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Reconstructive Surgery of the

Chest, Abdomen, and Pelvis

edited by

Gregory R. D. Evans
University of California at Irvine
Irvine, California, U5.A.

MARCEL

MARCEL DEKKER, INC.

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Preface

The art of plastic surgery is the restoration of form and function. We have become
proficient in the transfer of flaps for these functional restorations, but recent techniques have focused on these restorations with a more aesthetic approach and improvement in the quality oflife. It is with these newfound directions that reconstructive
surgery can expand beyond "just coverage of the wounds" and focus more on the
aesthetic restoration of soft and bony defects. In our search for these more focused
operations, reconstruction of the chest, abdomen, and pelvis are critical for maintaining ambulation, pulmonary function, and a sense of appearance. This book attempts
to expand upon these time-honored and new aesthetic techniques to the trunk. The
most common operative procedures likely to be encountered by the plastic surgeon
have been identified within this book. In each chapter, the authors attempt to
synthesize the myriad of historical data and techniques along with their own personal
experience to obtain those results to improve the quality of life and restore an aesthetic
appearance to the surgical area.
The approach to each chapter follows our approach to individual patients. This
includes an assessment of the defect, indica tions for the operation, pathophysiology of
the changes, operative techniques, and postoperative care. It is our hope that this approach will mimic the approach we take daily in the preparation of our patients.
Finally I would like to thank my associates, Mark Kobayashi, Michael Sundine,
and Jay Calvert, who have been an inspiration in my surgical skills. I would also like to
thank the endless number of students and residents who continue to push our knowledge and continue to drive us to perfection. I would be remiss if I did not especially
thank my loving family, who have provided me with endless support and understanding in my professional life and my commitment to patients and resident education.
I trust that you will find this work exciting and will spur each of you to strive for
those more aesthetic and quality-of-life issues we face daily.
Gregory R. D. Evans

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iii

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Contents

Preface
Contributors

iii
IX

CHEST
1.

Anatomy of the Chest Wall


William P. Adams, Jr. and Jeffrey E. Janis

2.

Preoperative Evaluation of Patients Undergoing Chest Wall


Reconstruction
Melissa A. Ka::.anolvski and GeofFey C Gurtner

17

Introduction to Surgical Infections of the Chest: Empyema


and Mediastinitis
Blanding U Jones, Jeffrey Jim. and Jeffrey C Milliken

29

3.

4.

Treatment of Sternal Clefts


Michael 1. Sundine

43

5.

Poland's Syndrome
Yvonne L. Karanas and James Chang

63

6.

Pleural Defects
Jay W. Calvert

73

7.

Alloplastic Reconstruction of Chest Wall Deformities


David 1. Rowe awl Arun K Gosain

87

8.

Reconstruction of Pectus Excavatum and Pectus Carinatum


Theodore S. Wright, Seem a Kumbhat, and Michael L. Bent:!

99

9.

Chest Wall Tumors


Mary Maish and Garrett Walsh

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113

Contents

vi

10.

Effects of Radiation and Chemotherapy on the Reconstruction


of the Chest, Abdomen, and Pelvis
Michael E. Budd and Gregory R. D. Evans

139

II.

Local Flaps and Skin Grafts for Chest Reconstruction


David W. Chang

153

12.

Rectus Abdominis for Chest Reconstruction


Andrew 1. L. Gear, Mark R. Migliori, and Warren Schubert

165

13.

Latissimus Dorsi and Serratus Anterior for Chest WalJ Reconstruction


Michael P. McConnell and Gregory R. D. Evans

183

14.

Pectoralis Muscle for Chest Reconstruction


Claire L. F. Temple and Charles E. Butler

195

15.

Chest Wall Reconstruction with Omentum


Juan Carlos Jimenez and Gregory R. D. Evans

215

l6.

Chest Wall Reconstruction with Scapula and Parascapula Flaps


Paul M. Gardner

223

17.

Trapezius Flap for Chest Reconstruction


Maurice Nahabedian

233

18.

Extended Flaps for Chest Wall Reconstruction


Peirong Yu and Geoffrey L. Robb

251

19.

External Oblique Myocutaneous Flap


William A. Zamboni, Lee M. Reese, and Allison K. Reese

263

20.

Free Flaps for Chest Wall Reconstruction


Vivian Ting and Julian 1. Priba::.

269

21.

Outcomes in Chest Wall Reconstruction


Elisabeth K. Beahm. Roman 1. Skoracki, and David H. Song

303

ABDOMEN AND PELVIS


22.

Anatomy and Physiology of the Abdominal Wall and Pelvis


Kenton D. Fong, HanJoon M. Song, Tony D. Fang.
Stephen M. Warren, and H. Peter Loren:

325

23.

Tumors of the Pelvis


Alan W. Yasko

339

24.

Direct Closure, Tissue Expansion, and Grafting of the Abdominal Wall


Dimitris P. Mastorakos and Joseph J. Disa

361

25.

Vast us Lateralis Muscle Flap


Jason Ganz and Christopher E. Allinger

377

26.

Reconstruction of the Abdomen and Pelvis with the Tensor Fascia Lata
Gregory R. D. Evans and Mark Kobayashi

391

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Contents

vii

27.

Gluteus Maximus
Jason Rosenberg and Bruce A. Mast

397

28.

Rectus Femoris Flap


Peter C. Ne/igan

407

29.

Rectus Abdominus Muscle in Reconstruction of Abdominal


and Pelvic Defects
Mohamed S. A. Elfar and Gregory R. D. Evans

415

Filet Flap Reconstruction of Abdominal and Pelvic Defect


from External Hemipelvectomy
Nho V. Tran

429

30.

31.

Free Flaps for Abdominal and Perineal Reconstruction


Joseph M. Ser/etti

435

32.

Outcomes of Perineal Reconstruction


Scott D. Oates

449

457

Index

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Contributors

William P. Adams, Jr.

University of Texas Southwestern Medical Center, Dallas,

Texas, U.S.A.
Christopher E. Attinger

The Limb Center, Georgetown University Hospital, Wash-

ington, DC, U.S.A.


Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center, Houston, Texas, U.S.A.

Elisabeth Beahm

Michael L. Bentz

Department of Surgery, University of Wisconsin Medical School,


Madison, Wisconsin, U.S.A.

Division of Plastic Surgery, University of California at Irvine,


Irvine, California, U.S.A
Michael E. Budd

Department of Plastic Surgery, University of Texas M. D.


Anderson Cancer Center, Houston, Texas, U.S.A

Charles E. Butler

Division of Plastic Surgery, University of California at Irvine, Irvine,


California, U.S.A.

Jay W. Calvert

David W. Chang Department of Plastic Surgery, University of Texas M. D.


Anderson Cancer Center, Houston, Texas, U.S.A.
James Chang Division of Plastic Surgery, Stanford University Medical Center,
Stanford, California, U.S.A.
Joseph J. Disa

Memorial Sloan-Kettering Cancer Center, New York, New York,

U.S.A.

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ix

Contributors

Mohamed S. A. Elfar Division of Plastic Surgery, University of California at Irvine,


Irvine. California. U.S.A.
Gregory R. D. Evans Division of Plastic Surgery, University of California at Irvine,
Irvine, California, U.S.A.
Tony D. Fang Division of Plastic Surgery, Stanford University School of Medicine,
Stanford, California, U.S.A.
Kenton D. Fong Division of Plastic Surgery, Stanford University School of Medicine,
Stanford, California, U.S.A.
Paul M. Gardner
USA.
Jason Ganz
U.S.A.

University of Alabama at Birmingham, Birmingham, Alabama,

The Limb Center, Georgetown University Hospital, Washington, D.C.,

Andrew J ..L. Gear Department of Plastic Surgery, University of Minnesota and


Regions Hospital. St. Paul, Minnesota, U.S.A.
Amn K. Gosain Department of Plastic Surgery. Medical College of Wisconsin,
Milwaukee. Wisconsin, U.S.A.
Goeffrey C. Gurtner Institute of Reconstructive Plastic Surgery, New York University School of Medicine, New York, New York, U.S.A.
Jeffrey E. Janis
U.S.A.

University of Texas South'vvestern Medical Center, Dallas, Texas.

Jeffrey Jim Division of Cardiothoracic Surgery, University of California at Irvine,


Irvine, California, U.S.A.
Juan Carlos Jimenez Division of Plastic Surgery, University of California at Irvine,
Irvine, California, U.S.A.
BlandingU. Jones Department of Surgery, University of California at Irvine, Irvine,
California, USA.
Yvonne L. Karanas Division of Plastic & Reconstructive Surgery, Stanford University Medical Center, Stanford, California, U.S.A.
Melissa A. Kazanowski Institute of Reconstructive Plastic Surgery, New York
University School of Medicine, New York, New York, U.S.A.
Mark Kobayashi Division of Plastic Surgery. University of California at Irvine,
Irvine, California. U.S.A.

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Contributors

xi

Seema Kumbhat Department of Surgery, University of Wisconsin Medical School,


Madison, Wisconsin, U.S.A.
H. Peter Lorenz Division of Plastic Surgery, Stanford University School of Medicine, Stanford, California, U.S.A.
Mary Maish Department of Thoracic and Cardiovascular Surgery, University of
Texas M. D. Anderson Cancer Center, Houston, Texas, U.S.A.
Bruce A. Mast Division of Plastic and Reconstructive Surgery, Department of
Surgery, University of Florida College of Medicine, Gainesville, Florida, U.S.A.
Dimitris P. Mastorakos
York, U.S.A.

Memorial Sloan-Kettering Cancer Center, New York, New

Michael P. McConnell Division of Plastic Surgery, University of California at Irvine,


Irvine, California, U.S.A.
Mark R. Migliori Department of Plastic Surgery, University of Minnesota and
Regions Hospital, St. Paul, Minnesota, U.S.A.
Jeffrey C. Milliken Division of Cardiothoracic Surgery, University of California at
Irvine, Irvine, California, U.S.A.
Maurice Nahabedian
U.S.A.
Peter C. Neligan
Canada

Johns Hopkins Medical Institutions, Baltimore, Maryland,

Toronto Hospital, University of Toronto, Toronto, Ontario,

Scott D. Oates Department of Plastic Surgery, University of Texas M. D. Anderson


Cancer Center, Houston, Texas, U.S.A.
Julian J. Pribaz Department of Surgery, Harvard Medical School, Boston, Massachusetts, U.S.A.
Lee M. Reese Surgical Resident, University of Nevada School of Medicine, Las
Vegas, Nevada, U.S.A.
Geoffrey L. Robb Department of Plastic Surgery, University of Texas M. D.
Anderson Cancer Center, Houston, Texas, U.S.A.
Jason Rosenberg Division of Plastic and Reconstructive Surgery, Department of
Surgery, University of Florida College of Medicine, Gainesville, Florida, U.S.A.
David J. Rowe Department of Plastic Surgery, Medical College of Wisconsin,
Milwaukee, Wisconsin, U.S.A.

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Contributors

xii

Department of Plastic Surgery, University of Minnesota and


Regions Hospital, St. Paul, Minnesota, U.S.A.

Warren Schubert

Division of Plastic Surgery, University of Rochester School of


Medicine, Rochester, New York, U.S.A.

Joseph M. Serletti

Department of Plastic Surgery, University of Texas M. D.


Anderson Cancer Center, Houston, Texas, U.S.A.

Roman J. Skoracki

David H. Song Division of Plastic Surgery, University of Chicago Hospitals,


Chicago, Illinois, U.S.A.

Division of Plastic Surgery, Stanford University School of


Medicine, Stanford, California, U.S.A.

HanJoon M. Song

Michael J. Sundine Division of Plastic Surgery, University of California at Irvine,


Irvine, California, USA.
Claire L. F. Temple Department of Plastic Surgery, University of Texas M. D.
Anderson Cancer Center, Houston, Texas, U.S.A.
Vivian Ting Division of Plastic Surgery, University of California, San Francisco,
California, U.S.A.
Nho V. Tran

Department of Plastic Surgery, Mayo Clinic, Rochester, Minnesota,

U.S.A.
Garrett Walsh Department of Thoracic and Cardiovascular Surgery, University of
Texas M. D. Anderson Cancer Center, Houston, Texas, U.S.A.

Division of Plastic Surgery, Stanford University School of


Medicine, Stanford, California, U.S.A.

Stephen M. Warren

Department of Surgery, University of Wisconsin Medical


School, Madison, Wisconsin, U.S.A.

Theodore S. Wright

Alan W. Vasko Department of Plastic Surgery, University of Texas M. D. Anderson


Cancer Center, Houston, Texas, U.S.A.
Peirong Yu Department of Plastic Surgery, University of Texas M. D. Anderson
Cancer Center, Houston, Texas, U.S.A.
William A. Zamboni Department of Surgery, University of Nevada School of
Medicine, Las Vegas, Nevada, USA.

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1
Anatomy of the Chest Wall
WILLIAM P. ADAMS, JR. and JEFFREY E. JANIS
Universily of Texas Saul/HI'estern Medica/ Center, Dallas, Texas, US,A.

I.

INTRODUCTION

Techniques in thoracic reconstruction are often based on assessment of the defect


based on cause, location, and complexity. Once the defect has been assessed,
reconstructive options include local/regional flap transposition, microsurgical free
tissue transfer, and, in rare instances, tissue expansion, Most defects can be addressed
with local flap rotation,without the need for free flap transfer. Precise knowledge of the
anatomy of the chest wall is required when designing a reconstruction.
This chapter reviews the chest wall anatomy relevant for chest wall reconstruction. For purposes of discussion, the chest wall can be organized into three layers (from
deepest to most superficial): the pleural cavity, the thoracic skeleton, and the thoracic
soft tissues.
II.

PLEURAL CAVITY

The pleural cavity is lined by the visceral and parietal pleurae, which are derived from
separate embryological structures. These separate embryological origins result in
anatomical differences between these two membranes, including arterial supplies,
venous and lymphatic drainage patterns, and innervations (I). The pleurae, in general,
are smooth, serous membranes continuous with each other only at the lung hila and
the pulmonary ligaments. The pleural space is the potential cavity between these two
layers and serves to line the chest wall. The pleural space is divided into two separate
compartments by the mediastinum. Normally this space contains only a small amount
of pleural fluid, which serves as a lubricant between the two layers, but in certain
pathological circumstances it can contain much more, This fluid is formed as a plasma

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Adams and Janis

ultrafiltra te, but also contains molecules secreted by mesothelial cells of the pleura tha t
have surfactant-like properties.
The parietal pleura is organized into four areas: cervical, costal, mediastinal, and
diaphragmatic. The cervical pleura, also known as the cupula, encompasses the apex
of the hemithorax and extends above the level of the first rib to join stronger connective
tissue known as the Sibson fascia. The costal pleura lines the inner surface of the
thoracic cage, and is attached to the chest wall by a layer of loose connective tissue
called the endothoracic fascia. The mediastinal pleura envelops the pericardium as
well as other mediastinal structures. The diaphragmatic pleura serves as the floor
of the pleural cavity, and lines the diaphragm. The blood supply to the parietal
pleura is from systemic arteries, including the posterior intercostal, internal mammary, anterior mediastinal, and superior phrenic arteries. Its venous drainage is
through the corresponding systemic veins. The lymphatic drainage of the parietal
pleura is into regional lymph nodes, including intercostal, mediastinal, and phrenic
nodes. The majority of the innervation of the parietal pleura is from the intercostal
nerves; however, the mediastinal and central diaphragmatic parietal pleurae are
innervated by the phrenic nerves.
The visceral pleura envelops both lungs and follows all fissures. The pleural
spaces oppose one another anteriorly at the sternal angle, but diverge to accommodate
the heart (Fig. I). The blood supply to the visceral pleura is derived from both the
systemic and pulmonary circulations, as opposed to solely the systemic (as it is for its
parietal counterpart). Typically, the pulmonary capillaries form a subpleural network
for the visceral pleura. However, the contribution of branches of the bronchial arteries
to the visceral pleural arterial supply is increased by fibrosis and inflammation. The
venous drainage, however, is only through the low-pressure pulmonary veins. The
lymphatic drainage of the visceral pleura is to the mediastinal lymph nodes via a
subpleural plexus. The innervation to the visceral pleura is by vagal branches and the
sympathetic system. It has no somatic innervation and is, therefore, insensate.

COLLAPSED

INFLATED
rr-~r----

Cervical pleura

Pleural cavity ------,#--

Visceral pleura-4J'---iI

Parietal pleura
Root of lung

Figure 1

Diaphragmatic pleura
Mediastinal pleura

Anatomy or the pleural cavity.

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Anatomy of the Chest Wall

III.

THORACIC SKELETON

The osteocartilaginous thorax provides stable skeletal support. Its purpose is to


protect vital organs (such as the heart, lungs, great vessels, and some abdominal
organs), contribute to respiratory function, and support the upper extremities. The
osteocartilaginous thorax consists of 12 paired ribs and their associated cartilages,
the sternum, the clavicles, and the thoracic vertebrae (Fig. 2). The size and shape of
the thoracic ca vity are primarily functions of the dimensions of the ribs and sternum.
The ribs can be subdivided into so-called true ribs and false ribs. True ribs, or
vertebrosternal ribs (#1-7, sometimes #8), articulate directly with the sternum through
costal cartilages, while false ribs, or vertebrochondral ribs (#8- 12), connect with the
costocartilages superior to them rather than directly to the sternum. Ribs #11 and # 12
are termed floating ribs, or vertebral ribs, and do not communicate directly with either
the sternum or to ribs superior to them. Instead, they articulate only with their own
vertebral bodies. Each rib is composed of a head, neck, and shaft. The head is
subdivided into an upper facet and a lower facet. The upper facet articulates with the
vertebral body above it, while the lower facet articulates with the corresponding
vertebral body associated with that rib. The neck of the rib articulates with the tip of a
transverse process via an articular facet on the tubercle. This articulation creates the
costotransverse joint and gives strength to the posterior rib cage.

Scapula
2nd rib

Xiphoid process
of sternum

Figure 2

Anatomy of the thoracic cage.

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Adams and Janis

4
Clavicular notch
Costal notches:

Lunular (suprasternal) notch

I -

""'b"-

1st

2nd

1st costal
cartilage

_Sternal angle
Body (sternebrae):
1st

3rd

2nd
3rd

Xiphisternal junction
Xiphoid process

Figure 3

Anatomy of the sternum.

The sternum is a large, elongated, flat bone that measures 15-20 cm in length. It
is organized into three parts: the manubrium, the body, and the xiphoid (Fig. 3). The
manubrium is wider and thicker than the other two parts of the sternum, and has
articulations with the clavicles as well as the first costal cartilage. The angle of Louis
represents the junction of the manubrium and body of the sternum, which corresponds
to the articulation with the second rib. The body is the longest of the three parts, and is
located anterior to T5-T9. The xiphoid is the smallest and most variable portion. It
usually ossifies and unites with the sternal body around age 40.
Sternal defects are classified according to their location. The physiological
consequences of these defects vary on their location as well as their extent (2) (Table 1).
Although the specific size parameters of sternal rib defects that require
stabilization have not been formalized, based on the available literature a defect
involving fewer than three ribs or smaller than 5 cm in diameter likely does not need
stabilization. It should be noted, however, that anterior defects have a greater
physiological impact, in general, than posterior defects due to the stabilizing effects
of the scapula posteriorly.

Table 1

Physiological Conseq uences of Sternal Defects

Defect

Physiological deficit

Loss of upper sternal body and adjacent ribs


Loss of entire sternal body and adjacent ribs
Loss of manubriulll and upper sternal body with adjacent ribs

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Minimal
Moderate
S vere

Anatomy of the Chest Wall

IV.

THORACIC SOFT TISSUES

A.

Anatomy

The bony thorax is covered by muscle, subcutaneous tissue, and skin. The various
thoracic muscles can be subclassified into three groups: the primary and secondary
muscles of respiration, and those that serve to attach the upper extremity to the body.
The primary muscles of respiration include the diaphragm and intercostal
muscles (external, internal, and innermost). Between the internal and innermost

pinal (radiculc'H, 01' 51"srncnlal medullrll yl


br..\ nl h of po,terior infNcoSI . ~1 MINY

('nlf,]l rOol

Spinal $E""11 my

Oo(',al branch

tdOf!'..)l rOOt! ganglion

or posferior hHercostal anf'ry

Co totf'anSv('f,e Itg"unpnl
Inl(>r(O~l.,1 nerve

('-I('ntral
r.dfllUS o( Ihoracic '\pioal nerve)

lotF.'rnal intercostal me-mbrane

deep 10 eXlemal inlerco\,tal

musde--------.,
Serralu'.mterior

muscle

AJllt~(io( Qranch
oj l.:tlerlll culJneO\l'

brcu,\('ho(
inlet<o,tal n{'rvl?

L,lI(,l'aJ cUI.lneQu'"
hrallCh oj posterior

intercoslal i\rlcrv
Superior
,pigt.l~I(i(,

pf'(lorali< nhljor mv.,dE>

Anterior cutaneous branch 01 inlel'COSlal nerve

Figure 4

nrlc.ry

Reel U"i ahdominis muscle

Cross-sectional anatomy of the thoracic cavity.

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F'INnal int(,(((}5tal

membrafl~

Adams and Janis

intercostals run the neurovascular bundles. The bundles are positioned behind the
costal groove inferior to the rib, with the vein positioned most superiorly, followed by
the artery, and then the nerve, in descending order (VAN) (Figs. 4, 5). All 11
intercostal spaces are wider anteriorly, and each intercostal bundle falls away from
the rib posteriorly to become more central within each space.
The secondary muscles of respiration are the sternocleidomastoid, serratus
posterior (superior and inferior heads), and levator costarum.
The third muscle group attaches the upper extremity to the body, and helps
secure the scapula to the bony thorax. This muscle group can be further subclassified
into superficial and deep muscles. Superficial muscles include pectoralis major and
minor muscles (anterior), and the trapezius and latissimus dorsi (posterior). Deep
muscles include the serratus anterior and posterior, the levators, and the major and
minor rhomboids. In cases of respiratory distress, the pectoralis major and the serratus

Intervertebral disc

Rib
Internal intercostal
muscle
External intercostal
muscle

External intercostal
muscle
External intercostal
membrane

Costal cartilage

~ .Visceral pleura
. ~ Parietal pleura
. Lung
,r-,.

'0..
Vein
Artery
Nerve
External }
Internal
Intercostal muscles
Innermost

Figure 5

Relationship of the neurovascular bundle to the rib.

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Anatomy of the Chest Wall

anterior act as accessory muscles of respiration. They do so when a patient holds onto
a ta ble to fix their pectoral girdles (clavicles and sca pulae), so tha t these muscles can act
on their attachments to the ribs (Fig. 6).
The pectoralis major, latissimus dorsi, serratus anterior, and rectus abdominis
muscles provide adequate soft tissue coverage for most chest waH or intrathoracic
defects, and are the workhorses of chest waH reconstruction (Fig. 7).

B.

Internal Mammary Vessels

The internal mammary vessels are of particular interest to the plastic surgeon because
they serve as important and useful recipient sites for microvascular tissue transfer
(Fig. 8). Several anatomical studies have been performed that examine the characteristics of these vessels. Shaw (3) found that when the vessels were dissected at the level
of the 5th intercostal space, approximately 42% of internal mammary veins were
unsuitable for use. FeHen (4) concluded that the internal mammary vessels (artery and
vein) should not be used as recipient vessels because of the unpredictable anatomy of
the vein. However, Clark et al. (5) performed a cadaver study on the internal mammary vein that specificaHy addressed its size, location, and consistency. They found
Muscles or expiration

Muscil'S of inspiration

..

.--

\,

Accessory
SternocleidomastoId
lete-'aft>s stl'rnuml
Sc.len~

Anterior
Middle
PO$lerior

lel""ate and t.x


uppel ril~)

Principal
Eldefflal intefCoSlals
[elevate ribs. thus
increasing width 01
lhomcic cavIty)

Inll!.rcl)opd,al.pjln
of internal inte(cogla~
(also elevales ribs)

Diaphragm
(dnmes desc.-nd. rhus

tnaeasing v"rft<:al

dimension of tI10radc
cavitY: also !ilevates
lowerribsl

Figure 6

Muscles of respiration.

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A"_ _,,
Quiet b'f'lathing

'\

Adams and Janis

8
Slpftl()thvfOid rnu.. .dc

I:Wbled by
cervj(";11 fa:-cia

Subdaviu:, muscle invested

Pt;>rlQr('lling bfi1l1ch,cS oi j~lltiHldl

by

davll)CCIOfdl ia<;("iJ

lhorneiL df!(-'ry ..Hl{l .111!I~rro( ( (JI,lIH?Oll\

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hrilnch(.~",

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n(:fV(?<>

lhor.Koacronli."I! "rtC"y Ipetl0ral


brdlllhl <ll'lcll.1tercJl peclorJI n('rve

Medi"1
pectorill
rH~rve

long thoraoc

IlC:-Vf?

,lneltHer",1 ihlll',Hir. drlery

Di~il.)tion..; of
... crr(llll~

.H1;~'nor

nll,l"t1e

htr.?-mJI inierco",lai
I1Hi.'mbrdrw's. <lllterior I

mlerndl in/erc-oslal

ttlteral (l!lat)<..:OlI'" b!~lnche~ o(


inler< oSlal nerv(:,:- and

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p()sleriol int~lcosral <.Hteriei"


EXlern~1 (JhliquC'

il1u<'c..lr-

Booy .1l1d '\Iphoid pnH.:es.:-,


oi<.ternl.IIH

Ct..H,lIWt)(/" hr,lnche" 01 Ihor,H.. ()~\bdi)min, .. l


l,lbdomil)<lll1orlions oi In:'?'f('{hl<lIJ nerv':.
..1nd superior t"'pi~il"tnc Mler\

Figure 7

Anatomy of the anterior thoracic cavity, including available options for local
flap reconstruction.

that the internal mammary veins gradually become smaller distally and often
bifurcate, making them unsuitable for use as recipient vessels below the 4th int rcostal
space. They concluded that the most consistent interval to find suitable recipient
vessels was the 3rd intercostal space, where 40% of the veins on the left and 70% of the
veins on the right were ~ 3 mm in diameter. Furthermore, 90% of the veins bifurcated
by the 3rd rib on the left, and 40% bifurcated by the 3rd rib on the right.

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Anatomy of the Chest Wall

9
11l1C'1'1l,)!llIg.ul;H vein

Cl;wicle

Deltoro
muscle

Long lhor(lck nerve


and I"teral thorncic arIel Y

IrHern,d intl:lr~()~l~)l

Digitations 01

mlJ:-,cl~kuil

5,((alus anterior lllusde

Tr,,'tbver:-U"lhur,lli ...

L'llcrai (;Ulcll1eOU~

fntl~dl.

br(loche5 of iOlerCOstal
ner....es J!'1d postE"rior

Antt.'.lior inlen..o-:-til!

intercostal Jneriel-----"

brJndws of i!lINr1:\!
thoracic ,lrt~ry

Extern,:]1 inlerco!>Jal mll!>d~

External inlerc..oSI..ll membr;loe...


anterior to inte-rn<:l! inter(o~tal mw..c1e::

MllS< ltl(ll'hr~ntt. .. nN)-

"md v'in

Trall",e,,,,, "hrlon""" ",,,,de

\
Recluc; abdominb mU"de and ,heJlh (( un

Figure 8
structures.

v.

S~tpcriO( epigastric dIIPri(~... ,~Ild

\'f,inr;,

Anatomy of the internal mammary vessels in relation to anterior chest wall

CLINICAL CORRELATION FOR CHEST WALL DEFORMITIES

The following is a sequential depiction of the technique for vascular access to the
internal mammary vessels (Figs. 9-16).
There are a variety of congenital chest wall abnormalities (Table 2). Although
most of these result in no noticeable physiological impairment, some can be severe, or
even life-threatening.

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Adams and Janis

10

Figure 9 The 3rd costal cartilage is identified and marked. The pectoralis muscle is incised
parallel to its fibers.

A.

Depression Deformities (Pectus Excavatum)

Pectus excavatum, also known as funnel chest, is the most common chest wall
deformity, with an incidence of 1:400 children. It is approximately 10 times more
common than pectLls carina tum (pigeon chest). Males are affected more frequently
than females by a ratio of 4: 1. Over 30% of cases have a family history significant for
chest wall anomalies, although no definitive research has proven a genetic cause (6).
The disorder results from excessive growth of the lower costal cartilages, causing a

Figure 10 The muscle is retracted superiorly and inferiorly,


perichondriulll of the costal carlilage.

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xposing the under!. ing

Anatomy of the Chest Wall

11

Figure 11 The perichondrium is incised longitudinally. Superior and inferior perichondrial


flaps are developed.

posterior sternal depression. Rotation of the sternum can result if the depression is
deeper on the right side than the left. The defect is usually recognized within the
first year of life, and progressively worsens as the child grows older. It usually is
asymptomatic initially, but can eventually result in significant pulmonary abnormalities. This anomaly may result in a spectrum of severity, ranging from a mildly
depressed sternum to sternal depression abutting the vertebral column. Approximately 20% of cases are associated with other musculoskeletal abnormalities such as

Figure 12 Once the perichondrial flaps have been raised circumferentiaJly, the costal
cartilage is easily resected with a small rongeur.

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Adams and Janis

12

Figure 13

The posterior perichondrium is identified after resection of the costal cartilage.

scoliosis (15%) and Marfan's syndrome, whereas congenital heart disease is seen in
1.5% of patients (7).
The indications for reconstruction include:
Cosmesis
Psychosocial factors
Respiratory or cardiovascular insufficiency
Poor self-image is an important concern for many patients, particularly children
and young adults or adolescents who are teased by peers. Because of these concerns,
early repairs are supported, with the best results being reported between the age of 2
and 5 years (8).

Figure 14 The posterior perichondrium is carefully divided with Jamison scissors. The
dissection is performed from lateral to medial.

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Anatomy of the Chest Wall

13

Figure 15 Care should be taken to develop delicately the plane between the posterior
perichondrium and the vessels.

The surgical repair of pectus excavatum requires multiple osteotomies of the


sternum and the affected rib segments to help reposition the sternum and restore a
110rmal contour. Four procedures are mentioned here. The first procedure involves
making a sternal osteotomy in order to reposition the sternum anteriorly. The second
is a modification of this procedure that involves using a posterior strut (sternal strut) to
support the repositioned sternum. The third technique involves removing the sternum
and repositioning it in a front-to-back rotated position prior to stabilization. The

Figure 16 After minimal initial dissectiolJ, the operating microscope should be used to
prepare the vessels for anastomosis. Small branches encountered during the dissection are
isolated and ligated. Placement of vessel loops around the vessels minimizes trauma and
provides a mechanism for vessel traction.

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Adams and Janis

Table 2

Chest Wall Abnormalities

Depression deformities/pectus excavatum


Protrusion deformities/pectus carinatum
Poland's syndrome
Sternal defects
Cervical ectopia cordis
Thoracic ectopia cordis
Thoraceabdominal ectopia cordis
Bifid sternum

fourth technique uses a Silastic mold implanted into the subcutaneous space to fill the
defect without altering the thoracic cage (9).

B.

Protrusion Deformities (Pectus Carinatum)

Pectus carina tum, also known as pigeon chest, is a defect characterized by an anterior
protrusion deformity of the sternum and costal cartilages. This condition, like its
counterpart, affects males more than females (4: I), has a familial predisposition
(30%), and an association with scoliosis (15%) and congenital heart disease (20%)
(10). Unlike pectus excavatum, however, the defect typically is not appreciated until
after the first decade of life. Physiological symptoms are uncommon.
Three types of defects have been described in pectus carinatum:
I.

Chondrogladiolar protrusion
Anterior displacement of the body of the sternum and symmetrical
conca vity of the costal cartilages.
Most common of the three variants

2.

Lateral depression of the ribs on one or both sides of the sternum


Poland's syndrome frequently is associated with this type.

3.

Pouter pigeon breast


Consists of an upper chondromanubrial prominence with protrusion of
the manubrium and depression of the sternal body.
Least common type

C.

Poland's Syndrome

Poland's syndrome was originally described in 1841 (II) and occurs in approximately
I :30,000 births (12).lt has no gender prevalence, and the right side i affected twice
as frequently as the left. Although the definitive cause has yet to be proven, the current
theory postulates that the syndrome is caused by hypoplasia of the subclavian artery
secondary to kinking during the 6th week of gestation.
The essential components of the syndrome include (13-15):
Absence of the sternal heads of the pectoralis major muscle
Absence of costal cartilages
Hypoplasia or aplasia of the breast and subcutaneous tissue (including the nipple
complex)
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Anatomy of the Chest Wall

15

Deficiency of subcutaneous fat and axillary hair


Syndactyly or hypoplasia of the ipsilateral extremity
Additional findings may include:
Absence or hypoplasia of the pectoralis minor muscle
Shortening and hypoplasia of the forearm
Variable deformities of the serratus, infraspinatus, supraspinatus, latissimus
dorsi, and external oblique muscles
Total absence of the anterolateral ribs with herniation of the lung
Symphalangism with syndactyly and hypoplasia/aplasia of the middle phalanges
Occasionally, Poland's syndrome has been associated with Mobius' syndrome
(facial palsy and abducens ocuh palsy) or childhood leukemia
Patients who present with absent ribs are considered candidates for surgical
repair, as are female patients with breast asymmetry. Generally speaking, surgery in
females is delayed until after puberty to allow full development of the contralateral
breast. Hester has described one method of reconstruction for females with this
deformity. In his technique, the ipsilateral latissimus is mobilized over a customized
breast implant. The insertion of the latissimus is moved anteriorly on the humerus in
order to establish an anterior axillary fold.

REFERENCES
1.
2.
3.
4.
5.

6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

Moore KL. The Thorax. In: Satterfield TS, ed. Clinically Oriented Anatomy. 3d ed.
Baltimore: Williams and Wilkins, 1992:33-125.
Starzynski TE, Snyderman RK, Beattie EJ Jr. Problems of major chest wall reconstruction. Plast Reconstr Surg 1969; 44(6):525-535.
Shaw WW. Breast reconstruction by superior gluteal microvascular free Raps without
silicone implants. Plast Reconstr Surg 1983; 72(4):490-501.
Feller AM. Free TRAM. Results and abdominal wall function. Clin Plast Surg 1994;
21 (2):223-232.
Clark CP III, et al. An anatomic study of the internal mammary veins: clinical implications for free-tissue-transfer breast reconstruction. Plast Reconstr Surg 1997; 99(2):
400-404
Shamberger RC, Welch KJ. Surgical repair of pectus excavatum. J Pediatr Surg 1988;
23(7):615-622.
Shamberger RC, et al. Anterior chest wall deformities and congenital heart disease. J
Thorac Cardiovasc Surg 1988; 96(3):427-432.
Shamberger RC, Welch KJ. Chest wall deformities. In: Ashcraft KW, Holder TM, eds.
Pediatric Surgery. 2d ed. Philadelphia: WB Saunders, 1993:146-432.
Crump HW. Pectus excavatum. Am Fam Physician 1992; 46(1):173-179.
Shamberger RC, Welch KJ. Surgical correction of pectus carinatum. J Pediatr Surg 1987;
22(1):48-53
Poland A. Deficiency of the pectoralis muscle. Guy's Hosp Report] 841; 6191.
Freire-Maia N, et al. The Poland syndrome-clinical and genealogical data, derma toglyphic analysis, and incidence. Hum Hered 1973; 23(2):97-104.
Hester TR Jr, Bostwick J III. Poland's syndrome: correction with latissimus muscle
transposition. Plast Reconstr Surg 1982; 69(2):226-233.
Ohmori K, Takada H. Correction of Poland's pectoralis major muscle anomaly with
latissimus dorsi musculocutaneous flaps. Plast Reconstr Surg 1980; 65(4):400-404
Ravitch MM. Poland's syndrome-a study of an eponym. Plast Reconstr Surg 1977;
59(4):508-512.

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2
Preoperative Evaluation of Patients
Undergoing Chest Wall Reconstruction
MELISSA A. KAZANOWSKI and GEOFFREY C. GURTNER
Nell' York University School of Medicine. Nelli York, Nell' York. US.A.

I.

INTRODUCTION

As the population ages, preoperative evaluation of patients becomes more critical.


Chest wall resection and reconstruction are major undertakings associated with a
high risk of morbidity and mortality even in healthy patients. In addition to the
inherent risks of the procedure, many patients undergoing this type of surgery
have serious comorbid conditions, which increase morbidity and mortality. It is
essential to identify high-risk patients preoperatively to ensure satisfactory outcomes. By addressing specific risks early, it is possible to optimize comorbid conditions and minimize postoperative morbidity. For the patient undergoing chest
wall reconstruction, particular emphasis should be placed on his or her pulmonary, cardiac and nutritional status. Although in many centers the preoperative
work-up is the responsibility of the thoracic surgery team, it is important for reconstructive surgeons to understand the basic principles of evaluation for specific
risk factors.

II.

GENERAL EVALUATION: HISTORY AND PHYSICAL EXAMINATION

All patients should undergo a detailed history and a physical examination. General
risk factors include a history of smoking (I), malnutrition, obesity (2), and advanced
age. It has been demonstrated that patients over the age of 70 have a higher risk of
poor outcomes following chest wall surgery (3). For the reconstructive surgeon, it is
important to examine the patient for evidence of prior chest wall therapy, including
radiation, prior thoracotomy, or abdominal surgery. The presence of innervated

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17

18

Kazanowski and Gurtner

latissimus dorsi and pectoralis muscles should be specifically examined to determine


possible reconstructive options. The patient should be assessed for lymphadenopathy
and upper extremity weakness to estimate the extent of the patient's disease and
predict the resulting defect.

III.

SPECIFIC RISK FACTORS

A.

Smoking

One-third of patients undergoing surgery are smokers (4). These patients have an
increased risk of postoperative morbidity if they continue to smoke. Short-tenn
smoking cessation decreases the acute effects of carbon monoxide and nicotine on
the cardiovascular system, but improving lung function requires tobacco cessation for
a longer period (4). Moller demonstrated that smoking intervention 6-8 weeks before
surgery reduced postoperative complications by 34% and decreased hospital stay by 2
days. This study intervened with counseling and nicotine replacement therapy, and
defined success as smoking cessation or a 50% smoking reduction (5). Another option
is to delay surgery until the patient has ceased smoking. Carbon dioxide plasma levels
can be used to monitor patient compliance (6).

B.

Obesity

Obesi ty is a well-recognized risk factor for complica tions after chest wall resection and
reconstruction. Obese patients suffer from restricted motion of their diaphragm and
chest cage. In order to ventilate, the respiratory muscles must work harder to displace
the excess weight, which places additional strain on the patient postoperatively (7).
Obesity has also been shown to decrease forced vital capacity (FVC), functional
residual capacity (FRC), forced expiratory volume in 1 s (FEVl), and total lung
volume pre- and postoperatively (6).

C.

Infection

Patients with active infections have increased morbidity following chest wall reconstruction (8). Preoperative antibiotic therapy, debridement or infectious disease consultation may be required before definitive surgery to minimize perioperative risk.

D.

Radiation

Radiation presents significant obstacles to wound heali ng and increases morbidity and
mortality. When a patient has received radiation, it is important for the physician to
assess the remaining irradiated tissue in order to predict postoperative viability.
Knowledge concerning the prior extent of disease and the presence of an irradiated
lung or mediastinum is necessary. The presence of radiation-induced ulcera tion of the
anterior chest wall or parasternal area deserves particular attention. The physician
must rule out the potential involvement between the ulcer and the heart, great vessels,
or internal mammary vessels preoperatively to minimize the possibility of severe
intraoperative or postoperative hemorrhage (9).

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Preoperative Evaluation

E.

19

Surgical Procedure

For the reconstructive surgeon, the actual surgical procedure and the size of the pulmonary resection (10,11) are critical risk factors for postoperative morbidity. In a
recent study, Deschamps found that the extent of sternal or rib resection had no effect
on postoperative morbidity and mortality, but that reconstruction following a lung
resection was associated with a statistically significant adverse affect on operative
mortality. Whether this is due to the increased operative time or further alterations in
the pulmonary mechanics is unclear. With that in mind, it seems evident that all fullthickness skeletal defects, which may later paradox (i.e., involve more than three
adjacent ribs), need to be reconstructed (12,13). However, a lesion smaller than 5 cm or
a subscapular defect smaller than 10 cm in the posterior thorax may not require
reconstruction (12).
Despite the above risk factors, most morbidity and mortality in patients undergoing chest wall reconstruction result from complications related to pulmonary,
cardiac, or nutritional disease. The remainder of this chapter will examine the preoperative evaluation of these three systems to minimize these particular postoperative complications.

IV.

PULMONARY EVALUATION

All patients should be questioned regarding their smoking history, prior pulmonary
infections, and chronic pulmonary disease (emphysema, bronchitis, asthma, and
pulmonary emboli). It is important to inquire specifically about dyspnea on exertion
because it is a good indicator of gas exchange reserve (6). Since pulmonary dysfunction inevitably occurs following surgery, most patients should undergo formal
chest x-rays and pulmonary function tests (including simple spirometry and arterial
blood gas studies) as a baseline (6). Formal pulmonary consultations should be
obtained for patients with significant risk factors even if they are asymptomatic. In
particular, patients who have had a recent change in exercise capacity, a smoking
history of greater than 10 pack years, dyspnea on exertion, or are older than 45
years (6) should undergo formal pulmonary evaluation.
Routine preoperative pulmonary laboratory tests should include chest x-ray,
resting arterial blood gases on room air, and basic spirometry. The chest x-ray is
examined for thoracic volume, inspiratory effort, evaluation of rib osteopenia, and
interstitial or parenchymal diseases. The carbon dioxide partial pressure (PC0 2 ) level
on resting arterial blood gas studies can be utilized to predict postoperative risk.
A resting PC0 2 above 45 mmHg confers significant risk for pulmonary resection
unless medical treatment can improve alveolar ventilation. IfPC0 2 is still greater than
45 mmHg after treatment, the patient is at high risk for postoperative respiratory
insufficiency (6).
Preoperative spirometry is also useful to predict the patient's pulmonary
function postoperatively. Several indices have been developed in an attempt to provide
a single number to predict postoperative complications. Krammerer and Gross found
that by multiplying the FVC by the FEYI, one can predict a patient's ability to
undergo total or lobar lung resection (14).

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Kazanowski and Gurtner

20
Surgical Prediction by FVe Multiplied by FEV I
FEVI x FVe
> 2500
> 3500

< 2500

Surgical prediction
Patient
Patient
Patient
even

can tolerate the resection of I lobe


can tolerate a pneumonectomy
will have postoperative pulmonary dysfunction
if no pulmonary tissue is removed

Source: From Ref. 14.

Another index proposed by Peters evaluates the patient using the FVCI, FEVI,
maximum midexpiratory flow rates (FEV25 or FEV50) and minute ventilatory
volume (MVV). Using this system, a physician may categorize patients into low-,
moderate-, and high-risk groups for pulmonary resection.

Surgical Prediction by Basic Spirometry Values

Vital capacity (L)


FEVI (L)
MVV (L/min)
FEV 25-50% (Lis)

High

Moderate

Low

< 185
< 1.2

185-3.0
1.2-3.0
30-80
1.0-20

>40
> 3.2
> 80
>2.0

<28
< l.0

Source: From Ref. 15.

Still more esoteric pulmonary function tests can be used to predict bronchospasm by measuring bronchial hyperreactivity, small airway obstruction by flow
volume loops, and diffusing capacity to evaluate interstitial lung disease. Ferguson
suggests that the best predictor for postoperative success may be the predicted
postoperative diffusing capacity for carbon monoxide (PPODLCO%). The
PPODLCO% is estimated by multiplying the percentage of remaining unresected
lung segments by the preoperative DLCO. If the value is less than or equal to
40% of normal values, then the patient has a 20% mortality and a 56% morbidity
risk (16). Others have used exercise testing to measure cardiorespiratory performance and maximal oxygen consumption to predict postoperative complications and
mortali ty (17).
Current recommendations are that a predicted postoperative FEVI less than
800 ml (or 30% of the predicted value) or a V0 2 max less than 10 ml/kg/min are
considered to be the lower limits of pulmonary function with which a patient may
endure pulmonary resection (2,10,18). If the predicted postoperative FEYI is less than
1200 ml, further evaluation by a pulmonologist should be performed preoperatively
(6). There is no absolute level at which pulmonary surgery is unequivocally contraindicated, although certain levels are associated with a much higher ri k. Bisson
believes that in the case of lung cancer predicted postoperative outcome is not
important unless it indicates mortality (3). To summarize, we advise obtaining a
formal preoperative pulmonary evaluation on all patients who have risk factors or:lre

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Preoperative Evaluation

21

classified as anything other than low risk by preoperative analysis of chest x-ray,
arterial blood gas studies, and basic spirometry.

V.

CARDIAC ASSESSMENT

Chest wall reconstruction confers the same risks associated with other noncardiac
thoracic opera tions. Cardiac complications occur in as many as 30% of pa tients undergoing thoracic surgery (19), with atrial tachyarrhythmias being the most prevalent (20). Since many patients undergoing chest wall resection and reconstruction
are elderly, there is a high likelihood that many will have cardiac disease. The patient's preoperative evaluation should include questions about recent symptoms
(chest pain, dyspnea, palpitations) and history of arrhythmias, murmurs, myocardial
infarction, congestive heart failure, or treatment for coronary artery disease. Specific
risk factors for coronary artery disease should be sought including hyperlipidemia,
hypertension, diabetes, history of early coronary disease, and current cigarette use.
All patients should undergo a routine electrocardiogram. For patients who do
not have a history of angina pectoralis or myocardial infarction but have coronary
artery disease risk factors, it is advisable to seek out occult coronary disease. If the
electrocardiogram is abnormal, these patients should undergo an exercise stress
test with or without thallium or echocardiography to determine the extent of disease.
In both of these settings, formal cardiology consultation should be obtained, since
patients with any unmasked coronary artery disease may require coronary catherization prior to surgery. A normal stress test may obviate the need for catherization.
In order to predict postoperative cardiac events, a number of scoring systems
have been devised. The most useful comes from a clinical study involving 1001
patients, in which 39 variables were examined for how they related to cardiac events
following noncardiac surgery. Nine were found to be statistically significant independent risks and each was allotted a number of points based on its correlation to
postoperative events. In this table, each significant variable is listed along with its
score, estimating cardiac risk in noncardiac surgical patients.
Goldman System of Categorizing Patients for Noncardiac Surgery
Finding

Points

S3 Gallop or JVD
Transmural or subendocardial myocardial infarction in past 6 months
> 5 premature ventricular contractions documented at any time
Premature atrial contractions or other than sinus rhythm on last preoperative
electrocardiogram
Age >70
Emergency operation
Intrathoracic, intra-abdominal, or aortic surgery
Evidence of aortic valvular stenosis
Poor general medical status a

11

10
7
7
5
4
3
3
3

a P0 2 < 60 mmHg, PCO l > 50 mmHg, serum K < 3.0 mEq/L, HC0 3 > 20 mEq/L, urea nitrogen> 50 mgl
dl, creatine> 3.0 mg/dl, elevated aspartate transferase or liver disease signs, any condition for which patient
is chronically bedridden.
Source: Ref. 21.

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Kazanowski and Gurtner

22
Scoring by Goldman Points
Group

Points

0-5
6-12
13-25

I
fI
III

> 26

IV

Risk

Low
Minimal
Moderate
Great

Source: Ref. 21

Using this scoring system, patients in class IV have a 78% chance of having a
perioperative Iife-tbreatening cardiac event and patients in a low-risk category have a
0.9% chance (21). The Goldman scale is probably the best overall predictor for cardiac
complications following noncardiac surgery and is widely used by anesthesiologists
and cardiologists in their preoperative evaluation of patients.
From the perspective of the reconstructive surgeon, cardiology consultation
should be obtained in all patients who score as moderate to great risk by the Goldman
scale. All patients with symptoms or a history of heart disease should also be formally
evaluated. Patients with a history of myocardial infarction have a 2.8-] 7% risk of
reinfarction with a mortality rate of 28-69%, while patients with no history of
preoperative infarction have a low (0.13%) risk of perioperative infarct (22).
The American College of Cardiology and American Heart Association have
issued guidelines to stratify moderate and high-risk patients into four subgroups. Each
requires a different evaluation and treatment protocol prior to thoracic surgery. The
subgroups and their most appropriate work-up are:
I.

2.
3.

4.

Patients with unstable coronary disease, decompensated congestive heart


failure, or significant arrhythmias should have surgery cancelled or delayed.
Patients who have undergone coronary revascularization during the prior 5
years with no recurrence of symptoms require no further investigation.
Patients who have undergone a negative coronary evaluation during the
prior 2 years and since remained asymptomatic require no further investigation.
Patients with symptoms or high-risk patients (by the Goldman criteria)
should be considered for coronary angiography prior to surgery (3).

Compared to coronary artery disease, which is often silent. the presence of


valvular heart disease is usually known by the patient prior to preoperative evaluation.
[f the patient has a history of valvular disease, its severity should be quantified by
echocardiography or angiography prior to surgery. Cardiology consultation should
also be obtained. [I. is important to identify the type of valvular pathology in order to
treat the patient preoperatively, since lesion is associated with a different and discrete
set of postoperative risks and potential interventions. Current recommendations
include the following:
I.
2.

Aortic stenosis poses the greatest risk for thoracic surgery. Valve replacement may be required before surgery.
Severe mitral stenosis is also a high-risk lesion and may benefit Crom balloon
mitral valvulopbsty or open surgical repair.

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Preoperative Evaluation

3.

4.

23

Aortic and mitral regurgitations require bacterial endocarditis prophylaxis


and attentive medical treatment (afterload reduction, diuretics) to provide
maximal hemodynamic stabilization in the perioperative period.
Patients with prior mechanical prosthetic valves require aggressive endocarditis prophylaxis and careful anticoagulation management, which
will include the use of short-acting anticoagulants in the perioperative period (3).

All of these patients require preoperative cardiology evaluation and close


follow-up in the perioperative period.

VI.

NUTRITIONAL ASSESSMENT

Postoperative recovery depends to a great extent on the patient's ability to heal. This
requires that the patient's nutrition is able to meet the increased metabolic demand of
the healing process. Administration of the appropriate metabolic support starts with a
thorough evaluation of the patient's nutritional status preoperatively (23). It is
unfortunate that unlike the pulmonary or cardiac work-up, there is far less agreement
on appropriate nutritional assessment. Nevertheless, it is important for the reconstructive surgeon to have a rudimentary understanding of the fundamental issues in
nu tri tiona I support.
Patients being seen for chest wall reconstruction are at high risk for nutritional
complications. Preoperatively, it is common for pulmonary patients to have a decrease
in body mass. Although the pathophysiology is not completely understood, it is
thought that the loss relates to the presence of a hypermetabolic state, which exists
in chronic obstructive airway patients. This physiological state is due to the increase
in oxygen consumption by the respiratory musculature, leading to a decrease in total
body energy reserve (24). Furthermore, these patients often have a decrease in surface
area, thickness, and total mass of their diaphragm muscle (25). It has been demonstrated experimentally that nutritional supplementation augments the contractile
force of the diaphragm (3) and lowers pulmonary morbidity. Conversely, clinical
malnutrition leads to a decrease in minute ventilation and vital capacity, reduced
cardiac contractility, impaired renal function, and increased thrombogenicity (23).
These abnom13lities may precipitate renal failure, wound healing dysfunction, and
respiratory failure (26).
Patients at risk for malnutrition are patients who have experienced near or
complete starvation for 5 or more days, patients with a recent weight loss of more
than 10-15% body weight, and patients whose recovery is expected to be prolonged
with regard to their return to adequate oral intake (27). No single test can reliably
assess a patient's nutritional status. Anthropometric analysis is widely used. Triceps
or subscapular skinfold thickness serve as an index of body fat and the midarm
muscle circumference estimates muscle mass. The accuracy in these measurements is
limited in the elderly population due to the variation in age-related changes in lean
body mass and fat (23). Other diagnostic tests include creatine-height index, body
weight, total lymphocyte count, serum transferrin, insulinlike growth factor, serum
cholesterol, urinary urea nitrogen, and response to antigenic stimuli (delayed hypersensitivity). However, none of these markers improves upon the sensitivity of serum
albumin testing (28).

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Kazanowski and Gurtner

Albumin can be used as a diagnostic test to assess global nutritional status. It is


a hepatically synthesized protein with a half-life of 18-21 days. Its plasma concentration is the integrated result of protein losses, degradation, synthesis and exchange
between extravascular and intravascular compartments (23). Due to a long half-life,
albumin levels are not accurate for acute changes in nutrition. For most patients in
whom the nutritional status is unclear, a serum albumin test should be performed
preoperatively. In 54,215 patients undergoing major noncardiac operations, a serum
albumin concentration of less than 2.1 g/dl was associated with substantial morbidity
and mortality (29).
To assess a patient's overall nutritional status preoperatively, the subjective
global assessment (SGA), combining patient history, physical examination, and
subjective evaluation, has been devised (30). The SGA guidelines identify five sets of
variables and assign them points. The variables are:
I.

2.
3.
4.
5.

Weight loss during the previous 6 months classified as severe (> 10%),
moderate (5-10%), or mild 5%) with allowances made for ascites and
edema.
Dietary intake classified as normal or abnormal based on changes in oral
intake, nutrients, and calories.
The presence of gastrointestinal symptoms that impair deglutition or eating
occurring daily for at least the previous 2 weeks (includes surgery).
Functional capacity classified as bedridden, less than fully active, or fully
active.
Physical signs, including subcutaneous fat loss in triceps and subscapular areas, muscle wasting in the temporalis muscle, quadriceps, and deltoids (3 I).

Using this information, the surgeon can categorize the patient into one of three
groups. Class A includes patients with less than a 5% weight loss or with a greater than
a 5% weight loss with recent evidence of improved appetite and weight gain. These
patients are considered well-nourished. Class B patients have a 5-10% weight loss
without recent weight gain, poor dietary intake, and mild decrease of subcutaneous
fat. These patients are moderately nourished. Patients in class C have a weight loss of
greater than 10% with severe loss of subcutaneous fat and muscle wasting. They often
suffer from edema. They are severely malnourished (23).
Although seemingly subjective, there is an 80% agreement in SGAs completed
by different physicians (30). The accuracy of an SGA has been confirmed by
comparison with transferrin and albumin levels, delayed cutaneous hypersensitivity,
creatine-height index, and anthropometrics (32). The SGA test can be used to assess
postoperative morbidity and delayed functional recovery irrespective of functional
dependence, comorbidity, and degree of acute illness (33). When combined with the
resul ts of serum albumin tests, SGA correctly increased the detection of malnourished
patients to 90% (34). It seems logical to perform both a SGA and a serum albumin test
all on patients undergoing chest wall resection and reconstruction. Patients who have
severely depressed albumin levels or who are categorized as class C should receive a
nutritional consultation and consideration or preoperative nutritional supplementation with delayed surgery.
An alternative system for nutritional assessment in patients at risk for postoperative malnutrition is the prognostic nutritional index (35). This index uses

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25

anthropometric data (skin fold, triceps), albumin, transferrin, and delayed hypersensitivity to gauge a patient's nutritional status using the following formula:
Prognostic Nutritional Index

158- 16.6 (ALB)- 0.78 (TSF) -0.2 (TNF)


-58 (DH)

where ALB = serum albumin (g/dl), TSF = triceps skin fold (percentage of standard
value), TNF = serum transferrin (mg/dl), and DH = delayed hypersensitivity
(0 = non-reactive, I = > 5mm induration, 2 = > 7.5mm induration).
A PNI score of
< 40
is considered low risk,
40--49
intermediate risk, and
> 50
high risk.
Although this system is accurate, it is relatively cumbersome, requires additional
testing, and does not greatly improve upon the accuracy by SGA. However, it is used
by many nutritional services at present.
For patients who are severely malnourished by any criteria, the value of preoperative hyperalimentation remains controversial. It does appear to decrease the
risk of wound infections after esophagogastrectomies (36) but has not been shown to
decrease morbidity in patients undergoing head and neck procedures (37) or cardiac
valve surgery (38). Other controversial issues include the length of nutritional supplementation, the mode of supplementation, and the resulting postoperative nutritional status or respiratory muscle function after hyperalimentation (3). In patients
who are severely malnourished (class C by SGA), it may be prudent to delay the
operation for 2-3 weeks in an attempt to correct the nutritional status. If the patient
is unable to attain normal nutritional status by the time of the operation, a feeding
gastrostomy or jejunostomy should be implanted at the time of surgery to allow
feeding postoperatively.
It has recently been proposed that growth hormone treatment may increase
weight gain and improve pulmonary function in patients undergoing major surgery.
However, it has not been proven that growth hormone improves pulmonary
function more than hyperalimentation treatment alone (39,40). It has been shown
in patients with end-stage chronic obstructive pulmonary disease that administration of recombinant human growth hormone improves expiratory tidal volume,
increases peak expiratory flow rate, and increases respiratory muscular strength
after 10 days of hormone therapy. In patients on long-term mechanical support,
growth hormone treatment improves respiratory strength and protein metabolism
(41), and reduces the duration of mechanical ventilation. This study suggests that
growth hormone treatment may be beneficial to patients following chest wall
resection and reconstruction.

VII.

CONCLUSION

Chest wall reconstruction can be performed relatively safely with long-term survival
in many patients (42). To guarantee safety and decrease postoperative morbidity
and mortality, thorough preoperative evaluation is essential. It is important to
assess a patient's pulmonary, cardiac, and nutritional status in detail to identify

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Kazanowski and Gurtner

26

high-risk patients so that correctable factors can be improved and morbidity and
mortality minimized.

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3
Introduction to Surgical Infections of the
Chest: Empyema and Mediastinitis
BLANDING U. JONES, JEFFREY JIM, and JEFFREY C. MILLIKEN
University of California, Irvine, California, U.S.A.

Like many other surgical subspecialties, the field of thoracic surgery evolved through
general surgeons developing a particular interest in treating diseases of the chest. Although specialized tools and instruments designed for chest surgery had been utilized
for many years, it was the advent of positive pressure ventilation and anesthesia in the
late 19th century that allowed surgeons to contemplate complex open chest surgeries.
Facing the challenges of wartime thoracic injuries in the early 20th century, as well as
dealing with the devastating effects of tuberculosis in the preantibiotic era, allowed
thoracic surgery to emerge as a legitimate and important subspecialty. Over the ensuing decades, prior to the arrival of open heart surgery nearly 50 years ago, thoracic
surgeons focused primarily on correcting infectious diseases and malignancies of the
lungs and chest wall.
The chest is a dynamic anatomical structure. The thoracic cage serves not only as
a protective shell for the lungs, heart, esophagus, and great vessels within but as a
compliant and elastic support structure that ultimately offers functional assistance and
limitations in the mechanics of breathing. Deformities of the chest wall, as a result of
surgical intervention, not only yield aesthetically displeasing appearance but can also
result in moderate to severe physiological disability. Thoracic surgeons over the years
have been extremely innovative and successful in managing and/or avoiding these
types of complications. More recently, the important role of the reconstructive
surgeon specialist has become better defined.
Although all organs of the chest are susceptible to specific opportunistic
microbes, primary pneumonia is the most common infectious process involving the
lungs to produce pleural effusion (I). Diffuse lung infections, isolated lung abscesses,

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Jones et al.

30

granulomatous disease, malignancy, tuberculosis, and primary infections of the esophagus and mediastinum can also produce para pneumonic fluid collections. Surgical
intervention in the thoracic cavity and trauma to the chest may provide for the introduction of foreign material and the development of fluid collections such as hemothorax. Undrained fluid collections serve as media for the progression of localized
to generalized thoracic and systemic infections.
Empyema, defined as purulent fluid in the thoracic cavity, and mediastinitis, are
two of the most severe types of chest infections (2). The invasive nature of such infectious processes may prod uce systemic effects including septic shock and chest wall
invasion. Prompt, radical surgical debridement and drainage of affected tissues of the
chest are the mainstays of life-sparing therapy (3).
Despite surviving the initial systemic manifestations of such invasive infections,
patients may face significant morbidity and potential mortality as a consequence of
surgical intervention. Frequently, patients develop an overall mass defect of the thorax
from scarification of the chest wall, resection of ribs, or with complete excision of the
sternum. The physiological result is a loss of chest wall compliance and overall physical volume. Restoration of function and form and the promotion of healing in such
cases are significant challenges to the thoracic surgeon and reconstructive surgeon.

I.
A.

EMPYEMA
Pathogenesis and Presentation

Empyema is a surgical condition first described by Hippocrates approximately 2400


years ago. His writings detail such techniques as opening an empyema cavity by knife
or cautery. Surprisingly little has changed in the treatment of empyema over the last
2000 years. Certainly, chest x-rays and computed tomography have allowed for earlier
diagnosis, while antibiotics and more effective, less invasive, techniques for drainage of
the empyema have greatly improved the outcome for the patient.
Empyema can be classified as primary or secondary. Primary empyema most
commonly results from parapneumonic effusion commonly seen in the inflammatory
processes of bacterial pneumonias, lung abscesses, or bronchiectasis (4). Secondary
empyema occurs as a complication of thoracic surgical procedures, trauma, or extension of infectious processes fr0111 the neck or the abdomen. The progression of primary
empyema occurs in essentially three stages: uncomplicated/exudative; complicated/
fibropurulent; and frank empyema. Initially, there is minimal neutrophilic effusion
that is sterile (5). The exudate is clear and yellow with a white blood cell count <500
cell/ml. Left untreated, fibroblastic proliferation accelerates leading to the development of heavy fibrin deposits on the pleural surfaces. Bacterial proliferation leads to an
increased number of neutrophils. The fibrin layers forming on both pleural surfaces
can lead to locular collections in the pleural space. The end stage of this process results
when the underlying lung becomes entrapped by a thick, adherent peel, and the effusion becomes grossly purulent.
Postsurgical pleural space infection, or secondary empyema, is the second most
common cause of empyema and can result from surgery of the esophagus, lungs, or
mediastinum. When empyema develops after pulmonary resection, additional complicating factors are often present. In many cases, there is a persistent communication
from the bronchial tree to the pleural space (bronchopleural fistula) that mu t be

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31

corrected. Furthermore, these patients often have underlying lung disease that
prevents full expansion of the remaining lung following partial lung resection. In
those patients who have had pneumonectomy, almost the entire pleural space can
become infected. These fixed spaces must be obliterated in order to cure the infection
fully. It is in the management of these most complex cases that the influence of the
reconstructive surgeon has been most important in recent years.
B.

Treatment

The effective management of empyema requires sterilization with antibiotics, drainage


of the purulent material, and obliteration of the empyema space.
Appropriate antibiotics should be initiated promptly in all patients (6). Antimicrobial therapy may be continued for at least 4-6 weeks. In community-acquired
disease, therapy should be started empirically against gram-positive and gramnegative bacteria. Anaerobic coverage should also be considered if the effusion is
large. For nosocomial disease, appropriate therapy will be based upon culture and
sensitivity results.
Various drainage techniques have been described. Although many authors have
reported successful treatment of empyema, they ha ve in many cases failed to diffentia te
the stage of the disease in which treatment was initiated. This is a very important
distinction, since earlier-stage disease responds much more readily to simple interventions. In most cases, if the purulent fluid is adequately drained, the lung tissue will
expand to obliterate the empyema space. During the 1800s, the concept of both thoracentesis and thoracoplasty were introduced. Thoracentesis may be performed under
local anesthesia to allow evacuation of the infected fluid. If the effusion is small, this
may be all that is necessary. Repeat thoracentesis can performed if indicated on raiographic studies. Cultures and analysis of the fluid for white blood cell count, pH, and
lactic dehydrogenase (LDH) levels should be carried out.
Larger infected effusions are less amenable to thoracentesis and often require
insertion of a thoracostomy tube for drainage. In fact, even well-formed empyema
cavities are often treated first with chest tube insertion. In some of these patients, the
remaining lung will gradually expand over time to lessen the pleural dead space. In
patients who are not operative candidates, or in those who become asymptomatic
when the fluid is completely drained, long-term dependent drainage of the cavity is
sometimes used. The tube can be cut offjust beyond the chest wall, and used to keep the
cavity open while it granulates from the inside out. In these types of cases, the
placement of a chest tube can also be performed in conjunction with local rib resection
in order to visualize better the empyema and keep the tract open at the skin. In cases in
which a bronchopleural fistula exists, this will not be effective in eliminating the space.
A plastic tube (32 Fr or larger) is placed into the most dependent area of the empyema
and placed under water seal with light suction. The addition of an intrapleural
fibrinolytic agent can aid in the treatment of locular empyema. Streptokinase and
urokinase can be administered to break up the pockets and aid in the drainage of the
pus material (7). Streptokinase (250,000 units) or urokinase (100,000 units) diluted in
100 ml saline is instilled into the pleural cavity through the tube, which is then clamped
for 4-6 h before drainage. This can be administered daily without systemic fibrinolysis. The tube can be removed if 24 h drainage is less than 50 ml and the lung has fully
expanded around the tube.

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If closed chest tube drainage is insufficient, an open technique can be performed


to allow for prolonged drainage. Open drainage is contraindicated in the acute phase
of empyema, as it will cause a pneumothorax if the lung is not fixed to the chest wall
and the empyema cavity sealed off from the pleural space. Radiographic studies must
demonstrate a fixed space before open drainage can be attempted. A closed chest tube
drainage system can be converted to an open drainage system by cutting the chest tube
a few centimeters from the chest wall. This can be done safely after 2-3 weeks. The
chest tube is then cut short a few centimeters per week and slowly withdrawn from the
chest cavity to allow granulation tissue to obliterate the tract.
A more invasive alternative to closed therapy was described in 1935 by Eloesser,
primarily for the treatment of tuberculous empyema. He developed a technique for the
creation of a one-way flap that allowed drainage of purulent material from the thoracic
cavity while preventing entry of air (8). After the cavity had been appropriately
drained, an inverted V-shaped flap is made on the chest wall corresponding to the most
inferior dependent portion of the empyema. A minimum of two underlying rib fragments are resected to create an adequate opening to prevent closing. The skin flap is
then sewn directly to the thoracic cage to prevent closure and allow prolonged drainage. Today, this technique is most appropriate for patients who are poor surgical
candidates or who have impaired healing.
When there is incomplete drainage or incomplete expansion of the lung tissue
with early complicated effusion, the definitive intervention used for breaking up loculi

Figure 1

Collapse, entrapped lung with empyema; contracted right thoracic cage volume

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33

Empyema and Mediastinitis

and debridement/drainage is open thoracotomy or thoracoscopic debridement.


Video-assisted thoracic surgery can aid in lysing the fibrinous adhesion, breaking up
the loculations, and allowing proper placement of the chest tube (Figs. 1-4). If thoracoscopy is unsuccessful, the procedure should be converted to an open thoracotomy
with formal decortication. The first successful decortication was described in 1893.
Decortication refers to the stripping of the thick visceral pleural peel from the lung
tissue, which then allows the lung to expand and fill the empyema space (9). This is
usually performed through a lateral or axillary thoracotomy. Depending on the stage
of the empyema and the adherence of the peel to the pleura, these operations can be

Figure 2

Decorticated lung, enucleated empyema, reexpansion of right lung field.

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very easy or extremely bloody and difficult. Even with successful decortication, full
expansion of the lung may take severa] weeks.

C.

Chronic and Postresectional Empyema

Tn most cases, empyema can be successfully treated using the techniques detailed
above. However, certain chronic empyemas tend to be more resistant to conventional

Figure 3 Same patient as that in Figure I and 2: helical images revealing emp. ema.
entrapped lung, and cortical raid.

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35

Figure 4 Individuals from WWIJ illustrating devastating effects of thoracoplasty. (From


Berry FB, ed. Surgery in World War II, Thoracic Surgery, vol I and 2. Washington, DC,
Office of the Surgeon General, Department of the Army, 1965).

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treatment modalities and more extensive surgical procedures are required. These types
of infected spaces can occur after pulmonary resections, when the remaining lung is
unable to fill the residual thoracic space or is associated wi th bronchopleural fistulas.
Thoracoplasty procedures were initially developed over 100 years ago to deal with
these difficult situations. Thoracoplasty is the resection of a portion of the chest wall to
create a smaller thoracic cavity to approximate the size of the underlying lung tissue.
Estandler first reported the resection of multiple ribs to collapse the chest wall over a
cavity caused by tuberculosis; as many as seven to ten ribs were required to be removed
for complete obliteration of postpneumonectomy space. Multiple modifications of
this procedure have been made to increase the success rate and lessen the significant
morbidity and mortality associated with these radically deforming procedures. The
Shede modification, described in the late 19th century, added the removal of
intercostal muscles and the underlying thickened parietal pleura to the rib resection
in order to provide a better collapse of the chest wall on the parietal pleura. The
development of effective chemotherapy for pulmonary tuberculosis, better experience
with decortication, and the advent of superior techniques of filling residual pleural
space have made these types of thoracoplasty procedures virtually obsolete.
Muscle flap transfers, to be discussed in greater detail elsewhere in this book,
have been shown to be very effective in treating residual infected pleural spaces,
whether prima ry or postresectiona 1. Muscle fla ps are ideal for filling remaining pleural
space because of their adequate size, good blood flow, and accessibility to the pleural
cavity (10). Various extrathoracic muscles can be brought via pedicled flap into the
pleural cavity through 4--5 cm rib resections. The most commonly used muscles
include the latissimus dorsi (obliterate 30-40% of pneumonectomy space), serratus
anterior (10-15%), pectoralis major (20-30%), pectoralis minor (0-2%), omentum
(5-15%), and rectus abdominus (5-15%). The latissimus is the largest and most
reliable flap used. However, the muscle is not available if a previous posterolateral
thoracotomy has been performed. Miller et a!. described their approach, in which the
acute stage is managed by closed chest drainage (I l). This can be converted to an open
drainage if necessary. If the patient is stable, then a single stage muscle flap procedure
can be performed in 3 months. For malignant disease, a wait of up to 1 year is
recommended. The muscle flap procedure is performed after appropriate systemic
chemotherapeutics are initiated. The pleural cavity should be sufficiently debrided to
ensure adequate formation of healthy granulation tissue. If a fistula is present, it can be
closed primarily if possible and buttressed with omentum from the abdomen. The
muscle flap is introduced into the pleural cavity to obliterate all residual space and the
incision site is primarily closed. The use of muscle flap transfers has been the most
effective and least morbid approach to the management of these difficult, recalcitrant
empyema spaces, and represents a major advance in the field of thoracic and
reconstructive surgery (Figures 5-8).

II.

MEDIASTINITIS

A.

Incidence

The era of open heart surgery began in the 1950s with the development of the heartlung machine and the performance of increasingly complex heart surgery f r concrenb
Ital defects. However, heart surgery was not really commonplace until the late 1960s.

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Figure 5

37

Normal postop sternotomy film.

when reliable mechanical prostheses for valve replacement and techniques for coronary bypass surgery became readily available. Then, as now, most of these operations
were performed through a median sternotomy incision. The midline chest incision
includes division of the manubrium, body of the sternum, and xyphoid to provide easy
access to the heart and grea t vessels. At the completion of most procedures, the pericardium is left open and one or more chest tubes left for drainage for I or more days.
The sternum is commonly secured with heavy stainless steel wires, and the subcutaneous tissues and skin are closed with absorbable sutures. Complications with this
approach are rare (12). Yet when deep sternal infection occurs with resultant mediastinitis, the mortality may be as high as 30-50% (13). The cause of death in these
cases is usually uncontrolled sepsis and multisystem organ failure. For this reason,
when these infections occur, they must be treated quickly and aggressively (14, 15).
Reported infection rates of median sternotomy wounds average between 3 and
4%, while deep sternal infections occur in approximately J % of patients, irrespective
of operation performed (16). Superficial postoperative infections do not involve the
underlying bony structures and are treated by local debridement and routine dressing
changes, as well as a short course of antibiotics. An occasional patient may develop
sterile nonunion or sternal dehiscence. Such a patient will usually respond to primary
or delayed sternal rewiring and wound closure. However, deep sternal infections with

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Figure 6

Normal wires postop.

mediastinitis and extensive septic invasion of the underlying tissues represent a


significantly more lethal and morbid complication.

B.

Presentation

Poststernotomy mediastinitis typically occurs between and 10 and 30 days following


surgery. Presenting symptoms may vary in degrees, thus making an early and precise
diagnosis difficult. Patients may demonstrate obvious sternal drainage, wound
dehiscence, and signs of sepsis. In this situation, there is little difficulty in making
the diagnosis. However, many cases present with unexplained chest pain, malaise, and
a leukocytosis with or without fever initially. This may subsequently progress to
sternal instability, with wound erythema, fJuctuance, and breakdown. By this time, a
severe, deep infection is in place, and hopes of conservative, nonoperative therapy are
gone. Computed tomography has been recommended to assist in determining the
severity and depth of sternal infections. However, retrosternal fluid collections are
normal in the early postoperative period, and these findings may be inconclusive or
misleading.
There are several classification schemes related to the diagnosis/severity of stornal infections. The Centers for Disease Control (CDC) guidelines indicate the in-

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Empyema and Mediastinitis

Figure 7

39

Abnormal wires in follow-up.

volvement of one of the following: isolation of an infective organism from mediastinal


contents; overt evidence of mediastinitis during operation; or chest pain, sternal
instability, and fever (> 38 DC) with purulence or positive culture. Gram-positive
bacteria (Staphylococcus aureus and S. epidermidis) are the most commonly isolated
microbes in mediastinitis. However, mixed infections including gram-negative organisms may be involved in 40% of cases (17).

C.

Risk Factors

Most patients presenting for cardiac surgery have myriad medical problems. These
comorbidities are additive in contributing to an immunosuppressive state and poor
wound healing. In a very large series of patients reported from the Cleveland Clinic,
the four following risk factors were significantly related to the development of postoperative mediastinitis: obesity, bilateral harvest of internal mammary artery grafts
with clinically significant diabetes (up to 8% incidence), prolonged operative time, and
the need for repeated blood transfusions in the early postoperative period (18).
However, in other series many other conditions have also been found to be risk factors. These include immunosuppressed states, steroid use, severe chronic obstructive
pulmonary disease (COPD), dialysis-dependent renal failure, advanced age, female
gender, need for re-exploration for any reason in the early postoperative period, and

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Figure 8

Dehiscene of sternum in follow-up.

patients with pre-existing remote infections. In general, the sickest patients preoperatively are the most prone to this complication, and many of these patients have more
than one risk factor.
D.

Treatment

Due to the severe nature of deep sternal infections and the usual systemic sequelae of
sepsis, mediastinitis must be treated aggressively and without delay. The type of
treatment employed depends to a great degree upon the stage of the infection. Administration of intravenons (IV) antibiotics followed by aggressive and early surgical
intervention remains the gold standard of therapy. Historically, local debridement
with serial packing of the open wound has carried up to a 50% mortality (19). Shumaker and Mandelbaum, in the 1960s, described a method of open surgical debridement followed by primary closure over an irrigation system. Small, anteriorly placed
tubes irrigate the mediastinum in cycles with antibiotic solution or dilute betadine,
while larger, posteriorly placed tubes drain the effluent while systemic antibiotic treatment is continued. The irrigation is continued for several days and then the tubes are
removed. This has been reasonably successful, and many programs continue to use thi
approach.

