The role of microsurgery in reconstruction of oncologic chest wall defects

Postoperative Complications of Flap Procedures in Chest Wall Defect Reconstruction: A Two-Center Experience

Background and Objectives: Chest wall defect reconstruction is a complex procedure aimed at restoring thoracic structural integrity after trauma, tumor removal, or congenital issues. In this study, postoperative complications were investigated to improve the care of patients with these critical conditions. Materials and Methods: A retrospective study of chest wall reconstructions from 2004 to 2023 was conducted at Klinikum Nürnberg and Evangelisches Waldkrankenhaus Spandau-Berlin. Data included patient demographics, comorbidities, defect etiology, surgery details, and complications using the Clavien-Dindo classification. Results: Among the 30 patients included in the study, a total of 35 complications occurred in 35 thoracic wall defect reconstructions. These complications were classified into 22 major and 13 minor cases. Major complications were more common in patients with cancer-related defects, and considerable variations were observed between free flap and pedicled flap surgeries. Notably, the use of the anterolateral thigh (ALT) flap with vastus lateralis muscle demonstrated promise, exhibiting fewer complications in select cases. The reconstruction of chest wall defects is associated with substantial complications regardless of the etiology of the defect and the particular surgical procedure used. Interestingly, there was a lower complication rate with free flap surgery than with pedicled flaps. Conclusions: The ALT flap with vastus lateralis muscle deserves further research in this field of reconstruction. Multidisciplinary approaches and informed patient discussions are crucial in this complex surgical field, emphasizing the need for ongoing research and technique refinement.

Microsurgical reconstruction using thoracoacromial vessels as recipients for complicated chest wall defects

BACKGROUND

Free tissue transfer is often required for the reconstruction of complex and deep anterior chest wall wounds, for which the identification of suitable recipient vessels is crucial. Although the internal mammary arteries (IMAs) are a representative option, identifying secondary options when these vessels are compromised remains a challenge. This report evaluated the efficacy of using the thoracoacromial vessels (TAVs) as recipients for chest wall reconstruction by reviewing our experience.

METHODS

We conducted a retrospective review of patients undergoing free-flap-based chest wall reconstruction using TAVs as recipient vessels from February 2020 to March 2023. Patient demographics and surgery-related characteristics data were collected. The primary outcome of interest was the occurrence of flap perfusion-related complications.

RESULTS

In total, 12 cases utilized TAVs as recipients, primarily for defects following sternotomy, where bilateral IMA was unavailable due to prior surgery. The TAVs with reliable perfusion were consistently identified beneath the pectoralis major muscle. The anterolateral thigh flap was predominantly employed, with musculocutaneous or chimeric flaps introduced for bony defects. The mean pedicle length of the harvested flap was 7.2 cm (range, 3-13), and in cases with a vascular gap, the pedicle was extended using an arteriovenous interposition graft. This resulted in a mean pedicle length needed to reach recipient vessels of 9.9 cm (range, 6.5-19). All flaps survived, with only one experiencing partial necrosis.

CONCLUSIONS

The TAV could be considered as an attractive alternative recipient vessel in microsurgical reconstruction of complicated chest wall defects when the use of IMA is not feasible.

Resection to restoration: Assessing the synergy of polypropylene mesh (Marlex®) combined with methyl-methacrylate and latissimus dorsi flap for primary chest wall sarcomas

BACKGROUND

Chest-wall sarcomas are treated with extensive resections and complex defect reconstruction to restore chest-wall integrity. It is a difficult surgical procedure that incorporates a multidisciplinary approach for the best outcome, preventing paradoxical chest movement issues and reducing complications.

OBJECTIVE

We aimed to describe our experience of chest-wall reconstruction using polypropylene mesh (Marlex® Mesh) combined with methyl-methacrylate and soft-tissue coverage with a latissimus dorsi flap following sarcoma resection.

PATIENTS AND METHODS

Among the 53 patients treated for primary chest-wall sarcomas at the European Institute of Oncology (IEO) in Milan, Italy, from 1998 to 2020, 14 cases underwent chest-wall resection and reconstruction using polypropylene mesh, methyl-methacrylate and the latissimus dorsi flap. Patients with locally advanced breast cancers, locally advanced lung cancers, squamous cell carcinomas, and other secondary chest-wall malignancies were excluded from the study, as were the patients with different types of chest-wall reconstruction.

RESULTS

In this study, 14 patients (6 men and 8 women) with various primary chest-wall sarcomas were enrolled. On an average, 2 ribs (range: 1-5) were removed during the surgeries, and the chest-wall defects ranged from 20 to 150 cm2 with an average size of 73 cm2. The mean follow-up period for these patients was approximately 63.80 months CONCLUSION: The combination of Marlex® mesh filled with methyl-methacrylate and covered using latissimus dorsi myocutaneous flap provides safe, low-cost and effective single-stage chest-wall reconstruction after surgery for primary sarcomas.

[Application of expanded anterolateral thigh myocutaneous flap in the repair of huge chest wall defect]

OBJECTIVE

To investigate the application of expanded anterolateral thigh myocutaneous flap in the repair of huge chest wall defect.

