Epidemiology of foot burns in a Dutch burn centre

Background:Although the feet involve a small percentage of the total body surface area,they can have major effects in daily life,caused by prolonged bed rest,hospitalization and high risk of both early and late complications.The aim of this study was to define the aetiology,treatment and outcomes of foot burns,with special interest in paediatric patients,patients with diabetic disease and burns acquired at the workplace.Methods:This is a retrospective cohort study of 82 patients who were admitted to one of the three burn centres in the Netherlands during the period 2004 to 2013.The patients had a median age of 43.5 years(range 0.01–85.9),and included 14 children and 8 diabetics.Data were collected from the hospital records.Results:Scalding was the most common cause of the injury.Almost all patients required surgical management.It is notable that most of hospitalized patients(82%)were not admitted on the day of injury.Children had a significantly shorter length of stay compared to adults(p=0.01).The eight patients with diabetes had a significantly longer length of hospital stay,more complications and more often residual defects compared to the non-diabetic patients.In 13 patients,the injury took place at work.Half of these burns were caused by scalding,and foot burns caused by chemicals at work were rare(two patients).Conclusions:Although the incidence of foot burns is low,there is a significant morbidity due to complications and long hospital stay.The following three points are suggested.Immediate referral to a burn centre is essential.It is important to educate diabetic patients on the risk of complications and adverse outcomes after burn injury.Preventative measures at the workplace are worth considering.

Enzymatic debridement shall not modify the global strategy for mass burn events

We read with interest the letter by Surowiecka et al.[1]about early burn wound excision in mass casualty events.We couldn’t agree more with their statement about the benefit of early burn wound excision.Still,we doubt whether applying this strategy to every patient during a mass burn event could be realistic.Of note,while there is an undisputed consensus that early burn wound excision is the gold standard of burn care,what‘early’actually means is still debated.Depending on the authors,the corresponding time limit typically varies from 24 h to a few days[2,3].

Burn Management at the 37 Military Hospital—A Tertiary Hospital in Accra, Ghana

Burn injuries have been and remain a very significant source of mortality and morbidity in low- and middle-income countries. As a country in this category, Ghana, is not exempted. Ghana has a population of 31 Million with only 21 Plastic Reconstructive and Burn surgeons. Moreover, the country can boast of only 3 major Burn centres. This notwithstanding the country in particular and Africa, in general, carries an extraordinary burden of Burn injuries with devastating consequences. Burn data from the 37 Military Hospital were analyzed from March 2018 to September 2019—a period of 18 months. In all, 217 burn cases were seen representing about 2.1% of all trauma and surgical cases. Our burn data analyzed the peculiarities of epidemiology, types of burn, the pattern of injuries, and the outcome of burn care at the 37 Military Hospital. Flame is emerging as the predominant cause of burns, most frequently occurring from the use of Liquid Petroleum Gas. In the pediatric population, however, the most frequent cause of burns is hot water burns. The mortality rate among the burn population was 1.8% (4 mortalities). This paper aims to point out management methods adopted by our unit which helped to improve burn outcomes and to reduce mortality.

Epidemiology of isolated foot burns in children presenting to a Queensland paediatric burns centre—a two-year study in warmer climate

Background: European studies of paediatric foot burns report scalds as the leading cause. Mechanisms of injury are different in warmer climates. We sought to characterize the mechanisms and outcomes of isolated foot burns in our population. Methods: Retrospective review of a prospectively collected database of all children aged 0–15 years presenting to a Queensland paediatric burns centre over a 26-month period. Non-parametric analyses such as the Mann-Whitney U and Pearson Chi-square were used. Results: There were 218 children with foot burns treated over a period of 2 years and 2 months of which 214 had complete records. There were significantly more boys than girls (n=134, 62.6% cf. n=80, 37.4%, p<0.0001). The leading mechanism of injury was a contact burn accounting for 63.1% (n=135) followed by scalds (23.8%, n=51). Friction, flame and chemical burns were a minority but were significantly deeper (p=0.03) and significantly more likely to require grafting (p=0.04) and scar management (p<0.0001) compared to contact and scald burns. Conclusions: In our population, contact burns are the most common mechanism of injury causing burns to the feet. The leading aetiology is campfire burns, which account for one-third of all burns to the feet. Prevention campaigns targeted at this population could significantly reduce the burden of morbidity from these burns. Friction, flame and chemical burns constitute a minority of patients but are deeper and more likely to require skin grafting and scar management.

