Flaps For Chest Wall Reconstruction Research Articles

Antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management for sternal infection after midline sternotomy

IntroductionDeep sternal wound infection (DSWI) after midline sternotomy of cardiac surgery is a challenging complication that affects the outcome of surgery. This study aims to assess the clinical effectiveness of the antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management in the treatment of DSWI.MethodsWe retrospectively analyzed 5 patients with DSWI who underwent antibiotic-loaded bone cement combined with bilateral pectoralis major muscle flaps for chest wall reconstruction after sternotomy for cardiac surgery in a tertiary hospital in China from January 2020 to December 2021. The clinical and follow-up data were retrospectively analyzed.ResultsAll patients had no perioperative mortalities, no postoperative complications, 100% wound healing, and an average hospital stay length of 24 days. The follow-up periods were from 6 to 35 months (mean 19.6 months). None of the cases showed wound problems after initial reconstruction using antibiotic-loaded bone cement combined with bilateral pectoralis major muscle flaps.ConclusionsWe report our successful treatment of DSWI, using antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management. The clinical and follow-up results are favorable.

The Best of Chest Wall Reconstruction: Principles and Clinical Application for Complex Oncologic and Sternal Defects

Learning Objectives: After studying this article, the participant should be able to: 1. Appraise and evaluate risk factors for respiratory compromise following oncologic resection. 2. Outline and apply an algorithmic approach to reconstruction of the chest wall based on defect composition, size, and characteristics of surrounding tissue. 3. Recognize and evaluate indications for and types of skeletal stabilization of the chest wall. 4. Critically consider, compare, and select pedicled and free flaps for chest wall reconstruction that do not impair residual respiratory function or skeletal stability. Summary: Chest wall reconstruction restores respiratory function, provides protection for underlying viscera, and supports the shoulder girdle. Common indications for chest wall reconstruction include neoplasms, trauma, infectious processes, and congenital defects. Loss of chest wall integrity can result in respiratory and cardiac compromise and upper extremity instability. Advances in reconstructive techniques have expanded the resectability of large complex oncologic tumors by safely and reliably restoring chest wall integrity in an immediate fashion with minimal or no secondary deficits. The purpose of this article is to provide the reader with current evidenced-based knowledge to optimize care of patients requiring chest wall reconstruction. This article discusses the evaluation and management of oncologic chest wall defects, reviews controversial considerations in chest wall reconstruction, and provides an algorithm for the reconstruction of complex chest wall defects. Respiratory preservation, semirigid stabilization, and longevity are key when reconstructing chest wall defects.

Single vertical incision thoracoabdominal flap for chest wall reconstruction following mastectomy of locally advanced breast cancer.

PurposeSkin grafts have been widely used in managing extensive chest wall defects after mastectomy for advanced breast cancer. However, their durability and tolerability to radiotherapy is still controversial. A thoracoabdominal (TA) flap with a few technical refinements can safely transfer a larger flap while minimizing complications.MethodsFrom January 2007 to February 2018, a retrospective review was performed to compare 2 groups after wide breast excision: skin graft group (group 1) and lateral-based, single vertical incision rotation-advancement TA flap (group 2). Patients' demographics, operative details, complications, hospital stay, postoperative outpatient visits, cost, and start of adjuvant therapy were analyzed between the 2 groups.ResultsDuring the study period, 34 patients received skin graft and 41 patients received TA flap. group 2 had a shorter hospital stay (6.41 ± 2.64 days vs. 12.62 ± 4.60 days, P < 0.001) and shorter time to complete wound healing (29.27 ± 18.68 days vs. 39.24 ± 27.70 days, P = 0.03) than group 1. There was also a difference in the period from surgery to initiation of adjuvant therapy (group 1, 45.04 days ± 17.79 days; group 2, 37.07 ± 15.38 days, P = 0.073). Although limitation in shoulder motion was more frequent in group 2, limitation of motion for >1 year was observed in 4 patients in only group 1 (43.90% vs. 38.24%, P = 0.613).ConclusionTA flap has a simple design that minimizes concerns involving the donor site. Moreover, it does not require complicated procedures and allows for re-elevation whenever necessary. Finally, it guarantees faster wound recovery than skin graft with fewer complications.