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41

Perhaps the best, most effective form of therapy for severe infection is radical
debridement of the operative site, followed by reconstruction of the chest wall. The
operation includes complete sternectomy, including most of the cartilage anteriorly.
After irrigation and drainage of the mediastinal structures, the mediastinum can be
covered with omentum and chest reconstruction can be primary or delayed. The most
common approach, which will be discussed in detail later in this book, is rotation of
pectoralis major flaps to appose centrally with primary closure of the subcutaneous
tissue and skin over drain (20). Early concerns regarding chest instability or ventilatory compromise secondary to absence of the rigid sternum have been unfounded.
Even those patients with preoperative respiratory insufficiency can do well with this
approach, and the muscle flaps provide adequate protection ofthemyocardium below.
It is interestingly that the muscular plane remains fairly distinct from the
mediastinal tissue below, making reoperative procedures on the heart Jess technically
challenging than expected. Most important is that with the aggressive application of
this approach, the overall mortality from postoperative mediastinitis can be dramatically reduced to the range of 1-10% (21). The reconstructive surgeon, working in
tandem with the cardiac team, has been extremely important in managing this
infection. While it is necessary for the cardiac surgeon to direct the exploration and
debridement of the mediastinum because of the familiarity with the previous operative
procedure, in many institutions the reconstructive surgeon determines the timing and
type of che.st closure re.quired.

REFERENCES
1.

2.
3.
4.
5.
6.
7.
8.
9.
10.

II.
12.

MandaI AK, Thadepalli H, Mandai AK, Chettipally U. Outcome of primary empyema


thoracic: therapeutic and microbiologic aspects. Ann Thorac Surg 1998; 66: 1782-1786.
Urschel JD, Takita H, Antkowiak JG. Necrotizing Soft Tissue Infections of the Chest
Wall. Ann Thorac Surg 1997; 64:276-279.
Vanway C III, Narrod J, Hopeman A. The Role of Early Limited Thoracotomy in the
Treatment of Empyema. J Thorac Cardiovasc Surg 1988; 96:436.
Fry, Willard A. Surgical Management of Empyema. Mastery of Cardiothoracic Surgery
1998:247-256.
Souza A, Offner PJ, Moore EE, et al. Optimal Management of Complicated Empyema.
Am J Surg 2000; 180:507-511.
Schumaker HB, Madelbaum 1. Continuous Antibiotic Irrigation in the Treatment of
Infection. Arch Surg 1963; 86:384-387
Robinson LA, Moulton AL, Flemin WH, et al. Intrapleural Fibrinolytic Treatment of
Multiloculated Thoracic Empyemas. Ann Thorac Surg 1994; 57:803.
Somers J, Faber LP. Historical Development in the Management of Empyema. Chest
Surg Clin North Am 1996; 6:403.
Lemmer JH, Botham MJ, Orringer MB. Modern Management of Adult Thoracic Empyema. J Thorac Cardiovasc Surg 1985; 90:849.
Nomori H, Horio H, Hasegawa T, Suemasu K. Intra-thoracic Transposition of a Pectoralis Major and Pectoralis Minor Muscle Flap for Empyema in Patients Previously Subjected to Posterolateral Thoracotomy. Surg Today 2001; 31:295-299.
Miller, Joseph 1. The History of Surgery of Empyema, Thoracoplasty, Eloesser Flap, and
Muscle Flap Transposition. Hist Thorac Surg 2000; 10(1 ):45-53.
Francel TJ, Kouchoukos NT. A Rational Approach to Wound Difficulties After Sternotomy: The Problem. Ann Thorac Surg 2001; 72:1411-1418.

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Jones et al.

13.

Francel, Thomas J, Kouchoukos, Nicholas T A Rational Approach to Wound Difficulties After Sternotomy: Reconstruction and Long-term Results. Ann Thorac Surg 2001;
72:1419-1429.
Carrier M, Perrault LP, Pellerin M, et al. Sternal Would Infection After Heart Transplantation: Incidence and Results with Aggressive Surgical Treatment. Ann Thorac Surg
2001; 72:719-724.
De Feo M, Gregorio R, Della Corte A, et al. Deep Sternal Wound Infection: The Role of
Early Debridement Surgery. Eur J Cardiol-thorac Surg 200 I; 19:811-816.
Grossi EA, Culliford AT, Krieger KH, et a1. A Survey of 77 Major Infectious Complications of Median Sternotomy: A Review of 7,949 Consecutive Operative Procedures.
Ann Thorac Surg 1984; 40:214-223.
Oakley RM, Wright JE. Postoperative Mediastinitis: Classification and Management.
Ann Thorac Surg 1996; 6l:l030-1036.
Loop FD, Lytle BW, Cosgrove DM, et al. Sternal wound complications after isolated
coronary artery bypass grafting: early and late mortality, morbidity, and cost of care.
Ann Surg 1990; 49:179-187
Braxton JH, Marrin CA, McGrath PD, et al. Mediastinitis and Long-teml Survival After
Coronary Artery Bypass Graft Surgery. Ann Thorac Surg 2000; 70:2004-2007.
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;
6:766--778.
EI Gamel A, Yonan NA, Haasan R, et al. Treatment of Mediastinitis: Early Modified
Robicsek Closure and Pectoralis Major Advancement Flaps. Ann Thorac Surg 1998;
65:41-47.

14.

15.
16.

17.
18.

19.
20.

21.

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4
Treatment of Sternal Clefts
MICHAEL J. SUNDINE

University of California at Irvine, Irvine, California, U.S.A.

Clefts of the sternum with or without ectopia cordis represent a rare clinical entity. In a
1977 review of all the available cases from the literature, Ravitch (I) was able to
identify only 44 patients who had surgical repair of a cleft sternum from 1888 to 1977
(2). In a 1998 review of the literature, Hazari et a1. (3) were able to identify 73 cases
reported in the literature since 1800. Daum and Zachariou (4) argue that there are
fewer than 100 reported cases of cleft sternum. Cleft sternum comprises a wide variety
of defects that include upper sternal clefts, lower sternal clefts, complete sternal clefts,
and clefts associated with ectopia cordis or Cantrell's pentalogy.
The first reported case of cleft sternum was by de Torres in 1740 (2,5,6). Perhaps
the most widely known patient with a cleft sternum was Herr Groux from Hamburg,
Germany. He would put himself on display, for a fee, at universities and hospitals in
Europe during the 19th century (2, 11). Greig performed an extensive review of the
available literature regarding cleft sternum in 1926 and was able to identify 39 cases of
cleft sternum (8). The first successful repair of a cleft sternum was by Burton in 1947
(9), and the first reported repair of a complete cleft sternum was by Maier and Bortone
in 1949 (10). Koop performed the first successful repair of ectopia cordis in 1975 as
reported by Saxena in 1976 (12,13).
Cleft sternum should be differentiated as a separate entity from ectopia cordis.
Although the cardiac pulsations are visible in the chest in cases of cleft sternum, the
heart is in an orthotopic location and does not require reduction when the chest is
closed. In the past some authors have referred to this as partial ectopia cordis. Ectopia
cordis is a term that should be reserved for those cases in which the naked heart is
actually located outside the chest (14).

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44

I.

Sundine

EMBRYOLOGY

The observations by Hanson in 1919 are perhaps the most widely accepted in terms of
the embryological development of the sternum (IS). The sternum arises from paired
longitudinal concentrations of mesenchymal tissue, which are separate from the ribs,
in the 6th week of development. There is also a single median anterior rudiment that is
associated with the shoulder girdle (16). These paired sternal bands and the anterior
sternal rudiment then converge ventrally and fuse in the midline in a cranial-to-caudal
direction and form a median cartilaginous plate. This fusion of the sternal bands is
usuaJly complete by 9 weeks of development. The tips of the ventrally growing ribs
then approach the midline sternum. The developing ribs are derived from the somites.
Resection of the somites in a developing embryo will prevent rib development, but will
not inhibit development of the sternum, thus further demonstrating the distinct origin
of these two structures (2).
The fused cartilaginous sternum subsequently segments into sternebrae, and
these lines of separation occur opposite the ends of each pair of ribs. At the fifth
month of development, there are one or more centers of ossification in each sternebrae
(16). The ossification of the sternum is then usually completed within the first year after
birth (5).
Cleft sternum is considered to arise as a failure of fusion of the sternal primordial
elements. Thus, it is somewhat paradoxical that the majority of the cases of cleft
sternum are fused inferiorly with an upper sternal cleft, even though normal fusion of
the sternum proceeds from a superior to inferior direction (2).
II.

CLASSIFICATION SCHEMES

There have been many proposed classification schemes for midline sternal defects. One
of the more commonly accepted classifications is that of Ravitch (I), which was
subsequently modified by Hersh et a1. (17) (Table I). However, perhaps a more
comprehensive classification of midline sternal defects and associated heart position is
that offered by Shamberger and Welch (12). (Table 2).
In Shamberger and Welch's classification scheme, thoracic ectopia cordis
consists of those cases in which there is a naked heart devoid of external covering.
The apex of the heart is anterior and often pointed in a cephalad direction (Fig. I).
These patients frequently have associated congenital heart defects. In descending

Table 1

Modified Ravitch Classification of Sternal Defects

1. Cleft sternum without associated anomalies


A. Partial to complete
B. Variable median abdominal raphe
Il. Cleft sternum with vascular dysplasia
III. True ectopia cordis
A. Cardiac lesions
B. Other associated midline malformations
IV. Cantell's pentalogy
SOI/rce:

From Ref. 17.

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Sternal Clefts

Table 2

Classification of Shamberger and Welch

1. Thoracic ectopia cordis


II. Cervical ectopia cordis
III. Thoracoabdominal ectopia cordis
IV. Cleft or bifid sternum
Source: From Ref. J 2.

order of frequency these defects include tetralogy of Fallot, transposition of great


vessels and pulmonary stenosis or atresia, pulmonary artery stenosis, ventricular septal defect (VSD) and atrial septal defect (ASD), and VSD alone. The prognosis for
patients with thoracic ectopia is extremely poor. In their 1990 review, Shamberger and
Welch were only able to identify three successful cases of repair of this defect in 29
attempts. Their own experience in three cases also resulted in three deaths (12).
Cervical ectopia cordis is an extraordinarily rare condition. In these cases the
heart is displaced cepahalad and there is often fusion between the heart and the mouth
with a band of tissue (Fig. 2). There is also a frequent association with severe
craniofacial anomalies. The prognosis for these patients is dismal and there have been
no reported survivors with this condition (12).
Thoracoabdominal ectopia cordis essentially comprises the group IV patients of
Hersh (17) or group III patients of Ravitch (2), and have Cantrell's pentalogy (18). In
1958 Cantrell et al. described a constellation of five congenital defects that now bears
his name. The anomalies involved in Cantrell's pentalogy include a midline supraumbilical abdominal wall defect, a defect of the lower sternum, a cresentic diaphragmatic defect, a pericardial defect allowing for a pericardial-peritoneal
communication, and congenital heart defects (Fig. 3). Most commonly the cardiac
defect involves a ventricular septal defect, although there is a very high frequency of
ventricular diverticulum associated with Cantrell's pentalogy. In this group of patients
the heart is usually covered with a thin membrane or skin, and does not have the severe
anterior rotation seen in patients wi th thoracic ectopia cordis. The prognosis for these

Figure 1

From Ref 12

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46

Figure 2

From A Rielander. Uber ectopia cordis congenita. Arch. GynaekoJ. 88: 88-93,
1909. Cited in Shamberger & Welch. Figure 2 on Page 160 in their paper.

patients is much improved compared to patients with thoracic ectopia cordis. The
major advance to improve the survival for these infants has been in the treatment of the
cardiac defects (12).
The final category is cleft sternum or bifid sternum. This category is reserved for
cases in which the heart is orthotopically sited, covered with skin, and there is an intact
pericardium. In cases in which there is a partial cleft of the sternum, the cleft is directed
superiorly (Fig. 4). This is in contrast to cases of thoracoabdominal ectopia cordis,
where in the event of a partially cleft sternum the cleft is directed inferiorly. Intrinsic
cardiac defects are rare in this category, but they have been reported (19,20). Ra itch
reported one case in which there was a distal sternal cleft not associated with a
pentalogy of Cantrell (I).
In general, isolated cleft sternum is rarely associated with other significant
anomalies, but there are a few well-described associations (2). One of the most com-

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Figure 3

47

From Ref. 2.

mon associated findings is the presence of a supraumbiJical raphe (2). This raphe
extends superiorly from the umbilicus but fails to reach the sternal cleft, and has the
appearance of a midline cutaneous scar or ridge (21). This defect is considered to
confirm the failure of midline fusion. There have been mUltiple reports of cleft sternum
in association with other manifestations, but these are uncommon (21-32).
Several authors have noted the association between sternal clefts and hemangiomas (17,21). Gorlin et aL found a marked female predominance in infants with
sternal clefts and supraumbilical raphe with facial hemangiomas (21) There was no
female predominance, however, in infants with sternal clefts without facial hemangIOmas.
Morton and Jordon reported a very rare association between midline a sternal
cleft and a cleft of the mandible (5,32).
Hebra et aL (29) and Rose et aL (30) have reported the association between
sternal clefting and a cystic chest wall mass that surrounded the margins of the ster-

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Figure 4

From Ref. 11.

nal cleft. Rose et al. (30) were also a ble to demonstrate this mass on fetal ultrasound examination.
Even though the embryology of sternal development is well known, the cause of
cleft sternum remains unclear. There has been only one familial case reported and
genetic transmission of the defect would appear to be unlikely (31). In that report
Haque described a brother and sister who both had sternal clefts. The girl also had a
hemangioma that involved the left side of her face. Haque's report is also remarkable
for the presentation of cases of total asternia.
Chronic nutritional deficiency and vitamin deficiency states (vitamin A, riboflavin, and folic acid) have also been implicated in the development of cleft sternum
(1,31). It has also been demonstrated that disruption of the Hoxb-4 gene may result in
sternal clefts (33).
Kaplan et al. (34) have hypothesized that ectopia cordis and cleft sternum are a
result of mechanical compression due to rupture of the chorion or yolk sac at about 3
weeks gestation (35). Isolated cleft sternum is believed to occur later in gestation and is
not associated with band disruptions (35).
In general, patients with isolated sternal clefts (i.e., upper sternal clefts and
complete sternal clefts) are asym ptomatic despi te the very alarming appeara nce of the
heart and great vessels beating through the sternal cleft covered only by a thin
membrane of skin (1). Sen et al. have reported a case of cleft sternum in which the
patient presented with complaints of dysphagia, difficulty in tongue protrusion,
difficulty in raising the pitch of his voice, and a bulging mass in the neck with straining
(36). They found the patient to have the sternohyoid and sternothyroid muscles
abnormally inserted into the lower edge of the sternal cleft that placed abnormal
tension on the hyoid bone.
The chest wall defect in isolated sternal clefts may range from a U-shaped defect
of the upper sternum to a v-shaped defect that may extend to the xiphoid process with
or without fusion of the lower sternum. The heart and great vessels can be 'een beating

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Sternal Clefts

under the thin skin, which may have ulcerations. The lungs may herniate through the
chest wall defect with expiration and a Valsalva maneuver and then collapse into the
defect with inspiration. As noted above, there is a frequent association with a linear
scarlike band extending from the umbilicus toward the sternal cleft, and also facial
hemangi omatosis (I).
Prenatal diagnosis of cleft sternum and omphalocele is possible using ultrasound
(37). Rose et al. were able to demonstrate the presence of a chest wall hamartoma n
their report using prenatal ultrasound but were unable to find the underlying sternal
cleft (30). In those cases in which an ectopia cordis has been diagnosed with prenatal
ultrasound, a cesarean delivery should be performed to prevent cardiac compromise or
injury to any of the herniated structures during a vaginal delivery.
III.

TREATMENT

The indications for repair of sternal clefts have been carefully outlined by Fokin (5)
(Table 3). The first reported repair of a cleft sternum was performed by Lanne10ngue in
1888 (2,7). However, his procedure was limited to excision of a circular ulcer overlying
the sternal defect (12).
There have been many different approaches to the treatment of sternal clefts.
These alternatives have included observation (1,38), primary closure with or without
the addition of muscle flaps (3,4, I0, 14, 16,29,39-48), pectoralis major muscle flaps only
(49), sliding chondrotomies (4,19,50,51), costal cartilage grafts (9,45,52,53), iliac crest
bone grafts and pectoralis major muscle flaps (54,55), temporal bone grafts (56), and
alloplastic materials (1,51,57,58).
Hoeffel et al. (38) reported on a 15-year-old girl with an upper sternal cleft who
was asymptomatic. They considered that because she was asymptomatic there was no
indication for repair of the cleft. While there are other examples of patients with sternal
clefts who functioned quite well despite their cleft (1), the vast majority of authors
believe that sternal clefts should be repaired.
The surgical treatment is individualized depending on the patient's age, type of
defect, and the underlying cardiac status (5). The majority of authors recommend early
closure of the sternal cleft, preferably within the first 2 months of life. The reason for
early intervention is that there is much improved chest wall compliance in the first

Table 3

Indications for Repair of Sternal Clefts

1. Lack of bony protection of underlying mediastinal structures makes the heart and great
vessels vulnerable to trauma.
2. The appearance of the protruding heart is alarming to both patients and parents.
3. Enlargement of the defect over time will worsen in appearance and make it more difficult
to correct.
4. In the presence of a dermopericardial sinus, the excision of the sinus is mandatory
to prevent pericardial infection.
5. Paradoxic respiratory movements of the chest induce dyspnea and predispose patients
to recurrent respiratory infections.
6. Impairment of venous return affects cardiac function.
Source: From Ref. 5.

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50

couple of months of life. The compliant chest wall allows for a direct approximation of
the sternal halves wi thout causing any cardiopulmonary em barrassment, and the chest
cavity can accommodate the thoracic viscera. As the child grows older, the chest wall
becomes less compliant and other methods of repair must be utilized to close the
defect. In cases of isolated sternal cleft there are rarely intracardiac defects and the
cardiac status is rarely a deterrent to closure of the defect. There are reports of repair of
congenital cardiac defects along with primary repair of the sternal cleft (19,20,46).
The general technique of operation for primary closure involves a vertical
incision over the sternal cleft. The thinned or ulcerated skin is usually excised, as is
the supraumbilical raphe if present. The pericardium is then dissected free from the
sternal margins and from the overlying skin. The pleura are also dissected free from
the sternal margins. Posteriorly based perichondrial flaps may be developed from the
margin of the sternum and are pushed posteriorly. Nonabsorbable sutures or steel
wires are then placed around the sternal bars and the sternal bars are gently
approximated (Figs. 5, 6).
While the sternal halves are approximated, the hemodynamic and pulmonary
status of the patient are carefully monitored (heart rate, electrocardiogram, arterial
pressure, central venous pressure, oxygen saturation, blood pressure). If there is no
significant change in the hemodynamic status, the sutures or wires are tied to
approximate the sternal halves. Osteotomies or chondrotomies of the sternum may
be necessary to allow for adequate approximation of the sternal halves (16) (Fig. 7). In
cases with an incomplete cleft of the sternum, a wedge of cartilage can be removed
from the inferior aspect of the sternum or xiphoid to allow primary closure of the
sternal halves. This repair may be supplemented with pectoralis major muscle

Figure 5

From Ref. 10.

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Sternal Clefts

Figure 6

From Ref. 10.

Figure 7

From Ref. 16

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52

advancement flaps (44,48). The sternohyoid, sternothyroid, and sternocleidomastoid


muscles have been released by several authors and sutured together medially to
prevent herniation of the lung into the neck (1,44,48).
In the case of the complete absence of the sternum, Snyder et al. (49) employed
bilateral pectoralis major muscle advancement flaps. In their case, the pectoralis major
muscles were detached from the sternal origin and sutured together in the midline over

Figure 8

From Ref. 5.

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Sternal Clefts

Figure 9

From Ref 9.

Figure 10

From Ref. 54.

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54

the pericardium. The rectus abdominus muscles were also approximated in the midline
and bilateral fasciocutaneous advancement flaps were employed to obtain skin
closure. See Chapter 14 for details of bilateral pectoralis major muscle advancement
flaps.
In older patients it may not be possible to approximate the sternal halves
primarily without cardiovascular or pulmonary compromise. The sternal margins
also may not be able to be approximated in cases in which the sternal bars are widely
separated. In these cases the sliding chondrotomy technique employed initially by
Sabiston may be employed (50). In this technique the costal cartilages on both sides of
the sternum are exposed with subperichondrial dissection. The costal cartilages are
then cut at an oblique angle (50) or they are step-cut (5) to allow approximation of the
sternal bars in the midline (Fig. 8). The sliding chondrotomy provides for contact
between the rib margins and maintains chest wall integrity while acting as a relaxing
incision to get the sternal halves approximated in the midline.
Perhaps the next best alternative in the event that the sternal halves cannot be
approximated primarily or with the use of relaxing incisions is the use of autogenous
grafts with or withot the use of supplemental muscle flaps (9,45,52-56). In the first
report on correction of a cleft sternum, Burton utilized a large costal cartilage graft
that was harvested from the costal margin. This cartilage graft was then wired into the
sternal defect to provide protection for the heart (9) (Fig. 9). Roccaforte et al.
employed a similar technique to Burton's in their report (52). They also provided
additional pectoralis major muscle advancement flaps to supplement their repair.
Chaukar et al. (53) actually used homologous cartilage for their repair. More recent
authors have used bone grafts harvested from the inner table of the iliac crest (54,55).

Figure 11

From Ref I.

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Figure 12

55

From Ref. I.

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These bone grafts were then either wired or plated into position and have been covered
with pectoralis major muscle flaps (Fig. 10). Asp and Sulamaa (56) used temporal bone
grafts to fill in the sternal defect.
Due to the potential for infection or extrusion, alloplastic materials should
probably be used as a last resort for treatment of the cleft sternum. Several different
materials have been employed including stainless steel mesh (Fig. 11) (1), Teflon felt
(Fig. 12) (I), a perforated acrylic plate (Fig. 13) (57), and Marlex mesh (51,58). These
materials have generally been used in those cases of late-presenting individuals with
sternal clefts.
As indica ted previously, the presence of thoracic ectopia cordis portends a grave
prognosis. In their 1990 review, Shamberger and Welch (12) were able to document
only three successful cases of successful coverage of ectopia cordis including the cases
of Saxena (13) and Dobell (59). In all the successful cases they found a consistent
pattern of pathology and treatment. There were no congenital heart defects, nor were
there any abdominal wall defects in any of the successful cases. Two of the cases were
treated in a staged fashion, first obtaining skin coverage and then returning to obtain
some structural coverage over the heart. Only in the case of Amato was complete
coverage performed in one stage (12,60). Another important distinction was that in the
successful cases there was no attempt to return the heart to its orthotopic position (12).
In the case of Dobell, a skin flap was first used for cardiac coverage and subsequent
protection was obtained through the use of split rib grafts that were covered with

Figure 13

From Ref I I.

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Sternal Clefts

pectoralis major muscle advancement flaps (59) (Figs. 14-16). Saxena's group placed a
composite alloplast composed of Marlex mesh and acrylic resin of Dacron was
inserted to protect the heart when the child was 7 months of age (13). The prosthetic
material had to be removed, however, due to infection secondary to necrosis of the
overlying skin flaps.
There is a much higher likelihood of successful closure of thoracoabdominal
ectopia cordis than ectopia cordis. Shamberger and Welch note that the initial
treatment must address the skin defects overlying the heart and abdominal viscera
(12). They recommend primary excision of the omphalocele and skin coverage to avoid
difficulties with infection and the development of mediastinitis. They also recommend
repair of any associated congenital heart defect prior to the placement of any mesh
material for restoration of sternal protection. They emphasize that the major advance
in the survival of these patients is the improvement in the treatment of the intracardiac
lesions. MUltiple approaches have been used for the treatment of this problem,
including the use of Marlex mesh and Silas tic pouches. An ingenious solution was

Figure 14

From Ref. 59.

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58

Figure 15

From Ref. 59.

Figure 16

From ReF. 59.

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59

offered by Hochberg et a!. (60), who used bilateral bipedicle flaps using the pectoralis
major muscle and rectus abdominus muscle coupled with intraoperative tissue expansion to reduce the tension from the flaps on the heart (Fig. 17).

IV.

LONG-TERM RESULTS

Fokin has outlined the postoperative results following repair of the cleft sternum (5).
Generally a solid chest with a satisfactory shape is obtained. In some cases, a fissurelike
funnel chest configuration may develop. There may also be some herniation of
thoracic contents and the base of the neck if the repair was not carried high enough
superiorly, and in some cases torticollis may develop in the early postoperative period.
The torticollis can be prevented by using an orthopedic collar postoperatively.

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5
Poland's Syndrome
YVONNE L. KARANAS and JAMES CHANG

Stanford University Medical Center. Stanford, California, U.S.A.

I.

HISTORY, CHARACTERISTICS, AND EPIDEMIOLOGY

In 1841 Alfred Poland described a case of a deficient pectoralis major muscle in


association with syndactyly of the ipsilateral hand (I). Clarkson, a hand surgeon,
named the syndrome Poland's syndrome after treating a patient with the hand
anomalies originally described by Poland (2). The disorder was probably originally
reported by Lallemand in 1826 when he described the chest wall deformity that we now
associate with Poland's syndrome (3). Poland's syndrome consists of a variable
constellation of findings that must include congenital absence of the sternal head of
the pectoralis major muscle (4). It may also include one or more of the following
anomalies (Fig. 1).
A.

Muscle Anomalies

These may include deficiencies of the latissimus dorsi, serratus anterior deltoid,
supraspinatus, and infraspinatus muscles.
B.

Chest Wall and Breast Anomalies

These may include the following:


Aplasia or hypoplasia of the ipsilateral breast
Absence or displacement of the ipsilateral nipple/areolar complex
Deficient subcutaneous chest tissue
Lack of axillary fat
Abnormalities of the ribs and costal cartilages
Aplasia of the subclavian artery
63

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Figure 1

A patient with Poland's syndrome shows absence of the sterna] bead of the pectoralis major muscle, breast hypoplasia, and brachydactyly. (Courtesy of Dr. Peter Johannet.)

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65

Figure 1

C.

Continued.

Upper Extremity Anomalies

These may include the following:


Hand hypoplasia
Brachysyndactyly
Forearm shortening
Hypoplasia/aplasia of the middle phalanges
Radial club hand with floating or absent thumb
Adactyly of some or all digits
Cleft hand
Phocomelia-like deficiency
Acheiria: congenital absence of one or both hands
One child out of 25,000 live births is affected by Poland's syndrome. Although
the incidence appears sporadic, there have been reports of a familial association. Males
are affected three times more often than females and 75% of cases occur on the right
side. Poland's syndrome has also been associated with Mobius' syndrome, hemifacial
microsomia, Klippel-Feil syndrome, SprengeJ's syndrome, scoliosis, foot anomalies,
certain leukemias, lymphomas, congenital spherocytosis, and renal hypoplasia (5-9).
Poland's syndrome is disfiguring and may cause the patient significant emotional and
psychological stress. However, the functional deficits are minimal and result largely
from the hand anomalies.
II.

PATHOGENESIS

There is no definitive explanation for the development of Poland's syndrome. The


most widely held hypothesis is the subclavian arterty supply disruption sequence

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66

(SASDS) described by Bouvet and Weaver in 1986. They hypothesized that disruption
of the subclavian artery distal to the vertebral artery but proximal to the internal
mammary artery during the 6th week of development could explain the absence of the
pectoralis major muscle, ipsilateral breast hypoplasia, and ipsilateral hand anomalies
seen in Poland's syndrome. In addition, disruption of the subclavian and vertebral
arteries at different locations could also explain the association of Poland's syndrome
with Mobius' syndrome, Klippel-Feil syndrome, Sprengel's syndrome, and hemifacial
microsomia. This disruption of the subclavian artery could be caused by mechanical,
environmental, or embryological events. These events would result in blood vessel
occlusion and absence of vessels or abnormalities within the vessel itself. The end result
would be decreased arterial flow with hypoxia and ischemia ultimately leading to the
anomalies associated with Poland's syndrome (10). Initially Poland's syndrome was
thought to be sporadic in nature; however, there have been several reports of familial
Poland's syndrome. Although the exact means of genetic transmission remains
unclear, there may be an inherited vascular anomaly that leads to compromise of
the developing vascular tree during the 6th week of gestation (11,12).

III.

TREATMENT

The treatment of Poland's syndrome is individualized to address each patient's


specific deficiencies. A wide variety of procedures have been described to correct
each of the anatomical abnormalities of Poland's syndrome, attesting to the complexity of the problem and the lack of satisfactory results. The surgical goal is to
restore the natural contour of the deficient area and to maximize the function of the
upper extremity.
A.

Female Chest and Breast

The goals of surgical correction of the chest in female patients are to correct the breast
hypoplasia, fill the subclavicuJar hollow, and create a normal-appearing nippleareolar complex. Although abnormalities or absence of the costal cartilages and ribs
may exist, they do not result in functional deficits. Routine chest wall reconstruction
with rib grafts or synthetic materials is usually not warranted. Minor cases of Poland's
syndrome may only include hypoplasia of the breast, which can often be treated with a
submammary implant for augmentation (Fig. 2). A contralateral mastopexy or
reduction may be required to achieve symmetry. However, the more severe deformities
of breast hypoplasia with subcla vicular hollowing req uire a more complex reconstruction. The main treatment options available are implants, autologous tissue transfer, or
a combination of the two.
For severe cases of Poland's syndrome, implant recon truction requires the use
of a customized, composite implant. In general, the implant consists of two
components: one to reconstruct the chest wall and subclavicular hollow and one
to reconstruct the breast. The implant may be solid silicone or contain a gel portion
to simulate the breast tissue. A plaster moulage is made from the patient's chest and
the implant is then created from this mold so that it exactly fills the defect. The
implant is placed subcutaneously and may be secured to the underlying ribs or
clavicle. Erosion, seroma formation, malposition, capsular contracture, and infection are the main complications from the use of these implants. However, there are

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Figure, 2 A patient with breast hypoplasia before and after implant reconstruction,
(Courtesy of Mentor Corporation,)

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Karanas and Chang

68

no additional scars or donor site morbidities. Several small series and case reports
have documented good results using customized, composite implants with minimal
complications in the short term (13-15). Latissimus dorsi muscle transposition may
be performed at a later date if the patient is unsatisfied with the result or has
complications from the implant.
In cases of severe deformity or deficiencies of subcutaneous tissue, the latissimus
dorsi muscle may transposed anteriorly to replace the deficient pectoralis muscle and
subcutaneous tissue. A sublatissimus implant is placed to reconstruct the breast. The
latissimus dorsi muscle fills the subclavicular hollow and provides soft tissue coverage
of the implant. If left innervated, the muscle should not atrophy. The insertion of the
muscle should be moved anteriorly to help re-create the anterior axillary line. The
functional deficits from transposition of the latissimus dorsi muscle are minimal, but
the procedure may require additional incisions to elevate and transpose the latissimus muscle onto the chest (Fig. 3). However, with endoscopic harvest of the muscle

Figure 3 . A schematic representation of latissimus dorsi muscle transposition and implant


reconstructIOn of the female chest In a patient WIth Poland's syndrome. (Fr m Ref. 24.)

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69

the amount of visible scar can be diminished (16). The submuscular placement of
the implant decreases the incidences of capsular contracture, implant erosion, and
implant visibility (17-19).
Free tissue transfer can be used to avoid the use of implants altogether. Longaker
and associates at New York University (NYU) reported a series of nine patients with
Poland's syndrome who underwent free flap reconstruction of the aplastic breast.
TRAM flaps were used most commonly followed by the superior gluteal flap. Despite
the longer surgery and risk of flap loss, the result is a permanent reconstruction
without the risk of future implant complications (20). Shaw has used free tissue
transfer in combination with preoperative tissue expansion in patients with a
deficiency of skin as well as breast tissue. The preoperative skin expansion creates a
breast envelope that can then be filled with the free flap so that there is no donor site
skin present on the chest wall. The aesthetic results are optimized; however, multiple
surgeries are required to complete the reconstruction (21).
In infrequent cases, patients with Poland's syndrome are missing the latissimus
dorsi muscle or its blood supply as part of the syndrome. In these cases free tissue
transfer is the only means available for autologous tissue reconstruction. The microsurgeon must be aware of the possibility of anomalous vasculature in selecting
recipient vessels. The only flap lost in the NYU series was due to venous thrombosis
in a patient with an anomalous venous blood supply.
B.

Male Chest

The chest wall abnormality seen in the male patient is characterized by hypoplasia or
aplasia of the pectoralis muscle. There may be abnormalities of the costal cartilages
or ribs and there is commonly a deficiency of subcutaneous tissue on the affected
side. The chest anomalies seen with Poland's syndrome in the male patient are
disfiguring and embarrassing to the patient. However, the functional consequences
are minimal.
Reconstruction can be performed with customized implants, latissimus dorsi
muscle transposition, or a combination of the two. The customized implants are
designed from a plaster moulage of the patient's chest so that the deficient areas are
reconstructed. The implants are commonly made of silicone and some can be
contoured intraoperatively as needed. Because of the lack of subcutaneous tissue in
many patients with Poland's syndrome, the implant is often visible beneath the skin,
giving an unsatisfactory appearance and a higher risk of erosion. In these cases, the
latissimus dorsi muscle can be transposed anteriorly to replace the deficient pectoralis
muscle and subcutaneous tissue. Despite maintaining its innervation, some surgeons
have found that the muscle does not provide sufficient volume in the long term to
match the contralateral developed pectoralis muscle. A combination of implant
reconstruction with latissimus dorsi muscle transposition offers a solution to the
problem of insufficient volume and implant exposure. Marks reported a series of eight
male patients who were treated for chest wall abnormalities due to Poland's syndrome.
They found that the latissimus dorsi muscle frequently atrophied and that patients
treated with a silicone implant alone often had areas where the implant was visible. The
use of the latissimus dorsi muscle in conjuction with an underlying implant provided
volume to match the contralateral chest wall and stable soft tissue coverage over the
long tenn (22-24).
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C.

Karanas and Chang

Upper Extremity

Poland's original case report described a patient with a hypoplastic hand, simple
syndactyly, missing middle phalanges, and short fingers. It has subsequently been
recognized that a broad spectrum of hand anomalies may be seen in patients with
Poland's syndrome. They range from a normal hand to acheiria with upper limb
abnormalities. Brachysyndactyly or symbrachydactyly are the most common anomalies seen. The syndactyly is usually simple and incomplete and may involve all of the
digits, resulting in a so-called mitten hand. The middle phalanges may by hypoplastic
or absent so that there is only one functioning interphalangeal joint (25). Gausewitz
realized that Poland's syndrome may present with more severe hand anomalies and
they classified these into four types: type 1 patients have all five digits present but some
or all are hypoplastic; type 2 patients have functioning border digits with absence of
the central digits, often mimicking a cleft hand; type 3 patients have no functional
digits with anomalies of the forearm; and type 4 patients have a radial ray deficiency
with abnormalities of the thumb (26). This classification was lacking the less
complicated congenital hand anomalies associated with Poland's syndrome. In 200 I
Al-Qattan published an expanded classification based on his experience with 20
patients. This classification includes those patients with an isolated pectoral muscle
abnormality and a normal hand. These classifications provide treatment guidelines
for these challenging patients (27).
The treatment of Poland's syndrome of the upper extremity is individualized
to each patient's specific anomaly. The specific deficiencies and abnormalities are
identified by physical examination and x-ray evaluation. A treatment plan is then
determined, including how many operations will need to be performed, the order
of procedures, and what will be accomplished by each surgery. Patients with isolated hypoplasia of the hand but five functioning digits require no treatment. The
most common finding, syndactyly, can be treated with standard separation or release
procedures and flap or skin graft closure. The lack of complicated syndactylies
in these patients makes the surgical correction more straightforward. The majority
of these procedures should ideally be completed by the time the child is 2 years
of age.
Deepening of the web spaces can be performed either concomitantly or later on
to add length to hypoplastic digits. Rotational osteotomy of the thumb may be
performed to correct the thumb position and improve function (28). For more severe
cases the surgeon may need to consider amputation of nonfunctioning digits if they
interfere with the overall function of the hand. Patients with adactyly of a single digit
usually require no treatment because the remaining hand functions well. Those
patients with a cleft hand and motion in both rays will benefit from cleft deepening
to improve key pinch and opposition. In the most severe cases of hand aplasia without
functional digits, toe to hand transfer may be performed.

IV.

SUMMARY

Poland's syndrome comprises a broad range of chest and upper extremity anomalies.
The chest abnormalities are disfiguring and may be a constant source of embarrassment and self-consciousness for the patient, but they have little or no functional
impact. The hand may have full function or may be entirely absent. The recol1-

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71

structive surgeon must be aware of the full constellation of findings associated with
Poland's syndrome and design a treatment strategy that addresses the individual
patient's anomalies.

REFERENCES
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StCharles S, DiMario FI, Gnmnet ML. Mobius sequence: further in vivo support for the
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Hicsonmez G, Ozsoylu S. Poland's syndrome and leukemia. Am 1 Dis Child 1982;
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Sackey K, Odone V, George SL, Murphy SB. Poland's syndrome associated with childhood non-Hodgkin's lymphoma. Am I Dis Child 1984; 138:600-601.
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Rojas-Martinez A, Garcia-Cruz D, Garcia AR, Sanchez-Corona I, Rivas F. PolandMoebius syndrome in a boy and Poland syndrome in his mother. Clin Genet 199 L 40:
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Gatti lE. Poland's deformity reconstruction with a customized, extrasoft silicone prosthesis. Ann Plast Surg 1997; 39:122-130.
Hodgkinson Dl. Chest wall implants: their use for pectus excavatum, pectoralis muscle
tears, poland's syndrome and muscular insufficiency. Aesthetic Plast Surg 1997; 21 :7-15.
Hochberg l, Ardenghy M, Graeber GM, Murray GF. Complex reconstruction of the
chest wall and breast utilizing a customized silicone implant. Ann Plast Surg 1994; 32:
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Borschel GH, Izenberg PH, Cederna PS. Endoscopically assisted reconstuction of male
and female Poland syndrome. Plast Reconstr Surg 2002; 109:1536-1543.
Hester TR, Bostwick l. Poland's syndrome: correction with latissimus muscle transposition. Plast Reconstr Surg 1982; 69:226-233.
Ohmori K, Takada H. Correction of Poland's pectoralis major muscle anomaly with
latissimus dorsi musculocutaneous flap. Plast Reconstr Surg 1980; 65:400-404.
Seyfer AE, Icochea R, Graeber GM. Ann Surg 1988; 208:776-782
Longaker MT, Glat PM, Colen LB, Siebert IW. Reconstruction of breast asymmetry in
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99:429-436.
Sayah DN, Shaw WW, Hoetflin IE. Component reconstruction of difficult Poland's
syndrome: the role of tissue expansion and free flaps. Presented at the American Society
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Marks MW, Argenta LC, Izenberg PH, Mes LGB. Management of the chest wall
deformity in male patients with Poland's syndrome. Plast Reconstr Surg 199 I; 87:674-681.
Seyfer AE, Icochea R, Graeber GM. Ann Surg 1988; 208:776-782.

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6
Pleu ral Defects
JAY W. CALVERT
UniversiTy of California aT Irvine, Irvine, California, U.S.A.

Pleural defects are often encountered in the setting of oncological surgery, trauma,
infection, and radiation injury of the chest wall (1-7). Proper reconstructive management of these defects is essential to achieving the best possible functional outcome. In
many cases, it is the difference between patients returning to their preoperative functional status and entering a long-term compromised state. Pleural defects may require
reconstruction as an isolated defect, or as a portion of am uch larger defect, such as a
full-thickness defect of the chest wall. This chapter outlines the types of pleural defects
encountered and proposes a reconstructive approach to these defects that includes
local and distant reconstructive options.

I.

GENERAL CONSIDERATIONS

Reconstruction of pleural defects requires careful planning and coordination of


care. Multidisciplinary planning is essential. Consultations with the thoracic surgery
service and anesthesia team are invaluable. Discussion of the individual patient's
needs is essential to obtaining the best possible outcome for each situation. Planning
should include attention to the type of anesthesia that will be used, the specific endotracheal tube that will be required, patient positioning, and postoperative management. The anesthesiologist should be very familiar with dual-lumen endotracheal
tubes (Fig. I), fiberoptic bronchoscopy, and single-lung ventilation (8). Critical care
systems and complimentary fixed facilities are part of a successful procedural plan.
It is important to have close at hand the radiographic studies that clearly demonstrate the relevant anatomy and pathology to be addressed. These studies are
important to have present for all planning sessions and in the operating room at

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Calvert

74

....

_--

Figure 1

the time of the operation. The plastic surgeon must keep in mind that many patients have undergone previous thoracic procedures that may have damaged or
destroyed local reconstructive options. Careful review of the operative records of
these patients will help to guide thinking and planning about the possibilities for
each patient.
The anesthesiologist will need to have a clear understanding of what is planned
for the operative procedure. The decision will need to be made preoperatively as
whether a dual-lumen endotracheal tube will be required. Intravenous access and
arterial lines are important considerations as well. Also, the position of the patient will
need to be determined since many flaps will be dissected from the abdomen or elsewhere, as is the case with free flaps. It will shorten operative time if two team
approaches can be arranged. Proper positioning of the patient is essential for this to
occur. Padding of pressure points and stable fixation of the patient are invaluable. An
axillary roll must be placed if the patient is going to be maintained in the lateral
decubitus position. Securing the patient's extremities and providing appropriate
support to the trunk also must be considered.
Thorough preoperative evaluation of the patient's general health is essential.
Pulmonary function tests, cardiac risk assessment. nutritional status, and evaluation of comorbid conditions will help guide the plan for the operation. With respect
to tumors and radiation injury, the ablative surgeon must be certain to perform the
resection without compromise. It will not help the patient to leave behind tumor
or damaged tissue. The plastic surgeon should then be able to perform the reconstruction with the knowledge that an appropriate resection or debridement ha been
performed (9).

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75

CHARACTERIZING THE PLEURAL DEFECT

Pleural defects that require reconstruction can be organized into two groups: those
associated with visceral pleural deficits only and those associated with full-thickness
parietal pleural defects. The visceral defects will generally be due to a failure of closure
of a bronchial stump due to pneumonectomy (10,11), empyema (12-15), or other
processes that leaves the bronchus compromised (16-19). Parietal pleural defects
involving the full-thickness chest wall are usually in a different class, since the reconstructive approach to these wounds involves not only the reconstruction of the
pleural but also functional reconstruction of the chest wall itself. There are several
considerations with each type of defect that allow for selection of a proper reconstructive option.
III.

VISCERAL PLEURAL DEFECTS

A.

Bronchopleural Fistula

Visceral defects of the pleura that require reconstruction usually involve a bronchus
that has been compromised for some reason. The most common reason for a plastic
surgeon to be seeing a patient for a visceral pleural defect is due to a bronchopleural
fistula. Bronchopleural fistula is a condition resulting from any disturbance of the
integrity of any bronchus and the visceral pleura. Most commonly, a bronchopleural
fistula will occur after pneumonectomy or empyema (20,21). Other disease processes
may result in this condition also. It is seen in 2% of patients undergoing pneumonectomy. It usually occurs as a result of a leak at a suture line. A patient's overall
nutritional status and disease state can also contribute to the establishment of a bronchopleural fistula.
The presentation of a bronchopleural fistula is usually one of sudden breathlessness and expectoration of serosanguinous fluid. The patient should be placed in the
lateral decubitus position with the operated side down. Oxygen should be administered and prompt drainage of the pleural space should be performed. The fistula
should then be repaired operatively with debridement and closure. Flaps may be
required to reinforce the repair.
B.

Reconstructive Options

1.

Pleural Flap

Flaps of parietal pleura are commonly used to reinforce surgical repair of bronchi after
pneumonectomy and lobectomy. Irradiation and active infection may be present as
well. They are also commonly used to reinforce the repair of a bronchopleural fistula
and for the repair of esophageal perforation. The requirements are tha t there be viable,
supple, vascularized pleural tissue to create a local flap (22). The blood supply to the
pleural flap is of a random origin and therefore it is recommended that a sufficiently
wide base for the flap be used to maintain viability (23). There is some question as to
how much of a pleural flap is actually surviving as a graft rather than as a flap. This
may be one reason why some pleural flaps fail.
Pleural flaps are designed to be as large as necessary to provide closure of the
defect in question. The parietal pleura is dissected starting at the thoracotomy wound

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margin toward the defect. Care is taken not to perforate the flap or produce any
fenestrations that might compromise the blood supply and strength of the tissue.
Dissection can usually be performed bluntly .. Once the appropriate size flap has been
developed, it can be sutured into the defect or wrapped around the structure in need.
Chest tubes or closed suction drains can then be positioned to drain the local region
and maintain the flap while it is healing in place.

2.

Intercostal Muscle Flap

The intercostal muscles may be elevated with the parietal pleura as a pedicled flap
based on the respective intercostal artery and vein. This type of flap creates a strip of
muscular tissue with a vascular pedicle that is useful in wrapping a bronchus repaired
by sutures. There is greater morbidity with an intercostal flap than with a pleural flap.
However, this option may be better for certain instances of bronchial reconstruction.
Intercostal muscle flaps can be created at any position within the chest. Entry
into the chest is made via the previous thoracotomy incision. A convenient intercostal
muscle group is identified based on its location to the diseased bronchus. The vascular
pedicle is found on the inferior border of the rib superior to the flap and care is take to
avoid injury to this crucial area. The parietal pleura and intercostal muscles are raised
as a composite flap from the ventral lateral chest wall toward the dorsal medial chest
wall, since the origin of the intercostal artery is the aorta. By maintaining the vascular
pedicle, a reliable, well-vascularized -flap can be created to manage difficult defects of
the visceral pleura. Strategic wrapping of the bronchus can then be performed.
Nonresorbable sutures are then placed to achieve closure. Closed suction drains and
chest tubes are then placed as appropriate.

3.

Diaphragm Muscle Flap

Much like the pleural flap and the intercostal flap, a pedicled diaphragm flap may be an
excellent local option for closure of intrathoracic pleural defects (24,25). This
technique generates a vascularized muscle flap from the diaphragm. It is a good
option for postpneumonectomy bronchopleural fistula.
Using the previous thoracotomy incision, a flap is designed on the diaphragm to
allow elevation of adequate tissue while still being able to close the diaphragm donor
site primarily. The flap is dissected in a radial manner starting from the pericardial
groove. The blood supply is axial from the phrenic artery (Fig. 2). A wide base should
be maintained in order to prevent flap necrosis. It is wise to mark the tip of the flap with
several surgical clips for radiographic identification of the flap location.
After elevation of the Aap, it is wrapped around the bronchial stump and sutured
in place with nonabsorbable sutures.1t is imperative to suture the flap to viable structures. It can then be sutured with nonabsorbable sLltures for final closure of the fistula.
Some have recommended the addition offibrin glue over the suture line. The donor site
is then closed with nonabsorbable interrupted sutures. Closed suction drains or chest
tubes are placed as necessary.

4.

Intrathoracic Transposition of Local Flaps

Many options are familiar to the plastic surgeon and reliable for intrathoracic
reconstruction of the visceral pleura (26,27). The location of the defect, the local
options available, and the morbidity of the flap harvest will determine the choice of
lhp for the patient. These factors vary from patient to patient and careful consider-

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Figure 2

ation of the options is necessary. It may be necessary to perform rib resections to make
the transfer of a local muscle or omental flap more technically feasible. It may also be
necessary to use a combination of flaps depending on the problem at hand.
Omentum is a reliable flap for reconstruction of a bronchial stump. Its ease of
transfer into the thoracic cavity makes it a favorable method of reconstruction (28).
The latissimus dorsi muscle, serratus anterior muscle, and pectoralis major muscle are
all easily transferred into the thoracic cavity (Fig. 3). Again, it is essential to evaluate
the viability of these muscles preoperatively since many patients have had procedures
that may have damaged or destroyed these local options. These muscles may be taken
as pure muscle flaps or as musculocutaneous flaps depending on the soft tissue volume
needed. They may be de-epithelialized and placed in to the chest cavity to gain more
volume for filling of residual cavities, such as in an empyema defect.
5.

Free Flaps

Free tissue transfer of various muscle and myocutaneous flaps have been used for
intrathoracic reconstruction of pleural defects (29,30). Free vascularized tissue
transfer is necessary when local options are not suitable for reconstruction (31). This
method of chest wall reconstruction provides an abundance of vascularized tissue
and does not rely on the local donor sites. These cases require the highest order of
reconstructive planning and deft execution of the plan to achieve excellent outcomes.
In these cases, the choice of donor tissue is designed to minimize the morbidity to the
patient. The most frequently used donor tissues include latissimus dorsi muscle,
rectus abdominus muscle, omentum, and serratus anterior (Fig. 4).
IV.

PARIETAL PLEURAL DEFECTS

Tumors of the chest wall may leave patients with a full-thickness chest wall defect (32).
These tumors may be benign, malignant, primary, or metastatic in nature (33-35). The
nature of the tumor is an important factor in deciding on the method and timing of
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Outline of serratus anterior m.

Serratus anterior m.

Skin incision

Scapula

Latissimus dorsi ffi.

Latissimus dorsi m.

Serratus anterior m. exposed


by dividing and elevating
the latissimus dorsi m.

Figure 3

reconstruction. Oncological surveillance, knowledge of clear margins, and future


therapy are all factors that may affect the type of reconstruction performed. The goals
of reconstruction must coincide with the management of the pa tient's primary disease
process. As mentioned previously, there must be complete control of the primary
process, otherwise any reconstructive effort is doomed to fail. Obtaining adequate
margins and proper tumor control methods are essential starting points for a
sLlccessful chest wall reconstruction.
Traumatic full-thickness chest wall defects require the same type of attention.
Again, an accurate diagnosis of the problem is es;;;ential to planning an appropriate
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79

Figure 4

reconstruction. With all traumatic wounds, it is first important to stabilize the patient
with attention to the ABC's of trauma. The plastic surgeon is usually involved at a
later time when the wound is clean, controlled, and the timing of the reconstruction
is appropriate.
The approach to reconstruction of the traumatic chest wall wound is similar to
other chest wall wounds. It is especially important to note the mechanism of injury.
Gunshot wounds are very different from avulsion injuries. Removal of devitalized
tissue is paramount to controlling the wound prior to any reconstructive efforts. Local
options may be compromised and therefore more distant options must be considered.
Failure of the reconstruction means failure to account for the factors that ensure
good healing.
Radiation necrosis of the chest wall is a special situation that presents certain
reconstructive dilemmas. Radiation necrosis is a process of continuing tissue destrucCopyrighted Material

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a
Figure 5

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b
Figure 5

Continued.

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d
Figure 5

Continued.

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83

f
Figure 5

Continued.

tion resulting from radiation damage tbat was greater than the tissue's ability to
recover from the initial insult from the radiation. Tbe chest wall is noted to have
necrotic tissue, bacterial colonization, and poor function (36). Tbe problems that arise
from radiation necrosis may occur throughout the life of the patient, causing problems
that evolve. Common malignancies treated with radiation, which result in radiation
necrosis, include breast cancers, lung primaries and recurrences, and metastatic
lesions. Due to the fujI-thickness chest wall damage and damage to the underlying

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structures including the lung, diaphragm, and sometimes the abdominal organs, a
careful work-up must be performed in order to anticipate the defect after resection of
the damaged tissue. The reconstructive options must be carefully scrutinized and plans
made for a secondary option in the case of failure of the first. Multiple approaches
have been used for the reconstruction after resection of radiation damaged tissue,
ranging from local flaps (37,38) to combinations of free flaps with alloplastic materials
and local flaps. The principle of providing chest wall stability while achieving airtight
closure with well-vascularized tissue holds true here as with all other approaches to
chest wall reconstruction (Fig. 5).

V.

ROLE OF ALLOPLASTIC MATERIALS IN PLEURAL


RECONSTRUCTION

Alloplastic materials are useful in pleural reconstruction. They can provide barrier
function, strength, and structural integrity. However, they generally cannot be used
without adequate soft tissue coverage and are not reliable in fields where bacterial
contamination or obvious infection is evident. This is the case in many pleural
reconstructions and other methods of repair must be considered without the use of
alloplastic materials. Goretex (W.F. Gore, Inc., Phoenix, AZ) and Proline Mesh
(Ethicon, Inc. Sommerville, NJ) are materials commonly used in pleural reconstruction (39). They are durable and capable of maintaining the support of the overlying or
underlying tissues that have been used in the reconstruction. These materials cannot
be used without well-vascularized soft tissue coverage. They can be used to reinforce a
bronchial stumri repair or as a patch for the chest wall where ribs or sternum have been
resected.

VI.

CONCLUSION

Pleural reconstruction is an integral part of any chest wall reconstruction. Sealing the
pleural cavity from visceral structures and the outside world takes careful planning
and judgement. The principles described in this chapter are the key to generating
favorable outcomes for patients. Making an accurate diagnosis, proper assessment of
the defect, and constructing a carefully designed surgical plan are the necessary steps to
achieve the best possible results.

REFERENCES
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Pairolero PC, Arnold PG. Chest wall reconstruction. Ann Thorac Surg 1981 Oct; 32(4):
325-326.
Larson DL, McMurtrey MJ. Musculocutaneous flap reconstruction of chest-wall defects:
an experience with 50 patients. Plast Reconstr Surg May 1984; 73(5):734-740.
CIcero R, del Vecchyo C, Porter JK. Open window thoracostomy and plastic surgery
with muscle flaps In the treatment of chronic empyema. Chest Mar 1986; 89(3):374-377.
Arnold PG, Pairolero Pc. Chest Wall Reconstruction: an account of 500 consecuti e
patients. Plast Reconstr Surg 1996; 98:5.

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J00 consecutive cases. Plast Reconstr Surg 1994; 93:324.
Arnold PG, Johnson CH. Chest wall reconstruction. Surg Oncol Clin 1997; 6: 1055.
Pearson EG. Thoracic Surgery. New York: Churchill Livingstone, 1995.
Arnold PG, Johnson CH. Chest Wall Reconstruction. Surg Oncol Clin 1997; 6:1055.
Arnold PG, Pairolero Pc. Chest Wall Reconstruction: an account of 500 consecutive
patients. Plast Reconstr Surg 1996; 98:5.
Deschamps C, Pairolero P C, Allen M S, Trasteck V F. Management of postpneumonectomy empyema and bronchopleural fistula. Chest Surg Clin North Am 1996; 6:519-527.
Miller n, Mansour C, Howe WR, Nahai F, Jurkiewicz MJ, Hatcher CR. Single stage
complete muscle flap closure of the postpneumonectomy empyema space: a new method
and possible solution to a disturbing complication. Ann Thorac Surg 1984; 38:227.
Shirakusa T, Ueda H, Takata S. Use of pedicled omental flap in treatment of empyema.
Ann Thorac Surg Sep J990; 50(3):420-424.
Perkins DJ, Lee KK, Pennington DG. Free flaps in the management of intrathoracic
sepsis. Br J Plast Surg Dec 1995; 48(8):546-550.
Cicero R, del Vecchyo C, Porter JK. Open window thoracostomy and plastic surgery
with muscle flaps in the treatment of chronic empyema. Chest Mar 1986; 89(3):374377.
Lau WF. Lam KH, Wong J, Ong GB. Surgical management of benign oesophagopleural fistula. Aust NZ J Surg Feb 1983; 53(1):43-47.
Gouge TH, Depan HJ, Spencer FC. Experience with the Grillo pleural wrap procedure
in 18 patients with perforation of the thoracic esophagus. Ann Surg May 1989; 209(5):
612-619.
Zumbro GL, Anstadt MP, Mawulawde K, Bhimji S, Paliotta MA, Pai G. Surgical management of esophageal perforation: Role of Esophageal Conservation in Delayed Perforation. Am Surg 2002; 68:36.
Karnak 1, Tanyel FC, Buyukpamkcu N. Esophageal perforations encountered during
the dilatation of caustic esophageal strictures. J Cardiovasc Surg 1998; 11:276.
Brooks JW. Complications of Pulmonary and Chest Wall Resection. Complications in
Surgery and Trauma. 2ed. 1990:331-332.
Arnold PG, Johnson CH. Chest Wall Reconstruction. Surg Oncol Clin 1997; 6:1055.
Foroulis C, Kotoulas C, Konstantinou M, Lioulias A. The use of pedicled pleural flaps
for the repair of pericardial defects, resulting after intrapericardial pneumonectomy. Eur
J Cardiothorac Surg Jan 2002; 21(1):92-93
Gouge TH, Depan HJ, Spencer FC. Experience with the Grillo pleural wrap procedure
in 18 patients with perforation of the thoracic esophagus. Ann Surg May 1989; 209(5):
612-619.
Mineo TC, Ambrogi V. Early closure of the postpneumonectomy bronchopleural fistula
by pedicled diaphragmatic flaps. Ann Thorac Surg 1995; 60:714-715.
Sayeed-Shah U, Strachan J, Elefteriades JA. Diaphragm flap for routine prophylactic
reinforcement of bronchial stump after pneumonectomy. Ann Thorac Surg J un 2001;
71(6):2081-2083.
Hallock GG. Intrathoracic application of the transverse rectus abdominis musculocutaneous flap. Ann Plast Surg Oct 1992; 29(4):357-361.
Rand RP, Maser B, Dry G, Vallieres E. Reconstruction of irradiated postpneumonectomy empyema cavity with chain-link coupled microsurgical omental and TRAM flaps.
Plast Reconstr Surg Jan 2000; 105(1):183-187.
Shirakusa T, Ueda H, Takata S. Use of pedicled omental flap in treatment of empyema.
Ann Thorac Surg Sep 1990; 50(3):420-424.
Cordeiro PG, Santamaria E, Hidalgo D. The role of microsurgery in reconstruction of
oncologic chest wall defects. Plast Reconstr Surg Dec 200 I; 108(7): 1924-1930.

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Molnar JA, Pennington DG. Management of postpneumonectomy bronchopleuralcutaneous fistula with a single free flap. Ann Plast Surg Jan 2002; 48(1):88-91.
Hammond DC, Fisher J, Meland NB. Intrathoracic free flaps. Plast Reconstr Surg Jun
1993; 91(7):1259-1264
Morgan RF, Edgerton MT, Wanebo HJ, Daniel TM, Spotnitz WD, Kron IL. Reconstruction of full thickness chest wall defects. Ann Surg Jun 1988; 207(6):707-716.
Sabanathan S, Shah R, Mearns AJ, Richardson J. Chest wall resection and reconstruction.
Br J Hosp Med Mar 19-Apr 1 1997; 57(6):255-259.
Larsson S, Pettersson G, Eldh J, Eriksson E. Reconstruction of large anterior fullthickness defect in the chest wall after resection of chondrosarcoma. Scand J Thorac
Cardiovasc Surg 1984; 18(1):63-67.
Boyd AD, ShawWW, McCarthyJG, Baker DC, Trehan NK,Acinapura AJ, Spencer
Fe. Immediate reconstruction of full-thickness chest wall defects. Ann Thorac Surg Oct
1981; 32(4):337-346.
Hines GL, Lee G. Osteoradionecrosis of the chest wall. Management of postresection
defects using Marlex mesh and a rotated latissimus dorsi myocutaneous flap. Am Surg
Nov 1983; 49(11):608-611.
Rand RP, Maser B, Dry G, Vallieres E. Reconstruction of irradiated postpneumonectomy empyema cavity with chain-link coupled microsurgical omental and TRAM flaps.
Plast Reconstr Surg Jan 2000; 105(1):183-187.
Hines G L, Lee G. Osteoradionecrosis of the chest wall. Management of postresection defects using Marlex mesh and a rotated latissimus dorsi myocutaneous flap. Am Surg
Nov 1983; 49(11):608-611.
Arnold PG, Johnson CH. Chest Wall Reconstruction. Surg Oncol Clin 1997; 6:1055.

31.
32.
33.
34.

35.

36.

37.

38.

39.

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7
Alloplastic Reconstruction of Chest
Wall Deformities
DAVID J. ROWE and ARUN K. GOSAIN

Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A.

I.

INTRODUCTION

Alloplastic reconstruction of the chest wall is used for the correction of various
deformjties: congenital, traumatic, or as the result of tumor resection. These materials
may not only provide sufficient or ideal cosmesis but, in some instances, may also
improve chest wall stability and thus respiratory and cardiopulmonary function. This
chapter will briefly describe some of the disease entities that benefit from the use of
alloplast in reconstruction of the chest wall, review various alloplasts that have been
used for chest wall reconstruction, and evaluate long-term outcomes and complications following reconstruction.

II.

HISTORY

It is postulated that Osias Aimar performed the first resection of the chest wall in 1778.
In the ensuing century, several other cases were reported (1). However, the efficacy of
the procedure was primarily based on the ability of the surgeon to avoid the pleural
space and thus avoid pneumothorax. Violations of the pleural space were repaired
with great haste and incurred significant morbidity and mortality.
The advent of endotracheal intubation improved the ability of the surgeon to
breach the pleura (1). With World War II came multiple advances in surgical
technology and technique, antibiotics, intensive care, and the ability to drain the
pleural ca vity adeq uately (2). Based on these experiences, the morbidity and long-term
survival of treated patients subsequently improved.

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As techniques in resection improved, reconstructive options were needed due to


the larger defects created. The advent of omental and myocutaneous ft.aps afforded
coverage for these larger defects. However, following extensive rib resection and subsequent soft tissue reconstruction, the resultant paradoxical movement often produced a physiological abnormality of the chest wall.
The use of alloplasts for reconstruction of any type was not possible until the
advent of asepsis by Lister in the 1860s. The earliest successful implants were used in
the plating of skeletal fractures in the early 1900s. The use of polymers in reconstruction began shortly after World War 11. Doctors found that pilots injured by fragments
of the aircraft canopy, which was made from polymethyl methacrylate, did not have
chronic reactions due to the implanted fragments. Ultimately, this suggested that longterm implantation of such materials could be tolerated (3).
By 1960, surgeons were developing techniques for the stable reinforcement of
large areas of resected chest wall. One of the earliest techniques developed was the use
of Marlex (CR Bard, Billerica, MA) mesh by Graham and colleagues (1960) (4). This
enabled relatively rigid reconstruction of the chest wall and resulted in lower morbidity
rates, shorter postoperative ventilator time, and shorter overall hospital time. Since
then, multiple alloplasts have been described for chest wall reconstruction

III.

PREOPERATIVE EVALUATION

Current mortality rates following resection and reconstruction of the chest wall are
approximately 4.1 % (5). It is therefore essential that adequate preoperative evaluation
be performed to identify and correct potential problems prior to surgery.
Preoperative evaluation of pulmonary status should include smoking history,
history of asthma or other pulmonary diseases, and chronic infections. Pulmonary
function evaluation is routine and includes spirometry with and without bronchodilation, arterial blood gas on room air, and chest radiographs (6). This evaluation will
allow the physician to optimize the pulmonary status of the patient prior to surgical
intervention, and may lead to decreased morbidity and mortality following the
procedure. Preoperative cardiovascular assessment should evaluate for hyper- and
hypotension, cardiac arrhythmias, past history of myocardial infarction, and congestive heart failure. Any cardiovascular abnormalities should be optimized prior to
surgery. Hypotension should be treated aggressively both intraoperatively and postoperatively, since prolonged or profound hypotension may lead to flap ischemia
and necrosis. This may subsequently lead to loss of any underlying alloplast used for
reconstruction.

IV.

AUTOGENOUS TISSUE

AbrashanofT first described in 1911 the use of autogenous tissue a nd muscle transposition in chest wall reconstruction (7). Today, autogenous tissue continues to be used
extensively for coverage. Many types of flaps are currently utilized for chest wall
coverage, including muscle flaps, myocutaneous flaps, omentum, and fascial flaps. The
use of autogenous tissue in reconstruction is optimal in situations with presumed
infection. Multiple techniques have been described for the treatment of osteomy litis,
chostochondritis, and infected median sternotomy wounds (8). In addition, tissue with
adeq mite viabili ty may be used following radiation or in cases of osteoradionecrosis.

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V.

PECTUS EXCAVATUM

The first surgical treatment reported in the literature for pectus excavatum was
performed in 1931 by Sauerbach (9). In 1949 Ravitch (10) developed a widely accepted
technjque to correct the pectus excavatum defect. This operation involved subperichondrial excision of the involved cartilage, transverse osteotomy, and internal
fixation. With minor alterations, this technique has been the basic procedure of choice
for five decades. However, this procedure has had equivocal results on increasing
pulmonary function, presumably due to the creation of a restrictive lung defect as well
as impingement on further chest wall growth. Following sternotomy and subsequent
fixation, the chest wall may have increased rigidity and hence decreased compliance.
In 1998, Dr. Nuss reported the first account of minimally invasive repair of
pectus excavatum (II). The technique involves the placement of a rigid bar substernally beneath the defect. Since its initial report, the technique has gained much
notoriety as a less invasive and more cosmetically appealing operation than the
Ravitch-type approaches. However, minimally invasive pectus excavatum surgery
has shown a high incidence of complications (12,13). The most common complication
has been displacement/rotation of the rigid bar, seen in 9% of patients. This
complication necessitates reoperation. The rate of pneumothorax following this
procedure is reported to be 5%. Despite these complications, 96.5% of patients report
that they were satisfied with this procedure. Due to the recent introduction of this
procedure, no long-term data are available.
Mild pectus excavatum deformities in young adults with little to no respiratory
or cardiopulmonary compromise may undergo contour restoration procedures for
correction of the deformity. Alloplasts have been used with success in this group of
patients, as well as in patients who have undergone more invasive forms of chest wall
reconstruction who still have residual deformities (see Fig. 4).
VI.

RECONSTRUCTION FOR PALLIATION

Surgery of the chest wall may be performed for palliative purposes. The basic tenets
in palliative surgery are to provide a safe, reproducible means for quick recovery (14).
In such circumstances, autologous tissues have been used extensively with low morbidity and mortality (15-17). Alloplastic materials have been used less freq uently in
cases of palliation. Rjvas (IS) reported the use of a combination of Gore-Tex (W.L.
Gore and Associates, Flagstaff, AZ) mesh and a latissimus dorsi flap in full-thickness
chest wall defects. These authors found respiratory function to be normal in 71 %
of patients.
VII.

ALLOPLASTS

A.

Reconstruction of Congenital Chest Wall Defects

1.

Silicone

Silicone is one of the most widely used biomaterials, as well as the one that has evoked
the most public controversy. The relationship between silicone breast implants and
various connective tissue disorders has led to research and litigation over the past
decade. To date, the associ a tion has been equivocal. Recent meta-analyses have shown

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that there may, in fact, be no statistically significant risk of connective tissue disorders
in association with silicone breast implants (18).
Silicone (polydimethyl siloxane) may take several forms including elastomer, gel,
fluid, and foam. The material itself is mechanically and chemically stable and has
significant durability. The elastomeric form of silicone is the form primarily used for
chest wall reconstruction.
Silicone prostheses have been used since the early 1970s to correct contour
defects in the chest wall (19-21). This technique represented a major breakthrough in
cosmetic reconstruction, because the prostheses were custom-fabricated to the size,
shape, and volume of the contour abnormality, thus aHowing for restoration of
normal contour. Silicone has been primarily used in the reconstruction of congenital
chest waH defects, most commonly pectus excavatum and Poland's syndrome.
Multiple techniques have been used to mold the silicone prosthesis. The inlay
method, originally described by Lash and colleagues in 1964 (22), involves the initial
construction of an alginate-plaster moulage of the chest wall. From the moulage, a
positive cast is then made using either acrylic or plaster. Subsequently, the defect area
in the positive cast is molded using wax. The silicone elastomer is then placed in the
defect mold and heated to the manufacturer's specifications to allow for polymerization (23,24). Our use of this technique is illustrated (Fig. 2).
The major pitfaH to this technique is the presence of soft tissue overlying the
defect. The actual contour and size of the pectus deformity may be partially obscured
by the varying thickness of the soft tissue in the chest wall. Many authors have
developed techniques for measuring the thickness of the skin (24,25), however this may
still result in a less than ideal implant fit. The resultant implant may be subject to
rotatory forces allowing for movement and tilting. Furthermore, the edges of the

Figure 1 A 16-year-old boy presented with congenital absence of the right pectoralis major
muscle. He noted slight weakness of the right arm, but was able to participate in sports
without impairment. The patient was extremely self-conscious and refused to remove his shirt
or be seen in a swimming suit in public. (Courtesy of Arun K. Gosain, M.D.)

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Figure 2 Left. A moulage was made preoperatively and used to fabricate a customized
silicone chest wall implant. Right. The customized silicone implant is shown intraoperatively.
A subcutaneous pocket has been dissected through a right transaxillary incision. (Courtesy of
Arun K. Gosain, M.D.)

implants may be visible, calling attention to the implant. This is illustrated in a male
patient with Poland's syndrome who underwent reconstruction of the chest wall using
a customized silicone implant (Figs. 1-3).
Newer techniques are also available to create the silicone prosthesis. Johnson
(26) has described a technique using computed tomography to guide the implant
dimensions. Three-dimensional reconstruction of the chest wall contour is used to
recreate the defect onto hand-traced sections of stacked foam board. The moulage,
as described above, is then created from the computed tomographic (CT) reconstruction. Johnson describes case studies of three patients with follow-up from I to 6

Figure 3 Three weeks after placement of a customized silicone implant to the right chest
wall. Although contour has been restored, a step off is still noticeable at the edges, which calls
attention to the implant. (Courtesy of Arun K. Gosain, M.D.)

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years. He reports that no implant demonstrated rocking or tilting, and none had
visible edges.
The silicone prostheses used in patients with Poland's syndrome are also customfit to the patient's contour. The typical moulage is made to interpret and design
adequately the solid silicone deformity prosthesis. Due to congenital absence of the
breast, the prosthesis may concomitantly contain a customized breast implant
matching the other breast (27). This technique allows total aesthetic reconstruction
of the chest wall.
2.

Medpor (Porous Polyethylene)

Medpor (Medpor, Porex Surgical, Atlanta, GA) is a linear high-density polyethylene.


It has an inherent porosity, with pore sizes ranging from 50 to 100 11m. This porosity

allows the material to also act as a microfilter, effectively filtering material larger than
5 11m. Advantages of Medpor include its strength, flexibility, and ease in passing
sutures through the material. Medpor also allows for fibroblastic ingrowth and thus
adds strength to the prosthetic~tissue interface (28).
There are several means by which to customize the Medpor implant to fit the
desired defect. First, the material itself can come in a rudimentary shape that the
surgeon may contour to match the defect intraoperatively. The material can be
contoured using a scalpel or a bur, without collapse of its porous architecture. Second,
a moulage of the chest wall defect can be made as described above for silicone
implants, and the Medpor prefabricated to match the moulage (see Fig. 5). Lastly,
Medpor can be contoured to a specific defect preoperatively using CT-generated threedimensional reconstructions. This may have the added advantage of creating the
customized Medpor implant to take into account the thickness of the soft tissue
overlying the defect, which cannot be done as accurately when using a moulage for
prefabrication. Whether the implant is prefabricated using a moulage or from threedimensional CT data, the surgeon is able further to contour the implant intraoperatively using a scalpel or bur as needed.
Medpor currently has had applications in orbital rim, skull base, and mandibular reconstruction, as well as reconstruction of cranial defects and facial contouring.
To our knowledge, there are no published reports on its use in chest wall reconstruction. However, it has been used for the reconstruction of congenital defects of the
chest wall by Dr. Gary Brody (29) and by us. Our use of Medpor for chest wall
reconstruction in a l4-year-old boy with pectus excavatum is illustrated (Figs. 4-6).
We found that the Medpor could be prefabricated with much thinner edges than its
silicone counterpart (Figs. 1-3), allowing a much more natural taper between the
implant and the adjacent soft tissues. Whereas a step off was seen after placement of
the prefabricated silicone implant (Fig. 3), no such step off could be appreciated after
placement of the prefabricated Medpor implant (Fig. 6).
B.

Reconstruction of Chest Wall Defects FollOWing Rib Resection

1.

Silastic Sheeting

Silastic sheeting has also been used to reinforce the chest wall when there is an absence
of rib, usually following trauma or tumor resection. The silastic sheet is a 0.20 cm thick
silicone sheet reinforced with a Dacron mesh. A study performed on implantation
of prostheses following che t wall reconstruction (30) observed that there was no

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93

Figure 4

A 14-year-old boy underwent repair of pectus excavatum using a Nuss technique


I year previously. This technique involves use of a substernal metal bar to elevate and support
the chest wall concavity. The patient has residual depressions over the right chest wall region
indicating incomplete correction of pectus excavatum. (Courtesy of Arun K, Gosain, M,D,)

difference in cosmetic or functional outcome between the use of polytetrafluoroethylene (PTFE) and Silastic sheeting,
2.

Mesh: Nylon and Marlex

The majority of meshes are used to augment soft tissue coverage of the chest wall
when extensive bony resection has been performed, Myocutaneous flaps allow large
amounts of durable soft tissue and skin with adequate blood supply, However, they do
not provide adequate structural support, The combination of mesh and soft tissue
reconstruction allows varying degrees of stability to be produced, thus minimizing
or preventing paradoxical movement of the chest wall and providing a more aesthetic result.

Figure 5 Left. A moulage was made preoperatively for fabrication of a customized MedpOl' (Porex Surgical, Inc, Atlanta, Georgia) implant for the chest wall. Right. Intraoperative
view of customized Medpor implant for correction of residual chest wall defom1ities, The
implant is placed through the chest wall incision previously made for the Nuss procedure.
(Courtesy of Arun K. Gosain, M.D.)

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Figure 6 Postoperative appearance 3~ months following placement of the customized


Medpor implant to the right chest wall. The contour deformities of the chest wall have been
corrected, and there is no visible step off at the peripheral margins of the implant The patient
has resumed all normal activities without any discomfort, and range of motion of the shoulders
and anns is normal. (Courtesy of Arun K. Gosain, M.D.)

Marlex is a monofilament polypropylene that has been used in chest wall


reconstruction for the past five decades. It is biologically inert and may be incorporated into clean wounds without extrusion. The mesh nature of Prolene allows
fibroblastic proliferation within the interstices, thus conferring added strength to the
prosthetic-tissue interface. However, Marlex can only provide tension and rigidity in
one direction. This is in contrast to Prolene mesh (Ethicon, Inc., West Sommerville,
NJ), and Gore-Tex mesh, which are able to provide multiple directions of rigidity.
Prolene mesh is a double-knitted monofilament polypropylene able to withstand
150 Ibs of pressure (31). Unlike Marlex mesh, the knitting process provides the Prolene
mesh with bidirectional elasticity.
Kroll and colleagues (32) analyzed the efficacy of Marlex mesh in chest wall
reconstruction. One hundred and one patients undergoing reconstruction [or primary
tumor, recurrent tumor, or radionecrosis were evaluated. Forty of the 101 patients
underwent reconstruction using a combination of Marlex mesh and myocutaneous
flaps, while the remainder of patients underwent reconstruction using flaps without
any underlying mesh. The mean number of days on ventilatory support was significantly lower in the group in which Marlex mesh and flaps were used (0.8 days) than
in those in which flaps alone were used (4.9 days). Patients in whom Marlex mesh
was used also had a decreased mean length of hospital stay 9.7 days vs. 17.5 days with
flaps alone).

3.

Composite Materials (Marlex or Prolene and Methylmethacrylate)

Composite materials, by definition, contain two or more distinct constituents that


differ in their micro- or macrostructure. These materials have al 0 been advocated
for use in chest wall reconstruction following extensive rib resection. A sandwich of
Marlex or Prolene and methylmethacrylate has been used to provide stability and
contour to the reconstructed chest wall. The addition of methylmethacrylate adds
additional tensile strength to the mesh structure. While some authors consider that
this combination provides the optimal results for stability (33), others believe that the

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95

added rigidity provided by combining materials is not needed for chest wall reconstruction (34). To our knowledge the comparison of composite materials and mesh
reconstruction has not been evaluated.
The technique for fabrication of composite materials for chest wall reconstruction begins by making an intraoperative impression of the defect (35). The mesh is
then excised to the specifications of the wound, allowing a 5 cm sewing surface around
the circumference. The methylmethacrylate solution is placed on the mesh and the
second layer of mesh is sandwiched to the mix. As the exothermic composite hardens, it is molded to the contour of the chest wall. The composite prosthesis may also
be contoured using the lateral thigh, which has a similar contour to the chest wall.
Care must be taken not to burn the patient with the exothermic reactant. Cold sodium chloride solution may be used to prevent heat injury to the lung, thigh, or
other soft tissues (36). The composite prosthesis itself is made smaller than the defect
to ensure that there is sufficient space for the prosthesis to move when the ribs flex.
This results in decreased sensations of pain and stiffness by the patient.
Lardinos et al. performed chest wall reconstruction on 26 patients using a
methylmethacrylate and Mersilene (polyethylene terephthalate; Ethicon, Sommerville, NJ) composite compound. Despite large anterolateral reconstructions, all patients were extubated immediately postoperatively and achieved an acceptable
aesthetic contour of the chest wall.
4.

