Definition of the Surgical Case Complexity in the Treatment of Soft Tissue Tumors of the Extremities and Trunk

BACKGROUND: We intend to establish a complexity score for soft tissue tumor surgeries to compare the complexities of different soft tissue tumor surgeries and to ultimately assign affected patients to appropriate treatments. METHODS: We developed a soft tissue tumor complexity score (STS-SCS) based on three pillars: in addition to patient-related factors, tumor biology and surgery-associated parameters were taken into account. The STS-SCS was applied to our sampling group of 711 patients. RESULTS: The minimum STS-SCS was 4, the maximum score was 34 and the average score 11.4 ± 5.9. The scores of patients with malignant diagnoses were notably higher and more widely scattered than those of patients with benign or intermediate malignant tumors. To better categorize the complexities of individual surgeries, we established four categories using the collected data as a reference dataset. Each of the categories contained approximately one-quarter of the registered patients. DISCUSSION: The STS-SCS allows soft tissue tumor surgeries to be retrospectively evaluated for their complexity and forms the basis for the creation of a prospective concept to provide patients with the right intervention in the right geographic location, which can lead to better results and provision of the most cost-effective overall treatment

Unlocking the Power of Benchmarking: Real-World-Time Data Analysis for Enhanced Sarcoma Patient Outcomes

Benchmarking is crucial for healthcare providers to enhance quality and efficiency, notably for complex conditions like sarcomas. Multidisciplinary teams/sarcoma boards (MDT/SBs) are vital in sarcoma management, but differences in their processes can affect patient outcomes and treatment costs, despite adherence to international guidelines. To address this issue, this study aimed to compare two MDT/SBs and establish an interoperable digital platform, Sarconnector$^{®}$, for real-time-world data assessment and automated analysis. The study included 983 patients, 46.0% of whom female, with a median age of 58 years, and 4.5% of patients presented with metastasis at diagnosis. Differences were observed in the number of first-time presentations, follow-up presentations, primary sarcomas, biopsies and chemotherapy indications between the two MDT/SB. The results highlight the importance of benchmarking and utilizing a harmonized data approach, such as the RWT approach provided by the Sarconnector$^{®}$, to standardize and evaluate quality and cost metrics. By identifying areas of improvement and making data-driven decisions on the meta-level, healthcare providers can optimize resources and improve patient outcomes. In conclusion, benchmarking with the RWT harmonized data approach provided by the Sarconnector$^{®}$ can help healthcare providers improve the overall effectiveness of the healthcare system and achieve better outcomes for their patients in terms of both outcomes and costs

Reconstruction of the heel, middle foot sole and plantar forefoot with the medial plantar artery perforator (MPAP) flap: clinical experience with 28 cases

INTRODUCTION: Defects in the weight-bearing region of the foot sole can represent a substantial restriction in quality of life and pose a challenge for reconstructive plastic surgery.The purpose of this article is to report our experience with the use of medial plantar artery perforator (MPAP) flap for reconstruction of defects of the foot sole in 3 different regions: heel, middle foot sole and plantar forefoot. PATIENTS AND METHODS: From January 2003 to May 2016, 28 patients (13 males and 15 females) with an average age of 54 years (range 12 to 84 y.o.) received reconstruction with 28 MPAP flaps.26 flaps were harvested as pedicle perforator flaps and 2 as free perforator flaps. All flaps were raised from the ipsilateral instep area. The defect locations included the heel (20 cases), middle foot sole (4 cases) and forefoot (4 cases).The causes of reconstruction were tumors in 18 patients (64%), decubitus in 8 patients (29%) and trauma in 2 patients (7%). RESULTS: The flap sizes varied from 2.5 × 2.5 cm to 5.5 × 9.5 cm. All of the flaps survived completely after surgery, apart from one. The donor sites were all covered with a split-thickness skin graft. Follow-up observations were conducted for 4 to 12 months, and all patients had good functional recovery with satisfactory cosmetic results. CONCLUSION: The MPAP flap can be considered an optimal method of foot sole reconstruction not only for covering the weight-bearing area of the heel but also for the middle and forefoot plantar region

Pedicled posteromedial thigh (pPMT) perforator flap and its application in loco-regional soft tissue reconstructions

INTRODUCTION: The posteromedial thigh (PMT) perforator flap is a valuable reconstructive option. In its pedicled form, the experience is currently limited to a few case reports. The purpose of this article is to describe various clinical applications of the pedicled posteromedial thigh (pPMT) flap for reconstruction of loco-regional soft tissue defects. PATIENTS AND METHODS: From 2014 to 2016, 15 patients underwent reconstruction with 15 pPMT flaps. The locations of the defects included the inguinal region (4 cases), the perineal and genital region (3 cases), the proximal and distal medial thigh (3 and 2 cases, respectively), and the popliteal fossa (3 cases). The perforator selected was a branch of the profunda femoris artery (PFA) in 12 cases and the medial circumflex fermoral artery (MCFA) in 3 cases. In all cases, the flap was harvested as a perforator-based island flap, while the mechanism of flap transfer varied between V-Y advancement, interpolation, or different degrees of axial pivoting around the skeletonized perforator (propeller flap design). RESULTS: The flap sizes varied from 5 × 4 cm2 to 29 × 8 cm2, and the pedicle could be skeletonized for up to 13 cm. All the flaps survived after surgery without complication. The donor sites were all primarily closed with minimal morbidity. Follow-up observations were conducted for 6 to 14 months, and all patients had good functional recovery. CONCLUSION: The pPMT perforator flap is a reconstructive option that can be considered when dealing with soft tissue defects located in body regions ranging from the groin down to the popliteal fossa. It avoids the need for a microsurgical transfer and easily fulfills the dictum of replacing "like tissue with like tissue.

