Objective To modify the operative techniques for satisfactory results for pressure ulcer reconstruction with freestyle perforator-based flaps.Methods Between May 2008 and March 2012, 16 patients with severely pressure ulcers were enrolled and treated.There were 6 males and 10 females, aged from 20 to 87 years, with disease duration from 3.5 months to 6 years, including two cases of recurrence ulcer.The size of wound defect ranged from 4 cm × 4 cm to 14 cm× 8 cm.All of them were diagnosed as degree Ⅳ or suspected deep tissue injury according to the staged standard of the National Pressure Ulcer Advisory Panel (NPUAP, 2007).The debridement including removal of slough, excision of necrosis, and smoothing plane of bone hump, was planned as early as possible when the patients could endured the operation.Moreover, the vacuum sealing drainage (VSD) technique was applied in cases with suspected necrosis tissue difficult to eliminate completely.In the second stage, the fresh granulation of the wounds was removed, island perforator flaps which pedicle contained skin sensory nerve were designed with the aid of a handheld Doppler device, and performed according to a modified procedure using microscopic technique, and then,transplanted to repair the defect.The donor sites sutured directly.Results Average surgical time was 30 minutes at the first stage and 1.5 to 2 hours at the second stage,respectively.The incisions of donor sites healed primarily.Fifteen of 17 perforator flaps healed uneventfully without complication.One case had partial necrosis in the distal end of the flap 3 days after operation, and the wound cured by measures of bedside debridement and dressing change within 6 weeks.One patient died of the complication of radiotherapy 5 weeks postoperatively, with wound dehiscence, osThe median length of hospital was 37 days (stays range, from 22 to 58 days).During a follow-up of 1 to 34 months, most of the flaps had good texture, color, and elasticity, furthermore, no recurrence of ulcer was observed.Conclusions Two-stage management for pressure ulcers with modified techniques and good postoperative care,including early debridement and freestyle perforator-based fasciocutaneous flap transplantation, could achieve simple preoperative preparation, short course of treatment, lower recurrence rates and satisfactory results.