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.     

Dedifferentiated chondrosarcoma of the chest wall: reconstruction with polypropylene mesh using a transverse rectus abdominis myocutaneous flap

We report a case of dedifferentiated chondrosarcoma of the chest wall. After resection, the chest wall defect was reconstructed using polypropylene mesh and a transverse rectus abdominis myocutaneous flap. A 61-year-old woman presented with a 16-year history of a slow-growing mass underneath the right chest wall. After percutaneous biopsy, preoperative cytopathological examination of the large mass revealed dedifferentiated chondrosarcoma. The tumor was resected with a wide margin along with the chest wall including skin, the right seventh to tenth ribs, and part of the diaphragm. The chest wall defect was reconstructed with a polypropylene (Marlex) mesh sheet followed by a left-side transverse rectus abdominis myocutaneous flap.     

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.     

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 。     

Comparison of aesthetic breast reconstruction after skin-sparing or conventional mastectomy in patients receiving preoperative radiation therapy

Many options exist for the surgical treatment of breast cancer in terms of tumor extirpation and reconstruction. Skin-sparing mastectomy (SSM) with immediate reconstruction offers patients a superior result, but this can be jeopardized by preoperative radiotherapy. We compared the outcomes of reconstruction after SSM or conventional mastectomy (CM) in the previously irradiated breast.We evaluated 41 patients over an 8-year period, who were divided into 3 categories: preoperative radiotherapy prior to SSM (n = 8), CM after preoperative radiation therapy (n = 9), and no chest wall irradiation prior to SSM (n = 20). The first group demonstrated significantly higher frequency of native flap compromise and capsular contracture formation than the other 2 groups.SSM with TRAM or latissimus with implant reconstruction is an esthetically optimal option for the treatment of patients without previous radiotherapy. However, for patients with preoperative chest wall radiation, TRAM flap reconstruction was superior to latissimus flap with implant after SSM.     

Chest wall reconstruction using a free rectus abdominis myocutaneous flap in a case of recurrence after bilateral breast cancer surgery

A 64 years old woman with anterior chest wall recurrence after bilateral mastectomy for breast cancer was treated by the resection of chest wall in full thickness involving the whole sternum and the anterior part of ribs except the first rib. The thoracic cage was reconstructed using a free rectus abdominis myocutaneous flap which was placed over Marlex mesh covering the defect of chest wall. By means of surgical microscope, inferior epigastric artery and vein of the graft were anastomosed with internal thoracic artery and vein at the neck, respectively. Postoperative course was uneventful and the patient is alive and well for one year after the surgery. A free myocutaneous flap method provides enough volume of soft tissue for coverage of a large defect and chest wall stability.     

Resection of a metastatic sternal carcinoma and reconstruction of the chest wall: a case report

A large metastatic squamous carcinoma of the anterior chest wall was managed by en-bloc resection of the thoracic wall. The extensive defect resulting from the resection was bridged with Marlex mesh superimposed on an omental flap that served as recipient to partial-thickness skin grafts. This composite reconstruction restored an efficient bellows action to the chest cage, manifested by the lack of anterior flailing and postoperative spirometry values, measured at the bedside, that were 75% of those obtained preoperatively. During the initial postoperative period, however, mechanical ventilatory assistance was required to treat an adult respiratory distress syndrome that together with mild anterior flailing made early extubation impossible.     

Sternal resection for metastasis from thyroid carcinoma and reconstruction with the sandwiched marlex and stainless steel mesh

A case of 69-year-old woman with a solitary sternal bone metastasis from thyroid carcinoma undergoing surgical therapy was reported here. On admission, most part of the body of the sternum was destroyed by tumor. Subtotal sternectomy was performed and a part of the major pectoral muscles adherent to the sternal tumor was also resected. The chest wall defect was reconstructed with a sandwiched Marlex and stainless steel mesh. Pathological examination of the resected specimen revealed metastatic papillary carcinoma of the thyroid. Her postoperative course was uneventful. The reconstruction with Marlex and stainless steel mesh seemed to be an appropriate procedure to prevent paradoxical movement of the thorax and protect the intrathoracic organs. Stainless steel mesh compensated for limited resiliency of Marlex mesh and remained rigid in all directions.     