METHODS

Between August 2018 and December 2020, 12 patients, including 4 males and 8 females, were treated with expanded anterolateral thigh myocutaneous flap to repair huge complex defects after thoracic wall tumor surgery. The age ranged from 28 to 72 years, with an average of 54.9 years. There were 4 cases of phyllodes cell sarcoma, 2 cases of soft tissue sarcoma, 1 case of metastatic chest wall tumor of lung cancer, and 5 cases of breast cancer recurrence. All cases underwent 2-7 tumor resection operations, of which 3 cases had previously received lower abdominal flap transplantation and total flap failure occurred, the other 9 cases were thin and were not suitable to use the abdomen as the flap donor site. After thorough debridement, the area of secondary chest wall defect was 300-600 cm ²; the length of the flap was (24.7±0.7) cm, the width of the skin island was (10.6±0.7) cm, the length of the lateral femoral muscular flap was (26.8±0.5) cm, the width was (15.3±0.6) cm, and the length of the vascular pedicle was (7.9±0.6) cm.

RESULTS

The myocutaneous flaps and the skin grafts on the muscular flaps were all survived in 11 patients, and the wounds in the donor and recipient sites healed by first intention. One male patient had a dehiscence of the chest wall incision, which was further repaired by omentum combined with skin graft. The appearance of the reconstructed chest wall in 12 patients was good, the texture was satisfactory, and there was no skin flap contracture and deformation. Only linear scar was left in the donor site of the flap, and slight hyperplastic scar was left in the skin harvesting site, which had no significant effect on the function of the thigh. All patients were followed up 9-15 months, with an average of 12.6 months. No tumor recurrence was found.

CONCLUSION

The expanded anterolateral thigh myocutaneous flap surgery is easy to operate, the effective repair area is significantly increased, and multiple flap transplantation is avoided. It can be used as a rescue means for the repair of huge chest wall defects.

The Best of Chest Wall Reconstruction: Principles and Clinical Application for Complex Oncologic and Sternal Defects

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Appraise and evaluate risk factors for respiratory compromise following oncologic resection. 2. Outline and apply an algorithmic approach to reconstruction of the chest wall based on defect composition, size, and characteristics of surrounding tissue. 3. Recognize and evaluate indications for and types of skeletal stabilization of the chest wall. 4. Critically consider, compare, and select pedicled and free flaps for chest wall reconstruction that do not impair residual respiratory function or skeletal stability.

SUMMARY

Chest wall reconstruction restores respiratory function, provides protection for underlying viscera, and supports the shoulder girdle. Common indications for chest wall reconstruction include neoplasms, trauma, infectious processes, and congenital defects. Loss of chest wall integrity can result in respiratory and cardiac compromise and upper extremity instability. Advances in reconstructive techniques have expanded the resectability of large complex oncologic tumors by safely and reliably restoring chest wall integrity in an immediate fashion with minimal or no secondary deficits. The purpose of this article is to provide the reader with current evidenced-based knowledge to optimize care of patients requiring chest wall reconstruction. This article discusses the evaluation and management of oncologic chest wall defects, reviews controversial considerations in chest wall reconstruction, and provides an algorithm for the reconstruction of complex chest wall defects. Respiratory preservation, semirigid stabilization, and longevity are key when reconstructing chest wall defects.

Bilateral Anterolateral Thigh Myocutaneous Flaps for Giant Complex Chest Wall Reconstruction

BACKGROUND

Extensive reconstruction of complex full-thickness chest wall oncological defects is challenging. Bilateral free anterolateral thigh (ALT) myocutaneous flap transfer for the complex reconstruction of a large area of the chest wall is discussed.

MATERIALS AND METHODS

We reported a single unit's experience in 1-staged multilayered reconstruction of large full-thickness chest wall defects in 22 patients (16 primary chest wall tumor cases, 5 locally advanced breast cancer cases, and 1 osteoradionecrosis case) treated between 2011 and 2018. Bilateral ALT myocutaneous flaps together with traditional cement implant or unmovable/movable joint conformable titanium struts were used for chest wall reconstruction. The anatomical characteristics of pedicle origin and pattern of the venae comitantes of the ALT myocutaneous flap, recipient vessels, and anastomosis patterns were described.

RESULTS

Bilateral ALT myocutaneous flaps were used for soft tissue reconstruction in 22 cases. Different methods of flap harvesting and vascular anastomosis were selected as needed. No vein grafts or arteriovenous loops were required. We observed 3 vascular patterns of the flap pedicle, including 1 oblique branch and descending branch (59.1%, n = 26), 2 single descending branch (9.1%, n = 4), and 3 double branches of the descending branch (31.8%, n = 14). The flap was harvested pedicled with solely the oblique branch in 7 (15.9%) cases, solely the descending branch in 28 (63.6%) cases to minimize the donor site morbidity, and pedicled with the oblique and descending branch in 9 (20.5%) cases to achieve multiple vascular anastomosis choices. Stable skeletal reconstructions were achieved using traditional cement implant (13.6%, n = 3) or conformable titanium struts (86.4%, n = 19), with good fixation strength. Complication risk was low. An algorithmic approach to management is presented and recommended.

CONCLUSION

Various forms of bilateral ALT myocutaneous flap transfer with different skeletal reconstruction presents as a reliable treatment for patients with large full-thickness chest wall defects. Anatomical variations in the pedicle and pattern of venae comitantes of the ALT myocutaneous flap are reported. In some challenging cases, finding the vessels in the recipient area is difficult. The clinical significance of each vascular pattern is delineated, and surgical technical considerations are discussed on the basis of the recipient area requirements and types of a flap's vascular anatomy.

Comparison of pedicled versus free flaps for reconstruction of extensive deep sternal wound defects following cardiac surgery: A retrospective study

BACKGROUND

Myocutaneous pedicled flaps are the method of choice for sternal reconstruction after deep sternal wound infection (DSWI) following cardiac surgery. We set out to investigate whether free flaps provide a superior alternative for particularly extended sternal defects.

