Most wounds in the buttock or gluteal area can be managed with direct closure, skin grafts, or local flaps. However, when there are extensive or multiple wounds, local tissue may be insufficient, making conventional techniques impractical. The tissue in this region is relatively thick, strongly adherent to underlying layers, and notably inelastic [1]. Patients with such lesions often have a long surgical history involving multiple attempts at primary closure or local and regional flaps, which frequently fail to achieve the desired outcomes [2]. In these cases, free flap reconstruction may be the only option to ensure durable coverage. This technique allows for tension-free closure of the defect and provides well-vascularized tissue with excellent outcomes. However, due to the scarcity of suitable recipient vessels and the challenges of postoperative care, free flap reconstruction in the buttock remains a significant challenge, even for experienced reconstructive surgeons [3]. Here, we present an interesting case of free flap buttock reconstruction performed under circumstances where no suitable recipient pedicle was available.

A 39-year-old woman was referred from an outside hospital with extensive necrosis in both buttock areas. She had experienced postpartum hemorrhage due to placenta previa, leading to an emergency uterine embolization after delivery. Initially, she was advised to undergo an emergency hysterectomy, but she refused the procedure. Her hemoglobin level dropped to 4.9 g/dL, and her international normalized ratio was below 3. The day after embolization, she underwent a cesarean hysterectomy due to failure to control the bleeding. As a complication of embolization, she developed extensive necrosis of the gluteus muscle and buttock skin, caused by occlusion of the superior and inferior gluteal arteries. At the outside hospital, she had undergone free latissimus dorsi myocutaneous flap reconstruction by a plastic surgeon and colostomy by a general surgeon. However, the flap experienced total necrosis due to arterial insufficiency, and the patient was referred to our hospital for further reconstructive management (Fig. 1). Local tissues were insufficient to provide adequate wound coverage. The proposed treatment involved wide debridement of the defect, followed by reconstruction using another free flap. Our secondary surgery was performed 2 months after the initial postpartum hemorrhage. A two-team approach was utilized: one team elevated a latissimus dorsi muscle flap, while the other prepared the recipient site (Fig. 2). A muscle-splitting approach was used to expose the superior gluteal vessels for anastomosis with the thoracodorsal flap vessels. However, due to extensive surrounding tissue necrosis, the initial pedicle exploration was unsuccessful, and no suitable superior or inferior gluteal vessels were identified. We opted to use the left descending branch of the lateral circumflex femoral artery (LCFA) as the recipient vessel to perfuse the flap. The LCFA vessel was tunneled subcutaneously to the gluteal wound (Fig. 3). After raising the muscle with a 30×11-cm skin island, the flap was detached from its donor vessels (Fig. 4). Arterial and venous anastomoses to the flap were successfully performed, and the flap was inset to fit the skin and soft-tissue defect (Fig. 5). The flap survived, and primary healing was achieved (Fig. 6). However, 3 months later, the patient developed a fistulous tract. This complication presented as a draining sinus at the upper margin of the free flap, with continuous pus drainage and Escherichia coli colonization in the remaining necrotic debris (Fig. 7). The patient was treated with systemic broad-spectrum antibiotics, and repetitive debridement of the dead space was performed, but the wound failed to resolve spontaneously. To address the dead space, we attempted local flap rotation coverage from the initial flap area. However, this approach also failed, as the infection persisted and purulent discharge continued from the fistulous tract. Ultimately, we decided to perform an omental flap harvest as a last resort. A combined procedure was planned, involving a general surgeon and a plastic surgeon. The plastic surgeon reopened the flap site and performed extensive surgical debridement (Fig. 8). Simultaneously, the senior general surgeon performed a laparoscopic omental harvest. The omentum, pedicled with the right gastroepiploic artery and vein, was sutured directly to the remaining buttock muscles and the previous flap structures, effectively obliterating the dead space (Fig. 9). The right descending branch of the LCFA vessel was once again delivered to the gluteal wound, and end-to-end microsurgical anastomosis was performed (Fig. 10). The available skin flaps were sutured over the omental flap without requiring additional skin grafts. The 9-year follow-up period has been uneventful, with good and stable coverage of the defect (Fig. 11).

Written informed consent was obtained from the patient for the publication of this report including all clinical images.

