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Chi D, Raman S, Tawaklna K, Zhu WY, Keane AM, Bruce JG, Parikh R, Tung TH. Free functional muscle transfer for lower extremity reconstruction. J Plast Reconstr Aesthet Surg 2023; 86:288-299. [PMID: 37797377 DOI: 10.1016/j.bjps.2023.09.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 08/30/2023] [Accepted: 09/12/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Free functional muscle transfer is a reconstructive strategy for the reconstruction of lost muscle units in the lower extremity after oncologic resection, trauma, compartment syndrome, or severe nerve injuries. Under appropriate circumstances, free functional muscle transfer may be the only suitable reconstructive option. This article reviews the underlying principles of free functional muscle transfer, its application to lower extremity reconstruction, appropriate patient selection, and surgical techniques. METHODS The underlying principles of free functional muscle transfer, its application to lower extremity reconstruction, appropriate patient selection, and surgical techniques are presented. Commonly used donor muscles appropriate for each type of functional defect are discussed. A review of recent publications on free functional muscle transfer in the lower extremity was also performed. RESULTS Good functional recovery with a Medical Research Council grade of up to 4/5 and full range of motion can be attained with free functional muscle transfer. Clinical outcomes and specific parameters for published case series in lower extremity free functional muscle transfer are presented and an illustrative case. CONCLUSION Free functional muscle transfer is a suitable treatment for the appropriate patient to restore essential functions and potentially regain ambulation. However, additional published clinical outcomes are needed and represent a major area for further investigation.
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Affiliation(s)
- David Chi
- Division of Plastic and Reconstructive Surgery, Washington University Medical Center, Saint Louis, MO, USA
| | - Shreya Raman
- Division of Plastic and Reconstructive Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Kenan Tawaklna
- Division of Plastic and Reconstructive Surgery, Washington University Medical Center, Saint Louis, MO, USA
| | - William Y Zhu
- Division of Plastic and Reconstructive Surgery, Washington University Medical Center, Saint Louis, MO, USA
| | - Alexandra M Keane
- Division of Plastic and Reconstructive Surgery, Washington University Medical Center, Saint Louis, MO, USA
| | - Jordan G Bruce
- Division of Plastic and Reconstructive Surgery, Washington University Medical Center, Saint Louis, MO, USA
| | - Rajiv Parikh
- Division of Plastic and Reconstructive Surgery, Washington University Medical Center, Saint Louis, MO, USA; Department of Plastic and Reconstructive Surgery, Medstar Georgetown, Washington, DC, USA
| | - Thomas H Tung
- Division of Plastic and Reconstructive Surgery, Washington University Medical Center, Saint Louis, MO, USA.
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Seldon C, Grossman JG, Shrivastava G, Fernandez M, Jin W, Conaway S, Rosenberg A, Livingstone A, Franceschi D, Jonczak E, Trent J, Subhawong T, Studenski MT, Yechieli R. CivaSheet® use for soft tissue sarcoma: A single institution experience. Brachytherapy 2023; 22:649-654. [PMID: 37271655 DOI: 10.1016/j.brachy.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 02/28/2023] [Accepted: 03/05/2023] [Indexed: 06/06/2023]
Abstract
OBJECTIVE CivaSheet is a palladium-103, implantable, intraoperative radiation therapy device which emits unidirectional radiation that enables boost doses in patients who have otherwise received the maximum radiation dose. Here, we present our initial clinical experience with the first 10 cases using this new technology. METHODS AND MATERIALS A retrospective chart review of all patients with STS treated with surgical resection and CivaSheet placement at the University of Miami Hospital, a tertiary care center, from January 2018 to December 2019, was performed. Adjuvant radiation was administered by a palladium-103 implant, which delivered an average of 47 Gy (35-55) to a depth of 5 mm. RESULTS Nine patients underwent CivaSheet placement from January 2018 until December 2019 for a total of 10 CivaSheets placed (1 patient had 2 CivaSheets inserted) and followed for a mean of 27 months (4-45 months). Four tumors were located in the retroperitoneum, two in the chest, two in the groin, and two within the lower extremity. At the time of tumor resection and CivaSheet placement, tumor sizes ranged from 2.5 cm to 13.8 cm with an average of 7.6 cm. Four patients necessitated musculocutaneous tissue flaps for closure and reconstruction. All patients with Grade 4 complications had flap reconstruction and prior radiation. Four patients' tumors recurred locally for a local recurrence rate of 40%. Three patients had modified accordion Grade 4 complications necessitating additional surgery for CivaSheet removal. Extremity tumors unanimously developed modified accordion Grade 4 adverse events. CONCLUSIONS CivaSheet may be an acceptable alternative treatment modality compared to prior brachytherapy methods.
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Affiliation(s)
- Crystal Seldon
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Julie G Grossman
- Department of Surgical Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Gautam Shrivastava
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Melanie Fernandez
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - William Jin
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Sheila Conaway
- Department of Orthopedic Surgery, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Andrew Rosenberg
- Department of Pathology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Alan Livingstone
- Department of Surgical Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Dido Franceschi
- Department of Surgical Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Emily Jonczak
- Department of Hematology Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Jonathan Trent
- Department of Hematology Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Ty Subhawong
- Department of Radiology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Matthew T Studenski
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL
| | - Raphael Yechieli
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL.
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Karakawa R, Yoshimatsu H, Fuse Y, Yano T. Multiple Flap Transfer for Multiple Local Recurrence of Soft Tissue Sarcoma. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1489. [PMID: 37629779 PMCID: PMC10456343 DOI: 10.3390/medicina59081489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/20/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023]
Abstract
Background and Objectives: Surgical management of local recurrence of soft tissue sarcomas (STS) is still challenging. In this article, we report on multiple flap reconstructions for multiple local recurrences of STS. Their feasibility will be validated by examining clinical cases. Materials and Methods: Patients who underwent multiple flap reconstructions for multiple local recurrences of STS between April 1997 and October 2021 were included in this retrospective study. Patient demographics, tumor characteristics, surgical characteristics, and postoperative complications were examined. Results: Twenty operations of eight patients were identified. The location of the defects was the back in two, the buttock in two, the groin in two, and the lower extremities in two. The average total number of wide resections was 4.0 and the average total number of flap reconstructions was 2.5. The average follow-up period was 109.4 months. The average size of the defect was 102.4 cm2 and the average flap size was 15.7 × 10.8 cm. The histological diagnoses were malignant fibrous histocytoma (MFH) in eight operations, osteosarcoma in two operations, myxoid liposarcoma in two operations, undifferentiated pleomorphic sarcoma (UPS) in six operations, and myxofibrosarcoma (MFS) in one operation. Of twelve subsequent operations, the resection of the previously transferred flap was performed in six operations (50%). The occurrence of take back, flap complications, and donor-site complications in the primary operation group was 25%, 25%, and 12.5%, respectively. The occurrence of take back, flap complications, and donor-site complications in the second and subsequent operation group was 0%, 0%, and 16.7%, respectively. Conclusions: Multiple operations including wide resections followed by flap reconstructions for multiple local recurrences are feasible. Reconstructive surgeons should choose the options of the flaps considering the future local recurrence for tumors with a high risk of recurrence.
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Affiliation(s)
- Ryo Karakawa
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo 135-8550, Japan
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Kuruoglu D, Bakri K, Tran NV, Moran SL, Vijayasekaran A, Carlsen BT. Microvascular Free Flap Reconstruction of Thigh Defects After Tumor Resection in the Setting of Radiation. Ann Plast Surg 2023; 90:456-461. [PMID: 37146310 DOI: 10.1097/sap.0000000000003542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
BACKGROUND Soft tissue reconstruction of the thigh defects can usually be achieved with local options. Free tissue transfer may be indicated in very large defects with exposed vital structures and/or a history of radiation therapy where the healing potential of local option is poor. In this study, we evaluated our experience on microsurgical reconstruction of oncological and irradiated thigh defects to assess the risk factors for complications. METHODS Institutional review board-approved retrospective case series study using electronic medical records from 1997 to 2020 was conducted. All patients with irradiated thigh defects derived from oncological resections who underwent microsurgical reconstruction were included. Patient demographics and clinical and surgical characteristics were recorded. RESULTS Twenty free flaps were transferred in 20 patients. Mean age was 60 ± 11.8 years, and median follow-up time was 24.3 months (interquartile range [IQR], 71.4-9.2 months). The most common type of cancer was liposarcoma (n = 5). Neoadjuvant radiation therapy was performed in 60%. Most commonly used free flaps were latissimus dorsi muscle/musculocutaneous flap (n = 7) and anterolateral thigh flap (n = 7) Nine flaps were transferred immediately after resection. Overall, 70% of arterial anastomoses were end-to-end, whereas 30% were end-to-side. Deep femoral artery branches were chosen as the recipient artery in the 45%. Median length of hospital stay was 11 days (IQR, 16.0-8.3 days), and median time to start weight-bearing was 20 days (IQR, 49.0-9.5 days). All were successful except for 1 patient who required additional pedicled flap coverage. The overall major-complication rate was 25% (n = 5, hematoma = 2, venous congestion requiring emergent exploration surgery = 1, wound dehiscence = 1, surgical site infection = 1). Cancer recurred in 3 patients. One required amputation due to cancer recurrence. Age (hazard ratio [HR], 1.14; P = 0.0163), tumor volume (HR, 18.8; P = 0.0006), and resection volume (HR, 2.24; P = 0.0019) were statistically significantly associated with having a major complication. CONCLUSIONS Based on the data, microvascular reconstruction of irradiated post-oncological resection defects shows high flap survival rate and success. Given the large size of flap required, the complex nature and size of these wounds, and history of radiation, wound healing complications are common. Despite this, free flap reconstruction should be considered in irradiated thighs with large defects. Studies with larger cohort and longer follow-up are still required.
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Affiliation(s)
- Doga Kuruoglu
- From the Division of Plastic Surgery, Mayo Clinic, Rochester, MN
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Wilke BK, Goulding KA, Sherman CE, Houdek MT. Soft Tissue Tumors. Radiol Clin North Am 2022; 60:253-262. [DOI: 10.1016/j.rcl.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Brambullo T, Azzena GP, Toninello P, Masciopinto G, De Lazzari A, Biffoli B, Vindigni V, Bassetto F. Current Surgical Therapy of Locally Advanced cSCC: From Patient Selection to Microsurgical Tissue Transplant. Review. Front Oncol 2021; 11:783257. [PMID: 34950589 PMCID: PMC8690035 DOI: 10.3389/fonc.2021.783257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/17/2021] [Indexed: 11/29/2022] Open
Abstract
Among the non-melanoma skin cancers (NMSC) the squamous cell carcinoma (SCC) is one of the most challenging for the surgeon. Local aggressiveness and a tendency to metastasize to regional lymph nodes characterize the biologic behavior. The variants locally advanced and metastatic require wide excision and node dissection. Such procedures can be extremely detrimental for patients. The limit of the surgery can be safely pushed forward with a multidisciplinary approach. The concept of skin oncoplastic surgery, the ablative procedures and the reconstructive options (skin graft, pedicled flap, microsurgical free flap) are discussed together with a literature review.
