Sarcoma Soft Tissue Reconstruction with Pedicled Perforator Flaps

Recently perforator flaps such as the ALT and DIEP flap have become more and more important in my practice. As I continue to provide patients with the best reconstructive options for reconstruction after removal of tumors whether from the head and neck, breast, or extremities it is always challenging. The more we are able to perform these procedures and get our patients back to work, become pain free or just have the ability to walk or sit without significant pain each case gets more difficult. There are special circumstances that arise with large tumors of the pelvic and groin region. These tumors are difficult to access for the cancer surgeons and often involve blood vessels and nerves. These types of complicated tumors are best treated with a multidisciplinary approach at a facility where cancer surgeries are routinely performed. Once the tumors have been removed and the blood vessels have been reconstructed by another surgeon, a vascular surgeon, the plastic surgeon then has to design away to provide stabe soft tissue coverage in this area. This can be carried out using a wide variety of techniques but I have found great success in using pedicled perforator flaps like the DIEP flap and the ALT. One can come from the opposite side of the abdomen and one can come from the opposite thigh. I say this because in the cancer surgery the cancer surgeon has to remove many of the branches of the blood vessels on the side where the tumor was removed. The vascular surgeon has to reconstruct the large vessels so there is blood flow to the foot. The smaller vessels the plastic surgeon would use are not reconstructed. Therefore I use tissue from places away from the injury and use the natural blood vessel anatomy to help me reconstruct these areas where tumors have been removed. I consider these operations limb saving procedures because in many instances a patient can avoid a hemipelvectomy and loss of their leg. If you or one of your friends or family have been told this is the only way to help them I would suggest a second opinion to see if there is any chance that an alternative exists. I participate in the procedures routinely at Froedtert and the Medical College of Wisconsin where I am a Staff Plastic Surgeon, Assistant Professor of Plastic Surgery and the Microfellowship Director.

Soft tissue sarcoma is a cancer that begins in the muscle, fat, fibrous tissue, blood vessels or other supporting tissue of the body. These are relatively rare cancers but if detected early and treat properly can be controlled. A number of people would ask why would a plastic surgeon be involved with cancer surgery. Plastic surgeons are involved with a number of types of cancer patients. In the last 6 months I have performed reconstructions on patients with squamous cell cancer of the Head and Neck, total breast breast reconstruction after mastectomy for breast cancer, as well as reconstructions of the arms and legs from removal of Sarcomas. In addition to performing the most function reconstruction for these patients I am also very aware of how these reconstructions will look for these patients.I am part of a special multidisciplinary group that cares for patients with Sarcoma at Froedtert and the Medical College of Wisconsin. This group is composed Orthopedic Surgeons who specialize in Musculoskeletal Oncology, Radiation Oncologist, Medical Oncologists, Radiologists, Interventional Radiologists, Thoracic Surgeons, General Surgeons and Plastic Surgeons. This Group meets once a week to discuss new patients and plans for existing patients. As a Plastic Surgeon who performs reconstructions for these patients these are particularly challenging. First of all it is imperative that if you are given the diagnosis of a sarcoma that you seek out the types of doctors I have mentioned to get the most appropriate care. Many times we are performing additional surgery because someone went to their doctor with a lump and had it removed only to find out later that it was cancer and ultimately it was a sarcoma. This creates some issues in terms of how to care for the patient at the next phase. At this point it is especially important that the patient be seen by physicians for comfortable with providing care for those patients with sarcomas that may have been removed without the appropriate surgical margin. Meaning that part of the sarcoma could have been left behind or that it was so close that there may be microscopic disease left that will probably return over time. For my part I try to provide these patients with the most durable and appropriate reconstructions. I prefer to use perforator flaps for these reconstructions. I use the ALT, DIEP and DIEAP, the medial thigh flap as well design of freestyle flaps depending on the defects. The use of these perforator flaps allows the patients to avoid skin graft in nearly all situations. Also it leaves the Plastic Surgeon to create the most functional outcome through flap contouring.