Anterior Chest Wall Reconstruction Research Articles

Mind the gap! Interdisciplinary approach to anterior chest wall reconstruction after total sternectomy

BackgroundThere are various reconstructive methods after total sternectomy. Reproducibility is scarce due to overall small patient numbers. Therefore we present a standardized, interdisciplinary approach for thoracic and plastic surgery.MethodsFour patients underwent interdisciplinary chest wall reconstruction with STRATOS® titanium bars and myocutaneous vastus lateralis muscle free flap in our center.ResultsAll patients reported chest wall stability after reconstruction. They reported good quality of life, no dyspnea, prolonged pain or impairment in lung function from rigid reconstruction. FEV1/FVC was overall better after surgery. Secondary wound healing was not impaired and there was no implant defect in follow up.ConclusionsWe recommend an interdisciplinary surgical approach in chest wall reconstruction after total sternectomy. The combination of rigid reconstruction with titanium bars and a myocutaneous vastus lateralis muscle free flap renders excellent results in patient satisfaction and is objectifiable via spirometry.

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

Background Anterior chest wall defects have a wide range of etiologies in the pediatric population, ranging from infection, tumor, and trauma to congenital diseases. The reconstructive goals include restoring skeletal stability, obliterating dead space, preserving cardiopulmonary mechanics, and protecting vital underlying mediastinal organs. Although various reconstructive methods have been described in the literature, selecting the optimal method is challenging for the growing pediatric skeleton. Here, we report a case of previously thoraco-omphalopagus twins who underwent successful separation and reconstruction and presented for definitive anterior chest wall reconstruction. Methods A pair of previously thoraco-omphalopagus conjoined twins underwent definitive anterior chest wall defect reconstruction using cadaveric ribs and omental flap. Twin A received 2 cadaveric ribs, whereas twin B had a much larger sternal defect that required 3 cadaveric ribs combined with an omental flap for soft tissue chest coverage. Both twins were followed up for 8 months. Results Twin A's postoperative course was uneventful, and she was discharged on postoperative day 6. Twin B's course was complicated, and she was discharged on supported ventilation on postoperative day 10. At 8 months postoperatively, both twins healed well, and chest radiographs confirmed the stability of the chest reconstructions. The rib grafts in the twin with a tracheostomy were not mobile, and the patient had a solid sternum with adequate pulmonary expansion. The construct initially did not facilitate pulmonary functioning, but after a healing process, it eventually allowed for the twin with the tracheostomy who required pulmonary assistance to no longer need this device. Conclusions Cryopreserved cadaveric ribs and omental flaps offer safe and reliable reconstructive methods to successfully reconstruct congenital anterior chest wall skeletal defects in the growing pediatric population. The involvement of multidisciplinary team care is key to optimizing the outcomes.

Sternal Reconstruction Using 3D-Printed Titanium Custom-Made Prosthesis for Sternal Dehiscence After Cardiac Surgery.

Sternal dehiscence is an important complication that increases mortality and morbidity in cardiac surgery. Titanium plates have been used to reconstruct the chest wall for a long time. However, with the rise of 3D printing technology, a more sophisticated method, is making a breakthrough. Custom-made 3D-printed titanium prostheses are increasingly used in chest wall reconstruction because they allow almost perfect fitting to the patient's chest wall and lead to good functional and cosmetic results. This report presents a complex anterior chest wall reconstruction using a custom-made titanium 3D-printed implant in a patient with a sternal dehiscence after coronary artery bypass surgery. At first, reconstruction of the sternum was performed using conventional methods, which failed to give adequate results. Finally, a 3D-printed titanium custom-made prosthesis was used for the first time in our center. On the short- and mid-term follow up, good functional results were achieved. In conclusion, this method is suitable for sternal reconstruction after complications in the healing process of median sternotomy wounds in cardiac surgery, especially where other methods do not provide satisfactory results.

