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Breidung D, Delavari S, Grimme S, Habild G, Billner M, Kraus D, Reichert B, Megas IF. Postoperative Complications of Flap Procedures in Chest Wall Defect Reconstruction: A Two-Center Experience. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:834. [PMID: 38793017 PMCID: PMC11123380 DOI: 10.3390/medicina60050834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 05/26/2024]
Abstract
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.
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Affiliation(s)
- David Breidung
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Klinikum Nürnberg, Paracelsus Medical University, 90471 Nuremberg, Germany; (S.D.); (S.G.); (M.B.); (B.R.); (I.-F.M.)
- Department of Health Management, Friedrich Alexander University Erlangen-Nuernberg (FAU), 91054 Erlangen, Germany
| | - Sarina Delavari
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Klinikum Nürnberg, Paracelsus Medical University, 90471 Nuremberg, Germany; (S.D.); (S.G.); (M.B.); (B.R.); (I.-F.M.)
- Department of General and Visceral Surgery, Hospital Martha-Maria, 90491 Nuremberg, Germany
| | - Sebastian Grimme
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Klinikum Nürnberg, Paracelsus Medical University, 90471 Nuremberg, Germany; (S.D.); (S.G.); (M.B.); (B.R.); (I.-F.M.)
| | - Götz Habild
- Department of Orthopedic and Trauma Surgery, Center of Plastic Surgery, Hand Surgery and Microsurgery, Evangelisches Waldkrankenhaus Spandau, 13589 Berlin, Germany
| | - Moritz Billner
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Klinikum Nürnberg, Paracelsus Medical University, 90471 Nuremberg, Germany; (S.D.); (S.G.); (M.B.); (B.R.); (I.-F.M.)
| | - Dietmar Kraus
- Department of General, Visceral and Thoracic Surgery, Klinikum Nürnberg, Paracelsus Medical University, 90419 Nuremberg, Germany;
| | - Bert Reichert
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Klinikum Nürnberg, Paracelsus Medical University, 90471 Nuremberg, Germany; (S.D.); (S.G.); (M.B.); (B.R.); (I.-F.M.)
| | - Ioannis-Fivos Megas
- Department of Plastic, Reconstructive and Hand Surgery, Center for Severe Burn Injuries, Klinikum Nürnberg, Paracelsus Medical University, 90471 Nuremberg, Germany; (S.D.); (S.G.); (M.B.); (B.R.); (I.-F.M.)
- Department of Orthopedic and Trauma Surgery, Center of Plastic Surgery, Hand Surgery and Microsurgery, Evangelisches Waldkrankenhaus Spandau, 13589 Berlin, Germany
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Kim J, Lee KT. Microsurgical reconstruction using thoracoacromial vessels as recipients for complicated chest wall defects. Microsurgery 2024; 44:e31164. [PMID: 38530144 DOI: 10.1002/micr.31164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 01/09/2024] [Accepted: 02/15/2024] [Indexed: 03/27/2024]
Abstract
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.
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Affiliation(s)
- Jisu Kim
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kyeong-Tae Lee
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Mayer HF, Palacios Huatuco RM, Ramírez MF. Reverse abdominoplasty as a salvage procedure for infected bilateral implant-based breast reconstruction. Int J Surg Case Rep 2024; 117:109490. [PMID: 38484459 PMCID: PMC10955662 DOI: 10.1016/j.ijscr.2024.109490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 02/27/2024] [Accepted: 03/06/2024] [Indexed: 03/24/2024] Open
Abstract
INTRODUCTION Infection is one of the most feared complications of implant-based breast reconstruction and is difficult to manage in irradiated patients. We present the first case of bilateral breast reconstruction with infected expanders salvaged by performing a reverse abdominoplasty. PRESENTATION OF CASE A 64-year-old woman with a history of locally advanced bilateral breast cancer underwent modified bilateral radical mastectomy and postmastectomy radiotherapy. We performed two-stage breast reconstruction with implants. However, the patient developed a mild infection of the expanders, which was treated with targeted oral antibiotic therapy. The response to treatment was favorable, allowing us to salvage the reconstruction with a reverse abdominoplasty. DISCUSSION Traditionally, the management of infected breast prostheses has consisted of removal of the infected implant, a complication that forces a delay in the reconstructive process. Successful reports of salvage of infected prostheses have been described in the literature. On the other hand, we were able to salvage the reconstruction by performing a reverse abdominoplasty, which allowed us to resect the irradiated tissue and provide adequate non-irradiated soft tissue coverage for the replaced implants. CONCLUSION Reverse abdominoplasty offers an acceptable aesthetic result with much less donor site morbidity and represents a valid alternative to other complex reconstruction techniques.
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Affiliation(s)
- Horacio F Mayer
- Plastic Surgery Department, Hospital Italiano de Buenos Aires, University of Buenos Aires Medical School, Hospital Italiano de Buenos Aires University Institute (IUHIBA), 4190 Peron St., 1st. floor (C1991ABB), Buenos Aires, Argentina
| | - René M Palacios Huatuco
- Plastic Surgery Department, Hospital Italiano de Buenos Aires, University of Buenos Aires Medical School, Hospital Italiano de Buenos Aires University Institute (IUHIBA), 4190 Peron St., 1st. floor (C1991ABB), Buenos Aires, Argentina.
| | - Mariano F Ramírez
- Plastic Surgery Department, Hospital Italiano de Buenos Aires, University of Buenos Aires Medical School, Hospital Italiano de Buenos Aires University Institute (IUHIBA), 4190 Peron St., 1st. floor (C1991ABB), Buenos Aires, Argentina
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Hsieh PJ, Shi MY, Pu CM. Subtotal Thigh Flap for Large Abdominal Wall Defect Reconstruction in Patient With Recurrent Dermatofibrosarcoma Protuberans: A Case Report and Literature Review. Ann Plast Surg 2024; 92:S41-S44. [PMID: 38285995 DOI: 10.1097/sap.0000000000003785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
BACKGROUND Harvesting an adequate-sized flap is challenging for reconstructing large defects on the abdominal wall. A subtotal thigh flap would be one of the choices as it provides a well-vascularized large flap with muscle components. Moreover, dermatofibrosarcoma protuberans (DFSP) is a low-grade dermal neoplasm with a high recurrence rate. There is still no consensus on the extent of resection to prevent a recurrence. OBJECTIVES We present a case of a patient who underwent the reconstruction of a large abdominal wall defect with a subtotal thigh flap after the resection of recurrent DFSP. MATERIALS AND METHODS A 59-year-old man killed from a recurrent huge mass in the lower abdomen with an invasion of the small intestine. His baseline characteristics and records of operations, medications, and outcomes were reviewed. RESULT After tumor excision, a 28 × 30-cm subtotal thigh flap was harvested from his left thigh to reconstruct the abdominal defect. A microvascular anastomosis with left deep inferior epigastric vessels was made eventually. The flap was in good condition, and the donor site was covered with a split-thickness skin graft. CONCLUSIONS Subtotal thigh flap may be considered for large abdominal wall defect reconstruction as it allows good perfusion of relatively large skin paddles compared with other free flaps. Also, patients with DFSP need definite margin-free resection and close follow-up to prevent a recurrence.
