Plastic surgery

PART IX

TRUNK AND LOWER EXTREMITY

CHAPTER 92  CHEST WALL RECONSTRUCTION

JOSEPH N. CAREY, LEO R. OTAKE, ANTHONY ECHO, AND GORDON K. LEE

HISTORY

Chest wall reconstruction became more formalized as a result of reconstructing mastectomy defects. Tansini is credited with the first latissimus dorsi flap for reconstruction of a mastectomy defect in 1896. He developed fasciocutaneous, muscle, and musculocutaneous flaps for radical mastectomy defects. The surgical treatment of breast cancer at the time included resection of the breast, the pectoralis major, and the axillary contents. Halsted, who first performed the procedure in 1882, proposed skin graft closure or healing by secondary intention. Tansini’s experiments with random fasciocutaneous, muscle, and eventually pedicled musculocutaneous flaps gave him experience with partial and full flap necrosis. His tribulations led him to describe the concepts of blood flow in flaps and to conclude that the musculocutaneous latissimus flap was the most reliable method of reconstructing a mastectomy defect.

Tansini’s concept of mastectomy closure was lost for many years, as the Halsted method of breast cancer treatment was adopted, and admonitions about the use of flaps in cancer treatment were heeded. As the use of muscle and myocutaneous flaps was popularized in the 1970s by Mathes and Nahai and Bostwick, however, the superiority of flaps in the closure of mastectomy defects was demonstrated.

Similarly, as the surgical treatment of thoracic diseases evolved, large chest wall defects were created, presenting reconstructive challenges. Arnold and Pairolero in the 1970s and 1980s made substantial contributions using several muscle flaps (including the external oblique, pectoralis major, and latissimus dorsi) and omentum for chest wall reconstruction.

Modern-day chest wall reconstruction uses the gamut of the reconstructive armamentarium, including negative pressure wound therapy (Chapter 3), local flaps, pedicled flaps, and free tissue transfers. Alloplastic and prosthetic materials are also frequently used and their use has increased in recent years with the advent of biological prosthetic materials. This chapter focuses on the description of chest wall wounds, and the algorithm and materials available to the reconstructive surgeon to solve the problems associated with ablative surgery, trauma, and infection of the chest wall.

CHEST WALL ANATOMY AND FUNCTION

The chest wall consists of muscle, cartilage, and bone arranged in a conical fashion and consisting of an apex and a base (Figure 92.1). The junction of the first thoracic vertebrae, the first ribs, and the manubrium forms the apex or “thoracic outlet.” The base is formed by the diaphragm and its attachments to the inferior ribs, the xiphoid process, and the spine. The anterior surface of the chest wall consists of the sternum and its cartilaginous attachments to the anterior ribs. The chest wall is connected to the upper extremities anteriorly via the sternoclavicular joint and posteriorly through the soft tissue attachments of the scapulae.

The arterial supply to the chest wall consists primarily of paired intercostal arteries that originate from the aorta posteriorly, run through the intercostal spaces, and join the internal mammary arteries. The secondary arterial supply originates from the subclavian and axillary arteries via thoracoacromial, lateral thoracic, and thoracodorsal branches. The venous drainage parallels the arterial supply, however, in the posterior mediastinum the intercostal veins terminate in the azygous system. Paired intercostal nerves corresponding to the anterior rami of the T1 to T11 thoracic nerves travel with the neurovascular bundles in the intercostal spaces and provide motor innervation to the intercostal muscles as well as sensation to the overlying skin (Chapter 4).

The functions of the chest wall include (1) sturdy protection of the thoracic viscera; (2) assistance with respiratory function via muscular contraction and structural stability; (3) symmetric attachment of the upper extremity musculature and stabilization of the shoulder joint; and (4) symmetric attachment of the breasts.

Respiratory function depends on chest wall musculature and the stability of the rib cage. The chest wall muscles are arranged in three layers similar to the abdominal wall. Contraction narrows the intercostal spaces and changes the thoracic volume to change the intrathoracic pressure to effect air movement.

ETIOLOGY OF CHEST WALL DEFECTS

Chest wall deformities occur from a variety of causes, including trauma, tumor extirpation, infection, and iatrogenic injuries such as radiation. The origin of the defect, the age of the patient, and concomitant comorbidities all affect the reconstructive decisions.

