Case 13 2026: Fillet Flap Reconstruction Following Hemicorporectomy for Recurrent High-Grade Gluteal Sarcoma

The flap was designed as a near-total fillet of thigh flap. The patient had a trochanteric and ischial pressure injury on his left leg posteriorly, which limited the use of the entire skin envelope, though the majority of the envelope was included with the flap. The longitudinal markings were made at the interval between the adductor magnus and biceps femoris while the lateral incision was made between the vastus lateralis and hamstrings.

A posterior to anterior approach was implemented with spinal surgery after marking the patient at the beginning of the case. Typically, after ligation of the inferior vena cava, Batson’s plexus becomes engorged, leading to a more challenging dissection and marked blood loss during division of the vertebral structures and spinal cord. Having experienced this problem in prior cases, a back-to-front approach was utilized with early division of the vertebral structures and spinal cord, pre-empting engorgement of Batson’s plexus, thus minimizing blood loss and neurogenic hypotension.

An incision was made just superior to the patella. After division of the quadriceps tendon, dissection proceeded distally to the femur. Medial dissection followed the interval between the adductor magnus and biceps femoris until the medial and lateral incisions were connected. The femoral artery entering the popliteal fossa was identified and controlled. The popliteal vessels were suture-ligated prior to transection.

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With the vascular pedicle identified, the flap was elevated while incorporating the adductor musculature for additional coverage. The muscle was dissected off the femur from all directions as the flap was elevated in the distal to proximal direction. Care was taken to maintain the integrity of the quadriceps muscles as well as the gracilis, sartorius, adductor longus and their vascular pedicles. The flap was then elevated up to the level of the iliac crest.

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Orthopedic surgery completed the pelvic disarticulation. A midline abdominal incision was performed, and the common iliac vessels were transected using a vascular stapler. The tumor was dissected from the external iliac vessels, and the internal iliac artery was divided.

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The remaining posterior structures including psoas muscle, paraspinal muscles, and posterior soft tissue were divided, completing the hemicorporectomy specimen.

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Early venous congestion of the flap was noted.

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Leech therapy was used for approximately 5 days postoperatively when the flap was noted to be hyperemic and slightly tense. The team used a low threshold in deciding to initiate leech therapy given the significant change in habitus and somewhat unavoidable pressure to the flap. Gradual improvement of the hyperemia was noted over the course of the 5 days of leech therapy, with leeches aborted 24 hours after skin stability was noted.

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Patient underwent minor serial debridements intraoperatively to heal superficial dehiscences at the flap edges. Debridements were managed with wound vacs until good wound edge approximation was observed, at which point dressings were changed to mepilex. During this time the patient was downgraded from the Surgical ICU to the step down unit, transitioned to a pressure-offloading air mattress, and initiated physical therapy with a bedside trapeze to improve independence and activities of daily living.

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The patient was medically optimized by the multidisciplinary team over the subsequent month and was discharged home with home health care at approximately 2 months postoperatively. At this point the patient was functional with most activities of daily living, including using a wheelchair. He was subsequently followed in the plastic surgery clinic on an outpatient basis with continued wound care to his fillet flap and no major sequelae to date.

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