Following partial or total sacrectomy, extensive soft tissue defects are frequently created by the oncologic ablation. These ablations typically involve an anterior as well as a posterior approach creating a large communication between the abdominal cavity and the central gluteal region. While several flap options exist for reconstruction of the sacral area, local flaps are usually not sufficient for definitive closure of these large defects. In addition, with division of the hypogastric and gluteal vessels during resection, the blood supply to local flaps is usually sacrificed. We have found that the most useful option for reconstruction in these cases is a vertical rectus abdominis myocutaneous (VRAM) flap, passed transabdominally through the peritoneal cavity into the sacral defect during the initial anterior-approach portion of the procedure. The flap is then inset following completion of the posterior-approach final resection. Advantages of the VRAM flap are that it can supply ample skin as well and soft tissue bulk, is easy to perform, and does not require microvascular techniques.
Utilizing a prospectively maintained database, all patients over the last 14 years who underwent reconstruction utilizing a transabdominal vertical rectus abdominis myocutaneous (VRAM) flap following extensive partial or total sacrectomy with intra-abdominal communication were identified. A retrospective chart review was then performed.
Our study population consisted of 12 patients, 8 males and 4 females with a mean age of 58.5 years (range 21-85). Following a partial or total sacrectomy, all patients underwent reconstruction with a VRAM flap, while one patient underwent bilateral gluteal advancement flaps in addition to a VRAM to reconstruct an increased extent of dead space. Flap sizes averaged 9.1 x 27 cm (range 7-15 cm x 18-40 cm). Seven patients were reconstructed immediately following the extirpative procedure, and five patients had the flap created, raised and left in the peritoneal cavity after the initial anterior approach was performed until 24-48 hours later when the definitive posterior approach was completed and the flap was finally inset for closure.
Early flap complications included three small (less than 3 cm) areas of flap necrosis at the distal, superior portion of the flap, two of which required minimal operative intervention of debridement and re-closure. One healed secondarily treated with bedside debridement and dressing changes. One patient suffered a recurrence of their tumor in the right buttock region, and underwent re-excision of this mass with intraoperative as well as postoperative radiation therapy. No late flap complications have occurred, and all 12 patients completely healed with a mean follow-up time of 20 months (range 2-72 months).
Following partial or total sacrectomy, extensive soft tissue defects are created in the sacral/peroneal area and communicate with the abdominal cavity. In these situations, we have found the inferiorly-based pedicled VRAM, passed transabdominally, to be the most reliable and useful choice of flap reconstruction. It has a low incidence of complications, low morbidity, and is easy to perform with a high success rate. A detailed description of our operative technique as well as a more extensive review of our patient experience in utilizing this flap will be presented.