The Value of a Modified Posterior Thigh Flap with Z-Plasty for Reconstruction of Ischial Tuberosity Pressure Ulcers: A Retrospective Single Center Analysis

Abstract

Pressure ulcers are a persistent and growing challenge in modern medicine, with prevalence rates ranging from 3.4% to 32.4% globally. Demographic changes suggest an increasing number of patients at risk, emphasizing the need for effective prevention and advanced treatment strategies. These ulcers, particularly stages III and IV, often require surgical intervention due to severe tissue damage. Among the surgical options, the Posterior Thigh Flap has emerged as a reliable fasciocutaneous flap, frequently referred to as a "work-horse flap", for defect coverage in the ischial region. To improve outcomes and minimize recurrences in weight-bearing areas, our clinic combined this flap technique with a Z-plasty modification to achieve redistribution of scar tissue to reduce localized pressure. In this retrospective study, six patients with seven ischial pressure ulcers were treated between 2003 and 2024 using this approach. Following debridement and wound conditioning with negative pressure therapy, defect coverage was performed. The results show clinically acceptable complication rates (42.9%) and a low recurrence rate (14.3%), with recurrences occurring no earlier than 12 months post-treatment. The Z-plasty effectively shifted scar zones away from high-pressure areas, reducing tension and recurrence risk. This study highlights the potential benefits of combining fasciocutaneous flaps with scar management techniques to improve long-term outcomes for ischial pressure ulcers and provides an innovative approach to treating ischial pressure ulcers.

Keywords: Posterior Thigh Flap; Z-plasty; decubitus ulcer; fasciocutaneous flap; ischial pressure sore.

Figure 1

(a) Grade 4 decubitus ulcer on the right ischial tuberosity before initial debridement; (b) 1 week postoperatively after defect coverage using a Posterior Thigh Flap and Z-plasty.

Figure 2

(a) Grade 4 pressure ulcer on the left side after initial debridement; (b) postoperative final result after defect coverage using a Posterior Thigh Flap and Z-plasty; (c) 4 weeks postoperatively after defect coverage.

Figure 3

Schematic illustration of the preoperative marking (a), the rotation of the Z-plasty/two transposition flap (A and B) and the Posterior Thigh Flap (b), and the scar pattern after surgery (c); created by Maximilian C. Stumpfe.