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CORRESPONDENCE AND COMMUNICATION Reconstruction of hand and forearm after sarcoma resection using anterolateral thigh free flap Soft-tissue reconstruction following tumour resection in the hand and forearm remains a challenge to plastic surgeons. In the past, amputation of affected limb was the treatment of choice. Over the past several decades, advances in diagnosis, staging, imaging and adjuvant chemotherapy and radiotherapy have allowed limb-salvage surgery to become a realistic option in upper limb malignancies. 1e5 Recently, the anterolateral thigh free flap first described by Song et al. has gained popularity in the realm of soft-tissue reconstruction. 4 Figure 1 (a) A 46-year-old man with synovial sarcoma on the right thenar area. (b) After tumour resection, there was 10 Â 5-cm sized defect. Bone graft from fibula was performed. (c) An anterolateral thigh flap, 10 Â 5 cm in size, was designed on the left thigh. (d) Elevation of the flap. (e) Immediate postoperative view. 1748-6815/$ - see front matter ª 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.11.118 Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, e584ee586

Reconstruction of hand and forearm after sarcoma resection using anterolateral thigh free flap

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Page 1: Reconstruction of hand and forearm after sarcoma resection using anterolateral thigh free flap

Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, e584ee586

CORRESPONDENCE AND COMMUNICATION

Reconstruction of hand andforearm after sarcoma resectionusing anterolateral thigh free flap

Soft-tissue reconstruction following tumour resection in thehand and forearm remains a challenge to plastic surgeons.

Figure 1 (a) A 46-year-old man with synovial sarcoma on the righsized defect. Bone graft from fibula was performed. (c) An anterothigh. (d) Elevation of the flap. (e) Immediate postoperative view.

1748-6815/$-seefrontmatterª2009BritishAssociationofPlastic,Reconstrucdoi:10.1016/j.bjps.2008.11.118

In the past, amputation of affected limb was the treatmentof choice. Over the past several decades, advances indiagnosis, staging, imaging and adjuvant chemotherapy andradiotherapy have allowed limb-salvage surgery to becomea realistic option in upper limb malignancies.1e5 Recently,the anterolateral thigh free flap first described by Songet al. has gained popularity in the realm of soft-tissuereconstruction.4

t thenar area. (b) After tumour resection, there was 10� 5-cmlateral thigh flap, 10� 5 cm in size, was designed on the left

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Page 2: Reconstruction of hand and forearm after sarcoma resection using anterolateral thigh free flap

Correspondence and communication e585

Between March 2006 and May 2008, we treated sixpatients, including two with synovial sarcoma (Figure 1), twowith leiomyosarcoma (Figure 2), one with malignant fibroushistiocytoma and one with fibrous sarcoma. The patientsincluded four men and two women, with ages ranging from39 to 65 years. The recipient sites included the forearm(n Z 3), wrist (n Z 2) and hand (n Z 1). The size of soft-tissue defects ranged from 10� 6 cm to 15� 10 cm.

The size of flap varied from 10� 6 cm to 15� 10 cm. Thedonor defects were closed primarily in five patients and

Figure 2 (a) A 65-year-old man with leiomyosarcoma on theleft forearm. (b) After tumour resection, there was a largesoft-tissue defect with tendon loss. The tendon graft washarvested from ipsilateral fascia lata. (c) Postoperative view.The defect was covered with the anterolateral free flap.

closed with split-thickness skin grafts in one patient. Sixflaps survived completely. Only one flap developed distalnecrosis, which was treated successfully with debridementand a subsequent secondary intention. The surviving flaphealed with the surrounding tissue within 3 weeks. Exerciseof hand started at the end of 3 weeks. The follow-up periodwas at least 3 months. All patients were satisfied with theirresult, and the texture, colour and thickness of the flapmatched the surrounding tissue.

Soft-tissue sarcoma of the hand and forearm are usuallysmall lesions detected at a relatively early stage. Despitetheir small size, sarcoma of the hand and forearm tend tobe aggressive, and it has been observed that thesetumours may carry a worse prognosis than similarly sizedtumours in other anatomical locations. So the primaryconcern in any oncological setting is clearly the perfor-mance of an adequate and complete resection. Surgicalmargins should never be sacrificed in an attempt tomaintain hand function. However, safe reconstruction bymeans of a reliable coverage of the defect is also critical.Soft-tissue defect over the hand and forearm with expo-sure of bone and tendon need to be covered by flaps.Anterolateral thigh free flaps are ideal to cover skin andsoft-tissue defect over the hand and forearm. The flap alsohas long vascular pedicle and provides convenience inaccessing recipient vessel in the upper extremity. Theoperation can be performed by two teams working simul-taneously. Harvesting the flap usually does not requirea change in the patient’s position. One team is able toresect the tumour mass, while another team elevates theflap. Hence, the mean time of execution in our series wasabout 2 h. The thickness of the flap is adjustable. Forreconstruction of hand and forearm, a pliable flap isrequired; therefore, the suprafascial elevation techniquepermits harvesting of a thin flap with less donor-sitemorbidity by preserving the fascia. It is also useful fortendon graft using tensor fascia lata when tendon is alsoresected. The anterolateral thigh flap can be harvested asa sensate flap, including lateral femoral cutaneous nerve.Compared with other donor sites, the morbidity of ante-rolateral thigh flap is minimal, and a defect of less than9 cm in width can be closed primarily.5 The resulting scarmay be acceptable in female patients.

However, there are also many difficulties associatedwith flap harvesting because of concerns about theconsistency of their anatomy and because of complicateddistribution of vessels to skin.5 However, these difficultiescan be overcome using Doppler tracing of the vascularpedicle preoperatively.

Despites these disadvantages, anterolateral thigh freeflaps appear to be ideal for reconstruction of hand andforearm after sarcoma resection.

Disclosure: None of the authors has any financial inter-ests in the companies producing or distributing productsused for this study.

References

1. Simon GT, Edward AA, Peter GC, et al. Soft tissue reconstructionfollowing tumor resection in the hand. Hand Clin 2004;20:181e202.

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e586 Correspondence and communication

2. Upton J, Kocher MS, Wolfort FG. Reconstruction followingresection of malignancies of the upper extremity. Surg OncolClin N Am 1996;5:847e92.

3. Fleegler EJ. An approach to soft tissue sarcomas of the hand andupper limb. J Hand Surg[Br] 1994;19:411e9.

4. Song YG, Chen GZ, Song YL. The free thigh flap: A new free flapconcept based on the septocutaneous artery. Br J Plast Surg1984;37:149.

5. Wei FC, Jain V, Celik N, et al. Have we found an ideal soft-tissueflap? An experience with 672 anterolateral thigh flaps. PlastReconstr Surg 2002;109:2219e26.

Naeho LeeSigyun Roh

Kyungmoo YangDepartment of Plastic & Reconstructive Surgery, Chonbuk

National University Hospital, Jeonju, Republic of KoreaE-mail address: [email protected]

Jungryul KimDepartment of Orthopedic Surgery, Chonbuk National

University Hospital, Jeonju, Republic of Korea