Trauma. The most common cause of chest trauma in the United States is blunt trauma associated with motor vehicle accidents (MVAs). An estimated 7% of MVAs result in serious thoracic injury and 20% of all trauma deaths involve thoracic injury. In addition, penetrating, blast, or burn injuries may necessitate chest wall reconstruction.

Tumor. Tumor extirpation results in chest wall defects that range from small to massive. Among the most common neoplastic causes for chest wall resection are breast carcinoma and soft tissue sarcoma. However, extrathoracic extension of thoracic visceral tumors and primary bone and cartilage tumors are also causes of large chest wall defects. The specific adjuvant treatments for each type of tumor are taken into consideration, including the potential need for chemotherapy and radiation.

FIGURE 92.1. Chest wall anatomy. A. Sternum and rib cage. B. Anterior view. C. Posterior view.

Infection. Infections involving the chest wall and thoracic cavities are common indications for reconstruction. Origins of intrathoracic infections include empyema, bronchopleural fistula, pneumonia, and surgical site infections following thoracic surgery. Mediastinal sepsis and sternal osteomyelitis may occur following heart surgery and require prompt and complete debridement and coverage.

Radiation. Radiation treatment of tumors in the chest wall, most commonly breast cancers, results in difficult to manage wounds that require resection and coverage with vascularized tissue. Osteoradionecrosis of ribs and the sternum may occur years following treatment of carcinomas and lymphomas, and results in recurrent infection and drainage.

Congenital. Congenital chest wall defects requiring reconstruction are most commonly pectus excavatum, pectus carinatum, and Poland’s syndrome (Chapter 64). Other conditions include lymphatic and vascular malformations.

Trauma of the Chest Wall

Rib fractures indicate significant chest trauma and may be associated with intrathoracic and intra-abdominal injury. Fractures of three adjacent ribs in two or more places may result in a flail chest and paradoxical motion, and may lead to respiratory compromise. Blast and electrical injuries may induce zones of injury not immediately apparent in the acute setting and require close cardiac and respiratory monitoring.

Treatment. After stabilization of life-threatening injuries, patients with flail chest may require operative stabilization of rib fractures. While the mainstay treatment of rib fractures is nonoperative, rib plating systems are currently available for the stabilization of rib fractures in a flail chest segment. Rigid fixation systems contain a standard plate and screws, as well as intramedullary rods.

In traumatic wounds, coverage after debridement of nonviable tissues is approached similarly to infections and tumor defects (see below).

Tumors of the Chest Wall

Primary malignancies of the chest wall may be classified into eight main categories: muscular, vascular, fibrous and fibrohistiocytic, peripheral nerve, osseous and cartilaginous, adipose, hematologic, and cutaneous. The diversity of malignancies and attendant surgical extirpation may result in significant defects. Reconstruction must also take into account postoperative oncologic therapy such as radiation.

Treatment. After extirpation of the tumor, the dimensions and components of the chest wall requiring reconstruction are evaluated. Restoration of pleural cavity integrity as well as protection of intrathoracic structures may be required. Classic teaching recommends skeletal reconstruction for defects involving four or more ribs or greater than 5 cm in diameter; however, this varies depending on the location of the defect.

An option for skeletal reconstruction includes the so-called methylmethacrylate and synthetic mesh “sandwich.” The methylmethacrylate is molded into the desired shape of the defect, and Marlex or Prolene mesh is placed on each side of the construct and sutured together. The methylmethacrylate and mesh sandwich can be sutured to the surrounding structures. Some patients experience pain with respiration since the methylmethacrylate is much more rigid than the chest wall. This method of skeletal reconstruction provides protection to the underlying cardiac and pulmonary structures and can be used for even large defects in tandem with soft tissue flaps (Figure 92.2).