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Affiliation(s)
- Tito Brambullo
- Clinic of Plastic Surgery, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Gian Paolo Azzena
- Clinic of Plastic Surgery, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Paolo Toninello
- Clinic of Plastic Surgery, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Giuseppe Masciopinto
- Clinic of Plastic Surgery, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Alberto De Lazzari
- Clinic of Plastic Surgery, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Bernardo Biffoli
- Clinic of Plastic Surgery, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Vincenzo Vindigni
- Clinic of Plastic Surgery, Department of Neurosciences, Padua University Hospital, Padua, Italy
| | - Franco Bassetto
- Clinic of Plastic Surgery, Department of Neurosciences, Padua University Hospital, Padua, Italy
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Samà L, Binder JP, Darrigues L, Couturaud B, Boura B, Helfre S, Chiche L, Nicolas N, Tzanis D, Bouhadiba T, Gentile D, Perlbarg-Samson J, Bonvalot S. Safe-margin surgery by plastic reconstruction in extremities or parietal trunk soft tissue sarcoma: A tertiary single centre experience. Eur J Surg Oncol 2021; 48:526-532. [PMID: 34702592 DOI: 10.1016/j.ejso.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Tertiary centers recruit a large proportion of locally advanced or recurrent soft tissue sarcomas (STSs) that may have been preoperatively irradiated. The objective of this study was to evaluate the results of oncoplastic surgery (OPS) for patients affected by extremities or parietal trunk STS. MATERIALS AND METHODS This retrospective study includes patients who underwent a flap reconstruction after sarcoma resection between January 2018 and December 2020 at Institut Curie. The primary endpoint was the evaluation of the impact of OPS on the quality of surgical margins. The secondary endpoint was to quantify the morbidity of OPS and identify predictive factors for wound complications. RESULTS Of 211 patients, 89 (42.2%) had a flap reconstruction. Surgery was realized on an irradiated field in 56 (62.9%) patients. Without OPS, all patients were candidates either for amputation (n = 9,10.1%) due to vessels/nerve infiltration, or R1/R2 resection (n = 80,89.9%). Seventy-two (80.0%) pedicle flaps and 18 (20.0%) free flaps were used. No R2 resections were performed. R0 and R1 margins were achieved in 82 (92.1%) and 7 (7.9%), respectively. The median closest margin was 3 mm (IQR 1-6 mm). Among R1 patients, 5 had positive margins along a preserved critical structure, 2 patients had well-differentiated liposarcomas. The surgical morbidity rate was 33.3% (30/90 flaps). The reoperation rate was 15.7% (14/89 patients). CONCLUSIONS In a referral sarcoma center, the collaboration between the surgical oncologist and the plastic surgery team should be considered upfront in the surgical plan, allowing the most adequate wide oncological resection with acceptable postoperative morbidity.
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Affiliation(s)
- Laura Samà
- Department of Surgical Oncology, Institute Curie, Paris Sciences et Lettres University, Paris, France; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy; Sarcoma, Melanoma and Rare Tumors Surgery Unit, IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy.
| | | | - Lauren Darrigues
- Division of Plastic and Reconstructive Surgery, Institute Curie, Paris, France
| | - Benoit Couturaud
- Division of Plastic and Reconstructive Surgery, Institute Curie, Paris, France
| | - Benoit Boura
- Department of Vascular Surgery, Hospital Saint Joseph, Paris, France
| | - Sylvie Helfre
- Department of Radiation Oncology, Institute Curie, Paris, France
| | | | - Nayla Nicolas
- Department of Radiology, Institute Curie, Paris, France
| | - Dimitri Tzanis
- Department of Surgical Oncology, Institute Curie, Paris Sciences et Lettres University, Paris, France
| | - Toufik Bouhadiba
- Department of Surgical Oncology, Institute Curie, Paris Sciences et Lettres University, Paris, France
| | - Damiano Gentile
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy
| | | | - Sylvie Bonvalot
- Department of Surgical Oncology, Institute Curie, Paris Sciences et Lettres University, Paris, France.
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A Prospective Evaluation of Intraoperative Indocyanine Green Fluorescence Angiography for Soft Tissue Sarcomas. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2021; 5:e21.00187-6. [PMID: 34411035 PMCID: PMC8378787 DOI: 10.5435/jaaosglobal-d-21-00187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 07/18/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Postoperative wound complications after resection of soft-tissue sarcomas are challenging. Indocyanine green (ICG) angiography has previously been used to predict wound complications, but not for soft-tissue sarcomas. We aimed to evaluate whether this technology could help lower wound complications after soft-tissue sarcoma resections. MATERIALS AND METHODS We conducted a prospective study from 10/2017 to 9/2019 using ICG angiography during sarcoma resection surgery. Rates of wound complications were compared with a historical control consisting of surgeries before utilization of ICG angiography. RESULTS A total of 88 patients were included in the study. We found significantly lower rates of infection (11.8% versus 38%; P = 0.03) and wound dehiscence (11.8% versus 42.3%; P = 0.02) in the ICG angiography cohort compared with the historical controls. CONCLUSION ICG angiography use during soft-tissue sarcoma resections is promising technology and warrants further investigation to help reduce postoperative complications.
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Cost Variance in Patients With Soft Tissue Sarcoma Who Develop Postoperative Wound Complications. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2021; 5:01979360-202107000-00004. [PMID: 34232931 PMCID: PMC8265859 DOI: 10.5435/jaaosglobal-d-21-00147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 06/12/2021] [Indexed: 12/24/2022]
Abstract
Background: Wound complications after a soft-tissue sarcoma surgery are common, occurring in up to 30% to 40% of patients who undergo preoperative radiation therapy. Although risk factors for developing complications are well-known, there is a paucity of literature on the increased healthcare costs after a wound complication. The purpose of this study was to detail these additional costs after a soft-tissue sarcoma surgery. Methods: A retrospective review of 99 patients from January 2013 to October 2019 was performed. Hospital and professional charges for the primary surgical procedure and any subsequent hospitalization or procedure related to a wound complication were compiled. Costs were inflated to 2019 dollars. Results: Total costs were 21.3% higher for patients who developed a wound complication (P = 0.006). Most patients (32 of 42; 76.2%) who developed a complication required a return trip to the operating room. The average number of return trips was 1.2 (range 0 to 5). For each return trip to the operating room because of a wound complication, an associated increased overall cost of 13.2% was noted (P < 0.001). Conclusion: Wound complications after a soft-tissue sarcoma resection are common and add considerable expense to the episode of care. A reduction in wound complications may markedly decrease the cost of treating soft-tissue sarcomas and continues to be an opportunity for improvement.
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Intraoperative Indocyanine Green Fluorescence Angiography Is Sensitive for Predicting Postoperative Wound Complications in Soft-Tissue Sarcoma Surgery. J Am Acad Orthop Surg 2021; 29:433-438. [PMID: 32947348 DOI: 10.5435/jaaos-d-20-00355] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/23/2020] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Indocyanine green (ICG) angiography is a novel technology that has been predictive of postoperative wound complications. It is unknown whether this technology can successfully predict complications after sarcoma resection. In this study, we aimed to evaluate the sensitivity and specificity of ICG angiography in predicting postoperative wound complications after soft-tissue sarcoma resection. METHODS A prospective cohort study of 23 patients was performed beginning October 2017 at our institution. Patients who underwent soft-tissue sarcoma resection were included. After tumor resection and wound closure, evaluation of tissue perfusion in skin edges was performed with ICG angiography. Wound complications were recorded in the postoperative follow-up. RESULTS Eight patients developed postoperative wound complications. Six patients were predicted to have wound complications on the final ICG scans. The accuracy of ICG angiography was dependent on the anatomic location, with improved accuracy in the lower extremity. ICG angiography had a sensitivity of 50%, a specificity and a positive predictive value of 100%, and a negative predictive value of 70% for wound complications after soft-tissue sarcoma resections located in the lower extremity. CONCLUSION ICG angiography has a high predictive value in the lower extremity for postoperative wound complications. LEVEL OF EVIDENCE Level III, Diagnostic.
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Immediate Versus Staged Soft Tissue Reconstruction After Soft Tissue Sarcoma Resection Has Similar Wound and Oncologic Outcomes. Ann Plast Surg 2021; 85:163-170. [PMID: 31913884 DOI: 10.1097/sap.0000000000002192] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this study was to compare the wound complication rate and oncologic outcome in patients undergoing immediate versus staged soft tissue reconstruction after soft tissue sarcoma (STS) resection. METHODS This is a retrospective analysis of a single sarcoma referral center between 2006 and 2016 which identified a cohort that underwent resection of an extremity or trunk STS with reconstruction surgery (split thickness skin graft or flap coverage). Patients were divided into 2 groups based on the reconstruction timing: immediate (same day) versus staged (later date). Demographic characteristics, wound complications, and oncologic outcomes were compared. RESULTS Of the 491 patients who underwent resection of an extremity or trunk STS, 81 (16%) received reconstructive surgery, with 26 patients undergoing immediate reconstruction and 55 patients undergoing staged reconstruction. Overall wound complication (58% vs 45%, P = 0.347) and infection rates (35% vs 25%, P = 0.602) were similar between immediate and staged groups, respectively. Likewise, local recurrence (8% vs 7%, P = 1.000), metastasis (19% vs 20%, P = 0.755), and all-cause mortality (27% vs 27%, P = 1.000) rates after reconstruction was similar. Patients in the staged group with positive margins after resection were re-excised before definitive reconstruction, whereas those in the immediate group were not. The staged group required fewer surgical intensive care unit stays after resection surgery (22% vs 58%, P = 0.006). The mean ± SD final follow-up was 38 ± 33 months. CONCLUSIONS Wound complication rates and oncologic outcomes remain similar, regardless of timing for reconstruction. Staged reconstructions were associated with fewer surgical intensive care unit stays, while also affording opportunity for reintervention after positive margins with little additional morbidity.
