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.     

Resection of Sternal Tumors and Reconstruction of the Thorax: A Review of 15 Patients

Purpose We report our experience of resecting sternal tumors, followed by reconstruction of the skeletal and soft-tissue defects, and discuss the usefulness of sandwiched Marlex and stainless-steel mesh. Methods Fifteen patients underwent resection of a sternal tumor and chest wall reconstruction with autologous bone grafts, sandwiched Marlex and stainless-steel mesh or a titanium plate, and musculocutaneous flaps. The sternal tumors were from locally recurrent breast carcinoma in ten patients, metastasis from other organs in three, and primary chondrosarcoma in two. Results All patients were extubated without paradoxical respiration just after surgery. There was no operative mortality. A wound infection developed in the acute phase after a sandwiched Marlex and stainless-steel mesh reconstruction in one patient. A second repair with Marlex and stainless-steel mesh was required in two patients; for flail chest after an autologous bone graft in one; and following re-recurrence of breast carcinoma in another patient who had undergone a musculocutaneous flap repair. No signs of breakdown, dislodgment, severe depression, or deformity were seen in any of the six patients who underwent reconstruction with Marlex and stainless-steel mesh during a median follow-up period of 56 months. Conclusions Wide resection of sternal tumors provides good local control. Reconstruction with Marlex and stainless-steel mesh seems to be the most effective technique for repairing a wide anterior chest wall defect.     

Chest wall reconstruction after resection of primary malignant chest wall tumours

In order to review the development of chest wall reconstruction, 37 cases of primary malignant skeletal chest wall tumours treated since 1958 were studied. These included chondrosarcomas (20), Ewing's tumours (7) and solitary plasmacytomas (10). Skeletal reconstruction was performed in 24 patients. Before 1972, Marlex mesh alone was used. Since then, a sandwich of two layers of Marlex mesh with a filler of methyl methacrylate was utilised successfully producing better functional and cosmetic results. Primary soft tissue closure was possible in all but 5 cases in whom latissimus dorsi myocutaneous flaps were used. All but one patient had an uneventful postoperative recovery with none requiring postoperative ventilatory support. The overall survival of 46% at 5 years and 27% at 10 years was encouraging. Familiarity with the techniques of chest wall reconstruction enables wide excision of primary chest wall tumours and the palliation and treatment of other malignant, infective and degenerative conditions since even large defects can be reconstructed with little functional disturbance.     

Immediate Reconstruction of Full-Thickness Chest Wall Defects

Twenty-one patients had full-thickness chest wall defects reconstructed at the New York University Medical Center in the last ten years. Marlex mesh provided chest wall stability in 5 patients. In 9 patients with radiation ulcers Marlex mesh was not required; a severe fibrotic reaction had obliterated the pleural space and prevented paradoxical motion. Partial sternal resections did not require Marlex stabilization, while a total sternectomy resulted in marked ventilatory insufficiency in a patient who would have benefited from the use of a stabilizing material. Random pattern flaps were used initially; more recently, axial pattern, myocutaneous, and myocutaneous free flaps were employed. Necrosis developed in 4 (36%) of the 11 patients with random pattern flaps, but was not seen with the newer flap techniques. Myocutaneous free flaps provided uncomplicated coverage of and stability to three large, potentially contaminated defects. It seems that with the currently available flap techniques and the methods of chest wall stabilization, immediate repair of all full-thickness chest wall defects is possible.     

Current techniques for chest wall reconstruction: expanded possibilities for treatment

Myocutaneous flaps and prosthetic materials have greatly facilitated reconstruction after massive chest wall resection. This series includes 112 such procedures. Latissimus dorsi, rectus abdominis, omental, pectoralis major, and contralateral breast flaps were used in 80 patients. Early in the series, 3 flaps were lost because of technical problems. Minor areas of incomplete healing that resolved completely with local wound care occurred in 16 of 80 flaps. Skeletal reconstruction was performed in 82 patients without complication. Marlex mesh was used for flat surfaces, and Marlex mesh with methyl methacrylate was used for the sternum and the curved surface of the lateral chest wall. These results have allowed an expansion of the indications for chest wall resection to include the curative treatment of primary chest wall tumors and palliative treatment for breast cancer patients with osteoradionecrosis, local recurrence (in select patients), chest wall infection, and tumors metastatic to the chest wall.     

Problems in resection of chest wall sarcomas.

