Staged Flap Reconstruction of Massive Abdominal Loss of Domain and Sacral Pressure Injury to Restore Quality of Life: A Case Report.

Simultaneous massive abdominal wall loss of domain (LOD) and chronic sacral pressure injury presents an exceptional reconstructive challenge. Optimal sequencing of reconstruction in patients with multifocal defects and impaired mobility remains poorly defined. In this case report, we describe a strategically staged approach prioritizing restoration of trunk stability to enable definitive pressure ulcer reconstruction in a complex patient. A 34-year-old male developed a 32 × 25 cm ventral abdominal wall defect with LOD and a persistent stage IV sacral ulcer following catastrophic complications of a gastric bypass. Severe abdominal LOD resulted in truncal flexion deformity and wheelchair dependence. Reconstruction was staged to prioritize abdominal wall restoration to improve mobility and allow effective pressure offloading before sacral reconstruction. AWR was performed using transversus abdominis release (TAR) with retromuscular mesh placement, partial fascial bridging, and a free anterolateral thigh (ALT) musculocutaneous flap to provide durable fascial reinforcement and soft-tissue coverage. Restoration of abdominal domain significantly improved trunk stability and ambulation. Eight months later, the 14 × 10 cm sacral ulcer was definitively reconstructed using bilateral keystone perforator flaps. Both reconstructions healed without complication, resulting in marked functional recovery and elimination of wheelchair dependence. This case shows the effectiveness of a staged, multidisciplinary strategy for a patient with severe, multifocal soft-tissue defects and supports the notion that a carefully staged and individualized reconstructive approach may provide durable restoration, substantially improving mobility, functional independence, and overall quality of life.