Perforator versus traditional flaps in extremity soft-tissue sarcoma reconstruction: A comparative cohort study

Introduction Limb-sparing resection of extremity soft-tissue sarcoma (eSTS) often leaves complex defects that require reliable coverage. Although perforator flaps offer theoretical advantages, their reliability in eSTS reconstruction remains debated. We directly compared outcomes between perforator and traditional (i.e., non-perforator) flaps for eSTS reconstruction. Methods This retrospective cohort study included patients who underwent limb-sparing eSTS excision with flap reconstruction at a quaternary cancer center between 2016 and 2021. Patients were categorized into perforator and traditional flap groups. Outcomes included operative time, surgical site complications, prolonged wound care, reoperation, readmission, and need for eventual amputation. Results A total of 156 patients were included (53 perforator and 103 traditional flaps). Perforator flaps were more frequently used for tumors distal to the elbow (17% vs. 1.9%, p = 0.002) and for recurrent tumors (21% vs. 7.8%, p = 0.019). Operative time and overall complication rates were comparable between the groups. Among free tissue transfers, perforator flaps were associated with a shorter length of stay than traditional flaps (6 vs. 11 days, p = 0.003); however, this association was not maintained on multivariable analysis. Conclusions Perforator flaps provide oncologically safe, functionally reliable reconstruction for eSTS, with similar complication rates compared to traditional flaps. These findings support their integration into the eSTS reconstructive armamentarium.