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Affiliation(s)
- Pei-Ju Hsieh
- From the Division of Plastic Surgery, Department of Surgery, Cathay General Hospital
| | - Min-Yen Shi
- Department of General Surgery, Cathay General Hospital, Taipei City
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Merhej H, Ali M, Nakagiri T, Zinne N, Selman A, Golpon H, Goecke T, Zardo P. Long-Term Outcome of Chest Wall and Diaphragm Repair with Biological Materials. Thorac Cardiovasc Surg 2023. [PMID: 37914155 DOI: 10.1055/a-2202-4154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
INTRODUCTION Chest wall and/or diaphragm reconstruction aims to preserve, restore, or improve respiratory function; conserve anatomical cavities; and upkeep postural and upper extremity support. This can be achieved by utilizing a wide range of different grafts made of synthetic, biological, autologous, or bioartificial materials. We aim to review our experience with decellularized bovine pericardium as graft in the past decade. PATIENTS AND METHODS We conducted a retrospective analysis of patients who underwent surgical chest wall and/or diaphragm repair with decellularized bovine pericardium between January 1, 2012 and January 13, 2022 at our institution. All records were screened for patient characteristics, intra-/postoperative complications, chest tube and analgesic therapy duration, length of hospital stay, presence or absence of redo procedures, as well as morbidity and 30-day mortality. We then looked for correlations between implanted graft size and postoperative complications and gathered further follow-up information at least 2 months after surgery. RESULTS A total of 71 patients either underwent isolated chest wall (n = 51), diaphragm (n = 12), or pericardial (n = 4) resection and reconstruction or a combination thereof. No mortality was recorded within the first 30 days. Major morbidity occurred in 12 patients, comprising secondary respiratory failure requiring bronchoscopy and invasive ventilation in 8 patients and secondary infections and delayed wound healing requiring patch removal in 4 patients. There was no correlation between the extensiveness of the procedure and extubation timing (chi-squared test, p = 0.44) or onset of respiratory failure (p = 0.27). CONCLUSION A previously demonstrated general viability of biological materials for various reconstructive procedures appears to be supported by our long-term results.
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Affiliation(s)
- Hayan Merhej
- Department of Cardiothoracic Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Mohammed Ali
- Department of Cardiothoracic Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Tomoyuki Nakagiri
- Department of Cardiothoracic Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Norman Zinne
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Medizinische Hochschule Hannover Zentrum Chirurgie, Hannover, Germany
| | - Alaa Selman
- Department of Cardiothoracic Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Heiko Golpon
- Department of Pneumology and Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Tobias Goecke
- Department of Cardiothoracic Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Patrick Zardo
- Department of Cardiothoracic Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Niedersachsen, Germany
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Qin C, Xia Q, Chen Z, Zhou Q, Zheng X. En bloc resection of the recurrent pleural mesothelioma and reconstruction of the chest wall after immunotherapy: A case report. Thorac Cancer 2023; 14:3063-3066. [PMID: 37658846 PMCID: PMC10599967 DOI: 10.1111/1759-7714.15095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/19/2023] [Accepted: 08/21/2023] [Indexed: 09/05/2023] Open
Abstract
Malignant pleural mesothelioma (MPM) is associated with previous asbestos exposure, while more clinical insights into this disease have come from other case studies. Maximal cytoreduction is critical in disease control and might help to improve the prognosis. Here, a 41-year-old female presented with a 6-month history of a mass detected in the chest wall following resection of a right pleural mesothelioma 2 years previously. A fluorodeoxyglucose positron emission tomography/computed tomography scan showed a right chest wall mass with a blurred boundary 8.9 cm × 3.7 cm in size. The patient had received one cycle of bevacizumab, carboplatin, and pemetrexed, and two cycles of nivolumab, ipilimumab, and gemcitabine 5 months before admission. We subsequently resected the tumor, the involved diaphragm, and the fifth and sixth ribs, and titanium mesh and continuous suture were used to close the thoracic cage. The fixed paraffin-embedded tissues showed epithelioid pleural mesothelioma. The patient received nivolumab and ipilimumab postoperatively, and no recurrence was detected 16 months after surgery. En bloc resection with reconstructive surgery effectively removed the locally advanced malignancy and restored the biological function of the thorax with a favorable prognosis. Neoadjuvant immunotherapy might therefore be conducive to radical resection and perioperative immunotherapy might improve the prognosis.
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Affiliation(s)
- Changlong Qin
- Lung Cancer Center, West China HospitalSichuan UniversityChengduPeople's Republic of China
- Lung Cancer Institute, West China Hospital, Sichuan UniversityChengduPeople's Republic of China
| | - Qinghong Xia
- Operating Room of Anesthesia Surgery Center, West China HospitalSichuan UniversityChengduPeople's Republic of China
- West China School of NursingSichuan UniversityChengduPeople's Republic of China
| | - Zi‐Jia Chen
- Lung Cancer Center, West China HospitalSichuan UniversityChengduPeople's Republic of China
- Lung Cancer Institute, West China Hospital, Sichuan UniversityChengduPeople's Republic of China
| | - Qinghua Zhou
- Lung Cancer Center, West China HospitalSichuan UniversityChengduPeople's Republic of China
- Lung Cancer Institute, West China Hospital, Sichuan UniversityChengduPeople's Republic of China
| | - Xi Zheng
- Lung Cancer Center, West China HospitalSichuan UniversityChengduPeople's Republic of China
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Petro CC, Melland-Smith M. Open Complex Abdominal Wall Reconstruction. Surg Clin North Am 2023; 103:961-976. [PMID: 37709399 DOI: 10.1016/j.suc.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
This article provides an approach to open complex abdominal wall reconstruction. Herein, the authors discuss the purpose of component separation as well as its relevant indications. The techniques and anatomical considerations of both anterior and posterior component separation are described. In addition, patient selection criteria, preoperative adjuncts that may assist with fascial or soft tissue closure, and complications of component separation will be discussed.
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Affiliation(s)
- Clayton C Petro
- Lerner College of Medicine, Cleveland Clinic Center for Abdominal Core Health, 9500 Euclid Avenue A-100, Cleveland, OH 44195, USA.
| | - Megan Melland-Smith
- Lerner College of Medicine, Cleveland Clinic Center for Abdominal Core Health, 9500 Euclid Avenue A-100, Cleveland, OH 44195, USA
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Roberts DJ, Leppäniemi A, Tolonen M, Mentula P, Björck M, Kirkpatrick AW, Sugrue M, Pereira BM, Petersson U, Coccolini F, Latifi R. The open abdomen in trauma, acute care, and vascular and endovascular surgery: comprehensive, expert, narrative review. BJS Open 2023; 7:zrad084. [PMID: 37882630 PMCID: PMC10601091 DOI: 10.1093/bjsopen/zrad084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 07/28/2023] [Accepted: 07/28/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND The open abdomen is an innovation that greatly improved surgical understanding of damage control, temporary abdominal closure, staged abdominal reconstruction, viscera and enteric fistula care, and abdominal wall reconstruction. This article provides an evidence-informed, expert, comprehensive narrative review of the open abdomen in trauma, acute care, and vascular and endovascular surgery. METHODS A group of 12 international trauma, acute care, and vascular and endovascular surgery experts were invited to review current literature and important concepts surrounding the open abdomen. RESULTS The open abdomen may be classified using validated systems developed by a working group in 2009 and modified by the World Society of the Abdominal Compartment Syndrome-The Abdominal Compartment Society in 2013. It may be indicated in major trauma, intra-abdominal sepsis, vascular surgical emergencies, and severe acute pancreatitis; to facilitate second look laparotomy or avoid or treat abdominal compartment syndrome; and when the abdominal wall cannot be safely closed. Temporary abdominal closure and staged abdominal reconstruction methods include a mesh/sheet, transabdominal wall dynamic fascial traction, negative pressure wound therapy, and hybrid negative pressure wound therapy and dynamic fascial traction. This last method likely has the highest primary fascial closure rates. Direct peritoneal resuscitation is currently an experimental strategy developed to improve primary fascial closure rates and reduce complications in those with an open abdomen. Primary fascial closure rates may be improved by early return to the operating room; limiting use of crystalloid fluids during the surgical interval; and preventing and/or treating intra-abdominal hypertension, enteric fistulae, and intra-abdominal collections after surgery. The majority of failures of primary fascial closure and enteroatmospheric fistula formation may be prevented using effective temporary abdominal closure techniques, providing appropriate resuscitation fluids and nutritional support, and closing the abdomen as early as possible. CONCLUSION Subsequent stages of the innovation of the open abdomen will likely involve the design and conduct of prospective studies to evaluate appropriate indications for its use and effectiveness and safety of the above components of open abdomen management.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Ari Leppäniemi
