CHAPTER 55
i Surgical Techniques for the
Chest Wall and Sternum
CHEST WALL RESECTION
Geoffrey M. Graeber
Chest wall resection is usually performed for one of four
reasons: removal of neoplasms, eradication of entrenched
infection, excision of radiation injuries, and debridement
of traumatic wounds. These indications for chest wall
resection are not mutually exclusive, since infection can
be a major complication for each of the other three.
Recurrent tumor and infection together can complicate
radiation injuries. The following discussion delineates
the essential surgical principles governing chest wall re-
section for each of the four major indications. Before any
major resection, the surgeon should make a thorough
and accurate assessment of the patient in order to avoid
major complications (Azarow et al, 1989; Seyfer et al,
1986b). In the trauma patient the resection may have to
proceed even in victims who are poor operative risks,
since allowing devitalized material to remain invites cata-
strophic infection (Seyfer et al, 1986c).
RESECTION FOR NEOPLASMS
Before embarking on a biopsy of any chest wall neoplasm,
the surgeon must take a complete history and conduct a
thorough physical examination with the intent of identi-
fying any history of chest wall trauma and of uncovering
any malignancy that could spawn a chest wall metastasis.
Metastatic lesions and healing rib fractures are far more
prevalent than all primary chest wall neoplasms com-
bined (El-Tamer et al, 1989; Graeber et al, 1982). Either
a healing rib fracture or a chest wall metastasis may have
many of the same radiographic features as a primary
chest wall neoplasm (see Chapter 53). The age of the
patient, the presentation of the tumor, its physical loca-
tion and characteristics on the chest wall, and its radio-
graphic appearance will strongly suggest the true charac-
ter of the neoplasm (see Chapter 53).
The evaluation of a suspected primary chest wall tu-
mor includes standard chest radiographs plus a computed
tomographic (CT) scan of the thorax that completely
images all ribs, the totality of both leaves of the dia-
phragm, and the entire base of the neck. The treating
surgeon should seek several consultations before em-
barking on a biopsy (Graeber et al, 1982; Seyfer et al,
I wish to thank Mrs. Karen DeShong for her expert preparation of
the manuscript.
1986d). The first consultation should be with a radiolo-
gist who specializes in imaging of the thorax. After the
chest radiographs and CT scan have been reviewed by the
surgeon and radiologist together, they should determine
whether specialized diagnostic imaging techniques could
be useful in providing more information about the neo-
plasm. These specialized studies should be undertaken
before any diagnostic biopsy is conducted. The surgeon
should also consult with a medical oncologist and a
radiation therapist to see if any specialized studies need
to be conducted on tissue obtained at the time of biopsy.
Finally, a pathologist who regularly reads pathologic spec-
imens containing musculoskeletal neoplasms should be
consulted. The pathologist usually suggests how much
tissue is necessary to perform the tests required to achieve
a proper diagnosis. Continuing consultation with the
pathologist at the time of surgery is mandatory. Frozen
sections are generally of limited value in assessing chest
wall neoplasms since so many of them have bony or
cartilaginous components. The surgeon and the patholo-
gist should work together to obtain enough appropriate
material at the time of biopsy to ensure an accurate
diagnosis.
The question of how much tumor needs to be biopsied
remains controversial (El-Tamer et al, 1989; Graeber et
al, 1982). The technique of biopsy and how much tumor
is removed depends on the suspected type of tumor and
the pathologist. At one extreme is the needle biopsy, a
technique that has proved particularly effective for the
group at the University of Texas M. D. Anderson Cancer
Center in evaluating children with Ewing's sarcoma of
the chest wall (Ryan et al, 1989). In one study of primary
bone tumors, needle biopsy accurately diagnosed 83%
of malignant and 64% of benign neoplasms (Ayala and
Zornosa, 1983). Incisional biopsy is indicated if the nee-
dle biopsy is not diagnostic or if the pathologist needs
more tissue to make a definitive diagnosis. Conduct of
the incisional biopsy should be governed by the anticipa-
tion of possible radical resection if the tumor proves
malignant. The surgeon should bear in mind that 5 cm
of clear skin from the margin of the biopsy site should
be resected with radical surgical extirpation (Seyfer et al,
1986d). Meticulous surgical technique is mandatory since
hematoma within the wound predisposes to tumor exten-
sion. The biopsy site ideally should be closed without a
1441
1442 CHAPTER 55 • Surgical Techniques/Chest Wall Resection

drain because a drain increases the chance of infection,

which would complicate definitive resection and recon-
struction. Excisional biopsy is indicated for smaller le-
sions (2 to 3 cm) and also for chondromatous lesions,
since these neoplasms may well include benign as well
as malignant areas within the same neoplastic mass
(Graeber et al, 1982). Wide excision of osteochondromas
and neurofibromas is also indicated, particularly in pa-
tients suffering from the familiar syndromes of multiple
osteochondromas and neurofibromatosis, as malignant
degeneration has been recorded in both entities (Martini
et al, 1969).
Once the true nature of the primary chest wall neo-
plasm has been established, definitive therapy can be
undertaken. Proper resection of benign neoplasms con-
sists of surgical excision with preservation of the overly-
ing skin and surrounding musculature. In the event that
the benign neoplasm falls into one of the categories of
chondromatous lesions noted previously, wider excision
should be conducted (Ryan et al, 1989).
Although there has been some variance in reporting,
the generally accepted rate of malignancy for primary
chest wall neoplasms is 50% (Graeber et al, 1982; Groff
and Adkins, 1967; Stelzer and Gay, 1980). The most
common malignancies in most series are the chondrosar-
comas, with the incidence of fibrosarcoma not far behind.
Adjuvant chemotherapy and radiation therapy have a role
in treating some primary chest wall malignancies. For
this reason preoperative consultation with a radiation
therapist and a medical oncologist is indicated before
conducting a radical chest wall resection in any patient
suffering from a chest wall neoplasm.
The most common primary chest wall malignancy, FIGURE 55-1 • Large anterior lateral chest wall neoplastic
mass, such as would be seen with a chondrosarcoma. The
chondrosarcoma, is resistant to both chemotherapy and tumor has obvious physical margins. The dotted line represents
radiotherapy (Ryan et al, 1989). Appropriate radical re- the planned area of resection around the tumor, which
section with tumor-free margins of at least 5 cm has includes resection of an adequate, approximately 5-cm margin
yielded excellent results (Graeber et al, 1982; Arnold and of healthy tissue around the tumor itself. This is the best way
Pairolero, 1978; Pairolero and Arnold, 1985; King et al, to eliminate local recurrence, which is the most common cause
of treatment failure in chondrosarcomas. (From Seyfer AE,
1986; McAfee et al, 1985). Survival is related to the Graeber GM, Wind GG: Planning the reconstruction. In Seyfer
tumor's histologic grade and size and the adequacy of AE (ed): Atlas of Chest Wall Reconstruction. Rockville, MD,
resection (Fig. 55—1). In one series, patients with grade I Aspen, 1986e.)
lesions had a 10-year survival rate of 70%, and patients
with a tumor less than 6 cm in greatest dimension had
an 87% 10-year survival (McAfee et al, 1985). On the combination with other agents, appear to be effective
other hand, the same series noted that patients with (Ryan et al, 1989).
grade III or dedifferentiated chondrosarcomas had very Ewing's sarcoma generally presents in the second de-
poor survival. cade of life and is unusual in the ribs (Ryan et al, 1989).
Primary fibrosarcomas of the chest wall are usually When it presents as a chest wall tumor, it generally has
treated with aggressive surgical resection (Graeber et al, a worse prognosis than when it is a primary in a long
1982; Martini et al, 1969). Most chemotherapeutic agents bone of an extremity, since metastases to the lungs occur
have relatively little effect on these malignancies. Some in about half of the cases (Ryan et al, 1989). When
success has been reported with the use of radiotherapy Ewing's sarcoma is localized to the chest wall, the patient
for lower-grade fibrosarcomas (desmoids) of the chest is treated with CyVADIC (cyclophosphamide-vincristine-
wall (Ryan et al, 1989). Adriamycin-imidazole carboxamide) induction chemo-
Preoperative and postoperative chemotherapy appears therapy for 2 to 5 cycles before undertaking resection of
to be beneficial in treating primary chest wall osteosarco- the primary. In general, the goals of the resection are to
mas (Ryan et al, 1989). Although most series are small, excise the primary with minimal soft tissue margins and
primary radical surgical resection can yield long-term with the entirety of the affected rib(s) (Ryan et al, 1989).
survivors (Graeber et al, 1982). Preoperative chemother- CyVADIC is then continued for 7 to 8 cycles postopera-
apy causes a degree of necrosis in the primary, which tively without administration of radiation therapy (Ryan
may aid in selecting postoperative agents (Martini et et al, 1989). Although some few survivors have been
al, 1969). Cisplatin and doxorubicin, either alone or in reported with surgery alone, the prudent use of neoadju-
 CHAPTER 55 • Surgical Techniques/Chest Wall Resection
vant and adjuvant chemotherapy for treating primary
Ewing's sarcoma of the chest wall is strongly indicated
(Graeber et al, 1982; Ryan et al, 1989). Radiotherapy is
reserved only for patients who have residual disease after
definitive therapy (Rao et al, 1988; Ryan et al, 1989).
Primary solitary plasmacytomas are infrequent chest
wall neoplasms, which can be treated by radiotherapy or
by resection (Graeber et al, 1982). In general, the Walter
Reed group has favored primary resection with adequate
margins for several reasons (Graeber et al, 1982). Most
patients who present with primary chest wall plasmocyto-
mas return with multiple myeloma within 10 years. If
the primary has been eradicated by radiotherapy, the
amount of subsequent radiotherapy that may be available
for the patient may be small or nonexistent. Hence, the
patient may present later with severe pain due to my-
eloma of the thoracic spine and be unable to undergo
more radiotherapy because of having already received a
maximal dose of radiotherapy to the thorax. Resection is
indicated also for larger lesions, since radiotherapy alone
often does not eradicate the disease entirely. The patient
then presents with a partially treated neoplasm, which
has an open necrotic ulcer and infection. Resection and
reconstruction in such cases is much more difficult and
more likely to have complications.
Wide surgical excision remains the treatment of choice
for patients suffering from malignant fibrous histiocy-
toma (Ryan et al, 1989; Venn et al, 1986). Aggressive
surgical resection has been successful in selected cases in
eliminating locally recurrent disease. These tumors are
relatively resistant to r a d i o t h e r a p y and chemotherapy.
Consequently, radiotherapy is reserved for residual tumor
remaining in margins of resection where total resection
was not possible anatomically (Ryan et al, 1989).
R h a b d o m y o s a r c o m a s of the chest wall are usually
found in the pediatric population. They are responsive to
chemotherapy in most cases (Ryan et al, 1989). Manage-
ment generally consists of chemotherapy, complete surgi-
cal resection, and long-term postoperative chemotherapy.
Since radiotherapy is not particularly effective against
these tumors, it is employed only in treating lesions for
which complete surgical extirpation is not possible or in
which the margins of surgical resection are questionable
(Ryan et al, 1989).
Chest wall resection for breast cancer today is most
often conducted for recurrent local disease after failure
of other forms of therapy (Ryan et al, 1989; Seyfer et al,
1986d). Systemic recurrence is common, and chest wall
resection is directed at palliating pain, removing friable,
ulcerating tumor, and reducing odor. Patients must be
selected carefully in the light of survival expectancy. Che-
motherapy is beneficial prior to resection and as part of
continuing therapy after chest wall resection. The resec-
tion should be conducted with the aim of removing all
radiation-damaged chest wall, since allowing irradiated
tissue to remain often compromises healing. With appro-
priate chest wall stabilization and rotation of pedicled
flap(s) into the resected area, chest wall stability and
durability can be achieved. The most gratifying aspect of
these resections is the improved quality of life that this
resection affords, since pain and tenderness are almost
1443
always relieved. The patient's need for analgesics and
narcotics is always diminished if not relieved entirely.
Extension of primary lung tumors into the chest wall
requires resection in many cases, but chest wall recon-
struction is indicated only infrequently (El-Tamer et al,
1989; Seyfer et al, 1986d). Patients with primary lung
cancers invading the chest wall must be screened care-
fully before resection to confirm that systemic disease
that would preclude meaningful long-term survival is not
present. A 5-cm margin of uninvolved chest wall should
be resected en bloc with the primary. Entrance into the
chest is planned so that neither the tumor itself nor the
margin of resection is violated. Tumors that have ex-
tended through the chest wall and overlying musculature
to invade or ulcerate the skin are found infrequently,
since the disease is lethal systematically prior to such
local extension. Hence, in most cases the overlying mus-
cles of the upper extremity, subcutaneous tissues, and
skin remain intact over the site of chest wall resection,
and with so much intact tissue remaining, the need for
chest wall stabilization and flap reconstruction is quite
rare.
RESECTION FOR INFECTION
Currently the most common indication for chest wall
resection is probably infection due to a dehisced median
sternotomy incision. With the increase in cardiac surgery
and the use of a median sternotomy incision for access
to the heart, the absolute number of median sternotomy
dehiscences has increased, although the incidence of this
occurrence ranges from 1% to 3% (Miller and Nahai,
1989). Experimental work in the laboratory on the blood
flow to the sternum has shown a marked, precipitous
decrease in perfusion of the ipsilateral hemisternum im-
mediately after harvesting of the internal mammary artery
(Seyfer et al, 1988). This is one of many predisposing
factors that can increase the incidence of median stern-
otomy dehiscence. The association of internal mammary
artery harvesting with median sternotomy dehiscence re-
mains a clinical problem of continuing concern (Graeber,
1992). The reconstruction of the dehisced median stern-
otomy incision continues to be an area of interest for
n u m e r o u s investigators (Arnold and Pairolero, 1984;
Miller and N a h a i 1989; Pairolero a n d Arnold, 1986;
Seyfer et al, 1986h).
Initial evaluation of the patient with a dehisced me-
dian sternotomy incision consists of a precise physical
examination, which focuses on the median sternotomy
w o u n d a n d its characteristics (Arnold and Pairolero,
1984; Miller and Nahai, 1986; Pairolero and Arnold,
1986; Seyfer et al, 1986h). Tenderness and erythema
generally delineate the margins of the infected tissue.
Once these margins have been determined by careful
palpation, the anticipated margin of necessary resection
to achieve a clean wound and ensure a satisfactory recon-
struction is established. The wound is checked for fluc-
tuance, and any fluid that may be expressed from the
wound is sent for culture and sensitivities. Crepitus,
which may present to varying degrees, usually does not
represent clostridial infection but rather reflects air that
has entered the wound through the incision itself. When
1444 CHAPTER 55 • Surgical Techniques/Chest Wall Resection
the patient coughs or the ventilator cycles, the sternum
is generally unstable. This is heralded by a palpable
click, which may be present over varying amounts of
the sternum. Determination of exactly how much bone
remains unstable within the wound is important, since
preservation of as much sternum as possible is beneficial
for stabilizing respiratory mechanics.
Several different radiologic techniques have been
shown to be of benefit in evaluating these patients
(Schaefer and Burton, 1989). Standard posteroanterior
and lateral radiographs of the chest will generally show
air in the mediastinum and between the two halves of
the sternum. Occasionally, air may be seen lateral to
the primary incision. When this occurs, the evaluating
surgeon can usually suspect either a separation of the
bony and cartilaginous elements or the presence of pock-
ets behind the sternum. CT of the chest is helpful in
delineating any abscess pockets, recesses, and extensions
of the infectious process into the mediastinum. Although
a CT scan is not always necessary, it may be helpful in
determining where fluid collections may be extravasated.
Leaving any fluid collections, especially if they are in-
fected, complicates the subsequent reconstruction of the
wound.
Fluid and clot sequestrations may also be delineated
by echocardiography, which is also beneficial in evaluat-
ing ventricular function and whether or not any of the
fluid collection present in the mediastinum embarrasses
cardiac function in any way. Magnetic resonance* imaging
(MRI) may in some cases be of assistance in evaluating
these wounds. It appears to be most helpful in delineating
where fluid collections may be separated from major
vascular structures. The risks and benefits of this exami-
nation must be considered in the light of the patient's
general condition. The presence of wires within the
wound also causes a scattering effect on both the CT
and MRI procedures. One particularly helpful nuclear
medicine test is the bone scan. Because of its ability to
delineate active areas of inflammation, it may be very
useful in denoting areas of persistent osteomyelitis and
chondritis within a chronically infected median ster-
notomy incision.
Antibiotic therapy in these patients is directed at the
specific culture sensitivities and results (Miller and Na-
hai, 1989). The most commonly offending organisms
are Staphylococcus aureus and Staphylococcus epidermidis.
Enterobacteriaceae and Pseudomonas species are the most
common gram-negative bacilli that populate these
wounds (Miller and Nahai, 1989). Antibiotic therapy
should be directed at these species, as well as any patho-
gens that may be specifically delineated on the culture
results. The patient should receive systemic antibiotics 6
hours prior to the intended resection, with continuing
therapy throughout the time of resection and for 2 days
immediately thereafter. The antibiotics are started early
so that adequate levels may be maintained in the healthy
tissue surrounding the intended area of resection. Postop-
erative antibiotic coverage is directed at minimizing seed-
ing of other areas within the body associated with bacte-
remia.
In the operating room several important considera-
tions must be addressed during the positioning and prep-
aration of the patient (Seyfer et al, 1986h). The patient
should be placed in the supine position on the operating
table so that the entire anterior thorax is accessible to
the operating surgeon for debridement and for possible
repair of any cardiovascular injury that may occur during
the procedure. Full monitoring is instituted, just as it
would be for any patient undergoing a major cardiovascu-
lar procedure. This precaution is taken so that if the
patient does need to go on cardiopulmonary bypass (a
rare occurrence), the surgeon and anesthesiologist are
not compromised in their options. One or both groins
are prepared for placement of arterial and venous cannu-
las from a cardiopulmonary bypass machine should by-
pass be needed. Most surgeons prefer to avoid cannula-
tion through the infected incision, since when tissues are
inflamed, they may well be friable, and the repair of the
cannulation sites can be extremely difficult. A portion of
at least one leg is also prepared in case a segment of
saphenous vein should be needed to repair a bypass graft
or a major vascular structure.
Once the resection is undertaken, the wound should
be actively debrided of all dead tissue (Bellamy and Zajt-
chuk, 1991b). All nonvital prosthetic tissue and sutures
are removed when the wound is opened. Portions of the
sternum that show no evidence of bleeding from either
the periosteum or the marrow are resected until healthy
bleeding is encountered. Any musculature of the chest
wall that appears to be compromised is also debrided.
In the event that costal cartilages become exposed, the
cartilages are resected subperichondrally since the blood
supply to the cartilages is so poor. Once the cartilages
are exposed, they should be regarded as infected through-
out their entirety. The blood supply to the viable muscu-
lature of the chest wall and to any remaining tissues
should be preserved scrupulously. Care should be taken
to preserve any internal mammary arteries that may be
present, since they are the primary blood supply to the
rectus abdominis muscles. If one of these muscles is
needed as a flap for reconstruction, its arc of rotation
is seriously compromised, if not precluded, when the
ipsilateral internal mammary artery has been resected or
has been used as a cardiac conduit. The ultimate goal of
the resection is to remove all tissue that does not have
vital capabilities and does not bleed well. Once the resec-
tion has been conducted to healthy tissue margins, recon-
struction may be contemplated.
In some few cases the margins of resection after de-
bridement of a dehisced median sternotomy may be ques-
tionable. In such a case, the wound may be packed with
povidone-iodine-soaked gauze and treated as an open
wound for 48 hours (Seyfer et al, 1986h). After the
wound has been repacked several times by the surgical
team and the patient has been stabilized, the patient may
be returned for a secondary debridement and reconstruc-
tion. The goal of the secondary debridement is to remove
any other tissue that is questionable so that only a healthy
margin remains. By use of secondary debridement, persis-
tently infected, recalcitrant median sternotomy infections
may be treated successfully. Obviously, retention of any
tissue, bone, or cartilage that is devascularized compro-
mises subsequent reconstruction.
 CHAPTER 55 • Surgical Techniques/Chest Wall Resection 1445

