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.&nbsp; These are relatively rare cancers but if detected early and treat properly can be controlled.&nbsp; A number of people would ask why would a plastic surgeon be involved with cancer surgery.&nbsp; Plastic surgeons are involved with a number of types of cancer patients.&nbsp; 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.&nbsp; 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.&nbsp; 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.&nbsp; This Group meets once a week to discuss new patients and plans for existing patients.&nbsp; As a Plastic Surgeon who performs reconstructions for these patients these are particularly challenging.&nbsp; 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.&nbsp;&nbsp; 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.&nbsp; This creates some issues in terms of how to care for the patient at the next phase.&nbsp; 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.&nbsp; 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.&nbsp; For my part I try to provide these patients with the most durable and appropriate reconstructions.&nbsp; I prefer to use perforator flaps for these reconstructions.&nbsp; I use the ALT, DIEP and DIEAP, the medial thigh flap as well design of freestyle flaps depending on the defects.&nbsp; The use of these perforator flaps allows the patients to avoid skin graft in nearly all situations.&nbsp; Also it leaves the Plastic Surgeon to create the most functional outcome through flap contouring.&nbsp; </p>

The anterolateral thigh flap (ALT) is an extremely versatile flap.  The lateral thigh can be utilized to bring an island  of tissue that is approximately 8cm X 24cm.  This amount of tissue removal can be closed with one incision.  Depending on the size of the area to be covered by the flap it may be necessary to harvest more tissue from the thigh.  If this is the case a skin graft will be utilized to close the resulting defect on the thigh.  I personally have used ALT flaps up to 35/25cm to cover large wounds of the chest and back.  Normally I utilize the ALT flap for coverage of the arm and leg.  It is very useful for the foot.  There are multiple ways to reestablish the blood supply to the transferred tissue but usually the posterior tibial blood vessels are used.  Microsurgery is used to reestablish blood flow to the tissues.  This is normally done by a plastic surgeon who has had additional training in microsurgery.  Typically these procedure are performed in microsurgery units or facilities where microvascular surgery is performed on a routine basis.  I typically perform, ALT flap, Latissimus flaps, gracilis flaps, DIEP flaps, and freestyle free flaps depending on the needs of the patient after Sarcoma tumor removal, trauma, or infection.  One of the additional points regarding ALT flaps is that they can be easily modified after surgery.  Through thinning of the fat and advancement of the flap a very thin pliable flap can be created which can be then almost indistinguishable in clothing from normal tissue.  Obviously externally there is a scar around the transferred tissue.  I believe this is an ideal flap for multiple reconstructive challenges.

The anterolateral thigh flap (ALT) is an extremely versatile flap.  The lateral thigh can be utilized to bring an island  of tissue that is approximately 8cm X 24cm.  This amount of tissue removal can be closed with one incision.  Depending on the size of the area to be covered by the flap it may be necessary to harvest more tissue from the thigh.  If this is the case a skin graft will be utilized to close the resulting defect on the thigh.  I personally have used ALT flaps up to 35/25cm to cover large wounds of the chest and back.  Normally I utilize the ALT flap for coverage of the arm and leg.  It is very useful for the foot.  There are multiple ways to reestablish the blood supply to the transferred tissue but usually the posterior tibial blood vessels are used.  Microsurgery is used to reestablish blood flow to the tissues.  This is normally done by a plastic surgeon who has had additional training in microsurgery.  Typically these procedure are performed in microsurgery units or facilities where microvascular surgery is performed on a routine basis.  I typically perform, ALT flap, Latissimus flaps, gracilis flaps, DIEP flaps, and freestyle free flaps depending on the needs of the patient after Sarcoma tumor removal, trauma, or infection.  One of the additional points regarding ALT flaps is that they can be easily modified after surgery.  Through thinning of the fat and advancement of the flap a very thin pliable flap can be created which can be then almost indistinguishable in clothing from normal tissue.  Obviously externally there is a scar around the transferred tissue.  I believe this is an ideal flap for multiple reconstructive challenges.

The DIEP flap is an outstanding flap and ideal for large soft issue defects.  It has long been praised for the ability of this flap to provide a natural appearing breast reconstruction.  In addition to its utility in breast reconstruction this tissue flap is useful in a variety of other situations like arm and leg reconstruction after tumor removal like sarcoma.  In fact recently we have used the DIEP flap to care for patients with different sarcoma like angiosarcoma and fibromyoid sarcoma.  These patients have benefited from the quality and amount of skin and fat that can be transferred for their  arm and leg reconstruction just like the DIEP flap when it is used for breast reconstruction.  After multiple types of cancer surgeries the DIEP flap can be used.  Also it is very modifiable after the initial surgery has been performed.  Unlike a muscle flap and skin graft which has been traditionally performed for a number of years the DIEP flap is easily contoured through a combination of techniques involving liposuction of the fat and resection of the excess tissues.  Removal of the fat of the flap in the vertical dimension and the flap can be then stretched as well to flatten it even more.  This makes it ideal for the upper and lower extremity.  Of note this does remove the excess abdominal tissue that would normally be discarded in a tummy tuck procedure.  This procedure can be performed in a number of patients of different heights and weights.  If you are in need of reconstruction of the breast, large are or leg wounds the DIEP flap is a ideal source of healthy tissue.

This can be used in cases of osteosarcoma, rotationplasty involves a partial amputation of the leg above the knee. The lower leg and foot are rotated 180 degrees, the length is adjusted, and the tibia is then joined to the proximal femur using plates and screws. The foot is positioned where the knee used to be, with the heel portion in front and the toes pointing back. The ankle now functions in place of the knee joint. The primary reason for rotationplasty is to enhance the person's mobility as a prosthesis user. Placing the ankle joint in the position of the knee creates a functional, natural knee, and the toes provide important sensory feedback to the brain.

The appearance of the limb following rotationplasty is very unusual and is a concern for many people from both a cosmetic and a psychological standpoint. Patients and their families who are considering rotationplasty should talk with other people who have had the procedure and are now prosthesis users. For many, the functional advantages quickly outweigh their concerns about appearance. Children and young adults have a lifetime in front of them, and the increased mobility and freedom that may follow rotationplasty can be a significant improvement over the use of a traditional above-knee prosthesis.