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Matti Tolonen
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Panu Mentula
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Martin Björck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Andrew W Kirkpatrick
- TeleMentored Ultrasound Supported Medical Interventions (TMUSMI) Research Group, Calgary, Alberta, Canada
- Departments of Surgery and Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael Sugrue
- Department of Surgery Letterkenny, University Hospital Donegal, Donegal, Ireland
| | - Bruno M Pereira
- Department of Surgery, Masters Program in Health Applied Sciences, Vassouras University, Vassouras, Rio de Janeiro, Brazil
- Department of Surgery, Campinas Holy House General Surgery Residency Program Director, Campinas, Sao Paulo, Brazil
| | - Ulf Petersson
- Department of Surgery, Skane University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Federico Coccolini
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Rifat Latifi
- Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
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9
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Harrington MT, Hammond JB, Janbieh J, Haglin JM, Thornburg DA, Pearson D, Harold K, Rebecca AM, Howard MA, Teven CM. A 20-Year Analysis of Medicare Reimbursement for Abdominal Wall Reconstruction (2000 to 2020). Plast Reconstr Surg 2023; 152:644-651. [PMID: 36727728 DOI: 10.1097/prs.0000000000010247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate monetary trends in Medicare reimbursement rates for 30 abdominal wall reconstruction surgical procedures over a 20-year period (2000 to 2020). METHODS The Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid Services was used for each of the 30 included current CPT codes, and reimbursement data were extracted. Monetary data were adjusted for inflation to 2020 U.S. dollars using changes to the United States consumer price index. The R 2 values for the average annual percentage change and the average total percentage change in reimbursement were calculated based on these adjusted trends for all included procedures. RESULTS After adjusting for inflation, the average reimbursement for all procedures decreased by 17.1% from 2000 to 2020. The greatest mean decrease was observed for CPT code 49568 (the implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of débridement for necrotizing soft-tissue infection, -34.4%). The only procedure with an increased adjusted reimbursement rate throughout the study period was CPT code 20680 (+3.9%). From 2000 to 2020, the adjusted reimbursement rate for all included procedures decreased by an average of 0.85% each year, with an average R 2 value of 0.78, indicating a stable decline throughout the study period. CONCLUSIONS Reimbursement rates are declining when adjusted for inflation. Increased awareness of these trends is helpful to maintain access to optimal abdominal reconstruction care in the United States.
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Affiliation(s)
| | - Jacob B Hammond
- Department of Plastic and Reconstructive Surgery, Mayo Clinic
| | | | | | | | - David Pearson
- Department of Plastic and Reconstructive Surgery, Mayo Clinic
| | - Kristi Harold
- Department of Plastic and Reconstructive Surgery, Mayo Clinic
| | | | - Michael A Howard
- Department of Plastic and Reconstructive Surgery, Northwestern Medicine
| | - Chad M Teven
- Department of Plastic and Reconstructive Surgery, Northwestern Medicine
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Thomas B, Bigdeli AK, Nolte S, Gazyakan E, Harhaus L, Bischel O, Lehner B, Egerer G, Mechtersheimer G, Hohenberger P, Horch RE, Andreou D, Schmitt J, Schuler MK, Eichler M, Kneser U. 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). Cancers (Basel) 2022; 14:cancers14174312. [PMID: 36077847 PMCID: PMC9454490 DOI: 10.3390/cancers14174312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/26/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Benjamin Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
- Correspondence: (B.T.); (U.K.); Tel.: +49-(621)-6810-2944 (B.T.); +49-(621)-6810-2328 (U.K.)
| | - Amir K. Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Steffen Nolte
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
- Department of Otorhinolaryngology, Head and Neck Surgery, Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Emre Gazyakan
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Leila Harhaus
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Oliver Bischel
- Department of Trauma and Orthopedics, BG Trauma Center Ludwigshafen, 67071 Ludwigshafen, Germany
| | - Burkhard Lehner
- Department of Orthopaedics, Trauma Surgery and Paraplegiology, Heidelberg University Hospital, 69118 Heidelberg, Germany
| | - Gerlinde Egerer
- Department of Hematology, Oncology and Rheumatology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | | | - Peter Hohenberger
- Division of Surgical Oncology, Department of Surgery, Mannheim University Medical Center, University of Heidelberg, 68167 Mannheim, Germany
| | - Raymund E. Horch
- Department of Plastic and Hand Surgery, Comprehensive Cancer Center, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, 91054 Erlangen, Germany
| | - Dimosthenis Andreou
- Department of General Orthopedics and Tumor Orthopedics, University Hospital Münster, 48149 Münster, Germany
- Department of Orthopedics and Trauma, Medical University of Graz, 8036 Graz, Austria
| | - Jochen Schmitt
- National Center for Tumor Diseases (NCT/UCC), 01307 Dresden, Germany
- Center for Evidence-based Healthcare, University Hospital Carl Gustav Carus, Technical University Dresden, 01307 Dresden, Germany
| | - Markus K. Schuler
- Clinic and Polyclinic for Internal Medicine I, University Hospital Carl Gustav Carus, Technical University of Dresden, 01307 Dresden, Germany
| | - Martin Eichler
- National Center for Tumor Diseases (NCT/UCC), 01307 Dresden, Germany
- Clinic and Polyclinic for Internal Medicine I, University Hospital Carl Gustav Carus, Technical University of Dresden, 01307 Dresden, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
- Correspondence: (B.T.); (U.K.); Tel.: +49-(621)-6810-2944 (B.T.); +49-(621)-6810-2328 (U.K.)
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11
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Culbert M, Shock L, Fabricius MM, Nelson N. Reverse Abdominoplasty for Reconstruction Following Oncologic Resection of Extensive Breast Disease. Cureus 2022; 14:e28664. [PMID: 36196281 PMCID: PMC9525041 DOI: 10.7759/cureus.28664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2022] [Indexed: 11/13/2022] Open
Abstract
We present two cases of patients with extensive breast disease who underwent a reverse abdominoplasty for closure following resection: one of Paget’s disease extending beyond the breast borders and another of a locally recurrent triple-negative invasive ductal carcinoma following mastectomy in a patient who previously had an ipsilateral thoracotomy. The reverse abdominoplasty flap is a reconstructive option not readily considered for closure following mastectomy. However, we believe that the reverse abdominoplasty flap should be considered when evaluating patients for anterior chest wall reconstruction because it is a simple and versatile coverage option.
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12
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Abdominal Wall Reconstruction Using Pedicled Antero Lateral Thigh Flap. World J Plast Surg 2022; 11:63-71. [PMID: 36694686 PMCID: PMC9840762 DOI: 10.52547/wjps.11.3.63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 11/25/2022] [Indexed: 12/15/2022] Open
Abstract
Background Reconstructing abdominal wall defects has been a difficult task for surgeons. The abdominal wall defects range from defects of only soft tissue to full thickness defects including all the three layers of the abdomen. Only soft tissue defects are commonly caused by peritonitis and laparotomies, and full thickness defects can occur from en bloc resection of tumours as well as trauma. Treatment options available include component separation, partition technique, flap coverage, and more recently acellular dermal matrix. Methods This retrospective study done between 2016 and 2020 where 20 patients were operated for abdominal wall defect using Pedicled ALT flap in the Department of Plastic and Reconstructive Surgery, Sawai Man Singh Hospital, Jaipur, Rajasthan, India. Results The study consisted of total 20 patients, 14 males and 6 females. Eight patients were post electric burn, 5 patients had suffered trauma, 4 patients underwent resection of abdominal wall tumour and 3 patients were post laparotomy for peritonitis. Mean age of patients was 48 years (range from 36 to 62 years). Mean fascia defect size was 14.2 cm (range 12.2 to 16.4 cm). Mean operative time was 170 minutes (range from 140 minutes to 220 minutes). Postoperative hospital stay ranged from 8 days to 24 days (mean- 12 days). Conclusion Pedicled ALT flap has expanded the armamentarium of plastic surgeons for reconstruction of abdominal wall defects.
