Reconstruction Of Chest Wall Defects Research Articles

Non-rigid reconstruction of chest wall defects after resection of musculoskeletal tumors

We analyzed the techniques used and the complications occurring in chest wall reconstruction after resection of musculoskeletal tumors to identify the optimal reconstruction method. The medical records of 50 patients with primary or metastatic malignant tumors requiring chest wall full thickness resection were retrospectively reviewed. The surgical technique and rate of postoperative complications were investigated, and the factors influencing complications were identified. Flap transfer was used in 23 cases (46 %). For skeletal reconstruction, a prosthetic mesh was used in 19 cases. In 18 recent cases, no prosthetic mesh was used, and patients were treated using only suture stabilization. Postoperative complications were recognized in 11 cases (22 %). The analysis of factors influencing the development of complications identified the use of preoperative adjuvant chemotherapy (p < 0.05), the bone as the primary site (p < 0.05), an anterolateral location (p = 0.081) and resection of ≥ 3 ribs (p = 0.077) as significant factors. No significant difference in the rate of complications was noted between the groups divided based on whether mesh was used. We used non-rigid reconstruction for full thickness resection of the chest wall, and achieved good postoperative outcomes with no grade 4 complications or perioperative mortality. Non-rigid reconstruction using flap transfers and careful respiratory management is a useful method for treating patients requiring chest wall full thickness resection.

EComment. Substernal metal support after pectus excavatum open repair

We read with great interest the article by Stefani and colleagues reporting long-term results of the STRATOS system for stabilizing the sternum after severe pectus excavatum (PEx) open repair. This is an important contribution, since there are only 13 cases reported in the literature, although no long-term follow-up is available for them [1]. In severe asymmetric PEx with abnormal curvature of the anterior arc of ribs as shown in figure 1A of the article (chest CT-scan), we use a surgical strategy different from that described by Stefani and colleagues. After complete subperichondrial resection of the elongated/deformed cartilages and transversal wedge osteotomy across the anterior table of the upper sternum, an important step of our procedure is the correction of abnormal curvature of ribs by anterior wedge osteotomy, followed by gentle fracture of the posterior cortex. Then, the running suture of the perichondrial sheaths restores tension to the adjacent intercostal spaces, maintaining the anterior segment of ribs in an adequate position without any complementary rib osteosynthesis. Of 181 patients having undergone a PEx open repair, 15 had severe asymmetric deformity (8%). These 15 patients received additional rib osteotomy as described above, resulting in satisfactory thorax contour [2]. Another feature of our technique is sternum stabilization by means of a large (generally 20 to 22 cm long in the normal adult population) straight metal support bar (WURTZ thorax bar, Medicalex, Bagneux, France), passed substernally after minimal dissection at the level of the sixth perichondrial sheaths. The remaining parts of the bar are extrathoracic, inserted laterally anterior to the ribs and behind the muscles by means of a back and forth movement. The metal bar is then secured to the base of sternum in the midline with an absorbable suture [2]. This support reduces the risk of potential flail chest phenomenon postoperatively, and allows cartilage regeneration with osseous metaplasia in the proper position within 8 weeks. Finally, the bar is easily removed under local anaesthesia as an outpatient procedure, six months after the initial operation. The video description of this technique is currently available on the CTSNet website [3]. The WURTZ thorax bar has numerous advantages in comparison to the STRATOS system: (i) Placement through a significantly smaller incision (mean 13 cm long in adults). (ii) No fixation to the ribs causing pain or rupture as observed by Stefani and colleagues [1] most likely due to constant movements of the rib cage during the respiratory cycle phases. (iii) Excellent mechanical properties as we did not observe any untimely rupture or bending. (iv) Reduced risk for dislocation since the bar is removed at 6 months. Indeed, it has been shown that dangerous intrapericardial dislocation of hard materials used in PEx open repair is related to the time these materials are left in place, or as a consequence of delayed material rupture [4]. (v) No re-entry for material removal with the risk of iterative complications [1]. (vi) In the setting of concomitant cardiopulmonary bypass surgery, the use of our easily removable material inserted at the lower edge of the sternum does not impede a prompt re-entry or potential cardiopulmonary resuscitation manoeuvres if needed [5]. (vii) Significantly lower cost of the WURTZ titanium thorax bar (€810) in comparison with the STRATOS system: €2680 for 1 bar fixed to 2 rib clips, and €5360 when 2 bars are used (priced in 2010). Finally, the STRATOS system was found to be useful for chest wall defect reconstruction [1]. It would be interesting to see more information from large series that would allow the evaluation of the STRATOS materials in the field of PEx repair. Conflict of interest: none declared.

