The Evolving Role of a Plastic Surgeon in Sarcoma Management: Suggested Guidelines Based on a Reconstructive Case Series of 216 Patients By a Single Unit

Purpose:

700 new patients present to the London Sarcoma Unit each year with 5% requiring specialist reconstruction. Improved radio- and chemotherapy protocols drove the increased attempts at limb preservation surgery.

For the plastic surgeon this presents a reconstructive challenge. Peri-operative radiotherapy and pressure to start adjuvant therapies promptly, complicates the decision making process. Frequently primary closure is achievable, however larger tumours necessitate significant undermining of skin resulting in seroma formation and when subjected to radiotherapy, often breakdown. 

We present suggested guidelines based on a case series of 216 patients from the senior author’s experience.

Methods:

A prospective chart review of all referred patients from the London Sarcoma Unit requiring reconstruction between February 2006 and October 2013 was performed.  In spite of the large number of new referrals only 216 reconstructions were required.

Results:

The total number of operations performed was 216.  Mean follow-up was 14 months (1 – 36 months), 40% of patients had significant co-morbidities and 37 required revisional procedures. Patients could be separated into early (0-6 weeks post-operatively, n=117) and late reconstructions (>6 weeks post-operatively, n=99).  20 patients were reconstructed with skin grafts, 100 patients were managed with regional flaps and 96 patients were treated with free flaps.

Conclusions:

As a result of limb preserving treatments there is an increased demand for reconstructive surgery.  Our experience with limb-salvage has lead us to adhere to the following guidelines:  small defects are closed primarily if no significant underlying cavity is present and skin grafts are used when radiotherapy is not considered; all other defects should be closed with fascio-cutaneous or myocutaneous flaps.

Close communication between the cancer and reconstructive surgeons is crucial not only to identify patients that require reconstructions but also to minimise post-operative time period to adjuvant therapy.  All surgeons should attend a multi-disciplinary team meeting. Definitive reconstruction should be delayed until histological margins are available to avoid wider excisions once the reconstruction has been performed.  Patients should undergo primary excision and managed with a vacuum dressing until margins are clear and then be reconstructed. The choice of free or regional flap should be tailored to specific patient requirements.