Page 105 - Read Online

Marsden et al. Plast Aesthet Res 2019;6:24 I http://dx.doi.org/10.20517/2347-9264.2019.14 Page 7 of 11

OUR EXPERIENCE
The senior author has been part of the local sarcoma multi-disciplinary team (MDT) for over 10 years,
has been instrumental in advocating functional reconstruction for extremity STS in recent years and has
pioneered numerous reconstructive techniques in this field.

Preoperative radiotherapy is the preferred method in our institution for the management of all extremity
STS, because the sarcoma service feels the oncological outcomes are at least equivalent, and, functionally,
[25]
these patients do better overall . Preoperative radiotherapy is associated with better overall survival
but higher wound complications compared to postoperative radiation, which we feel is overcome by
[6]
the combination of wide resection and flap coverage with healthy vascularised tissue . Preoperative
radiotherapy allows the ability to give lower radiation doses due to improved limb perfusion and
[6]
[29]
oxygenation [4,28] , smaller radiotherapy targets and therefore decreased late toxicity compared to
postoperative methods. 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
[30]
previously been reported in the literature and the results are in keeping with the current literature, which
[31]
demonstrates a significant increase in complications if flaps were performed beyond this six-week period .

Over the past 10 years, the senior author has developed a systematic and regimented approach to STS
extremity functional reconstruction with the aim of minimising errors and maximising ergonomics and
improving functional outcomes. The general approach is as follows: after tumour excision by the resecting
team, haemostasis is thoroughly performed and local anatomy is examined for recipient vessels and nerves.
The defect is templated, taking into account the innervated muscle requirement, alongside the need for
skin and dead space filling. The flap is not detached until the recipient vessels and nerves are ready for
microsurgical anastomosis in order to minimise ischaemia time. The dichotomy of neurovascular pedicle
length versus vessel calibre is addressed, prior to pedicle detachment. The flap is transferred to the defect
and stretched to its original length in order to allow for the final inset and the lengths of the vessels and
nerves matched to the recipients. The flap is then secured proximally to prevent avulsion. The nearest
motor nerve, which has been tagged during the resection, is utilised for the neurorrhaphy. The recipient
nerves are stimulated intraoperatively before division with a handheld nerve stimulator in order to confirm
the presence of motor axons. Anastomosis is then performed on the veins, artery and finally the nerve.
The limb is then positioned appropriately depending on the compartment being reconstructed, e.g., knee
extended or flexed for quadriceps and hamstring, respectively, or hip extended for gluteal reconstruction,
before, finally, the distal end of the flap is tensioned and secured distally taking care to avoid tension on
the anastomosis. The flap is inset in layers over suction drains and covered with a waterproof dressing.
Postoperatively, the involved limb is immobilised in a fixed articulated splint for six weeks. For lower limb
reconstructions, the patient is confined to bed rest for six days and nursed appropriately depending of
position of the flap, before being mobilised on crutches. The uninvolved joints are allowed to move freely
postoperatively, encouraging locomotion to prevent stiffness, DVT and other postoperative complications.
After this six-week period, patients are allowed to start active and passive range of motion under guidance
from specialist physiotherapists. Strengthening exercises are commenced after 3-6 months for a minimum
period of 12 months.

Between 2009 and 2019, the senior author has performed 68 functional reconstructions, for extremity STS
resections following neoadjuvant radiotherapy, including 53 free (of which two were vascularised sural
nerve grafts) and 11 pedicled flaps [Table 2]. There were two patients who underwent non-vascularised
nerve grafts and two who had nerve transfers alone. There were seven patients who underwent non-
vascularised nerve grafts in combination with the flap coverage and four who had nerve transfers as well as
flap coverage. Nerve grafts and transfers are generally used in combination with flap coverage when major