Posterior and superior chest wall defects may not affect ventilation as much as anterior defects. In these cases, skeletal reconstruction may not be necessary; therefore, a variety of other products, both synthetic and biologic, may be appropriate. Synthetic products such as Gore-Tex, Marlex, and Prolene mesh may be used for smaller lateral defects. Synthetic mesh can be problematic in the lower chest wall since the mesh may come into contact with the intra-abdominal contents and lead to bowel adhesions or even fistulae (Chapter 93). Biological products, such as human allograft dermis and xenograft dermis, offer other options for reconstruction where rigid stability is not mandatory. They are not likely to cause adhesions with the viscera and may tolerate bacterial contamination better than a synthetic product since they may become revascularized by the surrounding host tissue. Although the discussion of biologic materials is beyond the scope of this chapter, surgeons have continued to expand applications in complex defects and wounds. Both biologic and synthetic mesh do not provide the same level of rigidity as methylmethacrylate or titanium mesh, but they do provide additional stability to the chest by spanning the defect.

Infections of the Chest Wall and Thorax

Empyema and Bronchopleural Fistula. A bronchopleural fistula and pleural empyema (pus in the pleural cavity) are complications of pneumonectomy that carry significant morbidity and mortality. As a first step, drainage of the infectious empyema is performed, and depending on its severity, may necessitate a delay in the reconstruction. Often the thoracic surgeon manages the empyema and requests help from a plastic surgeon for the transfer of flaps to reinforce the bronchial stump closure or to obliterate the pleural cavity.

FIGURE 92.2. Dermatofibrosarcoma protuberans. A. Patient with large dermatofibrosarcoma protuberans of chest wall. B. Post resection with exposed pericardium and chest wall defect. C. Marlex mesh sandwich tailored for support of reconstruction. D. Application of methylmethacrylate to mesh. E. Soft tissue coverage with pedicled latissimus dorsi/serratus chimaera, omentum/skin graft, and free tensor fascia lata flaps. (© Gordon Lee, M.D.).

Treatment

Eloesser Flap. To adequately drain the empyema cavity, a variety of procedures have been described. The Eloesser flap, originally described in 1935 for the drainage of tuberculous empyemas, externalizes the empyema. A 2-inch random-patterned fasciocutanous flap is created on the chest wall at the level of the empyema, a segment of rib is resected, and the flap is sewn to the pleural lining (Figure 92.3A). This allows for continual drainage of the empyema.

Clagett Procedure. The Clagett procedure involves creation of a window thoracotomy and the packing of the wound with antibiotic-soaked dressings that are changed every 48 hours. Once the pleural space contains healthy granulation tissue, the cavity is completely filled with antibiotic solution and the chest wall is closed in layers.

Thoracoplasty. Obliteration of the pleural space is necessary if the remaining lung does not fill the hemithorax. A post-pneumonectomy syndrome of tracheal deviation, inspiratory stridor, and exertional dyspnea may develop. Historically, a thoracoplasty was performed, where the skeletal support was removed, leading to the external collapse of the hemithorax (Figure 92.3B). While this procedure addressed the dead space from the pneumonectomy, it was quite morbid and disfiguring.

Flap Transposition. Regional flap transposition is the preferred method to fill intrathroacic dead space and to patch a bronchial stump. To seal off bronchopleural fistula, extrathoracic flaps are transposed through a second thoracotomy and sewn to the bronchial stump. Often a 7 to 10 cm segment of rib will require resection to allow passage of the flap into the pleural space. The following flaps are commonly used: latissimus dorsi, serratus anterior, intercostal muscle, pectoralis major, and rectus abdominis, and omentum. For larger intrathoracic defects, a musculocutanous flap such as the transverse rectus abdominis myocutaneous (TRAM) and vertical rectus abdominis myocutaneous (VRAM) can be used. If regional flaps are not available, free tissue transfer can be performed to bring in healthy tissue.

Adult Sternal Wounds. Historically, sternal wound infections were associated with a 70% mortality rate. In the 1960s, debridement and closure over an antibiotic irrigation system improved mortality rate to 20%. Then in the 1970s, the concept of utilizing flaps to cover the defects following the debridement of nonviable bone and cartilage brought the mortality rate into single digits. The incidence of sternal wound infections is on the order of 0.4% to 5% of all sternotomies performed. There is an increased risk of sternotomy infections associated with internal mammary artery (IMA) harvest, diabetes mellitus, and multiple reoperations. The risk of mediastinitis is particularly high when both internal mammary arteries are harvested for coronary artery bypass grafting. This occurs because the sternum does not contain separate nutrient vessels and relies solely on the segmental sternal branches of the IMA to supply the periosteal plexus for its nutrients. When both IMAs are used, the sternal vascularity is decreased significantly and is vulnerable to nonunion and infection.

