Letter to the Editor
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
Gabriel Hundeshagen, MD, MMS; and Ulrich Kneser, MD