Chest-wall reconstruction: an account of 500 consecutive patients

Primary Chest Wall Ewing Sarcoma: Treatment and Long-Term Results

OBJECTIVE

The aim of the study is to evaluate early and long-term results of chest wall primary Ewing's sarcoma patients treated in the time period February 2000-February 2023 by a multidisciplinary approach.

METHODS

We retrospectively reviewed the medical records of patients who underwent chest wall resection for a primary tumor. Treatment approach, extent of resection, 30-day mortality, overall survival (OS), local recurrence-free survival (LRFS), and metastasis-free survival (MFS) were analyzed.

RESULTS

Overall, n = 15 consecutive patients were treated for chest wall primary Ewing's sarcoma. A median of n = 3 ribs was resected with a median of n = 2 ribs adjacent to the lesion. Resections were extended to the adjacent structures in n = 5 patients (33.3%). In all cases, we performed a prosthetic reconstruction, associated with muscle flap (n = 10, 66.6%) or with rigid titanium bars and muscle flap (n = 6, 40%). A radical resection was accomplished in n = 13 patients (84.6%). The median surgical time was 310 ± 120 min; median hospitalization was 7.8 ± 1.9 days. Post-operative mortality was zero. We recorded n = 4 (30.7%) post-operative complication. The median follow-up (FU) was 26 months. Moreover, 5-year overall and event-free survival were 52% and 48%, respectively.

CONCLUSIONS

This case series confirms the benefit of the multidisciplinary approach for Ewing sarcomas in early and long-term results.

Expanded polytetrafluoroethylene mesh in chest-wall reconstruction: A 27-year experience

OBJECTIVE

The study objective was to evaluate the success of expanded polytetrafluoroethylene mesh in chest-wall reconstruction.

METHODS

We retrospectively reviewed patients who underwent expanded polytetrafluoroethylene (Gore-Tex) chest-wall reconstruction. The main outcome was a mesh-related event, defined as a mesh-related reoperation (eg, mesh infection requiring debridement with/without explant, tumor recurrence with explant) or structural dehiscence/mesh loosening with/without a hernia. Demographics and surgical outcomes were reported.

RESULTS

A total of 246 reconstructions met inclusion (1994-2021). Fifty-five reconstructions (22.4%) had mesh-related events within a median of 1.08 years (interquartile range, 0.08-4.53) postoperatively; those without had a stable chest for a median of 3.9 years (interquartile range, 1.59-8.23, P < .001). Forty-one meshes (16.6%) became infected, requiring reoperation. Eighty-eight percent (36/41) were completely explanted; 8.3% (3/36) required additional mesh placement. Predictors of mesh-related events were prior chest-wall radiation (odds ratio, 9.73, CI, 3.47-30.10, P < .001), higher body mass index (odds ratio, 1.08, CI, 1.01-1.16, P = .019), and larger defects (odds ratio, 1.48, CI, 1.02-2.17, P = .042). The risk of mesh-related events with obesity was higher with prior chest-wall radiation.

CONCLUSIONS

Most patients (78%) with an expanded polytetrafluoroethylene mesh had a stable reconstruction after a median of 4 years. Obesity, larger defects, and prior chest-wall radiation were associated with a higher risk of a mesh-related event mostly due to mesh infections. Seventeen percent of reconstructions had reoperation for mesh infection; 88% were completely explanted. Only 8% required replacement mesh, suggesting that experienced surgeons can safely manage them without replacement. Future studies should compare various meshes for high-risk patients to help guide the optimal mesh selection.

Postoperative Complications of Flap Procedures in Chest Wall Defect Reconstruction: A Two-Center Experience

Background and Objectives: Chest wall defect reconstruction is a complex procedure aimed at restoring thoracic structural integrity after trauma, tumor removal, or congenital issues. In this study, postoperative complications were investigated to improve the care of patients with these critical conditions. Materials and Methods: A retrospective study of chest wall reconstructions from 2004 to 2023 was conducted at Klinikum Nürnberg and Evangelisches Waldkrankenhaus Spandau-Berlin. Data included patient demographics, comorbidities, defect etiology, surgery details, and complications using the Clavien-Dindo classification. Results: Among the 30 patients included in the study, a total of 35 complications occurred in 35 thoracic wall defect reconstructions. These complications were classified into 22 major and 13 minor cases. Major complications were more common in patients with cancer-related defects, and considerable variations were observed between free flap and pedicled flap surgeries. Notably, the use of the anterolateral thigh (ALT) flap with vastus lateralis muscle demonstrated promise, exhibiting fewer complications in select cases. The reconstruction of chest wall defects is associated with substantial complications regardless of the etiology of the defect and the particular surgical procedure used. Interestingly, there was a lower complication rate with free flap surgery than with pedicled flaps. Conclusions: The ALT flap with vastus lateralis muscle deserves further research in this field of reconstruction. Multidisciplinary approaches and informed patient discussions are crucial in this complex surgical field, emphasizing the need for ongoing research and technique refinement.

Microsurgical reconstruction using thoracoacromial vessels as recipients for complicated chest wall defects

BACKGROUND

Free tissue transfer is often required for the reconstruction of complex and deep anterior chest wall wounds, for which the identification of suitable recipient vessels is crucial. Although the internal mammary arteries (IMAs) are a representative option, identifying secondary options when these vessels are compromised remains a challenge. This report evaluated the efficacy of using the thoracoacromial vessels (TAVs) as recipients for chest wall reconstruction by reviewing our experience.

METHODS

We conducted a retrospective review of patients undergoing free-flap-based chest wall reconstruction using TAVs as recipient vessels from February 2020 to March 2023. Patient demographics and surgery-related characteristics data were collected. The primary outcome of interest was the occurrence of flap perfusion-related complications.

RESULTS

In total, 12 cases utilized TAVs as recipients, primarily for defects following sternotomy, where bilateral IMA was unavailable due to prior surgery. The TAVs with reliable perfusion were consistently identified beneath the pectoralis major muscle. The anterolateral thigh flap was predominantly employed, with musculocutaneous or chimeric flaps introduced for bony defects. The mean pedicle length of the harvested flap was 7.2 cm (range, 3-13), and in cases with a vascular gap, the pedicle was extended using an arteriovenous interposition graft. This resulted in a mean pedicle length needed to reach recipient vessels of 9.9 cm (range, 6.5-19). All flaps survived, with only one experiencing partial necrosis.

CONCLUSIONS

The TAV could be considered as an attractive alternative recipient vessel in microsurgical reconstruction of complicated chest wall defects when the use of IMA is not feasible.