The clinical application of various forms of transverse rectus abdominis musculocutaneous flap in breast reconstruction and chest wall radiation ulcer repairment-Lessons learned and countermeasures

Objective To review outcome and experience in application of various forms of transverse rectus abdominis musculocutaneous flap in breast reconstruction and chest wall radiation ulcer repairment. Methods From January 2008 to February 2016, 61 cases (included 58 female patients and 3 male patients) were admitted, the age ranged from 39 to 57 years old. Among these cases, 37 cases received mastectomy and one-staged breast reconstructive operation and multiple chemotherapy preoperatively. The other 24 patients suffered from chest wall radiation ulcer, all occurred after mastectomy and radiotherapy, the course ranged from 12 to 56 months, all received long-time conservative therapy but the patient′s condition worsened. Of those patients 8 cases suffered radioactive bone injury , involved clavicle, rib and sterum; 3 cases suffered pleura injury; 2 cases suffered lung injury; 2 cases suffered brachial plexus injury and upper extremity lymphedema, resulted in upper extremity dysfunction. The patients were treated with pure pedicled transverse rectus abdominis musculocutaneous flap (TRAM) musculocutaneous flap in 31 cases, free TRAM musculocutaneous flap in 3 cases, pedicled TRAM musculocutaneous flap plus superficial inferior epigastric vein anastomosis in 13 cases, and pedicled TRAM musculocutaneous flap combined with contralateral free deep inferior epigastric perforator (DIEP) flap in 14 cases. Results The area of flap for chest wall reconstruction ranged from 22 cm×10 cm to 38 cm×15 cm, the size of flap for breast reconstruction ranged from 16 cm×10 cm to 22 cm×13 cm. The donor site was closed directly in all cases. Distal part necrosis and fat liquefaction were noted in 3 cases used pure pedicled TRAM musculocutaneous flap, in 1 case the defect was closed directly after radical debridement, in other 2 cases free anterolateral thigh flap was applied after debridement. All other 58 flaps survived uneventfully. All patients were followed up for 12-108 months with satisfied esthetic and functional results in reconstructed chest wall and breast. No local recurrence or ulcer happened. Only linear scar left in the donor sites, no hernia occurred. Conclusions Transverse rectus abdominis musculocutaneous flap is one of the first choice for breast reconstruction and chest wall radioactive ulcer.To ensure the operation success, it is efficient to apply different forms of transverse rectus abdominis musculocutaneous flap according to the flap size and blood supply. Key words: Surgical flaps; Rectus abdominis/SU; Epigastric arteries/SU; Mammaplasty; Skin ulcer/SU; Radiation injuries/SU; Thoracic injuries/SU

The Use of Vasopressors in Pedicled Flaps for Chest Wall Reconstruction.

The effect of vasopressors on flaps remains controversial in the literature. Often, surgeons avoid vasopressors with the thought that vasoconstriction reduces flap perfusion resulting in flap loss. A retrospective review was performed on patients who required chest wall reconstruction from 1998 to 2013. Patients were identified through the use of Current Procedural Terminology codes. The data collected included demographics, indications for surgery, prior debridement, preoperative albumin levels, and perioperative vasopressor use. Outcomes measures included flap survival, flap complications, reoperation rates, intensive care unit length of stay, and mortality. Of the 1220 patient records reviewed, 88 had chest reconstruction by a plastic surgeon. Twenty-one patient records were excluded due to incomplete data. One patient experienced complete flap loss; these data were excluded from statistical analysis. Fifty patients received perioperative vasopressors whereas 15 did not. There was no significant difference in flap survival or loss between groups who received perioperative vasopressors and those who did not receive vasopressors. Age, intensive care unit length of stay, flap complications, and reoperation rates were significantly higher in those with partial flap survival. Perioperative vasopressor use does not adversely affect the outcome of pedicled flaps for chest wall reconstruction. Further research is warranted to review the effects of vasopressor dose and type on pedicled flaps.

