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Chest Wall Reconstruction
PLASTIC SURGICAL RECONSTRUCTION: POSSIBILITIES IN SURGICAL ONCOLOGY I1
1055-3207/97 $0.00
+ .20
CHEST WALL RECONSTRUCTION P. G. Arnold, MD, and Craig H. Johnson, MD
The need to reconstruct the chest wall usually arises out of the management of trauma, tumor (primary or recurrent), infection, or radiation injury. Many patients, approximately 25% in our practice, have multiple combinations of the aforementioned indications for chest wall reconstruction, requiring significant preoperative planning and a secondary plan for closure should initial efforts fail to achieve a healed wound. Frequently, as is the case at our institution, the thoracic surgeon and plastic surgeon work in concert to manage these problems successfully. Consideration must be given to the status of the pleural cavity, skeletal support requirements, and soft-tissue coverage. It is generally agreed that an airtight seal at the time of closure is necessary to generate an intrathoracic negative pressure. The critical first step in management of chest wall problems and ultimate reconstruction is the initial resection and dkbridement. Even the most elegant of reconstructions is doomed to failure if residual tumor or radiation damaged tissue is left behind. Our ability to achieve complete eradication of involved tissue is aided by a team approach. The extirpative surgeon can resect aggressively without compromising the wound bed owing to concerns of closure. The plastic surgeon can plan from the outset to provide abundant, vascularized tissue for wound closure. Essentially, we have progressed to the point where resection margins, especially in radiation damaged wounds, are carried out to the extent and limits of the vascular tissue available for wound healing.
From the Divisions of Plastic Surgery (PGA, CHJ) and Hand Surgery (CHJ), Mayo Clinic and Mayo Foundation, Rochester, Minnesota
SURGICAL ONCOLOGY CLINICS OF NORTH AMERICA VOLUME 6 NUMBER 1. JANUARY 1997
91
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ARNOLD & JOHNSON
HISTORY
Many of the techniques for, and principles behind, chest wall reconstruction actually have been present and within the armamentarium of the surgeon for more than 100 years. The latissimus dorsi musculocutaneous flap was described nearly 100 years in 1906 for coverage of the anterior chest wall. Intrathoracic muscle transposition for control of bronchopleural fistula was described in 1911.l Other early modalities used for reconstructive techniques included the use of fascia lata and rib grafts as struts.5,l4 In the past several decades, these techniques and modalities have been refined, and more definitive management algorithms have been developed. Adjunctive and critical care supportive measures have further enhanced our ability to manage chest wall abnormalities. The development of positive pressure ventilation in conjunction with the importance of upper airway control provides major advances in control of the physiology of the cardiorespiratory tract in the perioperative and postoperative period.6, With the advent of the first successful pneumonectomy in ,~ pulmonary surgery and chest wall resection can the early 1 9 3 0 ~major be undertaken safely. The dawn of the musculocutaneous flap has been considered one of the foremost milestones in the long history of reconstructive surgery inasmuch as before this development all reconstructive flaps were limited by a lengthwidth ratio. As such, the development and refinement of the chest wall flaps along with their relative vascular leashes provided significant advances in the reconstructive management.
