Introduction to chest wall reconstruction: anatomy and physiology of the chest and indications for chest wall reconstruction

Three-dimensional printed pure-titanium implantation for chest wall reconstruction involving the sternum and ribs: a novel approach

Chest wall reconstruction is challenging due to the complex shape and large defect size. The three-dimensional printing technology enables the fabrication of customized implants, and 3D-printed pure-titanium could provide superior mechanical properties to conventional materials. The aim of this study was to evaluate long-term outcomes of patients undergoing chest wall reconstruction with a 3D-printed pure-titanium implant. Between August 2018 and May 2021, 5 patients underwent surgery due to sternal metastasis (n = 3), postoperative sternal wound infection (n = 1) and deformity (n = 1). The customized implant was designed and constructed based on the size and shape of the chest wall defect measured on computed tomography. All patients demonstrated uneventful recovery without complications during the hospital course. During the median follow-up of 20 months, 1 patient underwent revision surgery due to implant breakage, and 1 removed the implant due to trauma-related chest wall infection. One patient died from cancer progression, while 3 patients are alive without any implant-related complications. Chest wall reconstruction using a 3D-printed pure-titanium implant could be a novel alternative for patients with various conditions affecting the sternum and ribs.

Soft tissue reconstruction of the trunk with pedicled perforator and musculocutaneous flaps: A single-center comparative retrospective study

BACKGROUND

Soft tissue trunk reconstruction is often challenging. Although free microvascular flaps are a feasible option in case of extensive defects involving deep structures, pedicled flaps represent a good alternative, especially if harvested and dissected with a "microsurgical" approach. The aim of this study is to evaluate the feasibility of trunk reconstruction with the use of pedicled flaps, according to the application of our reconstructive algorithm, and to compare it to other reconstructive methods.

PATIENTS AND METHODS

From January 2017 to December 2021, we retrospectively analyzed patients who underwent soft tissue reconstruction of the trunk with pedicled flaps at the authors' institution. Patient's demographic, clinical and surgical characteristics and postoperative complications were recorded and analyzed by descriptive statistics. A comparative analysis was made between the study group and two other groups who underwent reconstruction of trunk defects with free flaps and skin grafts, respectively, at the authors' institution.

RESULTS

Forty-seven patients were included in the study. Patients' age ranged between 36 and 82 years (mean: 57.8 years). Twenty-eight patients were male, while 19 patients were female. In 76.6% of patients (36 out of 47), reconstructive procedures were performed to repair defects resulting from cancer resection. Reconstruction of superficial defects was always achieved with perforator flaps (n = 25). In case of full-thickness defects, reconstruction was carried out with musculocutaneous flaps (n = 22); latissimus dorsi and vastus lateralis were the most used flaps for chest and abdominal wall reconstruction, respectively. In our series, we observed only one case of total flap loss requiring re-operation under general anesthesia. Minor complications occurred in 8.5% of cases (4 out of 47 patients). We observed two cases of partial flap necrosis and two cases of wound dehiscence. In the skin grafts group (n = 53), the mean age was 54.5 years (range 39-85) and 56% of patients were male (n = 30). In 66% of cases (n = 30) the defect resulted from oncological resection. The overall complication rate was 18.8% (n = 10). In the free flaps group (n = 10), the mean age was 49.0 years (range 29-77) and 60% of patients (n = 6) were male. In 70% of cases (n = 7) the defect was caused by oncological resection. Complications occurred in two patients (20%). No statistically significant differences were found in terms of overall complication rate between the study group and the two comparative groups (p = .48). A significant correlation was found between the reconstructive method and the type and size of the defect, with reconstruction through free flaps being associated with larger (344.0 vs. 220.4 cm2 ) (p = .04) and full-thickness defects (80.0% vs. 46.8%) (p < .01) if compared to pedicled flaps.

