Flap Reconstruction of Sarcoma Defects in the Setting of Neoadjuvant and Adjuvant Radiation

Abstract

Background Limb-sparing treatment of extremity soft tissue sarcomas requires wide resections and radiation therapy. The resulting complex composite defects necessitate reconstructions using either muscle or fasciocutaneous flaps, often in irradiated wound beds. Methods A retrospective chart review was performed of all limb-sparing soft tissue sarcoma resections requiring immediate flap reconstruction from 2012 through 2016. Results Forty-four patients with 51 flaps were identified: 25 fasciocutaneous and 26 muscle-based flaps. Mean defect size, radiation treatment, and follow-up length were similar between groups. More often, muscle-based flaps were performed in younger patients and in the lower extremity. Seventeen flaps were exposed to neoadjuvant radiation, 12 to adjuvant radiation, 5 to both, and 17 to no radiation therapy. Regardless of radiation treatment, complication rates were comparable, with 28% in fasciocutaneous and 31% in muscle-based groups (p < 0.775). Muscle-based flaps performed within 6 weeks of undergoing radiotherapy were less likely to result in complications than those performed after greater than 6 weeks (p < 0.048). At time of follow-up, Musculoskeletal Tumor Society scores for fasciocutaneous and muscle-based reconstructions, with or without radiation, showed no significant differences between groups (mean [SD]: 91% [8%] vs. 89% [13%]). Conclusion The similar complication rates and functional outcomes in this study support the safety and efficacy of both fasciocutaneous flaps and muscle-based flaps in reconstructing limb-sparing sarcoma resection defects, with or without radiotherapy.

Advances in functional limb reconstruction in the irradiated setting

“…Single stage orthoplastic surgery is performed six weeks following completion of radiotherapy, with the oncologic surgeons performing wide excision and immediate reconstruction performed by the plastic surgeons. Our unit's protocol and experience with preoperative radiotherapy have previously been reported in the literature [30] and the results are in keeping with the current literature, which demonstrates a significant increase in complications if flaps were performed beyond this six-week period [31] .…”

“…Although the effect of neo-adjuvant therapy on functional reconstruction has not been investigated, numerous studies have demonstrated that preoperative radiotherapy does not increase complications when flaps are used for reconstruction [34][35][36] . In addition, there appears to be no difference in outcomes and complication rates with muscle flaps compared to fasciocutaneous flaps when used in the post radiotherapy setting [31] .…”

Postoperative Wound Complications in Fungating Extremity Soft Tissue Sarcomas

“…Potter et al suggested that neoadjuvant radiation is essentially contraindicated in ulcerating patients, with the example of a 100% rate of wound complications for the two patients who underwent pre-operative radiation in their series [11]. At least some of this risk may be mitigated by use of non-radiated free flap microvascular reconstruction techniques [14,15]. However, significant progression of ulceration due to radiation therapy may require larger tissue flaps and could potentially alter the proposed resection, perhaps precluding flap coverage for some patients.…”

Utilization of Modified Rhomboid Flap to Reconstruct Limb Defect after Wide Resection of Large Soft-tissue Sarcoma: Novel Application of an Old Technique

“…However, microvascular procedures usually require a plastic surgeon, and can be hardly performed by orthopedic oncologists. Although local flaps and pedicled musculocutaneous flaps are technically easier, these procedures are still restricted for coverage of large limb defects due to significant local tension [8]. Some flap designs are difficult to learn [8].…”

“…Although local flaps and pedicled musculocutaneous flaps are technically easier, these procedures are still restricted for coverage of large limb defects due to significant local tension [8]. Some flap designs are difficult to learn [8]. Because limb STS dictates multidisciplinary management and are primarily treated by orthopedic oncologists, flap reconstructive procedures that yield favorable efficiency and moderate difficulty are warranted to simplify the surgical procedures.…”