Thoracic reconstruction with the omentum: indications, complications, and results

A long-term follow up of the laparoscopically harvested free omental flap for breast reconstruction

BACKGROUND

There are different types of reconstruction after mastectomy and breast-conserving surgery. Autologous reconstructions are nowadays more often preferred over implant-based reconstructions for many reasons. A more natural looking breast with a durable long-term result is one of the advantages. The greater omentum is frequently used in the general field of reconstructive surgery but has not been widely adopted in breast surgery. This report is the first larger series of patients who underwent a breast reconstruction using the laparoscopically harvested omental free flap (LHOFF). The aim of this report is to provide information about indication, surgical technique, short- and long-term complications, and patient satisfaction with aesthetic outcomes and health-related quality of life (HR-QoL).

METHODS

Patients underwent a breast reconstruction with the LHOFF from 2014 to 2021 in Máxima Medical Center, Veldhoven, the Netherlands. All patients underwent a diagnostic laparoscopy prior to the reconstruction to examine whether the volume of omentum was deemed sufficient. Outcome measures included the Breast-Q for HR-QoL, patient satisfaction, short- and long-term complications, and abdominal complaints related to the transplanted omentum. Surgical data were retrieved retrospectively.

RESULTS

Twenty-six patients were included in this article. Patients were 40 to 71 years old with a mean BMI of 21.5 (range 17.0-25.0). Mean weight of the omental free flap was 228 g (range 112-395). Four out of 26 cases underwent surgery due to venous congestion. There was one case of flap failure due to venous thrombosis. Mean time of follow-up was 54 months (range 8-179). Secondary corrections include a nipple reconstruction (n = 11), lipofilling (n = 11), a contralateral breast reduction (n = 3) or a breast implant (n = 2). Patients reported improvement in HR-QoL and good satisfaction with aesthetic outcomes. No abdominal complications were reported during the follow-up period.

CONCLUSION

The LHOFF is an autologous breast reconstruction technique that results in a soft, small breast with natural ptosis and minimal donor site morbidities. Patients report satisfactory aesthetic outcomes and good quality of life. The main limitation of this technique is the limited amount of volume of the omentum and the possible need for secondary corrections. No abdominal complications were reported. In the future, larger prospective studies are required to support implementation of the LHOFF reconstruction on a broader scale.

Extended arc of rotation of Latissimus Dorsi Musculocutaneous Flap providing well-vascularized tissue for reconstruction of complete defects of the sternum: An anatomical study of flap pedicle modification

BACKGROUND

Deep sternal wound infections (DSWI) following cardiothoracic surgery represent a life quality endangering sequelae and may lead to sternal osteomyelitis. Radical debridement followed by Negative Pressure Wound Therapy (NPWT) may achieve infection control, provide angiogenesis, and improve respiratory function. When stable wound conditions have been established a sustainable plastic surgical flap reconstruction should be undertaken.

OBJECTIVE

This study analyses a method to simplify defect coverage with a single Latissimus Dorsi Myocutaneous Flap (LDMF).

METHODS

Preparation of 20 LDMF in ten fresh frozen cadavers was conducted. Surgical steps to increase pedicle length were evaluated. The common surgical preparation of LDMF was compared with additional transection of the Circumflex Scapular Artery (CSA).

RESULTS

Alteration of the surgical preparation of LDMF by sacrificing the CSA may provide highly valuable well-vascularized muscle tissue above the sensitive area of the Xiphisternum. All defects could be completely reconstructed with a single LDMF. The gain in length of flap tissue in the inferior third of the sternum was 3.86±0.9 cm (range 2.2 to 8 cm).

CONCLUSIONS

By sacrificing the CSA in harvesting the LDMF a promising gain in length, perfusion and volume may be achieved to cover big sternal defects with a single flap.

The Utility of the Omentum Flap for Complex Intrathoracic Problems

Introduction: Omentum flap is a viable reconstructive option for complex chest wall and mediastinal reconstruction. The impact of vasoconstrictors and the laminar pattern of blood flow associated with left ventricular assist devices (LVADs) on the outcomes of reconstructions has not been thoroughly evaluated. Methods: A retrospective review of all patients who underwent chest wall or mediastinal reconstruction using pedicled omentum flaps between 2003 and 2019. Results: Forty patients (60% males) underwent chest wall or mediastinal reconstruction using a pedicled omentum flap at a mean age of 58 years. The median follow-up was 24.3 months. The most common indication was the reconstruction of anterior chest wall/sternal defects (n = 16), followed by coverage of repaired bronchopleural fistula (n = 6), osteoradionecrosis of the anterolateral chest wall (n = 5), reconstruction of anterior/lateral chest wall following oncologic resections (n = 5), coverage of replaced infected LVAD (n = 4), and coverage of exposed/replaced aortic root vascular grafts (n = 4). Vasoconstrictors were used in 26 patients (65%). Eight flaps had partial necrosis, and none of the flaps had complete necrosis. There was no difference in flap complication rates in patients who received vasoconstrictors during the case compared to those who did not (P = 1.0). Thirteen (33%) flaps were skin grafted at a median of 13 days with 100% skin graft viability. Abdominal incisional hernia developed in 8 patients. In patients with LVADs, the omentum remained viable during the follow-up period. Conclusion: The ability of the omentum to easily reach various regions in the chest and the low failure rate make this flap a reliable reconstructive method.