Gore-Tex

Gore-Tex (PTFE; Gore and Associates, Flagstaff, AZ) is also able to provide stable
coverage for defects of the chest wall. Its chemical structure is analogous to that of
Teflon, which also has been used in mesh form. However, Teflon mesh was found to
have poor tensile strength, resulting in fraying of the material when under significant
tension (37). Gore-Tex material, unlike the meshes previously described, is created in a
sheet form primarily used in 2 mm thickness. The sheet is able to withstand traction to
22 kg/cm 2 (30). It cannot be contoured, although some authors prefer its ability to
stretch and the ease with which it can be sutured to the defect. Due to the properties of
PTFE, an impermeable membrane is created, resulting in a watertight seal of the
pleural space. However, there is also decreased adherence at the prosthetic-tissue
interface when the sheet form of PTFE is used.
In a retrospective study on the use of PTFE and polypropylene mesh in chest
wall reconstruction of 197 total patients, little difference was seen between the two
prostheses (5). An interesting finding was that despite the ability of PTFE to limit the
transfer of fluid and air between the pleural and subcutaneous spaces, the rates of
seroma (6.3% in polypropylene vs. 7.5% in PTFE) and wound infections (7.5% in
polypropylene vs. 3% in PTFE) were similar between the two materials.
5.

Less Pliable Alloplasts

Many other foreign materials have been used in reconstruction. These include metal
sheets, fiberglass cloth, steel struts, and Lucite. Use of these materials has been fraught
with difficulty and complications. Due to their inherent lack of pliability, they are
difficult to conform to the defect intraoperatively, and difficult to fashion to the defect
itself. Also, their incidence of rejection and concomitant extrusion from the implant
site is considerable. Metallic elements from implanted materials have also been
postulated to alter ion concentrations within the body (3). Even corrosion-resistant

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metals are not inherently inert and may lead to the release of some ionic elements. Of
especial concern is the alteration of divalent cation concentrations and thus the
alteration of some important enzymatic functions.
A composite technique combining Marlex and steel has recently been reported
for the correction of defects greater than 250 cm 2 (38). In this technique, the metal bars
are removed at varying time intervals between 3 and 16 months. Its long-term efficacy
following removal of the steel support bars has yet to be determined.

VIII.
A.

POTENTIAL COMPLICATIONS AND PITFALLS


Mortality

At the turn of the century, resection of the chest wall carried a 30% mortality rate (39).
Currently, 30 day mortality ranges from 0 to 5%, dependent on the nature and extent
of surgical resection performed (40). Due to the na ture of chest wall reconstruction
following tumor resection or trauma, one cannot separate the mortality of chest wall
resection from that of chest wall reconstruction, and patients and their families need to
be informed of the high risk intrinsic in these procedures. Reconstruction of congenital
deformities such as Poland's syndrome or pectus excavatum would be expected to
carry a significantly decreased mortality, since these procedures are usually perfonned
in a much healthier patient population and do not involve chest wall resection.
B.

Infection

Alloplasts covered by a healthy, well-vascularized tissue rarely become infected.


Multiple studies have shown an infection rate of approximately 5% when using
Marlex or Marlex composite (41,36). In a series of patients who had undergone chest
wall reconstruction using Marlex mesh, Kroll et al. (32) found that the only instances
of infection in the mesh occurred when there was local flap necrosis preceding the
infection. When infection occurs around the alloplast, some authors report salvage
of the reconstruction using irrigation and drainage. However, if infection persists
following conservative measures, removal of the prosthesis is required (35). This may
necessitate a delayed chest wall reconstruction once the infection has cleared.
However, successful chest wall reconstruction using mesh in infected wounds has
been reported anecdotally (42). When autologous tissue remains following removal of
an infected prosthesis, any resultant paradoxical movement of the chest wall is usually
accompanied by minimal dysfunction (8).
C.

Seroma

Seroma collection is found in all forms of mesh and PTFE implants, as well as Silastic
implants following chest wall reconstruction (43). Aspiration may be employed initially; however, the process is lIsually self-limiting.
IX.

LONG-TERM RESULTS

Despite the long history of alloplasts for chest wall reconstruction, there are few data
on long-term follow up. In a tudy of chest wall reconstruction vvith polypropylene
mesh and PTFE followed from 1 to 16 years, Deschamps et al. (5) found littl

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Alloplastic Reconstruction

difference between the two alloplasts. There were nine total wound infections (five
with polypropylene and four with PTFE). Eight operative deaths were reported for a
mortality rate of 4.1 %. Seromas were seen in 14 patients.

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8
Reconstruction of Pectus Excavatum
and Pectus Carinatum
THEODORE S. WRIGHT, SEEMA KUMBHAT, and MICHAEL L. BENTZ

Universiry of Wisconsin Nledical School, Madison, Wisconsin, U.S.A.

I.

A.

DEFINITIONS
Pectus Excavatum

Pectus excavatum is the most common congenital chest wall deformity and is
characterized by excessive depression and, frequently, rotation of the sternum
(Fig. 1). It occurs in an estimated I:300 live births, with many of these children
outgrowing their deformity. Also known as funnel chest, this anomaly develops from
the overgrowth of costal cartilages that curve dorsally and rotate, displacing the
caudal sternal body. Usually, this pattern is found at ribs 4--8 where there is frequently greater posterior rotation to the right. An abnormality in the growth of the
anterior diaphragm can accompany the development of this disease. The specific
cause of pectus excavatum is unknown (I); however, a family history of disease is
reported in 13--41 % of patients (10), suggesting a genetic predisposition. Histological
findings characteristic of necrosis and inflammation have been observed, but their
significance is unknown. Marfan's disease, scoliosis (15%), congenital heart disease
(2%), and functional heart murmurs are seen in association with pectus deformities.
Some authors recommend screening all patients with severe forms of pectus excavatum for Marfan's disease. This abnormality is rare among African-Americans. Males
are affected four times as often as females.
B.

Pectus Carinatum

Pectus carinatum is a less common disorder in which the sternum protrudes anteriorly, occurring 20% as frequently as pectus excavatum (Fig. 2). Depending on
99

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Wright et al.

Figure 1

Pectus excavatum with sternal depression and rotation.

the type, the adjacent costal cartilages or ribs adjoin symmetrically, in a concave
direction (chondrogladiolar protrusion), asymmetrically, or are depressed laterally.
The latter occurs most frequently. Occasionally, the superior chondromanubrial
joints and manubrium protrude and the remaining sternal body moves posteriorly.
Like pectus excavatum, a familial predisposition is evident in 30% of patients, and
an association with scoliosis and congenital heart disease is common. Males are
affected four times more frequently than females, but this defect does not generally
appear until after the first decade of life. Symptoms include dyspnea on exertion,
recurrent respiratory infections, and asthma, which is often more severe than with
excavatum deformities; these symptoms may often present out of proportion to the
physical deformity (2).

II.

CLASSIFICATION

One classification of pectus excavatum deformities is given by Willi tal (2). He classified
pectus excavatum into four types: 1, symmetrical depression: 11, asymmetrical
depression; Ill, symmetrical depression with platythorax; and IV, asymmetrical

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Figure 2

101

Pectus carina tum with sternal asymmetry.

depression with platythorax. In Fonkalsrud's series of375 patients (5), 30% had type
1. Few had platythorax or flat chest.
III.

CLINICAL PRESENTATION

The diagnosis of pectus excavatum is routinely made in the first year of life; however,
a delayed onset may occur in patients with Marfan's disease (3). Progression of disease
coincides with periods of rapid growth. Carina tum patients mainly desire surgery for
improvement of their respiratory symptoms, unlike many patients with pectus
excavatum who seek treatment due to their physical appearance. Some 85% of patients with peotus excavatum experience psychological problems ranging from social
anxiety to severe depression (as a result of a poor self-image). Einsiedel (4) reports
that children older than 11 years with pectus deformities suffer embarrassment,
stigmatization, limited' capacity for work and communication, feelings of failure,
and frustration.
Evidence of significant physiological consequences has been Infrequently
reported in the excavatum population. Subjective complaints of dyspnea on exertion
(30-70%), decreased exercise tolerance (compared to their peers), and worsening

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stamina and endurance (67%) are linked to the deformity. Affected adolescent patients choose more sedentary activities (i.e., computer programming over athletics)
(5), often isolating themselves from group physical education classes. More aggressive patients manage athletic competition by taking large diaphragmatic breaths,
usually participating in low-endurance activities.
Patients with pectus excavatum generally share a characteristic physical appearance. Their body habitus is asthenic with a narrow anterior-posterior chest diameter,
and a slouching posture. Younger children typically have a potbelly, accentuated by
flaring of the lower costal cartilages (5). Paradoxical breathing occurs and accentuates
the depression. Physical examination reveals a symmetrical or asymmetrical deformity, local or diffuse depression, and a depth as great as the thoracic vertebra. A loud
parasternal systolic murmur with a thrill and split-second heart sound is sometimes
heard (6), arising from sternal compression of the right heart.
Objective measures demonstrating a mild reduction in total lung capacity and
vital capacity have been obtained in patients with pectus excavatum. Recurrent
respiratory infections (32%) are frequently associated (5), and, retrospectively,
asthma has been reported in 5.2% of patients. These symptoms often correlate with
the severity of the sternal depression (7).

Figure 3 Lateral chest radiograph with barium contrast on chest wall highlio-hts the mild
'"
degree of sternal depression.

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IV.

103

IMAGING STUDIES

Imaging studies provide an indirect measure of the severity of the deformity and can
help to determine the type of treatment. Common radiographic findings include
prominence of the left upper cardiac border, shift of the heart to the left (further
depression on the right of the sternum rotates the heart upward and to the left), an
increase in density below the right hilum, failure to visualize the border of the right
heart, and accentuation of the downward angulation of the ribs. On plain lateral
radiographs, the distance between the posterior surface of the sternum and the
anterior border of the thoracic vertebra can define the extent of pectus (Fig. 3).
Accounting for differences in body size adds further precision to this measurement.
Other radiographic measurements include the distance from the sternal depression to the anterior chest wall, where greater than 3.0 cm is considered significant.
A nonimaging technique utilized to gauge pectus severity is the so-called hollow
index: the number of cubic centimeters of water that can be poured into the ste'rnal
depression is calculated, but this is not commonly performed.
Computed tomography is also employed to guide management. As given by
Haller (7), a ratio of the lateral inner wall to the anterior-posterior wall greater than
3.25 suggests the need for surgical correction. Echocardiography identifies additional
signs associated with the deformity. Two-dimensional echocardiography reveals
decreased right atrial, ventricular, and outflow tract output related to compression
of the right side of the heart by the sternum (9).

V.

INDICATIONS FOR SURGICAL MANAGEMENT

Indications for surgical management include aesthetic severity and symptoms such as
shortness of breath, fatigability (during exercise), and paradoxical breathing. Fewer
than 15% of patients with pectus excavatum undergo surgery. Ninety-five percent of
patients report no cardiovascular symptoms.
Surgical correction of pectus excavatum has achieved a performance benefit as
documented in several studies. Fonkalsrud studied the cardiopulmonary effects in
chjldren with pectus excavatum following repair. Initially, most patients with pectus
excavatum had reduced exercise tolerance when engaging in activity. Specifically,
patients complained of difficulty climbing stairs, increased respiratory infections,
exercise-induced asthma, and anterior chest wall pain following vigorous activity. At
4 months postoperatively, each could participate in vigorous activity such as running, hiking, swimming, and tennis; and each noticed dramatic improvement in
their symptoms. In 12 of 13 patients, a decrease in the frequency and severity of
respiratory infections occurred. Six of seven patients with asthma exhibited less
wheezing and a concomitant decrease in their medication requirement. Chest pain
considerably improved in the 3 postoperative months. Heart murmurs were no
longer audible in four of six patients. Eleven of 12 children who underwent preoperative measurement of vital capacity with incentive spirometry experienced
objective improvement within 6 months. Chest radiographs revealed a shift of heart
to a more normal position in half of these patients (5).
Haller at Johns Hopkins studied 36 teenaged patients (average age, 16) with
pectus excavatum who were otherwise healthy. These participants engaged in
preoperative and postoperative pulmonary function testing. Only three or four

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interspaces were resected. Patients with pectus excavatum were observed to have
significantly improved duration of exercise following surgery. Correction of sternal
depression relieved compression on the right heart, thus allowing greater stroke
volume and less myocardial contractility (7).
Zhao reported an objective measure of improvement in 13 patients with pectus
excavatum compared with 20 patients with normal thoraces who underwent supine
and sitting cycling and exercise measurements. Oxygen delivery and stroke volumes
were compared. Patients with pectus excavatum exercising in the sitting position had
reduced performance when compared to control, while supine exercise led to values
closer to control. Upright exercise capacity is affected by reduced filling of the heart
that occurs when not supine (8). Echocardiograms of the right ventricle revealed
greater stroke volumes in both diastolic and systolic phases 6 months after correction
of pectus excavatum (9).
VI.

SURGICAL TECHNIQUES FOR THE MANAGEMENT


OF PECTUS EXCAVATUM

Several techniques have been described for the correction of pectus excavatum
deformities. In general there are two types: those that address the deformity by
attempting to remodel the chest wall anatomically (to realize both the cosmetic and
physiological benefits of correction), and those that address the cosmetic issues alone.
Anatomical remodeling, originally performed with open surgical procedures, has now
been achieved with novel, minimally invasive techniques.
A.

Ravitch Technique

In 1949, Ravitch reported a technique for correction of pectus excavatum involving


excision of all deformed costal cartilages with their perichondrium (Figs. 4, 5),

Figure 4

Intraoperative appearance of chest wall following subperichondral cartilage re-

sectioll.

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Figure 5

105

Resected cartilage from four abnormal bilateral costal segments.

division of the xiphoid from the sternum, division of the intercostal bundles from
the sternum, and transverse osteotomy (Fig. 6). This allowed anterior displacement
of the sternum, with an approximation of normal chest wall contour (Fig. 7). Later
techniques modified this approach by preserving the perichondrial sheaths to promote cartilaginous ingrowth, and preservation of the intercostal bundles. These
techniques used silk sutures to fix the sternum. Later approaches have used bio-

Figure 6 Sternal mobilization following division of attached intercostal bundles, perichondral sheaths, and sternal osteotomy.

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Figure 7

Postoperative appearance of patient shown in Figure I. In men, a vertical incision


is commonly utilized, while the transverse approach is generally preferable in women.

absorbable materials (11), titanium miniplates (12,13), vascularized rib struts (14),
and, most commonly, stainless steel struts to provide internal stabilization. Haller
further advocated a so-called tripod fixation method in which, following sternal
osteotomy and subperichondrial cartilage resection, the normal 2nd and 3rd costal
cartilages are divided obliquely and allowed to override themselves, thus supporting the sternum in an anterior position.
Fonkelsrud has reported an experience of over 300 modified Ravitch repairs for
pectus excavatum, and 90 cases of pectus carinatum to date (5,15). After the induction
of general anesthesia, a transverse submammary incision (or vertical midline incision)
is completed. Pectoralis muscle flaps are then elevated to expose the underlying
sternum and abnormal cartilage. The xiphoid process is separated from the body of
the sternum. The sternum is then separated bluntly from the underlying mediastinal
structures. A transverse wedge osteotomy is performed on the anterior table of the
sternum. The posterior table is then incompletely fractured, to allow elevation of the
lower part of the sternum. The sternum is fixed in this position with interrupted
nonabsorbable suture material placed through the anterior table of the sternum. Care
is taken to maintain the blood supply to the lower part of the sternum, since

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devascularization of the sternum has been associated with recurrence of the deformity.
The sternum is supported by the reapproximated perichondrial sheaths of the lower
ribs in children younger than 4 years of age. Stainless steel struts are used in others. In
the latter case, the perichondrial sheaths and xiphoid are then reattached to the sternal
edges. The wound is drained via the right pleural space or, in some instances, with
closed suction drains in the subpectoral and subcutaneous spaces.
Pectus carinatum is repaired in a similar fashion. Exposure is obtained via
subpectoral flaps, and subperiostial resection of the most severely involved costal
cartilages is performed. However, the transverse sternal osteotomy is then filled with
costal cartilage to secure it in a more downward position. Asymmetrical protrusion
may require unilateral chondral resection or resection of the anterior table of one side
of the sternum (16).
Patients require hospitalization for 3--4 days after the procedure, and are
discharged with instructions to avoid chest wall trauma for 4-6 months. New
cartilaginous ingrowth is seen within 2 months; the support bar is removed in 5-6
months via alveolar incisions. Fonkelsrud reports a recurrence rate of less than 2%.
Done in this manner, the modified Ravitch repair has been the mainstay of surgical
technique for the correction of pectus deformities, giving reproducible functional and
cosmetic results.
Haller has discussed the complications of the traditional repair, which are
classified as early or late (17). Early complications include bleeding, pneumothorax,
and atelectasis in the lower lobes of the lungs, particularly the left (which can be
prevented with positive pressure ventilation), and infection.
Late complications include a slipped sternal support, recurrence of the pectus
excavatum, and postoperative restriction of the chest wall (acquired leune's syndrome). A slipped substernal support can present as a pleural or pericardial effusion, seen following vigorous activity. Prevention by limiting activity in the initial
postoperative period is important. Treatment is urgent removal of the support bar.
Recurrence, marked by return of the sternum to its previous dependent position,
occurs in fewer than 5% of patients. It is believed that recurrence results from rapid
growth of the chest during puberty, since this is when most recurrences are seen
clinically. Inadequate initial operation due to resection of only one or two costal
cartilages is also associated with a poorer long-term result. The treatment, should the
patient desire it, is reoperation. Altbough the dissection tends to be more difficult due
to adhesions, the size of the patient, and ossification of the costal cartilages,
satisfactory results can be achieved.
Postoperative restriction of the chest wall is due to failure of growth of the chest
wall. It is almost invariably associated with extensive subperichondrial dissection
(removal of five or more cartilages on each side), or surgery performed at a very young
age (less than 4 years). These patients usually present as older children or young adults
with symptoms of dypsnea on exertion, and noticeable retardation of chest wall
growth. Often they have bad recurrent pneumonias. Physical examination reveals a
small, immovable chest wall, without recurrence of pectus excavatum. Pulmonary
function tests confirm a marked restrictive abnormality with concurrent decreases in
forced vital capacity (FYC) and forced expiratory volume in I s (FEY I). Surgical
correction with anterior splinting has been described. Prevention of this complication
by avoiding operation in early infancy, and limiting dissection to only those areas of
abnormal growth, is helpful.

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B.

Wright et al.

Turnover Procedure

Juro Wada first carried out the sternal turnover procedure for pectus excavatum
in 1959, and has since amassed an experience of over 2500 patients (18). The basic
technique is an orthotopic bone transplantation of the reversed, contoured body of
the sternum. Through a midline or submammary approach, chondrotomy of the ribs
and myotomy of the intercostal muscles are carried out just medial to the edges of
the deformity. A transverse osteotomy is carried out just above the superior edge of
the deformity. The sternum is separated from the xiphoid process, and the sternum
mobilized. The sternum is then tailored to the chest wall with multiple transverse
incisions, which serve to elongate and flatten the gladiolus without tension. The bone
fragment is then positioned in the chest wall defect and secured to the costal margins
and the Xiphoid with strong suture material. This technique can be modified in cases
of extreme asymmetry by securing the sternal fragment anteriorly to the superior
sternal stump, thus elevating the costal margins and increasing the anteroposterior
diameter of the chest. Closed suction drains are placed above and below the surface of
the sternum. The pectoralis muscles are approximated, and the skin closed. Wada
reports a 2% recurrence rate. Although not the most commonly utilized technique for
pectus repair, it may have a role in patients in whom wide a costochondral resection
may not be tolerated, or in those whose pectus deformities have a significant
manubrial component.
C.

Minimally Invasive Approaches to Pectus Excavatum

Sternal elevation with a retrosternal bar without resection of costal cartilage has been
reported. This technique has formed the basis of minimally invasive pectus repair
(MIPR). Nuss reported his 10 year follow-up experience in 1998 with 42 patients under
the age of 15 whose defects were repaired in this manner (19). The technique required
the placement of a convex steel bar inserted under the sternum through bilateral
thoracic incisions. The bar was then removed when permanent remodeling of the
sternum had taken place. In his initial experience with 30 patients going on to removal
of the support strut at a mean of2.8 years after the initial correction, good to excellent
results were obtained in 26 patients.
Nuss has recently updated his experience with this technique, with the addition
of 201 patients treated under a standard protocol. Preoperative studies include
pulmonary function tests, echocardiography, electrocardiography (EKG), computed
tomography of the chest, and evaluation by a cardiologist. The indications for surgery are specific and include Haller index >32; Abnormal PFTs, Cardiology evaluation suggesting sternal compression of the heart as a direct cause of mitral valve
prolapse, Murmurs or dysrhythmia, documented progression of the deformity with
associated subjective symptoms, previous failed Ravitch procedure, and failed minimally invasive procedure.
1.

Technique

Under general anesthesia, two incisions are made in the anterior axillary line and a
specially designed introducer is used to create a substernal tunnel and provide initial
elevation of the depressed sternum. Initially this was done blindly, but it is now
routinely performed under thorocoscopic guidance via a thorocoscope placed two
interspaces below the desired area of bar insertion. An umbilical tape is then used to

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draw a prerneasured and shaped support bar into position. The bar is initially passed
with the desired convexity facing posteriorly. The bar is then flipped into position,
resulting in anterior fixation of the sternum. In larger patients, lateral stabilizer bars
are placed on the support strut to prevent displacement of the bar. Positive endexpiratory pressure is provided to expel insufflated carbon dioxide and air, and the
incisions are closed. The patients are then extubated and transferred to a surgical floor.
Patients are out of bed to a chair on the day of surgery. Postoperative analgesia is
routinely obtained with a thoracic epidural. The support bar is removed on an elective
basis as an outpatient 2-3 years after insertion.
2.

Results

Three hundred and three patients underwent MIPR, with a median age of 12.4 years
(range, 21 months to 29 years). In 265, repair was achieved with insertion of a single
bar; however, 38% of patients had a second support bar inserted. Seventy percent
required lateral stabilizers. Blood loss was minimal. Length of stay averaged 5 days
range, 3-10). Early complications included pneumothoraces that required a chest
tube or aspiration (2.6%), hemothorax in one patient, pneumonia (0.7%), superficial
wound infection (2.3%), and bar infection (0.7%). There were no cardiac injuries
reported; however, there was one case of right atrial and ventricular perforation
reported elsewhere (20) that encouraged the use of thorocoscopic visualization. There
were no associated deaths.
Late complications included bar displacement requiring repositioning (8.6%
overall, decreasing to 5% once lateral stabilization bars used) and two late hemothoraces, one after chest wall trauma. One percent of patients experienced allergies to
the stabilizer bar, requiring revision. In 3.6% there was overcorrection with the
creation of a pseudocarinatum. All patients in whom overcorrection occurred had
Marfan's or Ehlers-Danlos syndromes.
Early good or excellent functional results were reported in over 95% of patients. Of the 23% of patients who at the time of reporting had their support bar
removed, this number was 90%. This was significantly less, however (76%), in patients with Marfan's syndrome. Some 45% of patients had documented improvement
in their mitral valve prolapse documented by echocardiography. Conduction abnormalities resolved in 83% of patients. Late failures, when present, were seen with
titanium bars, which were considered to be insufficiently strong in the setting of
Marfan's syndrome; and in the case of stabilizer bar infection, in which the bar had to
be removed early.
Following the early learning curve associated with MIRP, a growing experience
with this technique is accumulating. In fact, of all pediatric surgeons surveyed, some
42% have used these techniques (21). The relative benefits of traditional Ravitch type
repair vs. MIRP are actively debated. Holcomb has presented a series of 80 patients
and compared them with a contemporaneous cohort of 32 patients treated with a
modified Ravitch repair (22). Holcomb cites advantages in MIPR in operative time
(143 vs. 53 min) and estimated blood loss, but no significant difference in postoperative
pain or analgesic requirements. Length of hospital stay, while increased overall, was
only statistically significant for children less than 10 years of age. Good to excellent
cosmetic results were achieved in 75-80% of patients; subjective functional improvement was achieved in greater than 90% of cases. An overall complication rate of 11 %,
was cited, including a strut dislodgement rate of 4.7%, which was similar to other

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reported series. Molik et al. compared results of 103 patients, of whom 68 underwent
the standard repair and 35 underwent MTRP (23). Although patients undergoing
MIRP had shorter operative times, smaller incisions, and less operative dissection, the
authors cited increased complication and reoperation rates as significant disadvantages. They also cited higher failure rates in patients with connective tissue disorders.
Finally, long-term results are yet to be determined.
VII.

PROSTHETIC IMPLANTS

Correction of pectus excavatum deformities with silicone implants has been used with
some success in certain subgroups of patients since-the mid 1970s (24) Wechselberger
reported a series of 24 adults with pectus excavatum in whom a custom silicone
prosthesis created from a cast of the chest wall was implanted su bcutaneously (25).
The vast majority of these patients were satisfied with their cosmetic results. Complications were minor, primarily seroma (65%) and hematoma (28%).
This technique forgoes remodeling of the chest wall required by the Ravitch
procedure, and so any physiological benefit. Its benefits are primarily cosmetic, and so
this technique is best suited for those patients with little or no functional impairment,
and/or adults, in whom growth is completed.
REFERENCES
Sabiston D lr. Congenital deformities of the chest wall. In: Sabiston, ed. Textbook of
Surgery. 15th ed. Philadelphia WB Saunders, 1997: 1890-1893.
2. Fonkalsrud, EW. Surgical management of pectus carinatum: 30 years' experience.
World J Surg 2001; 25:898-903.
3. Arn PH, Scherer LR. Outcome of pectus excavatum in patients with Marfan syndrome
and in the general population. J Pediatr Surg J989; 24:954-958.
4. Einsiedel E. Funnel chest. Psychological and psychosomatic aspects in children,
youngsters, and young adults. J Cardiovasc Surg 1999; 40(5):733-736.
5. Fonkalsrud EW. Repair of pectus excavatUl1l deformities: 30 years of experience with
375 patients. Ann Surg 2000; 231 (3).
6. Theerthakarai R. Severe pectus excavatum associated with cor pulmonale and chronic
respiratory acidosis in a young woman. Chest 2001; 119(6).
7. Haller lA. Cardiorespiratory function is significantly improved following corrective
surgery for severe pectus excavatum. J Cardiovasc Surg 2000; 41(J): I25-130.
8. Li Zhao. Why is exercise capacity reduced in subjects with pectus excavatum? J Pediatr
2000; 136(2).
9. Kowalewski J. Pectus excavatum: increase of right ventricular systolic, diastolic, and
stroke volumes after surgical repair. J Thorac Cardiovasc Surg 1999; I 18( 1):87-92.
10. Shamberger R, Welch K. Chest wall deformities. Thorac Surg 1988; 146-149.
11. Mastsui T. Bioabsorbable struts made from poly-L-Iactide and their application for
treatment of chest deformity. J Thorac Cardiovasc Surg July 1994; 108(1).
12. Bentz ML. Improved sternal fixation in the correction of pediatric pectus excavatul11.
Ann Plast Surg 1994; 32(6)
13. JC Agustin-Asensio. Titanium miniplates for the surgical correction of pectus excavatum. Am J Surg 88(4):455-458.
14. Nakanishi Y. A vascularised rib strut technique for funnel chest correction. Br J Plast
Surg 1992
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16.

17'.
18.
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20.
21.

22.

23.
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25.

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Fonkalsrud EW, Beanes S. Surgical management of pectus carinatum: 30 years experience. World J Surg 25:898~903
Fonkelsrud EW. Chest wall abnormalities. In: Baue AE, ed. Glenn's Thoracic and
Cardiovascular Surgery. 6th ed. Stamford, Connecticut: Appleton and Lange, 1996: 581592.
Haller JA Jr. Complications of surgery for pectus excavatum. Chest Surg Clin North Am
10(2):415-426
Wada J, Ade WR. Turnover procedure. Chest Surg Clin North Am 10(2):317-328.
Nuss D. A 10-year review of a minimally invasive technique for the correction of pectus
excavatum. J Pediatr Surg 1998; 33(4):545-552.
Moss RL. Major complications after minimally invasive repair of pectus excavatum:
case reports. J Pediatr Surg 2001; 36(1):155-158.
Nuss D, Hebra A, Swoveland B, Egbert M, Tagge E, Georgeson K, Otherson HB.
Outcome analysis of minimally invasive repair of pectus excavatum: review of 251 cases.
J Pedialr Surg 2000; 35(2):252-258.
Miller KA, Woods RK, Sharp RJ, Gittes GK, Wade K, Ashcraft KW, Snyder CL,
Andrews WM, Murphy JP, Holcomb GW III. Minimally invasive repair of pectus
excavatum: a single institution's experience. Surgery 2001; 130(4):652-659.
Molik KA. Pectus excavatum repair: experience with standard and minimal invasive
techniques. J Pediatr Surg 2001; 36(2):324-328.
Wechselberger G, Ohlbauer M, Haslinger J, Schoeller T, Bauer T, Piza-Kater H. Silicone
implant correction of pectus excavatum. Ann Plast Surg 200 I; 47(5):490-493.
Nordquist J. Silastic implant for reconstruction of pectus excavatum: an update. Scand J
Plast Reconstr Surg 2001; 35:65-69

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9
Chest Wall Tumors
MARY MAISH and GARRETT WALSH

Unil'ersity of Texas 1\1. D. Anderson Cancer Center, Houston. Texas, U.S.A.

I.

INTRODUCTION

Tumors of the chest wall are a diverse group of tumors that can be benign or
malignant. They can arise from the bony, cartilaginous, and/or soft tissue structures
that make up the chest wall itself and are classified according to origin: primary
neoplasms arising from the chest wall, metastatic neoplasms, and adjacent neoplasms
with local extension (Table I). Primary chest wall tumors are uncommon and
constitute 0.2-2% of all tumors (1). Metastatic disease and tumors of local extension
are more common. The overall incidence of malignancy in chest wall neoplasms is 5080%. Higher rates of malignancy are noted among tumors of soft tissue origin (2),
which represent nearly 50% of chest wall neoplasms in adults (3) and are becoming
more common in children (4). Malignant fibrous histiocytoma (MFH) and rhabdomyosarcoma are most common in this category. The remaining 50% of tumors arise
from cartilaginous and bony structures. Myeloma and chondrosarcoma are the most
common of this group and account for nearly 60% of all malignant rib tumors (5).
While the remaining tumors (Table 2) are less common, they may have an equal or
greater associated morbidity and are best treated with surgical resection. Regardless of
the origin or malignant potential, chest wall tumors challenge the thoracic and
reconstructive surgeon whether resection is done for palliation or cure.
II.

HISTORY

While chest wall tumors have been recognized for centuries, treatment of these tumors
has historically been limited. It was not until 1898 that Parham described the first
thoracic resection of a chest wall neoplasm (6). The initial surgical risks were often
associated with the development of a pneumothorax if the pleural envelope was
113

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Table 1

Classification of Chest
Wall Tumors

Primary neoplasms of the chest wall


Malignant
Benign
Metastatic neoplasms to the chest wall
Sarcoma
Carcinoma
Adjacent neoplasm with local invasion
Lung
Breast
Nonneoplastic disease
Cyst
Inflammation

breached, which could be fatal. Advances in anesthesia and controlled airway


ventilation with positive pressure allowed chest wall and pulmonary resections to be
done safely. In 1933 Graham and Singer described the first pneumonectomy (7).
However, chest wall resections brought about the additional postoperative complication of flail chest. This resulted in respiratory failure, often requiring prolonged
mechanical ventilation.
Chest wall surgery progressed when measures were taken to reconstruct the
defect left behind after the tumor was removed. Early attempts at reconstruction
included the use of fascia la ta (8), rib grafts (9), and myocutaneous flaps (l 0), which are
still used today. By the 1960s, several papers came out describing new methods for
reconstructing chest wall defects. Each provided valuable techniques to overcome the
unique anatomical and physiological challenges posed by resections in this location.
As early as 1960, Graham and Usher introduced the use of prosthetic materials when
they described using Marlex mesh to repair defects of the chest wall (11). By 1963 the
use of transposed omentum to supply a vascular bed was developed by Kiricuta (12).

Table 2 Malignant
Tumors of the Ribs
Cartilaginous
Chondrosarcomas
Bone
Myeloma
Osteogenic sarcomas
Primary
Radiation-induced
Ewing's sarcoma
Solitary plasmacytomas
Lymphoma
Askin's tumor
Primitive neuroectodermal

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The success of chest wall tumor resection is due to the advances in reconstructive
surgery that have evolved over the past century. Today, complete reconstruction
immediately following resection is the norm. A combination of prosthetic materials
and rotational and free flaps provides cosmetic and functional results that allow for
minimal postoperative mechanical ventilation and short hospital stays (13). With these
techniques, most chest wall tumors, benign or malignant, are treated definitively with
surgical resections. As a result, the prognosis for most patients with chest wall tumors
is good, and continues to improve as advances in surgical techniques, plastic
reconstructive, and critical care peri operative monitoring allow for better care of
these patients.
III.

ASSESSMENT

A.

Presentation

Chest tumors vary little in presentation. Most tumors are initially noted by the
patients who give a history of a small mass that has grown slowly over months.
Initially the lump may be asymptomatic; however, as it enlarges pain will often
develop. This is especially true for malignant tumors, although it is not a reliable
indicator of malignancy (2). Bone and cartilaginous tumors, or tumors that are
invading neurovascular structures, tend to be the most painful. Symptoms such as
cough from pleural irritation, shortness of breath from lung involvement, parasthesias from neural invasion, and fever can also accompany some of these tumors.
Results of physical examination are often nonspecific; however, fixed soft tissue
tumors may indicate malignancy. Rib tumors may not be apparent on physical
examination because of the overlying chest wall musculature and soft tissues, but are
noted as a convexity on a chest x-ray. Other findings on chest radiography such as socalled popcorn calcifications of chondrosarcoma, the mixed lytic and sclerotic pattern
of osteosarcoma, or isolated lytic lesions of plasmacytomas or metastasis can also be
noted (Fig. 1).
Although chest wall tumors are generally seen in all age groups, some tumors
tend to present more often in certain age groups. Malignant small round cell (MSRC)
tumors, particularly Ewing's sarcoma, primitive neuroectodermal, Askin's tumor, and
rhabdomysarcoma are more common in children and young adults (14). Primary
sarcomas and desmoid tumors are noted in middle-aged populations and plasmacytomas are most common in older patients. Osteochondroma, the most common of the
benign bone tumors, is usually seen in adolescents and adults. These tumors become
painful as they grow and therefore often go unnoticed until adulthood. Regardless of
the presentation, all patients presenting with a chest wall mass should undergo the
same detailed work-Up,
B.

Preoperative Evaluation

The preoperative evaluation begins with taking a detailed history. Nonspecific


symptoms such as fatigue, fever, and malaise should be noted as they could indicate
more advanced disease or a concomitant infectious component. Pain is often a complaint of patients with chest wall tumors and indicates partial or complete involvement of local nerve structures or bone. The duration, location, and type of pain that
the patient is experiencing are all important details to include. Documentation

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Figure 1 A. A 32-year old woman presented with severe right axillary pain. A chest x-ray
demonstrates the overlying lesion that was resected. The final pathological results demonstrated multiple benign hyaline cartilage neoplasms involving the rib. B. A similar presentation
of left axillary pain in a 46-year-old woman with a clinical and computed tomography imaging
findings suggestive of a benign rib lesion. The lesion was excised; however, the final pathological results demonstrate a surface dedifferentiated osteosarcoma. This is a rare and extremely aggressive tumor, for treatment of which the patient has received multiple courses of
chemotherapy postoperatively.

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of paresthesias is critical to identifying involvement of major neural bundles. Discrepancies between extremities, including temperature and swelling, may indicate
vascular involvement and should be addressed. A thorough assessment of factors that
impair wound healing including the use of steroids, smoking, previous exposure to
radiation or chemotherapy and the nutritional status of the patient are important
especially patients with for extensive chest wall tumors that may require plastic
surgical reconstruction. A history of cardiovascular and pulmonary disease, including
symptoms of chest pain or shortness of breath with exertion, is important to ascertain.
If the patient has had previous interventions for coronary artery disease and a history
of asthma or chronic obstructive lung disease, this should be noted in the work-up so
that further evaluation of these symptoms can be initiated.
After a thorough cardiovascular and pulmonary examination, the preoperative
physical examination should focus on ruling out other sites of disease. Assessment of
functional limitations (especially of the upper extremities) and evaluation of all nodal
stations including the neck, axillae, and groins should be performed. A concise
neurological exam and appraisal of upper body muscular groups are also important.
The chest wall itself should be examined for asymmetry, including sternal rotations or
deformity (Fig. 2). Any skin irregularities should be noted.
Routine tests to screen for comorbidities, such as diabetes mellitus, renal
insufficiency, liver disease, and cardiovascular disease, should be included in the
preoperative work-up. Studies to define the extent of disease, such as plain films and
computed tomographic imaging of the chest, are essential. Comparisons with previous
films are important to determine growth rate. Magnetic resonance imaging is the
preferred study when it is necessary to differentiate tumor from nerves or vascular
structures, soft tissue involvement, and for tumors in the region of the costovertebral
angle or involvement of the vertebral column or superior sulcus. Other studies such as
pulmonary function tests, xenon perfusion scans, bone scans, and cardiac stress tests
should be tailored to each patient depending on their comorbidities and the extent of
the resection anticipated.
Prior to definitive treatment it is important to obtain a pathological diagnosis.
Adequate sampling is critical and can be done with fine-needle aspiration or open
biopsy. Frozen section analysis may not be possible if special stains are required.
Regardless of the techniq ue, all biopsies should be planned carefully so that they do
not interfere with definitive resection. Excisional biopsies can be performed on small
chest wall tumors taking a minimum of a 1 cm margin. Our present management
includes fine-needle aspiration or core-needle aspiration with interpretation by a
pathologist experienced in bone and soft tissue tumors. There is little indication at the
present time for open, incisional biopsies (15).
Consideration needs to be given to combined-modality treatment prior to
surgical resection. In some sarcomas, the need for preoperative chemotherapy is
paramount, not only to shrink the primary tumor but also to treat micrometastatic
disease that is often present but not radiographically detectable. Adeq uate clinical and
hematological recovery is required (usually 4-6 weeks) before a patient can undergo a
major chest wall resection. Postoperative radiation therapy poses a challenge to the
reconstructive surgeon. Flaps that are created to fiJI the large defects created by the
thoracic surgeon rely on limited blood supply that can fail if subjected to large
amounts of radiation. Prior to proceeding with a treatment plan, these risks need to be
carefully weighed against the benefits.

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Figure 2 A. A 28-year old man known to have Von Recklinghausen's disease presented
with a progressive deformity of hIS lower sternum. B. The final pathological cross section
of the lower sternum demonstrates a neurofibroma involving the sternum and contiguous
soft tissues.

IV.

PATHOPHYSIOLOGY

A.

Benign Tumors

Benign tumors of the chest wall can originate from the soft, cartilaginous, or bony
tissues (Table 3). Soft tissue tumors vary in depth. Those that are superficial require
resection only when malignancy is in question or when cosmetically indicated.
Cutaneous nevi should be completely excised with adequate margins so that pathological diagnosis can be confirmed. Superficial hemangiomas (birthmarks) need only
be removed for cosmetic reasons. For cavernous hemangiomas, complete excision
should be done if there is no contraindication to surgery. Lipomas are genera II.
superficial lesions that do not require resection. However, some of these can be deep
enough to involve muscle and often become p'~jnful. In this instance, a wide resection

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Table 3 Benign
Tumors of the Chest
Wall
Superficial soft tissue
Cutaneous nevus
Hemangioma
Lipoma
Lymphangioma
Deep soft tissue
Desmoid Tumor
Fibroma
Neurofibroma
Rhabdomyoma
Cartilage
Chondroma
Bone
Fibrous dysplasia
Osteochondroma

should be undertaken. Transformation to liposarcoma is rare, but should be considered if there is suspicion of malignancy. Lymphangiomas only involve the thorax when
they are large and extend into the thoracic inlet from their origin in the neck. Complete
excision prevents their recurrence (Fig. 3).
Deep soft tissue tumors are rare. Desmoid tumors are the most common and the
chest wall is a favorite site for this tumor. They arise from fascia and connective tissue
of muscle. Although they are benign, they can often behave in a malignant fashion and
are often considered low-grade fibrosarcomas. They often present in the shoulder with
pain due to pressure on surrounding structures. Invasion into surrounding structures,
including nerves, vessels, and bone, makes them difficult tumors to control locally,
thus their recurrence rate is extremely high. Treatment is wide local excision for
primary and recurrent lesions (16). In addition, adjuvant external beam and brachytherapy are utilized for local recurrences that cannot be resected. A recent study by
Baliski et al. suggests that neoadjuvant treatment with doxorubicin and radiotherapy
is a better option than surgery alone, or surgery and adjuvant radiotherapy (17). Such
tumors are occasionally sensitive to chemotherapy or hormonal therapy, which may
permit shrinkage of very bulky desmoids prior to an attempted resection.
Fibromas are rare chest wall tumors that are often, but not exclusively, found
near joints. Resection is only recommended for symptomatic lesions or for cosmetic
reasons. Neurofibromas are usually multiple and associated with neurofibromatosis.
If a lesion is noted to be painful or enlarging, excisional biopsy should be done.
Malignant degeneration of these benign lesions can occur. If they are noted near a
vertebral body, documentation of involvement of the spinal canal should be done with
magnetic resonance imaging (MRI) to rule out a so-called dumbbell tumor. Neurosurgical collaboration should be sought for complete resection if spinal canal involvement is discovered.
Rhabdomyoma is a very rare benign tumor presenting as a mass in the muscle.
The tumor is usually slow growing, and should be biopsied to rule out malignancy.

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Figure 3

A. A 23-year old man presented with a progressive, painful, and enlarging mass
involving his back and left posterior chest wall. Fine-needle aspirate revealed Iymphangiomyomatosis. B. ]ntraoperative photograph or the mass that was resected for symptomatic
control or pain.

Complete resection is undertaken only when it interferes with function or is cosmetically indicated.
Chondromas are the only benign cartilaginous tumors of the chest wall; they
constitute 15% of the benign tumors of the rib cage. Usually presenting in the third
and fourth decades oflife, they present as slow-growing, slightly painful masses. They
are usually found on the anterior chest wall at the costochondral junction or sternum
(18). The radiographic appearance is that of an expansile lesion that ca uses thinni ng of
the cortex. Clinically there is no way to differentiate this benign tumor from its
malignant counterpart. On gross examination, however, it is a lobular mass charac-

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terized by lobules of hyaline cartilage microscopically. Histological differentiation


from chondrosarcoma can be difficult; therefore, this tumor should be treated as a
malignancy with wide local excision.
Fibrous dysplasia is a nonneoplastic lesion that is probably a developmental
abnormality characterized by fibrous replacement of the medullary cavity of the rib.
It presents as a slow-growing, painless mass on the posterior-lateral aspect of the
rib (Fig. 4). It begins in childhood but usually does not present until adolescence
or young adulthood and is often picked up on a screening chest x-ray. Its radiographic appearance is that of a medullary mass causing cortical thinning with a
central ground-glass appearance. Excision is recommended for symptomatic or
enlarging masses.
Osteochondroma is the most common of all benign bone tumors, representing
nearly 50% of all benign bone neoplasms. It is usually asymptomatic and most
commonly occurs in men. These tumors arise from the metaphyseal region of the rib
and will have a cartilaginous cap and bony stalk. Calcifications in and around the
tumor are usually seen radiographically. Growth is directed either inward or outward.
When the tumor grows inward it is not palpable, and is detected only on x-ray. If these
tumors present in childhood, resection should be undertaken only if they are painful.
Any tumor presenting in an adult, however, should be excised. Complete excision is
recommended because malignant transformation has been reported (19).
B.

Malignant Tumors

As previously discussed, desmoid tumors are the most common of all soft tissue
tumors and often present in the chest wall. Arising from fascia and connective tissue of
muscle, they are benign; however, they can behave in a malignant fashion. They are
often considered low-grade fibrosarcomas. Invasion into nerves, vessels, and bone

Figure 4 A 60-year old man was evaluated for primary hypoaldostronism and underwent
an MRI to evaluate for adrenal tumors or hyperplasia. An expansile lesion was incidentally
noted in the right tenth rib. The gross lesion and MRI images are demonstrated. This proved
to be a fibrous dysplasia of the rib.

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makes them a difficult tumor to control locally. Because they have a high recurrence
rate, the recommended treatment is wide local excision with adjuvant radiotherapy for
local recurrences.
As noted by Pairolero (20) and again by King et a1. (21), MFH is the most
common primary chest wall tumor that a thoracic surgeon is asked to evaluate. It
rarely occurs in children and is most commonly seen in men between the ages of 50 and
70 years. This tumor presents as a painless, slow-growing mass. In women, its growth
can be accelerated during pregnancy, which can result in pain. Some MFH tumors are
radiation-induced and are seen in patients who have undergone radiation for treatment of breast cancer, Hodgkin's lymphoma, myeloma (22), and laryngeal cancer (23).
It is difficult to control locally because of its tendency to spread along tissue planes. On
histological examination it varies from well-differentiated spindle cells to anaplastic,
pleomorphic, histiocyte-like cells. Wide local excision is the only option for treatment
of MFH because it is unresponsive to both chemo- and radiation therapy. It carries a
poor prognosis, with only a 38% 5-year survival (21).
A great variety of sarcomas compose the remainder of malignant soft tissue chest
wall tumors (15). Survival of patients with primary soft tissue sarcomas of the chest
wall after resection is similar to that of patients with sarcomas of the extremities (24).
Leiomyosarcomas are less common than MFH and are primarily seen in women. Most
present as a painful, slow-growing mass. Rarely, they have been noted to present in an
irradiated sternum (25). On gross examination they are grayish in appearance and
lobular with central necrosis. Cyst formation is common. On microscopical examination the tumor is composed of swirling spindlelike cells The recommended treatment is wide local excision. Recurrence is common both locally and distantly.
Liposarcoma is seen primarily in middle-aged men. It is usually not from
malignant degeneration of a lipoma; however, it is noted in areas of previous trauma.
On gross examination it appears as a well-encapsulated, lobular mass (Fig. 4).
Anaplastic lipoblasts are seen on microscopic examination. Complete local resection
is important to prevent local recurrence, which is common. This tumor is insensitive to
chemo- and radiation therapy (26).
Neurofibrosarcomas of the chest wall can be associated with von Recklinghausen's disease and are usually seen in men between the ages of 20 and 50. These tumors
occur along intercostal nerve bundles. On gross examination the tumor is encapsulated
and on microscopical examination spindlelike cells spread along nerve sheaths are
visible. Wide local excision is the recommended treatment.
Rhabdomyosarcoma is the second most common soft tissue neoplasm after
MFH. Jt occurs most often in children and young adults and affects men and women
equally. Unlike most other soft tissue tumors, this neoplasm presents as a rapidly
enlarging mass that involves striated muscle bundles. However, it is not usually
painful. On microscopical examination it has the characteristics of high cellularity and
central necrosis common to fast-growing tumors. Treatment with wide local excision
and adjuvant chemo- and radiation therapy results in a 70% 5-year survival.
Recurrences can occur locally as well as distantly (21,27).
Soft tissue sarcomas commonly occur after radia tion trea tment for other cancers
such as breast cancer and lymphoma (28). Trea tment recommenda tion is for wide local
excision. Survival is simi lar to tumors arising de novo.
Primary bone tumors of the chest wall are uncommon. In one of the largest
reviews done at the Mayo Clinic by Dahlin and Unni (1986), malignant neoplasms

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Chest Wall Tumors

made up 89% of all bony chest wall tumors and are found in the ribs (85%) more often
than in the sternum (15%) (5). The most common malignant neoplasms are myeloma,
chondrosarcoma, malignant lymphoma, and Ewing's sarcoma.
Chondrosarcomas are the most common neoplasm of the anterior chest wall.
Most often arising from the costochondral arches or the sternum, they account
for 30% of all primary malignant bone tumors (18). This tumor is seen most often
in men in their 40s and 50s; it is uncommon in patients under the age of 20 years.
The presentation is consistent with a slow-growing mass that may have been
painful for several months. The cause is unknown; however, there is an association
between chest trauma and later development of chondrosarcoma in the area of
injury (5).
On gross examination, chondrosarcomas are lobular and, iflarge enough, they
may grow into the pleural cavity or through the muscle into the subcutaneous tissues
(Fig. 5). Histological examination shows that the cells are plump, atypical, and contain
multiple nuclei, and can be difficult to differentiate from chondromas. Therefore,
all tumors of the costal cartilages should be considered malignant and treated with
wide resection.
On chest radiographs, chondrosarcoma appears in the medullary portion of the
bone as a lobular mass. Calcifications can be seen and the edges of the tumor are ill-

Figure 5

The CT scan and gross pathological specimen demonstrate a bilobular mass


involving the lower sternum and right chest wall that was resected en bloc. The final
pathological diagnosis was a chondrosarcoma of the sternum.

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defined (Fig. 6). Pathological fractures are not seen. Diagnosis can only be made
pathologically and can sometimes be difficult. It is important to sample several areas of
the tumor so that differentiation from chondroma can be made. Excisional biopsy is
recommended if possible when chondrosarcoma is suspected. Definitive treatment
consists of local control. Wide resection with a 4 cm margin on all sides of the tumor
results in a 10 year survival approaching 97% (29).
Unlike chondrosarcomas, osteogenic sarcomas carry a much less favorable
prognosis, with only a 15% 5-year survival despite radical resection and chemotherapy
(30). ]t is also less common, constituting only 6% of all primary bone tumors. ]t is
generally seen in teenagers and young adults and more commonly affects men. It
manifests as a rapidly enlarging mass that is often painful. The cause is unclear except

Figure 6 A. A 52-year old woman underwent a routine chest x-ray that revealed a round
mass at the costovertebral junction. A CT scan as shown here demonstrated a rim of
calcification of the mass. B. Intraoperative finding of a low-grade chondrosarcoma invol ina
several ribs posteriorly. An en bloc chest wall resection was performed with a 4 em l1largin~
The patient IS now 10 years postoperatively without any evidence of tumor recurrence.

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Chest Wall Tumors

in the cases of radiation-associated tumors, which behave the same as those arising de
novo and thus are treated the same. Serum alkaline phosphatase levels are often
elevated. Radiography reveals destruction of the bone with imprecise borders.
Calcifications can also be seen and a characteristic sunburst pattern is common.
Pathological fractures are not seen. On gross examination the tumor extends through
the cortical bone into surrounding soft tissues. On histological examination it can be
comprised of bony, cartilaginous, or fibrous components. Wide resection of the tumor
along with surrounding rib or sternum and soft tissues (including lung) is essential.
Chemotherapy for this aggressive malignancy is essential (31).
The most common of all primary bone malignancies is myeloma. Most patients
with myeloma in the ribs will eventually manifest symptoms of the systemic disease.
Those with a solitary lesion and no systemic manifestations have a rarer form of the
disease referred to as a plasmacytoma (Fig. 7). More than 60% of the cases occur in
men between the ages of 60 and 80. There is usually no palpable mass, but patients will
complain of considerable pain at the site of tumor burden.
Many patients with myeloma will be hypercalcemic and anemic, with abnormal
protein electrophoresis and Bence Jones proteinuria. On chest radiography, osteolytic
lesions are seen with thinning of the cortical bone. Pathological fractures are
commonly noted. On gross examination the tumor is friable with a grayish appearance. Characteristic sheets of closely packed cells are seen on histological examination.
Treatment for myeloma is radiation therapy for solitary lesions and radiation
and chemotherapy for multiple lesions. Surgery is only indicated for obtaining
diagnosis and for solitary plasmacytomas. Prognosis is poor, with a 5-year survival
of 20% (32).
Ewing's sarcoma is the most common of the MSRC tumors. It shares the same
chromosome 22 translocation with the other MSRC tumors (e.g., peripheral
neuroectodermal and Askin's tumors). Two-thirds of the time it occurs in youths
under the age of 20. It accounts for 1.8 % of all solid childhood cancers and 12% of
all primary malignant tumors of the bony thorax (33). Boys are affected twice as

Figure 7

CT scan demonstrates a plasmacytoma of the right rib.

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often as girls. A painful mass is usually noted by the patient. Nonspecific symptoms
such as fever, malaise, and anemia are common.
On chest radiograph, both lytic and blastic lesions occur. Elevation of the
periosteum and layers of subperiosteal new bone formation lead to the characteristic
onionskin appearance of the surface of the bone. Similar to osteogenjc sarcoma,
radiating spicules can also be seen on the surface of the bone. Pathological fractures
are unusual. On gross examination Ewing's sarcomas are soft and nonencapsulated.
Its histological appearance is similar to lymphoma.
Treatment for Ewing's sarcoma is multimodal; surgery and/or radiation therapy
is used for local control (34). Chemotherapy can be given for distant disease or to
shrink tumor burden prior to surgery. Prognosis is better than 60% in patients with
local disease only, but falls to 30% with distant disease.
Askin's tumor is an MSRC tumor found in the chest wall, while peripheral
neuroectodermal tumors are found in the soft tissues of the body. It is seen in females
three times as often as in males, and patients are usually between the ages 01'3 and 38. It
usually presents with chest wall pain, cough, and dyspnea. On radiographic studies a
soft tissue mass with underlying destruction of the bone can be seen. It has been
reported to occur in patients who have received radiation therapy for lymphoma (35).
Treatment is aggressive l11ultimodality therapy with primary surgical resection, preand postoperative chemotherapy, and postoperative radiation therapy in select cases.
Metastatic disease occurs 10% of the time. Prognosis is fair, with a 40% 2-year
survival (36).
Lymphomas can be classified into two categories: Hodgkin's and non- Hodgkin's
lymphoma. They are differentiated by the presence of Reed-Sternberg cells seen
histologically in Hodgkin's lymphoma. Both are primary tumors of the lymphatic
system found in immune-rich organs such as the spleen, lymph nodes, mediastinum,
and bone marrow. Hodgkin's appears in patients under the age of 30, while nonHodgkin's is seen in patients over the age of 40. Tumors involving the chest wall will
manifest with the same symptoms as lymphoma elsewhere: fever, malaise, night
sweats, and chills. Chest radiography may reveal mediastinal widening secondary to
lymph node involvement, but bony lesions are not seen.
Treatment of lymphoma is dependent on type and sites at presentation.
Radiation and chemotherapy are the mainstays of treatment. Except in a few
cases, the role of surgery is to obtain tissue for diagnosis. Prognosis is more favorable
for Hodgkin's than non-Hodgkin's lymphoma, but is dependent on type and stage
at presentation.

C.

Metastatic and Contiguous Tumors

Metastatic tumors to the chest wall occur from a variety of primaries including breast,
colon, renal, melanoma, prostate, salivary gland tumors, and sarcomas. They present
unique challenges: the site of primary disease needs to be assessed for local control
and other sites of metastatic disease need to be evalua ted prior to any trea tment of the
chest wall lesions. If the metastatic lesion to the chest wall is the only site of distant
disease, and the primary site is locally controlled. treatment is advocated (Fig. 8).
Wide local excision is recommended, with reconstruction if necessary. Sur ivaI is
related to the stage of the primary disease. Tumors that extend locally into the che t
wall include breast, lung and pleural tumors (Fig. 9). Resection of chest wall

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Figure 8 A. A 78-year-old woman presented with a tender, slowly enlarging mass of her
left chest wall. She had undergone resection of a salivary gland tumor over 30 years ago. A
core needle biopsy of this large (15 x 14 x 8 cm) mass demonstrated a myoepithelial cell
neoplasm that was thought to be consistent with a metastatic tumor from a salivary gland
primary. This lesion was therefore considered to represent a metastatic focus nearly three
decades after the resection of her primary head and neck tumor. B. Computed tomography
and pathological specimens demonstrate the pleural-lined surface of the tumor that has
destroyed the seventh and eighth ribs. Her chest wall was reconstructed with Gore-Tex and
she has done well since.
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involvement is done at the time of initial resection of the primary tumor Wide
excision with adequate margins is important. Adjuvant radiotherapy is recommended
for inadequate surgical margins.
The presence of a chest wall tumor is an indication for surgical intervention, with
few exceptions. All benign and malignant chest wall tumors should be resected for
potential cure at the time of initial presentation. In the case of some benign tumors,
such as lipoma and rhabdomyoma, resection can be delayed until the mass causes pain
or interferes with function. Complete resection with adequate margins is critical to
prevent recurrence. The best long-term results are in those patients whose tumors do
not recur.

Figure 9

A. A 67-year-old heavy smoker presented with a fungating chest wall mass below
his left areola. Fine-needle aspirate demonstrate non-small-cell carcinoma compatible with a
lung pnmary. B. Computed tomography demonstrated the chest wall invasion by the lung
cancer wlth dlrect extenslOll Into the left ventricle.

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While the initial goal of resection is cure, this may not always be possible. Some
tumors may be sufficiently large or in anatomical locations that would render a limb
or other vital structure functionless. In situations in which resection would compromise function, resection for local control should still be initiated. It is not necessary to
obtain adequate margins if cure is not the final intent; however, all attempts should be
made at the time of surgery to achieve this, if possible. Surgical palliation should be
done in the presence of incapacitating pain, functional limitations secondary to the
mass, or for local control of fungating, necrotic lesions (Fig. 10). The goals of
palliative resection are to preserve function and surrounding healthy tissue, while
eliminating pain and suffering (Fig. 11).

Figure 10 A. A 47-year-old man presented to the emergency room with a syncopal episode
secondary to this severely neglected, chronic chest wall process that was bleeding on a daily
basis. Biopsy demonstrated an invasive squamous cell carcinoma involving the chest wall as
shown It had originated as a 1 em skin lesion and progressed over 10 years. B En bloc
resection of the clavicle and first, second, and third ribs of this squamous cell carcinoma.

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131

OPERATIVE CONSIDERATIONS

The key to a successful chest wall tumor resection is obtaining wide margins at the time
of initial presentation. Failure to obtain adequate margins will result in recurrence,
often within a short period of time. Repeated resections of recurrent chest wall tumors
are more difficult with each subsequent operation. If extensive reconstruction has
already taken place, resection is often impossible. Therefore, all measures must be
taken initially to obtain wide margins and adequate reconstruction (37).
The definition of an adequate, wide margin is quite controversial. When
resecting benign tumors, a 2 cm margin is adequate for most tumors. For those
tumors with malignant potential or local invasiveness, such as chondromas and
desmoid tumors, wider margins should be obtained. Some surgeons may consider
any margin free of tumor to be adequate. Most would agree that this is appropriate for
metastatic disease but not primary chest wall tumors. Others follow the study by King
et al. in 1986 (21) showing a decreased 5-year survival of 29% in patients whose
margins were 2 cm compared with a 56% 5-year survival in those whose margins were
5 cm. Some define an adequate margin to be at least 4 cm. While the exact margin is
not clear, it is well understood that, up to a point, the wider the resection, the better
the prognosis.
Clearing margins is not the only important principle in chest wall tumor
resections. Low-grade malignancies may only require resection of surrounding soft
tissues, but high-grade tumors should have the surrounding bone resected along with
them. For soft tissue tumors this would include the bone contiguous with the tumor
and its margins only. For tumors of the ribs, however, this would entail removing the
involved rib, the anterior costal cartilages if the tumor is located anteriorly, and
portions of several ribs above and below. Tumors of the sternum req uire resection of
the involved bone and soft tissue structures underlying them as well as the costal
cartilages bilaterally.
The goal in resection of metastatic chest wall tumors is quite different than for
primary tumors. Quality, not duration, oflife is the principal focus and palliation, with
a tension-free wound that will heal without further infection or necrosis, is the goal.
Ulcerative and necrotic tumors are indications for resection and are sometimes
necessary for improved hygiene (38). Wide resection does not provide better results
or improved survival; margins that are cleared of tumor are adequate.
Chest wall resection and reconstruction are major operations that carry with
them life-threatenjng complications. Intraoperative monitoring should be tailored to
the needs of the patient, but should consist of cardiac monitoring, including pulmonary artery ca theters if pre-existing cardiac disease is presen t or concomi tant resection

Figure 11 A. A 37-year-old woman with a previous history of renal cell carcinoma


presented with a rapidly progressive and painful mass involving her manubrium that was
warm to the touch. B. The CT scan demonstrated a destructive lesion involving the
manubrium. C. A contrast arteriogram demonstrated the highly vascular nature of this tumor
as shown by injection through the right mammary artery, which was embolized. This lesion
was a metastatic renal cell carcinoma involving the upper sternum that required a resection
with bilateral rotational pectoraljs major flaps to close the defect. The upper portion of the
sternum was not reconstructed.

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of major pulmonary or cardiovascular structures is anticipated. Airway management


can be difficult and may require double-lumen endotracheal intubation or tracheostomy placement. Insertion of an epidural catheter should be considered if there is no
involvement of the spine.
The position of the patient will be determined by the location of the tumor.
Standard lateral decubitus positioning should be used for tumors located posteriorly
or la terally. Supine positioning should be adequate for anteriorly located tumors. All
tissues of potential resection or reconstruction should be prepped into the field. Access
to overlying and surrounding soft tissues, neurovascular structures, and underlying
structures of the thoracic ca vity should be considered. These decisions are best made
jointly by the thoracic and reconstructive surgeons.
Tumors located posteriorly should be approached via a posterolateral incision.
Access to bony and soft tissue structures is optimal from this incision. Vascular
pedicles to major muscle bundles, particularly the latissimus dorsi and serratus
anterior muscles, can be easily accessed. This incision is also optimal for tumors with
extensive lung involvement for which formal lung resection is anticipated. Anterolateral thoracotomy incisions can be made for tumors that are clearly anterior. This
incision gives access to the pectoralis muscle groups and their vascular supply. For
tumors involving the sternum or parasternal area, a hemiclamshell, or median,
sternotomy incision is best.
Surgical techniques vary but electrocautery should be used judiciously because it
can cause thermal injury to neural structures that can result in prolonged postoperative pain. Periosteal elevators can be used to dissect soft tissues and neurovascular bundles away from the rib edge. A guillotine rib cutter is best for taking clean
margins. Once the posterior and anterior extent of the resection is determined, a 1 cm
piece of rib should be resected on either side and sent to the Pathology Department for
permanent examination, or frozen section if there is any question of clean margins.
The remainder of the soft tissues can be dissected using electrocautery. Major neurovascular bundles should be ligated with heavy sutures. If the pleural space is entered,
digital exploration should guide the extent of the resection. Surgical clips can be placed
at the periphery of the resection to guide adjuvant radiation.
Chest wall tumors can vary greatly in size and extent. With the reconstructive
techniques now available, resection should not be compromised unless the patient is
physiologically incapable of tolerating the procedure. As previously discussed, a 4 cm
margin should be obtained for high-grade tumors or low-grade tumors with
a propensity to recur locally. A margin of 2 or 3 cm is acceptable for benign or lowgrade tumors, metastatic tumors, and those tumors involving the chest wall via
direct extension.
Small defects of the chest wall (less than 4 em in diameter) do not require
reconstruction. Defects larger than this should be reconstructed unless they are located
at the posterior apex of the chest where the scapula can protect the underlying lung. It
is important under the latter circumstance to ensure that the tip of the scapula is free
and does not become trapped beneath the rib edge bordering the inferior portion of the
defect. This is quite painful and can present in a similar manner to a dislocated
shoulder when the scapula becomes trapped in the chest wall defect. This may require
reoperation to alleviate. Larger defects or those overlying cardiac structures should be
reconstructed with polypropylene (Marlex) (13) or a polytetraf]uorethylene (PTFE)
mesh such as Gore-Tex (39).

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In cases in which a watertight seal is desired, as in a pneumonectomy, PTFE is


preferred. Otherwise, polypropylene is preferable since it provides a matrix for soft
tissue ingrowth and is less likely to ca use an overlying seroma. If chest wall contour for
improved functional or cosmetic results is desired, a mesh sandwich can be created
using two pieces of Marlex and a thin layer of methylmethacrylate inserted between
them. Contour can be obtained by placing the sandwich over the patient's thigh or
flank. A 1 cm sewing rim of mesh should be preserved.
The mesh is sewn to the superior and inferior ribs and to the anterior and
posterior cut ribs using a heavy monofilament suture. To avoid compression of the
intercostal nerves, 1 mm holes can be drilled into the ribs using a pneumatic drill or rib
punch. If approximation to soft tissues is necessary, as in the case of a pneumonectomy, a small monofilament suture should be used to ensure a watertight closure.
Reconstruction of chest wall vasculature is not necessary, but all attempts to
preserve the internal mammary artery should be made since it is often used in free flap
reconstruction. If there is invasion of intrathoracic vasculature, definitive repair and
reconstruction should be undertaken at the time of resection. Primary reconstruction
of major venous and arterial structures can be done if less than one-third the
circumference and less than 1 cm in length of the vessel is compromised. Closure
should be done to maximize intraluminal diameter. Beyond this degree of injury, patch
closure should be considered with autologous (saphenous) vein or PTFE material.
Venous reconstruction is best done with autologous vein, but in most cases ligation of
the vein is well tolerated. Arterial reconstruction is successful with either. Closure over
mesh should be done with muscle not attenuated adipose tissue.
If an extensive soft tissue dissection is required, reconstruction should be done in
tandem with a reconstructive surgeon (40). A rotational muscle flap (e.g., latissimus
dorsi, pectoralis major, rectus abdominis, serratus anterior or external oblique muscle)
can be considered. The blood supply to these flaps must be preserved during the
dissection and resection of the tumor for these flaps to be successful. A free flap using
these same muscle groups can be used if coverage is inadequate with rotation. If fullthickness chest wall reconstruction is needed, including skin, fat, and muscle, a
myocutaneous flap or a muscular-free flap with skin grafting can be used (Fig. 12).
Omental transposition is used successfully in areas of radiation necrosis where partialthickness reconstruction is needed (41). Regardless of the method of reconstruction,
respiratory mechanics should be preserved and functional limitations should
be minimized.
Careful surgical technique will provide good long-term results; anything less can
result in devastating complications. Ifinadequate resection is performed at the time of
initial presentation, recurrence rates are high. Repeated resections can be technically
difficult and pose threats to function. Local recurrences are not met with a favorable
prognosis in most cases.
The usual aseptic techniques control for infection in most surgical cases, but
chest wall tumor resections pose challenges that predispose to infection. Large
resections can leave gaping holes, the margins of which may be vascularly compromised. Rotational flaps rely on distant vasculature that, if compromised by tension or
other problems, can result in inadequate blood supply. Free flaps rely on local
vasculature that may be tenuous. Postoperative radiation can induce necrosis that
results in infection. Fluid collections that accumulate under flaps can become infected
over time and need to be closely evaluated. Applying careful aseptic technique,
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Figure 12 A. An invasive sarcoma involving the right clavicle, scapula, right upper lobe,
and upper four ribs of the chest wall with tumor infiltration as demonstrated to the level of the
manubrium. This patient presented with a non functioning right arm because of brachial
plexus involvement of the lesion. B. Extensive resection required including the right upper
lobe, ribs 1-5, manubrium, and right hemithorax to the spine posteriorly, including scapula
resection. C. Dissection of a right forearm filet Rap with removal of the ulna and radius, for
subsequent soft tissue closure of the large defect in the neck and chest with an anastomosis of
the brachial artery and vein to the stump of the subclavian artery and subclavian vein. The
patient required a prolonged period of postoperative ventilation be ause of the parad xic
motion of the free Rap and the eAtensive cbes~ \,v.;:t1Lilnd,puhnonary resection.

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Figure 12

Continued.

providing adequate coverage with good blood supply, and observing closely in the
postoperative period will help to avert postoperative infections.
Major neurovascular injury is uncommon if resection is isolated to the chest
wall. If the mass extends into the structures of the thoracic inlet or thoracic cavity,
sacrificing major structures or portions thereof may be unavoidable. Preoperative
documentation of function and sensation is essential to understanding the extent
of tumor involvement. In general, if there is involvement of major neurovascular
structures and function is already compromised, resection is done without question. However, if function is not compromised preoperatively, a decision must
be made at the time of surgery as to whether resection is necessary or reconstruction possible. Residual neurovascular injuries can be devastating and should be
avoided.
Radiation-induced injury is common but is dose-dependent. Low doses of
radiation are not likely to interfere with previously resected surgical sites. High
doses, however, can cause superficial ulcerations and full-thickness necrosis of chest
wall tissue. In an attempt to prevent this, the surgeons involved in resection and
reconstruction should collaborate to provide optimal tissue coverage. Reconstructed areas of the bony thorax should be covered with full-thickness soft tissues.
If this cannot be done primarily, partial or full-thickness flaps should be placed to
ensure adequate coverage. This will aid in preventing complications of adjuvant
radiation therapy.
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Surgical treatment of chest wall malignancies encompasses both the resection of


the tumor and the reconstruction of the chest wall defect. The results, therefore, reflect
the morbidity associated with each of these. The long-term results are favorable with
adequate resection. Both M. D. Anderson Cancer Center and the Mayo Clinic have
described survival of approximately 60% at 5 years (14), including lesions that are
recurrent lesions and reresected. Functional limitations complicate recovery resulting
in prolonged intubation, need for tracheostomy, pneumonia, and complete respiratory failure that may result in death. Infection and radiation necrosis can occur and
may require debridement and further reconstruction. Graft failure is unusual and
difficult to manage in patients with extensive resections. If sound surgical techniques
and principles as described in this chapter are applied, patients can expect to have good
functional recovery with a favorable disease-free interval.
VI.

CONCLUSION

Chest wall tumors, both benign and malignant, are relatively uncommon but
constitute an important aspect of any thoracic surgeon's practice. Familiarity with
the most common tumors and their presentation will facilitate an adequate work-up
and the development of a definitive treatment plan. An understanding of the surgical
principles behind the resection and reconstruction of these tumors is essential to obtain
good results. Aggressive surgical resection to obtain clear margins with adequate
reconstruction to preserve function and cosmesis give the patient the best chance for
recovery and long-term survival. With the techniques available today, most malignant
tumors of the chest wall can be successfully controlled with surgical resection and
reconstruction and should be managed in this manner.
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10
Effects of Radiation and Chemotherapy
on the Reconstruction of the Chest,
Abdomen, and Pelvis
MICHAEL E. BUDD and GREGORY R. D. EVANS

University of Califomia at Irvin.e, Irvine. California, US.A.

I.

INTRODUCTION

Multimodal interdisciplinary regimens are increasingly being used for the treatment
of cancer patients. Chemotherapy, radiation therapy, and surgery are commonly used
individually or in combination to allow functional preservation of structures that
otherwise would have been surgically sacrificed. Peri operative adjunctive therapy
decreases local recurrence by treating regional lymph nodes and/or sites of primary
extension in those patients with a high risk for microscopic involvement (1). Unfortunately, pre- and postoperative adjuvant therapies can compromise healing, causing
loss of tissue required for functional and aesthetic reconstruction following ablative
surgery (2,3). This chapter will outline the fundamentals of wound healing, the effects
of radiation- and chemotherapy-induced cellular changes, and how these changes
influence tissue transfers for the reconstruction of the chest, abdomen, and pelvis.
II.

FUNDAMENTALS OF WOUND HEALING

To understand the effect of adjuvant therapy on tissue transfers, it is important to


review the basic mechanisms and events of wound healing.
A.

Cell Cycle

All dividing cells pro'ceed through the cell cycle. There are three major groups of cells
separated by their regenerative capacity. Labile cells are continuously replacing

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140

Go

<::sJ)
Figure 1

The cell cycle.

themselves and include many epithelia such as the skin, oral cavity, ducts, gastrointestinal tract, and hematopoietic origins. Stable cells usually demonstrate a low level
of replication and include the liver, kidney, pancreas, vascular endothelial, and
mesenchymal cells. Permanent cells cannot undergo further mitotic division and
include nerve, cardiac, and skeletal muscle. Each cell cycles through five discrete
stages. Go are quiescent cells that have exited the cell cycle. These cells are neither
cycling nor dying and can be ind uced to re-enter the cell cycle with the correct stimulus.
The growth cycle (Fig. 1) consists of G 1 (presynthetic), S (DNA synthesis), G 2
(premitotic), and M (mitotic) stages. Most mature tissues contain variable portions
of dividing cells and, therefore, have varying sensitivities to radiation and chemotherapy. Typically, dividing cells are more susceptible to adjuvant therapies.

B.

Phases of Wound Healing

There are three major phases to wound healing. The inflammatory phase is characterized by redness, heat, swelling, and pain, and mediated by leukocyte margination,
adhesion, chemotaxis, and phagocytosis. This phase can last up to 4 days. The
proliferative phase is characterized by the synthesi of collagen tissue from fibroblasts
and rapid gain of tensile strength. This phase overlaps with the inflammatory phase
and may last up to 42 days. The remodeling phase is characterized by cross-linking of
collagen, which leads to the organization of the collagen andlhttening of the scar.
This phase begins approximately 6 weeks after wounding and may last lip to 2 years.
These phases are not alterable. However, the time required for each stage is variable
secondary to a variety of factors including adjuvant therapy.

III.

RADIATION AND CHEMOTHERAPY CELLULAR EFFECTS

A.

Radiation Delivery

The contemporary designation for the dose of radiation absorbed uses the unit Gray
(Gy) (1). The units of energy equivalent to this dosing are:
I Joule/kg

= I Gy = 100 rads

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I rad

= 0.01

Gy

141

= 1 cGy

When considering the effects of ionizing radiation on tissues, four treatment


factors must be taken into account: total dose, dose fraction size, total volume treated,
and elapsed time of irradiation, all of which are intimately related. The tolerance of
normal tissues to doses of radiation delivered at standard fractionation is 180-200
cGy/day (4). Therapeutic fractionated doses for carcinoma vary depending on tissue
toxicity and normally range between 45 and 80 Gy.
Radiation may be delivered by two major routes. The first is external beam
therapy such as linear accelerators or cobalt units. Radiation is administered from
machines that emit gamma rays from housed isotopes or from generated x-rays 1000
times stronger than those used for diagnostic purposes (5). A variety of energies are
used to treat tumors selectively while sparing normal structures. Electron beam energy
is used to treat superficial lesions while sparing deeper tissues. Proton beams are
administered to deliver irradiation to deep structures while sparing intervening tissues.
Neutron therapy is reserved for patients who have previously undergone aggressive
therapy or have large tumor burdens.
The second delivery method, Brachytherapy, consists of the placement of
afterloading catheters in the interstitial tissue, intracavitary, or in direct tumor
contact. These devices use radioactive isotopes (such as Iridium 192) and produce a
low dose rate of irradiation to the tumor and the immediately surrounding normal
tissues (4). This allows for higher radiation doses to be delivered to the tumor with a
relatively rapid fall off to the surrounding tissues. The advantages of brachytherapy
include the reduction of overall treatment times and the sparing of uninvolved tissues.
Brachytherapy catheters usually localize radiation to within 3 cm of the affected site.
Therefore, considerably less damage is done to normal tissue. Tissue hypoxia from
previous surgery and therapy greatly reduces the sensitivity of external beam radiotherapy and the application of brachytherapy can increase the efficacy of radiation
delivery (6). Because of the potential for wound complications, catheters are not
threaded with isotopes until postoperative day 5. External beam therapy is prescribed
in daily fractions (200 cGy/day) over a 5-6 week course. In contrast, brachytherapy
allows a continuous but limited application of radiation to the tumor bed.

