bioscaffold, negative-pressure wound therapy, ovine forestomach matrix, pressure injury, surgical reconstruction



  1. Awad, Samir S. MD, MPH, FACS
  2. Stern, James D. MD, FACS
  3. Milne, Cathy T. APRN, MSN, ANP/ACNS-BC, CWOCN-AP
  4. Dowling, Shane G. MSPAS, PA-C, CWS
  5. Sotomayor, Ron BA, RN, CWOCN
  6. Ayello, Elizabeth A. PhD, ETN, RN, CWON, FAAN
  7. Feo Aguirre, Leandro J. MD, FACS, FASCRS
  8. Khalaf, Basil Z. MD
  9. Gould, Lisa J. MD
  10. Desvigne, Michael N. MD, FACS, CWS
  11. Chaffin, Abigail E. MD, FACS, CWSP


OBJECTIVE: Stage 3 and 4 pressure injuries (PIs) present an enormous societal burden with no clearly defined interventions for surgical reconstruction. The authors sought to assess, via literature review and a reflection/evaluation of their own clinical practice experience (where applicable), the current limitations to the surgical intervention of stage 3 or 4 PIs and propose an algorithm for surgical reconstruction.


METHODS: An interprofessional working group convened to review and assess the scientific literature and propose an algorithm for clinical practice. Data compiled from the literature and a comparison of institutional management were used to develop an algorithm for the surgical reconstruction of stage 3 and 4 PIs with adjunctive use of negative-pressure wound therapy and bioscaffolds.


RESULTS: Surgical reconstruction of PI has relatively high complication rates. The use of negative-pressure wound therapy as adjunctive therapy is beneficial and widespread, leading to reduced dressing change frequency. The evidence for the use of bioscaffolds both in standard wound care and as an adjunct to surgical reconstruction of PI is limited. The proposed algorithm aims to reduce complications typically seen with this patient cohort and improve patient outcomes from surgical intervention.


CONCLUSIONS: The working group has proposed a surgical algorithm for stage 3 and 4 PI reconstruction. The algorithm will be validated and refined through additional clinical research.