Resection of Sternal Metastasis from Endometrial Carcinoma Followed by Reconstruction with Sandwiched Marlex and Stainless Steel Mesh: Report of a Case

We report the successful resection of sternal metastasis from endometrial carcinoma, followed by reconstruction of the chest defect, in an 87-year-old woman. We performed subtotal sternectomy and concurrent resection of the ribs and overlying soft tissue. The skeletal defect was then reconstructed with sandwiched Marlex and stainless steel mesh, and soft tissue coverage was accomplished by using a pectoralis major advancement flap. The patient had an uneventful postoperative course with no sign of recurrence during 5 years of follow-up. Thus, reconstruction with Marlex and stainless steel mesh could be an effective technique for preventing paradoxical movement of the thorax and protecting the intrathoracic organs.     

Reconstruction of anterior chest wall defect with ceramic bone grafts--a case of localized malignant mesothelioma

The reconstruction of an anterior chest wall defect was performed on a 61-year-old male after resecting a localized malignant mesothelioma. The tumor was resected with body of the sternum, the anterior portion of the bilateral second, third and fourth ribs, muscles, subcutaneous tissue and skin. The defect was 12.5 cm x 9.5 cm in size. The reconstruction of the defect was made with Marlex mesh, two ceramic bone grafts and a latissimus dorsi musculocutaneous flap. Double Marlex mesh was sewn under the edges of the ribs and the intercostal muscles of the defect by interrupted sutures. In order to fit the ceramic bone graft to the defect transversely, two pieces of ceramic bones (Iliac crest spacers) were selected from various sizes. They were connected by a stainless steel wire through the holes which were originally made at the edge for fixation, and the connected portion was covered with methyl methacrylate. Two ceramic bone grafts were fixed to each of the stumps of the bilateral third and fourth ribs by monofilament threads. A musculocutaneous pedicle flap made from the right latissimus dorsi covered the operative filed. There were no postoperative wound infection and no extrusion of the prostheses seven months after the operation.     

Thoracoplasty with marlex mesh following total resection of sternum: a case of chondrosarcoma of sternum.

Removal of the whole sternum for malignant tumor results in a large defect, causing a severe deformity and possible paradoxial movement of the chest wall. Many of thoracoplasty cases after total sternectomy require considerably complicated invasion. Recently, we performed on a patient with chondrosarcoma of the sternum total resection of the sternum including bilateral costal cartilage followed by thoracic reconstruction with polyethylene hard mesh (heavy Marlex mesh). In the present paper, we make a report of the case of thoracoplasty reliable to perform which has produced immediate chest wall stability without postoperative thoracic deformation. Postoperative CT confirmed that the mesh is well infiltrated with fibrous granulation tissue which connected chest muscle. Impairment of respiratory function after the operation is not observed.     

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.     

Surgical treatment of sternal metastases from thyroid carcinoma: report of two cases

Radioiodine therapy is currently the treatment of choice for metastasizing differentiated thyroid cancer (DTC); however, skeletal metastases are resistant to this form of therapy. The surgical removal of distant metastases from DTC offers the best chance for prolonged survival and improved quality of life. Furthermore, the surgical removal of a resectable skeletal metastasis can be a valuable complement to radioiodine therapy. This report describes two cases of sternal metastases from thyroid carcinoma that were managed successfully by surgery involving partial excision of the sternum followed by reconstruction of the chest wall with Marlex mesh. Both patients recovered uneventfully. Sternal resection with Marlex mesh reconstruction of the chest wall defect proved a simple and effective method for managing sternal metastasis. Thus, the surgical resection of distant bony metastases in patients with DTC is recommended as it can be curative, provide symptomatic palliation, or allow for more effective radioiodine treatment. Received: July 3, 2000 / Accepted: March 6, 2001     

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.     

Assessment of the abdominal wall function after pedicled TRAM flap surgery for breast reconstruction: Use of modified mesh repair for the donor defect

Background:

The pedicled TRAM flap has been a workhorse of autologous breast reconstruction for decades. However, there has been a rising concern about the abdominal wall donor site morbidity with the use of conventional TRAM flap. This has generally been cited as one of the main reasons for resorting to “abdominal wall friendly” techniques. This study has been undertaken to assess the abdominal wall function in patients with pedicled TRAM flap breast reconstruction. The entire width of the muscle and the overlying wide disk of anterior rectus sheath were harvested with the TRAM flap in all our patients and the anterior rectus sheath defect was repaired by a Proline mesh.

