Chest Wall Reconstr

SECTION II • Trunk Surgery
10
Reconstruction of the chest
David H. Song and Michelle C. Roughton
Access video content for this chapter online at expertconsult.com
(Fig. 10.1). Furthermore, use of tensor fascia lata (TFL) and

SYNOPSIS
thoracolumbar fascia as both graft and flap reconstruction has
been described. Little data exists as to outcome comparisons
■ Chest wall reconstruction frequently requires both bony and soft-tissue
between these options. However, in a retrospective review of
support.
■ Skeletal support is accomplished with mesh, acellular dermal matrix,
197 patients, PTFE and polypropylene appear to be equivalent
in complications and outcomes.1 Another smaller retrospective
or autogenous material.
review of 59 patients prefers Mersilene-methyl-methacrylate
■ Soft-tissue coverage can be achieved with local muscle flaps,
sandwich (MMM) to PTFE due of decreased paradoxic chest
omentum, or local tissue rearrangement.
wall motion.5 Yet another group retrospectively evaluated 262
■ Proper treatment of mediastinitis includes debridement, rigid sternal
patients and, despite an increased risk of wound complica-
fixation when possible, and soft-tissue coverage.
tions, prefers rigid to pliable mesh (MMM), especially for
■ Intrathoracic reconstruction is indicated for difficult empyemas and
larger resections.6 As alloplastic implants tend towards an
bronchopleural fistulas. Commonly latissimus is used for space filling increased infection rate when compared to autogenous mate-
and reinforcement of ischemia-prone areas.
rial or acellular dermal matrix, the authors prefer to avoid all
alloplastic mesh when possible.
Access the Historical Perspective section online at Chest wall reconstruction frequently requires some form of
soft-tissue coverage as many of these defects result from full-
http://www.expertconsult.com
thickness resections. Reconstructive goals include wound
closure with maintenance of intrathoracic integrity, restora-
tion of aesthetic contours, as well as minimization of donor
Introduction site deformity.
Recruitment of local muscles with or without overly-
Chest wall reconstruction can be generalized to include skel- ing skin is often the first line of reconstructive treatment.
etal support and soft-tissue cover. Skeletal support to prevent These muscles include pectoralis major, latissimus dorsi,
open pneumothorax and prevent or reduce paradoxic chest serratus anterior, rectus abdominus, and external oblique.
wall motion is usually required when the defect exceeds 5 cm The omentum may also be used. Commonly, the ipsilateral
in diameter. Generally, this corresponds to those defects latissimus muscle is divided during thoracotomy incisions,
exceeding a two rib resection. This rule of thumb, however, is and the authors encourage early communication between
somewhat region dependent (Table 10.1). Posterior chest wall surgeons if there are multiple teams.
defects may tolerate up to twice the size of those in the anterior
and lateral chest due to scapular coverage and support.1,2
Furthermore, without truly rigid chest wall reconstruction,
Pectoralis major
i.e., methyl methacrylate, titanium, or rib graft, some para- Pectoralis major, a muscle overlying the superior portion of
doxic chest wall motion is expected and is usually well toler- the anterior chest wall, is the workhorse for chest wall recon-
ated in patients without underlying pulmonary disease.3 struction, especially for defects of the sternum and anterior
Options for skeletal support include various mesh prod- chest. Its main function is to internally rotate and adduct the
ucts including polytetrafluoroethylene (PTFE, Gor-Tex), arm. Additionally, this muscle serves as the foundation for
polypropylene, Mersilene (polyethylene terephthalate)/ the female breast, and when absent, such as in Poland syn-
methyl methacrylate,4 titanium, and acellular dermal matrix drome, reconstruction may be indicated for aesthetic reasons
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238 SECTION II CHAPTER 10 • Reconstruction of the chest
Table 10.1 Chest wall regions

