Risks and benefits of using Marlex mesh in chest wall reconstruction

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.

Primary Lung Hernia After Blunt Chest Trauma: Chest Wall Repair Strategies

Lung herniation is a rare pathology seen after trauma. A case of acquired lung hernia is presented after blunt thoracic trauma that was repaired primarily. Surgical management and decision-making for this process are discussed.

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.

Bilateral Anterolateral Thigh Myocutaneous Flaps for Giant Complex Chest Wall Reconstruction

BACKGROUND

Extensive reconstruction of complex full-thickness chest wall oncological defects is challenging. Bilateral free anterolateral thigh (ALT) myocutaneous flap transfer for the complex reconstruction of a large area of the chest wall is discussed.

MATERIALS AND METHODS

We reported a single unit's experience in 1-staged multilayered reconstruction of large full-thickness chest wall defects in 22 patients (16 primary chest wall tumor cases, 5 locally advanced breast cancer cases, and 1 osteoradionecrosis case) treated between 2011 and 2018. Bilateral ALT myocutaneous flaps together with traditional cement implant or unmovable/movable joint conformable titanium struts were used for chest wall reconstruction. The anatomical characteristics of pedicle origin and pattern of the venae comitantes of the ALT myocutaneous flap, recipient vessels, and anastomosis patterns were described.

RESULTS

Bilateral ALT myocutaneous flaps were used for soft tissue reconstruction in 22 cases. Different methods of flap harvesting and vascular anastomosis were selected as needed. No vein grafts or arteriovenous loops were required. We observed 3 vascular patterns of the flap pedicle, including 1 oblique branch and descending branch (59.1%, n = 26), 2 single descending branch (9.1%, n = 4), and 3 double branches of the descending branch (31.8%, n = 14). The flap was harvested pedicled with solely the oblique branch in 7 (15.9%) cases, solely the descending branch in 28 (63.6%) cases to minimize the donor site morbidity, and pedicled with the oblique and descending branch in 9 (20.5%) cases to achieve multiple vascular anastomosis choices. Stable skeletal reconstructions were achieved using traditional cement implant (13.6%, n = 3) or conformable titanium struts (86.4%, n = 19), with good fixation strength. Complication risk was low. An algorithmic approach to management is presented and recommended.

CONCLUSION

Various forms of bilateral ALT myocutaneous flap transfer with different skeletal reconstruction presents as a reliable treatment for patients with large full-thickness chest wall defects. Anatomical variations in the pedicle and pattern of venae comitantes of the ALT myocutaneous flap are reported. In some challenging cases, finding the vessels in the recipient area is difficult. The clinical significance of each vascular pattern is delineated, and surgical technical considerations are discussed on the basis of the recipient area requirements and types of a flap's vascular anatomy.

Outcomes of major musculoskeletal oncological reconstructions using prolene mesh-a retrospective analysis from a tertiary referral centre

BACKGROUND

Adequate reconstruction of the soft tissue defect following resection of bone tumors is challenging. Prolene mesh, despite being a useful tool, is not widely used due to the fear of deep infection. The aim of this study was to evaluate the functional outcome and complications of using a Prolene mesh in oncological reconstructions.

METHODS

A retrospective study was conducted in bone tumor patients with soft tissue reconstruction using Prolene mesh between January 2017 and June 2019. Functional evaluation was done using MSTS 93 score. Complications were recorded and were classified as mechanical (dislocation and extension lag) or biological failure (wound problems and deep infection). Comparison was performed between groups with and without biological failure to identify predictive variables.

RESULTS

Of 116 patients, 68 were males and 48 were females, with median age of 22.5 years. Thirty nine patients had tumors of proximal tibia, 23 of proximal femur, 25 of proximal humerus, 24 of pelvis, and five tumors at other sites. Approximately two-thirds (62.9%) of our patients underwent endoprosthetic reconstruction while the rest underwent either biological or cement spacer reconstructions. Excellent or good functional outcomes were reported in 98.3% patients as per MSTS 93 scoring. Complications were noted in 22 patients (18.9%), of which 16 had biological failure, with four patients requiring debridement and mesh removal. Dislocation of prosthesis occurred in 2 patients of proximal femur replacement. Overall re-surgery rate was 5.1% (6 patients). There was no statistically significant difference between the groups with or without biological failure with respect to demographics, site of tumor, type of procedure, blood loss, duration of surgery and history of chemotherapy.

CONCLUSION

Prolene mesh is a useful tool to reconstruct the soft tissue defects following bone tumor resections. It is readily available, reliable and provides reproducible results, with no added risk of wound complications.

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.

Forequarter Amputation and Reconstructive Options

OBJECTIVE

This study aimed to present the results of a series of forequarter amputations (FQAs) and to evaluate the reconstructive methods used.

SUMMARY BACKGROUND DATA

Although FQA has become a rare procedure in the era of limb-sparing treatment of extremity malignancies, it is a useful option when resection of a shoulder girdle or proximal upper extremity tumor cannot be performed so as to retain a functional limb.

