Chest wall reconstruction in benign and malignant tumors with non-rigid materials: An overview

Sternal Resections: An Attempt to Find the Ideal Reconstruction Method

Background and Objectives: Sternal resections, although rare, pose significant challenges for the reconstruction of large anterior chest wall defects. Both stability and soft tissue reconstruction are essential for preventing respiratory complications and ensure structural stability. Despite the variety of techniques proposed, no consensus exists on an optimal method. Herein, we present our institutional experience using the novel "spider-web" technique combined with an anterolateral thigh (ALT) free flap for chest wall and soft tissue reconstruction following extensive sternectomies. Materials and Methods: Between January 2023 and November 2024, five female patients underwent partial or total sternectomy for oncologic indications. Chest wall stability was restored using the "spider-web" technique-based on non-resorbable polyester threads arranged in a geometric web pattern reinforced with polypropylene mesh-followed by soft tissue reconstruction using a free ALT myocutaneous flap. Data on demographics, surgical details, postoperative outcomes, and complications were prospectively analyzed. Results: Resections included two partial and three total sternectomies. The mean operative time was 385 min (range: 330-435 min). All patients were extubated postoperatively without the need for respiratory support. The "spider-web" construct provided adequate chest wall stability with no cases of paradoxical movement or chronic pain. No flap loss occurred; one case required revision for venous thrombosis, and one hematoma at the donor site was evacuated. No infections or wound dehiscence were observed. The median hospital stay was 11 days (SD ± 1.67 days), and 30-day mortality was 0%. Median follow-up was 10 months (SD ± 6.55 months), without long-term complications. Conclusions: The "spider-web" technique, combined with ALT myocutaneous free flap, is a simple, reliable, and cost-effective method for the reconstructing extensive chest wall defects following sternectomy. Its technical versatility and favorable outcomes suggest it as a valuable option, offering both structural stability and soft tissue coverage with minimal morbidity.

Expanded polytetrafluoroethylene mesh in chest-wall reconstruction: A 27-year experience

OBJECTIVE

The study objective was to evaluate the success of expanded polytetrafluoroethylene mesh in chest-wall reconstruction.

METHODS

We retrospectively reviewed patients who underwent expanded polytetrafluoroethylene (Gore-Tex) chest-wall reconstruction. The main outcome was a mesh-related event, defined as a mesh-related reoperation (eg, mesh infection requiring debridement with/without explant, tumor recurrence with explant) or structural dehiscence/mesh loosening with/without a hernia. Demographics and surgical outcomes were reported.

RESULTS

A total of 246 reconstructions met inclusion (1994-2021). Fifty-five reconstructions (22.4%) had mesh-related events within a median of 1.08 years (interquartile range, 0.08-4.53) postoperatively; those without had a stable chest for a median of 3.9 years (interquartile range, 1.59-8.23, P < .001). Forty-one meshes (16.6%) became infected, requiring reoperation. Eighty-eight percent (36/41) were completely explanted; 8.3% (3/36) required additional mesh placement. Predictors of mesh-related events were prior chest-wall radiation (odds ratio, 9.73, CI, 3.47-30.10, P < .001), higher body mass index (odds ratio, 1.08, CI, 1.01-1.16, P = .019), and larger defects (odds ratio, 1.48, CI, 1.02-2.17, P = .042). The risk of mesh-related events with obesity was higher with prior chest-wall radiation.

CONCLUSIONS

Most patients (78%) with an expanded polytetrafluoroethylene mesh had a stable reconstruction after a median of 4 years. Obesity, larger defects, and prior chest-wall radiation were associated with a higher risk of a mesh-related event mostly due to mesh infections. Seventeen percent of reconstructions had reoperation for mesh infection; 88% were completely explanted. Only 8% required replacement mesh, suggesting that experienced surgeons can safely manage them without replacement. Future studies should compare various meshes for high-risk patients to help guide the optimal mesh selection.

Long-Term Outcome of Chest Wall and Diaphragm Repair with Biological Materials

INTRODUCTION

 Chest wall and/or diaphragm reconstruction aims to preserve, restore, or improve respiratory function; conserve anatomical cavities; and upkeep postural and upper extremity support. This can be achieved by utilizing a wide range of different grafts made of synthetic, biological, autologous, or bioartificial materials. We aim to review our experience with decellularized bovine pericardium as graft in the past decade.