(Fig. 10.2). It originates from the sternum and clavicle and
inserts along the superomedial humerus in the bicipital
Anterior Between anterior axillary lines groove. Its dominant pedicle is the thoracoacromial trunk,
Lateral Between anterior and posterior axillary lines which enters the undersurface of the muscle below the clavicle
Posterior Between posterior axillary lines and the spine
at the junction of its lateral and middle third. Segmental blood
supply is derived from internal mammary artery (IMA)
B C
Fig. 10.1 Implantable mesh products including polypropylene, polytetrafluorethylene (PTFE, Gore-Tex), and acellular dermal matrix.
A B
C D
Fig. 10.2 Left sided Poland’s syndrome. With tissue expander and acellular dermal matrix (ADM), placed through a lateral transverse incision. (Courtesy of Dr. Roughton.)
Introduction 239
A B
C D
E
Fig. 10.3 Pectoralis anatomy and flap reach, standard and as turnover.
perforators. It will easily cover sternal and anterior chest wall paddle. Donor site deformity including scar placement
defects as an island or advancement flap. It can also be turned and loss of anterior axillary fold may be aesthetically
over, based on the IMA perforators, and, with release of its displeasing.7
insertion, cover sternal, mediastinal, and anterior chest wall
defects. As a turnover flap, the anterior axillary fold may be
preserved. In order to place the muscle intrathoracically, a
Latissimus dorsi
portion of the second, third, or fourth rib will be resected (Fig. Latissimus dorsi, a large, flat muscle covering the mid and
10.3). The muscle may be harvested with or without a skin lower back is often recruited for chest wall reconstruction
especially when significant bulk and mobility is required. It

is easily placed into the chest for intrathoracic space-filling. It
is known as the climbing muscle and adducts, extends, and
internally rotates the arm. It originates from the thoracolum-
bar fascia and posterior iliac crest and inserts into the superior
humerus at the intertubercular groove. Superiorly it is attached
to the scapula, and care must be taken to carefully separate
this muscle from the serratus at this point to avoid harvesting
both muscles. Its dominant blood supply is the thoracodorsal
artery, which enters the undersurface of the muscle 5 cm from
the posterior axillary fold.8 Segmental blood supply is derived Serratus anterior
from the posterior intercostal arteries as well as the lumbar
artery. Based upon its thoracodorsal pedicle, the muscle can
easily reach the ipsilateral posterior and lateral chest wall
including those defects involving anterior chest wall, sternum, Latissimus dorsi
or mediastinum. It can also be turned over and based upon
the lumbar perforators. In this fashion, it can reach across the
midline and back again. Again, it can be moved intrathoraci-
cally with rib resection. Donor site morbidity can include
shoulder dysfunction as well as unattractive scarring.9
However, our experience suggests these concerns are minimal. A
Also, transposition of this muscle can blunt or obliterate the
posterior axillary fold resulting in some asymmetry.7 We
advise caution in patients who have undergone previous
thoracotomy and modified radical mastectomy as the muscle
or blood supply may have been divided. Muscle sparing
thoracotomy incisions may be helpful in preoperative plan-
ning. (See Figs. 10.4 & 10.5.)
B
Serratus anterior
Serratus anterior is a thin broad multi-pennate muscle lying
deep along the anterolateral chest wall. It originates from the
upper eight or nine ribs and inserts on the ventral-medial
scapula. It functions to stabilize the scapula and move it
forward on the chest wall such as when throwing a punch. It
has two dominant pedicles including the lateral thoracic and
the thoracodorsal arteries. Division of the lateral thoracic
pedicle will increase the arc posteriorly, and similarly division Serratus anterior
of the thoracodorsal will increase the arc anteriorly. The
muscle will reach the midline of the anterior or posterior
chest. More commonly, however, it is used for intrathoracic
coverage, again requiring rib resection. An osteomyocutane-
ous flap may be harvested by preservation of the muscular
connections with the underlying ribs. Donor site morbidity is
related to winging of the scapula and can be avoided if the C
muscle is harvested segmentally and the inferior three or four Fig. 10.4 Muscle sparing thoracotomy. (From: Ferguson MK. Thoracic Surgery
slips are harvested.7 (See Fig. 10.6.) Atlas. Edinburgh: Elsevier©; 2007.)
Rectus abdominus
Rectus abdominus is a long, flat muscle that constitutes the hernia, and at times, mesh reinforcement of the abdominal
medial abdominal wall. It originates from the pubis and wall is necessary. Caution is also advised for patients with
inserts onto the costal margin. It can easily cover sternal and prior abdominal incisions as the skin perforators or intra-
anterior chest wall defects and can also fill space within the muscular blood supply may have been previously violated.7
mediastinum. It has two dominant pedicles, the superior (See Fig. 10.7.)
and inferior epigastric arteries and functions to flex the
trunk. With division of the inferior pedicle, the muscle will
cover the mediastinum and the anterior chest wall. It can be
External oblique
harvested with an overlying skin paddle, and usually the External oblique is a broad, flat muscle that originates from
resulting cutaneous defect can be closed primarily. When the lateral lower eight ribs and inserts onto the iliac crest and
taken with overlying fascia, there is a risk for resultant linea semilunaris. It easily covers lower anterior chest wall
Introduction 241
Thoracodorsal
artery
Fig. 10.5 Latissimus anatomy and arc of rotation standard and turn over.
resected. Furthermore, when transposing the omentum over

