Reconstruction of complex chest wall defects

doi:10.1016/S0002-9610(96)00058-X

The American Journal of Surgery

Volume 172, Issue 1, July 1996, Pages 35-40

https://doi.org/10.1016/S0002-9610(96)00058-X Get rights and content

Background

Reconstruction of complex chest wall defects represents a major challenge and requires close cooperation between the cardiothoracic and reconstructive surgeon to achieve an optimal outcome and reduce the incidence of complications. The principles of chest wall reconstruction include control of infection, local wound care, wide debridement of all necrotic and devitalalized tissues, obliteration of all residual cavities and spaces with well-vascularized tissues, reestablishment, when necessary, of the continuity and skeletal stability of the chest wall, and immediate or early definitive coverage of all defects with well-vascularized tissues.

Methods

This paper is based on our experience with 113 patients who underwent chest wall reconstruction for a variety of defects resulting from infection, trauma, tumor extirpation, and radionecrosis. All patients were treated with a variety of muscle flaps and/or omentum which provided obliteration of dead space and coverage. Seven patients with large anterolateral defects required additional skeletal stability with synthetic patches or mesh.

Results

88.6% of patients healed without significant problems. 8.8% had major complications requiring reoperation and prolonged hospitalization while 4.4% had minor complications. Conclusions: Based on long-term experience, we believe that currently the use of well-vascularized tissue is the method of choice for reconstruction of complex chest wall defects. This provides stable coverage, reduces hospital stay, and thus lowers overall care cost for these patients.

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Cited by (65)

