Upper Extremity Reconstruction Following Resection of Soft Tissue Sarcomas: A Functional Outcomes Analysis
Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 443, Houston, TX 77030, USA. Annals of Surgical Oncology
(Impact Factor: 3.93).
11/2004; 11(10):921-7. DOI: 10.1245/ASO.2004.06.026
Treatment for soft tissue sarcoma of the upper extremity has evolved to include limb salvage techniques. We reviewed our experience with limb salvage therapy for upper extremity sarcomas with an emphasis on functional outcomes following the reconstructive surgery.
A retrospective analysis was performed of 81 consecutive patients with soft tissue sarcoma of the upper extremity who had limb salvage therapy with reconstruction by a plastic surgeon. Univariate and multivariate regression analyses of relevant outcome variables were performed. Enneking functional scores were obtained from 43 patients.
The study included 16 microvascular reconstructions and 67 non-microvascular reconstructions for a total of 83 reconstructions in 81 patients. The mean defect size was 129 cm(2) (standard deviation: 106 cm(2)). The mean total functional score was 23.1 (range, 9 to 30). Any reconstruction-related complication and preoperative chemotherapy use were associated with a 7.3 point (P = .03) and 4.7 point (P = .01) decrease in total functional score, respectively. Kaplan-Meier product-limit analysis showed 82% 5-year overall survival and 67% 5-year disease-free survival rates.
For soft tissue sarcoma of the upper extremity, limb salvage with good functional outcome is possible with a judicious approach to reconstruction.
Available from: Darrell Brooks
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ABSTRACT: INTRODUCTION: Local procedures such as the cross-finger flap, island flap, and flag flap, etc. are well described
for the treatment of soft tissue defects of the hand.Their effectiveness is, however, limited in cases of multi-digit
injury, defects greater than 5cm in length, and defects located on the radial side of the index, ulnar side of the small
finger and tip of the thumb.The hand is covered with thin supple tissue and requires like tissue for the best possible
reconstruction.The bulkiness of conventional microvascular tissue transplantation can limit its overall effectiveness
in hand reconstruction.We present our experience with the transplantation of venous flaps for reconstruction of
thin soft tissue cover of the hand.
METHODS: A retrospective study between 6/2000 and 2/2005 involved 50 venous flaps that were transplanted
for reconstruction of soft tissue defects of the hand. Patient charts were reviewed to document multiple parameters
in the cases. Indications for the venous flap included location, size,multi-digit injury, need for cover over vital
structures, need for digital revascularization/replantaion or reconstruction of tendon, nerve, or bone with
composite venous flaps.The flaps were classified as AVA,AVV,AVA/A,AVV/V, or VVV depending on their vascular
anastomoses. Donor sites included SAPH (saphenous vein), CEPH (cephalic vein),VPF (volar proximal forearm),
VDF (volar distal forearm), DH (dorsal hand), and DF (dorsal finger). Outcome was classified as successful in cases
in which there was 100% survival of the flap, partial thickness (PT) survival in which there was loss of epidermis
with maintenance of subcutaneous cover, and partial full thickness (PFT) if epidermis and subcutaneous tissue
werre lost but went on to heal by secondary intention.The flap was considered a failure if there was complete loss
of the flap or significant loss that lead to exposure of vital structures and need for an alternate procedure.
RESULTS:Forty-one flaps had 100% survival (80%), 4 flaps were considered PT (8%), 3 were considered PFT
(6%), and 2 were considered failures (4%).The overall success rate was 48/50 (96).There were often multiple
indications for the venous flap in individual cases.Coverage of vital structure was the indication in 50,
revascularization of the hand or a digit in 16,multi-digit injury in 8, location of the defect in 20, and digit
replantation in 10 cases.Twenty-seven flaps were classified as AVA, 14-AVV,1-VVV, 3-AVA/A, 4-AVV/V, and 1-
AVA/VVV. Eight flaps had multiple in-flow and/or outflow anastomoses to nourish larger flaps, to reconstruct
simultaneous arterial inflow and venous out flow in ring avulsion replants, or to provide cover and revascularization
for multiple digits by creation of digital syndactyly.The donor was the VDF in 40 patients (80%),VPF in 5 patients
(10%), SAPH in 3 patients (6%), DH in 1 (2%), and the DF in 1 (2%). Size of the flaps ranged from 2X2 cm to 9X6
PLASTIC SURGERY 2005, Abstract Supplement
cm.The majority of flaps were 2X3 cm.The donor sites were closed primarily in the majority of cases.
CONCLUSION: Venous flaps can provide reliable coverage for small and medium sized soft tissue defects of the
hand when conventional methods are less effective.Venous flaps have the additional benefit of low donor site
morbidity, no major vessel sacrafice, stable cover over vital structures, thin supple tissue, reconstruction of vascularin-flow and/or outflow to amputated and devitalized components.
Available from: Darrell Brooks
Plastic & Reconstructive Surgery 01/2005; 116:106-107. DOI:10.1097/00006534-200509011-00093 · 2.99 Impact Factor
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ABSTRACT: This review focuses on the surgical management of soft tissue sarcomas of the hands and the feet. With recent advances in limb salvage surgery and radiotherapy delivery, local control of soft tissue sarcoma in the extremity has become optimized, and the associated functional results of this treatment have taken on extreme importance. Techniques to limit the amount of normal tissue resected and to reconstruct the resulting defects are critical to the final functional result.
Several features of soft tissue sarcoma unique to the hand and foot have been reported. Certain histologic subtypes of soft tissue sarcoma have been noted to arise preferentially in the hand and the foot, such as epithelioid sarcoma, clear cell sarcoma, and synovial sarcoma. Patients with hand and foot sarcomas have been described as having improved overall survival, but this is likely a result of the smaller size of tumors arising in these locations. Reconstruction of bone defects using various techniques, vascular reconstruction, tendon transfers, and soft tissue reconstruction using regional flaps in the hand and free flaps in the foot have resulted in good functional outcomes. Amputation and early prosthetic fitting still have a role in management of some soft tissue sarcomas, most frequently in the foot.
Limb salvage remains the standard of care for extremity soft tissue sarcomas. Given the fact that patients have good oncologic and functional outcomes with limb salvage in tumors in the hand and foot, surgical oncologists should have this goal for each patient.
Current Opinion in Oncology 08/2005; 17(4):366-9. DOI:10.1097/01.cco.0000166651.38417.c8 · 4.47 Impact Factor
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