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overall bypass-related complications including thrombosis and emboli as well as infections. Common wound
complications that occur are wound healing difficulties, infections, and lymphatic fistulas.

NEOADJUVANT AND ADJUVANT THERAPY
Surgery with wide margins alone can be implemented to treat sarcoma of the extremities that is
subcutaneous or intramuscular, small in size, or low in grade. However, if the resected margin is close, or
if there is extramuscular involvement, surgery must be combined with adjuvant radiotherapy. For those
[46]
that are high-grade or large in size, neoadjuvant chemotherapy must also be considered . The need for
additional therapy is often a determining factor in flap selection, as wound-healing difficulties can delay the
onset of adjuvant therapy and negatively affect long-term survival.

Radiotherapy may be administered either pre- or postoperatively with similar local control and overall
[47]
survival rates . The concern with radiation therapy is the complications it causes with wound healing.
Reported complications have ranged from 33%-44% in the past, with severe morbidity in 22%-27% of
[5]
patients [48-50] . Abramson et al. however only reported a 12.5% wound complication rate, including a
patient who developed radiation necrosis and required a second free tissue transfer months after his initial
treatment.

While preoperative radiotherapy results in higher rates of wound complications [51-53] , patients treated with
[54]
postoperative radiotherapy experience more long-term fibrosis, edema and joint stiffness . The National
Cancer Institute of Canada (NCI Canada) conducted a randomized control trial comparing wound
complications in patients who received preoperative vs. those postoperative radiotherapy and found that
35% of those in the preoperative group had major wound complications compared to 17% of those in the
[51]
[51]
postoperative group . O’Sullivan et al. found higher rates of wound complications and reoperations
in patients who received preoperative radiation. However a larger percentage of patients with wound
complications in the postoperative radiation group required other invasive procedures.

[55]
Townley et al. compared patients with preoperative irradiation to a control group who received no
radiation and found similar microvascular complication rates such as those requiring intra-operative
revision or flap reexploration or loss. Though wound healing complications were more common in the group
who received radiation, the ultimate outcomes were similar between both groups. Some factors associated
with wound complications in sarcoma patients who receive preoperative radiation are tumor size > 10 cm,
[48]
tumor proximity to skin surface < 3 mm, and current smoking status .
Chao and associates compared complication rates between patients receiving neoadjuvant and adjuvant
irradiation and found no significant difference in perioperative complication rates or rates of salvaged pedicle
thrombosis between the two groups. However, the rate of total free flap loss was lower in patients receiving
neoadjuvant radiation, suggesting that the introduction of new, well-vascularized tissue counteracts the
effects of the radiation. The authors also attributed this finding to the fact that higher doses and larger fields
of irradiation are involved with adjuvant therapy, and with neoadjuvant therapy, irradiated tissue may be
excised during tumor resection. Additionally, they found that late recipient-site complications (occurring
> 30 days after surgery) occurred more frequently in patients who received adjuvant radiation (26.1% vs. 6.8%,
[56]
P = 0.0006), although the reoperation rate following these complications was similar between the groups .
Because wound complications are generally treatable without resulting in permanent damage, preoperative
[48]
radiotherapy is preferred by many practitioners .
Brachytherapy, another form of adjuvant therapy, is a method of administering radioisotopes directly into
[57]
a surgical wound to treat residual tumor . Addition of brachytherapy to surgical excision has been shown
[58]
to reduce tumor recurrence rates from 14% to 4% . Brachytherapy was initially administered during