Pedicled flap transfer after chest wall malignant tumor resection and potential risk of postoperative respiratory problems for patients with low FEV1.0

Introduction

Musculoskeletal transfer for chest wall tissue defects is a crucial method, and pedicled flaps around the chest wall are preferred in terms of location and simplicity of transfer. These require special care because of complications such as partial necrosis, fistula, wound dehiscence, infection, hematoma and restricted function of the arm or shoulder. However, studies of respiratory function are rare. In the present study, we investigated the complications including respiratory problems after wide resection for malignant chest wall tumors with musculoskeletal pedicle transfer.

Methods

A total of 13 patients (15 operations) who underwent wide resection of primary, recurrent, or metastatic malignant chest wall tumors and musculoskeletal pedicle transfer for coverage of tissue defects were enrolled in the present study. A retrospective review of all patients was performed using data collected from hospital records and follow-up information. The complications of musculoskeletal transfer after chest wall wide resection, including respiratory problems, are evaluated.

Results

Rib or sternal resection was performed in 12 operations, and only soft tissue resection was performed in 3 operations. Latissimus dorsi (LD) pedicle transfer was performed in 13 operations, and pectoralis major (PM) pedicle transfer was performed in 2 operations; basically, wounds were closed primarily. Surgical complications were observed following 5 of the 15 operations (33.3%). Respiratory complications were seen in 7 of the 15 operations (46.7%). Patients with respiratory complications showed significantly lower preoperative FEV1.0% values than those without respiratory complications (p = 0.0196). Skin resection area tended to be higher in the complication group than in the no complication group (p = 0.104).

Discussion

Pedicled myocutaneous flap transfers such as LD, PM, and rectus abdominus can be used following multiple resections. After harvesting LD or PM, the wound can be closed primarily for an 8-10-cm skin defect in patients with normal respiratory function. However, for patients with low FEV1.0%, after primary closure of LD or PM transfer for wide soft tissue defects, attention should be paid to postoperative respiratory complications.

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.

Anterior Chest Wall Reconstruction After Separation of Thoraco-Omphalopagus Conjoined Twins With Cadaveric Rib Grafts and Omental Flap

BACKGROUND

Anterior chest wall defects have a wide range of etiologies in the pediatric population, ranging from infection, tumor, and trauma to congenital diseases. The reconstructive goals include restoring skeletal stability, obliterating dead space, preserving cardiopulmonary mechanics, and protecting vital underlying mediastinal organs. Although various reconstructive methods have been described in the literature, selecting the optimal method is challenging for the growing pediatric skeleton. Here, we report a case of previously thoraco-omphalopagus twins who underwent successful separation and reconstruction and presented for definitive anterior chest wall reconstruction.

METHODS

A pair of previously thoraco-omphalopagus conjoined twins underwent definitive anterior chest wall defect reconstruction using cadaveric ribs and omental flap. Twin A received 2 cadaveric ribs, whereas twin B had a much larger sternal defect that required 3 cadaveric ribs combined with an omental flap for soft tissue chest coverage. Both twins were followed up for 8 months.

RESULTS

Twin A's postoperative course was uneventful, and she was discharged on postoperative day 6. Twin B's course was complicated, and she was discharged on supported ventilation on postoperative day 10. At 8 months postoperatively, both twins healed well, and chest radiographs confirmed the stability of the chest reconstructions. The rib grafts in the twin with a tracheostomy were not mobile, and the patient had a solid sternum with adequate pulmonary expansion. The construct initially did not facilitate pulmonary functioning, but after a healing process, it eventually allowed for the twin with the tracheostomy who required pulmonary assistance to no longer need this device.

CONCLUSIONS

Cryopreserved cadaveric ribs and omental flaps offer safe and reliable reconstructive methods to successfully reconstruct congenital anterior chest wall skeletal defects in the growing pediatric population. The involvement of multidisciplinary team care is key to optimizing the outcomes.

Outcome Analysis of Treatment Modalities for Thoracic Sarcomas

BACKGROUND

Primary chest wall sarcomas are a rare and heterogeneous group of chest wall tumors that require multimodal oncologic and surgical therapy. The aim of this study was to review our experience regarding the surgical treatment of chest wall sarcomas, evaluating the short- and long-term results.

METHODS

In this retrospective single-center study, patients who underwent surgery for soft tissue and bone sarcoma of the chest wall between 1999 and 2018 were included. We analyzed the oncologic and surgical outcomes of chest wall resections and reconstructions, assessing overall and recurrence-free survival and the associated clinical factors.

RESULTS

In total, 44 patients underwent chest wall resection for primary chest wall sarcoma, of which 18 (41%) received surgery only, 10 (23%) received additional chemoradiotherapy, 7% (3) received surgery with chemotherapy, and 30% (13) received radiotherapy in addition to surgery. No perioperative mortality occurred. Five-year overall survival was 51.5% (CI 95%: 36.1-73.4%), and median overall survival was 1973 days (CI 95% 1461; -). As determined in the univariate analysis, the presence of metastasis upon admission and tumor grade were significantly associated with shorter survival (p = 0.037 and p < 0.01, respectively). Five-year recurrence-free survival was 71.5% (95% CI 57.6%; 88.7%). Tumor resection margins and metastatic disease upon diagnosis were significantly associated with recurrence-free survival (p < 0.01 and p < 0.01, respectively).

CONCLUSION

Surgical therapy is the cornerstone of the treatment of chest wall sarcomas and can be performed safely. Metastasis and high tumor grade have a negative influence on overall survival, while tumor margins and metastasis have a negative influence on local recurrence.

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.

Analysis of the Chest Wall Reconstruction Methods after Malignant Tumor Resection

Background  The chest wall defects can be caused by various reasons. In the case of malignant tumor resection of the chest wall, it is essential to reconstruct the chest wall to cover the vital tissue and restore the pulmonary function with prevention of paradoxical motion. With our experience, we analyzed and evaluated the results and complications of the chest wall reconstructions followed by malignant tumor resection. Methods  From 2013 to 2022, we reviewed a medical record of patients who received chest reconstruction due to chest wall malignant tumor resection. The following data were retrieved: patients' demographic data, tumor type, type of operation, method of chest wall reconstruction of the soft and skeletal tissue and complications. Results  There were seven males and six female patients. The causes of reconstruction were 12 primary tumors and one metastatic carcinoma. The pathological types were seven sarcomas, three invasive breast carcinoma, and three squamous cell carcinomas. The skeletal reconstruction was performed in six patients. The series of the flap were eight pedicled latissimus dorsi (LD) myocutaneous flaps, two pectoralis major myocutaneous flap, two vertical rectus abdominis myocutaneous free flap, and one LD free flap. Among all the cases, only one staged reconstruction and successful reconstruction without flail chest. Most of the complications were atelectasis. Conclusion  In the case of accompanying multiple ribs and sternal defect, skeletal reconstruction would need skeletal reconstruction to prevent paradoxical chest wall motion. The flap for soft tissue defect be selected according to defect size and location of chest wall. With our experience, we recommend the reconstruction algorithm for chest wall defect due to malignant tumor resection.

