Chest Wall Reconstruction Without Prosthetic Material

Suture fixation of traumatic rib fracture flail segment with Klebsiella osteomyelitis

We report the case of a 71-year-old male who initially presented with urosepsis and was found to have a rib fracture of his right 6th rib with a flail segment and an associated abscess. Given the concern for infection, surgical rib fixation with titanium plating was not pursued during the washout of his abscess and instead, he successfully underwent rib fracture stabilization with bilateral suture transfixation. He was continued on a prolonged course of antibiotics for Klebsiella pneumonia osteomyelitis and was discharged uneventfully with optimal pain control and adequate respiratory effort.

New perspectives in prosthetic reconstruction in chest wall resection

The extension of chest wall resection for the treatment of primary and secondary tumours is still widely debated. The reconstructive strategy after extensive surgery is challenging as well as chest wall demolition itself. Reconstructive surgery aims to avoid respiratory failure and to guarantee intra-thoracic organs protection. The purpose of this review is to analyse the literature on this issue focusing on the planning strategy for chest wall reconstruction. This is a narrative review, reporting data from the most interesting studies on chest wall demolition and reconstruction. Representative surgical series on chest wall thoracic surgery were selected and described. We focused to identify the best reconstructive strategies analyzing employed materials, techniques of reconstruction, morbidity and mortality. Nowadays the new "bio-mimetic" materials in "rigid" and "non-rigid" chest wall systems reconstructive represent new horizons for the treatment of challenging thoracic diseases. Further prospective studies are warranted to identify new materials enhancing thoracic function after major thoracic excisions.

Repair of Large-Scale Rib Defects Based on Steel-Reinforced Concrete-Designed Biomimetic 3D-Printed Scaffolds with Bone-Mineralized Microenvironments

Tissue engineering technology provides a promising approach for large-scale bone reconstruction in cases of extensive chest wall defects. However, previous studies did not consider meticulous scaffold design specific to large-scale rib regeneration in terms of three-dimensional (3D) shape, proper porous structures, enough mechanical strength, and osteogenic microenvironments. Thus, there is an urgent need to develop an appropriate bone biomimetic scaffold (BBS) to address this problem. In this study, a BBS with controllable 3D morphology, appropriate mechanical properties, good biocompatibility and biodegradability, porous structure suitable for cell loading, and a biomimetic osteogenic inorganic salt (OIS) microenvironment was successfully prepared by integrating computer-aided design, 3D-printing, cast-molding, and freeze-drying technologies. The addition of the OIS in the scaffold substantially promoted ectopic bone regeneration in vivo, which might be attributed to the activation of osteogenic and angiogenic signaling pathways as well as upregulated expression of osteogenic genes. More importantly, dual long rib defects could be successfully repaired and medullary cavity recanalized by the rib-shaped mature cortical bone, which might be mediated by the activation of osteoclast signaling pathways. Thus, this paper presents a reliable BBS and proposes a new strategy for the repair of large-scale bone defects.

Horse-Shoe Flap Reconstruction Technique in Breast Surgery: From The Smallest Defect to The Biggest—A Case Series

Chest wall resections and reconstructions are routinely performed to close defects after primary breast tumor resections. Depending on the size of primary breast tumors, the reconstructive technique requires more challenging approaches. In this study, we would like to introduce a novel technique which can be applied as a method in covering various sizes of skin defects after mastectomy termed as “horse-shoe flap technique.” We conducted a series of case reports of patients who underwent chest wall coverage after primary breast tumor resections between October 2018 and November 2019 and selected five cases of breast cancer patients. These patients were treated with the horse-shoe flap technique which relies on shape as its main concept. All chest defects must form a circular shape, based on the principle that adequate safe tumor margins are best achieved with a circular incision. The donor flap was drawn and taken from the outer circle area with a larger arc, depending on the defect's diameter size. Five post-mastectomy chest wall defect cases had been successfully closed with this technique. Patients were all female, ranging from 36 to 55 years of age. The smallest chest defect was 4 cm in diameter, and the largest was 26 cm. All the defects were closed using a 120-degree horse-shoe flap design. One patient experienced marginal necrotic skin, and one case had formed postoperative seroma. The horse-shoe flap technique proves to be an excellent option for closing chest skin defects which can be applied for various sizes of skin defects with minor complications.