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Perrault DP, Lee GK, Yu RP, Carre AL, Chattha A, Johnson MB, Gardner DJ, Carey JN, Tseng WW, Menendez LR, Wong AK. Risk Factors for Wound Complications After Soft Tissue Sarcoma Resection. Ann Plast Surg 2021; 86:S336-S341. [PMID: 33234885 DOI: 10.1097/sap.0000000000002592] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
ABSTRACT Soft tissue sarcomas are a heterogenous group of malignant tumors that represent approximately 1% of adult malignancies. Although these tumors occur throughout the body, the majority involved the lower extremity. Management may involve amputation but more commonly often includes wide local resection by an oncologic surgeon and involvement of a plastic surgeon for reconstruction of larger and more complex defects. Postoperative wound complications are challenging for the surgeon and patient but also impact management of adjuvant chemotherapy and radiation therapy. To explore risk factors for wound complications, we reviewed our single-institution experience of lower-extremity soft tissue sarcomas from April 2009 to September 2016. We identified 127 patients for retrospective review and analysis. The proportion of patients with wound complications in the cohort was 43.3%. Most notably, compared with patients without wound complications, patients with wound complications had a higher proportion of immediate reconstruction (34.5% vs 15.3%; P = 0.05) and a marginally higher proportion who received neoadjuvant radiation (30.9% vs 16.7%; P = 0.06).
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Affiliation(s)
| | - Gene K Lee
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
| | - Roy P Yu
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
| | - Antoine Lyonel Carre
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
| | | | - Maxwell B Johnson
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
| | | | - Joseph N Carey
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
| | | | - Lawrence R Menendez
- Department of Orthopedic Surgery, Keck School of Medicine of USC, Los Angeles, CA
| | - Alex K Wong
- From the Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles
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Use of the Profunda Femoris Artery Perforator Flap for Reconstruction after Sarcoma Resection. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3289. [PMID: 33425601 PMCID: PMC7787329 DOI: 10.1097/gox.0000000000003289] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/13/2020] [Indexed: 02/06/2023]
Abstract
Background: Soft tissue sarcomas are rare neoplasms that can occur on any part of the body. The operative position for the resection is determined depending on the site of the soft tissue sarcomas; intraoperative repositioning may be needed for reconstruction. We present the profunda femoris artery perforator (PAP) flap harvest technique (wherein the flap can be used in any position), and suggest that the PAP flap transfer can eliminate the need for intraoperative repositioning. Methods: From December 2018 to January 2020, 7 patients with an average age of 68 years underwent reconstructions using a PAP flap after wide resection of STS. The mean defect size was 11.3 × 16.5 cm (range, 5.5–25 × 11–26 cm). The location of the defects was the medial thigh in 2 patients, the posterior thigh in 1, the popliteal fossa in 1, the groin in 1, and the buttock in 2. The PAP flap was elevated in the supine “frog-leg” position, the prone position, the jack-knife position, or the lateral “crisscross” position; the lateral decubitus position with the donor lower extremity on the bottom. Results: Of the 7 cases, the operations were performed in the supine “frog-leg” position in 3 cases, the prone position in 2 cases, the jack-knife position in 1 case, and the lateral “crisscross” position in 1 case. There were no intraoperative position changes in all cases. The mean size of the PAP flap was 8.7 × 19.9 cm (range, 6–11 × 17–24 cm). One patient had donor site dehiscence, which was treated conservatively. The PAP flaps survived completely in all cases. The mean follow-up period was 10.5 months (range, 6–17 months). Conclusion: Since the PAP flap elevation is feasible in every position, the PAP flap can be considered a versatile reconstruction option after sarcoma resection.
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The Role of Plastic Reconstructive Surgery in Surgical Therapy of Soft Tissue Sarcomas. Cancers (Basel) 2020; 12:cancers12123534. [PMID: 33256182 PMCID: PMC7760015 DOI: 10.3390/cancers12123534] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 11/21/2020] [Accepted: 11/25/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Soft tissue sarcoma (STS) treatment is an interdisciplinary challenge. Along with radio(chemo)therapy, surgery plays the central role in STS treatment. Little is known about the impact of reconstructive surgery on STS, particularly whether reconstructive surgery enhances STS resection success with the usage of flaps. Here, we analyzed the 10-year experience at a university hospital's Comprehensive Cancer Center, focusing on the role of reconstructive surgery. METHODS We performed a retrospective analysis of STS-patients over 10 years. We investigated patient demographics, diagnosis, surgical management, tissue/function reconstruction, complication rates, resection status, local recurrence and survival. RESULTS Analysis of 290 patients showed an association between clear surgical margin (R0) resections and higher-grade sarcoma in patients with free flaps. Major complications were lower with primary wound closure than with flaps. Comparison of reconstruction techniques showed no significant differences in complication rates. Wound healing was impaired in STS recurrence. The local recurrence risk was over two times higher with primary wound closure than with flaps. CONCLUSION Defect reconstructions in STS are reliable and safe. Plastic surgeons should have a permanent place in interdisciplinary surgical STS treatment, with the full armamentarium of reconstruction methods.
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Karakawa R, Yoshimatsu H, Tanakura K, Imai T, Yano T, Sawaizumi M. Triple-lobe combined latissimus dorsi and scapular flap for reconstruction of a large defect after sarcoma resection. Microsurgery 2020; 41:26-33. [PMID: 32721049 DOI: 10.1002/micr.30627] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 04/20/2020] [Accepted: 06/26/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND In the setting of the reconstruction for a large defect, we must make the maximum use of the limited human tissue with the minimum damage. In this article, we report on reconstruction using a combination of three-skin paddle latissimus dorsi and a scapular flap for a large defect after soft tissue sarcoma resection to minimize donor site morbidity. METHODS From 2000 to 2012, six patients underwent primary reconstruction using free or pedicled triple-lobe combined latissimus dorsi and scapular flap after wide resection of soft tissue sarcoma. There were five male patient and one female, and their average age was 66.8 (range, 49-80 years). The location of the defects was the thoracic wall in three, the thigh in one, the knee in one, and the shoulder in one. The average size of the defect was 18.8 × 13.9 cm. RESULTS The average size of the ascending scapular flap and the skin paddle of the latissimus dorsi flap was 6.8 × 13 cm and 7.3 × 14.7 cm. One patient had partial necrosis of the skin paddle of the latissimus dorsi flap, which was treated conservatively. The triple-lobe combined latissimus dorsi and scapular flaps survived completely in five cases. Neither anastomosis complications nor infections were encountered. The average follow-up period was 63.67 months. All patients were satisfied functionally and esthetically with the reconstruction outcomes at the end of follow-up. CONCLUSION In conclusion, the triple-lobe combined latissimus dorsi and scapular flap is one of the options for reconstruction of a large defect after sarcoma resection to minimize donor site morbidity.
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Affiliation(s)
- Ryo Karakawa
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hidehiko Yoshimatsu
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kenta Tanakura
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomohiro Imai
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomoyuki Yano
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masayuki Sawaizumi
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
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Spencer RMSSB, de Camargo VP, Silva MLG, Pinto FFE, Costa FD, Cequeira WS, Munhoz RR, Mello CA, Schmerling RA, Filho WJD, Coelho TM, Ambrosio AVA, Leite ETT, Hanna SA, Nakagawa SA, Baptista AM, Pinheiro RN, de Oliveira JL, de Araújo MS, de Araujo RLC, Laporte GA, de Almeida Quadros C, de Oliveira AF, Lopes A. Brazilian consensus on the diagnosis and treatment of extremities soft tissue sarcomas. J Surg Oncol 2020; 121:743-758. [PMID: 31970785 DOI: 10.1002/jso.25847] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 01/05/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Soft tissue sarcomas (STSs) are rare tumors and constitute only 1% of all tumors in adults. Indeed, due to their rarity, most cases in Brazil are not treated according to primary international guidelines. METHODS This consensus addresses the treatment of STSs in the extremities. It was made by workgroups from Brazilian Societies of Surgical Oncology, Orthopaedics, Clinical Oncology, Pathology, Radiology and Diagnostic Imaging, and Radiation Oncology. The workgroups based their arguments on the best level of evidence in the literature and recommendations were made according to diagnosis, staging, and treatment of STSs. A meeting was held with all the invited experts and the topics were presented individually with the definition of the degree of recommendation, based on the levels of evidence in the literature. RESULTS Risk factors and epidemiology were described as well as the pathological aspects and imaging. All recommendations are described with the degree of recommendation and levels of evidence. CONCLUSION Recommendations based on the best literature regional aspects were made to guide professionals who treat STS. Separate consensus on specific treatments for retroperitoneal, visceral, trunk, head and neck sarcomas, and gastrointestinal stromal tumor, are not contemplated into this consensus.