Chondrosarcoma of the Chest Wall: A Single Institution Review of 50 Cases

INTRODUCTION

Chondrosarcoma (CS) is most common primary osseous tumor of the chest wall. The aim of this study was to report results from surgical procedures and evaluate clinical factors predicting survival of patients with chest wall CSs treated in a single tertiary sarcoma center.

MATERIALS AND METHODS

Fifty patients with primary CS located in the ribs and sternum were included. Details of the clinical data and oncological outcomes, including local recurrence (LR) and disease-specific survival (DSS), were collected.

RESULTS

The tumor was primarily originated in the sternum in 6 patients (12.5%) and in ribs 2 to 11 in the remaining patients. Specimens were histologically graded 1 in 13 patients (26%), 2 in 28 (56%), 3 in 8 (16%), and 1 (2%) as mesenchymal grade 3 CS. R0 margins were obtained in all cases. Reconstruction was warranted in 47 (94%) cases. Local recurrence developed in 3 (6%) patients, and the median time to LR was 17 (range, 16-68) months. Eight (16%) patients developed metastasis. Increasing tumor volume was a statistically significant factor for reduction of DSS.

CONCLUSIONS

Chondrosarcoma of the chest wall can be treated effectively with clear margins, resulting in lower LR rate and higher DSS than CS of the extremities and pelvis. Metastasis of the chest wall mostly occurs in high-grade tumors, and the locations of the metastases differ greatly from those observed in CS of the extremities and pelvis. Metastases are commonly extrapulmonary, indicating the need for postoperative follow-up with multiple imaging modalities to monitor recurrence and metastases.

Combined pectoralis and rectus abdominis flaps are associated with improved outcomes in sternal reconstruction

BACKGROUND

Mortality increases nearly 5-fold in the approximately 5% of patients who develop sternal wound complications after cardiothoracic surgery. Flap-based reconstruction can improve outcomes by providing well-vascularized soft tissue for potential space obliteration, antibiotic delivery, and wound coverage; however, reoperation and readmission rates remain high. This study used the high case volume at a tertiary referral center and a diverse range of reconstructive approaches to compare various types of flap reconstruction. Combined (pectoralis and rectus abdominis) flap reconstruction is hypothesized to decrease sternal wound complication-related adverse outcomes.

METHODS

A retrospective cohort study of consecutive adult patients treated for cardiothoracic surgery sternal wound complications between 2008 and 2018 was performed. Patient demographics, comorbidities, wound characteristics, surgical parameters, and perioperative data were collected. Multivariable regression modeling with stepwise forward selection was used to characterize predictive factors for sternal wound-related readmissions and reoperations.

RESULTS

In total, 215 patients were assessed for sternal wound reconstruction. Patient mortality at 1 year was 12.4%. Flap selection was significantly associated with sternal wound-related readmissions (P = .017) and reoperations (P = .014). Multivariate regression demonstrated rectus abdominis flap reconstruction independently predicted increased readmissions (odds ratio 3.4, P = .008) and reoperations (odds ratio 2.9, P = .038). Combined pectoralis and rectus abdominis flap reconstruction independently predicted decreased readmissions overall (odds ratio 0.4, P = .031) and in the deep sternal wound subgroup (odds ratio 0.1, P = .033).

CONCLUSION

Although few factors can be modified in this complex highly comorbid population with a challenging and rare surgical problem, consideration of a more surgically aggressive multiflap reconstructive approach may be justified to improve outcomes.

The Therapeutic Role of Plastic and Reconstructive Surgery in the Interdisciplinary Treatment of Soft-Tissue Sarcomas in Germany-Cross-Sectional Results of a Prospective Nationwide Observational Study (PROSa)

Simple Summary

The mainstay of soft-tissue-sarcoma treatment remains ablative surgery with complete tumor resection. In this context, reconstructive plastic surgery has become an important aspect of multidisciplinary sarcoma therapy aiming at limb preservation as an alternative to amputations. In this present study, cross-sectional data collected prospectively at 39 study centers across Germany were analyzed, focusing on both the inhouse availability of plastic surgery and external accessibility to plastic surgery in 621 cases. In summary, unplanned and incomplete primary tumor resections carried out at centers with lower degrees of specialization were associated with a significantly increased need for subsequent flap-based defect coverage. In line with this, a readily available team of plastic surgeons was independently associated with successful defect reconstruction, which in turn was associated with significantly higher chances of limb preservation. We conclude that easily accessible plastic surgery and a high degree of expertise in the field of sarcoma treatment are indispensable for limb preservation following sarcoma resection. Plastic and reconstructive surgery therefore plays a vital role in achieving the best possible outcomes in the interdisciplinary treatment of soft-tissue sarcomas.

Abstract

Although the involvement of plastic surgery has been deemed important in the treatment of sarcoma patients to avoid oncological compromises and ameliorate patient outcomes, it is not ubiquitously available. The accessibility of defect reconstruction and its therapeutic impact on sarcoma care is the subject of this analysis. Cross-sectional data from 1309 sarcoma patients were collected electronically at 39 German study centers from 2017 to 2019. A total of 621 patients with surgical treatment for non-visceral soft-tissue sarcomas were included. The associated factors were analyzed exploratively using multifactorial logistic regression to identify independent predictors of successful defect reconstruction, as well Chi-squared and Cochran–Mantel–Haenszel tests to evaluate subgroups, including limb-salvage rates in extremity cases. A total of 76 patients received reconstructive surgery, including 52 local/pedicled versus 24 free flaps. Sarcomas with positive margins upon first resection (OR = 2.3, 95%CI = 1.2–4.4) that were excised at centers with lower degrees of specialization (OR = 2.2, 95%CI = 1.2–4.2) were independently associated with the need for post-oncological defect coverage. In this context, the inhouse availability of plastic surgery (OR = 3.0, 95%CI = 1.6–5.5) was the strongest independent predictor for successful flap-based reconstruction, which in turn was associated with significantly higher limb-salvage rates (OR = 1.4, 95%CI = 1.0–2.1) in cases of extremity sarcomas (n = 366, 59%). In conclusion, consistent referral to specialized interdisciplinary sarcoma centers significantly ameliorates patient outcomes by achieving higher rates of complete resections and offering unrestricted access to plastic surgery. The latter in particular proved indispensable for limb salvage through flap-based defect reconstruction after sarcoma resection. In fact, although there remains a scarcity of readily available reconstructive surgery services within the current sarcoma treatment system in Germany, plastic and reconstructive flap transfer was associated with significantly increased limb-salvage rates in our cohort.