Omental Flap for Complex Sternal Wounds and Mediastinal Infection Following Cardiac Surgery

INTRODUCTION

Omental flap (OF) is a traditional surgical option to counteract severe postcardiotomy mediastinal infection and to cover extensive sternal defects. We reviewed our experience with omental flap transfer (OFT) in various clinical circumstances, in which omentoplasty may be considered by cardiac surgeons.

METHODS

Twenty-one patients, who underwent OFT from January 2012 to December 2021, were studied. The main indication was treatment of infected foreign material implants including vascular grafts and ventricular assist devices or prevention of its infection (16 patients). In five patients, an OFT was used to cure mediastinitis following deep sternal wound infection after median sternotomy.

RESULTS

All patients had a high surgical risk with 3 ± 1.9 previous sternotomies and a mean Euro Score II of 55.0 ± 20.1. OF was successful in its prophylactic or therapeutic purpose in all patients, no complications related to the operative procedure were noted, that is, no early or late flap failure and no herniation of abdominal organs occurred. In-hospital mortality was six patients as three patients each died from multiple organ dysfunction syndrome and cerebral hemorrhage. All fifteen patients discharged demonstrated rapid recovery, complete wound healing without fistula, and no late gastrointestinal complications. The mean follow-up of 18 months was uneventful.

CONCLUSION

OFT seems to be an excellent solution for extensive mediastinal and deep sternal wound infections.

A Novel Fat-Augmented Omentum-Based Construct for Unilateral and Bilateral Free-Flap Breast Reconstruction in Underweight and Normal Weight Women Receiving Nipple or Skin-Sparing Mastectomies

BACKGROUND

Autologous tissue has proven advantages, however it is often not an option for women of low or normal body mass index (BMI). Omentum has been used sparingly, typically as a pedicled flap to correct breast deformities, but is considered suboptimal for full breast reconstruction. We developed a new construct, the omental fat-augmented free flap (O-FAFF) as an alternative for breast reconstruction.

METHODS

O-FAFF involves laparoscopic omentum harvesting, creation of an acellular dermal matrix shell for its encasement, and lipoinjection to augment volume. The gastroepiploic vessels are microsurgically anastomosed to internal mammary vessels. Tissue and O-FAFF construct weights as well as outcomes are reported.

RESULTS

Thirty-four consecutive women (50 breasts) received O-FAFF breast reconstruction after 18 unilateral and 16 bilateral mastectomies (10 non-nipple-sparing, 40 nipple-sparing). Thirty-seven were immediate and 13 were revisions of previous breast reconstructions. Patient mean age was 48.2 (range 23-73) years and mean BMI was 22.3 (range 17.6-32.4) kg/m². Mean follow-up was 14.8 (range 3-33) months. The median weight of the omentum was 161.7 g (range 81-852, interquartile range [IQR] 102) and the mean ratio of fat to omentum weight was 0.73 (range 0.22-1.38) and 1.97 (range 0.24-3.8) for unilateral and bilateral cases, respectively. Postoperative pain scores and oral morphine equivalent consumption were more favorable for the O-FAFF group compared with controls (p < 0.001). Follow-up breast MRI demonstrated intact perfusion and no fat necrosis.

CONCLUSIONS

The O-FAFF is ideally suited for women of lower BMI and could dramatically increase the number of women who are candidates for autologous breast reconstruction.

Reconstruction of a Large Thoracic Radiation-Induced Ulcer Using a Free Extended Vertical Rectus Abdominis Myocutaneous Flap

Radiation therapy-induced skin ulcers are complex wounds that are unable to heal spontaneously. This affects the patient's quality of life and poses a major health problem. The most reliable curative treatment involves extensive debridement of the affected tissue and covering the wound with well-vascularized tissue. We report the case of a 76-year-old woman with a huge clavicle osteoradionecrosis ulcer that required complex resection and reconstruction with an extended vertical rectus abdominis myocutaneous flap.

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.

Extending the Indication of the Superior Thyroid Artery as a Recipient Vessel for Complex Upper Body Defects

BACKGROUND

Reconstruction of complex chest and upper back defects can pose a challenge to microsurgeons, especially when prior surgery, scarring, tumor resection, or radiotherapy, have caused a shortage of recipient vessels. Although already being a standard approach for head and neck reconstructions, we investigated whether the indication of the superior thyroid artery (STA) as a safe and universal recipient vessel could be extended for reconstruction in aforementioned regions.

METHODS

Seventeen patients received free myocutaneous vastus lateralis (MVL) muscle flaps for reconstruction of upper body defects (chest n = 11; upper back n = 6). In all cases, the STA was used for microvascular anastomosis because of a lack of standard recipient vessels. A retrospective chart review was performed and the data was screened for patients' demographics, intraoperative and perioperative details, flap survival, surgical complications, and overall long-term outcomes. Patients had a minimum follow-up of 6 months.