the costal margin, by necessity a portion of the abdominal
fascia must be left open to allow egress. This area is prone to
hernia.7 (See Figs. 10.9–11.)
Key points
Subclavian artery
■ Skeletal chest wall support may be achieved with mesh,
acellular dermal matrix, or autogenous material such as
tensor fascia lata. The former is more prone to infection.
Rigid skeletal support prevents paradoxic chest wall
motion although this is usually well tolerated.
■ Pectoralis muscle is the workhorse for sternal and
anterior chest wall defects.

■ Latissimus muscle is known for its bulk and ability to
Thoracodorsal
artery reach intrathoracic defects. Caution is advised for
patients with previous thoracotomy incisions as it may
have been divided. Less commonly the thoracodorsal
vessels will have been clipped during modified radical
mastectomy.
■ Serratus muscle is less bulky than the latissimus but will
function to cover lateral chest wall defects and some

intrathoracic needs.
■ Rectus abdominus is an excellent choice for sternal and
anterior chest wall defects, especially the lower two-

thirds. Furthermore, it can be used to fill space within the
mediastinum.
■ External oblique is well positioned for a rotational flap
and easily covers lower anterior defects.

■ The omentum can reach almost any chest wall defect. Its
greatest advantage is its pedicle length, which can be

extended by dividing the arcades.
Fig. 10.6 Serratus anatomy and arc of rotation. Patient selection/approach to patient
The importance of a multidisciplinary approach to chest wall
reconstruction cannot be underestimated. These patients,
defects as a rotational flap and has a segmental blood supply whether suffering from malignancy, infection, or trauma, are
from the posterior intercostal arteries, which enter the muscle often also plagued with cardiac or respiratory insufficiency,
at the midaxillary line. It functions in situ as an important diabetes, obesity, malnutrition, tobacco use, and generalized
strength layer of the abdominal wall, and thus its harvest deconditioning. Thorough workup including pulmonary
tends to be a second-line option when the latissimus is function testing, physical therapy and nutritional assessment,
not available. A similar flap can be made with overlying smoking cessation, and preoperative control of blood sugar,
soft tissue leaving the muscle intact as well.7 (See Fig. 10.8 – outcomes may be optimized. Furthermore, communication
external oblique anatomy and arc of rotation.) between referring surgeon and reconstructive plastic surgeon
is crucial to properly define preoperative reconstructive
expectations as well as incision planning with caution to spare
Omentum chest wall musculature if required. Occasionally preoperative
The omentum comprises visceral fat and blood vessels that imaging may be used to confirm suspected vascular injury to
arises from the greater curve of the stomach and is also commonly used muscle pedicles, e.g., thoracodorsal vessels
attached to the transverse colon. This flap can easily cover during mastectomy.
wounds in the mediastinum and anterior, lateral, and poste- Acquired chest wall deformities are commonly the result
rior chest wall. It has two dominant pedicles, the right and of iatrogenic injury. Chest wall wound infections, mediastini-
left gastroepiploic arteries. The greatest benefit of this flap is tis, osteoradionecrosis (ORN), refractory empyemas, and
the pedicle length that can be easily elongated with division bronchopleural fistulae can all necessitate a reconstructive
of internal arcades. The flap is mobilized onto the chest or surgeon. The surgeon is generally well prepared to reconstruct
into the mediastinum from a tunnel through the diaphragm or any defect with utilization of the workhorse flaps described
over the costal margin. Caution is again advised for patients above, combined with general principles of thorough debride-
with prior laparotomy incisions as the omentum may have ment and skeletal stabilization. Common chest wall recon-
significant intra-abdominal adhesions or have been previously structive problems are described below.
Historical perspective 242.e1
Historical perspective
Throughout history, the ability to perform surgical resections
has been limited by their survivorship. Chest wall resections,
in particular, were difficult given the intimate relationship of
the chest to vital structures beneath – the heart, lungs, and
great vessels. In particular, sequelae, such as pneumothorax,
were challenging for surgeons in the era preceding positive
pressure ventilation and closed chest drainage.
Despite adversity, however, and as early as 1906, the latis-
simus dorsi was used for chest wall coverage following radical
mastectomy.10 This was similarly performed by Campbell in
1950.11 The earliest use of fascia lata grafts appears in 1947.12
Axially based flaps regained popularity in the 1970s, and in
1986 Pairolero and Arnold published their series of 205
patients managed with muscle flaps purporting their safety
and durability.13
Patient selection/approach to patient 243
Superior
epigastric
artery
Inferior
epigastric
artery
A
Fig. 10.7 Rectus anatomy and arc of rotation.
A B C
Fig. 10.8 External oblique anatomy and arc of rotation.
Original Omentum
incision
Incision
A
Omentum
C
B
Left gastroepiploic vessels divided
Fig. 10.9 Omentum anatomy.
common benign tumor is osteochondroma and is resected