Classification. Sternal wound infections are classified into three categories: Class 1 infections occur 1 to 3 days postoperatively, are manifested by serous drainage, and cultures are sterile. Class 2 infections occur 1 to 3 weeks postoperatively, are manifested by purulent mediastinitis, and cultures are positive for bacterial pathogens. Class 3 infections occur months to years after the initial surgery, are manifested by a chronic draining sinus tract, and cultures are positive for pathogens.

Treatment. Initial treatment consists of debridement. Class 1 infections are treated with minimal debridement, irrigation, and re-wiring of the sternum. Class 2 and 3 infections require a thorough debridement, antibiotics, and flap coverage.

FIGURE 92.3. Eloesser flap and thoracoplasty. A. Schematic of Eloesser flap. B. Radiograph post-thoracoplasty.

While it may be common to perform multiple debridements of the wound prior to flap coverage, it has been shown that a single-stage radical debridement and concomitant flap coverage has a similar success rate. Multiple surgical debridement is to allow the wound to demarcate and may help the surgeon adequately debride the nonviable tissue, which may not have been evident at the initial surgery. The condition of the patient and the specific nature of the wound dictates the appropriate debridement.

Negative pressure wound therapy has provided another treatment modality for sternal wounds. The greatest benefit occurs after the initial debridement. Since the negative pressure wound dressing is only changed every 2 to 3 days, it drastically reduces the frequency, pain, and inconvenience of dressing changes. In addition, the wound contracts, thereby reducing the tissue required for coverage. In some cases, negative pressure wound therapy may result in complete closure and obviate the needs for any flaps.

Median sternotomy wound closure is usually successful with soft tissue flaps only and skeletal stabilization is not required. On occasion, these patients complain of pain because of motion of the sternum or rib segments, which has led to the development of sternal plating systems. The need for rigid fixation, however, remains controversial.

Within the past decade, the concept of rigid skeletal fixation of the sternum following median sternotomies and of the ribs following traumatic injuries has been revisited. The traditional sternal closure consists of wire cerclage to reapproximate the sternal margins. Titanium sternal plating systems may be best reserved for high-risk patients with multiple comorbidities, and in re-operative patients with sternal instability, fracture, and poor bone quality. By adhering to the osteosynthesis principles for rigid skeletal fixation, reduction of micromotion across the bone fragments enables bone healing and decreases infection. Early results demonstrate that the titanium sternal plating systems in these high-risk populations may decrease or even prevent the incidence of mediastinitis. Complications from titanium sternal plating system include plate fracture, infection, and seromas.

Pectoralis Major Flap. The pectoralis major muscle inserts onto the proximal humerus and is attached broadly to the anterior chest wall from the clavicle and ribs one through six. It receives blood supply from the thoracoacromial vessels, branches of the lateral thoracic artery, and from perforators of the internal mammary and intercostal arteries. Motor innervation is from the medial and lateral pectoral nerves.

The pectoralis major flap is the workhorse flap for sternal reconstruction due to its close proximity. This flap is commonly based on the thoracoacromial artery and rotated toward the sternotomy defect (Figure 92.4). The insertion on the humerus can be divided to allow better mobilization. The limitation of this flap is the inability to cover the lower third of the sternum. If the IMA on that side was not harvested, the pectoralis major muscle flap can be based on the IMA perforators and used as a turnover flap, which allows coverage of the lower sternum. As a turnover flap, the pectoralis major muscle can be split to provide coverage to the superior and inferior sternum. For sternal dehiscence without a deep cavity, the two pectoralis major muscles can simply be advanced to each other.