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Affiliation(s)
- Ranyell M S S B Spencer
- Department of Directory, Brazilian Society of Surgical Oncology (BSSO), Rio de Janeiro, Brazil
| | - Veridiana P de Camargo
- Department of Directory, Brazilian Society of Clinical Surgical (BSCO), São Paulo, Brazil
| | - Maria L G Silva
- Department of Directory, Brazilian Society of Radiation Oncology (BSRO), São Paulo, Brazil
| | - Fabio F E Pinto
- Department of Directory, Brazilian Society of Orthopaedics and Traumatology (BSOT), São Paulo, Brazil
| | | | - Wagner S Cequeira
- AC Camargo Cancer Center, Department of Diagnosis and Imaging, São Paulo, Brazil
| | - Rodrigo R Munhoz
- Department of Directory, Brazilian Society of Clinical Surgical (BSCO), São Paulo, Brazil
| | - Celso A Mello
- Department of Directory, Brazilian Society of Clinical Surgical (BSCO), São Paulo, Brazil
| | - Rafael A Schmerling
- Department of Directory, Brazilian Society of Clinical Surgical (BSCO), São Paulo, Brazil
| | - Waldec J D Filho
- Department of Directory, Brazilian Society of Clinical Surgical (BSCO), São Paulo, Brazil
| | - Tharcisio M Coelho
- Department of Directory, Brazilian Society of Radiation Oncology (BSRO), São Paulo, Brazil
| | - Alexandre V A Ambrosio
- Department of Directory, Brazilian Society of Radiation Oncology (BSRO), São Paulo, Brazil
| | - Elton T T Leite
- Department of Directory, Brazilian Society of Radiation Oncology (BSRO), São Paulo, Brazil
| | - Samir A Hanna
- Department of Directory, Brazilian Society of Radiation Oncology (BSRO), São Paulo, Brazil
| | - Sueli A Nakagawa
- Department of Directory, Brazilian Society of Orthopaedics and Traumatology (BSOT), São Paulo, Brazil
| | - Andre M Baptista
- Department of Directory, Brazilian Society of Orthopaedics and Traumatology (BSOT), São Paulo, Brazil
| | - Rodrigo N Pinheiro
- Department of Directory, Brazilian Society of Surgical Oncology (BSSO), Rio de Janeiro, Brazil
| | - Jadivan L de Oliveira
- Department of Directory, Brazilian Society of Surgical Oncology (BSSO), Rio de Janeiro, Brazil
| | - Marcelo Sá de Araújo
- Department of Directory, Brazilian Society of Surgical Oncology (BSSO), Rio de Janeiro, Brazil
| | - Raphael L C de Araujo
- Department of Directory, Brazilian Society of Surgical Oncology (BSSO), Rio de Janeiro, Brazil
| | - Gustavo A Laporte
- Department of Directory, Brazilian Society of Surgical Oncology (BSSO), Rio de Janeiro, Brazil
| | | | - Alexandre F de Oliveira
- Department of Directory, Brazilian Society of Surgical Oncology (BSSO), Rio de Janeiro, Brazil
| | - Ademar Lopes
- Department of Directory, Brazilian Society of Surgical Oncology (BSSO), Rio de Janeiro, Brazil
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A reconstructive algorithm after thigh soft tissue sarcoma resection including predictors of free flap reconstruction✰. J Plast Reconstr Aesthet Surg 2019; 72:1304-1315. [DOI: 10.1016/j.bjps.2019.04.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 04/02/2019] [Accepted: 04/27/2019] [Indexed: 11/20/2022]
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Lim Z, Strike SA, Puhaindran ME. Sarcoma of the Lower Limb: Reconstructive Surgeon's Perspective. Indian J Plast Surg 2019; 52:55-61. [PMID: 31456613 PMCID: PMC6664852 DOI: 10.1055/s-0039-1688101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Management of sarcomas in the lower extremities have evolved from amputations to limb-preserving surgeries with evidence to support that they have equal overall survival, albeit with better functional outcome. The challenge of reconstruction lies in providing a durable, functional, and aesthetically pleasing limb. However, limb-preserving intention should not delay interventions that provide a survival benefit such as chemotherapy and radiotherapy. The advent of radiotherapy and chemotherapy also has implications on wound healing and should be considered during the reconstructive process. This article reviews the methodical approach, reconstructive strategies, and considerations for the reconstructive surgeon with respect to the lower extremity after sarcoma excision.
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Affiliation(s)
- Zhixue Lim
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore, Singapore
| | - Sophia A Strike
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore, Singapore
| | - Mark E Puhaindran
- Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore, Singapore
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Kapoor T, Banuelos J, Adabi K, Moran SL, Manrique OJ. Analysis of clinical outcomes of upper and lower extremity reconstructions in patients with soft-tissue sarcoma. J Surg Oncol 2018; 118:614-620. [DOI: 10.1002/jso.25201] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 07/19/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Trishul Kapoor
- Department of Surgery, Division of Plastic Surgery; Mayo Clinic; Rochester Minnesota
| | - Joseph Banuelos
- Department of Surgery, Division of Plastic Surgery; Mayo Clinic; Rochester Minnesota
| | - Kian Adabi
- Department of Surgery, Division of Plastic Surgery; Mayo Clinic; Rochester Minnesota
| | - Steven L. Moran
- Department of Surgery, Division of Plastic Surgery; Mayo Clinic; Rochester Minnesota
| | - Oscar J. Manrique
- Department of Surgery, Division of Plastic Surgery; Mayo Clinic; Rochester Minnesota
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Heidekrueger PI, Ehrl D, Ninkovic M, Thiha A, Prantl L, Herter F, Mueller C, Broer PN. The spreaded gracilis flap revisited: Comparing outcomes in lower limb reconstruction. Microsurgery 2017; 37:873-880. [DOI: 10.1002/micr.30245] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 08/22/2017] [Accepted: 09/05/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Paul Immanuel Heidekrueger
- Department for Plastic, Reconstructive, Hand, and Burn SurgeryStKM‐Klinikum Bogenhausen, Academic Teaching Hospital, Technical University MunichMunich Germany
- Center of Plastic, Hand and Reconstructive SurgeryUniversity Medical Center RegensburgRegensburg Germany
| | - Denis Ehrl
- Department for Plastic, Reconstructive, Hand, and Burn SurgeryStKM‐Klinikum Bogenhausen, Academic Teaching Hospital, Technical University MunichMunich Germany
| | - Milomir Ninkovic
- Department for Plastic, Reconstructive, Hand, and Burn SurgeryStKM‐Klinikum Bogenhausen, Academic Teaching Hospital, Technical University MunichMunich Germany
| | - Aung Thiha
- Center of Plastic, Hand and Reconstructive SurgeryUniversity Medical Center RegensburgRegensburg Germany
| | - Lukas Prantl
- Center of Plastic, Hand and Reconstructive SurgeryUniversity Medical Center RegensburgRegensburg Germany
| | - Frank Herter
- Department for Plastic, Reconstructive, Hand, and Burn SurgeryStKM‐Klinikum Bogenhausen, Academic Teaching Hospital, Technical University MunichMunich Germany
| | - Camillo Mueller
- Department for Plastic and Hand SurgeryCHUV Centre de la MainLausanne Switzerland
| | - Peter Niclas Broer
- Department for Plastic, Reconstructive, Hand, and Burn SurgeryStKM‐Klinikum Bogenhausen, Academic Teaching Hospital, Technical University MunichMunich Germany
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21
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Sahijwani H, Warikoo V, Salunke AA, Shah J, Bhavsar P, Wagh R, Pathak S. Anterior Tibial Artery Perforator Plus Flaps: Role in Coverage of Posttumor Excision Defects Around the Knee Joint and Upper Leg. Asia Pac J Oncol Nurs 2017; 4:342-347. [PMID: 28966964 PMCID: PMC5559946 DOI: 10.4103/apjon.apjon_32_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective: Posttumor excision defects can be very large, and many do require postoperative radiotherapy. It is therefore important to provide stable and durable wound coverage to provide ability to withstand radiotherapy as well as providing cover to vital structures. Methods: Between July 2014 and June 2016, eight females and six male patients with defects around the knee were operated upon using a perforator plus flap from the anterior tibial artery perforator. In all except two patients, the defects were the result of posttumor extirpation, while in the latter, it was due to impending implant exposure following bone tumor excision and tibial prosthesis. A constant perforator at the neck of the fibula was found using hand-held Doppler. The base of the flap was always kept intact. The flap was then transposed toward the defect and inset in a tensionless manner. Results: The average flap dimension was 14 cm × 5.5 cm. The mean follow-up was 11 months (6–20 months). All the flaps survived well except in one patient who developed partial tip necrosis, providing stable coverage of the wound. Two patients developed local recurrence and had to undergo above-knee amputation. Conclusions: The planning for the reconstruction of defects following tumor resection is to be done in accordance with a multidisciplinary team approach involving oncosurgeon, reconstructive plastic surgeons, and radiation specialist. The perforator plus flap is an excellent choice in defects around the knee to cover neurovascular structures, bone, or implant.
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Affiliation(s)
| | - Vikas Warikoo
- Department of Oncosurgery, Gujarat Cancer Research Institute, Ahemdabad, Gujarat, India
| | | | - Jaymin Shah
- Department of Oncosurgery, Gujarat Cancer Research Institute, Ahemdabad, Gujarat, India
| | - Preetish Bhavsar
- Plastic Surgeon, Lakshmi Hospital, Dombivali, Mumbai, Maharashtra, India
| | - Rahul Wagh
- Department of Oncosurgery, Gujarat Cancer Research Institute, Ahemdabad, Gujarat, India
| | - Subodh Pathak
- Orthopedic Surgeon, Pramukswami Medical College, Anand, Gujarat, India
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22
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Franco MJ, Nicoson MC, Parikh RP, Tung TH. Lower Extremity Reconstruction with Free Gracilis Flaps. J Reconstr Microsurg 2016; 33:218-224. [PMID: 28024305 DOI: 10.1055/s-0036-1597568] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background There have been significant advancements in lower extremity reconstruction over the last several decades, and the plastic surgeon's armamentarium has grown to include free muscle and fasciocutaneous flaps along with local perforator and propeller flaps. While we have found a use for a variety of techniques for lower extremity reconstruction, the free gracilis has been our workhorse flap due to the ease of harvest, reliability, and low donor site morbidity. Methods This is a retrospective review of a single surgeon's series of free gracilis flaps utilized for lower extremity reconstruction. Demographic information, comorbidities, outcomes, and secondary procedures were analyzed. Results We identified 24 free gracilis flaps. The duration from injury to free flap coverage was ≤ 7 days in 6 patients, 8-30 days in 11 patients, 31-90 days in 4 patients, and > 90 days in 3 patients. There were 22 (92%) successful flaps and an overall limb salvage rate of 92%. There was one partial flap loss. Two flaps underwent incision and drainage in the operating room for infection. Two patients developed donor site hematomas. Four patients underwent secondary procedures for contouring. Our subset of pediatric patients had 100% flap survival and no secondary procedures at a mean 30-month follow-up. Conclusion This study demonstrates the utility of the free gracilis flap in reconstruction of small- to medium-sized defects of the lower extremity. This flap has a high success rate and a low donor site morbidity. Atrophy of the denervated muscle over time allows for good shoe fit, often obviating the need for secondary contouring procedures.