Chest wall tumors only when symptomatic. The most common primary malig-
nant tumors are sarcomas, chondrosarcoma from the bony
Basic science/disease process structures, and desmoid tumors from the soft tissue. Sarcoma
resection is recommended to include a 4 cm margin of normal
Primary tumors of the chest wall comprise only 5% of thoracic tissue and thus will almost always necessitate significant
neoplasms.14 Half of these are considered benign.15 The most chest wall reconstruction16 (Figs. 10.12 & 10.13). Over half of
Left lobe of liver
Incision in diaphragm
Omentum passing
through diaphragm
into thoracic cavity
Stomach
Fig. 10.10 Omentum is passed through cruciate incision in

diaphragm under the left lobe of the liver.
Chest wall tumors 245
malignant chest wall lesions represent metastatic disease,

with breast and lung cancers being the most common.17
Diagnosis/presentation/patient selection
For relief of symptoms including pain, ulceration, and foul
odor, and occasionally for disease control, even metastatic
lesions may necessitate resection. (See Fig. 10.14.)
Treatment/surgical technique
Like other neoplasms, metastatic tumors are resected with a
margin of normal tissue, and thus they too will frequently
require skeletal support as well as recruitment of soft tissue
in the form of pedicled or free flaps.
Outcomes
Not all metastatic resections are palliative. The 5-year survival
Fig. 10.11 Omentum arc of rotation. rate following resection of chest wall recurrence of breast
cancer is reported to be as high as 58%.18
A B
C D
Fig. 10.12 Multipe recurrent osteosarcoma. Initial reconstruction included ipsilateral latissimus, free contralateral latissimus. Third recurrence, resection involved 6 ribs and
the previously implanted mesh. Reconstructed with free anterolateral thigh (ALT) flap to the deep inferior epigastric artery/deep inferior epigastric vein (DIEA/DIEV).
(Courtesy of Dr. Song.)
A B
Fig. 10.13 Radiation-induced rhabdomyosarcoma of anterolateral chest wall,