METHODS

Thirty-four patients were treated with FQA in 1989 to 2017. Various reconstructive techniques were used, including free fillet flaps from the amputated extremity.

RESULTS

All patients presented with intractable symptoms such as severe pain, motor or sensory deficit, or limb edema. Seventeen patients were treated with palliative intent. Chest wall resection was performed in 9 patients. Free flap reconstruction was necessary for 15 patients, with 11 free flaps harvested from the amputated extremity. There was no operative mortality, and no free flaps were lost. In curatively treated patients, estimated 5-year disease-specific survival was 60%. Median survival in the palliatively treated group was 13 months (1-35 months).

CONCLUSIONS

Limb-sparing treatment is preferable for most shoulder girdle and proximal upper extremity tumors. Sometimes, FQA is the only option enabling curative treatment. In palliative indications, considerable disease-free intervals and relief from disabling symptoms can be achieved. The extensive tissue defects caused by extended FQA can be safely and reliably reconstructed by means of free flaps, preferably harvested from the amputated extremity.

Reconstruction of Oncologic Sternectomy Defects: Lessons Learned from 60 Cases at a Single Institution

Oncologic sternectomy results in complex defects where preoperative planning is paramount to achieve best reconstructive outcomes. Although pectoralis major muscle flap (PMF) is the workhorse for sternal soft tissue coverage, additional flaps can be required. Our purpose is to evaluate defects in which other flaps beside PMF were required to achieve optimal reconstruction.

Clinical Outcomes of Surgical Treatment for Primary Chest Wall Soft Tissue Sarcoma

Background

This study investigated the clinical outcomes of surgical treatment of primary chest wall soft tissue sarcoma (CW-STS).

Methods

Thirty-one patients who underwent surgery for CW-STS between 2000 and 2015 were retrospectively reviewed. The disease-free and overall survival rates were estimated using the Kaplan-Meier method, and prognostic factors were analyzed using a Cox proportional hazards model.

Results

The median follow-up duration was 65.6 months. The most common histologic type of tumor was malignant fibrous histiocytoma (29%). The resection extended to the soft tissue in 14 patients, while it reached full thickness in 17 patients. Complete resection was achieved in 27 patients (87.1%). There were 5 cases of local recurrence, 3 cases of distant metastasis, and 5 cases of combined recurrence. The 5-year disease-free rate was 49%. Univariate analysis indicated that incomplete resection (p<0.001) and stage (p=0.062) were possible risk factors for recurrence. Multivariate analysis determined that incomplete resection (p=0.013) and stage (p=0.05) were significantly associated with recurrence. The overall 5- and 10-year survival rates were 86.8% and 64.3%, respectively. No prognostic factor for survival was identified.

Conclusion

Long-term primary CW-STS surgery outcomes were found to be favorable. Incomplete microscopic resection and stage were risk factors for recurrence.

Epithelioid sarcoma in the chest wall: a case report and literature review

BACKGROUND

Epithelioid sarcoma (ES) is a rare variant of soft tissue sarcoma. The proximal type of ES occurs in various locations. We present a resected case with proximal-type ES that occurred in the chest wall and discuss the relevant literature.

CASE PRESENTATION

A 47-year-old woman was referred for a 6-month history of a right anterior chest mass with tenderness. Chest computed tomography showed an invasive chest wall mass with calcification surrounding the third rib. Aspiration biopsy cytology suggested malignancy. We performed wide resection, including the middle part of the pectoralis major muscle, the pectoralis minor muscle, the third and fourth ribs, and reconstruction of the chest wall, using a 2-mm polytetrafluoroethylene patch. Severe deformation of the chest wall was avoided. Postoperative physical therapy of the shoulder was effective for the continuous pain and weakness of the arm. She has remained alive for 1 year and 10 months without recurrence. Our literature review showed five previously reported cases of ES in the chest wall, and all of these were surgically resected. Two of these patients suffered from frequent local recurrence and died of disease.

CONCLUSIONS

ES in the chest wall is rare. Previous reports have indicated that surgical resection with tumor-free margins is essential for treatment. We performed complete resection of the tumor in our case, and a polytetrafluoroethylene patch was effective for reconstructing the deficit in the chest wall.

Sternum reconstruction using titanium plates matched with "sandwich" Gore-Tex meshes

Chest wall reconstruction after extensive resection may be technically difficult, and which technique permits to obtain the right compromise between rigidity and plasticity of the chest wall is still argument of debate. Indeed, many techniques and materials have been proposed and tested to cover chest wall defects and to ensure correct respiratory movements, but unique results still miss. We herein report the case of a 55-years old woman with soft-tissue sarcoma involving the sternum treated with sternum and anterior ribs arch resection (from the second to the fourth). The chest wall defect was repaired using titanium plates and Gore-Tex meshes combined as a "sandwich". The scope was to obtain a synchronous movement of the prosthesis with the titanium ribs, reducing the scratching between the different materials and avoiding paradox chest wall movements.