STERNAL RESECTIONS
Both primary and secondary, or recurrent, malignancies can develop within the region of the sternum, requiring major resection for oncologic control. In this situation, the thoracic surgeon and plastic surgeon are presented with several areas of concern. Previous writings in the literature have suggested that the physiologic insult resulting from sternal resection has depended on the extent of the skeletal components lost. Loss of the upper sternal body and adjacent ribs was believed to provide minimal physiologic deficit. In fact, the entire sternal body, xyphoid, and adjacent ribs could be resected with minimal compromise. It was, however, believed that loss of the manubrium and upper sternal body with adjacent ribs carried with it a more significant functional impact. Our own personal experience indicates that when necessary, resection of the entire sternum, including the manubrium and adjacent costochondral junction with adjoining cartilage, can be tolerated without signifi-
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cant alteration in lifestyle. Previous studies show that the patient who has normal pulmonary function preoperatively can withstand this resection and, in general, show no significant change in postoperative pulmo.~ patients who have undergone sternal resection for nary f ~ n c t i o nOften, malignancy may have radiation therapy as adjunctive treatment, either preoperatively or postoperatively. We have found that the radiation fibrosis induced to the chest wall by the radiation treatment often provides significant structural stiffness, perhaps to reduce some of the flail condition resulting from significant rib and sternal resection. The pectoralis major muscles are well suited when attempting closure of sternal wounds after resection. The pectoralis major, mobilized on its thoracoacromial vascular leash, provides excellent coverage to defects of the anterior chest wall, particularly in the upper, central portion of the chest (Figs. 1 and 2). When the thoracoacromial neurovascular leash is preserved, the muscle remains not only viable but also functional. We prefer thoracoacromial axial perfusion over perforators of the internal mammary vessels for various reasons. When based on the internal mammary perforators, the muscles are placed at risk should a secondary midline incision be needed or should either primary or secondary surgery place the internal mammary artery at risk. Skin paddles can be designed on the pectoralis major, which are transposed easily to fill full-thickness defects of the anterior chest wall. We have not found a good solution nor a preponderance of need for structural reconstruction of the sternum. Indeed, the most significant comments from patients after wound closure after sternal resection appear to be aesthetic rather than functional, physiologic, or due to lack of wound healing. The search for the perfect solution to both the functional and aesthetic reconstruction of the midline anterior chest wall continues, but certainly pectoralis transposition has provided excellent results with respect to wound healing per se. Secondary methods of closure with anterior midline wounds include the use of rectus abdominis based on its superior epigastric artery perfusion. Omentum, transposed on the right gastroepiploic artery and veins, can be used as a salvage procedure should initial efforts with pectoralis transposition fail. Omental transposition is, however, our first choice for coverage in certain circumstances, especially radiation damaged beds and partial-thickness resections (Fig. 3). The external oblique muscle and musculocutaneous flap can provide coverage to the anterior and lateral chest wall to approximately the level of the inframammary fold. The donor site is closed in a V-Y fashion or grafted. The muscle can be split to address both diaphragmatic and chest wall defects.
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Figure 1. See legend on opposite page
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Figure 1 (Continued). A, A 23-year-old woman with one-year history of slowly enlarging mass located in the area of the right first rib and manubrium. 8, The mass clinically measures 5 x 9 cm (chondrosarcoma). C, lntraoperative specimen resection. D, Intraoperative view of chest wall defect with exposed lung. illustration continued on following page
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Figure 1 (Continued). E, Right pectoralis major mobilization. F, Two years postoperative healed wound.
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CHEST WALL
The need for reconstruction of the chest wall can present in any of the circumferential locations surrounding the thoracic cavity. Reconstructive efforts, therefore, are largely dictated by location and extent of missing elements as well as the status of the pleural cavity. With this in mind, several musculocutaneous units have been used for chest wall reconstruction. The latissimus dorsi muscle and musculocutaneous unit, based on its thoracodorsal neurovascular leash, provide some of the most reliable and durable reconstructive tissue available (Fig. 4). Nearly two thirds of the back can be transposed to the anterolateral chest with a high degree of reliability. Dorsal midline coverage of the back provides a particularly difficult problem, but often the latissimus muscle or musculocutaneous flap can be mobilized and advanced in a bilateral fashion toward the midline in order to manage these difficult problems. These problems, in our experience, usually occur as a result of neurosurgical resection for tumor. Occasionally, the trapezius muscle and myocutaneous unit have been used for coverage of dorsal upper midline chest wall wounds. It can be based on the transverse cervical branch of the thyrocervical