Chest, Core, Pelvic, and Spine Reconstruction

Introduction

Core and pelvic reconstruction covers the soft-tissue work that closes complex defects of the chest, abdomen, spine, and pelvis after cancer resection, infection, radiation injury, or trauma. The cases are usually multidisciplinary. The plastic surgeon does not work alone — cardiothoracic surgery, surgical oncology, colorectal surgery, urology, gynecologic oncology, and orthopedic spine surgery each lead the resection or hardware portion of the operation, and the reconstructive surgeon closes the defect with vascularized, durable tissue when standard closure is not adequate.

I practice as a dual board-certified plastic and hand surgeon in Austin, Texas, with academic appointments at Dell Medical School and clinical privileges at Dell Seton Medical Center. Reconstructive work in the trunk and pelvis is part of my practice, and my published work in this area includes a textbook chapter on thoracic and abdominal reconstruction in the Michigan Manual of Plastic Surgery and a peer-reviewed paper in Hernia on a novel approach to wound dehiscence repair in a complicated patient. My research group at Dell has additionally presented work on perioperative factors affecting free tissue transfer outcomes, including heparin-induced thrombocytopenia and norepinephrine use during microsurgical reconstruction.

This page covers the major regions of core and pelvic reconstruction and the principles that guide them. For facial reconstruction after Mohs surgery, see [facial and Mohs reconstruction]. For extremity work, see [extremity reconstruction and limb salvage].

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Chest Wall Reconstruction

Chest wall reconstruction is most often required after one of three pathologies: oncologic resection (lung cancer, sarcoma, breast cancer with chest wall invasion, recurrent disease), osteoradionecrosis (bone death from prior radiation therapy), and infection. Each scenario brings different soft-tissue and structural problems.

The reconstructive principles are consistent. Vascularized soft tissue must cover any exposed bone, hardware, lung, or great vessels. Structural support is restored when full-thickness chest wall has been removed — typically with mesh, biologic matrix, or rigid prosthetic material — to prevent flail chest physiology. The flap choice depends on the location and size of the defect: pectoralis major flaps for upper anterior chest defects, latissimus dorsi flaps for lateral and posterior chest, rectus abdominis or omental flaps for lower anterior chest defects, and free tissue transfer for the largest or most complex reconstructions. Coordination with cardiothoracic surgery is the standard pathway.

Sternal wound infections — typically after coronary artery bypass surgery or open cardiac surgery — represent a specific subcategory with high stakes. Mediastinitis exposes the heart and great vessels, and standard wound care alone does not work. Pectoralis major or rectus abdominis flap reconstruction, often combined with debridement and prolonged antibiotic therapy directed by infectious disease, is the durable solution. Salvage of these patients is one of the more consequential reconstructive scenarios.

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Spine Reconstruction

Soft tissue coverage of complex spine wounds is required after multilevel spine surgery, after revision surgery in previously operated and irradiated patients, and after wound complications that expose hardware or dura. The spine wound has specific challenges: the soft tissues over the spine are thin, the underlying hardware is unforgiving when wound coverage fails, and radiation or prior surgery has often compromised the local tissue.

Reconstructive options include paraspinous muscle advancement flaps, latissimus or trapezius flaps for higher thoracic defects, and gluteal-based flaps for lumbosacral defects. Free tissue transfer is reserved for the largest or most compromised wounds. Coordination with the spine surgical team — orthopedic or neurosurgical — is essential, both for the timing of the soft-tissue reconstruction and for management of the underlying instrumentation.

Given the huge demand for spine surgery in Austin, TX and the number of skilled spine surgeons recruiting difficult cases here, this is one of the more common reconstructive surgeries I am called to perform. I work frequently with orthopedic and neurosurgical spine specialists on complex spine issues from head to sacrum including deformity, trauma, and cancer.

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Abdominal Wall Reconstruction and Complex Hernia

Abdominal wall reconstruction covers a wide spectrum, from elective repair of large incisional hernias to emergent management of contaminated open abdomens. The reconstructive challenge increases with defect size, the presence of contamination or active infection, prior mesh failures, loss of domain (in which the abdominal contents have spent enough time outside the cavity that they no longer fit comfortably back inside), and prior radiation.

Modern approaches include component separation techniques (anterior or posterior, with or without transversus abdominis release) that mobilize the rectus and oblique musculature to allow midline closure under reduced tension; mesh repair using either synthetic mesh in clean cases or biologic matrix in contaminated or potentially contaminated fields; and pedicled or free flap reconstruction when local tissue is inadequate. The choice depends on defect size, contamination, prior surgical history, and patient comorbidities.

The published case I authored in Hernia described a novel approach to wound dehiscence repair in a complicated patient — the kind of individualized solution that complex abdominal wall reconstruction sometimes requires when standard algorithms do not fit the situation. Modern abdominal wall surgery is increasingly its own subspecialty, with collaboration between plastic surgery and general/colorectal surgery the standard model in complex cases.

