Circumferential forearm fasciocutaneous free flap reconstruction of forequarter amputation/chest wall resection using simultaneous extra-anatomic revascularization (SEAR)

Background: This report describes a technique in which temporary extra-anatomic revascularization of an amputated part was used to preserve a free flap while tumor resection and chest wall reconstruction were performed. Methods: A patient with multiple local recurrences of basosquamous carcinoma of the shoulder underwent forequarter amputation with en bloc resection of the upper chest wall. During the resection, an elbow disarticulation of the amputated limb was performed. The vascular pedicle of the amputated forearm was joined to the dorsalis pedis vessels of the foot. Following completion of tumor resection and chest wall reconstruction, the forearm was disconnected from the foot and re-anastomosed to thoracic vessels, and a circumferential fasciocutaneous free flap was then harvested and inset. Results: No ischemic flap complications occurred, and the patient recovered well. Ample time was afforded for complete tumor resection with negative margins and prosthetic reconstruction of the chest wall. Conclusions: The technique of temporary, simultaneous extra-anatomic revascularization of an amputated part for later free flap harvest may be helpful in avoiding potentially long flap ischemia times in selected complex oncologic resections. Presented at the Cine Clinic, 50th Annual Cancer Symposium, Society of Surgical Oncology, March 21, 1997, Chicago, Illinois. The opinions expressed in this article are those of the authors alone, and are not the opinions of the United States Air Force or the Department of Defense.     

A rare case of chest wall reconstruction in a child

IntroductionEwing sarcoma/primitive neuroectodermal tumour (ES/PNET) is the most common malignant tumour of the chest wall in children and young adults. Chest wall defect left after complete resection of the involved ribs and chest wall defect requiring reconstruction, is surgically challenging for cosmetic as well as for functional purposes especially in growing children.ImportanceA rare but feasible and simple technique for a case of chest wall tumour reconstruction has been described here with its successful outcome with available composite muscular vascularised flap.     

Internal mammary artery perforator flap for reconstruction of the chest wall

Abstract

We used internal mammary artery perforator (IMAP) flaps from the opposite side for reconstruction of small-to-medium-sized defects in the chest wall. The IMAP flaps were used in two patients who had unhealed, localised ulcers of the chest wall with exposure of the ribs after radical mastectomy. The lesion was excised widely, and the flap, based on a perforator vessel in the second or third intercostal space of the opposite chest wall, was raised. The flap was rotated from 90° to 180° along the vascular axis to the chest wall defect. The donor site was closed primarily. Both flaps showed stable postoperative circulation and survived completely. Defects of the chest wall could be covered with healthy, well-vascularised tissue on one perforator without deep infection. The IMAP flap is a reliable and less invasive option to be considered for medial, localised, reconstruction of the chest wall.     

Subscapularis muscle flap for reconstruction of posterior chest wall skeletal defect

IntroductionChest wall skeletal defects are usually closed using muscle flaps or prosthetic materials. Postoperative prosthetic infections are critical complications and often require plastic surgery support. We report a new surgical technique, involving a subscapular muscle flap, for covering posterior chest wall defect.Presentation of caseA 75-year-old man was admitted to our hospital. We performed a right upper lobectomy with posterior chest wall resection between the third and sixth ribs. The resulting chest wall defect was covered with a polytetrafluoroethylene mesh that became infected postoperatively. We removed the infected mesh and used the subscapularis muscle, the nearest muscle to the defect, to cover the chest wall defect. The scapular tip was lifted and the lower half of the muscle was dissected. The free end of the flap was sutured to the stumps of the anterior serratus and rhomboid major muscles. Computed tomography, 1 month later, revealed that the flap was engrafted to the chest wall.DiscussionNo previous study has reported the use of a subscapularis muscle flap for chest wall reconstruction. The lower third of the scapula was excised since blood supply to the scapula tip may be reduced after dissection of the subscapularis muscle, and to prevent the scapula tip from falling into the thoracic cavity.ConclusionThe use of a subscapularis muscle flap to repair chest wall defect is a simple and safe technique that can be conducted in the same surgical field as the initial reconstruction surgery and does not require plastic surgery support.     

