Modified total thigh musculocutaneous flap: 'operation of last resort' for massive pressure ulcers.

Massive bilateral pressure ulcers of dependent areas may complicate spinal cord injuries. These may be life threatening to patients and challenging for reconstructive surgeons. In massive recurrent ulcers, local tissue is either inadequate or previously exhausted. The total thigh musculocutaneous flap is an operation of last resort; we present a new variation of this procedure and a case of life threatening pressure ulcers with underlying osteomyelitis. A paraplegic patient had recurrent, extensive, bilateral pressure areas with some preserved tissue bridges. The nature of the pressure areas and lack of local options in this patient required modification of previously described total thigh flaps. An extended total thigh flap was partially de-epithelialised to fill the extensive sacral defect and a tunnelled extension was fashioned to cover the contralateral trochanteric defect. The timing of surgery was determined by balancing pre-operative nutritional optimisation against life-threatening drug resistance of infective organisms. The total thigh flap can close massive bilateral pressure ulcers. Modifications are presented which preserve viable local tissue and demonstrate the versatility of this technique. It remains a 'last-resort' salvage procedure.