Clavicular Malignancies: A Borderline Surgical Management

Nearly 1% of all bone cancers are primary clavicular tumors and because of their rarity, treating clinicians are unfamiliar with their diagnosis, classification, treatment options, and prognosis. In terms of preserving function and avoiding complications, clavicle reconstruction seems logical; however, further studies are needed to support this measure. Reconstruction techniques are difficult taking into account the anatomical structures surrounding the clavicle. When chest wall defects are present, a multidisciplinary team, including an orthopedist and thoracic and plastic surgeons, is of paramount importance for optimal surgical management. Malignant clavicle tumors may include primary and secondary malignancies and neighboring tumors with clavicular invasion. Surgical resection of complex thoracic tumors invading the clavicles can result in larger defects, requiring chest wall reconstruction, which is a substantial challenge for surgeons. Correct diagnosis with proper preoperative planning is essential for limiting complications. Post-resection reconstruction of the partial or total claviculectomy is important for several reasons, including maintaining the biomechanics of the scapular girdle, protecting the vessels and nerves, reducing pain, and maintaining the anatomical appearance of the shoulder. The chest wall resection and reconstruction techniques can involve either partial or full chest wall thickness, influencing the choice of reconstructive technique and materials. In the present paper, we aimed to synthesize the anatomical and physiopathological aspects and the small number of therapeutic surgical options that are currently available for these patients.

Resection and reconstruction of huge tumors in the chest wall

OBJECTIVE

To evaluate the experience and effects of resection and reconstruction of 4 cases of huge tumors in the chest wall.

METHODS

The clinical data of 4 patients with huge tumors in the chest wall from July 2015 to January 2020 were collected and analyzed. There were 2 males and 2 females.Chondrosarcoma was diagnosed in 2 cases, giant cell tumor was diagnosed in 1 case,and metastasis from breast cancer was diagnosed in 1 case.All patients underwent extensive tumor resection and had thoracic exposure after tumor resection.Two patients underwent reconstruction with mesh and titanium mesh, and the incision was closed directly.The third patient underwent reconstruction with mesh and latissimus dorsi flap,and the fourth patient underwent reconstruction with mesh,titanium mesh and latissimus dorsi flap.

RESULT

One patient had incision infection after operation,which resolved after debridement.All patients were followed up for 2-6 years, no tumor recurrence or metastasis was noted during follow-up.None of patients had abnormal breathing, dyspnea or other physical discomfort.

CONCLUSION

It is difficult to resect the huge tumors in the chest wall,and it is more reasonable and safer to choose a reconstruction method using mesh and titanium mesh.The latissimus dorsi flap can achieve good results in repairing soft tissue defects.Close perioperative management and multidisciplinary team discussions can help to achieve better curative effects.

Defect Coverage after Forequarter Amputation—A Systematic Review Assessing Different Surgical Approaches

Autologous fillet flaps are a common reconstructive option for large defects after forequarter amputation (FQA) due to advanced local malignancy or trauma. The inclusion of osseous structures into these has several advantages. This article therefore systematically reviews reconstructive options after FQA, using osteomusculocutaneous fillet flaps, with emphasis on personalized surgical technique and outcome. Additionally, we report on a case with an alternative surgical technique, which included targeted muscle reinnervation (TMR) of the flap. Our literature search was conducted in the PubMed and Cochrane databases. Studies that were identified were thoroughly scrutinized with regard to relevance, resulting in the inclusion of four studies (10 cases). FQA was predominantly a consequence of local malignancy. For vascular supply, the brachial artery was predominantly anastomosed to the subclavian artery and the brachial or cephalic vein to the subclavian or external jugular vein. Furthermore, we report on a case of a large osteosarcoma of the humerus. Extended FQA required the use of the forearm for defect coverage and shoulder contour reconstruction. Moreover, we performed TMR. Follow-up showed a satisfactory result and no phantom limb pain. In case of the need for free flap reconstruction after FQA, this review demonstrates the safety and advantage of osteomusculocutaneous fillet flaps. If the inclusion of the elbow joint into the flap is not possible, we recommend the use of the forearm, as described. Additionally, we advocate for the additional implementation of TMR, as it can be performed quickly and is likely to reduce phantom limb and neuroma pain.

Hybrid nanocomposite as a chest wall graft with improved vascularization by copper oxide nanoparticles

Chest wall repair can be necessary after tumor resection or chest injury. In order to cover or replace chest wall defects, autologous tissue or different synthetic materials are commonly used, among them the semi-rigid gold standard Gore-Tex® and prolene meshes. Synthetic tissues include composite materials with an organic and an inorganic component. On the basis of previously reported hybrid nanocomposite poly-lactic-co-glycolic acid amorphous calcium phosphate nanocomposite (PLGA/aCaP), a CuO component was incorporated to yield (60%/35%/5%). This graft was tested in vitro by seeding with murine adipose-derived stem cells (ASCs) for cell attachment and migration. The graft was compared to PLGA/CaCO3 and PLGA/hydroxyapatite, each providing the inorganic phase as nanoparticles. Further characterization of the graft was performed using scanning electron microscopy. Furthermore, PLGA/aCaP/CuO was implanted as a chest wall graft in mice. After 4 weeks, total cell density, graft integration, extracellular matrix components such as fibronectin and collagen I, the cellular inflammatory response (macrophages, F4/80 and lymphocytes, CD3) as well as vascularization (CD31) were quantitatively assessed. The nanocomposite PLGA/aCaP/CuO showed a good cell attachment and cells migrated well into the pores of the electrospun meshes. Cell densities did not differ between PLGA/aCaP/CuO and PLGA/CaCO3 or PLGA/hydroxyapatite, respectively. When applied as a chest wall graft, adequate stability for suturing into the thoracic wall could be achieved. Four weeks post-implantation, there was an excellent tissue integration without relevant fibrotic changes and a predominating collagen I matrix deposition within the graft. Slightly increased inflammation, reflected by increased infiltration of macrophages could be observed. Vascularization of the graft was significantly enhanced when compared with PLGA/aCaP (no CuO). We conclude that the hybrid nanocomposite PLGA/aCaP/CuO is a viable option to be used as a chest wall graft. Surgical implantation of the material is feasible and provides stability and enough flexibility. Proper tissue integration and an excellent vascularization are characteristics of this biodegradable material.