Experience with titanium devices for rib fixation and coverage of chest wall defects

To describe our experience with two new titanium-based devices for chest wall reconstruction and stabilization. A retrospective analysis of 18 consecutive patients (multiple rib fractures n = 9, iatrogenic rib fracture n = 2, lung herniation n = 2, chest wall tumour n = 5) who underwent surgery for rib fractures or chest wall tumours requiring chest wall resection and reconstruction between October 2010 and March 2012 was conducted. Chest wall defects and rib fractures were fixed with titanium clips and bars or titanium plates and screws through a posterolateral thoracotomy. There were 12 males, and the median age was 61 years. There were no postoperative deaths. The only postoperative complication observed was a pleural effusion requiring drainage in one patient who had titanium clips for the fixation of multiple traumatic rib fractures. Median length of stay of the drain and median length of hospital stay were 3 days (range 1-6) and 4 days (range 2-42 days), respectively. The average follow-up period of operatively managed patients was 6 months, (range 2-14 months). Two cases of hardware failure occurred in two patients treated for a lung hernia with large chest wall defects involving the anterior costal margin with either devices. Titanium devices (clips and bars; screws and plates) are effective and safe for repair of rib fractures and large chest wall defect reconstruction with minimal complications and good long-term results.

Massive chondrosarcoma of sternum: A surgical challenge in resection and reconstruction of a rare tumor

Introduction: Reconstruction of chest wall defects remains a very challenging issue and often requires prosthetic repair to prevent flail chest and paradoxical breathing. Case Report: We report a case of chest wall reconstruction following resection of a long standing, massive, well differentiated, primary chondrosarcoma of the sternum which was involving the entire body of sternum and adjoining costal cartilages. Excision of entire sternum (except manubrium) and 3rd to 8 th ribs left a large defect (20x15 cm) in the chest wall which was reconstructed with a simple and new three layer technique using Prolene-Vicryl mesh, long split rib grafts and lattissimus dorsi muscle (LD) flap. Patient was weaned off the ventilator on seventh post operative day and discharged after four weeks. Conclusion: This is a simple chest wall reconstruction technique for wide chest wall defects and is effective, safe, low cost and easily reproducible.

The Use of Human Acellular Dermal Matrix for Chest Wall Reconstruction

Reconstruction of chest wall defects has evolved, but challenges remain. This is particularly true when defects are large or contamination is present. Although numerous materials are available for reconstruction, acellular dermal matrix has the advantage of becoming vascularized and incorporated autologously. By its resistance to infection and lack of adhesion formation, it is a promising although expensive alternative to synthetic materials in some circumstances. This report examines our experience with human acellular dermal matrix (HADM) in reconstruction of major chest wall and diaphragmatic defects. A retrospective study was conducted of all patients who underwent thoracic reconstruction using HADM between March 2007 and March 2010 at Harbor-University of California-Los Angeles Medical Center. Data acquisition included demographics, surgical indications, operative details, complications, and follow-up evaluation. Ten patients were identified. Indications included thoracic tumor resection in 5, Clagett procedure modification for postpneumonectomy empyema in 2, resection of chest wall osteomyelitis in 2, and pneumonectomy for multiple aspergillomata in 1. Complications occurred in 4 patients and included respiratory failure, pneumonia, and wound seromas. All wounds healed without need to remove or revise the HADM, and sound chest wall closure was achieved in every case. HADM is an effective but expensive alternative to synthetic mesh in reconstruction of chest wall and diaphragmatic defects. It is particularly attractive for use under conditions of potential or overt contamination.

Chest wall reconstruction in a canine model using polydioxanone mesh, demineralized bone matrix and bone marrow stromal cells

Extensive chest wall defect reconstruction remains a challenging problem for surgeons. In the past several years, little progress has been made in this area. In this study, a biodegradable polydioxanone (PDO) mesh and demineralized bone matrix (DBM) seeded with osteogenically induced bone marrow stromal cells (BMSCs) were used to reconstruct a 6 cm × 5.5 cm chest wall defect. Four experimental groups were evaluated ( n = 6 per group): polydioxanone (PDO) mesh/DBMs/BMSCs group, polydioxanone (PDO) mesh/DBMs group, polydioxanone (PDO) mesh group, and a blank group (no materials) in a canine model. All the animals survived except those in the blank group. In all groups receiving biomaterial implants, the polydioxanone (PDO) mesh completely degraded at 24 weeks and was replaced by fibrous tissue with thickness close to that of the normal intercostal tissue ( P > 0.05). In the polydioxanone (PDO) mesh/DBMs/BMSCs group, new bone formation and bone-union were observed by radiographic and histological examination. More importantly, the reconstructed rib could maintain its original radian and achieve satisfactory biomechanics close to normal ribs in terms of bending stress ( P > 0.05). However, in the other two groups, fibrous tissue was observed in the defect and junctions, and the reconstructed ribs were easily distorted under an outer force. Based on these results, a surgical approach utilizing biodegradable polydioxanone (PDO) mesh in combination with DBMs and BMSCs could repair the chest wall defect not only in function but also in structure.