CONCLUSIONS

In the new era of microsurgery, pedicled flaps represent a valid alternative to free flaps for the majority of soft tissue defects of the trunk. In our series, no statistically significant differences in terms of complications were found between reconstructions of similar defects achieved with pedicled and free flaps, and free flap use was limited to extensive full-thickness defects. In addition, the rate of postoperative complications with pedicled flaps found in our cohort was lower than the rate reported in the literature.

The impact of using the internal mammary artery as a recipient vessel on medial mastectomy skin flap perfusion in autologous breast reconstruction: An observational study using indocyanine green

BACKGROUND

The internal mammary artery (IMA) is the preferred recipient vessel for microvascular anastomosis in immediate autologous breast reconstruction following skin-sparing mastectomy (SSM). Although the IMA accounts for approximately 60% of the blood supply to the breast, the exact contribution to the mastectomy skin flap perfusion is unclear. The aim of this observational study was to investigate the impact of using the IMA as a recipient vessel on medial mastectomy skin flap perfusion assessed with indocyanine green angiography (ICGA).

METHODS

This observational study included ten consecutive women who underwent immediate autologous breast reconstructions following SSM. Two intraoperative indocyanine green (ICG) assessments were performed to assess tissue perfusion of the upper and lower part of the medial mastectomy skin flap: the first following the SSM and the second after clamping the IMA. During a 120-second angiography, three additional images were made after 60, 90, and 120 s. The ICG inflow time and mean, minimum, and maximum fluorescence intensities (FIs) were obtained.

RESULTS

Four unilateral and six bilateral autologous breast reconstructions were included. There was no difference in tissue perfusion when comparing the inflow time (24.1 s vs. 23.0 s, P = 0.348), the mean FI (131.4 vs. 124.0, P = 0.126), minimum FI (28.6 vs. 33.4, P = 0.086), and maximum FI (253.1 vs. 247.6, P = 0.166) before and after clamping the IMA.

CONCLUSION

According to this study, the use of the IMA as a recipient vessel does not reduce medial mastectomy skin flap perfusion in patients undergoing immediate autologous breast reconstructions following SSM.

Single stage chest wall soft tissue reconstruction with ipsilateral pectoralis major turnover flap, rhomboid skin flap, and inferior nipple transposition

Extravasation injury is a well-known complication of central venous catheter placement, with potential for extensive soft tissue necrosis. Here, we describe the case of a patient who developed a large right chest well soft tissue defect, due to a chest wall abscess from calcium gluconate infusion via a right internal jugular central venous catheter. After multiple debridements, the chest wall defect was reconstructed with a single stage ipsilateral pectoralis major turnover flap, rhomboid skin flap, and inferior nipple transposition to match the contralateral nipple. There was no further infection, no nipple necrosis, and patient regained full range of motion of the ipsilateral shoulder.

The sternum reconstruction: Present and future perspectives

Sternectomy is a procedure mainly used for removing tumor masses infiltrating the sternum or treating infections. Moreover, the removal of the sternum involves the additional challenge of performing a functional reconstruction. Fortunately, various approaches have been proposed for improving the operation and outcome of reconstruction, including allograft transplantation, using novel materials, and developing innovative surgical approaches, which promise to enhance the quality of life for the patient. This review will highlight the surgical approaches to sternum reconstruction and the new perspectives in the current literature.

Outcomes of Autologous Free Flap Reconstruction Following Infected Device Explantation

Background Following implant-based breast reconstruction (IBR) infection and explantation, autologous reconstruction is a common option for patients who desire further reconstruction. However, few data exist about the outcomes of secondary autologous reconstruction (i.e., free flap breast reconstruction) in this population. We hypothesized that autologous reconstruction following infected device explantation is safe and has comparable surgical outcomes to delayed-immediate reconstruction.

Methods We conducted a retrospective analysis of patients who underwent IBR explantation due to infection from 2006 through 2019, followed by secondary autologous reconstruction. The control cohort comprised patients who underwent planned primary delayed-immediate reconstruction (tissue expander followed by autologous flap) in 2018.