resection of ribs 3–5, and adherent right middle lobe (RML). Reconstruction with
C porcine acellular dermal matrix (ADM) and latissimus myocutaneous flap and skin
graft. (Courtesy of Dr. Roughton.)
Mediastinitis
Basic science/disease process
Mediastinitis occurs in 0.25–5% of patients undergoing
median sternotomy.19–21 Historically, mortality approached Table 10.2 Classification of infected sternotomy wounds
50% in these patients.9 Sternal wound infections may be clas- Type I Type II Type III
sified into three distinct types as described by Pairolero (Table
Occurs within first Occurs within first Occurs months to
10.2).22 Type I wounds occur in the first several postoperative
few days few weeks years later
days and are usually sterile. This is consistent with early bony
Serosanguineous Purulent drainage Chronic draining sinus
nonunion and may represent the earliest stage of infection
drainage Cellulitis present tract
and perhaps even the portal of entry for skin flora. Type II
Cellulitis absent Mediastinal Cellulitis localized
infections, occurring in the first several weeks postoperatively,
Mediastinum soft suppuration Mediastinitis rare
are consistent with acute deep sternal wound infection includ-
and pliable Osteomyelitis Osteomyelitis,
ing sternal dehiscence, positive wound cultures, and cellulitis.
Osteomyelitis and frequent, costochondritis, or
Type III infections, presenting months to years later, represent
costochondritis costochondritis retained foreign body
chronic wound infection and uncommonly represent true
absent rare always present
mediastinitis. They are usually confined to the sternum and
Cultures usually Cultures positive Cultures positive
overlying skin and may be related to osteonecrosis or persis-
negative
tent foreign body.
Speculation exists that dehiscence of the sternum precedes (Adapted from Pairolero and Arnold. Chest wall tumors. Experience with 100
consecutive patients. J Thorac Cardiovasc Surg. 1985;90:367–372.)
infection of the deeper soft tissues within the mediastinum.
Mediastinitis 247
A C
B Fig. 10.14 Sternal metastases from breast cancer, resection, and vertical rectus
abdominus myocutaneous [FLAP] (VRAM) flap coverage. (Courtesy of Dr. Song.)
Like other fractures in the body, such as the lower extremity 10.15),27 will require adequate drainage and debridement.
and the mandible, sternal instability may perhaps encourage Quantitative tissue culture facilitates this debridement.
infection rather than result from it.23 If tissue culture is positive, >10 organisms per cm3 of tissue,
indicating deep sternal wound infection rather than early
sternal dehiscence, early debridement is encouraged and
Diagnosis/patient presentation should be performed urgently. A thorough debridement
Preoperative risk factors for the development of mediastinitis includes the removal of sternal wires and extraneous foreign
include older patients, chronic obstructive pulmonary disease bodies including any unnecessary pacing wires and chest
(COPD), smoking, end stage renal disease (ESRD), diabetes tubes (Fig. 10.16). Sharp debridement of necrotic and/or
mellitus (DM), chronic steroid or immunosuppressive use, purulent tissue is performed until remaining tissue appears
morbid obesity including large, heavy breasts, prolonged healthy and bleeding .28,29 Radical sternectomy is not indicated,
ventilator support (>24 h), concurrent infection, and reopera- and sternal salvage should be attempted if the bone is viable.
tive surgery. Other variables include off midline sternotomies, This may be determined by bleeding from the marrow and
osteoporosis, use of left internal mammary artery (LIMA) or the presence of hard, crunchy cortical bone. Topical antimi-
right internal mammary artery (RIMA), long cardio-pulmonary crobials such as silver sulfadiazine and mafenide creams are
bypass runs (>2 h), and transverse sternal fractures.24,25 A high employed to gain and maintain bacteriologic control of the
index of suspicion is encouraged for any patient with sternal wound. Subatmospheric pressure wound therapy may be
instability or “click”. However, firm diagnosis of mediastinitis utilized to increase wound blood flow and expedite granula-
or deep sternal wound infection is made by isolation of an tion tissue, thereby decreasing dead space.30,31 This has been
organism from mediastinal fluid or tissue and observing chest shown to decrease the number of days between operative
pain or fever associated with bony instability.26 debridement and definitive closure of sternal wounds. 20
Fixation of the sternum or residual sternal bone is
Treatment/surgical technique (Video 10.1 ) crucial for bony healing. Furthermore, this fixation pre-
vents paradoxic motion of the anterior chest wall and may
Consistent with fundamental plastic surgery principles, treat- improve many complications seen with sternal nonunion
ment of infection, including that of the mediastinum (Fig. such as chronic chest wall pain and abnormal rubbing or
Sternal wound with

• Instability or "click"
• Both bony dehiscence
Evaluation of wound/
debridement/
tissue sampling
+ Topical
antimicrobial
therapy
Quantitative tissue Quantitative tissue
culture >105 culture <105
Inadequate Adequate remaining

remaining viable bone viable bone
Sternal plating
Adequate soft- Inadequate soft-

tissue coverage tissue coverage
Primary closure Defect in upper Defect in Both upper and

or midsternum lower pole lower poles
Pectoralis major Rectus abdominus

Both
muscle flap myocutaneous or
+/- STSG muscle flap +/- STSG Or
Omentum
+ STSG Fig. 10.15 Management of sternal wounds. Split thickness skin graft
(STSG).
Fig. 10.16 Thorough debridement requires

