flaps. This technique accelerates healing and makes the wound area more resistant to pressure.

After treatment, preventive strategies such as repositioning, specialized mattress systems, and skin care should be implemented. Nutritional supplementation and multidisciplinary follow-up increase the success of the reconstruction. With proper planning, permanent healing and improved quality of life can be achieved.

What Is Pressure Ulcer (Decubitus) Treatment?

Pressure ulcer (decubitus) treatment is the set of medical approaches aimed at healing wounds that develop in the skin and underlying tissues due to prolonged pressure. Treatment includes relieving pressure, providing regular wound care, controlling infection, using appropriate dressing products, and performing surgical procedures when needed. In addition, improving the patient’s nutritional status and ensuring regular repositioning are critical for the healing process.

Why Do Pressure Ulcers Occur and What Happens in Our Skin?

The basic mechanism of pressure ulcers is actually based on the laws of physics. Every tissue in our body needs blood—oxygen and nutrients—to survive. The smallest vessels that carry blood, the capillaries, have a certain internal pressure. If external pressure exceeds this internal pressure, blood flow in that area stops. You can compare this to stepping on a garden hose while watering; just as the flow of water stops, blood flow stops in the tissue trapped between a bony prominence and the bed.

Even in sleep, a healthy person senses pressure and the brain triggers an automatic change of position. However, in paralyzed, elderly, or sensory-impaired patients, this warning system does not work. This is where the danger begins. Tissue that does not receive blood is deprived of oxygen and nutrients, and cells slowly start to die.

There is an important detail here: muscle tissue is much less tolerant of oxygen deprivation than the skin. So while you may see only mild redness on the surface, the muscle tissue closer to the bone may already be dying. This is why sometimes a huge cavity can exist beneath a small opening. In addition to direct pressure, “friction” and “shear” forces—caused when a patient slides down in bed—can tear small vessels inside the tissue and accelerate the process.

Which Factors Make Pressure Ulcers More Likely?

Immobility is certainly the greatest enemy, but it is not the only culprit. The patient’s overall health status is the main factor determining whether a wound develops. When the body’s resistance decreases, the skin’s ability to withstand pressure also diminishes.

Key factors that increase the risk of pressure ulcers include:

• Spinal cord injuries
• Advanced age
• Diabetes
• Smoking
• Heart failure
• Poor nutrition
• Severe underweight
• Obesity
• Urinary incontinence
• Prolonged intensive care stays

How Are Pressure Ulcer Stages Identified?

We evaluate these wounds in four stages based on severity. This staging is the most important guide that helps us decide which treatment to apply.

• Stage 1: This stage is essentially the body’s “Help!” signal. Skin integrity is intact and no open wound is present. However, when you press on the red area (for example the heel or tailbone) and release, the redness does not blanch. Normally it turns white briefly and then the color returns. In Stage 1, the redness persists. Surgery is not needed, and it can be reversed with excellent care.
• Stage 2: The surface of the skin is now damaged. There may be a blister (bulla) or a shallow crater-like abrasion. The top layer of skin has peeled. It may be painful. This stage usually heals with proper dressings and pressure relief.
• Stage 3: This is where things become serious. There is full-thickness skin loss. When you look into the wound, you can see subcutaneous fat tissue. The wound is deep, but bone or muscles are not yet exposed. Infection risk generally increases at this stage.
• Stage 4: This is the most severe condition. Bone, muscle, tendon, or joint capsule can be seen at the base of the wound. It is often accompanied by foul odor, discharge, and black necrotic tissue. This stage can be life-threatening and usually requires surgical intervention.

What Adjustments Should Be Made Before Surgery?

One of the most common misconceptions I encounter as a plastic surgeon is the expectation that the patient should be taken to surgery immediately upon arrival. However, pressure ulcer surgery is not an emergency, unprepared procedure like an appendectomy. You cannot build a new floor on a building with a weak foundation; first, we must strengthen the foundation.

The first thing we assess while preparing a patient for surgery is nutritional values. Especially if the blood protein level “albumin” is low, no matter how perfect the sutures are, the wound will not heal. Anemia should be corrected. In addition, if the patient has uncontrolled muscle spasms (spasticity), these must be controlled with medication or physical therapy. Because severe spasms can tear apart the reconstructed tissue.

The wound bed must also be clean. We cannot close an infected, inflamed wound filled with dead tissue. Therefore, before surgery we sometimes apply special dressings or negative pressure vacuum therapy for weeks. Our goal is to “prepare” the wound—creating a well-vascularized, viable, and clean base.

Which Foods Should Be Consumed During the Nutrition Process?

Wound healing requires enormous energy. The body turns into a construction site and this construction needs bricks and mortar. The regular diet of a healthy person is not enough for patients in a wound healing period.

Nutrition should emphasize:

• Eggs
• Red meat
• Fish
• Dairy products
• Legumes
• Fruits rich in vitamin C
• Green leafy vegetables
• Zinc supplements
• Plenty of water

What Is Flap Surgery Used in Pressure Ulcer Reconstruction?

Now we come to the surgical part. Pressure ulcer reconstruction is not simply “bringing the wound edges together and stitching,” as commonly believed. Since there is tissue loss, it is impossible to pull the edges together; even if you could, the sutures would fail quickly due to tension. The procedure we perform is called “Flap Surgery.”