METHODS

Between October 2008 and February 2020, 86 patients with DSWI underwent sternal reconstruction with myocutaneous flaps at our institution. Patients were retrospectively grouped into pedicled (A; n = 42) and free flaps (B, n = 44). The objective was to compare operative details, outcome variables, surgical as well as medical complication rates between both groups, retrospectively. Binary logistic regression analysis was applied to determine the effect of increasing defect size on flap necrosis.

RESULTS

Rates of partial flap necrosis (>5% of the skin island) were significant higher in pedicled flaps (n = 14), when compared to free flaps (n = 4) (OR: 5.0; 33 vs. 9%; p = .008). Increasing defect size was a significant risk factor for the incidence of partial flap necrosis of pedicled flaps (p = .012), resulting in a significant higher rate of additional surgeries (p = .036). Binary regression model revealed that the relative likelihood of pedicled flap necrosis increased by 2.7% with every extra square-centimeter of defect size.

CONCLUSION

To avoid an increased risk of partial flap necrosis, free flaps expand the limits of extensive sternal defect reconstruction with encouragingly low complication rates and proved to be a superior alternative to pedicled flaps in selected patients.

Extensive Microsurgical Reconstruction of Chest Wall Defects for Locally Advanced Breast Cancer: A 10-Year Single-Unit Experience

BACKGROUND

Despite improvements in the early detection of breast cancer, locally advanced breast cancer (LABC) involving the chest wall exists in developing countries. Surgical resection remains a controversial management option. This study aims to demonstrate the value of chest wall reconstructive techniques for large LABC defects and report long-term outcomes.

MATERIALS AND METHODS

We report a 10-years single-unit experience in the reconstruction of large defects (>300 cm). From 2007 to 2017, all LABC cases managed with large surgical resection with immediate microsurgical chest wall reconstruction were included in this study. Herein, we present the demographics, comorbidities, clinicopathological LABC characteristics, surgical techniques (free flap choice, recipient vessels), and outcomes (survival, complication, cosmesis, and patient satisfaction).

RESULTS

Of the 104 LABC cases, free deep inferior epigastric artery perforator flap was performed in 41 (39.4%) cases, free anterolateral thigh flap in 5 (4.8%), free deep inferior epigastric artery perforator combined with pedicled transverse rectus abdominis myocutaneous (TRAM) flap in 23 (22.1%), free muscle-sparing transverse rectus abdominis muscle flap in 30 (28.9%), and free transverse upper gracilis flap in 5 (4.8%). Complications were low. Over a median follow-up of 49.5 months, the 3-year local recurrence rate and distant metastasis-free survival were 13.9% and 84.9%, respectively. In addition, the 3-year disease-free survival and overall survival were 84.2% and 92.0%, respectively. The rate of excellent and good ratings by the esthetic assessment panel was 83.0%, and the patient satisfaction rate was 90.0%.

CONCLUSION

Wide resection and microvascular free tissue transfer is oncologically safe in LABC with huge tumors and provides versatile solutions for the reconstruction of extensive chest wall defects. With favorable long-term survival and cosmetic outcomes, surgical resection of LABC combined with flap reconstruction may offer a practical approach in difficult and complicated cases.

IMPLICATIONS FOR PRACTICE

In this retrospective review, it was demonstrated that wide resection followed by distinct chest wall reconstructive free flaps transfer is oncologically safe in LABC with huge tumors and provides useful solutions for the reconstruction of extensive chest wall defects.

Complex Microsurgical Reconstruction After Tumor Resection in the Trunk and Extremities

Reconstruction of soft tissue defects following tumor ablation procedures in the trunk and extremities can challenge the microsurgeon. The goal is not just to provide adequate soft tissue coverage but also to restore form and function and minimize donor site morbidity. Although the principles of the reconstructive ladder still apply in the trunk and extremities, free tissue transfer is used in many cases to optimally restore form and function. Microsurgery has changed the practice in soft tissue tumors, and amputation is less frequently necessary.

Muscle flaps for sternoclavicular joint septic arthritis

Septic arthritis of the sternoclavicular joint (SC) is rare. The most accepted technique for reconstruction of the defect after SC joint resection is the use of muscle flaps. We hypothesized that resection of ribs with the SC joint impacts timing, type and outcomes of reconstruction. This is a retrospective review of 44 patients who underwent wound closure with muscle flap following resection of the SC joint for septic arthritis over 14 years period from a single institution. Patients were divided into two groups based on the resection of the adjacent ribs with the SC joint. We found 18 (40.9%) patients with SC joint resection only and 26 (59.1%) with concomitant resection of the adjacent ribs. Patients in the rib resection group were younger, did not need SC joint fluid aspiration, and had higher tissue culture positivity (p < .05). Rib resection with the SC joint was found to be associated with delayed reconstruction (57.7% vs 22.2%, p = .030), need for serial debridement's (2 vs 1, p = .009), increased days from debridement to reconstruction for a subset of patients (75% percentile of 8 days vs. 0 days, p = .024), and longer hospital stay (18 vs 9, p = .006). Flap complications were higher in rib resection group (26.9% vs 5.6%, p = .67). Reconstruction following resection of the SC joint for septic arthritis is guided by the surgeon's impression regarding source control of infection. Rib resection concomitantly with joint resection appears to be a useful indicator of disease extent and may help guide clinical decision making in this challenging scenario.

Forequarter Amputation and Reconstructive Options

OBJECTIVE

This study aimed to present the results of a series of forequarter amputations (FQAs) and to evaluate the reconstructive methods used.

