-
2013 Elsevier Ltd, Inc, BV
when the defect exceeds 5 cm in diameter. Generally, this
cor-responds to those defects exceeding a two rib resection. This
rule of thumb, however, is somewhat region dependent (Table 10.1).
Posterior chest wall defects may tolerated up to twice the size of
those in the anterior and lateral chest due to scapu-lar coverage
and support1,2 Anecdotally, patients who have undergone radiation
and have decreased chest wall compli-ance will tolerate larger
resections without skeletal replace-ment due to an overall fibrosis
of their viscera.
Options for skeletal support include various mesh prod-ucts
including PTFE (Gore-Tex), polypropylene, Mersilene
(polyethylene-terephthalate)/methylmethacrylate,3 and acel-lular
dermal matrix (Fig. 10.1). Furthermore, use of TFL as both graft
and flap reconstruction has been described. Little data exists as
to outcome comparisons between these options. However, in a
retrospective review of 197 patients, PTFE and polypropylene appear
to be equivalent in complications and outcomes.1 Another smaller
retrospective review of 59 patients prefers
Mersilene-methylmethacrylate sandwich to PTFE due of decreased
paradoxic chest wall motion.4 As alloplastic implants trend towards
an increased infection rate when com-pared with autogenous material
or acellular dermal matrix, the authors prefer to avoid mesh when
possible.
Chest wall reconstruction almost always requires some form of
soft tissue coverage as very few defects will close primarily.
Reconstructive goals include wound closure with maintenance of
intrathoracic integrity, restoration of aesthetic contours, as well
as minimization of donor site deformity.
Recruitment of local muscles with or without overlying skin is
often the first-line of reconstructive offense. These muscles
include pectoralis major, latissimus dorsi, serratus anterior, and
rectus abdominus. The omentum may also be used. Commonly the
ipsilateral latissimus muscle is divided during thoracotomy
incisions and the authors encourage early communication between
surgeons if there are multiple teams in order to mitigate against
routine division. Muscle sparing thoracotomies help to preserve
both the latissimus and serratus muscles while providing adequate
intrathoracic access (Fig. 10.2).
SynopS i S
Rigidchestwallsupportmaybeachievedwithmesh,acellulardermalmatrix,orautogenousmaterialsuchastensorfascialata.ofthese,alloplasticmeshismostpronetoinfection.
Softtissuecoveragecanbeachievedwithlocalmuscleflaps.
propertreatmentofmediastinitisincludesdebridement,rigidsternal
fixationwhenpossible,andsofttissuecoverage.
pectoralismuscleistheworkhorseforsternalandanteriorchest
walldefects.
Latissimusmuscleisknownforitsbulkandabilitytoreach
intrathoracicdefects.Cautionisadvisedforpatientswithpreviousthoracotomyincisionsasitmayhavebeendivided.
Musclesupplieslessbulkthanthelatissimusbutwillfunctiontocoverlateralchestwalldefectsandsomeintrathoracicneeds.
Rectusabdominusisanexcellentchoiceforsternalandanteriorchestwalldefects,especiallythelowertwo-thirds.Furthermore,itcanbeusedtofillspacewithinthemediastinum.
Theomentumcanreachalmostanychestwalldefect.itsgreatestadvantageisitspediclelength,whichcanbeextendedbydividingthearcades.itdoes,however,requirealaparotomyforharvest.
10SeCTionii
Reconstruction of the chest
David H. Song and Michelle C. Roughton
Trunk Surgery
IntroductionCommon etiologies for chest wall defects include
tumor resection, deep sternal wound infections, chronic empyemas,
osteoradionecrosis and trauma. Although each mechanism carries
individual nuances, they will all require adequate deb-ridement
and, when possible, replacement of like with like. Fundamentally,
the chest wall must be restored for the pro-tection of underlying
viscera, maintenance of respiratory mechanics, and base for the
upper limb and shoulder.
Chest wall reconstruction can be generalized to include skeletal
support and soft tissue cover. Skeletal support to prevent
paradoxic chest wall motion is usually required
AccesstheHistoricalperspectivesectiononlineathttp://www.expertconsult.com
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240 SectIon II Reconstructionofthechest10
Table 10.1 Regions of the chest wall
Anterior Between anterior axillary lines
Lateral Between anterior and posterior axillary lines
Posterior Between posterior axillary lines and the spine
Fig. 10.1 Implantable mesh products including polypropylene,
PTFE (Gore-Tex), and acellular dermal matrix.
A
B
C
Fig. 10.2 Muscle sparing thoracotomy. (From: Ferguson MK.
Thoracic Surgery Atlas. Edinburgh: Elsevier; 2007.)
Latissimus dorsi
Serratus anterior
Serratus anterior
A
B
C
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241Commonflapsforreconstruction
deformity including scar placement and loss of anterior
axil-lary fold may be aesthetically displeasing.5
Latissimus dorsiLatissimus dorsi, a large, flat muscle covering
the mid and 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
five centimeters from the posterior axillary fold.6 Segmental blood
supply is derived from the posterior inter-costals arteries as well
as the lumbar artery. Based upon its thoracodorsal pedicle, the
muscle can easily reach the ipsilat-eral posterior and lateral
chest wall, including those defects involving either the anterior
chest wall, sternum, or mediasti-num. It can also be turned over
and based upon the lumbar perforators. In this fashion, it can
reach across the midline back. Again, it can be moved
intrathoracically with rib resec-tion. Donor site morbidity can
include shoulder dysfunction, weakness and pain, as well as
unattractive scarring.7 However, our experience suggests these
concerns are minimal. Also, transposition of this muscle can blunt
or obliterate the poste-rior axillary fold, resulting in some
asymmetry (Figs 10.5, 10.6).5 Care must be taken to properly drain
the donor site, as seromas are common. Quilting or progressive
tension sutures may mitigate against seroma formation.