Flap surgery means lifting a living piece of tissue—fed by its own vascular system—from a nearby or more distant area and transferring it to the defect. This is not a “patch,” because a patch (graft) is only a thin layer of skin and cannot be placed over exposed bone. A flap is thick, robust, and living tissue that includes skin, subcutaneous fat, and sometimes muscle.

During surgery, we first remove dead tissue, infected pockets, and if present, compromised bone parts. We smooth sharp bony edges so they do not pierce the new tissue from inside. Then we advance or rotate the prepared living tissue like a puzzle piece to cover the wound.

In the past, muscle-containing flaps were used frequently. Today, however, we prefer a more modern approach called the “perforator flap.” In this technique, instead of sacrificing muscle, we identify the small perforating vessels running through the muscle and transfer only the overlying skin and fat. This allows the patient to recover from the wound without losing muscle strength.

Which Areas Are Most Commonly Affected by Pressure Ulcers?

The locations of pressure ulcers vary depending on the patient’s lying or sitting position. Areas where bony prominences are closest to the skin are always the primary candidates.

The most common regions include:

• Tailbone (sacrum/coccyx)
• Sitting bones (ischial tuberosities)
• Lateral hip prominences
• Heels
• Shoulder blades
• Elbows
• Back of the head
• Outer ear

How Is Tailbone Pressure Ulcer Treated?

Tailbone (sacral) ulcers are typically seen in patients lying on their back and are the most common type we encounter. This region carries a higher infection risk due to proximity to urinary and fecal contamination, and it also experiences significant tension because it lies near the body’s midline.

For reconstruction, we usually use tissue prepared from the gluteal area. The fullness of the buttock acts as an excellent cushion over bone. After closing the wound, the goal is not only to cover the skin but also to create a thick barrier between the bone and the outside world. If the patient is ambulatory, we try to avoid cutting the gluteal muscle. If the patient is bedridden, we may also use part of the muscle as additional bulk.

Is Ischial Pressure Ulcer Reconstruction Difficult?

Yes—this group is often the most challenging and has the highest recurrence risk. Ischial ulcers are commonly seen in paraplegic patients who use wheelchairs. Consider that, while sitting, the entire body weight is concentrated on two small bony points. The pressure is so high that even transferred healthy tissue may fail if strict precautions are not followed.

For reconstruction, we typically use tissues from the posterior thigh region. Sometimes we include muscle, and sometimes we transfer only skin-fat tissue. Postoperatively, sitting is prohibited for a long period.

What Is the “21-Day Rule” in Postoperative Recovery?

I always tell my patients: “Surgery was the easiest part—now the real challenge begins.” Because the success of this surgery depends 100% on postoperative care. Our golden rule is the “21-Day Rule.”

No pressure should be applied to the operated area for at least 3 weeks (21 days). If you had surgery on the tailbone, you must lie face down or on your side for 3 weeks. Lying on your back is strictly forbidden—even during meals.

Why 21 days? Because the transferred tissue needs this time to adhere securely, the vessels need to heal, and the suture lines need to strengthen. Any early pressure or a wrong movement can cause the sutures to fail and the wound to reopen—often larger than before.

We also use thin tubes called “drains” to prevent blood and fluid accumulation in the surgical area. These drains remove fluid and help the tissue adhere. They usually remain in place for 5–7 days until the output decreases.

How Is the Postoperative Sitting Protocol Applied?

After the 21-day bed rest period ends, we cannot immediately place the patient in a wheelchair and say “Go for a ride.” The tissue must be gradually conditioned to pressure. This is called the “Sitting Protocol.”

The steps of this protocol are:

• Day 1: Sit for only 15 minutes
• Skin check and rest
• Day 2: Sit for 30 minutes
• Re-check the wound area
• Day 3: Sit for 45 minutes
• Increase by 15 minutes each day
• If redness occurs, return to the previous duration

Do Pressure Ulcers Recur?

Unfortunately, yes. In fact, when we look at the medical literature, recurrence rates are quite high. This is not due to surgeon failure or a “bad surgery.” The reason is that the conditions that caused the wound in the first place often still exist. The patient may still be immobile and may still have sensory loss. If the patient returns to old habits, neglects repositioning, or worsens nutrition after surgery, recurrence becomes inevitable.

As surgeons, we restore the lost tissue and repair the area. But protecting that reconstructed site depends entirely on the patient and caregivers. Surgery is not a “happy ending”—it is the beginning of a new life that requires greater attention.

Which Measures Should Be Taken for Prevention?

Treating pressure ulcers is difficult, costly, and time-consuming. Preventing them is far easier. “Prevention is better than treatment” is perhaps nowhere more true than here.

To prevent pressure ulcers:

• Regular repositioning
• Use of an alternating air mattress
• Using silicone or gel cushions
• Daily skin inspection
• Moisturizing cream use
• High-protein nutrition
• Plenty of water intake
• Smoking cessation
• Attention to urinary hygiene
• Keeping bed sheets taut and wrinkle-free

What Are the Responsibilities of Caregivers?

The greatest burden in this process often falls on caregivers and family members. You should examine the patient’s skin every day as if inspecting a precious jewel. Using a mirror, check the tailbone and heels. Take even the slightest redness seriously. Saying “It will pass by tomorrow” is the biggest mistake. The moment you see redness, you must completely remove pressure from that area.

Repositioning is not a chore—it is a life-saving necessity. Even during nighttime sleep, the patient’s position should be changed. Relying only on an air mattress and stopping repositioning is a major mistake; the mattress is only an aid, and the real work is done by repositioning.