SUMMARY BACKGROUND DATA

Although FQA has become a rare procedure in the era of limb-sparing treatment of extremity malignancies, it is a useful option when resection of a shoulder girdle or proximal upper extremity tumor cannot be performed so as to retain a functional limb.

METHODS

Thirty-four patients were treated with FQA in 1989 to 2017. Various reconstructive techniques were used, including free fillet flaps from the amputated extremity.

RESULTS

All patients presented with intractable symptoms such as severe pain, motor or sensory deficit, or limb edema. Seventeen patients were treated with palliative intent. Chest wall resection was performed in 9 patients. Free flap reconstruction was necessary for 15 patients, with 11 free flaps harvested from the amputated extremity. There was no operative mortality, and no free flaps were lost. In curatively treated patients, estimated 5-year disease-specific survival was 60%. Median survival in the palliatively treated group was 13 months (1-35 months).

CONCLUSIONS

Limb-sparing treatment is preferable for most shoulder girdle and proximal upper extremity tumors. Sometimes, FQA is the only option enabling curative treatment. In palliative indications, considerable disease-free intervals and relief from disabling symptoms can be achieved. The extensive tissue defects caused by extended FQA can be safely and reliably reconstructed by means of free flaps, preferably harvested from the amputated extremity.

Surgical configurations of the pectoralis major flap for reconstruction of sternoclavicular defects: a systematic review and new classification of described techniques

OBJECTIVES

The pectoralis major flap has been considered the workhorse flap for chest and sternoclavicular defect reconstruction. There have been many configurations of the pectoralis major flap reported in the literature for use in reconstruction sternoclavicular defects either involving bone, soft tissue elements, or both. This study reviews the different configurations of the pectoralis major flap for sternoclavicular defect reconstruction and provides the first ever classification for these techniques. We also provide an algorithm for the selection of these flap variants for sternoclavicular defect reconstruction.

METHODS

EMBASE, Cochrane library, Ovid medicine and PubMed databases were searched from its inception to August of 2019. We included all studies describing surgical management of sternoclavicular defects. The studies were reviewed, and the different configurations of the pectoralis major flap used for sternoclavicular defect reconstruction were cataloged. We then proposed a new classification system for these procedures.

RESULTS

The study included 6 articles published in the English language that provided a descriptive procedure for the use of pectoralis major flap in the reconstruction of sternoclavicular defects. The procedures were classified into three broad categories. In Type 1, the whole pectoris muscle is used. In Type 2, the pectoralis muscle is split and either advanced medially (type 2a) or rotated (type 2b) to fill the defect. In type 3, the clavicular portion of the pectoralis is islandized on a pedicle, either the thoracoacromial artery (type 3a) or the deltoid branch of the thoracoacromial artery (type 3b).

CONCLUSION

There are multiple configurations of the pectoralis flap reported in the English language literature for the reconstruction of sternoclavicular defects. Our classification system, the Opoku Classification will help surgeons select the appropriate configuration of the pectoralis major flap for sternoclavicular joint defect reconstruction based on size of defect, the status of the vascular anatomy, and acceptability of upper extremity disability. It will also help facilitate communication when describing the different configurations of the pectoralis major flap for reconstruction of sternoclavicular joint defects.

Thoracic wall ischemia after repair of thoracoabdominal aortic aneurysm requiring large microvascular soft tissue reconstruction

A 67-year-old man presented to the vascular service with a Crawford extent I thoracoabdominal aortic aneurysm. He underwent open thoracoabdominal aortic replacement from just distal to the left subclavian artery to just proximal to the origin of the superior mesenteric artery under deep hypothermic circulatory arrest. His postoperative course was complicated by thoracic wall ischemia, resulting in a life-threatening defect of the chest wall that exposed lung parenchyma and the aortic graft. Successful microvascular soft tissue reconstruction was performed using an anterolateral thigh flap and arteriovenous loop. This is a case report of a large chest wall defect resulting from thoracoabdominal aortic aneurysm repair. This case highlights the feasibility of microvascular reconstruction techniques to repair even the largest defects.

The Microsurgical Calcaneus Osteocutaneous Fillet Flap After Traumatic Amputation in Lower Extremities: Flap Design and Harvest Technique

BACKGROUND

Attempts to salvage upper and lower extremities have performed more frequently in recent decades, although there are clear cases that cannot be salvaged. The purpose of this retrospective study was to present our experience in using free calcaneus osteocutaneous fillet flap for preserving below-knee amputation stump after traumatic amputations or functional preserving after nonsalvageable lower extremities.

METHODS

Between January 2012 and May 2017, 11 free calcaneus osteocutaneous fillet flap were used to preserving or lengthening below-knee amputation stump secondary to amputation on 8 males and 3 females. Patients' information and postoperative data were collected, including age of patient, sex, amputation site, flap survival, sensation recovery, and number of complications.

RESULT

All amputations were trauma related and secondary to motor vehicle accidents (n = 8) and industrial accidents (n = 3). The age of the patients ranged from 16 to 59 years, with a mean of 34.4 years. Free calcaneus osteocutaneous fillet flap were designed and harvested from all patients. All flaps survived and 2 complications developed in 2 patients. Nine of 11 patients obtained protective sensory recovery during the period of follow-up.

CONCLUSIONS

The free calcaneus osteocutaneous fillet flap harvested from the amputated limb provides reliable and robust tissue for reconstruction of large defects of the residual limb without additional donor-site morbidity.

Perforator Flaps Covering Alloplastic Materials in Full-Thickness Chest Wall Defects Reconstruction: A Safe Option?