Rectus Abdominis Flap. The rectus abdominis muscle flap is a potential option for sternal wound coverage. For the purpose of chest wall reconstruction, the flap is based on the superior epigastric artery, a continuation of the IMA, and can provide coverage over the lower sternum (Figure 92.5). A skin paddle can be harvested with the muscle in the form of a VRAM flap or a TRAM flap if additional volume or skin coverage is needed. In cases where the IMA has been harvested, the flap can still be transferred on the eighth intercostal vessels from the musculophrenic artery. In this scenario, the skin paddle and the distal muscle may be unreliable.

Omentum Flap. The omentum is a large and versatile flap for sternal wound reconstruction. An upper laparotomy incision is needed for access into the peritoneal cavity. After dividing the short gastric arteries, this flap can be based on the left or right gastroepiploic artery; however, the left gastroepiploic artery offers the greatest flap length (Figure 92.6). This flap has the benefit of having a large surface area and being relatively thin, which allows it to be easily contoured. It can easily cover the entire length of the sternal wound, wrap around vascular grafts in the chest, fill any small cavity around the wound, and even can be skin grafted. Previous abdominal surgery limits the use of the flap due to adhesions. The drawbacks of the omentum flap include a possible epigastric hernia, bowel obstruction, bowel adhesions, and the insult of a laparotomy on a sick patient.

Latissimus Dorsi Flap. The latissimus dorsi muscle is a broad, fan-shaped muscle that has attachments to the back along the fascia of the paraspinous muscles, and the lumbar fascia. It has insertions onto the proximal humerus and is involved in adduction and internal rotation of the arm. Its blood supply is from the thoracodorsal artery, which originates from the subscapular system, as well as thoracolumbar perforators. Motor innervation is from the thoracodorsal nerve, which runs along with the blood supply.

The latissimus dorsi muscle flap is not the first choice of flaps for sternal wound reconstruction, but it may be used in occasional circumstances. The flap is based on the thoracodorsal artery from the subscapular system (Figure 92.7). The flap is harvested in the lateral or prone position, necessitating position changes during surgery. While the distal portion of the flap may reach the sternum, the blood supply may be tenuous. The latissimus dorsi muscle flap is best reserved for coverage of lateral or anterolateral chest wall defects.

Pediatric Sternal Wounds. Pediatric sternal wounds present some subtle differences. While the debridement of the wound should be thorough, excessive debridement of the sternum and the costal cartilages should be avoided. Since ossification of the skeletal structures is not complete in a young pediatric patient, over-resection of these structures may occur. Second, the pectoralis major muscle is smaller relative to the size of the patient and will definitely not reach the lower half of the sternum. Furthermore, elevation of a pectoralis flap in a female patient may damage the developing breast and inhibit breast development in the future. Finally, the pediatric omentum is thin and may not provide adequate bulk for sternal coverage. The rectus abdominis muscle is a better option, especially in infants since this muscle is relatively wide, thin, and long.

Left Ventricular Assist Device Pocket Infections. When first developed, left ventricular assist devices (LVADs) were large devices with proportionately large power units for patients with heart failure awaiting a heart transplantation. As the devices have become more compact and longer lasting battery packs have been developed, their use for destination therapy has become more common. Patients who were previously confined to a hospital setting awaiting a heart transplant are now able to return to their previous lives with the newer LVADs. As with any prosthetic implant, infections can occur.

Treatment. Infections usually occur around the driveline or the LVAD pocket. The infection is ideally treated with removal of the LVAD; however, unless the patient’s heart failure has improved or a donor heart is available, device removal is not an option. The LVAD and its pocket, however, do require debridement. Once the LVAD pocket is clean and there are signs of granulation, regional flaps are used to cover the device. The omentum or rectus abdominis muscles are the most readily available flaps due to their close proximity to the defect and their ability to cover a large surface area. It should be noted that the driveline for the LVAD is usually placed though one of the rectus abdominis muscles, which can potentially damage the vascular pedicle and preclude transfer of that muscle.

FIGURE 92.4. Pectoralis major flap. A. Sternal wound after debridement; B. closure with bilateral advancement pectoralis major flaps; C. thoracoacromial pedicle; D. turnover flap with intercostal perforators. (AB: © Gordon Lee, MD).