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Affiliation(s)
- Michael J Franco
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Michael C Nicoson
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Rajiv P Parikh
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Thomas H Tung
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
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Slump J, Ferguson PC, Wunder JS, Griffin A, Hoekstra HJ, Bagher S, Zhong T, Hofer SO, O'Neill AC. Can the ACS-NSQIP surgical risk calculator predict post-operative complications in patients undergoing flap reconstruction following soft tissue sarcoma resection? J Surg Oncol 2016; 114:570-575. [DOI: 10.1002/jso.24357] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 06/20/2016] [Indexed: 11/07/2022]
Affiliation(s)
- Jelena Slump
- Division of Plastic and Reconstructive Surgery; Department of Surgical Oncology; University of Toronto; Toronto Canada
- University Health Network; Department of Surgery; University of Toronto; Toronto Canada
| | - Peter C. Ferguson
- University Health Network; Department of Surgery; University of Toronto; Toronto Canada
- University Musculoskeletal Oncology Unit; Department of Surgical Oncology; Mount Sinai Hospital; Toronto Canada
| | - Jay S. Wunder
- University Health Network; Department of Surgery; University of Toronto; Toronto Canada
- University Musculoskeletal Oncology Unit; Department of Surgical Oncology; Mount Sinai Hospital; Toronto Canada
| | - Anthony Griffin
- University Health Network; Department of Surgery; University of Toronto; Toronto Canada
- University Musculoskeletal Oncology Unit; Department of Surgical Oncology; Mount Sinai Hospital; Toronto Canada
| | - Harald J. Hoekstra
- University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - Shaghayegh Bagher
- Division of Plastic and Reconstructive Surgery; Department of Surgical Oncology; University of Toronto; Toronto Canada
- University Health Network; Department of Surgery; University of Toronto; Toronto Canada
| | - Toni Zhong
- Division of Plastic and Reconstructive Surgery; Department of Surgical Oncology; University of Toronto; Toronto Canada
- University Health Network; Department of Surgery; University of Toronto; Toronto Canada
| | - Stefan O.P. Hofer
- Division of Plastic and Reconstructive Surgery; Department of Surgical Oncology; University of Toronto; Toronto Canada
- University Health Network; Department of Surgery; University of Toronto; Toronto Canada
| | - Anne C. O'Neill
- Division of Plastic and Reconstructive Surgery; Department of Surgical Oncology; University of Toronto; Toronto Canada
- University Health Network; Department of Surgery; University of Toronto; Toronto Canada
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24
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Irradiated superficial femoral artery rupture after free flap: a case report and review of the literature. Ann Plast Surg 2016; 74 Suppl 1:S15-8. [PMID: 25774967 DOI: 10.1097/sap.0000000000000432] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Radical oncologic resection can result in large soft tissue defects with exposure of underlying vessels. Unless immediately covered with viable soft tissue, these vessels are vulnerable to desiccation from air exposure and mechanical trauma. Local radiation treatment also contributes to a decline in vessel wall strength. We present an index case of a patient with prolonged exposure of her femoral bone and superficial femoral artery after an initial failed reconstruction of a soft tissue sarcoma resection defect. We provided coverage using a free latissimus dorsi muscle flap. Two weeks after the initial free flap operation, the patient was readmitted to emergency service with profuse bleeding from beneath the free flap. Intraoperative inspection revealed a 2-cm defect of the irradiated superficial femoral artery. The defect was repaired with cryopreserved human arterial graft, and the flap was reset. This case highlights the importance of immediate coverage of soft tissue defects after oncologic resection. If any vessels are left exposed, they should be closely inspected before a delayed flap coverage to rule out future sources of bleeding that may jeopardize the outcomes of an otherwise successful free flap operation.
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López JF, Hietanen KE, Kaartinen IS, Kääriäinen MT, Pakarinen TK, Laitinen M, Kuokkanen H. Primary flap reconstruction of tissue defects after sarcoma surgery enables curative treatment with acceptable functional results: a 7-year review. BMC Surg 2015; 15:71. [PMID: 26055763 PMCID: PMC4460917 DOI: 10.1186/s12893-015-0060-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 05/29/2015] [Indexed: 12/31/2022] Open
Abstract
Background Sarcomas, a heterogeneous group of tumors, are challenging to treat and require multidisciplinary cooperation and planning. We analyzed the efficacy of flap reconstruction in patients with bone and soft tissue sarcoma. Methods Patient charts and operative records were retrospectively reviewed from January 2006 through October 2013 to identify sarcoma patient characteristics, postoperative complications, revisions, recurrences, and survival. Pedicled and/or free flap reconstruction was performed in 109 patients. Flap selection was based on defect size, and exposure of anatomically critical structures or major orthopedic implants. Results Of 109 patients, 71 (65.1 %) were men, and mean age was 56.4 years. Tumors most frequently located in a lower extremity (38.7 %). Primary sarcomas comprised 79.2 % and recurrences occurred in 18.9 %. Wide resection was performed for 65.7 %, and there were 10 planned amputations combined with flap reconstruction. A total of 111 tumors received 128 flaps: 76 pedicled flaps, 42 free flaps, and 5 combined (10 total) pedicled + free-flaps. The success rate was 94 % for the pedicled flap group, 97 % for the free-flap group, and 100 % for the pedicle + free-flap group. Of 35 patients, 5 developed deep prosthetic infections. Only one amputation due to disease progression was performed. Satisfactory functional outcome was achieved in 69 %. Survival rate during a mean (standard deviation) 3(2) year follow-up was 83.5 %. Conclusions Primary flap reconstruction after sarcoma surgery satisfies oncologic goals. Large tumors in difficult areas can be removed and complete tumor resection achieved. Our findings indicate a high survival rate after sarcoma surgery utilizing flap reconstruction and a low recurrence rate.
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Affiliation(s)
- Jenny Fabiola López
- Department of Plastic Surgery, Unit of Musculoskeletal Diseases, Tampere University Hospital, Pirkanmaa Hospital District, Teiskontie 35, PO BOX 2000, Tampere, 33521, Finland.
| | - Kristiina Elisa Hietanen
- Department of Plastic Surgery, Unit of Musculoskeletal Diseases, Tampere University Hospital, Pirkanmaa Hospital District, Teiskontie 35, PO BOX 2000, Tampere, 33521, Finland
| | - Ilkka Santeri Kaartinen
- Department of Plastic Surgery, Unit of Musculoskeletal Diseases, Tampere University Hospital, Pirkanmaa Hospital District, Teiskontie 35, PO BOX 2000, Tampere, 33521, Finland
| | - Minna Tellervo Kääriäinen
- Department of Plastic Surgery, Unit of Musculoskeletal Diseases, Tampere University Hospital, Pirkanmaa Hospital District, Teiskontie 35, PO BOX 2000, Tampere, 33521, Finland
| | - Toni-Karri Pakarinen
- Department of Orthopedics and Trauma, Unit of Musculoskeletal Diseases, Tampere University Hospital, Tampere, Finland
| | - Minna Laitinen
- Department of Orthopedics and Trauma, Unit of Musculoskeletal Diseases, Tampere University Hospital, Tampere, Finland
| | - Hannu Kuokkanen
- Department of Plastic Surgery, Unit of Musculoskeletal Diseases, Tampere University Hospital, Pirkanmaa Hospital District, Teiskontie 35, PO BOX 2000, Tampere, 33521, Finland
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Lower Limb Core Scale: a new application to evaluate and compare the outcomes of bone and soft-tissue tumours resection and reconstruction. BIOMED RESEARCH INTERNATIONAL 2014; 2014:652141. [PMID: 25162021 PMCID: PMC4137603 DOI: 10.1155/2014/652141] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 07/03/2014] [Accepted: 07/07/2014] [Indexed: 11/18/2022]
Abstract
Several methods are used to evaluate the functional outcome of tumour resections and reconstructions in the lower limb. However, one of their most common limitations is that they are specifically developed to evaluate only oncological patients. We introduced the Lower Limb Core Scale (LLCS) to overcome this limitation. The aim of this study was to evaluate the functional and subjective results in the lower limb and to evaluate the use of the LLCS. We conducted a retrospective cohort study using various tools to investigate the outcomes. The results of the LLCS were correlated with the results of other functional tests. A total of 44 patients were included in the study. None of the demographic variables correlated with the functional or health-related quality of life (QoL) scores except for gender, whereby male patients had an increased functional score. The correlation between LLCS and other scores was positive (r (2) = 0.77). The satisfactory QoL scores, and functional outcomes scores indicated the LLCS to be a reliable option for general and specific evaluation of lower limb reconstructions. We suggest using the LLCS for comparisons of oncological reconstructions with lower limb reconstructions in different disciplines.
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27
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Schneider LF, Kaplan KA, Mehrara BJ. Pedicled peroneal artery flap for popliteal fossa reconstruction. J Plast Reconstr Aesthet Surg 2014; 67:282-4. [DOI: 10.1016/j.bjps.2013.07.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 07/15/2013] [Accepted: 07/15/2013] [Indexed: 11/15/2022]
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Predictive Factors of Wound Complications After Sarcoma Resection Requiring Plastic Surgeon Involvement. Ann Plast Surg 2013; 71:283-5. [DOI: 10.1097/sap.0b013e31827c7973] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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29
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Senchenkov A, Sim FH. The use of ovarian vessels for microvascular tissue transfer in lower extremity limb salvage. Microsurgery 2012; 33:148-51. [PMID: 23152123 DOI: 10.1002/micr.22056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 08/29/2012] [Accepted: 09/04/2012] [Indexed: 11/10/2022]
Abstract
Limb salvage procedures in previously operated, radiated, and vessel-depleted fields rely heavily on the use of microvascular tissue transfer. This report illustrates the feasibility of the use of ovarian vessels for the revascularization of a free flap. We have achieved success with the use of rectus abdominis muscle free flap for coverage of exposed vascular reconstruction in the 75-year-old soft tissue sarcoma patient with twice chemoradiated femoral and hypogastric defect, preventing external hemipelvectomy.
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Affiliation(s)
- Alex Senchenkov
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA.
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Functional reconstruction of sarcoma defects utilising innervated free flaps. Sarcoma 2012; 2012:315190. [PMID: 22969309 PMCID: PMC3434415 DOI: 10.1155/2012/315190] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 07/16/2012] [Indexed: 11/17/2022] Open
Abstract
Soft-tissue reconstruction following preoperative radiotherapy and wide resection of soft tissue sarcoma remains a challenge. Pedicled and free tissue transfers are an essential part of limb sparing surgery. We report 22 cases of sarcoma treated with radiotherapy and wide excision followed by one-stage innervated free or pedicled musculocutaneous flap transfers. The resection involved the upper limb in 3 cases, the lower limb in 17, and the abdominal wall in 2. The flaps used for the reconstruction were mainly latissimus dorsi and gracilis. The range of motion was restored fully in 14 patients. The muscle strength of the compartment reconstructed was of grades 4 and 5 in all patients except one. The overall function was excellent in all the cases with functional scores of 71.2% in the upper limb and 84% in the lower limb. The only 2 major complications were flap necrosis, both revised with another flap, one of which was innervated with restoration of function. Innervated flaps are valuable alternatives for reconstruction after sarcoma resection in the extremity and in the abdominal wall. The excellent functional results are encouraging, and we believe that innervated muscle reconstruction should be encouraged in the treatment of sarcoma after radiotherapy and wide resection.
