Purpose: The purpose of this report of a small series was to describe the technique of total sacrectomy reconstruction using a pedicled vertical rectus abdominis musculocutaneous (VRAM) flow-through flap anastomosed to a free fibula flap. Methods: We reviewed all consecutive total sacrectomy reconstructions performed from 2009 to 2011. Surgical technique and patient outcomes were assessed. Results: Total sacrectomy reconstructions included three two-stage and three-stage VRAM flow-through flap to free fibula flap patients all of which ambulated by discharge. Flap survival was 100%. Pelvic ring defects were reconstructed with A-frame fibula flap struts anastomosed to the distal epigastric vessels of pedicled trans-pelvic VRAM flaps. Complications such as wound healing, infection or hardware failure were not observed. Bony union occurred at an average 2.7 ± 0.6 months. Conclusions: Total sacrectomy reconstruction using a VRAM flow-through flap anastomosed to a two-strut free fibular flap allows initial assessment of the recipient vessels during the first and ensuing operative stages, satisfies the bone and soft tissue requirements of the defect, and provides a durable, functionally optimized reconstruction.