Sarcomas are neoplasms of the connective tissues derived from mesenchymal origins throughout the body, accounting for 1% of adult malignancies and 7% to 15% of pediatric malignancies.1 Sarcomas of the extremity, which are the scope of this chapter, represent 50% to 60% of all sarcoma diagnoses,2 with the thigh being the most common location.3 A deep knowledge of the principles of reconstructive surgery is of paramount importance to the oncological surgeon. In the same manner that tumor invasion of a vital structure can render the disease unresectable, a soft tissue defect that cannot be repaired results in either unacceptable morbidity, severely impairing the patient's quality of life, or an amputation in the cases of extremity tumors. A current familiarity with state of the art reconstructive techniques helps to identify cases that will present reconstructive challenges while also preparing the surgeon to properly advise the oncologic surgeon and patient of what options are truly tenable. In addition, cooperative efforts between the oncologic surgeon and plastic surgeon are more likely to result in satisfactory treatment of the wound with shorter recoveries and decreased length of hospital stay.
The majority of wounds created by tumor extirpation, whether benign or malignant, can be managed by primary closure or skin grafting. This is not true of complex wounds which are typically large, composite defects like those seen with postradiation ulcerations or traumatic or infected wounds (i.e., osteomyelitis). On occasions when the wound cannot be closed primarily or with a skin graft, the use of flaps becomes the most appropriate option. The type and location of the soft tissue defect will dictate what type of flap is required. Considerations include whether the coverage needed is of skin alone or composite tissues, such as a combination of skin, muscle, and bone. An essential principle of reconstruction of complex defects is the selection of a flap that can most closely replicate the lost tissue, regardless of the complexity of the procedure.
The obligation of the oncological surgeon is to perform what he considers the best extirpative procedure that will, to the highest degree possible, ensure adequate resection of the tumor and best tumor-free survival for the patient. The reconstructive surgeon must be well-versed in all reconstructive modalities so that he may attend to the defect presented, choosing an appropriate reconstruction, regardless of complexity, to assure rapid healing with minimal complications. Specifically, the resection must never be compromised to accommodate reconstruction.
This does not mean that an optimization of the surgical approach through team discussion is prohibited, especially when such discussions are likely to enhance the patients’ outcome. The possibility of working simultaneously with separate teams can also prove to be an important consideration. When possible, tandem procedures will shorten the overall operative time, particularly if the reconstructive surgeon is planning a microvascular reconstruction. Separate operative personnel and instrument setup limits the possibility of cross-field contamination.