Results We identified 38 secondary autologous reconstructions after failed primary IBR and 52 primary delayed-immediate reconstructions. Between secondary autologous and delayed-immediate reconstructions, there were no significant differences in overall complications (29 and 37%, respectively, p = 0.45), any breast-related complications (18 and 21%, respectively, p = 0.75), or any major breast-related complications (13 and10%, respectively, p = 0.74). Two flap losses were identified in the secondary autologous reconstruction group while no flap losses were reported in the delayed-immediate reconstruction group (p = 0.18).

Conclusion Autologous reconstruction is a reasonable and safe option for patients who require explantation of an infected prosthetic device. Failure of primary IBR did not confer significantly higher risk of complications after secondary autologous flap reconstruction compared with primary delayed-immediate reconstruction. This information can help plastic surgeons with shared decision-making and counseling for patients who desire reconstruction after infected device removal.

Chest wall and diaphragm reconstruction; a technique not well established in literature - case report

INTRODUCTION

Regardless of its rarity, and indolent clinical course, chest wall tumor places high morbidity and burden on patients especially when invasion to a neighboring structure is found. Once detected, surgery is the cornerstone for treatment of such etiology combined with chemo-radiotherapy. In order to maintain intact respiratory function, chest wall reconstruction must be performed whenever resection is done. Herein, we present a case of chest wall tumor that necessitated three ribs and part of hemidiaphragm resection and reconstruction with optimal post-operative results.

CASE PRESENTATION

A 27-year-old male patient who had chest wall and diaphragm reconstruction for a chest wall Ewing sarcoma, using a single patch of expanded polytetrafluoroethylene (ePTFE) mesh with diaphragm implanted into the middle of the mesh. There were no immediate nor post-operative complications. The patient received post-operative radiotherapy with good functional and cosmetic results.

CONCLUSION

We present a novel and safe technique for combined chest wall and diaphragmatic resection following excision of an invading tumor while ensuring cosmesis and functionality of the ribcage as well as the diaphragm.

Epidemiology of combined clavicle and rib fractures: a systematic review

Purpose

The aim of this systematic review was to provide an overview of the incidence of combined clavicle and rib fractures and the association between these two injuries.

Methods

A systematic literature search was performed in the MEDLINE, EMBASE, and CENTRAL databases on the 14^th of August 2020. Outcome measures were incidence, hospital length of stay (HLOS), intensive care unit admission and length of stay (ILOS), duration of mechanical ventilation (DMV), mortality, chest tube duration, Constant–Murley score, union and complications.

Results

Seven studies with a total of 71,572 patients were included, comprising five studies on epidemiology and two studies on treatment. Among blunt chest trauma patients, 18.6% had concomitant clavicle and rib fractures. The incidence of rib fractures in polytrauma patients with clavicle fractures was 56–60.6% versus 29% in patients without clavicle fractures. Vice versa, 14–18.8% of patients with multiple rib fractures had concomitant clavicle fractures compared to 7.1% in patients without multiple rib fractures. One study reported no complications after fixation of both injuries. Another study on treatment, reported shorter ILOS and less complications among operatively versus conservatively treated patients (5.4 ± 1.5 versus 21 ± 13.6 days).

Conclusion

Clavicle fractures and rib fractures are closely related in polytrauma patients and almost a fifth of all blunt chest trauma patients sustain both injuries. Definitive conclusions could not be drawn on treatment of the combined injury. Future research should further investigate indications and benefits of operative treatment of this injury.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01701-4.