Fig. 10.3 Pectoralis major serves as the foundation for the
female breast and when absent, such as in Poland syndrome,
reconstruction may be indicated for aesthetic reasons.
A B
common flaps for reconstruction
Pectoralis majorPectoralis major, a muscle overlying the
superior portion of the anterior chest wall, is the workhorse for
chest wall recon-struction, especially for defects of the sternum
and anterior chest. Its main function is to internally rotate and
adduct the arm. Additionally, this muscle serves as the foundation
for the female breast and when absent, such as in Polands syndrome,
reconstruction may be indicated for aesthetic reasons (Fig. 10.3).
It originates from the sternum and clavicle and inserts along the
superomedial humerus in the bicipital groove. Its dominant pedicle
is the thoracoacromial trunk which enters the undersurface of the
muscle below the clavicle at the junc-tion of its lateral and
middle third. Segmental blood supply is derived from internal
mammary artery (IMA) perforators. Based on the thoracoacromial
blood supply, it will easily cover sternal and anterior chest wall
defects as an island or advancement flap. Division of the
pectoralis major muscle insertion can also aid in advancing the
muscle flap into a properly debrided mediastinal wound. The muscle
can also be turned over based on the IMA perforators and with
release of its insertion, cover sternal, mediastinal, and anterior
chest wall defects. Importantly, when used as a turnover flap, the
internal mammary vessels and their perforators must be examined and
deemed intact particularly in the setting of post-sternotomy
mediastinitis. This vessel may be absent (left more commonly used
than right) due to harvest for coronary artery bypass grafting or
damaged during wide debridement of a post-sternotomy wound. The
muscle may also be placed intrathoracically, however, this will
necessitate resection of a portion of the 2nd, 3rd, or 4th rib
(Fig. 10.4). The muscle may be harvested with or without a skin
paddle. Donor site
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242 SectIon II Reconstructionofthechest10
Fig. 10.4 Pectoralis anatomy and flap reach, standard and as
turnover.
A B
C D
E
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243Commonflapsforreconstruction
Fig. 10.5 Latissimus dorsi, anatomy and standard arc of
rotation.
A
B
C
D
Thoracodorsalartery
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244 SectIon II Reconstructionofthechest10
Serratus anteriorSerratus anterior is a thin broad multi-pennate
muscle lying deep along the anterolateral chest wall. It originates
from the upper 8 or 9 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
domi-nant pedicles including the lateral thoracic and the
thoraco-dorsal arteries. Division of the lateral thoracic pedicle
will increase the arc posteriorly and similarly division of the
tho-racodorsal will increase the arc anteriorly. The muscle
will
Fig. 10.6 Latissimus turnover flap. Thoracodorsal pedicle
ligated, muscle turned over based upon thoracolumbar perforators.
Provides coverage of contralateral posterior chest wall.
A
B
Thoracodorsalartery Lumbar perforator
arteries
Subclavianartery
Fig. 10.7 Serratus anatomy and arc of rotation.
Thoracodorsalartery
Subclavian artery
reach the midline of the anterior or posterior chest. More
com-monly, however, it is used for intrathoracic coverage, again
requiring rib resection. An osteomyocutaneous 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 muscle is harvested segmentally and the
superior five or six digitations are pre-served (Fig. 10.7).5
Rectus abdominusRectus abdominus is a long, flat muscle which
constitutes the medial abdominal wall. It originates from the pubis
and inserts onto the costal margin. It can easily cover sternal and
anterior chest wall defects and can also fill space within the
mediastinum. It has two dominant pedicles, the superior 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 may be utilized
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245Commonflapsforreconstruction
internal arcades. The flap is mobilized onto the chest or into
the mediastinum through the diaphragm or over the costal margin.
Ideally, the flap is mobilized through a cruciate inci-sion in the
right diaphragm as the liver helps to buttress the incision and
prevent diaphragmatic hernia. Furthermore, right-sided
transposition obviates the need to navigate the flap around the
heart. Care must be taken when interpolating the omentum as it is
often of very little substance and can easily be avulsed during
passage through the diaphragm. Strategies to protect the omentum
during transposition include placing the omentum into a bowel bag.
The empty bag can be passed from the mediastinum into the abdomen
via the diaphragm incision, past the left lobe of the liver. The
omentum is then gently packed into the bowel bag with tension
transferred to the bowel bag rather than the omentum during
interpolation. Caution is again advised for patients with prior
laparotomy incisions as the omentum may have significant
intra-abdominal adhesions or have been previ-ously resected (Figs
10.910.11).5
despite previous IMA harvest based upon its minor pedicle, the
8th intercostals artery. It can be harvested with overlying skin
paddle and usually the resulting cutaneous defect can be closed
primarily. When taken with overlying fascia, there is a risk for
resultant hernia, and at times, mesh reinforcement of the abdominal
wall is necessary. Caution is also advised for patients with prior
abdominal incisions as the skin perforators or intramuscular blood
supply may have been previously violated (Fig. 10.8).5
omentumThe omentum is comprised of visceral fat and blood
vessels which arises from the greater curve of the stomach and is
also attached to the transverse colon. This flap can easily cover
wounds in the mediastinum, anterior, lateral and posterior chest
wall. It has two dominant pedicles, the right and left
gastroepiploic arteries. The greatest benefit of this flap is the
pedicle length, which can be easily elongated with division of
Fig. 10.8 Rectus anatomy and arc of rotation.
A
B
Superiorepigastric artery
Inferiorepigastric artery
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246 SectIon II Reconstructionofthechest10
Fig. 10.9 Omentum anatomy.