B.

Radiation Injury

The tissue injury from ionizing radiation is thought to be caused by two discrete
mechanisms: DNA disruption and oxygen free radical formation, which may damage
cellular DNA or have a direct toxic effects on other aspects of cell function. As a
consequence, radiosensitivity is partially based upon the oxygen tension in the tumor.
However, cell death more commonly occurs from the disruption of normal cell
division. Berstein et a1. (4) describes three types of injury. Lethal damage is irreversible, nonrepairable, and leads to cell death. Sublethal damage can be repaired by a
cell in hours unless a second dose is added to create lethal damage. Potentially lethal
damage may be modified by changing the cells' environment following radiation.
This damage can not be repaired in rapidly dividing tissues such as tumors and in
some normal tissues (i.e., skin, bone marrow).
In general, cells are most sensitive to radiation in the Gz-M phase and most
resistant in the last S phase (7). This concept is important for radiation and chemoradiation protocols. By fractionating the radiation dose, different populations of cells
will be killed at different times dependent upon their cell cycle stage.

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Chemotherapy may also cause direct damage to both DNA and other cellular
components required for cellular division. These drugs are alkylating agents, DNA
structural analogs, and direct inhibitors of cellular functions. A majority of these
drugs do not form oxygen free radicals and are not as dependent on the oxygen
tension for their tumoricidal effect.

IV.

RADIATION EFFECTS

Radiation has both acute and delayed effects on the body's ability to heal. Damage
is caused by the ionization of atoms. Acute radiation effects occur during or within
1-24 h after the course of radiation therapy with as little as 4.5 Gy (8) They are
usually seen in rapidly proliferating tissues (labile cells) such as the skin and mucosal
surfaces. Most patients will manifest these changes in the form of erythema and/or
hyperpigmentation of the skin (Fig. 2). Individual cells also vary as to their response
to radiation therapy.

A.

Keratinocytes

The acute effects of radiation are characterized by an inflammatory reaction that is


seen in keratinocytes (9), and appears to be progressive and permanent. The early
reaction is believed to be related to activation of proteolytic enzymes resulting in an
increase in capillary permeabili ty and local inflammatory response (9). Early erythema

Figure 2

A 54-year-old man with acute radiation changes to the neck.

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is usually unrecognized and lasts only 2 or 3 days, while pigmentary changes usually
do not follow a single dose of irradiation (4). The main erythematous reaction
may appear approximately 8 days after a single dose of 8 Gy and may reach peak
intensity 8 days after exposure (8). This reaction is thought to represent damage to the
basal cell population of the epidermis (4). Mucosal surfaces may exhibit mucositis or
cystitis limited to the portal of therapy. Dry desquamation occurs at moderate radiation doses and moist desquamation at higher doses. The acute response usually
resolves within 1 month after the cessation of radiation therapy.

B.

Melanocytes

The pigmentary changes seen in radiation-damaged skin are believed to be the


result of the increased transfer of melanin from the melanocytes in the basal layer
of the skin to keratinocytes via melanosomes (6,9). In addition, epidermal
melanocytes may deposit pigment in the dermis that is engulfed by macrophages
resulting in pigmentary changes. At higher doses, there may be depigmentation of
the skin secondary to destruction of the melanasomes (4). This creates areas of
alternating hypo- and hyperpigmentation with telangiectasia and atrophy (8).
Pigmentary changes are most frequently noted in the chronic phase of radiation
therapy (Fig. 3).

C.

Fibroblasts and Collagen

Acute radiation damage to the dermis may result in dermal inflammation and edema
of the collagen bundles (8). There is a decrease in the ability of dermal fibroblasts to
proliferate (4). Necrosis of the dermis may lead to ulcer formation. In addition, late
radiation effects are believed to occur secondary to the decreased ability of fibroblast
proliferation.

D.

Vasculature

The early erythematous reaction is seen when superficial vessels dilate after irradiation. Other vessels may show endothelial cell proliferation and edema of the vascular
walls, which lead to thrombosis (8). Telangiectasia of superficial blood vessels may
occur after thrombosis and recanalization of deeper vessels (4). Large vessels near
ulcerations are usually occluded and lymphedema in the superficial dermis may also be
evident (8).

E.

Bone

Early radiation effects have little impact on developing osteoradionecrosis (ORN).


However, osteocytes are directly damaged from exposure to radiation, which results
in immediate and delayed cellular death (10). Over time, the blood supply to
irradiated bone is diminished by progressive endarteritis and may manifest in
decreased blood flow through haversian and Volkmann's canals (10). Eventually,
as cellular reparative capacity is diminished, bone density is lost leading to microfractures in stress-bearing areas.
Osteoradionecrosis is essentially bone death secondary to radiation injury, and is
defined as exposed bone that has failed to heal over 3 months (II). Marx (11) describes
three types of osteoradionecrosis. Type lORN develops shortly after radiation and is

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Figure 3 A 34-year-old woman with changes consistent with chronic radiation. Note the
pigmentation and fibrosis of the skin.

due to the synergistic effects of surgical trauma and radiation closely coupled in time.
Type II ORN develops years after irradiation and following a traumatic event. It
rarely occurs less than 2 years after exposure, and usually is seen 6 years or later. Type
II ORN is secondary to a progressive endarteritis and vascular occlusion of the
nutrient vessels in the bone and periosteum (10). Type III ORN occurs spontaneously
without a preceding traumatic event and is a result of immediate cellular damage and
death. It usually manifests between 6 months to 3 years after exposure (10).
Osteoradionecrosis is most commonly associated (but not exclusively) with total
radiation dosages in excess of 70 Gy or fractions greater than 2 Gyjday (II).
In contrast to acute radiation effects, late radiation changes may be exhibited by
any tissue type. There is no association between the intensity of the acute reaction and
the late radiation effects. However, factors that appear important in the development
of these chronic changes are the total dose and fractiona tion of the radia tion therapy.

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Late changes produce an irregular epidermis with areas of atrophy alternating with
variable hyperplasia (4). These epidermal cells have atypical nuclei and arrange
themselves in a disorderly fashion (4). The thrombosis of blood vessels will ultimately
lead to fibrosis with hypocellular tissue containing a paucity of blood vessels. Both of
these contribute to the skin becoming fragile, easy to injure, and more susceptible to
infection. Venous drainage is compromised by the radiation-induced fibrosis and
venous constriction (12).
F.

Wound Healing

Carefully sutured tissue has approximately 70% of the strength of nonwounded skin.
When sutures are removed, usually I week after wounding, the skin strength is 10% of
nonwounded skin. This rapidly increases over the next 4 weeks and peaks at 70-80%
of nonwounded skin in approximately 2 years. The critical cellular events in wound
healing seem to occur within the first 5-7 days and treatment given after this time
should be safe (13,14). However, studies have demonstrated increased rates of fistulas,
flap loss, and carotid artery blowouts following radiation therapy (6). This controversy is probably related to the varying effects of radiation on tissues at differing doses,
radiation type, and the timing of the therapy. It also rela tes to the type of closure and
whether vascularized or nonirradiated tissue has been utilized.
Preoperative radiation therapy appears to influence wound healing. Drake et a!.
demonstrated that a single dose of 300 cGy or less given preoperatively does not
significantly affect wound healing. However, doses of 1000 cGy or more when given
within 3 weeks of surgery did alter healing (15,16). When completely healed, these
wounds appeared to attain the same tensile strength as nonirradiated wounds. The
minimal dose that impairs healing varies from tissue type to tissue type. In fact most of
these complications have been well worked out for these individual tissues based on an
acceptable standard of a 5% complication rate.

v. CHEMOTHERAPY INJURY
Compared with the amount ofliterature documenting radiation effects on tissue, there
is a relative scarcity of information on the effects of chemotherapy on soft tissues and
surgical healing. The surgeon should know the type of chemotherapeutic drug used,
the time interval from the last dose, the absolute white blood cell count, and the
patient's response to the previous regimen (15). Most classes of chemotherapy have
different effects on cells, but most influence DNA in one form or another. In general,
drug dose correlates directly with the effect on wound healing, and the critical dose for
most agents has not been identified (15). Many studies report no significant increase in
postoperative complications compared with stage-matched controls (17).
Most, if any, detrimental effects on wound healing are seen when chemotherapy is given 2 weeks preceding surgery or within 1 week after wounding (18,19).
In contrast to radiation-induced effects, which are cumulative and progressive,
chemotherapy effects appear to be transient (15). Neutropenia can severely affect
the healing process. Neutrophils and monocytes are key elements in the healing
cascade. They release local humoral factors that stimulate mitogenesis, angiogenesis,
and fibroplasia. It is widely recognized that an absolute neutrophil count below 500
is clearly detrimental to wound healing and strength (16). A decreased monocyte

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count appears to correlate with collagen production and the regulatory control that
the monocyte exerts over fibroplasia (16).
The antibiotic Doxorubicin hydrochloride (adriamycin) has been widely studied
and is thought to inhibit DNA-dependent synthesis of RNA A white blood cell nadir
occurs at 10-14 days and recovery occurs by 21 days. Doxorubicin hydrochloride has
been demonstrated to reduce wound tensile strength if given 1 week before or I week
after wounding (20,21). A so-called recall effect occurs on previously irradiated tissue.
After receiving doxorubicin hydrochloride, patients who have undergone radiation
therapy develop blisters and inflammation at previously irradiated skin sites consistent
with acute radiotherapy changes (22,23).
Methotrexate acts by competitively bonding to dihydrofolate reductase, which is
critical to the biosynthesis of purines for DNA production. Its effects on wound
healing are transient (18,19).
Cyclophosphamide retards wound tensile strength if given as a 100 mg/kg or
higher dose I week after wounding (15).

VI.

COMBINATION RADIATION/CHEMOTHERAPY INJURY

When chemotherapeutic agents are used in conjunction with radiation therapy, either
as radiosensitizers or in organ-preservation protocols, their effects are profound. On
histological examination, their effects mirror and intensify the changes produced by
radiation alone (24). There is proportionally greater obliterative endarteritis and
increased fibrosis (24). There is a small reduction in the amount of inflammatory cells
(24). Granulation tissue is also decreased and has abnormal architecture (24). The
formation of collagen is retarded and the appearance of mature collagen is delayed
(24). These affects are dose-dependent; progressively larger doses of chemoradiation
cause more depletion of capillaries and fibroblasts (24).

VII.

EFFECT OF RADIATION AND CHEMOTHERAPY ON CHEST,


ABDOMEN, AND PELVIS RECONSTRUCTION

Wounds affected by radiation or chemotherapy challenge surgeons in all disciplines.


Wound healing complications or even tissue loss are more prevalent and solutions are
fewer. Free tissue transfer using microvascular techniques have improved this
scenario, but controversy continues to surround the clinical effect of perioperative
adjuvant therapy on tissue transfer.
The use of recipient vessels in irradiated fields is controversial, most probably
dependent on the size of the vessel selected (22,23). In addition to the well-documented
effects on fibroblast and myofibroblasts in conjunction with mitochondrial damage
and inhibition of wound contraction, vascular changes such as endothelial proliferation, subintimal fibrosis, and reduction in the vessel lumen may lead to vessel
occlusion in irradiated tissues (25-28). Masters et a1. recommended from their
experience that chronic radiation injury is best treated with uninvolved tissue from
outside the primary field of irradiation (29). Recent reports suggest that irradiation to
the transposed muscle's nutrient vessels does not compromise flap viability (30).
Arnold et al. reviewed 100 patients who received radiation therapy (30). They
demonstrated a complication rate of 32% when irradiated muscle was transposed
(14% total flap loss). The subgroup using nonirradiated muscle had a complication

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rate of 19.3% (no total flap loss). The total complication rate for transposition of
muscle to close an irradiated wound was 25%. The incidence of hematoma, seroma,
infection, and fistula was comparable in both groups. Arnold et a1. concluded that the
single most important consideration in the treatment of radiation wounds is adequate
debridement (31-34). Many wounds appeared healthy in the operating room after
fresh debridement, but demonstrated continuing necrosis the following day. Secondary to this outcome, they recommended delaying closure of debrided wounds for
24-48 h to determine if a wound site is sta ble and using transposed free tissue that is
well-vascularized to augment the healing process. The ability of nonirradiated wellvascularized musculocutaneous flap to resist bacterial inoculation and clear residual
infection is a definite advantage. However, the progressive vascular damage seen in
irradiated tissues appeared to reduce this advantage when muscle transfers comes
from the primary field of radiation (30).
Aitasalo et a1. documented a success rate of 91 % in nonirradiated patients and
88% complication rate in patients with head and neck tumors receiving 50-65 Gy
3-5 weeks prior to surgery (35,36). Patients with radiation doses of 60-70 Gy showed
the highest frequency of wound healing disorders and partial graft losses. When the
transition zone between the free flap and flap bed was evaluated histologically, the
tissues irradiated with 60-70 Gy showed significant reduction of vascularization and
significant decrease of mean capillary lumen (34). Vessels with diameters less than 10
11m were affected, whereas vessels with a diameter of more than 10 11m were affected
secondarily (37). However, patients treated with a combination of lower-dose
radiation, 40-50 Gy, and cisplatinj5-fluorouracil had no differences in the mean
histomorphometric vascularization and mean capillary lumen size compared to
nonirradiated tissues (34). Treating tissue with chemotherapy 1-1.5 months prior
to surgery did not affect the graft tissue (34).
New studies suggest that lower-dose radiation therapy and a shorter time
interval to reconstruction may increase flap survival rates (34). Intervals of 4--6 weeks
between irradiation and grafting are favorable for vascularization of grafting tissue
(34). These results are similar to other studies in the literature that demonstrate more
favorable success rates of 88-100% for reconstruction within 3-5 weeks following
irradiation (35). After an interval of71 months, failure rates increased to 40% (41).
This observation is most likely secondary contributed to the steady decrease in vessel
density per total area and mean capillary lumen observed after radiation therapy. It is
hypothesized that this effect is secondary to the blocking of the endothelial repair
processes through qualitative changes in the DNA of endothelial cells and an increase
of apoptosis after irradiation (38-41).
A.

Chest Reconstruction

Radiation-related wounds of the chest wall pose life-threatening hazards to the


patient, but a variety of regional muscle flaps are available to provide coverage of
defects in the chest wall. Once an ulcer starts, it has a progressive nature until excised. Therefore, complete removal of the affected tissue is vital and reconstruction
with well-vascularized tissue, as opposed to local tissue advancement, are necessary
for protection and preservation of vital structures.
Barwick et al. described a series of 82 patients who received preoperative
radiation therapy (42). Primary closure with free tissue flaps was compared to

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conventional wound closure by skin reapproximation. There were fewer complications with free tissue transfers than with skin reapproximation (19% vs. 51 %), fewer
secondary procedures for wound closure were required (10% vs. 35%), and shorter
average hospitalization days when using free tissue transfers (42).
The high complication rate in wound healing of irradiated tissue suggested that
almost no tension can be tolerated in these wound closures. In protocols that include
preoperative irradiation, wound complications after dosages of 35-62 Gy ranged
from 20 to 50% (43-45). In contrast, lower levels of preoperative radiation, 17.5-28
Gy, in combination with intra-arterial chemotherapy produced lower complication
rates, 0-7.3% (46,47). Postoperative radiation also resulted in fewer complications
(43,44,48,49). Again, damage to cellular DNA, dermal elastic fibers, fibroblasts, and
myofibroblasts were major causes of complications.
Local wound care is used to treat radiation ulcers but, secondary to the nature
of the radiation injury, a progressive necrosis of the ulceration occurs. Prior to
debridement and reconstruction, a biopsy is in order to detect tumors. Radiationinduced tumors such as basal cell carcinoma, squamous cell carcinoma, and sarcoma
are not uncommon. It is preferred to remove the entire zone of irradiated tissue prior
to reconstruction.
It is important to consider the size and location of the chest wall defect as well
as the amount of tissue remaining outside the irradiated area. Available chest wall
muscles are based on the axial vessels and include the pectoralis major and latissimus dorsi. The serratus and trapezius muscles may also be used with their pedicles
well beyond the radiation fields (50-52). Radiation-induced fibrosis of the axilla
may inhibit the arc of rotation of a latissimus dorsi muscle flap, thereby limiting
reconstruction (52).
Chest wall defects in nonirradiated tissue less then 5 cm in diameter, limited to
two adjacent ribs or those located under the scapula above the fourth rib, can be
reconstructed with tissue alone (51). The skeletal component can be ignored. Defects
that are larger than 6 cm require composite prosthesis of Marlex mesh and methylmethacrylate for reconstruction. However, with open irradiated ulcers that have
bacterial contamination, synthetic materials should be used cautiously. Flaps alone
can stabilize the chest wall and prevent paradoxical chest wall movement econdary to
their bulky nature and fibrosis of the lung and chest wall from radiation therapy. When
thin flaps are used (i.e., omentum) in addition to resection of three or more ribs,
synthetic materials should be considered to maintain proper chest wall stability and
pulmonary function.

B.

Pelvic Reconstruction

A variety of factors must be considered in pelvic reconstruction. The patient's


nutritional status, previous radiation exposure, and the extent of the resection are
all vital components when planning reconstruction. Nutrition has importance not only
for the cellular/inflammatory phases of wound healing but also for the long-term
deposition of collagen matrix that will allow the tissue to load bear and prevent
herniation of tbe pelvic contents. Radiation portals must be considered with regard to
the choice of flaps. donor vessels, and axis of flap rotation and inset (53). Persistent
perineal sinuses and chronic perineal wounds that remain unhealed for 6 months or
more are the significant sources of morbidity in this group of patients (54). The

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Effects of Radiation and Chemotherapy

149

incidence of these complications after surgery alone has been reported as high as 55%
(55). Late complications are perineal hernia or evisceration, fistula, and pseudoaneurysms. The incidence of these complications correlates directly with the dosage of
absorbed radiation coupled with extensive surgery (56). The high concentration of
enteric organisms demands secure watertight closures with well-vascularized tissues.
Musculocutaneous flaps resist bacterial infection both on the skin and on the deep
surface (55). They also provide a conduit for delivery of host defenses and provide
stable coverage in the face of bacterial colonization in 93% of patients (56).
Perhaps future use of brachytherapy for pelvic cancers will reduce the complication rates for free tissue transfers. When brachytherapy is delivered within 5 days of
surgery, it has been associated with significant wound complications (48%) (57-59). In
contrast, delaying brachytherapy beyond 5 days increases wound collagen content
and wound breaking strength (57-60)
VIII.

FUTURE TRENDS

Cancer research is expanding and patients will be treated with multimodal therapies
with increasing frequency. Therefore, it is vital for the plastic surgeon to be familiar
with current studies that are necessary to evaluate the effect of these interventions
on tissue transfers. Critical doses and time intervals of radiation and chemotherapy that cause flap loss and increased complications must also be determined. By
determining ideal dosing regimens and the correct operative window, the cost to the
health care system can be reduced by minimizing both days of hospitalization and
secondary procedures for flap loss or other complications. Not only will local and
regional control of disease be vital in the establishment of our surgical techniques,
but long-term functional assessments, aesthetic, and quality-of-life values must also
be considered.
IX.

SUMMARY

Although many believe that the transfer of vascularized tissue into irradiated wounds
improves healing, the underlying mechanism for this phenomenon has yet to be
defined. It has been demonstrated that vascularized tissue can increase oxygen and
introduce polymorphonuclear leukocytes with enhanced antibacterial activity into the
surrounding tissue (61-63). Other cell components, functional myofibroblasts, and
macro phages may also be brought into wounds, which may improve collagen
formation and integration of the ground matrix (61-63). Prophylactic placement of
the flaps should be considered if suspected postoperative wound healing complica tions
will occur.
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11
Local Flaps and Skin Grafts
for Chest Reconstruction
DAVID W. CHANG

University of Texas 1\1. D. Anderson Cancel' Center, Houston, Texas, US.A.

I.

ASSESSMENT

The appropriate technique for chest wall reconstruction is determined largely by the
type and extent of the defect requiring repair. Coverage of a chest wall defect may be as
simple as a skin graft or as complicated as a microvascular free tissue transfer,
depending on the specific defect and the patient's condition. The design of a
reconstructive procedure must take into account the requirement for skeletal support
and the soft-tissue deficit. In addition, the patient's overall medical condition must be
assessed and cardiopulmonary function optimized. It is also important to know
whether the patient has undergone previous chest wall surgery or radiation therapy
to the chest wall.
The reconstruction of an irradiated chest wall deserves special attention, since it
is complicated by the presence of scarred, fibrotic tissues and by the questionable
vascularity of the recipient bed and adjacent tissues. Skin grafts or local flaps that
include tissues that have been irradiated are generally not recommended in this setting,
because they are prone to high rates of complication and failure. Reconstruction of the
irradiated chest wall is best done with non irradiated, well-vascularized tissue, if
possible (1).
II.

HISTORY

The history of flaps used for chest wall reconstruction closely parallels the evolution
of flap surgery in general. With the popularization of skin flap surgery following
World Wars I and II, the previously used simple closure of chest wall defects was

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Chang

154

supplemented with a variety of local rotation flaps, often performed in stages over
several weeks or months. Such local flaps were often limited in size, disfiguring,
cumbersome, and unsuccessful.
An important advance was the development of the epigastric and deltopectoral flaps, which were trunk flaps based on a specific arterial supply (2,3). As surgeons' understanding of the regional blood supply of the trunk improved, the
concept of axial-pattern arterial skin Raps became more important in the planning
of chest wall reconstruction.

III.

INDICATIONS

The need for chest wall reconstruction can result from trauma, tumor resection,
infection, radiation ulcers, and congenital defects. For large, complex defects, local
flaps have been largely replaced by muscle and musculocutaneous Raps, with microvascular free flaps reserved for situations in which regional options are unavailable or
have previously failed.
However, there are still situations in which local Raps can be successfully used
and are indicated. For a partial-thickness defect or even a small full-thickness defect,
particularly in patients undergoing palliative resections, lesser procedures such as
local flaps may be considered. Even some large defects, including the absence of ribs,
with a consequent concern about flailing, may be repaired using local flaps in selected
cases. Full-thickness flaps with underlying subcutaneous tissue may provide enough
substance to minimize flailing without the use of underlying synthetic mesh. Welldesigned local flaps can close a defect and redistribute the local tissues to avoid
limitations of motion or distortion of adjacent structures.
For large, complex defects and in patients with a questionable vascular bed, as in
wounds that are contaminated or have been irradiated, reconstruction with nonirradiated, well-vascularized tissue is preferred.

IV.

ANATOMY

The blood supply to the skin and subcutaneous tissues of the chest wall is derived from
branches of the lateral thoracic, internal mammary, superior epigastric. thoracoacromial, and intercostal arteries (4). The lateral thoracic arteries are tributaries of the
second portion of the axillary artery, which descends to the anterior and lateral
portions of the chest, turning around the free edge of the pectoralis muscle. Multiple
perforators supply the overlying skin. The pectoral branch of the thoracoacromial
artery supplies the pectoral muscles, and its perforators supply the overlying skin. The
internal mammary artery gives olf the anterior intercostal vessels. The upper six
intercostal spaces are supplied by two such anterior intercostal vessels. The perforating
branches of these vessels supply the overlying skin. with the second, third, and fourth
branches being dominant. A series of cutaneous perfora tors branch olf the intercostal
vessels and supply the skin through anterior. lateral, and posterior perforators. which
are interconnected extensively in the subcutaneous layer. The superior epigastric
artery anastomoses with the internal mammary artery and supplies the area of the
rectus abclominis sheath and overlying skin.
The circumflex artery of the scapula consistently has large cutaneous bran he
supplying the upper lateral back. A vertical row of medial posterior perforators on

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155

each side of the spine is similar to that of the internal mammary perforators of the
anterior aspect. The posterior intercostal arteries send branches to the posterior and
lateral chest wall, the breast, and the overlying skin and subcutaneous tissue. Between the anterior and posterior perforators, a row of lateral perforators is located
approximately along the midaxillary line. Intramuscular and subcutaneous interconnections of the three systems occur in a network fashion that is oriented horizontally.
V.

RECONSTRUCTIVE TECHNIQUES

A.

Skin Grafts

Partial-thickness defects of the chest wall are relatively straightforward to repair and
may be covered by skin grafts. However, skin grafts require a vascular bed and will
seldom take in exposed bone or cartilage devoid of its periosteum or perichondrium
or in a wound bed that is contaminated or has been heavily irradiated. Skin grafts
are often used in combination with local flaps; skin and subcutaneous tissue are
transferred into the area of greatest motion, while a skin graft is placed onto the
adjacent area.
Full-thickness defects are best repaired with vascularized muscle, fascia, or
skin flaps.
B.

Local Flaps

Whenever possible, local flaps should be designed to contain the maximal blood
supply and to take advantage of well-known principles of flap surgery. The lengthto-width ratio, although convenient for descriptive purposes, is not the most important factor in determining the blood supply of the flap. More important is that
the base of the flap should be centered over a regional blood supply source, and the
design of the flap should be aligned along the principal direction of the subcutaneous
vessel network. Inclusion of the deep fascia generally improves the reliability of a
skin flap (5). Because of the greater elasticity of the skin along the vertical axis and
because of the more limited circumference transversely, tension is better tolerated
vertically than horizontally. In addition, rotation or transposition flaps generally
should be designed sufficiently large to enable adequate movement and closure without tension.
The quality of tissue adjacent to the defect is important. The inclusion of heavily
irradiated, scarred, inflamed, or traumatized tissue in a local flap invites failure. When
such tissue is present, the repair is best done using distant vascularized flaps.
1.

Thoracoepigastric Skin Flaps

Thoracoepigastric skin flaps can be designed as laterally or medially based flaps (6).
While a laterally based flap is preferable in most instances, if the area that might serve
as its base has been compromised by surgery or irradiation, a medially based flap may
be appropriate. Like the laterally based flap, the medially based flap may be elevated
without delay, providing it does not extend beyond the anterior axillary line. Unlike
with a laterally based flap, however, the donor site defect from a medially based flap
cannot usually be closed primarily, and a skin graft is frequently required. Properly
designed and executed, la terally and medially based transverse thoracoepigastric skin
flaps can be expected to acmeve success with minimal significant morbidity.

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Chang

156

Most commonly, the laterally based thoracoepigastric skin flap should be


designed as an oblique flap extending downward and medially, so that rotation or
transposition occurs at a favorable angle. It is important that the inferomedial border
be oblique, so that even with very large flaps the donor site defect can be closed
primarily with mobilization of the skin at the inferior perimeter for a V-Y advancement closure if necessary (Fig. I). If the medial border of the flap is not directed
obliquely in the inferior and lateral direction, primary closure may not be possible, and
skin grafting becomes necessary. To enlarge or extend this flap, a portion of the
external oblique muscle may be included.
The laterally based flap is incised down to the fascia and elevated to the anterior
axillary line. As the flap is elevated laterally, large penetrating vessels are seen; these
should be spared, although this is essentially a random flap with a favorable width-tolength ratio. Once elevated, the flap is rotated into the defect, with mobilization of the
inferior and lateral defect skin and with some back-cutting, as necessary.

.....

[OCO( reel oeSl(~n


01 IltlO

}\

Ii

"

Cj!~

,/'/
.

-~

"

laterally based",
oblique thoroco-',
abdominal flop

-::':"7

,~_ ..~

. .)y
'" '.

,.

Figure 1 A. The laterally based thoracoepigastric skin flap should be designed as an


oblique flap extending downward and medially, so that rotation or transposition occurs at a
favorable angle. B, C. It is important that the inferomedial border be oblique, so that even
with very large flaps the donor site defect can be closed primarily with mobilization of the skin
at the inferior perimeter for a V-Y advancement closure if necessary. (From Ref. 6.)
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157

Local Flaps and Skin Grafts

The medially based upper abdominal or thoracoepigastric skin flap differs from
the lateral flap in that it is essentially an axial flap based on perforators from the
superior epigastric artery by means of the rectus abdominis muscle. For this reason,
the flap is designed in a transverse orientation, taking full advantage of the medial
blood supply. The flap is designed with a width to fit the defect and a length to reach it.
The medially based flap is elevated with the subcutaneous tissue down to the
fascia from its lateral extreme toward the midline, with the dissection stopping about
2 cm from the midline to avoid damaging the perforating blood supply (Fig. 2). The
flap is rotated into place and sutured appropriately. The skin edges of the donor
defect are mobilized, advanced to minimize the open area, and sutured to the
underlying fascia. A split-thickness skin graft is used to cover the remaining defect,
with a bolus dressing for graft immobilization.
2.

Deltopectoral Flap

Deltopectoral flaps were first described by Bakamjian for pharyngeal reconstruction


but also have been used to repair defects of the anterior chest wall (7,8). Because of its
arc of rotation, the deltopectoral flap can reach most of the anterior chest surface, and

Figure 2 The medially based thoracoepigastric skin flap is designed in a transverse orientation, taking fuJI advantage of the medial blood supply. The flap is rotated into place and
sutured appropriately. The skin edges of the donor defect are mobilized, advanced to minimize
the open area, and sutured to the underlying fascia. A split-thickness skin graft is used to cover
the remaining defect, with a bolus dressing for graft immobilizatioIl. (From Ref. 6.)

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158

the flap is easily and quickly elevated (8). Inclusion of the underlying fascia may result
in a more reliable blood supply.
A variation of the deltopectoral flap has been described in which the flap is
simply turned over into the defect after removal of its epithelium (9). The exposed
subcutaneous undersurface is then skin grafted. If the defect is located medially, a onestage reconstruction can be achieved. However, if the defect is located more laterally, a
longer flap is required and division and return of the pedicle are preferred (Fig. 3).
The principal blood supply of the deltopectoral flap is derived from one or two
large perforating arteries from the second or third intercostal space located lateral to
the sternal border. The axial arteries pass just above the muscle fascia for a short
distance and disappear into the subcutaneous fatty layer heading toward the shoulder.
Laterally, they form collateral connections with the thoracoacromial perforators over
the coracoid process, extending the potential vascular territory of the flap to the skin
over the anterior shoulder.
The upper margin of the deltopectoral flap usually lies over the medial half of
the clavicle and continues superolaterally toward the acromion. A parallel lower
margin usually spares the nipple and heads toward the anterior axillary fold. Most
deltopectoral flaps are raised without delay, whereas longer flaps are better delayed
during the first stage by elevating the lateral part of the flap to ligate the thoracoacromial perforators.
Extension of the flap in an inferior direction over the upper arm has also been
described; the additional skin is supplied by additional collateral connections to the
muscular cutaneous perforators over the deltoid muscle. The flap width can cover
the entire chest, although excessive width would limit rotation and does not add to
the useful length of the flap.
Flap elevation is commenced laterally to medially in the plane above the muscle.
Some surgeons prefer to include the pectoralis major'muscle fascia with the flap to
minimize injury to the axial vessels. Near the lateral border of the sternum, the
dissection must be done carefully. When the second or third perforators are observed
exiting the muscle, the dissection has reached its limit. Back-cuts can be done on
the skin at the base to improve rotation; however, one must be careful not to compromise the perforating vessels.

Figure 3 A. If the defect is located medially, a one-stage reconstruction can be achieved.


The exposed subcutaneous undersurface is then skin grafted. B. if the defect is located more
laterally, a longer flap is required, and division and return of the pedicle is preferred. (From
AG Leonard. Deeoithelialized turnover deltopectoral flap. In: Strauch B, Vasconez LO, HallFindlay E.J, eds. Gragg's Encyclopedia of Flaps. 2d ed. Philadelphia: Lippincott-Raven. 1998.
pp. 1397.)
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Local Flaps and Skin Grafts

For medial defects, the medial margin of the defect should be extended at least to
the midline or to the contralateral border of the sternum. The deltopectoral flap is
raised with dissection carried medially until the perforating branches of the internal
mammary artery are seen. The flap is de-epithelialized and then turned over like a page
of a book to lie in the defect, where it is sutured in place. The exposed undersurface of
the flap and the secondary defect are covered with a split-thickness skin graft.
F or a lateral defect, only an area a t the end of the f1a p, correspondi ng to the size
of the defect, is de-epithelialized. The reconstruction is staged, with division and return
of the pedicle at 3 weeks.
3.

Contralateral Transverse Thoracoabdominal Skin Flap

The contralateral transverse thoracoabdominal skin flap does not resemble an axial
flap but is more like a random flap. The flap receives its blood supply from the lateral
branches of the segmental arteries at the T6-Tl 0 level and from the supraumbilical
and infraumbilical plexus formed by the perforating musculocutaneous branches that
originate in the arcade of the upper and lower deep epigastric arteries (10). It is
imperative that, as one elevates this flap, several of the perforators be maintained to
ensure fla p reliabili ty.
The thoracoabdominal skin flap is outlined in a triangular shape (Fig. 4). The
length of the flap may vary from 30 to 40 cm and its base width from 20 to 25 em. Its

A.S

Figure 4 A. The thoracoabdominal skin flap is outlined in a triangular shape. B. Elevation


of the flap is done at the level of the abdominal aponeurosis. The flap is then rotated 90 degrees
to cover the defect. To prepare for closure of the donor area, the subcutaneous tissue covering
the anterolateral wall of the abdomen is dissected almost to the inguinal fold. (From RL
Baroudi. Contralateral transverse thoracoabdominal skin flaps. In: Strauch B, Vasconez LO,
Hall-Findlay EJ, eds. Gragg's Encyclopedia of Flaps. 2d ed. Philadelphia: Lippincott-Raven,
1998, pp. 1388.)

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maximum length-to-width ratio is 2: I, and its size is limited by two transverse parallel
lines: one that passes along the inframammary sulcus, and one that passes through the
upper abdomen. The distal end of the flap is situated at the contralateral hypochondrium. The lower edge, which begins very close to the umbilicus, is convex and longer
than the upper edge. The flap reaches from one hypochondrium to the other, passing
through the epigastric region.
The elevation of the flap is done at the level of the abdominal aponeurosis,
from the distal end back to the base of the flap. The flap is then rotated 90 degrees to
cover the defect. To prepare for closure of the donor area, the subcutaneous tissue
covering the anterolateral wall of the abdomen is dissected almost to the inguinal
fold. The donor site can usually be closed primarily, and the flap can be mobilized
and directly rotated without delay (11,12).
4.

Bipedicled Skin Flaps

Bipedicled skin flaps are easily developed on the thorax and are simple solutions for the
coverage of many superficial defects. Because of the multiple systems supplying blood
to the chest wall, such flaps may be oriented equally well in a vertical or horizontal
direction depending on the needs of the patient (13). When properly designed,
bipedicled flaps are robust, allowing mobilization of well-vascularized tissue. However, the distance they can be moved is limited, and most of the time secondary skin
.
grafting is req uired.
Vertically oriented bipedicled flaps lend themselves extremely well to the repair
of defects of the sternum. The juxtaposition of two bipedicled flaps, one from each side
of the defect, is especially useful for the closure of large defects. Bipedicled skin flaps
may be used in combination with underlying synthetic material such as MarJex mesh
or with homologous muscle flaps. Most defects of the anterior and lateral chest walls
are best closed with transversely based flaps, taking advantage of the transverse
orientation of the intercostal vessels (Fig. 5).
A bipedicled skin flap should always be at least 25%, and preferably 50%, larger
than the defect. This allows overlap of the defect so that some contact may be made
with adjacent vascularized tissue. Since all bipedicled flaps include some random area,
a flap width of at least half the length of the flap is recommended.
The success and ease of mobilization of this flap depend largely on the initial
relaxing incision made parallel to the defect. To avoid tension on and kinking of the
flap, the relaxing incision should be at least twice as long as the defect. Curving the
relaxing incision, with the concave side toward the defect, facilitates mobilization of
the flap.
Undermining is done at the level of the fascia. While inclusion of the fascia may
preserve additional blood supply, it limits mobilization. As many perforating vessels
as possible are left intact, as long as they do not interfere with transposition of the flap.
When the flap is transposed to the defect, extension of the relaxing incision or even
judicious back-cutting of the flap may be required. The donor site defect is closed with
a split-thickness skin graft.
5.

Breast Flap

The breast flap is also referred to as the cyclops flap, because nipple from the breast
used in the flap generally ends up in the center of the chest (14). The breast flap is

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Local Flaps and Skin Grafts

---r------;\

161

-'iJI',,--\\

~) ) '\"
I

~-;'/

..

Figure 5 Vertically oriented bipedicled flaps lend themselves extremely well to the repair of
defects of the sternum. Most defects of the anterior and lateral chest walls are best closed with
transversely based flaps, taking advantage of the transverse orientation of the intercostal
vessels. (From Ref. 13.)

comparatively uncomplicated and can be done expeditiously, without delay. The flap
usually has a good blood supply.
The disadvantages of the breast flap include the transfer of tissue at risk for
cancer, and the unaesthetic result. This flap destroys the normal breast for the patient
and essentially deforms the entire chest walL The results, while providing a healed
wound in a difficult clinical setting, nevertheless create a significant deformity.
The usefulness of the breast flap is thus limited, but it may be an alternative when
other flaps are not available (15). It is perhaps more readily tolerated in debilitated
patients, for whom the procedure is palliative and a less extensive and briefer
procedure is desirable, An appropriate candidate might well be an older woman with
a chronic, painful, ulcerating wound who is not concerned about aesthetic deficiencies
(16-18),

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The breast flap is an axial-pattern flap nourished by the lateral thoracic artery
and the varia ble external mammary artery (14). There are also anterolateral intercostal
perforators that enter the breast laterally. This allows the breast to be elevated on its
lateral pedicle. This lateral pedicle perfuses the most medial portion of the breast
through anastomotic communications, so the medial portion may be divided from its
arterial inflow, derived from the internal mammary artery.
The incision for the breast flap is usually made in the inframammary crease and
extended as far laterally in the crease as necessary (Fig. 6). After incision, the surgeon
elevates the soft tissues at the level above the fascia of the pectoralis major muscle.
The mobilization continues as far as the anterior axillary line, if necessary. If the
defect is large and lateral, or the donor breast is small, the breast flap may be transposed as well as rotated.
A variety of modifications can be used, depending on the size and location
of the defect and of the donor breast. Coverage of a large defect can be obtained by
one or several incisions on the deep surface of the breast parenchyma to allow the
skin component to be advanced farther laterally. This should be done cautiously to
preserve circulation to the medial portion of the flap (14).
If the defect is small and medial or the donor breast is large, only the medial
portion of the breast may be needed (19). If the breast is very large or ptotic, there may
be sufficient tissue in the inferior quadrants to use as a medially based pedicled flap
(19,20). This creates a long, narrow flap, and a delayed procedure may be necessary. In
either case, the remaining breast tissue can be rotated into the defect created at the
donor site to minimize the deformity and avoid the cyclops problem.
For a larger chest wall defect, or in a patient with a small breast, additional skin
beyond the breast may be needed. The skin beneath the inframammary crease can be
included, either as part of the rotation flap or by creation of a transposition flap
(16,21). The skin beyond the midline may be necessary for an extensive lateral defect,
but a delayed procedure may be wise in such a case.

~.

_;' .':.. _

"',.

tI

,/

\C
{\,'-""

r.-, ~
"=-

'I

Figure 6 A. The incision for the breast A.ap is usually made in the inframammary crease
and is extended as far laterally in the crease as is necessary. B. After incision, the surgeon
elevates the soft tissues at the level above the fascia of the pectoralis major muscle. -The
mobilization continues as far as the anterior axillary line, if necessary. (From Ref. 15.)

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163

Local Flaps and Skin Grafts

The cyclops breast deformity can be decreased by judicious thinning of the


transposed breast and by excision of the nipple-areola complex, which can be replaced
appropriately on the remaining breast mound. Skin grafting of the donor site defect is
often necessary.
6.

Other Arterialized Skin Flaps

Other arterialized skin flaps can be designed in the chest and abdomen based on the
cutaneous perforators from the internal mammary, lateral intercostal, paraspinal,
thoracoacromiaL lateral thoracic, and circumflex of scapula arteries (22). The vascular
architecture of the posterior chest skin is remarkably similar to that of the anterior
chest skin, and skin flaps based medially on the posterior perforators can also be
designed. Most simple rotation or transposition skin flaps are designed similarly to,
but not as long as, the deltopectoral flap, and the cutaneous perforators are usually not
seen. The la teral thoracic and parascapular flaps can be dissected as island flaps, and
the vessels may be skeletonized for better reach and versatility.

REFERENCES
1.
2.
3.

4.
5.
6.

7.
8.
9.
10.

11.
12.
13.

14.

Arnold PG, Pairolero Pc. Surgical management of the radiated chest wall. Plast Reconstr Surg 1986; 77:605-612.
Shaw D, Payne RL. One stage tubed abdominal flaps. Surg Gynecol Obstet 1946;
83:205-209
Bakamjian VY, Culf NK, Bales HW. Versatility of the deltopectoral flap in reconstructions following head and neck cancer surgery. In: Transactions of the International
Congress of Plastic Surgeons, 4th Congress. Amsterdam: Excerpta Medica, 1967:808.
Palmer JH, Taylor GI. The vascular territories of the anterior chest wall. Br J Plast Surg
1986; 39287-299.
Ponten B. The fasciocutaneous flap-its use for soft tissue defects of the lower leg. Br J
Plast Surg 1981; 34:215-220.
Woods JE. Transposition and advancement skin flaps. In: Strauch B, Vasconez LO,
Hall-Findlay EJ, eds. Gragg's Encyclopedia of Flaps. 2d ed. Philadelphia: LippincottRaven, 1998:1383-1386.
Bakamjian VY. A two-staged method for pharyngeal reconstruction with a primary
pectoral skin flap. Plast Reconstr Surg 1965; 36: 173-184.
Robinson DW. The deltopectoral flap in chest wall reconstruction. Br J Plast Surg 1976;
29:22-26.
Leonard AG. Reconstruction of the chest wall using a deepithelialized turn-over deltopectoral flap. Br J Plast Surg 1980; 33187
Baroudi RL. Contralateral transverse thoracoabdominal skin flaps. In: Strauch B,
Vasconez LO, Hall-Findlay EJ, eds. Gragg's Encyclopedia of Flaps. 2d ed. Philadelphia:
Lippincott-Raven, 1998: 1387-1390.
Brown RG, Vasconez LO, Jurkiewicz JM. Transverse abdominal flap and the deep
epigastric arcade. Plast Reconstr Surg 1975; 55:416--421.
Tai Y, Hasegawa H. A transverse abdominal flap for breast cancer. Plast Reconstr Surg
1974; 5352-54.
Argenta LC, Duus EC. Bipedicle skin flap. In: Strauch B, Vasconez LO, Hall-Findlay
EJ, eds. Gragg's Encyclopedia of Flaps. 2d ed. Philadelphia: Lippincott-Raven, 1998:
1391-1392
Hughes KC, Henry MJ, Turner J, Manders EK. Design of the cyclops flap for chest-wall
reconstruction. Plast Reconstr Surg 1997; 100:1146-1151, Discussion 1152.

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15.
16.
17.
18.
19.
20
2 J.

22.

Gingrass RP. Breast flaps. In: Strauch B, Vasconez LO, Hall-Findlay EJ, eds. Gragg's
Encyclopedia of Flaps. 2d ed. Philadelphia: Lippincott-Raven, 1998:1393-1395.
Maier HC Surgical management of large defects of the thoracic wall. Surgery 1947;
22:169-178.
Pierce GW, Wiper T, Magladry G, et al. Reconstruction of a large defect on the entire
thickness of the chest wall. Am J Surg 1961; 102:720-723.
Rees TO, Converse JM. Surgical reconstruction of defects of the thoracic wall. Surg
Gynecol Obstet 1965; 121:1066-1072.
Latham WD. Operative treatment for postradiation defects of the chest wall. Am Surg
1966; 32:700~ 708
Pickrell KL, Kelly JW, Marzoni FA. The surgical treatment of recurrent carcinoma of
the breast and chest wall. Plast Reconstr Surg 1948; 3: 156-172.
Bennett JE, Carter O. The surgical management of extensive necrosis after radiation
therapy. In: Transactions of the Third International Congress of Plastic Surgery. Amsterdam: Excerpta Medica, 1964: 113.
Shaw WW, Aston SJ, Zide BM. Reconstruction of the trunk. In: McCarthy JG, ed.
Plastic Surgery. Vol. 6. Amsterdam: WB Sa under, 1990:3675-3689.

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12
Rectus Abdominis for
Chest Reconstruction
ANDREW J. L. GEAR, MARK R. MIGLIORI, and WARREN SCHUBERT

University of Minnesota and Regions Hospital, St. Paul, Minnesota, U.S.A.

I.

PRESENTING PROBLEM

Chest wall defects typically occur in the context of cancer, irradiation, infection, or
trauma. Conditions requiring reconstruction include recurrent or locally invasive
breast cancer, primary chest wall tumors, postradiation necrosis and ulceration, and
poststernotomy mediastinitis with wound dehiscence. Goals of the reconstruction
include skin and soft tissue coverage, restoration of chest wall stability, and maintenance of pulmonary function (l).

II.

HISTORY

Muscle and myocutaneous flaps did not become standard of care in chest reconstruction until fairly recently. Tansini transposed a latissimus dorsi muscle for coverage of
an anterior chest wall defect following radical mastectomy in 1896 (2). Unfortunately,
surgeons neglected muscle and mycocutaneous flaps for over 40 years, favoring
instead immediate or delayed skin flaps. In j 939, Hutchins used a latissimus dorsi
myocutaneous flap to reconstruct radical mastectomy defects. Campbell later combined the latissimus with skin grafts for full-thickness defects of the anterior chest wall
(3,4). Once again, these methods of reconstruction went unnoticed. Myocutaneous
flaps were resurrected during the 1970s, with use of the latissimus dorsi (5-14),
pectoralis major (15), and rectus abdominis muscles (16-19). Mathes reported the
first clinical application of the rectus abdominis muscle in 1977 (16). He described
secondary reconstruction of an abdominal wall with a vertically oriented rectus
abdominis myocutaneous flap based on the superior epigastric artery. Another early

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166

use of the rectus abdominis involved reconstruction of infected sternotomy wounds


with muscle flaps (16,19,20).
Further refinement of rectus-based reconstruction occurred in breast surgery,
with development of the vertical rectus abdominis myocutaneous (V RAM) (21-24)
and transverse rectus abdominis myocutaneous (TRAM) flaps (17,25). Many of these
concepts were extrapolated to chest reconstruction. The first free TRAM flap was
described by Holmstrom in 1979, and Hidalgo and others appropriated this technjque
for chest reconstruction (26,27). Rectus abdominis muscle and myocutaneous flaps
have now been applied to chest wall reconstruction as single pedicle muscle flaps,
TRAM and VRAM flaps (28-32); bipedicled TRAM flaps (33); free TRAM flaps
(34,35); endoscopically assisted muscle flaps (36); supercharged muscle flaps (37);
supercharged TRAM flaps (38); supercharged VRAM flaps (39); extended TRAM
flaps (40); and bipedicled extended free TRAM flaps (41).
III.

ANATOMY

The anterior abdominal wall stretches from the costal margins to the pubis, and to the
midaxillary line laterally. The layers of the anterior abdominal wall are skin, superficial fascia (Camper's and Scarpa's fascia), abdominal muscles, transversalis fascia,
extra peritoneal fascia, and peritoneum. The muscles of the anterior abdominal wall
form three broad, thin sheets that are aponeurotic anteriorly and muscular posterolaterally. They are, from exterior to interior, the external oblique, internal oblique, and
transversus abdominis. On either side of the midline lie two vertically oriented muscles:
the rectus abdominis.
The rectus abdominis is a flat, straplike muscle that orjginates from the anterior
surfaces of the fifth, sixth, and seventh costal cartilages and xiphoid process, and
inserts anteriorly onto the symphysis pubis and pubic crest. It is broad superiorly, and
lies close to the midline, being separated by the linea alba. The anterior surface of the
muscle is marked by three tendinous inscriptions that adhere strongly to the anterior
wall of the rectus sheath, at the tip of the xiphoid, the umbilicus, and halfway between
the two (Fig. I). The muscle is enclosed by a fibrous sheath that also contains the
pyramidalis muscle, anterior rami of the lower six thoracic nerves, and superior and
inferior epigastric vessels and lymph vessels. The shea th is formed by aponeurotic slips
of the external oblique, internal oblique, and transversalis abdominis muscles. Above
the anterior superior iliac spine, the internal oblique muscle bifurcates to form anterior
and posterior layers of the rectus sheath, with anterior reinforcement from the external oblique and posterior reinforcement from the transversus abdominis (Fig. 2). Below the anterior superior iliac spine, the aponeuroses of all three muscles converge
anteriorly, with absence of a posterior wall (Fig. 3). At this juncture, the posterior
surface of the rectus abdominis is in contact with transversalis fascia only. This
transition occurs at what is called the arcuate or semicircular line, just parallel to the
anterior superior iliac spine.
The rectus abdominis, a class III flap according to the Mathes and Nahai
classification, possesses a dual blood supply via the superior epigastric artery (SEA)
and deep inferior epigastric artery (D1EA) (42). The SEA is a terminal branch
of the internal mammary artery (lMA), which in turn comes off the first portion
of the subclavian artery (Fig. I). The D1 EA is a branch of external iliac artery
(Fig. 1). The SEA enters the muscle posteriorly from the costal margin and is
visible piercing the undersurface of the mUScle. The DIEA enters the rectus sheath
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167

Superior

\\--=~----rl- Epigastric
Artery

External
Oblique
Muscle
Umbilicus
Linea Alba
Arcuate Line
Rectus
Abdominis
Muscle

Pyramidalis -J~~~~--t~
Muscle

Deep Inferior
Epigastric
Artery

- - External
Iliac
Artery

Figure 1 The rectus abdominjs is a flat, straplike muscle that originates from the anterior
surfaces of the fifth, sixth, and seventh costal cartilages and xiphoid process, and inserts
anteriorly onto the symphysis pubis and pubic crest. It is broad superiorly, and lies close to the
midline, being separated by the linea alba. The anterior surface of the muscle is marked by
three tendinous inscriptions that adhere strongly to the anterior wall of the rectus sheath, at
the tip of the xiphoid, the umbilicus, and halfway between the two. The rectus abdominis
muscle possesses a dual blood supply, consisting of the superior epigastric artery which is a
terminal branch of the internal mammary artery, and the deep inferior epigastric artery, which
is a branch of external iliac artery.

laterally near the arcuate line, and is visible along the inferior, posterior surface of
the muscle before becoming intramuscular just above the arcuate line. The superior
and inferior vascular systems then arborize and interconnect at the muscle's
midpoint. The DIEA is the dominant pedicle of the rectus abdominis muscle.
The abdominal wall's cutaneous blood supply has been well defined anatomically, and is derived in part from rectus abdominis musculocutaneous perforators (43).
The primary perforators are periumbilical, the largest of which appear at the medial
and lateral edges of the rectus sheath, representing a watershed area. Delineation of
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168

External Oblique Muscle


Internal Oblique Muscle
Transverse Abdominis Muscle

Rectus Abdominis Muscle

Rectus Sheath
(Anterior and Posterior)

Aponeurosis forming Layers


Of Rectus Sheath

......- - - - Above Arcuate Line------'


Figure 2 Rectus sheath above the arcuate line: the rectus sheath between the costal margin
and anterior superior iliac spine consists of anterior and posterior slips of the internal oblique
muscle, along with anterior reinforcement from the external oblique and posterior reinforcement from the transversus abdominis.

External Oblique Muscle

Rectus Abdominis Muscle

Internal Oblique Muscle

Rectus Sheath
(Anterior)

Aponeurosis forming Layers


Of Rectus Sheath

Transversalis
Fascia

.....- - - - Below Arcuate Line -------'


Figure 3 Rectus sheath below the arcuate line: between the level of the anterior superior
iliac spine and pubis, the aponeuroses of all three muscles converge anteriorly, with the
absence of an aponeurotic posterior wall. The posterior surface of the rectus abdominis is in
contact with transversalis fascia only.

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Rectus Abdominis

Superficial
Inferior Epigastric
Artery

169

Musculocutaneous
Perforators

Collaterals
Across Midline

Random
AXial/pattern
Vessels
I

.11\;

Figure 4 Vascular zones within a single pedicle TRAM. Zone I: skin directly overlying
muscle; zone 2: skin over contralateral rectus; zone 3: skin lateral to the ipsilateral rectus; zone
4: lateral to contralateral rectus. Zone I is fed directly by musculocutaneous perforators,
which also supply zone 2 via collateral vessels. Zones 3 and 4 are supplied in a random fashion.
TRAM viability correlates with zone number (zone I > zone 2 > zone 3 > zone 4).
vascular territories or so-called angiosomes has led to the designation of zones within
the TRAM skin island (44). For a single-pedicle TRAM, zone I refers to skin directly
overlying muscle; zone 2 overlies the contralateral rectus; zone 3 includes skin lateral
to the ipsilateral rectus; and zone 4 is lateral to the contralateral rectus (Fig. 4). Each
zone possesses variable degrees of direct and indirect blood supply, and thus the
viability differs between each zone (zone I > zone 2 > zone 3 > zone 4).
IV.

INDICATIONS

The rectus abdominis flap has historically been used for central and anterior chest wall
defects (42). Central chest wall defects, such as infected median sternotomies, are often

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amenable to reconstruction with the pectoralis major muscle. However, a rectus


abdominis flap is applicable when the pectoralis is unavailable; a larger volume of
tissue is required; tissue is needed in the epigastric region; or a narrow, central,
vertically oriented mediastinal wound is present. The rectus abdominis has also been
used to supplement pectoralis flaps for large central defects (45,46). An alternative for
recurrent central chest wounds, or wounds that possess significant mediastinal dead
space, is the omental flap (47,48).
In ventrolateral chest wounds, the rectus abdominis is appropriate when the
latissimus dorsi has been sacrificed, as in the context of posterolateral thoracotomy
incisions, or when a larger surface area and volume of tissue is necessary. Rectus
myocutaneous flaps have also been used in conjunction with latissimus myocutaneous
flaps for large venterolateral defects (49).

V.

TECHNIQUE

A.

Overview

Options for rectus-based chest reconstruction are many and include muscle; muscle
with a skin graft; upper, mid, or lower TRAM with an ipsilateral or contralateral
pedicle; bipedicled TRAM; VRAM; supercharged TRAM and VRAM; delayed
TRAM; endoscopically assisted rectus muscle; and a free TRAM. The size, location,
depth, and surgical context of a chest defect influence flap design. If adequate
cutaneous coverage exists, a pedicled muscle flap based on the SEA is usually
satisfactory. In this setting, the muscle can be flipped over and will extend up to the
region of the sternal notch if the entire length of the muscle is harvested.
When skin and soft tissue are lacking, a musculocutaneous unit is required. A
muscle flap with split-thickness skin can be appropriate for partial-thickness defects.
Skin grafting over compromised muscle can lead to exposure of prosthetic materials,
and may be unwise for full-thickness defects in the context of radiation. Small fullthickness defects can be reconstructed with either single-pedicle TRAMs or VRAMs
depending on defects' shape and location. VRAM flaps are appropriate for long, thin
vertical defects, particularly those that extend into the axilla, upper arm, shoulder,
or neck.
As defects increase in size, compromise skeleton support, or enter the pleural
cavity, reconstruction becomes more complex, and reliable, well-vascularized soft
tissue is mandatory. Reconstruction with single pedicle TRAM or VRAMs is limited
by areas of random blood supply with unpredictable viability (TRAM = zones 3 + 4;
VRAM = distal segment of a VRAM) (37,50-52). Various techniques have been
described to improve TRAM or VRAM circulation, including bipedicled (33), delayed
(53), free (34,35,54), microvascularly augmented TRAMs (40,55,56), and microvascularly augmented VRAMs (39). Indications for a double-pedicle TRAM include the
need for large tissue volume and extended flap length, high-risk patients such as
smokers or irradiated patients, and abdominal scarring that prohibits a single-pedicle
TRAM such as a Kocher's incision. Disadvantages are abdominal wall weakness.
length of operation, and blood Joss. A delayed TRAM is a two-stage procedure and
may not be appropriate in some contexts of chest reconstruction.
In a majority of cases, pedicled flaps will suffice for chest reconstruction. Sacrifice
of the IMA does not absolutely contraindicate a superiorly based rectus flap. due to
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Rectus Abdominis

the rich collateral blood flow via intercostal, musculophrenic, and costomarginal
arteries (44). A pedicled rectus muscle flap can be developed based on the 8th
intercostal perforator as it enters the muscle near the superior pedicle. Although some
authors have reported success using the rectus abdominis in this context, most
clinicians would choose alternatives for chest reconstruction (57). Contraindications
to pedicled TRAMs include bilateral subcostal incisions, an aesthetic abdominoplasty with disruption of periumbilical perforators, and any procedure requiring periumbilical perforator violation (58). Relative contraindications to pedicled TRAMs
are extreme obesity, smoking, diabetes, and vascular disease.
Creation of a musculocutaneous flap requires an understanding of the skin's
blood supply. The primary musculocutaneous perforators are located periumbilically
and can be identified preoperatively by Doppler ultrasound studies. The design of the
skin island must incorporate these vessels. The skin island can be oriented vertically
over the desired rectus muscle or transversely in the upper, mid, or lower abdomen
(Fig. 5). A VRAM skin paddle can safely extend the entire length of the harvested
muscle ifit is accurately centered over the underlying muscle and its perforators. In a
TRAM, a symmetrical ellipse of skin is harvested from the abdomen but, depending
on the technique, only a portion of this paddle will remain viable. One can safely
transfer all of zone I, a portion of zone II, and the majority of zone III with a typical

VR AM -+-----1~

TRAM

[~----L-J
\--';",--,.'~~

Figure 5 Depiction of upper, mid, or lower TRAM skin island placement, in addition to
VRAM depiction. Note that the lower TRAM resembles an abdol1linoplasty, with a superior
incision line that lies 1-2 cm above the umbilicus, and an inferior incision line that lies within
the pubic crease. A VRAM skin island is also shown.
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TRAM (Fig. 4) Risk factors such as obesity, smoking, and diabetes alter viability
outside of zone I, and the presence of these comorbidities or a larger tissue deficit may
require a bipedicled TRAM (harvesting both muscles attached to the same skin
island), microvascular augmentation, or free tissue transfer.
There are several important points to remember when designing a TRAM flap.
The lower abdominal TRAM has several advantages, including ample soft tissue with
a long vascular pedicle. It also provides the opportunity to perform an abdomjnoplasty with a relatively well-hidden scar. In contrast, the upper or midabdominal
TRAM is thought to provide more robust soft tissue, since it feeds off the primary
vascular territory of the deep SEA in the upper abdomen, and is a shorter operation
(58). This flap is also useful in the presence of lower abdominal scars from previous
surgery that can compromise a lower TRAM, and in patients with chest wall defects
who require well-vascularized tissue with low morbidity. Some surgeons have advocated the upper abdominal TRAM for chronic sternal wounds (58). The primary
disadvantage of upper or mid TRAM flaps is a short pedicle.
When the IMA has been divided, a free tissue transfer based on the OlEA is a
good alternative. Specific indications for free flap chest reconstruction include
disruption of the blood supply of pedicled flaps during ablative surgery or irradiation,
including sacrifice of the IMA during cardiac surgery; extensive defects that cannot
be adequately covered by regional flaps; defects that cannot be reached by regional
flaps; and a combination of these factors (27,38,59,60). The entire muscle can be
harvested if necessary, and inflow can be provided by the intercostals vessels, contralateral IMA, or even the aorta and grea t vessels.
In the rare instance of defects extending into the axilla, upper arm, shoulder, or
neck, a free TRAM may not provide adequate soft tissue due to questionable viability
of zone 4, and a VRAM alone is also questionable (61). In these circumstances, some
authors have used a so-called turbocharged VRAM, in which both the artery and vein
are augmented microvascularly (39). The decision to perform microvascular augmentation ofa pedicled TRAM or VRAM flap is often made intraoperatively based on the
stigmata of either venous or arterial compromise. Depending on clinical signs, the
venous or arterial blood supply can be supplemented, although many authors
recommend both (38).
Prior to soft tissue reconstruction, a decision must be made regarding reconstruction of the skeletal wall. Skeletal wall reconstruction has evolved significantly
over the last 20 years. At one time, resection of two or more ribs was considered a
criterion for skeletal reconstruction. Now, criteria include resection of more than four
ri bs or en bloc removal of greater than 5 cm of chest wall. The decision also hinges
upon clinical parameters, including defect location. Defects that underlie the scapula
or involve the costal margin do not typically require stabilization. Posterior chest wall
and sternal defects require less stabilization than anterior and lateral defects (29). Very
large defects can often be reconstructed using musculocutaneous flaps alone, particularly in the context of prior radiation, which stiffens soft tissues and makes wall
motion abnormalities less likely (62,63). A litany of autologous and alloplastic
materials are available, including metal struts, Lucite, tantalum, Ivalon, fiberglass
cloth, lyophilized dura, fascia lata, free or vascularized rib grafts, Teflon, acrylic,
Prolene mesh, Marlex mesh, a Marlex and methylmethacrylate sandwich, and GoreTex. As a general rule, prosthetic material should be avoided in contaminated wounds
and jn the context of radiation ulcers (62,64).

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B.

Basic Technique

1.

Muscle Flap

Dissection of the muscle flap is relatively straightforward. The skin incision can be
midline, paramedian, or transverse lower abdominal. Dissection is carried through
the subcutaneous tissue down to rectus fascia. The anterior surface of the rectus
sheath is exposed over the longitudinal center of the muscle, and an incision is made
along this line through the rectus sheath. This incision can be made sharply or with
low current cautery, but care must be exercised over the inscriptions to prevent fullthickness injury to the underlying muscle. Once inside the sheath, dissection is
continued over the anterior surface of the muscle to peel away the leaves of the
anterior rectus fascia and expose the entire width of the muscle. The intercostal
neurovascular perforators enter the muscle from the lateral edge of the rectus sheath
and should be ligated with surgical clips or ligatures. There are also one or two large
perforators entering the undersurface of the muscle near its medial edge at the level of
the umbilicus. These should also be ligated. The muscle can then be freed from the
posterior rectus sheath by blunt dissection. Now the muscle is tethered by muscular
attachments at the costal margin and pubis, and possesses a superior and inferior
epigastric blood supply.
The muscle is divided inferiorly from the pubis with electrocautery. The inferior
epigastric vessels are identified and individually ligated. The muscle is now flipped
superiorly, pivoting upon the superior epigastric vessels, which should be visible
posteriorly along the medial third of the muscle. The muscular attachments at the
costal margin should be maintained if possible to protect the superior epigastric
vessels. If necessary, the flap's arc of rotation can be improved by judicious division of
these attachments.
2.

VRAMfTRAM

The procedure commences after the appropriate skin island is outlined (Fig. 5). In a
TRAM, the incision circumscribes the skin island, and subcutaneous dissection is
beveled away from the island down to anterior rectus fascia to avoid undermining the
flap (Fig. 6A). In order to protect the perforators, a strip of anterior rectus fascia must
be harvested around these vessels, usually over the middle third of the muscle. In a
VRAM flap, this is located immediately below the skin paddle, and the strip of
anterior rectus fascia is harvested the length of the skin island (Fig. 7A). With either
technique, the perforators should be visualized to limit fascial harvest. In a single
pedicle TRAM, this is performed by elevating zone III until the lateral rectus
perforators are seen exiting the rectus fascia, followed by elevation of zones IV and
II up to the linea alba, where the medial periumbilical perforators are found (Fig. 6B).
The fascia is then incised around these perforators to preserve them. In a pedicle
TRAM using the whole muscle, proximal muscle dissection mirrors the pedicle
muscle flap. Some authors advocate removal of a I cm strip of fascia over the
midportion of the proximal muscle to protect the underlying SEA during the
dissection. In a free TRAM, it is only necessary to remove the muscle directly
beneath the skin paddle. While consensus exists regarding limiting fascial harvest in
proximity to perforators, use of the remaining muscle and its influence on flap
viability is a source of controversy. Some advocate dissection of the entire width of
the muscle from the remaining rectus sheath, while others favor a muscle sparing

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174

Figure 6 A. For a TRAM, the incision is first made through the superior limb of the skin
island, beveling outwards within the subcutaneous tissue to maximize incorporation of
perforators. The dissection is carried down to anterior rectus fascia. A subcutaneous tunnel is
then created to the defect. B. After completion of the skin incision inferiorly, the lateral wings of
the TRAM are elevated off external oblique fascia. In a single-pedicle TRAM, careful sharp
dissection must be performed within zone III until the lateral deep epigastric perforators are
identified, followed by dissection through zones IV and II up the linea alba to expose the medial
perforators. C. After the rectus sheath is opened, dissection is continued over the anterior
surface of the muscle to peel away the leaves of the anterior rectus fascia and expose the entire
width of the muscle. The muscle can then be freed from the posterior rectus sheath as well as the
muscular attachments at the costal margin and pubis. Once the inferior epigastric vessels are
ligated, delicate flap transfer and inset are critical to prevent kinking of the vascular pedicle. In
this figure, the flap is rotated approximately 120 degrees. D. Abdominal wall closure is achieved
with interrupted figure of eight closures with nonabsorbable suture. Care must be taken to
incorporate contributions of the internal and external oblique aponeuroses to the anterior
rectus fascia. Soft tissue closure resembles an abdominoplasty with umbilical repositioning.
approach. Witb either technique, it is essential that perforators remain in continuity
with their nutrient pedicle. In our experience, harvesting the entire muscle is the most
reliable way to accomplish tbis (Fig. 6C)
Once muscle harvest is complete, delicate flap transfer and inset are critical to
preven t kinking of the vascular pedicle and partial or complete flap loss (Figs. 6C, 7B,
C). Hartrampf has described the range of pedicle rotation in breast reconstruction
based on the use of ipsilateral or contralateral rectus muscles (65). However the flap is

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175

Defect

,..,
Incisions ..-+----1

Skin
Island

Figure 7 A. After the VRAM skin island is marked, the skin is incised through
subcutaneous tissue to expose the rectus sheath. B. The anterior sheath is incised around the
periphery of the skin island. Superiorly, the anterior sheath can be incised along the midline.
The muscle is harvested as in a TRAM and raised to the costal margin. C. After creation of a
subcutaneous tunnel and inset, the rectus fascia is closed with interrupted figure-of-eight
nonabsorbable sutures.

utilized, it is imperative that the pedicle lie in such a way that it will not be compressed
and compromised.
Closure of the abdominal defect is more difficult after a myocutaneous flap.
Sacrifice of part of the anterior rectus fascia is typical and th us closure will occur under
tension. Interrupted figure eight closures with nonabsorbable suture may be advisable.
Care must be taken to incorporate contributions of the internal and external oblique
aponeuroses to the anterior rectus fascia. Primary closure of the rectus defect is usually
possible even with harvest of both muscles. However, use of mesh should be given if
there is any concern regarding undue tension. Skin closure with a VRAM is achieved in
a simple, vertical, paramedian fashion (Fig. 7C). The TRAM is closed similarly to an
abdominoplasty with umbilical repositioning (Fig. 6D). Once again, drains are used
where appropriate above the fascia to eliminate dead space.
3.

Free TRAM

Early dissection of a free TRAM is similar to the pedicled version. The DIEA IS
then identified as it crosses the lateral aspect of the rectus muscle below the level
of the arcuate line (Fig. 1). It travels under the muscle and enters the undersurface of the muscle just above the level of the arcuate line. The vessels are dissected
free of the surrounding preperitoneal fat. There are a number of small branching
vessels off of the main lEA trunk, which should be ligated. The lEA can be dissected
to its takeoff from the iliac vessels, thus maximizing pedicle length. The superior
muscle and pedicle should be left intact as a security measure until the inferior vessels
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Gear et al.

have been identified, dissected and preserved. Once this is accomplished, the superior
muscle can be divided, leaving the flap tethered by the pubic muscular attachments
and the inferior pedicle. At this point, the flap can be allowed to perfuse while the
recipient vessels are prepared. Leaving the inferior muscle attachments in place
during this phase will prevent inadvertent traction on the inferior epigastric vessels.
The recipient vessels usually consist of the intercostals vessels or internal mammary
vessels and can be exposed by segmental resection of the costochondral junction.
Other vessels can also be identified for this purpose. When the preparation is complete, the flap can be harvested. Many authors describe a muscle-sparing technique
for free TRAMs, in which a relatively small cuff of muscle is left around the DIEA
(Fig. 8A, B) (54,66). We like to incorporate the entire width of the muscle. The
muscle can be divided at this point to maximize exposure. The artery is divided first
and double ligatures are placed at the proximal stump near the iliac vessels. The vene
comitantes are divided last to prevent any venous congestion of the flap prior to

Figure 8 A, B. For a muscle-sparing free TRAM, the ipsilateral and contralateral wings of
the flap are elevated until the large medial and lateral rows of perforators are visualized. The
rectus sheath is incised, beginning just lateral to the lateral row of perforators. A small cuff of
rectus fascia and muscle is left around the perforators. The superior rim of this cuff is incised
only after satisfactory recipient vessels have been identified. C. Microvascular inset of a fr e
TRAM within the axiIJa to the thoracodorsal artery and vein.

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transfer and revascularization. The flap is then transferred and anastomosed to the
recipient vessels, in this case the thoracodorsal atery and vein (Fig. 8C).
Closure of the donor site is similar regardless of the method of flap transfer. The
incision of the anterior rectus fascia can be reapproximated wi th running or interrupted
suture. Since there is no loss offascia with this technique, there will be no tension on the
closure and little risk for hernia. With good hemostatic technique, there should be no
need to place drains in the rectus sheath. However, if there has been any undermining of
the fat to expose the rectus sheath during the initial dissection, it may be prudent to
place a drain in the subcutaneous space to prevent seroma formation in the dead space.

VI.

COMPLICATIONS AND PITFALLS

Operative mortality for chest wall resection and reconstruction is relatively low (3.84.5%) (1,67,68). Patients with advanced stages of cancer are more likely to experience
complications. Mortality is around 2% for smaller tumors that do not require skeletal
reconstruction (69). Chest wall resection in the context of metastatic disease has
complication rates of 10--46% (29,70). Pulmonary complications after chest wall
reconstruction include respiratory insufficiency, chest wall instability, pneumonia, air
leak, atelectasis, pleural effusion, pleural infection, hemothorax, and pylothorax.
Transient postoperative support for respiratiory insufficiency is required in 10-15% of
patients (1). Chest wall instability following musculocutaneous reconstruction without skeletal reconstruction is thought to be rare, even in the context of sternectomy
and up to four or five rib resections (71). Arnold and others failed to document "any
significant long-term impairment of pulmonary function, protection and maintenance
of vital structures within the thoracic cage or mediastinum, or significant functional
impairment with respect to activities of daily living" when combining musculocutaneous reconstruction with a 2 mm thick Gore-Tex or Prolene patch, despite an
institutional average of four rib resections (30,32).
Complications related to rectus reconstruction include hematoma, seroma,
infection, pneumothorax, abdominal wall hernia, vessel thrombosis, and partial or
total flap loss. The use of double-pedicle or free TRAMs is thought by some to lessen
the incidence of flap ischemia and partial flap loss (66,72). Infection, which occurs in
approximately 5% of patients undergoing chest wall reconstruction following malignancy, can place prosthetic materials at risk and precipitate flap failure (28) and even
death (1).

VII.

LONG-TERM RESULTS

In the setting of chest reconstruction, the rectus abdominis muscle and musculocutaneous flap appears to be a durable reconstructive tool, and has now been successfully
used for over 25 years (32,73).

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Olivari N, The latissimus flap, Br 1 Plast Surg 1976; 29: 126-128,
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Robbins TH, Rectus abdominis myocutaneous flap for breast reconstruction. Aust NZ
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Robbins TH. Post-mastectomy breast reconstruction using a rectus abdominis musculocutaneous island nap. Br 1 Plast Surg 1981; 34:286-290,
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Grotting JC, Urist MM, Maddox WA, Vasconez LO. Conventional TRAM flap versus
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Latissimus Dorsi and Serratus Anterior
for Chest Wall Reconstruction
MICHAEL P. McCONNELL and GREGORY R. D. EVANS
University of California at irvine, Irvine, California, U.S.A.

I.

OVERVIEW

Reconstructive surgeons manage a wide array of chest wall abnormalities that range
from genetic deformities to postablative tissue defects. Trunk and chest wall reconstruction encompasses a large range of wounds that vary in complexity from the
simplest superficial skin closures to intricate vital organ involvement and bone
replacement. Over the years, chest wall reconstruction has grown more complex as
surgical techniques and advancements have increased our ability for resection,
frequently involving both intra- and extrathoracic repair.
Chest wall defects present a challenge to reconstructive surgeons due to the
functional environment of the thorax coupled with the vital nature of the organs
protected within. Unlike peripheral tissue defects, chest wall wounds warrant prompt
repair, because prolonged exposure can prove life-threatening. Reconstructive surgeons must be cognizant of chest wall compliance and functional capacity while
placing priority on coverage of vital organs.

II.

PRINCIPLES AND GOALS OF RECONSTRUCTION

Chest wall reconstruction represents a complex and intricate challenge to plastic


surgeons. Given the collection of vital structures within the chest, and life-sustaining
functions of the chest cavity as a whole, a multidisciplinary approach to functional
repair affords improved assessment and treatment options. Combining the efforts of
surgeons trained in general surgery, thoracic, and plastic surgery allows for broader

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184

specialization and improved patient benefit. A team approach to treatment should


start at diagnosis, and continue beyond the reconstructive element.
The goals of chest wall reconstruction are to achieve primary wound healing,
protect vital structures, restore form, and maximize cosmesis in an expedient and
reliable manner. A failed reconstruction that prolongs hospitalization time and
increases cost does not improve the quality of life. The reconstructive principles
should focus on stabilization of skeletal structure, closure of defects associated with
infection or dehiscence, obliteration of dead space with well-vascularized soft tissue.
III.

ASSESSMENT

Chest wall defects primarily result from tumor extirpation, infection, radiation
exposure, and trauma. The defect may be superficial, involve partial or full-thickness
defects of the chest wall soft tissues and musculature, or extend into the skeletal
integrity of the thorax and beyond to include intrathoracic elements and those in the
mediastinum (Fig. 1).
Superficial skin and soft tissue losses can often be closed with skin grafts if a
viable recipient bed exists. Deeper wounds, radiated areas, and those involving
exposed nerve, bone, or blood vessels may require local flap coverage.
Significant chest wall defects including large-diameter wounds, full-thickness
chest wall involvement, and areas of radiation necrosis or infection often require
coverage with more bulk and greater tissue viability than are provided by skin grafts or
local flaps alone (1). Myocutaneous flaps or free tissue transfer may be the first choice
in these difficult cases.

Figure 1 A 54-year-old man with sarcoma to the left chest wall requiring resection. The
resulting defect included exposed lung parenchyma 3nd a large soft tissue defect.

