Reconstruction of large sacral defects following total sacrectomy

Total sacrectomies for cancer ablation often result in extensive defects th at are challenging to reconstruct. In an effort to elucidate the criteria t o select the most effective reconstructive options, we reviewed our experie nce with the management of large sacral wound defects. All patients who had a sacral defect reconstruction after a total sacrectom y at our institution between January of 1993 and August of 1998 were review ed. The size of the defect, the type of reconstruction, postoperative compl ications, and functional outcome in each patient were assessed. A total of 27 flaps were performed in 25 patients for sacral defect reconst ruction after a total sacrectomy. Diagnoses consisted of chordoma (n = 13), giant cell carcinoma (n = 2), sarcoma (n = 5), rectal adenocarcinoma (n = 4), and radiation induced necrosis (n = 1). The size of sacral defects rang ed from 18 to 450 cm(2) (mean, 189.8 cm?). Ten patients, including five who had preoperative radiation therapy, underwent transpelvic vertical rectus abdominis myocutaneous (VRAM) flap reconstruction for sacral defects with a mean size of 203.3 cm(2). Of these, five patients (50 percent) had complic ations (four minor wound dehiscences and one seroma). Eight patients, inclu ding one who had preoperative radiation therapy, underwent bilateral glutea l advancement flap reconstruction for sacral defects with a mean size of 19 8.0 cm(2). They had no complications, Two patients, both of whom had preope rative radiation therapy, underwent gluteal rotation flap reconstruction fo r sacral defects of 120 cm(2) and 144 cm(2). Both patients had complication s (one partial flap loss and one nonhealing wound requiring a free flap). T hree patients, including one who had preoperative radiation therapy, underw ent reconstruction with combined gluteal and posterior thigh flaps for sacr al defects with a mean size of 246 cm(2); two of these patients had partial necrosis of the posterior thigh flaps. Three patients, all of whom had pre operative radiation therapy, underwent free flap reconstruction for sacral defects with a mean size of 144.3 cm(2). They lad no complications. Our experience suggests that there are three reliable options for the recon struction of large sacral wound defects: bilateral gluteal advancement flap s, transpelvic rectus myocutaneous flaps, and free flaps. In patients with no preoperative radiation therapy and intact gluteal vessels, the use of bi lateral gluteal advancement flaps should be considered. In patients with a history of radiation to the sacral area and in patients whose gluteal vesse ls have been damaged, the use of the transpelvic VRAM flap should be consid ered. If the transpelvic VRAM flap cannot be used because of previous abdom inal surgery, a free flap should be considered as a last option.