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Kim TG, Kim IK, Kim YH, Lee JH. Reconstruction of lower extremity complex wounds with combined free tissue transfer using the anterolateral thigh flap as a link. Microsurgery 2012; 32:575-9. [PMID: 22807276 DOI: 10.1002/micr.22014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Revised: 05/10/2012] [Accepted: 05/14/2012] [Indexed: 11/08/2022]
Abstract
In this report, the authors present the experience on the reconstruction of the totally degloved foot and extremely long soft tissue defect of a lower limb with the combined free tissue transfer using the anterolateral thigh flap as a link in two male patients between October 2009 and December 2010. The anterolateral thigh flap has been commonly used as a link between the recipient site and the distal flap. The anterolateral thigh flap and latissimus dorsi muscle flap were selected for the distal flap, according to their reconstructive needs. Two combined free flaps survived without major complication. The authors could salvage of the lower extremity through the reconstruction of complex wound with the combined free tissue transfer using the anterolateral thigh flap as a link. This combined flap may be an alternative for reconstruction of complex soft tissue defect in the lower extremity.
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Affiliation(s)
- Tae-Gon Kim
- Department of Plastic and Reconstructive Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea.
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Grainger MF, Grimer RJ, Carter SR, Tillman RM. Wound complications following resection of adductor compartment tumours. Sarcoma 2011; 5:203-7. [PMID: 18521315 PMCID: PMC2395462 DOI: 10.1080/13577140120099191] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Purpose Limb salvage surgery of soft tissue sarcomas is associated with both a risk of local recurrence and wound complications.
Although the lower limb appears to be at greater risk of wound-related morbidity, few studies separate anatomical
compartments. We believe that the adductor compartment of the thigh has a particularly high rate of complications and so
performed a retrospective analysis of all soft tissue sarcomas arising in this region undergoing limb salvage. Patients Patients with intermediate and high grade adductor compartment tumours were identified from our database and
the case notes were reviewed for patient, tumour, surgical and wound variables, identifying those with wound complications
both before and after discharge. Results Of 49 patients who underwent limb salvage surgery, 22 (42.9%) developed complications. Twelve patients (24.5%)
required further surgery prior to wound healing and 10 patients had delays in post-operative radiotherapy. There were significant
differences in the rates of preceding surgery, open biopsy performed at other centres and previous radiotherapy to this
region between the complicated and uncomplicated groups. Discussion The management of these difficult tumours carries a high rate of wound complications and requires careful planning
prior to tissue biopsy. Open biopsies should be performed by the tumour surgeon to allow easy inclusion of this site in
the definitive procedure. In previously irradiated or operated limbs, alternative strategies for wound management may need
to be considered.
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Steinau HU, Daigeler A, Langer S, Steinsträsser L, Hauser J, Goertz O, Lehnhardt M. Limb salvage in malignant tumors. Semin Plast Surg 2010; 24:18-33. [PMID: 21286302 PMCID: PMC2887000 DOI: 10.1055/s-0030-1253240] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Limb-sparing resection and reconstruction has become the treatment of choice in extremity malignancies, as amputation does not provide better long-term survival rates or functional advantages. R0 resection, the removal of the tumor in sano, remains the prerequisite and most important oncologic parameter to avoid local recurrence. Successful treatment requires the combination of surgical eradication and the patient's specific functional and aesthetic rehabilitation. Our clinical rationale resulting from more than 2000 cases will be demonstrated. The problematic aspects of different tumor entities and the locoregional clearance of lymphatic pathways will be discussed. Differential diagnosis and multimodality treatment in high-volume tumor centers is likely to achieve superior oncologic statistics. Long-term survivors after microsurgical reconstructions and possible secondary malignancies will be addressed.
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Affiliation(s)
- Hans-Ulrich Steinau
- Department of Plastic Surgery and Burns, Sarcoma Reference Center, BG–University Hospital “Bergmannsheil,” Ruhr-University, Bochum, Germany
| | - Adrien Daigeler
- Department of Plastic Surgery and Burns, Sarcoma Reference Center, BG–University Hospital “Bergmannsheil,” Ruhr-University, Bochum, Germany
| | - Stefan Langer
- Department of Plastic Surgery and Burns, Sarcoma Reference Center, BG–University Hospital “Bergmannsheil,” Ruhr-University, Bochum, Germany
| | - Lars Steinsträsser
- Department of Plastic Surgery and Burns, Sarcoma Reference Center, BG–University Hospital “Bergmannsheil,” Ruhr-University, Bochum, Germany
| | - Jörg Hauser
- Department of Plastic Surgery and Burns, Sarcoma Reference Center, BG–University Hospital “Bergmannsheil,” Ruhr-University, Bochum, Germany
| | - Ole Goertz
- Department of Plastic Surgery and Burns, Sarcoma Reference Center, BG–University Hospital “Bergmannsheil,” Ruhr-University, Bochum, Germany
| | - Markus Lehnhardt
- Department of Plastic Surgery and Burns, Sarcoma Reference Center, BG–University Hospital “Bergmannsheil,” Ruhr-University, Bochum, Germany
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Davidge KM, Wunder J, Tomlinson G, Wong R, Lipa J, Davis AM. Function and health status outcomes following soft tissue reconstruction for limb preservation in extremity soft tissue sarcoma. Ann Surg Oncol 2010; 17:1052-62. [PMID: 20107912 DOI: 10.1245/s10434-010-0915-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND While advances in reconstructive surgery have facilitated limb preservation in extremity soft tissue sarcoma (ESTS), limited information exists as to the functional outcome of patients with these reconstructed extremities. The primary objective of this study is to evaluate the impact of flap reconstruction on postoperative function and health status in patients undergoing limb-salvage surgery for ESTS. METHODS Clinical and outcome data for eligible patients were extracted from a prospectively maintained database of sarcoma patients. Four outcome measures were used to assess three domains of function (impairments, activity limitations, and participation restrictions), and health status. The effect of soft tissue reconstruction on function and health status at 1-2-year follow-up was analyzed using univariate and multivariate regression. RESULTS Two hundred and forty-seven patients met eligibility criteria, including 56 patients receiving flap reconstruction and 191 patients treated with primary closure. Patients receiving flaps had larger (9.8 versus 7.1 cm; P = 0.003), higher-grade (93% versus 72%; P = 0.001) tumors, and more frequently received radiotherapy (89% versus 72%; P = 0.007), and bone (20% versus 4%; P = 0.001) and motor nerve resection (21% versus 10%; P = 0.032). Flap reconstruction was associated with more postoperative impairments [Musculoskeletal Tumor Society (MSTS) score 30.4 versus 32.2; P = 0.004] and activity limitations [Toronto Extremity Salvage Score (TESS) score 83.3 versus 89.5; P = 0.0132] on univariate analyses, but did not significantly predict postoperative function or health status outcomes on multivariate analyses. CONCLUSIONS Flap reconstruction was not an independent predictor of function and health status outcomes in patients with ESTS. However, ESTS patients receiving flaps had other clinical features placing them at risk for worse postoperative outcomes.
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Affiliation(s)
- Kristen M Davidge
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Canada.
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Takeuchi A, Tsuchiya H, Shirai T, Hayashi K, Nishida H, Tomita K. Occlusive dressing for large soft tissue defects following soft tissue tumor excision. J Orthop Sci 2009; 14:385-90. [PMID: 19662471 DOI: 10.1007/s00776-009-1353-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2008] [Accepted: 03/13/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Reconstructive surgery using pedicles or free muscle-skin flaps and skin grafting reduces wound complications and promotes favorable limb function; however, the sacrifice of normal tissue remains problematic and complicated. Occlusive dressings are widely employed for management of injuries, burns, and surgical wounds. However, their effectiveness for treating soft tissue defects following a soft tissue tumor excision has not been fully elucidated. The purpose of this study was to evaluate the effectiveness and safety of an occlusive dressing treatment method for soft tissue defects following soft tissue tumor excisions. METHODS We retrospectively reviewed eight patients (three men, five women) whose wounds were treated with polyurethane foam occlusive dressings to allow reconstruction of the soft tissue defect following soft tissue tumor excision. Their mean age was 64.5 years (range 23-83 years), and the mean size of the defect was 60.1 cm(2) (range 20-144 cm(2)). The wound was covered with a hydrophilic polyurethane dressing material. The treatment periods, incidence of complications, and ultimate outcomes were evaluated. RESULTS Seven defects were completely healed by secondary intention without the requirement of any additional surgery. Mean treatment periods were 21.6 weeks (range 13.5-44.0 weeks). Mean follow-up periods were 33.1 months (range 15.8-48.6 months). One patient with a recurrent malignant fibrous histiocytoma (MFH) who had a history of radiotherapy required a posterior thigh flap 44 weeks after the surgery. Recurrence due to a positive surgical margin was observed in only one patient with recurrent MFH. None of the patients exhibited clinical evidence of superficial or deep infection. CONCLUSIONS This treatment method is simple, safe, and reliable. We concluded that the highly favorable indications of this treatment are ideal for patients who wish to avoid sacrificing their normal tissue, have no history of radiotherapy before surgery, and do not require chemotherapy or radiotherapy after the operation.
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Affiliation(s)
- Akihiko Takeuchi
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Science, 13-1 Takara-machi, Kanazawa, Japan
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Abstract
The current recommendation for surgical treatment of tumors of the lower extremity is a limb-sparing resection. Limb-sparing resection coupled with complex reconstructive techniques and complemented by new chemotherapeutic agents and adjuvant radiation therapy has allowed us to achieve survival rates that are comparable to those of amputation with a better functional outcome. Recent advances in microsurgical techniques and the associated technologies and a better understanding of microvascular anatomy has allowed us to customize flaps to the specific needs of the patients and to achieve a lower donor site morbidity. Increased communication between the specialties of the multidisciplinary treatment team has also improved outcomes. The reconstructive component has become an integral part of the multidisciplinary care for patients with lower extremity tumors. It not only allows them to rapidly resume adjuvant therapies but also enables them to more easily resume their activities of daily living.
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Affiliation(s)
- Lior Heller
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Chattar-Cora D, Perez-Nieves R, McKinlay A, Kunasz M, Lyons RC. Free tissue transfer at an army medical center. EUROPEAN JOURNAL OF PLASTIC SURGERY 2006. [DOI: 10.1007/s00238-006-0093-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Nagoshi N, Anazawa U, Morioka H, Mukai M, Yabe H, Toyama Y. Epithelioid sarcoma arising on the forearm of a 6-year-old boy: case report and review of the literature. Pediatr Surg Int 2006; 22:771-3. [PMID: 16786373 DOI: 10.1007/s00383-006-1690-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2006] [Indexed: 10/24/2022]
Abstract
Epithelioid sarcoma is a rare malignant tumor that occurs mainly in young adults and most frequently involves the distal portion of the upper extremities. The tumor is particularly rare in children and more frequently involves the head and neck; only one case involving the forearm has been reported in a child under 10 years of age, and he was treated with amputation. We report the case of a 6-year-old boy with an epithelioid sarcoma of the forearm whose initial management had been inappropriate. The patient was ultimately treated with limb sparing surgery. Two years later, no local recurrence was evident but pleural metastases were detected.