Large buttock defects are very rarely encountered in clinical practice. In adult patients, the unique anatomical characteristics of this area make successful coverage of such defects a challenging task. Adequate debridement and prevention of wound infection are critical and cannot be overemphasized. Unfortunately, antibiotics alone are insufficient for complete management. Instead, dead spaces must be entirely obliterated with an appropriate volume of transferred tissue. Attempts to use local or regional flaps to cover these defects often result in necrosis at the flap edges due to excessive tension, increasing the risk of infection and leading to unstable wounds. The skin in this region is highly adherent to the underlying subcutaneous tissue, thick, and difficult to mobilize. Large-volume loss of both skin and fat cannot be effectively addressed without the use of free flaps [4]. Free flap reconstruction of the buttock remains a complex procedure. In adult patients, the anatomical features of this area present additional challenges to achieving successful defect coverage. Fasciocutaneous flaps require extensive undermining of the skin, posing greater risks compared to muscle flaps, especially in adults. Muscle flaps are often the preferred option as they provide a robust soft-tissue pad with a large volume of well-vascularized tissue. In our opinion, for wide, recurrent, unstable, and infected wounds of the gluteal region, the latissimus dorsi myocutaneous flap is the procedure of choice. It offers an effective and reliable solution [5]. The free latissimus dorsi flap has numerous advantages: the muscle is highly reliable, easily harvested, and serves as a free flap providing a large, tension-free, and well-vascularized tissue volume. It is particularly well-suited to cover large defects while offering excellent soft-tissue padding [6].

Reconstruction using the gastro-omental free flap to manage chronic infected wounds requires collaboration between experienced general surgeons and plastic surgeons. The donor site morbidity is minimal, with no functional compromise or deformity, as the omentum harvest is performed laparoscopically. The omental flap’s pedicle is long, making it easier to access for anastomosis with the recipient vessel. Additionally, the omental flap is less bulky, which facilitates easier closure of the flap [7]. Another advantage of using the omental free flap for compromised chronic wounds is its unique wound-healing properties, attributed to the rich fibroblast and progenitor cell population in the omentum. The flap also has a dense lymphatic network and the ability to provide a sufficient, flexible, vascularized volume for soft-tissue defect restoration. Its immunologic and neovascularization properties promote healing in contaminated or chemically irradiated wounds [8]. Furthermore, the omental flap’s lymphatic tissue content helps protect against recurrent infections after the reconstructive procedure. However, one limitation of using this flap is that it may not be suitable for patients with a history of abdominal surgery, due to the risk of peritoneal adhesions, prolonged enteric feeding, intraperitoneal infections, or cachexia. While these factors are not absolute contraindications for omental free flap use, they can make the harvesting process more challenging [7,8].

Successful free flap transfer requires adequate recipient vessels, especially in the buttock area, where the availability of suitable vessels is crucial, particularly in a scarred bed. When possible, the local gluteal vessels should be preferred. A muscle-splitting approach to expose these vessels offers greater vessel length, facilitating easier and less tenuous anastomoses. This technique also results in less damage to the gluteal muscle, which is important for ambulatory patients [9]. When the gluteal vessels are inadequate, alternative recipient vessels can be considered, such as perforators of the deep femoral vessels, the superficial femoral trunk, intercostal vessels, or the use of long vein grafts and staged transfers with carrier vessels. Although located deeply, the deep femoral vessels can be easily accessed from the posterior aspect of the thigh. The inferior epigastric vessels are long enough to be transposed laterally and posteriorly, even beyond the great trochanter or posterior superior iliac spine [10]. In our case, we found the superior and inferior gluteal vessels to be unsuitable. The use of the descending branch of the LCFA as the recipient vessel has not been previously reported. This highlights the importance of having regional options when the gluteal vessels are inadequate. By using this approach, we achieved stable coverage of the defect with well-vascularized, tension-free tissue, eliminating the risks of tight closure and infection.

Proper postoperative care is as important as adequate preoperative planning and meticulous surgical execution. The patient’s position—whether prone or in another suitable posture that avoids compression on the flap or pedicle—is critical. Flap circulation and airway patency should be carefully monitored in the intensive care unit during the first week. Preoperative education for the patient is also helpful in promoting postoperative cooperation. Frequent and careful repositioning is essential to prevent pneumonia, deep vein thrombosis, and recurrence of pressure ulcers.

In conclusion, the use of a free flap for reconstruction of the buttock area is rarely indicated and is typically reserved for cases where conventional local flaps are unavailable or inadequate. Our experience demonstrates its reliability when supported by thorough reconstructive planning and proper selection of recipient vessels.