To illustrate the problems of reconstruction in major chest wall resection, five patients with a variety of soft tissue tumors of the chest wall, located at different sites, are presented. Patients, who underwent a lateral or posterolateral chest wall resection required removal of two to five ribs sequentially as well as the adjacent soft tissue. Those who underwent an anterior chest wall resection required resection of the manubrium or the body of sternum as well as of adjacent costal cartilages. To prevent instability of the chest, herniation, and to minimize flailing, the chest defect was bridged with the use of Marlex mesh. Whenever possible, the omentum was brought into the chest cavity to increase the vascularity of the reconstruction. Since, in most instances, the tumors involved the skin because of previous damage from radiation therapy, extensive skin coverage was planned well in advance of resection. Pedicle skin flaps or rotation flaps were used to cover the skin defect. Ventilatory support by volume respirator, was required for three to four days. In all patients, the chest wall was completeley stable after three to six weeks.     

Chest wall resections and reconstruction: a 25-year experience

Background. Chest wall defects continue to present a complicated treatment scenario for thoracic and reconstructive surgeons. The purpose of this study is to report our 25-year experience with chest wall resections and reconstructions.

Methods. A retrospective review of 200 patients who had chest wall resections from 1975 to 2000 was performed.

Results. Patient demographics included tobacco abuse, hypertension, diabetes mellitus, alcohol abuse, coronary artery disease, chronic obstructive pulmonary disease, and human immunodeficiency virus. Surgical indications included lung cancer, breast cancer, chest wall tumors, and severe pectus deformities. Twenty-nine patients had radiation necrosis and 31 patients had lung or chest wall infections. The mean number of ribs resected was 4 ± 2 ribs. Fifty-six patients underwent sternal resections. In addition 14 patients underwent forequarter amputations. Immediate closure was performed in 195 patients whereas delayed closure was performed in 5 patients. Primary repair without the use of reconstructive techniques was possible in 43 patients. Synthetic chest wall reconstruction was performed using Prolene mesh, Marlex mesh, methyl methacrylate sandwich, Vicryl mesh, and polytetrafluoroethylene. Flaps utilized for soft tissue coverage were free flap (17 patients) and pedicled flap (96 patients). Mean postoperative length of stay was 14 ± 14 days. Mean intensive care unit stay was 5 ± 9 days. In-hospital and 30-day survival was 93%.

Conclusions. Chest wall resection with reconstruction utilizing synthetic mesh or local muscle flaps can be performed as a safe, effective one-stage surgical procedure for a variety of major chest wall defects.     

胸壁肿瘤切除与重建方法探讨

目的探讨胸壁肿瘤切除及胸壁缺损修补重建的方法。方法回顾性分析7例胸壁肿瘤患者的临床资料,其中肋骨分化型软骨肉瘤、肋骨分化型骨肉瘤、肋骨骨巨细胞瘤及肋骨骨旁骨肉瘤各1例,肺癌胸壁转移癌2例,乳腺癌复发胸壁转移1例。行扩大根治切除4例,姑息性切除2例,限制性切除1例。切除肋骨1-3根,胸壁骨性缺损面积（4 cm×15 cm）-（15 cm×15 cm）。胸壁缺损重建6例：用部分膈肌修补加固下胸壁缺损1例,应用钢丝支架并腹壁转移肌皮瓣修补缺损1例,应用M arlex网片修补骨性缺损并同时覆盖周围肌肉瓣4例。1例限制性切除患者仅行拉拢缝合,未行胸壁重建。结果应用双层M arlex网片修补骨性缺损并同时覆盖周围肌肉瓣的3例术后胸壁稳定性满意,限制性切除的1例胸壁外观正常,余3例均出现反常呼吸。术后随访6例,时间5月-6年,4例原发性肋骨肿瘤患者均健在,3例转移癌患者死亡1例,失访1例,健在1例。结论依据胸壁缺损的位置和大小,应用双层聚丙烯网片结合自体肌肉瓣覆盖是修补重建胸壁的可靠方法 。     

Surgical therapy of primary malignant bone tumours and soft tissue sarcomas of the chest wall: a two-institutional experience

Purpose

Primary malignant bone tumours and soft tissue sarcomas of the chest wall are exceedingly rare entities. The aim of this study was a retrospective two-institutional analysis of surgical therapy with respect to the kind and amount of the resection performed, the type of reconstruction and the oncological outcome.

