RE: Large-defect Resurfacing: A Comparison of Skin Graft Results Following Sarcoma Resection and Traumatic Injury Repair

We have read the article by Hanada et al¹ from the July 2019 issue of Wounds with great interest and acknowledge that split-thickness skin grafting (STSG) following sarcoma resection is a feasible and noninvasive means of defect reconstruction. The comparison to traumatic defects certainly underpins the safety and efficacy of the method. However, regarding the given defect sizes and localizations, as well as associated defects in tissue volume, we propose free or pedicled flap reconstruction not only would have been feasible, but superior to STSG in most of their¹ cases.

Success rates of free flap reconstruction can exceed 96%,² be safely undertaken in the elderly and multimorbid, and on the trunk and extremities alike with excellent donor site outcomes.³ Time to epithelialization, as reported by the authors,¹ is significantly longer than the expected healing time of a free or pedicled flap. Although data regarding tumor grading are missing, it can be expected that a significant number of patients would have needed either neoadjuvant or adjuvant radiotherapy. It is well known that these patients definitely benefit from more stable soft tissue reconstruction⁴; moreover, there is ongoing concern that instable STSG reconstruction causes delay in radiotherapy with worse oncologic outcome.

The authors¹ describe insufficient or unfeasible immobilization of mobile joints as a source for complications in epithelialization. Commonly, no or at most short (not exceeding 3–5 days) periods of immobilization are needed in free or pedicled flap-based sarcoma or traumatic defect reconstruction.⁵

In conclusion, while skin grafts are an adequate option for small or superficial defects, we propose free or local flap-based reconstruction as the first line of therapy for large and complex oncologic and traumatic defects, as were demonstrated in the present study.¹ Therefore, plastic surgeons familiar with the whole armamentarium of reconstructive surgery should augment any multidisciplinary sarcoma team.⁶

Sincerely,

Gabriel Hundeshagen, MD, MMS; and Ulrich Kneser, MD

Affiliation

Department of Hand, Plastic, and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany; and University of Heidelberg, Heidelberg, Germany

Correspondence

Gabriel Hundeshagen, MD, MMS, Resident, BG Unfallklinik Ludwigshafen, Hand, Plastic, and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwig-Guttmann Street 13, Ludwigshafen am Rhein 67071, Germany; gabrielhundeshagen@gmail.com

References

1. Hanada M, Kadota H, Yoshida S, et al. Large-defect resurfacing: a comparison of skin graft results following sarcoma resection and traumatic injury repair. Wounds. 2019;31(7):184–192.

2. Carney MJ, Weissler JM, Tecce MG, et al. 5000 free flaps and counting: a 10-year review of a single academic institution’s microsurgical development and outcomes. Plast Reconstr Surg. 2018;141(4):855–863.

3. Xiong L, Gazyakan E, Wähmann M, et al. Microsurgical reconstruction for post—traumatic defects of lower leg in the elderly: a comparative study [published online September 6, 2016]. Injury. 2016;47(11):2558–2564.

4. Abouarab MH, Salem IL, Degheidy MM, et al. Therapeutic options and postoperative wound complications after extremity soft tissue sarcoma resection and postoperative external beam radiotherapy [published online December 5, 2017]. Int Wound J. 2018;15(1):148–158.

5. Payne CE, Hofer SO, Zhong T, Griffin AC, Ferguson PC, Wunder JS. Functional outcome following upper limb soft tissue sarcoma resection with flap reconstruction [published online February 21, 2013]. J Plast Reconstr Aesthet Surg. 2013;66(5):601–607.

6. Misra A, Mistry N, Grimer R, Peart F. The management of soft tissue sarcoma [published online November 25, 2008]. J Plast Reconstr Aesthet Surg. 2009;62(2):161–174.