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Marsden et al. Plast Aesthet Res 2019;6:24 I http://dx.doi.org/10.20517/2347-9264.2019.14 Page 9 of 11

of which only 55 were FFMT and 17 were nerve reconstructions, with the remainder comprising tendon
[23]
[33]
transfers . Nelson et al. investigated the difference between functional reconstruction of the extremities
following STS resection and soft tissue coverage alone. The study demonstrated that, although there
was an increased cost and slightly extended surgical time associated with functional reconstruction, the
postoperative functional outcome was better, and they concluded that this justified its use.

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 [34-36] . 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
[31]
setting .

One area which continues to be a topic for debate is the reconstruction of major nerve defects, particularly
of the sciatic nerve. The senior author has utilised different techniques for reconstructing major nerve gaps,
including cable nerve grafts and vascularised sural nerve grafts. Our results are in keeping with those in
[37]
the literature, which show mixed sensory outcomes. Tokumoto et al. reported three cases of vascularised
sural nerve grafts for sciatic nerve reconstruction, whereby they aimed to selectively reconstructed
sensation to the plantar surface of the foot. They demonstrated some sensory recovery to the sole in
two patients; however, limited protective sensation was achieved. They stated poor results in the setting
[38]
[37]
of postoperative radiation therapy, although this was only the case in one patient . Melendez et al.
reported five sciatic nerve reconstructions with cable sural nerve grafts. They demonstrated the return of
partial distal sensory recovery in three patients and some protective sensation in the other two, with a mean
[38]
follow up of one year . From our experience and that of the limited reports in the literature, although the
chances of marked sensory recovery are slight, the amount of reinnervation is such that attempts at nerve
reconstruction are justified.

In the opinion of the senior author, the difference between raising an innervated free flap as opposed to
a non-innervated free flap is small, especially in the case of the latissimus dorsi and gracillis flap, where
the nerves lie in close proximity to the vascular pedicle. Although dissecting out recipient nerves and
appropriately securing and tensioning the musculotendinous components are critical in achieving a good
outcome, this is not hugely time-consuming and can be learned quickly.

[23]
As Martin et al. concluded in their review paper, there is a significant lack of high-level evidence
regarding the use of functional reconstruction in extremity sarcoma. We describe here the senior author’s
experience in this challenging and innovative field, and demonstrate how excellent functional outcomes
can be achieved with a systematic and logical approach. However, large well-designed studies are required
to clarify the differences in functional and non-functional reconstruction in terms of cost, donor morbidity
and functional outcomes to cement its role in sarcoma surgery.

CONCLUSIONS
Limb sparing surgery following neo-adjuvant radiation has become the preferred treatment for
extremity STS. However, adequate tumour resection can compromise critical limb function. Functional
reconstruction in extremity sarcoma is a relatively new concept, with limited experience published in the
literature. The use of advanced microsurgical techniques such as nerve transfer and FFMT provides the
reconstructive surgeon with a way of not only salvaging limbs, but restoring function following loss of
critical motor and sensory structures in upper and lower extremity sarcoma resection. We feel that the
functional benefits outweigh the slightly increased cost and operative time of soft tissue only reconstruction
and should be considered in patients undergoing extremity sarcoma resection following radiotherapy.