Large full-thickness chest wall reconstruction requires an alloplastic material to ensure chest wall stability, as well as a flap that provides good soft-tissue coverage. The choice not to use perforator flaps over any mesh or inert material is often based on the concern that the vascularization would be inadequate. However, perforator flaps have shown good results in several reconstructive fields, minimizing donor-site morbidity and offering versatility when local tissues are unavailable or affected by radiotherapy. In this study, we present 4 cases of patients with full-thickness chest wall defects that were repaired with a double Marlex mesh, acrylic cement (n = 2) or a double patch of Goretex (n = 2) in combination with perforator flaps (3 deep inferior epigastric artery perforators and 1 lumbar artery perforator flap). The results we obtained are encouraging, and we believe the use of perforator flaps in combination with alloplastic materials should be considered as a reliable option for full-thickness chest wall defect reconstruction.

Complex Microsurgical Reconstruction After Tumor Resection in the Trunk and Extremities

Reconstruction of soft tissue defects following tumor ablation procedures in the trunk and extremities can challenge the microsurgeon. The goal is not just to provide adequate soft tissue coverage but also to restore form and function and minimize donor site morbidity. Although the principles of the reconstructive ladder still apply in the trunk and extremities, free tissue transfer is used in many cases to optimally restore form and function. Microsurgery has changed the practice in soft tissue tumors, and amputation is less frequently necessary.

Two-stage free anterolateral thigh flap in the management of full-thickness chest wall resection

Free tissue transfers are sometimes required in the reconstruction of large full-thickness chest wall defects. To minimize the risk of viscera exposure in case of free flap complications, we describe a two-stage procedure using an anterolateral thigh flap.

A Twelve-Year Consecutive Case Experience in Thoracic Reconstruction

Background:

We describe the second largest contemporary series of flaps used in thoracic reconstruction.

Methods:

A retrospective review of patients undergoing thoracomyoplasty from 2001 to 2013 was conducted. Ninety-one consecutive patients were identified.

Results:

Thoracomyoplasty was performed for 67 patients with intrathoracic indications and 24 patients with chest wall defects. Malignancy and infection were the most common indications for reconstruction (P < 0.01). The latissimus dorsi (LD), pectoralis major, and serratus anterior muscle flaps remained the workhorses of reconstruction (LD and pectoralis major: 64% flaps in chest wall reconstruction; LD and serratus anterior: 85% of flaps in intrathoracic indication). Only 12% of patients required mesh. Only 6% of patients with <2 ribs resected required mesh when compared with 24% with 3–4 ribs, and 100% with 5 or more ribs resected (P < 0.01). Increased rib resections required in chest wall reconstruction resulted in a longer hospital stay (P < 0.01). Total comorbidities and complications were related to length of stay only in intrathoracic indication (P < 0.01). Average intubation time was significantly higher in patients undergoing intrathoracic indication (5.51 days) than chest wall reconstruction (0.04 days), P < 0.05. Average hospital stay was significantly higher in patients undergoing intrathoracic indication (23 days) than chest wall reconstruction (12 days), P < 0.05. One-year survival was most poor for intrathoracic indication (59%) versus chest wall reconstruction (83%), P = 0.0048.

Conclusion:

Thoracic reconstruction remains a safe and successful intervention that reliably treats complex and challenging problems, allowing more complex thoracic surgery problems to be salvaged.

Important considerations in chest wall reconstruction

Chest wall reconstruction represents one of the most challenging tasks in plastic surgery. Over the past several decades, a more profound understanding of surgical anatomy and physiology along with tremendous advances in surgical technique have resulted in substantial improvements in postoperative outcomes. Conceptually, the reconstructive goals include dead space obliteration, restoration of skeletal stability with protection of intrathoracic structures, and stable soft tissue coverage. Ideally, these goals are achieved with minimal aesthetic deformity. J. Surg. Oncol. 2016;113:913-922. © 2016 Wiley Periodicals, Inc.

Multi-staged flap reconstruction for complex radiation thoracic ulcer

INTRODUCTION

Chest wall reconstruction due to previous radiation therapy can be challenging and complex, requiring a multidisciplinary approach.

PRESENTATION OF CASE

The authors present the case of a 84-year-old woman with a right chest wall radionecrosis ulcer, that was submitted to an ablative surgery resulting in a full-thickness defect of 224 cm², firstly reconstructed with a pedicled omental flap. Due to partial flap necrosis, other debridements and chest wall multi-staged flap reconstruction were performed.

DISCUSSION

This case highlights that the reconstructive choice should be individualized and dependent on patient and local factors. The authors advise that surgical team should work closely and be well versed in chest wall reconstruction with a variety of pedicled flaps, when a complication occurs.

CONCLUSION

A multi-staged flap reconstruction could be a salvage procedure for the coverage of complex, great and complicated chest wall defects due to previous radiation therapy.

[Forearm osteomusculocutaneous free filet flap for arm reconstruction after amputation as an alternative to shoulder disarticulation]

We report the case of a 55-year-old woman suffering from a type I neurofibromatosis (also known as Von Recklinghausen neurofibromatosis) who was diagnosed with a high-grade schwannosarcoma of the median nerve, between the upper third and the medium third of the arm, upon contact with the humerus, invading the humeral vessels. The oncologic treatment of this tumour consisted in the amputation of the arm through the surgical neck of the humerus. In order to create a laterothoracic claw, to bring a partial function of the upper limb back, we decided to realize a free fillet forearm flap. This composite flap was composed of the radius and the ulna, all the forearm muscles and the skin of the anterior side of the forearm. A humeroradial plate osteosynthesis was done and the flap was then harvested with the radial pedicle, and anastomosed to the axillar artery. This procedure gave our patient a functional stump, giving back the arm functionality, especially the claw movement.