Reconstruction of Chest Wall Defects After Rib Tumor Resection: A Comparison of Autogenous, Prosthetic, and Composite Techniques in 44 Dogs

To compare short- and long-term outcome and complications of chest wall reconstruction in dogs using autogenous, prosthetic, and composite autogenous-prosthetic techniques. Historical cohort. Dogs (n=44) with spontaneous tumors arising from or involving the chest wall. Medical records were reviewed for dogs with rib and/or sternal tumors treated by chest wall resection and reconstruction. Signalment, preoperative clinical features, intraoperative findings and complications, reconstruction technique (autogenous muscle flap, prosthetic mesh, or composite autogenous-prosthetic technique), and short- (< or =14 days) and long-term (>14 days) postoperative complications were determined from the medical records and telephone contact with owners and referring veterinarians. Associations between chest wall reconstruction technique and postoperative complications were tested with Cox proportional hazards. Chest wall defects were reconstructed with autogenous muscle flaps (29 dogs), prosthetic mesh (3), and a composite technique of prosthetic mesh and either autogenous muscle or omental pedicle flap (12). Early postoperative complications were recorded in 8 dogs (18.2%) and included seroma (5) and pleural effusion and peripheral edema (3). One dog had a late complication (2.3%) with a mesh-related infection 767 days postoperatively. Overall, complications occurred in 10.3% of autogenous, 25.0% of composite, and 66.7% of prosthetic reconstructions. Chest wall reconstruction with Marlex mesh alone was associated with a significantly increased risk of postoperative complications compared with autogenous reconstruction (P=.027). Reconstruction of sternal defects (3), 2 of which were performed with Marlex mesh alone, was associated with a significantly increased risk of complications compared with lateral chest wall reconstructions (P=.037). Large chest wall defects can be reconstructed with autogenous and composite techniques, but prosthetic mesh should be covered with well-vascularized autogenous muscle or omentum to decrease the risk of postoperative complications. Sternal defects should be reconstructed with rigid techniques. Chest wall reconstruction with autogenous muscle flaps or a combination of autogenous techniques with prosthetic mesh is associated with a low rate of infection and other complications.

Customised silicone prostheses for the reconstruction of chest wall defects: technique of manufacture and final outcome

Chest wall reconstruction with a customised silicone prosthesis in 13 patients (five patients with pectus excavatum, six Poland's syndrome and two with post-surgical chest wall deformity) is presented. An alginate impression or CT scan with three-dimensional reconstruction was used to produce the final mould from which the silicone prosthesis was fabricated. The surface of the silicone implant was roughened to reduce capsular contracture and holes were incorporated to allow for tissue integration. Twelve patients had aesthetically acceptable results after a mean of 5 years follow up. This series indicates that accurate assessment of the defect, modifications on manufacture and proper placement of the implant result in a more satisfactory final outcome.

Chest wall defect reconstruction with cotranlateral breast

Journal of Surgical OncologyVolume 95, Issue 8 p. 680-681 Letter to the Editor Chest wall defect reconstruction with cotranlateral breast Wojciech M. Wysocki MD, Corresponding Author Wojciech M. Wysocki MD [email protected] Departament of Surgical Oncology, Maria Skłodowska-Curie Memorial Institute of Oncology, Kraków, PolandDepartament of Surgical Oncology, Maria Skłodowska-Curie Memorial Institute of Oncology, ul. Garncarska 11, 31-115 Kraków, Poland. Fax: +48-12 422-66-80.Search for more papers by this authorAndrzej L. Komorowski MD, Andrzej L. Komorowski MD Departament of Surgical Oncology, Maria Skłodowska-Curie Memorial Institute of Oncology, Kraków, PolandSearch for more papers by this authorLeszek S. Kołodziejski MD, PhD, Leszek S. Kołodziejski MD, PhD Departament of Surgical Oncology, Maria Skłodowska-Curie Memorial Institute of Oncology, Kraków, PolandSearch for more papers by this author Wojciech M. Wysocki MD, Corresponding Author Wojciech M. Wysocki MD [email protected] Departament of Surgical Oncology, Maria Skłodowska-Curie Memorial Institute of Oncology, Kraków, PolandDepartament of Surgical Oncology, Maria Skłodowska-Curie Memorial Institute of Oncology, ul. Garncarska 11, 31-115 Kraków, Poland. Fax: +48-12 422-66-80.Search for more papers by this authorAndrzej L. Komorowski MD, Andrzej L. Komorowski MD Departament of Surgical Oncology, Maria Skłodowska-Curie Memorial Institute of Oncology, Kraków, PolandSearch for more papers by this authorLeszek S. Kołodziejski MD, PhD, Leszek S. Kołodziejski MD, PhD Departament of Surgical Oncology, Maria Skłodowska-Curie Memorial Institute of Oncology, Kraków, PolandSearch for more papers by this author First published: 07 March 2007 https://doi.org/10.1002/jso.20765Citations: 2AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume95, Issue815 June 2007Pages 680-681 RelatedInformation