Retinoic Acid Signaling Plays a Crucial Role in Excessive Caffeine Intake-Disturbed Apoptosis and Differentiation of Myogenic Progenitors

Whether or not the process of somitogenesis and myogenesis is affected by excessive caffeine intake still remains ambiguous. In this study, we first showed that caffeine treatment results in chest wall deformities and simultaneously reduced mRNA expressions of genes involved in myogenesis in the developing chicken embryos. We then used embryo cultures to assess in further detail how caffeine exposure affects the earliest steps of myogenesis, and we demonstrated that the caffeine treatment suppressed somitogenesis of chicken embryos by interfering with the expressions of crucial genes modulating apoptosis, proliferation, and differentiation of myogenic progenitors in differentiating somites. These phenotypes were abrogated by a retinoic acid (RA) antagonist in embryo cultures, even at low caffeine doses in C2C12 cells, implying that excess RA levels are responsible for these phenotypes in cells and possibly in vivo. These findings highlight that excessive caffeine exposure is negatively involved in regulating the development of myogenic progenitors through interfering with RA signaling. The RA somitogenesis/myogenesis pathway might be directly impacted by caffeine signaling rather than reflecting an indirect effect of the toxicity of excess caffeine dosage.

Use of pedicled latissimus dorsi flap in anterior chest wall reconstruction

Successful surgical management of chest wall tumours relies on extensive chest wall resection with adequate margins. In large complex tumours, return to form and function is determined by appropriate skeletal and soft tissue reconstruction of the chest wall defect. We report an original case of a large 11×16×3 cm ulcerative basosquamous carcinoma of the anterior chest wall. Soft tissue reconstruction was performed with a unilateral pedicled latissimus dorsi flap. A multidisciplinary approach between thoracic and plastic surgeons was used in the planning, intraoperative and follow-up periods. This case highlights a good long-term functional and cosmetic outcome in complex chest wall reconstruction as a result of successful cross-specialty collaboration.

Soft-Tissue Reconstruction after Composite Vertebrectomy and Chest Wall Resection for Spinal Tumors

BACKGROUND

Oncologic resections involving both the spine and chest wall commonly require immediate soft-tissue reconstruction. The authors hypothesized that reconstructions of composite resections involving both the thoracic spine and chest wall would have a higher complication rate than reconstructions for resections limited to the thoracic spine alone.

METHODS

The authors performed a retrospective analysis of all consecutive patients who underwent a thoracic vertebrectomy and soft-tissue reconstruction from 2002 to 2017. Patients were divided into two groups: those whose defect was limited to the thoracic spine and those who required a composite resection involving the chest wall.

RESULTS

One hundred patients were included. Composite resection patients had larger defects, as indicated by a greater incidence of multilevel vertebrectomies (70.2 percent versus 17 percent; p = 0.001). Thoracic spine patients were older (58.2 ± 10.4 years versus 48.6 ± 13.9 years; p < 0.001) and had a greater incidence of metastatic disease (88.7 percent versus 38.3 percent; p = 0.001). Univariate and multivariate logistic regression analyses demonstrated that composite resections were not significantly associated with a higher rate of surgical, medical, or overall complications. Multivariate logistic regression analysis of composite resection subgroup demonstrated that flap separation of the spinal cord from the intrapleural space was protective against complications (OR, 0.22; 95 percent CI, 0.05 to 0.81; p = 0.03).

CONCLUSIONS

Despite the large defect size in composite resection patients, there was no increase in complications compared to thoracic spine patients. In composite resection patients, separating the exposed spinal cord from the intrapleural space with well-vascularized soft tissue was protective against complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Reconstruction of massive chest wall defects: A 20-year experience

BACKGROUND

Large chest wall resections can result in paradoxical chest wall movement leading to prolonged ventilator dependence and major respiratory impairment. The purpose of this study was to determine as to which factors are predictive or protective of complications in massive oncologic chest wall defect reconstructions.

METHODS

A retrospective review of a prospectively maintained database of consecutive patients who underwent immediate reconstruction of massive thoracic oncologic defects (≥5 ribs) was performed. Univariate and multivariate logistic regression analyses identified risk factors.

