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Azadgoli et al. Plast Aesthet Res 2018;5:3 I http://dx.doi.org/10.20517/2347-9264.2017.32 Page 9 of 12
[49]
the immediate postoperative period and resulted in high rates of wound complications . Waiting until
[59]
[22]
at least the 5th postoperative day is associated with significantly lower rates . In a study by Lee et al. ,
brachytherapy was initiated about 7 days after free tissue transfer and resulted in a 29% complication rate,
including partial-thickness skin necrosis, venous thrombosis necessitating flap exploration, kinking of the
[60]
brachytherapy catheters, and partial flap skin loss. Hidalgo et al. described 3 patients who were treated
with adjuvant brachytherapy 7-10 days postoperatively with no wound-healing complications. Although
considered typically safe, the number of wound complications requiring reoperation has been shown to
[61]
be higher with brachytherapy than with external beam radiation therapy . Preoperative intraarterial
[62]
chemotherapy is another option and has been shown to have no effect on free flap results .

OUTCOMES AND RECURRENCE
Because of the prolonged surgical time and extensive periods of bed rest combined with immunosuppresive
therapy following sarcoma resection, surgical treatment of these tumors is generally associated with high
[2]
numbers of postoperative complications. Lopez et al. found that patients who received combined pedicled
+ free flaps after sarcoma resection had significantly higher wound complications rates compared to patients
who received just one, although systemic complications were distributed equally between all groups.

Recurrence rates are generally high following flap reconstruction after resection of advanced, high-
[64]
[63]
grade sarcomas . Popov et al. found a statistically significant correlation between recurrence and
extracompartmental tumor location (P < 0.01) and large tumor size (> 4 cm) (P < 0.01). Postoperative wound
complications can also lead to amputation following tumor resection and flap reconstruction.

CONCLUSION
As wide local excision has become the most commonly accepted approach to the surgical treatment of
sarcomas, reconstructive surgical techniques become crucial to the success of this line of therapy. Although
pedicled flaps have been traditionally preferred for oncologic resections, their use is sometimes precluded
by the use of neoadjuavant radiation as well as the size of the defect left after the resection. The need to re-
establish function also makes the use of a pedicle/local flap less optimal. Several recent studies have reported
successful functional and aesthetic results using free tissue transfer as the main modality for reconstruction
after sarcoma resection of the limb [6,7,56] . Free tissue transfer allows for the application of healthy vascularized
tissue to the defect while also providing freedom of flap positioning as well as avoidance of stretching or
[2]
kinking of the vasculature . Studies of sarcoma resection and free tissue reconstruction have reported
high success rates, with complication rates ranging between 2%-22% [7,64,65] and limb salvage rates close to
100% [6,57,64,65] . Flap choice is dependent on tumor and defect size, tissue type and function, as well as donor
site availability, thus resulting in numerous different treatment options. Given the low incidence and
prevalence of lower extremity sarcomas as well as the heterogeneity of the sarcomas and their respective
neo-adjuvant treatments, there are currently no clear treatment guidelines or specific algorithms for the
reconstruction of soft tissue defects following oncologic resection. The lack of significant case volume makes
it difficult for any single institution to conduct a study comparing the success rates of various flaps, and
although a systematic review would be helpful, the innate nature of the pathology also leads to a paucity of
literature consisting largely of studies describing small numbers of isolated cases. This descriptive review
however attempts to provide an overview of the various reconstructive options that are available, as well
as the considerations that must be taken into account when treating patients with soft tissue defects of the
lower limb following sarcoma resection.

DECLARATIONS
Authors’ contributions
Performed the literature search and reviewed the articles: Azadgoli B, Perrault DP