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13
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A staged reconstruction technique utilizing bioprosthetic mesh reinforcement in the repair of giant omphalocele. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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14
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Akıncı O, Kutluk F, Cin S, Ertürk S, Yüceyar S, Perek A. Heterotopic ossification of the anterior abdominal wall. Turk J Surg 2022; 38:208-210. [PMID: 36483167 PMCID: PMC9714656 DOI: 10.47717/turkjsurg.2022.4008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/03/2018] [Indexed: 12/24/2022]
Abstract
Heterotopic ossification (HO) is a bone formation in a tissue other than the skeletal system. It is more often seen as a complication of orthopedic surgery; however, it is a pathological condition that might be observed during the healing process of abdominal incisions in the midline. The aim of this study is to present a case of a 63-year-old male patient with the complaints of induration and pain on the region of his previous incision through which he had been operated for achalasia. HO is also discussed in the light of the current literature.
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Affiliation(s)
- Ozan Akıncı
- Department of General Surgery, İstanbul University Cerrahpaşa Medical Faculty, İstanbul, Turkey
| | - Fadime Kutluk
- Department of General Surgery, İstanbul University Cerrahpaşa Medical Faculty, İstanbul, Turkey
| | - Selçuk Cin
- Department of Pathology, İstanbul University Cerrahpaşa Medical Faculty, İstanbul, Turkey
| | - Süphan Ertürk
- Department of General Surgery, İstanbul University Cerrahpaşa Medical Faculty, İstanbul, Turkey
| | - Serdar Yüceyar
- Department of General Surgery, İstanbul University Cerrahpaşa Medical Faculty, İstanbul, Turkey
| | - Asiye Perek
- Department of General Surgery, İstanbul University Cerrahpaşa Medical Faculty, İstanbul, Turkey
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15
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Chest Wall Reconstruction: A Comprehensive Analysis. CURRENT SURGERY REPORTS 2022. [DOI: 10.1007/s40137-022-00318-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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16
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Hybrid nanocomposite as a chest wall graft with improved vascularization by copper oxide nanoparticles. J Biomater Appl 2022; 36:1826-1837. [DOI: 10.1177/08853282211065624] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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The Best of Chest Wall Reconstruction: Principles and Clinical Application for Complex Oncologic and Sternal Defects. Plast Reconstr Surg 2022; 149:547e-562e. [PMID: 35196698 DOI: 10.1097/prs.0000000000008882] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
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.
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18
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Microvascular Free Tissue Transfer for Reconstruction of Complex Abdominal Wall Defects. Plast Reconstr Surg 2022; 149:74e-78e. [PMID: 34936627 DOI: 10.1097/prs.0000000000008669] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
SUMMARY Patients with significant loss of abdominal wall soft tissue represent a reconstructive challenge. The purpose of this study was to describe the authors' experience using microvascular free tissue transfer to repair complex abdominal wall defects with insufficient overlying soft tissue. In this report, the authors highlight their techniques and experiences in performing microvascular free tissue transfer to the abdominal wall for these massive, complex defects. In total, 14 patients who underwent 16 free-flap reconstructions were included in the series. The patients' mean age was 50 ± 14 years, and mean body mass index was 27 ± 5 kg/m2. The mean hernia defect size was 412 ± 149 cm2. Ten flaps were fasciocutaneous anterolateral thigh flaps, one myocutaneous anterolateral thigh flap, two subtotal thigh flaps, one myocutaneous latissimus dorsi flap, one parascapular/latissimus dorsi flap, and one free filet of the lower leg. Five cases (36 percent) developed hernia recurrence, and seven developed surgical site complications. All flaps survived, with no total flap loss. This report highlights that microsurgical free tissue transfer in combination with mesh repair is a safe and reliable method for restoring complex, large, full-thickness abdominal wall defects. This case series illustrates a number of techniques and considerations that are of importance to achieve a favorable outcome when faced with these complex defects. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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19
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Zhou X, You P, Huang S, Li X, Mao T, Liu A, Yan R, Zhang Y, Zhuo W, Wang S. Resection and reconstruction of a giant primitive neuroectodermal tumour of the abdominal wall with an ultra-long lateral circumflex femoral artery musculocutaneous flap: a case report. BMC Surg 2021; 21:90. [PMID: 33602207 PMCID: PMC7890968 DOI: 10.1186/s12893-021-01095-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 02/09/2021] [Indexed: 12/05/2022] Open
Abstract
Background Primitive neuroectodermal tumours are clinically rare. Here, we report a case of a large peripheral primitive neuroectodermal tumour of the abdominal wall. The defect was reconstructed with the longest lateral circumflex femoral artery musculocutaneous flap reported to date. Case presentation A 15-year-old male suffered rupture and bleeding of an abdominal wall mass with a volume of approximately 23*18*10 cm3, involving the whole layer of the abdominal wall. Pathological examination revealed a peripheral primitive neuroectodermal tumour. The tumour was removed via oncologic resection, and the abdominal wall was reconstructed with a bilateral 44*8 cm2 lateral circumflex femoral artery musculocutaneous flap combined with a titanium polypropylene patch. The patient had smooth recovery postoperative, and the functions of the donor and recipient areas of the flap were not significantly affected. Conclusion In this case report, we describe a rare primitive neuroectodermal tumour of the abdominal wall, which invaded almost the entire abdominal wall due to delay of treatment. After thoroughly removing the tumour, we immediately reconstructed the abdominal wall with an ultra-long lateral circumflex femoral artery musculocutaneous flap and achieved better appearance and function after the operation. This case suggests that we should adopt an integrated scheme of surgery combined with radiotherapy and chemotherapy in the treatment of peripheral primitive neuroectodermal tumours. Under the premise of determining the blood supply, the lateral circumflex femoral artery musculocutaneous flap can be cut to a sufficient length.
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Affiliation(s)
- Xin Zhou
- Department of Plastic and Cosmetic Surgery, Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, Sichuan, 646000, People's Republic of China
| | - Pan You
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Army Medical University, Xinqiao Road, Sha Ping Ba District, Chongqing, 400037, People's Republic of China
| | - Shuqing Huang
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Army Medical University, Xinqiao Road, Sha Ping Ba District, Chongqing, 400037, People's Republic of China
| | - Xiang Li
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Army Medical University, Xinqiao Road, Sha Ping Ba District, Chongqing, 400037, People's Republic of China
| | - Tongchun Mao
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Army Medical University, Xinqiao Road, Sha Ping Ba District, Chongqing, 400037, People's Republic of China
| | - Anming Liu
- Department of Plastic and Cosmetic Surgery, Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, Sichuan, 646000, People's Republic of China
| | - Rongshuai Yan
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Army Medical University, Xinqiao Road, Sha Ping Ba District, Chongqing, 400037, People's Republic of China
| | - Yiming Zhang
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Army Medical University, Xinqiao Road, Sha Ping Ba District, Chongqing, 400037, People's Republic of China
| | - Wenlei Zhuo
- Cancer Institute, Xinqiao Hospital, Army Medical University, Chongqing, 400037, People's Republic of China
| | - Shaoliang Wang
- Department of Plastic and Cosmetic Surgery, Xinqiao Hospital, Army Medical University, Xinqiao Road, Sha Ping Ba District, Chongqing, 400037, People's Republic of China.