Combined pectoralis and rectus abdominis flaps are associated with improved outcomes in sternal reconstruction
2022, Surgery (United States)
Mortality increases nearly 5-fold in the approximately 5% of patients who develop sternal wound complications after cardiothoracic surgery. Flap-based reconstruction can improve outcomes by providing well-vascularized soft tissue for potential space obliteration, antibiotic delivery, and wound coverage; however, reoperation and readmission rates remain high. This study used the high case volume at a tertiary referral center and a diverse range of reconstructive approaches to compare various types of flap reconstruction. Combined (pectoralis and rectus abdominis) flap reconstruction is hypothesized to decrease sternal wound complication–related adverse outcomes.
A retrospective cohort study of consecutive adult patients treated for cardiothoracic surgery sternal wound complications between 2008 and 2018 was performed. Patient demographics, comorbidities, wound characteristics, surgical parameters, and perioperative data were collected. Multivariable regression modeling with stepwise forward selection was used to characterize predictive factors for sternal wound–related readmissions and reoperations.
In total, 215 patients were assessed for sternal wound reconstruction. Patient mortality at 1 year was 12.4%. Flap selection was significantly associated with sternal wound–related readmissions (P = .017) and reoperations (P = .014). Multivariate regression demonstrated rectus abdominis flap reconstruction independently predicted increased readmissions (odds ratio 3.4, P = .008) and reoperations (odds ratio 2.9, P = .038). Combined pectoralis and rectus abdominis flap reconstruction independently predicted decreased readmissions overall (odds ratio 0.4, P = .031) and in the deep sternal wound subgroup (odds ratio 0.1, P = .033).
Although few factors can be modified in this complex highly comorbid population with a challenging and rare surgical problem, consideration of a more surgically aggressive multiflap reconstructive approach may be justified to improve outcomes.
Unique way of chest wall reconstruction using Integra Dermal Regeneration Template (IDRT) in a patient with post traumatic mucormycosis: A case report
2022, International Journal of Surgery Case Reports
Necrotizing soft tissue infections (NSTI) are caused by toxin-producing bacteria and fungi that results in rapid progression of disease with significant local tissue destruction.
We present a case report of a 57-year-old male patient in line with the SCARE 2020 criteria. He was admitted to the emergency department with a small abrasion on the right antero-lateral chest wall, and a diffuse necrotic patch of skin and soft tissues with purulent discharge.
Clinical examination, routine blood investigations, CT scan chest, and chest x-ray were performed. Patient underwent debridement six times, followed by negative pressure wound therapy (NPWT). After negative culture report, Integra Meshed Dermal Regeneration Template (IMDRT), measuring 4 × 5 in. was applied and NPWT continued. The outer layer of IDRT was removed on Day 19. Split thickness skin grafting (STSG) was performed once neodermis formation was confirmed. NPWT was continued post skin grafting for a week. IDRT was successfully taken up over the raw area with exposed lung. Patient was discharged 10 days after STSG. The patient's condition improved remarkably and he was able to breathe normally. There was no puckering or tethering effect on the grafted area and not much fibrosis. He showed speedy recovery with healed donor site and 100% uptake of grafted tissue.
IDRT along with NPWT is an effective and useful technique for spontaneous regeneration of the dermis and basement membrane to promote wound healing in traumatic patients with NSTIs.
Level V.
Therapeutic.
Complex Microsurgical Reconstruction After Tumor Resection in the Trunk and Extremities
2020, Clinics in Plastic Surgery
Citation Excerpt :
Large central chest wall defects can be challenging when local flaps are not possible because of resection or vascular compromise. Pedicled VRAM/TRAM flaps serve well in this setting because they provide the volume to obliterate dead space and provide very large skin paddles.10,16,17,29,31,32 In patients with abdominal scars from prior abdominal operations, microvascular augmentation with supercharging/turbocharging of the inferior epigastric vessels and even using bilateral inferior epigastric vessels as a bipedicled flap has been shown to improve perfusion.17,29
Complex Microsurgical Reconstruction After Tumor Resection in the Trunk and Extremities
2017, Clinics in Plastic Surgery
Citation Excerpt :
Other options include transposition of the external jugular and the cephalic veins. Complex microsurgical reconstruction after tumor resection in the trunk reduces the morbidity of prolonged hospital stays, multiple operations for debridement, and open wounds in patients in whom local flap reconstruction is not feasible.25,27–32 Three microsurgical methods are generally used in chest wall reconstruction.
Late results following flap reconstruction for chest wall recurrent breast cancer
2013, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
In cases of full-thickness defects of the bony chest wall with exposure of the vital structures, depending on anatomical location and defect size, some form of chest wall stabilisation may be required. Large anterior and antero-lateral thoracic wall defects usually require stabilisation to prevent flail chest and paradoxical breathing and to protect the underlying lungs and/or heart.8–11 A synthetic mesh is most commonly employed.