A B removal of necrotic tissue and foreign bodies.
(Courtesy of Dr. Song.)
Empyema and bronchopleural fistula 249
can be used. This may be harvested with a skin island and

allow chest wound closure.35 Skin grafting, if required, may
be employed for closure of either the sternal wound or flap
donor site.18
Empyema and bronchopleural fistula

Empyema is defined as a deep space infection between the
layers of visceral and the parietal pleura. Empyema and
bronchopleural fistulas often are found in concert and plague
pneumonectomy and partial pneumonectomy defects. The
chest cavity, unlike most other regions in the body, is rigid
and non-collapsible. Thus deep space infections, such as
empyemas, are unlikely to heal without collapse of dead
space or filling of the cavity. Older techniques, such as open
chest drainage and the use of Eloesser flaps, designed to
decrease intrathoracic dead space, (Fig. 10.20) have fallen out
of favor.
Fig. 10.17 Rigid fixation is crucial for sternal union.
clicking sensations.32 For adults, titanium plates are used

(Fig. 10.17).
Occasionally, sternal dehiscence occurs early in the postop-
erative course, consistent with type I sternal wound infections.
This is secondary to mechanical failure of wire closure rather
than infection. The wounds are sterile and should proceed
to rigid sternal fixation. More commonly, however, patients
will present with sternal nonunion in a delayed fashion.
In the absence of infection, the residual viable bone can be
plated directly. Importantly, a paradigm shift has occurred in
the authors’ institution such that patients who are deemed
high risk for mediastinitis and sternal dehiscence are plated
prophylactically.33,34 Several plating systems exist all designed
to facilitate ease of application as well as emergent chest
re-entry. A
Once rigid fixation is achieved, soft-tissue closure must be
addressed. As very limited soft tissue exists over a normal
sternum, residual local tissue following debridement of
mediastinitis will often prove inadequate for plate coverage.
Thus muscle flap coverage is indicated. When the wound
involves the upper two-thirds of the sternum, pectoralis major
muscle advancement or turnover flaps are easily harvested
and are the first line therapy for wound closure (Fig. 10.18).
Caution is advised for turnover flaps when the ipsilateral IMA
has been harvested for coronary artery bypass graft (CABG).
Furthermore, emergent chest re-entry will, by definition,
devascularize this turnover flap. Additionally, when the lower
sternal pole lacks coverage, the pectoralis may be inadequate
based on its limited arc of rotation. For these cases, the rectus
abdominus muscle flap is a better choice (Fig. 10.19). It may
be used despite LIMA or RIMA harvest based upon the eighth
intercostal artery, its minor pedicle. If the rectus is unavailable
secondary to previous surgery, a pedicled omental flap should B
be considered for soft-tissue sternal coverage. Finally, if the
omentum has been previously resected or the patient has had Fig. 10.18 Bilateral pectoralis advancement flaps. Muscle sutured together in
multiple prior abdominal operations, the latissimus dorsi flap midline. (Courtesy of Dr. Roughton.)
A B
C Fig. 10.19 Oblique rectus abdominus myocutaneous flap for inferior pole sternal
coverage. (Courtesy of Dr. Roughton.)
Ribs to be resected
Left lung
Proposed inverted Tongue flap

“U” incision
A B
Drained empyema
cavity
Parietal pleura
Skin flap attached to

base of empyema
cavity
Skin flap
Diaphragm
Ribs resected E
Tongue flap
C D Completed procedure
with tongue flap sewn down
Fig. 10.20 Eloesser flap. Skin flap sewn to parietal pleura.
Osteoradionecrosis 251
Stapled bronchus
Latissimus dorsi muscle
Middle lung lobe retracted
Fig. 10.21 Bronchopleural fistula with latissimus muscle

introduced intrathoracically for reinforcement.
The bronchial stump, created after pneumonectomy, can 100 patients with severe intrathoracic infections.28 Several
also become a reconstructive challenge. If it dehisces, by defi- smaller and more recent studies report even higher rates of
nition, a bronchopleural fistula is created. This phenomenon, success.26,40,41 In fact, prophylactic use of the latissimus muscle
a massive air leak between the large airways and the chest for reinforcement of the bronchial stump in high-risk patients
cavity, is unlikely to resolve without the interposition of is the standard of care in some centers.42
healthy tissue in the form of flap coverage.36 (See Fig. 10.21.)
Surgical technique Osteoradionecrosis