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20
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Brito ÍM, Teixeira S, Paupério G, Choupina M, Ribeiro M. Giant chondrosarcoma of the chest wall: a rare surgical challenge. AUTOPSY AND CASE REPORTS 2020; 10:e2020166. [PMID: 33344295 PMCID: PMC7703468 DOI: 10.4322/acr.2020.166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Íris M Brito
- Coimbra University Hospital Center, Department of Plastic Surgery and Burns Unit. Coimbra, Portugal
| | - Sérgio Teixeira
- São João Hospital Center, Department of Plastic, Reconstructive and Maxillo-Facial Surgery. Porto, Portugal
| | - Gonçalo Paupério
- Portuguese Institute of Oncology - Porto, Department of Thoracic Surgery. Porto, Portugal
| | - Miguel Choupina
- Portuguese Institute of Oncology - Porto, Department of Plastic and Reconstructive Surgery. Porto, Portugal
| | - Matilde Ribeiro
- Portuguese Institute of Oncology - Porto, Department of Plastic and Reconstructive Surgery. Porto, Portugal
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21
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Nemir S, Mericli AF, Adelman DM, Liu J, Feig BW, Lin PP, Roubaud MS. A reconstructive algorithm of oncologic defects of the upper trunk and shoulder girdle: Factors predicting complexity and outcomes. J Surg Oncol 2020; 122:283-292. [PMID: 32363601 DOI: 10.1002/jso.25957] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/19/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND Locally advanced malignancies of the upper torso and shoulder girdle (UT-SG) necessitate extensive resection and complex reconstruction. Due to the infrequent nature of these operations, a global reconstructive algorithm has not been defined. METHODS A retrospective review of all patients who received reconstructive surgery following malignant tumor extirpation in the UT-SG from 2008 to 2018 at the University of Texas MD Anderson Cancer Center. Factors predicting the need for flap reconstruction and risk for postoperative complications were evaluated. RESULTS In total, 252 procedures met inclusion criteria. The most common pathology was sarcoma (76%) and 52% were primary tumors. The median defect area was 112 cm2 (range 4-1350 cm2 ). Reconstructive techniques included pedicled flaps (46%), local tissue rearrangement (38%), and free flaps (16%). On univariate analysis, the probability of needing a free flap increased 39% when the defect size increased by 100 cm2 . The strongest independent predictors of requiring a free flap were major vessel exposure (adjusted odds ratio [OR] = 4.92, 95% confidence interval [CI], 1.36-17.84, P = .015) and major peripheral nerve exposure (adjusted OR = 3.2, 95% CI, 1.1-9.2, P = .031). CONCLUSION Despite the aggressive nature of their malignancies, patients requiring an UT-SG resection demonstrate high survival rates and therefore demand a durable reconstruction. Exposed critical structures and defect size were predictive of free tissue transfer.
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Affiliation(s)
- Stephanie Nemir
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Alexander F Mericli
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David M Adelman
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jun Liu
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Barry W Feig
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Patrick P Lin
- Department of Orthopaedic Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Margaret S Roubaud
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
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22
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Giordano S, Garvey PB, Clemens MW, Baumann DP, Selber JC, Rice DC, Butler CE. Synthetic Mesh Versus Acellular Dermal Matrix for Oncologic Chest Wall Reconstruction: A Comparative Analysis. Ann Surg Oncol 2020; 27:3009-3017. [PMID: 32152778 DOI: 10.1245/s10434-019-08168-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Management of chest wall defects after oncologic resection is challenging due to multifactorial etiologies. Traditionally, skeletal stabilization in chest wall reconstruction (CWR) was performed with synthetic prosthetic mesh. The authors hypothesized that CWR for oncologic resection defects with acellular dermal matrix (ADM) is associated with a lower incidence of complications than synthetic mesh. METHODS Consecutive patients who underwent CWR using synthetic mesh (SM) or ADM at a single center were reviewed. Only oncologic defects involving resection of at least one rib and reconstruction with both mesh and overlying soft tissue flaps were included in this study. Patients' demographics, treatment factors, and outcomes were prospectively documented. The primary outcome measure was surgical-site complications (SSCs). The secondary outcomes were specific wound-healing events, cardiopulmonary complications, reoperation, and mortality. RESULTS This study investigated 146 patients [95 (65.1%) with SM; 51 (34.9%) with ADM] who underwent resection and CWR of oncologic defects. The mean follow-up period was 29.3 months (range 6-109 months). The mean age was 51.5 years, and the mean size of the defect area was 173.8 cm2. The SM-CWR patients had a greater number of ribs resected (2.7 vs. 2.0 ribs; p = 0.006) but a similar incidence of sternal resections (29.5% vs. 23.5%; p = 0.591) compared with the ADM-CWR patients. The SM-CWR patients experienced significantly more SSCs (32.6% vs. 15.7%; p = 0.027) than the ADM-CWR patients. The two groups had similar rates of specific wound-healing complications. No differences in mortality or reoperations were observed. CONCLUSIONS The ADM-CWR patients experienced fewer SSCs than the SM-CWR patients. Surgeons should consider selectively using ADM for CWR, particularly in patients at higher risk for SSCs.
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Affiliation(s)
- Salvatore Giordano
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Patrick B Garvey
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Mark W Clemens
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Donald P Baumann
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jesse C Selber
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David C Rice
- Department of Thoracic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charles E Butler
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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23
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Hallock GG. The extended latissimus dorsi-serratus anterior chimeric local free flap for salvage of the complicated posterolateral thoractomy incision. Injury 2019; 50 Suppl 5:S8-S10. [PMID: 31784056 DOI: 10.1016/j.injury.2019.10.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Geoffrey G Hallock
- Division of Plastic Surgery, Sacred Heart Hospital, Allentown, Pennsylvania, St. Luke's Hospital, 1230 S. Cedar Crest Blvd., Suite 306, Allentown, Bethlehem, PA, United States.
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24
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Song D, Li Z, Zhou X, Zhang Y, Peng X, Zhou B, Lü C. [Modified pedicled anterolateral thigh myocutaneous flap for large full-thickness abdominal defect reconstruction]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:1305-1309. [PMID: 31544444 PMCID: PMC8337640 DOI: 10.7507/1002-1892.201903030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 08/01/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate the reconstructive methods and effectiveness of modified pedicled anterolateral thigh (ALT) myocutaneous flap for large full-thickness abdominal defect reconstruction. METHODS Between January 2016 and June 2018, 5 patients of large full-thickness abdominal defects were reconstructed with modified pedicled ALT myocutaneous flaps. There were 3 males and 2 females with an average age of 43.7 years (range, 32-65 years). Histologic diagnosis included desmoid tumor in 3 cases and sarcoma in 2 cases. The size of abdominal wall defect ranged from 20 cm×12 cm to 23 cm×16 cm. Peritoneum continuity was reconstructed with mesh; lateral vastus muscular flap was used to fill the dead space and rebuild the abdominal wall strength; skin grafting was applied on the muscular flap, the rest abdominal wall soft tissue defects were repaired with pedicled ALT flap. The size of lateral vastus muscular flap ranged from 20 cm×12 cm to 23 cm×16 cm, the size of ALT flap ranged from 20 cm×8 cm to 23 cm×10 cm. The donor site was closed directly. RESULTS All flaps and skin grafts survived totally, and incisions healed by first intention. All patients were followed up 6-36 months (mean, 14.7 months). No tumor recurrence occurred, and abdominal function and appearance were satisfying. No abdominal hernia was noted. Only linear scar left in the donor sites, and the function and appearance were satisfying. CONCLUSION Modified pedicled ALT myocutaneous flap is efficient for large full-thickness abdominal defect reconstruction, decrease the donor site morbidity, and improve the donor site and recipient site appearance.
