title: Soft-tissue reconstruction after total en bloc sacrectomy.
abstract: OBJECT Total en bloc sacrectomy is a dramatic procedure that results in extensive sacral defects. The authors present a series of patients who underwent flap reconstruction after total sacrectomy, report clinical outcomes, and provide a treatment algorithm to guide surgical care of this unique patient population. METHODS After institutional review board approval, data were collected for all patients who underwent total sacrectomy between 2002 and 2012 at The Johns Hopkins Hospital. Variables included demographic data, medical history, tumor characteristics, surgical details, postoperative complications, and clinical outcomes. All subtotal sacrectomies were excluded. RESULTS Between 2002 and 2012, 9 patients underwent total sacrectomy with flap reconstruction. Diagnoses included chordoma (n = 5), osteoblastoma (n = 1), sarcoma (n = 2), and metastatic colon cancer (n = 1). Six patients received gluteus maximus (GM) flaps with a prosthetic rectal sling following a single-stage, posterior sacrectomy. Four required additional paraspinous muscle (PSM) or pedicled latissimus dorsi (LD) fasciocutaneous flaps. Three patients underwent multistage sacrectomy with an anterior-posterior approach, 2 of whom received pedicled vertical rectus abdominis myocutaneous (VRAM) flaps, and 1 of whom received local GM, LD, and PSM flaps. Flap complications included dehiscence (n = 4) and infection (n = 1). During the 1st year of follow-up, 2 of 9 patients (22%) were able to ambulate with an assistive device by the 1st postoperative month, and 6 of 9 (67%) were ambulatory with a walker by the 3rd postoperative month. By postoperative Month 12, 5 of 9 patients (56%)-or 5 of 5 patients not lost to follow-up (100%)-were able to able to ambulate independently. CONCLUSIONS The authors' experience suggests that the GM and pedicled VRAM flaps are reliable options for softtissue reconstruction of total sacrectomy defects. For posterior-only operations, GM flaps with or without a prosthetic rectal sling are generally used. For multistage operations including a laparotomy, the authors consider the pedicled VRAM flap to be the gold standard for simultaneous reconstruction of the pelvic diaphragm and obliteration of dead space.
authors: Departments of 1Plastic and Reconstructive Surgery and.|2Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland.
authors: Jennifer E
authors: JE
authors: Kim
authors: Departments of 1Plastic and Reconstructive Surgery and.
authors: John
authors: J
authors: Pang
authors: Departments of 1Plastic and Reconstructive Surgery and.
authors: Joani M
authors: JM
authors: Christensen
authors: Departments of 1Plastic and Reconstructive Surgery and.
authors: Devin
authors: D
authors: Coon
authors: 2Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland.
authors: Patricia L
authors: PL
authors: Zadnik
authors: 2Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland.
authors: Jean-Paul
authors: JP
authors: Wolinsky
authors: 2Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland.
authors: Ziya L
authors: ZL
authors: Gokaslan
authors: 2Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland.
authors: Ali
authors: A
authors: Bydon
authors: 2Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland.
authors: Daniel M
authors: DM
authors: Sciubba
authors: 2Neurosurgery, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland.
authors: Timothy
authors: T
authors: Witham
authors: Departments of 1Plastic and Reconstructive Surgery and.
authors: Richard J
authors: RJ
authors: Redett
authors: Departments of 1Plastic and Reconstructive Surgery and.
authors: Justin M
authors: JM
authors: Sacks
mesh_terms: D000328:Adult; D000368:Aged; D002817:Chordoma / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000379:methods; D011183:Postoperative Complications; D019651:Plastic Surgery Procedures / Q000379:methods; D012189:Retrospective Studies; D012447:Sacrum / Q000601:surgery*; D013125:Spinal Neoplasms / Q000601:surgery*; D013524:Surgical Flaps / Q000601:surgery*; D016896:Treatment Outcome
keywords: AP = anterior-posterior; BMI = body mass index; DM = diabetes mellitus; EBL = estimated blood loss; GM = gluteus maximus; LD = latissimus dorsi; LOS = length of hospital stay; PSM = paraspinous muscle; RT = radiation therapy; VAC = vacuum-assisted closure; VRAM; VRAM = vertical rectus abdominis myocutaneous; plastic surgery; sacral tumor; sacrectomy; soft tissue defect; spine surgery