Giant Anterior Chest Wall Basal Cell Carcinoma: An Approach to Palliative Reconstruction

Anterior chest wall giant basal cell carcinoma (GBCC) is a rare skin malignancy that requires a multidisciplinary treatment approach. This case report demonstrates the challenges of anterior chest wall GBCC reconstruction for the purpose of palliative therapy in a 72-year-old female. Surgical resection of the lesion included the manubrium and upper four ribs. The defect was closed with bilateral pectoral advancement flaps, FlexHD, and pedicled VRAM. The palliative nature of this case made hybrid reconstruction more appropriate than rigid sternal reconstruction. In advanced metastatic cancers, the ultimate goals should be to avoid risk for infection and provide adequate coverage for the defect.

Dynamic 3D printed titanium copy prosthesis: a novel design for large chest wall resection and reconstruction

Due to high rates of complications, chest wall resection and reconstruction is a high risk procedure when large size of resection is required. Many different prosthetic materials have been used with similar results. Recently, thanks to the new advances in technology, personalized reconstruction have been possible with specific custom-made prosthesis. Nevertheless, they all generate certain amount of stiffness in thoracic motion because of his rigidity. In this report, we present a forward step in prosthesis design based on tridimensional titanium-printed technology. An exact copy of the resected chest wall was made, even endowing simulated sternochondral articulations, to achieve the most exact adaptation and best functional results, with a view to minimize postoperative complications. This novel design, may constitute an important step towards the improvement of the functional postoperative outcomes compared to the other prosthesis, on the hope, to reduce postoperative complications.

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.

Esophageal stricture caused by rib osteoma in a cat: case report

Case summary

A 6-year-old male domestic shorthair cat presented with frequent food regurgitation and dysphagia. Plain thoracic radiographs revealed a calcified mass overlying the topography of the mediastinum, as well as dilation of the cervical portion of the esophagus due to an accumulation of food. Endoscopic examination showed a severe extraluminal esophageal stricture at the mediastinum entrance. Surgery and a gastric tube were declined by the cat’s owner, with palliative support preferred. However, 1 year later, the cat presented with severe cachexia, dysphagia, salivation, dehydration and inspiratory dyspnea. Thoracic computed tomography was performed to evaluate the possibility of surgical resection. A mass of bone density originating in the second left rib was observed. The mass did not appear to have invaded adjacent structures but marked compression of the mediastinal structures was observed. Surgical resection was performed and a prosthetic mesh was used to reconstruct the thoracic wall. Transient Horner’s syndrome developed in the left eye postoperatively, and was resolved within 4 weeks. Histopathology revealed a benign osteoma. Thirty-two months after surgery, the cat was well and free of disease.

Relevance and novel information

Rib tumors should be included in a differential diagnosis in cats with extraluminal esophageal stricture. CT should be performed for treatment planning. Surgical treatment was curative in this case.

Chest Wall Reconstruction: Evolution Over a Decade and Experience With a Novel Technique for Complex Defects

BACKGROUND

Chest wall reconstruction (CWR) with biologic matrices has gained popularity over the last decade; however, data on this topic remain sparse. The aim of this study is to review the different methods and materials used for CWR while reviewing and highlighting a novel approach using a biologic inlay and synthetic onlay technique for larger, complex high-risk defects.

METHODS

A retrospective review was performed of all patients who underwent full thickness chest wall resection and reconstruction during a 10-year period. Patient characteristics, comorbidities, operative data, as well as postoperative wound complications and outcomes were reviewed. Different reconstructive methods and materials were reviewed and compared.

RESULTS

From December 2003 to January 2014, a total of 81 patients underwent CWR. The indications for resection/reconstruction included oncologic in 49 patients (60.5%), desmoids tumors in 10 (12.3%), bronchopleural fistula in 3 (3.7%), infection in 7 (8.6%), and anatomic deformity in 7 (8.6%) patients. Synthetic and/or acellular dermal matrices (ADM) reconstruction was used in 59 patients (10 biologic, 22 synthetic, and 27 biologic ADM inlay/synthetic onlay combination). On average, 2.5, 3.5, and 3.6 ribs were resected in the biologic, synthetic, and combination group, respectively (P = 0.1). A greater number of patients in the combination group had a history of chemotherapy and/or radiation therapy (P = 0.03) than the synthetic or biologic alone groups. Risk analysis demonstrated an association between the number of ribs resected and postoperative chest wall complications. The incidence of chest wall/wound complications in the synthetic, combination, and biologic groups was 31.8%, 22.2%, and 10%, respectively (P = 0.47).

CONCLUSIONS

In the largest single institution study comparing the use of different reconstructive materials, including ADM in CWR, the authors demonstrate that a biologic inlay/synthetic onlay may be used effectively for high-risk, large complex defects. Early outcomes with this technique are promising. The authors believe this combination highlights benefits from both materials because the ADM facilitates tissue ingrowth and revascularization, whereas the synthetic component provides structural durability. Additional studies with larger sample sizes are necessary to further explore the benefits of the combination technique to determine if outcomes are better than either material alone when used to reconstruct high-risk wounds after larger resections.