Physics of Open Fractures: Reconsidering Tissue Viability, Contamination Risk and Importance of Wound Debridement

Understanding basic physics behind open fractures leads to a better understanding of mechanism of injury, open fractures pathophysiology and management. Explaining local changes in viability of open fracture involved tissues, importance of debridement and reconsidering contamination risks will be ultimate objectives after going through this review. The controversy is still there between minimal/conservative debridement of open fracture wounds in favour of direct closure of soft tissue on the same session against generous debridement and delayed closure by more complicated choices on the reconstructive ladder to avoid infection, delayed healing, wound chronicity, limb loss and prolonged hospital stay. In the article, basic physics behind open fractures is highlighted to gain a deeper understanding of tissue viability changes and contamination risks after injury.

Ex vivo expansion of hematopoietic stem and progenitor cells: Recent advances

Hematopoietic stem cells(HSCs) have become the most extensively studied stem cells and HSC-based cellular therapy is promising for hematopoietic cancers and hereditary blood disorders. Successful treatment of patients with HSC cells depends on sufficient number of highly purified HSCs and progenitor cells. However, stem cells are a very rare population no matter where they come from. Thus, ex vivo amplification of these HSCs is essential. The heavy demands from more and more patients for HSCs also require industrial-scale expansion of HSCs with lower production cost and higher efficiency. Two main ways to reach that goal:(1) to find clinically applicable, simple and efficient methods(or reagents) to enrich HSCs;(2) to find new developmental regulators and chemical compounds in order to replace the currently used cytokine cocktails for HSCsamplification. In this Editorial review, we would like to introduce the current status of ex vivo expansion of HSCs, particularly focusing on enrichment and culture supplements.

The scalp as a donor site for skin grafting in burns: retrospective study on complications

Background:Split skin grafting(SSG)is the cornerstone in the treatment of deep burns and large skin defects.Frequently used donor sites are the thigh,abdomen and buttocks.The scalp is less common while considered as a reliable donor site.Advantages are a large surface area,rapid wound healing,cosmetically favourable results and multiple harvests from the same donor site.Complications include scab formation,chronic folliculitis and alopecia but have been recorded sporadically in previous studies.This article evaluates the complication rate of the scalp donor site in the treatment of deep burns in the Beverwijk Burn Centre.Methods:A retrospective study was performed of all patients who received a skin graft from the scalp at the Beverwijk Burn Centre between January 2004 and December 2012.Data were collected from medical files of included patients,including gender,age,type of burn(scald,flame,other)and total body surface area(TBSA)burned at the time of first surgery.Postoperative variables were healing time of the donor site and incidence of complications.During follow-up,the incidence of late complications was reviewed.Results:A total number of 105 grafts were analysed in 93 patients:58 males(62%)and 35 females(38%),with a median age of 2 years and 3 months old.Of the patients,30(32%)had flame burns and 57(61%)had scald burns.Eighty-seven percent of patients had a TBSA burned of 5%or less.All donor sites healed within 14 days.No alopecia or scar hypertrophy developed at the donor sites.Two patients(2.2%)developed folliculitis;one patient(1.1%)showed scab formation.Conclusions:The scalp as a donor site in our Burn Centre shows a comparable short-term complication rate to the previous literature,with quick healing and no long-term complications.Therefore,we propose the consideration of the scalp as a primary donor site,especially in young children,where the scalp offers a larger donor site area than the buttocks or thighs.

Skin bioprinting:the future of burn wound reconstruction?

Burns are a significant cause of trauma,and over the years,the focus of patient care has shifted from just survival to facilitation of improved functional outcomes.Typically,burn treatment,especially in the case of extensive burn injuries,involves surgical excision of injured skin and reconstruction of the burn injury with the aid of skin substitutes.Conventional skin substitutes do not contain all skin cell types and do not facilitate recapitulation of native skin physiology.Three-dimensional(3D)bioprinting for reconstruction of burn injuries involves layer-by-layer deposition of cells along with scaffolding materials over the injured areas.Skin bioprinting can be done either in situ or in vitro.Both these approaches are similar except for the site of printing and tissue maturation.There are technological and regulatory challenges that need to be overcome for clinical translation of bioprinted skin for burn reconstruction.However,the use of bioprinting for skin reconstruction following burns is promising;bioprinting will enable accurate placement of cell types and precise and reproducible fabrication of constructs to replace the injured or damaged sites.Overall,3D bioprinting is a very transformative technology,and its use for wound reconstruction will lead to a paradigm shift in patient outcomes.In this review,we aim to introduce bioprinting,the different stages involved,in vitro and in vivo skin bioprinting,and the various clinical and regulatory challenges in adoption of this technology.

