The skin is the largest organ of the body. It serves to protect our inner structures from the external environment. As such it is constantly exposed to injurious environmental impacts, particularly solar exposure. However, skin is also the most accessible part of our bodies, where the impact of disease or treatment may be readily visible.

It is estimated that more than 5.6 million cases of new skin cancer are diagnosed in over 3.5 million people in the US each year. Although a majority are low risk basal and squamous cancers, more than 22,000 deaths will occur from higher risk variants.

Soft tissue sarcomas, which may affect the skin and connective tissues, are much less common, accounting for more than 13,000 new cases each year. However, these tumors are more dangerous, leading to more than 5,400 deaths each year.

The intersection of cosmetic concern, functional treatment impact, and disease threat, can make management of skin and soft tissue cancers complex. Surgery continues to be important in the staging and control of primary disease. As high-risk skin and soft tissue tumors may spread beyond the primary tumor mass, generous excisions to achieve suitably clear resection margins, are necessary for good outcome.

The cosmetic and functional results of standard soft tissue cancer surgery is often suboptimal. Standard surgical resections may leave open wounds, structural deformities, and even scarring that are unsightly and which can limit function.The use of oncologic surgical techniques, combined with the incorporation of plastic surgical principles (Oncoplasty), allow better cancer surgery with better cosmetic outcomes. Such techniques optimize adequacy of resection. They provide a better chance of complete tumor removal, even when disease may be large and infiltrative.

Resection defects can often be reconstructed immediately using local tissue rearrangement with adjacent flaps to fill in gaps and create replacement structures. Careful planning minimizes the impact of scar while providing adequate operative resection. Incisions can be placed in natural lines of tension, hiding much of the healed scar while maintaining natural contour. Tissue expanders may stretch existing skin while skin grafts may be used to replace lost skin.

In some cases, several techniques may be combined over multiple stages. An example is aggressive scalp cancer, where local tissue flaps may reduce the size of a large defect, followed by placement of an artificial skin graft substitute for coverage of a residual defect. Over several weeks, ingrowth of blood vessels and connective tissue provides a platform for secondary skin grafting. Exposed skull is protected with soft tissue and the cosmetic result can be excellent.

In other cases, tissue flaps can be constructed that fall within natural skin creases and distribute tension away from critical structures like the corners of the eye or mouth. This technique can produce excellent coverage and good cosmetic results. It also avoids the functional impairment of standard closures under tension.

Transposition flaps and advancement flaps allow coverage of defects using full thickness local tissue, rotated into position. Although a small prominence may be present at the point of tissue “pivot”, this usually flattens out in time, or may be removed in the office.

Tubed pedicle flaps may be a useful way to reconstruct defects in protruding structures like the rim of the ear. A tongue of tissue taken from the upper neck, behind the ear, may be rotated in to a sizable defect, with blood supply initially coming from the base of the flap. Over time, new blood supply grows in from the edge of the former defect, allowing the base of the flap to be cut, removed and closed. The new free end of the flap may be curled around to provide tissue coverage for the the back side of the defect.

Oncoplastic soft tissue surgery represents an ability to combine the best in oncologic skin and sarcoma cancer management with well established plastic surgical techniques It is a significant improvement in care that should be available to all soft tissue tumor patients. Oncoplastic surgery achieves more effective cancer intervention, while maximizing form and function.