What are the benefits and risks of reconstructive surgery for treating pressure ulcers?

Key messages

- We are uncertain about the benefits and risks of reconstructive surgery (sometimes known as plastic surgery) for treating pressure ulcers (sometimes known as bedsores, pressure sores or pressure injuries). 

- We found one small study (20 participants) that investigated reconstructive surgery in deep, hard-to-heal pressure ulcers, but we were unable to reach any conclusions from the reported results.

- Larger, well-designed studies are needed to explore this priority area.

What are pressure ulcers?

Pressure ulcers are skin and tissue injuries that are usually caused by people staying in the same position for long periods of time. When external pressure is constantly applied to parts of the body, blood flow is restricted to the skin and underlying tissues. This can cause the skin or underlying tissue to break down, especially in areas that have less fat such as the lower back and heel.

People at risk of developing pressure ulcers include older adults, people with mobility problems (e.g. wheelchair users) and people who spend long periods in hospital.

How are pressure ulcers treated?

Pressure ulcers are serious wounds that are costly to treat, so care is mainly focused on preventing them. When ulcers do occur, treatment options include wound dressings, antibiotics and antiseptics.

Reconstructive surgery is usually reserved for deep or hard-to-heal pressure ulcers. There are different types of reconstructive surgery, but most involve removing dead tissue from the wound then using soft tissue such as muscle, fat or skin from other parts of the person's body to fill the wound cavity.

What did we want to find out?

We wanted to assess the benefits and risks of reconstructive surgery for treating pressure ulcers compared with no surgery; and the benefits and risks of different types of reconstructive surgery compared with each other. The results we were interested in were:

- complete wound healing;
- wounds reopening or new ulcers occurring at the same site as previous ulcers;
- resource use and costs;
- health-related quality of life;
- wound infection; and
- new ulcers occurring at different sites from previous ulcers. 

What did we do? 

We searched electronic databases and trials registers for randomised controlled trials, which are clinical studies that randomly allocate participants to different treatment groups. This type of study design can provide the most reliable evidence about the effects of a treatment. We included studies that investigated the effects of reconstructive surgery for treating pressure ulcers compared with no surgery. We also included studies that compared different types of reconstructive surgery for treating pressure ulcers. We applied no restrictions on language, date of publication, or where the study was conducted. We rated our confidence in the evidence, based on factors such as study methods and the number of people included. 

What did we find? 

We found one small study, which was carried out in the USA and recruited 20 participants in hospital. This study investigated two different reconstructive surgical techniques for treating stage IV pressure ulcers, which have full-thickness skin and tissue loss. The study did not provide enough information on wound healing, wound reopening, ulcer recurrence or wound infection for us to judge the effectiveness of the different surgical techniques.

What are the limitations of the evidence?

We are uncertain what effect the two surgical techniques had on wound healing, reopening or recurrence, because the trial was not well conducted or reported, and it included a small number of participants. 

We are uncertain about the benefits and harms of reconstructive surgery, and of different surgical techniques, for treating pressure ulcers. More rigorous research is needed in this area, as patients, carers and health professionals consider it a priority issue.

How up to date is this evidence?

This is an update of a previous review. The evidence is up to date to January 2022.

Authors' conclusions: 

Currently there is very little randomised evidence on the role of reconstructive surgery in pressure ulcer management, although it is considered a priority area. More rigorous and robust research is needed to explore this intervention.

Read the full abstract...

There are several possible interventions for managing pressure ulcers (sometimes referred to as pressure injuries), ranging from pressure-relieving measures, such as repositioning, to reconstructive surgery. The surgical approach is usually reserved for recalcitrant wounds (where the healing process has stalled, or the wound is not responding to treatment) or wounds with full-thickness skin loss and exposure of deeper structures such as muscle fascia or bone. Reconstructive surgery commonly involves wound debridement followed by filling the wound with new tissue. Whilst this is an accepted means of ulcer management, the benefits and harms of different surgical approaches, compared with each other or with non-surgical treatments, are unclear. This is an update of a Cochrane Review published in 2016.


To assess the effects of different types of reconstructive surgery for treating pressure ulcers (category/stage II or above), compared with no surgery or alternative reconstructive surgical approaches, in any care setting.

Search strategy: 

We used standard, extensive Cochrane search methods. The latest search date was January 2022.

Selection criteria: 

Published or unpublished randomised controlled trials (RCTs) that assessed reconstructive surgery in the treatment of pressure ulcers.

Data collection and analysis: 

Two review authors independently selected the studies, extracted study data, assessed the risk of bias and undertook GRADE assessments. We would have involved a third review author in case of disagreement.

Main results: 

We identified one RCT conducted in a hospital setting in the USA. It enrolled 20 participants aged between 20 and 70 years with stage IV ischial or sacral pressure ulcers (involving full-thickness skin and tissue loss). The study compared two reconstructive techniques for stage IV pressure ulcers: conventional flap surgery and cone of pressure flap surgery, in which a large portion of the flap tip is de-epithelialised and deeply inset to obliterate dead space. There were no clear data for any of our outcomes, although we extracted some information on complete wound healing, wound dehiscence, pressure ulcer recurrence and wound infection. We graded the evidence for these outcomes as very low-certainty. The study provided no data for any other outcomes.