Complex wound process in cardiac surgery. Tactics of anterior chest wall reconstruction

Objective. The postoperative wound complications are an integral part of the treatment process in any surgical practice. The aim of this work is to optimize the tactics of management and the choice of a method for reconstructing the anterior chest wall of cardiosurgical patients with postoperative sternomediastinitis.
 Materials and methods. The development of sternomediastinitis in patients undergoing open heart surgery is the highest risk factor for life. According to many authors, it occurs in 0.511 % of patients, while the fatality of this complication can reach up to 4050 %. This condition develops in a number of patients in a cardiac surgery hospital who have certain developmental predictors.
 Results. Thus, in our work, we consider preoperative, intraoperative and postoperative risk factors for the development of sternomediastinitis. Based on all the data studied in the world literature and our own experience, we algorithmized the approach to choosing the tactics of anterior chest wall reconstruction, determined the time frame and gave specific recommendations based on clinical examples, which confirms the practical effectiveness of the proposed methods.
 Conclusions. A differentiated approach to the choice of the method of plastic intervention is given, the tactical priority of using muscle flaps or segmental resection of the sternum is substantiated, and the importance of omentoplasty of a chest defect in severe purulent-septic lesions of a large scale is also updated.

802 Preservation of a Reconstructed Breast Whilst Undertaking Total Sternal Resection for Metastatic Breast Cancer with a Pedicled Latissimus Dorsi Flap and a Methyl Methacrylate Mesh Sandwich

Abstract Background Sternal resection and reconstruction are a complex and challenging procedure that requires a multidisciplinary approach and input from both thoracic and plastic surgeons. Limited data exist on sternal resection and reconstruction for secondary breast malignancies. The goals of sternal and anterior chest wall reconstruction are to maintain chest wall integrity, rigidity, and the negative pressure necessary for respiratory and cardiac functions, protect intrathoracic contents, and restore the chest wall contour. Case Presentation A 40-year-old lady developed a solitary sternal metastatic lesion three years after her initial diagnosis with BRCA2 positive breast cancer. She had previously undergone left mastectomy, axillary clearance and implant reconstruction followed by right prophylactic mastectomy and implant reconstruction. She also had neoadjuvant chemotherapy and adjuvant chest wall radiotherapy. Her solitary sternal metastasis was managed with curative intent by complete sternal resection and a combined alloplastic and autologous sternal reconstruction with methyl methacrylate sandwiched between a polypropylene mesh and covered with a pedicled latissimus dorsi flap. The flap was successfully tunnelled under the previous implant-based breast reconstruction capsule. The surgical margins were clear, there were no post-operative complications and no further disease. The patient achieved good cosmetic outcomes. Conclusions We describe the first case of breast implant preservation whilst undertaking total sternal resection for an isolated sternal metastasise and reconstruction with a pedicle latissimus dorsi flap and methyl methacrylate mesh sandwich. We advocate combined approach with thoracic and plastic surgery, which allows a safe single stage procedure.

Complex anterior chest wall reconstruction after extensive oncologic resections: a narrative review.

Objective:This report serves to showcase four cases of rare, malignant primary neoplasms of the anterior chest wall [chondrosarcoma and basal cell carcinoma (BCC)] that thoracic surgeons may encounter, and different approaches to complex reconstruction that may be necessary following resection.Background:Approximately 60% of the anterior chest wall neoplasms are malignant. The most common types of primary sternal tumors are chondrosarcoma and osteosarcoma. While guidelines for resection of these tumors have been previously described in the literature, guidelines regarding reconstructive techniques of the subsequent large defects are infrequently demonstrated.Methods:The medical records of four adult patients with primary chest wall tumors who underwent resection of the sternum from October 2016 to March 2021 were retrospectively reviewed. Radical resection with tumor-free surgical margins offers the best chance for survival, but results in a wide full-thickness defect. Hence, closure of the anterior chest wall defect with skeletal reconstruction is an essential step of the procedure and allows us to highlight surgical techniques and materials that have been used over recent years. Methods described herein include skeletal reconstruction with various hardware or allograft, as well as defect coverage using regional flaps, free tissue transfer, and mesh.Conclusions:Primary chest wall tumors of the sternum are an extremely rare diagnosis with a high malignancy rate. Full-thickness radical en-bloc resection is the most effective treatment option. Subsequent reconstruction of a wide chest wall defect is the most challenging aspect, though crucial in the preservation of the rigidity of the chest wall and protection of underlying structures. Different techniques and materials have been described without clear guidelines in treatment approaches; this paper serves to delineate and describe techniques that achieved successful outcomes.

