Case 22 2026: Superior Gluteal vessel: A rarely used recipient for free flap reconstruction of lumbosacral defects: a case report.

Tushar Dutta; Arun PS; Swati Sattavan

Journal of Plastic, Breast & Reconstructive Surgery·Peer-reviewed, open-access surgical case reportsPeer-reviewed · Open access

Case 22 2026: Superior Gluteal vessel: A rarely used recipient for free flap reconstruction of lumbosacral defects: a case report. · JPBRS

Case report

Case 22 2026: Superior Gluteal vessel: A rarely used recipient for free flap reconstruction of lumbosacral defects: a case report.

Tushar Dutta¹, Arun PS¹, Swati Sattavan¹

¹State Cancer Institute, Guwahati, Assam, India

Published May 28, 2026681 views6 min read

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Abstract

Lumbosacral defects that are too large for local flap reconstruction should be considered for microvascular free tissue transfer. However, lack of suitable recipient vessels in the area makes the task technically difficult. Options such as thoracodorsal and inferior gluteal vessels extended with vein grafts and AV loops have been described. Each option has its own drawbacks. Despite having a short course at its origin, the superior gluteal vessel is a viable alternative. We describe here a case where the vessel was dissected out with adequate length and used as a recipient for free flap reconstruction. Patient medical history The patient was a 41-year-old lady with no known comorbidities. She presented to us with a large lumbosacral mass that had been growing for one year. Before visiting our center, she had been operated twice at other institutions and had recurrences after each occasion. During the last three months the mass had started to grow rapidly and caused ulceration. There was no pain or fever. There was no neurological involvement of lower limbs. Patient had an ECOG status 1. Before and After Patient examination A 17x 22 cm mass was noted encompassing the left part of lumbosacral region and crossing the midline to the opposite side. The superior limit of the lesion was at the L3 vertebra and inferior extent was near the coccyx. Skin ulceration was noted at the center of the mass. On palpation, the mass was warm to touch, hard in consistency and immobile. Skin was fixed and fixity was also noted to the underlying muscle. No tenderness was elicited. Surrounding possible donor sites for flap harvest showed no scars. Pre-operative considerations Preoperative biopsy co

Key learning points

Pearls

A bespoke design (boomerang shaped) of the skin paddle of the latissimus dorsi flap may permit primary closure of the donor site. This would avoid the need for skin grafting.
The superficial branch of the superior gluteal artery may be approached by splitting the muscle instead of transecting it. By this technique, The Superior gluteal artery perforator may be traced back to its origin. This method however is tedious, and risks injury to the vessel.

Pitfalls

After emerging at the greater sciatic notch, the superior gluteal vessel has a short length before division into superficial and deep branches. Any injury at this point may cause it to retract causing torrential bleeding that is difficult to control.

The other superior gluteal artery should be preserved, and territories of the opposite latissimus dorsi flap should not be violated. In case the free flap fails, these can be kept as lifeboats. Delay procedures may be needed to ensure reach and flap survival.

Patient history

The patient was a 41-year-old lady with no known comorbidities. She presented to us with a large lumbosacral mass that had been growing for one year. Before visiting our center, she had been operated twice at other institutions and had recurrences after each occasion. During the last three months the mass had started to grow rapidly and caused ulceration. There was no pain or fever. There was no neurological involvement of lower limbs. Patient had an ECOG status 1.

Examination

A 17x 22 cm mass was noted encompassing the left part of lumbosacral region and crossing the midline to the opposite side. The superior limit of the lesion was at the L3 vertebra and inferior extent was near the coccyx. Skin ulceration was noted at the center of the mass.
On palpation, the mass was warm to touch, hard in consistency and immobile. Skin was fixed and fixity was also noted to the underlying muscle. No tenderness was elicited.
Surrounding possible donor sites for flap harvest showed no scars.

Pre-operative considerations

Preoperative biopsy confirmed it to be a case of spindle cell sarcoma. MRI imaging showed its extension to the depth of the underlying muscles with abutment to the sacrum. Considering the multiple recurrences the patient had suffered earlier, it was decided to radically excise the tumour with wide, liberal margins. As the anticipated defect would well encroach into the opposite gluteal region, local flaps options for reconstruction were very limited. Other options such as lumbar artery perforator flaps and reverse latissimus dorsi flap were also considered, but the size and extent of the defect precluded their selection. A decision for free tissue transfer using the free latissimus dorsi flap was taken (as it could be harvested with minimal position change), with the right superior gluteal vessels as recipient. The other alternative recipient vessels such as thoracodorsal vessels and inferior gluteal vessels with vein grafts and AV loops were deemed too complex with high possibility of thrombosis.

Step 1 — Wide local excision of the lumbosacral mass

With nearly three centimeters of margin, wide local excision of the lumbosacral mass was done with a cuff of underlying muscles. Part of the sacrum was also shaved. Frozen section biopsy was done to confirm negative margins

References

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Hung SJ, Chen HC, Wei FC. Free flaps for reconstruction of the lower back and sacral area. Microsurgery: Official Journal of the International Microsurgical Society and the European Federation of Societies for Microsurgery. 2000;20(2):72-6.
Matschke J, Armbruster R, Reeps C, Weitz J, Dragu A. AV loop free flap: an interdisciplinary approach for perineal and sacral defect reconstruction after radical oncological exenteration and radiation in a colorectal cancer patient. World Journal of Surgical Oncology. 2019 Sep 2;17(1):154.
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