RESECTION FOR RADIATION INJURY

Resection for radiation injuries of the chest wall is usually
conducted for palliation. In most such patients there are
several concurrent indications for chest wall resection.
Many patients have concurrent infection as well as recur-
rent tumor in the irradiated field. Complete and thorough
evaluation of the patient is necessary, since the benefits
and detriments of the resection and reconstruction need
to be viewed in the light of the patient's predicted sur-
vival. The palliation that is afforded by the resection in
terms of decreased pain, improved cosmesis, and decrease
in odor must be weighed against the total survival of the
patient. Although a number of chest wall tumors may be
irradiated, the malignancy most often associated with
chest wall radiation is carcinoma of the breast (Seyfer,
1988). Extensive experiences have been recorded by sev-
eral institutions in dealing with the irradiated chest wall
(Arnold and Pairolero, 1986, 1989; Pairolero and Arnold,
1986; Seyfer, 1988).
Preoperative evaluation of these patients starts with
thorough metastatic evaluation. Biopsies are taken from
any portions of the irradiated field that are suspected of
having recurrent tumor. The chest wall should be evalu-
ated to determine the margins of viable tissue. When FIGURE 55-2 • Method for determining resection of
doing this, it is very important to consider the contralat- recurrent cancer in an irradiated field. Note that the line of
eral chest as an example of healthy tissue for the region. resection, denoted by the heavy dotted line, is drawn at the
Once the tissue becomes discolored, the epidermis ap- margin of skin showing any radiation change. The chest wall
excision should include all tissue that is apparently damaged
pears thin, and the vascularity appears abnormal, the even though the defect may be large. Healing will be better if
tissue should be regarded as tenuous. Evaluation should the flaps are approximated to healthy tissues. (From Seyfer AE,
always be conducted with an eye toward conserving as Graeber GM, Wind GG: The rectus abdominis muscle and
much healthy tissue as possible, yet not leaving any musculocutaneous flaps. In Seyfer AE (ed): Atlas of Chest Wall
of the radiation-damaged chest wall behind. Radiation- Reconstruction. Rockville, MD, Aspen, 1986e.)
damaged tissue provides an unstable margin for recon-
struction. In planning the resection, the entire margin of
irradiated tissue should be removed (Fig. 55-2). that may be rotated into the wound and the surgical
The same principles that govern surgical resection edges of resection are considerable.
for infection govern resection for radiation injury, since
infection is often present at the time of surgery. Prepara-
tion of the patient is similar to that for resection of
RESECTION FOR TRAUMA
infection, as described in the previous section. In the Traumatic injuries of the chest wall may be broadly cate-
case of infection localized to one area of ulceration, I and gorized as either blunt or penetrating (Pate, 1989). In
my colleagues use a double preparation technique. The most cases penetrating wounds are the ones most often
first step is to prepare the ulcerated, irradiated tissue with responsible for serious chest wall injury requiring surgi-
a separate instrument set and to isolate this area from cal repair. Since there has been a tremendous increase in
the remaining surgical area with a povidone-iodine-im- domestic trauma, particularly related to criminal activity,
pregnated gauze sponge, which is placed in the wound the need for understanding these wounds and treating
and then covered with a piece of plastic sheeting or them appropriately is great (LoCicero and Mattox, 1989).
rubber glove (Fig. 55-3). A second preparation is then Military weapons, including handguns, shoulder weap-
conducted throughout the entire operative field on the ons, automatic rifles, and assault weapons, are all being
patient so that there is no contamination from the in- used with greater frequency in domestic violence today.
fected ulcer. Resection is then carried out to healthy Patients who suffer blast injuries to the chest from deto-
tissue margins (Seyfer, 1988). nated ordinance rarely live to reach an emergency center.
Even though the resection may be extensive, it is Early attempts at treating chest wall injuries were
necessary to achieve healthy margins throughout the rudimentary at best. In the first part of the 20th century,
wound so that good tissue healing may occur. Radiation- during World War I, most chest wounds were left open
damaged tissue does not heal well, and it offers further to granulate. If the patient survived, it was purely owing
chance for breakdown at the margins of the wound. Such to luck and personal fortitude (Fig. 55-4). Few patients
tissue offers poor structural support to the chest wall and with significant injuries of the chest ever survived during
is inadequate to allow firm fixation of any stabilization this period. By the time of World War II, there were
material. If marginal tissue is retained at the edges of some organized efforts at treating wounds of the chest
resection, the chances for poor healing between any flaps effectively. After thorough debridement, local flaps of
1446 CHAPTER 55 • Surgical Techniques/Chest Wall Resection

FIGURE 55-3 • A, The patient has been placed in a supine position on the operating table, and the anticipated margins
of resection have been drawn on the chest wall. The dotted lines on the extremities show the preparation of the patient.
In this case, a transverse musculocutaneous rectus abdominis (TRAM) flap based on the left rectus muscle will be used to
reconstruct the defect. The solid line on the lower abdomen depicts the skin island that will be taken with the flap.
Preparation of the patient for resection includes a double preparation, the first of which is directed at cleaning the
ulcerated wound on the chest. Once this has been closed and covered with a gauze sponge impregnated with providone-
iodine solution, which is covered with a piece of plastic or a section of rubber after being placed in the wound, a second
preparation can be conducted over the entire area. 6, Close-up of the way the ulcer is filled with the gauze sponge in
the defect. Note that the rubber patch, a portion- of the glove, or a piece of sterile impermeable drape is stapled in
placed so that the entirety of the ulcer is excluded from the field during the second preparation. (A From Seyfer AE,
Graeber GM, Wind GG: The rectus abdominis muscle and musculocutaneous flaps. In Seyfer AE (ed): Atlas of Chest Wall
Reconstruction. Rockville, MD, Aspen, 1986a. B, From Seyfer AE, Graeber GM, Wind GG: The omentum. In Seyfer AE (ed):
Atlas of Chest Wall Reconstruction. Rockville, MD, Aspen, 1986i.)

tissue were advanced to attempt coverage of the wound
(Fig. 55-5). Currently, effective management consists of
thorough debridement and stabilization of the wound
followed by flap reconstruction. Since all the wounds are
severely infected, chest wall stabilization with synthetic
materials is not recommended.
The devastating nature of military and civilian weap-
ons has been well documented (Bellamy and Zajtchuk,
1991a, 1991b). Detonation of antipersonnel devices such
as grenades, mines, and heavy ordinance are rarely en-
countered in civilian practice; however, in today's world
some few patients suffering blast injuries may come to a
thoracic surgeon for treatment. The critical effects of
blasts have recently been well documented by several
authors in military publications (Phillips and Zajtchuk,
1991; Stuhmiller et al, 1991). Frequently, weapons of
civilian origin also cause significant injuries to the chest
wall that need resection. The most common weapon of
this type is the shotgun, which causes a devastating soft
tissue loss of the chest wall while penetrating the lung
and underlying viscera.
Preoperative preparation is directed at stabilizing the
patient and giving broad-spectrum antibiotics to cover
the bacteremia, which is always present with such
wounds. The patient is given vigorous fluid resuscitation
to restore cardiodynamic integrity and is transported to
the operating room as soon as possible. Surgery is di-
rected at stabilizing the life-threatening injuries within
the thorax and at debridement of the chest wall. It is
necessary to emphasize that the lung should be managed
in a conservative fashion because of its tremendous re-
generative capacity. The need for total lobectomy and/
or pneumonectomy remains infrequent, since the major
vessels and bronchi may be closed on the surface of the
lung without radical extirpation. Once the lung has been
stabilized, it should be ventilated and expanded to its
greatest extent. Pleural abrasion is very helpful in secur-
ing fixation of the lung to the remaining chest wall. Chest
tubes should be placed so that they are not exposed in
the open defect but rather drain the inferior as well as
the superior portion of the chest of all possible fluid and
air that may remain in the pleural cavity (Fig. 55-6).
The resection of the chest wall itself is most important,
since removal of all devitalized tissue, foreign material,
portions of clothing, dead skin, and hair should be con-
ducted vigorously. The resection should be conducted so
that healthy muscle is seen throughout the margin of
the wound and there is active bleeding throughout all
remaining tissues. The four major qualities consistent
with a high degree of viability are color, consistency,
contractility, and circulation (Bellamy and Zajtchuk,
1991b). The lung is expanded to the margins of resection
and the defect is closed with an impregnated providone-
iodine gauze to secure an airtight seal on the chest wall.
The chest tubes evacuate any blood or air that accumulate
in the pleural cavity and maintain expansion of the lung
 CHAPTER 55 • Surgical Techniques/Chest Wall Resection 1447

FIGURE 55-4 • Patient with severe chest wall wound that has been
treated in accordance with the principles of military medicine as
dictated in the early part of the 20th century. Note that the wound has
been debrided widely and allowed to granulate. Some patients treated
in this manner, including soldiers wounded in World War I, survived
despite their wounds. The wound continued to granulate and remain
superficially infected, causing severe nutritional depletion of the
patient. Hence, the patient looked quite ca'chectic, because depletion
occurred slowly over time. Few of these individuals survived the long
term. (From Seyfer AE, Graeber GM, Wind GG: Some historical aspects
of chest wall reconstruction. In Seyfer AE (ed): Atlas of Chest Wall
Reconstruction. Rockville, MD, Aspen, 1986c.)

FIGURE 55-5 • Closure of wounds in World War II usually

consisted of mobilization of local slips of muscle for closure over
the previously debrided defect. This drawing depicts one of the
attempts at closure, which was conducted on a patient suffering an
anterior thoracic wall wound during World War II. Note that the
area had been debrided widely and that closure was attempted
only when all evidence of infection had receded. (From Seyfer AE,
Graeber GM, Wind GG: Some historical aspects of chest wall
reconstruction. In Seyfer AE (ed): Atlas of Chest Wall
Reconstruction. Rockville, MD, Aspen, 1986c.)
1448 CHAPTER 55 • Surgical Techniques/Chest Wall Resection
FIGURE 55-6 • Placement of chest tubes as they would be
situated for an anterolateral thoracic wound. In placing the
tubes, care is taken to remain away from the wound site itself
so that the tubes do not traverse the area of the open chest
wall. One tube is placed over the apex of the chest to drain
any air that may be remaining within the pleural cavity; the
other tube is placed low and posterior so that it will evacuate
any blood or tissue fluids that may collect in the posterior
costophrenic sinus. (From Seyfer AE, Graeber GM, Wind GG:
Resection and debridement of the chest wall. In Seyfer AE (ed):
Atlas of Chest Wall Reconstruction. Rockville, MD, Aspen,
1986d.)
against the remaining chest wall. A second debridement
is often necessary 24 and 48 hours after the initial injury
since additional tissue may lose viability in this time.
The necessity for close observation of the wound and
subsequent debridement cannot be underestimated. Re-
tention of foreign material and devitalized tissue within
the margins of the wound can lead to clostridial infection
and rapid demise of the patient. Fortunately, with ade-
quate initial debridement this is rare.
In the final analysis, the viability of the patient de-
pends on the individual surgeon's persistence, skill, and
creativity. The patient must be observed constantly for
any evidence of pending sepsis and evaluated for evi-
dence of crepitus within the margins of the wound. Cre-
ativity must be constantly exhibited, since the wound
will have to be tailored when it has become stabilized.
Constant attention to patients is mandatory since they
can deteriorate and die very quickly.
• KEY REFERENCES
McCraw JB, Arnold PG: McCraw and Arnold's Atlas of Muscle and
Musculocutaneous Flaps, Norfolk, VA, Hampton Press, 1986.
This excellent atlas depicts the major muscular and musculocuta-
neous flaps that may be harvested throughout the human body.
Copiously illustrated, this provides an excellent guide for the
anatomic dissection of most existing muscular and musculocuta-
neous flaps. It should be considered an excellent reference for
chest wall reconstruction since it depicts both pedicled and free
flaps.
Seyfer AE, Graeber GM (eds): Chest wall reconstruction, Surg Clin
North Am 69(5):142-145, 1989.
This monograph specifically addresses chest wall reconstruction
in all its major aspects. Major authorities in the field of chest wall
reconstructions discuss each of the major flaps that may be used.
Specific problems encountered in chest wall reconstruction, such
as the dehisced median sternotomy and radiation injuries of the
chest wall, are covered in depth. The monograph provides an
excellent review of the entire field since each of the articles has
an extensive list of references.
Seyfer AE, Graeber GM, Wind GG: Atlas of Chest Wall Reconstruction.
Rockville, MD, Aspen Publishers, 1986a.
This atlas specifically delineates the methods used in chest wall
reconstruction. It covers most aspects of chest wall reconstruction,
starting from the evaluation of the patient and continuing through
postoperative care. Major emphasis is placed on pedicled flap
reconstruction and on specific problems afflicting the chest wall.
The illustrations depict all the major steps necessary in each of
the reconstructions cited.
• REFERENCES
Arnold PG, Pairolero PC: Chondrosarcoma of the manubrium. Resec-
tion and reconstruction with pectoralis major muscle. Mayo Clin
Proc 53:54, 1978.
Arnold PG, Pairolero PC: Chest wall reconstruction: Experience with
100 consecutive patients. Ann Surg 199:725, 1984.
Arnold PG, Pairolero PC: Surgical management of the radiated chest
wall. Plast Reconstr Surg 77:605, 1986.
Arnold PG, Pairolero PC: Reconstruction of the radiation-damaged
chest wall. Surg Clin North Am 69:1081, 1989.
Ayala AG, Zornosa J: Primary bone tumors: Percutaneous needle biopsy.
Radiology 149:675, 1983.
Azarow KS, Mallow M, Seyfer AE, Graeber GM: Preoperative evaluation
and general preparation for chest wall operations. Surg Clin North
Am 69:899, 1989.
Bellamy RF, Zajtchuk R: The weapons of conventional land warfare. In
Bellamy RF, Zajtchuk R (eds): Conventional Warfare: Ballistic,
Blast, and Burn Injuries. In Textbook of Military Medicine. Part I:
Warfare Weaponry and the Casualty. Vol 5. Washington, DC,
Office of the Surgeon General. U.S. Army, 1991a.
Bellamy RF, Zajtchuk R: Assessing the effectiveness of conventional
weapons. In Bellamy RF, Zajtchuk R (eds): Conventional Warfare:
Ballistic, Blast, and Burn Injuries. In Textbook of Military Medi-
cine. Part 1: Warfare Weaponry and the Casualty. Vol 5. Washing-
ton, DC, Office of the Surgeon General. U.S. Army, 1991b.
Bellamy RF, Zajtchuk R: The physics and biophysics of wound ballistics.
In Bellamy RF, Zajtchuk R (eds): Conventional Warfare: Ballistic,
Blast, and Burn Injuries. In Textbook of Military Medicine. Part 1:
Warfare Weaponry and the Casualty. Vol 5. Washington, DC,
Office of the Surgeon General. U.S. Army, 1991c.
Bellamy RF, Zajtchuk R: The management of ballistic wounds of soft
tissue. In Bellamy RF, Zajtchuk R (eds): Conventional Warfare:
Ballistic, Blast, and Burn Injuries. In Textbook of Military Medicine
Part I: Warfare Weaponry and the Casualty. Vol 5 Washington,
DC, Office of the Surgeon General. U.S. Army, 1991d.
El-Tamer M, Chaglassian T, Martini N: Resection and debridement of
chest-wall tumors and general aspects of reconstruction. Surg Clin
North Am 69:947, 1989.
Graeber GM: Harvesting of the internal mammary artery and the healing
median sternotomy (Editorial). Ann Thorac Surg 53:7, 1992.
Graeber GM: Snyder R], Fleming AW et al: Initial and long-term results
in the management of primary chest wall neoplasms. Ann Thorac
Surg 34:664, 1982.
Groff DB, Adkins PC: Chest wall tumors. Ann Thorac Surg 4:260, 1967.
King RM, Pairolero PC, Trastek VF et al: Primary chest wall tumors:
Factors affecting survival. Ann Thorac Surg 41:597, 1986.
 CHAPTER 55 • Surgical Techniques/Chest Wall Stabilization
LoCiceroJ, Mattox KL: Epidemiology of chest trauma. Surg Clin North
Am 69:15, 1989.
Martini N, Starzynski TE, Beattie EJ: Problems in chest wall resection.
Surg Clin North Am 49:313, 1969.
McAfee MK, Pairolero PC, Bergstrahl EJ et al: Chondrosarcoma of the
chest wall: Factors affecting survival. Ann Thorac Surg 140:535,
1985.
Miller JI, Nahai F: Repair of the dehisced median sternotomy incision.
Surg Clin North Am 69:1091, 1989.
Pairolero PC, Arnold PG: Management of recalcitrant median ster-
notomy wounds. J Thorac Cardiovasc Surg 88:357, 1984.
Pairolero PC, Arnold PG: Chest wall tumors: Experience with 100
consecutive patients. J Thorac Cardiovasc Surg 90:367, 1985.
Pairolero PC, Arnold PG: Thoracic wall defects: Surgical management
of 205 consecutive patients. Mayo Clin Proc 61:557, 1986.
Pate JW: Chest wall injuries. Surg Clin North Am 69:59, 1989.
Phillips YY, Zajtchuk JT: The management of primary blast injury. In
Bellamy RF, Zajtchuk R (eds): Conventional Warfare: Ballistic,
Blast, and Burn Injuries. In Textbook of Military Medicine. Part I:
Warfare Weaponry and the Casualty. Vol. 5. Washington, DC,
Office of the Surgeon General. United States Army, 1991.
Rao BN, Hayes FA, Thompson EI et al: Chest wall resection for Ewing's
sarcoma of the rib: An unnecessary procedure. Ann Thorac Surg
46:40, 1988.
Ryan MB, McMurtrey MJ, Roth JA: Current management of chest-wall
tumors. Surg Clin North Am 69:1061, 1989.
Schaefer PS, Burton BS: Radiographic evaluation of chest-wall lesions.
Surg Clin North Am 69:911, 1989.
Seyfer AE: Radiation-associated lesions of the chest wall. Surg Gynecol
Obstet 167:129, 1988.
Seyfer AE, Graeber GM, Wind GG: Preoperative care and considera-
tions. In Seyfer AE (ed): Atlas of Chest Wall Reconstruction.
Rockville, MD, Aspen Publishers, 1986b.
I CHEST WALL STABILIZATION
Geoffrey M. Graeber
The first step in chest wall reconstruction is preservation
of function through stabilization. In some cases the resec-
tion itself does not sufficiently compromise chest wall
function and thereby also respiratory mechanics to war-
rant stabilization. If stabilization is necessary, a number
of materials have been used successfully to preserve chest
wall integrity and respiratory mechanics. Some have re-
mained useful and have earned a secure place in chest
wall reconstruction, while others have proved marginally
or minimally successful and have been abandoned. The
indications for chest wall stabilization as a part of an
integrated reconstruction are reviewed; the materials,
both biologic and synthetic, that have been used in this
capacity are listed; and the most popular methods used
by surgeons today are summarized.
INDICATIONS FOR STABILIZATION
Chest wall reconstruction is generally viewed as a proce-
dure with two aspects, chest wall stabilization and soft
tissue reconstruction. In some cases the consistency of
1449
Seyfer AE, Graeber GM, Wind GG: Some historical aspects of chest
wall reconstruction. In Seyfer AE (ed): Atlas of Chest Wall Recon-
struction. Rockville, MD, Aspen Publishers, 1986c.
Seyfer AE, Graeber GM, Wind GG: Resection and debridement of the
chest wall. In Seyfer AE (ed): Atlas of Chest Wall Reconstruction.
Rockville, MD, Aspen Publishers, 1986d.
Seyfer AE, Graeber GM, Wind GG: Planning the reconstruction. In
Seyfer AE (ed): Atlas of Chest Wall Reconstruction. Rockville,
MD, Aspen Publishers, 1986e.
Seyfer AE, Graeber GM, Wind GG: The rectus abdominis muscle and
musculocutaneous flaps. In Seyfer AE (ed): Atlas of Chest Wall
Reconstruction. Rockville, MD, Aspen Publishers, 1986f.
Seyfer AE, Graeber GM, Wind GG: The pectoralis major muscle and
musculocutaneous flaps. In Seyfer AE (ed): Atlas of the Chest
Wall Reconstruction. Rockville, MD, Aspen Publishers, 1986g.
Seyfer AE, Graeber GM, Wind GG: The dehisced median sternotomy
incision. In Seyfer AE (ed): Atlas of Chest Wall Reconstruction.
Rockville, MD, Aspen Publishers, 1986h.
Seyfer AE, Shriver CD, Miller TR, Graeber GM: Sternal blood flow after
median sternotomy and mobilization of the internal mammary
arteries. Surgery 104:899, 1988.
Stelzer D, Gay WA: Tumors of the chest wall. Surg Clin North Am
60:779, 1980.
Stuhmiller JH, Phillips YY, Richmond DR: The physics and mechanisms
of primary blast injury. In Bellamy RF, Zajtchuk R (eds): Conven-
tional Warfare: Ballistic, Blast, and Burn Injuries. In Textbook of
Military Medicine Part I: Warfare Weaponry and the Casualty. Vol
5. Washington, DC, Office of the Surgeon General. U.S. Army,
1991.
Venn GE, Gellister J, DaCosta PE et al: Malignant fibrous histiocytoma
in thoracic surgery practice. J Thorac Cardiovasc Surg 91:234,
1986.
the soft tissue reconstruction affords satisfactory stabiliza-
tion to preserve respiratory mechanics (Seyfer et al,
1986a, 1986b), whereas in others, the flaps used in pro-
viding soft tissue coverage have little intrinsic consistency
(e.g., omentum flaps) and usually need stabilization (Fix
and Vasconez, 1989; Seyfer et al, 1986c). Each case must
be assessed and handled individually since respiratory
mechanics must be preserved. The final decision of
whether chest wall stabilization is necessary involves
consideration of multiple factors, the most important of
which are the general condition and respiratory capabili-
ties of the patient, the size and location of the resection
performed, the integrity and quality of the structures
overlying the defect, and the intrinsic qualities of the
flaps used for soft tissue coverage. The final goal is to
provide a reconstruction that has minimal if any paradox-
ical chest wall motion during respiration so that the
patient can be weaned from ventilatory support as soon
as possible after reconstruction (McCormack, 1989;
Seyfer et al, 1986a, 1986b). Satisfactory cosmesis is an
important secondary goal that merits careful consider-
ation (Seyfer et al, 1986a, 1986b).
1450 CHAPTER 55 • Surgical Techniques/Chest Wall Stabilization
The general condition and respiratory capabilities of
the patient are major factors in determining whether
chest wall stabilization is required as a part of chest
wall reconstruction (Seyfer et al, 1986d). The operating
surgeon must evaluate the patient who will undergo chest
wall resection carefully to determine just how much res-
piratory embarrassment the patient can tolerate and yet
still be able to be weaned from a respirator early in the
postoperative period. A reasonable guiding principle is
that any patient who is able to tolerate a pulmonary
lobectomy based on pulmonary function studies, arterial
blood gas determination, and exercise testing will also be
able to tolerate a major chest wall resection (Seyfer et al,
1986e). Special consideration should be given to the
unusual patient who needs a pulmonary resection in
conjunction with a major chest wall resection and recon-
struction. Obviously, a younger, more robust patient with
excellent nutrition will tolerate a large resection and
reconstruction better than a frail, elderly patient who
suffers from cachexia.
The location and size of the chest wall resection are
major determinants of whether chest wall stabilization is
required as a part of successful reconstruction. Small
defects (5 to 7 cm in greatest diameter) seldom need
stabilization, since the amount of paradoxical motion is
small and can be tolerated by most patients (McCormack,
1989; Pairolero and Arnold, 1986). Larger defects almost
always need some form of chest wall stabilization to
preserve respiratory function (Pairolero and.Arnold,
1986; Seyfer et al, 1986e). Location of the resection is
important, since major structures of the ipsilateral upper
extremity may provide the necessary overlying support.
The scapula is an example of such a structure posteriorly,
but its relation to the defect may impinge on the margin
requiring partial resection of the inferior scapular pole
(Pairolero and Arnold, 1986). Anteriorly the pectoralis
major muscle, if it and its overlying skin and subcutane-
ous tissues are left intact, may provide sufficient support
that chest wall stabilization is not necessary. Resections
that are lateral and inferoanterior generally require stabi-
lization, since major muscles and bones do not overlie
the chest wall in these regions.
The size of the flap employed in soft tissue reconstruc-
tion and its intrinsic consistency have direct bearing on
whether chest wall stabilization is required. As noted
previously, the omentum usually is very flaccid, with
little intrinsic rigidity; hence stabilization is almost al-
ways required when the omentum is used. In contrast, a
large musculocutaneous flap (such as a latissimus dorsi)
has an intrinsic robust quality, which may allow coverage
of a defect without stabilization. All flaps, like any other
surgically manipulated tissues, generate edema within 48
hours of the procedure. Because edema tends to make
tissues more rigid, the flap has less paradoxical motion
on the second through fourth postoperative days. The
flap becomes less robust as the edema fluid is mobilized
later in the postoperative period, but usually the patient
has been weaned from the ventilator by this time.
MATERIALS USED IN CHEST WALL
STABILIZATION
A host of materials have been used to stabilize the chest
wall and preserve respiratory mechanics since the incep-
tion of chest wall resection and reconstruction. An excel-
lent review by McCormack (1989) has summarized most
of these and should be consulted. The following discus-
sion is based on experiences recorded in the literature
by other authors and on personal observations recorded
during major reconstructions performed on patients by
myself and colleagues at our respective university institu-
tions. This section presents a classification of materials
that have been used to stabilize the chest wall. The last
section of this review highlights the major methods used
in chest wall stabilization which are practiced regularly
because of ease in handling, durability, relative radio-
graphic permeability, and superior performance.
The first major category is biologic implants. The
assets of autogenous tissues are availability and biocom-
patibility. Their liabilities include poor resistance to infec-
tion, increased operating time, substantially increased pa-
tient discomfort, and relative flaccidity when compared
with synthetic materials (McCormack, 1989; Seyfer et al,
1986a). Their presence in a wound can be disastrous if
infection supervenes. Fascia lata is devascularized tissue,
which acts as a perfect culture medium for bacteria. Bone
chips added to fascia lata provide no stabilization since
they are resorbed (McCormack, 1989). Their presence on
fascia lata compounds the problem of infection, since
they act as yet another source of devascularized tissue on
which microorganisms can thrive. For all the aforemen-
tioned reasons, fascia lata alone or in conjunction with
bone chips has fallen into disfavor.
BIOLOGIC MATERIALS USED FOR CHEST
WALL STABILIZATION
Human tissues
Autogenous
Fascia lata
Bone grafts
Ribs, whole and longitudinally split
Tibia
Fibula
Iliac crest
Composite
Preserved
Dura mater
Fascia
Pericardium
Preserved animal tissues
Dura mater
Pericardium
Os fascia
Bone grafts can be used judiciously in selected in-
stances for chest wall stabilization. Although portions of
tibia, fibula, and iliac crest have been used successfully,
their harvesting adds another operative site, with its asso-
ciated discomfort and potential for complications
(McCormack, 1989; Seyfer, et al, 1986a). Rib grafts have
the advantage of being more likely to follow the natural
curvature of the chest wall, but they have significant
liabilities. If they are harvested in a subperiosteal fashion,
 CHAPTER 55 • Surgical Techniques/Chest Wall Stabilization
the resultant chest wall instability may be consequential
and the rib may regenerate from the remaining perios-
teum poorly or not at all. Ribs that are partially resected
by using a longitudinal line of resection leave a compro-
mised rib in place at the donor site while providing a
graft that is particularly frail. The result is suboptimal
stabilization at both the donor and recipient sites.
The use of rib grafts by my colleagues and me has
been limited to carefully selected patients who need
protection for vital intrathoracic structures (such as the
heart and great vessels) while maintaining an acceptable
cosmetic contour to the reconstruction. The patient
must have relatively good pulmonary function, since the
discomfort from the donor site, when compounded with
that of the reconstruction, can produce a serious de-
crease in respiratory function. Placement of an epidural
catheter to maintain regional anesthesia in the immedi-
ate postoperative period has decreased patient discom-
fort in our experience, so that early weaning from the
ventilator is the rule. If rib grafts are placed properly,
marrow from the intact ribs at the margins of the resec-
tion grow into and vascularize the marrow of the graft,
ensuring its prolonged viability (Seyfer et al, 1986a)
(Fig. 55-7). Rib grafts in any position are dependent on
FIGURE 55-7 • Use of rib grafts in anterior chest wall
stabilization. Note that the grafts, as well as the ribs, are
notched so that they can be secured with transfixing
permanent sutures. Notching also allows a greater area of
interface between the rib and the graft marrow cavities. The
greater interface of the two marrows increases the likelihood
that the bone graft will survive, because the marrow of the
graft is dependent on the ingrowth of cellular material from
the end of the rib. (From Seyfer AE, Graeber GM, Wind GG:
Planning the reconstruction. In Seyfer AE (ed): Atlas of Chest
Wall Reconstruction. Rockville, MD, Aspen, 1986a.)
1451
surrounding tissues, particularly on the rib to which
they are attached, for postoperative viability (Graeber et
al, 1985). If a rib graft or any bone graft does not receive
a new blood supply, the graft is resorbed by the body,
leaving only a fibrous remnant (Graeber et al, 1985;
McCormack, 1989).
Preserved tissues, human or animal, were mostly used
before synthetic cloth and sheeting became available and
proved so successful (McCormack, 1989; Seyfer et al,
1986a). There have been some recent proponents of these
tissues for chest wall stabilization (Kuakowski and Ruka,
1987). Although these membranes may provide substan-
tial initial stability, they may become flaccid with time
owing to peripheral stress on anchoring tissues as well as
to intrinsic weakening of structural proteins. The patient's
body reacts to these materials as it does to any foreign
body, with an intense fibrous reaction. These facts, plus
the relatively inferior resistance of biologic materials to
infection, has led to a decrease in their use.
The rise in the use of synthetic materials for chest
wall stabilization has been fostered by their variety and
availability, their perceived inert nature, and their general
ease of handling (McCormack, 1989; Seyfer et al, 1986a).
At the outset, any surgeon should realize that absolutely
no material is completely inert when placed in a patient.
The patient's natural healing process will at least respond
to any foreign material with a fibrous reaction to form a
pseudocapsule.
Rigid materials have had some popularity in chest wall
reconstruction, but they have some liabilities, which have
limited their application (McCormack, 1989; Seyfer et al,
1986a). Since the chest wall is a dynamic structure,
which is constantly active in respiration, rigid materials
have a tendency to migrate and fracture. Migration, when
it is external, finally causes dermal erosion, which expo-
ses the rigid material. Infection of the entire capsule
surrounding the rigid support ensues quickly, requiring
removal of the foreign material. If the rigid bar or strut
erodes internally, major viscera (such as the lung) and
great vessels may be entered serious if not lethal hemor-
rhage producing (McCormack, 1989). Metallic struts are
for the most part currently limited to stabilization of the
sternum after repair of a severe pectus deformity (Garcia
et al, 1989; Seyfer et al, 1986f). In most cases these struts
are not permanent but are removed after the chest wall
has become stable (Fig. 55-8).
Most synthetic materials used for human implantation
are produced as sheets or as meshes. Many of these
have been employed, with varying degrees of success, as
stabilizing membranes in chest wall reconstruction (Boyd
et al, 1981; McCormack, 1989; Pairolero and Arnold,
1985, 1986). Each has its assets and liabilities. For exam-
ple, Marlex mesh can be stretched along one axis while
it is rigid along the perpendicular axis. Prolene mesh is
a double-stitch knit, which is rigid along all axes. Gore-
Tex, which is very malleable as a soft tissue patch, is
impervious to air and water but is most difficult to
contour and sew in place tightly. Although each of these
materials is relatively inert, they all provoke an intense
fibrous reaction when placed in the chest wall. Even
polypropylene, which has been touted as quite unreac-
1452 CHAPTER 55 • Surgical Techniques/Chest Wall Stabilization