History of burns: The past, present and the future

Burn injuries are one of the most common and devastating affl ictions on the human body.In this article we look back at how the treatment of burns has evolved over the centuries from a primarily topical therapy consisting of weird and wonderful topical concoctions in ancient times to one that spans multiple scientifi c fi elds of topical therapy,antibiotics,fl uid resuscitation,skin excision and grafting,respiratory and metabolic care and nutrition.Most major advances in burn care occurred in the last 50 years,spurred on by wars and great fi res.The use of systemic antibiotics and topical silver therapy greatly reduced sepsis related mortality.This along with the advent of antiseptic surgical techniques,burn depth classifi cation and skin grafting allowed the excision and coverage of full-thickness burns which resulted in greatly improved survival rates.Advancements in the methods of assessing the surface area of burns paved way for more accurate fl uid resuscitation,minimising the eff ects of shock and avoiding fl uid over-loading.The introduction of metabolic care,nutritional support and care of inhalational injuries further improved the outcome of burn patients.We also briefl y discuss some future directions in burn care such as the use of cell and pharmalogical therapies.

A systematic review of objective burn scar measurements

Background:Problematic scarring remains a challenging aspect to address in the treatment of burns and can significantly affect the quality of life of the burn survivor.At present,there are few treatments available in the clinic to control adverse scarring,but experimental pharmacological anti-scarring strategies are now beginning to emerge.Their comparative success must be based on objective measurements of scarring,yet currently the clinical assessment of scars is not carried out systematically and is mostly based on subjective review of patients.However,several techniques and devices are being introduced that allow objective analysis of the burn scar.The aim of this article is to evaluate various objective measurement tools currently available and recommend a useful panel that is suitable for use in clinical trials of anti-scarring therapies.Methods:A systematic literature search was done using the Web of Science,PubMed and Cochrane databases.The identified devices were then classified and grouped according to the parameters they measured.The tools were then compared and assessed in terms of inter-and intra-rater reproducibility,ease of use and cost.Results:After duplicates were removed,5062 articles were obtained in the search.After further screening,157 articles which utilised objective burn scar measurement systems or tools were obtained.The scar measurement devices can be broadly classified into those measuring colour,metric variables,texture,biomechanical properties and pathophysiological disturbances.Conclusions:Objective scar measurement tools allow the accurate and reproducible evaluation of scars,which is important for both clinical and scientific use.However,studies to evaluate their relative performance and merits of these tools are scarce,and there remain factors,such as itch and pain,which cannot be measured objectively.On reviewing the available evidence,a panel of devices for objective scar measurement is recommended consisting of the 3D cameras(Eykona/Lifeviz/Vectra H1)for surface area and volume,DSM I colorimeter for colour,Dermascan high-frequency ultrasound for scar thickness and Cutometer for skin elasticity and pliability.

Comparative effectiveness of Biobrane^(■),RECELL^(■)Autologous skin Cell suspension and Silver dressings in partial thickness paediatric burns:BRACS randomised trial protocol

Background:Mixed partial thickness burns are the most common depth of burn injury managed at a large Australian paediatric hospital specialty burns unit.Prolonged time until re-epithelialisation is associated with increased burn depth and scar formation.Whilst current wound management approaches have benefits such as anti-microbial cover,these are not without inherent limitations including multiple dressing changes.The Biobrane^(■)RECELL^(■)Autologous skin Cell suspension and Silver dressings(BRACS)trial aims to identify the most effective wound management approach for mixed partial thickness injuries in children.Methods:All children presenting with an acute burn injury to the study site will be screened for eligibility.This is a single-centre,three-arm,parallel group,randomised trial.Children younger than 16 years,with burns≥5%total body surface area involving any anatomical location,up to 48 h after the burn injury,and of a superficial partial to mid-dermal depth,will be included.A sample size of 84 participants will be randomised to standard silver dressing or a Regenerative Epithelial Suspension(RES^(TM))with Biobrane^(■)or Biobrane^(■)alone.The first dressing will be applied under general anaesthesia and subsequent dressings will be changed every 3 to 5 days until the wound is≥95%re-epithelialised,with re-epithelialisation time the primary outcome.Secondary outcomes of acute pain,acute itch,scar severity,health-related quality of life,treatment satisfaction,dressing application ease and healthcare resource use will be assessed at each dressing change and 3,6 and 12 months post-burn injury.Discussion:The findings of this study can potentially change the wound management approach for superficial partial to mid-dermal burns in children locally and worldwide.Trial registration:The Australian New Zealand Clinical Trials Registry(ACTRN12618000245291)approved prospective registration on 15 February 2018.Registration details can be viewed at https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374272&isReview=true.