Five recipient vessels for metachronous chest wall reconstruction: Case report and literature review

Selecting potential recipient vessel options for free flap anastomosis is an important consideration in microsurgical breast and chest wall reconstruction. In these settings, the most common comprise the internal mammary and thoracodorsal vessels, although alternative anastomotic sites have also been described. On occasion, consideration of these alternatives becomes a necessity. The use of five separate recipient vessels is highlighted in a unique case of recurrent locally advanced breast cancer requiring multiple complex reconstructions using free tissue transfer. A 56‐year‐old lady presented for delayed breast reconstruction one year after radical mastectomy for locally advanced lobular breast cancer. Despite wide resections, local chest‐wall recurrence five times necessitated five microsurgical reconstructions, using separate recipient pedicles: internal mammary vessels, thoracodorsal vessels, serratus branch of thoracodorsal vessels, intercostal vessels and thoracoacromial vessels. All flaps survived completely, without donor or recipient complications. There has not been a subsequent recurrence at 6 months since last reconstruction. The purpose of this report is to present the first reported case of microsurgical chest wall reconstruction using five separate free flaps requiring anastomosis to multiple recipient vessels for anterior chest wall coverage, to present a literature‐based and clinical review of the regional vascular anatomy of the anterior chest wall, and to present an operative approach algorithm. In such complex cases, this understanding can facilitate a streamlined approach to management. © 2014 Wiley Periodicals, Inc. Microsurgery 37:66–70, 2017.     

Clinical studies on reconstruction procedure of total layer chest wall resection

The results of clinical studies on 16 reconstruction procedure after total layer chest wall resection in 14 cases of malignant tumor of the chest wall were reported. The 14 cases consisted of two cases with recurrent primary chest wall tumor, two cases of primary breast cancer, seven cases of recurrent breast cancer, and others. The reconstruction procedure after total layer chest wall resection was conducted using only various myocutaneous flaps (eight cases using latissimus dorsi of the resected side, three cases using the abdominitis of the resected side, three cases using latissimus dorsi of the non-resected side, and two cases using a pectoralis major myocutaneous flap of the non-resected side). reconstruction only using a myocutaneous flap proved to be satisfactory for preventing early stage postoperative respiratory distress and maintaining the stability of the chest wall and respiratory function during prolonged observation. Namely, use of myocutaneous flap is the best approach of reconstruction the chest wall after total layer chest wall resection. We confirmed that reconstruction with latissimus dorsi myocutaneous free flap of the non-resected side with microvascular anastomosis of thoracodorsal vessels was useful for posterior chest wall tumors invading the latissimus dorsi muscle. Also, our results demonstrated the insertion of an omental flap under the myocutaneous flap was useful for cases with secondary chest wall infection or vascular damage caused by preoperative high dose irradiation.     

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.     

Reconstruction of large chest wall defects using a combination of a contralateral latissimus dorsi and a rectus abdominis musculocutaneous flap.

A combination of a contralateral latissimus dorsi musculocutaneous flap and a rectus abdominis musculocutaneous flap used in the reconstruction of large chest wall defects is reported in three patients. This combination is an easy and reliable procedure, without microsurgery, for reconstructing large chest wall defects or deformities and is applicable to patients whose ipsilateral branches of the subclavicular and axillary vessels cannot be used, and to those who need reconstruction of the subclavicular area and axilla as well as the breast mound area.     

Flow‐through omental flap to free anterolateral thigh flap for complex chest wall reconstruction: Case report and review of the literature

Despite the options currently available for chest wall reconstruction, patients with complex composite defects may still pose a significant challenge for the reconstructive surgeon when only using conventional methods. In particular, prior radiotherapy and/or large en bloc resection may leave inadequate regional flaps and recipient vessels for free tissue transfer. Here, we describe a case in which we reconstruct a 14 cm × 18 cm complex chest wall defect, secondary to tumor resection and infected sternum debridement, with a pedicled flow‐through omental flap to a 14 cm × 22 cm free anterolateral thigh flap using the omental gastroepiploic vessels as recipient vessels. Reconstruction was successful with excellent flap viability, and no complications at recipient or donor sites. We review the literature on complex chest wall reconstruction and introduce this valuable option of utilizing a pedicled omental flap as a flow‐through flap to a free flap for patients without viable recipient vessels or local flaps. © 2015 Wiley Periodicals, Inc. Microsurgery 36:70–76, 2016.     

肺癌根治术后胸壁缺损重建方法的探讨

目的 探讨肺癌直接侵犯胸壁的根治性手术和胸壁重建的不同方法和效果.方法 回顾性总结27例肺癌直接侵犯胸壁根治手术的临床资料,行肺叶切除24例,全肺切除3例,所有患者手术中同时切除肺癌直接侵犯的胸壁,胸壁切除范围从6.5 cm×5.4 cm×5.0 cm至15.5 cm×12.5 cm×10.0 cm,切除肿瘤所侵犯的肋...     