Response to “chest wall defect reconstruction with cotranlateral breast”

Response to “chest wall defect reconstruction with cotranlateral breast”

Experimental study of degradable chitin long fiber reinforced polycaprolactone for reconstruction of chest wall defects

To investigate the application of a novel degradable biomaterial as a chest wall prosthesis and provide valuable scientific basis for clinical application. Preparation of chitin long fiber reinforced polycaprolactone (PCL) by means of melt blending and modeling. Full-thickness chest wall defects of 10 cm x 8 cm was created in 10 dogs and then repaired with long chitin fiber reinforced PCL artificial rib in 8 dogs (tested group) and Marlex mesh in 2 dogs (control group). It was dynamically observed that the situation of the implanted chest wall prosthesis and the progress of the regeneration of the chest wall tissue postoperatively. No operative and perioperative deaths were observed in all experimental dogs. In tested group, slight paradoxical respiration occurred in 2 dogs and could not be seen in 2 weeks. No chest wall subsidence and infection occurred. New bone tissue obviously regenerated around both resection ends of the ribs and integrated tightly with artificial ribs. In control group, there were evidently paradoxical respiration and chest wall subsidence. Marlex mesh folded and was enveloped by fibrous tissue. Degradable chitin long fiber reinforced PCL can provide effective support to chest walls and is a practicable material for chest wall reconstruction.

Microsurgical reconstruction of chest wall defect after necrotizing fasciitis

Chest wall necrotizing fasciitis is a rare and often fatal infection that usually requires extensive debridements and reconstructive procedures. We describe the therapeutical course of an uncommon case of perforating thoracic wound complicated with necrotizing fasciitis, with consecutive debridements and a resultant full-thickness subscapular defect. We agree that free flaps, although seldom required, must be considered when treating more complex defects. Latissimus dorsi free-flap was enough for pleural reconstruction and wall stabilization. There are no previous references in the literature to primary chest wall fasciitis treated successfully with microsurgical reconstruction.

Reconstruction of chest wall defects with homologous dura mater grafts

Reconstruction of chest wall defects with homologous dura mater grafts

Reconstruction of chest wall defects after resection of large neoplasms: ten-year experience

We review our experience in the treatment of complex large chest-wall defects needing a multidisciplinary approach due to primary or secondary neoplasms. Non-small cell lung cancer with chest-wall invasion cases are excluded. Fifteen patients underwent whole thickness resection of the chest wall due to lesions affecting at least three ribs, sternum, clavicle or thoracic spine and the surrounding soft tissue. Previously operated breast cancer and sarcoma were the most frequent diagnoses. Partial or total sternectomy plus rib resection was performed in 8 patients. Immediate closure of the defects was performed in all cases: 12 with single prosthesis placement and 3 with a rigid one of methylmethacrylate. Coverage was achieved using myocutaneous flaps in most cases and, in one case, using the greater omentum that supported a free split-thickness skin graft. No 30-days mortality was recorded. Three patients had a post-operative complication. Mean hospital stay was 11.7+/-9 days. All cases of primary tumours were alive at the time of review (range: 6-126 months). In conclusion, resection and immediate reconstruction of large chest wall defects can be accomplished without operative mortality and low morbidity whenever close cooperation between plastic and thoracic teams exists.

Laparoscopically harvested omental flap for chest wall and intrathoracic reconstruction.