RESULTS

Defects resulted from infections after cardiac surgery (n = 10), infections after spinal neurosurgery (n = 2) or tumor resection (n = 5). Average defect size measured 144.6 (range, 40-286 cm2; ±67.9 cm2), with a mean size of the MVL free flaps of 266.8 (range, 160-384 cm2; ±69.5 cm2). The flap success rate was 100%, with minor complications in 4 patients. No major complications were observed in any of the patients.

CONCLUSIONS

The STA is a viable and safe alternative as a recipient vessel for reconstruction of upper body defects, especially when other vessels in proximity to the defect are deprived.

Omental free flap for surgical treatment of chronic osteomyelitis of lower limb: A technical note

Soft tissue reconstruction of chronic lower extremity wounds with bone infection entails an important challenge in reconstructive surgery. We report our experience using the omentum free flap to provide coverage in two patients suffering chronic osteomyelitis of the lower limbs. After extensive soft tissue and bone debridement, an omentum free flap was performed in both cases, providing dead space obliteration and soft tissue coverage in behalf of its large size and pliability. As a result, the chronic illness was eradicated in both patients, with satisfactory outcomes and infection resolution.

Deep sternal wound infection following cardiac surgery: A comparison of the monolateral with the bilateral pectoralis major flaps

Deep sternal wound infections are a serious complication following sternotomy for cardiothoracic surgery. "Conventional" treatment provides debridement and secondary closure or closed catheter irrigation. The combination of the Negative Pressure Therapy with flap coverages is an accepted technique and one or both Pectoralis Major muscles could be chosen. A multistep protocol was adopted. One hundred and sixty seven patients were treated with the combination of Negative Pressure Therapy with the Pectoralis Major muscle flap: 86 monolateral flap and 81 bilateral flap reconstruction. The main complications (hematoma, seroma, dehiscence, and re-infection), the need for re-intervention, mortality rates, Intensive Care Unit, and hospitalisation time were assessed. The mono-pectoralis group had fewer complications and need for revision, with a shorter hospital stay. A statistically significant difference emerged for the hematoma rate (P = .0079). Monolateral flap should to be preferred because with the same coverage effectiveness, it guarantees the saving of controlateral muscle with its functionality and the possibility of its use in case of failure. Furthermore, as the technique is less invasive, it can be reserved for more fragile patients.

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.

Radiation-induced thoracic necrosis with a pulmonary cutaneous fistula repaired using a free omental flap: a case report

Background

Chest wall necrosis can manifest as a late effect of radiation therapy for breast cancer. Only two cases of fistulas communicating with the respiratory tract as a result of radiation-induced necrosis of the lungs or bronchi have been reported. To the best of our knowledge, we report the first case of a pulmonary cutaneous fistula arising as a late effect of radiation therapy for breast cancer, which was successfully repaired using a free omental graft.

Case presentation

A 64-year-old woman underwent Halsted surgery and postoperative radiation therapy for breast cancer 25 years earlier. One year before visiting our hospital, she developed a fistula and bleeding in her left clavicular region, which was expanding. On initial examination, a 6-cm-wide skin defect was observed in the left clavicular region and the clavicle appeared sequestrated. Computed tomography revealed part of the first to third left ribs, part of the left clavicle, the subclavian artery, and the brachial plexus to be missing. Several rounds of debridement revealed approximately 10 bronchial stumps on the surface of the collapsed lung, from which exhaled air and sputum were effusing. Surgery was performed to implant a free omental flap with vascular anastomosis and a skin graft in the neck region, and the pulmonary cutaneous fistula was closed. Two years after surgery, emphysema remained inside the omentum, which spontaneously resolved by the 3rd postoperative year.

Conclusions

Various treatment options are conceivable for the repair of pulmonary cutaneous and bronchocutaneous fistulas induced by radiation damage (e.g., free tissue grafts and endoscopic bronchial occlusion); however, these are rarely reported, and the most reliable method thus remains unclear. Positive outcomes in our case indicate that implanting a free omental graft may be effective. Furthermore, spontaneous healing can be expected for the residual emphysema inside the omentum.

Single- versus 2-stage reconstruction for chronic post-radiation chest wall ulcer: A 10-year retrospective study of chronic radiation-induced ulcers

Radiation therapy can have adverse effects on normal tissue and cause chronic ulcers. The purpose of this study was to compare breast cancer patients who underwent single-stage reconstruction with patients who underwent 2-stage reconstruction for chronic radiation-induced necrotic ulcers of the chest wall.This retrospective study comprised of 50 patients with chronic radiation-induced chest wall ulcers who underwent chest wall reconstruction in our hospital between January 2002 and January 2016. All patients developed ulcers after undergoing breast cancer surgery, followed by radiation therapy. These patients were divided into 2 groups: group A, patients who underwent debridement and reconstruction with tissue flaps simultaneously in a single-stage procedure; group B, patients who underwent debridement and omentum majus tamping in the 1st stage, followed by surgical reconstruction with skin grafting or flap transfer 2 weeks later. The postoperative complications and outcomes were evaluated and compared.These patients were followed up for 48 to 55 months (mean: 50 months), and overall survival was 98%. One patient in group A died of septicemia 5 days after the operation. Six patients in group A developed flap infection, among which 4 patients progressed to flap necrosis (group A: 6/25 vs group B: 0/25; P = .000).Compared to single-stage reconstruction, surgical reconstruction in 2 stages was safer and more effective in treating chronic radiation-induced ulcers of the chest wall, and is associated with fewer postoperative complications. The omentum majus flap was the most ideal tissue for the repair of these defects.