PATIENTS AND METHODS

 We conducted a retrospective analysis of patients who underwent surgical chest wall and/or diaphragm repair with decellularized bovine pericardium between January 1, 2012 and January 13, 2022 at our institution. All records were screened for patient characteristics, intra-/postoperative complications, chest tube and analgesic therapy duration, length of hospital stay, presence or absence of redo procedures, as well as morbidity and 30-day mortality. We then looked for correlations between implanted graft size and postoperative complications and gathered further follow-up information at least 2 months after surgery.

RESULTS

 A total of 71 patients either underwent isolated chest wall (n = 51), diaphragm (n = 12), or pericardial (n = 4) resection and reconstruction or a combination thereof. No mortality was recorded within the first 30 days. Major morbidity occurred in 12 patients, comprising secondary respiratory failure requiring bronchoscopy and invasive ventilation in 8 patients and secondary infections and delayed wound healing requiring patch removal in 4 patients. There was no correlation between the extensiveness of the procedure and extubation timing (chi-squared test, p = 0.44) or onset of respiratory failure (p = 0.27).

CONCLUSION

 A previously demonstrated general viability of biological materials for various reconstructive procedures appears to be supported by our long-term results.

Surgical management of a chest wall osteosarcoma with pleural and lung invasion through en-bloc chest resection and complex reconstruction. Case report

Osteosarcomas of the ribs are rarely reported but have a high potential for pulmonary metastases. The therapeutic strategies for this disease are not well defined. The primary treatment recommendations include wide resection with clear surgical margins and chest wall reconstruction if needed. We present a case of costal osteosarcoma with pleural and lung extension successfully treated by en-bloc thoracic resection with free surgical margins and chest wall reconstruction with rib titanium bars, polypropylene mesh and a rectus abdominis free flap with microvascular anastomoses. This case demonstrates the importance of this therapeutic strategy and highlights the need of early intervention in managing this disease.

Complications of chest wall around malignant tumors: differences based on reconstruction strategy

BACKGROUND

Malignant chest wall tumors need to be excised with wide resection to ensure tumor free margins, and the reconstruction method should be selected according to the depth and dimensions of the tumor. Vascularized tissue is needed to cover the superficial soft tissue defect or bone tissue defect. This study evaluated differences in complications according to reconstruction strategy.

METHODS

Forty-five patients with 52 operations for resection of malignant tumors in the chest wall were retrospectively reviewed. Patients were categorized as having superficial tumors, comprising Group A with simple closure for small soft tissue defects and Group B with flap coverage for wide soft tissue defects, or deep tumors, comprising Group C with full-thickness resection with or without mesh reconstruction and Group D with full-thickness resection covered by flap with or without polymethyl methacrylate. Complications were evaluated for the 52 operations based on reconstruction strategy then risk factors for surgical and respiratory complications were elucidated.

RESULTS

Total local recurrence-free survival rates in 45 patients who received first operation were 83.9% at 5 years and 70.6% at 10 years. The surgical complication rate was 11.5% (6/52), occurring only in cases with deep tumors, predominantly from Group D. Operations needing chest wall reconstruction (p = 0.0016) and flap transfer (p = 0.0112) were significantly associated with the incidence of complications. Operations involving complications showed significantly larger tumors, wider areas of bony chest wall resection and greater volumes of bleeding (p < 0.005). Flap transfer was the only significant predictor identified from multivariate analysis (OR: 10.8, 95%CI: 1.05-111; p = 0.0456). The respiratory complication rate was 13.5% (7/52), occurring with superficial and deep tumors, particularly Groups B and D. Flap transfer was significantly associated with the incidence of respiratory complications (p < 0.0005). Cases in the group with respiratory complications were older, more frequently had a history of smoking, had lower FEV1.0% and had a wider area of skin resected compared to cases in the group without respiratory complications (p < 0.05). Preoperative FEV1.0% was the only significant predictor identified from multivariate analysis (OR: 0.814, 95%CI: 0.693-0.957; p = 0.0126).

CONCLUSIONS

Surgical complications were more frequent in Group D and after operations involving flap transfer. Severe preoperative FEV1.0% was associated with respiratory complications even in cases of superficial tumors with flap transfer.

