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We have collected data on the second follow-up of 27 patients who underwent musculocutaneous flap closure of their ischial pressure sores. Thirty-seven ulcers were operated on between 1988 and 1993 using the V-Y advancement hamstring musculocutaneous island flap. At the initial follow-up (mean = 20 months) in 1993, despite 33% of patients having had recurrent ulcers and 14.8% having undergone re-advancements, only 14% of patients had non-healing ulcers. In 1997, follow-up period ranged from 18 to 90 months, with a mean of 62 months. Four patients were lost to follow-up resulting in 23 patients (n = 23) for the current study. Nine patients were tetraplegic and the remaining 14 were paraplegic. Four of the 23 patients had died at follow-up therefore making the number of living patients 19 (n = 19). The total number of ulcers operated on in the current study was 29 (U = 29). Overall, ulcer and patient recurrence rates were 41.4% and 47.8% respectively. Despite this, 89.5% of patients had intact flaps at the time of follow-up. We recommend the use of the hamstring V-Y musculocutaneous flap as a reliable and safe reconstructive modality in the management of ischial pressure sores and by identifying the group of patients susceptible to ulcer recurrence we have proposed a protocol for their long-term follow-up.

Thirty-seven ischial pressure ulcers were repaired in 27 patients (eight quadriplegic, 19 paraplegic) between 1988-1993 using the V-Y advancement hamstring myocutaneous island flap. Twenty-one ulcers (57%) arose de novo and 16 were recurrent, with five patients having bilateral ulcers. The average duration of the ulcer was 5 months (range 1-30). All ulcers extended through the deep fascia (clinical grade IV), with the average diameter being 4.7 cm (range 2-10). There were four major flap complications (11%). All but one of the ulcers healed at discharge (97%). Mean follow up was 20 months (range 5-54) in 21 patients (78%), with six patients being lost to follow up. Seven of the 21 (33%) patients developed recurrent ulcers, with four of these having flap re-advancement with successful healing, and one patient having two re-advancements. Overall, 18 of the 21 (86%) patients with follow up had healed ulcers at time of follow up. The V-Y advancement hamstring myocutaneous island flap is versatile, reliable, easy to perform, has few complications, and can be re-advanced in the event of recurrence.

The pectoralis major myocutaneous island flap is useful for axillary reconstruction following resection of tumour and skin in the axilla. It is a useful alternative to the latissimus dorsi flap, particularly when the vascular pedicle of the latissimus dorsi muscle is infiltrated by tumour or has been sacrificed by previous surgery.

The forehead can be reconstructed using a bi-pedicled bone flap based on the temporalis muscles. The technique is illustrated by the description of a patient in whom post-operative radio-isotope scanning was used to demonstrate the viability of the transposed bone. The technique is useful when there has been previous infection.