Minimally invasive surgery has gained popularity in the last decade and its applications to plastic surgery are expanding. Pedicled omental flaps are used for the reconstruction of chest wall defects following debridement of sternal infections and mediastinitis. The main advantages of using an omental flap are its large size and bulk to fill large 3-dimensional dead spaces, long pedicle, and rich vascular and lymphatic networks. Recently, laparoscopic techniques have been described for harvesting omental flaps. Over the last 5 years in our institution, 9 laparoscopic omental flap harvests were performed. Seven were used in the reconstruction of complicated chest wall defects, sternal infections, mediastinal abscesses, and mediastinitis following cardiac surgery. Two were used to repair intrathoracic viscera. Prior abdominal surgery was not a contraindication to the laparoscopic harvest. In 1 patient, the omental transfer was converted to a free flap due to the detachment of the pedicle, and in 1 patient the omental harvest was converted to open technique due to technical difficulty due to severe abdominal adhesions. None of the patients had major intraabdominal complications postoperatively. One patient had a small transdiaphragmatic hernia treated by laparoscopic techniques. The use of laparoscopy techniques facilitated the harvesting of the omentum, making it ideal in the treatment of complicated patients with multiple comorbidities. With these techniques, pedicled omental flaps will be a reasonable treatment option for chest wall reconstruction.

Reappraisal of fascia lata grafts for reconstruction of chest wall defects.

Large chest wall defects require surgical reconstruction to ensure structural stability and to prevent flail chest. We used autologous fascia lata grafts to reconstruct skeletal chest wall defects in 8 consecutive patients. Sufficient chest wall stability was obtained; and no complications, such as flail chest, infection, or seroma, have been observed in any of the cases to date.

Repair and care of chest wall defects.

The formidable challenge of chest wall repair calls upon a multidisciplinary health care approach. The vital organs housed within the chest must be protected and the vascularity of available tissues used for repair must be maintained. Once chest wall reconstruction is complete, the patient must be closely monitored for stability and tissues must be protected from internal and external assaults. The following discussion will review the options for repair and the care of the patient undergoing chest wall defect reconstruction.

Surgical treatment in patients with primary bronchogenic carcinoma involving the chest wall.

To sum up experience of surgical treatment for patients with bronchogenic carcinoma involving the chest wall. Thirty-five patients with bronchogenic carcinoma invading chest wall underwent surgical treatment. Extra pleural-pulmonary resection for group one ( n = 16) and en bloc resection of chest wall-pulmonary for group two ( n = 19) were performed. There was no operative mortality. The 3 and 5 year survival rates in group one were 38. 5 % and 18. 2 % , and 41. 2 % and 35. 7 % in group two respectively. In patients with N(0) disease , 3 and 5 year survival rates were 63. 2 %(12/ 19) and 42. 9 %(6/ 14) respectively , but there was only one patient with N(1-2) disease surviving for over 5 years. The operation types and lymph node status play important roles in the prognosis after operation. Reconstruction of chest wall defect could be successful with 2-0 Prolene suture and covering with muscles of chest and back.

A new extended external oblique musculocutaneous flap for reconstruction of large chest-wall defects.

A new extended external oblique musculocutaneous flap utilized in the reconstruction of chest-wall defects is described. The flap is drawn as a V-Y rotation flap on the ipsilateral abdominal wall. It is laterally based, and its pedicle coincides with the five lowest costal insertions of the external oblique. The flap extends above the transiliac line, from the posterior axillary line to the linea alba, and includes the dynamic territory of the external oblique muscle. Vascular supply is provided by the musculocutaneous perforating arteries of the intercostal vessels and their subcutaneous branches. The flap is raised medially and includes the anterior sheath of the rectus. Undermining continues between the external and the internal oblique muscles as far as the posterior axillary line. The donor site on the abdominal wall is reinforced by the plication of the internal oblique sheath. This flap was used in 13 patients with major anterior chest-wall excisional defects. The mean chest-wall defect was about 390 cm2. Marginal necrosis with distal skin loss was observed in one patient. All other flaps healed without complications. The extended external oblique musculocutaneous flap differs from other external oblique flaps already described in several aspects that allow it to obtain better functional and aesthetic results.

The utility of polyglactin-910 mesh in the plastic reconstruction of the chest wall after en-bloc resection

From January 1991 to December 1994 the reconstruction of chest wall defects following en-bloc resection for 12 lung carcinomas involving the anterior chest wall, or requiring large chest wall resections, has included the use of a permeable and absorbable mesh of polyglactin-910. There was no operative mortality, and respiratory support was not required in any patient. There were no wound complications and the minor pulmonary problems were easily treatable. Hospitalization ranged from 7 to 15 days. The authors encourage the use of polyglactin-910 mesh in plastic reconstruction of the chest wall after en-bloc resections.