Chest wall reconstruction after oncological resections

Most chest wall defects requiring reconstruction result from tumor resection. Bone and soft tissue sarcomas and recurrent mammary cancer are the most common tumors. Careful preoperative evaluation, meticulous surgical technique and active postoperative treatment are important. The selection of reconstruction is based on the nature, size and location of the defect as well as on the general health and prognosis of the patient. The goals of the reconstruction are adequate stability, water- and airtight closure of the chest cavity, and acceptable cosmetic appearance. The pedicled muscular or musculocutaneous flaps are usually the first choice for tis-sue coverage. These include flaps such as latissimus dorsi, vertical or transverse rectus abdominis and pectoralis. In certain cases also the breast flap or omental flap can be used. In selected cases, a free flap reconstruction is indicated if the local options for reconstruction have been used, or if they are unreliable due to earlier scars or radiotherapy. The free flaps to be used for chest wall can be harvested from the thigh (tensor fascia latae flap, anterolateral thigh flap), from the abdomen (transverse rectus abdominis flaps, deep epigastric perforator flaps) or from the chest wall (latissimus dorsi flap and other flaps based on the subscapular artery). Sometimes a fillet forearm can be used as a flap to cover a defect after extended forequarter amputation. Artificial meshes are commonly used to give stability in the defect and to give a platform for the flap. Methylmethacrylate embedded between the two layers of a mesh, or one or two rib grafts fixed to the mesh, can be used to give additional stability in extensive defects to prevent paradoxical movement.

Abdominoplasty and thoraco-epigastric flaps for large anterior trunk defects after dermatofibrosarcoma protuberans wide resection: Two illustrative cases

INTRODUCTION

Excision of large dermatofibrosarcoma protuberans in the anterior aspect of the trunk often results in large surgical defects that frequently dictate the need for microsurgical reconstruction. However, this option is not always available.

PRESENTATION OF CASE

The authors describe two patients with very large anterior trunk dermatofibrosarcoma protuberans: one in the epigastric region and the other in the hypogastric region. In the patient with the hypogastric tumor, a classical abdominoplasty flap associated with umbilical transposition was used to cover the skin defect after muscle and fascial plication, and placement of a polypropylene mesh. In the patient with the epigastric tumor, a synthetic mesh was also placed, and the skin and subcutaneous defect was reconstructed with a reverse abdominoplasty flap and two thoraco-epigastric flaps. In both cases, complete closure was possible without immediate or late complications.

DISCUSSION

The local options described in this paper present several potential advantages compared to microsurgical reconstruction, namely they are easier and faster to perform and teach; they provide a good skin color and texture match; they are not associated with distant donor site morbidity; follow-up is usually less cumbersome; the post-operative hospital stay tends to be shorter; they are less costly; they are less prone to complete failure.

CONCLUSION

The authors believe that these two patients clearly show that local flaps, although frequently neglected, continue to be valid options for reconstructing large anterior trunk defects, even in the current era of microsurgery enthusiasm.

Microsurgical chest wall reconstruction after oncologic resections

Defect reconstruction after radical oncologic resection of malignant chest wall tumors requires adequate soft tissue reconstruction with function, stability, integrity, and an aesthetically acceptable result of the chest wall. The purpose of this article is to describe possible reconstructive microsurgical pathways after full-thickness oncologic resections of the chest wall. Several reliable free flaps are described, and morbidity and mortality rates of patients are discussed.

Management of chest wall reconstruction after resection for cancer: a retrospective study of 22 consecutive patients

AIM

In this study, we report our experience on immediate reconstruction after resection of primary or metastatic chest wall tumors, to restore protective function and elasticity of chest or sternum.

METHODS

Between 2005 and 2009, 22 patients underwent reconstruction using a free or pedicled flap combined, or not, to alloplastic materials (Goretex®) in order to cover full-thickness defects of the chest wall after cancer surgery. Reconstruction was immediate in all cases.

RESULTS

Mean follow-up was 27 months. Of these, 18 patients were alive at the end of the study (81.5%). Eighteen patients had malignant tumors (82%); within these patients, 12 were alive without recurrence at the end of the study (67%). The average size of the chest wall defect was 255 cm². Goretex® Mesh was used in 8 patients. All patients benefited from reconstruction with a flap: pedicled or free latissimus dorsi flap (n = 15), pedicled great omentum (n=3), deep inferior epigastric perforator free flap (n = 3), and parascapular pedicled flap (n=1).

CONCLUSION

In this series, we were able to achieve long-term palliation and even cure in some patients by resecting full-thickness chest wall in local primary or recurrence of breast cancer without increasing morbidity. The same process was used successfully in association with adjuvant treatment in other tumors like skin sarcoma. We have followed a surgical algorithm according to the tumor localization and etiology.

Reconstruction of complex thoraco-abdominal defects with extended anterolateral thigh flap

Background:

The reconstruction of complex thoraco-abdominal defects following tumour ablative procedures has evolved over the years from the use of pedicle flaps to free flaps. The free extended anterolateral thigh flap is a good choice to cover large defects in one stage.

Materials and Methods:

From 2004 to 2009, five patients with complex defects of the thoracic and abdominal wall following tumour ablation were reconstructed in one stage and were studied. The commonest tumour was chondrosarcoma. The skeletal component was reconstructed with methylmethacrylate bone cement and polypropylene mesh and the soft tissue with free extended anterolateral thigh flap. The flaps were anastomosed with internal mammary vessels. The donor sites of the flaps were covered with split-skin graft.