Pedicled chimeric sensitive fasciocutaneous anterolateral thigh (ALT) and vastus lateralis muscle (VLM) flap for groin defect reconstruction: a case report

The anterolateral thigh (ALT) flap is one of the most commonly used flap worldwide, as both free flap and pedicled local flap. Here, we report the use of a pedicled chimeric sensitive ALT and vastus lateralis muscle (VLM) flap in a patient with a 12 cm × 8 cm contaminated soft tissue defect of the right inguinal region with exposed femoral vessels. The flap was harvested based on two perforators, one musculocutaneous and one pure muscular, each nourished separately a sensitive fasciocutaneous component and a vastus lateralis muscle component, respectively. The muscle part was tailored to wrap around the exposed vascular structures, while the innervated skin and fascia component of the flap provided a tension-free closure of the wound. The post-operative course was uneventful and the patient was discharged at 1 week post-operative. Even though it requires technical skills and experience in perforator dissection, we believe that the pedicled chimeric sensitive ALT and VLM flap may be one of the best solutions in case of exposed femoral vessels in contaminated wounds

The use of inverted-L posteromedial thigh (L-PMT) flap for autologous breast reconstruction: a case report

The posteromedial thigh (PMT) flap has been described for breast reconstruction in vertical fashion (vPMT). However, it might not incorporate enough soft tissue for reconstruction of a medium size breast. Here, we present a case utilizing the free inverted-L posteromedial thigh (L-PMT) flap for autologous reconstruction of the breast. A 65-year-old woman with a body max index (BMI) of 24.5 kg/m2 underwent nipple sparring mastectomy and received immediate unilateral breast reconstruction. The flap was raised based on the first medial perforator of the profunda femoris artery (PFA). The internal mammary artery and vein were dissected as recipient vessels. The flap size was 25 cm × 25 cm. The mastectomy specimen and weight of the flap was 260 g and 310 g, respectively. The flap survived completely after surgery. The donor site was primarily closed with minimal morbidities. Follow-up observations were conducted from 1 to 6 months. The patient was satisfied with the reconstruction. The free L-PMT flap may be suitable for breast reconstruction in women with moderate breast size. The inverted-L pattern of the PMT flap allows the surgeon to include a bigger quantity of flap soft tissue enabling a more anatomical shape of the breast and represents an alternative design that may be used for autologous breast reconstruction in selected patients

Reconstruction of an upper posterior thigh extensive defect with a free split-anterolateral thigh (s-ALT) flap by perforator-to-perforator anastomosis: A case report

The anterolateral thigh (ALT) flap is one of the most commonly used flap worldwide in reconstructive surgery, as both free flap and pedicled local flap. Here, we report the use of a free split anterolateral thigh (s-ALT) flap for reconstruction of a 14 cm × 16 cm soft tissue defect of the left upper posterior thigh region due to sarcoma resection in a patient. The ALT flap was harvested based on two musculocutaneous perforators from the right thigh and anastomosed to the contralateral descending branch of the lateral circumflex femoral artery (LCFA) in perforator-to-perforator manner, in order to gain more pedicle length and being able to cover the posterior thigh defect. The post-operative course was uneventful and the patient was discharged at 1 week post-operative. Eleven months after the operation, the aesthetic outcome was satisfactory with no functional deficit. Even though it requires technical skills and experience in perforator dissection, we believe that the s-ALT flap anstomosed to the contralateral LCFA in perforator to perforator fashion, may be a good solution in case of such a difficultly located extensive defect of the posterior thigh

The bipedicled medial plantar flap: vascular enhancement of a reverse flow Y-V medial plantar flap by the inclusion of a metatarsal artery perforator for the reconstruction of a forefoot defect - A case report

The pedicled medial plantar (MP) flap is an optimal solution for defects involving the weight-bearing areas of the foot. However, venous congestion is a frequently encountered complication, especially with the reverse-flow variants of the flap, and several strategies have been reported in literature both to prevent and to manage it. In this article, we present the use of a medial plantar flap based distally on the lateral plantar artery with the adjunct of an extra metatarsal perforator from the dorsalis pedis artery as a vascular enhancement to avoid the venous congestion and to improve the overall circulation. This bipedicled flap was successfully advanced to cover a 5 × 3 cm soft-tissue defect located at the level of the first and second metatarsal heads of the right foot resulting from the excision of a squamous cell carcinoma in an 80-year-old male patient with a history of cardiovascular disease. The postoperative course was uneventful. The patient was discharged 7 days after the operation and was able to walk after 6 weeks wearing normal shoes. We believe that preserving plantar metatarsal perforators during the harvesting of an MP flap based distally on the lateral plantar artery may be a precious adjunct as it increases blood supply, especially the venous drainage of the flap