Introduction: Many different locoregional flap configurations have been described for posterior trunk reconstruction, especially for spinal wounds and pressure sores. Reconstruction of oncologic resection defects, however, can be complicated by their wide variety of locations, large size, use of perioperative radiotherapy, limited remaining local tissue, and exposure of bone, neurovascular structures, and/or hardware. The purposes of our study were to precisely define anatomic zones of the posterior trunk (based on vascular supply, tissue characteristics, and adjacent structures) that can be used to facilitate selection of locoregional flap configurations for oncologic reconstruction and to develop a flap-selection algorithm for each subunit and retrospectively compare it to surgeons’ clinical flap choices.

Methods: The medical records of 65 consecutive patients who underwent posterior trunk reconstruction following cancer resection over a 2-year period (2001-2003) at The University of Texas M. D. Anderson Cancer Center were retrospectively reviewed. Patient, defect, and reconstructive characteristics and surgical outcomes were analyzed. The posterior trunk was divided into 5 separate subunits based on vascular and anatomic considerations, and the arc of rotation of adjacent locoregional flaps. An algorithm for flap selection was proposed for each subunit that took into consideration the defect characteristics and donor tissue condition and availability. Surgeons' flap choices in the study population were compared to those suggested by the anatomic subunit algorithm, and complications were examined.

Results: Reconstruction involved locoregional flaps in 62 patients (performed by 9 different plastic surgeons) and free tissue transfer in 3 patients. The incidence of perioperative radiotherapy use and bone exposure was 94% and 48%, respectively. Locoregional flap reconstruction was performed with 10 different flaps, with 14% of patients requiring at least 2 flaps. For each of the 5 subunits, an algorithm was constructed for flap selection contingent on the specific defect and local tissue characteristics. This strategy for flap selection was highly predictive of the flap type actually used in the study population, despite the large number of different types of flaps used. Complications were higher when the flap used differed from the algorithm-suggested choice.

Conclusions: The anatomic subunit-based algorithm for flap selection correlated well with the surgeons’ clinical judgment in the majority of cases. A subunit-based algorithm may be a helpful adjunct to the surgeon's judgment in flap selection for posterior trunk reconstruction following oncologic resection to optimize outcome.