Enhanced recovery after chest wall resection and reconstruction: a clinical practice review

Since the late 1990s, and Henrik Kehlet's hypothesis that a reduction of the body's stress response to major surgeries could decrease postoperative morbidity, "Enhanced Recovery After Surgery" (ERAS) care pathways have been streamlined. They are now well accepted and considered standard in many surgical disciplines. Yet, to this day, there is no specific ERAS protocol for chest wall resections (CWRs), the removal of a full-thickness portion of the chest wall, including muscle, bone and possibly skin. This is most unfortunate because these are high-risk surgeries, which carry high morbidity rates. In this review, we propose an overview of the current key elements of the ERAS guidelines for thoracic surgery that might apply to CWRs. A successful ERAS pathway for CWR patients would entail, as is the standard approach, three parts: pre-, peri- and postoperative elements. Preoperative items would include specific information, targeted patient education, involvement of all members of the team, including the plastic surgeons, smoking cessation, dedicated nutrition and carbohydrate loading. Perioperative items would likely be standard for thoracotomy patients, namely carefully selective pre-anesthesia sedative medication only in some rare instances, low-molecular-weight heparin throughout, antibiotic prophylaxis, minimization of postoperative nausea and vomiting, avoidance of fluid overload and of urinary drainage. Postoperative elements would include early mobilization and feeding, swift discontinuation of intravenous fluid supply and chest tube removal as soon as safe. Optimal pain management throughout also appears to be critical to minimize the risk of respiratory complications. Together, all these items are achievable and may hold the key to successful introduction of ERAS pathways to the benefit of CWR patients.

Pedicled flap transfer after chest wall malignant tumor resection and potential risk of postoperative respiratory problems for patients with low FEV1.0

Introduction

Musculoskeletal transfer for chest wall tissue defects is a crucial method, and pedicled flaps around the chest wall are preferred in terms of location and simplicity of transfer. These require special care because of complications such as partial necrosis, fistula, wound dehiscence, infection, hematoma and restricted function of the arm or shoulder. However, studies of respiratory function are rare. In the present study, we investigated the complications including respiratory problems after wide resection for malignant chest wall tumors with musculoskeletal pedicle transfer.

Methods

A total of 13 patients (15 operations) who underwent wide resection of primary, recurrent, or metastatic malignant chest wall tumors and musculoskeletal pedicle transfer for coverage of tissue defects were enrolled in the present study. A retrospective review of all patients was performed using data collected from hospital records and follow-up information. The complications of musculoskeletal transfer after chest wall wide resection, including respiratory problems, are evaluated.

Results

Rib or sternal resection was performed in 12 operations, and only soft tissue resection was performed in 3 operations. Latissimus dorsi (LD) pedicle transfer was performed in 13 operations, and pectoralis major (PM) pedicle transfer was performed in 2 operations; basically, wounds were closed primarily. Surgical complications were observed following 5 of the 15 operations (33.3%). Respiratory complications were seen in 7 of the 15 operations (46.7%). Patients with respiratory complications showed significantly lower preoperative FEV1.0% values than those without respiratory complications (p = 0.0196). Skin resection area tended to be higher in the complication group than in the no complication group (p = 0.104).

Discussion

Pedicled myocutaneous flap transfers such as LD, PM, and rectus abdominus can be used following multiple resections. After harvesting LD or PM, the wound can be closed primarily for an 8-10-cm skin defect in patients with normal respiratory function. However, for patients with low FEV1.0%, after primary closure of LD or PM transfer for wide soft tissue defects, attention should be paid to postoperative respiratory complications.

Management of complications after chest wall resection and reconstruction: a narrative review

BACKGROUND AND OBJECTIVE

Chest wall resection and reconstruction procedures carry high postoperative morbidity. Therefore, successful outcomes necessitate prevention, prompt identification, and appropriate management of ensuing complications. This narrative review aims to provide a comprehensive overview of evidence-based strategies for managing complications following chest wall resection and reconstruction.

METHODS

A literature search was conducted using the PubMed database for relevant English-language studies published since 1980.

KEY CONTENT AND FINDINGS

Complications following chest wall resection and reconstruction can be broadly classified into surgical site-related, respiratory, or other systemic complications. Surgical site and respiratory complications are the most common, with reported incidence rates of approximately 40% across some series. Predisposing factors for respiratory morbidity include greater numbers of resected ribs and concurrent pulmonary lobectomy. Definitive correlations between specific prosthetic materials and complications remain elusive. Management should be tailored to the type and severity of the complication, surgical variables, and patient factors. Specific approaches for managing common complications are discussed in detail. Emerging preventive approaches, such as minimally invasive surgical techniques, are also briefly highlighted to help guide future research.

CONCLUSIONS

An emphasis on anticipating and judiciously managing complications of chest wall resection and reconstruction, alongside a coordinated multidisciplinary approach, can optimize outcomes for patients undergoing this intrinsically complex surgery.

