Surgical Science, 2010, 1, 49-52
doi:10.4236/ss.2010.12010 Published Online October 2010 (http://www.SciRP.org/journal/ss)
Reconstruction of Hemipelvectomy Defect Using a Fillet
Flap with Femoral Periosteum
Masaki Yazawa1, Tsuyoshi Kaneko2, Sumitoshi Katsumata3, Kazuo Kishi1
1Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, Tokyo, Japan
2Department of Plastic and Reconstructive Surgery, National Center of Child Health and Development, Tokyo, Japan
3Department of Plastic Surgery, Chiba-Nishi General Hospital, Chiba, Japan
Received August 6, 2010; revised August 6, 2010; accepted August 6, 2010
Abstract
Backgrounds: Reconstruction after hemipelvectomy is very important for rehabilitation into society. The
pelvis plays an important role for support of the intra-abdominal organs. Methods: We operated 3 cases using
fillet flaps with the femoral periosteum for reconstruction of hemipelvectomy defect. Results: It is useful to
elevate the flap all around with the femoral periosteum, because the periosteum can be sutured to supporting
pelvic structures with the aim to support intra-abdominal organs. Conclusion: Without alternative supports
for the bony pelvis, pelvic reconstructions are at risk for hernia and it may be difficult for outpatients to fit
their habiliments after radical cure. The rigid support for the intra-abdominal organs occurs in association
with the suture pelvic and femoral periosteum.
Keywords: Hemipelvectomy, Reconstruction, Fillet Flap, Periosteum
1. Introduction
Hemipelvectomy is indicated for cases of primary pelvic
or hip tumor without metastasis that are resectable for
radical correction. Metastatic pelvic tumor that can be
controlled at the primary focus, for example, a pelvic
metastasis of thyroid cancer, is also indicated. Recon-
struction after hemipelvectomy is important for the im-
provement of quality of life in the early postoperative
stage and for rehabilitation into society. In the recon-
struction after hemipelvectomy, some cases require re-
vascularization and urinary diversion, however, plastic
surgeons are needed for wound closure for skin defects
and filling dead spaces using flaps [1,2]. In cases of he-
mipelvectomy, some innovative techniques for skin de-
fects have been reported. Most of them have used local
thigh flaps without tumor invasion for pelvic closure
[3-6]. The pelvis plays an important role for support of
the intra-abdominal organs. Without alternative supports
for the bony pelvis, pelvic reconstructions are at risk for
hernia and it may be difficult for outpatients to fit their
habiliments after radical cure. Some cases that have the
benefit of using the lateral thigh can usually obtain
enough support using the strong tensor fascia lata. We
report cases using fillet flaps with the femoral perio-
steum for reconstruction of hemipelvectomy defect.
2. Case Report
2.1. Case 1
A 42-year-old man underwent resection of an osteosar-
coma in the right greater trochanter. A giant tumor was
found around the hip joint, and it was necessary to ex-
tensively remove skin (Figure 1). The tumor was com-
pletely removed and a safety margin was kept. The flap
was planned at the medial thigh with femoral periosteum,
and the vascular pedicle was external iliac vessels. But
this flap was not planned as a complete island flap be-
cause we wanted to preserve the sensory of skin near the
ischium (Figures 2, 3). This femoral periosteum was
sutured to the pelvic periosteum (Figure 4), and dead
spaces in the pelvis were filled with the muscle in the
flaps and the pelvic stump was covered with the skin
portions of the flap. No recurrence has been seen 8
months postoperatively (Figure 5). Wearing an artificial
limb, he can walk with the help of crutch.
2.2. Case 2
A 15-year-old woman underwent resection of a chon-

M. YAZAWA ET AL. 50
Figure 1. Preoperative CT showing an osteosarcoma in the
right greater trochanter.
Figure 2. Schematic illustration of the operation. Excised
tissue is in dark gray. Denuded area to preserve the sensory
of skin near ischium is in light gray.
Figure 3. The elevated medial thigh flap was connected with
vascular pedicle to the trunk. The pedicle is external iliac
vessels divided into common femoral vessels. The center of
this flap is the femoral periosteum.
Figure 4. Femoral periosteum sutured to the sacral perio-
steum posterior to the bone.
Figure 5. Eight-month postoperative lateral view.
drosarcoma in the left pelvis. Strong radiodermatitis had
occurred in the gluteal and posterior thigh region by
preoperative radiation therapy, so we decided to use a
musculocutaneous flap with periosteum from the medial
thigh for pelvic reconstruction (Figure 6). Following
hemipelvectomy, the tumor was completely removed and
a safety margin was kept. The flap was planned at the
medial thigh as an island flap with femoral periosteum,
and the vascular pedicle was external iliac vessels. As
with Case 1, this femoral periosteum was sutured to the
pelvic periosteum, and dead spaces in the pelvis were
filled with the muscle in the flaps and the pelvic stump
was covered with the skin portions of the flap. No recur-
rence has been seen 4 years postoperatively.
2.3. Case 3
A 65-year-old man underwent resection of metastatic
bone tumors from thyroid cancer in the left iliac bone.
He had already received radiotherapy with a total amount
of 60 Gy. The tumor was completely removed and a
safety margin was kept. The flap was planned at the an-
terior thigh with femoral periosteum, and the vascular
denude
Flap

