neligan vol 4 chapter 10 main

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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



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




Fig. 10.4 Pectoralis anatomy and flap reach, standard and as turnover.

A B

C D

E




Fig. 10.5 Latissimus dorsi, anatomy and standard arc of rotation.

A

B

C

D

Thoracodorsalartery




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




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




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



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).




Fig. 10.13 Chondrosarcoma, resected and reconstructed with VRAM flap.

A B

C D

E



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




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:



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.




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



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




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



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.



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



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.



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.



neligan vol 4 chapter 10 main

Documents

chest wall reconstruction

posterior chest wall

lateral chest

chest wall compliance

serratus muscles

ptfe goretex

serratus anterior

latissimus dorsi