All About Pressure Ulcers

Pressure Ulcer of the Sacrum. Photo © Millicent Odunze

The world of plastic surgery is not all glitz and glamour. Although cosmetic plastic surgery is often more in the spotlight, reconstructive plastic surgery is just as important in helping people feel good about themselves.

The treatment of pressure ulcers falls under the category of reconstructive plastic surgery. Plastic surgeons are trained to treat pressure ulcers, just as they are trained to perform face lifts and liposuction.


A pressure ulcer is an area of skin that breaks down when constant pressure, or pressure in combination with shear and/or friction, is placed against the skin. This skin breakdown can ultimately result in exposure of the underlying tissue, including bone.

Pressure ulcers usually occur over a bony prominence, such as the sacrum (tail bone), hip bone, elbow, or ischium.​

Alternative names include pressure sore, decubitus ulcer, decubiti, and bedsore.

Approximately 1.3 million to 3 million adults yearly are reported to have a pressure ulcer.

High-Risk Populations for Pressure Ulcers

The highest incidences of pressure ulcers are found in the following populations:

  • Elderly patients with hip fractures -- 66 percent have a pressure ulcer
  • Quadriplegic patients -- 60 percent have a pressure ulcer
  • Neurologically impaired young (children with paralysis, spina bifida, brain injury, etc.)
  • Chronically hospitalized patients

    Causes of Pressure Ulcers

    Ulceration (skin breakdown) is caused by sustained pressures on the skin. The increased pressure narrows or collapses blood vessels, which decreases blood flow to the skin and underlying tissues. This ultimately leads to tissue death.

    Pressure Ulcer Classification

    Pressure ulcers are classified according to stages describing the amount of tissue loss.

    • Stage 1: Intact skin with persistent redness of a localized area. Darkly pigmented skin may differ in color from the surrounding area.
    • Stage 2: Partial thickness loss of dermis. The wound looks like a shallow open ulcer or an intact or ruptured blister.
    • Stage 3: Full thickness loss of dermis. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed.
    • Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle.

    Some pressure ulcers are unstageable due to the extent of tissue loss or coverage by an eschar.

    Pressure Ulcer Sites

    Pressure ulcer can occur anywhere prolonged pressure is applied. However, the most common susceptible areas are bony prominences:

    • Ischium -- 28 percent of pressure ulcers are on the ischium
    • Hip bone -- 19 percent of pressure ulcers are on the hip bone
    • Sacrum (Tail Bone) -- 17 percent of pressure ulcers are on the sacrum
    • Heel -- 9 percent of pressure ulcers are on the heel
    • Scalp


    Pressure ulcers are managed both medically and/or surgically.

    Stage 1 and 2 pressure ulcers can be managed without surgery. Frequent dressing changes are used to keep the wound clean and fight off bacteria. Sometimes, topical antibiotic medications are used on the pressure ulcer as well.

    Stage 3 and 4 pressure ulcers frequently require surgical intervention. The first step is to remove all the dead tissue. This is known as "debridement." Debridement of the pressure ulcer is followed by flap reconstruction. Flap reconstruction involves using your own tissue to fill the hole/ulcer


    Pressure ulcers are preventable. Here are some tips on how you can avoid them.

    • Minimize moisture to avoid skin maceration and breakdown. This means avoiding prolonged contact with feces, urine, or sweat.
    • Use caution when transferring to and from your bed or a chair. This avoids friction and shearing of the skin.
    • Avoid sitting or laying in one position for a prolonged period of time. Switching positions gives your skin a break and allows the return of blood flow.
    • Maintain proper nutrition. Eating a healthy diet keeps your skin healthy and improves its ability to avoid injury and fight infection.


    • Hematoma
    • Infection
    • Wound dehiscence
    • Recurrence


    Disa JJ, Carlton JM, Goldberg NH. Efficacy of operative cure in pressure sore patients. Plast Recon Surg 89:272, 1992.

    Evans GR, Dufresne CR, Manson PN. Surgical correction of pressure ulcers in an urban center: Is it efficacious? Adv Wound Care 7:40,1994.

    Kierney PC, Engrave LH, Isik FF, et al. Results of 268 pressure sores in 158 patients managed jointly by plastic surgery and rehabilitation medicine Plast Recon Surg 1-2:765, 1999.

    Miller H, Delozier J. Cost implications of the pressure ulcer treatment guideline. Columbia: Center for Health Policy Studies, 1994.

    National Pressure Ulcer Advisory Panel. Updated Staging System.

    Relander M, Palmer B. Recurrence of surgically treated pressure sores. Scand J Plast Recon Surg 22:89, 1988.

    Tavakoli K, Rutkowski S, Cope C, et al. Recurrence rates of ischial sores in para-and tetraplegics treated with hamstring flaps: An 8-year study. Br J Plast Surg 52:476, 1999.

    Continue Reading