Giant Back Defect Secondary to Sarcoma: From Rotational Flaps to Definitive Microvascular ALT Reconstruction

Introduction: Soft tissue sarcomas of the back present unique reconstructive challenges, particularly when they reach massive dimensions requiring extensive excision. Large posterior trunk defects often exceed the limits of primary closure and local flap coverage, demanding advanced reconstructive strategies. While rotational flaps may offer a practical and versatile initial coverage option, their reach and reliability can be compromised in extensive defects or after multiple surgeries. Microvascular free tissue transfer, particularly the anterolateral thigh (ALT) flap, offers a versatile and durable solution with ample tissue volume, long pedicle length, and reliable vascularity. We present the case of a giant back defect following sarcoma resection, initially managed with rotational flaps, ultimately requiring definitive reconstruction with a free ALT flap. Case Series: We present the case of a A 46-year-old patient with a history of wide resection of a back sarcoma, initially managed with rib reconstruction using the ERASMUS system, and local flap coverage presented with tissue dehiscence and pleural exposure at the T4 level, measuring 12 × 5 cm. We the perforators from the descending branch of the lateral circumflex femoral artery of the latissimus dorsi muscle. Microvascular arterial and venous anastomoses were performed under an operating microscope using 8-0 and 9-0 nylon sutures without complications, achieving adequate blood flow. The postoperative course was uneventful, with good evolution and adequate, durable coverage of the defect. Discussion: Although multiple reconstructive strategies exist for large posterior trunk defects, the anterolateral thigh (ALT) free flap remains a highly versatile and reliable option. Its generous skin paddle, long vascular pedicle, and robust blood supply allow for effective coverage of extensive three-dimensional defects, even in previously operated or compromised fields. In this case, after the failure of local rotational flaps, the ALT flap provided durable, tension-free coverage and restored structural integrity over a critical thoracic area with pleural exposure, underscoring its value as a definitive solution in challenging back reconstructions. Conclusion: This case highlights the effectiveness of the ALT free flap as a reconstructive option for extensive posterior trunk defects, particularly in patients with prior oncologic surgery and failed local flaps. Its versatility, reliability, and ability to provide durable coverage make it an invaluable tool for achieving both functional protection and structural restoration in challenging back reconstructions.