Chest wall reconstruction after oncological resections

Most chest wall defects requiring reconstruction result from tumor resection. Bone and soft tissue sarcomas and recurrent mammary cancer are the most common tumors. Careful preoperative evaluation, meticulous surgical technique and active postoperative treatment are important. The selection of reconstruction is based on the nature, size and location of the defect as well as on the general health and prognosis of the patient. The goals of the reconstruction are adequate stability, water- and airtight closure of the chest cavity, and acceptable cosmetic appearance. The pedicled muscular or musculocutaneous flaps are usually the first choice for tis-sue coverage. These include flaps such as latissimus dorsi, vertical or transverse rectus abdominis and pectoralis. In certain cases also the breast flap or omental flap can be used. In selected cases, a free flap reconstruction is indicated if the local options for reconstruction have been used, or if they are unreliable due to earlier scars or radiotherapy. The free flaps to be used for chest wall can be harvested from the thigh (tensor fascia latae flap, anterolateral thigh flap), from the abdomen (transverse rectus abdominis flaps, deep epigastric perforator flaps) or from the chest wall (latissimus dorsi flap and other flaps based on the subscapular artery). Sometimes a fillet forearm can be used as a flap to cover a defect after extended forequarter amputation. Artificial meshes are commonly used to give stability in the defect and to give a platform for the flap. Methylmethacrylate embedded between the two layers of a mesh, or one or two rib grafts fixed to the mesh, can be used to give additional stability in extensive defects to prevent paradoxical movement.

Free tensor fascia lata flap and synthetic mesh reconstruction for full-thickness chest wall defect

A large full-thickness chest wall defect over 10 cm in diameter requires skeletal reconstruction and soft tissue coverage. Use of various flaps for soft tissue coverage was previously reported, but en bloc resection in each case affects these flap pedicles and sizes. We present a case of a 74-year-old man with a soft tissue tumor involving the left lateral chest wall. We performed an en block resection and skeletal reconstruction using a mesh, free tensor fascia lata (TFL) flap for soft tissue coverage. This procedure could be performed in one position. A fixed fascia lata of the flap was also useful for tight reconstruction with the mesh. We suggest that free TFL and/or anterior lateral thigh flap is a useful technique to reconstruct anterior to posterior lateral chest wall defects.

Reconstruction of chest wall using a two-layer prolene mesh and bone cement sandwich

Wide surgical resection is the most effective treatment for the vast majority of chest wall tumors. This study evaluated the clinical success of chest wall reconstruction using a Prolene mesh and bone cement prosthetic sandwich. The records of all patients undergoing chest wall resection and reconstruction were reviewed. Surgical indications, the location and size of the chest wall defect, diaphragm resection, pulmonary performance, postoperative complications, and survival of each patient were recorded. From 1998 to 2008, 43 patients (27 male, 16 female; mean age of 48 years) underwent surgery in our department to treat malignant chest wall tumors: chondrosarcoma (23), osteosarcoma (8), spindle cell sarcoma (6), Ewing's sarcoma (2), and others (4). Nine sternectomies and 34 antero-lateral and postero-lateral chest wall resections were performed. Postoperatively, nine patients experienced respiratory complications, and one patient died because of respiratory failure. The overall 4-year survival rate was 60 %. Chest wall reconstruction using a Prolene mesh and bone cement prosthetic sandwich is a safe and effective surgical procedure for major chest wall defects.

Stabilization of the chest wall: autologous and alloplastic reconstructions

The goals of chest wall stabilization include maintenance of a rigid airtight cavity, protection of the thoracic and abdominal contents, optimization of respiration, and, whenever possible, an aesthetic reconstruction. Evidence suggests that bony fixation results in reduced ventilator dependence, a shorter overall hospital stay, and improved upper extremity function. We prefer to accomplish this with autologous tissue alone (such as the pectoralis major, latissimus dorsi, or rectus abdominus muscle flaps) for small to moderate defects. En bloc resection of defects larger than 5 cm or containing four or more ribs will likely benefit from chest wall stabilization. For patients previously treated with radiation, even larger defects may be tolerated owing to fibrosis. For these larger defects, methyl methacrylate composite meshes are used and covered with vascularized tissue. Contaminated wounds are generally reconstructed with bioprosthetic mesh rather than synthetic mesh. Using these principles, the reconstructive plastic surgeon can devise a comprehensive and safe plan to repair tremendous defects of the chest wall.

Chest Wall Resection and Reconstruction a True Thoracoscopic Approach

We set out to perform resection of a chest wall mass with subsequent reconstruction using a pure thoracoscopic approach. Using video-assisted thoracic surgery via a three-incision approach, we successfully removed an 8.5 × 3.5–cm specimen en bloc. We then reconstructed the chest wall with 2-mm polytetrafluoroethylene. A total thoracoscopic approach to chest wall resection and reconstruction represent an additional option in this area of thoracic surgery. This approach avoids some of the drawbacks of more invasive procedures. This report outlines a totally thoracoscopic approach that we feel represents a safe and viable option for patients requiring chest wall resection and reconstruction.

