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

Isha Joshi; Zachary Erlichman; Nia Nikkhahmanesh; Christina Chopra; Jason Ganz

Journal of Plastic, Breast & Reconstructive Surgery·Fagfællebedømte kirurgiske case-rapporter med åben adgangFagfællebedømt · Open access

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

Case-rapport

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

Isha Joshi¹, Zachary Erlichman¹, Nia Nikkhahmanesh¹, Christina Chopra¹, Jason Ganz¹

¹Stony Brook University Hospital, Stony Brook, New York

Publiceret 28. maj 2026309 visninger7 min læsning

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Resumé

Background: Tissue from non-salvageable limbs may be used in reconstruction of complex defects and represent the principle of the “spare- parts” concept.[1] Fillet flaps advantages include soft tissue coverage of large defects, biocompatibility of an autologous donor, and donor tissue resembling native tissue due to proximity. Case: Fewer than 100 hemicorporectomies have been published in the literature.[2] We present the case of a 53-year-old male who underwent hemicorporectomy for recurrent gluteal sarcoma followed by reconstruction using a near-total thigh fillet flap. Conclusions: Fillet flaps provide soft-tissue coverage of large defects, biocompatible autologous tissue, and donor tissue resembling native anatomy. Patient medical history Primary Diagnosis: In 2015, the patient was diagnosed with a 15-cm high-grade (grade 3) spindle cell carcinoma thought to represent a fibrosarcoma with transformation to dermatofibrosarcoma protuberans, located superior to the buttock. The tumor was resected at an outside hospital (OSH) without perioperative complications. First Recurrence: In 2016, the patient presented to the OSH with recurrent mass in the tumor bed measuring 12.2 cm with erosion of lower coccyx, extension into posterior pelvis, and deviation of the anus. He underwent neoadjuvant radiation and systemic therapy. In 2017, he underwent tumor debulking and permanent diverting colostomy placement. After relocating to New York, he established care at our institution and subsequently underwent conversion of a loop colostomy to an end stoma with mucous fistula in 2020. Secondary Recurrence: In 2022, imaging demonstrated a recurrent tumor above the buttock. The pat

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Pearls

Pre-operative Planning: Hemicorporectomy reconstruction requires extensive multidisciplinary coordination.
Careful operative sequencing is necessary to minimize blood loss and maintain hemodynamic stability.
Flap Design: The thigh fillet flap functions as an axial-pattern flap capable of providing extensive soft-tissue coverage without creating additional donor-site morbidity.
Postoperative Support: Patients require extensive psychological evaluation and counseling regarding:
perioperative mortality risk
lifelong functional limitations
need for prolonged postoperative care and rehabilitation.

Pitfalls

Early Venous Congestion
Fillet flaps are susceptible to venous congestion, which may require early intervention such as medicinal leech therapy.
Pressure Offloading
Failure to offload pressure on the flap may lead to wound dehiscence and flap necrosis. This risk is increased in patients with:
prior radiation therapy
chronic pressure injuries
prolonged immobility.
Use of air-fluidized beds and strict repositioning protocols is essential.

Patient history

Primary Diagnosis: In 2015, the patient was diagnosed with a 15-cm high-grade (grade 3) spindle cell carcinoma thought to represent a fibrosarcoma with transformation to dermatofibrosarcoma protuberans, located superior to the buttock. The tumor was resected at an outside hospital (OSH) without perioperative complications. First Recurrence: In 2016, the patient presented to the OSH with recurrent mass in the tumor bed measuring 12.2 cm with erosion of lower coccyx, extension into posterior pelvis, and deviation of the anus. He underwent neoadjuvant radiation and systemic therapy. In 2017, he underwent tumor debulking and permanent diverting colostomy placement. After relocating to New York, he established care at our institution and subsequently underwent conversion of a loop colostomy to an end stoma with mucous fistula in 2020. Secondary Recurrence: In 2022, imaging demonstrated a recurrent tumor above the buttock. The patient underwent extensive oncologic resection including: abdominoperineal resection, sciatic nerve excision, and ischium excision by surgical oncology and orthopedic surgery. Plastic surgery reconstruction included a pedicled right vertical rectus abdominis muscle flap and a right vastus lateralis muscle flap. Following surgery, the patient's functional status progressively declined from ambulating with a cane to becoming bedbound. Between 2022 and 2024, he developed chronic urinary retention requiring indwelling foley catheter and progressive back pain requiring cordotomy and midline myelotomy Tertiary recurrence: In 2025, imaging demonstrated a large recurrent mass measuring 18 × 16 cm. After multidisciplinary evaluation, the patient elected to proceed with curative resection via hemicorporectomy. Plastic surgery was consulted for definitive soft-tissue reconstruction.

Examination

At presentation, the patient was bedbound with severe functional limitations following prior surgeries and radiation therapy. Examination demonstrated a large recurrent gluteal mass involving previously reconstructed tissue. There existed significant radiation-associated fibrosis and chronic pressure injuries over the trochanteric and ischial regions. The patient was noted to have limited mobility with dependence on wheelchair and bed positioning. Given the extent of disease and compromised surrounding tissue, reconstruction using local or regional flaps alone was not feasible. A fillet flap using tissue from the non-salvageable lower extremity was therefore planned.

Pre-operative considerations

Multidisciplinary Planning. This operation required coordination among:
Surgical oncology
General Surgery
Orthopedic Surgery
Neuro- spine surgery
Plastic surgery
Anesthesia
Surgical ICU teams

Intraoperative Planning
Operative Timing.
The procedure was scheduled for 36 hours with an anticipated time of 20-30 hours. (Total operative time yielded 20 hours.)
Prone to Supine Positioning.
Typically, ligation of the inferior vena cava leads to engorgement of Batson’s plexus, which can significantly increase bleeding during spinal division. To minimize blood loss and neurogenic hypotension, the vertebral structures and spinal cord were transected early prior to major venous congestion.
Consideration of Prior Pressure Ulcers.
The patient had trochanteric and ischial pressure injuries, which limited the usable skin envelope of the thigh. Flap design therefore preserved viable skin while excluding compromised tissue.

Referencer

cher MV, Erdmann D, Homann HH, Steinau HU, Levin SL, Germann G. The concept of fillet flaps: classification, indications, and analysis of their clinical value. Plast Reconstr Surg. 2001;108(4):885-896. doi:10.1097/00006534-200109150-00011
Greendyk JD, Haider SF, Allen WE, Prasath V, Chokshi RJ. Redefining the Role of Hemicorporectomy in the Modern Era and Shifting Trends Toward Non-Malignant Indications. Am Surg. 2025;91(9):1526-1533. doi:10.1177/00031348251346533