M. YAZAWA ET AL. 51
Figure 6. Schematic illustration of the operation. Excised
tissue is in dark gray. Radiation dermatitis is in light gray.
pedicle was external iliac vessels. As with Case 1, this
flap was not planned as a complete island flap, because
we wanted to preserve the sensory of skin near the is-
chium (Figure 7). As with Cases 1 and 2, the femoral
periosteum was sutured to the pelvic periosteum, and the
dead spaces in the pelvis were filled with the muscles in
the flap and the pelvic stump was covered with skin por-
tions of the flap. This patient could get around in a
wheelchair 2 weeks after the operation, and he could
maintain a standing position between parallel bars 3
weeks after the operation.
3. Discussion
Reconstruction after hemipelvectomy by plastic surgery
is very important for rehabilitation into society. In the
hemipelvectomy, pelvic tissue and various lower limbs
are removed depending on the stages of cancer progress.
Simple reconstruction for the skin defect and dead spaces
in the pelvis gives birth to complications. Especially in
the hemipelvectomy, various complications, for example,
infection, poor adaptation, pelvic dead space infection,
ileus, and hernia, are frequently reported. Poor suturing,
excessive weight of intra-abdominal organs against
wounds, and the existence of pelvic dead spaces may
cause these complications. These complications not only
prolong wound repair but also disturb postoperative ra-
diotherapy, chemotherapy, and rehabilitation into society.
In our procedure, it is important to have a conversation
preoperatively with orthopaedists about the amount of
removal, whether large vessels will be involved (external
iliac artery and vein, etc.), operative body position, past
Figure 7. Schematic illustration of the operation. Excised
tissue is in dark gray.
history (radiation therapy, etc.), scheduled postoperative
therapy and expected activities of daily living. Musculo-
cutaneous flaps from the gluteal region and posterior
thigh are usually available. If they are not available be-
cause of tumor invasion and the influence of radiation
therapy, a local flap from the medial or anterior thigh can
be used. Flaps with external iliac vessels or femoral ves-
sels are planned distally from tumors and are elevated as
musculocutaneous flaps with femoral periosteum. The
blood supply to this periosteum is from the deep femoral
artery given off by the femoral artery. The rigid support
for the intra-abdominal organs occurs in association with
the suture femoral and pelvic periosteum from the pubis
to the sacral. The femoral periosteum can be sutured not
only to the pelvic periosteum anterior or posterior to the
bone but also to the pelvic bone itself. Muscles in the
flaps play the role of filler to dead spaces and a cushion
against habiliments. Because of the progress in plastic
surgery involving blood circulation, the volume of flaps
for large skin defects, and pelvic dead spaces, these
problems can be solved in most cases. In addition, wider
tumor radical surgery became possible in several types of
surgeries [7], including hemipelvectomy. However in
hemipelvectomy, this technique sometimes leaves flaps
that are unable to hold up the intra-abdominal organs.
It is difficult in hemipelvectomy to keep a clean sur-
gical field because of the long operation time. So, in ad-
dition to the preoperative radiotherapy, postoperative
infection odds are high. Accordingly, the tissue for the
closure of the pelvic space must have good blood circu-
lation. In cases of poor support after the reconstruction,
we sometimes use not only artificial materials like pro-
line mesh but also free nonvascularized fascia. In several
radiation
dermatitis
Flap
Flap

M. YAZAWA ET AL. 52
cases, the tumor, even in the indication for the hemipe-
lvectomy, rarely extends to the lower limb. If the flap
from the lateral or posterior thigh is available, tensor
fascia lata and gluteal muscles are useful. If, however,
only the flap from the anterior or medial thigh is avail-
able, enough support may not be given to the reconstruc-
tion, because the flaps from the anterior and medial thigh
are weaker than the flaps from the lateral and posterior
thigh. Therefore, the anterior and medial thigh flaps may
result in postoperative displacements of intra-abdominal
organs. Consequently, it is useful to elevate the flap all
around with the femoral periosteum, because the perio-
steum can be sutured to supporting pelvic structures with
the aim to support intra-abdominal organs. Periosteum is
widely available in the thigh flaps without tumor inva-
sion to the femur. In Cases 1 and 2, the covering skin in
the flap was not sufficient, and it was necessary to ele-
vate the free flap from the distal limb after the amputa-
tion and to inosculate the vessels at the pelvic stump
[8,9]. A free flap requires time-consuming operation and
is at risk for vascular anastomosis. On the other hand, by
preserving femoral vessels, it is possible to elevate the
musculocutaneous flap with femoral periosteum and to
use vascularized pedicle without vascular anastomosis.
This fillet flap with periosteum is a useful choice for
reconstruction after hemipelvectomy and extends the
possibilities for the indication of hemipelvectomy.
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