Chest wall reconstruction using Latismus Dorsi Flap: our experience

Background: Covering a big chest wall defect is the main clinical issue in cancer resection whether it is due to locally advanced breast cancer or any other carcinomas extending to chest wall or injuries leading to chest wall defect. The main aim of the study was to discuss the role of latissmus dorsi flap in chest wall reconstruction.Methods: Study reviewed 15 patients with chest wall defect within a period of two years January 2015 - December 2016, who underwent chest wall reconstruction after tumor resection or burns.Results: Among 15 patients, 12 patients were having locally advanced breast tumors, only one patient with recurrent desmoids tumor of abdominal tumor of abdominal wall extending to chest wall and 2 cases were of electrical burn injuries. The age range varied from 40-60 years. Among these patients 13 were females and 2 were males. The defect size varied from 12x15 cm to 26 x 20 cm. There were no major complications except for partial graft loss in two patients.Conclusions: Lattissmus Dorsi flap is safe and very good flap for chest wall reconstruction.

Fascio-cutaneous flaps for chest wall reconstruction after massive inflammatory breast cancer: a case series

Background Inflammatory breast cancer represents a rare condition that presents poor prognosis with high risk of recurrences and greatly affects patients’ quality of life. The resective surgical treatment frequently requires challenging reconstructive solutions to restore a proper tissue layer for the chest wall. Reconstructive methods are nowadays still matter of debate.

Articulated endoscopic linear cutter stapler facilitates minimal access harvest of the latissimus dorsi muscle flap for chest wall reconstruction in Poland syndrome.

Articulated endoscopic linear cutter stapler facilitates minimal access harvest of the latissimus dorsi muscle flap for chest wall reconstruction in Poland syndrome.

The transverse musculocutaneous gracilis flap for chest wall reconstruction in male patients with Poland's syndrome

Poland's syndrome represents a congenital unilateral deformity of the breast, chest wall, and upper limb with extremely variable manifestations. In most cases, the problem is mainly cosmetic, and the reconstruction of the chest wall should use a method designed to be performed easily and to achieve minimal scarring and donor site morbidity. We describe using a transverse musculocutaneous gracilis (TMG) flap for chest wall and anterior maxillary fold reconstruction in three male patients. In two patients, only the pectoralis major muscle was missing. In the third case, the ipsilateral latissimus dorsi muscle was also absent. The indication for surgical treatment was purely cosmetic. In all patients, a free TMG flap was performed to reconstruct the anterior axillary fold and the soft tissue defect. There was no flap loss, and all three patients had a clearly improved appearance of the chest wall. In this article, we demonstrate our experience with the use of a TMG flap for chest wall reconstruction in male patients with Poland's syndrome.

Uncommon Flaps for Chest Wall Reconstruction

The omentum, external oblique musculocutaneous, and thoracoepigastric flaps are uncommonly used for chest wall reconstruction. Nevertheless, awareness and knowledge of these flaps is essential for reconstructive surgeons because they fill specific niche indications or serve as lifeboats when workhorse flaps are unavailable. The current report describes the anatomic basis, technical aspects of flap elevation, and indications for these unusual flaps.

External Oblique Musculocutaneous Flap for Chest Wall Reconstruction

External Oblique Musculocutaneous Flap for Chest Wall Reconstruction

Use of the Extended V-Y Latissimus Dorsi Myocutaneous Flap for Chest Wall Reconstruction in Locally Advanced Breast Cancer

The extended V-Y latissimus dorsi myocutaneous flap described by Micali and Carramaschi provides an innovative method of closing large anterior chest defects after resection of breast cancer. The technique provides robust chest wall coverage that is able to withstand immediate postoperative radiotherapy. The aim of this article is to confirm the usefulness of the flap's design and describe modifications to the technique. The modifications to technique include: a curvilinear design that recruited more skin for closure in patients with wounds extending laterally or superiorly, routine transposition of latissimus dorsi insertion inferio-medially onto the chest wall to maximize pedicle reach, and the use of small split skin grafts or delayed primary closure if there was tension in closing. Twelve patients who underwent resection of locally advanced breast cancer had immediate chest wall reconstruction with the extended V-Y latissimus dorsi musculocutaneous flap. The V to Y design of the flap's cutaneous island allowed primary closure of chest wound and donor defect. There were no instances of chest wound dehiscence. The chest wounds healed, allowing patients to undergo adjuvant radiotherapy in a mean time interval of 6 weeks after surgery.