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Affiliation(s)
- Dajiang Song
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Zan Li
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008,
| | - Xiao Zhou
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Yixin Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200000, P.R.China
| | - Xiaowei Peng
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Bo Zhou
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Chunliu Lü
- Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital, Changsha Hunan, 410008, P.R.China
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Song D, Li Z, Zhou X, Zhang Y, Peng X, Zhou B, Lü C. [Application of pedicled anterolateral thigh myocutaneous flap for full-thickness abdominal wall reconstruction after tumor resection]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:712-716. [PMID: 31197998 PMCID: PMC8355767 DOI: 10.7507/1002-1892.201901005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 04/22/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To explore the effectiveness of pedicled anterolateral thigh myocutaneous flap for full-thickness abdominal wall reconstruction after tumor resection. METHODS Between September 2010 and December 2017, 18 patients with abdominal wall tumors were collected. There were 11 males and 7 females, with an average age of 45.2 years (range, 29-68 years). Histologic diagnosis included desmoid tumor in 8 cases, sarcomas in 6 cases, malignant teratoma in 2 cases, and colon adenocarcinoma in 2 cases. All abdominal wall defects were full-thickness defects. Peritoneum continuity was reconstructed with mesh; the lateral vastus muscular flaps were used to fill the dead space and rebuild the abdominal wall strength; the abdominal wall soft tissue defects were repaired with pedicled anterolateral thigh flaps. The size of abdominal wall defects ranged from 15 cm×6 cm to 25 cm×22 cm; the size of lateral vastus muscular flap ranged from 10 cm×8 cm to 22 cm×10 cm; the size of anterolateral thigh flap ranged from 14.0 cm×8.0 cm to 21.0 cm×8.5 cm. The bilateral pedicled anterolateral thigh myocutaneous flaps were harvested to repair the extensive abdominal wall defects in 2 cases. All donor sites were sutured directly. RESULTS All wounds healed smoothly and all flaps survived totally. All donor sites healed smoothly. The mean follow-up time was 22.5 months (range, 11-56 months). No tumor recurrence occurred, the abdominal function and appearance were satisfactory, no abdominal hernia was noted. Only linear scar left at the donor sites. CONCLUSION Pedicled anterolateral thigh myocutaneous flap combined with mesh is fit for large full-thickness abdominal defect reconstruction.
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Affiliation(s)
- Dajiang Song
- Department of Oncology Plastic Surgery, Hunan Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Zan Li
- Department of Oncology Plastic Surgery, Hunan Cancer Hospital, Changsha Hunan, 410008,
| | - Xiao Zhou
- Department of Oncology Plastic Surgery, Hunan Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Yixin Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200000, P.R.China
| | - Xiaowei Peng
- Department of Oncology Plastic Surgery, Hunan Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Bo Zhou
- Department of Oncology Plastic Surgery, Hunan Cancer Hospital, Changsha Hunan, 410008, P.R.China
| | - Chunliu Lü
- Department of Oncology Plastic Surgery, Hunan Cancer Hospital, Changsha Hunan, 410008, P.R.China
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Yoon SH, Jung JC, Park IK, Park S, Kang CH, Kim YT. Clinical Outcomes of Surgical Treatment for Primary Chest Wall Soft Tissue Sarcoma. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2019; 52:148-154. [PMID: 31236374 PMCID: PMC6559192 DOI: 10.5090/kjtcs.2019.52.3.148] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 11/07/2018] [Accepted: 11/08/2018] [Indexed: 11/16/2022]
Abstract
Background This study investigated the clinical outcomes of surgical treatment of primary chest wall soft tissue sarcoma (CW-STS). Methods Thirty-one patients who underwent surgery for CW-STS between 2000 and 2015 were retrospectively reviewed. The disease-free and overall survival rates were estimated using the Kaplan-Meier method, and prognostic factors were analyzed using a Cox proportional hazards model. Results The median follow-up duration was 65.6 months. The most common histologic type of tumor was malignant fibrous histiocytoma (29%). The resection extended to the soft tissue in 14 patients, while it reached full thickness in 17 patients. Complete resection was achieved in 27 patients (87.1%). There were 5 cases of local recurrence, 3 cases of distant metastasis, and 5 cases of combined recurrence. The 5-year disease-free rate was 49%. Univariate analysis indicated that incomplete resection (p<0.001) and stage (p=0.062) were possible risk factors for recurrence. Multivariate analysis determined that incomplete resection (p=0.013) and stage (p=0.05) were significantly associated with recurrence. The overall 5- and 10-year survival rates were 86.8% and 64.3%, respectively. No prognostic factor for survival was identified. Conclusion Long-term primary CW-STS surgery outcomes were found to be favorable. Incomplete microscopic resection and stage were risk factors for recurrence.
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Affiliation(s)
- Seung Hwan Yoon
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Joon Chul Jung
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - In Kyu Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Samina Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Hyun Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young Tae Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Hayashi T, Sakakura N, Ishimura D, Kozawa E, Yoshida M, Sakao Y, Yamada H, Tsukushi S. Surgical complication and postoperative pulmonary function in patients undergoing tumor surgery with thoracic wall resection. Oncol Lett 2019; 17:3446-3456. [PMID: 30867783 PMCID: PMC6396184 DOI: 10.3892/ol.2019.9997] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 01/23/2019] [Indexed: 11/16/2022] Open
Abstract
Postoperative complications of thoracic wall resection include respiratory complications, skin necrosis and infection. The aim of the present study was to examine postoperative complications in patients who required combined thoracic wall resection during the surgical removal of a tumor. The present study included 68 patients; there were 50 patients with lung tumors and 18 patients with musculoskeletal tumors. The clinical factors associated with complications were compared between the two groups. Preoperative and postoperative pulmonary function tests were performed to examine the residual pulmonary function in 16 patients. Thoracic cage reconstruction was performed in 46 patients. Postoperative complications occurred in 30 (44.1%) patients, and one patient died from postoperative pneumonitis. Compared with the pulmonary function preoperative test results, the postoperative results revealed a decrease in the mean vital capacity percentage and an increase in the mean forced expiratory volume within 1 sec as a percent of the forced vital capacity. In patients with lung tumors, pneumonectomy can result in an increased rate of complications following thoracic wall resection. Residual pulmonary function is affected by impaired thoracic cage expansion and removal of the lung. However, the results of the present study demonstrated that these complications can be somewhat stabilized by thoracic wall reconstruction.
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Affiliation(s)
- Takuma Hayashi
- Department of Orthopedic Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi 464-8681, Japan.,Department of Orthopedic Surgery, Fujita Health University, Toyoake, Aichi 470-1192, Japan
| | - Noriaki Sakakura
- Department of Respiratory Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi 464-8681, Japan
| | - Daisuke Ishimura
- Department of Orthopedic Surgery, Fujita Health University, Toyoake, Aichi 470-1192, Japan
| | - Eiji Kozawa
- Department of Orthopedic Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi 464-8681, Japan
| | - Masahiro Yoshida
- Department of Orthopedic Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi 464-8681, Japan
| | - Yukinori Sakao
- Department of Respiratory Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi 464-8681, Japan
| | - Harumoto Yamada
- Department of Orthopedic Surgery, Fujita Health University, Toyoake, Aichi 470-1192, Japan
| | - Satoshi Tsukushi
- Department of Orthopedic Surgery, Aichi Cancer Center Hospital, Nagoya, Aichi 464-8681, Japan
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Hijji T, AlShammari A, AlHammad A, AlKhalefah G, Hashem F, Almomen S, Aburahmah M. Incisional hernia repair with plication and utilization of Botox injections: First case report from Saudi Arabia for a 19-year-old female. Clin Case Rep 2019; 7:311-315. [PMID: 30847196 PMCID: PMC6389482 DOI: 10.1002/ccr3.1984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 12/02/2018] [Indexed: 11/24/2022] Open
Abstract
This article reports on the use of Botox preoperatively for the treatment of a complex ventral hernia which would have typically been treated with component separation technique. The case demonstrates that using the recently developed technique can aid in performing a tension-free hernia repair with potentially lower complication and recurrence rates.