Congenital Chest Wall Defects

Pectus Carinatum and Pectus Excavatum. Pectus carinatum is a protrusion of the sternum secondary to a deformity of the costal cartilages. Overall prevalence is 0.6% with a male preponderance and genetic association both in isolation and as a component of a syndrome. Pectus excavatum, a concavity of the sternum and adjacent costal cartilages, has an overall incidence of 1:400 to 1:1,500 births with a 3:1 male preponderance; it is also associated with Marfan’s and Ehler-Danlos syndromes. In severe cases, these chest wall deformities can cause physiological disturbances, including measured decreases in forced expiratory volume, cardiac stroke volume, and output. Surgical correction can improve exercise tolerance.

Treatment. Indications for surgical correction of pectus deformities include cardiopulmonary impairment and progression of the deformity with age. Correction of pectus carinatum involves bilateral resection of deformed costal cartilages, osteotomy, and repositioning of the sternum with reapproximation of the distal sternum to the xyphoid. The pectoralis major muscles are reapproximated over the sternoplasty. A variation of this procedure, including pectoralis muscle splitting without detachment, cartilage resection with bioabsorbable plating, and postoperative external compression splinting, has been described.

Mild pectus excavatum deformities can be disfigured with custom sternal implants or to some extent with breast implants in female patients. Two options for surgical correction of pectus excavatum have been described: the “open” Ravitch procedure and the “closed” Nuss procedure. In the former, deformed cartilages are removed, the xyphosternal articulation is divided, and a transverse osteotomy of the sternum is performed at the superior limit of the deformity. The corrected position is maintained using autologous or synthetic mesh support (Figure 92.8A). In the closed Nuss procedure, a convex metal bar is introduced under thoracoscopic guidance across the chest in a substernal tunnel and rotated to force the sternum anteriorly (Figure 92.8B); the bar is left in place for up to 5 years.

FIGURE 92.5. Rectus abdominis flap pedicled on superior epigastric and eighth intercostal arteries. A. Sternal wound after debridement; B. rectus abdominis muscle flap; C. closure of sternal wound and flap donor site. (AC: © Gordon Lee, MD). D. Schematic illustration of rectus abdominis flap pedicled on the superior epigastric and eighth intercostal arteries.

Recontouring of the chest wall after these corrective procedures may be required. Autologous cartilage grafting has been described for the correction of minor chest wall deformities or for “fine tuning” of the result. Breast augmentation for female patients is an alternative.

Poland Syndrome. Poland syndrome is a rare condition occurring in 1:16,500 births as a constellation of symptoms, including hypoplasia of the pectoralis major, hypoplasia of the bone and cartilage of the ipsilateral upper extremity and trunk, as well as hypoplasia/agenesis of the latissimus dorsi. In addition, hypoplasia or absence of the breast and nipple may be present (Chapter 64).

Treatment. Reconstruction of the male chest has been described using customized silicone implants. Reconstruction of the female breast is dependent upon the degree of breast hypoplasia. An algorithm developed by Freitas et al., in 2007, describes the use of silicone prosthetic versus tissue expander/silicone prosthetic reconstruction for mild and severe presentations of breast hypoplasia, respectively, and describes the use of implant/latissimus dorsi myocutaneous flap reconstruction for more severe cases involving hypoplastic pectoralis muscles (Figure 92.9). The latissimus dorsi muscle flap helps recreate the anterior axillary fold, which is deficient in these patients and is difficult to reconstruct otherwise. In the event of hypoplasia or absence of the latissimus dorsi muscle, free tissue transfer techniques may be employed, including perforator flaps. More recently, fat transfer techniques have been applied to the correction of the female breast deformity in Poland syndrome.

Alternative Flaps for Chest Reconstruction

Pedicled Perforator Flaps. Perforator-based fasciocutaneous flaps have recently been applied to chest wall reconstruction. The use of the deep inferior epigastric artery perforator flap in breast reconstruction decreases donor-site morbidity, and this concept has been applied to the IMA, thoracoacromial artery, the thoracodorsal artery, and most other axial vessels in the body. The IMA perforator flap is a transversely oriented fasciocutaneous skin paddle up to 7 × 26 cm based on an eccentric perforating vessel of the internal mammary system. Flaps have been effectively designed on perforators from the second to the eighth intercostal space. The flaps are then rotated up to 180°. Intercostal artery perforator flaps are useful in a variety of settings to cover sternal wounds and partial breast defects.

