Sir: Ischial pressure sores have been a significant problem for the reconstructive surgeon. Despite various flap alternatives, the rate of recurrence is high.1 Muscle and musculocutaneous flaps remain the most preferred and reliable options.2 Introduction of perforator flaps to the reconstructive surgeon’s choice of techniques has improved the reconstructive strategy during the past decade. The posteromedial thigh skin flap pedicled on the cutaneous perforator of the adductor magnus muscle was described in 2001 by Angrigiani et al.3 Our experience with this flap is presented. Between December of 2001 and May of 2003, seven flaps were used in six paraplegic patients who had grade IV ischial pressure sores (Table 1). The primary disease was spinal trauma in all patients. The patient in case 1 was also diabetic. After thorough debridement, rectangular transposition flaps based on the cutaneous perforator of the adductor magnus muscle were elevated. A cutaneous paddle ranging between 2 and 3 cm over the perforator was always preserved and the perforator was not skeletonized. A distal deepithelialized triangular portion was needed to obliterate the debrided cavity. Donor sites were skin grafted in five cases. The patients were followed up for a mean period of 42 months.Table 1: Patient DataHealing was uneventful in all cases, and no complications were encountered. Recurrence was seen in two patients 30 and 49 months after the procedure. A grade IV sacral pressure sore was also noted in one patient (Fig. 1, left). The hamstring muscle flap with a skin graft for the ischial defect and a gluteus maximus musculocutaneous flap for the sacral defect were used concomitantly. No recurrence was noted after an 8-month follow-up period (Fig. 1, right). In the other patient, the recurrence was bilateral, grade IV on the left and grade I on the right side. Reconstruction was achieved with reelevation and readvancement of the flap on the left side. Healing was uneventful in the early period.Fig. 1.: Patient 5. (Left) Recurrence with an additional sacral ulcer. (Right) Eight-month postoperative view after reconstruction with additional flap options.Ischial repair differs from the others (sacral and trochanteric) by means of two pitfalls: higher pressure over the ischial area during the sitting posture and tension exerted across it with different leg positions. The gluteus maximus musculocutaneous flap provides sufficient bulk and can be designed in various forms based on superior and/or inferior gluteal vessels.4 However, the procedure is invasive and the effort to spare the perforators for future flap options may further complicate it. Perforator fasciocutaneous flaps from the gluteal region5 have been good alternatives for ischial sores and for other locations, although long-term outcome data are not yet available. We tend to preserve the gluteal region for future flap options, which was the case in patient 5. Although lacking bulk, posterior thigh skin, which can be transferred based on several different vascular sources, provides abundant tissue for coverage of ischial defects. Considering the inevitable recurrence, the aim should be to lengthen the sore-free survival in these patients. The versatility in flap design, the long-term durability, the possibility of readvancing the flap, and the sparing of other potential flaps for future reconstruction constitute the major benefits of the adductor perforator flap for reconstruction of ischial pressure sores. Gozu Aydin, M.D. Kul Zekeriya, M.D. Ozsoy Zafer, M.D. Vakif Gureba Research and Education Hospital Plastic and Reconstructive Surgery Department Istanbul, Turkey