A prospective study of time to healing and hypertrophic scarring in paediatric burns:every day counts

Background: It is commonly accepted that burns taking longer than 3 weeks to heal have a much higher rate of hypertrophic scarring than those which heal more quickly. However, some of our patients develop hypertrophic scars despite healing within this 3-week period. Methods: We performed a prospective study of 383 paediatric burns treated non-operatively at a regional burns centre over a 2-year period from May 2011 to April 2013. Scar assessment was performed by a senior burns therapist using the Vancouver Scar Scale. Results: Overall rates of hypertrophic scarring were 17.2%. Time to healing was the strongest predictor of developing hypertrophic scarring, and the earliest hypertrophic scar developed in a patient who was healed after 8 days. The risk of hypertrophic scarring was multiplied by 1.138 for every additional day taken for the burn wound to heal. There was a trend towards higher rates of hypertrophic scarring in non-white skin types but this did not reach statistical significance. Conclusions: The risk of hypertrophic scarring increases with every day and, therefore, every effort should be made to get the wound healed as quickly as possible, even within the traditional 3-week period usually allowed for healing. We believe that the traditional dogma of aiming for healing within 3 weeks is overly simplistic and should be abandoned: in paediatric burns, every day counts.

Burns in the elderly:a nationwide study on management and clinical outcomes

Background:In modern-day burn care,advanced age remains an important predictor for mortality among burn victims.In this study,we compared the complete treatment trajectory(including prehospital and surgical treatment)and the outcomes between an elderly burn population and a younger adult burn population.Methods:In this nationwide study,data from the Dutch Burn Repository were used.This is a uniform national registration for Dutch specialized burn care.All adult patients that were admitted to one of the three Dutch burn centres from the period 2009 to 2015 were included in the analysis.Burn patients were considered as elderly when≥65 years of age,and were then further subdivided into three age categories:65–74,75–85 and 85+years.Younger adults in the age category 18–64 years were used as the reference group.Surgical managementwas studied comprehensively and included timing of surgery,the number of procedures and details on the surgical technique,especially the technique used for debridement and the grafting technique that was applied.For the comparison of clinical outcome,the following parameters were included:mortality,wound infections,length of stay/TBSA(total body surface area)burned,discharge disposition and secondary reconstructions.Results:During the study period,3155 adult patients were included(elderly,n=505).Burn severity,reflected by the median TBSA,varied between 3.2–4.0%and was comparable,but aetiology and pre-hospital care were different between elderly and the younger adult reference group.Surgical treatment was initiated significantly faster in elderly burn patients(p<0.001).Less selective techniques for surgical debridement were used in the elderly burns patients(hydrosurgery,42.0%vs 23.5–22.6%),and on the other hand more avulsion(5.3%vs 7.3–17.6%)and primary wound closure(6.7%vs 24.5%).The most frequently used grafting technique was meshed skin grafts(79.2–88.6%);this was not related to age.Mortality increased rapidly with a higher age and showed a high peak in the 85+category(23.8%).Furthermore,considerable differences were found in hospital discharge disposition between the elderly and the reference group.Conclusions:In conclusion,elderly burn patients who require specialized burn care are vulnerable and medically challenging.Differences in aetiology,comorbidity,physiology and the management prior to admission possibly affect the initial surgical management and result in significantly worse outcomes in elderly.Elderly patients need optimal,timely and specialized burn care to enhance survival after burn injuries.