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.

Chest wall reconstruction with implantable cross-linked porcine dermal collagen matrix: Evaluation of clinical outcomes

Objectives

The aim of the study is to evaluate clinical applications, safety, and effectiveness of a porcine-derived acellular cross-linked dermal matrix biological mesh in chest wall reconstruction.

Methods

We retrospectively analyzed a prospective multicenter database of chest wall reconstructions using a biological mesh in adult patients undergoing operation between October 2013 and December 2020. We evaluated preoperative data, type of resection and reconstruction, hospitalization, 30-day morbidity and mortality, and overall survival.

Results

A total of 105 patients (36 women [34.2%]; mean age, 57.0 ± 16.1 years; range, 18-90 years) were included, they have admitted for: primary chest wall tumor (n = 52; 49.5%), secondary chest wall tumor (n = 29; 27.6%), lung hernia (n = 12; 11.4%), trauma (n = 10; 9.6%), and infections (n = 2; 1.9%). The surgical sites were preoperatively defined as at high risk of infection in 28 patients (26.7%) or as infected in 16 (15.2%) patients. Thirty-days morbidity was 30.5% (n = 32 patients); 14 patients (13.3%) had postoperative complications directly related to chest wall surgical resection and/or reconstruction. We experienced no 30-day mortality; 1-year and 2-year mortality was 8.4% and 16.8%, respectively.

Conclusions

Biological mesh represents a valuable option in chest wall reconstruction even when surgical sites are infected or at high-risk of infections. This mesh shows low early and late postoperative complication rates and excellent long-term stability.

Chest Wall Reconstruction Utilizing Ovine-Derived Reinforced Tissue Matrix

BACKGROUND

Chest wall reconstruction (CWR) can be a challenge. The perfect material does not exist to restore CW stability. Synthetic materials have been the mainstay for reconstruction. Biological material use has increased. Recently, we initiated the use of a biosynthetic material (BSM) for CWR that is composed of ovine-derived extracellular tissue matrix and monofilament polypropylene suture.

METHODS

We respectively reviewed all patients who underwent CWR with a BSM from January 2020 - June 2021.

RESULTS

Twenty-five patients underwent CWR. Median age was 35 years (18 - 68); 64% were men. Indication for CWR was tumor resection in 10, chest wall defect after pectus repair in 7, radiation necrosis in 5, chest wall infection in 2 and lung herniation in 1. Infection was present in 28%. Median CW defect was 7 x 10 cm (3.5 - 22.5 cm). Bioabsorbable bars were used in combination with the BSM patch in 15 patients (60%) and BSM alone in 10; 5 patients underwent myocutaneous advancement flaps. There were no operative deaths. Postoperative complications occurred in 6 patients (24%). Median hospital stay was 5 days (3 - 14). Late complications occurred in 4 patients (16%). No patient developed paradoxical motion, chest wall instability, or required BSM removal at a median follow-up of 12 months (1 - 18).

CONCLUSIONS

This novel BSM combines the benefits of biologic material and polymer reinforcement to provide a more natural CWR compared to mesh products made of synthetic material alone. Early results are promising in this first series in the literature.

[Application of modified designed bilobed latissimus dorsi myocutaneous flap in chest wall reconstruction of locally advanced breast cancer patients]

Objective

To explore the effectiveness of the modified designed bilobed latissimus dorsi myocutaneous flap in chest wall reconstruction of locally advanced breast cancer (LABC) patients.

Methods

Between January 2016 and June 2019, 64 unilateral LABC patients were admitted. All patients were female with an average age of 41.3 years (range, 34-50 years). The disease duration ranged from 6 to 32 months (mean, 12.3 months). The diameter of primary tumor ranged from 4.8 to 14.2 cm (mean, 8.59 cm). The size of chest wall defect ranged from 16 cm×15 cm to 20 cm×20 cm after modified radical mastectomy/radical mastectomy. All defects were reconstructed with the modified designed bilobed latissimus dorsi myocutaneous flaps, including 34 cases with antegrade method and 30 cases with retrograde method. The size of skin paddle ranged from 13 cm×5 cm to 17 cm×6 cm. All the donor sites were closed directly.

Results

In antegrade group, 2 flaps (5.8%, 2/34) showed partial necrosis; in retrograde group, 6 flaps (20%, 6/30) showed partial necrosis, 5 donor sites (16.7%, 5/30) showed partial necrosis; and all of them healed after dressing treatment. The other flaps survived successfully and incisions in donor sites healed by first intention. There was no significant difference in the incidence of partial necrosis between antegrade and retrograde groups ( χ ²=2.904, P=0.091). The difference in delayed healing rate of donor site between the two groups was significant ( P=0.013). The patients were followed up 15-30 months, with an average of 23.1 months. The appearance and texture of the flaps were satisfactory, and only linear scar left in the donor site. No local recurrence was found in all patients. Four patients died of distant metastasis, including 2 cases of liver metastasis, 1 case of brain metastasis, and 1 case of lung metastasis. The average survival time was 22.6 months (range, 20-28 months).

Conclusion

The modified designed bilobed latissimus dorsi myocutaneous flap can repair chest wall defect after LABC surgery. Antegrade design of the flap can ensure the blood supply of the flap and reduce the tension of the donor site, decrease the incidence of complications.

The pectoralis major musculo-mammary transposition flap to close a radical mastectomy defect: the breast switch

The latissimus dorsi myocutaneous flap is the most commonly used workhorse flap to provide soft tissue closure of large breast amputation defects. When the thoracodorsal vascular pedicle is resected during a mastectomy, local tissue from lateral, contralateral, and inferior regions must be used. In this case report, complete transposition of the contralateral breast based on the pectoralis major muscle and its dominant pedicle was performed to close a massive mastectomy defect up to the anterior axillary line. The donor site defect that resulted at the inferior region was closed with a reverse abdominoplasty flap. A V-Y advancement overlying the ipsilateral latissimus dorsi muscle was advanced to close the lateral defect up to the anterior axillary line, connecting it to the contralateral breast switch.

Thoracic Wall Reconstruction: Surgical Planning in Extended Malignant Resections

INTRODUCTION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Complex Microsurgical Reconstruction After Tumor Resection in the Trunk and Extremities

Reconstruction of soft tissue defects following tumor ablation procedures in the trunk and extremities can challenge the microsurgeon. The goal is not just to provide adequate soft tissue coverage but also to restore form and function and minimize donor site morbidity. Although the principles of the reconstructive ladder still apply in the trunk and extremities, free tissue transfer is used in many cases to optimally restore form and function. Microsurgery has changed the practice in soft tissue tumors, and amputation is less frequently necessary.