Originalincision
Incision
Omentum
Left gastroepiploic vessels divided
Omentum
A
BC
Fig. 10.10 Omentum is passed through cruciate incision in
diaphragm under the left lobe of the liver.
Omentum passing through diaphragm into thoracic cavity
Left lobe of liver
Stomach
Incision in diaphragm
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247Chestwalltumors
Fig. 10.11 Omentum arc of rotation.
Fig. 10.12 Recurrent breast cancer, sternal metastases.
A
B
C
Patient selection/approach to patientThe importance of a
multidisciplinary approach to chest wall reconstruction cannot be
underestimated. These patients, whether suffering from malignancy,
infection, or trauma, are often also plagued with cardiac or
respiratory insufficiency, diabetes, obesity, malnutrition, and
generalized decondition-ing. Thorough work-up including pulmonary
function testing, physical therapy and nutritional assessment, and
pre-operative control of blood sugar may optimize outcomes.
Furthermore, communication between referring surgeon and
reconstructive plastic surgeon is crucial for properly defined
preoperative reconstructive expectations as well as incision
planning. For example, it may be advantageous to spare chest wall
musculature, such as the latissimus dorsi, during thoracotomy.
Acquired chest wall deformities are commonly the result of
iatrogenic injury. Usually encountered in conjunction with cardiac
or thoracic surgery, wound infections, mediastinitis,
osteoradionecrosis, refractory empyema and bronchopleural fistulas,
can all necessitate chest wall reconstruction.
Utilizing the workhorse flaps described above combined with
general principles of thorough debridement and skeletal
stabilization the surgeon is generally well prepared to
recon-struct any deficit. Common chest wall reconstructive
prob-lems are described below.
chest wall tumors
Basic science/disease processPrimary tumors of the chest wall
comprise only 5% of thoracic neoplasms.21 Half of these are
considered benign.22 The most common benign tumor is osteochondroma
and is resected only when symptomatic. The most common primary
malig-nant tumors are sarcomas; chondrosarcoma from the bony
structures and desmoid tumors from the soft tissue. Sarcoma
resection is recommended to include a 4 cm margin of normal tissue
and thus, will almost always necessitate significant
chest wall reconstruction.23 Over half of malignant chest wall
lesions represent metastatic disease with breast and lung cancers
being the most common.24
Diagnosis/presentation/patient selectionFor relief of symptoms
including pain, ulceration, foul odor, and occasionally for
disease-control, even metastatic lesions may necessitate resection
(Fig. 10.12).
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248 SectIon II Reconstructionofthechest10
Fig. 10.13 Chondrosarcoma, resected and reconstructed with VRAM
flap.
A B
C D
E
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249Mediastinitisandsternalnonunion
Diagnosis/patient presentationPreoperative risk factors for the
development of mediastinitis include older patients, COPD, smoking,
ESRD, DM, chronic steroid or immunosuppressive use, morbid obesity
including large, heavy breasts, prolonged ventilator support
(>24 h), concurrent infection and reoperative surgery. Other
variables include off midline sternotomies, osteoporosis, use of
LIMA or RIMA, long cardiopulmonary bypass runs (>2 h), and
transverse sternal fractures.30,31 A high index of suspicion is
encouraged for any patient with sternal instability or click.
However, firm diagnosis of mediastinitis or deep sternal wound
infection is made by isolation of an organism from mediastinal
fluid or tissue, chest pain, or fever associated with bony
instability.32
Sternal nonunion commonly results from failure of boney healing
following median sternotomy. However, it is also seen in
association with chest wall trauma. Patients with nonunion may
complain of pain or clicking associated with respiration.
treatment/surgical techniqueConsistent with fundamental plastic
surgery principles, treat-ment of infection including that of the
mediastinum (Fig. 10.14),33 will require adequate drainage and
debridement. Quantitative tissue culture facilitates this
debridement and guides antimicrobial therapy.
If tissue culture is positive, >105 organisms/cm3 of tissue,
indicating deep sternal wound infection rather than early sternal
dehiscence, early debridement is encouraged and should be performed
urgently. A thorough debridement includes the removal of sternal
wires and extraneous foreign bodies including any unnecessary
pacing wires and chest tubes (Fig. 10.15). Sharp debridement of
necrotic and/or purulent tissue is performed until remaining tissue
appears healthy and bleeding.34 Radical sternectomy is not
indicated and sternal salvage should be attempted if the bone is
viable. This may be determined by bleeding from the marrow and the
presence of hard, crunchy cortical bone. Topical antimi-crobials
such as silver sulfadiazine and mafenide creams are employed to
gain and maintain bacteriologic control of the wound.
Subatmospheric pressure wound therapy (e.g., V.A.C.) may be
utilized to increase wound blood flow and expedite granulation
tissue, thereby decreasing dead space.35,36 This has been shown to
decrease the number of days between operative debridement and
definitive closure of sternal wounds, from 8.5 to 6.2 days, as well
as the number of flaps required per patient, 1.50.9.19
Subatmospheric pressure wound therapy is now standard practice for
the treatment of mediastinitis at many institutions.3740
Fixation of the sternum or residual sternal bone is crucial for
bony healing. Furthermore, this fixation prevents para-doxic motion
of the anterior chest wall and may improve many complications seen
with sternal nonunion such as chronic chest wall pain and abnormal
rubbing or clicking sensations.20,41 For adults, titanium plates
are used (Fig. 10.16).