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In 1977 McGraw described cutaneous flaps that derived their blood supply from
the perforators of the underlying musculature (2). Since that time, many myocutaneous flaps have been described for a variety of anatomical reconstructions. The
myocutaneous flap is transferred as a skin-muscle unit with a dominant pedicle
providing the blood supply. These flaps have the advantage over local flaps in their
improved vascularity, regional versatility, avoidance of transferring adjacent disease/
infection as seen with local flaps, and their increased bulk. Disadvantages include
donor site morbidity, limitations to the arc of rotation, prolonged operative time, and
inequality of flap characteristics and color.
The chest wall is enveloped in a protective layer of several broad muscle groups,
each of which can be utilized in myocutaneous flap reconstruction. Once the structural integrity and bony defects of the chest wall have been addressed, the location
of the chest wall defect and characteristics of tissue coverage requirements should
determine flap selection. The surgeon should have a firm knowledge of flap characteristics with respect to blood supply, arc of rotation, and anatomical range prior
to selection. Defects should be characterized by their location to include sternal,
anterior, posterior, lateral and paraspinal chest wall defects, to aid in appropriate
flap selection.
Many pedicle flaps have been described for repair of chest wall defects; however,
the selection is largely dependent on the individual surgeon. Due to the abundance of
native musculature in the chest cavity, free tissue transfer is not commonly employed.
With time and experience, most reconstructive teams familiarize themselves with a
select group of reliable flaps. Two commonly used chest wall reconstructive options
that will be described in this chapter are the latissimus dorsi and serratus anterior
myocutaneous flaps.

IV.

LATISSIMUS DORSI FLAP

The latissimus dorsi musculocutaneous flap first descri bed by Tansini, and later reused
by Olivari, is a versatile flap that provides well-vascularized coverage for a variety of
defects on most areas of the chest, both intra and extrathoracic (3,4).
A.

Anatomy

The latissimus dorsi is a paired muscle that arises from the posterior third of the outer
ridge of the iliac crest, from the lumbar and sacral processes, and from the dorsal
segment of the lumbodorsal fascia. It is a thin, diamond-shaped muscle that gains
thickness as it approaches the axilla and inserts posterior to the intertubercular groove
of the humerus. The latissimus dorsi muscle is innervated by the thoracodorsal nerve
(C6-C8). It functions to adduct, extend, and internally rotate the humerus.
The latissimus dorsi muscle has a dual blood supply, receiving the dominant
blood flow from the thoracodorsal artery, with a smaller percentage supplied by the
segmental perforating branches off of the intercostal and lumbar arteries. As the
thoracodorsal vessels enter the proximal part of the muscle, they divide into an upper
horizontal branch that traverses along the superior border of the muscle and a lower
oblique branch that runs along the anterior border of the muscle. Both of these vessels
course along the deep aspect of the muscle and contribute perforators and other
branches throughout (Fig. 2).

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Figure 2

Elevation of the latissimus dorsi muscle for coverage of this chest wall defect
following alloplastic reconstruction of the resected ribs.

B.

Technique

The landmarks for the latissimus dorsi may be marked preoperatively with the patient
standing. First, the anterior and superior edges of the muscle should be marked to
indicate the extent of potential harvest. The maximum functional size of the flap is
approximately 20 x 40 em. Next, determine the location of the skin island to be used if
one is required. A cutaneous paddle is most often employed because skin grafting
directly on the muscle may not serve as reliable coverage if postoperative radiation
therapy is required. Measure the distance from the tissue defect to the pectoralhumeral junction. The subscapular artery arises 1-2 em below this area. In ideal
circumstances, the island should be placed along the upper two-thirds of the muscle
where the perforators are most prevalent.
The ideal position for latissimus dorsi access is lateral thoracotomy. Usually
patients are supine initially, then positioned following endotracheal intubation. The
lateral buttock and thigh should be prepped along with the anterior field in anticipation of skin grafting if needed for the muscle or the flap donor site.
Once the patient is prepped and draped in a standard surgical fashion, the skin
island should be selected and marked appropriately if not previously performed while
awake. To avoid split-thickness skin grafting to the donor site, the skin island should
be designed so that its width is no more than 8-10 em. The skin island is positioned
over the proximal two-thirds of the flap. where the perforators are more numerous. As
an alternative, if more cutaneous tissue, is desired, a fleur-de-lys pattern can be
designed. This allows a larger cutaneous paddle; however, donor site wound complications may be more apparent.
The skin is incised in an oblique fashion from the posterior axillary fold to and
along the outlined skin island. Depending on the defect and its location, this skin

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187

paddle may be developed in a variety of alternative patterns. For example, in a young


woman, the skin paddle may be developed in a horizontal pattern, allowing the scar to
fall within the bra line. The dissection should be beveled away from the skin island to
incorporate as many perforators as possible. The overlying skin is then elevated
proximally and distally until only the skin island remains.
In instances in which myocutaneous harvest would yield too much bulk, or
skin paddles are not necessary, the muscle alone can be harvested. Incision should
proceed without subcutaneous beveling. As an alternative, perforator flaps can be
harvested to provide cutaneous coverage alone. This is usually transferred in the
form of a free flap and may be utilized when excessive dead space fill is not required.
The latissimus dorsi muscle may also be split, leaving a portion of the innervated
muscle behind for maintainence of function. This option is discussed further at the
end of this section.
The submuscular dissection begins at the anterior-lateral border of the muscle
(near the serratus origin) and proceeds caudally. Elevation of the deep surface can be
approached via the free lateral border of the middle portion of the muscle. This zone of
safety is bordered between the muscle's secondary origin from the lower four ribs
inferiorly and serratus anterior insertion and the vascular pedicle superiorly. Definition of this plane and gentle traction facilitate separation of the latissimus from the
serratus anterior and confluence of the external oblique, serratus posterior inferior,
and latissimus from the inferior four ribs (5). Once this is completed, the dissection
should turn distal toward the spine and posterior iliac crest (Fig. 3).
Large musculocutaneous perforators, which are encountered originating from
the paraspinous and posterior intercostal systems, should be carefully ligated. Failure
to do so properly risks potential flap-threatening postoperative hematomas. One
must also be careful in dissection of the flap toward the spine because accidental
elevation of the trapezius muscle may occur. Once the origin of the muscle is divided
from the spinal attachments, the muscle is released and retracted. The submuscular
plane over the ribs can be bluntly dissected, and the cephalad margin is then sharply
freed from any attachments to the scapula working towards the axilla. Care must be
taken to avoid inadvertent elevation of the serratus anterior near the spine. The
thoracodorsal neurovascular bundle should be identified entering the posterior
surface of the muscle approximately 10 cm below the humeral insertion. Working
proximally toward the vascular pedicle, identification and preservation of the long
thoracic nerve are imperative.
Once the thoracodorsal neurovascular bundle is identified, the split latissimus
muscle flap option can be employed if desired. Carefully dissect the thoracodorsal
neurovascular bundle at the site of entrance into the muscle. The lateral portion of the
muscle can then be split so that half of the muscle is harvested off the lateral branch.
The medial portion of the remnant latissimus will remain innervated so long as the
medial branch of the thoracodorsal nerve is intact.
The subcutaneous tunnel is then dissected off the deep fascia anteriorly between
the axilla and the chest wall defect. The tunnel should be adequate to permit free and
direct route to the chest wall defect. For additional arc, the serratus branch of the
thoracodorsal vessel can be divided, and the insertion of the muscle can also be
transected. Care must be taken to avoid excessive tension on the vascular pedicle. The
flap should then be anchored to the chest wall with sutures and the skin, if used,
sutured into the defect and adequate drainage completed. If positional instability is a

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muscle

Confluence of
tissue planes

Figure 3

Dissection of the latissimus dorsi flap. Planes of dissection must be diligent in


order to prevent incorrect elevation of one of the surrounding muscles.

concern following flap placement, bolster sutures may be utilized for additional
support. Primary closure of the donor site can be aided by mobilization of the skin
and subcutaneous fat at the level of the deep fascia. Blake drains are brought out
through separate stab incisions to drain the most dependent portions of the wound and
exit near the midaxillary line to avoid pressure necrosis and patient discomfort.

C.

Postoperative Care

Close monitoring and frequent physical examination are imperative in the immediate
postoperative period. The robust nature of the la tissimus precludes frequent Doppler
studies. Perioperative parenteral antibiotics should be switched to oral forms once the
patient is tolerating oral intake and continued for 5-7 days. This may be prolonged
while drains remain in place.
To avoid seroma formation, maintain bulb suction drainage of the wound for a
minimum of 2 weeks or until drainage is less than 30 ml over a 24 h period for 2
consecutive days. Range-of-motion exercises should begin on or about postoperative
day 3, and continue throughout the recovery period.

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D.

189

Operative Hints

Take time to identify and ligate with 3-0 silk sutures any encountered posterior
branches of the intercostal and paraspinous perforating vessels. Imperfect hemostasis
can lead to large postoperative hematomas. If the insertion is divided, avoid excessive
tension on the pedicle by suturing the muscle to a different location on the chest wall.
Avoid placing the skin islands too close to the distal end of the flap since superficial
blood supply to these areas is most tenuous. Lastly, elevate the latissimus dorsi flap
from lateral to medial to avoid inadvertent elevation of the serratus anterior.

V.

SERRATUS ANTERIOR FLAP

The serratus anterior myocutaneous flap provides a smaller more pliable flap that
shares the durability of the latissimus dorsi. The serratus anterior flap is less freq uently
used than the latissimus dorsi, but provides an excellent option for repair of intrathoracic defects such as bronchopleural fistulas. Although the serratus can be used
alone, it is often harvested in conjunction with the latissimus dorsi flap or pectoralis
major to provide added bulk or greater surface area in larger wounds.
A.

Anatomy

The serratus anterior muscle is located on the anteriolateral and portions of the
posterior chest from the lateral borders of the pectoralis major muscle to the scapula.
It arises from the seventh through tenth ribs, and inserts on the vertebral border of
the scapula, with the posterior portion being completely covered by the latissimus
dorsi muscle. The serratus provides support to the scapula and aids in adduction.
Loss of serratus function leads to medial winging, or outward protrusion of the
vertebral border of the scapula. The muscle is innervated by the long thoracic nerve
(C5-C7).
The serratus anterior muscle has a dual blood supply that enters proximally and
that arises in the axilla. The lateral thoracic artery enters and is visible on the lateral
surface of the serratus anterior muscle. The second source, a branch of the thoracodorsal artery, enters the posterior aspect of the muscle before it terminates in the
latissimus dorsi muscle. The larger of the two, the thoracodorsal branch is encountered
as the latissimus dorsi muscle is elevated on its vascular pedicle (Fig. 4).
B.

Technique

Given the deep location of the serratus anterior, preoperative markings largely consist of anatomical boundaries such as the scapula, latissimus dorsi, and paraspinous
musculature.
The serratus anterior is best approached through a standard posterolateral
thoracotomy position. The patient should be placed in the lateral decubitus position
and appropriately supported by an inflatable beanbag, kidney rests, and supports.
Place the patient's back so that it is flush with the operative table closest to the
primary surgeon.
The entire hemithorax should be prepped to include the ipsilateral arm. The arm
should be covered with a stockinette to allow for intraoperative manipulation to
optimize exposure.

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Subscapular
artery and vein

Circumflex
artery and vein

Thoracodorsal
artery and vein

Branches to
serratus anterior

Figure 4

Vascular supply of the latissimus dorsi and serratus anterior. Note the extent of
the variable number of flaps that can be developed off this vascular arcade.

Initial incision and dissection mimic that of the latissimus dorsi. Begin the
incision through the dermis via a posterolateral thoracotomy approach with the
scalpel. Combined sharp and blunt dissection coupled with electrocautery allows for
the muscle to be easily elevated. Care is taken so that the bulk of the muscle is not
divided or devascularized through this approach. Once the muscle fibers are encountered, the muscle is elevated first from inferior to superior. Following elevation,
dissection should continue in an anterior to posterior direction. Meticulous dissection
is required to avoid damage to the serratus branch of the thoracodorsal artery, which
can be seen coursing along the surface of the muscle.
The chest wall attachments are taken down in continuity until the mu cle is
bound only by its vascular pedicle in the apex of the axilla. Once the muscle is freed
from its attachments, it is ready for transposition into the thoracic cavity. Create a 710 cm defect in the midaxillary line at the level of the second or third rib. Removal of
the second or third rib may be necessary to avoid tenting of the flap or constriction
following transposition. Following removal of the second or third rib, the flap can
easily be transposed intrathoracically through the defect created. Careful attention
must ensure that the flap sits freely and loosely so as to place the least amount of

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tension on the vascular base. Vascular integrity can be assessed via bleeding from the
distal edges.
Blake or Jackson Pratt drains should be used to drain the dependent portions of
the wound. Separate stab incisions should be created, and again, like the latissimus
dorsi flap, should be sutured along the midaxillary line to reduce patient discomfort.
C.

Postoperative Care

Postoperative management of the serratus anterior flap is similar to the latissimus.


Parenteral antibiotics should be continued until oral intake begins, then switched to
oral forms for 5-7 days or until drains are removed. Bulb suction should be maintained
for at least 7-10 days to reduce the likelihood of postoperative seroma formation.
Physical therapy should begin by postoperative day 5 and be limited to range
of motion initially.
D.

Operative Hints

To minimize the winging of the scapula, maintain an innervated three-slip segment of


the muscle superiorly to maintain support of the scapulae. As with the latissimus dorsi
flap, hemostasis is paramount to postoperative flap survival and pedicle integrity.
VI.

LATISSIMUS DORSI AND SERRATUS ANTERIOR


COMBINED FLAP

Due to the anatomical proximity of the two muscles, a combination flap may be
harvested to provide greater bulk or improved arc of rotation. Latissimus dorsi
muscle pedicled on the lumbar perforators in combination with the last three
digitations of the serratus anterior supplied by the thoracic branch of the thoracodorsal artery can add distance and variation to the standard latissimus flap (6). These
dual-pedicle flaps can be positioned in varied locations within their respective arcs,
affording greater defect coverage options without sacrificing perfusion reliability.
Due to the increased size of the combined flap, chest wall tacking sutures and bolster
sutures may be employed for stability.
VII.

COMPLICATIONS

Postoperative complications in chest wall reconstruction can be as disfiguring and


life-threatening as the initial tissue loss. A skilled, experienced multidisciplinary team
approach reduces these complications significantly, but does not eliminate them.
Aside from postablative tumor recurrence, common postoperative complications
include flap loss, infection, and fistula formation. The same approach and goals
of reconstruction should be employed in managing complications: expedient and
reliable repair.
Partial and complete flap loss can be seen in pedicled flap reconstructions. The
management of flap loss depends largely upon the degree of loss. Small to moderate
partial flap losses may be left to healing by secondary intention, whereas larger losses
may require debridement, grafting, and even a second flap. Requirements of postoperative adjuvant therapy may, however, call for early alternative flap coverage for
these partial defects. Total flap loss is seen almost exclusively as a result of failure of

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vascular pedicle integrity. Early recognition and intervention through exploration can
often make this a reversible complication. Postoperative management in a surgical
intensive care unit with a team cognizant of flap reconstruction can expedite flap
salvage should problems arise.
Flap infections present in much the same fashion as other surgical wound
infections, with erythema and wound drainage. Prompt recognition and treatment
with antibiotics and wound care are necessary to minimize the threat of flap loss.
Wound infections that contain excessive amounts of drainage should be evaluated for the presence of a fistula.
Surgical revision may be necessary to improve function or alter aesthetic results.
Revision should be delayed, when possible, until after the acute wound changes have
resolved. Flap debulking, scar revisions, and contracture release are common reconstructive revisions.

VIII.

OUTCOME

The assessment of chest wall reconstruction outcome lies not only in surgical success
but also in functional results. Despite advancements in surgical technique, many
patients still remain susceptible to the morbidity and mortality associated with their
initial diagnosis. Long-term survival of patients undergoing chest wall reconstruction
often reflects elements related to the original causative mechanism, such as malignancy or underlying cardiopulmonary dysfunction.
With continued advancement in surgical technique, myocutaneous flap coverage has significantly improved our ability to provide expedient, reliable reconstructions. Myocutaneous flap reconstruction in chest wall defects has proven reliable
and beneficial in multiple studies. A large study of 500 consecutive chest wall reconstructions at the Mayo clinic demonstrated that greater than 80% of patients
were alive 30 days after operation with excellent aesthetic results and healed wounds
(7). It is unfortunate that almost half of these 500 patients died of complications
related to their initial diagnoses. Cohen et al. (8) demonstrated similar reliability in
a review of 113 patients undergoing chest wall reconstruction (8). Nearly 90% of
patients in their study population healed without significant complications, and only
8% required reoperation (8).

IX.

SUMMARY

Surgical reconstruction to repair chest wall abnormalities involves a complex array of


functional and aesthetic considerations. Restoration of form and function as well as
quality of life remains a difficult challenge. The management of chest wall defects
requires a thorough knowledge of all treatment options, from the simplest to the most
complex. Future advancements in genetic engineering may one day obviate the need
for reconstructive efforts. Until that time, surgeons must continue to strive for
improved methods and better outcomes.

REFERENCES
1.

Cormack GC, Lamberty BG. The vascular territories and the clinical application to the
planning of flaps. In: Cormack GC, Lamberty BG, eds. The Arterial Anatomy of Skin
Flaps. 1st ed. London: Churchill Livingston, 1986:27-34.

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193

McGraw JB, Dibbell DG, Carraway JH. Clinical definition of independent myocutaneous
vascular territories. Plast Reconstr Surg 1977; 60:341.
3. Maxwell GP. Iginio Tansini and the origin of the latissimus dorsi musculocutaneous flap.
Plast Reconstr Surg ] 980; 65:686.
4. Olivari N. The latissimus flap. Br J Plast Surg 1976; 29:126.
5. Evans GR. Breast reconstruction with the latissimus dorsi flap. In: Evans GR, ed. Operative Plastic Surgery. New York: McGraw-HilL 2000:648-649
6. Meyer C, Blucher G, Bruand-Rodier C, Wilk A. Combined latissimus dorsi and serratus
anterior reverse flow pedicle flap. Report of a clinical case. Ann Chir Plast Esthet 1998;
43:269-274.
7. Arnold PG, Pairolero PC. Chest-wall reconstruction: an account of 500 consecutive patients. Plast Reconstr Surg 1996; 98:804-810.
8. Cohen M, Ramasastry SS. Reconstruction of complex chest wall defects. Am J Surg 1996;

2.

172:35~0.

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14
Pectoralis Muscle for
Chest Reconstruction
CLAIRE L. F. TEMPLE and CHARLES E. BUTLER
University of Texas M. D. Anderson Cancer Center, Houston, Texas. US.A.

The pectoralis major muscle flap (PMMF) is one of the most reliable and versatile flaps
for reconstruction of the anterior chest wall. Its convenient location, consistent
vascular supply, and proven reliability have obviated free tissue transfer for many
anterior chest defects. The PMMF's use for treatment of infected sternal wounds
following coronary artery bypass grafting (CAB G) is consistently successful. Recent
refinements in the segmental harvest of the pectoralis major (PM) muscle have enhanced the versatility of this flap and reduced the associated morbidity.
I.

ASSESSMENT

Careful analysis of chest wall defects including the cause, location, size, depth,
deficient structures, and condition of the adjacent tissue directs the surgeon to the
appropriate reconstructive choice. The cause of chest wall defects includes infection,
oncological resection, radiation, and trauma, and will influence whether or not rigid
chest wall support is indicated for the reconstruction. In cases due to infection, such as
in mediastinitis following CABG, reconstruction rarely requires rigid chest wall
support. Likewise, in irradiated wounds, the adjacent tissues are often rigid from
fibrosis and may not require additional stabilization. In posttraumatic or postoncological defects, there may be a requirement for prosthetic support depending on the
defect size and location (I).
Mathes (1) has delineated six clinically relevant locations of chest wall defects
(Table 1). Each has unique reconstructive requirements and proximity to available
regional tissues. The PM muscle is useful primarily for the sternal and anterior chest
wall regions on which this chapter will focus The PMMF plays a limited role in

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196

Temple and Butler

Table 1

Classification of Chest Defect Location


Horizontal boundaries

Vertical boundaries

Parasternal line to anterior axillary line


Base of neck to acromioclavicular joint
Anterior to posterior axillary line
Between parasternal lines
Posterior midline to posterior axillary line
Within the thoracic cavity

Clavicle to inferior costal margin


Deltopectoral groove to scapular spine
Apex of axilla to inferior costal margin
Jugular notch to xiphisternal junction
Scapular spine to posterior costal margin
Within the thoracic cavity

Location
Anterior
Superior
Lateral
Sternal
Posterior
Intra thor:tcic
SOl/ree: From Ref. I.

reconstruction of intrathoracic defects and is rarely used for supenor, lateral, or


posterior defects.
The depth of a chest wall defect may include skin, subcutaneous tissue, muscle,
bone, and intrathoracic structures. In all locations except the sternal area, a deficiency
of skin and subcutaneous tissue alone will expose muscle at the wound base. In these
instances, a skin graft or local flaps may suffice, particularly in a nonirradiated wound.
With increasing depth of the wound, however, muscle flap coverage with or without
restoration of chest wall stability is necessary, particularly if there is exposure of bone,
cartilage, or intrathoracic structures.

II.

HISTORY

The PMMFwas first described by Pickrell (2) in 1947, who used it asa turnover flap for
repair of chest wall defects. In 1962, Sisson (3) used bilateral PMMFs rotated around
the medial edge of the muscle to protect the great vessels after mediastinal dissection.
In 1968, Hueston (4) described a single case of mobilization of the PM muscle as a
myocutaneous flap on what was described as its acromiopectoral blood upply.
Despite these scattered case reports. the usefulness of the PMMF was underrecognized until two contemporary descriptions of its use for both head and neck, and
chest wall reconstruction. In 1979, Ariyan (5) described the versatility and reliability of
the PM muscle in reconstructing head and neck defects. Through anatomical cadaver
dissections, he detennined the consistency of the thoracoacromial artery on which the
flap is based. Ariyan's described uses of the PMMF offered improved success for
reconstruction over Bakamjian's deltopectoral flap (6). Following Ariyan's description of the PMMF for head and neck reconstruction, Arnold and Pairolero (7)
reported a series of six patients with anterior chest wall defects successfully reconstructed with PMMFs. Arnold's use of muscle flaps in postCABG mediastinitis
heralded widespread acceptance of the technique (8), with dramatic improvement in
survival rates over closed suction irrigation (9,10). Until free tissue transfer became
routinely used for reconstruction of the head and neck (11,12), the PMMF was the
workhorse of head and neck reconstruction (13,14). The PMMF remains the flap of
choice for anterior and midline thoracic defects.

III.

PATHOPHYSIOLOGY

One of the most common causes of chest wall defects is infection. Although the
incidence of wound infection following median sternol.omy is only 1.5% (Table
the

:n.

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Pectoralis Muscle

Table 2

Incidence of Wound Infection Following Median Sternotomy

Author (Ref)

Year

No. of patients

Infection rate (%)

Grmoljez et al. (51)


Culliford et al. (16)
Jurkiewicz et al. (52)
Cosgrove et al. (17)
Nahai et al. (44)
Galbut et al. (58)
He et al. (54)
Parisian Group (55)

1975
1976
1980
1988
1989
1990
1994
1996

1550
2594
3239
500
15,595
1087
5222
1830

0.8
15
1.5
1.8
1.6
15
13
2.3

frequency of cardiac revascularization procedures means that mediastinits is an


important health problem. According to the American Heart Association, 355,000
patients underwent CABG in 1999 in the United States (15). This translates into
approximately 5300 patients developing mediastinitis in a single year.
Risk factors for the development of sternal wound infections are classified into
patient and operative factors. Patient factors include perioperative infection, obesity,
diabetes, pneumonia, emphysema, malnutrition, and immunodeficiency. Operative
factors include emergency operation, prolonged cardiopulmonary bypass time, hemorrhage, re-exploration, depressed postoperative cardiac output, sternal dehiscence
following external cardiac massage, prolonged ventilation, and the presence of a
tracheostomy (16). There is some evidence that use of the internal mammary artery
reduces the vascularity of the sternum and results in a higher infection rate,
particularly in the case of bilateral harvest of internal mammary arteries (17). The
most commOn bacterial isolates in mediastinitis include Staphylococcus aureus,
Staphylococcus epidermidis, Serratia marcescens, Pseudomonas aeruginosa, and
enterococci (18).
Another common indication for chest wall resection and reconstruction is
neoplasm (19). Resection of the chest wall may be necessary in the treatment of breast
cancer in cases of advanced primary tumors and recurrent tumors invading the chest
wall. Sarcomas such as chondrosarcoma, osteogenic sarcoma, and Ewing's sarcoma
often necessitate radical excision. This usually involves thoracotomy with segmental
resection of multiple ribs. Primary or metastatic chest wall tumors may require
adjuvant radiotherapy, emphasizing the need for well-vascularized, reliable flap
coverage. Occasionally, primary skin cancers such as melanoma present at an
advanced stage and require full-thickness excision and reconstruction of the chest
wall. Metastatic chest wall lesions from thyroid and prostate cancers and other
primary tumors may also require chest wall resection. Radiation-associated sarcomas typically occur many years following chest wall irradiation for the treatment of
breast cancer, lymphoma, or thyroid carcinoma. These may require the most radical
of excisions to resect both the tumor and the surrounding previously radiationinjured tissue.
Another indication for chest wall reconstruction is the treatment of radiation
ulcers and osteoradionecrosis, which may evolve slowly over months to years.
Following radiation therapy, tissue ischemia results from progressive radiation
vasculopathy including intimal thickening, subendothelial fibrosis, and adventitial

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Temple and Butler

fibrosis (20). Vascular changes and impaired function of irradiated fibroblasts result
in an inability to repair injury (21). Radiation injuries represent a zone of
progressive ischemia and resultant fibrosis, and often progress to fult-thickness
defects including bone. Irradiated chest walt tissues are often stiff and fibrotic; under
certain circumstances these properties preclude the need to provide additional rigid
stabilization (22).
The principles applied to reconstruction of the above chest wall defects also
apply to traumatic chest wall defects. However, traumatic defects requiring
reconstruction are frequently posterior and not amenable to reconstruction with
PMMF (18).

IV.

INDICATIONS FOR CORRECTION

Specific indications for the use of the PMMF include eradication of mediastinal
infection, protection of vital intrathoracic structures, obliteration of dead space, repair
of bronchopIeural fistulae, and coverage of prosthetic mesh (23). Due to the frequency
of median sternotomies performed for CABG, the PMMF is most commonly used for
complications of sternotomy wounds (24). Jones (25) classified infected median
sternotomy wounds into three groups and proposed a treatment algorithm based on
a 20 year experience (Table 3). Type I infections can be treated by incision, drainage,
and healing by secondary intention. Type 2A infections can be treated by soft-tissue
debridement and closure in the absence of residual infection. In type 2B wounds, the
sternum can be rewired if the wound is sterile; however. if there is any concern that the
sternum cannot withstand rewiring, sternal debridement and flap closure are indicated. Type 3 wounds require urgent, radical debridement and either primary or
delayed flap closure.
The purported benefits of mesh reconstruction are to reduce ventilator dependence, improve chest wall mechanics, shorten hospital stay, re-establish chest wall
contour, and protect intrathoracic structures (26). However, the specific indications
for additional rigid support of the chest wall are not universally agreed upon. The
decision about skeletal reconstruction is based upon size and location of the defect. It
has been proposed that prosthetic support is required to preserve ventilatory mechanics if a defect of four ribs or 6 cm exists in the lateral thorax (I). Upper posterior defects
usually do not require rigid reconstruction as the scapula provides the necessary
support. The placement of prosthetic materials acutely should be avoided in the face of
active infection.

Table 3
Type

JA
IB
2A
2B
3A
3B

Classification of Infected Median Sternotomy Wounds


Depth

Description

Superficial
Superficial
Deep
Deep
Deep
Deep

Skin and subcutaneous tissue dehiscence


Exposure of sutured deep fascia
Exposed bone. stable wired sternotomy
Exposed bone. unstable wired sternotomy
Exposed necrotic or fractured bone. unstable, heart exposed
Types 2 or 3 with septicemia

Source: From Ref. 25.

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V.

199

OPERATIONS

The principles of chest wall reconstruction have been well described in the literature
(18). Although a variety of regional flaps are available to reconstruct chest wall defects,
the general principles are similar (Table 4).
A.

Anatomy

Knowledge of the basic anatomy of the PM muscle is essential for proper harvest of the
PMMF. The PM muscle is one of four muscles (pectoralis major and minor,
subclavius and serratus anterior) that move the pectoral girdle and attach to the chest
wall (27). The PM muscle adducts and internally rotates the humerus, and displaces
the scapula in an anteroinferior direction.
The inferolateral border of the PM muscle forms the anterior axillary fold and
the anterior wall of the axilla. The muscle originates from the anterior medial clavicle
(clavicular head) and the anterior sternum and the first six costal cartilages (sternal
head) (28). The PM muscle inserts on the lateral lip of the intertubercular groove of the
humerus. The tendons of insertion rotate 90 degrees such that the sternal half of the
PM tendon inserts posterior to the clavicular portion.
Innervation is from the lateral (CS, C6) and medial pectoral (C7, C8, T1) nerves
to the clavicular and sternocostal heads, respectively. The vascular supply is consistent with a Mathes and Nahai (29) type V muscle flap, with one dominant vascular
pedicle and multiple segmental secondary pedicles. The dominant pedicle is the
thoracoacromial artery (a branch of the second segment of the axillary artery), and
the secondary pedicles are the internal mammary perforators. Contributions laterally from the lateral thoracic artery and medially from the intercostal perforators are
also present.
Although the clavicular and sternal heads, as described above, are commonly
described in anatomy texts, the PM muscle has actually evolved from three separate
muscles: the pectoralis superficialis, pectoralis profundus, and pectoralis externus
(30,31). Each of these three heads retains segmental vascular supply (32) (Fig. I).
These three heads are labeled the clavicular, sternocostal, and external heads. The
anatomy of the clavicular and sternocostal heads are as described above; the
external head originates from the anterior ribs and upper abdominal wall, specifically the external oblique aponeurosis and rectus abdominis fascia. The clinical
implication is that each head can be raised separately while preserving function of
the others. Table 5 summarizes the neurovascular anatomy of the three heads of the
PM muscle.

Table 4

Principles of Chest Wall Reconstruction

Eradication of infection
Local wound care
Extensive debridement of devitalized soft tissue. cartilage, and bone
Obliteration of all residual spaces with well-vascularized flaps
Re-establishment of skeletal stability if needed
Early definitive flap coverage of defects
Source: From Ref. J 8.

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Figure 1 The PM muscle has clavicular (C), sternocostal (S), and external (E) heads. The
vascular anatomy corresponds to the muscle segments. The thoracoacromial artery (T)
branches into an upper branch (U) to the clavicular segment, and a pectoral branch (P) to the
sternocostal segment. Internal mammary perforators (I) supply the sternocostal segment medially through each interspace. The external segment is supplied by the lateral thoracic vessels
(L). (From Ref 31.)

B.

Configurations of PMMF Design

There are various configurations in which the PMMF can be transferred. The muscle
can be harvested with or without a skin island. The muscle can be advanced on its
thoracoacromial axis or turned over on its internal mammary blood supply. Elegant
function-sparing options have been more recently described. With myocutaneous

Table 5
Head

Neurovascular Anatomy of the Three Heads of the PM Muscle


Origin

Nerve

Artery
STA: branches; T A: clavicular,
deltoid, and pectoral branches
TA: pectoral branch; lMA: upper
perforator; LTA: pectoral
branches
IMA: lower perforator; LTA:
pectoral branch

Clavicular

Anteromedial clavicle

LPN: superior branches

Sternocostal

Anterior sternum and first


6 costal cartilages

LPN: inferior branches


MPN: superior branches

External

Anterior ribs, external


oblique aponeurosis, and
rectus abdominis fascia

MPN

LPN, lateral pectoral nerve; MPN, medial pectoral nerve; STA, supreme thoracic artery; TA, thoracoacromial
artery; IMA, internal mammary artery; LTA, lateral thoracic artery.
Source: From Refs. 30-32, 34.

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flaps, the skin paddle design may vary based on the patient's gender and on the
location and orientation of the defect.
1.

Muscle Flaps

The most common design of a PMMF is a muscle-only advancement flap based on the
thoracoacromial blood supply (Fig. 2). The pedicle is found on the deep surface of the
muscle. The course of the thoracoacromial artery can be identified using surface
landmarks. It originates from the axillary artery, travels inferiorly from the midpoint

Figure 2 On the patient's left, a PM advancement flap is illustrated. The muscle is


mobilized from all deep and superficial attachments and released from its humeral attachment
through an axillary counterincision. The PMMF is advanced medially on its thoracoacromial
blood supply and inset into the defect. On the patient's right, a PM turnover flap is illustrated.
The thoracoacromial vessels are ligated, and the flap is based medially on perforating branches
of the internal mammary artery and vein. After the humeral insertion is incised, the PMMF is
turned over medially to cover sternal wounds. A superiorly based rectus abdominis muscle flap
is also illustrated; this is useful for correction of sternal defects that extend inferiorly to the
xiphoid region since the PMMF may not reach this area. (From Ref. 44.)
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of the clavicle, and arcs medially to follow the line between the acromion and the
xiphoid (Fig. 3) (57).
The PM muscle is usually accessed through the previous median sternotomy
incision. If no previous incision exists, excellent exposure is gained through a parasternal incision, extended into an inframammary incision, if needed. The overlying
skin and subcutaneous tissues are elevated off the PM fascia, with care taken to
cauterize or ligate all myocutaneous perforating vessels. The dissection proceeds
toward the axilla. Once the superficial dissection is complete, a plane is developed
between the chest wall and the undersurface of the PM. Perforating vessels from the
internal mammary artery and vein are carefully ligated. Care is taken to avoid
elevating the pectoralis minor muscle with the flap. Multiple insertions of the PM
on the rectus abdominis and external oblique aponeuroses must be released. As the
dissection proceeds superolaterally, the thoracoacromial axis becomes visible on the
undersurface of the PM. The vessels emerge deep and inferior to the clavicle from
the second portion of the axillary artery and pierce the clavi pectoral fascia. The
thoracoacromial vessels then pass medial to the pectoralis minor insertion on the
corocoid process, and travel along the undersurface of the PM in a fatty layer before
entering the substance of the PM. If necessary, a counterincision in the anterior

Figure 3 The thoracoacromial artery emerges from beneath the clavi Ie, travels inferiorly
along a lIne perpendIcular to the claVicle. and courses medially along a line from acromi n t
xiphoid. (From Ref. 57.)

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axillary fold can be used to release the humeral insertion of the PM muscle, with care
taken to preserve the cephalic vein in the deltopectoral groove. The PM muscle is
now completely freed except for its pedicle attachment and overlying muscular
attachments to the clavicle. The muscle is then advanced to cover the defect.
If the above dissection does not afford sufficient reach, an island flap design will
further extend the PM muscle's reach. This requires elevation as an advancement flap
with further release of all clavicular muscle attachments directly overlying the
thoracoacromial artery. This release must be done with care to avoid injury to the
pedicle. The flap's arc of rotation may be further increased by performing an
osteotomy of the clavicle; however, this technique is generally used to gain additional
superior flap reach for head and neck, rather than chest wall, reconstruction.
The PMMF may also be designed to turn over on its medial, internal mammary
blood supply (Fig. 2). Dissection of a turnover PMMF commences above the muscle
fascia in a medial to superolateral direction. The humeral insertion is released, often
through a counterincision in the anterior axillary fold, allowing the dissection to then
proceed from lateral to medial. The thoracoacromial vessels are encountered and
divided. Muscle fibers inserting on the chest wall are divided. The internal mammary
perforating vessels become visible as the dissection reaches a point 2-3 cm lateral to the
sternal border, at which point the dissection is halted. The muscle is turned over
medially and inset without tension.
In sternal wound infections a single PM advancement flap will often suffice. For
larger defects, bilateral muscle flaps may be required, as turnover flaps, advancement
flaps, or a combination of the two (Fig. 4). If the defect extends inferiorly to the
xiphoid region, the PMMF is often inadequate, and a rectus abdominis muscle flap or
omental flap is required. The chest wall skin can be advanced over the muscle and
closed primarily; however, if this creates too much tension, a skin graft should be
placed on the muscle flap.
Function-sparing modifications of the advancement and turnover designs have
evolved in an effort to reduce donor site morbidity. Tobin's muscle-splitting refinement involves dividing the PM muscle into its three anatomical heads and transferring only the portion that is needed without sacrifice of the entire muscle (Fig. 5)
(33). This idea is consistent with Manktelow's anatomical study revealing that the
sternocostal portion of the PM muscle contains a discrete neurovascular supply (34).
The sternocostal segment based on the pectoral branch of the thoracoacromial artery
can be harvested, leaving the innervated clavicular and external segments intact to
preserve motor function. The sternocostal portion may be advanced iuto midline
sternal defects or passed into the thorax to obliterate bronchopleural fistulae. The
clavicular muscle segment, based on the superior branch of the thoracoacromial
artery, is useful for small sternal defects or for supraclavicular wounds such as
exposed subclavian grafts. The external segment, based on the lateral thoracic artery,
can also reach the supraclavicular area but is more useful for axillary coverage.
Morain described a segmental approach using one or two long intercostal
segments pedicled on their medial segmental blood supply (Fig. 6) (35). Two
muscle-splitting incisions are extended laterally to the humeral junction, and the
muscle is incised laterally. The flap is reflected medially, dividing multiple motor
branches to provide unrestricted flap mobility. Care is taken to ensure that the fatty
areolar tissue on the deep side of the muscle is left in situ, preserving the main
neurovascular supply to the remaining muscle. This modification is suited for smaller
defects such as exposed subclavian vascular grafts or small sternal wounds.
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Figure 5 On the patient's right, the entire PMMF has been advanced, with sacrifice of
motor function and loss of the anterior axillary fold. On the patient's left, using Tobin's
muscle-splitting refinement, the sternocostal portion has been split from the clavicular and
external segments, preserving some motor function and form. (From Ref. 33.)

Nahai described another technique for mediastinal coverage that preserves form
and function (36). The PM harvest is similar to a turnover design, with the flap based
medially on the internal mammary perforators. The thoracoacromial pedicle is
identified on the deep surface of the muscle, and the muscle is then divided just medial
to the blood supply (Fig. 7). This corresponds to the junction of the medial two-thirds
and lateral one-third of the PM muscle and preserves the thoracoacromial blood
supply to the lateral PM segment. The nerve supply to the medial segment is divided,
and the clavicular origin is released. Dissection is carried to within 2-3 em of the
sternal border, and the muscle is folded over into the mediastinum as a turnover flap.
By suturing the remaining lateral PM remnant to the pectoralis minor muscle and rib
periosteum, the anterior axillary fold is recreated.

Figure 4 This patient had a chondrosarcoma of the manubrium requiring excision of the
manubrium, upper sternum, medial segments of both clavicles, and a portion of the right PM
muscle. A. Chest wall rigidity was re-established with methylmethacrylate sandwiched between
two layers of polypropylene mesh. B. The majority of the defect and alloplast reconstruction
was covered with a left PM advancement flap. The remaining right PM muscle was mobilized and advanced to cover the superior aspect of the defect. C. The skin was closed primarily
over the muscle flap reconstruction. (Courtesy of GP Reece, MD Anderson Cancer Center,
University of Texas.)

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Figure 6 Intercostal segmental variation of the PMMF. A long intercostal segment is


based on its medial segmental blood supply. Two muscle-splitting incisions are made, and the
flap is divided laterally. The flap is then retracted medially. with division of all motor branches
to ensure optimal mobility. (From Ref. 35.)

2.

Myocutaneous Flaps

Although the requirement for a skin paddle is more common in head and neck
reconstruction, PM myocutaneous flaps do playa role in chest wall reconstruction.
The skin paddle can be located anywhere over the PM and may extend beyond the
muscle as described below. This flexibility in design in PM myocutaneous flaps allows
the flap to be tailored specifically to a defect.
A central skin paddle is placed just medial to the nipple and is oriented along
an oblique line from acromion to clavicle to incorporate the main clavicular branch
of the thoracoacromial artery (Fig. 8). To capture as many cutaneous perforators as
possible, the skin paddle can be designed larger than the cutaneous defect size and
the redundant portion de-epithelialized and buried (24). Thi central design is
aesthetically acceptable in men but there may be nipple displacement after donor
site closure.
In women, the breast interferes with a central skin paddle design. A better option
may be an inframammary skin paddle that reduces breast deformity (Fig. 9) (37,38).

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~ .~

.. ~~~
;1'",-

Thoraco-acromial A.

. _l.

Pectoral N.

_~. ,

')

"'-,

Site of Muscle
Transection

',.~ ''',~ll
.'

Figure 7 A. Nahai's function preserving technique involves dividing the PM and maintaining the thoracoacromial blood supply to the lateral segment. B. The muscle is folded medially as a turnover flap. A new origin for the PM muscle is created by suturing the lateral
segment to the chest wall. (From Ref. 36.)

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Defect

Skin island

Figure 8

For a central skin paddle design, the skin paddle is located over the pectoral
branch of the thoracoacromial axis. (From Ref. 24.)

Figure 9 Skin paddles for PM myocutaneous flaps can be d signed beyond the PM muscle
borders by including the underlying fascia. Examples of these orientations are parasternal (A),
inframa1l11l1ary (B), and epigastric (C).

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Figure 10 A. An inframammary skin paddle includes less breast tissue and causes less
breast defonnity than a central skin paddle design would. Preservation of the rectus abdominis
and serratus anterior fasciae enhance vascularity to the skin. B. An infraclavicular incision
aids in mobilization of the flap. (Courtesy of CE Butler, MD Anderson Cancer Center,
University of Texas.)

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This extended paddle design incorporates a skin paddle beyond the muscle belly itself.
The superior border of the flap is 1-2 cm above the inframammary fold. Vascularity of
the skin paddle is enhanced by inclusion of the serratus and rectus fasciae because the
vessels in this fascia support the distal skin segment. The flap is then harvested by
dissection above and below the muscle and pedicled on the thoracoacromial vessels.
Because of the distance between the inframammary donor site and the clavicle, an
infraclavicular incision often facilitates the dissection (Fig. 10).
A parasternal skin paddle is another permutation by which the skin paddle is
oriented vertically over the sternal origin of the muscle and may extend across the
sternum (39). The paddle's vertical dimensions are from sternomanubrial junction
to the xiphoid, and may curve laterally into the inframammary region as required
(Fig. 8). The paddle is thin: it incorporates presternal skin and the skin overlying the
tapered origin of the muscle. This design is applicable in both male and female
patients because minimal distortion of the breast occurs. After the skin paddle is
designed and incised, the lateral chest wall skin and fat, including the breast in
women, are elevated off the muscle in a suprafascial plane. The plane beneath the
muscle is dissected and the humeral attachment divided. The muscle origin from the
sternum is divided with ligation of the internal mammary and intercostal perforators. The flap is then passed into the recipient site, and the donor site skin defect
is closed primarily.
VI.

POTENTIAL COMPLICATIONS AND PITFALLS

The incidence of complications associated with the PMMF has varied in the literature.
Potential recipient site complications include partial and total flap failure, wound
dehiscence, infection, hematoma, and seroma. Potential donor site complications
include vascular injury to the pedicle, infection, seroma, hematoma, chest contour
deformity, and arm weakness (Table 6).
In addition to the commonly cited complications, a few case reports indicate rare
but notable consequences of PMMF transfer. Painful PM myospasm has been
reported (40), presenting as frequent intermittent fasciculations of the muscle mass
with extreme tenderness to light palpation. Drug therapy in the reported case was
ineffective, but bilateral pectoral neurectomies brought complete resolution. Wound
dehiscence has been observed in female patients with large, pendulous breasts. To
prevent this complication, two groups have advocated combining a reduction mammaplasty with PMMF for median sternotomy closure to prevent this complication

Table 6

Complication Rates (%) for Flap Reconstruction of Infected Median Sternotomy Wounds

Author (ref.)

Year

No. of
patients

Flap
loss

Nahai (44)
PairoJero (56)
Yuen (47)
.fones (25)

1989
199J
1995
1997

211
100
88
186

08
2
304
0

Partial
loss

304
3.8

Dehiscence

Infection

Hematoma

Seroma

3.3

5.7
8
IlA

9.0
6

3.3

23
6.J

'-', Complication rate not reported.

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(41,42). An alternative approach involves using suspensory tape under the breasts to
prevent dehiscence of the xiphisternal region (25).
VII.

LONG-TERM RESULTS

The most dramatic impact of PMMF reconstruction in median sternotomy wounds is


the marked improvement in survival. Mediastinitis was initially associated with a
mortality rate of 50% when wounds were treated with debridement and dressing
changes (43). Closed-catheter irrigation, described by Shumaker (10), lowered the
mortality rate to 20% (9). The use of muscle flaps further decreased mortality to 5%
(44). The long-term morbidity of PM sacrifice is considered an acceptable tradeoff for
the increase in survival rates using these flaps.
Several publications have reported long-term results using the PMMF for
median sternotomy wounds (25,45-48). Interpretation of these studies is limited
owing to the absence of a control group such as CABG patients without sternal
wound infections. Nevertheless, the following cohort studies offer useful information
about the morbidity of the PMMF harvest.
In 1984, Arnold reported a series of 100 patients with sternal wound infections
treated with debridement and PMMF closure (45). Twenty-six patients had recurrent infection within a median of 5.5 months. Eighteen of these patients had repeat
debridement and 10 required an additional flap. The long-term success rate in
achieving a healed chest wall was 92%. Failure was attributed to persistent infection
due to inadequate debridement of necrotic cartilage, bone, and other foreign bodies.
In 1994, Ringelman reported long-term results of 133 patients who underwent
debridement and PMMF reconstruction for sternal wound infections (46). Ninetynine percent of patients had healed wounds. Fifty-one percent had persistent shoulder
pain and 44 % noted hypoethesia and/or paresthesias on the chest. Forty-three percent
reported symptoms of sternal instability, which was confirmed on examination in half
of these patients. Thirty-three percent reported shoulder weakness, but this was not
confirmed on physical examination. Thirty-six percent of patients were limited in their
activities of daily living and recreational activities, and half of eligible patients did not
return to work.
In 1995, Yuen evaluated subjective patient outcomes in 32 patients who underwent PMMF reconstruction for median sternotomy wounds (47). One quarter of
patients complained of arm weakness, and half complained of chest contour deformity. Delayed osteomyelitis and costochondritis occurred in 8%.
In 1996, Arnold analyzed 500 patients with chest-wall reconstruction for tumor
resections, infected median sternotomies, and radiation necrosis (48). Of the patients
alive 30 days after surgery, 84% had a healed wound. In 1997, in a series of 440 patients with median sternotomy wounds reconstructed with PMMFs, the perioperative
and sternal-wound-related mortality rate was 8% (25). Recurrent sternal infection
occurred in 6.5%.
Meadows studied the physiological effect of resection of the sternum and
manubrium with muscle transposition in six patients (49). Total lung capacity was
unchanged but vital capacity decreased by 11.5%. Static compliance, retractive force,
and diffusing capacity decreased by 16%,26%, and 13%, respectively. In a separate
study, Larson found an improvement in postoperative forced expiratory volume in 1 s
(FEY I) and vital capacity following chest wall resection and reconstruction with
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myocutaneous flaps (50). Larson's group included oncological resections only, and it
was believed that the postoperative improvement was related to relief of chest wall
restriction from tumor and radiation, and to relief of pain. From these data, it appears
that sternectomy and muscle flap reconstruction are well tolerated, with only minor
changes in pulmonary function.
Carefully controlled studies of long-term morbidity in patients with chest wall
defects reconstructed with PMMFs are necessary to evaluate traditional and refined
approaches to flap harvest. The dramatic reduction in mortality that this flap has
offered to patients with the devastating complication of post-CABG mediastinitis
cannot be ignored. The PMMF remains the workhorse for chest wall reconstruction.

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Ringelman PR, Vander Kolk CA, Cameron D, Baumgartner WA, Manson PN. Longterm results of flap reconstruction in median sternotomy wound infections. Plast Reconstr Surg 1994; 93:1208-1214
Yuen JC, Zhou AT, Serafin D, Georgiade GS. Long-tenn sequelas following median
sternotomy wound infection and flap reconstruction. Ann Plast Surg 1995; 35:585-589.
Arnold PG, Pairolero Pc. Chest-wall reconstruction: an account of 500 consecutive
patients. Plast Reconstr Surg 1996; 98:804-810.
Meadows JAA III, Staats BA, Pairolero PC, Rodarte JR, Arnold PG. Effect of resection
of the sternum and manubrium in conjunction with muscle transposition on pulmonary
function. Mayo Clin Proc 1985; 60:604-609
Larson DL, McMurtrey MJ. Musculocutaneous flap reconstruction of chest-wall defects:
an experience with 50 patients. Plast Reconstr Surg 1984; 73:734-740.
Grmoljez PF, Barner HH, Willman VL, Kaiser Gc. Major complications of median
sternotomy. Am J Surg 1975; 130:679.
Jurkiewicz MJ, Bostwick J Ill, Hester TR, Bishop JB, Craver J. Infected median
sternotomy wound: succesful treatment by muscle flaps. Ann Surg 1980; 191:738-744.
Galbut DL, Traad EA, Dorman MJ, DeWitt PL, Larsen PB, Kurlansky PA, Button JH,
Ally JM, Gentsch TO. Seventeen-year experience with bilateral internal mammary artery
grafts. Ann Thorac Surg 1990; 49: 195-201
He GW, Ryan WH, Acuff TE, Bowman RT, Douhit MB, Yang CQ, Mack MJ. Risk
factors for operative mortality and sternal wound infection in bilateral internal
mammary artery grafting. J Thorac Cardiovasc Surg 1994; 107: 196-202.
The Parisian Mediastinitis Study Group. Risk factors for deep sternal wound infection
after sternotomy: a prospective, multicenter study. J Thorac Cardiovasc Surg 1996;
I 111200-1207.
Pairolero PC, Arnold PG, Harris JB. Long-term results of pectoralis major muscle
transposition for infected sternotomy wounds. Ann Surg 1991; 213:583-590.
Ariyan S. Further experiences with the pectoralis major myocutaneous flap for the
immediate repair of defects from excisions of head and neck cancers. Plast Reconstr Surg
1979; 64605-612

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15
Chest Wall Reconstruction with Omentum
JUAN CARLOS JIMENEZ and GREGORY R. D. EVANS

Universil)' of California al Irvine, Irvine, California, U.S.A.

I.

HISTORY

The use of omentum for tissue transfer has come about through a b'rief but significant
series of historical developments. Antoine Joseph Jobert de Lamballe, a French
surgeon during the Napoleonic era, was the first to describe the use of the omentum to
prevent bowel injury through adhesion formation in wounded soldiers on the battlefield (I). Nicholas Senn, an American surgeon at the University of Chicago, described
the use of the omentum to protect intestinal suture lines in the late 1880s (1). In 1963,
Kiricuta was the first surgeon to describe the use of omentum for coverage of a
radionecrotic chest wall defect. Arnold et al. took this a step further by its use with
split-thickness skin graft for breast reconstruction (2). Goldsmith has described several uses for transfer to both the central and peripheral nervous system for treatment
of diseases such as Alzheimer's and spinal cord injury (3,4). With its popularity, Saltz
et al. in the early 1990s used laparoscopic harvest for omental free flap transfer,
decreasing the potential morbidity associated with open omental harvest (2).
II.

ANATOMY AND PATHOPHYSIOLOGY

The omentum consists of a free-hanging complex trabecular network of arteries,


veins lymphatics, and adipose tissue arising from the greater curvature of the
stomach. It extends to the ventral surface of the transverse colon as the gastrocolic
ligament and extends over the anterior surface of the abdominal viscera. The anterior
and posterior layers, attached to the greater curvature of the stomach and transverse
colon, respectively, fuse at the level of the transverse colon covering the small bowel.
The right margin attaches to the duodenum while the left attaches to the spleen as the
sustenaculum lienis ligament. The surface area varies from 300 to 500 cm 2 allowing

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for a large area for wound coverage (1). The arterial supply of the omentum is derived
from both the left and right (dominant) gastroepiploic arteries. The left gastroepiploic
arises from the splenic artery and measures 10-3.0 mm; the right emerges from the
gastroduodenal artery measuring 15-4.5 mm in diameter. The right and left gastroepiploic arteries form anastomoses along the greater curvature of the stomach,
producing the gastroepiploic arch (types I-III) (2). The venous drainage parallels
the arteries and drains into the portal system.
From the gastroepiploic arch arise multiple small branches that ascend toward
the greater curvature of the stomach. Three major omental arteries bisect the
omentum into thirds. The middle omental artery anastomoses at its terminal portion
with right and left omental arteries forming the arterial network of the greater
omentum. An accessory omental artery is usually present but does not anastomose
with the arterial network mentioned above.
Angio- and immunogenic properties make the omentum a versatile flap for chest
wall reconstruction (5). Several authors have described the ability of the omentum to
induce neovascularization in both clinical and experimental tissues (6-10). This
angiogenesis has been seen in as early as 3 days following omental transfer (7). The
mechanism for this induction is still unclear but it is believed to be derived from
aniogenetic factors present in the abundant lipid fraction present (8,9).
Omentum-associated lymphoid tissue is also abundant and plays a functional
role in the mobilization of tissue-fixed macrophages in the event of intra-abdominal
irrita tion (I). The omentum has also been reported to induce hemostasis, secrete and
absorb fluids and particles for processing by macrophages and immunocompetent
cells, and curb infection (7,10,11). Often called the policeman of the abdomen,
omentum has been indicated for a wide variety of infectious cardiothoracic complications, breast reconstruction, and radionecrotic chest wall defects (7).

III.

SURGICAL PROCEDURES

Omental transposition flaps can be used to cover extensive defects of the chest wall.
Their advantages over muscle flaps include the aforementioned immunological and
angiogenic properties for coverage of previously irradiated and infected wounds, as
well as plasticity and sufficient volume of tissue for correction of a variety of tissue
defects (1). Clear, consistent anatomy allows straightforward harvest and transfer as
a pedicle or free flap. Common indications include soft tissue coverage following
chest wall resection, radionecrosis, and poststernotomy mediastinitis (Fig. I) (4).
Omental tissue transfer, either free or pedicled, can be used to cover bronchial stumps
following pneumonectomy or in the event of acute bronchopleural fistula. Tracheal,
carinal, and esophageal defects can be covered. Omental transfer can also be used as a
secondary back-up flap following failed reconstruction with regional muscle or
fasciocutaneous naps (12). Coverage following breast and pectus deformities has
been performed as well as reconstruction of the head and neck, typically in patients
wi th progressive hemifacial a trophy (12).

A.

Omental Harvest

Following debridement of the distant pre-existing wound and/or formation of the


chest wall defect, midline laparotomy or paramedian incisions are the most direct

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Omentum

Figure 1 Anterior chest wall defect resulting from the surgical resection of malignant
fibrous histiocytoma tumor in a 42-year-old man.
open approaches (13). Recipient vessels may be prepared in the event of free tissue
transfer. Mobilization of the greater omentum includes blunt dissection from the
greater curvature of the stomach and the transverse colon. In cases where increased
length is needed, the omentum can be incised from the anterior surface of the
transverse colon in an avascular plane. The right and left gastroepiploic artery and
vein are identified and the omentum is removed from the abdominal cavity and
stomach. Care must be taken to avoid tension, which can damage omental tissue
and vessels. A pedicle based on the right gastroepiploic vessels is usually preferable
due to its increased vessel diameter and length, wluch can be extended from 9 to 12 em.
Barkow's marginal artery is formed by anastomoses between the descending epiploic
arteries and courses around the peripheral portion of the greater omentum. This
collateral can also be used for increased length. The short branches extending from
the gastroepiploic arch to the greater curvature of the stomach are then ligated and
divided. The flap can then be extended either through a diaphragmatic defect for
lesions within the thoracic cavity or exteriorized through the anterior abdominal wall.
Depending on the size and location of the associated defect, the gastroepiploic artery
and vein can be isolated on either side, then ligated and divided to optimize and
extend flap length for necessary coverage (Fig. 2).
In free omental flaps, the vascular pedicle is divided and the abdominal wound is
closed completely. Recipient vessels vary according to size and location. However, the
internal mammary artery, external carotid artery and the transverse cervical artery are
commonly employed donor vessels (14). Based on the patient's need, a split-thickness
skin graft can then be mobilized to cover the flap or skin flaps can be used to bury the
flap completely.
Laparoscopic harvest of the greater omentum for tissue transfer has also been
described and can be performed with less donor site morbidity and decreased length
of hospitalization (2,15-17). Following administration of general anesthesia and

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Jimenez and Evans

Figure 2

Omental harvest.

insufflation of the abdomen with CO 2 , the laparascope can be inserted through a 5


mm umbilical incision and directed caudally. A 5 mm right upper quadrant incision is
then made for an additional cannula. A grasping instrument can then be inserted to
help isolate and dissect along the greater curvature of the stomach, transverse colon,
and other surrounding structures. Once the desired omental segment is identified,
small branches can then be clipped and ligated within the peritoneal cavity or
exteriorized and ligated outside the peritoneal cavity following extension of the right
upper quadrant incision. Electrocautery can be used to achieve an appropriate level of
hemostasis. However, care must be taken near the gastroepiploic vessels supplying
flap circulation. If necessary, peritoneal drains may be placed.
Limitations of laparoscopic omental harvest include difficult visualization and
exposure of the vascular pedicle base. Laparoscopy may be contraindicated in patients
with large thoracic reconstructions due to increased hemodynamic instability and
severe pulmonary disease aggravated by pneuomoperitoneum (12). Care must be used
in selecting appropriate candidates for safe laparoscopic omental harvest.

B.

Omental Flaps for Coverage of Sternal Wound Infections

In 1976, Lee et al. first described the use of omental transposition for correction of
sternal defects following radical sternectomy for severe mediastini tis (Fig. 3) (18).
Subsequently, several series have been published highlighting the efficacy of this novel
operation (19-24). The omentum's rich amount of immunologically active cells and
the blood supply make it an effective flap for coverage following chronic infection
(23). It also appears to provide sufficient bulk for complete obliteration of dead space
following extensive sternal resection. It should be noted, however. that the omentum
may not provide as much bulk as required. Following radical wound debridement,
with removal of all exposed foreign bodies and necrotic tissue using mediastinal
irrigation, the omentum can be mobilized and brought up over the anterior mediastinum through a small incision in the diaphragm and secured to the upper part of the
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Figure 3

Placement of tbe omentum into the defect. Split-thickness skin grafting was used
to cover the omentum. Photograph shows the reconstruction 6 months after surgery.

mediastinum. This can be done with bolster sutures. Care must be taken not to tear
the thin omentum when securing the flap to the defect. Split-thickness skin grafts or,
as an alternative, skin or muscle coverage can be used to cover the entire defect.
Yasuura et a!. described 44 consecutive patients who underwent omental flap
transposition following deep sternal wound infection (20). Of those, 37 patients were
discharged from the hospital with healed wounds and have subsequently had good
long-term results. The use of prolonged ventilatory support and hemodialysis was a
strong predictor of in-hospital death following omental transposition. Thus, treatment of sternal wound infections with omental flap transfer is an effective method for
coverage. In patients requiring prolonged postoperative ventilatory support or
hemodialysis, mediastinal irrigation with postponed omental flap coverage may be
preferable (20).
Milano et al. compared the efficacy of omental vs. pectoralis muscle flaps for
poststernotomy mediastinitis in 59 patients over a 10 year period (24). All patients had
prior cardiac operations at the same institution and developed infected mediasternal
wounds. Twenty-one underwent omental transposition and 38 underwent pectoral
muscle flaps. Cases with combined omental and pectoralis flaps were excluded.
Patients with omental flaps had significantly shorter hospitalization (10.7 days vs.
18.8 days) and shorter procedure times (221 min vs. 284 min). Incidence of subcutaneous infection respiratory failure, hemorrhage, persistent sepsis, and flap failure was
also significantly decreased (24).
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As with other intra-abdominal operations, dissection may predispose to postoperative ileus. Clinical signs indicating return of bowel function must be carefully
assessed prior to resuming oral intake. Peritoneal drains may be placed based on the
amount of adhesions, bleeding, and/or surgeon's preference.

C.

Other Defects

Defects of the anterior chest and intrathoracic complications are also amenable to
closure with the omentum. The omentum can be passed through the diaphragm or
brought up through the subcutaneous tissue to fill these other defects. The omentum
must also be secured to the defect with sutures or bolsters.

IV.

POTENTIAL COMPLICATIONS AND PITFALLS

Despite the efficacy and safety of omental flaps for chest wall reconstruction, several
potential complications have been described (25). In a recent review of 135 omental
flaps performed over 25 years, Hultman et al. found that abdominal wall infection
was the most common donor site complication (n = 9). Other complications included
dehiscence (n = 8) and ventral hernia (n = 8).
Omental harvest may be complicated in patients who have undergone prior
laparotomy due to the presence of intraperitoneal adhesions or patients with concurrent abdominal disease. This can increase the risk of enterotomy and prolonged
postoperative ileus. Serious complications include gastrointestinal hemorrhage,
pedicle avulsion, splenic rupture, and volvulus (5). Compression and/or tension on
the gastroepiploic pedicle may lead to vascular compromise and flap necrosis. In a
retrospective review of 60 patients undergoing thoracic reconstruction with the
omentum, a 12% rate of partial flap loss was noted, with 20% of patients requiring
subsequent flap revision (5).

V.

SUMMARY

Angio- and immunogenic properties, along with its large surface area and rich
vascular supply, make the greater omentum a useful and versatile flap for reconstruction of the chest wall. Tissue transfer may be accomplished through either
pedicle or free flap techniques. Harvest may be accomplished by either open technique
or via laparoscopic guidance; however, care must be taken in selecting appropriate
candidates. Donor site complications such as abdominal wall infection and ventral
hernia are the most common. Omental transfer nevertheless remains a good, safe
option for both primary and secondary reconstruction of the chest wall over a diverse
array of clinical scenarios.

REFERENCES
I.

2.
3.

Liebermann-Meffert D. The greater omentum: anatomy, embryology and surgical


applications. Surg Clin North Am 2000; 80(1 ):275-293
Cothier-Savey I, Tamtawi B, Dohnt F, et al. Immediate breast reconstruction using a
laparoscopically harvested omenlal flap. Plast Reconstr Surg 2001; 107(5):1156-1163.
Goldsmith HS. Omental transposition ror Alzheimer's disease. Neurol Res 1996; 18(2):
103-108.

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Goldsmith HS, De La Torre Jc. Axonal regeneration after spinal cord transection and
reconstruction. Brain Res 1992; 598(2):217-224.
Hultman CS, Culbertson JH, Jones GE, et al. Thoracic reconstruction with the
omentum: indications, complications, and results. Ann Plast Surg 2001; 46(3):242-248.
Tisinai K, Shedd F, Harris R. Comparison of growth, neovascularization, and enzymatic
function of fetal intestinal grafts in the omentum and renal capsule. J Pediatr Surg 1990;
25(8):914-916.
Adams W, Ctercteko G, Bilous M. Etrect of an omental wrap on the healing and vascularity of compromised intestinal anastomoses. Dis Colon Rectum 1992; 35(8):731738.
Goldsmith HS, Griffith AL, Catsimpoolas N. Increased vascular perfusion after administration of an omental lipid fraction. Surg Gyneol Obstet 1986; 162(6):579-583.
Goldsmith HS. Griffith AL, Kupferman A, et al. Lipid angiogenic factor from the
omentum. JAM A 1984; 252(15):2034-2036.
Iglesias M, Butron P, Cortes E, et al. Preservation of a digital osteotendinous structure
with an omental flap. Plast Reconstr Surg 2000; 106(5): 1062-1068.
Levashev YN, Akopov AL, Mosin IV. The possibilities of greater omentum usage in
thoracic surgery. Euro J Cardio Thorac Surg 1999; 15:465-486.
Hultman CS, Carlson GW, Losken A, et al. Utility of the omentum in the reconstruction
of complex extraperitoneal wounds and defects. Donor-site complications in 135 patients
from 1975 to 2000. Ann Surg 2002; 235(6):782-795.
Hultman CS, Culbertson JH, Jones GE. Thoracic reconstruction with the omentum:
Indications, complications, and results. Ann Plast Surg 200 I; 46(3):242-249.
Cordeiro PG, Santamaria E, Hidalgo D. The role of mIcrosurgery in reconstruction of
oncologic chest wall defects. Plast Reconstr Surg 200 I; 108(7): 1924-1930.
Lee AB, Schimert G, Shatkin S. Total excision of the sternum and thoracic pedicle
transposition of the greater omentum: useful stratagems in managing severe mediastinal
infection following open-heart surgery. Surgery 1976; 80:433-436.
Kamei Y, Torii S, Hasegawa T, et al. Endoscopic omental harvest. Plast Reconstr Surg
1998; 102(7):2450-2453.
Saltz R, Stowers R, Smith M, et al. Laparoscopically harvested omental free flap to cover
a large soft tissue defect. Ann Surg 1993; 217(5):542-547.
Luciani N, Lapenna E, De Bonis M, et al. Mediastinitis following graft replacement of
the ascending aorta: conservative approach by omental transposition. Euro J Cardiol
Thorac Surg 2001; 20:4J8-420.
Yasuura K. Okamoto H, Morita S. Results of omental flap transposition for deep sternal
wound infection after cardiothoracic surgery. Ann Surg 1998; 227(3):455-459.
Belcher P, McLean N, Breach N, et aJ. Omental transfer in acute and chronic sternotomy
wound breakdown. Thorac Cardiovasc Surg 1990; 38(3): 186-191.
Wening JV, Thoma G, Emmerman A, et aJ. Repair of infected defects of the chest wall
by transposition of greater omentum. Br J Clin Pract 1990; 44(8):311-313.
Schroeyers P, Wellens F, Degrieck 1, et al. Aggressive primary treatment of poststernotomy acute mediastinitis: our experience with omental and muscle flaps surgery.
Euro J Cardio Thorac Surg 2001; 20:743-746.
Wornom IL, Maragh H, Pozez A, et aJ. Use of the omentum in the management of
sternal wound infection after cardiac transplantation. Plast Reconstr Surg 1995; 95(4):
697-702.
Milano CA, Georgiade G, Muhlbaier LH, et a1. Comparison of omental and pectoralis
flaps for poststernotomy mediastinitis. Ann Thorac Surg 1999; 67:377-381.
Van Garderen JA, Wiggers T, Van Geel AN. Complications of the pedicled omentoplasty. Neth J Surg 1991; 43(5)171-174.

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16
Chest Wall Reconstruction with
Scapula and Parascapula Flaps
PAUL M. GARDNER

University of Alabama al Birmingham, Birmingham, Alabama, U.S.A.

The scapula and parascapula provide variable-sized flaps with consistent and reliable
anatomy for chest wall reconstruction. As pedicled flaps they can be used to reconstruct local chest, axillary, neck, and extremity wounds. When used as free flaps,
the circumflex scapular vessels provide a lengthy pedicle that allows coverage of a
variety of defects, and also allows the combination of multiple tissue types. A number
of modifications, including preoperative expansion, further increase the use of these
versatile flaps.

I.

HISTORY

The anatomy and vascular pedicle of the scapula flap were first described in 1980 by
Dos Santos (I). Nassif described the parascapular flap based on the parascapular
cutaneous artery (2). Cormack studied the vascular anatomy of a vertically oriented,
superiorly based, posterior axillary lateral thoracic flap using the parascapular artery
and associated veins as its pedicle in 1983 (3). The circumflex scapular artery was
injected and studied radiographically by Kim and associates in 1987 (4). This study
defined the cutaneous territory limits of the pedicle.
A number of reports followed in rapid succession outlining the use of flaps based
on these vessels. Pedicled and, more commonly, free flaps were described. In 1982,
Mayou and associates described using the scapular flap as a free flap in the repair of
defects of the foot, leg, face, axilla, and breast (5). Diamond published a case report in
1983 based on treatment of an axillary burn scar contracture with an island scapular
flap (6). Other reports described its use in coverage of defects of the scalp (7), upper

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224

extremity (8), and back (9). Modifications were later reported including expanded (10),
osteocutaneous (11), and extended flaps (12).
II.

ANATOMY

The scapula and parascapula flaps are based on branches of the circumflex scapular
artery, which is a branch of the subscapular artery. The subscapular artery arises from
the third portion of the subclavian artery on its inferior margin. It is 4-4.5 mm in
external diameter and courses 2-4 em on the subscapularis muscle before dividing into
the thoracodorsal and circumflex scapular arteries (5).
Rowsell and associates studied 100 cadavers to evaluate the subscapularthoracodorsal arterial system. They found that the subscapular artery comes directly
off the axillary artery, and the circumflex scapular artery branches off the subscapular
artery in 97% of cases. They also found that the thoracodorsal artery branches directly
off the subscapular artery in 94%. This anatomy is important to confirm before
combining the latissimus and scapular flaps (13).
The circumflex scapular artery passes into the triangular space bounded by the
teres major muscle inferiorly, the teres minor superiorly, and the long head of the
triceps laterally. It measures 2.5-3 cm in external diameter, is 3-4 cm long, and gives
rise to two terminal cutaneous branches: the horizontal scapular cutaneous artery, and
the vertical or descending parascapular cutaneous artery. These are consistently
located two-fifths of the distance between the spine of the scapula and the inferior
angle of the scapula (14). The scapular cutaneous artery parallels the spine of the

""------,'_+_

Teres minor m.
Circumflex scapular a.
& v. exiting triangular space
Teres major m.
Long head of triceps m.

Scapular cutaneous a.

Parascapular cutaneous a.

Figure 1 The circumflex scapular vessels emerging from the triangular space bounded by
the long head of the triceps, teres major, and teres minor muscles. The flaps are designed over
the scapular cutaneous and parascapular cutaneous vessels.

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scapula in the plane above the muscular aponeurosis of the infraspinatus muscle. It
terminates in the dem1al subcutaneous plexus at the midvertebralline. The descending
branch (the parascapular cutaneous artery) runs inferiorly parallel to the lateral
border of the scapula. It terminates in the dermal subcutaneous plexus at the inferior
angle of the scapula. The parascapular cutaneous artery is usually the dominant vessel
of these two terminal branches (15) (Fig. I).

III.

FLAP DISSECTION

Dissection of the scapula and parascapula flap can be done with the patient in the
prone or lateral decubitus position. The lateral position allows access to the axilla for a
counterincision, which is helpful if an extended pedicle is anticipated. The patient
should be carefully positioned with all pressure points padded and precautions taken
against compression of the axillary neurovascular structures. A beanbag is helpfuL A
wide prep and drape is done. If the lateral decubitus position is chosen, the arm should
be left free and prepped into the field.
The pedicle is identified with the use of Doppler ultrasound and marked as it
comes out of the triangular space. It is found by drawing a line from the midportion
of the spine of the scapula down to its inferior angle along the lateral border.
Another line is drawn 2 cm above the posterior axillary crease parallel to the spine of
the scapula, about two-fifths of the distance of the lateral border from the spine (14).
The skin paddle is now marked. If a horizontal flap is used, the transverse line
from the axillary crease to the spine of the scapula described above is used as the axis.
The maximal width of the flap is 10 em, and is marked 5 cm above and below this
transverse line. The length is drawn from midway between the axillary fold and lateral
border of the scapula to midway between the medial border of the scapula and the
posterior midline. The length can be up to 20 cm, although flaps as long as 25 cm have
been reported.
Dissection of the scapular flap begins by incising the superomedial portion of the
flap down to the muscular aponeuorsis of the infraspinatus muscle. If a fasciocutaneous flap is desired, the fascia is incised to gain access to the subfascial plane. Others
report dissecting in the loose areolar plane superficial to the fascia. As the dissection is
carried laterally, the flap is retracted inferiorly exposing the cutaneous branches of the
circumflex scapular vessels found in the loose areolar tissue coming out of the
triangular space. The descending or parascapular vessels can be seen branching off
the horizontal vessels. These are ligated. The inferior incision is made and dissection is
taken superiorly to the vessels (5).
The circumflex scapular vessels are then dissected as they emerge from the
triangular space. At this point the pedicle is 4--6 cm long with a diameter of 1.5-2 mm.
Dissecting more proximally to the origin of the circumflex scapular vessels off the
subscapular artery can lengthen the pedicle. If a pedicled flap is used, the dissection is
taken proximally as far as possible. However, there are numerous branches going off to
the muscle, which makes dissection difficult in this space. The exposure can be
improved by making a counterincision in the posterior axilla and finding the
thoracodorsal vessels at the lateral border of the latissimus muscle. These can then
be dissected back to the junction of the circumflex scapular vessels, allowing easier
dissection to the subscapular vessels (5).
The parascapular flap is marked by drawing a line from the triangular space to
the posterior iliac spine. The flap is centered over this line with the proximal end
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Figure 2 Axillary contracture with breakdown of skin in the proximal arm of a burn
patient 2 years after skin grafting. The parascapular flap has been marked by drawing a line
from the triangular space to the posterior iliac spine. The flap is centered over this line.

inferior to the posterior axillary crease, and the distal end midway between the tip of
the scapula and the posterior iliac spine (Fig. 2).
Dissection begins with incision of the distal aspect of the flap down to and
through the fascia of the latissimus. As the flap is dissected superiorly, the descending
parascapular vessels are encountered, the flap position is checked to ensure that it is
centered over these vessels, and then the rest of the flap incisions are made (2). The rest
of the dissection proceeds as with the scapula flap (Fig 3).

Figure 3

The flap has been raised with the parascapular cutaneous vessels at the tip of
the instrument.

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The lateral portion of the scapula can be included based on branches to the bone
from the parascapular vessels to create an osteocutaneous flap. The axillary portion of
the bone from the inferior angle to the level of the articular surface with the humerus
can be included. After the descending parascapular vessels are identified, the origins of
the teres major muscle are separated from the scapula leaving a cuff of muscle on the
bone to protect the descending vessels. The segment of bone to be included is cut with
an osteotome. The remainder of the dissection is similar to the standard parascapular
flap (II).
Continuity between the subscapular and thoracodorsal arteries should be preserved in case the latissimus muscle is needed in future reconstructions. An exception to this is when further length of the pedicle is needed. Another is when the circumflex scapular artery arises directly from the axillary artery. This occurs in 3%
of cases (13). This anatomical variant precludes the use of the combined scapular
and latissimus flap.

IV.

SURGICAL PROCEDURE

Moderate-sized defects of the chest wall can be effectively covered with scapula and
parascapula flaps. As pedicled flaps, they can be used to cover defects of the chest,
posterior neck, axilla, and upper extremity. As free flaps, they are rarely used for the
chest wall since other local flaps with a larger arc of rotation are usually available, such
as the latissimus and rectus flaps. However, for distant coverage they can be used to
cover defects virtually anywhere on the body.
The most common use of the scapula and parascapula flaps on the chest wall is
for contractures involving the axilla (6,16). They are especially useful for burn scar
contractures. The flap can be oriented oriented vertically as a parascapular flap, or
horizontally. When oriented vertically, it may result in a decreased contracture rate
and may eliminate the need for splinting (17). The flap can be transposed as a
fasciocutaneous flap, or an island flap if more length is needed (Fig. 4).
If some of the skin of the flap skin has been burned or grafted, it is still an option.
However, it is advisable to include the deep fascia as a fasciocutaeous flap. The donor
site may be closed primarily if the tissues are lax, or may require a skin graft if the
tissues are tight from surrounding burns.
Large defects in the axilla from excision of hidradenitis supporativum also can be
effectively covered with scapula or parascapula flaps. Although the donor site leaves a
considerable scar, the axilla is resurfaced with soft, pliable skin. When compared to
primary closure and grafting, ra tes of contracture are diminished (18,19).
Repair of defects of the anterior and posterior aspects of the neck, as well as the
ipsilateral shoulder and arm, has been reported (20,23). The pedicled flap is passed to
the anterior thorax, neck, or extremity through the triangular space by retracting the
teres major muscle and creating a tunnel (21 ,22). When the defect involves the shoulder
or upper arm, the proximal portion of the flap may require de-epithelialization to
allow tunneling of the distal part of the flap for coverage. The posterior neck is covered
by simple rotation.
Preoperative expansion of the skin territory of these flaps allows coverage of
larger areas. Expansion decreases the thickness of all layers of the skin except the
epidermis. This allows its use in areas where thinner skin is needed, such as the neck

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Figure 4 The flap has been transposed into the defect after release of the contracture and
excision of ulcerated skin.

and the foot (Fig. 5). The expansion also produces a delay phenomenon that augments
the blood flow to the flap, allowing larger areas of skin to survive on a single vascular
pedicle. Care should be taken to ensure that the expanders are not placed close to the
pedicle to avoid fibrosis of the vessels (10).
Larger defects of the chest wall can be covered with pedicle flaps, but this usually
requires combining the subscapular vessels with other pedicles or flap territories. For

Figure 5 Heel defect after excision of a squamous cell carcinoma in a patient with epidermolysis bullosa.