Laparoscopic Harvesting of Omental Flaps for Breast Reconstruction-A Review of the Literature and Outcome Analysis

Background

Evidence on the use of omental flaps for breast reconstruction in patients with breast cancer is lacking, and no published reviews report an outcome-based assessment of such flap. This review explores available data and evidence for change in complication rates following the shift toward laparoscopic harvesting.

Methods

We searched the databases Excerpta Medica database, MEDLINE, and PubMed from inception until December 2015 using search terms "omental flaps" and "breast reconstruction." Data extracted were patient characteristics, technique used, and outcome measures reported and were then analyzed based on the technique of harvesting.

Results

Twenty-two articles reporting 651 patients who underwent mastectomies and breast-conserving surgeries were included in this review. Most flaps, 537 (82.5%), were harvested by laparoscopy, and 626 (96.2%) of the flaps were pedicle flaps. The mean age was 47.7 years (standard deviation: 4.29), and mean follow-up was 38.1 months. There were 88 reported complications among 562 patients in 16 reports. The rate of any complication was calculated to be 15.0%, with a higher rate (29.1%) occurring with the open technique in comparison to laparoscopy (12.6%). The commonest complications were postoperative infection and breast firmness each reported in 2.22%. Most authors reported advantages of malleability and excellent aesthetic outcomes and disadvantages in terms of inability to estimate the volume of the flap and variability in size.

Conclusion

Omentum use is safe and has advantages in breast reconstruction where other options are limited including a natural feeling and minimal donor site morbidity if harvested laparoscopically.

[Greater omentum flap: Treatment of chronic wounds and seroma: About a case]

INTRODUCTION

Cicatricial complications after abdominal or pelvic surgery are more frequent in obese patients. In this case, infection, seroma and delays in scarring can be extremely difficult to treat. The objective of this technical note is to present an original case of an obese patient operated nine years ago of a hysterectomy by laparotomy and chronically presenting a non-resolving septic seroma despite multiple surgical procedures whose healing could be obtained by a flap of greater omentum.

SURGICAL TECHNIQUE

The ideal is to carry out this intervention in a double team with a digestive surgeon in case of intra-abdominal visceral or vascular wound during dissection. The greater omentum flap was raised in a conventional manner over the gastroepiploic artery. A sufficiently wide orifice should be left at the level of the abdominal aponeurosis in order to avoid any compression of the pedicle. Finally, the flap must be spread over the whole surface of the detachment and fixed to the anterior aponeurosis.

CONCLUSION

Reliability and vascular and lymphatic richness make the greater omentum flap a very effective method in chronic wound cases associated with important seroma. The scarring obtained in the clinical case presented thus highlights the specific qualities of this flap.

Limited Bilateral Advancement of the Sternocostal Head of Pectoralis Major for Sternal Reconstruction: Preserving the Axillary Fold

The introduction of well-vascularized flaps for infected sternotomy wound reconstruction has improved mortality rates dramatically. Multiple variations of the pectoralis major flap have been described in this context. However, unresolved limitations of this flap include poor cosmesis and problematic coverage of the inferior third of the sternotomy wound. We describe an approach to address these issues. The humeral attachments are preserved and bilateral muscles are advanced in a limited fashion. The left sternocostal head is advanced medially and rotated anticlockwise, using this portion to fill the upper half of the sternum while the caudal portion of the right pectoralis muscle is used as a turnover flap at the lower half of the wound. In all 25 patients, the anterior axillary fold was preserved bilaterally and the infection completely resolved. Complications included 3 cases of hematoma, 2 cases of coagulopathy, and 1 late bone sequestrum (aseptic). Although the study had a limited sample size, we had a high rate of success and few complications. With the preservation of bilateral axillary folds, good cosmesis, and adequate wound coverage, we recommend this modification of the pectoralis major flap in even complicated cases of mediastinitis.

Chest wall reconstruction after extended resection

Extensive chest wall resection and reconstruction is a challenging procedure that requires a multidisciplinary approach, including input from thoracic surgeons, plastic surgeons, neurosurgeons, and radiation oncologists. The primary goals of any chest wall reconstruction is to obliterate dead space, restore chest wall rigidity, preserve pulmonary mechanics, protect intrathoracic organs, provide soft tissue coverage, minimize deformity, and allow patients to receive adjuvant radiotherapy. Successful chest wall reconstruction requires the re-establishment of skeletal stability to prevent chest wall hernias, avoids thoracoplasty-like contraction of the operated side, protects underlying viscera, and maintain a cosmetically-acceptable appearance. After skeletal stability is established, full tissue coverage can be achieved using direct closure, skin grafts, local advancement flaps, pedicled myocutaneous flaps, or free flaps. This review examines the indications for chest wall reconstruction and describes techniques for establishment of chest wall rigidity and soft tissue coverage.

