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.     

Chest wall reconstruction using a turbocharged chimaeric anterolateral thigh flap.

Extremely large chest wall defects may result following salvage oncological surgery. Typically these defects involve a large skin defect combined with a variable resected area of underlying muscle and ribs. In situations where the skin defect is very large the use of a large latissimus dorsi flap may require skin grafting to the donor site if a myocutaneous flap is used or to the recipient defect if a muscle-only flap is used. Alternatively a transverse rectus abdominis flap is a second option but in certain cases this may not be available. We describe the use of a free anterolateral thigh flap to reconstruct a chest wall defect and demonstrate the principle of side-to-side stacking of separate skin paddles to achieve skin closure of a massive defect whilst permitting primary closure of the donor site. The principle of turbocharging components of a chimaeric flap is also described.     

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.     

A Compound Pectoral Flap

The principle of including an underlying skeletal muscle in the design of a large skin flap, to assure a safer blood supply during transfer, has been applied to the chest wall. Pectoralis major is included in a chest flap used for the repair of a large defect of all layers of the anterior chest wall, including the medial ends of the clavicles and upper two ribs and the manubrium sterni.     

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.     

Multiple primary chest wall hydatid cysts associated with spinal canal involvement

Primary multiple chest wall hydatid cysts associated with spinal canal involvement through an intervertebral foramen is an uncommon clinical entity. We present a 54-year-old man who underwent cystotomy and total resection of ribs five through seven via a left posterolateral thoracotomy followed by Th5-Th6 anterolateral partial pediculotomies for removal of cysts in the spinal canal. Although spinal reconstruction was not required, the chest wall defect was repaired with mersilene mesh-methyl methacrylate sandwich graft. Hydatid disease should be considered in the differential diagnosis of mass lesions located in the chest wall. In cases of spinal canal involvement, detailed visualization of spinal canal utilizing MRI and/or CT is essential for planning surgical approach.     

Chondromyxoid fibroma of the chest wall in an infant

Chondromyxoid fibroma of the chest wall in a 3-month-old boy was described. The patient was presented with respiratory distress, and a large calcified mass of the left lung field was seen on the chest roentgenogram. Treatment consisted of excision on the tumor with removal of 5th to 8th ribs. There is no evidence of recurrence during the two years folow-up.     

Large Chest Wall Reconstruction Using a Pedicled Osteomuscle Composite Flap: Report of a Case

A 67-year-old man with diabetes mellitus and chronic renal failure underwent resection of a grade 1 chondrosarcoma. We performed chest wall reconstruction of the massive defect, using a pedicled osteomuscle composite flap comprising the 6th, 8th, and 10th ribs, and the latissimus dorsi and serratus anterior muscles. This flap is ready to mobilize as a pedicled graft to cover a large chest wall defect; it is strong enough to buttress the chest cage without the need for artificial materials, and it is associated with a lower risk of infection than prosthetic materials.     

Pedicled full‐thickness abdominal flap combined with skin grafting for the reconstruction of anterior chest wall defect following major electrical burn

Successful reconstruction of extensive anterior chest wall defect following major electrical burn represents a very challenging surgery. Herein we report the first case using pedicled full‐thickness abdominal flap combined with skin grafting to treat this injury with severe infection and exposure of pericardium and ribs in a Chinese patient. Following the performance of chest debridement to remove necrotic and infected tissues and the injection of broad‐spectrum antibiotics to reduce infection, a pedicled full‐thickness abdominal flap was used to cover the exposed pericardium and ribs, and skin grafting from the right leg of the patient was done to cover the exposed vital tissues. The patient was followed up for a total of 3·5 years, and satisfactory cosmetic and functional outcomes were obtained without complications. This report provides an effective method for the surgeons who encounter similar cases where reconstruction of extensive anterior chest wall is required.     

A method for reconstruction of large full-thickness defects of the bony thorax

Wide resection in 12 cases of malignant or potentially malignant lesions of the chest wall resulted in full-thickness loss of skeleton and frequently of overlying soft tissues (defect greater than or equal to 15 cm in its smallest diameter or at least 90% of the sternum resected). In reconstruction of the defect, steel bars were used to replace lost ribs and a double layer of Marlex mesh for intercostal spaces. Soft-tissue coverage and primary closure were accomplished with current plastic surgical procedures and good stability of the chest wall was achieved. Protracted respiratory support was required in only one case. Postoperative pain was managed with epidural anesthesia and routine analgesics. Functionally and cosmetically satisfactory long-term results were obtained, with no infection and no need for removal of prosthetic material. The overall 5-year and 10-year actuarial survival rates were 60% and 37.5%. If lesions are radically resectable, the extent of thoracic wall resection need not be restricted because of inability to close the defects.     

Large Chest Wall Reconstruction Using Titanium Micromesh and a Pedicled Latissimus Dorsi Musculocutaneous Flap: Report of a Case

The patient was a 54-year-old woman with a dermatopleural fistula and necrosis of the third to the fifth anterior ribs after postoperative adjuvant radiation for right breast cancer. After resection of the chest wall and combined partial resection of the right upper and middle lobes of the lung, the thoracic cage defect was stabilized by titanium micromesh and the soft tissue defect was covered by an ipsilateral pedicled latissimus dorsi musculocutaneous flap. The dorsal skin defect was covered by split-thickness skin grafts 3 weeks later. The advantages of titanium micromesh lie not only in its good biocompatibility and mechanical strength, but also in its light weight and low radiological interference. No paradoxical movement or other prosthesis-related complications occurred during the follow-up period. Thus, we consider that titanium micromesh is a suitable material to use in the reconstruction of a large chest wall defect.     