A number of synthetic materials can be produced with

variable degrees of firmness. Success has been reported
with acrylic, silicone, Silastic, and methyl methacrylate
prostheses (Eschaposse et al, 1977; Mendelson and Mas-
son, 1977; Allen and Douglas, 1979; Marcove et al, 1977).
They may be used alone or in composites as prosthetics
in chest wall reconstruction (Hochberg et al, 1994). Al-
though such techniques have been available since well
before the early 1980s, recent concerns about silicone,
particularly as it has been used in mammary implants,
indicate extreme caution in its use (Lavey et al, 1982;
deCamara et al, 1993). Current U.S. Food and Drug
Administration guidelines for implanting silicone should
be consulted before embarking on such a reconstruction.
In current practice, customized prostheses are used for
both chest wall stabilization and partial chest wall recon-
struction only in selected cases in which standard stabili-
zation and flap reconstruction either has failed or offers
exceptionally limited options (Hochberg et al, 1994).
Such individualized prostheses may be created to recon-
struct complex defects with rounded contours; however,
they are difficult to secure to the chest wall, require
FIGURE 55-8 • Use of a Steinmann pin in stabilizing a sophisticated, computerized techniques to generate the
repaired sternum as part of a correction for pectus excavatum. prosthetic, and are subject to all the recognized liabilities
The pin is secured to the ribs lateral to the repair. It will be of a firm foreign body in the dynamic chest wall. Excel-
removed in most cases after the repair has healed. (From lent long-term results have been recorded in carefully
Seyfer AE, Graeber GM, Wind GG: Congenital defects: Poland's
syndrome, pectus deformities and sternal clefts. In Seyfer AE
selected patients with very special reconstructive needs
(ed): Atlas of Chest Wall Reconstruction. Rockville, MD, Aspen, (Hochberg et al, 1994).
19861)
McCormack and others have had particularly benefi-
cial experience with composite prostheses generated in
the operating room from Marlex mesh and methyl meth-
tive, was found to provoke an intense fibrous reaction acrylate monomer (McCormack et al, 1981; McCormack,
from the lung and pleura in one experimental model 1989). A customized prosthesis is made by measuring
(Graeber et al, 1985). the size of the defect on the patient, laying a piece of
Marlex mesh over a surface of similar contour, applying
the methyl methacrylate to the Marlex to match the size
ALLOPLAST1C AND SYNTHETIC MATERIALS and shape of the defect as determined by the previously
USED IN CHEST WALL STABILIZATION measured pattern, and then applying another layer of
Plates and struts Marlex over the still soft methyl methacrylate so that the
Metal Marlex bonds to it. The resulting prosthesis has a firm,
Tantulum steel contoured center of polymethyl-methacrylate, which lies
Stainless steel between two layers of Marlex. The 5-cm rim of Marlex
Other materials that extends beyond the hard central polymethyl-methac-
Lucite rylate prosthesis acts as a sewing ring for securing it to
Fiberglass the chest wall defect. The prosthesis has several assets:
it has an absolutely rigid center, conforms well to the
Synthetic materials anticipated curve of the chest wall, and has a pliable
Sheets and meshes sewing ring. One of its true liabilities arises with its
Polytetrafluorethylene (Teflon) sheeting and patch creation: the reaction leading to the hardening of the
Nylon methyl methacrylate is extremely exothermic, often
Polypropylene reaching temperatures near 140°E Appropriate curvature
Prolene mesh may be obtained by shaping the prosthesis over a chest
Vicryl mesh tube collection bottle or over the patient's thigh, which
Solid and firm prosthetics can be protected with towels to prevent the exothermic
Acrylic reaction from causing thermal tissue injury. Once in
Teflon place, the prosthesis is subject to all the problems, as
Silastic noted previously, attendant on rigid prostheses in a dy-
Silicone namic environment.
Composite
Investigators working at the National Cancer Institute
Marlex mesh combined T prosthesis have identified another problem associated with methyl
Methyl methacrylate f
methacrylate prostheses (Pass, 1989). In their method for
creating the prosthesis, the lung is dropped away from
 CHAPTER 55 • Surgical Techniques/Chest Wall Stabilization
the defect in the chest wall and the prosthesis is actually
created on the patient from Marlex, steel mesh, and
methyl methacrylate. After the prosthesis has been cre-
ated, the lung is re-expanded against the prosthesis. A
metabolic acidosis, which is secondary to anion replace-
ment with methyl methacrylate, ensues. This has to be
corrected during the reconstruction.
METHODS OF IMPLANTATION
Chest wall stabilization is necessary to provide a firm
surface on which to set the soft tissue flaps that complete
the reconstruction. The key point to remember is that
stabilization is directed at reducing paradoxical motion
of the chest wall and maintaining its contour. Technical
aspects of the three most popular methods of stabilization
are discussed subsequently. It should be remembered that
creativity is necessary in all aspects of chest wall recon-
struction, including achievement of a desired cosmetic re-
sult.
There are several important points to consider in im-
planting the polymethyl-methacrylate "sandwich." The
prosthesis has a central rigid area, which follows the
chest contour and is extremely rigid. The sewing ring,
which consists of the 5-cm rim of Marlex around the
central hard prosthesis, is used to join the prosthesis to
the chest wall. If sutures have to be placed through the
central, hard portion of the prosthesis, a tunnel has to be
created with a drill to allow passage of the needle since
the methyl methacrylate sets to the same consistency as
a football helmet.
Stabilization with either mesh or screening requires
creative tailoring to suture the material to the chest wall
(Fig. 55-9). The margin of resection should be palpated
to determine the most stable point, which is usually a rib
or a remaining portion of the sternum. A horizontal
mattress suture of braided, permanent synthetic material
is placed through the edge of the patch or the screening
FIGURE 55-9 • A successful method for
securing synthetic mesh or sheeting to a
chest wall defect to achieve stabilization.
Note that the sutures are placed on the
cephalad aspect of the ribs to avoid the
neurovascular bundles that course along the
caudad surfaces of the ribs. Sutures are
placed starting at one point in the defect
and are placed sequentially and radically to
achieve a relatively taut surface on which to
place the flap(s) used to reconstruct the soft
tissue defect. (From Seyfer AE, Graeber GM,
Wind GG: Planning the reconstruction. In
Seyfer AE (ed): Atlas of Chest Wall
Reconstruction. Rockville, MD, Aspen,
1986a.)
1453
and through the periosteum of the bone and is tied in
place. A second suture is placed through the synthetic
material so that it can be secured firmly to the most
stable point 180 degrees opposite to the original suture.
Another set of sutures is placed through the prosthetic
material at the edge of the resection so that the material
is drawn tight and secured to the periosteum along an
axis perpendicular to the line between the first two su-
tures. Sutures are then placed in a radial fashion so that
the material is drawn tightly across the wound. Once the
entirety of the prosthesis has been adjusted in place, any
excess margins are trimmed.
An alternative method is to start with the firmest point
on the margin of resection and secure the prosthesis to
the periosteum. Sutures are then placed sequentially in a
radial fashion around the defect, drawing the synthetic
material progressively tighter. Tailoring cuts are made in
the prosthetic material after each suture so that the mate-
rial will tuck underneath the edges of the margin neatly.
If the sutures are placed appropriately by either method,
a firm, taut surface for accepting the soft tissue flaps
is created.
In some patients with very difficult reconstructive
problems, a customized prosthesis can be made to
achieve chest wall stabilization and replace the soft tissue
defect (Fig. 55-10). In such cases there has to be soft
tissue coverage of the prosthesis after it is in place.
Usually, the soft tissue placed over the prosthesis is the
native tissue remaining at the site, but in some cases a
musculocutaneous flap is necessary for sufficient cover-
age. The customized prosthesis is generated via computer
modeling: the opposite side of the patient's chest wall is
surveyed, measurements are taken, a mirror image of the
chest wall is created through a computer model, the
dimensions of the model are printed, and a plaster model
is created (Hochberg et al, 1994).
In the case illustrated in Figure 55-10, the patient also
needed a breast prosthesis. A silica gel prosthesis was
1454 CHAPTER 55 • Surgical Techniques/Chest Wall Stabilization
FIGURE 55-10 • Composite prosthesis with two components:
a hard Silastic posterior segment, which replaces the upper
anterior thoracic wall, and a soft gel prosthesis, which gives
contour and shape to the absent breast. Note that there are
three integral plastic tabs on the margins of the prosthesis.
These plastic tabs are used to secure the prosthesis to bones
on the thoracic wall and thereby prevent migration. (From
Hochberg J, Ardenghy M, Graeber GM, Murray GF: Complex
reconstruction of the chest wall and breast utilizing a
customized silicone implant. Ann Plast Surg 32:524, 1994.)
added to the heavy Silastic contoured model of the chest
wall. The composite model is custom manufactured, and
the prosthesis is sterilized by the manufacturer and deliv-
ered to the surgeon for implantation in the patient. Im-
plantation of this model is dependent on integral plastic
tabs, which may be seen in Figure 55-10. These tabs are
sutured to stable skeletal structures so that the prosthesis
does not migrate. In the case cited, the three tabs were
secured respectively to the sternum medially, the clavicle
superiorly, and the ribs laterally. Heavy, braided synthetic
sutures were placed through the plastic tabs and through
the periosteum of the bony structures noted. In some
situations, as with the clavicle or the sternum, the sutures
may actually be placed around the entire structure to
provide added security.
One final point cannot be overemphasized. Each re-
construction must be individualized and creative in order
to achieve an excellent contour and reduce paradoxical
motion in the chest wall to a minimum.
• REFERENCES
Allen RG, Douglas M: Cosmetic improvement of thoracic wall defects
using a rapid setting silastic mold: A special technique. J Pediatr
Surg 14:745, 1979.
Boyd AD, Shaw WW, McCarthy JG et al: Immediate reconstruction of
full-thickness chest wall defects. Ann Thorac Surg 32:337, 1981.
deCamara D, Sheridan JM, Kammer BA: Rupture and aging of silicone
gel breast implants. Plast Reconstr Surg 91:828, 1993.
Eschaposse M, Gaillard J, Fournial G et al: Use of acrylic prosthesis for
the repair of large defects of the chest wall. Acta Chir Belg
76:281, 1977.
Fix RJ, Vasconez LO: Use of the omentum in chest-wall reconstruction.
Surg Clin North Am 69:1029, 1989.
Garcia VF, Seyfer AE, Graeber GM: Reconstruction of congenital chest-
wall deformities. Surg Clin North Am 69:1103, 1989.
Graeber GM, Cohen DJ, Patrick DR et al: Rib fracture healing in
experimental flail chest. J Trauma 25:903, 1985.
Hochberg J, Ardenghy M, Graeber GM, Murray GF: Complex recon-
struction of the chest wall and breast utilizing a customized
silicone implant. Ann Plast Surg 32:524, 1994.
Kuakowski A, Ruka W: Dura mater (Lyodural) in reconstruction of the
abdominal and chest wall defects after radical excision of soft
tissue neoplasms: case reports. Eur J Surg Oncol 23:63, 1987.
Lavey E, Aplelberg DB, Lash H et al: Customized silicone implants of
the breast and chest. Plast Reconstr Surg 69:646, 1982.
Marcove RC, Egwele R, Searfoss R et al: Chest wall reconstruction with
methyl methacrylate implantation. Compr Ther 3(12):5, 1977.
McCormack PM: Use of prosthetic materials in chest-wall reconstruc-
tion: Assets and liabilities. Surg Clin North Am 69:965, 1989.
McCormack PM, Bains MS, Beattie EJ et al: New trends in skeletal
reconstruction after resection of chest wall tumors. Ann Thorac
Surg 31:45, 1981.
Mendelson B, Masson JK: Silicone implants for contour deformities of
the trunk. Plast Reconstr Surg 59:538, 1977.
Pairolero PC, Arnold PG: Chest wall tumors: Experience with 100
consecutive patients. J Thorac Cardiovasc Surg 90:367, 1985.
Pairolero PC, Arnold PG: Thoracic wall defects: Surgical management
of 205 consecutive patients. Mayo Clin Proc 61:557, 1986.
Pass HI: Primary and metastatic chest wall tumors. In Roth JA, Ruch-
deschel JC, Weisenferges TH (ed): Thoracic Oncology. Philadel-
phia, WB Saunders, 1989.
Seyfer AE, Graeber GM, Wind GG: Planning the reconstruction. In
Seyfer AE (ed): Atlas of Chest Wall Reconstruction. Rockville,
MD, Aspen Publishers, 1986a.
Seyfer AE, Graeber GM, Wind GG: Postoperative care. In Seyfer AE
(ed): Atlas of Chest Wall Reconstruction. Rockville, MD, Aspen
Publishers, 1986b.
Seyfer AE, Graeber GM, Wind GG: The omentum. In Seyfer AE (ed):
Atlas of Chest Wall Reconstruction, Rockville, MD, Aspen Publish-
ers, 1986c.
Seyfer AE, Graeber GM, Wind GG: Embryology, anatomy and physiol-
ogy of the chest wall. In Seyfer AE (ed): Atlas of Chest Wall
Reconstruction, Rockville, MD, Aspen Publishers, 1986d.
Seyfer AE, Graeber GM, Wind GG: Preoperative care and considera-
tions. In Seyfer AE (ed):Atlas of Chest Wall Reconstruction. Rock-
ville, MD, Aspen Publishers, 1986e.
Seyfer AE, Graeber GM, Wind GG: Congenital defects: Poland's syn-
drome, pectus deformities and sternal clefts. In Seyfer AE (ed):
Atlas of Chest Wall Reconstruction. Rockville, MD, Aspen Publish-
ers, 1986f.
 CHAPTER 55 • Surgical Techniques/Soft Tissue Reconstruction 1455

I SOFT TISSUE RECONSTRUCTION

Geoffrey M. Graeber

Soft tissue reconstruction of the chest wall has been flaps have limited roles in this region, but they may be
revived and expanded since the early 1970s. The concept used if the main options have been exhausted or if their
of pedicled flap reconstruction has been the mainstay of rotation is not possible (McCraw and Arnold, 1986).
this movement since its inception. Tissue reconstruction Reconstruction of the chest wall posteriorly is more
has continued to grow, with delineation of new applica- difficult because of limited options (Fig. 55-13). The
tions of pedicled flaps to repair increasingly complex latissimus dorsi muscular and musculocutaneous flap is
defects. Free flap transfer has had some limited applica- clearly the best choice for cephalad rotation. On the upper
tions in carefully selected cases. The following discussion
presents the major considerations in planning soft tissue
coverage of a chest wall defect, the salient characteristics
of the pedicled flaps, and the complications associated
with specific reconstructions. Several major works have
focused on this field, with comprehensive treatments of
all aspects of chest wall reconstruction (McCraw and
Arnold, 1986; Seyfer et al, 1986a; Seyfer and Graeber,
1989). Surgeons contemplating chest wall reconstruction
should consult these texts for a thorough understanding
of the complexities associated with successful thoracic
reconstruction.

