Background: advanced sacral pressure ulcers represent a significant reconstructive challenge, particularly in patients with extensive soft tissue loss and exposure of underlying bone. Staged management strategies, including debridement, negative pressure wound therapy (NPWT), adipose-based techniques, and flap reconstruction, are commonly used to achieve definitive wound closure. Objective: to present the management of an advanced sacral pressure ulcer treated with staged surgical reconstruction and to review current literature regarding adipose-based techniques and flap reconstruction in complex sacral defects. Methods: a literature review was performed using PubMed, Cochrane Library, and Google Scholar databases, selecting relevant articles related to pressure ulcer reconstruction, adipose-based therapies, and flap techniques. In addition, a clinical case of an adult male with an advanced sacral pressure ulcer and bone exposure managed through staged debridement, NPWT, adipose tissue grafting, and subsequent gluteus maximus rotational flap reconstruction is described. Results: the literature supports the use of NPWT as an effective method for wound bed preparation and highlights the regenerative potential of adipose-based therapies in selected cases. However, in large defects with bone exposure, flap-based reconstruction remains the most reliable method for definitive closure. In the present case, adipose tissue grafting alone did not achieve satisfactory healing, and definitive coverage was successfully achieved using a unilateral gluteus maximus rotational flap, resulting in favorable wound healing and functional recovery. Conclusion: advanced sacral pressure ulcers require staged and individualized management. Although adipose-based techniques may provide regenerative benefits, flap reconstruction remains the gold standard for large and deep defects. Early recognition of inadequate wound progression and timely flap reconstruction are essential to optimize clinical outcomes.