A Novel Local Transposition Flap for Lateral Breast Reconstruction After Breast Conserving Surgery

BACKGROUND

Breast conserving surgery (BCS) followed by radiotherapy is used for the management of early-stage breast cancers. There are different techniques to reconstruct the breast after BCS, each has its own advantages and disadvantages. In this study, we aim to present a novel local transposition flap and report the follow-up results of patients who underwent breast reconstruction using this method in the short and long term.

MATERIAL AND METHODS

We enrolled 100 patients who underwent BCS in the form of upper or lower outer quadrant lumpectomy with or without axillary lymph node dissection. After lumpectomy, the patients underwent breast reconstruction using the local transposition flap technique. We followed the patients for 1 year, and the satisfaction results are assessed and reported postoperation, after radiochemotherapy, and after 1 year.

RESULTS

The patients' mean age is 47.6 (±11.7) years, and the mean BMI is 32.4 (±2.5). The duration of hospitalization was 1 day in 96 patients and 2 days in 2 patients. There were 2 patients hospitalized for 3 days. Three patients developed seroma and there were no cases of any other complication. The surgeon and patients satisfaction surveys conducted postop, after the radiochemotherapy course, and 1 year after BCS shows that the excellent and good satisfaction rate is 85%, 85%, and 92% respectively.

CONCLUSION

We believe that the local transposition flap can be an excellent substitution for the existing methods in the reconstruction of the lateral side breast defects.

Optimal chest wall prosthesis: comparative study of mechanical and functional behaviour

OBJECTIVES

Chest wall resections are most commonly performed for tumours, infection, radiation necrosis and trauma. Defects in the anterior chest greater than 5 cm, posterior defects more than 10 cm or resection including more than 3 ribs, independently of the location, require skeletal prosthetic reconstruction. The aim of this paper was to evaluate the strength of prostheses that reproduced the normal human anatomy using different materials subjected to the most dangerous loading conditions.

METHODS

The biomechanical behaviours of different prosthetic materials under critical rib fracture conditions were analysed using the finite element method and then validated through mechanical testing of 3-dimensional polymethylmethacrylate ribs as a prosthesis reproducing the native anatomy of the human ribcage.

RESULTS

The prosthetic materials and the polymethylmethacrylate prosthesis were tested under 3 load conditions: sternal load (an anterior-posterior load applied at the third rib); lateral load (strength applied at the lateral arch of the fifth rib) and vertical load (vertical load applied at the first sternocostal junction) and showed the same results in terms of failures compared to the results from the finite element method model simulation (same location and number of fractures were detected). Although the displacement error between the finite element method and experimental test was up to 5% overall, no other microcracking was observed.

CONCLUSIONS

This experimental study demonstrated that all prosthetic materials currently available for human use show optimal mechanical behaviour in term of resistance and organ protection. Specifically, polymethylmethacrylate was a good candidate as a prosthetic material in term of lightness, resistance and prosthetic weight.

Combined use of ipsilateral latissimus dorsi flap and anterolateral thigh flap to reconstruct extensive trunk defects

Reconstruction of a full-thickness trunk defect is challenging because of the complex nature of such defects, which include the chest wall, abdominal wall, and diaphragm. We herein describe three patients in whom extensive trunk defects after sarcoma resection were reconstructed with a latissimus dorsi flap and an anterolateral thigh flap. In two patients, the defect included both the chest wall and the abdominal wall. The other patient had an extensive full-thickness chest wall defect. The size of the anterolateral thigh flap for each patient was 34 × 10 cm, 26 × 15 cm, and 23 × 5 cm, respectively. Although one patient required take-back for additional venous drainage, all wounds healed with no other complications. No respiratory dysfunction or abdominal wall hernia occurred in any patients. The combined use of a latissimus dorsi flap and an anterolateral thigh flap may provide reliable coverage of an extensive trunk defect and robust support of the chest and abdominal walls. Additionally, the availability of a two-team approach without a positional change makes this combination a versatile reconstructive option.

Spontaneous Chest Wall Herniation in Centrally Obese Patients: A Single-Center Experience of a Rare Problem

BACKGROUND

Spontaneous rib fractures, especially in association with chest wall herniation, represent an uncommon pathology. As such, there are little data analyzing approaches to treatment or regarding the success of intervention. The goal of this study was to analyze our cumulative experience with this unusual condition.

METHODS

A case series of 12 patients was gathered from a single institution based on outpatient visits between February 2015 and October 2018. Each chart was retrospectively reviewed with particular attention to age, gender, BMI, area of injury, and smoking history. Patients presented with complaints of dyspnea or pain related to rib fractures with or without intercostal neuralgia. Each of these patients was noted to have rib fractures with lung herniation either on imaging, outside hospital records, or physical exam. A thorough medical history was obtained with attempts to find common predisposing factors as well as data regarding any previous surgical intervention for their herniation.

RESULTS

Nine of the 12 patients reviewed had recent or prior surgical intervention. Every patient seen in the clinic with a spontaneous fracture and herniation incidentally had a BMI >30 and was therefore classified as obese. Additionally, every patient who had a recurrence after their first surgical attempt at repair had a BMI greater than or equal to 35. All 12 patients seen at our institution were males. The failure rate of operative intervention was 66%.

CONCLUSIONS

Obesity was a prevalent comorbidity in the patient population we reviewed. Given the role obesity plays in abdominal and hiatal hernia repair success rates, it should be considered that obesity is a significant contributor to chest wall herniation if rib fractures occur. With 66% chest wall repair failure, patient selection is critical in the success of surgical intervention. Perhaps additional patient optimization, especially weight loss, should be considered prior to surgery.

Surgical Management of Chest Wall Sarcoma

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

Giant chondrosarcoma of the chest wall: a rare surgical challenge

The chest wall chondrosarcoma (CWC) is a rare slowly growing primary tumor of the chest wall with an incidence of <0.5 per million person-years. We present the case of a giant CWC that caused a mass effect on the mediastinum, heart, and lung. Large tumors with thoracic structures compression may be life threatening, and its resection and subsequent chest wall reconstruction represent a significant multidisciplinary surgical challenge. In this case, despite the large tumor dimensions, the preoperative planning—sparing key reconstructive options without compromising the tumor resection—allowed a complete en bloc tumor excision of a grade III chondrosarcoma with negative histologic margins. Successful reconstruction of the large full-thickness chest wall defect, with a latissimus dorsi muscle flap and methyl methacrylate incorporated into a polypropylene mesh in a sandwich fashion, was accomplished. Patient recovery was uneventful with good functional and aesthetic outcomes, and no evidence of recurrence at 1.5 years follow-up. This case report illustrates the main clinical, radiological, and histologic features of a CWC while discussing the surgical goals and highlighting the principles for chest wall reconstruction following extensive resection of a large and rare entity.