PLANNING THE RECONSTRUCTION

Pedicled reconstruction of chest wall defects may be
conducted on any anatomic region of the chest wall.
Certain areas have more options for reconstruction than
others. Selection of appropriate flaps is mandatory, be-
cause tension on a flap's margin or its pedicle spells
disaster. Designation of secondary flaps in each instance
is essential, since one flap may not cover the entire defect
without introduction of supplemental tissue, and rotation
of replacement flaps may become necessary if the primary
flap proves unsuitable (Azarow et al, 1989; Seyfer et
al, 1986b).
Coverage of the anterior and anterolateral chest wall
offers the most options because several pedicled flaps
may be rotated successfully (Azarow et al, 1989; Seyfer
et al, 1986b). Major pedicled flaps that may be used in
this area include the pectoralis major, rectus abdominis,
and latissimus dorsi muscular and musculocutaneous FIGURE 55-11 • Anterior and anterolateral areas of the chest
flaps as well as the omentum (Fig. 55-11). The serratus wall and the pedicled flaps that may be used to reconstruct
anterior muscular flap may be used in some limited these areas. The sternum has been divided into upper, middle,
and lower sections. The area over the pectoralis major muscle
applications. has been designated by a solid line extending from the
The lateral chest wall has more limited options for shoulder around the clavicle to the sternum and to just below
pedicled reconstruction (Azarow et al, 1989; Seyfer et al, the breast; this is the upper lateral region. The lower lateral
1986b). The latissimus dorsi muscular and musculocuta- region is directly below this area and covers the rest of the
thoracic cage from the anterior axillary line to the sternum.
neous flap is the first choice (Fig. 55-12). The rectus The areas of transfer for each muscle are shown by arrows: the
abdominis muscular or musculocutaneous flap is the sec- first choice for coverage of a given area is designated by a
ond choice for these areas, and the omentum is the third solid arrow, the second choices by dashed arrows, and the
choice. The serratus anterior flap and abdominal wall third choices by dotted arrows. Each of the flaps is designated
by a letter: L, latissimus dorsi; O, omentum; P, pectoralis major;
R, rectus abdominis. (From Seyfer AE, Graeber GM, Wind GG:
I wish to thank Ms. Karen DeShong for her assistance in the Planning the reconstruction. In Seyfer AE (ed): Atlas of Chest
preparation of this manuscript. Wall Reconstruction. Rockville, MD, Aspen, 1986b.)
1456 CHAPTER 55 • Surgical Techniques/Soft Tissue Reconstruction

tus abdominis flaps to close large contralateral defects

have been reported (Matsuo et al, 1991).

FLAPS FOR RECONSTRUCTION

Each of the flaps used in reconstruction of the chest wall
has assets and liabilities as well as a defined are of
rotation. Transposition of any of the flaps requires precise
understanding of the blood supply. Successful rotation of
any flap depends on preservation of the blood supply and
prevention of any tension on the pedicle and on the
margins of the flap. Previous surgical procedures and
pathologic conditions may preclude successful rotation
of specific flaps.

Pectoral is Major Muscle

One of the most frequently used muscular and musculo-
cutaneous flaps is the pectoralis major. The utility and
durability of this flap has been shown in several series

FIGURE 55-12 • The lateral areas of the chest wall may be

reconstructed with either latissimus dorsi or rectus abdominis
muscular or musculocutaneous flaps or the omentum. The t w o
distinct areas, which are outlined by solid lines, represent an
upper and a lower region. Note that the latissimus dorsi
(designated by L) is the primary pedicled flap for
reconstruction in both areas, the rectus abdominis (designated
by R) is the secondary flap, and the omentum (designated by
O) is the tertiary flap for reconstructing these areas. The heavy
black line designates the latissimus as the primary flap for
reconstruction in both areas, the dashed arrows indicate the
rectus as the secondary flap, and the dotted line, associated
with the omentum, indicates that it is the third choice. (From
Seyfer AE, Graeber GM, Wind GG: Planning the reconstruction.
In Seyfer AE (ed): Atlas of Chest Wall Reconstruction. Rockville,
MD, Aspen, 1986b.)

chest, the trapezius muscle may be rotated to cover spinal

and paraspinal defects. In extreme cases, free flap transfer
may be used as long as suitable arterial and venous supply
is maintained, the pedicle is not placed under tension,
and the margins of the flap are not overextended.
Occasionally, a defect may be so large that more than
one flap may be necessary to provide for adequate soft
tissue coverage (Azarow et al, 1989; Seyfer et al, 1986b).
In such cases secondary and tertiary flaps may be rotated
to achieve satisfactory soft tissue coverage without ten-
sion on the pedicle(s) or on the margins of the flaps. In
some extreme circumstances, the pedicles of the flaps
may be dissected maximally, and the size of the flap
may extend to its extreme to achieve coverage. Such
reconstructions using combined latissimus dorsi and rec-
FIGURE 55-13 • The limited options for reconstruction of the
posterior aspect of the chest wall are delineated. Note that
there are t w o areas for reconstruction: the upper spinous and
the paraspinous area and the lower, larger area that
encompasses most of the back. The primary flap for
reconstruction of the upper area is the trapezius muscle
(designated by T). The latissimus dorsi (designated by L) is the
muscle and musculocutaneous flap that can be used most
effectively to cover most of the back. (From Seyfer AE, Graeber
GM, Wind GG: Planning the reconstruction. In Seyfer AE (ed):
Atlas of Chest Wall Reconstruction. Rockville, MD, Aspen,
1986b.)
 CHAPTER 55 • Surgical Techniques/Soft Tissue Reconstruction 1457

FIGURE 55-14 • The primary and secondary

blood supply for the right pectoralis major
muscle. Note that the thoracoacromial artery
and vein constitute the primary supply, with
the major vessel directed from cephalad to
caudad. The next most abundant vascular
supply to the muscle consists of the internal
thoracic artery and vein, which course along
the lateral aspect of the sternum to give rise
to perforators, which penetrate the intercostal
spaces and give blood to the pectoralis major
muscle. The tertiary supply consists of some
random branches of the lateral thoracic artery
and of the intercostal arteries as they give rise
to small vessels that perforate the muscle.
Pedicled flaps have been described that are
based on the thoracoacromial neurovascular
bundle and on the internal thoracic artery and
its penetrating branches that supply the
medial aspect of the pectoralis major muscle.
(From Seyfer AE, Graeber GM, Wind GG: The
pectoralis major muscle and musculocutaneous
flaps. In Seyfer AE (ed): Atlas of Chest Wall
Reconstruction: Rockville, MD, Aspen, 1986c.)

(Arnold and Pairolero 1984; Graeber et al, 1982; Pairo-
lero and Arnold, 1986b). Because of its primary and
secondary blood supply, it can be transferred as a pedicled
flap based on the thoracoacromial neurovascular bundle
or on the perforators arising from the ipsilateral internal
mammary artery (Seyfer et al, 1986b; Tobin, 1989) (Fig.
55-14). It is particularly well suited for use in repairing
defects of the upper anterior chest wall and in the upper
part of the ipsilateral pleural space (Arnold and Pairolero
1978, 1979) (Fig. 55-15).
Major assets of the pectoralis major muscle and mus-
culocutaneous flap are its ability to be based on two
different blood supplies and thus allow successful transfer
and its intrinsic ability to be divided into segments so
that structure and function may be preserved while main-
taining the natural contour of the thoracic wall. It may
be moved into the upper portion of the pleural space,
into a dehisced median sternotomy incision, or into the
head and neck for reconstruction depending on the pa-
thology present (Seyfer et al, 1986c; Tobin, 1989).
It has relatively few problems, which can be addressed
successfully if they are appreciated prior to reconstruc-
tion (Seyfer et al, 1986c; Tobin, 1989). One is elimination
of a pedicle due to trauma or removal of the primary
blood supply for a pedicle. These complications are quite
rare for the primary pedicle, the thoracoacromial neuro-
vascular bundle. They are not uncommon, unfortunately,
for the secondary pedicle, the internal thoracic (mam-
mary) artery. If the ipsilateral internal thoracic artery has
been harvested for revascularization of the myocardium,
rotation of the pectoralis based on the secondary pedicle
(ipsilateral internal thoracic artery) is contraindicated,
since the muscle pedicle would be based on the tertiary
blood supply, the intercostal vessels. Under these condi-
tions, the viability of the flap would be extremely ques-
tionable. The blood supply to the flap can also be com-
promised by a sternal wire that perforates the internal
thoracic vessels. Hence, closure of a dehisced median
sternotomy incision with pectoralis major muscular flaps
based on the ipsilateral internal thoracic artery and vein
must be undertaken only after thorough evaluation of
the integrity of these vessels.
One of the most common indications for use of the
pectoralis major muscular flap is the reconstruction of
the dehisced median sternotomy (Miller and Nahai, 1989;
Pairolero and Arnold, 1984, 1986a). One method de-
scribes advancement of the pectoralis major muscular
flaps into the wound based on their primary pedicles, the
thoracoacromial neurovascular bundles. In such cases
both muscles in their entirety are dissected free of their
origins and insertions and are advanced into the wound
together to reconstruct the wound closure (Seyfer et al,
1986c) (Fig. 55-16). An alternative is to base the flaps
on the perforators arising from the respective internal
thoracic arteries, divide the thoracoacromial vessels, and
turn the flaps over into the dehisced median sternotomy
wound (Morain et al, 1981; Nahai et al, 1982) (Fig.
55-17). Variations of these two approaches based on the
segmental anatomy of the pectoralis major muscle have
been described, in which the first method is used on
one side and a variation of the second is used on the
contralateral side (Miller and Nahai, 1989; Tobin, 1989).
1458 CHAPTER 55 • Surgical Techniques/Soft Tissue Reconstruction

FIGURE 55-17 • The pectoralis major muscular flap may be

FIGURE 55-15 • The arc of rotation of the pectoralis major
muscular and musculocutaneous flap when based on the
thoracoacromial neurovascular bundle. Note that the ctrigin
and the insertion of the muscle have been cut and have
retracted toward the center. The muscle may be rotated over
the entire anterolateral chest wall and into the head and neck
region. (From Seyfer AE, Graeber GM, Wind GG: The pectoralis
major muscle and musculocutaneous flaps. In Seyfer AE (ed):
Atlas of Chest Wall Reconstruction. Rockville, MD, Aspen,
1986c.)
based on the internal thoracic perforators arising along the
origin of the muscle just lateral to the sternum. In this
dissection, the inferior part of the muscle is saved to preserve
function and cosmesis. (From Seyfer AE, Graeber GM, Wind
GG: The pectoralis major muscle and musculocutaneous flaps.
In Seyfer AE (ed): Atlas of Chest Wall Reconstruction. Rockville,
MD, Aspen, 1986c.)

FIGURE 55-16 • A, Mobilization of the pectoralis major flaps for reconstruction of the upper anterior thorax. Both muscles have
been pedicled on their respective thoracoacromial arteries and veins. Note that the origins of both muscles as well as the
insertions have been transected. 6, Muscles reconstructed over the sternal defect. Note that the pectoralis major muscles join
together in the midline to add support to the wound. (From Seyfer AE, Graebar GM, Wind GG: The pectoralis major muscle and
musculocutaneous flaps. In Seyfer AE (ed): Atlas of Chest Wall Reconstruction. Rockville, MD, Aspen, 1986c.)
 CHAPTER 55 • Surgical Techniques/Soft Tissue Reconstruction
FIGURE 55-18 • The pectoralis major musculocutaneous flap
has been placed over the repaired esophagus, which is
posterior. The skin island is being joined to the open area of
the trachea so that the membranous portion is being replaced.
Any exposed portion of the muscle that remains after the
reconstruction will be covered with meshed, split-,thickness skin
grafts, (From Seyfer AE, Graeber GM, Wind GG:
Tracheoesophageal and bronchopleural/cutaneous fistulas. In
Seyfer AE (ed): Atlas of Chest Wall Reconstruction. Rockville
MD, Aspen, 1986d.)
In addition to reconstruction of the anterior chest wall
after tumor resection and reconstruction of the dehisced
median sternotomy, the pectoralis major muscular and
musculocutaneous flap has been useful in reconstruction
of the radiation-damaged chest wall, in treating bron-
chopleural fistulas and their associated empyemas, and
in repairing tracheoesophageal fistulas. In the experience
at the Mayo Clinic, the pectoralis major and latissimus
dorsi flaps have been the most commonly used in treating
patients with radiation damage of the chest wall (Arnold
and Pairolero, 1989). The pectoralis major muscular flap
has been successful in treating high bronchopleural fistu-
las and their associated empyemas (Pairolero and Arnold,
1989). For this application the flap has been based on
the thoracoacromial neurovascular bundle in most cases
(Pairolero and Arnold, 1989). Reconstruction of tracheo-
esophageal fistulas has also been successfully performed
by using this flap (Seyfer et al, 1986d). A skin island
appended to the flap may be used to reconstruct the
membranous trachea, or alternatively, a meshed, split-
thickness skin graft may be used for this purpose and
for epithelializing any exposed portions of the muscle
(Fig. 55-18).
Rectus Abdominis Muscle
The rectus abdominis muscle has been important in chest
wall reconstruction both as a muscular and as a musculo-
cutaneous flap. It is a large muscle, with the capacity to
1459
carry substantial islands of tissue to repair defects on the
chest wall and in the thorax. It can have both a longitudi-
nal and a transverse cutaneous island. Its blood supply is
particularly favorable in that it usually has a balance
between the superior and inferior epigastric arteries. The
intercostals, which end in the rectus sheaths along the
abdominal wall, are the tertiary blood supply. Flaps may
be constructed based on the superior or inferior epigas-
tric artery. In some cases involving particularly large de-
fects of the chest wall, flaps have been rotated based on
both rectus muscles and both internal thoracic arteries
(Glafkides and Toth, 1991). Accurate, comprehensive de-
scriptions of the methodologies for rotating these muscu-
lar and musculocutaneous flaps are available (Coleman
and Bostwick, 1989; Seyfer et al, 1986e). This muscle,
and particularly its musculocutaneous flap, has been
quite useful in reconstruction of the breast, with several
authors presenting extensive experiences with this mus-
cle for breast reconstruction (Bunkis et al, 1983; Dinner
et al, 1982; Hartrampf et al, 1982; Jacobsen et al, 1994).
The rectus abdominis muscle has a large arc of rota-
tion, which allows it or its musculocutaneous flap to be
rotated onto most of the anterior, anterolateral, and lat-
eral thoracic wall (Seyfer et al, 1986e). The domain of
the flap for chest wall reconstruction is extensive and
covers virtually all of the anterior and lateral thorax (Fig.
55-19). Besides its significant use in reconstruction of
the breast, it has been particularly effective in repair of
the dehisced median sternotomy. It must be used care-
fully in this capacity since its blood supply is dependent
on the integrity of the internal thoracic artery (see later).
Because of the amount of tissue that can be transferred,
the rectus abdominis muscular and musculocutaneous
flap has been particularly useful in the reconstruction of
anterior and lateral chest wall defects after resection of
malignant tumors. These flaps have also been used exten-
sively in reconstruction of the chest wall after radiation
injuries, particularly those associated with breast cancer
therapy.
The blood supply to the rectus abdominis muscle
allows rotation of the entire muscle and an associated
subcutaneous and cutaneous island along with the flap
onto the greater part of the chest wall (Seyfer et al,
19860- The superior epigastric vessels, which are the
direct extensions of the internal thoracic artery and vein,
are the principal vessels in the pedicle on which this
muscular and musculocutaneous flap is based for rotation
onto the anterior and lateral thoracic wall (Brown et al,
1975; Miller et al, 1988). Because of the rich vascular
plexus within the muscle, the entire length of the rectus
abdominis may be transferred cephalad with the superior
epigastric vessels used as the sole pedicle (Figs. 55-20
and 55-21). In some very rare cases, both rectus abdomi-
nis muscles and a large associated subcutaneous and
cutaneous island may be rotated onto the anterior thorax
based on both pairs of epigastric vessels (Ishii et al,
1985). This flap must be rotated with great care, since
the blood supply must be preserved.
Obviously, previous abdominal incisions can have a
deleterious effect on the blood supply to the muscle and
hence to the flap. Incisions that may modify or preclude
the use of this flap include the paramedian, midline,
and upper transverse incisions (Fig. 55-22). The upper
1460 CHAPTER 55 • Surgical Techniques/Soft Tissue Reconstruction

FIGURE 55-19 • The rectus abdominis muscle and musculocutaneous

flap are particularly useful in reconstruction of the anterior and lateral
chest wall. In all instances of this application, the pedicle is based on
the superior epigastric vessels, which are continuations of the internal
thoracic (mammary) artery and vein. (From Seyfer AE, Graeber GM,
Wind GG: The rectus abdominis muscle and musculocutaneous flaps. In
Seyfer AE (ed): Atlas of Chest Wall Reconstruction. Rockville, MD,
Aspen, 1986e.)

FIGURE 55-20 • The rectus abdominis muscle may be based on either

the superior or the inferior epigastric vascular pedicles. The rich
anastomosis between the vessels, which is in the center portion of the
muscle, ensures the viability of the distal portion of the flap when it is
based on either pedicle. (From Seyfer AE, Graeber GM, Wind GG:
Blood supply to the skin of the chest wall. In Seyfer AE (ed): Atlas of
Chest Wall Reconstruction. Rockville MD, Aspen, 19861)
 CHAPTER 55 • Surgical Techniques/Soft Tissue Reconstruction 1461

FIGURE 55-21 • This anatomic dissection shows the direct

dependence of the superior epigastric vessels on the extension of
the internal thoracic artery and vein. The rectus abdominis has
been divided in its midportion to show the rich plexus of
penetrating vessels, which allow viability of the skin when
transferred with the muscular flap. (From Seyfer AE, Graeber GM,
Wind GG: Blood supply to the skin of the chest wall. In Seyfer AE
(ed): Atlas of Chest Wall Reconstruction. Rockville, MD, Aspen,
1986f.)