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Affiliation(s)
- N Nagoshi
- Department of Orthopedic Surgery, Keio University School of Medicine, Shinanomachi 35, Shinjuku-ku, Tokyo, 160-8582, Japan.
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Hoy E, Granick M, Benevenia J, Patterson F, Datiashvili R, Bille B. Reconstruction of Musculoskeletal Defects Following Oncologic Resection in 76 Patients. Ann Plast Surg 2006; 57:190-4. [PMID: 16862001 DOI: 10.1097/01.sap.0000216255.18106.e1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Between 1990 and 2002, 76 patients underwent 102 muscle flap reconstructions for extremity sarcomas. The patients had radical resection with immediate reconstruction. Reconstructions were performed by the Musculoskeletal Oncology and Plastic Surgery services. The mean age of our patients was 39.1 years. Patients were studied for a mean of 25.4 months. There were 79 pedicle flaps and 23 free flaps. Complications occurred in 23.7% of patients, including wound necroses, seromas, postoperative bleeding, postoperative infections, and flap loss. Five patients required a secondary flap procedure. The overall flap survival rate was 98%. Three patients had local recurrences. Sixteen patients (21.1%) have died of their disease. Five patients are alive with metastases. In 54 patients, Musculoskeletal Tumor Society (MSTS) functional evaluation scores averaged 27.1 (range, 12-30). In this large series of patients, we have demonstrated that, although minor complications are common, functional limbs can be salvaged following oncologic resection from the extremities.
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Affiliation(s)
- Erik Hoy
- Department of Surgery, Division of Plastic Surgery, New Jersey Medical School, UMDNJ, Newark, NJ, USA
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40
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Rivas B, Carrillo JF, Oñate-Ocaña LF. Functional Evaluation After Reconstruction With Myocutaneous and Fasciocutaneous Flaps for Conservative Oncological Surgery of the Extremities. Ann Surg Oncol 2006; 13:721-7. [PMID: 16523368 DOI: 10.1245/aso.2006.04.044] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2005] [Accepted: 11/10/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND Limb-preservation surgery has evolved during the last two decades through application of pedicled and free flaps and has obtained oncological results similar to those with amputation for malignant neoplasms of the extremities. However, functional evaluation has not been performed comprehensively after these advanced reconstructive procedures. The aim of this study was to describe the oncological, surgical, and functional outcomes achieved in these patients. METHODS Patients had malignant neoplasms of the extremities and/or shoulder and hip girdle, underwent resective surgery and reconstruction with limb-preservation purposes, and were treated from 1997 to 2002. Survival analysis was performed, and functional evaluation after resection was performed with the Enneking system 1 year after surgery. RESULTS Thirty-two patients were included. The mean overall survival of the cohort was 5.6 years. Functional evaluation mean rating percentages for the upper and lower extremities were 86.5% and 75.2%. Functional outcomes were better for reconstruction with free flaps than with pedicled flaps in the lower extremities (rating percentages, 67% and 79.6%, respectively; P = .018). CONCLUSIONS Limb-preservation surgery is a safe treatment for malignant neoplasms. It can be performed with low morbidity and good oncological outcomes. Functional results in our series were good. Lower limb preservation has superior scores with free flap reconstructions because of their potential to cover extensive defects, and better results were obtained in walking, gait, and weight bearing.
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Affiliation(s)
- Bernardo Rivas
- Plastic Surgery Service, Surgery Division, Instituto Nacional de Cancerologia, San Fernando 22, México D.F., 14080, Mexico.
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Leow AM, Halim AS, Wan Z. Reconstructive treatment following resection of high-grade soft-tissue sarcomas of the lower limb. J Orthop Surg (Hong Kong) 2005; 13:58-63. [PMID: 15872402 DOI: 10.1177/230949900501300110] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To review the role of free tissue transfer in reconstructive surgery following resection of high-grade soft-tissue sarcomas of the lower limb. METHODS Medical records of all consecutive patients with high-grade soft-tissue sarcomas of the lower limbs between August 1997 and September 2003 were reviewed. RESULTS Of 8 patients (6 women and 2 men) aged between 19 and 65 years, 4 had malignant fibrous histiocytoma, one had malignant peripheral nerve sheath tumour, one had synovial sarcoma, one had recurrent liposarcoma, and one had epitheloid sarcoma. The tumour sizes ranged from 132 cm(2) to 483 cm(2). The soft-tissue defects following tumour extirpation ranged from 153 cm(2) to 896 cm(2). The flaps used were 3 free latissimus dorsi flaps, 2 free osteoseptocutaneous fibula flaps (one vascularised fibula flap and one 'double barrel' fibula flap), one free rectus abdominis flap, 2 free mini-transverse rectus abdominis flaps, and one pedicled rectus abdominis flap. Five patients did not have local recurrence and systemic metastases. CONCLUSION Tissue transfer allows early adjuvant therapy facilitating the multimodal approach for the high-grade soft-tissue sarcomas of the lower extremity.
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Affiliation(s)
- A M Leow
- Reconstructive Sciences Department, Hospital Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
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Spierer MM, Alektiar KM, Zelefsky MJ, Brennan MF, Cordiero PG. Tolerance of tissue transfers to adjuvant radiation therapy in primary soft tissue sarcoma of the extremity. Int J Radiat Oncol Biol Phys 2003; 56:1112-6. [PMID: 12829149 DOI: 10.1016/s0360-3016(03)00200-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
PURPOSE Treatment of extremity sarcomas occasionally requires tissue transfer in the form of pedicle flaps, free flaps, or skin grafts to repair surgical defects. These tissues are often subject to radiation (RT) and are therefore at risk for wound breakdown requiring reoperation. This study reviews a single center's experience with tissue transfer and postoperative RT. METODS AND MATERIALS: Between 1983 and 2000, 43 adult patients (>16 years old) with primary high-grade soft tissue extremity sarcomas underwent limb-sparing surgery and reconstruction of their surgical defects, followed by adjuvant RT. The reconstructions were as follows: pedicle flaps (n = 14), free flaps (n = 10), skin grafts (n = 4), or a combination (n = 15). Postoperative external beam radiation therapy (EBRT) (median dose: 63 Gy) alone was given to 27 patients (63%). Adjuvant brachytherapy (BRT) was given to 16 patients (37%); BRT alone (median dose: 45 Gy) was given to 12 patients and combined with EBRT for 4 patients (EBRT: 45 Gy; BRT: 20 Gy). Comorbid conditions such as diabetes, hypertension, tobacco use, and obesity (calculated using body mass index >or=30) were present in 30 patients (70%). Tumor characteristics were as follows: 26 were >5 cm in size, 37 were deep, and 30 were in the lower extremity. The median follow-up time, calculated from the date of operation, was 32 months. Five of 43 patients suffered wound complications necessitating reoperation; however, 3 patients developed complications before initiation of RT and were therefore excluded from the analysis. Two of 43 patients (5%) required reoperation for wound complications after RT; 1 of these patients ultimately required amputation for necrosis. The 5-year overall wound reoperation rate was 6% (95% confidence interval: 0-14%). The influence of patient and tumor characteristics, as well as the type of RT, on the wound reoperation rates is as follows: BRT vs. EBRT (17% vs. 0%, p = 0.06); upper vs. lower extremity (0% vs. 8%, p = 0.41); <or=5 cm vs. >5 cm (8% vs. 4%, p = 0.9); comorbidity vs. no comorbidity (3% vs. 13%, p = 0.8); age <or=50 vs. >50 (8% vs. 4%, p = 0.8). CONCLUSION Based on this review, most tissue transfers (95%) tolerated subsequent adjuvant radiation therapy well. Although more wound complications necessitating reoperation were seen in patients who received BRT, whether this is because of the inherent susceptibility of flaps and skin grafts to breakdown in the immediate postoperative period vs. the direct result of BRT needs further investigation.
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Affiliation(s)
- Marnee M Spierer
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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Mastorakos DP, Disa JJ, Athanasian E, Boland P, Healey JH, Cordeiro PG. Soft-tissue flap coverage maximizes limb salvage after allograft bone extremity reconstruction. Plast Reconstr Surg 2002; 109:1567-73. [PMID: 11932598 DOI: 10.1097/00006534-200204150-00012] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Limb salvage after extremity tumor ablation may include the use of allograft bone. The primary complication of this method is infection of the allograft, which can lead to limb loss in up to 50 percent of cases. The purpose of this study is to evaluate the efficacy of primary muscle flap coverage in the setting of allograft bone limb salvage surgery. This study is a prospective review of all patients with flap coverage of extremity allografts over the 10-year period 1991 to 2001. There were 20 patients (11 male and nine female patients) with an average age of 28 years (range, 6 to 72 years). Flap coverage was primary in 16 patients and delayed in four. Delayed coverage was performed for failed wounds that did not have a primary soft-tissue flap. Pathologic findings included osteosarcoma in nine patients, Ewing sarcoma in five patients, malignant fibrohistiocytoma in two patients, chondrosarcoma in two patients, synovial sarcoma in one patient, and leiomyosarcoma in one patient. Allograft reconstruction was performed for the upper extremity in 12 patients and for the lower extremity in eight patients. Flap reconstruction was accomplished with 20 pedicle flaps in 17 patients (latissimus dorsi, 12; gastrocnemius, four; soleus, three; and fasciocutaneous flap, one) and four free flaps (rectus abdominis, three; latissimus dorsi, one) in four patients. All pedicled flaps survived. There was one flap failure in the entire series, which was a free rectus abdominis flap. This case resulted in the only limb loss noted. The follow-up period ranged from 1 to 50 months (average, 12.35 months). At the time of final follow-up, three patients were dead of disease and 17 were alive with intact extremities. The overall limb salvage rate in the setting of bone allograft and soft-tissue flap coverage was 95 percent (19 of 20). Reoperation for bone-related complications was required in 50 percent (two of four) of cases receiving delayed flap coverage compared with 19 percent (three of 16) of patients with primary flap coverage (statistically not significant). The results of this study support the use of soft-tissue flap coverage for allograft limb reconstruction. In this series, no limb was lost in the setting of a viable flap. Reoperation was markedly reduced in the setting of primary flap coverage. Pedicled or microvascular transfer of well-vascularized muscle can be used to wrap the allograft and minimize devastating wound complications potentially leading to loss of allograft and limb.