Combined Free Fibula Osteocutaneous and Anterolateral Thigh-Vastus Lateralis Free Flaps for Clavicule and Extensive Chest Wall Reconstruction After Sarcoma Resection

Combined extensive chest and neck reconstructions is a challenging procedure. The rapid development in microvascular surgery has allowed the cancer surgeons to successfully resect and reconstruct advanced malignancies in the neck and thoracic region. Herein we present a young female diagnosed with malignant mesenchymal sarcoma of the right side of the neck extending to right upper lung and anterior mediastinum. The patient was successfully treated with two microvascular free flaps in a multidisciplinary approach. Wide local resection of the tumor was done along with removal of right upper pulmonary lobe and the subclavian vessels. Vascular reconstruction was done with polytetrafluoroethylene grafts. A free fibula osteocutaneous flap was used for stabilization and reconstruction of the clavicle. Anterolateral thigh flap with vastus lateralis muscle was used for soft tissue reconstruction. All flaps survived and the patient had a good recovery at three months of follow-up. Future reports suggesting guidelines or algorithms for complex chest wall reconstruction should benefit of similar scenarios to the one reported here.

Delayed post-traumatic presentation of severe sternal osteomyelitis: A strong multidisciplinary effort and a novel reconstruction technique for a challenging case

Sternal osteomyelitis is a morbid and challenging condition, which can rarely occur after trauma, with no established consensus over best therapeutic options. In this case, a 47-year-old man with history of intravenous drug use presented 11 weeks after a minor blunt chest trauma with a severe necrotizing osteomyelitis involving sternum, muscles, fascia and subcutaneous tissue and positive blood cultures for Methicillin Sensitive Staphylococcus aureus. Alongside tailored antibiotic therapy, extensive surgical debridement was performed, leaving a full thickness 3 × 4 cm sternal defect and a large skin defect. After 4 weeks of antibiotics and Vacuum-Assisted-Closure pump, a novel reconstruction technique was utilized, with full collaborations of thoracic surgeons, orthopaedic surgeons and plastic surgeons. An autologous tricortical iliac crest bone graft was harvested and shaped to fit the full-thickness sternal defect, while two titanium sigmoid-shaped clavicle plates were used for internal fixation of the autograft. The large skin defect was covered with a pedicled myocutaneous latissimus dorsi flap. Integrity and stability of the chest wall was fully restored, and infection was completely eradicated. No complications occurred and the patient was well at the 18 months follow-up. To the best of our knowledge, this is the first report on autologous iliac crest bone graft in the treatment of sternal osteomyelitis. In this case, it proved to be a viable therapeutic option, providing good long-term clinical and cosmetic results.

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.

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.

Sternochondral replacement: use of cadaveric allograft for the reconstruction of anterior chest wall

Background

Sternum may be involved by different diseases such as trauma, infection after cardiac surgery, tumors (primary and secondary) or chest wall deformities. Surgical excision with a safety margin is the primary goal after sternal resection for tumors, prevention of respiratory impairment due to flail chest and deformity and protection of surrounding organs are other important aims. Various techniques and materials have been used for this operation. We describe the use of cadaveric sternal allograft to reconstruct the chest wall in fourteen patients.

Methods

Between October 2008 and February 2017, five males and nine females underwent surgical procedure because of primary sternal neoplasm, single-site metastatic disease, neuroendocrine thymic carcinoma and sternal dehiscence after cardiac surgery.

Results

Fourteen sternectomy were undertaken. A muscle flap of pectoralis major was prepared to cover the graft in 9 patients. Adjuvant chemotherapy and radiotherapy were performed after surgery in three patients. No postoperative complications happened in 11 cases (84.6%). One (7.1%) patient died 9 days after surgery because of pulmonary embolism. Two patients (15.4%) had complications: one presented fever caused by systemic candidiasis and one had a muscle flap bleeding. Hospitalization median time was 11 days (range, 6-31 days). At follow up, 7 patients were alive in absence of disease, 1 patient is alive with recurrence, 6 patients died but nor infection neither rejection of the graft happened. No respiratory impairment or flail chest were registered in any patients.

Conclusions

This technique for sternal replacement in our experience can be considered safe with long term results, providing optimal chest wall stability. The allograft resulted well-tolerated permitting an optimal graft integration in the host.

Chest wall resection and reconstruction for recurrent breast cancer - A multidisciplinary approach

BACKGROUND

Despite therapeutic advances in the management of breast cancer, a significant number of patients present with locoregional recurrence. Treatment with hormonal, chemo or radiotherapy remains standard in such cases. However, in selected patients of recurrent breast cancer involving chest wall, multidisciplinary surgical approach could be considered.

METHODS

Between 2010 and 2018, 21 patients with recurrent breast cancer, involving chest wall, were treated at a tertiary care center with resection and reconstruction. The mean age of the patients was 55 years (22-77 years).

RESULTS

The median interval from first breast resection to chest wall resection (CWR) for recurrent disease was 6 years (1-24 years). Eighteen patients underwent bony resection and 3 patients required extensive soft tissue resection. Complete resection was achieved in 90% of patients. All patients had chest wall reconstruction. There was no in-hospital mortality. During follow-up, 8 patients died, of which 7 were due to distant metastases. The 1 year and 3-year overall survival were 90% (95% CI 66-97) and 61% (95% CI 31-81) respectively. The disease-free survival at 1 and 3 years was the same at 70% (95% CI 45-86). At a mean follow up of 23 months, the average survival in patients operated for local recurrence is 51.7 months (95% CI 37.7-65.7) and 24.5 months (95% CI 7.3-41.7) for patients with distant metastatic recurrence.

CONCLUSION

A multidisciplinary oncoplastic approach for recurrent breast cancer, which includes chest wall resection and reconstruction is a useful adjunct in selected group of patients. This improves local disease control, symptoms and possibly disease-free survival.