FIGURE 55-22 • Whenever the rectus abdominis muscle is

contemplated for reconstruction of the thorax, the surgeon must
analyze the previous incisions on the abdomen. In this instance, an
upper right subcostal incision precludes the use of the rectus based
on the superior epigastric vessels. If a flap based on these vessels
were to be rotated, any tissue distal to the line of incision would
die, because all this tissue has become dependent on the inferior
epigastric vessels after the transverse incision. (From Seyfer AE,
Graeber GM, Wind GG: Planning the reconstruction. In Seyfer AE
(ed): Atlas of Chest Wall Reconstruction. Rockville, MD, Aspen,
1986b.)
1462 CHAPTER 55 • Surgical Techniques/Soft Tissue Reconstruction

a musculocutaneous flap with either a transverse or a

longitudinal orientation. The transverse rectus abdominis
musculocutaneous (TRAM) flap is very popular for re-
construction of the breast and of radiation injuries of the
anterior chest wall (Bunkis et al, 1983; Dinner et al,
1982; Hartrampf et al, 1982; Jacobsen et al, 1994) (Figs.
55-23 and 55-24). The TRAM flap has been used in
many creative ways to reconstruct absent breasts (Figs.
55-25 and 55-26). The longitudinal musculocutaneous
flap is particularly beneficial in repairing a severely de-
hisced median sternotomy incision. The longitudinal is-
land may be rotated with the flap to completely fill a
severe defect associated with the severe dehiscence of a
median sternotomy wound, such as those more fre-
quently seen in diabetic patients (Fig. 55-27). If one of
the internal mammary arteries has been harvested for
myocardial revascularization, the rectus abdominis mus-
culocutaneous flap used for repair of a dehisced median
sternotomy should be rotated based on the opposite supe-
rior epigastric vessel. If both mammaries have been har-
vested for myocardial revascularization, the rectus abdo-
minis should not be rotated into the wound, since the
muscular or musculocutaneous flap will most likely die
FIGURE 55-23 • The potential viability of skin and in this situation.
subcutaneous tissues when transferred with the rectus
abdominis as a transverse musculocutaneous rectus abdominis
(TRAM) flap is depicted. The skin and subcutaneous tissues
directly overlying the rectus muscle have the highest
probability of viability after transfer. These are denoted by the
cross-hatched area. Other areas that are directly juxtaposed to
this well-vascularized tissue may remain viable but ca'n still
suffer necrosis under certain conditions. These areas are
denoted by the vertical and the oblique lines. The soft tissue
that is far distal to the main flap is of questionable viability
and should not be used; this area is represented by the
stippled area on the right anterior abdominal wall. This
drawing depicts a left rectus flap; if a right rectus flap were
contemplated, the areas of tissue viability would be the mirror
image of that shown here. (From Seyfer AE, Graeber GM,
Wind GG: Blood supply to the skin of the chest wall. In Seyfer
AE (ed): Atlas of Chest Wall Reconstruction. Rockville, MD,
Aspen, 19861)

transverse incisions, which cross either rectus abdominis

muscle, almost always interrupt the superior epigastric
vessels so that the muscle distal to the incision becomes
dependent on the inferior epigastric vessels for its viabil-
ity. Cephalad rotation based on the superior epigastric
vessels is therefore not indicated, since the distal portion
of the muscle will die under these circumstances. A
midline incision limits the amount of subcutaneous tissue
and skin that may be transferred on the distal portion of
the flap, since the subcutaneous and cutaneous blood
supply will be interrupted lateral to the midline incision.
Under these circumstances, any soft tissue that is lateral
to the midline incision and is transferred with the flap
will most likely succumb. Paramedian incisions generally
disrupt the entire vascular plexus and preclude success-
ful rotation. FIGURE 55-24 • A TRAM flap being harvested to repair a
There are several methods for using this muscular and radiation defect of the right anterior chest wall. Note that the
musculocutaneous flap in chest wall reconstruction. The flap is based on the left rectus abdominis muscle and that the
muscle itself may be transposed to fill a dehisced median distal transverse subcutaneous and cutaneous skin island is
being transferred in continuity with the rectus muscle. (From
sternotomy incision. The muscle itself may also be ro- Seyfer AE, Graeber GM, Wind GG: Blood supply to the skin of
tated to close a particularly low fistula within the thorax. the chest wall. In Seyfer AE (ed): Atlas of Chest Wall
Most frequently, the rectus is rotated into the chest as Reconstruction. Rockville, MD, Aspen, 19861)
 CHAPTER 55 • Surgical Techniques/Soft Tissue Reconstruction 1463

FIGURE 55-25 • A musculocutaneous

flap based on the left rectus
abdominis muscle has been
completed and is ready for transfer
into the thoracic defect in the right
chest wall. Note that the muscle, the
attached subcutaneous tissue, and
the skin can all be transposed into
the defect by rotation underneath
the bridge of intact soft tissue on
the upper abdominal wall. (From
Seyfer AE, Graeber GM, Wind GG:
The rectus abdominis muscle and
musculocutaneous flaps. In Seyfer AE
(ed): Atlas of Chest Wall
Reconstruction. Rockville, MD, Aspen
1986e.)

FIGURE 55-26 • A, Planned reconstruction of the right breast using a left rectus abdominis TRAM flap. There is no
associated radiation ulcer of the chest wall. B, The completed left rectus abdominis TRAM flap rotated up into the
thoracic defect. The lower abdominal incision can then be closed with preservation of the umbilicus. The flap may
be tailored to provide for adequate reconstruction of the breast. (From Seyfer AE, Graeber GM, Wind GG:
Reconstruction of the breast following mastectomy. In Seyfer AE (ed): Atlas of Chest Wall Reconstruction. Rockville,
MD, Aspen, 1986g.)
1464 CHAPTER 55 • Surgical Techniques/Soft Tissue Reconstruction

FIGURE 55-27 • A, The rectus abdominis myocutaneous flap may be used in reconstructing defects of the sternum and the
dehisced median sternotomy as long as the ipsilateral internal thoracic vessels are intact. A longitudinal musculocutaneous flap has
been fashioned for anterior wall reconstruction in this drawing. B, The completed longitudinal musculocutaneous flap ready to be
rotated based on the superior epigastric vessels. The longitudinal flap will be laid into the defect and adjusted to the edges. The
blood supply to the musculocutaneous flap must be scrupulously maintained. The viability of the internal thoracic artery for this
type of reconstruction is absolutely mandatory. (From Seyfer AE, Graeber GM, Wind GG: The rectus abdominis muscle and
musculocutaneous flaps. In Seyfer AE (ed): Atlas of Chest Wall Reconstruction. Rockville, MD, Aspen, 1986e.)

The use of the rectus abdominis has been extended by
free transfer and by creative vascular anastomoses. Free
flap transfers of the rectus abdominis muscle, the omen-
tum, and the latissimus dorsi have been reported in the
management of complex intrathoracic problems (Ham-
mond et al, 1993). These free flaps have been most useful
in repairing bronchopleural-cutaneous fistufas. The rec-
tus itseif may have its blood supply enhanced and its
vertical configuration of tissue transfer enlarged by anas-
tomosing the inferior epigastric artery and vein to their
axillary counterparts (Yamamoto et al, 1994). Flaps en-
hanced in this manner have been particularly useful in
filling large anterior wall defects.
The Latissimus Dorsi Muscle
Pedicled muscular and musculocutaneous flaps based on
the latissimus dorsi muscle have found wide application
in chest wall reconstruction, since this muscle has an
extensive arc of rotation when the pedicle is based on
the thoracodorsal neurovascular bundle (Moelleken et al,
1989; Seyfer et al, 1986h) (Fig. 55-28). When a latissi-
mus dorsi muscular or musculocutaneous flap has been
based on its primary blood supply, the flap can be used
to cover defects on the anterior, lateral, and posterior
aspects of the thorax (McCraw et al, 1978). When the
pedicle of a latissimus dorsi flap is based on its secondary
blood supply (the ipsilateral ninth through eleventh in-
tercostal arteries and their perforators), the flap's arc of
rotation is more limited, and the flap is best suited for
posterior intrathoracic applications (Moelleken et al,
1989).
The primary blood supply to this large, flat muscle
located on the posterolateral aspect of the chest wall is
the thoracodorsal artery and its associated veins (Rowsell
et al, 1984). In the vast majority of cases, the axillary
artery gives rise to the subscapular artery, which divides
to create the thoracodorsal artery and the artery or arter-
ies to the serratus anterior muscle (Rowsell et al, 1984).
In 74% of cadavers .studied by Rowsell and co-workers
(1984), the artery to the serratus anterior was single; in
24% it was represented by two or more branches. The
thoracodorsal artery, which is a direct extension of the
subscapular artery in most cases, descends to the body
of the latissimus dorsi, where it most commonly divides
into two branches (Fig. 55-29). The more anterior
branch descends parallel to the lateral border of the
muscle; the medial branch usually traverses more hori-
zontally in the body of the muscle. Both branches form
collaterals with the secondary blood supply (the ninth
through the eleventh intercostal arteries and their perfo-
rators) in the body of the muscle.
 CHAPTER 55 • Surgical Techniques/Soft Tissue Reconstruction 1465

FIGURE 55-28 • A, Arc of rotation over the anterior chest for latissimus dorsi muscular and musculocutaneous flaps
based on the thoracodorsal neurovascular pedicle. The tape measure depicts the length of the flap and its rotation when
the posterior aspect of the tape is held against the anticipated pedicle. Note that this flap has a great ability to
reconstruct defects in the lateral, anterior, and superior aspects of the chest wall. This flap is not recommended for
covering defects in the region of the distal sternum and xiphoid process. B, The arc of rotation of the latissimus dorsi
muscle when it is pedicled on the thoracodorsal neurovascular bundle. This muscular and musculocutaneous pedicle is the
most useful one for covering defects of the posterior thoracic wall. (From Seyfer AE, Graeber GM, Wind GG: The
latissimus dorsi muscle and musculocutaneous flaps. In Seyfer AE (ed): Atlas of Chest Wall Reconstruction. Rockville, MD,
Aspen, 1986h.)

The blood supply to the latissimus dorsi has allowed
some creativity with the primary pedicle. When the sub-
scapular artery has been divided by previous surgery, a
latissimus dorsi muscular or musculocutaneous flap may
still be rotated by basing it on the continuity of the
arteries from the serratus anterior muscle to the thoraco-
dorsal (Fisher et al, 1983; Moelleken et al, 1989). When
the pedicle for rotation has been created in this fashion,
the integrity of the arteries from the serratus anterior
must be maintained scrupulously. As might be expected,
the arc of rotation in this situation is more limited by the
need to preserve the vessels to the serratus anterior.
Some serious limitations to the use of latissimus dorsi
muscular and musculocutaneous flaps based on the thor-
acodorsal pedicle have been found to exist (Moelleken et
al, 1989; Seyfer et al, 1986h). Previous radiation to the
axilla can cause constriction of the thoracodorsal vessels,
which limits blood supply and rotation. Probably the
most common cause of this problem has been radiation
to the chest wall and axilla during therapy for breast
carcinoma (Moelleken et al, 1989). Another serious prob-
lem with use of latissimus dorsi arises when a full pos-
terolateral thoracotomy has been performed (Moelleken
et al, 1989; Seyfer et al, 1986h). Division of the muscle
and the thoracodorsal vessels causes the distal part of the
muscle to become dependent on the secondary blood
supply. If the entire muscle is raised as a flap based on
the thoracodorsal vessels, the tissues distal to the scar
undergo necrosis. Hence, the entire muscle can no longer
be transferred to reconstruct chest wall defects or to
repair intrathoracic problems such as bronchopleural-
cutaneous fistulas (Fig. 55-30).
A number of authors have favored the use of muscle-
sparing thoracotomies so that the blood supply to the
latissimus dorsi and the serratus anterior is preserved.
The necessity for muscle-sparing incisions is particularly
apparent in the pediatric population (Malczyewski et al,
1994; Soucy et al, 1991).
Despite these limitations, the latissimus dorsi pedicled
muscular and musculocutaneous flaps have found wide
appreciation for reconstruction of all types of chest wall
defects (Moelleken et al, 1989; Seyfer et al, 1986h). The
use of these flaps in repairing posterior and spinal defects
is well recognized (McCraw et al, 1978). Even though
radiation may have been applied to the axilla in treating
mammary or other malignancies, these flaps may still be
1466 CHAPTER 55 • Surgical Techniques/Soft Tissue Reconstruction

FIGURE 55-29 • Arterial supply to the Iatissimus dorsi based on

the thoracodorsal artery. Note that the subscapular artery
originates from the axillary artery. The subscapular artery divides
into two branches: a branch that courses medially to the serratus
anterior, and the thoracodorsal artery, which is the direct extension
of the subscapular artery. Once the subscapular artery enters the
Iatissimus dorsi muscle, it divides into a lateral and a medial branch
The dotted line represents the maximal domain of the cutaneous
island that may be carried with this muscle. (From Seyfer AE,
Graeber GM, Wind GG: The Iatissimus dorsi muscle and
musculocutaneous flaps. In Seyfer AE (ed): Atlas of Chest Wall
Reconstruction. Rockville, MD, Aspen, 1986h.)

FIGURE 55-30 • If the patient has had a previous posterolateral

thoracotomy incision, the distal portion of the Iatissimus dorsi muscle
and any cutaneous elements that may overlie the muscle receive their
blood supply from the secondary vessels that penetrate the
lumbodorsal fascia. If the entire muscle were raised on a pedicle
based on the thoracodorsal vessels, the distal portion of the muscle
beyond the incision would undergo necrosis. Rotation of the entire
muscle based on the thoracodorsal pedicle after a posterolateral
thoracotomy incision is contraindicated. (From Seyfer AE, Graeber
GM, Wind GG: Planning the reconstruction. In Seyfer AE (ed): Atlas of
Chest Wall Reconstruction. Rockville, MD, Aspen, 1986b.)
 CHAPTER 55 • Surgical Techniques/Soft Tissue Reconstruction
used quite effectively in breast reconstruction, closure of
defects secondary to resection of radiation-induced chest
wall necrotic tissue, and reconstruction of the axilla
(Seyfer, 1988). This musculocutaneous flap may have its
capacity for closing defects enhanced by tissue expansion
(Slavin, 1994).
Omentum
The omentum may be used in chest wall reconstruction.
It has tremendous ability to reach all portions of the
anterior and lateral chest wall as well as both pleural
spaces (Fix and Vasconez, 1989; Seyfer et al, 1986i).
Indeed, the omentum has been lengthened so that it has
been used to repair cervical and cranial defects as well
(Fig. 55-31). It has the distinct asset of being able to
contain infection well. Since the omentum has no dermal
covering, it must be covered to achieve cutaneous conti-
nuity; probably the most efficacious method of doing so
is application of a meshed, split-thickness skin graft.
When the mesh remains small, the continuity of the skin
graft follows promptly and provides for a smooth surface.
The blood supply of the omentum is based on the
right and left gastroepiploic arteries and veins (Powers et
al, 1976). These vessels create a continuous arcade, which
runs along the greater curvature of the stomach. A pedi-
cled flap may be created that is based on either the right
FIGURE 55-31 • The arc of rotation of the omentum is quite
large when the pedicle is based on the epiploic vessels. This
shows the potential realm of application for the omentum in
reconstruction of chest wall defects. The omentum is
particularly useful in treating contaminated and infected
defects of the anterior and lateral chest wall. (From Seyfer AE,
Graeber GM, Wind GG: The omentum. In Seyfer AE (ed): Atlas
of Chest Wall Reconstruction. Rockville, MD, Aspen, 1986i.)
1467
FIGURE 55-32 • The omentum enjoys a dual blood supply,
which is based on the right and left gastroepiploic vessels. This
drawing represents the arcades that are usually found in the
omentum. The main arterial arcade runs along the greater
curvature of the stomach and is continuous between the right
and left gastroepiploic arteries. There are usually two
secondary arterial arcades that descend into the omentum.
(From Seyfer AE, Graeber GM, Wind GG: The omentum. In
Seyfer AE (ed): Atlas of Chest Wall Reconstruction. Rockville,
MD, Aspen, 1986i.)
or the left gastroepiploic artery or on both. The caliber
of the right and left gastroepiploic arteries may vary from
individual to individual. One artery may be larger than
the other and therefore may be more suitable as a pedicle
on which to base an omental flap. The omentum in any
given individual is subject to variation of the blood sup-
ply.
The most common anatomic variation has two arcades
that are continuous with one another (Fig. 55-32). The
omentum may be lengthened by judicious division of the
arcades (Alday and Goldsmith, 1972) (Fig. 55-33). Great
care should be taken to maintain pulses distally in the
omentum when the arcades are divided. Appropriate
blood supply may be maintained by testing with a Dopp-
ler ultrasound device prior to the division of any of the
arcades. The point of division of each of the arcades
should be occluded by soft vascular clamps prior to the
actual division. If the pulse remains good distal to the
anticipated points of division, there is a high probability
that the distal portion of the omentum will remain viable.
The blood supply to the omentum also allows free flap
transfer to new positions to achieve soft tissue coverage
and repair. The omentum has been used as a free flap to
cover defects on the extremities or on the head and neck
and to repair intrathoracic problems such as bron-
chopleural fistulas (Arnold and Irons, 1981; Jurkiewicz
and Nahai, 1982). Unique aspects of the omental blood
supply, its ability to contain infection, and its malleable
nature have allowed creative transfer and sculpting to fill
complex defects.
A number of liabilities may be associated with pedicled
omental flaps when they are used for chest wall recon-
1468 CHAPTER 55 • Surgical Techniques/Soft Tissue Reconstruction

FIGURE 55-34 • A, Arterial supply to the left serratus anterior muscle. The major arterial pedicle comes from the
subscapular artery at the origin of the thoracodorsal. Other arteries enter the cephalad aspect of the muscle from the
axillary artery. B, Because the serratus anterior is often spared in performing a posterolateral thoracotomy, this muscle may
be used effectively in repairing bronchopleural fistulas after pulmonary resection. This line drawing depicts the use of the
muscle developed on its primary blood supply arising from the subscapular artery. The muscle has been introduced into the
chest through the second intercostal space. Portions of the second and/or third rib may be resected to facilitate
transposition of the muscle into the pleural space. As with all muscle transpositions, there should be no tension on the
muscle itself or its primary blood supply.
 CHAPTER 55 • Surgical Techniques/Soft Tissue Reconstruction 1469

struction (Mathiesen et al, 1988; Seyfer et al, 1986i).

Previous abdominal surgery or abdominal infection may
preclude use of the omentum. Gastric surgery, in particu-
lar, may have interrupted the arcades and may eliminate
many possibilities for omental transfer. Previous infection
may have caused so many adhesions that the omentum
cannot be harvested without jeopardizing portions of it.
The omentum can also be a channel for spreading infec-
tion from the chest to the abdomen; although this com-
plication is rare, it has been documented. Finally, there
is the ever-present complication of chest wall or dia-
phragmatic hernia associated with thoracic reconstruc-
tion using the omentum. The omentum has to be brought
to the anterior chest wall through an epigastric hernia.
Most often, an iatrogenic anterior defect has to be created
in the diaphragm to allow the omentum to pass into
either pleural space. Such defects offer the potential for
herniation of abdominal viscera into the thoracic cavity.
Obviously, an epigastric hernia may be filled with more
than omentum as the healing process progresses.
Despite its liabilities, the greater omentum has been
used to cover virtually all possible types of chest wall
defects (Mathiesen et al, 1988). It has been particularly
helpful in repairing dehisced median sternotomies and in
repairing radiation injuries to the chest wall (Miller and
Nahai, 1989; Seyfer, 1988). In such applications its ability
to contain infection and to fill irregular defects has
proved most useful. FIGURE 55-35 • The trapezius muscle may be used to
reconstruct defects in the region of the shoulder or the spine.
Its limited domain of rotation includes the area of the scapula,
the apex of the shoulder, and the vertebral region. It is an
Serratus Anterior excellent muscle for closing small defects in these areas. It may
be used alone or in addition to a latissimus dorsi flap. (From
The serratus anterior muscle has found some specific Seyfer AE, Graeber GM, Wind GG: The trapezius muscle and
applications in thoracic reconstruction. The most com- musculocutaneous flap. In Seyfer AE (ed): Atlas of Chest Wall
Reconstruction. Rockville, MD Aspen, 1986j.)
mon one is transposition into the thoracic cavity for
control of bronchopleural fistulas (Pairolero and Arnold,
1989). Since this muscle is often spared with a lateral or
posterolateral thoracotomy, it may be transposed intact also finds some limited use in correcting defects at the
with its cephalad blood supply to close chest wall or extreme apex of the pleural space (Fig. 55-35).
intrathoracic defects. It has a rather limited arc of rotation
since the pedicle must be based on the artery to the
• KEY REFERENCES
serratus anterior, which arises from the subscapular ar-
tery (Fig. 55-34). When the serratus anterior is intro- McCraw JB, Arnold PG: McCraw and Arnold's Atlas of Muscle and
duced into the chest, the secondary blood supply, which Musculocutaneous Flaps. Norfolk, VA, Hampton Press Publish-
consists of small arteries arising from the axillary artery ing, 1986.
and some perforators from the intercostals, must be tran- This is an excellent atlas that depicts the development and use of
sected. The muscle may be brought through an intercostal all the major pedicled flaps. Excellent dissections are provided to
space; however, a portion of the second or third rib show the major aspects of constructing each flap, and the text is
supplemented by clear photographic illustrations of all the flaps.
may be resected to facilitate intrathoracic transposition Since most of the flaps were constructed on cadavers, the anatomic
(Fig. 55-34). landmarks, blood supply, and individual characteristics of each
flap are clearly depicted.
Seyfer AE, Graeber GM (eds): Chest Wall Reconstruction. Surg Clin
Trapezius North Am 69:1989.