The omentum, latissimus dorsi, serratus anterior, pectoralis
major, and rectus abdominus muscles have all been described Basic science/disease process
for space filling and reinforcement of the bronchial stump.37,38
An often encountered problem with intrathoracic space filling The use of adjuvant radiation therapy is becoming increas-
is the sheer volume required to totally obliterate the thoracic ingly common in the treatment of both breast and lung cancer.
cage. This can be overcome with thoracoplasty (meaning As such, osteoradionecrosis (ORN) of the ribs is becoming an
partial rib/cage collapse) or with the use of multiple flaps.39 increasing problem for reconstructive surgeons. Radiation
As a single flap, however, the latissimus muscle is often the injury and tissue damage may not become clinically apparent
preferred choice given its volume. for months to years after exposure, especially in tissues with
slow cell turnover such as bone. Although the mechanism is
poorly understood, radiation leads to an increased production
Outcomes of cytokines, collagen deposition, and scarring within affected
Outcomes following muscle flap transposition are reported tissues, as well as vascular damage leading to relative hypoxia
as quite successful with 73% resolution or prevention of (Figs. 10.22 & 10.23). The severity of radiation-induced necro-
infection in Arnold and Pairolero’s retrospective review of sis is related to several factors including total dose, dose per
A B C
Fig. 10.22 (A) Osteoradionecrosis of ribs following chest wall radiation for breast cancer. (B,C) Following radical resection, serratus thoracoabdominal flap is planned and
inset. Note all incisions kept supraumbilical to preserve lower abdominal donor site for future autologous breast reconstruction. (Courtesy of Dr. Gottlieb.)
A B
C D
Fig. 10.23 Osteoradionecrosis following chest wall radiation for breast cancer treated with omentum and skin graft. (Courtesy of Dr. Roughton.)
Traumatic chest wall deformities 253
fraction, frequency of administration, and whether it is com-