Sternal dehiscence also occurs early in the postoperative
course, consistent with type 1 sternal wound infections. This is
secondary to mechanical failure of wire closure rather than
treatment/surgical techniqueLike 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
(Fig. 10.13).
outcomesNot all metastatic resections are palliative. The 5-year
survival rate following resection of chest wall recurrence of
breast cancer is reported to be as high as 58%.25
Mediastinitis and sternal nonunion
Basic science/disease processMediastinitis occurs in 0.255% of
patients undergoing median sternotomy.13,17,26 Historically,
mortality approached 50% in these patients.13 Sternal wound
infections may be clas-sified into three distinct types as
described by Pairolero and Arnold27 (Table 10.2). Type 1 wounds
occur in the first several postoperative days and are usually
sterile. This is consistent with early bony nonunion and may
represent the earliest stage of infection and perhaps even the
portal of entry for skin flora. Type 2 infections, occurring in the
first several weeks postoperatively are consistent with acute deep
sternal wound infection, including sternal dehiscence, positive
wound cul-tures, and cellulitis. Type 3 infections, presenting
months to years later, represent chronic wound infection and
uncom-monly represent true mediastinitis. They are usually confined
to the sternum and overlying skin and may be related to
osteonecrosis or persistent foreign body.
Speculation exists that dehiscence of the sternum precedes
infection of the deeper soft tissues within the mediastinum.
Similar to other bones in the body such as in the lower extrem-ity
or even the mandible, sternal instability may perhaps encourage
infection rather than result from it.20 With absent bacterial
contamination and resulting infection, this instabil-ity will
develop into sternal nonunion as opposed to post-sternotomy
mediastinitis and osteomyelitis.28,29
Table 10.2 Classification of infected sternotomy wounds
Type I Type II Type III
Occurs within first few daysSerosanguineous drainageCellulitis
absentMediastinum soft and pliableOsteomyelitis and costochondritis
absentCultures usually negative
Occurs within first few weeksPurulent drainageCellulitis
presentMediastinal sup-purationOsteomyelitis fre-quent,
costochon-dritis rareCultures positive
Occurs months to years laterChronic draining sinus
tractCellulitis localizedMediastinitis rareOsteomyelitis,
cos-tochondritis, or re-tained foreign body always presentCultures
positive
(Reprinted from Pairolero and Arnold. Chest wall tumors.
Experience with 100 consecutive patients, J Thorac Cardiovasc Surg
1985;90:367-72).
Video1
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250 SectIon II Reconstructionofthechest10
advancement or turnover flaps are easily harvested and are the
first-line therapy for wound closure (Fig. 10.17). Caution is
advised for turnover flaps when the ipsilateral IMA has been
harvested for 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 rota-tion. For these cases,
the rectus abdominus muscle flap is a better choice. It may be used
despite LIMA or RIMA harvest based upon the 8th intercostal artery,
its minor pedicle. If the rectus is unavailable secondary to
previous surgery, a pedi-cled omental flap should be considered for
soft-tissue sternal coverage. Finally, if the omentum has been
previously resected or the patient has had multiple prior abdominal
operations, the latissimus dorsi flap can be used. This may be
harvested with a skin island and allow chest wound closure.43
Skin
infection. The wounds are sterile and surgeons should proceed to
immediate 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.28 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.29,42 Several plating systems exist, all designed
to facilitate ease of application as well as emergent chest
re-entry.
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
medi-astinitis 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
Fig. 10.14 Management of sternal wounds. (From: Roughton MC,
Song DH. Sternal wounds. In: Marsh J, Perlyn C, eds. Decision
Making in Plastic Surgery. St Louis, MO: Quality Medical;
2009:63.)33
Sternal instability/dehiscence
Debridement
VAC therapy
Reassess wound
Topical antimicrobialsand IV antibiotics
Plate fixationof sternum
Inadequate softtissue coverage
Rectus abdominusmuscle flap
If rectus unavailable
If omentum unavailable
Pectoralis majormuscle flap
Upper/mid pole defect Lower pole defect
Skin graftif necessary
Adequate softtissue coverage
Primary closure
Quantitative tissue cultures
< 105> 105
A:
D:
C:
B:
E:
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251Mediastinitisandsternalnonunion
nerves when the residual sternal edges abut one another.44
Although not formally addressed in the literature, however
anecdotally appreciated by the authors, restoration of sternal
union achieved through rigid fixation relieves the pain associ-ated
with instability.
Strength, following use of popular muscle flaps (i.e.,
pectoralis major, latissimus dorsi, and rectus abdominus), has been
both surveyed and objectively measured and is somewhat decreased
following sternectomy and muscle flap reconstruction.
Interestingly, the objective decrease in pectoralis muscle function
is seen on both the operated side and the contralateral side and
may be more related to sternal instability than pectoralis
disinsertion. Patients ability to perform activities of daily
living (ADLs) and return to preoperative activities was found to be
no different when compared to their peers with uneventful healing
post-sternotomy.45
Pulmonary function following sternectomy and recon-struction
with pectoralis muscle flaps has been measured pre- and
postoperatively and seems to be nearly unchanged following
reconstruction. In a small group of six patients, pulmonary
function testing (PFTs), specifically FVC, FEV1, retractive force,
and static lung compliance were mildly diminished postoperatively,
while TLC remained unchanged. This suggests maintenance of full
inspiration with some decreased ability to maximally exhale.
Additionally, the authors noted three patients with increased
dependence on abdominal breathing.46 Another group compared PFTs
between those undergoing sternal resection and muscle flaps, n =
13, to those with sternotomy and primary healing, n = 15. They
found no significant differences between the two groups.47
And perhaps most telling, when patients were surveyed regarding
their general condition following sternal osteo-myelitis and
reconstruction, 83% of patients reported improvement in quality of
life following their chest wall reconstruction.48
grafting, if required, may be employed for closure of either the
sternal wound or flap donor site.25
outcomesThe importance of reconstruction is underscored when
follow-up data on quality of life is assessed. When surveyed, as
many as half of patients undergoing sternal debridement and muscle
flap reconstruction complained of persistent chest and shoulder
pain. Of the patients, 43% complained of sternal instability. This
is felt to result from irritation of intercostal
Fig. 10.15 Thorough debridement requires removal of necrotic
tissue and foreign bodies.
