Stabilization of the chest wall: autologous and alloplastic reconstructions

Abstract

The goals of chest wall stabilization include maintenance of a rigid airtight cavity, protection of the thoracic and abdominal contents, optimization of respiration, and, whenever possible, an aesthetic reconstruction. Evidence suggests that bony fixation results in reduced ventilator dependence, a shorter overall hospital stay, and improved upper extremity function. We prefer to accomplish this with autologous tissue alone (such as the pectoralis major, latissimus dorsi, or rectus abdominus muscle flaps) for small to moderate defects. En bloc resection of defects larger than 5 cm or containing four or more ribs will likely benefit from chest wall stabilization. For patients previously treated with radiation, even larger defects may be tolerated owing to fibrosis. For these larger defects, methyl methacrylate composite meshes are used and covered with vascularized tissue. Contaminated wounds are generally reconstructed with bioprosthetic mesh rather than synthetic mesh. Using these principles, the reconstructive plastic surgeon can devise a comprehensive and safe plan to repair tremendous defects of the chest wall.

Keywords: Chest wall; alloplastic; autologous; reconstruction; stabilization.

Figure 1

A 28-year-old man with a chondrosarcoma of the lateral chest wall. (A) En bloc resection included the overlying previous biopsy site and three ribs. (B) Deep surface of the resection specimen. (C) The resultant resection defect was stabilized using inlay polypropylene mesh. (D) The mesh was covered with a free vertical rectus abdominus myocutaneous flap anastomosed to the thoracodorsal pedicle that had been transected during the resection.

Figure 2

(A) A 64-year-old man with recurrent squamous cell carcinoma of the chest wall previously treated with composite resection and pectoralis flap reconstruction with postoperative radiotherapy and chemotherapy. (B) Preoperative CT scan demonstrating involvement of the anterior and right chest wall. (C) Resection defect included the sternum, ribs 2 to 6, and the right upper lobe. (D) The defect was reconstructed with a composite polypropylene mesh/poly(methyl methacrylate) sandwich. (E) An ipsilateral pedicled latissimus dorsi muscle flap was harvested for soft tissue coverage and covered with a split-thickness skin graft from the thigh. (F) Appearance of chest wall reconstruction 2 months postoperatively. (Photographs courtesy of Donald P. Baumann, M.D.)

Figure 3

(A) Preoperative photograph of a 76-year-old woman with left chest wall radiation-associated sarcoma after segmental mastectomy and postoperative radiotherapy 12 years prior. (B) The left chest wall resection included the medial sternum and anterolateral segments of ribs 3, 4, and 5. (C) Composite chest wall resection specimen. (D) The defect was reconstructed with an onlay bioprosthetic mesh and a left pectoralis majors myocutaneous rotation advancement flap. (E) Appearance of the reconstructed composite defect postoperatively. (Photographs courtesy of Donald P. Baumann, M.D.)