The laparoscopically harvested omentum as a free flap for autologous breast reconstruction

BACKGROUND

In autologous breast reconstruction, abdominal based flaps are by far the most common choice from the wide range of free flaps available. In selected cases, a laparoscopically harvested omental free flap (LHOFF) can be used. Patient satisfaction has not been reported until now. In this article, we report our experience using LHOFF in breast reconstruction including our technique, patient satisfaction, and donor/recipient site complications.

PATIENTS AND METHODS

Between 2007 and 2014, six patients underwent autologous breast reconstruction with LHOFF. Four patients had undergone radical mastectomy and two patient developed prosthesis complications after lumpectomy and breast augmentation. The omentum was harvested laparoscopically. The gastroepiploic vessels were anastomosed to the internal mammary vessels. A retrospective chart review was performed to retrieve surgical data. All the patients completed a questionnaire about their outcome.

RESULTS

Mean weight of the omentum was 224 g. There were no flap failures. Two patients required a second surgical procedure due to complications. In one patient, a salvage procedure was required due to a venous thrombosis, whereas in the other, there was necrosis of the skin flap. No abdominal complications or volume loss occurred. Mean follow-up was 30.5 months. The aesthetic results were very satisfactory with minimal scars and good breast volume.

CONCLUSION

Autologous breast reconstruction using an LHOFF can be used effectively in selected cases. The aesthetic results are pleasing with minimal scarring, good volume, and a soft, natural feeling breast.

A Twelve-Year Consecutive Case Experience in Thoracic Reconstruction

Background:

We describe the second largest contemporary series of flaps used in thoracic reconstruction.

Methods:

A retrospective review of patients undergoing thoracomyoplasty from 2001 to 2013 was conducted. Ninety-one consecutive patients were identified.

Results:

Thoracomyoplasty was performed for 67 patients with intrathoracic indications and 24 patients with chest wall defects. Malignancy and infection were the most common indications for reconstruction (P < 0.01). The latissimus dorsi (LD), pectoralis major, and serratus anterior muscle flaps remained the workhorses of reconstruction (LD and pectoralis major: 64% flaps in chest wall reconstruction; LD and serratus anterior: 85% of flaps in intrathoracic indication). Only 12% of patients required mesh. Only 6% of patients with <2 ribs resected required mesh when compared with 24% with 3–4 ribs, and 100% with 5 or more ribs resected (P < 0.01). Increased rib resections required in chest wall reconstruction resulted in a longer hospital stay (P < 0.01). Total comorbidities and complications were related to length of stay only in intrathoracic indication (P < 0.01). Average intubation time was significantly higher in patients undergoing intrathoracic indication (5.51 days) than chest wall reconstruction (0.04 days), P < 0.05. Average hospital stay was significantly higher in patients undergoing intrathoracic indication (23 days) than chest wall reconstruction (12 days), P < 0.05. One-year survival was most poor for intrathoracic indication (59%) versus chest wall reconstruction (83%), P = 0.0048.

Conclusion:

Thoracic reconstruction remains a safe and successful intervention that reliably treats complex and challenging problems, allowing more complex thoracic surgery problems to be salvaged.

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.

Thoracic Wall Reconstruction after Tumor Resection

Introduction

Surgical treatment of malignant thoracic wall tumors represents a formidable challenge. In particular, locally advanced tumors that have already infiltrated critical anatomic structures are associated with a high surgical morbidity and can result in full-thickness defects of the thoracic wall. Plastic surgery can reduce this surgical morbidity by reconstructing the thoracic wall through various tissue transfer techniques. Sufficient soft-tissue reconstruction of the thoracic wall improves quality of life and mitigates functional impairment after extensive resection. The aim of this article is to illustrate the various plastic surgery treatment options in the multimodal therapy of patients with malignant thoracic wall tumors.

Materials and methods

This article is based on a review of the current literature and the evaluation of a patient database.

Results

Several plastic surgical treatment options can be implemented in the curative and palliative therapy of patients with malignant solid tumors of the chest wall. Large soft-tissue defects after tumor resection can be covered by local, pedicled, or free flaps. In cases of large full-thickness defects, flaps can be combined with polypropylene mesh to improve chest wall stability and to maintain pulmonary function. The success of modern medicine has resulted in an increasing number of patients with prolonged survival suffering from locally advanced tumors that can be painful, malodorous, or prone to bleeding. Resection of these tumors followed by thoracic wall reconstruction with viable tissue can substantially enhance the quality of life of these patients.

Discussion

In curative treatment regimens, chest wall reconstruction enables complete resection of locally advanced tumors and subsequent adjuvant radiotherapy. In palliative disease treatment, plastic surgical techniques of thoracic wall reconstruction provide palliation of tumor-associated morbidity and can therefore improve patients’ quality of life.

