Once the ulcer is clean and a granulation tissue bed well established, definitive coverage/closure needs to be addressed. Small superficial ulcers heal by secondary intention as long as pressure is kept off the affected area. Larger lesions can be treated surgically with split-thickness skin grafting; occasionally, primary skin closure is accomplished by mobilization of adjacent skin flaps. Large ulcers occasionally require full-thickness coverage with a local full-thickness rotational skin flap and the assistance of a plastic surgeon. At the time of flap rotation the underlying bony prominences may be removed or remodeled to reduce the potential for recurrent pressure ulcers. Negative pressure wound therapy has been a significant advancement in the treatment of pressure ulcer wounds. Negative pressure wound therapy can facilitate fibrinous debridement at dressing changes the way wet-to-dry do and also isolates the wound from contamination while removing edema and local moisture. It also encourages contraction of the wound and may limit the extent of coverage needed. In areas that are particularly vulnerable to recurrence, rotation of a myocutaneous flap to provide greater padding over the bony prominence should be considered.
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