If this ulceration involves only a small area of skin or a partial thickness skin loss, the sore may still be treated nonsurgically. Again, it is a medical emergency requiring relief of pressure, and if hospitalization is necessary to accomplish this, it should be done. These rarely heal without operative closure unless the area of skin loss and the zone of undermining are both very small. The management of these deep ulcers cannot stop with skin flap closure by the plastic surgeon. It must also include additional training in skin care, transfers, etc.
Skin flaps are never as durable as the original skin cover.
If the patient's skin care habits permitted his original skin to break down, flaps have little to no chance without a change in behavior. Once the physiatrist or primary care physician is convinced that the patient is better able to care for his skin, ulcer closure, usually with flap tissue, is indicated. If the patient or his support system cannot be educated in skin care, then closure of the ulcer is not possible, and open wound care must be provided for the remainder of the patient's life. Care of deep ulcers at the University of Washington is provided on the Rehabilitation Service, as for other problems related to spinal cord injury. The first step is evaluation by the physiatrist.