trunk or used as a turnover flap based on paraspinal perforators. In the event of large surface area tissue demands, the serratus anterior muscle also may be carried with the latissimus dorsi on the thoracodorsal neurovascular leash to provide for extensive size requirements, but in our practice the most common use for the serratus anterior muscle is intrathoracic transposition. The decision to reconstruct the skeletal structure of the chest wall has been considered and debated for many years. It was previously believed that resection of more than a two-rib segmental unit could not be overcome by soft-tissue reconstruction alone and demanded skeletal stabilization. The decision whether to reconstruct the skeletal defect depends on the size and location of the full-thickness defect and the presence or absence of wound infection. Recent reviews at our institution spanning the past two decades have demonstrated, however, that the most common rib resection usually resulted in the loss of four ribs3 Most of these patients have not undergone reconstruction with skeletal support. Our current practice uses 2-mm-thick Gortex (W. F. Gore, Inc., Phoenix, AZ) sheeting, or Prolene (Ethicon, Inc., Sommerville, NJ) mesh, which is sutured tightly in a circumferential fashion around the skeletal defect to provide some substance of firm support. The role of the Gortex patch is not so much rigid support as it is maintenance of a watertight seal. This Gortex patch is then covered with a muscle or musculocutaneous unit to provide durable, well vascularized, thick, soft-tissue coverage (Fig. 5). Review of these patients from our institution has not demonstrated
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Figure 2. A, A 56-year-old woman with recurrent adenocarcinoma of the breast. This patient had previous breast reconstruction with transverse rectus abdominis myocutaneous flap. B, Tumor involvement of the chest wall including the 3rd to 6th ribs and the sternum necessitating a complete sternectomy. Manubrium was resected partially. C, lntraoperative specimen. D, Reconstruction of chest wall with 2-mm thin Gortex patch. E, Mobilization and coverage of Gortex patch with bilateral pectoralis major muscle transposition. illustration continued on opposite page
Figure 2 (Continued). illustration continued on following page
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Figure 2 (Continued). F, Completed wound closure in the operating room. G, Postoperative appearance of the wound at 9 months.
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any significant long-term difficulty with respect to pulmonary function, protection and maintenance of vital structures within the thoracic cage and mediastinum, or significant functional impairment with respect to activities of daily living.3,l2 Indeed, as has been stated with the sternum, the main complaint is of an aesthetic rather than functional nature. In those patients in whom infection is present and a large defect has been created in the chest wall with exposed pleural contents, consideration can be given to soft-tissue reconstruction alone. Should the specific pulmonary parameters indicate that the patient would be unduly compromised, or if the defect is larger than six ribs, consideration can be given to rib or split rib graft. We have had minimal experience with methyl methacrylate sandwich, although there have been reports of success at other centers.
INTRATHORACIC TRANSPOSITION
In the past, bronchopulmonary fistulae were commonly seen as sequellae of pneumonia in the preantibiotic era. Bronchopleural fistula usually presents as a postthoracic surgical complication, often after pulmonary resection for malignancy. Reconstructive endeavors useful for management of this difficult problem also can be used for management of patients with postpneumonectomy empyema. Current management at our institution includes reopening of the pleural space and vigorous irrigation with a jet lavage, meticulous debridement of all nonviable tissue, including fibrinous exudate and debris, and a prolonged period of open dressing changes. This often requires a prolonged stay in the intensive care unit with ventilatory support. Most patients, however, can be managed without tracheostomf; after a period of 1 to 2 weeks of frequent dressing changes, a healthy granulation bed appears within the depths of the pleural cavity, indicating timing for obliteration of the pleural space. During the initial surgical debridement, should a bronchopleural fistula be identified, the fistula is surgically closed, followed by intrathoracic muscle transposition in order to seal the repaired bronchus from the pleural space. We most often use the intrathoracic transposition of the serratus anterior muscle, usually delivered through a second thoracotomy by removing a 7- to 10-cm segment of rib at the second or third interspace so that the muscle and vascular leash can be passed through. We have found that attempts at passing the intrathoracic muscle transposition through the original thoracotomy, usually located at the unresected bed of the fifth or sixth rib, do not allow the muscle to reach the bronchus and often compromise the vascular leash. Thus, a second thoracotomy is necessary. Muscle is then tacked in circumferenText continued on page 109
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Figure 3. See legend on opposite page
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Figure 3 (Continued). A, A 58-year-old woman with radiation necrosis of the right anterior chest wall. This patient had previous right modified radical mastectomy. B, Photograph taken after radical debridement and transposition of the greater omentum. C, Postoperative dressing used for coverage of the greater omentum. D, Postoperative wound appearance at 9 months.