Free Tissue Transfer. The abundance of local and regional flap options usually makes free flaps for chest wall reconstruction unnecessary. However, situations do exist where local and regional flaps are not available or reliable. Free flaps may be indicated in the manubrial region, or other central sternal defects, or when the pectoralis muscles are unavailable due to resection or debridement. A free flap may also be the best option in a radiated chest wall where a latissimus flap has already been used. Various free flaps for chest wall reconstruction have been described, including the anterolateral thigh, vastus lateralis, tensor fascia lata, latissimus, and free abdominal flaps. The choices of commonly used recipient vessels include the internal mammary, thoracodorsal, or transverse cervical arteries. In the case of the vessel-depleted patient, arteriovenous loops can be created using the cephalic and thoracoacromial vessels.

FIGURE 92.6. Omentum flap pedicled on right or left gastroepiploic arteries. A. Sternal wound after debridement; B. omentum flap raised prior to inset; C. coverage with omentum flap and split thickness skin graft. (AC: © Gordon Lee, MD). D. Schematic illustration of omentum flap pedicled on the right gastroepiploic artery.

FIGURE 92.7. Latissimus dorsi flap. A. Planned latissimus dorsi (LD) flap; B. skin island raised with LD flap; C. infra-axillary subcutaneous tunnel for passage of flap to anterior chest wall. (AC: © Gordon Lee, MD). D. Schematic illustration of latissimus dorsi flap pedicled on the thoracodorsal artery.

SUMMARY

When managing patients with chest wall defects, the plastic surgeon takes into account the nature of the defect, the indication for surgery (form and/or function), and the condition of the patient. If multiple ribs and/or sternum are missing, skeletal reconstruction is considered with methylmethacrylate, titanium mesh, plate and screw fixation, or mesh only (synthetic or biologic). Options for soft tissue coverage include the pectoralis major, rectus abdominis, latissimus dorsi muscles, omentum, or free tissue transfer. A multidisciplinary approach between the thoracic surgeon and plastic surgeon yields the best results.

FIGURE 92.8. Nuss and Ravitch procedures for correction of pectus excavatum deformity. A. Illustration of the Ravitch procedure with excision of costal cartilages and elevation of the sternum. B. Illustration of the Nuss procedure with placement of retrosternal bar.

FIGURE 92.9. Poland syndrome and deformity correction. A. Illustration of a patient with Poland syndrome. Note the severe hypoplasia of right breast, nipple–areola complex, and pectoralis major. B. Correction of deformity with combination of right tissue expansion with second-stage exchange for silicone prosthesis under latissimus dorsi flap reconstruction. Reprinted with permission from Freitas Rda S, o Tolazzi AR, Martins VD, Knop BA, Graf RM, Cruz GA. Poland’s syndrome: different clinical presentations and surgical reconstructions in 18 cases. Aesthetic Plast Surg. 2007 March–April;31(2):140–146.

Suggested Readings

Arnold PG, Pairolero PC. Chest-wall reconstruction: an account of 500 consecutive patients. Plast Reconstr Surg. 1996 October;98(5):804-810.

Banic A, Ris HB, Erni D, Striffeler H. Free latissimus dorsi flap for chest wall repair after complete resection of infected sternum. Ann Thorac Surg. 1995 October;60(4):1028-1032.

Brown RE, McCall TE, Neumeister MW. Use of free-tissue transfer in the treatment of median sternotomy wound infections: retrospective review. J Reconstr Microsurg. 1999 April;15(3):171-175.

Coleman JJ 3rd, Bostwick J. Rectus abdominis muscle-musculocutaneous flap in chest-wall reconstruction. Surg Clin North Am. 1989 October;69(5):1007-1027.

Del Frari B, Schwabegger AH. Ten-year experience with the muscle split technique, bioabsorbable plates, and postoperative bracing for correction of pectus carinatum: the Innsbruck protocol. J Thorac Cardiovasc Surg. 2011 June;141(6):1403-1409.