Although posterior defects are generally infrequent, the
trapezius muscle offers an option for closure of such
defects. The muscle may be used in conjunction with the
pedicled latissimus dorsi flap or may be used alone to
cover selected defects. This musculocutaneous flap is
most useful in covering defects around the shoulder, the
suprascapsular region, and the perispinous region. It is
usually rotated on the descending branch of the trans-
verse scapular artery (Seyfer et al, 1986i). The muscle
This monograph addresses all the major aspects of chest wall
reconstruction. A number of authors who have contributed much
to the field of thoracic reconstruction have written major chapters.
The entire monograph is richly illustrated; the reference lists are
extensive; and the text is clear and conveys all major points
concerning chest wall reconstruction in a sequential fashion.
Seyfer AE, Graeber GM, Wind GG: Atlas of Chest Wall Reconstruction.
Rockville, MD, Aspen Publishers, 1986a.
This atlas is based on the large experience of the authors at Walter
Reed Army Medical Center in Washington, DC. Each of the flaps
1470 CHAPTER 55 • Surgical Techniques/Soft Tissue Reconstruction
is precisely illustrated, and the techniques of developing each one
are carefully described. The drawings are particularly helpful,
since the artist is also a surgeon.
• REFERENCES
Alday ES, Goldsmith HS: Surgical technique for omental lengthening.
Surg Gynecol Obstet 135:103, 1972.
Arnold PG, Irons GB: The greater omentum: Extensions in transposition
and free transfer. Plast Reconstr Surg 67:169, 1981.
Arnold PG, Pairolero PC: Chondrosarcoma of the manubrium. Resec-
tion and reconstruction with pectoralis major muscle. Mayo Clin
Proc 53:54, 1978.
Arnold PG, Pairolero PC: Use of the pectoralis major muscle flaps
to repair defects of the anterior chest wall. Plast Reconstr Surg
63:205, 1979.
Arnold PG, Pairolero PC: Chest wall reconstruction: Experience with
100 consecutive patients. Ann Surg 199:725, 1984.
Arnold PG, Pairolero PC: Reconstruction of the radiation-damaged
chest wall. Surg Clin North Am 69:1081, 1989.
Azarow KS, Malloy M, Seyfer AE, Graeber GM: Preoperative evaluation
and general preparation for chest wall operations. Surg Clin North
Am 69:899, 1989.
Brown R, Vasconez L, Jurkiewicz M: Transverse abdominal flaps and
the deep epigastric arcade. Plast Reconstr Surg 55:416, 1975.
Bunkis J, Walton R, Mathes S et al: Experience with the transverse
lower rectus abdominis operation for breast reconstruction. Plast
Reconstr Surg 72:819, 1983.
Coleman JJ, BostwickJ: Rectus abdominis muscle—musculocutaneous
flap in chest-wall reconstruction. Surg Clin North Am 69:1007,
1989.
Das SK: The size of the human omentum and methods of lengthening
it for transplantation. Br J Plast Surg 29:170, 1976.
Dinner M, Labandter H, Dowden R: The role of the rectus abdominis
myocutaneous flap in breast reconstruction. Plast Reconstr Surg
69:209, 1982.
Fisher J, Bostwick J, Powell RW: Latissimus dorsi blood supply after
thoracodorsal vessel division: The serratus collateral. Plast Re-
constr Surg 72:502, 1983.
Fix RJ, Vasconez LO: The use of the omentum in chest-wall reconstruc-
tion. Surg Clin North Am 69:1029, 1989.
Glafkides MC, Toth BA: Split bipedicle transverse rectus abdominis
flaps: Expanding their uses in breast reconstruction. Ann Plast
Surg 27:9, 1991.
Graeber GM, Snyder RJ, Flemming AW et al: Initial and long-term
results in the management of primary chest wall neoplasms. Ann
Thorac Surg 34:664, 1982.
Hammond DC, Fisher J, Meland NB: Intrathoracic free flaps. Plast
Reconstr Surg 91:1259, 1993.
Hartrampf C, Scheflan M, Black P: Breast reconstruction with a trans-
verse abdominal island flap. Plast Reconstr Surg 69:216, 1982.
Ishii C, Bostwick J, Raine T et al: Double-pedicle transverse rectus
abdominis myocutaneous flap for unilateral breast and chest wall
reconstruction. Plast Reconstr Surg 76:901, 1985.
Jacobsen WM, Meland NB, Woods JE: Autologous breast reconstruction
with use of transverse rectus abdominis musculocutaneous flap:
Mayo Clinic experience with 47 cases. Mayo Clin Proc 69:635,
1994.
Jurkiewicz MJ, Nahai F: The omentum: Its use as a free vascularized
graft for reconstruction of the head and neck. Ann Surg 195:756,
1982.
Malczyewski MC, Colony L, Cobb LM: Latissimus-sparing thoracotomy
in the pediatric patient: A valuable asset for thoracic reconstruc-
tion. J Pediatr Surg 29:396, 1994.
Mathiesen DJ, Grillo HC, Vlahakes GJ et al: The omentum in the
management of complicated cardiothoracic problems. J Thorac
Cardiovasc Surg 95:677, 1988.
Matsuo K, Hirose T, Hayashi R, Kiyono M: Reconstruction of large
chest wall defects using a combination of a contralateral latissimus
dorsi and a rectus abdominis musculocutaneous flap. Br J Plast
Surg 44:102, 1991.
McCraw JB, Penix JO, Baker JW: Repair of major defects of the chest
wall and spine with a latissimus dorsi myocutaneous flap. Plast
Reconstr Surg 62:97, 1978.
Miller JI, Nahai F: Repair of the dehisced median sternotomy incision.
Surg Clin North Am 69:1091, 1989.
Miller L, Bostwick J, Hartrampf C et al: The superiorly based rectus
abdominis flap: Predicting and enhancing its blood supply based
on an anatomic and clinical study. Plast Reconstr Surg 81:713,
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Moelleken BRW, Mathes SA, Chang N: Latissimus dorsi muscle-muscu-
locutaneous flap in chest-wall reconstruction. Surg Clin North Am
69:977, 1989.
Morain WD, Cohen LV, Hutchings JC: The segmental pectoralis major
muscle flap: A function-preserving procedure. Plast Reconstr Surg
67:753, 1981.
Nahai F, Morales L Jr, Bone DK et al: Pectoralis major muscle turnover
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Pairolero PC, Arnold PG: Bronchopleural fistula: Treatment by transpo-
sition of pectoralis major muscle. J Thorac Cardiovasc Surg
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Pairolero PC, Arnold PG: Management of recalcitrant median ster-
notomy wounds. J Thorac Cardiovasc Surg 88:357, 1984.
Pairolero PC, Arnold PG: Management of infected median sternotomy
wounds. Ann Thorac Surg 42:1, 1986a.
Pairolero PC, Arnold PG: Thoracic wall defects: Surgical management
of 205 consecutive patients. Mayo Clin Proc 61:557, 1986b.
Pairolero PC, Arnold PG: Intrathoracic transfer of flaps for fistulas,
exposed prosthetic devices and reinforcement of suture lines. Surg
Clin North Am 69:1047, 1989.
Powers JC, Fitzgerald JF McAlvanah MJ: The anatomic basis for the
surgical detachment of the greater omentum from the transverse
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Rowsell AR, Davies DM, Eisenberg N et al: The anatomy of the subscap-
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Seyfer AE: Radiation-associated lesions of the chest wall: Longitudinal
experience with 31 patients. Surg Gynecol Obstet 167:129, 1988.
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Seyfer AE, Graeber GM, Wind GG: The pectoralis major muscle and
musculocutaneous flaps. In Seyfer AE (ed): Atlas of Chest Wall
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Seyfer AE, Graeber GM, Wind GG: Tracheoesophageal and bron-
chopleural/cutaneous fistulas. In Seyfer AE (ed): Atlas of Chest
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Seyfer AE, Graeber GM, Wind GG: The rectus abdominis muscle and
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ing mastectomy. In Seyfer AE (ed): Atlas of Chest Wall Reconstruc-
tion. Aspen Publishers, Rockville, MD, 1986g
Seyfer AE, Graeber GM, Wind GG: The latissimus dorsi muscle and
musculocutaneous flaps. In Seyfer AE (ed): Atlas of Chest Wall
Reconstruction. Rockville, MD, Aspen Publishers, 1986h.
Seyfer AE, Graeber GM, Wind GG: The omentum. In Seyfer AE (ed):
Atlas of Chest Wall Reconstruction. Rockville, MD, Aspen Publish-
ers, 1986i.
Seyfer AE, Graeber GM, Wind GG: The trapezius muscle and musculo-
cutaneous flap. In Seyfer AE (ed): Atlas of Chest Wall Reconstruc-
tion. Rockville, MD, Aspen Publishers, 1986J
Slavin SA: Improving the latissimus dorsi myocutaneous flap with tissue
expansion. Plast Reconstr Surg 93:811, 1994.
Soucy P, Bass J, Evans M: The muscle-sparing thoracotomy in infants
and children. J Pediatr Surg 26:1323, 1991.
Tobin GR: Pectoralis major muscle-musculocutaneous flap for chest-
wall reconstruction. Surg Clin North Am 69:991, 1989.
Yamamoto Y, Nohira K, Shintomi Y et al: Turbo-charging the vertical
rectus abdominis myocutaneous (turbo-VRAM) flap for recon-
struction of extensive chest wall defects. Br J Plast Surg 47:103,
1994.
 CHAPTER 55 • Surgical Techniques/Supraclavicular Approach for Thoracic Outlet Syndrome 1471
I SUPRACLAVICULAR APPROACH FOR
THORACIC OUTLET SYNDROME
Susan Mackinnon
G. Alexander Patterson
The supraclavicular approach to relieve thoracic outlet
syndrome by decompression of the brachial plexus and
excision of the first rib releases structures that compress
soft tissue in the region of the interscalene portion of the
brachial plexus. The lower nerve trunk and C8 and Tl
nerve roots can be completely identified and protected as
the most posterior aspect of the first rib is resected under
direct vision. Any cervical ribs or prolonged transverse
processes are easily removed by this supraclavicular ap-
proach. This operative procedure is detailed in Figure
55-36.
Loupe magnification (4.5 X) and microbipolar cautery
are used, and a portable nerve stimulator (Concept 2,
Clearwater, FL) is frequently applied throughout the pro-
cedure. A sandbag is placed between the scapula and the
neck and extended to the nonoperative side. Long-acting
paralytic agents are avoided. An incision in a neck crease,
parallel to and 2 cm above the clavicle, is made in the
supraclavicular fossa.
The supraclavicular nerves are identified just beneath
the platysma and mobilized to allow vessel loop retrac-
tion. The omohyoid is divided and the supraclavicular
fat pad is elevated, after which the scalene muscles and
the brachial plexus are easily palpated. The lateral portion
of the clavicular head of the sternocleidomastoid is di-
vided, and at the end of the procedure is repaired. The
phrenic nerve is seen on the anterior surface of the
anterior scalene muscle, and similarly, the long thoracic
nerve is noted on the posterior aspect of the middle
scalene muscle.
The anterior scalene muscle is divided from the first
rib. The subclavian artery is noted immediately behind
this, and an umbilical tape is placed around the subcla-
vian artery. The phrenic nerve is not mobilized, but rather
is simply avoided. The upper, middle, and lower trunks
of the brachial plexus are easily visualized and gently
mobilized. The middle scalene muscle is now divided
from the first rib. It has a broad attachment to the first
rib, and care must be taken to avoid injury to the long
thoracic nerve, which in this position may have multiple
branches and may pass through and posterior to the
middle scalene muscle. With division of the middle sca-
lene muscle, the brachial plexus is easily visualized and
mobilized, and the lower trunk and the C8 and Tl
nerve roots are identified above and below the first rib.
Congenital bands and thickening in Sibson's fascia are di-
vided.
The first rib is then encircled and divided where it
is easily visible with bone-cutting instruments, and its
posterior segment is removed back to its spinal attach-
ments by rongeur technique. By using a fine elevator, the
soft tissue attachments to the first rib are separated.
Finally, the posterior edge of the first rib is grasped firmly
with a rongeur, and then a rocking and twisting motion
is used to remove the entire aspect of the rib, so that the
cartilaginous components of its articular facets with both
the costovertebral and costotransverse joints can be iden-
tified on the specimen. The anterior portion of the first
rib is removed in a similar fashion in order to decompress
the neurovascular elements.
Cervical ribs or long transverse processes are removed
by the same technique (Fig. 55-37). We use a technique
described by Nelems to open the pleura, facilitating
drainage of any postoperative blood collection into the
chest cavity rather than allowing the blood to collect in
the operative site around the brachial plexus. When the
pleura is opened, care is taken to protect the intercostal
brachial nerve, which is noted on the dome of the pleura.
The wound is closed in a subcuticular fashion, and a
simple suction drain is placed and sealed after wound
closure and maximal inflation of the lungs by the anes-
thetist.
COMMENTS AND CONTROVERSIES
The surgical approach selected for management of tho-
racic outlet varies with the experience, expertise, and
the skill of the operator. Our preference is to use the
supraclavicular approach for arterial reconstruction (end-
arterectomy and bypass) combined with the infraclavicu-
lar approach for the distal anastomosis. To use the supra-
clavicular approach for primary neurogenic and venous
compression, the surgeon must retract the brachial plexus
and vascular structures to expose the first rib and to
perform the dorsal sympathectomy that is often needed.
Although some authors have an excellent record with this
approach, the standard of care shows that nerve injury is
much higher with this than with any other approach
because of the level of skill required to properly retract
the brachial plexus. Cosmetically, the supraclavicular ap-
proach is not as desirable, because 80% of these patients
are women.
H. C. U.
1472 CHAPTER 55 • Surgical Techniques/Supraclavicular Approach for Thoracic Outlet Syndrome

D
FIGURE 55-36 • A, The surgical incision is parallel to the clavicle. B, The supraclavicular nerves are protected. C, The fat
pad has been retracted to identify the phrenic nerve on the scalene anticus muscle and the long thoracic nerve exiting
from the posterior border of the scalene medius muscle, with the brachial plexus noted in the interscalene position. D,
The phrenic nerve is protected, and the scalene anticus is divided. The subclavian artery can now be seen in its location
behind the scalene anticus muscle.
 CHAPTER 55 • Surgical Techniques/Supraclavicular Approach for Thoracic Outlet Syndrome 1473

FIGURE 55-36 • {Continued). E, The scalene medius muscle is divided from the first rib with care to protect the long thoracic
nerve. F, The upper portion of the brachial plexus is retracted to identify the first rib. T1 can be seen below the first rib. G, The
first rib is divided where it is easily visualized, and then the posterior and anterior aspects of the rib are removed. The relationship
of T1 and C8 to the head of the first rib can be seen. H, The nerve roots are reflected anteriorly, and with a twisting motion using
rongeurs, the posterior aspect of the first rib is removed. /, The entire posterior portion of the first rib is removed so that no
residual first rib remains to produce new bone formation and subsequent recurrence of symptoms. The articular facets of the
costovertebral and costotransverse joints are noted {asterisks). J, The brachial plexus has been completely decompressed. The
phrenic and long thoracic nerves have been protected.
1474 CHAPTER 55 • Surgical Techniques/Supradavicular Approach for Thoracic Outlet Syndrome

FIGURE 55-37 • A, Radiograph demonstrating a prominent transverse process on the right

(asterisk) and a large cervical rib on the left. The pseudojoint noted in the cervical rib (single
arrow) is a frequent finding. The cervical rib can be seen to articulate with the first rib
(double arrow). B, Operative photograph corresponding to radiograph, demonstrating the
relationship between the branchial plexus (BP) and the cervical rib (arrows). Note
supraclavicular nerve retracted (asterisk).
 CHAPTER 55 • Surgical Techniques/Transaxillary Approach with Dorsal Sympathectomy for Thoracic Outlet Syndrome
I TRANSAXILLARY APPROACH
WITH DORSAL SYMPATHECTOMY
FOR THORACIC OUTLET
SYNDROME
Harold C. Urschel, Jr.
In surgery to relieve thoracic outlet syndrome, the trans-
axillary route is an expedient approach for complete
removal of the first rib with neurovascular decompression
and dorsal sympathectomy when indicated. First rib or
cervical rib resection can be performed without the need
for major muscle division, as in the posterior approach
(Clagett, 1962); without the need for retraction of the
brachial plexus, as in the anterior supraclavicular ap-
proach (Falconer and Li, 1962); and without the diffi-
culty of removing only the posterior segment of the rib,
as in the infraclavicular approach. In addition, transaxil-
lary first rib resection shortens postoperative disability
and provides better cosmetic results than the anterior
and posterior approaches, particularly because 80% of
patients are female (Roos, 1966; Urschel and Razzuk,
1972; Urschel et al, 1968, 1971, 1993, ,1995, 1998).
The patient is placed in the lateral position with the
involved extremity abducted to 90 degrees by traction
straps wrapped around the forearm and attached to an
overhead pulley. An appropriate weight, usually 2 lb, is
used to maintain this position without undue traction
(Urschel and Razzuk, 1972).
A transverse incision is made below the axillary hair-
line between the pectoralis major and the latissimus dorsi
muscles and is deepened to the external thoracic fascia
(Fig. 55-38). Care should be taken to prevent injury to
the intercostobrachial cutaneous nerve, which passes
from the chest wall to the subcutaneous tissue in the
center of the operative field.
The dissection is extended cephalad along the external
thoracic fascia to the first rib. With gentle dissection, the
neurovascular bundle and its relation to the first rib and
both scalenus muscles are clearly outlined to avoid injury
to its components. The insertion of the scalenus anticus
muscle is identified, skeletonized, and divided. The scale-
nus anticus muscle is resected into the neck so it will
not reattach to Sibson's fascia. The first rib is dissected
with a periosteal elevator and separated carefully from the
underlying pleura to avoid pneumothorax. A triangular
segment of the middle portion of the rib is resected with
the vortex of the triangle at the scalene tubercle. After
the costoclavicular ligament is divided, the anterior por-
tion of the rib is resected to the costochondral junction.
The posterior segment of the rib is resected at the articu-
lation with the transverse process. The scalenus medius
muscle should carefully be stripped with a periosteal
elevator to avoid injury to the long thoracic nerve that
lies on its posterior margin.
1475
The head and neck of the first rib are removed com-
pletely with a long, reinforced Urschel double-action pi-
tuitary rongeur. The C8 and Tl nerve roots are carefully
protected. If a cervical rib is present, its anterior portion,
which usually articulates with the first rib, should be
resected at a point at which the middle portion of the first
rib is removed. The remaining segment of the cervical rib
should be removed after removal of the posterior seg-
ments of the first rib.
A No. 20 chest tube is used for drainage. Only the
subcutaneous tissues and skin require closure because no
large muscles have been divided. The patient is encour-
aged to use the arm for self-care but to avoid heavy lifting
until at least 3 months after the operation.
It is preferable to remove the first rib entirely, includ-
ing the head and neck, to avoid future regeneration and
recurrent symptoms.
• KEY REFERENCES
Clagett OT: Presidential Address: Research and prosearch. J Thorac
Cardiovasc Surg 44:153, 1962.
Roos DB: Transaxillary approach for first rib resection to relieve thoracic
outlet syndrome. Ann Surg 163:354, 1966.
The transaxillary approach to first rib resection was initially de-
scribed by Atkins and popularized by Roos.
Urschel HC Jr, Cooper JD: Atlas of Thoracic Surgery, New York,
Churchill Livingstone, 1995.
Urschel HC Jr, Paulson DL, McNamara JJ: Thoracic outlet syndrome.
Ann Thorac Surg 6:2, 1968.
Urschel HC Jr, Razzuk MA: Neurovascular compression in the thoracic
outlet: Changing management over 50 years. Ann Surg 228:609,
1998.
• REFERENCES
Falconer MA, Li FWP: Resection of the first rib in costoclavicular
compression of the brachial plexus. Lancet 1:59, 1962.
Urschel HC Jr, Razzuk MA: Current management of thoracic outlet
syndrome. N Engl J Med 286:21, 1972.
Urschel HC Jr, Razzuk MA, Wood RE, Paulson DL: Objective diagnosis
(ulnar nerve conduction velocity) and current therapy of the
thoracic outlet syndrome. Ann Thorac Surg 12:608, 1971.
Urschel HC Jr: Video-assisted sympathectomy and thoracic outlet syn-
drome. Chest Surg Clin North Am 3:299, 1993.
COMMENTS AND CONTROVERSIES
Our preferred approach for primary neurogenic and ve-
nous compression is the transaxillary route wherein the
rib is proximal to the operator, and retraction of the
brachial plexus or blood vessels is not required.
H. C. U.
1476 CHAPTER 55 • Surgical Techniques/Transaxillary Approach with Dorsal Sympathectomy for Thoracic Outlet Syndrome

FIGURE 55-38 • A, A schematic drawing illustrating the relationship of the neurovascular

bundle to the scalene muscles, first rib, costoclavicular ligament, and subclavius muscle. B,
Inset: A transaxillary incision below the axillary hairline between the pectoralis major and the
latissimus dorsi muscles. The scalenus anticus muscle is isolated and divided at its insertion in
the first rib.
CHAPTER 55 • Surgical Techniques/Transaxillary Approach with Dorsal Sympathectomy for Thoracic Outlet Syndrome 1477

FIGURE 55-38 • Continued. C, The triangular portion of the rib is removed with the vortex of the triangle at
the scalene tubercle. The scalenus anticus muscle is resected back up into the neck. 0, The costoclavicular
ligament is divided and the anterior part of the rib is resected to the costocartilage of the sternum. E, The
axillary subclavian vein and artery are decompressed. The posterior part of the rib is resected to the transverse
process of the vertebrae and divided.
Illustration continued on following page
 1478 CHAPTER 55 • Surgical Techniques/Transaxillary Approach with Dorsal Sympathectomy for Thoracic Outlet Syndrome

FIGURE 55-38 • (Continued). F, The head and neck of the rib are removed with a special reinforced Urschel pituitary rongeur,
with care taken to avoid injury to the C8 and T1 nerve roots. The complete rib is thus excised. G, The dorsal sympathetic chain is
identified by sweeping the pleura inferiorly from the T1 nerve root. H, The T1, T2, and T3 ganglions are removed along with the
chain.
 CHAPTER 55 • Surgical Techniques/Recurrent Reoperation for Thoracic Outlet Syndrome 1479

I RECURRENT REOPERATION THROUGH

THE POSTERIOR THORACOPLASTY
APPROACH WITH DORSAL
SYMPATHECTOMY FOR THORACIC
OUTLET SYNDROME
Harold C. Urschel Jr.

