As surgery for more advanced and complex pelvic malignancies continues to expand to include larger and more exenterative techniques, dealing with the resulting pelvic and perineal defect has become an increasingly frequent necessity. The goal is both to close the defect and to accomplish complete healing. Methodology for managing the perineal wound, which results after proctocolectomy for cancer and more recently, after exenterative resection of the rectum, sacrum, uterus, vagina, bladder and larger areas of soft tissue (i.e. perineum), varies between simple closure on one hand and creation of complex gluteal and rectus abdominus flaps on the other. We examined these methodologies in terms of indications, technical details, complications and outcomes. Finally, the newest techniques for eliminating persistent perineal sinus tracts are detailed.