A B
Fig. 10.16 Rigid fixation is crucial for sternal union.
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252 SectIon II Reconstructionofthechest10
Fig. 10.17 Bilateral pectoralis advancement flaps. Allis clamps
on pectoralis muscle. Muscle sutured together in midline.
A B
empyema, bronchopleural fistula, and chest wall
osteomyelitis
Basic science/disease processEmpyema is defined as a deep space
infection between the layers of visceral and parietal pleura.
Empyema and broncho-pleural fistulas often are found in concert and
plague pneu-monectomy 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, designed to decrease intratho-racic dead
space, such as open chest drainage and the use of Eloesser flaps,
the creation of pleural fistulas (Fig. 10.18), have fallen out of
favor.
The bronchial stump, created after pneumonectomy, can become a
reconstructive challenge. If it dehisces, by defini-tion, a
bronchopleural fistula is created. This phenomenon, a massive
airleak between the large airways and chest cavity, is unlikely to
resolve without the interposition of healthy tissue in the form of
flap coverage (Fig. 10.19).49
Chest wall osteomyelitis most commonly results from contiguous
spread of infection, either from pneumonia and empyema.
Hematogenous spread is also possible. Infectious etiology tends to
be bacterial, with mycobacterial and fungal sources less likely.
Osteomyelitis produces symptoms includ-ing fever, chest pain, and
localized swelling of the chest wall.50
Surgical techniqueThe omentum, latissimus dorsi, serratus
anterior, pectoralis major, and rectus abdominus muscles have all
been described
for space filling and reinforcement of the bronchial stump.51,52
An often encountered problem with intrathoracic space filling is
the sheer volume required to totally obliterate the thoracic cage.
This can be overcome with thoracoplasty (partial rib/cage collapse)
or with the use of multiple flaps.53 As a single flap, however, the
latissimus muscle is the preferred choice given its sheer size.
Similar to osteomyelitis of other areas of the body,
antibiot-ics and surgical excision are recommended for bony
infection of the chest wall. Reconstruction should proceed
similarly to other areas of resection with rigid support when
indicated and soft tissue coverage in the form of local muscle
flaps.
outcomesOutcomes following muscle flap transposition are
reported as quite successful, with 73% resolution or prevention of
infec-tion in Arnold and Pairoleros retrospective review of 100
patients with severe intrathoracic infections.52 Several smaller
and more recent studies report even higher rates of
success.49,54,55 In fact, prophylactic use of the latissimus muscle
for reinforce-ment of the bronchial stump in high-risk patients is
the stand-ard of care in some centers.56
osteoradionecrosis
Basic science/disease processThe use of adjuvant radiation
therapy is becoming increas-ingly common in the treatment of both
breast and lung cancer. As such, osteoradionecrosis (ORN) of the
ribs is becoming an increasing problem for reconstructive surgeons.
Radiation injury and tissue damage may not become clinically
apparent
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253Traumaticchestwalldeformities
Fig. 10.18 Eloesser flap. Skin flap sewn to parietal pleura.
Proposed inverted U incision
Ribs to be resected
Tongue flap
Tongue flap
Ribs resected
Completed procedurewith tongue flap sewn down
Left lung
Diaphragm
Parietal pleura
Drained empyemacavity
Skin flap attached tobase of empyemacavity
Skin flap
A B
C D
E
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 of
cytokines, collagen deposition and scarring within affected tissues
as well as vascular damage leading to relative hypoxia (Fig.
10.20). The severity of radiation-induced necrosis is related to
several factors including total dose, dose per frac-tion, frequency
of administration, and whether it is combined with chemotherapy.
Smaller doses per fraction appear to be better tolerated.57
treatment/surgical techniqueSome advocate hyperbaric oxygen
(HBO) therapy for osteora-dionecrosis. However, for
osteoradionecrosis of the mandible, a prospective, randomized,
placebo-controlled trial showed the HBO group actually fared worse
than their counterparts.58 Anecdotally, the authors have not found
this therapy to be essential and do not routinely pursue it.
Management of ORN of the chest wall consists of surgical excision
and reconstruc-tion. Again, should more than two ribs be resected
from the anterior chest wall, skeletal support will traditionally
be required. Radiation damage also affects overlying soft tissues,
creating hyperpigmentation, decreased pliability, and even
ulceration. Thus, recruitment of healthy tissue in the form of
local myocutaneous flaps is recommended.
traumatic chest wall deformities
Basic science/disease processChest trauma results from both
penetrating and blunt injuries, which damage underlying bony and
soft tissues. This may occur with or without further injury to
vital organs or great vessels within the thoracic cage.
Diagnosis/patient presentationsParadoxic chest wall motion, in
the form of flail chest, may be seen following significant chest
trauma. This results from multiple adjacent rib fractures, broken
in two or more places, creating a flail segment.
Patient selection/treatment/surgical techniquePatients with
traumatic chest wall deformities should initially be stabilized
according to ATLS protocol. Chest tubes and positive pressure
ventilation should be initiated as indicated. For patients with
respiratory compromise, rigid fixation of this flail chest segment
may be indicated. This is accomplished
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254 SectIon II Reconstructionofthechest10
Fig. 10.19 Bronchopleural fistula with latissimus muscle
introduced intrathoracically for reinforcement.
Stapled bronchus
Middle lung lobe retracted
Latissimus dorsi muscle
Fig. 10.20 (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.