Management of Patients (ASA III, IV) with Sternum Osteomyelitis

The authors reported on their treatment of a selective group of patients with sternum osteomyelitis. The patients had had multiple previous operations ( El Oakley III to V) and their overall morbidity led to a classification of ASA III or IV. All patients needed a free flap for chest wall reconstruction.

Vertical rectus abdominis musculocutaneous flap for chest wall reconstruction after irradiation.

We have used a contralateral vertical rectus abdominis musculocutaneous flap based upon the superior epigastric vessels in six patients to provide coverage after resection of locally recurrent breast carcinoma in irradiated tissues. Primary healing of defects as large as 16 cm X 35 cm has been obtained using this technique. Although there is no evidence to suggest that such a procedure significantly lengthens survival, it was clearly beneficial to the quality of life in these patients. Our results suggest that older patients with relatively indolent disease receive the greatest benefit from this procedure.

Reconstruction of the Chest Wall

Reconstruction of the chest wall can now be accomplished reliably and expeditiously. Past experience with local flaps and split-thickness skin grafts recommends their continued use when appropriate. Recent studies in blood flow have demonstrated that very large muscles with or without the overlying skin can be moved primarily and reliably. The four most reliable myocutaneous flaps for chest wall reconstruction are described. Microsurgery allows movement of large segments of skin and muscle from expendable areas of the body to the chest wall.

The omentum in facial reconstruction

THREE times a year on average, we are called upon to treat patients with gunshot injuries to the mid and lower face which involve loss of much facial soft tissue, intra-oral lining and intervening bone; in addition, there are often cornminuted fractures of the bones adjacent to the open wound. Primary treatment has usually consisted only of debridement, stabilisation of the fractures and perhaps dressing the wounds with skin grafts. Later the oral lining and the skin defect have been reconstructed with local tissues and/or skin flaps. Still later, efforts have been made to reconstruct the missing skeleton with bone grafts but exposure of the remaining facial skeleton is difficult and the graft bed is often fibrotic. Although many of these patients have had 30 to 35 operations, the results are disappointing. In searching for a better solution to the problem we considered the case of a sculptor patching a damaged clay model. First he would build an armature into the damaged area and upon this replace the missing clay. Finally a glaze would be applied to protect the reconstruction. By analogy, in a complex facial reconstruction, the armature could be bone grafts to simulate the facial skeleton, the clay could be the vascular omentum and the outer protective layer could be a skin graft. In the rather meagre literature on reconstruction of the maxilla, there is one article of note. Obwegeser (1973) describes an ingenious reconstruction of the maxilla using a lattice of split rib grafts fixed to the remaining stable points. The bone bending forceps of Tessier are essential to bend the ribs to the proper cont0ur.l During the past 3 years, we have used the omentum as a pedicled flap for chest wall reconstruction in 12 patients with radiation necrosis (Jurkiewicz, 1977x as pioneered by Kiricuta (1963) and DuPont and Menard (1972). We had no significant complications and were impressed with the ease with which skin grafts took upon the omentum. More recently, our colleague, Dr P. G. Arnold (Arnold et al., 1976) impressed us with the use of the omentum as a “vascular putty” to cover a Silastic gel prosthesis in reconstructing a breast; even though the reconstruction was covered with a skin graft, the contour of the reconstructed breast more nearly corresponded to that of the normal breast than any other reconstruction we have seen. Alday and Goldsmith (1972) and Das (1976) have defined the vascular anatomy of the omentum and its variations. There are usually 3 main omental vessels which arise from the gastro-epiploic arcade. In 1972, McLean and Buncke first reported the free transfer of the omentum by microvascular anastomosis to repair a scalp defect. The gastro-epiploic vessels are 1.5 to 3.0 mm in diameter and their anastomosis to similar sized vessels is relatively easy. Friendly collaboration and support from surgical colleagues, operating room staff and anaesthetist is essential; in the case to be described the anaesthetic time was 144 hours !