Recurrent thoracic outlet syndrome occurs infrequently.
It is most commonly observed in patients in whom the
first rib was not removed completely at the first proce-
dure. A segment of rib allows osteoblasts to grow from
the end, producing a fibrocartilage that can compress
the neurovascular structures. If the initial operation was
performed through the supraclavicular or transaxillary
approach, it is far safer to perform the reoperation
through the posterior high thoracoplasty approach (Figs.
55-39 to 55-44). This provides a virgin field and allows
careful neurolysis of the nerve roots and brachial plexus
as well as release of the vascular structures when indi-
cated. A dorsal sympathectomy is usually performed be-
cause the sympathetic-maintained pain syndrome and
causalgia are present in most cases of recurrent thoracic
outlet syndrome. Reoperation is indicated when conser-
vative management has failed (Urschel et al, 1995, 1998).
• REFERENCES
Urschel HC Jr, Cooper JD: Atlas of Thoracic Surgery. New York,
Churchill Livingstone, 1995.
Urschel HC Jr, Razzuk MA: Neurovascular compression in the thoracic
outlet: Changing management over 50 years. Ann Surg 228:609,
1998.

FIGURE 55-39 • A, Inset: A high thorocoplasty incision is performed halfway between the angle of the
scapula and the spine and extends about 4 cm above and 2 cm below the angle of scapula. 6, The incision is
carried through the skin and the subcutaneous tissue to the trapezius muscle. The trapezius and rhomboid
muscles are split along their fiber lines.
1480 CHAPTER 55 • Surgical Techniques/Recurrent Reoperation for Thoracic Outlet Syndrome

FIGURE 55-40 • 7, The rib remnant or recurrent piece of the first rib is identified, and a cautery is used to incise the periosteum.
2, The rib stump is removed subperiostially. 3, The rongeur is used to remove the rib at its head and neck part. 4, The T1 nerve
root is identified and touched with a nerve stimulator.

FIGURE 55-41 • Neurolysis of the scar over the T1 nerve root is carefully performed with
magnification so that the nerve sheath is not injured.
 CHAPTER 55 • Surgical Techniques/Recurrent Reoperation for Thoracic Outlet Syndrome 1481

FIGURE 55-42 • The neurolysis is

completed on the C8 and T1 nerve roots,
and a piece of the second rib is removed
posteriorly.

FIGURE 55-43 • The dorsal sympathetic

chain and the stellate ganglion are
identified.

FIGURE 55-44 • The T1, T2, and T3 ganglia are

removed with the dorsal sympathectomy.
1482 CHAPTER 55 • Surgical Techniques/Combined Exposure of the First Rib Approach for Thoracic Outlet Syndrome
COMMENTS AND CONTROVERSIES
Recurrent thoracic outlet syndrome, in our opinion, is
best operated on posteriorly with a high thoracoplasty
approach and a muscle-splitting incision, because this
method gives excellent exposure in virgin territory. The
usual rib remnant and fibrocartilage impinging on the
brachial plexus is easier to remove posteriorly. This ap-
COMBINED EXPOSURE OF THE FIRST
RIB: A MODIFIED APPROACH FOR
THE TREATMENT OF THORACIC
OUTLET SYNDROME
Francis Robicsek
Since its first description, much controversy has existed
over the condition known as "thoracic outlet syndrome."
Urschel and associates (1968) give credit to Bramwell,
who, in 1903, recognized the first rib as the possible
cause of neurovascular compression in the thoracic inlet,
and Murphy, who was the first to resect it in 1910 to
relieve the symptoms associated with this condition. It
is generally recognized that first-rib resection—with or
without scalenotomy—is a requisite in the treatment of
most, if not all, cases of thoracic outlet syndrome (Cla-
gett, 1962; Ferguson et al, 1958; Roos, 1966; Urschel et
al, 1968).
Even with over a century of experience, surgeons have
yet to define the ideal method for the treatment of tho-
racic outlet syndrome. Different authors recommend vari-
ous approaches. The three principal methods applied are:
1. The posterior approach, that is, the "old-fashioned"
thoracoplasty exposure (Clagett, 1962).
2. The axillary approach, which allows the removal of
the first rib through a small, cosmetically pleasing inci-
sion (Roos, 1966).
3. The anterior approach, which exposes the thoracic
inlet through a supraclavicular incision (Nelson and
Davis, 1969).
All three types of exposure have their virtues and
shortcomings. Although the posterior and axillary ap-
proaches appropriately expose the first rib, they do not
provide satisfactory exposure of other important struc-
tures that are important in the pathophysiology of the
thoracic inlet: the subclavian vessels, the nerves, and the
anterior scalene muscle. When the symptoms of neuro-
vascular compression are induced by bony spurs or
proach also allows expeditious neurolysis of the brachial
plexus and dorsal sympathectomy. The supraclavicular
approach may also be used for neurolysis of the brachial
plexus; however, it is difficult to remove the rib stump
posteriorly without retracting the brachial plexus, and
doing so requires great skill and experience.
H. C. U.
anomalous ligaments, the posterior and axillary ap-
proaches may leave them undetected, and thus, untreated
(Stoney and Cheng, 1995). An additional advantage of
the supraclavicular approach is that it allows easy divi-
sion of the anterior scalene muscle, an important compo-
nent in the development of thoracic outlet narrowing.
The disadvantage of the anterior supraclavicular ap-
proach, however, is that it provides only a limited expo-
sure to the first rib, making its removal difficult and,
more often than not, incomplete. For these reasons, re-
currences are frequent. An additional shortcoming of
the procedure is that it requires the insertion of sharp
instruments, such as rongeurs, blindly under the clavicle
to resect the anterior portion of the first rib, and, through
necessity, the subclavian artery may be left overlying
ragged bony edge.
The difficulties of the anterior approach were realized
by Quarfordt and colleagues (1984) who used the ante-
rior approach for radical scalenotomy but in addition
removed the first rib through a separate transaxillary
incision. In cases of "effort" subclavian vein thrombosis,
Thompson and colleagues (1992) suggested simultaneous
separate supraclavicular and infraclavicular incisions to
remove the first rib. Gol's technique involved the resec-
tion of the entire first rib using an infraclavicular incision
(Gol et al, 1968).
In our view, the "ideal" operation for adequate decom-
pression of the thoracic inlet should include the follow-
ing:
1. Adequate exposure, through a single skin incision,
of all potentially compromised neurovascular structures.
2. Easy access to both radical scalenotomy and re-
moval of the entire first rib.
 CHAPTER 55 • Surgical Techniques/Combined Exposure of the First Rib Approach for Thoracic Outlet Syndrome 1483

FIGURE 55-45 • Exposure of the first rib with the

"above-under" approach.

To accomplish these goals, we now recommend the We have found this modified approach very useful in
following approach (Robicsek and Eastman, 1997). A decompressing the thoracic inlet. The technique allows
single 6- to 9-cm-long skin incision is made 1 cm above both supraclavicular and infraclavicular exposure of the
and parallel with the clavicle. The subcutaneous fat and first rib through a single skin incision, and it provides
the platysma are divided while the phrenic nerve is care- excellent visualization of the important structures of the
fully protected. The anterior scalene muscle is divided thoracic inlet, thus ensuring both safety and radical inter-
using electrocautery. The brachial plexus and the subcla- vention.
vian vessels are exposed and retracted laterally and down-
ward, respectively. The dorsal aspect of the first rib is
cleared of its periosteum, and the rib is divided with a
rongeur at approximately 2 cm distal of its junction with
the costotransversal process. The divided rib is elevated,
freed of all of its soft tissue connections, followed under
the clavicle, and transected with a rongeur just behind
the subclavian vessels (Fig. 55-45 and 55-46). After the
mobilized proximal half of the first rib is removed, an
incision is made under the retroactive inferior skin-flap
across the clavicular attachment of the pectoralis msucle.
Using sharp and blunt dissection, the remaining anterior
portion of the first rib is exposed and grabbed with an
alligator forceps, and its attachment to the sternocostal
cartilage is divided. The first rib is then removed in its
entirety. The pectoralis muscle is re-attached to the clavi-
cle, and the subcutaneous tissues, as well as the skin, are
closed. If the pleural cavity is inadvertently entered, a
Robinson catheter is inserted through the incision, placed FIGURE 55-46 • The posterior portion of the first rib, A, is
on water-sealed drainage for a few hours, then removed. removed supra, and the sternal portion, S, is removed
infraclavicular^. Dotted lines represent lines of rib transection.
1484 CHAPTER 55 • Surgical Techniques/Thoracoscopic First Rib Resection for Thoracic Outlet Syndrome
COMMENTS AND CONTROVERSIES
This approach is an optional one and is rarely used in
the treatment of thoracic outlet syndrome. It requires
significant retraction of the various structures, as does
the supraclavicular approach, evidenced by the multiple
retractors shown in the illustration. It is an acceptable
approach for arterial bypass, as is the supraclavicular and
infraclavicular approach, however it is not the preferred
approach for treatment of nerve or venous compression or
for re-operation.
H. C. U.
• REFERENCES
Bramwell E: Lesion of the first dorsal nerve root. Rev Neurol Psychiatry
1:236, 1903.
Clagett CT: Research and prosearch. J Thorac Cardiovasc Surg 44:153-
166, 1962.
Ferguson TB, Burford TH, Roper CL: Neurovascular compression at
I THORACOSCOPIC FIRST RIB
RESECTION FOR THORACIC
OUTLET SYNDROME
Randall K. Wolf
Alvin H. Crawford
Beverly Hahn
Resection of the first rib is performed for surgical treat-
ment of thoracic outlet syndrome (TOS). Thoracic outlet
syndrome refers to compression of the subclavian vessels
or the brachial plexus by the first rib and adjacent struc-
tures at the superior aperture of the chest (MacKinnon
etal, 1995).
The anatomy, clinical presentation, and evaluation of
the patient with thoracic outlet syndrome has been exten-
sively reviewed by Urschel (1989, 1990, 1995), and the
reader is referred to Urschel's atlas (1995) for clear, con-
cise, and exhaustive information concerning the history,
anatomy, presentation, testing and accepted management
of TOS. This chapter presents a new minimally invasive
thoracoscopic surgical technique for excision of the first
rib for treatment of thoracic outlet syndrome.
ANATOMY
On thoracoscopic examination, the first rib can be easily
identified in the "roof" of the thorax. The first rib is a
wide, flat rib that forms a "C" in the apex of the chest
the superior thoracic operature: Surgical management. Ann Surg
167:573-579, 1958.
Gol A, Patrick DW, McNeal DP: Relief of the costoclavicular syndrome
by infraclavicular removal of the first rib: Technical note. J Neuro-
surg 28:81, 1968.
Murphy T: Brachial neuritis caused by compression of the first rib. Aust
Med J 15:582, 1910.
Nelson RM, Davis RW: Thoracic outlet compression syndrome. Ann
Thorac Surg 48:437-451, 1969.
Qvarfordt PG, Ehrenfeldt WK, Stoney RJ: Supraclavicular radical scalen-
ectomy and transaxillary first rib resection for the thoracic outlet
syndrome. A combined approach. Am J Surg 148:111-116, 1984.
Robicsek F, Eastman D: "Above-under" exposure of the first rib: A
modified approach for the treatment of thoracic outlet syndrome.
Ann Vase Surg 11:304-306, 1997.
Roos DB: Transaxillary approach for first rib resection to relieve thoracic
outlet syndrome. Ann Surg 163:354-358, 1966.
Stoney JR, Cheng SWK: Neurogenic thoracic outlet syndrome. In Ruth-
erford RB (ed): Vascular Surgery, 4th ed. Philadelphia, WB Saun-
ders, 1995, pp 976-992.
Thompson RW, Schenider PA, Nelken NA et al: Circumferential veno-
lysis and paraclavicular thoracic outlet decompression for "effort
thrombosis" of the subclavian vein. J Vase Surg 16:723-732, 1992.
Urschel HC Jr, Paulson DL, McNamara JJ: Thoracic outlet syndrome.
Ann Thorac Surg 6:1-10, 1968.
cavity. It is clearly visualized endoscopically and can be
"palpated" indirectly using an endoscopic Kitner. Care
should be taken to note the relationship of the internal
mammary artery anteriorly and the sympathetic chain
posteriorly to the borders of the first rib. On the left, the
subclavian artery is also easily visualized on thoracos-
copic examination (Fig. 55-47).
PROCEDURE
Room setup is depicted in Figure 55-48. The surgeon
positions himself or herself on the anterior or posterior
side of the patient. The patient is placed in the lateral
position after induction of general anesthesia with a dou-
ble-lumen tube. Three 10-mm thoracic ports are used for
the operation: the two highest ports, in the anterior
third or fourth and lateral fifth intercostal spaces for the
working instruments, and a lower port on the lateral wall
in the sixth intercostal space for a rigid 30-degree scope
(Fig. 55-49). The thoracoscopic approach to first rib
resection has been presented by Wolf and his co-workers
 CHAPTER 55 • Surgical Techniques/Thoracoscopic First Rib Resection for Thoracic Outlet Syndrome 1485

FIGURE 55-47 • A, The anatomy of the left superior thorax as seen through the thoracoscope—asterisk, left first rib; large
arrow, internal mammary artery; star, left subclavian artery; small arrow, phrenic nerve. B, An accompanying artist's rendition.
(From Wolf RK, Crawford AH, Hahn B: Thoracoscopic first rib resection for thoracic outlet syndrome. In Yim APC, Hazelrigg SR,
Issat MB et al [eds]: Minimal Access Cardiothoracic Surgery. WB Saunders, Philadelphia, 2000.)

(1999). Endoscopic instruments including endoscopic el-
evators, curets, and rongeurs (Sofamor Danek, Tenn)
were altered from the regular orthopedic tools by exten-
sion and modification to pass through 10-mm endoscopic
ports (Regan, 1995). In the initial report by Ohtsuka and
associates (in press), an endoscopic drill (Midas Rex,
Pneumatic Tools Inc, Tex) capable of pulverizing bone
through ports with a coarse ball tip revolving at high
speed was also used. The Harmonic Scalpel (Ethicon
Endo-Surgery, Cincinnati, Ohio), which operates with
ultrasonic energy producing less smoke and lower heat
than regular electrocautery, was developed to facilitate
endoscopic dissection (Amaral, 1994).
After double-lumen endotracheal intubation, the pa-
tient is placed in the lateral decubitus position. The
kidney rest is raised to slightly open the ribs, and selec-
tive ventilation is initiated. Three 10-mm ports are placed
(see Procedure): two are flexible ports (Flexipath, Eth-
icon Endo-Surgery, Cincinnati, Ohio), and one is a rigid
port. A 10-mm, 30-degree endoscope with three-chip
camera is placed through the rigid inferior port. The
flexible ports are used for placement of the orthopedic
instruments. The anatomy is carefully evaluated. The
thoracoscopic rib resection begins by dissecting the pari-
etal pleura as well as intercostal muscles from the costal
edge of the first rib using the Harmonic Scalpel (Figs.
55-50 and 55-51). The subclavian vein and artery and
brachial plexus, lying from anterior to posterior in each
groove of the first rib, are freed from the bone bluntly
using an endoscopic Cobb elevator and endoscopic curets
(Fig. 55-52). Next, cautious dissection with a spinous
process elevator frees the ribs circumferentially. Recently,
special angled elevators have been manufactured to facili-
tate this maneuver. To divide the rib in two cases, an
endoscopic drill was then used. The subclavian vessels
and nerves were protected from the revolving drill by
placing an endoscopic elevator behind the rib. The pow-
dered tissue was evacuated by suction. Currently, the
drill has been replaced by an endoscopic rib cutter (Fig.
55-53). The endoscopic rib cutter is simpler, easier to
use, and safer than the drill. The endoscopic rib cutter
is employed to divide the first rib both anteriorly and
posteriorly in its midportion. The divided rib is then
removed through one of the port incisions (Fig. 55-54).
Endoscopic orthopedic rongeurs are then used to trim
the resected ends of the rib back to the transverse process
posteriorly, and anteriorly to the manubrium (Fig. 55-
55). Final assessment should include palpation of the
transverse process posteriorly, as well as the costochon-
dral junction anteriorly. This allows for complete excision
of the first rib, a point emphasized by Urschel.
A few technical points of the thoracoscopic first rib
resection are worth emphasizing. Care must be taken in
developing the plane of dissection, and it is recom-
mended to dissect anterior to the vein initially. After
transection of the rib, any additional muscle attachments,
such as scalenus anticus or medius, can be divided under
direct vision. The rib can be delivered easily through one
of the port sites after removing the port. During this
dissection, the mammary artery anteriorly and the sympa-
thetic chain posteriorly are clearly observed and pre-
served. Port sites are best placed at some distance from
the target to allow adequate manipulation of the instru-
ments in a comfortable arc. After complete thoracoscopic
first rib excision, the contents of the neurovascular bun-
dle drape gently across the apex of the pleural cavity. The
extent of rib resection and its immediate effect on the
structures of the thoracic outlet are clearly visualized.
RESULTS
In seven cases performed by Wolf and colleagues (1999),
the first rib was removed by this technique to decompress
1486 CHAPTER 55 • Surgical Techniques/Thoracoscopic First Rib Resection jor Thoracic Outlet Syndrome

FIGURE 55-48 • Room setup for thoracoscopic first rib resection. (From Wolf RK, Crawford AH,
Hahn B: Thoracoscopic first rib resection for thoracic outlet syndrome. In Yim APC, Hazelrigg SR,
Issat MB et al [eds]: Minimal Access Cardiothoracic Surgery. WB Saunders, Philadelphia, 2000.)

the subclavian vessels and brachial plexus lying on the
first rib. In the first patient, who presented with right
subclavian vein thrombosis, the symptoms on the right
side resolved completely after the procedure. He subse-
quently developed symptoms in the left arm and under-
went the same procedure on the left side. The duration
of the initial operation was 110 minutes. However, the
operation times were reduced with experience to 100
minutes for the second case and 75 minutes for the third.
Blood loss was minimal in each case, and hospital stay
was 3, 2 and 1 day in the first, second, and third cases,
respectively. Currently, a 1-day stay in the hospital is
routine. Three years after surgery, the patient with Paget-
Schroetter syndrome remains asymptomatic. More re-
cently, in the last three patients the endoscopic rib cutter
has been used to transect the first rib. The rib cutter
appears to add safety to the division maneuver and is
relatively easy to use compared with the drill. Richard
Fischel (Personal communication) has completed six
cases of first rib resection with histories including
trauma, sudden onset of numbness, and long-standing
pain and weakness secondary to an overhead lifting job.
These patients had all failed conservative treatments. All
had good improvement with relief of pain and numbness.
 CHAPTER 55 • Surgical Techniques/Thoracoscopic First Rib Resection for Thoracic Outlet Syndrome 1487

Axillary hair

Scapula
Port placements

FIGURE 55-49 • A, Topical anatomy, and 6 and C, port sites for thoracoscopic first rib resection. (A and 6, From
Wolf RK, Crawford AH, Hahn B: Thoracoscopic first rib resection for thoracic outlet syndrome. In Yim APC, Hazelrigg
SR, Issat MB et al [eds]: Minimal Access Cardiothoracic Surgery. WB Saunders, Philadelphia, 2000.)

First rib

Phrenic nerve Subclavian vein

Internal
mammary artery (IMA)

Subclavian artery
Lung

FIGURE 55-50 • Thoracoscopic view of the left first rib. (From Wolf RK,
Crawford AH, Hahn B: Thoracoscopic first rib resection for thoracic outlet
syndrome. In Yim APC, Hazelrigg SR, Issat MB et al [eds]: Minimal Access
Cardiothoracic Surgery. WB Saunders, Philadelphia, 2000.)
1488 CHAPTER 55 • Surgical Techniques/Thoracoscopic First Rib Resection for Thoracic Outlet Syndrome

FIGURE 55-51 • Initial dissection of the pleura overlying the

first rib as performed with the harmonic scalpel. (From Wolf
RK, Crawford AH, Hahn B: Thoracoscopic first rib resection for
thoracic outlet syndrome. In Yim APC, Hazelrigg SR, Issat MB
et al [eds]: Minimal Access Cardiothoracic Surgery. WB
Saunders, Philadelphia, 2000.)

FIGURE 55-52 • The right rib is freed from its muscular attachments
with an elevator.

FIGURE 55-53 • Thoracoscopic rib cutter

(Sofamor Danek, Medthronic, Minneapolis, MN)
used on subsequent cases. (From Wolf RK,
Crawford AH, Hahn B: Thoracoscopic first rib
resection for thoracic outlet syndrome. In Yim
APC, Hazelrigg SR, Issat MB et al [eds]: Minimal
Access Cardiothoracic Surgery. WB Saunders,
Philadelphia, 2000).
 CHAPTER 55 • Surgical Techniques/Thoracoscopic First Rib Resection for Thoracic Outlet Syndrome 1489

FIGURE 55-54 • The resected right first rib is shown before removal.