Contralateral unaffected breast augmentation using zone IV as a SIEA flap during unilateral DIEP flap breast reconstruction

BackgroundContralateral breast augmentation during unilateral breast reconstruction is a good option for women with small breasts. In patients with adequate lower abdominal tissues, the deep inferior epigastric perforator (DIEP) flap is often the first choice for unilateral autologous breast reconstruction. We use Zone IV, which is usually excised owing to its insufficient blood circulation, as a superficial inferior epigastric artery (SIEA) flap for contralateral breast augmentation.MethodsBetween October 2004 and January 2016, 32 patients underwent unilateral breast reconstruction using a DIEP flap and an attempted simultaneous contralateral breast augmentation with an SIEA flap. The unilateral DIEP flap attached to the contralateral SIEA flap was split into two separate flaps after indocyanine green angiography. In all patients, ipsilateral internal mammary vessels were used as recipient vessels for DIEP flap breast reconstruction. The SIEA flap pedicle was anastomosed to several branches of the deep inferior epigastric vessels. The SIEA flap was inset beneath the contralateral breast through the midline.ResultsOf 32 patients, 27 underwent DIEP flap breast reconstruction and simultaneous unaffected breast augmentation using 25 SIEA or 2 superficial circumflex iliac artery perforator (SCIP) flaps. All DIEP flaps survived, and total necrosis occurred in one SIEA flap. The mean weight of the final inset for DIEP flap reconstruction and SIEA or SCIP flap augmentation was 416 g and 112 g, respectively.ConclusionsUnilateral DIEP flap breast reconstruction and contralateral SIEA flap breast augmentation may be safely performed with satisfactory results.     

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.     

Salvage of knee joint tumor prosthesis using turnover reverse-flow descending branch of lateral circumflex femoral artery as recipient vessel for the free ALT flap: a case report

To report an unusual case using free anterolateral thigh (ALT) fasciocutaneous flap to salvage a knee joint tumor prosthesis. The turnover reverse-flow descending branch of the ipsilateral lateral circumflex femoral artery (LCFA) was successfully used as a recipient vessel for the contralateral free ALT flap. A 30-year-old male patient with high-grade and fibroblastic-type osteogenic sarcoma at the right proximal tibia received a tumor resection and tumor prosthesis to salvage the right knee joint. No local antegrade recipient vessels were available near the defect at the right knee. No sizable perforator could be found when trying to harvest the reverse ipsilateral ALT flap. The turnover reverse-flow descending branch of the ipsilateral LCFA and its concomitant veins were used as recipient vessels to supply the contralateral free ALT flap. The flap survived well without obvious venous congestion or sequela. The turnover reverse-flow descending branch of the LCFA and its concomitant veins can be successfully used as recipient vessels to supply a free ALT flap.     

Chondrosarcoma of the chest wall: a clinical analysis

Purpose. To discuss the management of different histological types of chondrosarcoma (CS) in the chest wall based on our clinical experience. Methods. The subjects of this study were 16 patients with CS of the chest wall surgically treated by resection at our institute between September 1981 and August 2000. There were 11 men and 5 women ranging in age from 23 to 74 years. The median follow-up period was 54 months. The tumor was located only in the ribs in ten patients, in the sternum and ribs in three, only in the sternum in two, and in the ribs and spine in one. The surgical margins were wide in 12 patients and marginal in four. Reconstruction using Marlex mesh combined with moldable metal plates was carried out to prevent flail chest in nine patients, resection alone was performed in five patients, and a muscular flap was used in two patients. Results. The survival rate was 86% after a median follow-up period of 54 months. One operative death (6.2%) occurred, and another required temporary tracheostomy. There were no infections in this series. Oncological outcome was clinically related to surgical margins and recurrence. The postoperative respiratory function test result was 10% less than the preoperative one. Conclusion. This series demonstrated that wide resection is the treatment of choice for chest wall CS and that Marlex mesh combined with metallic mouldable plates is a reliable technique for reconstruction. Received: April 3, 2001 / Accepted: November 20, 2001     

Diaphragm reconstruction combined with thoraco-abdominal wall reconstruction after tumor resection

Background: Thoraco-abdominal wall resection including diaphragm resection results in a challenging surgical defect. Various methods have been used for diaphragm reconstruction. The aim of this study was to describe our methods of diaphragm and thoraco-abdominal wall reconstruction after combined resection of these anatomical structures.

Methods: Twenty-one patients underwent diaphragm resection at our institution between 1997 and 2015. We used a mesh or direct closure for diaphragm defect and a mesh for chest wall stabilization. A pedicled or free flap for soft tissue coverage was used when direct closure was not possible.

Results: Indications for resection were primary sarcoma (n?=?14), cancer metastasis (n?=?4), desmoid tumor (n?=?2), and solitary fibrous tumor (n?=?1). The median patient age was 58.9 years. The diaphragm was pulled to its original position and sutured directly (n?=?15) or reconstructed with mesh (n?=?6). Chest wall reconstructions were performed with a mesh (n?=?14), mesh and a pedicled flap (n?=?4), mesh and a free flap (n?=?3). No perioperative mortality occurred. One-year and 5-year survival rates were 85.7 and 65.9%, respectively, while overall recurrence-free rates were 80.4 and 60.8%, respectively.

