[Complete chest wall reconstruction after en bloc excisions with Gore-Tex/Marlex/Flap sandwich. A retrospective study of 14 cases]

[Severe thoracic radionecrosis: muscle-sparing latissimus dorsi flap (MSLD)]

INTRODUCTION

Cutaneous radionecrosis and osteoradionecrosis are severe complications of the radiotherapy which can arise after a variable free interval. The loss of substance is frequently associated with a peripheral radiodermatitis and stays an infectious front door exposing patients to a sepsis. The reference treatment remains surgical and consists in realizing the debridment of necrosis tissues associated with flap in order to cover the soft tissus defect. The purpose of our study is to estimate efficiency and tolerance of management radionecrosis thoracique by muscle-sparing latissimus dorsi flap (MSLD).

MATERIAL AND METHODS

We realized a study on a series of cases of thoracic radionecrosis with costal exposure covered by MSLD. Fat transfer into peripheral radiodermitis was performed at the same time surgical. Efficiency and tolerance surgery were estimated. The duration of the postoperative antibiotic treatment was estimated. The complications (hematoma, infection, cutaneous suffering, necrosis, seroma, radionecrosis relapse) were screened. The follow-up was realized by the same surgeon.

RESULTS

Seven patients managed by the same surgeon were included, They had radionecrosis after radiotherapy for processing adjuvanting of mastectomy after breast cancer. The average age was 66 years (from 61 to 76 years). The average time of hospitalisation was of four days. The average follow-up was of six months. The average treatment of the antibiotic treatment was four weeks. We didn't notice any complications and any recurrence of the radionecrosis. We noticed one dorsal collection (30 cm(3)) 15 days after surgical procedure for one patient. The follow-up showed a stable and good quality cutaneous cover in six months postoperative.

CONCLUSIONS

MSLD flap is reliable and reproducible to cover moderate thoracic defect. The surgical parage-wash has a fundamental importance to avoid any infectious complication. The management of the thoracic radionecrosis is complex and multidisciplinary. In conclusion, MSLD flap seems to be an elegant surgical alternative insuring a custom-made optimal cover with a reduction of the morbidity of the site donor.

[Moldable titanium mesh for chest wall reconstruction, an elegant solution about a case report]

INTRODUCTION

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.

CASE REPORT

We have in our care a 54 years-old patient suffering from a previous loss of chest wall tissue measuring 7 cm(2) 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.

DISCUSSION

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.

CONCLUSION

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.

[Combined latissimus dorsi and serratus anterior reverse flow pedicle flap. Report of two clinical cases]

The use of combined flap involving the distally based latissimus dorsi muscle pedicled on the lumber perforating arteries and prolonged by the last digitations of the serratus anterior flap muscle supplied by the thoracic branch of thoracodorsal vessels is uncommon but has ever been described. We describe the use of this flap in two original cases. The first case is for coverage of a controlateral dorsal radionecrosis. The second case describes its use in emergency following ballistic chest trauma.

Reconstruction des pariétectomies thoraciques effectuées pour récidive de cancer du sein

Some recurrences of breast cancer require wide chest wall resection as curative or palliative therapy. We report a retrospective review of 14 chest wall resections and reconstructions. The width of the anterior chest wall excision was 150 cm(2) (80 to 360 cm(2)). Two defects were full-thickness ones, with sternal or costal resection. The reconstruction required synthetic mesh covered by a latissimus dorsi musculocutaneous flap. The 12 other resections were superficial ones, and have been covered by a skin graft in 5 patients, and by a regional flap in 7 patients (5 latissimus dorsi, 1 DIEP, and 1 bilobed flap). Two patients had a chest wall irradiation after the surgical procedure. We have analysed the factors, which had influenced our choice of the type of reconstruction. The reconstruction is performed by a regional flap, most commonly a latissimus dorsi pedicled flap, in case of full-thickness defect, of nodular isolated recurrence, or when a radiation therapy is provided after the surgical procedure. The coverage is made by a skin graft in case of palliative excision, or of multiple nodular chest wall recurrence (which have a high risk of recurrence in the same form).

[Efficiency of the combination of Mersilene-musculocutaneous flap in the reconstruction of full-thickness chest wall defects. A retrospective study of 14 cases]

SUBJECT

The tumors of chest wall can be responsible of large full-thickness defects. The skeletal stabilization by different synthetic materials with numerous modalities of use and the superficial coverage of the defect by a musculocutaneous flap are the two imperatives parts of this reconstruction.

PATIENTS AND METHODS

From January 1997 to January 2006, 14 patients, 10 males and 4 females, aged between 17 and 63 years old and suffering from full-thickness chest wall defects secondary to tumor resection have benefited from a simple reconstruction, wherever the defect, by a Mersilene Mesh and a muscular or musculocutaneous flap. These defects measured between 8 x 12 cm and 14 x 16 cm and were located in the anterior part of the chest in 3 cases, with resection of the upper half of the sternum and the internal part of both clavicles and the first three ribs, and in the lateral part of the chest in 11 cases with resection between 3 and 5 ribs. The histological diagnoses of these tumors were 3 chondrosarcomas, 3 sternum and 1 rib metastases, 2 desmoid tumors, 1 Ewing's sarcoma, 4 benign tumors. The flaps used were pedicled in 13 cases and based on the latissimus dorsi muscle, the serratus muscle and the pectoralis major muscle; in 1 case, the latissimus dorsi musculocutaneous flap was free.

RESULTS

The skeletal stabilisation seems satisfying. There was no problems with the pulmonary function except in 4 cases where a dyspnea appears in sustained effort. No vascular complication on these flaps was noted. With a mean follow up of 46 months, there was no local recurrence of the malignant tumors. Two patients were deceased 1 year after surgery.0.

CONCLUSION

The Mersilene mesh associated with a locoregional musculocutaneous flap represent a simple and efficient solution for the treatment of such defects.

[Interdisciplinary surgery of the thorax-from the general surgeon's point of view]

Interdisciplinary professional management is the most important basic principle for successfully mastering thoracic operations including the thoracic wall and adjacent regions such as neck, axilla, mediastinal vessels, upper limb, and spine. Extended oncological resection in advanced malignant diseases, side-effects of radiotherapy and trauma explain the diversity of possible operative procedures. For technical success, the necessity of vascular grafting, reconstruction of the brachial plexus, spine surgery, cardiac surgery, plastic thoracic wall reconstruction, stabilization of the thoracic wall, modern equipment, and know-how are mandatory. We chose some show-cases which-in our opinion-might be appropriate for demonstrating interdisciplinary therapy management. Functional, oncological, and cosmetic/reconstructive aspects should be considered when approaching these cases.