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Affiliation(s)
- Talal Hijji
- College of MedicineAlfaisal UniversityRiyadhSaudi Arabia
| | - Abdullah AlShammari
- College of MedicineAlfaisal UniversityRiyadhSaudi Arabia
- King Faisal Specialist Hospital and Research Center (KFSH&RC)RiyadhSaudi Arabia
| | - Alanoud AlHammad
- King Faisal Specialist Hospital and Research Center (KFSH&RC)RiyadhSaudi Arabia
| | - Ghadah AlKhalefah
- King Faisal Specialist Hospital and Research Center (KFSH&RC)RiyadhSaudi Arabia
| | - Fuad Hashem
- King Faisal Specialist Hospital and Research Center (KFSH&RC)RiyadhSaudi Arabia
| | - Salha Almomen
- King Faisal Specialist Hospital and Research Center (KFSH&RC)RiyadhSaudi Arabia
| | - Mohammad Aburahmah
- College of MedicineAlfaisal UniversityRiyadhSaudi Arabia
- King Faisal Specialist Hospital and Research Center (KFSH&RC)RiyadhSaudi Arabia
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Mella JR, Ross KM, Li GZ, Pomahac B, Raut CP, Orgill DP. Cutaneous Breast Radiation-associated Angiosarcoma: Anterior Chest Wall Reconstruction Options Following Extra-radical Resection. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1938. [PMID: 30349797 PMCID: PMC6191213 DOI: 10.1097/gox.0000000000001938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 07/18/2018] [Indexed: 11/25/2022]
Abstract
Background Radiation-associated angiosarcoma (RAAS) of the breast is a rare complication following breast irradiation with high rates of recurrence and death. To improve survival, we have advocated for an extra-radical resection where the entire irradiated skin and subcutaneous tissue is excised. This results in very large chest defects for which we describe our reconstructive experience. Methods We performed a retrospective review of patients diagnosed with RAAS and treated with extra-radical resection followed by immediate reconstruction between 1999 and 2017. We analyzed reconstructive options, complications rates, length of stay, and operative times. Results Extra-radical resections were performed in 35 patients. We reconstructed these large defects with abdominal advancement flaps with split-thickness skin grafting in 25 patients and added a pedicled latissimus dorsi or omental flap in the 10 other patients. Skin grafts took well over the irradiated pectoralis major muscle with a median take rate of over 90%. Average operative times were 150 minutes for those treated with an abdominal advancement flap and skin grafting with a median length of stay of 5 days for all patients. Conclusion Large anterior chest soft-tissue defects caused by extra-radical resections leaves defects too large to be covered by traditional breast reconstruction flaps. Abdominal advancement, latissimus dorsi muscle, and omental flaps along with skin grafts can be safely performed while leaving other traditional options open for future breast reconstruction.
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Affiliation(s)
- Juan R Mella
- Department of Plastic Surgery, Lahey Clinic, Burlington, Mass.,Division of Plastic Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Kimberly M Ross
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, Mass
| | - George Z Li
- Division of Surgical Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Mass
| | - Bohdan Pomahac
- Division of Plastic Surgery, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Mass
| | - Chandrajit P Raut
- Division of Surgical Oncology, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Mass.,Center for Sarcoma and Bone Oncology, Dana Farber Cancer Institute, Boston, Mass
| | - Dennis P Orgill
- Division of Plastic Surgery, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Mass
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LDT classification and therapeutic strategy of congenital body wall defects. J Plast Reconstr Aesthet Surg 2017; 71:384-393. [PMID: 29029959 DOI: 10.1016/j.bjps.2017.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 07/09/2017] [Accepted: 09/04/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Repairing body wall defects is a critical step in the treatment of some congenital deformities, and this procedure may need the help from plastic surgeons. Although there are many articles about congenital deformities, body wall defects of these malformations are rarely studied as independent targets. METHODS In this article, the authors present an LDT classification for congenital body wall defects according to the position of the defects, the tissue layers involved, and the surgical urgency, each of which is represented by letters L, D, and T, respectively. That is, the defects in different areas (L), full-thickness (D1), or partial (D0A, D0B) defects, defects needing instant repair (T2), semi-elective repair (T1), or elective repair (T0). Based on this classification system, the authors have performed body wall reconstruction on two pairs of thoraco-omphalopagus twins, one pair of ischiopagus tetrapus twins, and an infant and an adult, both of whom were diagnosed with pentalogy of Cantrell associated with ectopia cordis. RESULTS Except for one pair of thoraco-omphalopagus twins who died after emergency separation, all the other patients survived. Another pair of thoraco-omphalopagus twins suffered from wound dehiscence and partial flap necrosis, respectively, after surgery. An expanded polytetrafluoroethylene mesh in one sister of the ischiopagus twins was removed because of infection. CONCLUSIONS LDT classification not only can help doctors categorise different congenital body wall defects rapidly and easily, but can also guide the reconstruction of these defects. It may have clinical value to plastic surgeons to some extent.
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Extensive Abdominal Wall Incisional Heterotopic Ossification Reconstructed with Component Separation and Strattice Inlay. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2016; 4:e816. [PMID: 27536495 PMCID: PMC4977144 DOI: 10.1097/gox.0000000000000814] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 05/17/2016] [Indexed: 01/11/2023]
Abstract
Symptomatic heterotopic ossification of abdominal surgical incisions is a rare occurrence. We present a 67-year-old man with severe discomfort caused by heterotopic ossification extending from the xiphoid to the umbilicus. The patient underwent an abdominal aortic aneurysm repair 3 years before our treatment. A 13 × 3.5 cm ossified lesion was excised. The resulting midline defect was closed using component separation and inlay Strattice. Tension-free midline adaptation of the recti muscles was achieved. A computed tomography scan of the abdomen 6 months after the surgery showed no recurrence or hernias. Heterotopic ossification in symptomatic patients has previously been treated with excision and primary closure. We believe that tension-free repair is important to prevent recurrence. Acellular dermal matrix may add to this effect and also compartmentalize the process.
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Posterior Component Separation with Transversus Abdominis Release: Technique, Utility, and Outcomes in Complex Abdominal Wall Reconstruction. Plast Reconstr Surg 2016; 137:636-646. [PMID: 26818302 DOI: 10.1097/01.prs.0000475778.45783.e2] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ventral hernia formation is a frequent and increasingly difficult problem. Nonmidline hernias, parastomal hernias, hernias near bony landmarks, and recurrent ventral hernias (especially after anterior component separation) present particular challenges. Typical reconstructive techniques may struggle to reestablish abdominal domain and to create a lasting repair. Posterior component separation with transversus abdominis release is a novel technique that offers a durable solution to a variety of complex ventral hernias. METHODS The posterior rectus sheath is incised and the retrorectus plane is developed. In a modification of the Rives-Stoppa technique, the transversus abdominis is released medial to the linea semilunaris to expose a broad plane that extends from the central tendon of the diaphragm superiorly, to the space of Retzius inferiorly, and laterally to the retroperitoneum. This preserves the neurovascular bundles innervating the medial abdominal wall. Mesh is placed in a sublay fashion above the posterior layer. In an overwhelming majority of patients, the linea alba is reconstructed, creating a functional abdominal wall with wide mesh reinforcement. RESULTS The technique is reliable and durable, with a 5 percent recurrence rate at 2 years. Although wound complications occur with a frequency similar to that of other techniques, they tend to be less severe, rarely requiring operative débridement. The technique is applicable to a broad range of hernias, including midline, parastomal, flank, subcostal, and recurrent hernias after prior component separations. CONCLUSION Posterior component separation with transversus abdominis release is a versatile, easy-to-learn technique of hernia repair that offers a reliable, durable solution to complex abdominal wall reconstruction.