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Affiliation(s)
- Dimitrios P Mastorakos
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, and the Weill College of Medicine, Cornell University, New York, NY 10021, USA
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Langstein HN, Chang DW, Miller MJ, Evans GRD, Reece GP, Kroll SS, Robb GL. Limb salvage for soft-tissue malignancies of the foot: an evaluation of free-tissue transfer. Plast Reconstr Surg 2002; 109:152-9. [PMID: 11786807 DOI: 10.1097/00006534-200201000-00025] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Free flaps may safely allow meaningful ambulation, durable limb preservation, and better quality of life in patients undergoing resections of soft-tissue cancers of the foot. To prove this, the records of a series of patients at The University of Texas M. D. Anderson Cancer Center (n = 67) who underwent limb salvage following tumor-related resection (n = 71 procedures) from 1989 to 1999 were retrospectively reviewed. Eighteen patients who were not candidates for local flaps or skin grafts received a total of 20 free flaps to preserve their limbs. Most defects (mean size, 78 cm2; range, 20 to 150 cm2) were on a weight-bearing surface of the foot (nine on a weight-bearing heel, three on a plantar foot); the remainder were on a non-weight-bearing surface (six on dorsum, two on a non-weight-bearing heel). Melanoma was diagnosed in nine cases (50 percent); soft-tissue sarcoma, in seven (39 percent); and squamous cell carcinoma, in two (11 percent). Fasciocutaneous and skin-grafted muscle flaps were used on both weight-bearing and non-weight-bearing surfaces. Free-tissue transfer was successful in 17 of 20 cases (85 percent); the three flap losses occurred in two patients. Minor complications (i.e., small hematoma, partial skin graft loss, and delayed wound healing) occurred in five patients. In all cases of successful free-tissue transfer, patients began partial weight bearing at a mean of 7.4 weeks (range, 2 to 12 weeks), and all ultimately achieved full weight bearing. Sixty-seven percent still required special footwear. In one patient, an ulceration on the weight-bearing portion of the flap resolved after a footwear adjustment. Only one patient was lost to follow-up (mean, 23 months). In the 17 remaining patients, limb salvage succeeded in 15 (88 percent). Of these, nine (60 percent) were alive without evidence of disease, three (20 percent) were alive with disease, and three (20 percent) had died of disease. Local recurrence developed in two patients but was successfully treated by excision and closure. No late amputations were required for local control. Thus, it seems that free flaps help facilitate limb salvage and that they may preserve meaningful limb function in patients who undergo resection of soft-tissue malignancies of the foot.
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Affiliation(s)
- Howard N Langstein
- Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030-4395, USA.
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Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Understand the indications for the use of free-tissue transfer in lower extremity reconstruction. 2. Understand modalities to enhance the healing and care of soft tissue and bone before free-tissue transfer. 3. Understand the lower extremity reconstructive ladder and the place of free-tissue transfer on the ladder. 4. Understand the specific principles of leg, foot, and ankle reconstruction. 5. Understand the factors that influence the decision to perform an immediate versus a delayed reconstruction. Free-tissue transfer using microsurgical techniques is now routine for the salvage of traumatized lower extremities. Indications for microvascular tissue transplantation for lower extremity reconstruction include high-energy injuries, most middle and distal-third tibial wounds, radiation wounds, osteomyelitis, nonunions, and tumor reconstruction. The authors discuss the techniques and indications for lower extremity reconstruction.
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Affiliation(s)
- L Heller
- Division of Plastic, Reconstructive, Maxillofacial, and Oral Surgery, Duke University Medical Center, Durham, NC 27710, USA
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46
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Melendez M, Brandt K, Evans GR. Sciatic nerve reconstruction: limb preservation after sarcoma resection. Ann Plast Surg 2001; 46:375-81. [PMID: 11324878 DOI: 10.1097/00000637-200104000-00004] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Limb salvage for extremity sarcoma has become the standard of care when possible. This review attempts to determine the outcome of sciatic nerve reconstruction after surgical tumor resection. The authors' objective was to determine the clinical value of extremity salvage with such a defect. Five patients (two male, three female) were selected from a department database at The University of Texas M.D. Anderson Cancer Center between 1995 and 1999 who met the following criteria: lower limb tumor resection involving a gap in the sciatic nerve with subsequent nerve autograft reconstruction. An additional patient who underwent primary sciatic nerve neurorrhaphy was also included. The average tumor size was 203 cm2. The most common tumor histology was spindle cell sarcoma. The average autograft length was 13 +/- 3.2 cm with one to four cables employed. Currently, 3 patients are still alive. Four of the 5 patients who received sciatic autonerve grafts reported partial distal sensory recovery subjectively. The patient who underwent primary neurorrhaphy has both motor and sensory innervation 42 months after surgery. Although not ideal for all patients, sciatic nerve reconstruction is a viable option for those willing to undergo limb preservation. Notable limitations to daily activity do not appear to be present, and patients are able to ambulate with or without assistive devices. With aggressive rehabilitation, some patients are able to function quite well with this bioprosthesis. Patients should consider, however, that their extremity is on loan. Substantial wound complications or infections may ultimately lead to amputation.
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Affiliation(s)
- M Melendez
- Department of Plastic Surgery, The University of Texas, MD Anderson Cancer Center, Houston, USA
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47
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Redett RJ, Robertson BC, Chang B, Girotto J, Vaughan T. Limb salvage of lower-extremity wounds using free gracilis muscle reconstruction. Plast Reconstr Surg 2000; 106:1507-13. [PMID: 11129178 DOI: 10.1097/00006534-200012000-00010] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
An extensive series reviewing the benefits and drawbacks of use of the gracilis muscle in lower-extremity trauma has not previously been collected. In this series of 50 patients, the use of microvascular free transfer of the gracilis muscle for lower-extremity salvage in acute traumatic wounds and posttraumatic chronic wounds is reviewed. In addition, the wound size, injury patterns, problems, and results unique to the use of the gracilis as a donor muscle for lower-extremity reconstruction are identified. In a 7-year period from 1991 to 1998, 50 patients underwent lower-extremity reconstruction using microvascular free gracilis transfer at the University of Maryland Shock Trauma Center, Johns Hopkins Hospital, and Johns Hopkins Bayview Medical Center. There were 22 patients who underwent reconstruction for coverage of acute lower-extremity traumatic soft-tissue defects associated with open fractures. The majority of patients were victims of high-energy injuries with 91 percent involving motor vehicle or motorcycle accidents, gunshot wounds, or pedestrians struck by vehicles. Ninety-one percent of the injuries were Gustilo type IIIb tibial fractures and 9 percent were Gustilo type IIIc. The mean soft-tissue defect size was 92.2 cm2. Successful limb salvage was achieved in 95 percent of patients. Twenty-eight patients with previous Gustilo type IIIb tibia-fibula fractures presented with posttraumatic chronic wounds characterized by osteomyelitis or deep soft-tissue infection. Successful free-tissue transfer was accomplished in 26 of 28 patients (93 percent). All but one of the patients in this group who underwent successful limb salvage (26 of 27, or 96 percent) are now free of infection. Use of the gracilis muscle as a free-tissue transfer has been shown to be a reliable and predictable tool in lower-extremity reconstruction, with a flap success and limb salvage rate comparable to those in other large studies.
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Affiliation(s)
- R J Redett
- Department of Surgery, the Johns Hopkins School of Medicine, Baltimore, MD, USA
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48
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Abstract
Microvascular reconstruction has revolutionized the care of the lower extremity oncology patient. Radical limb-sparing surgeries may now be performed with the reconstructive option of unlimited transfer of tissues from elsewhere in the body. In its infancy, free tissue transfer provided vascularized tissue for wound closure. Experience with microsurgery and creative thinking have now combined to address limb function and aesthetics. In oncologic surgery, limb salvage of a functional lower extremity is currently the rule, not the exception. Semin. Surg. Oncol. 19:272-281, 2000.
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Affiliation(s)
- M R Zenn
- Division of Plastic and Reconstructive Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA.
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49
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Ohjimi H, Taniguchi Y, Kawano K, Kinoshita K, Manabe T. A comparison of thinning and conventional free-flap transfers to the lower extremity. Plast Reconstr Surg 2000; 105:558-66. [PMID: 10697161 DOI: 10.1097/00006534-200002000-00013] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study compares the application of conventional free flaps and thinning flaps to the lower extremities. Thirty patients whose skin and soft tissue of the lower extremities had been reconstructed were divided into two groups: a conventional flap group, reconstructed using conventional free flaps (15 cases), and a thinning flap group, reconstructed using thinning flaps (15 cases). Postoperative complications, long-term results, and revisional surgery were studied in the two groups. Although survival after surgery was the same in both, in the conventional flap group, 11 patients required secondary revisional surgery, the excessive bulk of the flap resulting in poor aesthetics and difficulty in wearing shoes. The conventional flap group also required longer treatment. In the thinning flap group, only 5 of 15 patients received secondary revisional surgery. As a reconstruction material for the lower extremities, thinning flaps are both aesthetically and functionally superior to conventional bulky flaps.
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Affiliation(s)
- H Ohjimi
- Department of Plastic and Reconstructive Surgery, School of Medicine, at Fukuoka University, Japan.
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50
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Kane JM, Gibbs JF, McGrath BE, Loree TR, Kraybill WG. Large, deep high-grade extremity sarcomas: when is a myocutaneous flap reconstruction necessary? Surg Oncol 1999; 8:205-10. [PMID: 11128834 DOI: 10.1016/s0960-7404(99)00046-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The surgical treatment of large, deep high-grade extremity soft tissue sarcomas frequently produces a significant tissue defect. In addition, the management of the surgical wound is often further complicated by preoperative radiation or adjuvant therapies. The use of either pedicled or free myocutaneous flaps allows for more rapid and predictable wound healing in this situation. Myocutaneous flaps provide well-vascularized coverage of lost tissue volume, exposed vital structures, and prosthetic reconstruction materials. When harvested from unirradiated sites, flap coverage can overcome the detrimental effects of radiation therapy and chemotherapy on postoperative wound healing. Reconstruction of the soft tissue defect may also improve patient satisfaction with aesthetic issues. The use of innervated myocutaneous flaps can even address the functionality of the extremity following resection of major muscle groups. Myocutaneous flaps are an extremely versatile option for reconstruction in the treatment of large, deep high-grade extremity soft tissue sarcomas.
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Affiliation(s)
- J M Kane
- Roswell Park Cancer Institute, Buffalo, NY 14263, USA
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