Clinical Presentation
A 55-year-old White female had residual sarcoma over her left upper arm after previous resection. She underwent a wide local excision of the sarcoma by the surgical oncology service. The plastic surgery service was asked to perform a soft tissue reconstruction after additional resection of residual sarcome. After the wide local excision, there was an 11 × 8 cm full-thickness skin and subcutaneous tissue defect down to the underlying muscles ( Fig. 16.1 ).
Operative Plan and Special Considerations
Based on the size and location of the skin defect over the lateral upper arm, a large adjacent skin rotational flap could be planned. The portion of the soft tissue defect could be closed directly after significant undermining and the rest of the defect would be reconstructed by the skin rotational flap. In this way, the most critical part of the wound could be covered by the more reliable tissue and the patient would have better overall reconstructive outcome. Although a skin graft-only procedure can be selected to close this defect, the resulting contour of the reconstruction would probably not be optimal. In addition, a direct skin graft to the underlying muscles may result in tethering, which would compromise the function of those muscles.
Operative Procedures
Under general anesthesia with the patient in a supine position, the soft tissue defect was assessed and the intraoperative decision was made to perform a large adjacent skin rotational flap to cover the defect and a skin graft to close the flap donor site. After significant undermining, the lateral soft tissue defect was closed. A large adjacent skin rotational flap was designed ( Fig. 16.2 ). The proposed skin incision was then infiltrated with 1% lidocaine with 1:100,000 epinephrine. Once the skin incision had been made, the flap was elevated in the suprafascial plane. The flap was rotated and advanced into the defect without very much tension. The temporary inset of the flap was performed with towel clips and skin staples. This left an 8 × 5 cm skin defect over the flap donor site. The donor site defect was closed with a split-thickness skin graft harvested from the left lateral thigh. This was a sheet graft, which was placed on the flap donor site and secured with skin staples. The skin graft site was covered with Xeroform and VAC dressing. There was a small portion of dog ear along the inferolateral aspect of the closure that was corrected by a direct excision ( Fig. 16.3 ).
