Simple to Extreme: Following the Reconstructive Ladder for Complex Posterior Trunk Reconstruction

Summary: Reconstruction of the posterior trunk and torso defects presents unique challenges to the reconstructive surgeon, particularly in the setting of oncologic resection and adjuvant multimodality therapy such as chemotherapy and radiation. The operation can be more complicated in the setting of hardware exposure. Although local flaps represent the primary workhorse option, reconstruction using a microvascular free tissue transfer should be considered when local flap options have been exhausted. Here, we present a unique case reconstructing a complex, radiated back wound with exposed hardware that failed prior bilateral paraspinous, latissimus dorsi, and trapezius muscle flaps. A unilateral free TRAM flap was used and revascularized through an arteriovenous loop to provide stable coverage of the 15 × 25 cm defect. The patient also had preexisting upper extremity ischemia, which limited flap perfusion and positioning options. The usage of arteriovenous loops and free musculocutaneous flaps can provide another potential adequate option for the treatment of these complex defects.