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. 2023 Oct;166(4):1262-1272.e2.
doi: 10.1016/j.jtcvs.2023.05.018. Epub 2023 May 24.

The contribution of microvascular free flaps and pedicled flaps to successful chest wall surgery

Stijn Vanstraelen  1 , Barkat Ali  2 , Manjit S Bains  1 , Farooq Shahzad  2 , Robert J Allen Jr  2 , Evan Matros  2 , Joe Dycoco  1 , Prasad S Adusumilli  1 , Matthew J Bott  1 , Robert J Downey  1 , James Huang  1 , James M Isbell  1 , Daniela Molena  1 , Bernard J Park  1 , Valerie W Rusch  1 , Smita Sihag  1 , Peter G Cordeiro  2 , Michelle R Coriddi  2 , Joseph H Dayan  2 , Joseph Disa  2 , Colleen M McCarthy  2 , Jonas A Nelson  2 , Carrie Stern  2 , Babak Mehrara  2 , David R Jones  3 , Gaetano Rocco  4
Affiliations

The contribution of microvascular free flaps and pedicled flaps to successful chest wall surgery

Stijn Vanstraelen et al. J Thorac Cardiovasc Surg. 2023 Oct.

Abstract

Objective: Pedicled flaps (PFs) have historically served as the preferred option for reconstruction of large chest wall defects. More recently, the indications for microvascular-free flaps (MVFFs) have increased, particularly for defects in which PFs are inadequate or unavailable. We sought to compare oncologic and surgical outcomes between MVFFs and PFs in reconstructions of full-thickness chest wall defects.

Methods: We retrospectively identified all patients who underwent chest wall resection at our institution from 2000 to 2022. Patients were stratified by flap reconstruction. End points were defect size, rate of complete resection, rate of local recurrence, and postoperative outcomes. Multivariable analysis was performed to identify factors associated with complications at 30 days.

Results: In total, 536 patients underwent chest wall resection, of whom 133 had flap reconstruction (MVFF, n = 28; PF, n = 105). The median (interquartile range) covered defect size was 172 cm2 (100-216 cm2) for patients receiving MVFF versus 109 cm2 (75-148 cm2) for patients receiving PF (P = .004). The rate of R0 resection was high in both groups (MVFF, 93% [n = 26]; PF, 86% [n = 90]; P = .5). The rate of local recurrence was 4% in MVFF patients (n = 1) versus 12% in PF patients (n = 13, P = .3). Postoperative complications were not statistically different between groups (odds ratio for PF, 1.37; 95% confidence interval, 0.39-5.14]; P = .6). Operative time >400 minutes was associated with 30-day complications (odds ratio, 3.22; 95% confidence interval, 1.10-9.93; P = .033).

Conclusions: Patients with MVFFs had larger defects, a high rate of complete resection, and a low rate of local recurrence. MVFFs are a valid option for chest wall reconstructions.

Keywords: chest wall reconstruction; chest wall resection; microvascular free flap; pedicled flap.

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Conflict of interest statement

Disclosures: Matthew J. Bott is a consultant for AstraZeneca. James M. Isbell has stock ownership in LumaCyte and is a consultant/advisory board member for Roche Genentech. Daniela Molena serves on a steering committee for AstraZeneca and as a consultant for Johnson & Johnson, Bristol Myers Squibb, Merck, and Genentech. Bernard J. Park has served as a proctor for Intuitive Surgical and as a consultant for COTA. Valerie W. Rusch reports grant support (institutional) from Genelux and Genentech, travel support from Intuitive Surgical, and travel support and payments from NIH/Coordinating Center for Clinical Trials. Babak Mehrara is a consultant for PureTech and Mediflix and receives royalty payments from PureTech. He is also the recipient of investigator-initiated awards from PureTech, Regeneron, and Pfizer. David R. Jones serves as a consultant for AstraZeneca and on a Clinical Trial Steering Committee for Merck. Gaetano Rocco has a financial relationship with Scanlan, AstraZeneca, and Medtronic. The other authors have no conflicts of interest to disclose.

Figures

Figure 1.
Figure 1.
Reconstruction after extensive chest wall resection frequently requires myocutaneous tissue transfer. Compared with pedicled flaps, microvascular free flaps cover larger defects and achieve high rates of R0 resection, with comparable postoperative outcomes. Microvascular free flaps can safely be used in a patient-tailored strategy to ensure adequate oncologic margins.
See this image and copyright information in PMC

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