Macromastia as a Factor in Sternal Wound Dehiscence Following Cardiac Surgery: Management Combining Chest Wall Reconstruction and Reduction Mammoplasty

Major sternal wound infection occurs in nearly 2% of patients following coronary artery bypass graft surgery. The relationship of this complication to gender has not been reported in detail, nor has female breast size previously been implicated as a factor increasing the risk of sternotomy dehiscence. We report two cases of sternotomy wound dehiscence in women with large, pendulous breasts undergoing myocardial revascularization surgery and postulate that the weight of large, unsupported breasts produced inferolateral tension on the midline sternotomy incisions, contributing to dehiscence of the wounds. Chest wall reconstruction was accomplished using pectoralis muscle flaps, and the procedures were combined with amputative reduction of the size of the breasts, with subsequently successful healing in each case. Combining sternal reconstruction with breast reduction surgery may lead to improved secondary outcome, and postoperative use of supportive brassieres may reduce the frequency of this complication.     

Chest Wall Reconstruction in Pediatric Patients with Chest Wall Tumors: A Systematic Review

BackgroundResection of pediatric chest wall tumors can result in large defects requiring reconstruction for function and cosmesis. Multiple reconstructive methods have been described. We performed a systematic review of the literature to describe commonly used approaches and outcomes.MethodsA systematic literature search was performed for English-language publications describing chest wall tumor resection and reconstruction using implantable materials in patients ≤21 years, excluding soft tissue resection only, sternal resection, and reconstruction by primary repair or muscle flaps alone. Data were collected on diagnoses, reconstructive method, and outcomes. Rigid chest wall reconstruction was compared to mesh reconstruction.ResultsThere were 55 articles with 188 patients included. The median age was 12 years. Most tumors were malignant (n = 172, 91.5%), most commonly Ewing's sarcoma (n = 65, 34.6%), followed by unspecified sarcomas (n = 34, 18.1%), Askin's tumor (n = 16, 8.5%; a subset of Ewing's sarcoma) and osteosarcoma (n = 16, 8.5%). A median of 3 ribs were resected (range 1–12). Non-rigid meshes were most common (n = 138, 73.4%), followed by rigid prostheses (n = 50, 26.6%). There were 19 post-operative complications (16.8%) and 22.2% of patients developed scoliosis. There were no significant differences in complications (20.5% rigid vs. 10.6% non-rigid, p = 0.18) or scoliosis (22.7% vs. 14.0%, p = 0.23) by reconstruction method, but complications after rigid reconstruction were more likely to require surgery (90.0% vs. 53.9%, p = 0.09). The median follow-up duration was 24 months.ConclusionsIn this review of the literature, there were no significant differences in overall post-operative complications or scoliosis development by reconstruction method, yet complications after rigid reconstruction were more likely to require surgical intervention.Level of evidenceLevel IV.     

Chest Wall Reconstruction With Methacrylate Prosthesis in Poland Syndrome

Poland syndrome is a rare congenital malformation. This syndrome was described in 1841 by Alfred Poland at Guy's Hospital in London. It is characterized by hypoplasia of the breast and nipple, subcutaneous tissue shortages, lack of the costosternal portion of the pectoralis major muscle and associated alterations of the fingers on the same side. Corrective treatment of the chest and soft tissue abnormalities in Poland syndrome varies according to different authors. We report the case of a 17-year-old adolescent who underwent chest wall reconstruction with a methyl methacrylate prosthesis. This surgical procedure is recommended for large anterior chest wall defects, and it prevents paradoxical movement. Moreover it provides for individual remodeling of the defect depending on the shape of the patient's chest.     

Clinical Course of Breast Cancer Patients with Isolated Sternal and Full-Thickness Chest Wall Recurrences Treated With and Without Radical Surgery

Background

The role and outcome of radical surgery in contemporary multidisciplinary management of breast cancer patients presenting with isolated sternal or full-thickness chest wall (SCW) recurrence are undefined compared with patients treated without surgery.

Methods

Detailed analyses of all patients with isolated SCW recurrence treated from 1992 to 2011 at a large cancer institution were performed. Univariate and multivariate comparisons of clinicopathologic and treatment characteristics were analyzed. Overall and progression-free survival were compared using the Kaplan–Meier method.

Results

Seventy-six patients were identified, 44 treated surgically and 32 nonsurgically. Overall survival at 5 years was not statistically different between patients who underwent surgery and those who did not (30.6 and 49.6 %, respectively; P = 0.52) although patients selected for surgery presented with more advanced and biologically aggressive disease. Surgically treated patients were more likely to have triple-negative breast cancer at recurrence (52 vs. 17 %; P = 0.006). Among surgical patients, 95 % received preoperative systemic therapy. Clinical response with systemic therapy was significantly different, with surgically treated patients more likely to have responsive or stable disease (54 vs. 25 %, P = 0.04). Complications related to radical surgical resection occurred in 25 % of patients. For hormone receptor–positive recurrence, 5-year progression-free survival was significantly higher among surgical patients (46.3 vs. 14.5 %; P = 0.01).

Conclusions

Among patients with isolated SCW recurrence, hormone receptor-positive recurrence is associated with improved survival. Systemic therapy should be the initial treatment, and clinical response can be used to help select patients who may benefit from radical resection.     

Reconstruction of the Chest Wall

Reconstruction of the chest wall can now be accomplished reliably and expeditiously. Past experience with local flaps and split-thickness skin grafts recommends their continued use when appropriate. Recent studies in blood flow have demonstrated that very large muscles with or without the overlying skin can be moved primarily and reliably. The four most reliable myocutaneous flaps for chest wall reconstruction are described. Microsurgery allows movement of large segments of skin and muscle from expendable areas of the body to the chest wall.     

Reconstruction of the Chest Wall

Three cases of large chest wall defects necessitating reconstructive procedures, are described. Two of them followed radical resection of chondro-sarcomas and one after earlier unorthodox thoracotomy. A reconstructive technique including costal grafts (homo- or auto-grafts), two layers of fascia lata or dacron nets and bone-chips, is presented and recommended.