Breast necrosis secondary to vasopressor extravasation: management using indocyanine green angiography and omental flap closure

Extravasation is a rare but serious complication of vasopressor administration. A 60-year-old female who underwent ascending and hemiarch repair of the aorta along with aortic valve replacement developed extensive right breast and chest wall necrosis after vasopressor extravasation from an internal jugular vein central line. The patient underwent a total mastectomy due to deep tissue necrosis detected by laser-assisted indocyanine green dye angiography, and eventually required omental flap reconstruction to obtain adequate sternal coverage. This case represents a previously unreported complication of internal jugular central line extravasation of vasopressors with resultant breast and chest wall necrosis, and highlights the utility of the omentum in chest wall reconstruction.

Omentum for Mammary Disorders: A 30-Year Systematic Review

PURPOSE

Although the safety of applying omentum to the female breast for total breast reconstruction is controversial, it has recently been used to treat certain mammary disorders as well. A systematic review was therefore conducted to analyze and establish the suitability and safety of applying omentum to the breast.

METHODS

Covereing the interval from January 1984 to December 2013, we performed searches in MEDLINE, Embase, SciELO, and Google-Scholar for original articles describing the applicability of greater omentum to the breast and its clinical complications.

RESULTS

Sixty observational articles with 985 women were chosen. The main clinical indications were total breast reconstruction after mastectomy due to breast cancer (45 studies), radiation damage (23 studies), and congenital Poland syndrome (4 studies). Altogether, 273 complications were identified among the 985 women treated. The most frequent was flap necrosis (26.74 %). The most serious was injury to the digestive system (1.10 %). There was a 35.48 % incidence of local breast cancer recurrence in eight observational studies on oncological risk. Seven of the eight included only women with advanced cancer. One of these studies reported the incidence and relapse time predominantly according to the primary tumor size.

CONCLUSIONS

Although the oncological risk remains unclear, there was a high volume of complications that affected the digestive system. These findings suggest that omentum has well established applicability, but only for total breast reconstruction of huge defects, where muscular/myocutaneous or perforator flaps may be unsuitable.

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.

Reconstruction of chest wall chondrosarcoma with an anterolateral thigh free flap: An illustration of decision-making in chest wall reconstruction

INTRODUCTION

Chondrosarcomas are the most common primary chest wall malignancy. The mainstay of treatment is radical resection, which often requires chest wall reconstruction. This presents numerous challenges and more extensive defects mandate the use of microvascular free flaps. Selecting the most appropriate flap is important to the outcome of the surgery.

PRESENTATION OF CASE

A 71-year-old male presented with a large chondrocarcoma of the chest wall. The planned resection excluded use of the ipsilateral and contralateral pectoralis major flap because of size and reach limitations. The latissimus dorsi flap was deemed inappropriate on logistical grounds as well as potential vascular compromise. The patient was too thin for reconstruction using an abdominal flap. Therefore, following radical tumour resection, the defect was reconstructed with a methyl methacrylate polypropylene mesh plate for chest wall stability and an anterolateral thigh free flap in a single-stage joint cardiothoracic and plastic surgical procedure. The flap was anastomosed to the contralateral internal mammary vessels as the ipsilateral mammary vessels had been resected.

DISCUSSION

The outcome was complete resection of the tumour, no significant impact on ventilation and acceptable cosmesis.

CONCLUSION

This case demonstrates the complex decision making process required in chest wall reconstruction and the versatility of the ALT free flap. The ALT free flap ensured adequate skin cover, subsequent bulk, provided an excellent operative position, produced little loss of donor site function, and provided an acceptable cosmetic result.

Our experience with pectoralis major flap for management of sternal dehiscence: A review of 25 cases

Objective:

To report our experience of the pectoralis major flap as the treatment modality for post coronary artery bypass sternal wound dehiscence.

Materials and Methods:

A retrospective study of 25 open heart surgery cases, performed between January 2006 and December 2010 at Deenanath Mangeshkar Hospital, Pune, was carried out. Unilateral or bilateral pectoralis major muscle flap by the double breasting technique using rectus extension was used in the management of these patients. The outcome was assessed on the basis of efficacy of flap surgery in achieving wound healing and post-surgery shoulder joint movements to evaluate donor site morbidity. The follow-up ranged from 5 months to 3.5 years.

Results:

Twenty-three (92%) patients were discharged with complete wound closure. One patient (4%) had wound dehiscence after flap surgery. One patient (4%) died in the hospital in the immediate postoperative period due to mediastinitis. No recurrent sternum infection has occurred till date in 24 patients (96%). For one patient (4%) who had wound dehiscence, daily dressing was done and wound healing was achieved with secondary intension. At follow-up, shoulder joint movements were normal in all the patients.

Conclusions:

The double breasting technique of the pectoralis major muscle flaps with rectus sheath extension is efficient in covering the entire length of the defect and can reduce the morbidity, without affecting the function of the shoulder joint.

Omentum-wrapped scaffold with longitudinally oriented micro-channels promotes axonal regeneration and motor functional recovery in rats

Background

Tissue-engineered nerve scaffolds hold great potential in bridging large peripheral nerve defects. However, insufficient vascularization of nerve scaffolds limited neural tissues survival and regeneration, which hampered the successful implantation and clinical application of nerve scaffolds. The omentum possesses a high vascularization capacity and enhances regeneration and maturation of tissues and constructs to which it is applied. However, combined application of nerve scaffolds and omentum on axonal regeneration and functional recovery in the treatment of large peripheral nerve defects has rarely been investigated thus far.