Chest wall sarcoma: outcome in 22 patients after resection requiring thoracic cage reconstruction

Purpose. To evaluate the outcome after resection of malignant chest wall sarcoma, requiring reconstruction of the chest wall.

Subjects. Twenty-two patients, 15 with primary tumours, were operated on in our institution between 1983 and 1996. Four patients underwent surgery after a previous intralesional or marginal excision and three patients because of a local recurrence.

Methods. The tumour was resected ‘en bloc’, including skin, muscle and thoracic skeleton. When necessary, adjacent organs invaded by the tumour, such as lung, pericardium and diaphragm, were also removed to obtain a wide margin. Reconstruction of the chest wall was performed with Marlex mesh (n=9), methylmethacrylate cement (n=2) or a Marlex methylmethacrylate ‘sandwich’ (n=11).

Results. The median tumour size was 9.5 (2–20) cm. The most common type of tumour was chondrosarcoma (12 cases). No patient died in hospital. Five patients required reoperation because of complications, two patients because of loosening of the acrylate prosthesis, two because of necrosis of soft tissue coverage and one was reoperated because of bleeding. Four patients died of generalized tumour disease between 5 and 77 months after surgery and one patient died of a local recurrence 32 months after the primary operation. Seventeen patients are alive, with a median follow-up of 36 (4–162) months. Microscopic radicality (negative margin) was achieved in 17 patients but 5 of these had local recurrences. Two of five patients with positive margins had a local recurrence of the tumour. Of the seven patients with local recurrences, two also developed metastases.

Discussion. Large chest wall sarcomas can be successfully resected and the chest wall reconstructed with low morbidity and mortality.

Reconstruction of the thoracic wall-long-term follow-up including pulmonary function tests

PURPOSE

Thoracic wall reconstructions have become a standard procedure for the reconstructive plastic surgeon in the larger hospital setting, but detailed reports about long-term results including pulmonary function and physical examination are rare.

MATERIALS AND METHODS

The data of 92 consecutive patients with full thickness chest wall resections were acquired from patient's charts and contact to patients, their relatives or general practitioners, with special reference to treatment and clinical course. At a mean follow-up of 5.5 years, 36 patients were examined physically and interviewed. Twenty-seven of them underwent additional pulmonary function tests. Kaplan-Meier method was used to calculate survival. Regression tests were undertaken to identify factors influencing the outcome.

RESULTS

Postoperative complications were observed in 42.4%, but neither mesh implantation nor the size of the defect contributed significantly. The 5-year mortality was worse for patients with recurrent mamma carcinoma (90.6%) than for patients with soft tissue sarcoma (56.3%). No medical history or operation parameter (resection size and localization) besides the general patients' conditions increased mortality. Pulmonary function parameters were only moderately reduced and not significantly affected by the resections' size or its localization. Majority of patients suffer from sensation disorders and motion-dependent pain, which contributed significantly to hypoxemia. Quality-of-life parameters were significantly reduced compared to the healthy control group but similar to the control group with cancer according to the Short Form-36 protocol. We could not detect a relevant decrease in quality of life comparing post- to preoperative values.

CONCLUSIONS

Thoracic wall reconstruction provides sufficient thoracic wall stability to maintain pulmonary function, but postoperative pain and sensation disorders are considerable. However, chest wall repair can contribute to palliation and even cure after full-thickness resections.

Reconstruction of complex chest wall defects by using polypropylene mesh and a pedicled latissimus dorsi flap: a 6-year experience

BACKGROUND

Reconstruction of full thickness defects of the chest wall is controversial and presents a complicated treatment scenario for thoracic and reconstructive plastic surgeons. It requires close cooperation between the cardiothoracic and reconstructive surgeons to achieve an optimal outcome and reduce the incidence of complications.

OBJECTIVE

The purpose of this study is to evaluate our results in patients who underwent prosthetic bony reconstruction with polypropylene mesh and pedicle latissimus dorsi flap after chest wall resection. The principles of chest wall reconstruction include: wide excision of primary chest wall tumour with macroscopically healthy margins, wound excision and debridement of necrotic devitalised and irradiated tissues, control of infection and local wound care.

STUDY DESIGN

This is a descriptive study. It includes 20 patients who underwent chest wall resection due to various causes and followed by reconstruction with polypropylene mesh along with pedicled latissimus dorsi flap.

PLACE AND DURATION OF STUDY

The study was conducted at the Department of Plastic and Reconstructive Surgery, Federal Postgraduate Medical Institute, Sheikh Zayed Hospital Lahore, over a period of 6 years from August 1999 to August 2005.

PATIENTS AND METHODS

This study included 20 patients who underwent chest wall reconstruction using polypropylene mesh and pedicled latissimus dorsi flap from August 1999 to August 2005. Patient demographic data including age, sex, pathological diagnosis, extent and type of resection, size of defect, and outcome were recorded. All patients were followed up in our outpatients department for 1 year.