Conclusions: We have described our surgical methods for the resection of tumors of the chest or abdominal wall, including our method of distal diaphragm resection with wide or clear surgical margins. The method is safe and the reconstructions provided adequate stability, as well as water-tight and air-tight closure of the chest cavity. There were no cases of paradoxical movement of the chest or of diaphragm or thoraco-abdominal hernia.     

A case report of chest wall reconstruction utilizing microvascular surgery

A 62-year-old man underwent left chest wall reconstruction after resection of the chest wall including 4-6th ribs for the metastatic tumor of squamous cell carcinoma of the left lung. The chest wall defect measuring 15 x 10 cm was reconstructed with double Marlex mesh in skeletal chest and covered with pedicled free mucocutaneous flap of tensor fasciae latae which was implanted by the vascular anastomoses to the thoracodorsal artery and vein using microvascular surgical technique. The flap was attached well and its blood supply was excellent on postoperative angiography.     

Flow-through anterolateral thigh flap for a free osteocutaneous fibula flap in secondary composite mandible reconstruction.

Head and neck reconstruction after tumour ablation and radiotherapy often requires complex surgery. The need for free composite tissue transfer and the poor quality of the recipient site increase the level of difficulty substantially. We report a case in which the mandible, floor of the mouth and skin of the neck needed to be reconstructed in a heavily irradiated field. A single osteocutaneous fibula flap was insufficient to reconstruct the defect, and a free anterolateral thigh (ALT) flap was also used for external neck skin resurfacing. As the recipient vessels in the ipsilateral neck had been heavily irradiated the free ALT flap was used as an interposition conduit for the free osteocutaneous fibula flap enabling it to reach the healthy recipient vessels in the contralateral neck without needing vein grafts.     

The transverse musculocutaneous gracilis flap for chest wall reconstruction in male patients with Poland's syndrome

Poland's syndrome represents a congenital unilateral deformity of the breast, chest wall, and upper limb with extremely variable manifestations. In most cases, the problem is mainly cosmetic, and the reconstruction of the chest wall should use a method designed to be performed easily and to achieve minimal scarring and donor site morbidity. We describe using a transverse musculocutaneous gracilis (TMG) flap for chest wall and anterior maxillary fold reconstruction in three male patients. In two patients, only the pectoralis major muscle was missing. In the third case, the ipsilateral latissimus dorsi muscle was also absent. The indication for surgical treatment was purely cosmetic. In all patients, a free TMG flap was performed to reconstruct the anterior axillary fold and the soft tissue defect. There was no flap loss, and all three patients had a clearly improved appearance of the chest wall. In this article, we demonstrate our experience with the use of a TMG flap for chest wall reconstruction in male patients with Poland's syndrome. © 2013 Wiley Periodicals, Inc. Microsurgery, 2013.     

胸三角皮瓣修复乳癌术后复发病灶及放射性溃疡

目的 探讨乳癌根治术后复发病灶及放射性溃疡的胸壁大块深度缺损修复方法.方法 采用对侧以第2、3肋间前胸穿支为血管蒂的岛状皮瓣修复乳癌根治术后局部复发病灶清除后缺损创面4例及放射性溃疡8例.结果 12例皮瓣全部成活,其中l例皮瓣远端表皮坏死经换药后痊愈.随访6个月～4年,伤口愈合稳定,外形恢复满意.结论 以第2、3肋间前胸穿支为血管蒂的岛状皮瓣是一期修复乳癌根治术后局部复发病灶的清除缺损创面及放射性溃疡简便易行的理想方法.     

Full-thickness chest wall resection for recurrence of breast malignancy

We present outcomes in 13 consecutive patients with solitary, local chest wall recurrence subsequent to mastectomy for breast malignancy who were operated on in 1983--2001. All patients underwent full-thickness chest wall resection (FTCWR) and immediate reconstruction. The mean chest wall defect area was 108 cm(2). The choice of reconstruction method was individualized. The reconstruction was accomplished with the patient's own tissues, in three cases supported by artificial mesh. Most commonly we used the contralateral breast or myocutaneous flap. We did not observe postoperative complications. The tissues used for the reconstruction provided sufficient stiffness of the rib cage. In all specimens the surgical margins were negative. The estimated 5-year survival after excision of recurrent tumor is 62%. FTCWR with immediate reconstruction with soft tissues should be considered in patients with local solitary recurrence after mastectomy for breast malignancy. This option offers good long-term results and minimal morbidity.