The Best of Chest Wall Reconstruction: Principles and Clinical Application for Complex Oncologic and Sternal Defects

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Appraise and evaluate risk factors for respiratory compromise following oncologic resection. 2. Outline and apply an algorithmic approach to reconstruction of the chest wall based on defect composition, size, and characteristics of surrounding tissue. 3. Recognize and evaluate indications for and types of skeletal stabilization of the chest wall. 4. Critically consider, compare, and select pedicled and free flaps for chest wall reconstruction that do not impair residual respiratory function or skeletal stability.

SUMMARY

Chest wall reconstruction restores respiratory function, provides protection for underlying viscera, and supports the shoulder girdle. Common indications for chest wall reconstruction include neoplasms, trauma, infectious processes, and congenital defects. Loss of chest wall integrity can result in respiratory and cardiac compromise and upper extremity instability. Advances in reconstructive techniques have expanded the resectability of large complex oncologic tumors by safely and reliably restoring chest wall integrity in an immediate fashion with minimal or no secondary deficits. The purpose of this article is to provide the reader with current evidenced-based knowledge to optimize care of patients requiring chest wall reconstruction. This article discusses the evaluation and management of oncologic chest wall defects, reviews controversial considerations in chest wall reconstruction, and provides an algorithm for the reconstruction of complex chest wall defects. Respiratory preservation, semirigid stabilization, and longevity are key when reconstructing chest wall defects.

Evaluation of Clinical Performance of TiNi-Based Implants Used in Chest Wall Repair after Resection for Malignant Tumors

In this study, we assessed the outcomes after surgical treatment of thoracic post-excision defects in 15 patients, using TiNi knitted surgical meshes and customized artificial TiNi-based ribs. Methods: Eight patients were diagnosed with advanced non-small cell lung cancer (NSCLC) invading the chest wall, of which five patients were T₃N₀M₀, two were T₃N₁M₀, and one was T₃N₂M₀. Squamous cell carcinoma was identified in three of these patients and adenocarcinoma in five. In two cases, chest wall resection and repair were performed for metastases of kidney cancer after radical nephrectomy. Three-dimensional CT reconstruction and X-ray scans were used to plan the surgery and customize the reinforcing TiNi-based implants. All patients received TiNi-based devices and were prospectively followed for a few years. Results: So far, there have been no lethal outcomes, and all implanted devices were consistent in follow-up examinations. Immediate complications were noted in three cases (ejection of air through the pleural drains, paroxysm of atrial fibrillation, and pleuritis), which were conservatively managed. In the long term, no complications, aftereffects, or instability of the thoracic cage were observed. Conclusion: TiNi-based devices used for extensive thoracic lesion repair in this context are promising and reliable biomaterials that demonstrate good functional, clinical, and cosmetic outcomes.

Thoracic Wall Reconstruction: Surgical Planning in Extended Malignant Resections

INTRODUCTION

The reconstruction of defects in thoracic wall remains a challenge for plastic surgeons. Advances in surgical treatment of illnesses of thoracic wall have been fostering the treatment of lesions within more advanced levels. Consequently, larger and more complex defects are generated, demanding soft tissue covering and framework repair.

OBJECTIVE

The aim of this study was to report the experience in chest wall reconstruction and demographics of a tertiary cancer center.

METHODS

All patients submitted to thoracic wall reconstruction by the plastic surgery department from January 2012 to May 2018 in a tertiary cancer center were evaluated.

RESULTS

Thirty-two patients have undergone thoracic wall reconstruction. The majority of patients in our series were submitted to surgical treatment of locally advanced breast cancer (84.3%). The most common defect location was the right anterolateral region (65.6%). The latissimus dorsi musculocutaneous flap was the most used in thoracic wall reconstructions. Three cases of thoracectomy with rib resection were reconstructed with methylmethacrylate and polypropylene surgical mesh associated with musculocutaneous flap. Four patients presented major complications, and 12 patients (37.5%) presented minor complications. There were no deaths related to procedures or instability of thoracic wall. Twenty-two patients presented progression of the disease, and 16 died due to the primary pathology.

CONCLUSIONS

Extended resection of the chest wall is associated in most cases with advanced disease, especially advanced breast cancer. Despite poor prognosis associated to locally advanced disease, it is imperative to perform chest wall reconstruction and allow the patient to continue adjuvant therapy (radiotherapy or chemotherapy) and improve quality of life.