Result:

All the flaps survived well. One flap required re-exploration for venous congestion and was successfully salvaged. Two flaps had post operative wound infection and were managed conservatively. All flap donor sites developed hyper-pigmentation, contour deformity and cobble stone appearance.

Conclusion:

Single-stage reconstruction of the complex defects of the thoraco-abdominal region is feasible with extended anterolateral thigh flap and can be adopted as the first procedure of choice.

Combined free vascularized iliac osteocutaneous flap and pedicled pectoralis major myocutaneous flap for reconstruction of anterior chest wall full-thickness defect

Large defects of the anterior chest wall lead to gross chest instability that can result in paradoxic respiration. Osteoradionecrosis of the lower sternum and multiple left ribs resulted in a huge, full-thickness defect of the left anterior chest wall in a 67-year-old woman. An iliac osteocutaneous flap (bone segment 3 × 14 cm) was harvested for reconstruction of the bone defect. The skin defect was covered by the skin paddle of the iliac osteocutaneous flap and a contralateral rotational pectoralis major muscle flap. Months postoperatively, the patient was physically active, the chest was stable, and the vascularized iliac bone was incorporated into the recipient bone.

Principles of chest wall resection and reconstruction

Despite significant improvements in surgical technique and perioperative care, the management of patients requiring chest wall resection and reconstruction is an ongoing challenge for thoracic surgeons. A successful approach includes a thorough assessment of the patient and the lesion, an adequate biopsy to confirm tissue diagnosis, and a well-established treatment plan. In the case of a primary tumor of the chest wall, the extent of the resection should not be limited by the size of the resulting defect. Following resection, chest wall reconstruction mandates an appreciation for restoration of functional and structural components. An algorithmic approach to chest wall reconstruction begins with the assessment of the nature of the defect, taking into consideration factors such as infection, tumor location, previous radiation therapy, and surgical intervention. The latter factors bear influence on the type of tissue required as well as whether reconstruction can be performed in a single stage or whether it is better delayed. Finally, patient factors including lifestyle and work, as well as prognosis, are considered to determine the best reconstructive option.

Arteriovenous loops in microsurgical free tissue transfer in reconstruction of central sternal defects

OBJECTIVE

In some patients with chest wall defects, free tissue transfer is indicated. Complications arise if multiple operations have left the trunk devoid of recipient vessels. In such patients, an arteriovenous loop between the cephalic vein and the thoracoacromial artery can be used.

METHODS

A review of all our patients who underwent chest wall reconstruction with a cephalic vein-thoracoacromial artery loop between 2000 and 2009 was performed (n = 29, 19 women and 10 men). The mean age was 64.9 years. Underlying causes were sternal osteomyelitis (n = 20), tumor (n = 4), and osteoradionecrosis (n = 5). All patients were in American Society of Anesthesiologists classes III and IV. Flap selection, intraoperative and postoperative complications, operative time, time of ventilatory support, mean hospital stay, and midterm survival were recorded.

RESULTS

Twenty-five patients received a tensor fascia lata flap, 2 a vertical rectus myocutaneuos flap, and 2 a deep inferior epigastric perforator flap. Mean duration of surgery was 6.8 hours (4.7-10.5 hours). Two transplanted tissue flaps died and/or had to be removed and 4 were revised successfully. Seven patients had wound complications such as infection or prolonged wound healing. Mean time for ventilator support was 93.6 hours (4-463 hours). The median intensive care unit time was 11 days and the overall hospital stay 27.4 days (11-102 days). One-year survival in the whole group was 69.8%.

CONCLUSIONS

The concept of arteriovenous loops allows creation of neovessels at the recipient site and has proven to be a superb tool to facilitate free tissue transfer or to provide an exit strategy in situations with unexpected vascular problems at the recipient site.

Reconstruction of massive oncologic defects using free fillet flaps

BACKGROUND

Forequarter and hind-limb amputations are used with curative and palliative intent in the setting of proximal limb, thorax, or truncal malignancies. For these large defects that require a free flap, the distal portions of these limbs can be harvested as fillet flaps and represent the "spare parts" concept of surgical reconstruction.

METHODS

The authors performed a retrospective review of 27 patients (mean age, 51.4 years) who had undergone immediate reconstruction with free fillet extremity flaps between 1991 and 2008. Seventeen patients received preoperative radiotherapy, and 21 received preoperative chemotherapy. Resections included seven hemipelvectomies, 16 forequarter amputations, and four hindquarter amputations.

RESULTS

The mean defect size was 1126 cm (range, 480 to 3500 cm). All 27 flaps survived and all wounds healed. Four patients (15 percent) had complications; three patients developed partial flap necrosis and required operative débridement, and there were two episodes of flap vascular compromise. Mean follow-up time was 14 months. One patient was lost to follow-up. Eight patients (30 percent) were still alive at the end of the study. The remaining 18 patients died within 22 months of resection, for a mean survival of 7 months. There was no cancer recurrence within the flap itself. Phantom pain occurred in 11 patients. At the time of discharge, pain, tissue necrosis, and infection were improved in all patients.

CONCLUSION

The use of the fillet flap is oncologically sound, has no associated donor sites, has an acceptable incidence of major complications, and allows for a healed wound with an improvement in the quality of life.

Chest reconstruction: I. Anterior and anterolateral chest wall and wounds affecting respiratory function

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the indications for chest wall reconstruction. 2. Understand the function of the chest wall and implications for both reconstruction and the chest wall itself when components are missing or used for reconstruction. 3. List the reconstructive requirements of chest wall wounds. 4. Identify flaps for regional reconstruction of the chest wall. 5. Describe the role of microvascular surgery in chest wall reconstruction.