FIGURE 55-55 • A through C, Further thoracoscopic

dissection and division of the first rib. (From Wolf RK,
Crawford AH, Hahn B: Thoracoscopic first rib resection for
thoracic outlet syndrome. In Yim APC, Hazelrigg SR, Issat MB
et al [eds]: Minimal Access Cardiothoracic Surgery. WB
Saunders, Philadelphia, 2000.)
1490 CHAPTER 55 • Surgical Techniques/Surgery of the Clavicle
COMMENTS AND CONTROVERSIES
The use of the thoracoscope for resection of the first rib
from inside the chest cavity is a novel and creative one.
It allows direct access to the rib without retraction of any
of the structures, similar to the exposure of the transaxil-
lary approach. It also has the advantage of minimal
invasion as far as the length of an incision (although the
transaxillary incision is not painful and does not require
prolonged hospitalization).
It must be remembered that this thoracoscopic, intratho-
racic technique is experimental and very new as can be
evidenced by the small number of cases presented. How-
ever, I think that with development of better instruments,
this may become a standard approach in the future.
A major risk of this approach is injury to the nerves or
blood vessels that are on the other side of the rib and
difficult to visualize. Care must be taken with this proce-
dure and experience with thoracoscopy is critical.
H. C. U.
REFERENCES
Amaral JF: The experimental development of an ultrasonically activated
scalpel for laparoscopic use. Surg Laparosc Endosc 4:92-99, 1994.
I SURGERY OF THE CLAVICLE
Harold C. Urschel Jr.
J ere W. Lord
Total claviculectomy, although rarely performed, is a valu-
able clinical procedure for a variety of pathologic condi-
tions. It can be performed bilaterally without significant
limitation of function or cosmetic deformity and should
be part of the armamentarium of general, vascular, and
thoracic surgeons.
FUNCTIONAL ANATOMY
The sternoclavicular joint plays a considerable part in the
combined movements of the shoulder-girdle complex. It
possesses an intra-articular disk that adapts the shoulder
girth to a wider range of motion. The motion is gliding,
with the center of motion outside the joint. The fulcrum
of motion is the clavicular insertion of the costoclavicular
ligament, which not only contributes greatly to joint
stability but also lies close to the joint and gives greater
angular value to the excursions in comparison with the
gliding distance.
The upward and downward movement around the
sagittal axis has an excursion range of 60 degrees, the
forward and backward movement around the perpendicu-
Atkins HJB: Sympathectomy by the axillary approach. Cancer 1:538,
1954.
Lindgren KA, Oksala I: Long-term outcome of surgery for thoracic
outlet syndrome. Am J Surg 169:358-360, 1995.
MacKinnon SE: Thoracic outlet syndrome. Ann Thorac Surg 58:287-
289, 1994.
MacKinnon SE, Patterson GA, Urschel HC: Thoracic outlet syndromes.
In Pearson FG, Deslauriers J, Ginsburg RJ et al (eds): Thoracic
Surgery. New York, Churchill Livingstone, 1995.
Ohtsuka T, Wolf RK, Dunsker SB: Port-access first rib resection with
new instruments: A report of two cases. J Surg Endosc, in press.
Poole GV, Thomae KR: Thoracic outlet syndrome reconsidered. Am
Surg 62:287-291, 1996.
Regan JJ: Equipment and instrumentation for endoscopic spine surgery.
In Regan JJ, McAfee PC, Mack MJ (eds): Atlas of Endoscopic
Spine Surgery. New York, Quality Medical Publishing, 1995.
Roos DB: Transaxillary approach for first rib resection to relieve thoracic
outlet syndrome. Ann Surg 163:354-358, 1996.
Urschel He Jr, Cooper JD: Atlas of Thoracic Surgery. New York,
Churchill Livingstone, 1995.
Urschel HC: Thoracic outlet syndrome. In Shields (ed): General Tho-
racic Surgery. Philadelphia, Lea & Febiger, 1989.
Urschel HC: Thoracic outlet syndrome. In Sabiston S (ed): Surgery of
the Chest. Philadelphia, WB Saunders, 1990.
Wilson, et al. Thoracic outlet disorders, Vascular Surgery, Principles
and Practice. McGraw-Hill, 1987.
Wolf RK, Crawford AH, Hahn BY: Thoracoscopic First Rib Resection
for Thoracic Outlet Syndrome. In Yim Y et al (eds): Minimal
Access Cardiothoracic Surgery. Philadelphia, WB Saunders, 1999.
lar axis has an excursion range of 30 degrees, and the
length rotation movement around the frontal axis has an
excursion range of 30 degrees.
The acromioclavicular joint, the articulation between
the clavicle and acromion, is a weak, simple, arthrodial or
gliding joint with synovial cavity, capsule, and reinforcing
extracapsular ligaments, namely, the superior and inferior
acromioclavicular ligaments. The acromioclavicular joint
provides mobility between the clavicle and the scapula.
Its construction is reinforced by the powerful coracocla-
vicular ligament, providing a stronger union between the
two bones.
The subclavian artery leaves the thorax by arching
over the first rib behind the scalenus amicus muscle and
in front of the scalenus medius. It then passes under
the subclavius muscle and clavicle and enters the axilla
beneath the pectoralis minor muscle.
Except that it passes anterior, rather than posterior, to
the scalenus anticus muscle, the subclavian vein has an
identical course. The vein passes under the clavicle
through a tunnel bounded medically by the costoclavicu-
lar ligament, laterally by the scalenus anticus muscle,
 CHAPTER 55 • Surgical Techniques/Surgery of the Clavicle 1491

superiorly by the subclavius muscle and clavicle, and
inferiorly by the first rib. The brachial plexus follows the
route of the subclavian artery, but it lies a little more
posteriorly and laterally.
From its origin at the root of the neck to the lower-
most boundary of the axilla, the neurovascular supply of
the upper limb is closely confined within rather rigid
spaces by an overlying myofascial layer (Fig. 55-56).
From above downward, this consists of the fascia of
the omohyoid (so-called muscular fascial division of the
enveloping layer of the deep cervical fascia); the posterior
belly of the omohyoid, which is enclosed in this fascia;
below the omohyoid, this fascia splits to envelop the
subclavius muscle; it then joins again to form the clavi-
pectoral fascia, whose thickened lateral portion forms the
costocoracoid membrane; this fascial layer is prolonged
inferiorly and splits again to enclose the pectoralis minor;
finally, it rejoins again to form the suspensory ligament
of the axilla.
PATHOPHYSIOLOGY
Deformities of the clavicle may occur secondary to malig-
nant or benign tumors (primary or metastatic); trauma
with callous formation or fracture nonunion; or congeni-
tal defects. The pressure may involve one or more of the
structures passing below the clavicle in the thoracic out-

FIGURE 55-56 • From its origin

at the root of the neck to the
lower-most boundary of axilla,
the neurovascular supply of the
upper limb is closely confined
within rigid spaces by an
overlying myofascial layer. This
consists of the fascia of the
omohyoid, the posterior belly of
the omohyoid, the subclavius
muscle, the clavipectoral fascia,
the costocoracoid membrane, the
pectoralis minor, and the
suspensory ligament of the axilla.
(From Lord JW Jr, Rosati LM:
Thoracic-outlet syndromes. Clin
Symp 23:1, 1971. Illustrated by
Frank H. Netter, MD, 1971, CIBA-
Geigy Corp.)
1492 CHAPTER 55 • Surgical Techniques/Surgery of the Clavicle
let, such as the axillary-subclavian vein, artery, or nerve
(brachial plexus, peripheral asympathetic) (Fig. 55-57).
The Paget-Schroetter syndrome, or effort thrombosis
of the vein may be secondary to any of the aforemen-
tioned pathologic conditions superimposed on a congeni-
tal lateral insertion of the costoclavicular ligament;
weightlifting, which increases the size of the scalenus
anticus muscle; or trauma.
The subclavian artery may develop post-stenotic dila-
tion aneurysm or occlusion or severe intermittent spasm
secondary to any of the previously mentioned forces
operating in the thoracic outlet, requiring clavicular re-
section.
FIGURE 55-57 • The various
structural abnormalities that
cause compression. (From Lord
JW Jr, Rosati LM: Thoracic-
outlet syndromes. Clin Symp
23:1, 1971. Illustrated by Frank
H. Netter, MD, 1971, CIBA-
Geigy Corp.)
Total claviculectomy with excision of the periosteum
provides excellent exposure for safe removal of aneu-
rysms of the second and third portions of the subclavian
artery and, in selected patients, for reconstruction of
occlusions in this area.
DIAGNOSIS
Diagnosis is established clinically in patients with de-
formities of the clavicle secondary to tumors, bony abnor-
malities, or nonunion secondary to trauma or birth de-
fects. Diagnosis can be confirmed by special radiographic
views of the clavicle. Computed tomography (CT) or
 CHAPTER 55 • Surgical Techniques/Surgery of the Clavicle
magnetic resonance imaging (MRI) scans are helpful if
the tumor is medial. One patient presented as having an
intrathoracic mass initially thought to be in the lung
until location in the clavicle was confirmed by CT scan.
Careful clinical assessment should be made of arterial
pulses, the venous and sympathetic nervous systems, as
well as sensory and motor neurologic evaluation of the
extremity. A defined pain history is also critical.
Examination of the radial pulse in the various posi-
tions of compression may be helpful (e.g., hyperabduc-
tion, hyperextension, and the military position). Assess-
ment of arterial bruits and venous hums by auscultation
or Doppler scan in both the supraclavicular and infracla-
vicular positions is important for vascular lesions. Veno-
grams and arteriograms, both prograde and retrograde,
may be helpful for specific lesions and may demonstrate
the location of collateral circulation, which is important
to preserve in most patients. Stellate ganglion blocks may
be helpful for sympathetic-maintained pain syndrome.
In patients with predominant pain and paresthesia
who have nerve compression, electromyography is usu-
ally normal except that the conduction velocity is pro-
longed over the thoracic outlet (Miller, 1981; Urschel
and Razzuk, 1972, 1986, 1995, 1996). Preoperative nee-
dle biopsy of clavicle tumors is valuable in determining
whether or not the tumor is malignant. A malignant
tumor requires a wider excision and a greater margin
than a simple benign tumor, and it may be difficult to
diagnose by frozen section.
INDICATIONS FOR SURGERY
Indications for operation in the 11 cases with pathologic
clavicles were obvious; the other resections in 26 extremi-
ties were primarily for diagnosis of thoracic outlet syn-
drome that did not respond to conservative medical man-
agement or physical therapy. In one of these patients, a
transaxillary first rib resection had been unsuccessful in
managing symptoms; claviculectomy was successful (Fig.
55-58). In the past claviculectomy for thoracic outlet
syndrome was performed for severe symptomatology
prior to the popularization of the transaxillary or poste-
rior resection of the first rib.
OPERATIVE TECHNIQUE
The operation is carried out by an incision over the
length of the clavicle with subperiosteal resection of the
bone. The periosteum is completely and carefully re-
moved, avoiding injury to the subclavian vein (Fig. 5 5 -
59). The scalenus anticus muscle is sectioned at its inser-
tion into the first rib. Any anomalous bands are excised.
Following careful hemostasis, the incision is closed with-
out drainage in most cases. Occasionally, for a large mass
or bony abnormality, a round Jackson-Pratt suction cathe-
ter is brought out through a subcutaneous tunnel. Antibi-
otic solution is used, and antibiotics are given prophylac-
tically.
ANATOMIC AND FUNCTIONAL RESULTS
Removal of the clavicle eliminates angulation and pres-
sure on the subclavian artery and vein by the scalenus
1493
anticus muscle. When the clavicle is removed and the
scalenus muscle divided, the vessels roll down and for-
ward. Thus, the vessels are displaced anteriorly along
with the subclavian muscle. The elimination of the clavi-
cle allows the shoulder to move anteriorly and medially,
relaxing the pectoralis minor tendon, thereby function-
ally lengthening the artery, vein, and brachial plexus
(Fig. 55-60).
Cosmetically the appearance is satisfactory, and post-
operative function of the extremity is excellent. Bilateral
claviculectomy allows the shoulders to be brought to-
gether in the midline; however, there are no adverse
consequences, and function is excellent.
INDICATIONS AND CLINICAL STUDY
From 1950 through 1996, 37 clavicles were resected in 30
patients suffering from arterial, venous, and neurologic
symptoms involving the upper extremity. The patients
ranged in age from 17 to 78 years; there were 17 males
and 13 females. Eleven clavicles were pathologic: post-
traumatic nonunion (4), congenital nonunion (2), post-
traumatic abnormal bony union (2), neoplastic (2), and
post-radiation necrosis (1) (see Fig. 55-57). The subcla-
vian artery was occluded in 8 extremities and intermit-
tently obstructed in 21. The subclavian vein was occluded
in 6 extremities (Paget-Schroetter syndrome) (Urschel
and Razzuk, 2000) and intermittently obstructed in three.
Neurologic involvement occurred in 8 extremities involv-
ing sensory or motor symptoms of thoracic outlet syn-
drome. These generally occurred in the ulnar nerve distri-
bution, but they also presented, though less frequently,
in the medial nerve distribution. Several patients had
more than one system involved.
Mean follow-up for the 30 patients was 8 years. One
patient who failed to improve with transaxillary resection
of the first rib was completely relieved by claviculectomy
for large callous formation. Results in 37 clavicles were
classified as excellent in 19 extremities, good in 13, fair
in 4, and poor in 1 (Table 55-1). There was no mortality
and only one complication, leakage from the thoracic
duct, which was easily controlled without operation.
CASE REPORT
A 42-year-old woman had sustained bilateral fractures of
the clavicle 17 years prior to admission. Six weeks follow-
ing the clavicular fractures, overriding was noted, and
bilateral open reduction with fixation of the fragments by
kangaroo tendon was performed. A satisfactory functional
result was obtained on the right, but there was intermit-
TABLE 5 5 - 1 • Results of 37 Claviculectomies
Excellent 19 extremities
Good 13 extremities
Fair 4 extremities
Poor 1 extremity
Follow-up
Mean 8 yr
Range 1-33 yr
1494 CHAPTER 55 • Surgical Techniques/Surgery of the Clavicle

FIGURE 55-58 • The exaggerated military position, with the shoulders drawn downward and
backward, is used to detect compression in the costoclavicular interval. The subclavian vein
lies in the inner medial angle, between the insertion of the anterior scalene muscle
posteriorly and the inner end of the clavicle, with its underlying tendon of insertion of the
subclavius muscle and the costocoracoid ligament inserting into the first rib anteriorly. (From
Lord JW Jr, Rosati LM: Thoracic-outlet syndromes. Clin Symp 23:1, 1971. Illustrated by Frank H.
Netter, MD, 1971, CIBA-Geigy Corp.)
 CHAPTER 55 • Surgical Techniques/Surgery of the Clavicle 1495

FIGURE 55-59 • The operation is carried out by an incision over the length of the clavicle
with subperiosteal resection of the bone (A), Reflecting periosteum from the clavicle. Insert
shows a section of the clavicle that was hit with a Gigli saw (S). (Illustrations by Robin
Markovits Jensen, adapted from The New York Academy of Medicine, Diseases of the
Circulatory System, Macmillan, 1952.)
Illustration continued on following page
1496 CHAPTER 55 • Surgical Techniques/Surgery oj the Clavicle
D 1952.)
tent discomfort in the region of the clavicle and shoulder
on the left side.
Four months prior to admission, the patient noted
that her left arm was larger than the right and that this
arm fatigued more readily than the right. There was no
swelling of the forearm or hand, and no paresthesias were
noted. The swelling and weakness gradually increased
until 4 days prior to admission when, following a swim,
the whole left arm became markedly swollen. There was
extreme weakness of the extremity and a subjective sen-
sation of coolness.
Examination revealed a malunited fracture of the left
clavicle. Dilated superficial veins extended from the left
arm and shoulder to the pectoral region. The entire left
upper extremity was moderately swollen. Skin tempera-
ture of the arms was equal on gross testing. With the
patient recumbent and the left arm at her side, the radial
FIGURE 55-59 • (Continued)
Removal of the medial segment
of the clavicle is seen on the left;
removal of the lateral segment
of the clavicle is seen on the
right (O- The periosteum is
excised from the clavicular bed
(D). (Illustrations by Robin
Markovits Jensen, adapted from
The New York Academy of
Medicine, Diseases of the
Circulatory System, Macmillan,
pulse was strong. However, on sitting, which produced a
modified costoclavicular maneuver, the radial pulse was
obliterated by deep inspiration. Turning the head to either
side, or abduction of the left arm to 45 degrees, also
obliterated the pulse. Radiography of the clavicle revealed
a malunited fracture on the left, with significant overrid-
ing of the medial fragment (Fig. 55-61).
At operation, the patient was found to have a large
number of venous collateral channels in the retroclavicu-
lar space, and the subclavian vein was thrombosed. The
inner tip of the lateral clavicular fragment was pressing
on the subclavian artery and apparently was responsible
for the intermittent compression of this vessel on deep
inspiration or hyperabduction. The clavicular fragments,
including the periosteum, were resected. Immediately
after the operation, the patient could hyperabduct the left
arm to 180 degrees without obliterating the radial pulse.
 CHAPTER 55 • Surgical Techniques/Surgery oj the Clavicle 1497

FIGURE 55-60 • The elimination

of the clavicle allows the shoulder
to move anteriorly and medially,
relaxing the pectoralis minor
tendon and thus functionally
lengthening the artery, the vein,
and the brachial plexus.

FIGURE 55-61 • Radiograph of

the clavicle reveals a malunited
fracture of the left, with
significant overriding of the
medial fragment.
1498 CHAPTER 55 • Surgical Techniques/Surgery of the Clavicle
FIGURE 55-62 • Four years postoperatively, the left arm was
slightly larger than the right, but turning of the head,
depressing the shoulder, deep inspiration, and hyperabduction
did not dampen the left radial pulse.
The postoperative course was uncomplicated. The pa-
tient maintained her arm in a position of elevation, and
anticoagulant therapy was instituted and maintained for
approximately 1 month. At the time of discharge, 7 days
after the operation, the left upper arm was 2 inches larger
in circumference than the right. There was no difference
in size between the left and right forearms and hands.
The patient was fitted with an elastic sleeve.
Four years postoperatively (Fig. 5 5 - 6 2 ) , the left arm
remained slightly larger than the right. Turning the head,
depressing the shoulders, deep inspiration, and hyperab-
duction did not dampen the left radial pulse.
During the 21-year follow-up, the patient has had no
pain in the clavicular or shoulder region and has noted
no fatigue or paresthesias in the left upper extremity. It
is her impression that the collateral veins over the left
shoulder have become slightly more prominent. There
has been no evidence of clavicular regeneration.
DISCUSSION
The initial incentive to consider total claviculectomy was
for relief of neurovascular compression in the shoulder
girdle, later referred to as the thoracic outlet syndrome.
It came in part from the work of Fraser B. Gurd (1947),
who described several bones in the body, including the
clavicle, that could be removed without functional im-
pairment. Irving Wright, whose interest in the field has
been well documented (1945), encouraged the senior
author (J.L.) to develop the operation of total claviculec-
tomy, removal of the periosteum, and section of the
scalenus anticus muscle in patients with compression
syndromes unresponsive to conscientious conservative
therapy. (Lord, 1953).
Partial claviculectomy has been recommended for ex-
posure of the subclavian vessels by Elkin and Cooper
(1946), Shumacker (1947), and recently by Aziz and
associates (1986). This procedure has a potential for
complications. We resected the middle two-fourths of the
clavicle with relief of neurovascular compression in two
patients only to have complaints of "lightning-like" pain
down the arms when the shoulders were hunched for-
ward, causing the inner end of the lateral fragment to
impinge on the brachial plexus. Relief followed total
claviculectomy with removal of the periosteum.
In recent years, transaxillary resection of the first rib,
developed by Roos and Owens in 1966, has been the
procedure favored by many surgeons to relieve symptoms
due to pressure on the brachial plexus (thoracic outlet
s y n d r o m e ) (Miller, 1 9 8 1 ; Urschel and Razzuk, 1972,
1986, 1995, 1998). Other approaches for first rib resec-
tion include supraclavicular, posterior (thoracoplasty), or
combined (supraclavicular and thoracoplasty). It should
be emphasized that for the occasional operator, total
claviculectomy combined with scalenectomy is the safest
surgical approach (Lord and Urschel, 1988).
Following the initial success of total claviculectomy as
the preferred treatment for intractable thoracic outlet
syndrome in the early 1950s, excellent functional result
and adequate cosmetic appearance have justified its use
for other problems involving the clavicle and shoulder.
To know that one does not lose significant shoulder
function by resection of the clavicle on one side is valu-
able, but to know that if both clavicles are resected, the
patient is not significantly debilitated is even more help-
ful when planning any kind of treatment.
• REFERENCES
Aziz S, Straehley CJ, Whelan TJ Jr: Effort-related axillo-subclavian vein
thrombosis: A new theory of pathogenesis and a plea for direct
surgical intervention. Am J Surg 152:57, 1986.
Elkin DC, Cooper FW: Resection of the clavicle in vascular surgery. J
Bone Joint Surg 28:117, 1946.
Gurd FB: Surplus parts of the skeleton: A recommendation for the
excision of certain portions as a means of shortening the period
of disability following trauma. Am J Surg 74:705, 1947.
Lord JW Jr: Surgical management of shoulder girdle syndromes: New
operative procedures for hyperabduction, costoclavicular, cervical
rib, and scalenus anticus syndromes. Arch Surg 66:69, 1953.
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