The omentum: its use as a free vascularized graft for reconstruction of the head and neck.

The experience at Emory University Affiliated Hospitals with transplantation of the greater omentum as a free revascularized graft in 18 patients is presented. In each instance, there was realization of the therapeutic objective, either 1) the amelioration of congenital or acquired somatic deformity (14 patients) or 2) the control of infection (4 patients). Because the omentum is a syncytium of blood vessels and a variable amount of fat within redundant leaves of peritoneal membrane laden with macrophages, it is a tissue that serves admirably its extended role as an extracelomic free transplant. The greater omentum has been used for this purpose in five patients with hemifacial atrophy (Romberg's disease); three patients with hemifacial microsomia (first and second branchial arch syndrome); two patients with extensive losses of the maxilla, palate, and face due to a shotgun blast; two patients with atrophy and facial growth arrest due to x-irradiation; and two patients with deformity of the jaw and neck following tumor resection. In three additional patients, the omentum was used to obliterate the dead space after debridement of an infected open frontal sinus following failure of conventional therapy. In one instance, a revascularized free graft of omentum was used to salvage a patient with an exposed irradiated carotid artery graft and skin flap failure following radical neck dissection. In these 18 patients, there were no intra-abdominal complications consequent to harvest of the omentum. In one patient afflicted with hemifacial atrophy, there was spotty necrosis of the overlying attenuated facial skin flap and limited fat necrosis. In the follow-up period of four months to seven years, there has been no instance of late resorption. The method is reliable and has considerable promise in reconstructive surgery.     

Prosthetic reconstruction of the chest wall

Chest wall reconstructions can be complex and challenging procedures, especially when huge thoracic defects have been generated by radical excisions. Nonrigid reconstructions with meshes or patches have the goal of avoiding a lung hernia caused by the chest wall defect, or preventing the impaction of the scapula in case of posterior chest wall resections, especially when the resection is extended down to the 5th and 6th ribs. Large anterior and lateral resections result in thoracic instability and alteration of pulmonary physiology, and render intrathoracic structures vulnerable to external impact. They necessitate rigid reconstructions according to several techniques using alloplastic materials (eg, methyl methacrylate-based customized plates or neo-ribs, osteosynthesis systems, or dedicated prosthesis). Nowadays, the availability of these multiple, possibly combined, more adapted, and better tolerated materials have pushed past the limits of resection to those involving soft tissue coverage.     

Indication of the use of pedicled omentum in chest surgery

The omentum has been known to have a remarkable power of repair through neovascularization and scavenger function. Nine patients have been treated with the pedicled omentum. In 4 patients the omentum was used to obtain healing in the presence of infection. Bronchial fistulas were successfully closed in 3 patients with lung cancer and bronchial anastomotic leakage was repaired in one patient who received carinal reconstruction. In 5 patients, all of them had simultaneous resection of thoracic esophagus, the preventive use of omentum made a good result in two tracheoplasties, one pneumonectomy and one terminal tracheostomy. But one patient with esophago-tracheofistula after irradiation to esophageal cancer developed tracheal necrosis postoperatively. The omentum is useful in the case of postoperative empyema with bronchial fistula especially in patient with lung cancer. In the case of tracheobronchial resection after radiation therapy or with resection of thoracic esophagus, the suture line should be wrapped by omentum to prevent anastomotic leakage.     

Reconstruction of chest wall chondrosarcoma with an anterolateral thigh free flap: An illustration of decision-making in chest wall reconstruction

INTRODUCTIONChondrosarcomas are the most common primary chest wall malignancy. The mainstay of treatment is radical resection, which often requires chest wall reconstruction. This presents numerous challenges and more extensive defects mandate the use of microvascular free flaps. Selecting the most appropriate flap is important to the outcome of the surgery.PRESENTATION OF CASEA 71-year-old male presented with a large chondrocarcoma of the chest wall. The planned resection excluded use of the ipsilateral and contralateral pectoralis major flap because of size and reach limitations. The latissimus dorsi flap was deemed inappropriate on logistical grounds as well as potential vascular compromise. The patient was too thin for reconstruction using an abdominal flap. Therefore, following radical tumour resection, the defect was reconstructed with a methyl methacrylate polypropylene mesh plate for chest wall stability and an anterolateral thigh free flap in a single-stage joint cardiothoracic and plastic surgical procedure. The flap was anastomosed to the contralateral internal mammary vessels as the ipsilateral mammary vessels had been resected.DISCUSSIONThe outcome was complete resection of the tumour, no significant impact on ventilation and acceptable cosmesis.CONCLUSIONThis case demonstrates the complex decision making process required in chest wall reconstruction and the versatility of the ALT free flap. The ALT free flap ensured adequate skin cover, subsequent bulk, provided an excellent operative position, produced little loss of donor site function, and provided an acceptable cosmetic result.     

Fetal tissue engineering: chest wall reconstruction

Background/Purpose: This study was aimed at applying fetal tissue engineering to chest wall reconstruction.Methods: Fetal lambs underwent harvest of elastic and hyaline cartilage specimens. Once expanded in vitro, fetal chondrocytes were seeded onto synthetic scaffolds, which then were placed in a bioreactor. After birth, fetal cartilage constructs (n = 10) were implanted in autologous fashion into the ribs of all lambs (n = 6) along with identical, but acellular scaffolds, as controls (n = 6). Engineered and acellular specimens were harvested for analysis at 4 to 12 weeks postimplantation. Standard histology and matrix-specific staining were performed both before implantation and after harvest on all constructs.Results: Regardless of the source of chondrocytes, all fetal constructs resembled hyaline cartilage, both grossly and histologically, in vitro. In vivo, engineered implants retained hyaline characteristics for up to 10 weeks after implantation but remodeled into fibrocartilage by 12 weeks postoperatively. Mononuclear inflammatory infiltrates surrounding residual PGA/PLLA polymer fibers were noted in all specimens but most prominently in the acellular controls.Conclusions: Engineered fetal cartilage can provide structural replacement for at least up to 10 weeks after autologous, postnatal implantation in the chest wall. Fetal tissue engineering may prove useful for the treatment of severe congenital chest wall defects at birth.     