RESULTS

We identified 59 patients (median age, 53 years) with a mean follow-up of 36 months. Rib resections ranged from 5 to 10 ribs (defect area, 80-690 cm²). Sixty-two percent of the patients developed at least one postoperative complication. Superior/middle resections were associated with increased risk of general and pulmonary complications (71.4% vs. 35.3%; OR 4.54; p = 0.013). The 90-day mortality rate following massive chest wall resection and reconstruction was 8.5%. Two factors that were significantly associated with shorter overall survival time were preoperative XRT and preoperative chemotherapy (p = 0.021 and p < 0.001, respectively).

CONCLUSIONS

Patients with massive oncological thoracic defects have a high rate of reconstructive complications, particularly pulmonary, leading to prolonged ventilator dependence. Superior resections were more likely to be associated with increased pulmonary and overall complications. The length of postoperative recovery was significantly associated with the size of the defect, and larger defects had prolonged hospital stays. Because of the large dimensions of chest wall defects, almost half of the cases required flap coverage to allow for appropriate defect closure. Understanding the unique demands of these rare but challenging cases is critically important in predicting patient outcomes.

[Epidemiology, injury entities and treatment practice for chest wall injuries : Current scientific knowledge and treatment recommendations]

BACKGROUND

Fractures of the bony chest wall are common injuries. They affect almost every second severely injured person and are gaining more and more importance even after low-energy accidents, especially among older people. Complications mainly occur due to respiratory insufficiency, secondary pulmonary complications and remaining deformities with a functional disorder of the chest wall. In addition to the important conservative therapeutic measures, such as a differentiated pain therapy and pneumonia prophylaxis, operative stabilization of fractures can be an option; however, this is still controversially discussed.

OBJECTIVE

A thematically structured overview provides basic knowledge on rib and sternal fractures as well as the treatment options.

MATERIAL AND METHODS

Epidemiological facts are presented based on the relevant literature and clinical experience. Anatomical principles are intended to improve understanding of the various entities of rib and sternal fractures. For this purpose, the new AO‑/OTA classification system is presented and finally therapeutic options including different osteosynthesis procedures are presented and their importance discussed.

RESULTS AND DISCUSSION

Multimodal therapy concepts and closely controlled follow-up examinations of fractures avoid complications or can detect them early. Bony chest wall injuries should still be evaluated for complications and typical fracture patterns identified and classified. Modern osteosynthesis procedures with high patient safety and soft tissue-preserving tissue preparation for the surgical access route to the ribs and sternum provide an excellent opportunity for successful restoration of the anatomical and physiological integrity of the bony thorax.

Chest wall reconstruction: success of a team approach-a 12-year experience from a tertiary care institution

Background

The thoracic cavity was considered as a forbidden area in the past and anyone attempting to meddle with it was expected to be doomed. But the past several decades have seen a marked improvement in the management and reconstruction of complex chest wall defects. This study was undertaken to review our experience in chest wall reconstruction during the past 12 years and to stress upon the importance of a multidisciplinary team approach to this complex problem.

Methods

After obtaining the necessary clearance from institutional ethics committee, we did a retrospective review of all case records of chest wall reconstructions (CWR) performed in our institution during a 12-year period from May 2005 to September 2016. Patient characteristics, co-morbidities, operative data and post-operative complications and outcomes were reviewed.

Results

During the study period, a total of 32 patients underwent CWR. All patients were assessed, planned, operated and managed by a team consisting of thoracic surgeons, plastic surgeons, intensivists and pulmonologists. Patients were in the age group of 14-72 with a male:female ratio of 15:17. Indications for CWR were neoplasms (n = 13-40.62%), post-sternotomy wound dehiscence (n = 12-37.5%), osteoradionecrosis (n = 4-12.5%), tuberculosis (n = 2-6.25%) and osteomyelitis rib (1/32-3.125%). Inflammatory defects were mostly closed with soft tissue alone whereas skeletal stabilisation with soft tissue cover was required in tumour resections. All were pedicled flaps, the most common being pectoralis major (PM) muscle flap (n = 12). Others include latissimus dorsi (LD) muscle (n = 9); rectus abdominis (RA) muscle (n = 2); transverse rectus abdominis musculocutaneous flap (TRAM) (n = 2), deltopectoral (DP) (n = 1), omentum (n = 3) and breast flap (n = 3). Post-operative complications include wound dehiscence (12%), wound infection (21%) and recurrent sinus formation (7%). One partial flap failure was recorded. Post-operative mortality was 3%.