RESULTS

There was a total of 20 patients, 16 males and four females. The average age was 54 years (range 44-64 years). The indications for resection were primary chest wall tumours in 13 (65%) patients, local recurrence from breast tumours in one (5%) patient, post median sternotomy in three (15%) patients and radionecrosis in three (15%) patients. Ribs along with a part of sternum were resected in 14 (70%) patients, ribs along with clavicle in two (10%) patients and ribs only in four (20%) patients. The average area of chest wall defect after resection was 16.5 x 13 cm. In all patients, skeletal defect was reconstructed with polypropylene mesh. Soft tissue coverage was provided with a pedicled latissimus dorsi flap in all cases. Three patients with a chest wall tumour developed a recurrence within 6 months. Among these three, one patient died within 8 months of follow up due to myocardial infarction.

CONCLUSION

Chest wall resection and reconstruction with synthetic polypropylene mesh and local muscle flaps can be performed as a safe, effective one-stage surgical procedure for a variety of major chest wall defects.

Comparison of mersilene mesh-methyl metacrylate sandwich and polytetrafluoroethylene grafts for chest wall reconstruction

We report the outcomes of patients who underwent reconstruction with Mersilene mesh-methyl methacrylate (MM-MM) sandwich and polytetrafluoroethylene (PTFE) grafts after a large chest wall resection. Between June 1990 and September 2001, 59 consecutive patients (37 men, 22 women; mean age, 48.1 +/- 11.8 years; range 22-74 years) underwent large chest wall resection (greater than 5 cm diameter) and reconstruction with prosthetic material in our department. Twenty-one patients (33%) underwent reconstruction with a PTFE graft (group 2) between 1990 and 1994, and 38 patients (67%) underwent reconstruction with an MM-MM sandwich graft (group 1) between 1994 and 2001. Operative morbidity ratios were 5.2% (2/38) in group 1 and 24% (5/21) in group 2 (p = .036). The paradoxical respiration ratio was significantly higher (p = .018) in group 2 (5/21: 24%) than it was in group 1 (1/38: 2.6%). The operative mortality ratio was 4.5% (1/21) in group 2 and 0% in group 1. Mean hospital stay was 10.6 days (range 5-21 days) in group 1 and 13.3 days (range 7-36 days) in group 2 (p = .015). The MM-MM graft is inexpensive and easy to apply, provides better cosmetic options, and offers minimal morbidity. We therefore recommend that the MM-MM sandwich graft be used rather than the PTFE graft for large defects of the anterolateral chest wall and sternum where successful prevention of paradoxical respiration is required.

Reconstruction of the chestwall and thorax

Chest wall reconstructions can be complex and challenging procedures and may require a multidisciplinary approach. The most common indications for chest wall reconstruction are the repair of defects due to tumor ablation, infection, radiation necrosis, congenital deformities, and trauma. Flap reconstruction by plastic surgery is often required when skin is removed as part of the chest wall resection or when radiation therapy is given pre- or post-operatively. Tissue flaps may be needed to provide vascularized tissue over alloplastic materials used to stabilize the chest wall, to cover vital structures of the chest cavity, to fill dead space, and to improve cosmesis.

Chest wall/diaphragmatic complications

This article discusses the prevention and management of chest wall and diaphragmatic complications after extrapleural pneumonectomy, the prevention of thoracoplasty scoliosis, the complications after chest wall resection, and the presentation, prevention, and management of chest wall hernia. Appropriate preoperative assessment and patient selection, meticulous attention to detail intraoperatively, and diligent postoperative observation and care are needed to prevent these events.

A reconstructive algorithm for plastic surgery following extensive chest wall resection

Chest wall reconstruction following extensive resection is greatly facilitated by the use of vascularised flaps and prosthetic material. Plastic surgeons are often asked to assist with coverage of large chest wall defects. However, in addition to soft tissue coverage, we need to address other important issues such as the status of the pleural cavity, and the requirement for skeletal support. The purpose of this report is to analyse our experience, provide a reconstructive algorithm following the ablative procedure and review the literature. Two hundred chest wall resections were performed from 1975 to 2000. Defect location was divided into anterior (n = 73) lateral (n = 36) anterior-lateral (n = 36) posterior-lateral (n = 19) posterior (n = 22) and forequarter (n = 14) Average number of ribs resected was four. One hundred and fifty-eight patients (79%) required chest wall reconstruction with either prosthetic material and/or flap closure. Mesh closure was required in 85 cases (43%), being highest for lateral defects (61%), and lowest for anterior defects (31%). Vascularised flaps were needed in 112 patients (56%), more common in anterior defects (79%), and less common for the posterior-lateral defects (26%). Inpatient complication rate was 27% (43/158) following reconstruction, with a mortality of 6% (10/158). Chest wall reconstruction is common following extensive resection. This includes management of the pleural cavity, skeletal support and soft tissue coverage. A better understanding of the respiratory mechanics and local thoracoabdominal anatomy is crucial for managing these complex defects. The need for skeletal support was more prevalent in lateral and posterior-lateral defects. Flap reconstruction was required more often to cover large anterior defects, with regional flaps predominating.

