Free Flap Reconstruction of the Lower Back and Posterior Pelvis: Indications, Principles, and Techniques

Abstract

Reconstructive microsurgery can be successfully applied to major defects of the lower back and posterior pelvis. When present, the superior and inferior gluteal vessels can be excellent free flap recipient vessels. However, if they are absent as a result of trauma or tumor ablation, a wrist carrier can be used to transfer large blocks of tissue in a staged procedure. Five patients are presented with challenging defects for which these techniques were used.

Reconstruction of Lumbar Spinal Defects: Case Series, Literature Review, and Treatment Algorithm

“…The average level of evidence was 4.29, with 4 level 3 studies, 32 level 4 studies, and 20 level 5 studies. Multiple options for reconstruction were described including free style perforator flap, 3–9 lumbar artery perforator (LAP) flap, 6,8,10–12 paraspinous muscle flap, 2,13–17 SGAP, 10,14,18–22 inferior gluteal artery perforator, 19 intercostal artery perforator flap, 8,10,11,20,23,24 gluteus maximus musculocutaneous flap, 1,2,13,25–29 reverse latissimus dorsi flap, 2,7,13,27,30–35 lateral intercostal artery perforator–based latissimus dorsi flap, 36 external oblique musculocutaneous pedicled flap, 37 pedicled omental flap, 38–40 free flap, 7,13,14,41–55 and total leg flap. 56 The most frequently described method of lumbar wound reconstruction was free flap with 18 articles, followed by reverse latissimus dorsi flap reconstruction with 10 articles (Fig.…”

Free latissimus dorsi musculocutaneous flap for external hemipelvectomy reconstruction

“…The intraabdominal vessels are not suitable for anastomosis in lower abdomen because the location is deep and moved intraoperatively and postoperatively (Yamamoto et al, ). Previous studies have reported the use of the superior or inferior gluteal vessels or the radial vessels (Harris, Lewis, Nagle, Edelson, & Kim, ; O'Brien, Barton, & Pribaz, ). In the current study, the gluteal vessels were not available because of proximal ligation; thus, we used the contralateral deep inferior epigastric vessels as recipient vessels in all patients.…”

Reconstruction of Radiated Gluteal Defects following Sarcoma Resection with Pedicled Sensate Tensor Fascia Lata Flaps

“…In this population, large resection and prior radiation therapy often prohibit the use of local flap options. Although in these cases microsurgical reconstruction may be considered, these two factors also often render the gluteal vessels (the only recipient vessels in proximity) unsuitable for free tissue transfer, thereby necessitating a significantly more complicated procedure involving vein grafts and position changes during surgery [ 2 , 3 ]. The anterolateral thigh (ALT) flap represents a pedicled option for reconstruction of gluteal defects; however, this is often limited to lateral defects since it is located further from the buttocks than the TFL flap [ 8 , 9 ].…”

“…Previously described techniques involving local flaps are limited and can be particularly restricted in cancer patients such as sarcoma patients, where preoperative or intraoperative radiation therapy may compromise adjacent tissues [ 1 ]. Free flap reconstruction is an alternative but can be complicated by limited recipient vessels and demanding postoperative care [ 2 , 3 ].…”