A B C
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255Traumaticchestwalldeformities
traditionally with the use of mini-plates or Judet struts (Fig.
10.21). Significant chest wall loss, as can be seen in massive
crush injuries, should be managed with rigid support to the
remaining viable chest wall and concomitant soft tissue
coverage.
outcomesRib plating has been shown to reduce
ventilator-dependence and ICU stay as well as incidence of
pneumonia in patients with flail chest.59
Secondary proceduresChest wall reconstruction has been, over the
last three decades, very successful. Cases of failure commonly
result from inad-equate control of infection or residual tumor
burden. In either case, an aggressive resection is often indicated
and use of a second flap. Another unfortunate complication of
skeletal chest wall reconstruction is infection of alloplastic mesh
prod-ucts. In these cases, removal of the infected prosthesis and
use of acellular dermal matrix or autologous fascia or even
con-tralateral ribs may be indicated.
Fig. 10.21 Judet struts. (From: Surgical Stabilization of Severe
Flail Chest, Fig. 7, reproduced with permission from CTSNet, Inc.
2010. All rights reserved.)
Access the complete reference list online at
http://www.expertconsult.com
1. Deschamps C, et al. Early and long-term results of prosthetic
chest wall reconstruction. J Thorac Cardiovasc Surg.
1999;117(3):588592.The authors review their experience with nearly
200 patients requiring chest wall reconstruction over 15 years.
Mesh is utilized (polypropylene and polytetrafluoroethylene) for
skeletal support and over half of the patients required muscle
transposition for soft tissue coverage. Wound healing was complete
for 95% of patients, although 24% experienced local cancer
recurrence.
5. Mathes SJ, Nahai F. Reconstructive surgery. Principles,
Anatomy, and Technique. Edinburgh: Churchill Livingstone; 1997.This
textbook detailing nearly all commonly-used flaps in plastic
surgery continues to be an excellent reference for relevant
anatomy, flap selection, and arc of rotation.
29. Song DH, Lohman RF, Renucci JD, et al. Primary sternal
plating in high-risk patients prevents mediastinitis. Eur J
Cardiothorac Surg. 2004;26:367372.
This is a case-controlled study of prophylactic sternal plating
in high risk patients. The group who were plated experienced no
mediastinitis, while 14.8% of the control group, closed with wire,
developed mediastinitis.
34. Dickie SR, Dorafshar AH, Song DH. Definitive closure of the
infected median sternotomy wound: A treatment algorithm utilizing
vacuum-assisted closure followed by rigid plate fixation. Ann Plast
Surg. 2006;56(6):680685.This paper contains a treatment algorithm
for mediastinitis emphasizing debridement, the use of
subatmospheric pressure, rigid fixation, and soft tissue
coverage.
52. Arnold PG, Pairolero PC. Intrathoracic muscle flaps. An
account of their use in the management of 100 consecutive patients.
Ann Surg. 1990;211(6):656660.The authors detail a 73% success rate
with treatment and prevention of intrathoracic infection following
muscle transposition into the chest of high risk patients.
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-
245.e1History
HistoryThroughout 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 exceptionally challenging for surgeons in the era
preced-ing positive pressure ventilation and tube thoracostomy.
Despite adversity, however, and as early as 1906, the
latis-simus dorsi was used for chest wall coverage following
radical mastectomy.8 This was similarly performed by Campbell in
1950.9 The earliest use of fascia lata grafts appears in 1947.10
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.11
As surgical advances and innovations were made, the sequelae of
postoperative infection followed close behind.
Interestingly, the treatment of mediastinal infection has
changed dramatically since the first description of the ster-notomy
incision in 1957.12 Open chest drainage fell out of favor quickly
due to exposure of heart and mediastinum and subsequent risk of
rupture. Mortality rates were as high as 50% with open packing.13
Throughout the 1960s, closed chest drainage with antibiotic
catheter irrigation was advocated as the first-line therapy for
deep sternal wound infections.14,15 This innovative technique
reduced mortality to approximately 20%.16 Then, in 1980, Jurkiewicz
published a landmark paper revealing debridement and muscle flap
coverage was sig-nificantly more successful than antibiotic
catheter drainage alone.17 This advancement further reduced
mortality rates to 10%.18 In recent times, mediastinitis treatment
has advanced to include subatmospheric pressure wound therapy and
rigid fixation of residual sternal bone. These techniques address
the loss of chest wall integrity, paradoxic chest wall motion, and
chronic pain.19,20
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-
255.e1References
References1. Deschamps C, et al. Early and long-term results
of
prosthetic chest wall reconstruction. J Thorac Cardiovasc Surg.
1999;117(3):588592.The authors review their experience with nearly
200 patients requiring chest wall reconstruction over 15 years.
Mesh is utilized (polypropylene and polytetrafluoroethylene) for
skeletal support and over half of the patients required muscle
transposition for soft tissue coverage. Wound healing was complete
for 95% of patients, although 24% experienced local cancer
recurrence.
2. Hasse J. Surgery for primary, invasive, and metastatic
malignancy of the chest wall. Eur J Cardiothor Surg.
1991;5:346351.
3. Lardinois D, Muller M, Furrer M, et al. Functional assessment
of chest wall integrity after methylmethacrylate reconstruction.
Ann Thorac Surg. 2000;69:919923.
4. Kilic D, Gungor A, Kavukcu S, et al. Comparison of mersilene
mesh-methyl methacrylate sandwich and polytetrafluoroethylene
grafts for chest wall reconstruction. J Int Surg.
2006;19:353360.
5. Mathes SJ, Nahai F. Reconstructive surgery. Principles,
Anatomy, and Technique. Edinburgh: Churchill Livingstone; 1997.This
textbook detailing nearly all commonly-used flaps in plastic
surgery continues to be an excellent reference for relevant
anatomy, flap selection, and arc of rotation.