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Figure 6 A parascapular flap has been elevated with the pedicle emerging from the
triangular space. The teres minor muscle is just below the pedicle, which was dissected down to
the subscapular vessels.
example, combining the scapular skin with the latissimus muscle based on the
subscapularis pedicle can cover a large lateral defect (22). Combining the cutaneous
branch of the transverse cervical artery and some intercostal vessels allows for a much
larger skin paddle (9). Adding the pectoralis can cover more anterior defects (24).
Adding combinations of these, omentum, and rectus flaps can be used to cover massive
defects (25). When used as free flaps, the scapular and parascapular flaps can be used to
cover a wide array of defects (Figs. 6, 7).

Figure 7

The flap has been inset with a skin graft placed over the vessels to avoid com-

pression.

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One of the drawbacks of using these flaps is the unsightly scar that can result
from the donor site. This can be improved if a free flap is needed. Siebert and others
described an inframammary extended circumflex scapular flap that extends in a
curvilinear fashion from the inframammary fold to the triangular space. It is based
on a branch running anteriorly off the descending branch of the circumflex scapular
artery. Improvement in tbe donor site scar was reported in 20 patients (26).

V. ADVANTAGES
There are several advantages of using the scapula flap. It can be tailored to cover small
or large defects, and can be combined with the parascapula flap using the same pedicle
to increase its size. The anatomy is consistent and flap dissection usually proceeds with
minimal difficulty. The donor site can often be closed primarily in smaller flaps leaving
a wide but acceptable scar Adding other tissues such as bone from the scapula and
rib, muscle, and additional cutaneous territories, ifneeded, can increase the versatility
of the flap. Finally, ifused as solely as a cutaneous flap, it does not cause loss of muscle
function as do other local flaps of the chest wall.

VI. DISADVANTAGES
The disadvantages of using the scapula flap for chest wall reconstruction are most
often related to the donor site. The scar may widen in larger flaps. If the donor site
is unable to be closed primarily, a skin graft may be needed, leaving an unsightly
scar The other disadvantages include a limited arc of rotation in pedicled flaps,
and the possibility of needing secondary debulking procedures if a thin flap is
req uired (27).

REFERENCES
l.

2.
3.
4.

5.
6.
7.
8.
9.
10.

Dos Santos LF. The scapula flap: a new n"licrosurgical free flap. Rev Bras Cir 1980;
70: 133
Nassif TM, Vidal L, Bovet JL, Baudet J. The parascapula flap: a new cutaneous
microsurgical free flap. Plast Reconstr Surg 1982; 69:59l.
Cormack C. Lamberty BGH. The anatomical vascular basis of the axillary fasciocutaneous flap. Br J Plast Surg 1983; 36:425.
Kim PS, Gottlieb JR, Harris GD, Nagle DJ, Lewis VL. The dorsal thoracic fascia:
anatomic significance with clinical applications in reconstructive microsurgery. Plast
Reconstr Surg 1987; 79:72.
MayoLl BJ, Whitby D, Jones BM. The scapula flap: an anatomical and clinical study. Br
J Plast Surg 1982; 35:8
Diamond M, Bawich W. Treatment of an axillary burn scar contracture using an
arterialized scapular island flap. Plast Reconstr Surg 1983; 72:388.
Batchelor AGG, Sully L. A multiple territory free tissue transfer for reconstruction of a
large scalp defect. Br J Plast Surg 1984; 37:6.
Holmberg J, Ekerot L. The free scapula flap. Scand J Plast Reconstr Surg 1986; 20:219.
Maruyama Y, Terashima T. Case report: one-stage reconstruction of a defect with a
large fasciocutaneous flap. Br J Plast Surg 1987; 40:513.
Russell RC, Khouri RK, Upton J, Jones TR, Bush K, Lantieri LA. The expanded
scapular flap. Plast Reconstr Surg 1995; 96:884.

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Scapula and Parascapula Flaps

11.

12.
13.

14.
15.
16.
17.
18.

19.
20.
21.
22.

23.
24.

25.
26.

27.

231

Swartz WM, Banis JC, Newton ED, Ramasastry SS, Jones NF, Acland R. The osteocutaneous scapula flap for mandibular and maxillary reconstruction. Plast Reconstr Surg
1986; 77: 530
Thoma A, Heddle S The extended free scapula flap. Br J Plast Surg 1990; 43:709.
Rowsell AR, Davies DM, Eisenberg N, Taylor Gl. The anatomy of the subscapularthoracodorsal arterial system: study of 100 cadaver dissections. Br J Plast Surg 1984;
37:574
Gilbert A, Teot L. The free scapular flap. Plast Reconstr Surg 1982; 69:601.
Godina M. The free scapular flap. Plast Reconstr Surg 1982; 69:786.
Tolhurst DE, Haeseker B. Fasciocutaneous flaps in the axillary region. Br J Plast Surg
1982; 35:430.
Hallock GG, Okunski WJ. The parascapular fasciocutaneous flap for release of axillary
burn contracture. J Burn Care Rehab 1987; 8:387.
Soldin MG, Tuilley P, Kaplan H, Hudson DA, Grobbelaar AO. Chronic axillary
hidradenitis-the efficacy of wide excision and flap coverage. Br J Plast Surg 2000;
53434
Amarante J, Reis J, Santa Comba A, Malheiro E. A new approach in axillary hidradenitis treatment: the scapular island flap. Aesthet Plast Surg 1996; 20443.
Kim PS. Lewis VL Jr. Use of a pedicled parascapula flap for anterior shoulder and arm
reconstruction. Plast Reconstr Surg 1985; 76:942.
Gahos FN, Tross RB. Salomon Je. Scapular free-flap dissection made easier. Plast
Reconstr Surg 1985; 75: 115.
Mutaf M, Sensoz O. Use of a pedicled parascapular flap combined with latissimus dorsi
muscle for coverage of the forearm and reconstruction of elbow flexion. Plast Reconstr
Surg 1993; 94:868
Riaz M. Miller R, Small JO A pre-expanded island scapular flap for contracture of the
neck. Br J Plast Surg 1995; 48:520.
Okitsu H, Koganezawa 0, Moritani M, Amemiya R, Kimura K. A case of chest wall
reconstruction with scapular flap and rib autotransplantation for recurrent esophageal
cancer. Nippon Kyobu Geka Gakkai Zasshi 1991; 39469.
Bury TF, Reece GP, Janjan NA, Mcmurtrey MJ. Closure of massive chest wall defects
after full-thickness chest wall resection. Ann Plast Surg 1995; 34409.
Siebert JW, Longaker MT, Angrigiani e. The inframammary extended cirmcumflex
scapular flap and aesthetic improvement of the parascapular flap. Plast Reconstr Surg
1999; 9970
Holmberg J, Ederot L. The free scapula flap. Scand J Plast Reconstr Surg 1986; 20:219.

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17
Trapezius Flap for Chest
Reconstruction
MAURICE NAHABEDIAN
Johns Hopkins Medical fnslilUlions. Ballimore, Maryland, U.S.A.

The trapezius musculocutaneous flap is ideally suited for correction of defects in the
upper posterior thorax, head, and neck. Its use has been demonstrated for a variety of
acquired disorders and is well tolerated with excellent long-term outcome. Jaques first
descri bed clinical use of the trapezius flap for coverage of an exposed carotid artery in
1971 (1). The flap was based superiorly on the transverse cervical artery and mobilized
in a pedicled fashion into the neck. Since then, its use for acquired defects in the head
and neck has expanded and it is now also used for mandibular and oropharyngeal
reconstruction, cervicofacial reconstruction, facial paralysis procedures, and for
coverage of the occipital scalp.
Pairolero and Arnold first described use of the trapezius flap for complex defects
located in the upper thorax in 1986 (2,3). Since then, the trapezius has been applied for
a variety of thoracic defects that include complex wounds secondary to irradiation
therapy, postoperative wounds involving the lower cervical or thoracic spine, postpneumonectomy empyema with an associated bronchopleural fistula, and for repair of
myelomeningocele defects This chapter will focus on the anatomical considerations,
indications for use, techniques of elevation, and outcome following reconstruction
using thin flap.

I.

ASSESSMENT

Complex wounds involving the upper posterior thorax can pose a formidable
reconstructive challenge. Acq uired defects in this region can have a variety of causes;
the most common are trauma, tumor ablation, infection, and poor wound healing.

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Many of these wounds can be further complicated secondary to irradiation or


exposure of deep structures such as bone, lung, neural elements, or hardware.
Prior to reconstruction a careful assessment of the wound is necessary. Initial
evaluation requires assessment of the size, location, and depth of the wound as well as
exposure of deep structures such as lung, bone, neural elements, or hardware. It is
important to determine if the defect has been previously irradiated. Radiated wounds
add to the complexity and often require transplantation of healthy tissue for stable
wound coverage. In cases of tumor ablation, recurrent or persistent cancer must be
ruled out by biopsy. Reconstruction should not proceed until all tumor has been
removed. The infected wound must be thoroughly debrided to remove all devitalized
tissue and to ensure that no abscess is present. Intravenous antibiotic therapy is usually necessary to control infection. Exposed hardware following spinal stabilization
procedures may need to be removed prior to soft tissue reconstruction. The integrity of
the chest wall must be ascertained to determine stability and pulmonary function.
Reconstruction of the rigid chest wall may be necessary prior to soft tissue coverage to
prevent thoracic morbidity such as paradoxical chest movements, respiratory insufficiency, and flail chest.

II.

HISTORY

Importan t aspects of the history include factors related to the defect as well as factors
related to the patient. The cause of the wound and the wound healing potential must be
determined. Factors related to the defect or wound include prior surgery, duration,
prior irradiation, exposure of vital structures, and need for urgent intervention. The
most common operations that may result in acquired defects in this area include tumor
ablation, spinal instrumentation, and intrathoracic procedures. Other nonsurgical
causes include trauma, myelomeningocele, and bronchopleural fistula with empyema.
In cases of tumor ablation, a history of irradiation must be documented to assess the
wound healing potential. Congenital defects with exposure of neural elements may
require rapid soft tissue coverage to minimize long-term morbidity. Infection following spinal instrumentation procedures will occasionally require soft tissue coverage to
obtain a stable wound and salvage the hardware.
Factors related to the patient that may contribute to poor wound healing must
also be considered. These can include use of corticosteroid medication or tobacco,
presence of diabetes mellitus, advanced age, and poor nutritional status. The adverse effects of these conditions on collagen production, tissue blood supply, and
overall patient health have been well described (4-7). Reconstruction of the defect is
only considered when factors related to the patien t and the wound are controlled
and stabilized.

III.

PATHOPHYSIOLOGY

The pathophysiology of the conditions related to the wound can be related to a variety
of mechanisms econdary to irradiation, infection, exposed hardware, and congenital
deformities. Extrathoracic conditions are the most common and can include complex
wounds involving the thoracic spine or adjacent soft tissues. Intrathoracic conditions
are less common and can be the result of empyema and bronchopleural fistula.

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A.

235

The Irradiated Wound

The irradiated wound can be prone to poor wound healing (8-11). This can manifest as
incisional dehiscence, tissue necrosis, infection, and failure to progress through the
normal phases of wound healing. The reasons for this have been well studied and
described The adverse effects of radiation can cause soft tissue fibrosis and injury to
the microvasculature that are impediments to normal wound healing. These wounds
are often not susceptible to conservative measures such as healing by secondary
intention or delayed secondary closure. As a result, stable coverage usually requires
reconstruction using nonirradiated tissue from an adjacent or remote site in the form
of a pedicle flap or free tissue transfer.
B.

Empyema and Bronchopleural Fistula

Empyema is defined as the accumulation of pus within the pleural space that can be
life threatening (12,13). Although empyema is uncommon, it usually occurs following pneumonia or pneumonectomy. The postpneumonic and parapneumonic forms
are usually very responsive to intravenous antibiotic therapy and surgical intervention is rarely necessary. However, postpneumonectomy empyema can be more
difficult to control. Conservative surgical management in the form of closed or open
drainage is often successful. However, refractory cases can occur and may be due to
the formation of a bronchopleural fistula.
The chronic bronchopleural fistula with an associated empyema cavity can be
a difficult problem to eradicate (14). Conservative management is usually unsuccessful due to the inability of the fistula to seal. Healing is often further complicated
by previous irradiation and severe fibrosis. These cases usually require a team approach with the thoracic and plastic surgeons. Aggressive surgical intervention
consisting of closure of the fistula, muscle flap coverage, and obliteration of dead
space is usually necessary.
C.

Exposed Spinal Instrumentation

The incidence of infection following spinal operations with implanted prosthetic


instruments ranges from 1 to 4% (15~ 18). Risk factors for infection are variable and
include diabetes mellitus, corticosteroid medication, previous spinal operations,
obesity, chronic infection, tobacco use, extensive preoperative hospitalization,
extensive blood loss, and prolonged operative time (17). The rate of infection is
dependent on the approach to the spine and is significantly less following an anterior
approach than a posterior approach (16,17). In addition, infection appears to be
more common in patients undergoing fusion with prosthetic materials and in
patients with cancer metastatic to the spine (15).
Current strategies for the management of infected or exposed spinal instrumentation can include operative debridement, intravenous antibiotics, delayed closure, and flap coverage. The need to remove the hardware in cases of infection is
based on whether the spinal fusion is complete, which generally requires about
20 weeks. Hardware is usually removed if the infection occurs following complete
fusion; however, all attempts are made to preserve the hardware when infection
occurs prior to spinal fusion. Intravenous antibiotic therapy is administered until
the fusion is solid (18). In cases with exposed spinal hardware, the use of a flap for

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stable coverage may be necessary. The decision to use flap coverage is complex and
controversial. Most patients are successfully managed with serial debridement and
delayed closure. However, when confronted with a large soft tissue defect that is not
amenable to secondary closure, the use of a flap is often necessary. The trapezius
musculocutaneous flap has been used in these situations.

D.

Myelomeningocele

Myelomeningoceles are caused by a failure in neural tube formation during embryogenesis that results in spina bifida. Manifestations of myelomeningoceles include
malformations of the posterior spinal elements of the thoracic, lumbar, or sacral levels
as well as malformations of the meninges and soft tissues. Left untreated, this can be
life threatening.
The management of myelomeningoceles is controversial (19,20). It is well
accepted that operative intervention is necessary within the first few days of life to
minimize morbidity. Reconstruction should include reconstitution of the spinal cord
defect, repair of the dura, closure of the lumbodorsal fascia, closure of the subcutaneous tissues, and closure of the skin (20). In all cases, neurosurgical closure of the cord
and dura is necessary. Obtaining stable soft tissue coverage is dependent on the size
and location of the defect. Small myelomeningocele defects are usually closed using
simple techniques such as wide undermining and direct midline closure. However,
large myelomeningocele defects that are not amenable to this method usually require
more complex soft tissue reconstruction such as skin, fasciocutaneous, or musculocutaneous flaps. Indications for these procedures include myelomeningocele defects
exceeding 21-25 cm 2 , significant kyphosis or transverse lie, and when tensionfree
closure is not obtainable by any other methods (20).
Soft tissue coverage of myelomeningocele defects involving the thoracolumbar
and lumbosacral region is best managed using latissimus dorsi or gluteus maxim us
muscle flaps (21,22). Defects located in the upper thorax can be managed using
fasciocutaneous flaps and muscle flaps that include the latissimus dorsi and trapezius
(23,24).

IV.

INDICATIONS FOR CORRECTION

When considering reconstruction, the traditional principles of the reconstructive


ladder are applied. Arnold and Pairolero have established many of the guidelines
for management of the damaged chest wall (2,3). These include assessment for
persistent cancer, full vs. partial thickness, resectability, recon tructive options, and
back-up procedures. Choosing the appropriate option requires careful assessment of
the location, size, and depth of the wound. Simple techniques such as local wound
care, surgical debridement, secondary closure, and skin graft are often suitable for
small wounds without deep structure involvement. However, when deep structures
are exposed such as lung, bone, neural elements, or hardware, more aggressive
management is usually required. In these situations, stable soft tissue coverage is
needed and is best obtained by tissue transplantation in the form of a pedicle flap or
free tissue transfer.
Although there are a variety of flaps within the armamentarium of the reconstructive surgeon, only a limited number of flaps can be used to reconstruct defects in

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the upper posterior thorax. These include but are not limited to the latissimus dorsi,
trapezius, and paraspinous muscle flaps as well as various methods of adjacent tissue
rearrangement (24,25). The best option is dependent upon the size and location of the
defect. It has been recommended that the trapezius flap be used for small defects and
the latissimus dorsi and trapezius flaps for larger defects in the upper posterior thorax
(26). For defects in the midposterior thorax, the latissimus dorsi and paraspinous
muscle flaps are recommended. This chapter will focus on the use of the trapezius
musculocutaneous flap and its application for various defects located in the posterior
thoracic region.
The trapezius myocutaneous flap is ideally suited for defects located in the upper
third of the posterior thorax. The trapezius muscle is bordered by the cervical and
thoracic spine medially, the scapula laterally, and the latissimus dorsi muscle
inferiorly. This is a versatile flap that can be designed in a variety of orientations
based on the location of the wound. The wide arc of rotation allows for the coverage of
defects located around the shoulder, clavicle, scapula, as well as the cervical and upper
thoracic spine. Primary closure of the donor site is usually possible and dependent
upon the degree of skin laxity, the orientation of the flap, and the width of the flap.
Donor site defects that measure less than 8 cm can usually be closed primarily;
however, beyond this width a skin graft is usually necessary. Modifications in flap
design using a bilobe design may facilitate primary closure of the donor site, obviating
the need for a skin graft (27).

V.

SURGICAL TECHNIQUE

A.

Anatomy

The trapezius is a paired muscle that is flat and triangular. The muscle is approximately
34 cm long and 18 cm wide. Its origin is from the occipital protuberance, the medial
third of the superior nuchal line, and the spinous processes of the seventh cervical to
the twelfth thoracic vertebre. There are three separate portions of the trapezius that are
based on the insertion (Fig. 1). The superior fibers insert to the lateral third of the
clavicle, the middle fibers insert to the spine of the scapula, and the inferior fibers insert
to the acromion. The trapezius muscle the most superficial muscle of the posterior
thorax. It is bordered posteriorly by the rhomboid major and minor muscles between
the second and fifth thoracic vertebrae and the latissimus dorsi muscle between the
sixth and twelfth thoracic vertebre.
The trapezius has a type 2 vascular pattern as classified by Mathes and Nahai
(28). The dominant blood supply originates from the thyrocervical trunk in the
majority of people and includes the ascending and descending branches of the
transverse cervical artery and vein (Fig. 1). Minor vascular contributions arise from
the branches of the occipital, dorsal scapular, and perforating branches of the
intercostal arteries and veins. However, in some individuals the dominant blood
supply may be from the dorsal scapular vessels (29). Angiographic studies have defined
these vascular angiosomes (30). Motor innervation is from the spinal accessory nerve
and the sensory innervation is from the sensory branches of the third and fourth
cervical nerves as well and the posterior cutaneous branches of the intercostal nerves.
The function of the trapezius is to rotate the scapula in various directions based
on the fibers of insertion. The upper fibers serve to elevate the scapula, the middle

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Superior
trapezius
portion ----,,~~

;......t - -

Occipital
branch

:.~I::.._~

Middle
trapezius
portion --j.""::-.....;...."-,JoO<
Inferior
trapezius
portion---j~~-+---'-:_.:.......iI~

Ascending
branch

Descending
branch

Figure 1 The anatomy of the trapezius muscle. The functional portions of the muscle,
vascular territories, and outline of the upper and lower trapezius Aaps are shown.

fibers adduct the scapula toward the spine, and the lower fibers depress the scapula
(31). It is unusual for the trapezius to exert its effects on the scapula independently;
however, its fibers will function in concert with other muscles such as the serratus
anterior, levator scapulae, and rhomboid major.
The trapezius musculocutaneous flap can be raised as either a vertically oriented
flap based on the descending branch of the transverse cervical vessels or as a
horizontally oriented flap based on the ascending branch of the transverse cervical
artery (32-36). These vertical and horizontal orientations are frequently referred to as
the lower and upper trapezius flaps, respectively. The cutaneous portion of the
vertical flap is situated over the middle and inferior fibers of the trapezius muscle
while the cutaneous portion of the horizontal flap is si tuated over the upper fibers of
the trapezius.

B.

Vertical Trapezius Musculocutaneous Flap

The patient can be marked preoperatively in the upright or prone position. Landmarks for the cutaneous portion of the flap include the vertebral border of the spine
medially, the vertebral border of the scapula laterally, the mid portion of the scapula
superiorly, and the midpoint between the tip of the scapula and the posterior
superior iliac crest inferiorly. An extended lower trapezius musculocutaneous flap
can be designed and based on the dorsal scapular artery (37). A handheld Doppler
ultrasound scanner is used to delineate the course of the descending branch of the
transverse cervical artery. In general, the location of the descending bra ncb is along
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"'t~~-c+~-T-

Rhomboideus
nunor
muscle
Rhomboideus
major
muscle
Latissimus
dorsi
muscle

Figure 2 Elevation of the vertical trapezius musculocutaneous flap. The latissimus dorsi
muscle, rhomboideus muscles, and superior portion of the trapezius muscle are left intact.

Figure 3 An acquired defect of the upper posterior thorax following excision of a primary
spinal cord tumor and radiation therapy.

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Figure 4

The trapezius muscle and ascending branches of the transverse cervical vessels

are oLltlined.

the deep surface of the muscle and traverses between the spine and the scapula. The
territory of the cutaneous island must overlie the artery and vein and the dimensions
should not exceed 20 cm in length and 8 cm in width. The arc of rotation of the
trapezius flap will permit coverage of the upper posterior thorax, posterior scalp,
neck, and shoulder (Figs. 3-5).
In the operating room, the patient is positioned in the lateral decubitus or prone
position. A beanbag may be used to facilitate positionmg. The incisions are made
around the skin island and extended cephalad (Fig. 2). Dissection proceeds to the level
of the trapezius muscle. The origin of the muscle along the vertebral and scapular
borders is divided. The flap is then elevated in a caudal to cephalad direction, taking
notice of the descending branch of the transverse cervical vessels. Care must be taken
to avoid elevation of the rhomboid and latissimus dorsi muscles. The muscle is
detached from the thoracic vertebra; however, the superior muscle fibers are preserved
at the level of the lateral clavicle and acromioclavicular joint. The flap is then
transposed over the defect. Figures 6 through 9 illustrate a patient with an acquired
defect of the upper posterior thorax that was reconstructed with the vertical trapezius
myocutaneous flap.

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241

Figure 5 Postoperative view demonstrating a healed and viable trapezius musculocutaneous flap. Ptimary closure of the 10 x 6 em donor site was easily accomplished.

C.

Horizontal Trapezius Musculocutaneous Flap

As with the vertical flap, the horizontal flap can be delineated with the patient in the
upright or prone position. Cutaneous landmarks for this flap include the acromioclavicular joint and the lateral third of the clavicle. Again, a handheld Doppler ultrasound scanner should be used to delineate the course of the ascending branch of the
transverse cervical artery. The flap is delineated over the course of this artery and
usually placed over the superior fibers of the trapezius muscle located over the
shoulder region. The dimensions of the flap range from 6 to 10 cm in width and 8 to
30 cm in length. An extension of this flap, known as the cervicohumeral flap, can be
made by including the skin territory of the inferior aspect of the upper arm. The arc
of rotation of the horizontal flap will allow coverage of defects in the lower facial
region, oral cavity, and upper posterior thorax.
In the operating room, the patient is positioned in the supine or lateral decubitus
position. The flap is raised from lateral to medial. The distal fasciocutaneous portion is
elevated off the deltoid muscle. When the trapezius muscle is identified, it is divided at
its midpoint. This point is determined based on anatomical landmarks that include the

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Figure 6

A J 5 x 5 cm defect of the posterior thorax following excision of a spinal cord


tumor and radiation therapy.

lateral third of the clavicle, the acromion, and the spine of the scapula. With the
standard horizontal flap, the superior muscle fibers at the acromioclavicular joint are
divided. However, with the extended horizontal flap, these fibers are preserved to
maintain perfusion from the direct cutaneous and musculocutaneous perforating
vessels. The inferior portion of the flap should include muscle that is divided at the
junction of the superior and middle fibers. The length of the flap is based on the
required arc of rota tion.

VI.

POTENTIAL COMPLICATIONS AND PITFALLS

Although the trapezius musculocutaneous flap is an excellent reconstructive option,


factors related to this flap can be associated with adverse outcome (38,39). The
versatility of this flap is based on it vascularity, which permits design of the flap in a
variety of orientations. However, disruption of the blood supply will severely compromise use of this flap. Resection of tumors such as sarcomas involving the posterior
thorax or neck may require sacrifice of the transverse cervical artery that would
preclude use of the inferiorly based flap. Radical neck dissections may also result in

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Figure 7

243

A 15 x 5 cm trapezius musculocutaneous flap is designed and incised.

injury or sacrifice of this artery. When the vascular patency is questionable, an


arteriogram should be considered. Intraoperative confirmation of vascular patency
with a handheld Doppler ultrasound scanner is essential prior to flap harvest. A delay
procedure may sometimes be necessary prior to elevation of the flap. Other potential
complications include a shoulder-drop deformity following division of the superior
fibers of the trapezius.
The upper trapezius flap can be used when the transverse cervical artery has been
divided following a neck dissection (40). Deficiencies of this flap include a limited arc
of rotation and the need for a skin graft to close the donor site. This flap should be used
in select cases in which the defect involves the ipsilateral neck. It should not be used for
defects that extend beyond the midline of the neck.

VII.

LONG-TERM RESULTS

Long-term assessment of the trapezius musculocutaneous flap has been well documented. Although it has been used for a variety of acquired defects involving the
posterior thorax, the published reports are somewhat limited due to small sample size.

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Figure 8 The trapezius flap is transposed over the defect. The inferior and middle portions
of the trapezius muscle are elevated. The superior portion is left intact.

The majority of cases in which this flap has been used involve the head and neck region.
Therefore, long-term results and outcome will be discussed for all defects in which the
trapezius musculocutaneous flap is used.
A.

The Irradiated Back Wound

The turnover trapezius musculocutaneous flap has been demonstrated to be effective


in the management of the radiated upper back wound (26,41-43). Disa et at. have
reported on six patients with complex wounds of the cervicothoracic spine following
spinal operations for metasta tic or primary tumors (41). All patients had prior
radiation therapy and all patients had exposed dura. No wound was amenable to
primary closure due to poor tissue quality. infection. or exposed hardware. Flap
survival and wound stabilization were achieved in all patients. Complica tions included
a seroma in one patient and a malignant pleural effusion in one patient. Casas has
reported the successful use of the trapezius flap in combination with a latissimus dorsi
flap in a patient with a postoperative wound infection and cerebrospinal fluid (CSF)
leak following resection of a recurrent ependymoma with postoperative radiation
therapy (26). The wound measured 8 by 20 cm and located at the TI-T51evel.

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Figure 9 The trapezius musculocutaneous flap is inset and the donor site is closed by
primary intention.

B.

Myelomeningocele

McCraw et a1. have reviewed their experience with the latissimus dorsi and trapezius
musculocutaneous flap in 82 patients with myelomeningocele defects (24). The
trapezius flap was used in four patients. All repairs were closed in three layers and
no patient required a skin graft. There were no flap losses and all patients were
discharged from the hospital within 2 weeks. Wound dehiscence occurred in four
patients (4.9%) and all were all successfully closed secondarily. Stable wound coverage
was maintained in all patients with up to an 8 year follow-up.

c.

Exposed Spinal Instrumentation

Klink et al. have used the trapezius and latissimus dorsi flaps in five patients with
complex wounds of the spinal region that had failed to be corrected using the traditional and conservative treatment modalities (43). The wound cause was trauma in
two patients and tumor in three patients. Prior radiation was documented in three of
five patients. All patients obtained stable soft tissue coverage with up to 30-month

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follow-up without recurrence of infection. The surgical hardware was salvaged in


one of three patients.
D.

Empyema and Bronchopleural Fistula

The protocol utilized by Michaels et a1. includes pulse lavage irrigation and sharp
debridement of the empyema cavity, repair of the bronchopleural fistula using a
muscle flap, and minimization of the dead space using muscle flaps and thoracoplasty (44). The choice of flap is dependent upon the location of the defect. The
pectoralis major, latissimus dorsi, serratus anterior, rectus abdominis, and trapezius
muscles have been used. The trapezius flap is used primarily for apical defects.
Sixteen patients have been managed with this protocol, resulting in initial success
in 12 patients and eventual success in the remaining 4 patients following one additional procedure.
Watanabe et al. described using the lower trapezius island musculocutaneous
flap for the management of a bronchopleural fistula and empyema (45). Following
drainage of the empyema, serial debridement, partial rib resection, and control of the
infectious process, a contralateral trapezius flap was harvested, de-epithelialized, and
transposed through a subcutaneous tunnel into the abscess cavity over the bronchopleural fistula. Primary closure of the donor site was performed. The patient was doing
well at the 2-year follow-up with no functional impairment.
E.

Head and Neck

For acquired defects involving the head and neck region, the results and outcomes
following trapezius flap reconstruction have generally been mixed (31,40,46,47).
Excellent outcomes have been reported by Seyfer in which the lower trapezius flap
was used in six patients with wounds of the posterior skull and upper spine (47). The
wounds were compromised in four patients due to prior irradiation and leakage of
cerebrospinal fluid. Complete wound stabilization was achieved in all patients. No flap
was lost and no patient demonstrated weakness on shoulder motion. Follow-up
ranged from 8 months to 5 years.
Aviv et a!. have used the superior trapezius musculocutaneous flap in 30 patients
with acquired defects of the oral, laryngeal, and pharyngeal regions (40). The superior
flap was used because all patients had undergone an ipsilateral radical neck dissection
at time of ablation, with sacrifice of the transverse cervical artery. Thus the blood
supply to these flaps included the perforating branches of the paraspinious muscles as
well as the occipital and dorsal scapular arteries. The primary indication for use of this
flap was to cover the exposed carotid artery in 24 patients. There were no total flap
failures and two partial flap failures over a 14 year period. Closure of the donor site
required a skin graft in 20 patients.
A less optimal outcome following use of the trapezius flap for complex wounds
involving the head and neck has been reported by others. Chandraesekhar et a1. used
the inferior trapezius flap in 43 patients with various defects involving the cervicofacial, oropharyngeal, oromandibular, and craniofacial areas (31). The flaps were
musculocutaneous in all cases, with the size of the cutaneous paddle ranging from 5
to 10 cm in width and 10 to 20 cm in length. A variety of complications were observed
that included total flap necrosis in six patients, partial flap necrosis in nine patients,
and wound infection in four patients. In all cases, flap loss was the result of venous

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thrombosis. Additional flap procedures were needed in eight patients. Donor site
morbidity was rare and included only a seroma in three patients. No patient
developed a shoulder droop or unstable scapula. Although there are advantages to
use of the trapezius flap, care must be exercised during the elevation and transposition due to variability in blood supply, venous injury, and vascular compression.
Similar results have been observed by Cummings et a!. in which 8 of 14 patients
experienced partial or total flap loss following use of the lower trapezius flap for
defects of the buccal, oral, and oropharyngeal regions (46).

VIII.

CONCLUSION

The trapezius musculocutaneous flap is an excellent option for closure of defects


involving the upper posterior thorax. It is a reliable flap that will provide stable soft
tissue coverage when used in properly selected patients. Complications can be
minimized with a thorough knowledge of the basic anatomy and the possible
alterations that may occur with certain ablative procedures. The versatility, simplicity,
and reliability of this flap make it an excellent reconstructive option that should be
included in the armamentarium of the reconstructive surgeon.

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Levi AD, Dickman CA, Sonntag VK. Management of postoperative infections after
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surgery: a survey of 850 spinal procedures. 1 Spinal Disord 1998; I J:124-128.
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Blanco-Davila F. Luce EA. Current considerations for myelomeningocele repair. 1
Craniofac Surg 2000; 11:500-508.
deChalain TMB, Cohen SR, Burstein FD, Hudgins Rl, Boydston WR, O'Brien MS.
Decision making in primary surgical repair of myelomeningoceles. Ann Plast Surg 1995;
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approach to closure of large lumbosacral meningomyleocele defects. Plast Reconstr Surg
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Ramasastry SS, Cohen M. Soft tjssue closure and plastic surgical aspects of large open
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fasciocutaneous flap closure of large myelomeningoceles. Plast Reconstr Surg 1996;
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McCraw lB, Penix 10, Freeman BG, Vincent MP, Wirth FH. Soft-tissue repair of
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techniq ue. Arch Otolaryngol Head Neck Surg 1991; J 17:73-76.
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flap. Br 1 Plast Surg 1981; 34:157-161.
Chandraesekhar B, Terz 11, Kokal WA, Beaty lD, Gottleib ME. The inferior trapezius
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Urken ML, Naidu RK, Lawson W, Biller HF. The lower trapezius island musculocutaneous flap revisited: report of 45 cases and a unifying concept of the vascular supply.
Arch Otolaryngol Head Neck Surg 1991; 117:502-511.
36. Goodwin WJ, Rosenberg GJ. Venous drainage of the ipsilateral trapezius musculocutaneous island flap. Arch Otolaryngol 1982; 108:411--413.
37. Tan KC, Tan BK. Extended lower trapezius island myocutaneous flap: a fasciomyocutaneous flap based on the dorsal scapular artery. Plast Reconstr Surg 2000; 105: 17581763.
38. Netterville JL, Panje WR, Maves MD. The trapezius myocutaneous flap: dependability
and limitations. Arch Otolaryngol Head Neck Surg 1987; 113:271-281.
39. Nichter LS, Morgan RF, Ham1an DM, Horowitz J, Edlich RF. The trapezius musculocutaneous flap in head and neck reconstruction: potential pitfalls. Head Neck Surg
1984; 7:129-134.
40. Aviv JE, Urkin ML, Lawson W, Biller HF. The superior trapezius myocutaneous flap in
head and neck reconstruction. Arch Otolaryngol Head Neck Surg 1992; 118:702-706.
41. Disa JJ, Smith AW, Bilsky MH. Management of radiated reoperative wounds of the
cervicothoracic spine: the role of the trapezius turnover flap. Ann Plast Surg 2001;
47:394-397
42. Seyfer AE, Joseph AS. Use of trapezius muscle for closure of complicated upper spinal
defects. Neurosurgery 1984; 14:341-345.
43. Klink BK, Thurman RT, Wittpenn GP, Lauerman WC, Cain JE. Muscle flap closure for
salvage of complex back wounds. Spine 1994; 19:1467-1470.
44. Michaels BM, Orgill DP, Decamp MM, Pribaz JJ, Eriksson E, Swanson S. Flap closure
of postpneumonectomy empyema. Plast Reconstr Surg 1997; 99:437--442.
45. Watanabe H, Imaizumi M, Takeuchi S, Murase M, Hasegawa T. Treatment of empyema
by transposition of contralateral trapezius flap. Ann Thor Surg 1997; 63:837-839.
46. Cummings CW, Eisele DW, Coltrera MD. Lower trapezius myocutaneous island flap.
Arch Otolaryngol Head Neck Surg 1989; 115:1181-1185.
47. Seyfer AE. The lower trapezius flap for recalcitrant wounds of the posterior skull and
spine. Ann Plast Surg 1988; 20:414--418

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18
Extended Flaps for Chest Wall
Reconstruction
PEIRONG YU and GEOFFREY L. ROBB

University of Texas M. D. Anderson Cancer Center, Houston, Texas, U.S.A.

The majority of chest wall defects can be reconstructed using the commonly employed
flaps mentioned elsewhere in this book, such as the latissimus dorsi, pectoralis major,
and rectus abdominis musculocutaneous flaps. Depending on the size and location of
the defect, some extended, less commonly used flaps may provide adequate, reliable
coverage without the need for microsurgical tissue transfer. Under certain circumstances, a combination offlaps based on the same vascular system may be required to
provide large surface-area coverage. These flaps are reviewed and discussed herein.
I.

COMBINED FLAPS OF THE SUBSCAPULAR SYSTEM


(CHIMERIC FLAPS)

The subscapular system of flaps provides abundant potential chimeric options,


encompassing combinations such as scapular and parascapular fasciocutaneous flaps,
scapular and latissimus dorsi flaps with or without the serratus anterior muscle, and
composite flaps including vascularized rib or scapula.
A.

Anatomy

The subscapular artery is a short arterial trunk that arises from the third part of the
axillary artery, the diameter of which ranges from 2.5 to 4.0 mm. The subscapular
artery then bifurcates into the larger circumflex scapular artery and terminates as the
thoracodorsal artery. The circumflex scapular artery proceeds to the triangular space,
travels within the dorsal thoracic fascia, and supplies the territory of the scapular and
parascapular fasciocutaneous flaps in addition to the scapula. The thoracodorsal
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artery runs distally in the axilla and gives off an angular branch to the scapula and a
serratus arcade to the serratus anterior muscle before entering the latissimus dorsi
muscle. Based on this anatomy, a combination of flaps can be raised (Fig. I). For
example, the latissimus dorsi and serratus anterior flaps can be combined based on the
main thoracodorsal artery. For massive defects, the entire subscapular system can be
raised to include the scapular, parascapular, latissimus dorsi, and serratus anterior
flaps. However, certain vascular anomalies have been reported (1). For instance, the
circumflex scapular and thoracodorsal vessels were found to arise independently from
the axillary vessels in 2 of 36 cases. Other anomalies included an independent
subscapular artery, an independent subscapular vein, and an independent arterial
system of the serratus anterior muscle originating directly from the axillary artery in
one case (I).

B.

Surgical Technique

Flap design depends on the defect size and location. This chimeric flap can be
transferred either pedicled or free. This is useful when massive chest wall resection
with multiple rib resections and replacement with synthetic mesh and/or a methylmethacrylate sandwich is required. A surgical technique for individual flap elevation is
described elsewhere in this book. For ease of flap inset, each flap can be separated
based on its own vascular territory, with only the vascular pedicles attached to each

-angular branch

serratus branch -- ------

Figure 1

circumflex
scapular a.

Anatomy of the subscapular system.

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other. Skin grafts can also be placed on the latissimus dorsi and serratus anterior
muscles. Due to the possible vascular anomalies mentioned above, it is recommended
that the vascular pedicle in the axilla be explored before performing flap elevation
when free tissue transfer is planned. In addition, a significant number of these patients
have undergone prior surgery or radiation therapy to the axilla, which mandates
assessment of the vascular pedicle prior to flap elevation. In these situations, however,
other flaps should be considered first.

c.

Outcomes

Even in patients with advanced-stage breast cancer who undergo massive chest wall
reconstruction, our experience at The University of Texas M. D. Anderson Cancer
Center seems to suggest reasonable survival and operative morbidity with no mortality. Such reconstruction is justified in selected patients for improved quality of life.
Different combinations offlaps of the subscapular system have been successfully
used, mainly for limb reconstruction (1,2). The main concern with these flaps is related
to potential donor-site morbidity. For instance, persistent seroma has been found in
25% of such patients. When a significant amount of skin is taken, skin grafting of the
donor site is usually required. In addition, Germann et al. (I) reported a slightly
winged scapula in one-third of their patients after inferior strips of the serratus
anterior muscle had been taken, although their loss of shoulder function was clinically
negligible; all of the patients regained their normal range of motion after undergoing
physical therapy.

II.

EXTENDED LATISSIMUS DORSI FLAP

The extended latissimus dorsi flap includes fascial extension into the scapula and
parascapular flap territory. This flap was first described by Hokin (3) in 1983 for breast
reconstruction. By including the so-called extended fat fascia, a medium-sized breast
can be reconstructed without having to use an implant. Under the same principle, this
flap can be used to cover an extended or odd-shaped chest wall defect when a standard
latissimus dorsi flap is otherwise inadequate.
A.

Anatomy

The vascular anatomy of the dorsal thoracic fascia and its relationship with the
thoracodorsal system have been studied using Microfil injection. The circumflex
scapular artery lies within the layers of the dorsal thoracic fascia, supplying the fascia
and overlying skin. Its distal branches communicate among the circumflex artery,
myocutaneous perforators, and latissimus dorsi and trapezius muscles. By injecting
Microfil through the circumflex scapular artery, abundant communicating branches
were found in the latissimus dorsi muscle (4). Therefore, the dorsal thoracic fascia and
latissimus dorsi myocutaneous flap can be raised as one unit based on the circumflex
scapular or thoracodorsal vessels.
B.

Surgical Technique

In the extended latissimus dorsi flap, the flap design is marked preoperatively.
Specifically, the latissimus dorsi muscle and desired skin island are marked as with a
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standard latissimus dorsi flap; the fascial extension is then outlined. The boundaries of
the fascial extension are the scapular spine superiorly, the spinous processes medially,
and the posterior axillary line laterally (Fig. 2). The flap is raised with the patient in the
lateral position and shoulder elevated 90 degrees. The skin island is incised first, with
the incision extending to the posterior axillary fold to expose the neurovascular pedicle
of the latissimus dorsi muscle. Once the neurovascular pedicle is identified, the
latissimus flap is raised from anteriorly to the posterior midline. In the scapular
region, suprafascial dissection is performed superiorly toward the scapular spine. The
dorsal thoracic fascia, including the circumflex scapular vessels, is then dissected off
the underlying muscle. Next, the entire flap is rotated as a pedicled flap to cover the
chest wall defect. The humerus insertion of the latissimus dorsi muscle may be divided
for additional arc of rotation. A skin graft is then placed over the latissimus dorsi
muscle and dorsal thoracic fascia. The donor site can be closed primarily as with a
standard latissimus dorsi flap.

C.

Outcome

The majority of the reported extended latissimus dorsi flaps have been used for breast
reconstruction. Germann and Steinau reported on the largest series, in which 47

~ {

ftl.

Figure 2 Extended latissimus dorsi flap. Fascial extension is outlined in the dotted area
above the latissimus muscle.

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patients underwent reconstruction using this flap with no flap loss (5). The most
common complication was back seroma (19%), which resolved with aspiration.

III.

EXTENDED V-V LATISSIMUS DORSI

MUSCULOCUTANEOUS FLAP
The extended V-Y latissimus dorsi musculocutaneous flap can be used for large chest
wall defects when a conventional latissimus dorsi flap with a large skin island would
not allow for primary closure of the donor site.

A.

Surgical Technique

With the patient in a standing or lateral decubitus position and arm abducted 90
degrees, the latissimus dorsi muscle is outlined on the skin. The final chest wall defect is
then assessed, and the vertical dimension of the defect is measured, which determines
the vertical dimension of the leading edge of the flap. Next, the midline of the thoracic
spine is marked. The superior and inferior edges of the triangular flap are then outlined
starting at the anterior leading edge and merging at the posterior midline with a slight
downward curvature (Fig. 3). Afterward, the flap skin is incised down to the latissimus
fascia, and the muscle flap is raised in the usual fashion. The entire musculocutaneous
flap is then advanced anteriorly to the chest wall defect. The humerus insertion of the
latissimus dorsi muscle and serratus branch of the thoracodorsal vessels may be
divided to facilitate further advancement. Finally, the donor site is closed in a V-to-Y
fashion, and suction drains are placed accordingly under the flap.

B.

Outcome

Micali and Carramaschi (6) reported on their experience using extended V-Y
latissimus dorsi musculocutaneous flaps in eight cases of extensive anterior chest wall

B
A

Figure 3 Extended V-Y latissimus dorsi musculocutaneous flap The superior and inferior
edges of the flap are outlined starting from the anterior leading edge (A) and merging at the
posterior midline (B)

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defects caused by advanced breast cancer and irradiation. The defects extended from
the midsternum to the midaxillary line horizontally and from the clavicle to the
inframammary fold vertically. The defect sizes ranged from 15 x 15 cm to 19 x 21 cm,
while the flap sizes ranged from 12 to 17 cm vertically to 22 to 30 cm horizontally.
Small areas of skin-edge necrosis occurred in two patients, and epidermolysis occurred
in one patient. None of the patients was required to undergo additional surgery.

IV.

THORACODORSAL ARTERY PERFORATOR FLAP

For relatively small chest wall defects, the thoraco dorsal artery perforator (TAP) flap
provides excellent cutaneous coverage with minimal donor-site morbidity.
A.

Anatomy

After giving off the serratus branch, the thoracodorsal artery enters the latissimus
dorsi muscle on its deep surface approximately 8 cm from the origin of the subscapular
artery. Immediately after its entry to the muscle, the artery divides into a medial and
lateral branch running parallel to the upper and lateral border of the muscle,
respectively (7,8). Both of the primary muscular branches give origin to a multitude
of secondary branches that run through the latissimus dorsi muscle from the deep to
the superficial surface. Also, two to three cutaneous perforators branch off of the
lateral branch. The proximal perforator exits the latissimus dorsi muscle into the
subcutaneous tissue approximately 8 cm below the posterior axillary fold and 2~3 cm
posterior to the lateral border of the muscle. The diameter of this perforator ranges
from 0.4 to 0.6 cm. A second perforator arises 2-4 cm distal to the proximal perforator
and measures 0.2-0.5 cm in diameter. These two perforators were found in all 40
specimens upon cadaver dissection in a study by Angrigiani et al. (8); a third perforator
2-4 cm distal to the second one was found in 80% of the specimens.

B.

Surgical Technique

With the patient in a lateral position, a point is marked 8 cm caudal to the posterior
axillary fold and 2 cm posterior to the lateral border of the latissimus dorsi muscle
(Fig. 4A). This point represents the location of the proximal cutaneous perforator,
which can be detected via a handheld Doppler ultrasound scanner. A flap with a
dimension of up to 15 x 25 cm can be raised safely with its longitudinal axis oriented in
any direction; a longitudinal orientation is preferred because of the skin pliability at
the donor site and desirable final scar location. Also, the anterior half of the flap can be
designed outside the lateral border of the latissimus dorsi muscle. Primary closure of
the donor site is expected if the flap width is les than 8-10 cm (Fig. 4B).
After the desired flap dimension is outlined using a marking pen, the medial (or
posterior) margin is incised first, and suprafascial dissection is performed laterally (or
anteriorly) until the proximal skin perforator near the lateral border of the muscle is
seen. The rest of the flap is then incised and dissected off the latissimus dorsi muscle
with only the perforator vessels attached. The flap can then be rotated to cover the
defect if additional length is not required. However, freeing the thoracodorsal vascular
pedicle would provide a much greater arc of rotation and pedicle length. This is
obviously necessary iffree tissue transfer.is planned. The lateral edge of the latissimus

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Figure 4 The TAP flap. The location of the proximal cutaneous perforator is identified
with Doppler ultrasound studies and the flap is designed longitudinally (A). The donor site is
closed primarily (B).

dorsi muscle is then elevated, exposing the main thoracodorsal vessels. Next, the small
amount of muscle lateral to the skin perforator is transected to free the perforator. The
thoracodorsal vessels and skin perforator are then freed by dividing the muscular
branches. A pedicle length of 15-18 cm usually can be obtained, and the flap can reach
the anterior or posterior midline (Fig. 5).

C.

Outcome

Flaps up to 25 cm long usually survive well without partial necrosis (8). When used as a
pedicled flap, partial flap necrosis is largely due to twisting or kinking of the skin

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Figure 5 The TAP flap can reach over the anterior midline when the thoracodorsal vessels
are freed to increase the arc of rotation.

perforator or main pedicle. Therefore, as with any island flaps, especially perforator
flaps, careful flap positioning is extremely important. We had one c;ase of an obese
patient in whom we were unable to raise a TAP flap due to a lack of sizable skin
perforators. The donor site usually can be closed primarily if the flap width does not
exceed 8-10 cm. Because the latissimus dorsi muscle is not taken with the flap, seroma
formation and other donor-site morbidity are minimal.

V.

EXTENDED TRANSVERSE RECTUS ABDOMINIS


MYOCUTANEOUSFLAP

In thin patients with a large chest wall defect, an extended free transverse rectus
abdominis myocutaneous (TRAM) flap may provide additional skin for coverage.
Because of the excellent blood supply in a free TRAM flap vascularized by the deep
inferior epigastric system, the flap design can be extended far laterally without
increasing the risk of partial flap necrosis (9).
A.

Surgical Technique

The standard design of a conventional TRAM flap is marked on the lower abdomen.
With the patient in a supine position. the flaps are extended laterally as far as possible
to the operating table on the planned pedicle side (i.e., zone III) (Fig. 6). The flap is
then raised similarly to any other TRAM flap.

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Figure 6
B.

Design of the extended free TRAM flap. A: anterior view. B: lateral view.

Outcome

Kroll (9) reported six cases in which the extended free TRAM flap was used for breast
reconstruction. All six patients were unusually thin, which limited the availability of
abdominal tissue. However, all of the flaps survived without skin or fat necrosis. In
patients with moderate amount of abdominal fat, such an extended free TRAM flap
can provide adequate breast mound in addition to ample chest wall coverage (Fig. 7).

Figure 7 Chest wall reconstruction with the extended free TRAM flap. A. A patient with
advanced-stage breast cancer after irradiation. B. The extended free TRAM flap provided
adequate breast mound as well as ample chest wall coverage.
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260

VI.

Yu and Robb

EXTENDED EXTERNAL OBLIQUE MUSCULOCUTANEOUS FLAP

A conventional external oblique musculocutaneous flap may reach midlower chest


wall defects. By detaching the insertions of the external oblique muscle, the extended
flap may reach up to the second rib. The blood supply for this flap, like that for the
conventional flap described elsewhere in this book, is based on the 7th to 12th
intercostal perforators.
A.

Surgical Technique

The medial margin of the extended external oblique musculocutaneous flap is marked
at the anterior midline. At the level of the umbilicus, the marking proceeds inferiorly
and laterally toward the midinguinal ligament. It then turns superiorly and laterally
toward the anterior superior iliac spine to create a V shape (Fig. 8). The posterior
margin of the flap extends to the posterior axillary line, where the intercostal
perforators enter the muscle. Elevation of the flap starts at the anterior midbne and
subfascial dissection proceeds laterally under the anterior rectus sheath and between
the external and internal oblique muscles. Below the umbilicus in the V-shaped area,
however, dissection is carried out subcutaneously to preserve the integrity of the lower
abdominal wall. The costal and iliac insertions of the muscle are then'detached to
facilitate upward rotation of the flap. After flap elevation, the medial edge of the
internal oblique fascia is advanced over the rectus abdominis muscle and sutured to the
linea alba to reinforce the abdominal wall. The V-shaped area of the donor defect is
then closed primarily in a V-to-Y fashion. A split-thickness skin graft to the abdominal
donor site may be necessary in some cases.

II'

I
I

I
I

1
I
I

,"
I

"

/
/
/

'V

Figure 8 Outline of the extended external oblique flap (A). The flap is elevated at the
subcutaneous level in the V area and at the subfascial plane above it (B).

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Extended Flaps

B.

261

Outcome

In a series of 13 patients who underwent large chest wall reconstruction using the
extended external oblique musculocutaneous flap, a 2 cm marginal necrosis occurred
in one flap (10). All of the other flaps survived in their entirety. Follow-up to 5 years
demonstrated no donor-site complications.

REFERENCES
I.
2.
3.
4.

5.
6.
7.
8.
9.
10.

Germann G, Bickert B, Sternau HU, Wagner H, Sauerbier M. Versatility and reliability


of combined flaps of the subscapular system. Plast Reconstr Surg 1999; 103:1386-1399.
Hallock GG. Permutations of combined free flaps using the subscapular system. J
Reconstr Microsurg 1997; 13:47-54.
Hokin lA. Mastectomy reconstruction without a prosthetic implant. Plast Reconstr Surg
1983; 72:810-818.
Kim PS, Gottlieb JR, Harris GD, Nagle DJ, Lewis VL. The dorsal thoracic fascia:
anatomic significance with clinical applications in reconstructive microsurgery. Plast
Reconstr Surg 1987; 79:72-80.
Germann G, Steinau H. Breast reconstruction with the extended latissimus dorsi flap.
Plast Reconstr Surg 1996; 97:519-526.
Micali E, Carramaschi FR. Extended V-Y latissimus dorsi musculocutaneous flap for
anterior chest wall reconstruction. Plast Reconstr Surg 2001; 107: 1382-1392.
Rowsell AR, Eisenberg N, Davies DM, Taylor GI. The anatomy of the thoracodorsal
artery within the latissimus dorsi musc.le. Br J Plast Surg 1986; 39:206-209.
Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutaneous flap without
musde. Plast Reconstr Surg 1995; 96: 1608-1614.
Kroll SS. Bilateral breast reconstruction in very thin patients with extended free TRAM
flaps. Br J Plast Surg 1998; 51:535-537.
Moschella F, Cordova A. A new extended external oblique musculocutaneous flap for
rec.onstruction of large chest waH defects. Plast Reconstr Surg 1999; 103: 1378-1385.

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19
External Oblique Myocutaneous Flap
WILLIAM A. ZAMSONI, LEE M. REESE, and ALLISON K. REESE

University of Nevada School of Medicine. Las Vegas, Nevada, US.A.

I.

PRESENTING CONDITIONS

Chest wall defects most commonly are the result of primary or recurrent neoplasms,
radiation injury, and infections. In an effort to obtain wide clear margins at the time
of surgical excision of malignancy, primary closure is often not possible. In addition,
wide margins may include resection of extensive soft tissue and/or skeletal structures,
thus limiting the use of primary skin grafting. Radiation injury and infections
produce various degrees of tissue loss depending on their severity, and can be as
extensive as tumor resections. These often occur in the same patient simultaneously,
significantly complicating surgical reconstruction. A thorough knowledge of reconstructive options including the external oblique flap is needed to approach the chest
wall defect adequately.
II.

HISTORY AND INDICATIONS

Commonly employed surgical options for chest wall defects include pectoralis,
latissimus dorsi, and rectus flaps. Omental flaps with split-thickness skin grafts (STSG)
have also been employed in some cases. Often overlooked, but a well-documented flap,
is the external oblique myofasciocutaneous flap (EOMF). The pectoralis flap is useful
for medial defects with sternal involvement, but in many breast cancers that require
complex reconstruction, the pectoralis muscle is involved with tumor or has been
exposed to significant radiation. The latissimus dorsi flap, with or without skin,
although a hardy and well-proven flap, requires patient repositioning and is limited in
defects very superiorly or inferior medially located. The rectus flap has been used
reliably with both vertical or transverse skin paddles but may be limited in chest wall
reconstruction following coronary artery bypass complicated by sternal infections. An

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264

omental flap with STSG can provide coverage for many soft tissue defects but requires a laparotomy and should probably be used as a backup closure technique. The
EOM F is easy to harvest, does not require patient repositioning, and results in nearly
no physiological compromise due to loss of the anatomical position of the muscle.
Several reports on the use of the EOMF are available in the literature. In J 953
Lesnick and Davids reported using this flap for closure of a large lower abdominal wall
defect (J). In 1964 Hershey and Butcher used the flap for upper abdominal wall and
lower chest wall defects (2). Hodgkinson and Arnold in 1980 used the EOMF for
closure of a large chest wall defect (3). From that time to the present the EOMF has
been used for conditions ranging from primary breast reconstruction to complex
closure of full-thickness chest wall defects (4-6).

III.

ANATOMY

The external oblique is the largest of the flat muscles of the abdominal wall. It originates posteriorly from the 6th to 12th ribs and interdigitates with the latissimus dorsi
and the serratus muscles. The inferior fibers insert onto the iliac crest and the superior
fibers form the external oblique aponeurosis. The borders of the external oblique are
marked superiorly by the inferiormost aspect of the costal margin and inferiorly by
the iliac crest. The lateral border is marked by the midaxillary line and the medial
aspect, with the fasciocutaneous extension of the rectus, is the linea alba (Fig. I).

A.

Figure 1 Anatomical borders of the EOMF. A. Inferior costal margin. B. Iliac crest. C.
Linea alba. D. MidaxilJary line. E. Inguinal ligaJlJe\).t
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External Oblique Myocutaneous Flap

Figure 2

265

Blood supply to the EOMF. A. Intercostal arteries. B. Deep circumflex iliac artery.

The blood supply to the cranial aspect of the muscle is segmental and arises from
intercostal arteries. Two branches can be identified, one running on the anterior
surface of the digitations of the muscle and another along the posterior surface. Not all
digitations contain both branches. The upper digitations more often have vessels
running posteriorly, whereas the lower digitations have anterior surface branches.
The blood supply to the caudal aspect of the muscle comes from a main nutrient
artery. Most commonly the main artery is a branch of the deep circumflex iliac, but
occasionally it can arise from the iliolumbar artery (7) (Fig. 2).
Innervation of the EOMF is purely segmental in both the cranial and caudal
regions. The innervation arises from the lateral cutaneous branches of the spinal
nerves. The nerves run subfascially together with the intercostal arteries. The motor
branch is more proximal than the sensory branch, which approaches the rectus before
small nerve endings pierce the subcutaneous tissue (7).
IV.

OPERATIVE TECHNIQUE

Proper planning is essential for any flap used in chest wall reconstruction and the
EOMF is no exception. The EOMF can be used as a rotational flap, a subcutaneous
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tunneled flap, or even as a free flap. If used as a free flap, usually only the inferior aspect
is used, reflecting its dominant vessel blood supply. When rotating the flap superiorly
for a chest wall defect, the limits of coverage are generally thought to be the third or
fourth ipsilateral rib superiorly and 4-5 em beyond the midline at the level of the
xyphoid. Raising the flap is relatively straightforward and begins either at the midline
or at the lateral aspect of the rectus muscle. It is often helpful to include a portion of the
anterior rectus fascia to provide a more sturdy tissue for suturing. The flap is raised to
the level where the intercostal branches enter, usually at the midaxiallary line (Fig. 3).
Because the blood vessels interdigitate throughout the flap, viability of the flap is not
compromised if only one or two are inadvertently divided while raising the flap. The
muscle is freed from the iliac crest and the inferior-posterior free border of the muscle
can be partially divided to facilitate further rotation. Care should be taken when
dividing the inferior-posterior free border because this can compromise blood supply
to the flap. The abdominal wall defect is then strengthened using nonabsorbable
plication sutures at the medial aspect of the internal oblique and brought to the
midline, creating a secure fascia over the rectus muscle. If there are concerns about
abdominal weakness, a piece of mesh may be placed at the donor site to reinforce the

Figure 3

Raising the flap. A. Rectus abdominis. B. External oblique. C. Internal oblique.


D Transversus abdominis. E. Anterior rectus sheath.

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External Oblique Myocutaneous Flap

267

A..

B.

Figure 4

Arc of elevation of EOMF. A. Chest wall defect. B. Split-thickness skin graft.

abdominal wall, although this is rarely thought to be necessary in most reports. The
donor site defect is closed primarily or by skin graft (Fig. 4).

v.

SUMMARY

The external oblique myofasciocutaneous flap is often overlooked for closure of


chest wall defects but is a safe and reliable option for reconstruction. It is a large
sensate flap with a dependable blood supply. It is an easy flap to raise and does not
require patient repositioning. The flap is usually shielded from the area of radiation,
unlike the latissimus dorsi or pectoralis flaps. It results in little if any physiological
compromise because the rectus muscle remains intact, and hernias are extremely rare
at the donor site. No other potential flap territories are violated using this flap. Its
major disadvantage is the large scar at the donor site, and the limited ability to rotate
the flap above the third intercostal space, which may be prohibitive in some patients.
The EOMF should be considered as a useful reconstructive option for defects of the
chest wall.
ACKNOWLEDGMENT

Illustrations were prepared by Allison K. Reese, MA.


REFERENCES
I.

2.
3.

Lesnick G, Davids A. Repair of surgical abdominal wall defects with a pedicle musculofascial flap. Ann Surg 1953; 137:569.
Hershey F, Butcher H. Repair of defects after partial resection of the abdominal wall. Am
J Surg 1964; 107:586.
Hodgkinson D, Arnold P. Chest-wall reconstruction using the external oblique muscle. Br
J Plast Surg 1980; 33:216.

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268

4.
5.
6.

7.

Zamboni et al.

Marshall D, Anstee E, Stapleton M. Sort tissue reconstruction of the breast using an


external oblique myocutaneous abdominal flap. Br J Plast Surg 1982; 35:443.
Meland N, Ivy E, Woods J. Coverage of chest wall and pelvic defects with the external
oblique musculofasciocutaneous flap. Ann Plast Surg 1988; 21(4):297.
Bogossian N, Chaglassian T, Rosenberg P, Moore M. External oblique myocutaneous
flap coverage of large chest-wall defects following resection of breast tumors. Plast Reconstr Surg 1996; 97(1):97.
SchlellZ L Burggasser G, Kuzbari R, Eichberger H, Gruber H, Holle J. External oblique
abdominal muscle: a new look on its blood supply and innervation. Anat Rec 1999;
255:388

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20
Free Flaps for Chest Wall
Reconstruction
VIVIAN TING

University of California. San Francisco, California. U.S.A.


JULIAN J. PRIBAZ

Harvard Medical School, BaSIon, Massachusells, U.S.A.

I.

INTRODUCTION

The first known chest wall resection was performed in 1778 by Aimar, which involved
an osteosarcoma of the ribs (1). Parham in 1899 reported the first resection of a chest
wall tumor in the United States. He excised three ribs with the tumor and narrowly
avoided pneumothorax by rapid closure of the soft tissue defect (I). Later operations
described filling of pleural defects with gauze and wet towels so that the patients could
survive until a later closure could be designed (2). Mortality at the beginning of the 20th
century was reported at 20% due to sepsis and pleural injury (3,4). The availability of
endotracheal ventilation, closed chest drainage, and antibiotics decreased the risk of
these resections (5), leading to the first successful pneumonectomy by Graham and
Singer and further classification of chest wal1 tumors (6). The management of chest
.wall trauma in World War II resulted in the creation of algorithms for handling chest
wal1 injuries. Modern surgical techniques of managing chest wal1 tumors were not
developed until the 1960s. With the evolution of new methods of reconstruction,
acceptable morbidity and mortality rates were final1y achieved (5). Early reconstructions employed random-pattern flaps that were prone to necrosis, resulting in
complications that were not wel1 tolerated. Flap techniques developed over the years
have made closure of chest wal1 defects easier and more reliable. Axial pattern muscle,
myocutaneous, and fasciocutaneous pedicled flaps have a reliable intrinsic blood
supply that permit immediate reconstruction. These have become the mainstays of
routine reconstruction of chest wall defects following extirpation and radiation. With

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the advent of microsurgery, it has become possible to do single-stage reconstruction of


defects with greater magnitude and complexity than ever before. Given the wide array
of local options for chest coverage, indications for microsurgical chest wall reconstruction should be limited to specific conditions, as outlined in this chapter.

II.

HISTORY

Chest wall reconstruction after extirpative surgery dates to as early as 1919, when
Campbell and Pennefather discussed the reconstruction of the anterior chest wall (7).
The 1940s saw further innovation in chest wall reconstruction: Watson and James
implemented the use of fascia lata grafts for chest wall closure (8); Bisgard and
Swenson used horizontal rib grafts for replacement of sternal support (9); and Maier
described large cutaneous flaps including contralateral breast flaps for closure of
defects of the anterior thorax due to breast carcinoma and radiotherapy (10).
In 1950, Campbell described the first use of a muscle flap for thoracic reconstruction, involving transposition of the latissimus dorsi muscle covered immediately by a
split-thickness skin graft for repair of a full-thickness defect of the anterior chest (11).
Unfortunately, interest in the anatomy and refinement of muscle transposition did not
arise until nearly 20 years later. Other reconstructions of extensive defects by Converse
(12), Blades and Paul (13), and Myre and Kirklin (14) were also reported at this time.
The 1960s saw the further developmen t of chest reconstruction involving
multistage procedures. Kiricuta in 1963 described the first transposition of the greater
omentum for reconstruction of thoracic defects following cancer resections (15).
Greater understanding of the anatomy of the muscle and musculocutaneous flaps of
the latissimus dorsi, pectoralis major, serratus anterior, rectus abdominis, and external
oblique muscles over the next two decades permitted reconstruction of formidable
defects with single-stage procedures (6,16-18). At the same time, greater understanding of functional anatomy and blood supply has resulted in more aggressive
resections of chest wall tumors and surgical treatment following radiation damage (6).
With the birth of microsurgery, early reports of free tissue transfer for chest wall
reconstruction using the latissimus and tensor fascia lata muscles heralded greater
sophistication and ease of coverage for extensive chest wall defects (19-21). With the
overall success rate of free tissue transfer now more than 95%, the growing skill of
microsurgeons in free tissue transfer has yielded results that can be more reliable and
superior compared with unsafe locoregional options. In certain situations. it may be
more advantageous to provide well-vascularized healthy muscle from a distant site
than to sacrifice marginal viable muscle or skin immediately adjacent to the defect.
Local muscles help to retain their anatomical function and boundaries in a wound
where there is already a deficiency of functional musculature. It can be argued that
local flaps should be preserved as a secondary option to solve late complications due to
atrophy of free muscle flaps (22).

III.

PATHOPHYSIOLOGY

A.

Tumors

The majority of defects requiring reconstruction result from oncological resection.


Chest waJl tumors represent 5% of all thoracic cancers and 7% of primary bone

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lesions. Half of these tumors are malignant, and of these half originate in cartilaginous
tissue. Malignant lesions are primarily metastatic in origin, arising from lung and
breast primaries or lymphomas that invade the chest wall, or metastases from distant
organs such as the thyroid, kidney, testis, stomach, and colon. Sarcomas form the
majority of primary malignant chest wall tumors (23). Wide local en bloc excision is
the treatment of choice in most instances for potentially curative resections and the
extent of local and systemic control determines prognosis. In the past, incisions were
placed to avoid the tumor, but it is now clear that the incision can be centered over the
tumor if the skin is not involved, preserving vascularity of cutaneous flaps that may be
used in closure. Resection of adherent skin and subcutaneous tissues as well as biopsy
needle tracts and old biopsy scars is necessary. Incisional biopsies should be placed in
orientations that will not interfere with subsequent resection or reconstruction (23,
24). With resection of very large tumor beds, few local reconstructive options may
remain, making free tissue transfer necessary. A subset of these pa tien ts includes
individuals who have undergone forequarter amputation for tumors of the shoulder
girdle region. Some of these patients have extensive invasion of the chest wall and
involvement of branches of the axillary or subclavian vessels, which eliminates most
local pedicle flap options (25).
B.

Radiation Therapy

A second group of patients with challenging thoracic wounds include patients who
have sustained extensive soft tissue damage or osteoradionecrosis due to radiation
therapy for malignancy. Radiation therapy is used as definitive or adjunctive therapy
in over half of all patients with cancer. The extent of injury is dependent on the energy
level used, the number of fractions, the total dose, and the time interval between
irradiation and surgery. Ionizing radiation disrupts proteins and nucleic acids, and
generates free radicals, resulting in cellular death. Variation in cell proliferation rates
and oxygenation between normal cells and tumor cells permits greater targeting of
malignant cells.
Nom1al tissues are invariably damaged to some extent. Early radiation injuries
demonstrate hemorrhage and edema of subcutaneous tissue, small vessel occlusion,
and stasis. Late injuries occur after 3 months and are associated with thrombosis of
small vessels, periadventitial fibrosis, endothelial proliferation, and subintimal fibrosis.
Other effects include mitochondrial destruction, inhibition of wound contraction,
impaired leukcocyte function, and long-lasting effects on fibroblast and myofibroblast
function (26). Late complications include osteoradionecrosis and radiation-induced
sarcomas (27). Osteoradionecrosis can occur in bone exposed to ionizing radiation.
Obliterative endarteritis and hypocellularity with accumulation of soluble collagen are
seen (26).
Radiation-induced wounds of the chest wall can include large lesions that require
resection and may become potentially life-threatening. These defects can be formidable due to their size, hostile bed, and extensive loss of local pedicle options. The latter
may be due to the direct radiation damage of potential flap tissue or from radiation
fibrosis of vascular pedicles that might otherwise supply a more distant flap. In a
review of 100 consecutive cases of muscle flap transposition for irradiated wounds
performed at the Mayo Clinic, 72% of wounds involved chest wall or intrathoracic
reconstruction. The overall complication rate for muscle transposition in an irradiated

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field was 25%, compared with a complication rate of 11.6% of muscle transpositions
performed by the same surgeon in the same period of time in patients who did not
receive radiation therapy. Average hospital stays were also longer for those who
received irradiated flaps; 28 days compared with 20 days for those receiving nonirradiated flaps (28). Free tissue transfer may be required as an adjunct to pedicled
flaps for coverage of extensive defects, to provide additional blood supply in an otherwise inhospitable radiation bed, or to provide additional blood supply to marginally
perfused pedicle flaps that require so-called supercharging through microvascular
anastomoses to more reliable sources of inflow.

C.

Infection/Empyema

Another group of patients with chest defects that may benefit from free tissue
transfer includes patients with sternal osteomyelitis who have undergone median
sternotomy and extensive sternal resection. The incidence of mediastinal infection
following median sternotomy ranges from 0.39 to 8.4% (29). Lee in 1976 reported
the first use of transposed omentum following sternectomy for treatment of sternal
osteomyelitis. This represented the first use of vascularized tissue for sternal
reconstruction (30). Brown and associates transposed the pectoralis muscle for coverage of a midline chest wall defect following tumor resection (31). This led to the
development of the pectoralis turnover flap for sternal coverage (32), which paved
the way for the use of other muscle and musculocutaneous flaps such as the rectus
abdominis and latissimus dorsi. While the majority of these cases can be managed
with pedicled flaps, an extensive debridement involving total sternectomy and loss of
surrounding musculature including the pectoralis major and rectus might occasionally warrant use of a free flap, particularly in situations limited by previous
laparotomies or resections (33).
Complex defects of the thoracic cavity following empyema forma tion; fistulas of
the airway, esophagus, heart, and great vessels; and intrathoracic radiation require
challenging reconstructions. Intrathoracic muscle transposition was first described in
1911 by Abrashanoff to close a bronchopleural fistula (34). This was followed in 1915
by the first use of the latissimus dorsi muscle to obliterate an empyema cavity (35) and
the experimental demonstration of the ability of muscle flaps to seal bronchial leaks in
1929 (36). Local flap transposition is commonly employed to fill cavity dead space,
including pectoralis major, trapezius, and serratus anterior for apical-anterior sites,
latissimus for lateral and posterior sites, and rectus abdominis for basilar sites.
Options may be limited due to transection of muscles and pedic1es during previous
thoracotomies or resections. Free flaps may provide addi tional bulk, seal fistulas that
local flaps may not have access to, serve as coverage for exposed prosthetic devices,
and reinforce suture lines or vessels damaged by infection and radiation necrosis to
prevent massive hemorrhage (37-40).

D.

Congenital

Congenital anomalies involving chest musculature and skeletal components make up


the final group. Poland's syndrome, or pectoral aplasia-dysdactyly syndrome, was
first described by Alfred Poland, an anatomical prosector at Guy's Hospital almost
J50 years ago (41). It represents a constellation of unilateral hypoplastic deformities
involving the thorax and upper extremity that always includes partial or total absence

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Free Flaps

of the pectoralis major muscle. Associated conditions include brachysyndactyly,


breast aplasia or hypoplasia, absence of the latissimus dorsi muscle, and anomalies
of the axilla and skin. Skeletal anomalies range from deformities of the costochondral
cartilages, sternum, scapula, and vertebral column, to ipsilateral absence of ribs 2-4, to
a full-blown complex with segmental absence of all parietal components of the chest
wall except the skin and pleurofascial membrane (42). Standard methods of reconstruction include anterior transposition of the latissimus dorsi muscle with addition of
a mammary prosthesis as needed, the transverse rectus abdominis myocutaneous
(TRAM) flap, or use of custom-made silicone prostheses. Problems associated with
these techniques include inadequate tissue for reconstruction as well as implant or
prosthetic encapsulation or migration. Free tissue transfer may in some instances be
necessary for optimal reconstruction when local choices are inadequate or unavailable
(43). Another congenital condition that may warrant free tissue transfer involves
vascular malformations of the upper extremity. Resection of these entities is usually
extensive and may require limb amputation (44). Elements of the amputated part can
be salvaged for use in reconstruction (Fig. 1).

IV.

INDICATIONS FOR FREE FLAP RECONSTRUCTION

A.

Patient Evaluation

The majority of patients with chest wall defects undergoing reconstruction have advanced local disease (e.g., sarcoma), metastatic or recurrent disease (e.g., breast
cancer) or radiation-induced injury following adjuvant therapy for local disease.
Many have respiratory compromise due to pre-existing chronic obstructive pulmonary disease, pulmonary resection, or radiation pneumonitis, and have little pulmonary reserve. The prognosis for long-term survival is poor in many instances, with
reconstructive procedures often more palliative than therapeutic. The overall debility
of these patients from malignancy and the effects of adjuvant radiation and chemotherapy generate a higher risk of postoperative complications. The stability and
reliability of a local reconstruction are of paramount importance in these patients,
who have little tolerance for complications or lengthy hospitalizations. Wound
separations and flap edge necrosis that would be considered minor in other patients
can be the source of major systemic complications due to prosthetic mesh infection
and pulmonary compromise, with ultimately fatal outcomes in these patients (45).
B.

Local Flap Options

Many local flap options have been described. Early methods utilized random-pattern
skin and fasciocutaneous flaps from the axillary, lateral abdominal, and thoracoacromial regions, with length to width ratios of up to 4:1 (46). Disadvantages include
the need for delay procedures preventing immediate reconstruction, and large donor
defects that require skin graft coverage. Axial pattern flaps such as the deltopectoral
flap described by Bakamjian in 1965 have also been widely used (47-49). Deltopectoral, parascapular, and scapular axial fasciocutaneous flaps can be used for defects
near the shoulder, axilla, and lateral thoracic wall (50).
Numerous muscle and musculocutaneous flaps of the thorax and abdomen
are the most commonly used today for chest reconstruction. Transverse, oblique,

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E
Figure 1

A. Twenty-six-year-old patient with extensive arteriovenous malformation


involving his left shoulder and chest wall with ischemic ulceration producing excruciating
pain. B. Magnetic resonance imaging scan shows extensive involvement of chest wall and
shoulder with arteriovenous malformation. C. Intraoperative view following radical excision
of arteriovenous malformation involving forequarter amputation. The axillary artery and vein
have been preserved and a fillet flap of the distal arm, elbow, and forearm has been dissected.
D. Radiograph of bony attachment of distal humerus into a stump of clavicle. E. Appearance
I month postoperatively shows satisfactory shoulder contour.