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.     

Using the costal muscle flap with latissimus dorsi muscle to repair full-thickness anterior chest wall defects

Musculoosseous flaps with latissimus dorsi muscle are used for reconstruction of full-thickness anterior chest wall defects. The 11th and 12th ribs and the posterior parietal pleura are elevated with the latissimus dorsi muscle. The blood supply of the compound flap comes from the thoracodorsal pedicle and from perforating segmental vessels. The posterior thoracic wall island is transferred to the anterior chest wall defect to restore a skeletal plane and the transposed latissimus dorsi obliterates all the dead spaces that cannot be collapsed. The latissimus dorsi compound flap with the 11th and 12th ribs appears to be a "safe" procedure to reconstruct full-thickness anterior chest wall defects.     

Combined free vascularized iliac osteocutaneous flap and pedicled pectoralis major myocutaneous flap for reconstruction of anterior chest wall full-thickness defect

Large defects of the anterior chest wall lead to gross chest instability that can result in paradoxic respiration. Osteoradionecrosis of the lower sternum and multiple left ribs resulted in a huge, full-thickness defect of the left anterior chest wall in a 67-year-old woman. An iliac osteocutaneous flap (bone segment 3 × 14 cm) was harvested for reconstruction of the bone defect. The skin defect was covered by the skin paddle of the iliac osteocutaneous flap and a contralateral rotational pectoralis major muscle flap. Months postoperatively, the patient was physically active, the chest was stable, and the vascularized iliac bone was incorporated into the recipient bone.     

Progressive scoliosis following chest wall resection in children

The effect of partial chest wall resection on subsequent production of spinal deformity was studied in six pediatric patients. The following observations are made: Scoliosis secondary to chest wall resection in the pediatric age group is progressive. The degree of curvature is related to the number of ribs resected. Anterior resection of ribs does not produce significant scoliosis, whereas resection of the posterior aspect of the ribs promptly produces scoliosis. Scoliosis associated with marked pleural thickening secondary to recurrent tumor, irradiation scarring, and underlying pulmonary metastases is always convex toward the normal side. Scoliosis associated with empyema and chest wall osteomyelitis is likewise convex toward the normal side and may respond to removal of this thether in the growing child.     

Chest wall resection and reconstruction: a case series of 20 patients in Hospital Kuala Lumpur,Malaysia

Chest wall resection is defined as partial or full-thickness removal of the chest wall. Significant morbidity has been recorded, with documented respiratory failure as high as 27%. Medical records of all patients who had undergone chest wall resection and reconstruction were reviewed. Patients’ demographics, length of surgery, reconstruction method, size of tumor and chest wall defect, histopathological result, complications, duration of post-operative antibiotics, and hospital stay were assessed. From 1 April 2017 to 30 April 2019, a total of 20 patients underwent chest wall reconstructive surgery. The median age was 57 years, with 12 females and 8 males. Fourteen patients (70%) had malignant disease and 6 patients (30%) had benign disease. Nine patients underwent rigid reconstruction (titanium mesh for sternum and titanium plates for ribs), 6 patients had non-rigid reconstruction (with polypropylene or composite mesh), and 5 patients had primary closure. Nine patients (45%) required closure with myocutaneous flap. Complications were noted in 70% of patients. Patients who underwent primary closure had minor complications. In total, 66.7% of patients who had closure with either fasciocutaneous or myocutaneous flaps had threatened flap necrosis. Two patients developed pneumonia and 3 patients (15%) had respiratory failure requiring tracheostomy and prolonged ventilation. There was 1 mortality (5%) in this series. In conclusion, chest wall resections involving large defects require prudent clinical judgment and multidisciplinary assessments in determining the choice of chest wall reconstruction to improve outcomes.     

Giant chondromas arising from the ribs. A report of four cases.

Chondromas may arise from the ribs but seldom grow to giant size. In a series of twenty-one cases, four giant tumours were encountered. Three were treated by excision without leaving a significant defect of the chest wall or impairment of respiration; the fourth was examined by biopsy. No evidence of malignant change was discovered in these four large tumours.     

Resection of chondrosarcoma of anterior chest wall with pleural dissemination

A 52-year-old woman admitted with difficulty of breathing and had an anterior chest wall tumor. Primary lesion of the chest wall tumor invading the inferior one third of sternum, right third to sixth ribs, a part of the right middle lobe, the pericardium and a part of the diaphragma and small nodules on the parietal pleura were resected, and a diagnosis of chondrosarcoma of the right fifth or sixth rib and pleural dissemination of the tumor was established. The defect of pericardium was repaired with artificial dura mater and the defect of bony chest wall was repaired with a double layer of Marlex mesh. Although the resection was palliative because of pleural dissemination, she is now working as a housewife without difficulty of breathing.     

Repair of large chest wall defects using pedicle flaps

Three cases of chest wall resection illustrate the use of three different full thickness pedicle flaps which can be used to cover almost any area of the anterior chest wall. The medially based acromiothoracic flap was swung inferiorly to cover a lateral defect. Laterally based abdominal wall and axillary flaps were used to cover more medial defects. In case III bilateral axillary flaps were necessary to cover a huge central defect after resection of the anterior sternum and anterior cartilages of seven ribs for a sebaceous carcinoma.     

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.