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Momeni A, Kovach SJ. Important considerations in chest wall reconstruction. J Surg Oncol 2016; 113:913-22. [PMID: 26969557 DOI: 10.1002/jso.24216] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 02/16/2016] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Arash Momeni
- Division of Plastic Surgery, University of Pennsylvania Health Systems, Philadelphia, Pennsylvania
| | - Stephen J Kovach
- Division of Plastic Surgery, University of Pennsylvania Health Systems, Philadelphia, Pennsylvania
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Luan A, Galvez MG, Lee GK. Flow-through omental flap to free anterolateral thigh flap for complex chest wall reconstruction: Case report and review of the literature. Microsurgery 2015; 36:70-6. [DOI: 10.1002/micr.22444] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 01/20/2015] [Accepted: 02/17/2015] [Indexed: 11/06/2022]
Affiliation(s)
- Anna Luan
- Division of Plastic and Reconstructive Surgery, Department of Surgery; Stanford University Medical Center; Stanford CA
| | - Michael G. Galvez
- Division of Plastic and Reconstructive Surgery, Department of Surgery; Stanford University Medical Center; Stanford CA
| | - Gordon K. Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery; Stanford University Medical Center; Stanford CA
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Fernandez-Alvarez JA, Barrera-Pulido F, Lagares-Borrego A, Narros-Gimenez R, Gacto-Sanchez P, Gomez-Cia T. Coverage of supraumbilical abdominal wall defects: The tunnelled-pedicled ALT technique. Microsurgery 2015; 37:119-127. [PMID: 26109324 DOI: 10.1002/micr.22437] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Revised: 05/08/2015] [Accepted: 05/19/2015] [Indexed: 11/11/2022]
Abstract
Abdominal wall defects are a challenge for reconstructive surgeons. Although the utility of anterolateral thigh perforator (ALT) flap has been well established for lower abdominal wall reconstruction, pedicled ALT flap is usually not considered for supraumbilical defects in the most recent algorithms. The purpose of this paper is to report the results of a tunneled pedicled ALT flap for reconstruction of supraumbilical defect from a series of patients. From July 2009 to September2014, six patients underwent delayed abdominal wall coverage using pedicled ALT flaps and reinforcement with polypropylene meshes. Defects occurred after surgical complications and abdominal trauma. Flaps were tunneled beneath the rectus femoris and sartorius muscles to increase the pedicle length. The size of the skin islands ranged from 22-29 × 10-14 cm. All flaps survived and the healing of the wounds was successful. Partial dehiscence of donor site occurred in one patient, and small wound dehiscence due to minimal distal necrosis was observed in another patient. No functional problems were reported in donor site, and no complications occurred in 6-68 months of follow-up. The tunneled pedicled ALT flap may provide a reliable alternative method for abdominal wall reconstruction, including supraumbilical defects. © 2015 Wiley Periodicals, Inc. Microsurgery 37:119-127, 2017.
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Affiliation(s)
| | - Fernando Barrera-Pulido
- Department of Plastic and Reconstructive Surgery, Virgen Del Rocio University Hospital, Seville, Spain
| | - Araceli Lagares-Borrego
- Department of Plastic and Reconstructive Surgery, Virgen Del Rocio University Hospital, Seville, Spain
| | - Rocio Narros-Gimenez
- Department of Plastic and Reconstructive Surgery, Virgen Del Rocio University Hospital, Seville, Spain
| | | | - Tomas Gomez-Cia
- Department of Plastic and Reconstructive Surgery, Virgen Del Rocio University Hospital, Seville, Spain
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Chest Wall Reconstruction: Evolution Over a Decade and Experience With a Novel Technique for Complex Defects. Ann Plast Surg 2015; 76:231-7. [PMID: 25992971 DOI: 10.1097/sap.0000000000000502] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Chest wall reconstruction (CWR) with biologic matrices has gained popularity over the last decade; however, data on this topic remain sparse. The aim of this study is to review the different methods and materials used for CWR while reviewing and highlighting a novel approach using a biologic inlay and synthetic onlay technique for larger, complex high-risk defects. METHODS A retrospective review was performed of all patients who underwent full thickness chest wall resection and reconstruction during a 10-year period. Patient characteristics, comorbidities, operative data, as well as postoperative wound complications and outcomes were reviewed. Different reconstructive methods and materials were reviewed and compared. RESULTS From December 2003 to January 2014, a total of 81 patients underwent CWR. The indications for resection/reconstruction included oncologic in 49 patients (60.5%), desmoids tumors in 10 (12.3%), bronchopleural fistula in 3 (3.7%), infection in 7 (8.6%), and anatomic deformity in 7 (8.6%) patients. Synthetic and/or acellular dermal matrices (ADM) reconstruction was used in 59 patients (10 biologic, 22 synthetic, and 27 biologic ADM inlay/synthetic onlay combination). On average, 2.5, 3.5, and 3.6 ribs were resected in the biologic, synthetic, and combination group, respectively (P = 0.1). A greater number of patients in the combination group had a history of chemotherapy and/or radiation therapy (P = 0.03) than the synthetic or biologic alone groups. Risk analysis demonstrated an association between the number of ribs resected and postoperative chest wall complications. The incidence of chest wall/wound complications in the synthetic, combination, and biologic groups was 31.8%, 22.2%, and 10%, respectively (P = 0.47). CONCLUSIONS In the largest single institution study comparing the use of different reconstructive materials, including ADM in CWR, the authors demonstrate that a biologic inlay/synthetic onlay may be used effectively for high-risk, large complex defects. Early outcomes with this technique are promising. The authors believe this combination highlights benefits from both materials because the ADM facilitates tissue ingrowth and revascularization, whereas the synthetic component provides structural durability. Additional studies with larger sample sizes are necessary to further explore the benefits of the combination technique to determine if outcomes are better than either material alone when used to reconstruct high-risk wounds after larger resections.
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Temiz G, Şirinoğlu H, Yeşiloğlu N, Sarıcı M, Çardak ME, Demirhan R, Bozkurt M. A salvage maneuver for the caudal part of the pectoralis major muscle in the reconstruction of superior thoracic wall defects: The pectoralis kite flap. J Plast Reconstr Aesthet Surg 2015; 68:698-704. [PMID: 25704731 DOI: 10.1016/j.bjps.2015.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 01/11/2015] [Indexed: 11/18/2022]
Abstract
The pectoralis major muscle flap is the most commonly used option for chest wall reconstruction. However, its utilization should be avoided in chest wall tumors infiltrating the muscle. This article presents the utilization of the caudal part of the pectoralis major muscle as a pedicled flap in cases requiring the resection of the cranial part of the muscle due to tumor infiltration. Fourteen patients with a mean age of 60.3 years were operated for malignant thoracic wall tumors between 2011 and 2014. All tumors were located on the upper thoracic area with a mean defect size of 16.6 × 12 cm. During tumor resection, the thoracoacromial vessels and pectoral branch were preserved and dissected until reaching the pectoralis muscle. After the resection of the cranial part of the muscle, the caudal part is prepared as a pedicled island flap and used for the coverage of the resultant defect. The mean postoperative follow-up period was 10.9 months. All flaps survived without any partial or total flap loss. A case of local recurrence, two cases of hematoma requiring drainage, and two cases of local wound-healing problems were the encountered complications. The pectoral kite flap is a versatile and reliable option for the coverage of small to medium upper chest wall defects with minimal morbidity, and it gives the reconstructive surgeon the opportunity to use the non-infiltrated caudal part of the pectoralis muscle instead of an unnecessary resection of the whole muscle.
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Affiliation(s)
- Gökhan Temiz
- Dr. Lütfi Kırdar Kartal Training and Research Hospital, Department of Plastic Reconstructive and Aesthetic Surgery, Istanbul, Turkey
| | - Hakan Şirinoğlu
- Dr. Lütfi Kırdar Kartal Training and Research Hospital, Department of Plastic Reconstructive and Aesthetic Surgery, Istanbul, Turkey.
| | - Nebil Yeşiloğlu
- Dr. Lütfi Kırdar Kartal Training and Research Hospital, Department of Plastic Reconstructive and Aesthetic Surgery, Istanbul, Turkey
| | - Murat Sarıcı
- Dr. Lütfi Kırdar Kartal Training and Research Hospital, Department of Plastic Reconstructive and Aesthetic Surgery, Istanbul, Turkey
| | | | - Recep Demirhan
- Dr. Lütfi Kırdar Kartal Training and Research Hospital, Department of Thoracic Surgery, Istanbul, Turkey
| | - Mehmet Bozkurt
- Dr. Lütfi Kırdar Kartal Training and Research Hospital, Department of Plastic Reconstructive and Aesthetic Surgery, Istanbul, Turkey
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