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and vertical rectus abdominis flaps are the workhorses for coverage of the lower
two-thirds of the anterior chest wall, extending up to the inferior border of the
axilla. The type III blood supply and additional intercostals and lumbar perfusion
allow for great versatility in flap design (51). The pectoralis muscle covers the
region of the sternum and upper chest, as either an advancement or turnover flap.
Its segmental morphology and vascular anatomy allow it to be used in split-muscle
transfers and v-y myoplasty advancements (52). The latissimus dorsi muscle, the
most commonly used and most dependable flap for chest wall reconstruction, is the
flap of choice for anterior and lateral defects of the upper and middle third
portions of the thorax. It is a type V muscle, with the thoracodorsal artery as its
major pedicle, and posterior and lateral intercostals as minor pedicles. Its extensive
collateralization with the serratus, muscle and the presence of the thoracodorsal
artery branch to the serratus, whjch permits retrograde flow, allows the latissimus
to be used even in patients who have undergone division of the thoracodorsal
artery during axillary dissection (23). Because it can be used as a segmentally split
flap or turnover flap based on intercostals and lumbar perfusion adds to its
versatility for posterior coverage (53). Serratus and trapezius muscle flaps are
occasionally useful for limited defects involving intrathoracic and hjgh lateral chest
sites. The trapezius, a type II muscle, has the transverse cervical artery as its
dominant blood supply. This artery bifurcates into superficial and deep branches
that supply the middle and lower segments. The deep branch arises from the
subclavian in 66% of patients and from the transverse cervical in 30%. Vascular
patency must be confirmed during flap elevation (23). The serratus is more useful
as an intrathoracic muscle flap. The external oblique muscle is limited in range but
can be used for defects of the lower anterior chest wall or upper abdomen. It can
be transposed up to the level of the inframammary fold, and can carry a skin paddle (5).
The omentum, a bipedicled layer of fused peritoneum, is a useful tool for
reconstructing defects. Pedicled on either the right or left gastroepiploic artery, it can
reach almost anywhere on the chest wall. Its substance and vascularity provide for
excellent coverage of prosthetic meshes, contaminated wounds, and osteoradionecrosis, and permits skin grafting over its surface. The ability to form dense vascular
adhesions allows it to vascularize bone grafts (54). Limitations include young age of
the patient, gender and nutritional status, and previous laparotomy, which may limit
its availability and usefulness (55). Location of the defect dictates the type of flap
available for use (Table I). The overall reliability and variety of pedicled flaps should
in general make regional options the first consideration for most chest wall reconstructions.

C.

Indications for Microsurgery

Indications for microvascular reconstruction of the thorax should be limited to a select


group of individuals:
Patients with cancer who have one or more of the following conditions that
prevent use of local reconstructive options:
Massive defect unamenable to local flap coverage, usually full-thickness
defects that involve sternum with loss of major pedicle vessels

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Table 1 Local Pedicle Flap Options By Regional Defect


Region
Sternum and medial
chest wall

Location

Flaps

Superior half

Pectoralis major
Rectus abdominis
Latissimus dorsi
Omentum
Pectoralis major
Rectus abdominis
Omentum
Latissimus dorsi
Pectoralis major
Serratus anterior
Rectus
Omentum
Latissimus dorsi
Rectus abdominis
Thoracoepigastric flaps
Omentum
Latissimus dorsi
Deltopectoral fasciocutaneous
Scapular fasciocutaneous
Parascapular fasciocutaneous
Serratus anterior
Pectoralis major
Trapezius
Latissimus
Latissimus dorsi/reverse latissimus dorsi
Thoracodorsal fasciocutaneous

Inferior half

Lateral chest wall

Superior half

Inferior half

Shoulder and axilla

Upper back
Mid to lower thoracic
spine

All flaps can be raised as muscle or myocutaneous flaps unless otherwise stated.
Source: Adapted from Ref. 50.

Deficiency of local flaps due to extent of soft tissue resection


Location beyond the realm of local flaps (e.g., upper back)
Lack of reliability of local flap options due to previous dissection with
pedicle trauma or scarring
Radiation injury with extensive radionecrosis, or radiation injury of local
pedicle flaps necessitating supercharging with microvascular techniques
Patients with extensive defects due to nonmalignant conditions (empyema,
sternal resection) and paucity of local options
Individuals with congenital deformities of the chest wall and deficiency of local
reconstructive options due to aplasia (Poland's syndrome, pectus deformities,
vascular malformations).

D.

Goals of Reconstruction

Given the poor long-tenn outcome of many of these patients, the magnitude of their
operations, and their greater propensity for infection or wound healing complications,

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the goals of reconstruction are clear. These patients require stable, reliable, immediate
coverage that will permit an adequate margin of resection to eradicate or control
disease. The reconstruction should ideally maintain pulmonary mechanics, although
the need for bony stabilization is variable. Restoration of thoracic contour and
shoulder girth would be ideal, to facilitate dressing and fitting of garments. Choice
of flaps that add the least morbidity to the patient's already limited lifespan should
always be considered (25).

v.

TECHNICAL CONSIDERATIONS

The extent and location of the defect are the primary determinants of the type of flap
reconstruction that will be necessary. Published free tissue transfers that have been
used for chest wall reconstruction to date are listed in Table 2. When appropriate, use
of the nondiseased portion of the resected specimen should be a consideration, as in
salvage of the distal limb in forequarter amputation.
An algorithm for approaching the reconstruction of oncological chest wall
defects has been proposed by Cordeiro et al. (Fig. 2) (45) The algorithm can be exTable 2

Flap
Rectus

Free Flaps Used for Chest Wall Reconstruction as Found in the Literature

Flap Type

Potential Flap
Dimensions:
Width by
Length (cm)

Muscle

Muscle 25 x 6

Musculocutaneous

Skin:
VRAM6x21
TRAM 8-14x21
Muscle: 25 x 35

Largest
Chest Wall
Defect for
free flap (cm)
30x36

abdominis

Artery
Inferior
epigastric

Vein
Inferior
epigastric
venae

References

22, 40. 43. 64.


80,81

comitanles

Latissimus
dorsi

Tensor fascia
lata

Muscle

lOx 18

Thoracodorsal

Venae
comitantes

Musculocutaneous
Musculocutaneous

Skin: 5-7x 10-15


Muscle: 5xl5

15x35

Ascending
branch of
lateral

Venae

20. 22, 40, 43,


64,80,81,85.
86, 87, 88, 89
21,96.97.98,99

comitanles

circumflex
femoral

Anterolateral
thigh

Forearm fiUeI

Fasciocutaneous

Fasciocutaneous

Skin
Standard: IOx20
Extended or
delayed: 15x40
Skin: 12x20
(larger with
expansion or as
extended Hap)
Skin: 45 x25

21 x38

Descending
branch of

Venae

lateral
circllmf~ex

30x25

femoral
Brachial

Venae

comitantes
Basilic
Cephalic
Musculocutaneous
Composite

81. 100. 101

comitantes

Muscle
Bone

Source: from Refs. 20-22, 25, 40. 43. 64, 80, 81. 85-89, 96-101,103-107.

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106, 107

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Full-Thickness Defects

Partial-Thickness Defects

Regional Flaps +/ STSG

intact
vessels

Resected ribs
Sternum

Mesh

1 + - - - - Methylmethacrylate

----~~I

Latissimus Dorsi
Pectoralis Major
Rectus Abdominis
Omentum

absent
vessels

forequarter
amputation

Rectus abd
Lal.Dorsi
Others

Figure 2

Algorithm for reconstruction of chest wall defects. (From Ref. 45.)

panded to include defects involving nonmalignant conditions, such as intrathoracic


wounds and congenital anomalies.

A.

Chest Wall Stability

The loss of rigid skeletal support over a large area can result in paradoxical chest
motion and respiratory compromise. Various methods of skeletal replacement have
been devised. Autologous materials such as lyophilized dura (2), fascia lata (11,57,
58), and rib grafts (2) have been used. Autologous reconstructions are well tolerated
but have the disadvantages of additional donor site morbidity and less durability,
as seen in the flaccidity of dura and fascia lata graft repairs. When bone grafts are
poorly revascularized, fibrous replacement of the graft can lead to delayed instability (2).
Alloplasts have also been used including metal struts and stainless steelmesb
(59,60), tantalum (60,61), Lucite (62), Teflon (63), lvalon (64), and fiberglass cloth
(65). These can be difficult to manipulate, fracture over time. and incite local reaction.
Current techniques involve the use ofpolytetraftuoroethylene (Gore-Tex), Prolene or
Marlex mesh either alone or in combination with methylmethacrylate. Various socalled Marlex sandwiches, composed of methyl methacrylate embedded between layers
of Marlex mesh with or without a core of stainless steel mesh. have been described
(66,67). These materials are readily available, durable, and easily tailored to fit any
defect. A rigid prosthesis should be designed smaller than the original defect, since a
large prosthesis will cause pain and stiffness due to its lack of flexibility (68).
Which chest wall defects require stabilization? Some authors base their decision
on the diameter of the skeletal defect, with the opinion that defects 5 cm or less do not
pose a respiratory deficit and cia not require rigid replacement (2). Others use the
number of ribs resected as a guideline. Defects involving significant rib resection, more

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than three for some authors (21), four for others (54), or those resulting in paradoxical
respiration reg uire some form of skeletal prosthesis. This concept has been challenged
by other reconstructions that have avoided skeletal repair. Small defects, especially
ones that lie beneath the scapula or along the costal margin, do not require stabilization. Posterior chest wall and sternal defects require less stabilization than anterolateral ones (68).
Even large defects may be managed with soft tissue coverage alone. Ramming et
al. described two patients 'with bony defects as large as 20 cm 2 or encompassing the
entire right chest and sternum that were managed with pedicled muscle flaps. Although
both patients had an obvious flail chest defect with paradoxical motion, neither
experienced pulmonary compromise (17). At the MD Anderson Cancer center, patients with large full-thickness chest wall defects were managed using rectus or
latissimus dorsi myocutaneous flap coverage alone without evidence of functional
respiratory embarrassment. These findings were confirmed by pulmonary function
testing, which revealed minimal change in forced expiratory volume and vital capacity
(Fig. 3) (18). A flap inset may be adequate for chest reconstruction because the bulk of
the muscle flap used and local fibrosis of the lung and chest wall in irradiated patients
may serve to stabilize chest dynamics. The need for a prosthetic replacement may be
detem1ined more appropriately by the individual's baseline pulmonary status and
degree of restrictive lung disease. Prosthetic ma terials should be a voided al together in
the face of an open contaminated wound, and serioLlsly reconsidered in coverage of
radiation ulcers (56).

B.

Vessel Selection

The primary donor vessels used in microvascular chest wall reconstruction include the
internal mammary vessels, subscapular system, and divisions of the subclavian artery
I/sec

I/sec

[4

..

'" 3

iG

.
.

'S
:>

~ 2
Q,

I/sec

1 1
rf'"

Pre-operative FEVI

I/sec

Pre -operative vilal capacity

Figure 3 Pre- and postoperative pulmonary function in representative chest-wall defects.


Forced expiratory volume in I second (FEY!) and vital capacity are widely recognized as good
indicators of the functional capability of a patient. Apparent improvement in postoperative
results may be related to variations in testing from chest wall restriction due to tumor,
radiation, or local pain. Results were obtained in patients who underwent chest wall
reconstructions with inset of only a pedicled musculocutaneous Aap and no further structural
support. (From Ref 18.)

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including the thoracoacromial pedicle and thyrocervical trunk. Higher reconstructions can be based on branches of the external carotid system. Which system to use is
based on location of the defect, prior surgical dissection in the vascular territory,
previous irradiation, and size match with the selected flap for transfer. Recipient arteries and vessels that have been used in free flap chest wall reconstruction are listed in
Table 3.
The internal mammary vessels were first described for free tissue transfer by
Shaw in his article on the free gluteal musculocutaneous flap for breast reconstruction.
He found that the internal mammary vein was very small at the level of the fifth rib
(69), and later reported that he was able to use it in 75% of cases, presumably at a
superior level (70). Anatomical cadaver studies have since demonstrated that the most
consistent vein diameter was found at the level of the third rib, with 40% greater than
or equal to 3 mm on the left and 70% greater than or equal to 3 mm on the right. At the
fourth rib, the veins become smaller, with 20% of veins less than I mm, and often
bifurcate (71). Advantages of the internal mammary system include ease of dissection and exposure for anterior chest reconstruction, and preserva tion of the thoracodorsal vessels as a possible alternative for adverse flap outcomes. Use of the internal
mammary system for free tissue breast reconstruction has been reported with flap
survival rates of 99-100% (72-74).
Use of the subscapular system in free tissue transfer arose in conjunction with the
development of the free TRAM flap and its longer pedicle. Vessel measurements taken
on 23 patients undergoing breast free flap reconstruction revealed a mean artery
diameter of 1.79 0.34 mm, which is significantly smaller than the internal mammary
artery (5 I patients, diameter 2.36 0.50 mm). Vein diameter (2.5 I 0.50 mm) was not
found to be significantly different from the internal mammary vein (2.6 0.58 mm)
(74). Difficulties that can be encountered in use of the subscapular system include
difficult dissection of the axillary vessels following radiation or previous axillary
dissection; small diameter of the thoracodorsal artery requiring anastomosis to the

Table 3

Recipient Vessels Used in Chest Wall Reconstruction

Region
Head/neck

Artery
Common carotid
External carotid
Superior thyroid

Thorax

Internal mammary
Subclavian
Thoracoacromial trunk
Transverse cervical
Thoracodorsal
Circumllex scapular
Intercostal

Arm
A bdoillen/peivis

Axillary
Gastroepiploic

Vein

Jn ternal jugular
External Jugular
Superior thyroid
Facial
Internal mammary
Subclavian
Thoracoacromial trunk
Transverse cervical
Thoracodorsal
Circumflex scapular
Intercostal
Innominate
Cephalic
Gastroepiploic

Source: from Refs 21. 22. 25,40.43.64.80.81,85-87,89,97-99. tOI. 103-105. 112.

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circumflex scapular artery located more proximal in the system; avulsion of the
anastomosis with shoulder motion; transient brachial plexus symptoms due to
restricted motion; and the technical challenges of performing an anastomosis in the
axilla. It provides a useful site of vascular access for defects of the anterola teral chest
and upper and lower back (73).
The thoracoacromial axis has been described by Reid and Taylor in detailed
cadaver studies (75). Average length of the thoracoacromial trunk was 15 mm (range
10-34 mm), with a mean diameter of 3.9 mm. The main trunk divides consistently into
the pectoral artery, which supplies the sternocostal portion of the pectoralis major,
and the deltoid artery, which supplies the clavicular head of the muscle. Mean diameters for the pectoral artery and vein were 1.91 mm and 3.32 mm respectively,
whereas the deltoid artery and vein averaged at 2.4 mm and 3.8 mm respectively (75).
This can be a useful system for defects of the anterior chest. Other useful recipient
vessels for the anterior chest include the external carotid and superior thyroid artery in
the neck. For defects of the upper back, vascular access can be obtained by use of the
thyrocervical trunk, which is another branch of the subclavian artery (50). lfthe extent
of the resection includes abdominal wall or diaphragm, a useful recipient pedicle to
consider is the right or left gastroepiploic artery and vein, which can be brought out
through a subcutaneous tunnel for extra-abdominal anastomosis (76).
Several options exist when venous sites are unavailable. Both the internal and
external jugular veins have been used for free tissue transfer in the chest. Some
evidence suggests that there may be a higher incidence of anastomotic thrombosis
when the external jugular vein is used than with the internal. This may be due to
smaller caliber, lower flow rates, and valvular anatomy (77). The cephalic vein, which
lies in the deltopectoral groove, is the radial continuation of the dorsal venous arch of
the hand. At its termination with the axillary vein, the cephalic diameter is 5.4 mm.
Unlike lower-extremity veins, it is thin-walled and a better match for most flap vessels
(78). A long cephalic vein pedicle can be harvested to reach the contralateral neck and
trunk. It can be used for direct venous anastomosis, or sewn to a major artery to create
a venous interposition loop that is later divided and anatomosed to the flap artery and
vein. Advantages include the high-flow, low-pressure cephalic-subclavian system, its
consistency in anatomy, and its location outside the surgical ablative field (79). The
interposition arteriovenous loop graft is particularly useful in areas deficient in
recipient vessels, and allows the microvascular anastomosis to be performed well
outside of the zone of injury or irradiation. For instance, in the lumbar and lumbosacral regions where there is a paucity of adequate local vessels, vein grafts can be
utilized to join flaps to distant recipient vessels. The saphenous vein can be harvested
from the thigh and anastomosed to the femoral artery as an arteriovenous fistula. This
is then subsequently divided and anastomosed to the flap (50).
C.

Flap Selection

1.

Supercharged Flaps: Enhancing the Vascularity of Regional Flaps

Trauma or irradiation to the blood supply of a pedicled flap does not contraindicate its
use. The TRAM flaps can be used even after the internal mammary artery has been
irradiated. In a review of 150 chest wall reconstructions utilizing a superior pedicle
vertical rectus abdominis myocutaneous flap performed over a 10-year period at
Memorial Sloan Kettering Cancer Center, five flaps appeared to have insufficient

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Figure 4 A. A-sixty-year-old patient with a past history of mastectomy for breast


carcinoma and postoperative irradiation. She subsequently had a peripheral nerve sheath
sarcoma that had been widely resected and the area covered with a free radial forearm flap.
She now presented with a recurrence involving the left neck, strap muscles, left clavicle, and
upper chest wall. B. Intraoperative appearance following a radical resection of recurrent
sarcoma with defect measuring 35 x 16 em. Brachytherapy catheters have been inserted. C.
Double-pedicled rectus abdominis myocutaneous flap before dissection. D. Flap dissected and
attached only by inferior epigastric pedicles bilaterally. E. fmmediate postoperative appearance following anastomosis of both vascular pedicles to the neck vessels. F. Postoperative
appearance 1 month later.

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pedicle flow, Of these patients, 80% had undergone prior radiation therapy to the
anterior chest wall with potential injury to local pedicles, All of these flaps were
salvaged completely by augmenting both the arterial supply and venous drainage by
supercharging the flap, This involved microsurgical anastomoses of both inferior
epigastric artery and vein to thoracodorsal, axillary, subclavian, or neck vessels (45),
2.

Commonly Used Free Flaps

Rectus, Use of the free rectus muscle and myocutaneous flaps has been well
described, particularly for breast reconstruction. Due to its reliability and bulk, it
provides stable coverage of the chest wall. It has been utilized as a free or supercharged
flap (45,80; Fig, 4), as primary stabiliza tion for the chest wall and simultaneous breast
contour reconstruction following full-thickness resection for recurrent breast
carcinoma (22,64), as a replacement for large sternal defects that lack local pedicled
options (81), and as a filler of large intrathoracic defects (39,40,80), It has the
additional advantage of being able to carry a viable skin paddle, providing superior
cosmesis and stable flap coverage, In most patients, a TRAM flap skin island design
provides the greatest surface area, An important consideration is that anterior chest
wall defects may enlarge when the abdominal donor site is closed, Smaller defects may
be better handled with vertical skin islands (64),
Latissimus, The latissimus muscle or myocutaneousflap is the standard flap for
pedicled chest reconstruction, and its anatomy has been well described (11,82,83),
First reported as a free flap for scalp reconstruction (84), its versatility and broad
coverage as a free flap make it useful for coverage of contralateral large chest
wall defects in which the ipsilateral latissimus is unavailable due to prior resection,
devascularization or radiation (22,80,85,86), radiation ulcers (64,86-88) intrathoracic
defects (22,40), sternal necrosis with complete resection of the sternum (89), and
congenital chest wall defects (43). It can be harvested in combination with the serratus
anterior based on the subscapular-thoracodorsal artery complex, including the
underlying ribs, for defects requiring extensive coverage (90, 91; Fig, 5), In planning
a myocutaneous flap, the longest axis.of the latissimus extends from the axilla to the
spinous process of the fifth lumbar vertebra, This will permit a skin island that will
reach the contralateral axilla (85). In most instances, however, the extent of the
cutaneous defect would require a skin island too large to permit primary closure of
the donor site, and a latissimus muscle flap with skin graft coverage instead provides
the most rational option (87).
Scapulat"/Parascapu/ar. Fasciocutaneous flaps may also be potentially useful in chest
wall reconstruction. The circumflex scapular artery of the subscapular system gives
rise to the parascapular artery and the scapular artery. Parascapular and scapular flaps
can be based on these respective vessels, either separately or together as a large
combined flap with inverted Lor T configurations (92,93). Advantages include a long
and constant pedicle, and relative ease of dissection, The scapular flap can also be
extended across the posterior midline to provide greater length; up to 39 cm (94),
Parascapular and scapular flaps can potentially be combined with harvest of the
latissimus dorsi muscle as a monobloc flap based on the subscapular axis to provide
greater versatility, With the components separated but connected by vascular supply,
this could be used for extensive combination defects requiring intrathoracic muscle fill
defects and overlying chest wall reconstruction. Limitations include the ability to close

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J
Figure 5 A. Twenty-eight-year-old patient with radiation necrosis of the left chest wall and
recurrent carcinoma of the breast. B. Intraoperative appearance following radical chest wall
resection. The heart and left lung are in view. C. Lower half of wound repaired with an
ipsilateral pedicled latissimus dorsi muscle flap. D. Plan for contralateral free latissimus dorsi
myocutaneous flap. E. Harvested free latissimus dorsi myocutaneous plus serratus anterior
muscle flap prior to transfer. F. Postoperative view 3 months after flap transfer and skin
grafting of exposed muscle. G. The same patient 2 years later after a right mastectomy with
further painful chest wall recurrences and ulceration. H. Intraoperative appearance following
right chest wall resection. r. Pedicled omental flap raised prior to transfer to right chest. J.
Appearance 4 weeks postoperatively with healed skin graft over omental flap.

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the skin donor site, since defects greater than 12 cm are difficult to close, and skin
grafting of the back donor si te is less than optimal (92).

Tensor Fascia Lata and Antero!atem/ Thigh. The free tensor fascia lata (TFL)
myocutaneous flap has been well described by Nahai and colleagues (95, 96). Based
on the tensor fascia lata muscle supplied by the transverse branch of the lateral
femoral circumflex artery, it represents one of the earliest free flaps used in chest wall
reconstruction. Advantages include ease of positioning and harvest, which can be
performed simultaneously with the extirpative procedure; pristine flap tissue outside
of the thorax uninjured by prior surgery or irradiation; harvest that will not have an
impact on existing thoracic stability; a long pedicle (over 6 cm) that can be traced to
the profundus femoris if needed; the potential for its use as a sensate flap by means of
the lateral cutaneous nerve of the thigh; and its combination of semirigid fascial layer
and large skin paddle (15 x 20 cm) that is useful for chest repair (97). Boyd et al.
reported a series of three patien ts with extensive radiation necrosis defects ranging in
size from 8 x 10 cm to 15 x 20 cm, including loss of three to four ribs. Free TFL
myocutaneous flaps anastomosed to the transverse cervical vessels or thoracoabdominal artery and cephalic vein survived in all three patients with excellent primary
healing. A marked degree of stability was achieved because the flap was extended to
incorporate a length of vascularized fascia lata with overlying skin. This distal paddle
was de-epithelialized and turned under the flap to lie against the pleural defect.
Suturing of the fascia lata to the periosteum of the bony perimeter completed
stabilization of the skeletal defect (21).
Other authors (97-99) report similar outcomes in a total of 14 chest reconstructions, using free TFL flaps with dimensions up to 30 x 11 cm to repair complex defects
involving the chest and abdominal walL often including partial resection of the
diaphragm. Recipient vessels used in these reconstructions included the internal
mammary vessels, superior thyroid artery and external jugular vein, intercostal
vessels, tboracoacromial vessels, gastroepiploic artery and vein, and inferior epigastric
artery and vein using an arteriovenous vein graft loop as conduit. Complications
included one case of flap loss due to venous obstruction at 5 days involving a
thoracoacromial anastomosis, and one postoperative case of venous congestion in
an internal mammary anastomosis salvaged by use of a saphenous vein graft to the
jugular vein (97,99). In a series of seven patients with recurrent cancer in chest wall
defects previously treated with pedicled TRAM, vertical rectus abdominis myocutaneous (VRAM), and latissimus flaps, the free TFL was successfully used as a salvage
flap in all cases. Operating time with two teams averaged 5.5 h. Donor defects were
closed primarily or with skin grafts. Average hospital stay was 21 days (97).
Based on similar vascular anatomy, the free anterolateral thigh flap has also been
developed for microvascular tissue transfer. It is based on the descending branch of the
lateral femoral circumflex artery (length 8 cm; diameter ~ 2111111), branches of which
supply the rectus femoris, vastus lateralis and tensor fasciae latae muscles and the
overlying skin. When accessory cutaneous branches between the 111uscle g;oupS are
preserved, harvest ofa large cutaneous territory is possible (100). This has been used
for an extensive chest wall defect involving the entire sternum, costal cartilages, and
ribs with exposure ofpericarclium and pleurae in a patient with recurrent breast cancer
following bilateral radical mastectomies with radiation. A 21 x 38 C111 anterolateral

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thigh free flap incorpora ting portions of rectus femoris, vastus latera lis, and tensor
fascia lata was anastomosed to the internal mammary artery and external jugular vein.
No structural support was used. The donor site was covered with a skin graft, and
healing of flap and donor site were uneventful despite continued tumor presence and
chemotherapy (101).
Omentum. The omentum was first used in the chest for repair of bronchopleural
fistulas, followed by its use for chest wall defects as developed by Kiricuta (15).
Since then, it has been used extensively for resurfacing of the chest wall in a variety
of conditions: cancer resection; osteoradionecrosis; sternal infections; electrical
burns; pectus deformities; intrathoracic defects including aortocutaneous,
tracheoesophageal, or tracheoinnominate fistulas; exposed pharyngogastrostomy
or vascular suture lines; diaphragmatic weakness following surgery; and breast
reconstruction (102). Unique characteristics of omentum include pliability, allowing
it to fill contour irregularities; extensive breadth and mobility; versatile bipedicled
arterial anatomy, permitting mobilization on either right or left gastroepiploic
vessels; and a rich vascular and lymphatic supply that promotes angiogenesis,
revascularization, and wound healing. Because of its extensive reach and the
versatility possible in design, it is almost always used as a pedicled flap (55). In
unusual circumstances when local options have not been available due to extensive
resection and radiation, the omentum has been used for microvascular chest wall
recontruction, breast reconstruction in conjunction with implant, and intrathoracic
coverage of an exposed subclavian artery stump and lung following desmoid tumor
resection (102,40). It may serve as a useful adjunct to other pedicled or free flaps in
larger defects. Complications of harvest include ventral hernia, abdominal wound
infection, prolonged ileus, upper gastrointestinal hemorrhage, small bowel
obstruction, splenic injury, and flap hematoma (102).
Composite Forearm Musculocutaneous Fillet Flap for Reconstruction of Forequarter
Amputations. Salvage of forearm flaps for coverage following humeral amputations
was used initially for traumatic amputations of the upper limb, as a means of
resurfacing the defect as well as providing additional stump length for prosthetic
use (103). In contrast to traumatic avulsion amputations, forequarter amputation is
performed for large, invasive tumors of the shoulder girdle region, often involving
extensive posterior tumors with shoulder, chest wall, and scapular involvement. Such
tumor entities include soft-tissue sarcoma, osteosarcoma, malignant melanoma,
and epidermoid carcinoma. The overall 5 year survival rate for intended curative
forequarter amputation is 25%, making palliation often the indication for the
procedure (25).
Repair is complicated by the size of the defect, irradiated tissue and prior surgical
resections, use of prosthetic materials for skeletal support, and close proximity to great
vessels. Locoregional flaps may be inadequate or unavailable due to the extent of
resection or prior reconstructive attempts. Several variations of the forearm flap have
been described for use in coverage of these defects (25, 104-107). These include
fasciocutaneous flaps and musculocutaneous fillet of arm flaps based on the brachial
artery. The entire circumference of the forearm skin and underlying fascia can be
harvested based on the brachial artery and vein, and used to fill defects as large as 25 x

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30 cm (104). Even Iymphadematous arms can be used, with rapid resolution of the flap
lymphedema occurring in the first few postoperative days. Lymphedema may serve as
a na tural preoperative tissue expander, providing expanded tissue for coverage of the
amputation site (105). Recipient intrathoracic and neck vessels include the common or
external carotid; subclavian and thoracoacromial arteries; and the innominate,
subclavian, transverse cervical, and internal jugular veins (25, I05).
Cordeiro and associates reported one of the larger series of forequarter amputation reconstructions using a salvaged forearm flap. They designed a musculocutaneous variation described as the total volar forearm musculocutaneous free flap.
Fasciocutaneous flaps are elevated in the subfascial plane on the dorsal side of the
forearm from a dorsal longitudinal incision. At the extensor carpi ulnaris medially and
the first dorsal compartment laterally, the rest of the flap is elevated in a subperiosteal
plane, preserving all of the flexor muscles and discarding the extensors with the bone.
The brachial pedicle is then dissected separately to the desired length. The pedicle is
detached before the forequarter amputation is completed. Simple and rapid dissection
can be performed without tourniquet control, decreasing ischemic time. Long pedicle
lengths can be achieved using the brachial artery. The venae comitantes possess a large
diameter (3-6 mm), making it possible to drain the entire flap though a single venous
anastomosis. The brachial vein can be similarly used. The additional bulk provided by
the muscle tissue improves contour and function at the shoulder level, preventing
slippage of garments. Of the four patients who underwent this technique all had
lymphedema, three had previous irradiation, and three had chest wall and rib
involvement. Flap sizes averaged 25 x 30 cm. Postoperative complications included
one hematoma and three patients with respiratory insufficiency. All flaps healed primarily without flap loss or need for anastomotic re-exploration (25).
Our preference is to include the skeletal support of the elbow with the forearm,
thus effectively creating a composite free tissue transfer (Fig. 6). The distal humerus
can be secured to the end of the clavicle, allowing the elbow to remain in a flexed
position that mimics the normal contour of the shoulder. This provides a better
aesthetic contour and allows patients to wear normal garments. Flap harvest is very
rapid with this technique, requiring simple filleting apart of the volar skin and fascia
rather than elevation as a separate flap. Preservation of bony components for skeletal
support should be considered whenever the bone is not involved in the disease process.

D.

Potential Complications and Pitfalls

Every effort must be made to facilitate rapid and deliberate reconstruction. Reducing
operative time with the use of two surgical teams for flap harvest and for preparation
of the defect and exposure of the recipient vessels, minimizing blood loss while
ensuring adequate volume replacement, and avoidance of hypothermia will reduce
recovery time and risk of perioperative complications (45). In managing irradiated
beds, wound contamination and closure under tension must be avoided. A key factor
to remem beris the tendency of the edges of the surgical wound to retract from the
original defect once scarring and contracture are released during resection. To provide
tension-free coverage, the size of the flap planned for reconstruction must be 50-75%
greater than the size of the resected tissue (67). A special consideration in patients
undergoing palliative resection may be the potential for residual tumor and its thrombogenic effects. Residual tumor within anastomotic vessels or close vascular margins

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Figure 6 A. Sixty-five-year-old woman with a recurrent, fungating, necrotic tumor of the


right supraclavicular and shoulder girdle region. B. Intraoperative appearance during forequarter amputation. C. The edematous amputated arm will be filleted along its medial border
with amputation at the distal forearm and used as a composite flap to reconstruct the chest
wall and shouldet'. D. Early post-operative view,

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may contribute to flap failure. Postoperative flap monitoring is critical, and any suggestion of impending flap ischemia or congestion necessitates re-exploration. Flap
salvage is critical in these pa tients, given their limited secondary reconstructive options
and their compromised ability to tolerate even partial flap loss with the risk of exposed
viscera or mesh and subsequent infection.

VI.

OUTCOMES

A.

Oncological Resection

Several studies have examined outcomes after chest wall reconstruction for oncological defects using musculocutaneous pedicled flaps. One of the earlier studies from
Memorial-Sloan Kettering Cancer Center reviewed 155 patients who had undergone
chest wall resection for carcinomas or sarcomas from 1963 to 1978. Most of these early
resections were either closed primarily or utilized local cutaneous immediate or
delayed flaps for closure. Wound infections occurred in 5%. The overall perioperative
mortality in this group was 4.5%, with a 5 year survival of 20%. Most of the
peri operative deaths were due to pulmonary complications from pneumonia or
hemorrhage, but one patient's death was directly attributable to failure of a delayed
full-thickness skin flap from the abdomen that was used for coverage over a Marlex
sandwich. The flap sloughed in 3 days and led to infection and death (66).
Later studies demonstrated increased use of musculocutaneous flaps. In a series
of 100 consecutive chest wall reconstructions performed by Arnold and Pairolero
from 1977 to 1983,42 patients had primary or metastatic chest wall tumors, 19 had
radiation necrosis, 24 had infected median sternotomy wounds, and 15 had combination defects. Of the 100 patients, 63 underwent an average of 5.7 rib excisions, with
total or partial sternectomies in 29. Prolene mesh or autogeneous rib grafts were used
in 40 patients. A total of 92 patients underwent 142 muscle transpositions, including
latissimus dorsi, pectoralis major, rectus abdominis, serratus anterior, and external
oblique muscles. The omentum was transposed in ] 0 pa tients. Each patient had an
average of 2.1 operations with an average hospitalization of 17.5 days. Only two
patients required tracheostomy for prolonged ventilation. Fifteen patients experienced delayed healing due to irradiation that required prolonged care. Two patients
underwent removal of mesh that had been placed in open contaminated wounds at
the time of surgery. No intraoperative deaths occurred and one perioperative death
occurred due to pulmonary complications at 29 days. The remaining 99 patients all
experienced healing of their wounds. A mean follow-up period of21.1months (range,
11-70 months) demonstrated survival in 75%, with late deaths due to pulmonary or
oncological issues unrelated to reconstruction (5).
A similar review at the M.D. Anderson Cancer Center of 112 patients who had
undergone myocutaneous tlap chest reconstruction for malignancy or radionecrosis
from 1977 to 1985 demonstrated minor wound complications in 20% that did not
require repeat surgery. Major wound complications requiring operative intervention
occurred in 5% resulting from partial loss of a pectoralis major myocutaneous flap
closed under tension, partial loss of a latissimus dorsi flap, complete loss of a rectus
abdominis myocutaneous flap due to venous congestion, and incomplete healing due
to residual radionecrosis at the margin of one flap. Four perioperative deaths occurred

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from pulmonary embolism, pneumonia, and progressive malignant disease. Longterm mean follow-up at 4.2 years demonstrated that 3 of 82 patients who received a
Marlex mesh repair had infections that required local debridement (68).
With respect to long-term survival following chest wall reconstruction with
musculocutaneous flaps for oncological resection, a more recent review of 96 patients
at the M. D. Andersen Cancer Center from 1979 through 1988 revealed an overall
median survival of20.5 months. Tumors included breast cancer, sarcomas, melanoma,
bronchogenic carcinoma, and squamous cell carcinoma. Full-thickness resections
involving skin, ribs, and pleura were performed in 72% of patients, most of whom did
not require prosthetic support. Flaps used in reconstruction were latissimus dorsi,
pectoralis major, TRAM, and VRAM.
The patients were then classified into three subsets. Among those patients free of
known malignancy who were treated for radionecrosis, 80% were still alive with a
median survival of 60.0 months. For those with resectable disease and who were
tumor-free following surgery, median survival was 31.1 months. In the final group of
patients who had incompletely resected or metastatic disease, median survival was
only 12.5 months, but a few individuals with recurrent fibrosarcoma and breast cancer
had prolonged survival (up to 72 months) and therefore clearly benefited from
reconstructive surgery for palliative purposes. The complication rate from flap
reconstruction was 45.8% overall, with a rate of 47.8% for full-thickness defects
compared with 40.7% for partial thickness defects, and a rate of 40.7% for patients
with radionecrosis. Average length of hospitaLization was increased by 6.5 days in
patients with complications, but in the group of patients who had prolonged stays
(greater than 3 weeks), there was no difference in hospital stay between those who had
complications and those who did not (108).
There are few long-term series documenting chest free flap reconstruction of
oncological defects. The largest and most recent series was published by Cordeiro and
associates at the Memorial-Sloan Kettering Cancer Center. They reviewed 25 cases of
full-thjckness chest wall reconstruction performed between 1988 and 1998 using 20
free flaps and 5 supercharged pedicled flaps. Twenty of the free flaps were rectus
abdominis myocutaneous flaps, and five were forearm fillets after forequarter amputation. The reconstructions were performed in patients who had recurrent breast carcinoma, sarcoma, metastatic pulmonary carcinoma, radiation necrosis, or exposed
hardware. Previous radiation therapy to the anterior chest wall had been performed in
2
80% of patients. The mean size of the defect was 380 cm , with 28% undergoing
excision of more than four ribs, 52% with partial or total sternectomy, and 24% with
scapula resection. A Marlex-methylmethacrylate sandwich was used in 52% for
patients who had more than four ribs resected, and simple Gore-Tex or Marlex mesh
repair in 16%. No total flap losses occurred, with only one flap. undergoing loss of 10%
of the distal skin island. There was an 8% re-exploration rate for venous thrombosis
in two patients. No donor site complications or mesh exposures occurred. Minor
recipient site complications included one hematoma, one minor infection, and one
partial suture line dehiscence. Perioperative deaths occurred in three patients (12%),
unrelated to the repair. Perioperative morbidity included respiratory failure requiring
intensive care (20%), multisystem failure (12%), and arrhythmia (4%). Mean followup time of 37.3 months documented two deaths, with two patients lost to follow-up.
The 100% overall flap success rate in this review and low reoperative and compljcation

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rates support the use of microsurgical reconstruction in selected complex oncological


defects (45).

B.

Radiation Injury

It has been demonstrated that irradiated wounds require well-vascularized, nonirradiated tissue to be imported into the area in order to achieve reasonable healing.
As much as possible of the devitalized radiation-damaged tissue must be resected,
and the wound needs to be covered with a stable, highly vascular source of tissue,
ideally omentum, muscle, or musculocutaneous flaps (109). Reported complication
rates for treatment of radionecrosis with myocutaneous flaps in the past have been
high, ranging from 18.4 to 46.7%, including partial or total flap loss, wound dehiscence, infection, fistulae, and skin necrosis (86). Attempts to use local pedicled
flaps from within the irradiated field have contributed to these outcomes. Arnold
and Pai.roleio reviewed 100 consecutively previously irradiated wounds that were
reconstructed with transposed muscle or musculocutaneous flaps. Of these, 72%
involved chest wall or intrathoracic reconstruction. A wide variety of flaps was
included, the most common of which were latissimus dorsi, pectoralis major, and
serratus anterior. Complications assessed included partial or full muscle loss,
hematoma, seroma, infection, and fistula. Among those receiving a flap of transposed muscle that had been irradiated, there was a 32% complication rate, with
death of the entire muscle in 14% requiring a second reconstructive procedure. The
subgroup using nonirradiated transposed muscle had a complication rate of 19.3%,
with a partial muscle loss of 5.3%. No instances of complete flap loss were noted
among the nonirradiated flaps (26).
Avoiding the of use of irradiated tissue is readily achieved with free tissue
transfer from areas outside the mantle of radiation. A number of successful cases are
reported in the literature (28,64,86-88). Hidalgo and associ a tes reported their experience using free latissimus and rectus abdominis musculocutaneous flaps for reconstruction of chest wall defects in seven patients following excision of radiation ulcers
and recurrent breast cancers with a previous history of radiation. Recipient vessels
included the external carotid for high anterior defects, and the internal mammary or
subclavian vessels for central defects. There were no flap failures, with only one patient
experiencing a small portion of superficial skin necrosis that healed with conservative
care. The two patients with pure radiation ulcers were still alive at follow-up 56 and 57
months later (64). Employing microvascular techniques to avoid utilizing irradiated
tissue applies to selection of recipient vessels as well. In a retrospective review of 30
patients with radiation-induced injuries reconstructed with free flaps at the M. D.
Anderson Cancer Center. large-caliber vessels in the cervical, axillary, and inguinal
regions were used as recipient vessels. Sonl.e 76% of the recipient vessels were located
within the radiation field. Pedicle thrombosis occurred in three flaps, all of which used
irradiated recipient vessels, suggesting an increased risk of pedicle thrombosis when
using irradiated vessels that might be avoided by using sites outside the radiation
mantle (28). Even with optimal management, healing of reconstructed radiation
wounds may require adjunctive therapy such as hyperbaric oxygen therapy (HBO).
This is believed to promote angiogenesis into irradiated tissue with subsequent delivery of nonirradiated fibroblasts into the site that promote normal healing. HBO

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Free Flaps

has been used to facilitate healing of musculocutaneous flaps that failed to adhere
completely to chest radionecrotic defects (88).

C.

Sternal Coverage

As sta ted previously, most cases involving sternal osteomyeli tis can be successfully
treated with local pedicled flaps. Even in cases of total sternal necrosis with loss of
pectoralis or rectus abdominis options, latissimus dorsi flaps have been utilized and
transposed beneath the pectoralis muscle remnants to reach the midline for coverage
(110). Pedicled options do have limitations in their ability to obliterate completely the
defect, which is crucial to prevention of seroma and recurrent infection. Pectoralis
flaps tend to leave caudal defects, even when used as a turnover flap based on the
internal mammary artery. Pedicled latissimus flaps place the bulk of the muscle lateral
to the sternum. with only the fibrous portion of the muscle extending into the wound.
Use of both internal mammary arteries for cardiac bypass, or subcostal laparotomy
incisions can preclude use of the rectus abdominis flap. Even the omentum has its
limitations, including risk of hernia, colonic ischemia, and gastroparesis, as well as
being occasionally inadequate in bulk and failing to reach the superior portion of the
sternal defect in 12% of cases (33).
As a result, free tissue transfer has been examined for the treatment of median
sternotomy wounds. Banic et al. described seven patients with persistent sternal
infection in whom radical debridement of the sternum, costochondral arches,
manubrium, and sternoclavicular joints was performed. A free latissimus dorsi
myocutaneous flap was employed in all patients. Recipient vessels included the
superior thyroid artery and vein, internal mammary artery and external jugular vein,
and common carotid artery and external jugular vein. The authors noted that using
internal mammary stumps for microsurgical anastomosis was challenging due to
cardiac motion. Harvest time averaged 60 min, with a microvascular anastomotic
time of 30 min total. No sternal replacement was used, and the muscle was sufficient
to obliterate dead space completely. All flaps survived without need for anastomotic
revision and no evidence of recurrent infection. All patients had a degree of paradoxical chest movement, particularly in the superior half of the flap, but only required
external pressure on the flap in the immediate postoperative period to aid in
expectoration (89).
Brown and associates also reported a series of 12 free tissue transfers used in 11
patients. The flaps employed were 10 rectus abdominis myocutaneousflaps, one
anterolateral thigh flap, and one bilateral pectoralis muscle flap requiring pedicle
lengthening via interpositional vein grafts to the thoracoacromial vessels as a salvage
procedure following a failed free rectus flap. Average operative time was 6 h (range, 59 h). Average hospital stay was 20 days. Total flap loss occurred in one patient due to
venous thrombosis secondary to kinking. Intraoperative occlusion was salvaged in
another patient. Mean follow-up of 3.4 months revealed complete healing in three
cases of partial skin loss, marginal donor site breakdown in three pa tients, and two
abdominal hernias following rectus abdominis flap harvest (33). Microsurgical repair
of sternal osteomyelitis should be reserved for patients in whom the local options are
truly inadequate, and in whom the advantages of free flap transfer outweigh the
disadvantages of longer operative time and anastomotic complications.

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D.

Ting and Pribaz

Intrathoracic Free Flaps

A variety of free tissue transfers have been successfully used by microsurgeons to fill
intrathoracic defects (Fig. 7). These were generally performed when local muscles had
been either been transected by previous surgery or already utilized in unsuccessful
prior attempts at pedicle flap coverage. Hammond and associates reconstructed seven
patients with intrathoracic defects using three latissimus dorsi, one omental, and three
rectus abdominis muscle free flaps. Recipient vessels were all extrathoracic in location,
including the thoracodorsal vessels in five flaps and common carotid and transverse
cervical vessels in two. Five patients had chronic empyema and bronchopleural fistula;
the remaining two had complex defects including exposure of an irradiated bronchial
stump following resection of metastatic testicular carcinoma, and exposure of a subclavian stump and upper lobe of lung following repeated resection of a desmoid tumor that had eroded into the subclavian artery. All flaps survived. Four of the five
bronchopleural fistulas sealed, with reduction in the extent of leak in the fifth. There
were no postoperative infections (40). Other authors have obtained similar results
using combined latissimus dorsi~serratus anterior free muscle flaps for the treatment
of bronchopleural fistulas (22, Ill).
Advantages of intra thoracic free flaps include the ability to use muscles or tissues
that may be more pliable and provide greater coverage of difficult intrathoracic
contours. and the ability to design specialized flaps to fulfill multiple purposes. An
example of this is the use of a bivalved radial forearm free flap to provide outer chest
skin coverage as well as an inner lining for closure of a esophagocutaneous fistula
occurring after colonic interposition for esophageal reconstruction following esophagogastrectomy (112). As in the case of sternal coverage, the majority of intrathoracic
defects are manageable with thorough debridement and combination of local muscle
flap options to seal fistulas and provide dead space fill, making free tissue transfer a
secondary option (39).
E.

Poland's Syndrome Reconstruction

The first autologous reconstruction for congenital breast aplasia was first reported by
Fujino in 1975, who described the first use of the superior gluteal flap for breast
reconstruction (113). The largest series of microvascular reconstructions for Poland's
syndrome was reported by Longaker and associates in 1997, who utilized free TRAM.
superior gluteal, inferior gluteal, and latissimus dorsi musculocutaneous flaps in nine
patients. All flaps were anastomosed to divisions of the subscapular system (thoracodorsal artery and vein or circumflex scapular artery and vein). Four individuals had
skeletal deformities including pectus excavatum and absence of the third, fourth, and
fifth ribs. Soft tissue deficiencies including absence of the pectoralis major or latissimus
dorsi muscles were present in six patients. Complications included one superior gluteal
flap loss due to anomalous subscapular venous drainage. The patient subsequently
underwent a successful superior gluteal flap reconstruction utilizing cephalic venous
drainage (43).
Vascular anomalies in Poland's syndrome have been described including
dextrocardia with left subclavian artery stenosis. hypoplastic subclavian artery,
and absence of the thoracoacromial and thoracodorsal arteries (114). Vascular flow
studies of the arms of children with Poland's syndrome using Impedance plethysmography show decreased systolic flow velocity in the affected arm, consistent with

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i"

" +1

~.

Figure 7 A. Sixty-three-year-old woman with empyema and bronchopleural fistula after


right pneumonectomy for treatment of cancer and a Clagett window procedure. B. Outline of
free rectus abdominis myocutaneous flap. C. Intraoperative appearance following parietal
pleural decortication and insertion of free de-epithelialized rectus abdominis myocutaneous
flap to fill the cavity. D. Computed tomographic scan approximately I month postoperatively.
E. Patient with healed wound I month postoperatively.

the theory that hypoplasia of the subclavian artery may be the cause of the
malformation (115). Reports of ischemic necrosis of skin and hypoplastic pedicled
latissimus dorsi flaps elevated for reconstruction support the above findings
(116,117). It is therefore prudent to obtain preoperative angiographic studies in
any individual with Poland's syndrome who is being evaluated for microvascular
reconstruction (117).

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VII.

Ting and Pribaz

CONCLUSION

Significant advances in the field of chest wall reconstruction ha ve been made over the
past SO years, with greater understanding and utilization of muscle and musculocutaneous flaps, better alternatives for chest wall stabilization, and revolutionary changes
in respiratory support and intensive care. The great majority of full-thickness chest
wall defects can be reconstructed with regional pedicled flaps, even in patients with
complicating factors such as prior irradiation. More recent advances in the field of
microsurgery have led to numerous innovative applications for chest wall reconstruction. We offer the above recommendations as a guideline for thoughtful approach to
the repair of complex defects of the chest wall. It is hoped that appropriate patients
with thoracic lesions will be selected for free tissue transfer, many of whom have
incurable diseases and for whom quality of their remaining life is dependent upon a
stable reconstruction and rapid recovery with minimal morbidity.

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21
Outcomes in Chest Wall
Reconstruction
ELISABETH K. BEAHM and ROMAN J. SKORACKI

University of Texas M. D. Anderson Cancer Center. Houston. Texas, U.S.A.


DAVID H. SONG

University of Chicago Hospitals, Chicago, Illinois, U.S.A.

I.

INTRODUCTION

The plastic surgeon may be called upon to evaluate chest wall deformities resulting
from a spectrum of conditions. The underlying pathologic entities may include acquired deformities such as neoplasia, radionecrosis, infection. or trauma, as well as
those with a congenital cause. Despite the breadth of causal factors responsible for the
defects, there is a general consensus as to the overriding principles and surgical techniques employed in chest wall reconstruction. In many circumstances, the more critical
question centers on the appropriateness of a surgical intervention in a given clinical
circumstance. Guidelines for management of these often complex cases are poorly
defined, with minimal supportive information in the literature because outcome data
are generally lacking for chest wall reconstruction. An understanding of the overall
outcome of a surgical approach in terms of survival, morbidity, and quality of life
would seem to be important in order to evaluate fully the efficacy and benefit of
operative intervention in these cases. This assessment would need not only to encompass the patient's medical condition and ability to withstand the procedure but
also address the underlying cause of the defect as well as a number of critical pertinent
variables.
Outcome data for chest wall reconstruction are especially important in patients
with advanced or recurrent cancer to guide appropriate management. For this group
of patients, surgery often represents a palliative rather than a curative option. As

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such, the morbidity of any procedure must be carefully balanced against its benefits
and compared to the clinical outcome anticipated should a conservative treatment
plan alone be undertaken. Comparing the efficacy of surgical intervention for cases of
primary, recurrent, and metastatic lesions to the chest wall needs thought and care.
The magnitude of the operative procedure, including the donor site morbidity
and reconstructive effort required to complete the chest wall reconstruction, must be
carefully assessed to evaluate fully the anticipated outcome and efficacy of the planned
procedure. The depth and size of a given defect may suggest use of prosthetic materials
that may increase infectious complications and are accordingly controversial. Prior
or planned radiotherapy may greatly complicate a planned procedure and alter the
reconstructive strategy employed. Methods to deal best with the profound impairment
in wound healing caused by radiotherapy must be addressed in the proposed surgical
paradigm.
For chest wall reconstruction necessitated by a nonneoplastic entity, outcome
must also be considered in terms of both efficacy and quality-of-life parameters, and
include long-term evaluation of operative results. Mediastinitis (the most common
cause requiring chest wall reconstruction) has long been treated with muscle flap
coverage. While this approach demonstrated vast improvement over early techniques,
its morbidity is likely to be underreported (l). Novel means of treating sternal wounds
including subatmospheric pressure dressings and rigid plate fixation of the sternum
(both therapeutic and prophylactic) are also worthy of closer evaluation. Because the
correction of congenital chest walJ deformities is primarily done for aesthetic concerns,
the recidivism rate, complications, and longitudinal stability of available autologous
and alloplastic techniques need thorough, objective assessment.
The aforementioned considerations, which are highly salient to an accurate
assessment of outcomes for chest wall reconstruction, wilJ be examined in greater
depth in the ensuing sections. A preliminary review of currently available data suggests
that chest wall reconstruction, while often complex, appears to be well tolerated even if
multiple flaps are required to complete the procedure. Clearly however, additional
longitudinal study of chest wall reconstruction including patient evaluation for quality-of-life parameters is needed in order to ascertain outcome data. These investigations must also prospectively address the potential risks and benefits of prophylactic
chest wall reconstruction in patients likely to be at high risk for wound breakdown.
These data would provide invaluable information that might more accurately guide
the clinical management of chest wall deformitie .

II.

CHEST WALL RECONSTRUCTION FOR NEOPLASM

A.

Advanced Breast Cancer

The efficacy of chemotherapy for distant disease has expanded the role of surgical
intervention for palliation and local control of advanced breast cancer (2,3). In many
of these cases, radical ablative procedures may be required due to extensive skin
involvement and/or chest wall fixation. In such instances, reconstruction is necessary
to cover exposed vital structures, bring about timely wound closure, and avoid delay in
the administration of adjuvant therapy. Reconstructive surgery may enhance the
patient's quality of life in cases of advanced breast cancer by providing palliation for
bulky, necrotic tumors (4) (Fig. J).

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c
Figure 1

a. A 45-year-old woman with locally advanced breast cancer. b. Tumor excised en


bloc with chest wall. c. Resultant full-thickness defect included sternum and six ribs. d. Chest
wall reconstruction with Marlex mesh and methlylmethacrylate. e. A bilateral free TRAM and
pedicled ipsilateral latissimus dorsi myocutaneous flaps were used to cover the prostheses,
permitting primary closure of the donor site. Patient was seen 9 months after surgery and
radiation therapy, and has been disease-free for 24 months.

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e
Figure 1

Continued.

Surgical resection of chest wall recurrences of the sternum and ribs (likely to
originate in the internal mammary chain nodes) has been shown to result in an
improved survival rate (4,5). We have examined a series of over 90 patients with locally
advanced or recurrent breast cancer (stages llfb and IV) treated at the MD Anderson
Cancer Center over the last 12 years who required immediate chest wall reconstruction
as part of their surgical therapy (6). The average tumor size (pathological) was 6.8 cm
and the average defect size 264 cm2 (range, 70-900 C1112)' A variety of flaps (most
commonly the rectus abdominus and latissimus dorsi flaps) were used to reconstruct
these defects. Multiple flaps were required to achieve wound closure in 20% of these
patients, and prosthetic material was used to restore chest wall integrity in 25%. There
were no operative deaths, the average time of postopera tive intu bation was 2 days, and
the average hospital stay was just under 7 days (range, 2-34 days). Flap-related complications were approximately 25%, consisting primarily of self-limited wound infection or delayed healing, hematoma, and seroma. Total flap loss was just over I %.
Medical complications were primarily cardiorespiratory, including pneumonia, pul-

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monary edema, and pleural effusion with an incidence of approximately 27%. Patients
had a mean survival of just over 2-1/2 years. In agreement with prior studies, survival
appeared to relate to the disease state not the reconstructive surgery. It appeared that
patients tolerated these procedures well with minimal morbidity, supporting a role for
surgical palliation in patients with advanced breast cancer (4,7,8).
B.

Neoplasms of the Chest Wall

Survival after resection and reconstruction of primary chest wall tumors appears to be
primarily associated with tumor-related factors, most specifically tumor size, metastases, pathological type, and whether the resection was considered curative (5,9,10).
The role of surgical palliation and overall outcome from these procedures in terms of
quality of life and measures of operative morbidity is less well understood. Only a few
studies have included data relevant to outcome analyses such as levels of patient
satisfaction, the length of respiratory support, or in-hospital patient stay (7,11-16).
Current outcome data for solid tumors of the chest wall suggest that resection
and reconstruction can be a largely successful approach in terms of both quality of life
and survival, provided complete gross tumor excision is possible. In our institution,
median survival for patients with chest wall sarcomas that were completely resected
was 54 months, while patients with incomplete tumor removal survived only 8 months.
These figures are comparable to those noted in other published reports (14). In several
series of patients who underwent full-thickness chest wall resection and reconstruction
for primary chest wall tumors surgical morbidity appeared acceptable: There were no
30 day deaths, universal extubation after operation was achieved, and hospital stay
averaged 21-24 days (7,12,14,15).
Complications after chest wall resection for oncological reasons are frequent but
are also usually self-limited. These complications are predominantly seromas, infections, and air leaks. Respiratory complications occur in up to 46% of these patients
(17). The predictably low mortality (approximately 4%) and palliative benefits of
surgical resection in chest wall malignancy have led a number of authors to recommend resection and reconstruction of primary chest wall tumors if the patient's
predicted life expectancy exceeds I year, even if the surgery is to be undertaken only
for palliation (II). Palliative surgical intervention may provide relief from large,
ulcera ted, painful tumors and may be indica ted even for those pa tients with a poor
prognosis. This is particularly true when the quality of remaining life is diminished to
the point that the patient would prefer to accept the morbidity or mortality associated
with resection and reconstruction in an effort to achieve palliation (18).
C.

Lung Cancer With Chest Wall Involvement

Surgical resection remains the mainstay of treatment for non-small-cell lung tumors
and regional nodal disease. Chest wall involvement requiring excision and reconstruction affects 5-8% of these patients (19-21). Complete tumor resection, including pathological margins free of tumor cells, resection of involved nodes, and clinically confirmed total tumor removal has been demonstrated to result in a 5 year survival rate of
15-60%, depending on the nodal status and the depth of tumor invasion (22,23). Chest
wall reconstruction is usually required, since en bloc tumor resection, including margins that encompass at least one uninvolved rib and intercostal space, appear to decrease recurrence rates and increase 5 year survival (24,25).

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III.

CHEST WALL RECONSTRUCTION FOR INFECTIOUS CAUSES

A.

Sternal Wound Infection/Mediastinitis

The median sternotomy, popularized by Julian in 1957, remains the standard method
utilized by cardiac surgeons to access the anterior mediastinum. Over 650,000 sternotomies are performed each year in the United States (26). Although most patients
undergoing median sternotomy heal without complications, 0.2~5% of these patients
will develop deep sternal wound infections leading to mediastinitis (27-32). As such,
sternal wound infection affects a very large number of patients each year (33-35).
Aggressive debridement and myocutaneous flap closure of the sternal wound have
been the mainstay of surgical treatment for this condition over the last two decades.
This approach has dramatically reduced the morbidity of mediastinitis and decreased
the mortality from 22 to 0% (36,37).
Muscle flaps have been routinely used for correction of sternal wounds and are
considered by many surgeons to be the most efficacious surgical option in these cases.
This is because muscle (in comparison to fascial flaps) coapts well to irregular contours
and permits obliteration of dead space (38). Pedicled muscle flap closure is the most
frequently utilized type of reconstruction in sternal wounds, and usually involves use
of the pectoralis major, rectus abdominis, or latissimus dorsi muscles alone or in
combination. The omentum or local cutaneous flaps may also be used. Free tissue
transfer has been successfully performed when the aforementioned options appear
untenable. Although successful wound closure is usually obtained by muscle flap
reconstruction, this technique does carry a significant, and often overlooked, attendant morbidity (36,39). Twenty-five percent of patients treated for an open sternal
wound may have recurrent infections requiring further debridement of cartilage and
rib (40). A large percentage of patients with healed wounds experience chest wall pain
and instability. In a recent series, 43% of patients with mediastinitis treated with
debridement and flap closure experienced pain; 45% of patients noted sternal instability; and 25% reported upper extremity weakness after pectoralis muscle flap
closure (41). Patients also complained of a worsened appearance and overall dissatisfaction with the procedure (42).
In addition to subjective complaints, there may be functional issues associated
with treatment for mediastinitis. Pulmonary function can be impaired with loss of the
sternum, which is a consequence of debridement. In a series of patients followed for an
average of 10 months, the vast majority was found to have mild, restrictive impairment
of their lung function after flap closure with an average decrease of 20% in predicted
functional vital capacity (FYC) and forced expiratory volume in Is (FEYI) (43).
Although these sequelae may be considered a reasonable exchange for a healed wound
from this potentially life-threatening infection, recent approaches may provide the
opportunity to decrease this attendant morbidity.
B.

Alternative Strategies for Sternal Wound Infection

1.

The Vacuum-Assisted Closure Device

The treatment of sternal wound infections has been refined by the advent of
subatmospheric pressure dressings. The vacuum-assisted closure device (Y AC. dressing [KCl]) bas been used as an effective bridge between initial debridement and
definitive closure (Fig. 2). Application of the YAC dressing to a wound has been

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Figure 2 Vacuum-assisted closure (VAC) utilizes a compressible porus foam sponge that is
placed in the wound, sealed, and then subjected to a prescribed level (continuous or intermittent) of suction produced by the device. Portable units may also be used.

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demonstrated to lead to an increase in granulation tissue and angiogenesis, and to a


decrease in wound edema and bacterial count (44). These benefits are believed to be a
direct result of pressure gradient modulation on a cellular and subcellular level, with
an increased expression of secondary messengers. Healing is further facilitated
through clearing of interstitial fluid and chronic wound fluid (44,45). The surface
area and volume of the wound are also decreased, thus diminishing the requirements
for soft tissue reconstruction. It has been our experience that wounds treated with the
VAC dressing require a significantly less morbid reconstruction than those managed
with traditional debridement and dressing changes. In a matched cohort of patients
with sternal wound infection (17 received VAC therapy and 18 underwent traditional
twice-daily dressing changes), there was a significant decrease in the number of flaps
needed to reconstruct sternal wounds in the VAC-treated group. All the VAC-treated
patients required only one flap (the pectoralis major myocutaneous advancement
flap), while the majority of patients treated with twice-daily dressing changes required
at least two or more flaps. In this study, patients managed with VAC therapy also had
a trend toward a decreased interval from the time of debridement to ultimate closure
(Fig. 3). The VAC-treated group also had no donor site complications, whereas the
group treated with traditional twice-daily dressing changes had two omental flap
losses leading to subacute peritonitis and one patient with an evisceration after
harvest of a rectus flap (46).
2.

Rigid Fixation After Median Sternotomy

Recent approaches to reduce the morbidity of sternal wound infection have focused
on the principle of rigid fixation for both treatment and prevention. Although
techniques in osteosynthesis have transitioned from wire to rigid fixation in virtually
all specialties, sternal osteosynthesis continues to be widely performed with nonrigid
techniques using stainless steel wire. After circlage wire closure, bony healing of the
sternum appears to be adequate in the majority of cases, despite mobility of the
sternal segments, due to the rich vascularity of the sternum. Compromise of sternal
vascularity due to surgical and/or patient-related variables in the setting of nonrigid
fixation may help to tip the balance toward nonunion and subsequent infection.
Sternal instability is the common denominator in most cases of deep sternal wound
infections (28,47).
Gottlieb demonstrated the efficacy of precise debridement and rigid internal
fixation in the treatment of sternal wound infection. His study suggested that it may
be possible to avoid many of the long-term sequelae of sternal wound infection and
debridement by salvage of the sternum (28). The corollary of this treatment
approach may be the prevention of sternal instability and perhaps mediastinitis
by prophylactic rigid fixation after sternotomy. Certain risk factors have been identified that put the patient at high risk for poststernotomy mediastinitis: diabetes,
morbid obesity (body mass index > 25), chronic obstructive pulmonary disease, reoperative surgery, renal failure, concurrent systemic infection, iatrogenic or acquired
immunodeficiency, excessive cardiopulmonary bypass time (> 4 h), previous chest
wall irradiation, transverse sternal fractures, and off-midline sternal osteotomy. A
recent series of 45 high-risk patients (patients with three or more of the above risk
factors) who underwent primary rigid internal fixation of the sternum demonstrated
no case of poststernotomy mediastinitis, while a matched population of high-risk
patients closed with circlage wires (n = 207) had an incidence of 14.8% (Fig. 4).

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b
Figure 3 a. A 55-year-old diabetic man with peripheral vascular disease (PVD) and chronic
obstructive pulmonary disease (COP D) presented with an infected, draining sternal wound 16
days after three-vessel coronary artery bypass grafting (CABG). b. Patient received intravenous antibiotics and underwent a single wound debridement with quantitative bacteriological investigation and intraoperative application of a VAC. VAC dressing is seen in place
demonstrating a seal over tissues. c. Patient was discharged home with a closed wound 5 days
after a single pectoralis muscle advancement flap.

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c
Figure 3

Continued

Furthermore, there was a significantly decreased incidence of other problems


associated with sternal nonunion such as pain, sternal instability, upper extremity
weakness, impaired pulmonary function, and bleeding (1,28,41,43,48).
Wire fixation has been largely abandoned for osteosynthesis in a spectrum of
surgical disciplines. As acceptance of titanium plate fixation of the sternum after
median sternotomy increases, one may anticipate a decrease in the incidence of
nonunion, malunion, and deep sternal wound infections.
IV.

CHEST WALL RECONSTRUCTION FOR CONGENITAL


MALFORMATIONS

The most common congenital anomalies of the chest considered for reconstruction
are pectus excavatum, pectus carina tum, and Poland's syndrome (49,50). Reconstructions in the vast majority of these cases are undertaken to correct an aesthetic
concern. Even those patients with a visually severe deformity rarely have any
appreciable functional deficit. Reconstructive procedures to correct these contour
deformities of the anterior chest wall are generally classified into two groups: those
designed merely to camouflage the external deformity and those that strive to
normalize the three-dimensional arrangement of the bony and cartilaginous framework. These approaches may include the use of prosthetic materials, autologous
tissues, or a combination of techniques.
A.

Mild Deformity

Synthetic materials such as breast implants or custom-fabricated silicon prostheses


have been the mainstay of treatment for contour deformities of the chest waiL and
have a reportedly high rate of success and patient satisfaction (51).

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b
Figure 4 a. A 69-year-old high-risk patient with diabetes, COPD, obesity (body mass
index> 30) and off-midline sternotomy underwent four-vessel CABG (two saphenous vein
grafts [SVG], one left internal mammary [LIMA] to left anterior descendin'g artery [LAD], and
one radial artery), with prophylactic plating for rigid fixation of the sternum. b. Patient had a
stable postoperative course (apart from an infection of the saphenous vein harvest site that
required only local wound care) and was discharged home on postoperative day 5. He is shown 6
weeks after surgery.

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Complications of these procedures are relatively common, yet appear to be easily


managed. In several comprehensive series evaluating patients for over 5 years, seroma
was the most common complication and necessitated serial aspirations in 30-40%
of patients. Additionally, a number of patients complained of shifting of the implant
and asymmetrical placement of the prostheses, requiring explantation and replacement of the implant (4--6 weeks later) into a smaller pocket. No implant infections were
reported, and overall the authors quote an eventual 100% patient satisfaction rate
(51-53).
The pedicled latissimus dorsi (LD) muscle alone, or in conjunction with a breast
implant, has been widely employed for correction of the deformities associated with
Poland's syndrome. This technique permits augmentation of the hypoplastic soft
tissues of the anterior chest wall, filling the infraclavicular hollow, and creation of the
anterior axillary fold (particularly if the LD insertion is detached and transposed
anteriorly). In female patients the latissimus flap permits complete submuscular
placement of an implant that may improve symmetry with the contralateral side.
Caution should be exercised in more severe cases of the syndrome, since the ipsilateral
muscle may be severely hypoplastic or absent (54--56). Endoscopically assisted muscle
harvest may improve the aesthetic outcome of the sometimes-widened scar of the
donor site (57).
It has been thought in the past that there was little functional morbidity after a
latissimus dorsi flap, perhaps because of similar actions by the teres major and minor
muscles. Manual muscle testing of patients has supported this view (58,59). More
recent critical analyses utilizing both dynamic and static testing, however, suggest that
women (perhaps due to their relatively less well developed shoulder girdle musculature) have a significant reduction in strength in the affected extremity after latissimus
harvest, which is relatively greater than that seen in men (60). This decreased strength
does not appear to preclude normal activities, but must be considered in patients
heavily reliant upon their shoulder girdle strength (such as patients who use crutches or
a walker). In general, however, harvest of the latissimus muscle appears to be well
tolerated on both a functional and aesthetic level (57,61,62), and patients consider that
it is a reasonable sacrifice for their chest wall reconstruction (56).
B.

Severe Deformity

Procedures designed to reposition or replace the deformed structural components


(sternum, cartilage, and ribs) into a more normal architecture are usually employed for
correction of moderate or severe pectus deformities. Despite their visible deformity,
the majority of patients in these groups are not impaired functionally and seek correction primarily for aesthetic reasons. Symptoms such as dyspnea, dysesthesia, limited
physical stress tolerance, recurrent upper respiratory tract infections, and other symptoms have been described in association with pectus deformities and are considered
indications for surgery (10,50,55,63). However, while objective testing of cardiopulmonary function has not shown significant functional improvement, postoperatively
97% of patients state that the surgery has subjectively eliminated their functional
preoperative complaints (64).
Surgical correction ofa severe pectus excavatum deformity requires a transverse
osteotomy to advance the caudal portion of the sternum, which is then stabilized over
one or more metal struts or Marlex mesh (10.65). Complication rates range from 6 to

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40% and include pneumothorax, recurrence, infection, seroma, and wound dehiscence. The vast majority of patients (94%) state that they are satisfied with their longterm surgical results (10,66).
Pectus carinatum, in contrast, requires a transverse osteotomy to permit setback
of the sternum. This procedure is performed almost exclusively for aesthetic reasons.
While overall patient satisfaction appears high with this procedure with good initial
cosmetic improvement, long-term follow-up (specifically beyond the growth period
and into adulthood) has identified some recidivism and what might be termed a
relative recurrence of the deformity (56,67). A few patients do complain of pain with
this disorder, which is attributed to a compression of the intercostal nerves between
adjacent costochondral cartilages (55). Surgical intervention appears to improve this
pain. In one study 76% of patients complaining of preoperative discomfort had
complete pain relief after surgical set back of the prominent sternum (55).

V.

CHEST WALL RECONSTRUCTION FOR TRAUMA

Few traumatic injuries will result in a chest wall defect that comes to the attention of
the plastic surgeon. Thoracic trauma, which leads to significant chest wall defects, is
primarily caused by such overwhelming forces that if the patient survives, damage to
the intrathoracic structures takes precedence over the chest wall. Repair of these
defects follows general principles of wound closure. Foreign materials for acute
stabilization should be used with caution as these traumatic injuries are, by definition,
contaminated wounds. Smaller defects may be repaired by the thoracic surgeon.
Larger traumatic defects often require extensive and/or serial debridement, and coverage with regional or distant musculocutaneous flaps. The omentum has been utilized
in these cases to help obliterate dead space, or utilized with a skin graft for coverage of
large defects. Little information has been published on chest wall reconstruction resulting from traumatic injuries, likely due to the high mortality of the initiating event.
Closer investigation of these injuries may provide outcome data that could be used to
guide reconstructive efforts.

VI.

FULL-THICKNESS CHEST WALL DEFECTS: USE OF


PROSTHETIC MATERIALS

Loss of chest wall integrity will significantly alter the reconstructive strategy. Although
the spectrum offlaps employed in these cases is comparable to those utilized when the
structural integrity of the chest wall is intact, there are significant differences among
them. These defects are often larger, and the reliability of the autologous tissue covers
is more critical than is the case in superficial defects. Communication with the
mediastinum or pleural cavity or exposure of any prosthetic materials used for chest
wall stabilization can have profound and lethal consequences.
Rigid reconstruction of the rib cage is not usually necessary after resection of one
or two ribs if flap coverage is provided. Myocutaneous flaps offer enough intrinsic
strength to stabilize the chest wall, thus compensating for the loss of ribs (11,68). The
latissimus dorsi myocutaneous flap and the rectus abdominis flap (in either the vertical
or transverse configuration) are good options in these cases. The use of prosthetic
materials for reconstruction, especially rigid prosthetic materials, is controversial.

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Devastating infectious consequences can be associated with the use of alloplastic


materials. It is fortunate that this is rare. In fact, cadaveric materials or ribs are not
often used in chest wall reconstruction due to the reliability of the currently available
prosthetic materials (7). If a significant structural support is lost, such as a minimum of
three ribs or a resection including the sternum, it is often advisable to stabilize the chest
wall with prosthetic materials. Provided that the overlying tissues are healthy, the use
of mesh appears to enhance the outcome of a patient with a large, full-thickness defect
by allowing the patient to be weaned from the ventilator and discharged home earlier
than if mesh reconstruction is not undertaken (13). Although not routinely necessary
in the posterior thorax, mesh reconstruction may be beneficial if more than the first
four ribs are removed in order to avoid trapping of the scapula beneath the remaining
rib segment (II). In cases in which a very large full-thickness defect is present,
prosthetic mesh (MarJex, Prolene or Gore-Tex), possibly in combination with a rigid
material such as methylmethacrylate (often as a Marlex-methylmethacrylate~Marlex
sandwich), may be of benefit (11,12,69). The use of rigid material appears to enhance
both function and avoids the potential for a significant contour deformity. When the
costal margin is resected above the fifth rib, mesh alone or in combination with
methylmethacrylate may be necessary to provide a point of fixation for the diaphragm
while maintaining an adequate-sized chest cavity for effective respiration (II).
There are certain situations in which prosthetic materials should not be utilized
even in the presence of sizable defects. An infected or colonized wound is considered an
absolute contradiction to the use of prosthetic material (7). Prosthetic material could
theoretically be used in a delayed fashion, but usually the resultant fibrosis not only
precludes this approach but also results in enough stability of the chest wall to render a
reasonable function result with a muscle flap alone. In the setting of chest wall
reconstruction combined with radiotherapy it is imperative to achieve stable wound
coverage if prosthetic materials are needed, in order to avoid potentially horrific and
infectious sequelae (70). In these circumstances, therefore, local flaps that often are
prone to partial loss appear to be ofless utility than more robust axial patterned flaps
(7,70).
VII.

RADIOTHERAPY AND CHEST WALL RECONSTRUCTION

Radiation therapy, whether administered preoperatively or postoperatively, greatly


complicates reconstruction of the chest wall, and may lead to some of the most difficult
chest wall defects faced by the reconstructive surgeon. Its use compromises the quality
of the recipient bed, the availability of recipient vessels, and donor flap selection.
Injury caused by radiation was initially thought to be due to a vaso-occlusive process.
More recently, it has been postulated that these effects also result from a chromosomal
alteration of fibroblasts, a position supported by studies demonstrating an irreversible
inhibition of replication and dysfunction in collagen formation and breakdown in
fibroblasts after radiation (71-73).
In addition to overt injury to the skin, an increased incidence of delayed wound
healing and wound breakdown after radiation is well documented (74). For example, a
recent study from our institution demonstrates that more than 50% of patients who
underwent a mastectomy after radiation therapy for advanced breast cancer experienced wound complications (infection, dehiscence, necrosis), compared to 10% in a
study of nonirradiated patients (75). One-third of these patients required flap coverage

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for salvage. These findings suggest that a low threshold for prophylactic flap coverage
in irradiated wounds is prudent (76).
There also is a greatly increased complication rate with reconstructions performed in previously radiated tissues (7,77 ,78). The viability of radiated tissue is often
difficult to predict intraoperatively. Excision of all possible affected tissue is therefore
necessary to minimize subsequent wound breakdown (7). This significantly increases
the defect size and the reconstructive challenge. Prior radiation results in a hostile
recipient bed, and leads to increased flap complications such as fat necrosis (78).
Donor tissues must be harvested from sites well out of the irradiated field: total muscle
necrosis has been reported when irradiated muscles are transferred for reconstruction
(79,80). We often use microsurgical transfer of flaps to maximize tissue vascularity to
these compromised regions. It is unfortunate that radiation may also compromise the
quality of the recipient vessels available for microsurgical anastamosis.
Reconstruction prior to any planned radiation therapy, while technically easier,
must take into consideration the subsequent impact of radiation on the transferred
tissues. Radiation therapy after breast reconstruction appears to result in a complication rate of 30-87% (78,81,82). Flaps may demonstrate contracture and fibrosis, fat
necrosis, loss of skin grafts, or even partial flap loss after radiation. Although some of
these effects may be anticipated by the specific radiation dosage, ports, and boosts
utilized for treatment, patients manifest an individual response to radiation that is
often unpredictable and leads to a spectrum of clinical problems (77,78). In the setting
of breast reconstruction, radiotherapy leads to fibrosis and scarring, and may cause
painful and unattractive results (77,78). While aesthetic concerns may be less of an
issue in chest wall reconstruction than in breast reconstruction, patients clearly may
experience a lower quality of life due to pain or wound-healing problems.
Attempts to prevent the deleterious effects of radiotherapy are still in the early
phase. Substances called radioprotectors may reduce some of the early and late effects
of radiation while not affecting its antitumor efficacy. Use of amifostine (Ethyol), an
oxygen free radical scavenger, may be promising but has significant side effects such as
hypotension, and is still under investigation (83,84). The definitive treatment for severe
radiation injury remains the time-honored surgical principle of complete excision and
replacement of damaged tissues with well-vascularized tissue.
In summary, radiation has profound effects on chest wall reconstruction. It
adversely affects flaps utilized for wound closure when administered postoperatively.
Chest wall reconstruction performed in a previously radiated field may limit reconstructive options, result in a larger defect due to locally compromised tissue, and is
associated with an overall higher rate of complica tions (80,85). In our experience, the
more robust the tissues transferred for reconstruction, the better they fare with radiation. As such we favor a well-vascularized regional or free flap to ensure stable
coverage, and do not rely on local tissues.
VIII.