Conclusion

Chest wall reconstruction is a complex procedure and each defect needs an individualised approach for optimum outcome. Extensive chest wall resections can be safely undertaken with the support of the reconstructive surgeon and with good critical care back up.

The painless combination of anatomically contoured titanium plates and porcine dermal collagen patch for chest wall reconstruction

Background

A plethora of new biomaterials and dedicated rib fixator implant systems have been introduced into the field of chest wall reconstruction. The aim of our study is to evaluate the surgical outcomes of a novel combination of the anatomically contoured titanium rib implant and porcine dermal collagen patch for chest wall reconstruction.

Methods

We performed a retrospective review of eight consecutive patients who underwent chest wall resection and reconstruction between January 2014 to August 2015 in a single institution. MatrixRib Fixation System and Permacol Surgical Implant were utilized to achieve chest wall reconstruction.

Results

The indication for reconstruction was malignant infiltration in 50% of patients. Three other subjects (37.5%) had chest wall resections to achieve adequate and safe surgical exposure. One patient had a right lung apical mycetoma with chest wall invasion. All patients underwent lung resections with the removal of 2 to 6 (median 3) ribs. Reconstruction was performed using the MatrixRib system, with a median of 2.5 (range, 2-4) ribs fixed in each patient. There was no post-operative mortality. One patient had a superficial wound infection which resolved with one week of oral antibiotics. Upon discharge, the pain scores were near zero with minimal analgesic requirements. None of the patients required repeat surgery or removal of their implants.

Conclusions

Our early experience indicates that the combination of the MatrixRib system and Permacol patch for chest wall reconstruction is safe and feasible with promising results in terms of anatomical restoration of the chest wall mechanics, infection and pain.

Effects of Exercise on Cervical Angle and Respiratory Function in Smartphone Users

Objectives

The aim of this study was to determine whether exercises can change the cervical angle and respiratory function in smartphone users.

Methods

Thirty healthy volunteers were recruited. The subjects were randomly divided into an exercise group and a control group. All participants used a smartphone for 1 hour while maintaining a sitting posture. Then, each group performed their assigned activity. The exercise group performed two types of exercises and the control group maintained routine activities for 20 minutes. To investigate the changes in cervical angle and respiratory function, we measured the craniovertebral angle by using a spirometer.

Results

Statistically significant differences were noted in the craniovertebral angle, forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), FEV1/FVC ratio, peak expiratory flow, maximal inspiratory pressure, and maximal expiratory pressure of the two groups (p < 0.05).

Conclusion

Our findings showed that proper exercise could be a good method of improving the cervical angle and respiratory function in smartphone users.

Stabilization of flail chest injuries: minimized approach techniques to treat the core of instability

PURPOSE

Stabilizing techniques of flail chest injuries usually need wide approaches to the chest wall. Three main regions need to be considered when stabilizing the rib cage: median-anterior with dissection of pectoral muscle; lateral-axillary with dissection of musculi (mm) serratus, externus abdominis; posterior inter spinoscapular with division of mm rhomboidei, trapezius and latissimus dorsi. Severe morbidity due to these invasive approaches needs to be considered. This study discusses possibilities for minimized approaches to the shown regions.

METHOD

Fifteen patients were stabilized by locked plate osteosynthesis (MatrixRib^®) between May 2012 and April 2014 and prospectively followed up. Flail chest injuries were managed through limited incisions to the anterior, the lateral, and the posterior parts of the chest wall or their combinations. Each approach was 4-10 cm using Alexis^® retractor.