Pelvic and Perineal Reconstruction

Reconstruction after abdominoperineal resection (APR), pelvic exenteration, and other major pelvic oncologic operations is required because the resection often leaves a large, contaminated, irradiated wound that does not heal by primary intention. Untreated, these wounds produce chronic perineal sinuses, infection, fistulas, and prolonged disability. With appropriate flap reconstruction, the same patient can heal predictably and proceed to recovery and adjuvant therapy on schedule.

The most commonly used flap for these defects is the vertical rectus abdominis myocutaneous (VRAM) flap, which provides vascularized tissue from the abdominal wall to fill the pelvic dead space and resurface the perineum. Alternatives include gracilis flaps from the medial thigh, gluteal flaps for posterior perineal defects, and free tissue transfer for the largest reconstructions. The decision is made jointly with surgical oncology and colorectal surgery, and the reconstructive surgeon is usually involved before the resection begins so that flap planning aligns with the resection plan.

The clinical specialty listing of "General Oncologic Reconstruction — Melanoma, NMSCs, Sarcoma, Colorectal" reflects the breadth of this work. Pelvic exenteration in particular is a high-acuity, multidisciplinary operation that requires a center capable of supporting a long combined operation, post-operative ICU care, and the prolonged recovery that follows.

Genital Reconstruction (Urologic and Gynecologic)

Genital reconstruction in adults is performed for several distinct indications: oncologic resection (vulvar cancer, penile cancer, scrotal cancer), congenital anomalies presenting in adulthood, complications of prior surgery. The plastic surgeon's role is typically the soft-tissue coverage and contour reconstruction, working alongside the urologist or gynecologic oncologist who manages the genitourinary anatomy.

Reconstructive options include local advancement flaps for smaller defects, regional pedicled flaps (gracilis, anterolateral thigh, pudendal thigh, rectus abdominis) for larger defects, and free tissue transfer in the most complex cases. Vaginal reconstruction after vulvectomy or pelvic exenteration commonly uses a VRAM or gracilis flap to provide vascularized tissue and to recreate a functional canal. Scrotal and perineal reconstruction after Fournier's gangrene or oncologic resection follows similar principles. Each scenario is individualized and coordinated with the primary surgical team.

Additionally, I'm called frequently to assist in complex reconstruction for post-radiation bladder and prostate fistula reconstruction. These fistulas occur typically after bladder or prostate cancer treatment and can involve chronic infections and soft tissue necrosis that demand complex reconstructions. Often, in coordination with urologic specialists and colorectal surgery, we'll able to attempt repair of the bladder or urethra with flap coverage to separate the rectum or skin from the defect. Other times, more extensive operations like APRs may be necessary to truly treat the underlying tissue damage and infection.

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Hidradenitis Suppurativa

Hidradenitis suppurativa is a chronic inflammatory skin condition affecting apocrine-bearing skin in the axilla, groin, perineum, and inframammary regions. Severe disease produces recurrent abscesses, sinus tracts, and progressive scarring. While the medical management is led by dermatology, surgical excision and reconstruction is part of the treatment for advanced disease that has not responded to medical therapy.

Surgical management ranges from local excision and primary closure for limited disease to wide excision with reconstruction using skin grafts, local flaps, or regional flaps for extensive disease. The recurrence rate is significant even with aggressive surgery, and patients should expect that medical management continues after surgical clearance. Coordination with dermatology and, in selected cases, colorectal surgery for perianal disease is the standard pathway.

In my practice, dermatologic optimization is critical and will be needed prior to any surgical procedure.

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Outcomes

Core and pelvic reconstruction outcomes are determined as much by patient factors and the underlying disease as by the surgical technique. Smokers heal worse than non-smokers. Diabetic patients heal worse than non-diabetic patients. Patients with prior radiation, prior surgery, active infection, malnutrition, or active cancer treatment heal worse than patients without those factors. Honest preoperative counseling acknowledges this; the surgical plan addresses what can be optimized; the post-operative course is followed closely because complications are common in this population.

Successful reconstruction in core and pelvic surgery is measured against a different standard than elective cosmetic surgery. The goal is durable wound closure, restoration of structural integrity, and a return to the patient's pre-disease functional baseline. Aesthetics matter, but they are subordinate to wound healing and functional recovery. Most patients accept that trade-off readily; the alternative — chronic non-healing wounds, ongoing infection, or repeated surgery — is far worse.

My research group's work on perioperative factors affecting free tissue transfer outcomes — including the analyses of heparin-induced thrombocytopenia and intraoperative vasopressor use — speaks to one of the genuine challenges of this work: even technically excellent reconstructions can fail when systemic factors compromise flap perfusion. Recognizing and managing those factors is part of what determines the outcome.