Biomechanical characterization of custom-made dynamic implants fabricated by Electron Beam Melting for anterior chest wall reconstruction

Large thoracic defects need to be reconstructed to restore inner organs protection and normal ventilation. Early rigid implants have provided the stabilization of the ribcage; however, those have been associated with breathing restrictions. The evolution of additive manufacturing has enabled the production of 3D custom-made thoracic implants. This has led to case reports on reconstructions with these prostheses, particularly for large anterior resections. A novel design of thoracic implant with dynamic capacity has already been reported, with promising short-term outcomes. However, specific biomechanical studies are needed to clarify its mechanical behaviour. A study of the evolution of the design of dynamic thoracic implants was carried out and such implants were biomechanically tested. Furthermore, finite element analyses were carried out to obtain a simple and reliable model to predict the implant behaviour, considering a rib and its costal cartilage. In the models, the stiffness and stress distribution along the implant and the bone showed that the reconstructions exhibited adequate mechanical behaviour. One of the designs provided a flexibility that closely matched the native model and the maximum stress values did not exceed the 30% of the yield strength of Ti-6Al-4V. The implants strength was demonstrated to be sufficient under tested conditions.

Additional vascularization of the omental flap using mammary-gastroepiploic bypass grafting in the treatment of deep sternal wound infection

Incidence of postoperative sternomediastinitis depends on various risk factors and makes up 8%. Surgical debridement with local management of the wound are used to achieve wound sterility. In some cases, sternectomy or subtotal sternal resection are performed for total sternal osteomyelitis with osteoporotic bone and multiple fractures. This procedure results an extensive bone defect. The final stage is anterior chest wall reconstruction. The most popular method is wound closure with autologous muscle or omental flaps. The authors describe a patient with sternomediastinitis who underwent staged treatment. At the final stage, subtotal sternectomy with simultaneous omentoplasty were performed. Additionally, mammary-gastroepiploic bypass grafting with right internal mammary artery and right gastroepiploic artery was carried out for additional vascularization of the omental flap. We found no similar surgery for sternomediastinitis in the literature. Long-term treatment outcome was followed-up (>50 months of relapse-free period and good quality of life).

Anaesthetic management of a single stage surgery of anterior chest wall reconstruction and mitral valve replacement in a patient with loeys dietz syndrome

Introduction This syndrome is a rare genetic disease discovered quite recently in 2005 by Loey and colleagues 1. It is described by the syndrome of altered cardiovascular, craniofacial, neurocognitive and skeletal development caused by genetic mutations. The anaesthetic management of this patient involves that of plastic surgery and of cardiopulmonary bypass. Retrospective review of patients with LDS types 1-4 undergoing cardiovascular surgery during the years 1991-2016 showed 35 patients underwent 57 cardiac-related operations but no combined plastic and cardiothoracic case has been reported so far2. Methods This is a case report of rare and challenging anesthetic management of combined plastic surgery and cardiothoracic surgery. A 14 year old boy was referred to our centre for severe mitral regurgitation in failure planned for mitral valve replacement. He has underlying Loey's Dietz Syndrome in which he has severe pectus excavatum and thoracolumbar scoliosis. Echocardiography revealed severe mitral regurgitation, ERO 0.49cm2 and dilated annulus of 42cm. There is also mild aortic regurgitation and dilated sinus of valsalva of 42cm. The aortic annulus and sinotubular junction remained in normal range with 24mm and 28 mm respectively. Multidisplinary meeting has concluded to perform single stage surgery to avoid risk of adhesion with preservation of bilateral internal mammary artery to maintain perfusion to reconstruction site. The aortic root left untouched as it hoped by reducing volume from mitral valve replacement, the dilatation will not be worse. Results Patient underwent general anaesthesia with anterior osteomusculocutaneous chest wall island flap raised by plastic team first then proceed with cardiopulmonary bypass for mitral valve replacement (MVR). After good valvular function obtained post replacement, we proceeded with coming off bypass and anterior chest wall reconstruction by plastic team. Patient was sedated and paralysed overnight and extubated the next day. PCA fentanyl started as post-operative pain relief. Discussion The anaesthetic challenges in this case are mounting as we deal with rare congenital disease with multisystem involvement. It also combines both plastic surgery and cardiothoracic anaesthesia management with several parameters that require detailed monitoring. Further study may be required in regards to circuit priming in the case of combined cardiothoracic and plastic operation. This case however serves as a guide as to anaesthetic management in such combined procedure. Should this patient return for further cardiothoracic operation in the future, it will pose another great anaesthetic challenges.