Delay E, Sinna R, Chekaroua K, Delaporte T, Garson S, Toussoun G. Lipomodeling of Poland’s syndrome: a new treatment of the thoracic deformity. Aesthetic Plast Surg. 2010 April;34(2):218-225. Epub 2009 Nov 10.

Engel H, Pelzer M, Sauerbier M, Germann G, Heitmann C. An innovative treatment concept for free flap reconstruction of complex central chest wall defects – the cephalic-thoraco-acromial (CTA) loop. Microsurgery. 2007;27(5):481-486.

Freitas Rda S, o Tolazzi AR, Martins VD, Knop BA, Graf RM, Cruz GA. Poland’s syndrome: different clinical presentations and surgical reconstructions in 18 cases. Aesthetic Plast Surg. 2007 March–April;31(2):140-146.

Gonfiotti A, Santini PF, Campanacci D, et al. Malignant primary chest-wall tumours: techniques of reconstruction and survival. Eur J Cardiothorac Surg. 2010 July;38(1):39-45.

Hallock GG. The island thoracoacromial artery muscle perforator flap. Ann Plast Surg. 2011 February;66(2):168-171.

Hamdi M, Van Landuyt K, Ulens S, Van Hedent E, Roche N, Monstrey S. Clinical applications of the superior epigastric artery perforator (SEAP) flap: anatomical studies and preoperative perforator mapping with multidetector CT. J Plast Reconstr Aesthet Surg. 2009 September;62(9):1127-1134.

Kelly RE, Goretsky MJ, Obermeyer R, et al. Twenty-one years experience with minimally invasive repair of pectus excavatum by the Nuss procedure in 1215 patients. Ann Surg. 2010 December;252(6):1072-1081.

Lecours C, Saint-Cyr M, Wong C, Bernier C, Mailhot E, Tardif M, Chollet A. Freestyle pedicle perforator flaps: clinical results and vascular anatomy. Plast Reconstr Surg. 2010 November;126(5):1589-1603.

Lee CH, Hsien JH, Tang YB, Chen HC. Reconstruction for sternal osteomyelitis at the lower third of sternum. J Plast Reconstr Aesthet Surg. 2010 April;63(4):633-641.

Lee CJ, Kim CW, Kwak IH, Gil MS, Bang YH, Lee SI. The use of omentum as a free flap to reconstruct the upper portion of the mediastinum without a substernal tract. Ann Plast Surg. 2001 July;47(1):93-95.

Maia M, Oni G, Wong C, Saint-Cyr M. Anterior chest wall reconstruction with a low skin paddle pedicled latissimus dorsi flap: a novel flap design. Plast Reconstr Surg. 2011 March;127(3):1206-1211.

Maxwell GP. Iginio Tansini and the origin of the latissimus dorsi musculocutaneous flap. Plast Reconstr Surg. 1980 May;65(5):686-692.

Pereira LH, Sabatovich O, Santana KP, Picanço R, Sterodimas A. Surgical correction of Poland’s syndrome in males-a purposely designed implant. J Plast Reconstr Aesthet Surg. 61(4):393-399. Epub 2007 January 31.

Reichenberger MA, Harenberg PS, Pelzer M, et al. Arteriovenous loops in microsurgical free tissue transfer in reconstruction of central sternal defects. J Thorac Cardiovasc Surg. 2010 December;140(6):1283-1287.

Rocco G, Fazioli F, La Manna C, et al. Omental flap and titanium plates provide structural stability and protection of the mediastinum after extensive sternocostal resection. Ann Thorac Surg. 2010 July;90(1):e14-e16.

Villa MT, Chang DW. Muscle and omental flaps for chest wall reconstruction [Review]. Thorac Surg Clin. 2010 November;20(4):543-550.

Wong C, Maia M, Saint-Cyr M. Lateral intercostal artery perforator flap in combination with thoracoabdominal advancement flap for correction of contour deformities following autologous breast reconstruction. Plast Reconstr Surg. 2011 June;127(6):156e-158e.

Yang H, Lee H. Successful use of squeezed-fat grafts to correct a breast affected by Poland syndrome. Aesthetic Plast Surg. 2011 June;35(3):418-425. Epub 2010 October 17.