Methods

Between September 1999 and August 2010 31 patients (seven women and 24 men) were treated due to a primary malignant bone tumour or soft tissue sarcoma of the chest wall in two centres. Eight low-grade sarcomas were noted as well as 23 highly malignant sarcomas. The tumours originated from the sternum in six cases, from the ribs in 12 cases, from the soft tissues of the thoracic wall in 11 cases and from a vertebral body and the clavicle in one case each.

Results

In 26 cases wide resection margins were achieved, while four were intralesional and one was marginal. In all 31 cases the defect of the chest wall was reconstructed using mesh grafts. At a mean follow-up of 51 months 20 patients were without evidence of disease, three were alive with disease, seven patients had died and one patient was lost to follow-up. One recurrence was detected after wide resection of a malignant triton tumour.

Conclusions

Primary malignant bone tumour or soft tissue sarcoma of the chest wall should be treated according to the same surgical oncological principles as established for the extremities. Reconstruction with mesh grafts and musculocutaneous flaps is associated with a low morbidity.     

Management of sternal wounds with pectoralis major musculocutaneous advancement flaps in patients with a history of chest wall irradiation

Although debridement and pectoralis major musculocutaneous advancement flap closure has proved to be an effective treatment of sternal wounds in the general population, the purpose of this study was to examine the use of these flaps in patients with previously irradiated chest walls. The authors examined 5 patients with a history of breast cancer and chest wall radiation therapy who developed poststernotomy wound complications that were treated with debridement and pectoralis major musculocutaneous advancement flaps. The average patient age was 76 years. Three patients had previously undergone a radical mastectomy and had only 1 pectoralis major muscle remaining. There were no intraoperative deaths. One patient died during the 30-day postoperative period. There were no hematomas, seromas, or dehiscences. One woman developed a postoperative wound infection. Functional and aesthetic results were excellent. This study demonstrates that early, aggressive sternal debridement and closure with pectoralis major musculocutaneous advancement flaps is effective in patients with a history of chest wall irradiation, including those who have had 1 pectoralis major muscle previously resected.     

Utility of the free deep inferior epigastric perforator flap in chest wall reconstruction

Breast cancer chest wall recurrence is often treated with chemotherapy, radical surgery, and radiation. Extensive chest wall resection requires soft-tissue reconstruction with tissue that provides chest wall stability and durability for additional radiation. Local and regional muscle and musculocutaneous flaps are often used for reconstruction. Free flaps, such as the transverse rectus abdominis musculocutaneous flap, are used for large defects, although donor site morbidity can result. The free deep inferior epigastric perforator (DIEP) flap provides coverage for large defects and may have less donor site morbidity. We describe the use of the free DIEP flap to reconstruct large chest wall defects (mean, 501 cm2 defects) after the resection of recurrent breast cancer in two patients. One patient had 2% flap loss. No donor site morbidity occurred. The free DIEP flap is a durable and reliable flap that provided immediate and complete coverage of these large chest wall defects with no donor site morbidity and did not delay the administration of adjuvant therapy.     

Surgical management and reconstruction of extensive chest wall malignancies

Seven patients aged 8 to 77 years underwent massive resection for chest wall malignancies. Two had chondrosarcoma, one recurrent breast cancer, one malignant hemangioepithelioma, one embryonal cell sarcoma, one metastatic osteogenic sarcoma, and one lymphangiosarcoma. The smallest surgical defect was 17 by 19 cm, the largest 35 by 45 cm. Closure was done with Marlex mesh, full-thickness muscle flaps, or free island pectoralis or latissimus dorsi flaps. The rotation of myocutaneous island flaps (bilateral in two patients) greatly facilitated reconstruction. No infection, pulmonary compromise, or operative morbidity or mortality was encountered. The age of the patients and the location or size of the lesions were not significant factors. Designing a surgical strategy which provides adequate full-thickness margins and immediate reconstruction is critically important. Massive chest wall resection for malignancy should be pursued aggressively whenever these lesions are encountered. The operations can be performed safely and can be curative, and the benefits to patients in terms of comfort and prolonged survival justify this extensive surgery.     

