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Page 2 of 12 Azadgoli et al. Plast Aesthet Res 2018;5:3 I http://dx.doi.org/10.20517/2347-9264.2017.32

Quite often, sarcoma excision results in large anatomical soft tissue deficits with resultant exposure of
vital structures such as bones, tendons, and neurovascular bundles, necessitating complex soft tissue
reconstruction with vascularized soft tissue transfer thus facilitating further treatments as well as
maintaining or regaining structural function and integrity of the limb in question. To this end both pedicled
and free tissue transfers have become a central component of lower extremity salvage after resection and
chemo-radiation therapy. Recent data has shown that these complex reconstructions have provided faster
recovery with adequate soft tissue reconstruction and maintenance of functionality of the limb [2,6-11] .

Currently there is no standard treatment algorithm for limb reconstruction after large sarcoma resection.
In part this due to the low incidence of these tumors as well as the heterogeneity of extremity sarcoma. This
problem is further compounded by the multitude of neo-adjuvant modalities that are used to treat these
tumors as well as the timing of the oncological resection. Hence a comprehensive reconstructive approach
that maximizes the maintenance of function and aesthetics depends primarily on the location and size of
the defects as well as the muscles, tendon, blood vessels and nerves that were extirpated. The goal of this
literature review is to therefore outline various author reports published in the current literature describing
the various types of free tissue transfer used for the reconstruction of the lower limbs after sarcoma
resection.

METHODS
The PubMed database was used to review literature describing free tissue coverage of the lower extremity
following soft tissue sarcoma resection. The entire PubMed library was used dating to 2016. The following
search terms were used: “Neoplasms, Connective and Soft Tissue” [Mesh] OR (“sarcoma” [MeSH Terms] OR
“sarcoma” [All Fields]) AND (“lower extremity” [MeSH Terms] OR (“lower” [All Fields] AND “extremity”[All
Fields]) OR “lower extremity” [All Fields]) AND (“free tissue flaps” [MeSH Terms] OR (“free”[All Fields]
AND “tissue” [All Fields] AND “flaps” [All Fields]) OR “free tissue flaps” [All Fields]. All studies published
in the English language were included. Articles were excluded if they met the following criteria: exclusively
pediatric patients, cadaver subjects, pathology of the pelvic girdle, exclusively pathology related to trauma,
pathology related to skin neoplasms, and studies exclusively describing pedicled flaps. Table 1 lists the
studies included in this review. Table 2 describes the types of flaps used for lower extremity reconstruction
by region.

RECONSTRUCTION BASED ON TUMOR LOCATION
Thigh
Several factors must be taken into consideration when approaching reconstruction of the thigh. Primarily,
malignant sarcomas of the femur are generally challenging to treat because radical resection of the tumor
often requires simultaneous resection and reconstruction of the major femoral vessels. Tumor proximity to
critical neurovascular structures is particularly of concern in the adductor compartment, where outcomes
[12]
are generally poor, with high local recurrence rate, high complication rates and short long-term survival .
[13]
The first report of reconstruction of major vessels was by Fortner et al. for the treatment of seven
patients with sarcoma involving the iliac and femoral vessels. In their study, 3 out of 7 patients underwent
vascular reconstruction with polyester or vein grafts, resulting in less postoperative complications and
edema compared to the remaining 4 patients who did not undergo vascular reconstruction. In a series
[14]
by Muramatsu et al. , 12 out of 14 patients requiring arterial reconstruction underwent femoropopliteal
reconstruction using a contralateral greater saphenous vein (GSV) graft ranging from 12-30 cm, while the 2
who required femoroinguinal reconstruction received expanded polytetrafluoroethylene (ePTFE). Twelve of
their 15 patients additionally required venous reconstruction of the superficial vein, deep femoral vein, and
greater saphenous vein, which was also done using a GSV or ePTFE graft. Of these patients, 6 had received