Surgical Management of Chest Wall Sarcoma

Chest wall sarcoma is a rare and challenging pathology best managed by a multidisciplinary team experienced in the management of a multiple different pathologies. Knowledge of the management sequence is important for each sarcoma type in order to provide optimal treatment. Surgical resection of chest wall resections remains the primary treatment of disease isolated to the chest wall. Optimal margins of resection and reconstruction techniques have yet to be determined.

Management of chest impalement injury

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Impalement injuries are a challenging scenario involving several specialities.

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Surgeons were forced to operate in an even circumstances, not being able to turn the patient in a lateral position.

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The double thoracotomy and the expedient of the haemostatic plug allowed to control bleeding with absolute safety margins.

Presentation of case

We will describe the case of a man who impaled himself on a greenhouse pole by falling off a ladder.

Discussion

The belated radiological exclusion of any spine and neck lesions forced the surgeons to operate with the patient supine and on a spine board, which prevented them from performing the classic thoracotomy and reaching the entry hole in the right scapula area.

Conclusion

A double thoracotomy and the expedient of a haemostatic plug, positioned simultaneously with the extraction of the pole, allowed to control bleeding with absolute safety margins.

Combined bipedicled latissimus dorsi and groin flap for anterior chest wall reconstruction

We provide a case report of reconstruction of a massive chest wall defect after recurrent phyllodes tumour resections. The reconstruction used a bipedicled groin and latissimus dorsi flap, with composite rib autologous reconstruction. The patient successfully recovered from the operation. Our case illustrates the applicability of this flap in the armamentarium of anterior chest wall reconstructive options.

Treatment of open chest rib fractures with the matrix rib internal fixation system: A case report

RATIONALE

Rib fractures are common among patients with blunt chest wall trauma and often represent life-altering injuries.

PATIENT CONCERNS

A 31-year-old woman presented with right chest trauma, with pain and bleeding as a result of a traffic accident 1 hour previously.

DIAGNOSES

Chest computed tomography showed open chest trauma, multiple rib fractures, flail chest, hemopneumothorax, and lung contusion on the right side.

INTERVENTIONS

We decided to perform debridement via emergency, thoracoscopic exploration to remove blood and contaminants from the chest cavity. Thereafter, the third to seventh fractured ribs were fixed and reconstructed using the matrix rib internal fixation system, followed by suturing of the incision according to the original anatomical level.

OUTCOMES

The patient was discharged 15 days after surgery, and recovered well with satisfactory results.

LESSONS

We believe that initial chest reconstruction with internal fixation in the first stage following thorough debridement may be suitable for treating flail chest, and could save the patient's life in the early stages. However, the decision to perform the first-stage operation for the open contaminated wound should be carefully considered.

Chest wall reconstruction after tumor resection

Pediatric chest wall tumors are rare. Malignancies predominate of which sarcomas are the most common. Their resection and the subsequent reconstruction of the chest wall has been a surgical challenge since Dr. Frederick W. Parham published his first comprehensive account on the subject in 1898. Chest wall reconstruction is age, site and pathology dependent, must preserve long term function and cosmesis, must accommodate future growth and development, and must not be a hindrance to adjuvant radiotherapy. Bony reconstruction can be relatively simple or complex involving combinations of synthetic meshes, bioprosthetic materials, steel or titanium constructs, autografts, homografts and porcine or bovine xenografts. Soft tissue coverage can be achieved with direct closure, skin grafts, local advancement flaps, pedicled or free myocutaneous or osseomyocutaneous flaps or a combination of these. Complications to be avoided include scoliosis, pain and activity restriction, restrictive pulmonary deficits and interference with adjuvant radiotherapy which may result in tumor recurrence. Advances in cancer therapy have improved short- and long-term survival but significant functional and cosmetic challenges remain particularly for large chest wall defects in the very young. The future may lie with absorbable semi-rigid meshes, biointegratable acellular homografts and xenografts, demineralized bone matrices and bone marrow stromal cells, the patient's own lab-grown stem-cell based vascularized osseomyocutaneous chest wall grafts or the obsolescence of surgical resection altogether in the age of targeted anti-tumor and immune based therapy.