Microvascular reconstructions of full-thickness oncological chest wall defects

Abstract

Objective: To evaluate the suitability of microvascular flaps for the reconstruction of extensive full-thickness defects of the chest wall.

Summary background data: Chest wall defects are conventionally reconstructed with pedicular musculocutaneous flaps or the omentum. Sometimes, however, these flaps have already been used, are not reliable due to previous operations or radiotherapy, or are of inadequate size. In such cases, microvascular flaps offer the only option for reconstruction.

Methods: From 1988 to 2001, 26 patients with full-thickness resections of the chest wall underwent reconstruction with microvascular flaps. There were 8 soft tissue sarcomas, 8 recurrent breast cancers, 5 chondrosarcomas, 2 desmoid tumors, 1 large cell pulmonary cancer metastasis, 1 renal cancer metastasis, and 1 bronchopleural fistula. The surgery comprised 5 extended forequarter amputations, 5 lateral resections, 8 thoracoabdominal resections, and 8 sternal resections. The mean diameter of a resection was 28 cm. The soft tissue defect was reconstructed with 16 tensor fasciae latae, 5 tensor fascia latae combined with rectus femoris, and 3 transversus rectus abdominis myocutaneous flaps. In 2 patients with a forequarter amputation, the remnant forearm was used as the osteomusculocutaneous free flap.

Results: There were no flap losses or perioperative mortality. Four patients needed tracheostomy owing to prolonged respiratory difficulties. The mean survival time for patients with sarcomas was 39 months and for those with recurrent breast cancer 18 months.

Conclusions: Extensive chest wall resections are possible with acceptable results. In patients with breast cancer, the surgery may offer valuable palliation and in those with sarcomas it can be curative.

FIGURE 1. a: A 71-year-old woman with ulcerating local recurrence of breast cancer in the mastectomy scar invading into the chest wall. b: Full-thickness chest wall resection was performed, including the right half of the sternum and ribs. Stabilization was performed by free rib graft and synthetic mesh. c: Soft tissue was reconstructed with musculocutaneous transversus rectus abdominis free flap. d: The patient is disease free at 9 months.

FIGURE 2. A 73-year-old man with primary malignant hemangiopericytoma in the lateral chest wall. Preoperatively chest x-ray (a) and CT scans (b) were taken. c: Full-thickness chest wall resection was performed with resection of six ribs. d: The chest wall was reconstructed with musculocutaneous tensor fasciae latae free flap. e: The patient is disease free at 6 years.

FIGURE 3. a: A 46-year-old woman with local recurrence of breast cancer and metastases adjacent to brachial plexus, vessels, and upper limb. The limb was painful, lymphoedematous, ulcerated, and paralyzed. b: Palliative forequarter amputation with chest wall resection was performed. c: The soft tissue defect was reconstructed with tensor fasciae latae (including rectus femoris muscle) free flap. The patient survived 2 years 5 months after the operation and evidently died of the disease.

FIGURE 4. A 23-year-old woman with local recurrence of high-grade soft tissue sarcoma invading brachial plexus. The right upper limb was paralyzed and extremely painful. a: Palliative forequarter amputation with resection of the chest wall was performed. b: The amputated forearm was dissected and used as osteomusculocutaneous free flap to cover the defect. c: The ulna was osteotomized and fixed to sternum to reconstruct the chest wall stability and shoulder contour. The patient died of the disease 8 months after the operation.

FIGURE 5. a: A 52-year-old man with ulcerating high-grade primary soft tissue sarcoma in the inferolateral chest wall. b: Resection of the chest and abdominal wall was performed and tensor fasciae latae free flap was raised. c: The defect was reconstructed with synthetic mesh (d) and tensor fascia latae free flap. Great saphenous vein was dissected, divided distally, and transposed 180 degrees proximally. A vascular loop was formed, and the distal end of the vein was anastomosed to superficial femoral artery. The loop was divided and pedicle vessels anastomosed. The course of the vessels is marked on the skin. e: The patient was disease free at 1 year. Evidently, the disease recurred and progressed fast, and the patient died 1 year 6 months after the operation.

FIGURE 6. Overall survival (Kaplan-Meier method) of 26 patients with full-thickness resections of the chest wall reconstructed with microvascular flaps.