Chest wall reconstruction and advanced disease

Clinical experience supports a role for palliative procedures in patients with locally advanced or recurrent breast cancer, yet numerous challenges are entailed in both the extirpation and reconstruction of the chest wall in these cases. The defects may be profound and complicated by prior surgery, radiation therapy, or patient-related variables. The reconstructive techniques employed must neither encumber nor delay any necessary postoperative therapy and must not result in unacceptable morbidity or compromise quality of life. Our surgical approach to these cases incorporates a team of specialists from a broad spectrum of medical and surgical disciplines. Each operative plan is tailored to the specific needs and requirements of the individual patient.

Microvascular reconstructions of full-thickness oncological chest wall defects

OBJECTIVE

To evaluate the suitability of microvascular flaps for the reconstruction of extensive full-thickness defects of the chest wall.

SUMMARY BACKGROUND DATA

Chest wall defects are conventionally reconstructed with pedicular musculocutaneous flaps or the omentum. Sometimes, however, these flaps have already been used, are not reliable due to previous operations or radiotherapy, or are of inadequate size. In such cases, microvascular flaps offer the only option for reconstruction.

METHODS

From 1988 to 2001, 26 patients with full-thickness resections of the chest wall underwent reconstruction with microvascular flaps. There were 8 soft tissue sarcomas, 8 recurrent breast cancers, 5 chondrosarcomas, 2 desmoid tumors, 1 large cell pulmonary cancer metastasis, 1 renal cancer metastasis, and 1 bronchopleural fistula. The surgery comprised 5 extended forequarter amputations, 5 lateral resections, 8 thoracoabdominal resections, and 8 sternal resections. The mean diameter of a resection was 28 cm. The soft tissue defect was reconstructed with 16 tensor fasciae latae, 5 tensor fascia latae combined with rectus femoris, and 3 transversus rectus abdominis myocutaneous flaps. In 2 patients with a forequarter amputation, the remnant forearm was used as the osteomusculocutaneous free flap.

RESULTS

There were no flap losses or perioperative mortality. Four patients needed tracheostomy owing to prolonged respiratory difficulties. The mean survival time for patients with sarcomas was 39 months and for those with recurrent breast cancer 18 months.

CONCLUSIONS

Extensive chest wall resections are possible with acceptable results. In patients with breast cancer, the surgery may offer valuable palliation and in those with sarcomas it can be curative.

[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.

A single-institutional, multidisciplinary approach to primary sarcomas involving the chest wall requiring full-thickness resections

OBJECTIVE

Primary sarcomas involving the chest wall requiring full-thickness excision are rare. We reviewed our experience with these lesions in a tertiary referral cancer center by using multidisciplinary approaches.

METHODS

A 10-year retrospective study identified 51 patients referred with primary sarcomas of the chest wall: 40 for initial treatment and 11 after previous unsuccessful surgical excisions elsewhere (secondary referral). Presenting symptoms were pain alone in 23 (45%) of 51 patients, pain with an associated mass in 8 (16%) patients, and an asymptomatic mass alone in 13 (25%) patients. Median symptom duration was 241 days in the primary group and 225 days in the recurrent group. Tumor locations were the sternum (n = 11), the rib alone (n = 36), and the posterior rib with extension into vertebral bodies (n = 4). Histologic types included the following: chondrosarcomas (n = 15), malignant fibrous histiocytomas (n = 9), osteosarcomas (n = 4), Ewing sarcomas (n = 3), desmoid tumors (n = 7), and other types (n = 13). The median tumor volume of those referred initially was 311 cm(3) compared with 84 cm(3) in patients with recurrent lesions.

RESULTS

Twenty-six (51%) of 51 patients received treatment before resection, including chemotherapy alone (n = 22), radiation alone (n = 3), and combined chemotherapy and radiation therapy (n = 1). The complete sternum was removed in 6 of 11 patients, and the average number of ribs requiring resection was 3.8. Four patients had vertebral body resections. Prosthetic meshes alone were required in 16 of 51 patients, and meshes with methylmethacrylate were required in 18 of 51 patients. Muscle flap reconstructions by plastic surgery were required in 24 patients. Negative margins were obtained in 47 of 51 patients. There were no perioperative deaths with morbidities occurring in 12 (24%) of 51 patients (wound [n = 3], prolonged air leak [n = 1], prolonged ventilator requirement [n = 1], arrhythmias [n = 3], doxorubicin (Adriamycin)-induced cardiomyopathy [n = 1], and other [n = 3]). Postoperative treatment was administered to 13 patients (chemotherapy alone, n = 9; chemotherapy with radiation therapy, n = 4). The cumulative 5-year survival of all patients was 64% (initial referral, 61.3%; secondary referral, 72.7%). The average follow-up is 44.7 months.

CONCLUSIONS

A combined aggressive multidisciplinary approach to primary sarcomas of the chest wall resulted in no treatment-related deaths and a cumulative 5-year survival of 64% in patients referred to our tertiary care cancer center.