Methods

In the present study, an omentum-wrapped collagen-chitosan scaffold was used to bridge a 15-mm-long sciatic nerve defect in rats. Rats that received nerve autografts or scaffolds alone were served as positive control or negative control, respectively. The axonal regeneration and functional recovery were examined by a combination of walking track analysis, electrophysiological assessment, Fluoro-Gold (FG) retrograde tracing, as well as morphometric analyses to both regenerated nerves and target muscles.

Findings

The results demonstrated that axonal regeneration and functional recovery were in the similar range between the omentum-wrapping group and the autograft group, which were significantly better than those in the scaffold alone group. Further investigation showed that the protein levels of vascular endothelial growth factor (VEGF), brain-derived neurotrophic factor (BDNF) and nerve growth factor (NGF) were significantly higher in the omentum-wrapping group than those in the scaffold alone group in the early weeks after surgery.

Conclusion

These findings indicate that the omentum-wrapped scaffold is capable of enhancing axonal regeneration and functional recovery, which might be served as a potent alternative to nerve autografts. The beneficial effect of omentum-wrapping on nerve regeneration might be related with the proteins produced by omentum.

Risk analysis and outcome of mediastinal wound and deep mediastinal wound infections with specific emphasis to omental transposition

BACKGROUND

To report our experience, with Deep mediastinal wound infections (DMWI). Emphasis was given to the management of deep infections with omental flaps

METHODS

From February 2000 to October 2007, out of 3896 cardiac surgery patients (prospective data collection) 120 pts (3.02%) developed sternal wound infections. There were 104 males & 16 females; (73.7%) CABG, (13.5%) Valves & (9.32%) CABG and Valve.

RESULTS

Superficial sternal wound infection detected in 68 patients (1.75%) and fifty-two patients (1.34%) developed DMWI. The incremental risk factors for development of DMWI were: Diabetes (OR = 3.62, CI = 1.2-10.98), Pre Op Creatinine > 200 μmol/l (OR = 3.33, CI = 1.14-9.7) and Prolong ventilation (OR = 4.16, CI = 1.73-9.98). Overall mortality for the DMWI was 9.3% and the specific mortality of the omental flap group was 8.3%. 19% of the "DMWI group", developed complications: hematoma 6%, partial flap loss 3.0%, wound dehiscence 5.3%. Mean Hospital Stay: 59 ± 21.5 days.

CONCLUSION

Post cardiac surgery sternal wound complications remain challenging. The role of multidisciplinary approach is fundamental, as is the importance of an aggressive early wound exploration especially for deep sternal infections.

Sternal plate fixation for sternal wound reconstruction: initial experience (retrospective study)

Background

Median sternotomy infection and bony nonunion are two commonly described complications which occur in 0.4 - 5.1% of cardiac procedures. Although relatively infrequent, these complications can lead to significant morbidity and mortality. The aim of this retrospective study is to evaluate the initial experience of a transverse plate fixation system following wound complications associated with sternal dehiscence with or without infection following cardiac surgery.

Methods

A retrospective chart review of 40 consecutive patients who required sternal wound reconstruction post sternotomy was performed. Soft tissue debridement with removal of all compromised tissue was performed. Sternal debridement was carried using ronguers to healthy bleeding bone. All patients underwent sternal fixation using three rib plates combined with a single manubrial plate (Titanium Sternal Fixation System^®, Synthes). Incisions were closed in a layered fashion with the pectoral muscles being advanced to the midline. Data were expressed as mean ± SD, Median (range) or number (%). Statistical analyses were made by using Excel 2003 for Windows (Microsoft, Redmond, WA, USA).

Results

There were 40 consecutive patients, 31 males and 9 females. Twenty two patients (55%) were diagnosed with sternal dehiscence alone and 18 patients (45%) with associated wound discharge. Thirty eight patients went on to heal their wounds. Two patients developed recurrent wound infection and required VAC therapy. Both were immunocompromised. Median post-op ICU stay was one day with the median hospital stay of 18 days after plating.

Conclusion

Sternal plating appears to be an effective option for the treatment of sternal wound dehiscence associated with sternal instability. Long-term follow-up and further larger studies are needed to address the indications, benefits and complications of sternal plating.

Principles of chest wall resection and reconstruction

Despite significant improvements in surgical technique and perioperative care, the management of patients requiring chest wall resection and reconstruction is an ongoing challenge for thoracic surgeons. A successful approach includes a thorough assessment of the patient and the lesion, an adequate biopsy to confirm tissue diagnosis, and a well-established treatment plan. In the case of a primary tumor of the chest wall, the extent of the resection should not be limited by the size of the resulting defect. Following resection, chest wall reconstruction mandates an appreciation for restoration of functional and structural components. An algorithmic approach to chest wall reconstruction begins with the assessment of the nature of the defect, taking into consideration factors such as infection, tumor location, previous radiation therapy, and surgical intervention. The latter factors bear influence on the type of tissue required as well as whether reconstruction can be performed in a single stage or whether it is better delayed. Finally, patient factors including lifestyle and work, as well as prognosis, are considered to determine the best reconstructive option.