Follow-up in patients with a burn-related emergency department visit:a feasibility study

Background:Data on epidemiology, costs, and outcomes of burn-related injuries presenting at emergency departments (EDs) are scarce. To obtain such information, a questionnaire study with an adequate response rate is imperative. There is evidence that optimized strategies can increase patient participation. However, it is unclear whether this applies to burn patients in an ED setting. The objective of this feasibility study was to optimize and evaluate patient recruitment strategy and follow-up methods in patients with burn injuries presenting at EDs. Methods:In a prospective cohort study with a 6-month follow-up, patients with burn-related injuries attending two large EDs during a 3-month study period were included. Eligible patients were quasi-randomly allocated to a standard or optimized recruitment strategy by week of the ED visit. The standard recruitment strategy consisted of an invitation letter to participate, an informed consent form, a questionnaire, and a franked return envelope. The optimized recruitment strategy was complemented by a stamped returned envelope, monetary incentive, sending a second copy of the questionnaire, and a reminder by telephone in non-responders. Response rates were calculated, and questionnaires were used to assess treatment, costs, and health-related quality of life. Results:A total of 87 patients were included of which 85 were eligible for the follow-up study. There was a higher response rate at 2 months in the optimized versus the standard recruitment strategy (43.6%vs. 20.0%;OR=3.1 (95%CI 1.1–8.8)), although overall response is low. Non-response analyses showed no significant differences in patient, burn injury or treatment characteristics between responders versus non-responders. Conclusions:This study demonstrated that response rates can be increased with an optimized, but more labor-intensive recruitment strategy, although further optimization of recruitment and follow-up is needed. It is feasible to assess epidemiology, treatment, and costs after burn-related ED contacts.

Topical antimicrobial agents for pediatric burns

While topical antimicrobial agents are indicated for most if not all burn wounds, the choice of a topical agent must consider many factors such as the wound depth, anticipated time to healing, need for surgical intervention, and the known cytotoxicity of the agent. Especially relevant to the pediatric burn patient are the antimicrobial agent's properties related to causing pain or irritation and the required frequency of application and dressings. This article will discuss the general principles surrounding the use of topical antimicrobials on burn wounds and will review the most common agents currently in use.

Are there any differences in the provided burn care between men and women? A retrospective study

Background:Disparity between medical treatment for men and women has been recorded worldwide. However, it is difficult to find out if the disparities in both the use of resources and outcome depend entirely on sex-related discrimination. Our aim was to investigate if there are differences in burn treatments between the sexes. Methods:All patients admitted with burns to Link?ping University Hospital during the 16-year period 2000–2015 were included. Interventions were prospectively recorded using the validated Burn SCoring system (BSC). Data were analysed using a multivariable panel regression model adjusted for age, percentage total body surface area (%TBSA), and in-hospital mortality. Results:A total of 1363 patients were included, who generated a total of 22,301 daily recordings while they were inpatients. Males were 70%(930/1363). Sex was not an independent factor for daily scores after adjustment for age,%TBSA, and mortality in hospital (model R2=0.60, p<0.001). Conclusion:We found no evidence of inequity between the sexes in treatments given in our burn centre when we had adjusted for size of burn, age, and mortality. BSC seems to be an appropriate model in which to evaluate sex-related differences in the delivery of treatments.

Ventilation practices in burn patients—an international prospective observational cohort study

Background:It is unknown whether lung-protective ventilation is applied in burn patients and whether they benefit from it.This study aimed to determine ventilation practices in burn intensive care units(ICUs)and investigate the association between lung-protective ventilation and the number of ventilator-free days and alive at day 28(VFD-28).Methods:This is an international prospective observational cohort study including adult burn patients requiring mechanical ventilation.Low tidal volume(V_(T))was defined as V_(T)≤8 mL/kg predicted body weight(PBW).Levels of positive end-expiratory pressure(PEEP)and maximum airway pressures were collected.The association between V_(T) and VFD-28 was analyzed using a competing risk model.Ventilation settings were presented for all patients,focusing on the first day of ventilation.We also compared ventilation settings between patients with and without inhalation trauma.Results:A total of 160 patients from 28 ICUs in 16 countries were included.Low V_(T) was used in 74%of patients,median V_(T) size was 7.3[interquartile range(IQR)6.2–8.3]mL/kg PBW and did not differ between patients with and without inhalation trauma(p=0.58).Median VFD-28 was 17(IQR 0–26),without a difference between ventilation with low or high V_(T)(p=0.98).All patients were ventilated with PEEP levels≥5 cmH_(2)O;80%of patients had maximum airway pressures<30 cmH_(2)O.Conclusion:In this international cohort study we found that lung-protective ventilation is used in the majority of burn patients,irrespective of the presence of inhalation trauma.Use of low V_(T) was not associated with a reduction in VFD-28.Trial registration:Clinicaltrials.gov NCT02312869.Date of registration:9 December 2014.