The extended latissimus dorsi-serratus anterior chimeric local free flap for salvage of the complicated posterolateral thoractomy incision

BACKGROUND

Composite chest wall reconstruction, following the assurance of chest wall stability, often requires well-vascularized soft tissue coverage with flaps to insure adequate wound healing. Unfortunately, prior surgical approaches such as the posterolateral thoractomy incision or extensive wound breakdown may impede the availability of local or regional choices. A free flap would then be a reasonable option, but in the unstable patient a new donor site is unreasonable. Instead, the otherwise inadequate muscle remnants often transected by the usual thoracotomy incision can be extended by microvascular grafts to provide the necessary reach to the defect.

METHOD

The ipsilateral cephalic latissimus dorsi and/or serratus anterior muscle remnants following their transection by a posterolateral thoractomy incision can be simultaneously raised as a chimeric flap pedicled in common by the thoracodorsal vessels. The distance the pedicle must be extended to reach the defect requiring coverage is measured, and a vascular graft from the descending branch of the lateral circumflex femoral vessels of the same length is harvested. The thoracodorsal vessels are divided, the vascular graft inserted and anastomosed end-to-end to the cut ends of the former, and then the flap can be stretched the required distance for insetting.

RESULT

A case example of use of the ipsilateral latissimus dorsi-serratus anterior muscle remnants used after extension with arterial and venous grafts to the thoracodorsal vessels as the recipient site is presented with successful salvage of a life-threatening posteriolateral thoractomy wound dehiscence.

CONCLUSION

Transection of muscles from a posterolateral thoracotomy incision does not preclude their use as flaps in extenuating circumstances. Their pedicle can be extended using vascular grafts and microvascular techniques in a sense to create a local free flap to provide another solution to a challenging problem.

Review of Procedures for Reconstruction of Soft Tissue Chest Wall Defects Following Advanced Breast Malignancies

The purpose of this article is to review closure options for complex chest wounds in patients with locally advanced breast cancer. Experiences of the plastic and oncologic surgery teams at Moffitt Cancer Center were reviewed, and the literature researched for various surgical options of complex chest wound closure. Multiple treatment modalities exist for reconstruction of complex chest wall wounds with the external oblique and V-Y latissimus dorsi musculocutaneous advancement flaps serving as workhorses in reconstruction. Treatment of cancer has moved from simply a surgical solution to include other modalities such as hormonal therapy, chemotherapy, and radiation—the latter 2 having serious consequences for wound healing. A team approach and knowledge of available flap options are vital for closure of complex wounds in a timely manner. Appropriate planning can optimize the primary goal of the oncologic surgeon to remove the cancer and the plastic surgeon’s objective to reconstruct the defect and achieve a closed, durable wound prior to chemotherapy and radiation. We present the experience at the Moffitt Cancer Center in reconstructing challenging chest defects and review the reconstructive ladder.

Sternectomy for Treating Advanced Non-Melanoma Skin Cancer

Introduction

Skin cancer is a rare indication of sternectomy. Our goal is to report the clinical course of seven patients who underwent sternectomy for skin cancer.

Methods

The survey data were collected from medical records of patients treated between 2008 and 2018 at Ceará Cancer Institute.

Results

All patients had prolonged sunlight exposure and average disease time of two years and age of 60 years. Most patients recovered favorably after treatment with prolonged survival.

Conclusion

Sternectomy remains an option with curative purposes for locally advanced skin cancer.

Nanoparticle-modified chitosan-agarose-gelatin scaffold for sustained release of SDF-1 and BMP-2

Background

Stromal cell-derived factor 1 (SDF-1) is an important chemokine for stem cell mobilization, and plays a critical role in mobilization of mesenchymal stem cells (MSCs). Bone morphogenetic protein 2 (BMP-2) plays a critical role in osteogenesis of MSCs. However, the use of SDF-1 and BMP-2 in bone tissue engineering is limited by their short half-lives and rapid degradation in vitro and in vivo.

Methods

The chitosan oligosaccharide/heparin nanoparticles (CSO/H NPs) were first prepared via self-assembly. Chitosan-agarose-gelatin (CAG) Scaffolds were then synthesized via gelation technology using cross-linked chitosan, agarose, and gelatin, and were modified by CSO/H NPs. The encapsulation efficiency and release kinetics of SDF-1 and BMP-2 were quantified using an enzyme-linked immunosorbent assay. A CCK-8 assays were used to evaluate biocompatibility of NP-modified scaffolds. The biological activity of the loaded SDF-1 and BMP-2 was evaluated using the transwell migration assay and osteogenic induction assay. An animal MSC recruitment model was used to study the ability of SDF-1 released from NP-modified scaffolds to induce migration of MSCs.

Results

In this study, we developed a novel nanoparticle-modified CAG scaffold for the delivery of SDF-1 and BMP-2. CCK-8 assays demonstrated excellent biocompatibility of NP-modified scaffolds. In addition, we investigated the release of SDF-1 and BMP-2 from NP-modified scaffolds, and evaluated the effect of released SDF-1 on MSC migration. The effect of released BMP-2 on MSC osteogenesis was also examined. In vitro cell migration assays showed that SDF-1 released from NP-modified scaffolds retained its migration activity; osteogenesis studies demonstrated that released BMP-2 exhibited a strong ability to induce differentiation towards osteoblasts. Our in vivo recruitment assays showed continuous chemotactic response of MSCs to SDF-1 released from the NP-modified scaffold.

Conclusion

The simplicity of synthesizing CSO/H NP-modified CAG scaffolds, combined with its high cytokine loading capacity and sustained release effect, renders NP-modified CAG scaffold an attractive candidate for sustained release of SDF-1 and BMP-2 to promote bone repair and regeneration.

Novel Chest Wall Reconstruction Following Excision of an Xiphisternal Chondrosarcoma

Background

Chondrosarcoma, the most common primary malignant tumor of the chest wall, most frequently arises from the sternum, with limited reported cases of tumor origination from the xiphoid process. Because of the location, patients present with complaints of a large chest wall mass associated with pain and respiratory symptoms. These tumors are best managed by en bloc resection and chest wall reconstruction.

Case Report

A 49-year-old male nonsmoker with a strong family history of colon cancer presented with a large, painful chest wall mass associated with shortness of breath and exertional chest pressure. Computed tomography scan demonstrated a large mass arising from the xiphoid process; biopsy confirmed a grade 1 chondrosarcoma. The mass was removed en bloc and repaired with an innovative technique using omentum and PROCEED Surgical Mesh (Ethicon US, LLC). The wound was closed with a fasciocutaneous flap.

Conclusion

To our knowledge, this case is the first report of a chest wall reconstruction of a large inferior sternal defect using only polypropylene and omentum without a rigid support or muscular flap. This repair option could be considered for patients in whom traditional rigid repair methods have potential complications or limitations.

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.