Introduction: Soft tissue and skeletal reconstruction of lumbosacral wounds after tumor extirpation is a difficult problem. These defects are frequently large, irradiated and have failed conservative management. They also frequently require fixation devices and hardware. Local flap options may not be available, or of sufficient size, requiring the reconstructive surgeon to consider free tissue transfer.

Methods: We reviewed our patient database over a 12-year period. 9 patients were identified with complex mid-back wounds treated with free flap coverage.

Results: 7 different types of neoplasms were resected and 6 (67%) had been irradiated. 7 (78%) patients required saphenous vein arteriovenous fistulas and 2 (22%) received vascularization from local vessels. 4 of the 7 (57%) vein loops were staged 48 hours prior to flap transfer. There were 6 latissimus dorsi muscle flaps, 1 latissimus dorsi musculocutaneous flap, 1 rectus abdominus muscle flap and 1 rectus abdominus musculocutaneous flap used for reconstruction. 6 of the 9(67%) remained viable and healed without incident. 3 (33%) failed and required revision. 2 of the 3 failed flaps were in irradiated tissue beds and 1 had been transferred with a nonstaged vein loop.

Conclusion: Free tissue transfer for complex back wounds is a reasonable reconstructive option when locoregional techniques have been exhausted. It is our practice to perform a staged saphenous vein arteriovenous fistula 48 hours prior to tissue transfer. We feel this provides reliable inflow and drainage for subsequent free tissue transfer. Preferably, one would go directly to the iliac vessels in an end-to-side fashion. This was only possible in the minority of cases.