Page 106 - Read Online

Page 8 of 11 Marsden et al. Plast Aesthet Res 2019;6:24 I http://dx.doi.org/10.20517/2347-9264.2019.14

Table 2. Summary of the various functional reconstructions performed for extremity STS
Flap Defects Number
LD Gluteal, hamstrings, quadriceps, gastroc/soleus 21
Gracillis Hamstring, quadriceps, adductors, tibialis ant, biceps/brachialis, triceps 14
VRAM-Free Quadriceps, adductors 10
-Pedicled 10
TRAM Quadriceps, gluteals 4
Medial gastrocnemius Deltoid, biceps/brachialis 2
Vascularised sural nerve Common peroneal nerve, posterior cord 2
Rectus femoris (pedicled) Groin (including femoral nerve and hip flexors) 1
STS: soft tissue sarcomas; LD: latissimus dorsi; VRAM: vertical rectus abdominis muscle; TRAM: transverse rectus abdominis muscle

nerves are sacrificed as part of the oncologic resection (as shown in Figures 1, 2 and 4). In this series, the
most commonly resected nerves were the sciatic and femoral nerve, with one case of common peroneal
nerve, one ulnar nerve and one posterior cord resection for malignant peripheral nerve sheath tumour.

The mean age of patient was 63 (in the range of 35-87 years). Ninety percent of the reconstructions were of
the lower limb, most commonly the quadriceps, followed by the hamstring and gluteal compartments, and
10% were of the upper limb. There were three complete flap losses (4.4%) and one partial flap loss (1.5%)
in the series. Reinnervation was seen in the transferred muscle as early as three months postoperatively,
with a mean time of 12 months (follow up by the senior surgeon occurred at six weeks, and then 3, 6, 12 and
24 months, thus exact time points of reinnervation are estimates within these timeframes). The mean MRC
grade achieved was 4/5, with over 50% (n = 32) achieving MRC 5/5 at latest follow up. Seven of the cases
are too early in their follow-up to ascertain the level of functional recovery at the time of writing. With
regards to nerve reconstruction, there are two patients with adequate follow-up who have recovered some
protective sensation distally (one vascularised sural nerve graft and flexor carpi ulnaris (FCU) nerve branch
transfer to triceps for a right posterior cord sarcoma and one sural to tibial nerve transfer following tibial
nerve resection). The first patient has had an excellent result with M5/5 power of deltoid and triceps, and
wrist and finger extension at 18 months (see Videos 5 and 6). A third patient who underwent vascularised
sural nerve graft for common peroneal nerve (CPN) resection showed signs of sensory recovery five
months postoperatively, and we await longer-term follow-up to assess final outcome.

The senior author’s philosophy on functional limb reconstruction is: age is not a barrier to reconstruction
(see Figure 1); the status of the joints proximal and distal to the defect are vital; aim to perform a single
nerve coaptation either via nerve transfer or as part of an innervated free flap; and high axonal input is key
to proximal nerve reconstruction.

DISCUSSION
Microsurgical reconstruction after soft tissue sarcoma excision has expanded the indications for limb
salvage by allowing wider excision margins with the ability to adequately reconstruct the defect. However,
limb salvage surgery with oncological resection of extremity STS often leads to a significant detrimental
effect on mobility and the ability to perform activities of daily living, which has been shown to reduce
[32]
patient’s quality of life . Functional reconstruction of extremities following STS excision with FFMT can
provide the dual functions of active muscle contraction and soft tissue coverage in one operation.

The concept of limb salvage surgery has evolved from just anatomical preservation of the limb to
preservation with restoration of function and aesthetics. Despite this paradigm shift in recent years,
functional reconstruction following extremity sarcoma resection is still relatively uncommon. A recently
published review reported just 134 cases of functional sarcoma reconstruction of the limbs in the literature,