Locally extensive recurrent breast cancer usually portends a poor prognosis but certain cases can be treated surgically by wide soft-tissue resection as well as full-thickness chest wall resection (FTCWR). The resulting defect usually necessitates immediate flap coverage. The aim of this study was to assess local control, morbidity, choice of flap reconstruction, patient selection and overall long-term survival following surgical salvage of patients with chest wall recurrent breast cancer.
Forty patients were treated with wide soft-tissue resection and immediate flap reconstruction from 1984 to 2011 in a single institution. Demographic, treatment and mortality data were obtained from patients' files.
Mean age at surgery was 54 years. FTCWR was performed in 19 cases including three extended forequarter amputations. Chest wall stabilisation involved a synthetic mesh in 12 patients, fascia lata in two patients, free rib grafts in one patient and synthetic mesh and free rib graft in one patient. Soft-tissue reconstruction consisted of microvascular free flaps in seven patients and pedicled flaps in 33 patients. In-hospital mortality was 0%, 30-day mortality was 5%; there were two re-operations, six minor wound complications and one pulmonary embolism. There were no flap losses. In patients operated on with curative intent (n = 31) median disease-free interval was 31 months and median survival was 52 months.
In selected cases wide resections for extensive chest wall recurrent breast cancer can result in reasonable local control and survival. Several flap options exist for soft-tissue reconstruction.
Moldable titanium mesh for chest wall reconstruction, an elegant solution about a case report
2012, Annales de Chirurgie Plastique Esthetique
De nombreuses techniques chirurgicales sont disponibles pour reconstruire les pariétectomies thoraciques transfixiantes en fonction de la taille de la perte de substance, de son type, ainsi que de sa localisation. Nous proposons une solution inédite et jamais publiée.
Nous avons pris en charge une patiente de 54 ans atteinte d’une perte de substance thoracique antéro-supérieure gauche transfixiante de 7 cm² après traitement chirurgical d’une maladie de Hodgkin médiastinale avec envahissement sternal et costal. La demande portait sur les séquelles esthétiques de cette perte de substance pariétale. En effet, malgré une reconstruction première par plaque de Vicryl^© résorbable puis par lambeau dermo-graisseux glandulaire local, les battements cardiaques et le défect pariétal étaient encore visibles sous la peau. Notre choix de reconstruction a été la mise en place d’une grille de titane malléable, ainsi qu’une augmentation mammaire par prothèse de 200 g par côté dans le même temps opératoire. Aucune complication n’a été à déplorer. La patiente est satisfaite du résultat.
Il n’a pas été retrouvé dans la littérature de reconstruction thoracique par une grille de titane malléable seule. Ce choix est novateur dans notre discipline alors que ce matériau de reconstruction fait partie de l’arsenal thérapeutique d’autres spécialités chirurgicales.
L’utilisation d’une plaque malléable de titane permet la reconstruction des pariétectomies transfixiantes thoraciques stables, de petite taille n’entraînant pas de troubles fonctionnels mais génératrices de séquelles inesthétiques. Ce cas illustre les différentes facettes de notre spécialité : apporter une solution à la fois réparatrice, esthétique et unique en fonction des demandes de la patiente.
Several surgical techniques are available for full thickness chest wall reconstruction. The choice has to be adapted to the size of the loss of tissue, its location, and must finally be accepted by the patient's. We propose a new and unpublished solution.
We have in our care a 54 years-old patient suffering from a previous loss of chest wall tissue measuring 7 cm² due to surgical treatment of mediastinal Hodgkin's disease with sternal and costal invasion. Because of the sequelae, the goal focused on aesthetic reconstruction. Heartbeat was visible under the skin due to a loss of secondary left breast tissue from an initial treatment with absorbable Vicryl^© mesh followed by a local skin, and glandular flap. Our choice of reconstruction consisted of inserting a moldable titanium mesh followed by 200 g implants in each breast during the same operation. We did not experience any complications and the patient is satisfied with the results.
No example of reconstruction using only a moldable titanium mesh was found in the literature on chest wall reconstruction. Our elegant choice is innovative in our discipline. However, this reconstruction materiel is already part of therapy procedures in other specialized surgeries.
This case report illustrates the various facets of our speciality: bring a solution at once repair, aesthetic and unique according to the request of the patient. The use of a moldable titanium mesh allows the reconstruction of stable chest wall. The small size does not present any functional difficulties, but rather unsightly sequel.

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Reconstruction of complex chest wall defects

Background

Methods

Results

Ann Thorac Surg

Ann Thorac Surg

Trunk. Posterior trunk

A systematic approach to flap selection

Reconstruction of the chest wall

Use of pectoralis major muscle flaps to repair defects of anterior chest wall

Plast Reconstr Surg

Infected median sterno-tomy wounds: successful treatment by muscle flaps

Ann Surg

Pectoralis major muscle turnover flaps for closure of the infected sternotomy wound with preservation of form and function

Plast Reconstr Surg

Repair of major defects of the chest wall and spine with the latissimus dorsi myocutaneous flap

Plast Reconstr Surg

Osteoradionecrosis of the chest wall: Man-agement of post-resection defects using Marlex mesh and a rotated latissimus dorsi myocutaneous flap

Am Surg