bined with chemotherapy. Smaller doses per fraction appear
to be better tolerated.43 Note that this entity may be difficult
to diagnose radiographically and demands a high level of
clinical suspicion.
Treatment/surgical technique
Some advocate hyperbaric oxygen (HBO) therapy for ORN.
However, for ORN of the mandible, a prospective, random-
ized, placebo-controlled trial showed the HBO group actually
fared worse than their counterparts.44 Anecdotally, the authors
have not found this therapy to be essential or especially
helpful and do not routinely pursue it. Management of ORN
of the chest wall consists of wide local excision and recon-
struction. In addition to osteonecrosis, radiation damage also
affects overlying soft tissues creating hyperpigmentation, Fig. 10.24 Judet struts. (From: Surgical Stabilization of Severe Flail Chest, Fig. 7,
decreased pliability, and even ulceration. However, note that reproduced with permission from CTSNet, Inc. © 2010. All rights reserved.)
this decrease in chest wall pliability may make skeletal rein-
forcement unnecessary for borderline sized defects. Recruit-
ment of healthy tissue in the form of local myocutaneous flaps
is recommended for coverage of resultant chest wall defects Diagnosis/patient presentations
and any skeletal reinforcement as indicated.
Severe paradoxic chest wall motion, in the form of flail chest,
may be seen following significant chest trauma. This results
Osteomyelitis from multiple adjacent rib fractures, broken in two or more
places, creating a flail segment.
Patient selection/treatment/surgical technique
Chest wall osteomyelitis most commonly results from
contiguous spread of infection, either from pneumonia or Patients with traumatic chest wall deformities should initially
empyema. Hematogenous spread is also possible. Infectious be stabilized according to Advanced Trauma Life Support
etiology tends to be bacterial, with mycobacterial and fungal (ATLS) protocol. Chest tubes and positive pressure ventilation
sources less likely. It frequently coexists with ORN as well. should be initiated as indicated. For patients with respiratory
compromise, rigid fixation of the flail segment may be indi-
Diagnosis/patient presentation cated. This is accomplished traditionally with the use of
mini-plates, thicker titanium recon bars, or Judet struts (Fig.
Osteomyelitis produces symptoms including fever, chest 10.24). Significant loss of chest wall, seen in massive crush
pain, and localized swelling of the chest wall.45 injuries, should be managed again with rigid support to the
remaining viable chest wall and concomitant soft-tissue
Treatment/surgical technique coverage.
Similar to osteomyelitis of other areas of the body, antibiotics
and surgical excision are recommended. Chest wall recon- Outcomes
struction should proceed similarly to other areas of resection Traditionally patients were treated with expectant manage-
with rigid support when indicated and soft-tissue coverage in ment; however, rib plating has been shown to reduce ventila-
the form of local muscle flaps. In an infected field, however, tor dependence and ICU stay as well as incidence of
the authors strongly discourage use of prosthetic material. pneumonia in patients with flail chest.
When skeletal stabilization is indicated, autogenous material
or acellular dermal matrix is preferred. Secondary procedures
Chest wall reconstruction has been, over the last three decades,
Traumatic chest wall deformities very successful. Cases of failure commonly result from inad-
equate control of infection or residual tumor burden. In either
Basic science/disease process case, an aggressive resection is often indicated and the use of
a second flap. Another unfortunate complication of skeletal
Chest trauma results from both penetrating and blunt injuries, chest wall reconstruction is infection of alloplastic mesh
which damage underlying bony and soft tissues. This may products. In these cases, removal of the infected prosthesis
occur with or without further injury to vital organs or great and use of acellular dermal matrix, autologous fascia, or even
vessels within the thoracic cage. contralateral ribs may be indicated.
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support, and over half of the patients required muscle transposition for
28. Dickie SR, Dorafshar AH, Song DH. Definitive closure of the
soft-tissue coverage. Wound healing was complete for 95% of patients,
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vacuum-assisted closure followed by rigid plate fixation. Ann Plast
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resection and reconstruction with and without rigid prosthesis. Ann mediastinitis, emphasizing debridement, the use of sub-atmospheric
Thorac Surg. 2006;81(1):279–285. pressure, rigid fixation, and soft-tissue coverage.
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Clinical Applications. St Louis (MO): Quality Medical Publishing; high-risk patients prevents mediastinitis. Eur J Cardio-Thor Surg.
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surgery continues to be an excellent reference for relevant anatomy, flap plating in high-risk patients. The group who was plated experienced no
selection, and arc of rotation. mediastinitis while 14.8% of the control group, closed with wire,
13. Pairolero PC, Arnold PG. Thoracic wall defects: surgical developed mediastinitis.
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31. Morykwas MJ, Argenta LC, Shelton-Brown EI, et al. Vacuum
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SECTION II • Trunk Surgery

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(Fig. 10.1). Furthermore, use of tensor fascia lata (TFL) and

Table 10.1 Chest wall regions

especially when significant bulk and mobility is required. It

resected. Furthermore, when transposing the omentum over

anterior chest wall defects.

function to cover lateral chest wall defects and some

anterior chest wall defects, especially the lower two-

and easily covers lower anterior defects.

greatest advantage is its pedicle length, which can be

Fig. 10.8 External oblique anatomy and arc of rotation.

Left gastroepiploic vessels divided

Fig. 10.9 Omentum anatomy.

common benign tumor is osteochondroma and is resected

Left lobe of liver

Fig. 10.10 Omentum is passed through cruciate incision in

malignant chest wall lesions represent metastatic disease,

Fig. 10.13 Radiation-induced rhabdomyosarcoma of anterolateral chest wall,

Sternal wound with

Inadequate Adequate remaining

Adequate soft- Inadequate soft-

Primary closure Defect in upper Defect in Both upper and

Pectoralis major Rectus abdominus

Fig. 10.16 Thorough debridement requires

can be used. This may be harvested with a skin island and

Empyema and bronchopleural fistula

Fig. 10.17 Rigid fixation is crucial for sternal union.

clicking sensations.32 For adults, titanium plates are used

Proposed inverted Tongue flap

Skin flap attached to

Fig. 10.20 Eloesser flap. Skin flap sewn to parietal pleura.

Latissimus dorsi muscle

Middle lung lobe retracted

Fig. 10.21 Bronchopleural fistula with latissimus muscle

Surgical technique Osteoradionecrosis

fraction, frequency of administration, and whether it is com-

Access the complete references list online at http://www.expertconsult.com

References 25. Ridderstolpe L, Gill H, Granfeldt H, et al. Superficial and deep

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References 25. Ridderstolpe L, Gill H, Granfeldt H, et al. Superficial and deep