6. Saint-Cyr M, Nagarkar P, Schaverien M, et al. The pedicled
descending branch muscle-sparing latissimus dorsi flap for breast
reconstruction. Plast Reconstr Surg. 2009;123(1):1324.
7. Russell RC, Pribaz J, Zook EG, et al. Functional evaluation
of latissimus dorsi donor site. Plast Reconstr Surg.
2009;123(1):13344.
8. Tansini I. Sopra il mio nuovo processo di amputazione della
mammilla. Gazz Med Ital. 1906;57:141.
9. Campbell DA. Reconstruction of the anterior thoracic wall. J
Thoracic Surg. 1950;19:456.
10. Watson WL, James AG. Fascia lata grafts for chest wall
defects. J Thorac Surg. 1947;16:399.
11. Pairolero PC, Arnold PG. Thoracic wall defects: surgical
management of 205 consecutive patients. Mayo Clin Proc.
1986;61(7):557563.
12. Julian OC, Lopez-Belio M, Dye WS, et al. The median sternal
incision in intracardiac surgery with extra corporeal circulation:
a general evaluation of its use in heart surgery. Surgery.
1957;42(4):753761.
13. Sarr MG, Gott VL, Townsend TR, et al. Mediastinal infection
after cardiac surgery. Ann Thorac Surg. 1984;38(4):415423.
14. Shumacker Jr HB, Mandelbaum I. Continuous antibiotic
irrigation in the treatment of infection. Arch Surg.
1963;86(3):384387.
15. Bryant LR, Spencer FC, Trinkle JK. Treatment of median
sternotomy infection by mediastinal irrigation with an antibiotic
solution. Ann Surg. 1969;169(6):914920.
16. Grossi EA, Culliford AT, Krieger KH, et al. A survey of 77
major infectious complications of median sternotomy: a review of
7,949 consecutive operative procedures. Ann Thorac Surg.
1985;40(3):214221.
17. Jurkiewicz MJ, Bostwick 3rd J, Hester TR, et al. Infected
median sternotomy wound. Successful treatment by muscle flaps. Ann
Surg. 1980;191(6):738743.
18. Jones G, Jurkiewicz MJ, Bostwick J, et al. Management of the
infected median sternotomy wound with muscle flaps. The Emory
20-year experience. Ann Surg. 1997;225(6):766778.
19. Song DH, Wu LC, Lohman RF, et al. Vacuum assisted closure
for the treatment of sternal wounds: the bridge between debridement
and definitive closure. Plast Recon Surg. 2003;111(1):9297.
20. Gottlieb LJ, Pielet RW, Karp RB, et al. Rigid internal
fixation of the sternum in postoperative mediastinitis. Arch Surg.
1994;129(5):489493.
21. Perry RR, Venzon D, Roth JA, et al. Survival after surgical
resection for high-grade chest wall sarcomas. Ann Thorac Surg.
1990;49(3):363368.
22. Graeber GM, Snyder RJ, Fleming AW, et al. Initial and
long-term results in the management of primary chest wall
neoplasms. Ann Thorac Surg. 1982;34(6):664673.
23. King RM, Pairolero PC, Trastek VF, et al. Primary chest wall
tumors: factors affecting survival. Ann Thorac Surg.
1986;41(6):597601.
24. Pairolero PC, Arnold PG. Chest wall tumors: experience with
100 consecutive patients. J Thorac Cardiovasc Surg.
1985;90(3):367372.
25. Faneyte IF, Rutgers ET, Zoetmulder FAN. Chest wall resection
in the treatment of locally recurrent breast carcinoma. Cancer.
1997;80(5):886891.
26. Prevosti LG, Subramainian VA, Rothaus KO, et al. A
comparison of the open and closed methods in the initial treatment
of sternal wound infections. J Cardiovasc Surg. 1989;30:757763.
27. Pairolero PC, Arnold PG. Management of recalcitrant median
sternotomy wounds. J Thorac Cardiovasc Surg. 1984;88:357364.
28. Wu LC, Renucci JD, Song DH, et al. Sternal nonunion: a
review of current treatments and a new method of rigid fixation.
Ann Plast Surg. 2005;54(1):5558.
29. Song DH, Lohman RF, Renucci JD, et al. Primary sternal
plating in high-risk patients prevents mediastinitis. Eur J
Cardiothorac Surg. 2004;26:367372.This is a case-controlled study
of prophylactic sternal plating in high risk patients. The group
who were plated experienced no mediastinitis, while 14.8% of the
control group, closed with wire, developed mediastinitis.
30. Golosow LM, Wagner JD, Feeley M, et al. Risk factors for
predicting surgical salvage of sternal wound-healing complications.
Ann Plast Surg. 1999;43:3035.
31. Ridderstolpe L, Gill H, Granfeldt H, et al. Superficial and
deep sternal wound complications: incidence, risk factors and
mortality. Eur J Cardiothorac Surg. 2001;20:11681175.
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online or in print. This proof copy is the copyright property of
the publisher and is confidential until formal publication.
-
255.e2 SectIon II 10 Reconstructionofthechest
32. Mangram AJ, Horan TC, Pearson ML, et al. Guidelines for
prevention of surgical site infection 1999; Centers for Disease
Control and Prevention (CDC) Hospital Infection Control Practices
Advisory Committee. Am J Infect Control. 1999;27: 97132.
33. Roughton MC, Song DH. Sternal wounds. In: Marsh J, Perlyn C,
eds. Decision Making in Plastic Surgery. St Louis, MO: Quality
Medical; 2009:63.