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Figure 4. See legend on opposite page
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Figure 4 (Continued). A, Preoperative photograph of a 74-year-old woman with residual breast carcinoma after mastectomy involving the left anterior chest wall. B, After complete resection including the 7th, 8th, and 9th ribs (defect measured 15 x 20 cm). A 2-mm Gortex patch was secured. C, Immediate postoperative appearance after closure with latissimus dorsi myocutaneous flap. D, Postoperative appearance at 14 months.
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Figure 5. A, A 41-year-old woman with enlarging mass of the right anterior chest wall. B, Biopsy revealed desmoid tumor. C, After full-thickness chest wall resection and initial suture placement for securing 2-mm Gortex patch. illustration continued on opposite page
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Figure 5 (Continued). D, Gortex patch in position. E, Mobilization of right latissimus dorsi muscle. F, Muscle secured into position. illustration continued on following page
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Figure 5 (Continued). G, Appearance of wound at time of initial closure. H a n d I,Postoperative appearance at 4 months. J, Postoperative appearance at 7 years and after augmentation mammoplasty.
tial fashion over the hilar structures of the previously resected lung to achieve a sealed closure with viable, healthy tissue protecting the suture line from the contaminated pleural space. After repeated dkbridements and dressing changes over the next 1 to 2 weeks, determination is made for the timing of the closure. Although there are certain signs and conditions that one can look for to help guide in the timing of the closure, we cannot provide any firm guidelines on which to base this decision. Indeed, we often have remarked that we are uncertain as to the number of patients that we have waited too long to close, but we clearly know those whom we have closed too early. For obliteration of the pleural space, we prefer a Clagett type closure. Other authors have written about obliteration of the pleural space with multiple transposed muscle units from the chest wall.9 Our own experience leads us to believe that there is simply inadequate muscular tissue on the chest wall to obliterate the entire pleural space. In smaller wounds or postpneumonectomy empyema situations in which the volume of the cavity is minimal, this may be possible; but when obliterating the entire pleural space, we have found the Clagett procedure as the best and least destructive to the patient. Patients are returned to the operating room, where repeat cleaning and wound inspection is performed under general anesthesia. Should there be no evidence of ongoing purulence or contamination and the bronchopleural fistula has been
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controlled, the decision is made to close (Fig. 6). Antibiotic solution is then used to obliterate the pleural space entirely. We currently use Dabs solution based on a formula of 1 L normal saline combined with 80 mg of gentamicin, 500 mg of neomycin and 1 million U of polymyxin B. One must be certain that all air has been removed from the pleural cavity. Should there be any question of this, a cross-table lateral radiograph taken upon closure of the wound is often reassuring. The wound closure itself usually involves skin and subcutaneous tissue only because these patients often have inadequate muscle to achieve a multilayered closure. We do attempt to close as much of the chest wall and chest musculature as possible before skin closure with large, nonabsorbable sutures in a watertight fashion. We then use petroleum jelly gauze along the suture line itself to achieve a watertight closure. Fine suture approximates the dermal edges, and at 4 days after the operation, the large approximating nylon or Prolene suture is removed to prevent fistulization through the skin. Our past review of this technique and management of this difficult problem reveals a long-term success rate of 75% to 80% wound healing4However, we have yet to see the long-term successful management using the Clagett procedure in the patient who has the combination of radiation and fungal infection after contamination of the pleural space.
