Soft tissue reconstruction after total resection of sacral chordoma: Case report and literature review—is flap repair necessary?

Surgical resection of sacral chordomas often results in extensive soft tissue defects with high rates of surgical site infection and wound complications. This study aims to present a graduated, individualized treatment strategy for these complex wounds by illustrating two distinct and successful reconstructive approaches. We describe two cases of massive defects following total sacrectomy for chordoma. Case 1, a 65-year-old female with a deep three-dimensional cavity, was managed with a modified lumbar artery perforator flap after initial conventional vacuum sealing drainage (VSD) failed to resolve the dead space. Case 2, a 45-year-old male with a large surface defect, was treated conservatively using a modified VSD approach synergistically combined with silver ion dressings. In Case 1, the perforator flap provided stable, vascularized coverage, leading to complete and durable wound healing. In Case 2, the enhanced VSD and silver dressing regimen successfully controlled potential infection and promoted robust granulation, resulting in complete wound closure by secondary intention. At follow-up, both patients had well-healed wounds with no evidence of recurrence or major complications. This report highlights that a single reconstructive method is not universally applicable for post-sacrectomy defects. A graduated and individualized approach, ranging from advanced conservative management with modified VSD and antimicrobial dressings to complex perforator flap reconstruction, is essential. The selection of the appropriate strategy, guided by a multidisciplinary team, is critical for minimizing morbidity and achieving successful outcomes.