34. Dickie SR, Dorafshar AH, Song DH. Definitive closure of the
infected median sternotomy wound: A treatment algorithm utilizing
vacuum-assisted closure followed by rigid plate fixation. Ann Plast
Surg. 2006;56(6):680685.This paper contains a treatment algorithm
for mediastinitis emphasizing debridement, the use of
subatmospheric pressure, rigid fixation, and soft tissue
coverage.
35. Argenta LC, Morykwas MJ. Vacuum assisted closure: A new
method for wound control and treatment. Clinical experience. Ann
Plast Surg. 1997;38(6):563576.
36. Morykwas MJ, Argenta LC, Shelton-Brown EI, et al. Vacuum
assisted closure: a new method for wound control and treatment:
animal studies and basic foundation. Ann Plast Surg.
1997;38(6):553562.
37. Agarwal JP, Ogilvie M, Wu LC, et al. Vacuum-assisted closure
for sternal wounds: a first-line therapeutic management approach.
Plast Reconstr Surg. 2005;116(4):10351040.
38. Sjogren J, Malmsjo M, Gustafsson R, et al. Poststernotomy
mediastinitis: a review of conventional surgical treatments,
vacuum-assisted closure therapy and presentation of the Lund
University Hospital mediastinitis algorithm. Eur J Cardiothorac
Surg. 2006;30(6):898905.
39. Fleck T, Gustafsson R, Harding K, et al. The management of
deep sternal wound infections using vacuum assisted closure
(V.A.C.) therapy. Int Wound J. 2006;3(4):273280.
40. Baillot R, Cloutier D, Montalin L, et al. Impact of deep
sternal wound infection management with vacuum-assisted closure
therapy followed by sternal osteosynthesis: a 15-year review of
23,499 sternotomies. Eur J Cardiothorac Surg.
2010;37(4):880887.
41. Yuen JC, Zhou AT, Serafin D, et al. Long-term sequelae
following median sternotomy wound infection and flap
reconstruction. Ann Plast Surg. 1995;35(6):585589.
42. Lee JC, Raman J, Song DH. Primary sternal closure with
titanium plate fixation: plastic surgery effecting a paradigm
shift. Plast Reconstr Surg. 2010;125(6):17201724.
43. Nahai F, Rand RP, Hester TR, et al. Primary treatment of the
infected sternotomy wound with muscle flaps: a review of 211
consecutive cases. Plast Reconstr Surg. 1989;84(3):434441.
44. Ringelman PR, Vander Kolk CA, Cameron D, et al. Long-term
results of flap reconstruction in median sternotomy wound
infections. Plast Reconstr Surg. 1994;93(6):12081214.
45. Netscher DT, Eladoumikdachi F, McHugh PM, et al. Sternal
wound debridement and muscle flap reconstruction: functional
implications. Ann Plast Surg. 2003;51(2):115122.
46. Meadows 3rd JA, Staats BA, Pairolero PC, et al. Effect of
resection of the sternum and manubrium in conjunction with muscle
transposition on pulmonary function. Mayo Clin Proc.
1985;60(9):604609.
47. Kohman LJ, Auchincloss JH, Gilbert R, et al. Functional
results of muscle flap closure for sternal infection. Ann Thorac
Surg. 1991;52(1):102106.
48. Daigeler A, Falkenstein A, Pennekamp W, et al. Sternal
osteomyelitis: long term results after pectoralis muscle flap
reconstruction. Plast Reconstr Surg. 2009;123(3):910917.
49. Jadczuk E. Postpneumonectomy empyema. Eur J Cardiothorac
Surg. 1998;14:123126.
50. Bishara J, Gartman-Israel D, Weinberger M, et al.
Osteomyelitis of the ribs in the antibiotic era. Scand J Infect
Dis. 2000;32(3):223227.
51. Iverson LI, Young JN, Ecker RR, et al. Closure of
bronchopleural fistulas by an omental pedicle flap. Am J Surg.
1986;152(1):4042.
52. Arnold PG, Pairolero PC. Intrathoracic muscle flaps. An
account of their use in the management of 100 consecutive patients.
Ann Surg. 1990;211(6):656660.The authors detail a 73% success rate
with treatment and prevention of intrathoracic infection following
muscle transposition into the chest of high risk patients.
53. Rand RP, Maser B, Dry G, et al. Reconstruction of irradiated
postpneumonectomy empyema cavity with chain-linked coupled
microsurgical omental and TRAM flaps. Plast Reconstr Surg.
2000;105(1):183186.
54. Okumura Y, Takeda S, Asada H, et al. Surgical results for
chronic empyema using omental pedicled flap: long-term follow-up
study. Ann Thorac Surg. 2005;79:18571861.
55. Meyer AJ, Krueger T, Lepori D, et al. Closure of large
intrathoracic airway defects using extrathoracic muscle flaps. Ann
Thorac Surg. 2004;77:397405.
56. Abolhoda A, Bui TD, Milliken JC, et al. Pedicled latissimus
dorsi muscle flap. Routine use in high-risk thoracic surgery. Tex
Heart Inst J. 2009;36(4):298302.
57. Stone HB, Coleman CN, Anscher MS, et al. Effects of
radiation on normal tissue: consequences and mechanisms. Lancet
Oncol. 2003;4:529536.
58. Annane D, Depondt J, Aubert P, et al. Hyperbaric oxygen
therapy for radionecrosis of the jaw: a randomized,
placebo-controlled, double-blind, trial from the ORN96 Study Group.
J Clin Oncol. 2004;22(24):48934900.
59. Tanaka H, Yukioka T, Yamaguti Y, et al. Surgical
stabilization of [sic] internal pneumatic stabilization? A
prospective randomized study of management of severe flail chest
patients. J Trauma. 2002;52(4):727732.
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