Materials and Methods:

Abdominal wall function was studied in 21 patients who underwent simultaneous primary unipedicled TRAM flap reconstruction after mastectomy for cancer. In all the patients, the abdominal wall defect was repaired using wide sheet of Proline mesh both as inlay and onlay. The assessment tools included straight and rotational curl ups and a subjective questionnaire. The abdominal wall was also examined for any asymmetry, bulge, or hernia. The minimal follow-up was 6 months postoperative. The objective results were compared with normal unoperated volunteers.

Results and Conclusions:

The harvesting the TRAM flap certainly results in changes to the anterior abdominal wall that can express themselves to a variable degree. A relatively high incidence of asymptomatic asymmetry of the abdomen was seen. There was total absence of hernia in our series even after a mean follow-up period of 15.5 months. A few patients were only able to partially initiate the sit up movement and suffered an important loss of strength. In most patients, synergists took over the functional movement but as the load increased, flexion and rotation performances decreased. The lack of correlation between exercise tests and the results of the questionnaire suggests that this statistically significant impairment was functionally not important. The patients encountered little or no difficulty in theis day-to-day activities. Our modification of use of a wide mesh as inlay and onlay repair minimizes the donor site morbidity. This also avoids maneuvers meant for primary closure of the rectus sheath defects, which can result in distortion of umbilicus. Therefore, in conclusion, the unipedicled TRAM flap should be regarded as a valuable option in breast reconstruction provided careful repair of the abdominal wall defect is undertaken using Proline mesh.     

Complete chest wall reconstruction after en bloc excisions with Gore-Tex/Marlex/Flap sandwich. A retrospective study of 14 cases

To assess the results of surgical resection and chest wall reconstruction we reviewed our experience with the complete chest wall reconstruction after en bloc excisions according to an original algorithm based on the location of the thoracic defect. The 14 reconstructions were performed by the senior author. We found 5 central, 6 lateral and 3 borders locations. In the central locations with a total resection of the sternum the reconstruction was realized by Gore-tex's mesh in depth, metal hooks (staples) and Marlex's mesh under a musculocutaneous flap of coverage. In case of lateral location the reconstruction was realized by Gore-tex's mesh covered with a musculocutaneous flap, the borders locations were reconstructed by Marlex's mesh and flap of coverage. The histological diagnoses were: one desmoid tumor, eight sarcomas, a recurrence of hepatocarcinoma and four recurrences of breast cancer. The superficial coverage performed by latissimus dorsis flap 12 for cases and rectus abdominis flap for two cases. All the patients were able to produce a spontaneous breath after surgery. Two deaths at distance and an infection were to regret. On the whole the algorithm of reconstruction according to the location of the defect allows a simplification of the indications.     

Versatility of the turn-around technique of the lateral arm flap for hand reconstruction

Reestablishing anterior rectus fascial integrity remains a clinical challenge after transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. The main concerns include herniation and bulging due to abdominal weakness. Mesh-assisted closure of the fascial defect has improved bulging and herniation rates but infection, extrusion, and encapsulation are serious concerns with mesh use. Biologic tissue matrices may overcome some of these mesh-related complications. The initial experience of using Strattice for fascial closure after TRAM flap procedure is described in this article. Strattice was in-lain and sutured between the anterior and posterior layers of the rectus fascia, at the rectus muscle donor site. The abdominal wall was closed with progressive tension sutures. Postoperative complications at the donor site were assessed. A total of 16 unilateral and 9 bilateral reconstructions were performed in 25 patients. Length of hospital stay was 2 to 3 days which is shorter than with mesh repair (typically 4-5 days). During a mean follow-up period of 14.0 months, complications occurred in 7 patients (28%): seroma formation (2), minor skin separation (2), superficial skin infection (2), and superficial wound dehiscence (1). Complications were not directly related to Strattice and all, except one (superficial skin infection), were resolved without surgical intervention. In all patients, routine abdominal functions were restored 4 months postoperatively. Strattice is a safe, alternative option to synthetic mesh for fascial repair following TRAM flap breast reconstruction. When used in conjunction with progressive tension suture closure of the abdominal wall, dynamic reconstruction of the abdominal wall with resumption of abdominal function is possible with Strattice.     

Completely wide resection of malignant fibrous histiocytoma of the chest wall; expect for long survival.

Malignant fibrous histiocytoma (MFH) rarely occurs in the chest wall. A case of MFH originating from the chest wall is herein reported. We performed radical en-block resection of the whole chest wall together with the tumor and reconstructed it with Marlex mesh. There was no recurrence 4 years after operation. We consider radical en-block resection for MFH and reconstruction with Marlex mesh a safe operation and may provide a long-term survival.     

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.