Reconstruction of complex oncologic chest wall defects: a 10-year experience

The repair of complex chest wall defects presents a challenging problem for the reconstructive surgeon. Although the majority of such defects could be repaired with the use of local and regional musculocutaneous flaps, more complicated cases require increasingly sophisticated reconstructive techniques. This study reviews the experience at a single cancer center with chest wall reconstruction over a decade. A retrospective review was undertaken for each patient who underwent chest wall reconstruction from 1992 to 2002. Patient demographics and variables, including pathologic diagnosis, extent of resection, size of defect, method of reconstruction, and outcome were evaluated. There was a total of 113 patients, 88 females and 25 males. The average age was 58 years (range, 19-88 years). The most common diagnoses were breast cancer and sarcoma. The average area of the chest wall defect after resection was 266 cm. One hundred fifty-seven musculocutaneous or muscle flaps were performed for reconstruction of the chest wall. Eleven percent of patients underwent reconstruction with autologous free tissue transfer. One hundred six patients underwent a single operation. Seven patients required a second operation for salvage of a complication. In 19 cases (15%), more than 1 flap was used simultaneously to complete the reconstruction. Eighty-four percent of the patients achieved stable chest wall reconstruction with no complications. Seven patients (4%) had partial (>10%) flap loss. The most common remaining postoperative complications were delayed wound healing (3% of patients), infection (2.5%), and hematoma (2.5%). Immediate chest wall reconstruction is safe, reliable, and can most often be accomplished with 1 operation. A variety of flaps, both single and in combination, could be used to achieve definitive coverage of the chest wall after extirpative surgery. The reconstructive choice is dependent on factors such as size of the defect, location on the chest wall, arc of rotation of the flap, and availability of recipient vessels. Based on this single institutional experience over a decade, an algorithm to chest wall reconstruction is provided.     

Chest wall reconstruction using a combined musculocutaneous anterolateral�Canteromedial thigh flap

We present a massive 25 cm × 20 cm chest wall defect resulting from resection of recurrent cystosarcoma phyllodes of the breast along with six ribs exposing pleura. The chest wall was reconstructed with a Prolene mesh–methylmethacrylate cement sandwich while soft tissue reconstruction was carried out using a combined free anterolateral–anteromedial thigh musculocutaneous flap with two separate pedicles, anastomosed to the thoracodorsal and thoracoacromial vessels respectively. We explain our rationale for and the advantages of combining the musculocutaneous anterolateral thigh flap with the anteromedial-rectus femoris thigh flap.     

Immediate reconstruction of the chest wall by latissimus dorsi and vertical rectus abdominis musculocutaneous flaps after radical mastectomy for a huge pleomorphic liposarcoma

Abstract

We describe a 53-year-old woman who had a huge pleomorphic liposarcoma of the left breast. She had a left Halstead mastectomy, which left a huge defect in the chest wall. We did an immediate reconstruction of the chest wall with combined latissimuss dorsi musculocutaneous (for the upper half of the defect) and vertical rectus abdominis musculocutaneous flaps (for the lower half of the defect). She then had radiotherapy and chemotherapy during which time the flaps remained viable and provided satisfactory coverage for the irradiated area. Unfortunately four months later she was diagnosed with spinal cord and lung metastases and died seven months after the operation.     

应用胸大肌肌瓣治疗开胸术后胸骨骨髓炎

目的 探讨开胸术后胸骨骨髓炎的治疗方法。方法 术前先行分泌物培养 药敏；并行胸骨处窦道造影，确定其累及范围。术中切除感染之胸骨，并向胸骨后探查，清除感染的软组织；在一侧胸部设计胸大肌肌瓣转移填塞胸骨缺损处；术后采用滴注引流，同时全身应用敏感抗生素。结果 本组10例，术后2周伤口愈合，未见胸骨骨髓炎复发。结论 应用胸大肌肌瓣转移，是修复开胸术后胸骨骨髓炎较好的方法。     