RESULTS

One minimized approach offered sufficient access at least to four ribs posterior and laterally, four pairs of ribs anterior in all cases. There was no need to divide latissimus dorsi muscle. Trapezius und rhomboid muscles were only limited divided, whereas a subcutaneous dissection of serratus and abdominis muscles was necessary. A follow-up showed sufficient consolidation.

COMPLICATIONS

pneumothorax (2) and seroma (2).

CONCLUSION

Minimized approaches allow sufficient stabilization of severe dislocated rib fractures without extensive dissection or division of the important muscles. Keeping the arm and, thus, the scapula mobile is very important for providing the largest reachable surface of the rib cage through each approach.

Important considerations in chest wall reconstruction

Chest wall reconstruction represents one of the most challenging tasks in plastic surgery. Over the past several decades, a more profound understanding of surgical anatomy and physiology along with tremendous advances in surgical technique have resulted in substantial improvements in postoperative outcomes. Conceptually, the reconstructive goals include dead space obliteration, restoration of skeletal stability with protection of intrathoracic structures, and stable soft tissue coverage. Ideally, these goals are achieved with minimal aesthetic deformity. J. Surg. Oncol. 2016;113:913-922. © 2016 Wiley Periodicals, Inc.

A technique for pediatric chest wall reconstruction using custom-designed titanium implants: description of technique and report of two cases

PURPOSE

We present a surgical technique for chest wall reconstruction using custom-designed titanium implants developed for two female patients to provide both chest wall symmetry and adequate stability for staged breast reconstruction.

METHODS

A retrospective review was performed for two adolescent female patients with large chest wall defects who underwent the described technique. The etiology of the chest wall deficiency was secondary to Poland's syndrome in one patient, and secondary to surgical resection of osteosarcoma in the other patient. For each patient, a fine-cut computed tomography scan was obtained to assist with implant design. After fabrication of the prosthesis, reconstruction was performed though a curvilinear thoracotomy approach with attachment of the implant to the adjacent ribs and sternum. Wound closure was obtained with use of synthetic graft material, local soft tissue procedures, and flap procedures as necessary.

RESULTS

The two patients were followed post-operatively for 35 and 38 months, respectively. No intra-operative or post-operative complications were identified. Mild scoliosis that had developed in the patient following chest wall resection for osteosarcoma did not demonstrate any further progression following reconstruction.

CONCLUSIONS

We conclude that this technique was successful at providing a stable chest wall reconstruction with satisfactory cosmetic results in our patients.

Plastic surgery in chest wall reconstruction: relevant aspects - case series

Objective: to discuss the participation of Plastic Surgery in the reconstruction of the chest wall, highlighting relevant aspects of interdisciplinaryness. Methods: we analyzed charts from 20 patients who underwent extensive resection of the thoracic integument, between 2000 and 2014, recording the indication of resection, the extent and depth of the raw areas, types of reconstructions performed and complications. Results: among the 20 patients, averaging 55 years old, five were males and 15 females. They resections were: one squamous cell carcinoma, two basal cell carcinomas, five chondrosarcomas and 12 breast tumors. The extent of the bloody areas ranged from 4x9 cm to 25x40 cm. In 12 patients the resection included the muscular plane. In the remaining eight, the tumor removal achieved a total wall thickness. For reconstruction we used: one muscular flap associated with skin grafting, nine flaps and ten regional fasciocutaneous flaps. Two patients undergoing reconstruction with fasciocutaneous flaps had partially suffering of the flap, solved with employment of a myocutaneous flap. The other patients displayed no complications with the techniques used, requiring only one surgery. Conclusion: the proper assessment of local tissues and flaps available for reconstruction, in addition to the successful integration of Plastic Surgery with the specialties involved in the treatment, enable extensive resections of the chest wall and reconstructions that provide patient recovery.

Chest wall reconstruction after en bloc Pancoast tumour resection with the use of MatrixRib and SILC fixation systems: technical note

STUDY DESIGN

Technical note.