Anterior chest wall reconstruction for oncologic and non-oncologic pathology: a case series

Background: Utmost malignant, in addition to large benign tumors or deformity/trauma of the chest wall, typically require thoracic surgery to manage the abnormal growth promptly. Chest wall resection encompasses a variety of approaches from partial to full surgical removal of soft tissue, cartilage, sternum, and ribs. The reconstruction, using prosthetic materials may be employed to rebuild the skeletal structure.

Long-Term Metabolic Assessment of Cryopreserved Sternal Allograft: A Case Series

Sternal resection and reconstruction with cryopreserved allografts provides a safe alternative to traditional methods of anterior chest wall reconstruction. Despite favorable results, successful integration of the graft sternum has never been demonstrated owing to the invasiveness of bone biopsy. We describe our experience of using 18F-sodium fluoride positron emission tomography/computed tomography scans as a noninvasive method of evaluating graft integration. Seven patients underwent surgery and radiologic follow-up. Surgical indications were sternal metastases (n= 5) and sternal dehiscence (n= 2). Sternal reconstruction was performed using a cryopreserved cadaveric sternal allograft fixed in place with titanium plates and screws. Follow-up with 18F-sodium fluoride positron emission tomography/computed tomography scans was performed at 1 and 2 years after surgery. Three patients underwent total sternectomy. Two underwent partial upper sternectomy involving the manubrium, clavicle (1 patient only), and upper sternal body; and 2 had partial sternectomy of the sternal body and xiphoid process. Focal tracer accumulation occurred at the junctions between native bone and graft bone. The median maximum standardized uptake value at 1 year was 16.8 (range, 11.2 to 37.9; interquartile range, 13.6 to 19.4), and at 2 years it was 10.8 (range, 6.1 to 30.2; interquartile range, 8.9 to 15.1). In 6 cases accumulation was lower at the second scan, whereas in 1 patient the accumulation was higher at the second scan. Sternal reconstruction with cryopreserved allograft is safe and well tolerated. The 18F-sodium fluoride positron emission tomography/computed tomography scans are a useful and promising noninvasive method of demonstrating the metabolic activity of the graft and its incorporation into the host skeleton during follow-up.

Autologous ilium graft combination with Y-shaped titanium plate fixation for chest wall reconstruction after resection of primary sternal tumors-a clinical study from three institutions.

BackgroundThe technique for anterior chest wall reconstruction after resection of primary sternal tumors (PST) still continue to evolve.MethodsA total of 12 PST patients from three hospitals who underwent en-bloc resection were included in our study. After finishing sternum resection, autologous iliac bone combined with Y-shaped titanium plate were applied to rebuild the anterior chest wall. Postoperative outcomes were analyzed.ResultsThere were 10 different types of tumors located in manubrium (6 cases), sternum body (4 cases) and Louis’s angle (2 cases) in our research. For these patients, the median resected tumor size and the area of defect after sternal resection were 279.0 cm3 and 215.0 cm2, respectively. The mean operative time was 299.2±65.2 min and intra-operative blood loss was 431.2±213.0 mL. Mean duration of drainage was 9.9±2.6 days. In their perioperative period, significant circulatory and respiratory complications occurred in 8 patients. Postoperative chest X-ray and tridimensional CT images showed autogenous reconstruction of the sternum and titanium in good position. No side effects were observed 6–12 months post reconstructive surgery, but one patient suffered from anchor loss and prosthesis migration. Y-shaped titanium plates from two patients were separately removed at 24 and 26 months when the reconstructive sternum integrated with skeleton anterior chest wall well.ConclusionsOur study demonstrates the safety and feasibility of this new technique for anterior chest wall reconstruction after sternectomies.