Severe Candida infections in critically ill patients with COVID-19

The frequency of co-infections with bacterial or fungal pathogens has constantly increased among critically ill patients with coronavirus disease 2019(COVID-19)during the pandemic.Candidemia was the most frequently reported invasive fungal co-infection.The onset of candidemia in COVID-19 patients was often delayed compared to non-COVID-19 patients.Additionally,Candida invasive infections in COVID-19 patients were more often linked to invasive procedures(e.g.,invasive mechanical ventilation or renal replacement therapy)during the intensive care stay and the severity of illness rather than more“classic”risk factors present in patients without COVID-19(e.g.,underlying diseases and prior hospitalization).Moreover,apart from the increased incidence of candidemia during the pandemic,a worrying rise in fluconazole-resistant strains was reported,including a rise in the multidrug-resistant Candida auris.Regarding outcomes,the development of invasive Candida co-infection had a negative impact,increasing morbidity and mortality compared to non-co-infected COVID-19 patients.In this narrative review,we present and critically discuss information on the diagnosis and management of invasive fungal infections caused by Candida spp.in critically ill COVID-19 patients.

Fibroadhesive scarring of grafted collagen scaffolds interferes with implant–host neural tissue integration and bridging in experimental spinal cord injury

Severe traumatic spinal cord injury(SCI)results in a devastating and permanent loss of function,and is currently an incurable condition.It is generally accepted that future intervention strategies will require combinational approaches,including bioengineered scaffolds,to support axon growth across tissue scarring and cystic cavitation.Previously,we demonstrated that implantation of a microporous type-I collagen scaffold into an experimental model of SCI was capable of supporting functional recovery in the absence of extensive implant–host neural tissue integration.Here,we demonstrate the reactive host cellular responses that may be detrimental to neural tissue integration after implantation of collagen scaffolds into unilateral resection injuries of the adult rat spinal cord.Immunohistochemistry demonstrated scattered fibroblast-like cell infiltration throughout the scaffolds as well as the presence of variable layers of densely packed cells,the fine processes of which extended along the graft–host interface.Few reactive astroglial or regenerating axonal profiles could be seen traversing this layer.Such encapsulation-type behaviour around bioengineered scaffolds impedes the integration of host neural tissues and reduces the intended bridging role of the implant.Characterization of the cellular and molecular mechanisms underpinning this behaviour will be pivotal in the future design of collagen-based bridging scaffolds intended for regenerative medicine.

The modified bilobed flap for reconstructing sacral decubitus ulcers

Background:Sacral pressure ulcers are associated with high morbidity and,in some cases,result in mortality from severe sepsis.Local flaps are frequently used for reconstruction of stage III and IV pressure ulcers.An ideal flap should be simple to design,have a reliable vascular supply and minimal donor site morbidity.Our study evaluates the use of a bilobed flap based on the superficial branch of the superior gluteal artery or the posterior branch of the fourth lumbar artery to reconstruct the sacral pressure ulcer.Case presentation:We performed a retrospective analysis of paraplegic patients with sacral pressure ulcers treated with our bilobed flaps from January 2015 to December 2019.A description of our management,operative protocol,outcome and complications is outlined.Seven paraplegic patients(6 male,1 female;average age 53.1 years)with sacral pressure ulcers were treated with our bilobed flap based on the superficial branch of the superior gluteal artery or the posterior branch of the fourth lumbar artery.The average size of the pressure ulcers was 7×5 cm(range 6.2×4.5 cm to 11×10 cm).All 7 flaps survived.The patients were followed up for 12 months without significant complications,such as flap necrosis or recurrence.Conclusions:The superficial branch of the superior gluteal artery or the posterior branch of the fourth lumbar artery reliably supplies the bilobed flap.The superior cluneal nerve can be included in the design.The technique is simple and reliable.It should be included in the reconstructive algorithm for the management of sacral pressure ulcers.