BACKGROUND

Chest wall and mediastinum wounds may be life-threatening. They interfere with respiratory mechanics and may also be contaminated with exposed vital structures. Consideration is given to flap choice to restore function, resolve infection, and maintain suitable aesthetics.

METHODS

Literature search as well as the authors' personal experience enabled preparation of this article.

RESULTS

Where necessary, skeletal integrity must be restored, generally with prosthetic material, and then covered with well-vascularized soft tissue. "Living tissue" is required to help combat infection, buttress visceral repairs, and fill dead space. Soft-tissue deficiency must occasionally be augmented with large distant microvascular flaps.

CONCLUSION

Flap reconstruction has reduced morbidity and mortality of these complex problems without undue donor-site impairment of respiratory and upper extremity function.

Chest reconstruction: II. Regional reconstruction of chest wall wounds that do not affect respiratory function (axilla, posterolateral chest, and posterior trunk)

LEARNING OBJECTIVES

The reader of this review will develop knowledge and understanding of the following: 1. Indications for posterior trunk and axillary reconstruction. 2. The reconstructive requirements of posterior chest wall and axillary wounds. 3. Flaps for regional reconstruction of the torso and axilla. 4. Congenital posterior trunk deformities and their management. 5. The role of microvascular surgery in chest wall reconstruction. 6. The recent emphasis on the role of perforator flaps. 7. The relative advantages and disadvantages of muscle flaps versus perforator skin and fasciocutaneous flaps.

BACKGROUND

Regional reconstructions of the axilla, posterolateral chest, and posterior trunk may prove difficult because of relative inaccessibility for pedicle flaps, exposure of prosthetic material, and loss of function.

METHODS

Review of past and current medical literature, together with personal experience, has enabled development of this article.

RESULTS

A host of regional muscle and musculocutaneous pedicle flaps are available from both the upper and lower limb girdle. These muscle flaps, however, come at the price of compromising donor motor function. This donor morbidity can be reduced either by segmentally splitting muscle flaps or by recourse to perforator artery flaps. Some areas may be difficult to reach, especially the upper and lower back in the midline. Occasionally, microvascular reconstruction is required. Tissue expansion has a limited role in these reconstructions but most notably is an aid to separation of conjoined twins.

CONCLUSIONS

A variety of regional fasciocutaneous and musculocutaneous flaps are available to cover congenital or acquired defects of the posterior trunk and axilla. Use of perforator flaps has recently been popularized. One must be cognizant of possible functional deficits that may result when using regional muscle flaps both on ambulation and potential to power a manual wheelchair or use crutches.

Mammary myocutaneous-glandular flap for reconstruction of oncological defects of the anterior midline chest wall

We describe a mammary myocutaneous-glandular flap, which is a simple, convenient, reliable, and speedy reconstructive technique applicable for women that combines little or no morbidity with excellent cosmetic outcome and provides a simple solution to an extremely difficult problem.

Combined reconstruction of complex defects of the chest wall

Defects of the chest wall are often encountered, and good results can be obtained both cosmetically and functionally from their treatment. We treated 13 patients with full thickness chest wall defects. Follow up ranged from 12 days to 19 months. Three had had recurrent breast carcinoma, seven relapse after excision of a sarcoma, two had had lesions of the chest wall after irradiation, and one had a sternal fistula. Local skin, musculocutaneous and free latissimus dorsi and anterolateral thigh flaps were done to cover soft tissue. Fascia lata, polypropylene (Marlex) mesh, and Marlex mesh-methylmethacrylate sandwich prosthesis, were used to stabilise the skeleton in nine patients. Two of the patients died postoperatively, one early. The use of Marlex mesh-methylmethacrylate sandwich prostheses for the stabilisation of the skeleton and local musculocutaneous flaps for covering soft tissues after resection of three or more ribs is effective.

[Plastic surgical reconstruction of extensive thoracic wall defects after oncologic resection]

In defect reconstruction following radical oncologic resection of malignant chest wall tumors, adequate soft-tissue reconstruction must be achieved along with function, stability, integrity, and aesthetics of the chest wall. The purpose of this retrospective analysis was to evaluate the oncoplastic concept following radical resection of malignant chest wall infiltration with an interdisciplinary approach. Between 1999 and 2005, 36 consecutive patients (nine males, 27 females, mean age 55 years, range 20-78) were treated with resection for malignant tumors of the chest wall. Indications were locally recurrent breast carcinoma (patient n=22), thymoma (n=1), and desmoid tumor (n=1). Primary lesions of the chest wall were spinalioma (n=1), sarcoma (n=7), and non-small-cell lung cancer (n=2). There were distant metastases of colon and cervical cancer in one patient each. Soft-tissue reconstruction was carried out using primary closure (n=1), external oblique flap (n=1), pectoralis major myocutaneous flap (n=3), latissimus dorsi myocutaneous flap (n=18), vertical or transversal rectus abdominis myocutaneous flap (n=9), free tensor fascia lata- flap (n=6), trapezius flap (n=1), serratus flap (n=1), and one filet flap. In 15 reconstructive procedures microvascular techniques were used. An average of 3.4 ribs were resected. Stability of the chest wall was obtained with synthetic meshes. The latissimus dorsi flap is considered the flap of choice in chest wall reconstruction. However, alternatives such as pectoralis major flap, VRAM/TRAM flap, free TFL flap, and serratus flap must also be considered. Low mortality and morbidity rates allow tumor resection and chest wall reconstruction even in a palliative setting.

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).