Anterior chest wall reconstruction for cutaneous involvement of Hodgkin’s lymphoma

Hodgkin lymphoma with initial thoracic involvement is common and it is more frequently localized in the mediastinum, followed by lung parenchyma and the pleura. However, skin involvement of Hodgkin’s lymphoma is extremely rare. We report this case to illustrate a rare and unique presentation of a potentially curable disease, with resistance to standard treatment. Free tissue transfer was used as an adjunct to provide a better quality of life for the patient with Hodgkin lymphoma complicated with extensive anterior chest wall ulceration exposing lung and pericardium.

Anterior Chest Wall Reconstruction Using Polypropylene Mesh: A Retrospective Study.

Anterior chest wall resection for oncological purposes is usually combined with a form of reconstruction. Most surgeons are convinced that ventrally located defects more than 4 to 5 cm require adequate reconstruction to minimize the risk of lung herniation and respiratory distress through paradox motion. We describe our in-house results of ventral chest wall reconstruction using polypropylene mesh without the use of metallic or biological implants regardless of the extent of chest wall resection. Patient selection involved ventral chest wall resection and reconstruction by polypropylene mesh for all indications such as primary tumors, metastasis, or infiltration by lung cancer from January 2008 to December 2016. Primary end point was the difference between both sides. Secondary end points were postoperative complications such as infection, surgical revision, and pulmonary complications. Forty-five cases of isolated anterior reconstruction could be identified. In 34 cases, postoperative computed tomography scan of the thorax was available. Fifteen males and 19 females with a median age of 70.5 years were operated. The evaluation of maximum hemithorax diameter between operated and nonoperated sides was documented in centimeters, and the difference was documented in percentage. The mean percentage difference was 11.1% (minimum: 0.3, maximum: 44.4). In one case, wound infection with positive culture could not be treated conservatively and required operative revision and removal of the polypropylene mesh. Polypropylene mesh, though not rigid, can safely be used for anterior chest wall reconstruction.

Anterior Middle Chest Wall Reconstruction Using a Free Anterolateral Thigh Flap Resulted in Flail Chest: A Case Report.

Supplemental Digital Content is available in the text.

Clinical Application of the Internal Mammary Artery Perforator Adipofascial Flap.

Background:Skin ulcers on the anterior chest wall are caused mainly by radiation therapy for breast cancer and anterior mediastinitis after thoracotomy, and they are often refractory. Some muscle flaps are commonly used for anterior chest wall reconstruction, but muscle flaps accompany high invasion. We used the internal mammary artery perforator (IMAP) adipofascial flap and IMAP skin flap for the anterior chest wall reconstruction.Methods:We examined the IMAPs using a handheld Doppler device and contrast-enhanced computerized tomography preoperatively. Each flap was designed based on the location of the IMAP and the size of the flap was dependent on the coverage required by the size and location of the skin ulcer. The location of the IMAPs functioned as the pivot point of the flap and the flap was flipped or swung on the defect.Results:We used IMAP adipofascial flap for 2 cases and IMAP skin flap for 1 case. In those 3 cases, we could elevate the flap with no complications even after the internal mammary artery had been harvested. There was no recurrence of the skin ulcer or wound infection after the operation.Conclusions:In this study, we reported 3 cases of skin ulcer on the anterior chest wall reconstructed with the IMAP adipofascial and skin flap. To our knowledge, this is the first report of the use of the IMAP flap as an adipofascial flap. The IMAP adipofascial flap accompanies less invasion than muscle flaps and the surgical procedure is relatively easy. The IMAP adopofascial flap is considered as one of the effective means for anterior chest wall reconstruction.

Surgical reconstructive procedures of the chest wall after mediastinitis

Sternal osteomyelitis as adirect consequence of advanced mediastinitis or as in most cases after median sternotomy is still associated with a prolonged hospital stay, increased morbidity and postoperative mortality. Early diagnosis and an adequate surgical treatment are decisive for the prognosis. Prerequisites for asecondary stabilization of the chest wall using wires or plates are sterile wound conditions. Diverse reconstructive techniques are available for anterior chest wall reconstruction depending on the defect size and localization. The various reconstructive methods including local and free flap coverage are described in this review article.

A rigid and bioabsorbable material for anterior chest wall reconstruction in a canine model.

