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We read with great interest the comments of Dr Hamaji [1Hamaji M. Still a long way to go for anterior or extensive chest wall reconstruction (letter).Ann Thorac Surg. 2016; 101: 410Abstract Full Text Full Text PDF Scopus (2) Google Scholar]. Hamaji and colleagues [2Hamaji M. Kojima F. Koyasu S. et al.A rigid and bioabsorbable material for anterior chest wall reconstruction in a canine model.Interact Cardiovasc Thorac Surg. 2015; 20: 322-328Crossref PubMed Scopus (6) Google Scholar] reported favorable outcomes in a comparative experimental study evaluating bioabsorbable material in the reconstruction of anterior chest wall defects. Highlighting the rate (44%) of titanium implant failure [3Berthet J.P. Gomez Caro A. Solovei L. et al.Titanium implant failure after chest wall osteosynthesis.Ann Thorac Surg. 2015; 99: 1945-1952Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar], they suggest the use of bioabsorbable and rigid material as a reliable alternative to bridge the chest wall defect or to correct the chest wall deformity. Considering that removing a broken titanium implant is mandatory (related to life-threatening complications), the use of bioabsorbable material may of course avoid a redo operation. Nevertheless, the main current concern regarding bioabsorbable materials is that they may be degraded before dense reliable connective tissue has developed in the bony defect. The time between implantation and degradation is unknown or inconstant, thus exposing the patient to the paradoxical motion of the chest wall and related respiratory complications [4Berthet J.P. Canaud L. D'Annoville T. Alric P. Marty-Ane C.H. Titanium plates and Dualmesh: a modern combination for reconstructing very large chest wall defects.Ann Thorac Surg. 2011; 91: 1709-1716Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar]. It is our belief that the combination of both materials may be considered appropriate for future experimental studies. In our experience, the permanent anteroposterior bending of titanium implants was associated with a 59% rate of rupture. We believe that the related deformity of the patient's chest wall (evidenced by clinical assessment and computed tomographic scans with multiplanar reconstructions) appeared when the rupture was associated with displacement of the different broken parts of the implant. Considering histologic findings, we were unable to find specific damage in the chest wall of patients with implant failures. We are currently analyzing the scanning electron microscopic (SEM) images of the removed titanium implants, showing a specific breaking profile. This preliminary analysis of SEM images shows progressive cracking, indicating that the titanium implants may have ruptured because of failure by mechanical fatigue, which may suggest that the implant did not have enough flexibility (Fig 1). Further analysis of secondary cracks will enable us to check if corrosion under mechanical stress accelerated the process of rupture. Still a Long Way to Go for Anterior or Extensive Chest Wall ReconstructionThe Annals of Thoracic SurgeryVol. 101Issue 1PreviewI read with great interest the article by Berthet and colleagues [1] and would like to congratulate them on the excellent multiinstitutional study [1]. They have already reported on the excellent short-term outcomes of chest wall reconstruction with titanium products even in challenging situations [2, 3]. The strengths of this study are obvious. This is the first report on long-term outcomes of chest wall reconstruction with titanium combined with polytetrafluoroethylene mesh. No patient was lost to follow-up, but all were followed up with a standardized radiologic protocol, which allowed the authors timely detection and prevention of life-threatening postoperative adverse events. Full-Text PDF