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Risks

Risks specific to core and pelvic reconstruction include partial or total flap loss (more likely in patients with prior radiation, vascular disease, or active smoking); wound dehiscence; infection, including mesh or hardware infection in patients with foreign material; recurrent hernia in abdominal wall cases; persistent perineal sinus or fistula in pelvic cases; donor site complications including weakness or hernia at the harvest site; deep vein thrombosis and pulmonary embolism (these patients are often at higher baseline risk); and prolonged hospitalization with the associated medical complications. The risks are real and proportional to the complexity of the case. Most patients accept them because the alternative is worse, but the discussion before surgery is appropriately frank. These are risks in addition to the core risks associated with the multidisciplinary teams including other surgeons involved in these complex cases.

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Written by Brian P. Kelley, MD — Dual Board-Certified Plastic & Hand Surgeon Medically reviewed: May 4, 2026 · Last updated: May 4, 2026 Educational content. Not a substitute for individualized medical evaluation.

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Frequently Asked Questions

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Why do I need plastic surgery for an abdominal hernia or chest wound?

Standard repair of small hernias and small wounds does not require plastic surgery. Complex repairs — large hernias, recurrent hernias, contaminated fields, prior failed mesh, exposed hardware, or wounds that have not healed despite standard care — benefit from the soft-tissue and flap techniques that reconstructive plastic surgery brings. The decision to involve plastic surgery is typically made by the primary surgeon based on the complexity of the defect.

What is component separation surgery?

Component separation is a technique used in abdominal wall reconstruction to allow closure of large midline hernias under reduced tension. The lateral abdominal wall muscles are released through specific anatomic planes, allowing the rectus muscles to advance toward the midline and meet for closure. The technique reduces the recurrence rate of complex hernia repair and is part of modern abdominal wall surgery.

How long is recovery from major core or pelvic reconstruction?

Recovery depends on the operation. Complex abdominal wall reconstruction typically requires several weeks of restricted activity, several months before returning to lifting and core exertion, and often a year before reaching final functional baseline. Pelvic reconstruction after exenteration or APR has even longer recovery because the underlying disease and operation are more substantial. Hospital stays in this population range from several days to several weeks depending on complexity.

Can hidradenitis suppurativa be cured by surgery?

Surgical excision can clear active disease and disrupt the sinus tracts that perpetuate it, particularly in severe localized disease. Recurrence in adjacent or distant apocrine-bearing skin is common because hidradenitis is a chronic inflammatory disease, not just a surgical problem. Continued medical management with dermatology after surgery is the standard.

Will reconstruction delay my cancer treatment?

In most cases, reconstruction is planned to integrate with the oncologic timeline rather than delay it. And further, it's often necessary to have the reconstruction to heal complex wounds prior to chemoradiation since nothing can heal effectively once these start. Cases where reconstruction might meaningfully delay critical adjuvant therapy are discussed jointly with the oncology team, and the reconstructive plan is adjusted accordingly.

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Medical References

1. Kelley BP, Heller L. A Novel Approach to Repair of Wound Dehiscence in a Complicated Patient. Hernia. 2012;16(3):369–372. PMID: 21153749.
2. Kelley BP. Thoracic and Abdominal Reconstruction. In: Brown DL, Levi B (eds): Michigan Manual of Plastic Surgery, 2nd edition. JB Lippincott Company, Philadelphia, PA.
3. Sacks G, Zhong L, Waljee JF, Kozlow JH, Kelley BP. Heparin-Induced Thrombocytopenia and Thrombosis: Epidemiology and Systematic Review for Flap Salvage. Podium Presentation, Midwestern Association of Plastic Surgeons, Chicago, IL, April 2018.
4. Bashour L, Sacks G, Zhong L, et al. Free Tissue Transfer and Heparin-Induced Thrombocytopenia: Implications for Flap Loss and Tissue Salvage. Annual Meeting of the American Society of Plastic Surgeons, October 2020.
5. Bashour L, Frommer S, Manuel T, et al. 5-Year Retrospective Analysis of Norepinephrine Use in Free Tissue Transfer. Annual Meeting of the American Society of Plastic Surgeons, October 2020.
6. American Society of Plastic Surgeons — reconstructive procedures resources: https://www.plasticsurgery.org/.

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Related Topics

• Facial and Mohs Reconstruction
• Extremity reconstruction and limb salvage
• Hand and wrist surgery overview
• Facial and Body Reconstruction
• ‍Autologous Fat Grafting
• Nerves and Pain After Surgery or Amputation

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Closing Disclaimer

This article is educational and does not establish a doctor-patient relationship. It does not replace individualized consultation, examination, or review of personal medical history. Patients with chest wall, abdominal wall, spine, pelvic, perineal, or genital reconstruction needs are encouraged to schedule a consultation to discuss their specific situation and reconstructive options.