OBJECTIVE

In cases in which partial resection of the rib cage is accomplished with vertebrectomy, reconstruction of the chest wall may be challenging. That is because of lack of the anchor point which normally would be a proximal end of a rib or transverse process. We report a straightforward technique for chest wall reconstruction with the novel use of two systems of fixation commonly applied in spinal practice.

METHODS

The operation of a squamous cell carcinoma (Pancoast tumour) of the right lung infiltrating T2, T3 and T4 vertebrae was performed though T4 lateral thoracotomy. Posterior instrumentation with transpedicular screws T1-3-5 on the left and T1-5 on the right side was followed with the right upper lobectomy and hemivertebrectomy. The laminae and facet joints of T2-T4 vertebrae were removed on the side of the tumour. An osteotomy was performed medial to the pedicle at the lateral aspect of the dural sac on the side of the tumour. Proximal parts of four adjacent ribs were removed allowing radical en bloc resection with tumour-free margins. The distal end of each of four rib plates used (MatrixRib Precontoured Plate system) was attached to the proximal end of the rib. The proximal end of the plate was then attached to the rod of posterior fixation construct with the use of a flexible polyethylene terephthalate (PeT) band of the SILC™ fixation system. The other end of the PeT band was then passed through the top-loading clamp subsequently attached to the rod of the posterior fixation.

RESULTS

The patient did not require additional procedures for chest wall reconstruction. On the 7-month follow-up, in chest CT he was found with satisfactory expansion of the remaining lung tissue with proper spinal alignment and anatomical shape of the rib cage.

CONCLUSIONS

The reported technique can be applied for chest wall reconstruction in cases of total or subtotal vertebrectomy accomplished with the resection extending towards rib cage. It appears to be straightforward, safe and effective allowing good cosmetic and functional outcome.

Cross-sectional area of the abdomen predicts complication incidence in patients undergoing sternal reconstruction

BACKGROUND

Sternal reconstruction with vascularized flaps is central to the management of sternal wound infections and mediastinitis but carries a high risk of complications. There is a need to identify reliable predictors of complication risk to help inform patients and clinicians in preparation for surgery. Unfortunately, body mass index and serum albumin may not be reliable predictors of complication rates. Analytic morphomics provides a robust quantitative method to measure patients' obesity as it pertains to their risk of complications in undergoing sternal reconstruction.

METHODS

We identified 34 patients with preoperative computed tomography scans of the abdomen from a cohort of sternal reconstructions performed between 1997 and 2010. Using semiautomated analytic morphomics, we identified the patients' skin and fascia layers between the ninth and 12th thoracic spine levels; from these landmarks, we calculated morphomic measurements of the patients' abdomens, including their total body cross sectional area and the cross sectional area of their subcutaneous fat. We obtained the incidence of complications from chart review and correlated the incidence of complications (including seroma, hematoma, recurrent wounds, mediastinitis, tracheostomy, and death) with patients' morphomic measurements.

RESULTS

Sixty-two percent of patients (n = 21) suffered complications after their operation. Those who suffered from complications, relative to those who did not have complications, had increased visceral fat area (12,547.2 mm(2)versus 6569.9 mm(2), P = 0.0080), subcutaneous fat area (16,520.2 mm(2)versus 8020.1 mm(2), P = 0.0036), total body area (91,028.6 mm(2)versus 67,506.5 mm(2), P = 0.0022), fascia area (69,238.4 mm(2)versus 56,730.9 mm(2), P = 0.0118), total body circumference (1101.8 mm versus 950.2 mm, P = 0.0017), and fascia circumference (967.5 mm versus 868.1 mm, P = 0.0077). We also demonstrated a significant positive correlation between the previously mentioned morphomic measurements and the incidence of complications in multivariate logistic regression models, with odds ratios ranging from 1.19-3.10 (P values ranging from 0.010-0.022).

CONCLUSIONS

Increases in abdominal morphomic measurements correlate strongly with the incidence of complications in patients undergoing sternal reconstruction. This finding may influence preoperative risk stratification and surgical decision making in this patient population.