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Procedural technique
Procedural technique
Pressure ulcer reconstruction generally occurs in the operating room under general anesthesia. Before beginning, ulcers are debrided and excised to remove necrotic tissue.120 Typically, methylene blue dye is used to mark the ulcer extent and act as a visual aid to complete the excision.121
Proper preparation is critical to the success of any flap procedure.119 Using a marking pen, two lines should be drawn from the widest portion of the ulcer on either side and should meet at a single point away from the defect, making a V-shape. The two lines should have an angle of approximately 30 degrees between them to ensure the ease of primary closure. The incisions should be made with a scalpel with the aid of tissue forceps with teeth along these two lines. They should extend down to the subcutaneous fat to create a pedicle composed of subcutaneous fat and muscle fibers.107,111 The pedicle should be dissected until the flap becomes mobile.119 The cross-sectional area of the pedicle should be approximately equal to that of the overlying skin in order to preserve perfusion. A triangular island of skin should form that is two to three times as long as the diameter of the primary defect and has a width equal to the largest perpendicular diameter of the wound.112 The flap is then advanced over the primary defect, leaving a secondary defect at the donor area. The flap in then sutured in place and the donor area is closed in a linear fashion.