Omental transposition flap for sternal wound reconstruction in diabetic patients

In 2004, we published our 12-year experience with tissue transfer for deep sternal wound infection after median sternotomy, finding increased rates of reoperation for diabetic patients. Therefore, we decided to alter our treatment approach to diabetic patients to include sternal debridement followed by omental transposition. Eleven diabetic patients underwent omental transposition by our division during the study period. Hospital records were retrospectively reviewed to determine outcomes and complications. We found that diabetic patients treated after implementation of the new treatment approach were 5.4 times less likely to require reoperation for sternal wound management than were patients in the previous series, most of whom had been treated with pectoralis muscle flaps (95% confidence interval, 0.5- 50.5). By altering our treatment approach to use omental transposition as the initial surgical therapy, we were able to demonstrate a trend toward decreased need for flap revision in diabetic patients.

Sternal wound reconstruction: management in different cardiac populations

Poststernotomy mediastinitis is a feared complication for patients undergoing cardiac surgery associated with high rates of morbidity and mortality. Approximately 15% of patients will ultimately be readmitted for a recurrent sternal wound infection. The objective of this study is to review a large single surgeon experience with sternal wound patients managed with a variety of soft tissue flaps to assess mitigating factors, involved organisms, and treatment protocols as related to specific cardiac populations. Records for 136 sternal reconstruction patients treated from January 2000 to July 2007 were evaluated. Patients underwent a variety of cardiac surgeries including coronary artery bypass grafting (CABG), valve replacement, aortic reconstruction, heart transplantation, lung transplantation, and combinations of these procedures. A total of 39.2% of patients developed a sternal wound during the same admission as their cardiac surgery, at an average of 16.1 days. This rate was only 6% for CABG-only patients and rose to nearly 50% in heart transplant and CABG + valve patients. A total of 78.6% of heart transplant patients with a sternal wound had a history of ventricular assist device and 41% of all patients had at least 1 previous sternotomy. Thirteen patients (9.6%) had 1 or more recurrent infections requiring surgery; 50% occurring in transplant patients, most of whom had diabetes and/or renal insufficiency. The most common presenting symptom was drainage (n = 75, 55.6%) or wound dehiscence (n = 22, 16.3%). Twenty-five different organisms were identified; 26 patients (18.5%) had multiple organisms. Staphylococcus species were most common. Plastic surgery intervention occurred on average 109.2 days after cardiac surgery. CABG and CABG + valve patients most frequently received right pectoralis muscle turnover flaps or left pectoralis muscle advancement flaps. Ten heart transplant patients (37.0%) underwent omental flaps. The 30-day perioperative mortality rate was 13 patients (9.6%).

[Chest wall reconstruction in acquired defects]

Acquired chest wall defects present a challenging problem for thoracic surgeons. Many of such defects can be repaired with the use of local and regional musculocutaneous flaps, but larger defects compromising skeletal structure require increasingly sophisticated reconstructive techniques. The following discussion will review the options for repair acquired chest wall defects based in literature. The authors searched the Pubmed (www.pubmed.com) and found citations from January 1996 to February 2008. By reading the titles and the abstracts most of the citations were discharged because they focused in congenital chest wall defects or were cases report. However, many papers were found describing the outcome of large series of patients with acquired chest wall deformities. A review of recent literature shows that the repair of chest wall defects with soft tissues, if possible, remains the treatment of choice. Large chest wall defects require skeletal reconstruction to prevent paradoxical respiration. The selection of the most appropriate flap is primary dictated by the location and the size of the defect. It is important to transfer tissue with good vitality, so understanding the vascular supply is imperative. Autogenous grafts have been used in the past for skeletal reconstruction but a combination of synthetic materials with musculocutaneous flaps has been used lately. Based in the literature, the use of prosthetic material in chest wall reconstruction does not significantly increases the risk of wound infection.

[Restoration of intestinal continuity after Hartmann's procedure]

OBJECTIVE

To study was to investigate the associated morbidity and mortality of the restoration of intestinal continuity after Hartmann's procedure.

METHODS

Hospital records of 29 patients undergoing surgery to restoration of intestinal continuity after Hartmann's procedure at Hospital das Clínicas da Universidade Federal de Minas Gerais between January 1998 and December 2006 were retrospectively analyzed. Demographic, morbidity and mortality data were colleted.

RESULTS

There were 16 men and 13 women with mean age of 52.6 years. The median time between the Hartmann's procedure and the attempt of closure of colostomy was 17.6 months (range,1-84 months). The median operation time was 300 minutes (range, 180-720 min). The restoration of the continuity was successful in 27 patients (93%). Two patients had anastomotic leakage (7%) and 7 had wound infection (22%). The mortality rate was of 3.4% (1/29 patients). There were association between unsuccessful restoration of intestinal continuity and previous attempt of closure (p=.007), chemotherapy (p=.037) and long term stay with colostomy (p =.007).

CONCLUSION

The interval between the Hartmann's procedure and the restoration of intestinal continuity should not be long. The patients should be aware that in some circumstances the restoration of intestinal continuity after Hartmann's procedure is not possible due to local conditions of the rectum.

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.