Unité de chirurgie plastique et réparatrice, centre Léon-Bérard, 28, rue Laennec, Lyon, France.
Unité de chirurgie plastique et réparatrice, centre Léon-Bérard, 28, rue Laennec, Lyon, France.
Ann Chir Plast Esthet. 2020 Nov;65(5-6):394-422. doi: 10.1016/j.anplas.2020.05.009. Epub 2020 Aug 15.
Soft tissue sarcomas are rare malignant tumors with pejorative prognosis. They require a multidisciplinary approach in a specialized hospital belonging to the NetSarc network in France. In all cases treated with curative intent, the objective of excision surgery is to achieve wide, microscopically negative margins (R0 according to the UICC classification). When growing on a limb, sarcomas may threaten functionally relevant structures and even lead to amputation. Nowadays, when combined with radiation therapy, wide exeresis limb-sparing surgery is achievable in 90 to 95% of the cases, of which 25% will nevertheless require reconstructive surgery to preserve the limb, to limit postoperative complications and to manage possible sequelae. Progress in reparative surgery, particularly in microsurgery, has helped not only to improve limb salvage rates but also to create wider margins without altering oncologic goals of curative resection. After determining the range of resection, reconstructive surgery should be tailored to address the tissue defect. The converse is to be strongly discouraged. The extent of resection must not be compromised or reduced in order to facilitate reconstructive surgery. A plastic surgeon must master all the flap techniques, including microsurgery, while taking into account the impact of preoperative and postoperative radiation therapy on previously irradiated tissues or on wounds requiring adjuvant therapy. Recent developments, especially as regards perforator flaps, have helped to enhanced the quality of reconstruction procedure while reducing donor site morbidity. In our experience, perforator flaps are a workhorse in reconstructive surgeries subsequent to soft tissue sarcoma of the extremities. On a parallel track, lipofilling (otherwise known as fat grafting or fat transfer) has become the first-line treatment for patients with post-surgical functional or cosmetic sequalae. It is performed after long-term follow-up during disease-free survival. Strict clinical examination and MRI are mandatory prior to programming any local procedure. Usually, three to four sessions of fat grafting are needed to enhance local trophicity or the cosmetic aspect. Sequalae treatments are of great interest in terms of psychological as well as functional outcome.
软组织肉瘤是一种预后较差的罕见恶性肿瘤。在法国 NetSarc 网络的专业医院中，需要多学科的方法进行治疗。在所有以治愈为目的治疗的病例中，切除手术的目的是实现广泛的、显微镜下阴性的边缘（根据 UICC 分类为 R0）。当肉瘤生长在四肢上时，可能会威胁到功能相关的结构，甚至导致截肢。如今，结合放射治疗，广泛切除保肢手术在 90%到 95%的病例中是可行的，其中 25%的病例仍需要重建手术来保留肢体，以减少术后并发症，并处理可能的后遗症。修复手术的进展，特别是在显微外科方面，不仅有助于提高保肢率，而且还可以在不改变治愈性切除的肿瘤学目标的情况下扩大边缘。在确定切除范围后，重建手术应根据组织缺损进行定制。强烈反对相反的做法。为了便于重建手术，不能妥协或减少切除范围。整形外科医生必须掌握所有皮瓣技术，包括显微外科技术，同时考虑到术前和术后放射治疗对先前照射过的组织或需要辅助治疗的伤口的影响。最近的发展，特别是关于穿支皮瓣的发展，有助于提高重建手术的质量，同时减少供区的发病率。根据我们的经验，在四肢软组织肉瘤的重建手术中，穿支皮瓣是一种常用的方法。在并行轨道上，脂肪填充（也称为脂肪移植或脂肪转移）已成为术后功能或美容后遗症患者的一线治疗方法。在无病生存期间进行长期随访后进行。在编程任何局部手术之前，必须进行严格的临床检查和 MRI。通常，需要三到四次脂肪移植来增强局部营养或美容效果。后遗症治疗在心理和功能结果方面都非常重要。