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.     

The external dermo glandular mammary flap: an alternative technique for chest wall reconstruction

Chest wall reconstructions can be challenging procedures especially after large thoracic defects generated by cancer resections. We report a case of an anterior chest wall defect after a recurrent metaplastic carcinoma of the breast 7?years after the mastectomy. A partial sternectomy was carried out in conjunction with resection of the first four right ribs. Chest wall skeletal defects were reconstructed with polypropylene mesh folded in four under tension. Soft tissue reconstruction was performed with an external controlateral dermoglandular flap after a mammoplasty. The 12?×?38?cm flap remained on the external mammary vascularization and was tunneled to cover the defect. After follow-up, the patient remains disease-free with satisfactory quality of life. This new breast flap can expand the therapeutic arsenal to cover such chest wall defects offering, at the same time, a mammoplasty.     

The use of prosthetics in abdominal wall reconstruction

Large ventral or incisional hernias are often difficult to manage. Most commonly patients are referred to reconstructive surgeons after multiple failed attempts of hernia repair. The use of prosthetic and bioprosthetic materials have aided greatly in the management of complex abdominal wall defects. A full understanding of the advantages and disadvantages of specific prosthetic materials available, and the associated complications of use, remains elusive, however. This article provides information concerning the applications of appropriate prosthetic material for temporary or permanent closure of difficult abdominal wall defects.     

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.     

六例巨大胸壁缺损的修复

目的 探讨巨大胸壁缺损的修复方法.方法 2005年10月至2009年6月,为6例患者进行巨大胸壁缺损的修复,其中背阔肌肌皮瓣加钛网1例,逆行背阔肌肌皮瓣加聚丙烯网片和涤纶补片1例,游离股前外侧皮瓣1例,双侧胸大肌肌瓣1例,纵行腹直肌肌皮瓣2例.结果 随访1～24个月,皮瓣100%覆盖创面、皮瓣100%成活、心肺功能没有影响、外观满意;并发症:胸壁瘘管1例,胸壁窦道1例经再次清创愈合.结论 巨大胸壁缺损需要分层修复,胸廓缺损可以用鈦网或聚丙烯网片修补,软组织缺损根据部位、大小和范围及周围组织情况,选择不同的修复方法.背阔肌肌皮瓣组织量大、旋转弧度大、血供恒定、容易切取,可作为首选,胸大肌肌瓣、纵行腹直肌肌皮瓣或游离的股前外侧皮瓣,根据实际情况灵活掌握.     

Malignant mesenchymoma of the chest wall in an adult.

Mesenchymoma (hamartoma) of the chest wall is an extremely rare tumour presenting in early infancy or fetal life. Pleural, pulmonary, and lymph node metastases developed in a young man with malignant mesenchymoma of the chest wall. The tumour had several characteristics that differ from the mesenchymoma reported from the other parts of the body.     

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.     

External oblique muscle-cutaneous flap use of the in the reconstruction of large chest wall defects after mastectomy

The use of an external oblique muscle-cutaneous flap in the reconstruction of large chest wall defects after mastectomy is described. The flap is drown as a V-Y advancement-rotation flap, laterally based, on the ipsilateral abdominal wall. The flap extends from the posterior axillary line to the linea alba, vascular supply is provided by the musculo-cutaneous perforating arteries of the intercostal vessels. Mobilization starts medially including the anterior rectus sheath, décollement continues between the external and the internal oblique muscles as far as the posterior axillary line. The abdominal wall, after flap mobilization, is reinforced by the plication of the internal oblique sheath. The flap was used in 13 patients with major anterior chest-wall defects after mastectomy. In one patient a marginal skin necrosis of about 2 cm was observed. The flap described differs from other external oblique flaps already described in several technical innovations that allow to obtain better functional and esthetic results.     

Breast cancer invasion into the chest wall with resection and reconstruction.

Despite the advent of limited resections and radiation therapy in the treatment of breast cancer, a substantial number of women experience recurrence or persistent disease that invades the skin, soft tissues, and musculoskeletal layers of the chest wall. This problem, which can compromise local control of the tumor, can also involve pleura, lung tissue, and mediastinal structures. This article will cover some of the pertinent clinical decisions related to these lesions, their prognosis, and management by chest wall resection and reconstruction.     

带蒂大网膜移植在难治性胸壁结核外科治疗中的应用

目的探讨在难治性胸壁结核手术中带蒂大网膜移植的临床应用及其疗效。方法回顾性分析2008年3月至2009年6月9例难治性胸壁结核患者临床资料,复发6例,巨大病灶3例。采用带蒂大网膜移植填塞残腔并缝合固定,术后持续绷带加压包扎2个月;随访9个月至2年。结果所有患者都一次手术治愈,术后继续抗结核治疗6—12个月,随访无一例复发。结论带蒂大网膜移植用于难治性胸壁结核患者的胸壁重建效果良好,可预防胸壁结核的复发。