SUMMARY: ALGORITHM FOR CHEST WALL RECONSTRUCTION

Chest wall defects may be profound and complicated by prior surgery, radiotherapy,
or patient-related variables. Correction of a congenital chest wall deformity is largely
undertaken for aesthetic reasons. As such, the location and size of scars and potential
donor site deformities and the benefits of autologous vs. alloplastic techniques must be
carefully considered in these cases.

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Defects stemming from an infectious, traumatic, or neoplastic cause are, in


contrast, largely functional and primarily require stable wound coverage. For patients
with cancer it is especially imperative that the reconstructive techniques used neither
encumber nor delay any necessary postoperative therapy. They must not result in
unacceptable morbidity or compromise the patient's quality of life. Our surgical approach to these cases requires a multidisciplinary team, and each operative plan is
tailored to the individual patient. If the chest wall defect is superficial and small, local
flaps or skin grafts may be reasonable choices for wound closure. Chest wall defects
resulting from extirpation of extensive lesions, however, generally require wellvascularized flaps. The pedicled latissimus dorsi flap is our most common choice for
correction of moderate ipsilateral defects, but it may also be utilized as a free flap. The
rectus abdominis flaps provide an ample skin paddle, and have been of great utility in
larger defects. The decreased vascularity of zones III and IV in the pedicle transverse
rectus abdominis myocutaneous (TRAM) paddle leads us to prefer a free flap if these
regions are to be included for wound coverage.
Full-thickness chest wall defects pose an additional challenge. If only one or
two ribs are resected, rigid chest wall reconstruction is usually not required. Prosthetic
materials, primarily mesh, have been successfully employed in cases of larger defects,
with an acceptable complication rate, provided they are reliably covered with a wellvascularized flap. Multiple flaps may be necessary in this setting but are generally well
tolerated by patients. Chimeric flaps, such as the combination latissimus dorsi muscle,
serratus anterior muscle, and scapular territory skin, may be useful in providing
reliable large surface area coverage with only one arterial and venous microvascular
anastomosis (Fig. 5). In infected wounds, where use of prosthetic materials is to be
avoided, musculocutaneous flaps may provide adequate stability in addition to
providing wound coverage. Radiation therapy is frequently utilized in these patients,
and further complicates reconstruction. It compromises wound healing, as well as the
reconstructive options. Well-vascularized tissue must be brought to these wounds to
achieve coverage.
For all of the above-noted reasons, we most frequently use myocutaneous flaps
(specifically the rectus abdominis and latissimus dorsi flaps), in chest wall reconstruction. These flaps provide reliable, durable, quality coverage of defects and can tolerate
postoperative radiation. Flap harvest does, however, necessitate a donor site with
potential complications that should not be minimized. Myocutaneous flap harvest
may entail sacrifice of muscle function, with weakness, and/or abdominal hernia or
bulge. These donor site concerns may be limited with the use of perforator flaps. In a
setting where the relative decrease in flap vascularity seen in perforator flaps might
compromise reconstruction, such as a full-thickness chest wall defect. we are selective
in their use. Our experience suggests that the donor site deformity from a musculocutaneous flap harvest is generally well tolerated and the benefit- in the appropriate
patient seem clearly to outweigh the risks.

Figure 5

a. Chest wall resection included six ribs 1'01' trea tmen t or a breast ca ncer recurrence.
Marlex mesh-methylmethacrylate sandwich is in place. b. Chimeric flap consisted of latissimus
dorsi llJuscle, lower three slips of serratus anterior 1l1usclt:, and scapular/parascapular
fasciocutaneous territories raised on subscapular trunk c. Flap, partially skin grafted, was
healed at six-week follow-up visit. Donor site was closed primarily. (Case courtesy ~r Dr. Steven
Kronowitz.)

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320

Future longitudinal investigation will be needed to evaluate fully the efficacy of


newer approaches to chest wall reconstruction. Prospective study investigations will
need to address the potential benefits in terms of survival and quality of life of therapeutic as well as prophylactic intervention for chest wall reconstruction.

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22
Anatomy and Physiology of the
Abdominal Wall and Pelvis
KENTON D. FONG, HANJOON M. SONG, TONY D. FANG,
STEPHEN M. WARREN, and H. PETER LORENZ

STanford University School of Medicine, Stanford. California, U.S.A.

I.

INTRODUCTION

Complex abdominal wall and pelvic defects remain a challenge for plastic and
reconstructive surgeons. Both abdominal wall and pelvic defects can be congenital
(e.g., gastroschisis or omophalocele) or acquired (e.g., posttraumatic, infectionrelated, or postsurgical). Understanding the surgical anatomy and function of these
regions is crucial in planning reconstruction. In this chapter, we review the anatomy
and function of the adult abdominal wall and pelvis. We also highlight recent
anatomical studies in these regions that may be useful to the reconstructive surgeon.
This chapter will provide a surgical perspective to supplement the numerous atlases
that graphically depict the anatomy of the abdominal wall and pelvis (1-4).
II.

ABDOMINAL WALL

A.

Surface Anatomy, Skin, and Subcutaneous Tissues

The superficial landmarks of the abdomen include the costal arch, linea alba, linea
sumilunaris, umbilicus, anterior superior iliac spine, and symphysis pubis. Surgeons
have traditionally divided the abdomen into quadrants primarily for describing intraabdominal pathology. However, Hurwitz and Hollins first classified abdominal wall
defects into specific topographic subunits to aid in developing a systematic approach
to abdominal wall reconstruction (5). Rohrich et a!. recently described a simple and
perhaps more clinically useful classification (6). Their system divides the abdomen into

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six anatomical subunits (Fig. I). Subunits 1,2, and 3 correspond to upper, middle, and
lower midline regions, and subunits 4, 5, and 6 correspond to the upper, middle, and
lower lateral regions, respectively. The reconstructive approaches for defects in each of
these subunits will be discussed in other chapters.
The skin of the abdomen is well vascularized and thicker than on the extremities.
The redundant vascular supply of the skin comes from both superficial vessels and
perforators originating from the deep epigastric arteries; however, patients with a
prior history of incision may have significant disruptions in the cutaneous blood
supply. Thus, careful planning is necessary for new incision locations. Smoking, poor
nutritional status, and systemic disease can adversely affect cutaneous wound healing
and incisional scar tensile strength (7-10). In addition, a history of steroid or radiation
therapy can result in dermal attenuation and impaired wound healing (9).
The abdominal subcutaneous fat thickness is highly variable. Morbidly obese
patients have an increased wound disassociation risk and impaired wound healing;
thus, careful closure of the subcutaneous tissues in multiple layers in obese patients is
recommended (11-14). Separating the superficial fat layer and deep subcutaneous fat
layer is Scarpa's fascia, which laterally fuses with the fascia lata in the thigh. Medially
Scarpa's fascia forms Colles' fascia, which covers the perineal area (2,4). During

Figure 1 Six anatomical zones for organizing the anterior abdominal wall for surgical
reconstruction as described by Rohrich et al. (From Rer. 6.)

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abdominal wall reconstruction, the surgeon should attempt to preserve or reconstruct


the continuity of the superficial fat and fascial layer whenever possible to minimize
contour irregularities and optimize aesthetic outcomes.

B.

Muscles and Fascia

The primary muscles of the abdominal wall are the external oblique, internal oblique,
transversus abdominus, and rectus muscles. The fascial layers of the lateral muscles
(external oblique, internal oblique, and transversus abdominus) fuse to form the two
semilunar lines that border each side of the rectus. These fused fascial layers then split
and envelop the rectus muscle forming the anterior and posterior rectus sheaths that
join in the midline to form the linea alba.
The external oblique is the most superficial and broadest muscle of the anterolateral abdominal wall. The external oblique arises from the 5th-12th ribs. Its fibers
run downward and medially to mesh into the fascia of the linea semilunaris, anterior
rectus sheath, and linea alba. Posteriorly, the external oblique inserts into the iliac
crest.
The internal oblique muscle arises from the iliac crest, thoracolumbar fascia, and
the lateral half of the inguinal ligament. The internal oblique fibers run upward and
medially to insert superiorly on the 10th-12th ribs, medially at the xiphoid process
and linea alba after meshing into the fascia of the rectus sheath. Inferiorly, the internal
oblique fibers form the cremaster muscle and conjoined tendon. Some patients may
also have an accessory internal oblique that runs between the internal oblique and
transversus muscle, parallel to the arcuate line.
The third and deepest of the lateral abdominal muscles, the transversus
abdominus, arises from the 6-12th ribs, thoracolumbar fascia, iliac crest, and lateral
inguinal ligament. Similarly to the external and internal oblique muscles, the fibers
insert as an aponeurosis into the linea semilunaris and extend to the linea alba as part
of the rectus sheath.
The abdominal rectus muscle extends from the fifth to seventh intercostal
cartilages and xiphoid process to the superior ramus of the pubis. The paired recti
muscles are divided vertically by the linea alba and transversely by fibrous inscriptions
that attach the muscle firmly to the rectus sheath. There are usually three or four
transverse inscriptions along the length of the rectus muscle.
The pyramidalis muscles are minor abdominal muscles embedded within the
anterior wall of the rectus sheath. Arising from the pubis, the pyramidalis muscle
inserts into the linea alba below the umbilicus. Although commonly missing either
unilaterally or bilaterally, the pyramidalis muscle can be included with the rectus flap
to provide increased bulk for tissue transfers (2).
The rectus sheath is formed from the aponeuroses of the lateral abdominal
muscles (external oblique, internal oblique, and transversus abdominus) as they pass
anteriorly and posteriorly to the rectus muscle on their way to meeting at the linea alba
(Fig. 2). The external oblique aponeurosis always passes anterior to the rectus sheath.
However, the internal oblique aponeruosis may pass posteriorly, anteriorly, or both to
the rectus muscle. The arcuate line or semicircular line of Douglas is formed when the
internal oblique and transversus abdominus fibers in the superior abdominal wall that
were passing behind the rectus muscle abruptly switch to pass in front of the rectus
muscle (Fig. 2). Thus, in the inferior abdominal wall below the arcuate line, only the

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A.
~ . ~ Anterior Rectus Sheath

B.

EO

10
TA

~p~i~,
~:;.,,-;:-.(.. ~.

Posterior Rectus Sheath


.
of
jJ._~~"----TF

~~-

"-..P

c.
Figure 2

Arrangement of the rectus sheath components and abdominal wall fascia. A. At


the level above the costal margin. B. At the level below the costal margin and above the
arcuate line. C. At the level below the arcuate line. EO, External oblique; 10, Internal oblique,
TA, Transversus abdominis; RA, Rectus abdominis; TF, Transversalis fascia; P, Peritoneum.
(Modified and reprinted from Ref. 27.)

transversalis fascia is posterior to the rectus muscle. The arcuate line usually occurs
about one-third of the way down between the umbilicus and pubis. The external
oblique aponeurosis does not fuse with the internal oblique aponeurosis directly at the
linea semilunaris. Instead, it fuses medially to the linea semilunaris, allowing for the
reflection and use of the external oblique aponeurosis for reconstruction.
The deep or transversalis fascia surrounds the peritoneum and represents the
peri peritoneal fascias that exist below the transversus muscle. It is the only fascial layer
that completely envelops the entire abdominal cavity and is continuous with the
posterior rectus sheath, fascia of the diaphram, and fascia of the quadratus lumborum
and psoas muscles.
The external oblique, internal oblique, and transversus muscles act together to
compress the abdomen. This compression strengthens the inguinal canal and assists in
defecation, miturition, parturition, vomiting, forced expiration, and containment of
the abdominal viscera (3). The oblique and transversus muscles also act to depress the
thorax and flex and rotate the vertebral column. The rectus muscle acts as a depressor
of the thorax, flexor of the vertebral column, and upward rotator of the pelvis (2).

C,

Innervation

The neurocutaneous branches of the abdominal wall arise from the lower five or six
intercostals (T7-Til), the subcostal (T 12), and the iliohypogastric (T 12 and L 1) and
ilioinguinal nerves (L I). The lateral perforating branches of the intercostals, subcostal,
and iliohypogastric nerves innervate the external oblique. The internal oblique and
transversus abdominis muscles are also innervated by the intercostal, subcostal, and

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iliohypogastric nerves, and by the ilioinguinal nerve. The rectus abdominus muscle is
innervated by the five or six lower intercostals nerves and the subcostal nerve.
In the region of the arcuate line, the nerves pass superficial to the deep inferior
epigastric artery to penetrate the rectus muscle. Thus, when raising a perforator skin
flap based on the deep inferior epigastric artery pedicle, extra care must be taken if
function of the innerva tion of the rectus muscle is to be preserved (2). Hammond et al.
performed a detailed analysis of the rectus abdominis muscle innervation on 16
cadavers and found that 6-8 branches arising from the intercostal nerves passed into
the rectus muscle along a line extending from the xiphoid process to the pubis (15).
Most nerves entered the posterior side of the muscle in the lateral third (2-4 cm from
the lateral margin of the muscle). However, there were cases when the nerve entered
into the medial third of the rectus muscle near the midline. They also found two or
three nerves below the arcuate line that entered near the lateral margin of the rectus
abdominus muscle. In a concurrent clinical series, by means of a partial harvest of the
medial two-thirds of the rectus above the arcuate line, Hammond et al. were able to
preserve function of the full width of the remaining rectus muscle below the arcuate
line. In some patients, they were also able to preserve a degree of function in the la teral
third of the remaining rectus muscle above the arcua te line (15).
D.

Arteries, Veins, and Lymphatics

The major vessels in the abdominal wall are composed of both cutaneous and
musculocutaneous vessels. The superficial vessels include small branches from the
intercostals and anterior perforating branches that are derived from the superior and
inferior epigastric arteries. Along the length of the rectus muscle, both the superior and
inferior deep epigastrics send small perforators that penetrate the rectus from the
posterior side. The superficial iliac circumflex vessels and superficial epigastrics run in
the plane of the superficial fat and supply the abdominal wall close to the inguinal
ligament and iliac crest.
Although the abdominal surface anatomy may be divided into six subunits for
reconstructive planr\ing (see above), Huger has divided the abdominal wall into three
zones based on vascular supply (Fig. 3) (16). Zone I encompasses the midline area
between the xiphoid process and pubis with lateral borders being the lateral margins of
the rectus muscles. The primary arterial supply of zone I comes from the deep
epigastric arcade, composed of the deep superior epigastric artery from above and
the deep inferior epigastric artery from below with their respective branches and
perforators. The deep superior epigastric vessel runs between the posterior rectus
sheath and rectus muscle, and the deep inferior epigastric artery enters the rectus
sheath below the arcuate line. Both send branches to the rectus muscle, rectus sheath,
and overlying subcutaneous tissues and skin prior to their anastamosis within the
rectus muscle. Zone I also receives limited arterial perfusion at its lateral margins from
the anterior perforating branches of the intercostal arteries. Zone II encompasses the
lower abdomen below the level of the anterior iliac spine with the pubic and inguinal
creases as its inferior border. In zone II, the skin and subcutaneous tissue are supplied
by the superficial epigastric and superficial external pudendal arteries, both derived
from the femoral artery, as they course anterior to Scarpa's fascia. The deep inferior
epigastric artery supplies its overlying rectus muscle, fascias, and skin in the midline.
The deep circumflex iliac artery, with its superficial circumflex branch, supplies the

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Figure 3

Three vascular zones as described by Huger for abdominal lipectomy. (From Ref.

16.)

muscles and skin near the anterior iliac spine. The perforators of the deep and
superficial circumflex artery branches form important anastamoses. If the superficial
circumflex branch circulation is interrupted, the collaterals from the deep branch are
the only vascular supply to the skin and subcutaneous fa t in the lateral areas of zone II.
Zone III encompasses the areas lateral to zone 1. Zone III is supplied by the intercostals, subcostal, and lumbar arteries that arise from the aorta. For all the zones,
the venous return follows a similar pattern to the arterial supply.
With the development of the transverse rectus abdominal myocutaneous
(TRAM) flaps, several investigators have generated detailed maps of the anterior
abdominal wall vasculature (16-19). Boyd et al. used dye injections to trace the deep
superior and deep inferior epigastric arteries and their vascular territories (17). The
authors found that the deep inferior epigastric arteries were larger in diameter (average
3.4 mm compared to 1.6 mm) and had greater territories of cutaneous blood delivery
than the deep superior epigastric arteries. They also found tha t terminal branches from
the deep inferior epigastric artery constitute the highest concentration of perforators
that cross the an terior rectus shea th, and these perforators were most concentrated in
the periumbilical area. Boyd et al. also described staining in the periosteum, cortex,
and medulla of the 9-11 th ribs with injection of dye into the deep inferior epigastric
artery. Capitalizing on this finding, Yamamoto et al. designed and utilized a rectus
abdominis myocutaneous flap with a vascularized rib based on the superior or inferior
epigastric artery for reconstruction of mid face composite defects (20,21). El-Mrakby
et al. recently described in more detail the anatomy of the deep inferior epigastric

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vessels and its perforating branches (19). They concluded that the deep inferior
epigastric artery arises as a single vessel from the external iliac artery. In 80% of cases
the artery divided into two branches behind the muscle, and in 20% of cases there was
a third branch to the umbilicus. The lateral branch was the largest in 80% of cases and
had the most vessels that went on to perforate the anterior rectus sheath and run
beneath the surface of the skin. They found a bimodal pattern of blood supply to the
lower abdominal wall, with small perforators supplying the deep layers of the
subcutaneous fat and large perforators supplying the superficial layer of fat and
overlying skin. In all patients examined, a vessel to the umbilicus arose either directly
from the deep inferior epigastric artery or from one of its medial branches (18,19). This
may explain the ability of the isolated umbilicus to remain viable in patients undergoing abdominoplasty. Finally, the venous drainage of the TRAM flap was examined
by Carramenha e Costa et al. (22). They found that the deep inferior epigastric veins
contained valves that prevented retrograde flow. They also found that the primary
drainage was through periumbilical vertical perforators that emptied into the deep
superior epigastric veins. They concluded that TRAM flap design should attempt to
include as many periumbilical perforators as possible.
The Iympha tic drainage of the abdominal wall follows the venous drainage, but
with greater overlap. Superficially, zone II drains to the inguinal nodes, and at a deeper
level drains to the external iliac nodes via the deep epigastric vessels. Zone III drains to
the lateral lumbar nodes around the area of the iliac crest and to the superficial
inguinal nodes inferiorly. Zone I shares drainage with zone II by way of the deep
epigastric vessels, and it superficially shares drainage with zone III to the iliac crest and
lateral lumbar nodes.

III.

PELVIS

A.

Anatomical Overview

The bony boundaries of the pelvis form a complete ringlike structure bordered
anteriorly and laterally by innominate bones and posteriorly by the sacrum and
coccyx. The bones of the pelvis are formed from three components: iliac, pubic, and
ischial bones. These bones are bound by large ligaments and provide points offixation
for important pelvic and abdominal muscles. Anteriorly, the pelvic bones articulate at
the pubic symphysis and posteriorly meet at the sacrum to form the sacroiliac joints.
The inferior aspect of this ring is closed by the pelvic diaphram, composed of multiple
layers of muscle and fascia. In Anton and McVay's Surgical Anatomy, the authors
outline three main functions of the bony and ligamentous network comprising the
pelvic framework: protecting the pelvic visera, supporting the vertebral column, and
facilitating locomotion (23).
The bony ringlike structure of the pelvis can be further divided into two parts: the
greater (false pelvis) and lesser pelvis (true pelvis). These structures are separated by
the pelvic brim or iliopectineal line defined by the margin of the linea terminalis. The
greater pelvis is located in the abdominal cavity whereas the lesser pelvis is inferior and
houses the urinary and reproductive organs.
The greater pelvis lies above the linea terminalis and is defined posteriorly by the
ilium and lumbar vertebrae and laterally by the alae of the iliac bones. Conversely, the
lesser pelvis lies below the linea terminalis. The lesser pelvis is divided into an inlet and
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an outlet. The canal between the inlet and outlet forms the cavity of the pelvis, which
contains the pelvic organs. The pelvic outlet is bounded behind by the tip of the coccyx,
at the side by the ischial tuberosities, and in the front by the pubic arch. The bony wall
between the ischium and the ~occyx and sacrum is incomplete. The junctions are
bridged by the sacrospinous and sacrotuberous ligaments. These two ligaments also
form two foramina above and below the spine of the ischium: the greater and the lesser
sciatic foramen. Pelvic bony landmarks including the sacrum, coccyx, and posterior
iliac wings are useful as points of fixation for synthetic mesh when used for pelvic ring
and floor reconstruction (24).
The sacrum is comprised of five fused sacral vertebrae. Laterally, the sacrum
articulates with the pelvic bones. Inferiorly, the coccyx lies at the base of the sacrum.
The median sacral crest is the vertical ridge of bone on the external (posterior) surface
of the sacrum. On both sides of the median sacral crest are the anterior and posterior
sacral foramina through which the ventral and dorsal rami of the sacral nerves pass.
The overlying fat provides padding for the bony projections of the sacrococcygeal
region. However, in thin or poorly nourished patients, the padding in this region is
diminished, thus increasing the risk for pressure sore formation.
The intrinsic pelvic viscera refer to those organs that are directly fixed to the floor
and walls of the pelvis. In males, the pelvic viscera include the rectum, bladder,
prostate, ureters, seminal vesicles, and deferens ductae; in females, the viscera include
the rectum, urinary bladder, urethra, ureters, uterus, vagina, uterine tubes, and
ovaries. The uterus and vagina lie between the bladder and rectum in females, while
in males the prostate, seminal vesicles, and ductus deferens are stationed between the
bladder and rectum. Bowel segments that may prolapse into the cavity of the pelvis are
not considered part of the intrinsic pelvic viscera because they are fixed to the walls of
the abdomen and the false pelvis.
B.

Pelvic Diaphragm

The pelvic diaphragm is a concave structure, collectively consisting of muscles and


their associated aponeuroses, sitting at the most inferior aspect of the pelvis (Fig. 4).
The pelvic diaphram closes the inferior outlet of the pelvis and separates the pelvis
superiorly from the perineum below. One key function of the pelvic diaphragm is to
support the weight of the overlying viscera when the body is erect. The pelvic
diaphragm also functions during defecation, micturition, and birthing. An important
component of the pelvic diaphragm, the fibromuscular perineal body, represents the
convergence of several muscles including the levator ani and the external sphincter of
the anal canal. The perineal body is located posterior to the prostate in males and the
vagina in females. Damage to this important structure during surgical extirpation can
lead to pelvic floor laxity, thus increasing the risk for perineal herniation. Reconstruction of pelvic diaphragm defects is necessary to prevent herniation of the pelvic
and abdominal viscera. Synthetic materials such as Marlex mesh are commonly
employed, but gluteal myofascial flaps are other alternatives for diaphragm reconstruction.
The muscular part of the diaphragm consists of two groups of muscles: a pair of
levator ani and coccygeus muscles (Fig. 4). The anterior portion of the diaphragm is
not completely covered by these muscles. Each levator ani muscle is composed of a
lateral and a medial portion, termed iliococcygeus and pubococcygeus. The iliococ-

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,~

...,'"; m. {

Position of
Perineal body
Genital hiatus

Figure 4

Muscles of the pelvic diaphragm. (From Ref 26.)

cygeus arises from the posterolateral aspect of the body of the pubis and from the linea
tenninalis of the parietal pelvic fascia. Its fibers run obliquely downward and backward, passing under the puboccygeus and finally inserting into the anococcygeal
raphe. The pubococcygeus arises from the pubic body nearer to the median line than to
the lateral ligament. It is directed posteriorly along the lateral surface of the prostate or
vagina and, after entering into the composition of the central tendinous area of the
pelvic diaphram, blends with the longitudinal muscle of the rectum near the anal
margin. The levator ani muscles are innervated by the fourth sacral nerve and by
branches of the pudendal nerve. The coccygeus muscle forms the posterior part of the
diaphragm arising from the ischial spine to points of insertion on the lateral aspect of
the sacrum and coccyx. This muscle is innervated by the perineal branch of the fourth
sacral nerve.
In between the pelvic diaph agm and the pelvic peritoneum, lies the extraperitoneal space. This space can be divided into three compartments: lateral rectal,
retrorectal, and retrovesical compartments. The extra peritoneal space contains areolar tissue that is in communication with the gluteal and obturator region. Infection of
this space can travel upward into the iliac fossae and anterior abdominal wall. The
pelvic peritoneum, rising and depressing into the bladder, rectum, and pelvic genitals,
forms many recesses or cul-de-sacs. The lateral recesses around the rectum (Douglas
recesses) separate the rectum from the urogenital organs and descend to within 6-7 cm
of the perineum.

C.

Arteries and Veins

The common iliac arteries bifurcate into the internal and external iliac arteries. The
external iliacs form into the common femoral arteries and supply the lower extrem-

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ities. The internal iliacs (or hypogastric) arteries arborize to supply the pelvis and are
divided into two categories: parietal and visceral. An overview of the arterial supply
to the pelvis is shown in Figure 5. The parietal vessels supply the pelvic walls, and
visceral vessels supply the pelvic viscera. The hypogastric artery runs medial to the
psoas muscle along the sacroiliac joint line and descends almost vertically into the
pelvis. After giving off the iliolumbar and lateral sacral arteries, it divides into a
posterior trunk and a smaller anterior trunk at the upper margin of the greater sciatic
foramen. The posterior trunk gives rise to several vessels including the superior
gluteal artery, which passes through the suprapiriform space to the gluteal region.
The anterior branch is the primary artery supplying the pelvic organs (uterus,
bladder, and rectum). The anterior branch also gives rise to parietal branches: the
obturator artery, inferior gluteal artery, and internal pudendal branches. The obturator artery may be displaced and rise from the inferior epigastric artery. The
visceral and parietal veins form rich anastomostic plexuses in the presacral space that
eventually drain to the hypogastric veins.
D.

Nerve Supplies

The sciatic nerve (L4-S3) passes through the sciatic foramen and enters the buttocks
on its way to the lower extremity. In the buttocks, the sciatic nerve gives rise to the
superior and inferior gluteal nerves, and the nerves to the obturator internus,

Right common iliac a.

Umbilical a.
Internal iliac a.

External iliac a.
_Iliolumbar a.

Obturator a.
"""~;,z;....-"'_----',,.--

Lateral sacral a.

Medial umbilIcal
ligament

Superior gluteal a.
Pirifomlis m.
--- Inferior gluteal a.

Superior vesical aa.

Coccygeus m.
Inferior vesical a.
Obturator
Internus m.

Figure 5

Internal pudendal a.

Arterial supply of. the pelvis. (From Ref. 26.)

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quadratus femoris, and gemilli. One cutaneous branch, the posterior femoral cutaneous nerve, runs along the inferior gluteal artery and can be included for sensation in
posterior thigh flaps (24). The external genitals and most parts of the perineum are
supplied by the pudendal plexus. This plexus is made of the anterior divisions of the
second and third sacral nerves, the anterior division of the fourth and fifth sacral
nerves, and the coccygeal nerve.
E.

Gluteal Region

The gluteal region is often utilized for flap coverage to the pelvic and perineal area after
injury, tumor resection, or pressure ulcer formation. The gluteal skin is innervated
superiorly by the subcostal, iliohypogastric, and cutaneous branches of lumbar dorsal
rami and inferiorly by the posterior cutaneous nerve of the thigh. Three main muscles
lie in this region: gluteus maximus, gluteus medius, and gluteus minimus. The
remaining muscles in the gluteal region include the piriformis, gemelli, quadratus
femoris, and obturator internus muscle. The gluteus maximus arises from the iliac
bone and attaches to both the fascia lata (superficial fibers) and the femoral gluteal
tuberosity (deep fibers). Innervation to this thigh extensor muscle is from the inferior
gluteal nerve. The gluteus medius arises between the posterior and anterior gluteal line
of the iliacs, which is between the origins of the gluteus maximus and gluteus minimus
and ends on the lateral aspect of the greater trochanter of the femur. The innervation
to the gluteus medius is from the superior gluteal nerve. The gluteus minimus muscle
originates posterior to the gluteus medius and inserts on the greater trochanter of the
femor, just deep to the attachment site of the gluteus medius. Like the gluteus medius,
the gluteus minimus is an abductor of the thigh and is innervated by the superior
gluteal nerve. Both the superior and inferior gluteal arteries supply the gluteus
maximus, gluteus medius, and gluteus minimus. Each muscle can survive off either
artery alone as the superior and inferior gluteal arteries form cruciate anastomosises.
Both these arteries, in addition to other arteries in the gluteul region such as the
internal pudendal artery, give off many cutaneous perforators. The skin has a rich
blood supply, making gluteal myocutaneous and fasciocutaneous flaps useful for
reconstruction of perineal-buttock defects. The existence of direct cutaneous perforators also allows reconstructive surgeons to harvest perforator flaps that decrease flap
bulkiness and can improved functional outcomes after reconstruction (25).
F.

Ureters

The anatomy of the ureters deserves particular attention by reconstructive surgeons,


since these structures are intimately involved with many vital vessels and pelvic organs.
As a consequence, an understanding of the course of ureters as they pass from the
kidney to the trigone area of the bladder is important in decreasing the risk of
iatrogenic injury. The ureters are retroperitoneal structures approximately 13 cm long
that course their way from the kidneys to the bladder along the posterior abdominal
wall. The ureters begin their descent traveling along the psoas major muscle. Upon
passing the pelvic brim, the ureters cross the common iliac vessels before emptying in
the posterior portion of the urinary bladder, at the upper border of the trigone. In
males, the ductus deferens lies above the ureter, whereas in females the uterine artery is
superior to the ureter (26). Similarly to the urinary bladder, the ureters are innervated
by both parasympathetic and sympathetic fibers, although the exact nature of this

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innervation is unknown. The muscular wall of the ureter is responsible for its
peristaltic action. The blood supply to the ureters comes from various sources. At
the upper portion of the ureters, the blood supply comes mainly from branches of the
renal artery. Blood supply from the middle to lower portions of the ureters comes from
various branches of the aorta, testicular and ovarian arteries, as well as branches of the
internal iliac arteries.
IV.

CONCLUSIONS

For successful abdominal and pelvic reconstruction, a thorough understanding of the


anatomy and physiology is essential. This knowledge allows the reconstructive
surgeon to identify readily missing tissues in a defect and determine those that require
functional reconstruction. This chapter provides an overview of the muscular, fascial,
and neurovascular anatomy of the abdominal wall and pelvis, which will serve as a
foundation for abdominal wall and pelvic reconstructive approaches described in
subsequent chapters.
REFERENCES
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Netter FH. Atlas of Human Anatomy 1st ed. East Hanover, NJ: Novartis Pharmaceuticals Corp., 1989.
Hollinshead WH. Anatomy for Surgeons. 2nd ed. New York: Harper and Row, 1971.
Joseph J. A Textbook of Regional Anatomy. Baltimore: University Park Press, 1982.
Thorek P. Anatomy in Surgery. 3rd ed. New York: Springer-Verlag, 1985.
Hurwitz DJ, Hollins RR. Reconstruction of the abdominal wall and groin. In: Cohen M,
ed. Mastery of Plastic and Reconstructive Surtgery. Boston: Little, Brown, 1994.
Rohrich RJ, et aL An algorithm for abdominal wall reconstruction. Plast Reconstr Surg
2000; I05( I):202-216
Pontieri-Lewis V. The role of nutrition in wound healing. Med Surg Nurs 1997; 6(4) (187190,221; quiz 191-192).
Eneroth M, et aL Improved wound healing in transtibial amputees receiving supplementary nutrition. Int Orthop 1997; 21(2):104-108.
Hunt TK, HopfH, Hussain Z. Physiology of wound healing. Adv Skin Wound Care 2000;
13(2 Suppl):6-11.
Silverstein P. Smoking and wound healing. Am J Med 1992; 93(IA):22S-24S.
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and closure of subcutaneous tissue. Int J Gynaecol Obstet 1997; 57( I): 17-21.
Armstrong M. Obesity as an intrinsic factor affecting wound healing. J Wound Care 1998;
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Pavlidis TE, et aL Complete dehiscence of the abdominal wound and incriminating factors.
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Hammond DC, et a1. Rectus abdominis muscle innervation: implications for TRAM flap
elevation. Plast Reconstr Surg ]995; 96(1):105-110.
Huger WE Jr. The anatomic rationale for abdominal lipectomy. Am Surg 1979: 45(9):
612-617
Boyd J B, Taylor G I, Coriell R. The vascular territories of the superior epigastric and the
deep inferior epigastric systems. Plast Reconstr Surg 1984; 73(1):]-16.
EI-Mrakby HH, Milner RH. The suprafascial course of the direct paraumbilical perforator
vessels. Plast Reconstr Surg 2002; 109(5): 1766-1768.

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EI-Mrakby HH, Milner RH. The vascular anatomy of the lower anterior abdominal wall: a
microdissection study on the deep inferior epigastric vessels and the perforator branches.
Plast Reconstr Surg 2002; 109(2):539-543 (discussion 544-547).
20. Yamamoto Y, et al. The rectus abdominis myocutaneous flap combined with vascularized
costal cartilages in reconstructive craniofacial surgery. Plast Reconstr Surg 1997;
I00(2):439--444 (discussion 445--446).
21. Yamamoto Y, et al. An anatomic study for the rectus abdominis myocutaneous flap
combined with a vascularized rib. Plast Reconstr Surg 1995; 96(6): 1336-1340.
22. Carramenha e Costa MA, et al. An anatomic study of the venous drainage of the transverse
rectus abdominis musculocutaneous flap. Plast Reconstr Surg 1987; 79(2):208-217.
23. McVay C, Anson JB. Bony and Ligamentous Pelvis. In: McVay C, ed. Surgical Anatomy.
Philadelphia: WB Saunders, 1984;783-795.
24. Rosen JM, Mo ST, Liu A. Experience with the island inferior gluteal thigh flap compared
with other local flaps for the reconstruction of the pelvic area. Ann Plast Surg 1990;
24(6):498-509.
25. Hashimoto I, et al. The gluteal-fold flap for vulvar and buttock reconstruction: anatomic
study and adjustment of flap volume. Plast Reconstr Surg 2001; 108(7):1998-2005
26. Hall-Craggs E. The Pelvis. In: Hall-Craggs E, ed. Anatomy as a Basis for Clinical
Medicine. Baltimore: Urban and Schwarzenberg, 1990.
27. Forsman A. Anatomy Diagrams (http://faculty.etsll.edu/forsman).

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23
Tumors of the Pelvis
ALAN W. VASKO

Unil'ersily of Texas M.D. Anderson Cancer COlier, HOI/sian. Texas, U.S.A.

I.

INTRODUCTION

Tumors of the bony pelvis and sacrum are rare and diverse. They are problematic
clinically because the presenting symptoms commonly are vague, of long duration,
and can mirror those of nonneoplastic processes. A multidisciplinary approach is
recommended to optimize disease management. Preoperative planning is critical to the
success of the tumor extirpation and pelvic reconstruction in order to minimize the
myriad potential intraoperative and postoperative complications. As a result, most
primary tumors of the pelvis and sacrum present as locally advanced destructive
processes.
The range of surgical techniques available to address these tumors is broad. The
approach used is both disease- and site-specific and therefore should be individualized.
A review of the current surgical approaches to pelvic tumors and reconstruction is
presented in the following sections.
II.

CLINICAL PRESENTATION

The clinical presentation for most patients with primary malignancies of the bony
pelvis and sacrum is nonspecific. A long-standing history of vague groin, lower
abdominal, gluteal, low back, or sciatic pain is common. Abdominal fullness; bowel,
bladder, or sexual dysfunction; or a gluteal mass may prompt medical attention.
Patients with a known malignancy metastatic to bone commonly present with new
onset of skeletal pain localized to the lower back, pelvis, or hip.
The age spectrum for primary malignant tumors of the pelvis is wide. Primary
malignant tumors of the pelvis include chondrosarcoma, Ewing's sarcoma, and osteosarcoma. More than 50% of patients with chondrosarcoma are in their fourth, fifth,

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and sixth decade of life. Ewing's sarcoma and osteosarcoma are diseases of childhood
and adolescence. Chordoma is the most common primary malignancy of the sacrum.
The peak incidence for this tumor is in patients over 40 years of age. Secondary
malignancies including Paget's sarcoma and radiation-associated sarcoma occur only
rarely.
The most clinically significant primary benign tumor of the pelvis and sacrum is
giant cell tumor of bone. Although histologically benign, it exhibits locally aggressive
behavior resulting in marked bone loss. Giant cell tumor of bone occurs most
commonly in patients in their third and fourth decades of life.
Multiple myeloma, lymphoma, and metastatic carcinomas (most commonly
from the breast, prostate, kidney, and lung), more frequently involve the pelvis and
sacrum than do primary neoplasms of bone. A high index of suspicion for bone
metastasis should be maintained in patients over 40 years of age presenting with a bony
pelvic lesion.
III.

PREOPERATIVE ASSESSMENT

Appropriate imaging studies of the pelvis and sacrum are critical to the diagnosis and
local staging of pelvic and sacral tumors. Initial imaging should include an anteriorposterior plain radiograph of the pelvis to detect localized bone destruction when a
patient presents with pelvic, lower abdominal, or gluteal pain. Radiographs of the
pelvis should be obtained when no clearly defined lesion is noted in the lumbar spine in
patients presenting with low back or radicular pain (Fig. 1). Plain radiographs, however, are limited by the two-dimensional nature of the imaging technique, lack of
effective biplanar views, the interference of overlying bowel gas, and complex skeletal
anatomy. In the absence of a lesion on radiographs, technetium bone scans may be
helpful to identify an occult lesion prior to performing a cross-sectional imaging study.
Obvious or suspicious areas of abnormality on plain films or bone scan should be
imaged with a computed tomography (CT) and or magnetic resonance (MR) imaging.
Axial, sagittal, and coronal images provided by MR are critical to delineation of the
local extent of the osseous and extraosseous components of the tumor and their relationship to the retroperitoneal and midline abdominal structures (Fig. 2). A CT scan
provides crucial complementary information regarding the nature of the bone
destruction, periosteal reaction, tumor matrix mineralization pattern, and extent
and risk of bone for fracture (Fig. 3).
Whole-body technetium bone scan and chest radiographs (including CT scan of
the chest) are the appropriate staging studies to evaluate for metastatic disease once a
primary pelvic tumor has been diagnosed.
A biopsy is indicated to establi h the diagnosis unless a temporal relationship to
a known primary malignancy suggests a metastasis. Image-guided percutaneous
needle biopsy is recommended. The most commonly used modality is the CT scan.
The biopsy should be directed at the soft tissue mass, if present, and should avoid
contamination of the pelvic viscera and neurovascular structures. Transrectal biopsies
are to be avoided for sacral lesions with presacral soft tissue masses. Tumors arising in
the posterior ilium and sacrum are approached directly posterior. Tumors with
intrapelvic soft tissue masses usually are biopsied through the retroperitoneal space
to avoid intraperitoneal contamina tion. Fine-needle aspiration and core needle biopsy
yields adequate tissue for diagnosis in the vast majority of patients.

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(a)

(b)
Figure 1

Plain radiographs (anterior-posterior projection) of the pelvis demonstrating a


lytic lesion in the right acetabulum (a) and osteoblastic lesion in the left hemipelvis (b).

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(a)

(b)
Figure 2 Magnetic resonance images of a pelvic osteosarcoma in cross-section (a) and
sacral chordoma in sagittal view (b).

IV.

PATHOPHYSIOLOGY

Primary malignant tumors of the pelvis include osteosarcoma, Ewing's sarcoma, and
chondrosarcoma. The most common primary malignant tumor of the sacrum is chordoma. Osteosarcomas arise in the pelvis in approximately 10% of all cases (11,12,14).
Ewing's sarcoma of the pelvis occurs in approximately 20% of patients with this
diagnosis (13,29). The pelvis is the most frequent site of primary involvement of
chondrosarcoma, representing 20-30% of cases (21,27).

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Figure 3 Computed tomographic imagic of a pelvic chondrosarcoma. This study demonstrates the tumor matrix mineralization characteristic of secondary chondrosarcoma. The
extrapelvic extent of the tumor and absence of intrapelvic extension were delineated.

The bony pelvis and sacrum are susceptible to the long-term effects of the
treatment of gynecological and genitourinary cancers. Radiation-associated sarcomas
arise most frequently in patients with a history of gynecological and prostate
carcinomas for which local radiation was delivered as part of their local treatment.
Sarcomas (malignant fibrous histiocytoma or osteosarcoma) arising in pagetic bone
are rare, but can be observed in the pelvis since this site is commonly involved in
patients with Paget's disease.
The bony pelvis is rich in red marrow and thus is a fertile microscopic environment for bone metastases. The pelvis was involved in approximately 40% of patients
who died of cancer in one large series (6). Carcinomas of the breast, prostate, kidney,
and lung are most common. The most significant clinical lesions are those arising from
renal and thyroid carcinomas. They are commonly large, locally destructive, and
richly vascular. Not infrequently they are solitary.

V.

SURGICAL INDICATIONS

Contemporary treatment of primary malignancies of bone includes bimodal or


multi modal treatment regimens. Disease-specific induction chemotherapy is administered for osteosarcoma and Ewing's sarcoma in conjunction with en bloc surgical
excision. External beam radiation can be a critical part of the combined modality
approach to localized Ewing's sarcoma or as the primary local therapy. Chondrosarcoma and chordoma are treated by surgical excision. Secondary malignancies
(Paget's sarcoma or radiation-associated sarcoma) manifest typically as malignant fibrous histiocytoma or osteosarcoma and are treated similarly to primary
osteosarcoma.
In general, benign tumors of the pelvis and sacrum are treated by intralesional
excision using thorough curettage. Of the benign tumors that involve the pelvic bones,

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giant cell tumor of bone is clinically the most problematic because of its locally
aggressive behavioLIn selected cases of giant cell tumor of bone, the locally advanced
stage at presentation, with marked associated bone destruction, may preclude
curettage as a reasonable attempt to gain local tumor control. En bloc resection
may be considered to optimize local tumor control (25). Unresectable giant cell tumors
of the pelvis and sacrum may be approached with nonoperative therapy, including
radiation, serial transcatheter arterial embolization (15,17), or a combination (17).
Metastatic carcinomas, multiple myeloma, and lymphoma commonly involve
the pelvis and are treated with disease-specific multiagent chemotherapy and radiation. Surgery is indicated to palliate pain and to stabilize a fracture in the weightbearing regions of the pelvis (18). Solitary metastatic deposits primarily from renal
and thyroid carcinomas merit consideration of en bloc resection (4).
VI.

TREATMENT OBJECTIVES

As with the treatment of any malignant tumor involving the bone, there are two
objectives of surgery: local tumor control and restoration of function. The complexity
of the pelvic anatomy and locally advanced disease commonly observed in patients
make both objectives difficult to achieve.
The principal objective of surgery is local tumor control. The overriding surgical
tenet is to achieve a wide surgical margin through en bloc resection to reduce local
tumor recurrence. The en bloc resection of tumor usually results in removal of a
generous portion of the tumor-bearing portion of the bony pelvis and a cuff of the
enveloping hip girdle muscles. The gluteal muscles are at risk with large extrapelvic
extension of tumor into the buttocks. The iliacus and psoas muscles are vulnerable to
intrapelvic extension of tumors.
The second objective is restoration and optimization of function. The functional
outcome of the affected extremity is predicated on the degree of pelvic instability,
extent of remaining muscles about the hip, and the preservation of innervation of
muscles from the lumbosacral plexus. Not all pelvic resections require reconstruction.
VII.

SURGICAL PROCEDURES

Anatomical regions of the pelvis described by Enneking and Dunham are used to
define the scope of the limb-sparing pelvic resection performed (8) (Fig. 4). Region I
represents the ilium. A type I resection involves resection of part or all of the ilium,
sparing the acetabular region and hip joint integrity. Region II is the periacetabular
area and includes part of the ilum, pubis, and ischium that make up the walls of the
acetabulum. The convergence of the three innominate bones to form the acetabulum
results in the frequent sacrifice of the hip joint (type II resection) to accomplish the
objectives of surgery. Most pelvic resections involve the periacetabular region. Region
III represents the anterior pelvis structures including the pubis and ischium medial and
inferior to the acetabulum, respectively. Type III resections include all or part of the
pubis and ischium. Region IV (or region S) represents the sacrum. The epicenter of
tumor may be identifiable within one region, but the local extent of most tumors, and
therefore most pelvic tumor resections, involves two or more regions to achieve wide
oncological margins.

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Figure 4 Schematic diagram of the regions of the pelvis upon which the types of resection
are described.

A.

Type I Resections (Ilium)

The posterior arm of the ilioinguinal approach exposes the ilium, sciatic notch, and
ipsilateral sacral ala. If the tumor can be resected with satisfactory margins without
disrupting the pelvic ring, a wedge resection of the iliac wing can be performed. The
osteotomy is within the substance of the body of the ilium. More typically, the
osteotomy is performed through the sciatic notch anteriorly and through the sacroiliac
joint or sacral ala posteriorly (extended type I) either lateral to the sacral foramen,
through the foramen, or medial to the foramen (hemisacrectomy). Since the weightbearing arch of the pelvis is disrupted, reconstruction should be considered to optimize
pelvic stability.

B.

Type II Resections: (Peri-Acetabulum)

These resections use a generous ilioinguinal approach to mobilize the femoral nerve
and vessels anteriorly and medially to access the sciatic notch within and outside the
pelvis, to optimize exposure of the acetabulum. The osteotomy is performed through
the sciatic notch posteriorly and through both the anterior (at the lateral margin of the
pubis) and posterior (at the superior margin of the ischium) columns anteriorly.
Peri acetabular resections represent the most challenging surgical resections and
reconstructions of the pelvis. Reconstruction is performed most commonly for this
type of pelvic resection.

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C.

Vasko

Type III (Pubis and/or Ischium)

Anterior pelvic tumors commonly can be resected with preservation of the acetabulum. Often a portion of the acetabulum inferior to the fovea is resected in a type III
procedure. The inguinal arm of the ilioinguinal approach is developed to gain access to
the femoral nerve and vessels. Exposure of the intrapelvic and extrapelvic obturator
regions can be achieved through this approach. A perineal incision can be created to
gain additional exposure, if necessary, along the body of the pubis and inferior pubic
ramus. The osteotomy for the type III resections is performed through the pubic
symphysis or contralateral pubis medially and through the anterior column at the
lateral margin of the pubis and through the posterior column at the superior margin of
the ischium (lateral aspect of the obturator foramen) laterally.
For primary tumors of the sacrum, exposure of the anterior aspect is approached
through either a midline transabdominal incision or bilateral retroperitoneal approach through ilioinguinal incisions. The transabdominal approach permits full
visualization of the anterior sacrum through a single incision. The peritoneum overlying the iliac vessels is incised to reach the anterior sacrum. The rectum can be
mobilized or resected as dictated by local tumor extent. Direct visualization of the
sacrum, L5-S I disk, pelvic vasculature, and lumbosacral plexus can be achieved
through this single approach. As an alternative, unilateral or bilateral ilioinguinal
approaches can be used to expose the anterior sacrum.
Posterior exposure of the sacrum is performed through a longitudinal midline
approach. Less frequently, triradiate exposure can reveal the course of the sciatic
nerves caudally. Transection of the pelvic floor musculature from the sacral attachments allows access to the rectum and facilitates access to the presacral space.
Depending on the presacral extent of tumor, a subtotal sacral resection up through
S2 level can be performed through a single posterior approach. Partial sacrectomy
above the level of S2 and total sacrectomy usually are performed through combined
anterior and posterior approaches. Hemisacral resection is often performed in
conjunction with a type I pelvic resection; however, tumors emerging eccentrically
within the sacrum may be amenable to a hemisacral resection.
VIII.
A.

SURGICAL TECHNIQUE
Tumor Extirpation

The patient is placed in the lateral dec~lbitus position. with support for this position
maintained below the midline in both aspects with an inflatable bean bag to allow
al ternating exposure of the anterior and posterior aspects of the pelvis from beyond
midline abdomen to beyond midline sacral. The ipsilateral lower extremity is prepped
free. All regions of the pelvis can be exposed through part or all of an extended
ilioinguinal incision. Following the iliac crest. the anterior arm can be extended
beyond midline to gain exposure of the anterior pelvis including both pubic bodies. A
perineal arm of the inguinal incision made along the axi of the pubis body on the
affected side can extend the exposure for the extrapelvic obturator region. The
posterior arm can be extended to the posterior superior iliac spine or to the midline
of the vertebrae. Intrapelvic and extra pelvic exposure of the ilium can be achieved. The
incision posteriorly can be formed into a T along the spinous processes of the lumbar
spine and sarcrum if additional exposure of the sacrum i nece sary. This combined

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approach is effective in exposing the posterior pelvis through the lateral decubitus
position (28). The midincision also can be formed into a T and extended along the
anterolateral thigh to gain additional exposure of the lateral aspect of the adductor
compartment, hip joint, and extrapelvic course of the sciatic nerve. Anteriorly, the
internervous plane between the tensor fascia lata and the quadriceps muscles can be
developed easily. Posteriorly, the internervous plane between the gluteus medius and
gluteus maximus can be developed if the hip abductor muscles are involved. If the
abductor muscles can be preserved, the plane of extraperiosteal dissection can be deep
to the gluteus medius.
The objectives of the intrapelvic dissection are to mobilize the iliac vessels from
the tumor and pelvic sidewall to expose the sacroiliac, sciatic notch, and retropubic
regions. The plane of dissection to achieve these objectives varies, however; in general
the plane of dissection is medial to the iliacus muscle. The interval between the iliacus
and psoas muscles can be developed to mobilize the femoral nerve fully and expose the
LS nerve root along its course from its neural foramen to the sciatic notch. Transecting
the psoas muscle or developing the plane medial to the psoas muscle can facilitate full
exposure of the internal iliac vessels and the pelvic sidewall. Anteriorly, the obturator
nerve and vessels are identified as they course through the obturator foramen. Posteriorly, the LS nerve root is identified as a landmark for the sacral ala medial to the
sacroiliac joint and lateral to the sacral foramen. The common and external iliac vessels are preserved in the vast majority of tumors resections. The internal iliac vessels
may be sacrificed as they course along the pelvic sidewall and into the sciatic notch.
The obturator vessels are sacrificed if the anterior pelvis is resected. Nerves at risk for
resection or injury include the LS nerve root posteriorly along the sacrum, obturator,
and femoral nerves anteriorly, and the gluteal nerves within the sciatic notch. Bone is
exposed by subperiosteal dissection at the planned level of osteotomy.
Satisfactory oncological margins are obtained by adherence to the surgical principle of achieving a wide bone and soft tissue margin about the tumor. Bone margins
are determined preoperatively. A plane of soft tissue is maintained on the surface of
the extraosseous portion of the tumor. Usually the iliacus muscle is sacrificed when
intrapelvic soft tissue tumor extension is present. Portions of the hip abductor muscles
are resected when extrapelvic soft tissue extension is present. Muscle origins and insertions on the pelvis are transected extraperiosteally to maintain a cuff of normal
soft tissue along the abdominal and thigh muscles. Adductor muscle function loss
does not significantly affect use of the affected lower extremity. Usually the gluteus
maximus muscle can be preserved. Without retention of the gluteus medius, reconstruction of the bony pelvis and of a mobile hip joint is questionable. Dead space
following resection of the pelvis can be addressed by soft tissue reconstructive techniques discussed elsewhere in this text.
B.

Pelvic Reconstruction

Patient age, body habitus, medical condition, functional demands, extent of the tumor,
and the inherent risk/benefit ratio of the procedure influence selection of the reconstruction technique. Reconstruction options also are site- and disease-dependent. In
general, en bloc resection of the tumor-bearing portion of the pelvis and/or sacrum
results in an osseous defect that can be reconstructed in myriad ways using biological,
non biological, or combinations of both types of implants. The hip joint may be fused

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immobile by arthrodesis (iliofemoral or ischiofemoral).lt may also be reconstructed to


maintain a mobile joint by creating a pseudarthrosis or reconstructing the osseous
defect with an allograft-prosthesis composite, saddle prosthesis, or custom prosthetic
replacement.
The majority of lesions secondary to metastatic disease are not solitary and
therefore en bloc resection is not indicated. However, surgery is indicated for periacetabular tumors that cause pain and compromise hip function. Maximal preservation
of bone stock and soft tissues (i.e., hip musculature) results from intralesional excision
of the acetabular disease by curettage. Reconstruction of the acetabulum commonly
requires an antiprotrusion ring, cage, or pins to support the cemented acetabular
component of the total hip arthroplasty. Jmmediate weightbearing is permitted. Total
hip arthroplasty precautions are similar to those in patients undergoing standard hip
arthroplasty for nonneoplastic indications. An isolated metastasis of a tumor known
to be associated with potential long-term survival, such as renal cell carcinoma and
thyroid carcinoma, may be approached with en bloc resection in a manner similar to
that applied for a primary malignancy of bone. The method of reconstruction of the
pelvis defect after en bloc tumor resection varies according to the anatomical location,
extent of resection, and the goals of surgery.
Type I resections without disruption of the pelvic ring require no bony reconstruction (Fig. 5). With disruption of the ring, stability without reconstruction is
variable and dependent on the extent of the resection (Figs. 6, 7). Discontinuity of the
pelvic ring does not necessitate reconstruction in all patients, but fixation of the pelvis
to the sacrum or lower lumber vertebrae has been reported to prevent limb shortening associated with cephalad migration of the hip and anterior pelvis about the symphysis pubis (26). Autologous vascularized and non vascularized fibular strut grafts,

Figure 5 Postoperative plain radiographs show a type I wedge resection of the right ilium
(without pelvic ring disruption).
v

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Figure 6

349

Plain radiograph of a type I resection of the ilium with disruption of the pelvic

continuity.

structural segmental allografts, or a combination of both can be used. No large series


has been reported to establish the risk/benefit ratio for these reconstruction methods.
The peri acetabular area is the most complex to address surgically (type II
resections). Lower-extremity function in large part is predicated on the stability and
motor strength about the hip joint. The five general reconstructive approaches to the
pelvis in this region are reviewed below.

Figure 7

CT scan of the pelvis after sacroiliac joint resection (type I + partial IV).

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1.

Vasko

No Reconstruction/Pseudarthrosis or So-Called Flail Hip

The flail hip eliminates the construct-specific risks associated with more sophisticated
methods of reconstruction (Fig. 8a). Soft tissue reapproximation can reduce the resultant dead space, but it provides negligible restoration of control of the hip. Sitting
balance can be maintained, but full weightbearing on the affected lower extremity
cannot support unassisted standing. Attachment of the femur by nonabsorbable
suture (#5) or Mersilene tape (5 mm) to the remnant of pelvis (usually part of the pubis
and ischium) can facilitate a more stable pseudarthrosis. The advantages of no
reconstruction are the avoidance of reconstruction-related complications. It is a
reasonable alternative for sedentary or elderly patients. The disadvantages include
the instability and lack of active control of the hip and shortening of the affected leg
(for type II, II/III, or I/II/III resections).
2.

Saddle Prosthesis

The saddle prosthesis is a metallic articulating prosthesis that functions as a spacer to


span the acquired bony pelvic defect between the proximal femur and ilium following
periacetabular resections. A saddle-shaped articulating component, modular body
segments, and femoral component constitute the construct. A notch created in the
remaining ilium facilitates stability of the prosthesis (Fig. 8b). The advantages of this
prosthesis include the ease of insertion, restoration of limb length, and immediate
mobilization and weightbearing of the affected limb. The disadvantages include a high
rate of dislocation, fracture of the ilium, and infection. Dynamic stabilizers of the hip
(iliopsoas and gluteal muscles) must be present to maintain stability and minimize risk
of dislocation (for type II, II/lII resections).
3.

Allograft-Prosthesis Reconstruction

A composite of massive pelvic allograft and standard hip arthroplasty is the most
appealing method to restore the anatomy and optimize function. Patient-matched
massive allograft is used to restore bone stock. A standard total hip arthroplasty is
used to replace the proximal femur and facilitate hip function (Fig. 8c). Preoperative
planning is essential to obtain an allograft of similar dimensions to the host pelvis so
that contact points at the host bone-allograft interfaces anteriorly and posteriorly can
be maximized. If the entire hemipelvis is resected, stability of the construct is
predicated on rigid fixation at the sacroiliac junction, contralateral pubjs, or both.
Significant mismatches can result in poor bone-to-bone contact and suboptimal fixation. The advantages of this technique include restoration of the anatomical relationships of the hip joint and surrounding musculature, biological replacement with the
potential for healing and durable stability, and cosmetic appearance. The disadvantages include a high risk of allograft infection, fracture and nonunion, prosthesis
dislocation, and prolonged protected weightbearing on the affected side (6-12 months)
until healing occurs (for type l/ll, II, II/III, or l/II/III resections).
4.

Custom Prosthesis

This nonbiological construct is custom-manufactured to serve as an immediate


reconstruction of the resected pelvis to provide stability and facilitate hip function.
A standard femoral component is used with the custom-made pelvic prosth sis (2).
This method restores function immediately and may be indicated for patients with a

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(a)

(b)
Figure 8 Postoperative plain radiographs of periacetabular type II resections with (a) no
reconstruction (type II resection), (b) reconstruction with a saddle prosthesis (type II + III
resection), and (c) allograft-prosthesis composite (type I + n + III resection).

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352

(c)
Figure 8

Continued.

limited projected lifespan. The primary advantage of this method of reconstruction


includes the rigid fixation and immediate stability achievable with a custom implant.
The disadvantages of a nonbiological implant include infection, the lack of durable
fixation at the bone-prosthesis interface, and anticipated failure of the mechanical
device with time (for type I/II, II, II/III, I/ll/III).
5.

Arthrodesis

The lack of durable stability of the hip can be a purposeful objective or undesired
limitation of all mobile hip constructs. An arthrodesis of the femur to the remaining
ilium (iliofemoral) or ischium (ischiofemoral) provides a durable and stable union to
facilitate ambulation (9). An appropriate-length segmental structural allograft is fixed
between the remaining pelvis and the proximal femur to bridge the defect, restore
length of the extremity, and achieve fusion (Fig. 9). This is a very good choice for
young, very active patients. The advantages of this method include maintenance of
limb length, durability of a healed biological construct, and hip girdle stability. The
disadvantages include a nonmobile hip; potential Jimb length discrepancy; low back,
knee, and contralateral hip pain secondary to the mechanical alterations in the spinepelvis-hip relationship (for type l/ll, II. II/Ill resections).
Type III resections ll1clude the pubis and/or ischium. No reconstruction of the
bone is necessary for pelvic stability or lower extremity function (Fig. 10). The pelvic
floor should be reconstructed to prevent visceral herniation and protect the intrapelvic
structures. The ipsilateral tensor fascia lata or other rotation flap can be used with or
without surgical mesh for reconstruction.
Sacral resections are rarely total and therefore the spinopelvic relationship is
unafl~cted and no reconstruction is necessary. Total sacrectomy disrupts this relationship. Reconstruction to re-establish stability across the lumbar spine and pelvis can be
considered (Fig. I I). Without reconstruction, patients commonly complain of a sense
of their spine telescoping or sinking into the pelvis. Sitting or standing is uncomfort-

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Figure 9 Postoperative plain radiograph of an arthrodesis of the femur to the pubisl


ischium and sacrum using a structural allograft after a type I + II + III pelvic resection.

able. Contemporary posterior spinal instrumentation (rods and pedical screws)


transfixes the lumbar spine to the posterior ilium (l 0,31). This can be performed in
one or two stages. Soft tissue reconstruction with a rectus abdominis pedicled muscle
flap mobilized during the transabdominal approach can be pulled through posteriorly
after the sacrum is resected to provide stable wound coverage when the soft tissues
posterior to the sacrum are involved by tumor. If the tumor extirpation procedure
is lengthy, it may be advantageous to delay both bone and soft tissue reconstruction
(23).

IX.

POSTOPERATIVE MANAGEMENT

Thoughtful preoperative planning can facilitate the postoperative management of


patients following pelvic tumor surgery. A lengthy operative time can be anticipated
with most pelvic surgery when reconstruction is performed. Blood loss can be
excessive. Postoperative hemodynamic monitoring and ventilatory support often
are necessary in the surgical intensive care unit at least overnight. An epidural catheter
can be placed preoperatively to provide postoperative analgesia. A hip abduction
brace fitted preoperatively is used frequently to support the reconstruction and limit
hip motion as desired. Wound care is critical to avoid flap necrosis and infection that
may compromise the integrity of the reconstruction.
Patients are mobilized early to minimize pulmonary complications and reduce
the risk of deep venous thrombosis. Pharmacological anticoagulation is not recommended for these patients due to the large surface area of bone and soft tissue

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(a)

(b)
Figure 10 Plain radiographs of a type III resection for a chondrosaroma: (a) preoperative
and (b) postoperative views. No bony reconstruction was required for pelvic stability. The
pelvic floor was reconstructed with surgical mesh.

transected. Deep venous thrombosis prophylaxis is provided by elastic stockings and


compression boots. Intravenous antibiotics are continued until the patient is discharged from the hospital. Wound drains are maintained until hospital discharge.
Total hip arthroplasty precautions are maintained for patients who have undergone
pelvic reconstruction. Physical and occupational therapists are consulted routinely for
mobilization and gait training and to instruct patients with activities of dail living.

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Figure 11

X.

355

Plain radiograph of a sacral reconstruction after total sacrectomy.

HELPFUL HINTS

Preoperative planning is crucial to the success of pelvic surgery. Medical assessment


should be made well in advance of surgery. Medical and surgical consultations (internal medicine, general surgery, urology, vascular surgery, plastic surgery) should be
scheduled as indicated by the clinical and surgical setting. Bowel preparation is desirable to minimize fecal contamination in the case of incidental enterotomy. Ureteral
stent(s) are placed routinely to facilitate identifica tion and aid in the protection of these
structures from injury. Preoperative embolization for vascular tumors (thyroid, renal,
giant cell tumor) can reduce intraoperative blood loss. Preoperative assessment by
physical and occupational therapists can facilitate brace fitting, ambulation training,
and needs assessment for postdischarge activities of daily living.

XI.

POTENTIAL COMPLICATIONS

Preoperative and postoperative therapies can have an impact on the surgical outcome.
Chemotherapy and local radiation affect bone healing and place the surgical wound
at increased risk for complications. Peri tumoral fibrosis can be extensive following
preoperative radiation and will obscure the tissue planes of dissection, increasing the
risk of injury to vascular or neural structures. Intraoperative complications include
massive hemorrhage, nerve injury, incidental bowel, bladder, ureter, or urethral injury. Planned transection of the sacral nerve roots can result in bowel and urinary
incontinence, the severity of which is dependent on the level of resection (30).
Early complications can include local wound problems such as seroma, hematoma, wound margin necrosis, flap thrombosis, and infection. Systemic complications

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such as pneumonia, deep venous thrombosis, and pulmonary emboli are less common.
Deep wound infection, which is the most common complication, necessitates removal
of the reconstruction and therefore represents the most severe postoperative local
complication that can result in implant failure.
Late complications including wound dehiscence and infection as well as implantspecific complications place the reconstruction at continued risk of failure. Constructrelated complications include prosthesis dislocation, loosening of fixation, prosthesis
disassembly, fracture of host bone, allograft fracture, nonunion, or resorption and
prosthesis migration.

XII.

LONG-TERM FUNCTIONAL RESULTS

Oncological results vary by disease type and stage. Localjzed primary sarcomas of the
bony pelvis are associated with a worse prognosis than similar sarcomas arising in the
extremities. Local control is predicated on the surgical margins, but exceeds 20% in
most large series (11, I 2,14,27,29,34), irrespective of the type of surgery performed
(hemipelvectomy vs. limb-sparing pelvic resection). Local recurrence is treated usually
by hemipelvectomy.
The major determinant of satisfactory functional outcome is the status of the
abductor muscles following tumor resection and the stability of the reconstructed hip
joint. Functional preservation of hip girdle muscles coupled with a stable reconstructed pelvis yield better function. Optimization of function requires the acceptance
of surgery with a higher risk of failure in the short-term. The most complex restorative
proced ure for anatomy is the allograft-prosthesis composite construct. Complications
associated with massive pelvic allograft reconstructions are common. Yoshida et a!.
reported a 28% infection rate and hip arthroplasty migration within the allograft in
33 % of patien ts (35). Bell et a!. reported up to a 20% infection rate. Dislocation of the
hip arthroplasty occurred in 33% of patients. Only 12% required no further surgery
(3). Other authors report similar complications in smaller series (16,19).
The alternative to the allograft-prosthesis composite reconstruction to retain
hip joint function is the saddle prosthesis. Several series have documented the functional outcome and complications associated with the Saddle prosthesis. Aboulafla
et a!. reported on 17 patients, 70% of whom had good/excellent results. However, the
authors noted that 53% of patients had surgical complications (1). Others have
reported similar prosthesis-rela ted com plica tions (7,22,24).
Implantation of a custom metallic prosthesis is a method of reconstruction oftbe
hip joint and pelvis associated with the highest incidence of construct-threa tening complications. Abudu et a!. reported on a series of 35 patients with periacetabular tumors
treated with a resection of the hip joint and reconstruction with a custom pelvis prosthesis. They noted a 25% incidence of deep infection. 17% recurrent hip prosthesis
dislocation, and 24% local tumor recurrence for an overall complications rate of 60%.
Overall function was poor (2). Wirbel et a!. reviewed 39 patients with pelvic tumors.
Ten patients experienced infection and six prosthetic dislocation. Of the 17 patients
surviving at a mean follow-up of 58 months, 13 had good to excellent function (33).
Others have reported similar results (20.32). Nonmobile hip reconstruction reported
by Fuchs et a!. documented an 86% union rate with functional satisfaction better
than with pseudarthrosis at long-term follow-up (9). Campanacci and Capanna

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357

reported fusion in only 40% of their patients after attempted iliofemoral arthrodesis (5). Satisfactory results, however, were achieved with the resulting stable
pseudarthrosis.

XIII.

SUMMARY

Management of pelvic tumors requires strict attention to preoperative and postoperative details if patient outcome is to be optimized. Pelvic tumor resection and
reconstruction is extremely demanding due to the complex anatomy of the bony pelvis,
the juxtaposed vital neurovascular structures and viscen;l., and the locally advanced
presentation of the majority of patients. Contemporary reconstructive options are
associated with high perioperative risks and functional outcome remains variable.
Efforts that utilize the advantages of the durability of biological constructs and the
strength of metallic implants to promote biometallic composi te reconstruction continue to hold the greatest promise. The application of new technologies to this
approach will be required in the future if more predictable functional outcome at
lower operative risk is to be achieved.

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24
Direct Closure, Tissue Expansion,
and Grafting of the Abdominal Wall
DIMITRIS P. MASTORAKOS and JOSEPH J. DISA

Memorial Sloan-Kellering Cancer Center. New York. New York, U.S.A.

The flat muscles of the abdominal wall (external and internal oblique and transversus
abdominis) and the recti muscles are arranged to form a contractile, elastic layer
around the abdominal cavity and its contents. They protect the abdominal contents
and function as a constricting ring mechanism, while the pressure they exert helps
maintain the viscera in their respective proper positions. They also work in concert
with the visceral peristaltic mechanisms to assist in voiding and defecation (I). Defects
in this ring mechanism therefore have direct functional and social imfJlications.
Abdominal wall defects can be classified as full- or partial-thickness, depending
on the abdominal wall layers involved (skin, fascia, muscle) and as acquired and
congenital depending on the causative mechanism. Acquired defects are usually the
result of tumor resection, infection, and subsequent debridement or trauma. The cause
of the defect, its size, and the timing of the required reconstruction will define the
specific approach to be used in a specific patient. Given the key role of abdominal wall
integrity outbned above, many ways to restore the abdominal wall integrity have been
used. These include healing by secondary intention; direct closure, grafting with au to-,
allo-, or xenografts or alloplastic materials; flap closure (myocutaneous, fasciocutaneous, musculofascial flaps: pedicled or free flaps), and tissue expansion.
I.

HEALING BY SECONDARY INTENTION

This method is obviously applicable only to small defects, which will not present any
danger of herniation or future loss of abdominal wall mechanical integrity. Local
wound care is applied until healing of the defect is complete.

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362

II.

Mastorakos and Disa

DIRECT CLOSURE

When the abdominal wall undergoes only minor tissue loss, or when prior to resection
it was exposed to expansion, as is the case in massive abdominal tumors, there may be
enough tissue to approximate and satisfactorily close the abdomen at the end of the
extirpative surgery (2). Excision of the attenuated fascia and musculature has been
advocated as an integral part of the procedure to re-create the abdominal wall tone (2).
Once the tissue loss prohibits direct approximation of the abdominal wall,
provision of material to allow for tensionfree closure is necessary. Based on the Gillies
dictum of replacing like with like, one should strive to replace the skin, muscle, and
fascia layer with similar tissue. The so-called component separation technique advocated by Ramirez (3) allows one to mobilize the rectus sheath medially to allow for
tension free closure. With this technique the rectus muscle is separated from the posterior rectus sheath and the external oblique fascia is incised lateral to the rectus sheath.
This maneuver allows the medial translation of the rectus muscles and anterior rectus
sheath. Since the blood supply is found under the internal oblique, this dissection
protects the blood supply while it provides about 5 cm of tissue in the epigastrium,
about 10 cm at the level of the waist, and about 3 cm in the infraumbilical region, once
this technique is performed unilaterally. These amounts are almost doubled if this
dissection is performed bilaterally. This approach provides stable, innervated, and
vascularized tissue for abdominal wall sta ble closure (4,5) (Fig. I).
A similar approach involves mobilizing the rectus sheath by using what are
termed fascial partition/release incisions advocated by Thomas (6). In this approach
an incision is made in the external oblique and/or the transversus abdominis fascia to
allow medial translation as described above. Smaller defects, about 7 cm for the
external oblique and 2-4 cm for the transversus incisions, can be closed in thjs manner.
If the defect is wider than 10 cm, or if the rectus sheath is mostly or completely
lost to previous resection or debridement, either a staged reconstruction or use of graft
or prosthetic material is needed for closure.

III.

STAGED/DELAYED RECONSTRUCTION

At times the conditions are suboptimal for immediate reconstruction, and reconstruction should be deferred (7). To stage the reconstruction, the defect is temporarily
closed with any material available, nonabsorbable (Prolene, Marlex, Mersilene, GoreTex, open intravenous [IV] bag), or absorbable (Vicryl, Dexon), or can even be left
open to granulate over ifsufficient intra-abdominal adhesions will prevent evisceration
[8,9) (Fig. IA,B). The skin can be advanced over the closure or be left open to granulate
with dressing changes. Once sufficient granulation tissue has formed, after edema and
third spacing have subsided (2-3 weeks later), re-exploration follows. During the reexploration the prosthetic non-absorbable material is removed and the abdomen is
closed primarily, if possible. If this is still not possible, the wound is covered with a
split-thickness skin grafted (10) or closed with mobilization of skin flaps. This will
result in an incisional hernia, which can be corrected on an elective basis (II) (Fig. 2).
In this fashion, the patient is allowed to improve metabolically and nutritionally and
the tissues to recover from the inflammation and the swelling associated with the fir t
operative insult. Arter 6 -12 months an elective hernia repair, either with a component
separation techniq ue or wi th the use of grafting, prostheses. or tissue expansion, can be

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363

B
Figure 1 Large ventral hernia of abdomen after an abdominal gunshot wound. A. The
abdomen was allowed to heal by secondary intention. B. Lateral view. C. Delayed abdominal
wall reconstruction using a component separation technique. This figure demonstrates the
separation of components in the abdominal cavity. D. Primary fascial closure of the abdomen
after component separation technique. E. Late postoperative appearance, anterior view. F.
Late postoperative appearance, lateral view.

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E
Figure 1 Continued.

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365

F
Figure 1

Continued.

performed. It is important in abdominal wall reconstruction that a definitive procedure only be undertaken if the conditions are considered optimal. In other cases the
temporizing strategies outlined above should be considered instead. Once the conditions are optimal (satisfactory nutrition, corrected metabolic abnormalities, cleared
infection), then the closure of a defect larger than 10 cm is undertaken with the use of
tissue expansion, grafting, prosthetic materials, or flaps.

IV.

TISSUE EXPANSION

Tissue expansion has been proposed for the repair of partial or full-thickness defects of
the anterior abdominal wall (12-16). An intact skin layer is one of the requirements to
allow for complete coverage of the tissue expander during the period of the expansion.
Closure of the skin or skin grafting can be used to prepare a wound for tissue expansion. Once the wound is healed, the expanders are placed around the edges of the
fascial defect. The tissue layer and the incision of placement of the expanders have
varied depending on the layer intended for expansion. Subcutaneous placement (13)
has resulted in skin-only expansion and complete skin closure, while the fascial defect
has been addressed using an alloplastic mesh. Placement under the external and
internal oblique (12,14) going through the midline scar and the rectus sheath, or

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B
Figure 2

Abdominal wall defect secondary to gunshot wound. The abdomen was allowed
to granulate and a delayed split-thickness skin graft was applied. A. Appearance of abdominal
hernia with healed split-thickness skin graft. B. Late postoperative appearances after removal
of skin graft, mobilization of remaining fascia, and wound closure.

placement under the external oblique only (17) going through a lateral incision, which
avoids the dissection through the midline scar, allows for expansion of the skin and the
musculofascial layer. Both approaches preserve the innervation and blood supply of
the tissues expanded: this is a key concept. Once the expansion is complete, additional
innervated and vascularized skin and musculofascial tissue is available to close the
fascial as well as the skin layer. This approach not only avoids the use of alloplastic
materials but also provides functioning muscular and fascial tissue for closure of the
abdominal defect. The match to the color and texture of the skin is excellent and the
donor site morbidity is minimal. The only drawback is that of the prolonged expansion
period and the multiple procedures required to complete the reconstruction.

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Given the difficulty in expanding a tissue layer when the expander is not placed
on a rigid backing, a different approach has been utilized employing the intra-abdominal expansion to reach the same results. Pregnancy is the physiological equivalent
of tissue expansion (18): the possibility of expansion by intraperitoneal volume increase exists. This method has been used by insufflating ll1traperitoneal air (19) to expand the abdominal wall and allow for fascial closure. Although this approach has
added complications, including intracolonic air infusion, it does provide an intriguing
approach to tissue expansion for abdominal wall closure. This is true especially if the
insufflation is performed under sonographic guidance and possibly using nitrogen as
the expanding gas, given its low solubility and absorption.
When component separation is contraindicated or the defect at hand is wider
than 10 cm, tissue expansion can be a valuable tool to allow safe closure of the abdomen. Like is replaced with like and vascularized and innervated tissue is provided,
addressing at the same time all the layers of the abdominal wall.

V.

ALLOPLASTIC MATERIALS

Alloplastic materials have been used extensively in surgical procedures to repair defects of the fascial layer of the abdominal cavity. Inguinal, femoral, umbilical, as well
as incisional hernias have been repaired with satisfying results.
In the case of acquired defects of the abdominal wall, the principle remains the
same. Prosthetic materials can be used as an alternative to autogenous tissue repair
and can be used in the acute as well as the delayed setting. They can be produced in a
variety of sizes and shapes, incorporating characteristics such as antibacterial activity
in their manufacture. They do not incur any donor site morbidity and are widely
available. Ideal abdominal wall prostheses should have the following characteristics:
Noncarcinogenic
Biologically inert
Pliable, to avoid erosion into neighboring structures
Chemically stable
Sterilizable
Porous, to allow drainage of fluid
Long-lasting (20,21)
When used in the delayed setting, the application of alloplasts is identical to the
approach to a hernia repair. The alloplastic material is used to replace the missing
fascial layer under a cover of soft tiss