The optimal material for anterior chest wall reconstruction following chest wall resection remains controversial. The aim of this experimental study was to evaluate short-term, morphological and histological outcomes of anterior chest wall reconstruction with a rigid and bioabsorbable material in a canine model. Twenty adult beagle dogs underwent anterior chest wall resection. In the experimental group (n = 10), the anterior chest wall was reconstructed with a rigid and bioabsorbable material composed of poly-L-lactide acid matrix (60 wt%) and uncalcined and unsintered hydroxyapatite particles (40 wt%), whereas in the control group it was (n = 10) reconstructed with dual polypropylene mesh sheets. Short-term complication rates were compared with a χ(2) test. Postoperative sternal deviations were evaluated with sternal alignment angles using computed tomography and multiplanar reconstruction and were compared with Mann-Whitney U-test immediately after reconstruction, and at 1, 3, 6, 9 and 12 months postoperatively. Histological findings of the regenerated chest wall tissue were obtained after staining with haematoxylin and eosin and Elastica van Gieson (EVG) and compared at 3, 6, 9 and 12 months. There was not a significant difference in the short-term postoperative complication rate (P = 0.53) and the complication rate was 20% (wound infection, n = 1 and lethal mediastinitis, n = 1) in the control group and 10% (wound infection, n = 1) in the experimental group. The postoperative sternal deviation was significantly less remarkable at 1 month (123.3 ± 32.2° vs 159.4 ± 19.7°, P = 0.027), 3 months (109.8 ± 34.7° vs 150.9 ± 34.2°, P = 0.039) and 12 months (61 ± 15.6° vs 170.3 ± 6.6°, P = 0.046) in the experimental group than in the control group, whereas no significant difference was noted immediately after reconstruction (165.7 ± 6.4° vs 168.4 ± 9.1°, P = 0.50). Histological findings showed dense connective tissue in the regenerated chest wall in both groups and showed chondroblasts in the regenerated chest wall tissue at 3 and 6 months only in the experimental group. Our results suggest that anterior chest wall reconstruction with a rigid and bioabsorbable material is feasible and may be a valuable alternative to reconstruction with a non-rigid and non-absorbable material.

Superior epigastric artery perforator flap: anatomy, clinical applications, and review of literature.

To reduce donor site morbidity in anterior chest wall reconstruction, a flap based on perforators of the superior epigastric artery (SEA) was developed and successfully applied in a pedicled fashion for locoregional soft-tissue reconstruction. We combined our anatomical and clinical experience with superior epigastric artery perforator (SEAP) flap with a PubMed search of the English language literature for articles published on "SEAP flap". Reference lists of the articles found were then checked for other related articles of interest. Articles were compared looking at flap indication, preoperative imaging, perforator morphology, SEA integument area, surgical approach, and outcome of the flaps. The four best perforators were most frequently encountered in an area 2 to 6 cm from the midline and 0 to 10 cm below the xiphoid process. The territory of the SEAPs depends on the location of the perforator. Controversy exists in the current literature concerning preferable SEAP flap orientation. Although tip necrosis is the major complication, this can often be treated conservatively without affecting outcomes or can even be avoided by limiting flap length to the anterior axillary line and the zone below the midpoint between the xiphisternum and the umbilicus. The SEAP flap provides a useful approach for reconstruction of defects of the anterior chest, or of the abdominal wall. As a perforator or adipocutaneous flap, the flap is reliable and easy to raise, and spares donor site morbidity.

Pedicled full-thickness abdominal flap combined with skin grafting for the reconstruction of anterior chest wall defect following major electrical burn

Successful reconstruction of extensive anterior chest wall defect following major electrical burn represents a very challenging surgery. Herein we report the first case using pedicled full-thickness abdominal flap combined with skin grafting to treat this injury with severe infection and exposure of pericardium and ribs in a Chinese patient. Following the performance of chest debridement to remove necrotic and infected tissues and the injection of broad-spectrum antibiotics to reduce infection, a pedicled full-thickness abdominal flap was used to cover the exposed pericardium and ribs, and skin grafting from the right leg of the patient was done to cover the exposed vital tissues. The patient was followed up for a total of 3·5 years, and satisfactory cosmetic and functional outcomes were obtained without complications. This report provides an effective method for the surgeons who encounter similar cases where reconstruction of extensive anterior chest wall is required.