Sequential Perforator-Based Reconstruction of a Recurrent Stage IV Sacral Pressure Ulcer in a Paraplegic Patient: Primary Superior Gluteal Artery Perforator Flap Followed by a Freestyle Perforator Flap Salvage

Stage IV sacral pressure injuries remain a major reconstructive challenge in patients with spinal cord injury due to persistent mechanical loading, impaired sensibility, and high recurrence rates. Perforator-based reconstruction has emerged as a preferred surgical strategy because it provides durable coverage while preserving muscle and maintaining future reconstructive options. We report the case of a 43-year-old man with T11-T12 spinal cord injury and paraplegia who presented with a stage IV sacral pressure ulcer measuring 11 × 9 cm with exposed sacral bone. Serial surgical debridement, including burring of exposed bone, reduced the wound size to 8 × 8 cm. There was no evidence of osteomyelitis, wound cultures were negative, and hematologic and nutritional parameters were optimized prior to reconstruction. The defect was reconstructed using a superior gluteal artery perforator (SGAP) flap measuring 8 × 8.5 cm, identified through intraoperative perforator exploration. Initial postoperative healing was satisfactory. However, four months later, recurrent ulceration developed at the sacral region. Following repeat debridement, salvage reconstruction was performed using a freestyle perforator flap. The wound healed completely, and the patient remained ulcer-free after six months of follow-up. This case demonstrates the value of perforator-preserving reconstructive strategies that enable secondary reconstruction for recurrent sacral pressure ulcers in patients with spinal cord injuries.