Reconstructive Strategies in Pediatric Patients after Oncological Chest Wall Resection: A Systematic Review

An appropriate reconstruction strategy after surgical resection of chest wall tumors in children is important to optimize outcomes, but there is no consensus on the ideal approach. The aim of this study was to provide an up-to-date systematic review of the literature for different reconstruction strategies for chest wall defects in patients less than 18 years old. A systematic literature search of the complete available literature was performed and results were analyzed. A total of 22 articles were included in the analysis, which described a total of 130 chest wall reconstructions. All were retrospective analyses, including eight case reports. Reconstructive options were divided into primary closure (n = 21 [16.2%]), use of nonautologous materials (n = 83 [63.8%]), autologous tissue repair (n = 2 [1.5%]), or a combination of the latter two (n = 24 [18.5%]). Quality of evidence was poor, and the results mostly heterogeneous. Reconstruction of chest wall defects can be divided into four major categories, with each category including its own advantages and disadvantages. There is a need for higher quality evidence and guidelines, to be able to report uniformly on treatment outcomes and assess the appropriate reconstruction strategy.

Analysis of the Chest Wall Reconstruction Methods after Malignant Tumor Resection

Background  The chest wall defects can be caused by various reasons. In the case of malignant tumor resection of the chest wall, it is essential to reconstruct the chest wall to cover the vital tissue and restore the pulmonary function with prevention of paradoxical motion. With our experience, we analyzed and evaluated the results and complications of the chest wall reconstructions followed by malignant tumor resection. Methods  From 2013 to 2022, we reviewed a medical record of patients who received chest reconstruction due to chest wall malignant tumor resection. The following data were retrieved: patients' demographic data, tumor type, type of operation, method of chest wall reconstruction of the soft and skeletal tissue and complications. Results  There were seven males and six female patients. The causes of reconstruction were 12 primary tumors and one metastatic carcinoma. The pathological types were seven sarcomas, three invasive breast carcinoma, and three squamous cell carcinomas. The skeletal reconstruction was performed in six patients. The series of the flap were eight pedicled latissimus dorsi (LD) myocutaneous flaps, two pectoralis major myocutaneous flap, two vertical rectus abdominis myocutaneous free flap, and one LD free flap. Among all the cases, only one staged reconstruction and successful reconstruction without flail chest. Most of the complications were atelectasis. Conclusion  In the case of accompanying multiple ribs and sternal defect, skeletal reconstruction would need skeletal reconstruction to prevent paradoxical chest wall motion. The flap for soft tissue defect be selected according to defect size and location of chest wall. With our experience, we recommend the reconstruction algorithm for chest wall defect due to malignant tumor resection.

Mastery of chest wall reconstruction with a titanium sternum-rib fixation system: a case series

Background

Chest wall disease is a common disease in thoracic surgery. For most chest wall lesions, surgical resection is the mainstay of treatment. Reconstruction is indicated for a wide range of chest wall defects. Currently, various reconstruction materials are used in clinic, including 3D printing materials and various types of metal materials. At present, most of the studies using titanium sternum-rib fixation system for reconstruction are case reports. The purpose of this paper is to analyze the experience to discuss our essential surgical techniques for treating various types of chest wall reconstruction with a titanium sternum-rib fixation system over the last 5 years.

Case Description

A retrospective analysis was performed on patients with chest wall tumors treated with a titanium sternum-rib fixation system in our center from 2016 to 2020. Chest wall reconstruction techniques, experiences, postoperative complications, and quality of life including chest discomfort, chronic pain, average time to return to normal life, chest wall deformity after resection for various types of chest wall tumors were analyzed. In this study, a total of 57 patients were successfully operated without chest wall deformity and return to daily life early. With an average of 2.3 ribs removed, including 10 procedures involving sternotomy and reconstruction and 3 procedures involving sternoclavicular joint resection and reconstruction. The follow-up time of the whole group ranged from 3 months to 5 years. Postoperative chest discomfort occurred in 6 patients during follow-up; 2 patients had chronic pain. The average time to return to normal life was 1.4 months. One patient developed a deformed depression of the chest wall, and 2 patients developed wound infections. There was no perioperative death.

Conclusions

In our clinical experience, the titanium sternum-rib fixation system is safe, effective, and feasible. The technique is straightforward. The early and middle postoperative curative effect is satisfactory and can be used clinically.