Microvascular reconstructions of full-thickness oncological chest wall defects

OBJECTIVE: To evaluate the suitability of microvascular flaps for the reconstruction of extensive full-thickness defects of the chest wall. SUMMARY BACKGROUND DATA: Chest wall defects are conventionally reconstructed with pedicular musculocutaneous flaps or the omentum. Sometimes, however, these flaps have already been used, are not reliable due to previous operations or radiotherapy, or are of inadequate size. In such cases, microvascular flaps offer the only option for reconstruction. METHODS: From 1988 to 2001, 26 patients with full-thickness resections of the chest wall underwent reconstruction with microvascular flaps. There were 8 soft tissue sarcomas, 8 recurrent breast cancers, 5 chondrosarcomas, 2 desmoid tumors, 1 large cell pulmonary cancer metastasis, 1 renal cancer metastasis, and 1 bronchopleural fistula. The surgery comprised 5 extended forequarter amputations, 5 lateral resections, 8 thoracoabdominal resections, and 8 sternal resections. The mean diameter of a resection was 28 cm. The soft tissue defect was reconstructed with 16 tensor fasciae latae, 5 tensor fascia latae combined with rectus femoris, and 3 transversus rectus abdominis myocutaneous flaps. In 2 patients with a forequarter amputation, the remnant forearm was used as the osteomusculocutaneous free flap. RESULTS: There were no flap losses or perioperative mortality. Four patients needed tracheostomy owing to prolonged respiratory difficulties. The mean survival time for patients with sarcomas was 39 months and for those with recurrent breast cancer 18 months. CONCLUSIONS: Extensive chest wall resections are possible with acceptable results. In patients with breast cancer, the surgery may offer valuable palliation and in those with sarcomas it can be curative.     

Chest wall reconstruction using polyester mesh]

Using polyester, we prepared a new material for chest wall reconstruction. The polyester mesh has the same rigidity and elasticity as Marlex tracheal mesh. From January 1987 through July 1991, we performed chest wall reconstruction using the polyester mesh in 8 patients with lung cancer, 9 with empyema after open drainage, 2 with metastatic chest wall tumors, 1 with a primary osteogenic giant cell tumor originating from the rib and 1 with radiation dermatitis and costal chondritis. Three or more ribs were resected in 17 patients. The defects of the chest wall were reconstructed with the polyester mesh covered with a GORE-TEX soft tissue patch to achieve air tightness. Fifteen cases have passed at least one year with no sign of infection. In conclusion, the polyester mesh prevents flail chest and seems to be a satisfactory material for chest wall reconstruction.     

Surgical treatment of primary malignant chest wall tumours

Objective: Primary malignant tumours of the bony chest wall are uncommon and data concerning treatment and results are sparse. Methods: To assess the results of surgical resection and chest wall reconstruction we reviewed our experience with primary malignant chest wall tumours treated since 1958. Results: Of the 49 lesions, 42 were found in the ribs and the remaining 7 in the sternum. These included chondrosarcomas [22], solitary plasmacytoma [18], Ewing's tumours [7], Askin's tumour [1] and Desmoid tumour [1]. Skeletal reconstruction was performed in 36 of the 49 patients. Marlex mesh alone was used in 17 patients. Since 1972, a sandwich of two layers of Marlex mesh with a filler of methyl methacrylate was utilised [19] successfully, producing better functional and cosmetic results. Primary soft tissue closure was possible in all but 8 cases in whom latissimus dorsi myocutaneous flaps were used. Bilaterally, partially transposed pectoralis major muscle was used to cover upper sternal defects in 4 cases. All but 1 patient had an uneventful post-operative recovery none requiring ventilatory support. Survival: Overall survival at 5 and 10 years was 68%. The differential figures for 10-year survival were for chondrosarcoma 67%, Ewing's sarcoma 43%, and solitary plasmacytoma 59%. These were the results of radical en-bloc excisions. The patient with Desmoid tumour is alive at 5 years, following incomplete initial resection and the patient with Askin's tumour survived for 3 years. Conclusion: Radical en-bloc excision remains the treatment of choice in all primary malignant chest wall neoplasms except large solitary plasmacytomas where incisional biopsy followed by irradiation appears to be the method of preference. In Ewing's and Askin's tumours, additional chemotherapy and radiotherapy have to be used. The extent of surgical excision should only be limited by the amount of tissue necessary to remove for adequate malignant tissue clearance, since even large defects can be reconstructed with little functional disturbance.     

Repair of massive septic abdominal wall defects with Marlex mesh

Marlex mesh was used to close the abdominal wall defect in six patients with septic wound dehiscence and intra-abdominal infection. The mesh was implanted under local anesthesia and served as a protective covering for the bowel and allowed early ambulation, including prone positioning of the patient for easier wound care. In four surviving patients, the Marlex mesh was covered by full thickness skin flaps after granulation tissue had covered the material. No patients had infected sinus tract formation or extrusion. Two patients had incisional hernias develop when the Marlex mesh was not sutured to the abdominal wall permanently. The use of Marlex mesh to cover infected defects in the abdominal wall when primary closure cannot be accomplished is suggested by our experience.