Fleur-de-Lys Myocutaneous Flap for Complex Sacral Reconstruction

Abstract

INTRODUCTION: Massive sacral defect resulting from total sacrectomy presents a reconstructive challenge,1 and in some cases, the use of vertical or transverse Rectus Abdominis Muscle (RAM) flap may not provide enough soft tissue to reconstruct it. The use of Fleur-de-lys flap technique has been described in cases of autologous breast reconstruction and for thoracic wound defects.2,3 The aim of this study is to describe the surgical technique of the combination of Transversal Rectus Abdominis Muscle (TRAM) flap with the Vertical Rectus Abdominis Muscle (VRAM) flap, which assumes the form of a “Fleur-de-lys”, and to identify the population of patients reconstructed by this technique followed sacral resection. METHODS: A retrospective chart review was conducted on patients undergoing oncologic sacral resections followed by Fleur-de-lys myocutaneous flap for soft tissue reconstruction between December 2008 and December 2019. Demographics, clinical and surgical characteristics, postoperative outcomes, and complications were reviewed. RESULTS: Two patients underwent Fleur-de-lys myocutaneous flap to sacral reconstruction. A 44-year-old male and a 31-year-old female, both patients presented with a locally advanced sacropelvic chordoma requiring en bloc total sacrectomy and rectal resection. The mean tumor size was 2,139 cm3, and the soft tissue defect 13920 cm3. Patients underwent pelvic instrumentation with hardware and fibular grafts (1 patient bilateral free fibula flap; the other allograft fibular bone) for spine and pelvic reconstruction followed by pedicled Fleur-de-lys flap. The posterior abdominal wall was reconstructed in 1 patient with Alloderm to avoid bowel herniation. One patient developed a minor abdominal wound dehiscence, managed with dressing change, and wound vac. The other patient presented wound infection and minor dehiscence in the abdominal and sacral requiring surgical debridement with successful healing. The mean hospital stay was 74 days (63–85), and the follow-up was 13 months (7–19). One patient expired after 19 months of the initial surgery. CONCLUSION: The Fleur-de-lys myocutaneous flap obliterates massive soft tissue defects resulted from total sacral resections and avoids the need of other flaps with low morbidity associated. REFERENCES: 1. Kreutz-Rodrigues L, Banuelos J, Saleem HY, et al. The use of vertical rectus abdominis myocutaneous flap for pelvic reconstruction: what are the risk factors for complications? Plast Reconstr Surg Glob Open. 2019;7(8 Suppl):75–75. 2. Marshall DR, Ross DA. A Fleur de Lys modification of the TRAM flap for breast reconstruction. Br J Plast Surg. 1994;47:521–526. 3. Anthony JP, Foster RD. The reconstruction of complex thoracic wounds: a fleur-de-lys modification of the rectus abdominis myocutaneous flap. Plast Reconstr Surg. 2001;107:1229–1233.