Functional assessment of chest wall integrity after methylmethacrylate reconstruction

BACKGROUND

All patients with extensive resection of the anterolateral chest wall and the sternum followed by reconstruction with methylmethacrylate substitutes were assessed prospectively 6 months after the operation to delineate chest wall integrity with pulmonary function and cine-magnetic resonance imaging.

METHODS

Twenty-six patients underwent chest wall reconstruction by use of methylmethacrylate between 1994 and 1998 due to primary tumors in 35%, metastases in 27%, T3 lung cancer in 19%, and debridement for radionecrosis and osteomyelitis in 19% of patients. Three to eight ribs were resected and additional sternum resection was performed in 39% of patients.

RESULTS

There was no 30-day mortality. All patients were extubated after the operation without need for reintubation. Prosthesis dislocation occurred in 1 patient and infection in 2 patients during follow-up. Nineteen patients (73%) suffered no restrictions of daily activities. Clinical examination revealed normal shoulder girdle function in 77% of patients. There was no significant difference between preoperative and postoperative FEV1 (forced expiratory volume in 1 second) measurements in patients with lobectomy or wedge resections. Cinemagnetic resonance imaging revealed concordant chest wall movements during respiration in 92% of patients without paradoxical movements or implant dislocations being observed.

CONCLUSIONS

Large defects of the anterolateral chest wall and sternum can be reconstructed efficiently with methylmethacrylate substitutes with minimal morbidity and excellent cosmetic and functional outcome.

Early and long-term results of prosthetic chest wall reconstruction

OBJECTIVE

The purpose of this report is to evaluate our results in patients who underwent prosthetic bony reconstruction after chest wall resection.

METHODS

We retrospectively reviewed all patients who underwent chest wall resection and reconstruction with prosthetic material at the Mayo Clinic.

RESULTS

From January 1, 1977, to December 31, 1992, 197 patients (109 male patients and 88 female patients) underwent chest wall resection and reconstruction with prosthetic material. Median age was 59 years (range, 11-86 years). The indication for resection was recurrent chest wall malignancy in 65 patients (33.0%), primary chest wall malignancy in 62 patients (31.5%), contiguous lung or breast carcinoma in 58 patients (29.4%), and other reasons in 12 patients (6.1%). Three patients (1.5%) each had an open draining wound. This review covers 2 time periods. Sixty-four patients (32.5%) underwent reconstruction with polypropylene mesh during the period from 1977 to 1986. One hundred thirty-three patients (67.5%) underwent reconstruction with polytetrafluoroethylene from 1984 to 1992. Soft tissue coverage was achieved with transposed muscle in 116 patients (58.9%), local tissue in 81 patients (41.1%), and omentum in 3 patients (1.5%). There were 8 deaths (operative mortality rate, 4.1%). Ninety-one patients (46.2%) experienced complications. Seromas occurred in 14 patients (7.1%). Wound infections occurred in 9 patients (4.6%; 5 patients with polypropylene mesh and 4 patients with polytetrafluoroethylene). The prosthesis was removed in all 5 patients with polypropylene mesh and in none of the patients with polytetrafluoroethylene. Follow-up was complete in 179 operative survivors (94.7%) and ranged from 1 to 204 months (median, 26 months). A well-healed asymptomatic wound was present in 127 patients (70.9%).

CONCLUSIONS

Chest wall resection and reconstruction with prosthetic material will yield satisfactory results in most patients. Little difference exists between polypropylene mesh and polytetrafluoroethylene.

Capsular replacement with synthetic mesh: effectiveness in preventing postoperative dislocation after wide resection of proximal femoral tumors and prosthetic reconstruction

We describe a surgical technique for replacing the hip joint capsule using synthetic mesh after oncological resections of the proximal femur that resulted in gross intraoperative instability of the prosthetic reconstruction. The results of its use in 13 patients, 6 of whom also had pelvic resections, are described. These patients were selected from a total group of 88 patients undergoing proximal femoral replacement, 75 of whom did not require capsular replacement (none of these 75 patients have experienced dislocation). In the group requiring capsular reconstruction, 1 of 4 patients with bipolar hemiarthroplasty and 4 of 9 patients with total hip replacements experienced dislocation after operation. Of the dislocated total hip replacements, 1 remains chronically dislocated, and 3 were successfully stabilized by open reduction with further capsular augmentation. Given that the resections involved removal of most of the soft tissues stabilizing the hip joint, we believe that the technique of capsular reconstruction is useful in this difficult group of patients.

Closure of complex defects in the chest wall with muscle flaps

Aggressive treatment of thoracic malignancy may be complicated by complex defects in the chest wall. These may be associated with serious complications such as chronic infection, respiratory or cardiac failure, or major haemorrhage. Closure of the defect and restoration of the integrity of the chest wall is important for both functional and cosmetic reasons. Local flaps are often used, but may be inadequate or unavailable. Reconstruction with free flaps is better in these cases, as this provides as much abundant well-vascularised tissue as is required. We present 12 patients treated successfully for complex chest wall defects using various forms of local and free flap reconstruction. There were five complications, three healed spontaneously and two required secondary procedures before they healed.