Reconstruction of Large Sacral Defects With Freestyle Perforator Propeller Flaps

Large midline sacral defects pose a significant reconstructive challenge. While freestyle perforator propeller flaps offer a muscle-sparing solution, long-term patient-reported aesthetic outcomes are not well documented. We performed a retrospective review of 41 consecutive patients who underwent freestyle perforator propeller flap reconstruction for large midline sacral defects arising from pressure ulcers (n=22), hidradenitis suppurativa (n=13), and sarcoma (n=6). Primary outcomes were complications and length of stay; secondary outcomes included patient- and observer-rated 5-point Likert scale aesthetic scores at 12-month follow-up. The mean flap size was 134.9±45.2 cm ² . Postoperative complications occurred in 12 patients (29.3%), including 1 total and 1 partial flap loss. The mean hospitalization was 4.71±4.01 days. Patient- and observer-rated satisfaction scores improved significantly from a baseline of 1.41±0.74 and 1.35±0.63 to 4.85±0.36 and 4.34±0.42, respectively, at 12 months ( P <0.001). In this series, freestyle perforator propeller flaps provided durable coverage with manageable complication rates and were associated with substantial improvements in patient- and observer-rated aesthetic outcomes. These findings support their use as a reliable reconstructive option in appropriately selected patients.