RADIATION NECROSIS
Cancer patients who have received radiation treatments to the chest wall provide another challenging dilemma to thoracic and plastic surgeons. Although radiation therapy undoubtedly has provided much in the way of long-term survival in both primary and secondary treatment, when surrounding tissue succumbs to the effects of radiation, a significant wound problem can develop that may or may not be full thickness with respect to the chest wall. Radiation changes are ongoing and can progress to serious and even life-threatening difficulties. Considerations with respect to the irradiated wound include whether recurrent cancer is present, whether the radiation site involves partial-thckness or fullthickness loss, and whether some attempt can be made at reasonably ascertaining the boundaries of the irradiated wound, which often extend far beyond what initially appears to be the borders. An important aspect in management of these difficult problems includes complete and adequate resection of radiation damaged and nonviable tissue. Our current surgical approach is to resect virtually all tissue within the immediate area affected by the radiation that we can close safely with our transposed tissue. We prefer transposition of tissue
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from outside the irradiated field because total muscle necrosis can occur when irradiated muscles are used.2 For partial-thickness defects of the chest wall secondary to radiation injury, we prefer transposition of the greater omentum. Past reports in the literature have somewhat relegated the omentum to a secondary role for fear of the laparotomy incision required for its harvest and transposition. In the past, we have not been particularly impressed with postoperative difficulties after the upper midline incision required to mobilize and transpose the omentum. The risk of contamination of a second body cavity requires care in technique and a clean set of instruments. We actually find the omentum ideally suited for this problem, because it can cover a wide area with wellvascularized tissue. We suggest a delay of skin grafting until early granulation tissue has formed on the transposed omentum. Problems in the past have included dressing management while waiting the 72 to 96 hours required for an adequate bed to reliably accept a skin graft. Our current practice includes placement of an entire large, sterile, sticky plastic operating room drape over the entire chest wall wound (see Fig. 3C). This is used to cover a saline soaked gauze sponge that is in contact with the omentum. On the first postoperative day, the sterile drape is slit in the middle, and the dressing is changed to a Nugel (Johnson and Johnson, New Brunswick, NJ) type dressing, which is then changed on a daily basis. We have found the Nugel to provide excellent coverage and maintenance of an environment that allows proliferation of granulation tissue from the omentum, but it also is somewhat hydrophilic so that the wound does not become unduly macerated or soggy. We try to avoid prosthetic mesh if possible in the situation of radiation wounds, because many times these wounds are also colonized with bacteria. We find that most often the radiation fibrosis allows little, if any, pneumothorax to develop within the pleural space, and the lung often firmly adheres to the parietal pleura.
SUMMARY
Chest wall resection and reconstruction continue to provide a formidable challenge. Prolonged hospitalization of 2 to 3 weeks is often necessary, and patients at our institution have undergone an average of two operations to achieve final closure. However, in multiple reviews of the senior author's personal experience, 85% of patients alive 30 days after operation had a healed, asymptomatic chest wall. Most late deaths occur as a result of the underlying disease process, usually malignancy.
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Figure 6. A, A 70-year-old male patient with right empyema. The cavity has been drained, and after multiple debridements and prolonged course of dressing change, the wound is clean with a healthy granulation bed. 8,The right latissimus dorsi muscle is sutured to the inferior portion of the thoracotomy incision for partial closure. C, Wound appearance after Clagett procedure. D, Postoperative appearance of the wound at 2.5 years.
References 1. Abrashanoff: Plastiche Methode der Schiessung von Fistelgangen, welche von inneren Organen kommen. Zentralbl Chir 38:186, 1911 2. Arnold PG, Lovich SF, Pairolero PC: Muscle flaps in irradiated wounds: An account of 100 consecutive cases. Plast Reconstr Surg 93:324, 1994 3. Arnold PG, Pairolero PC: Chest wall reconstruction: An account of 500 consecutive patients. Plast Reconstr Surg 98:5, 1996 4. Arnold PG, Pairolero PC: Intrathoracic muscle flaps: A 10 year experience in the management of life threatening infections. Plast Reconstr Surg 84:92, 1989 5. Bisgard JD, Swenson SA Jr: Tumors of the sternum: Report of a case with special operative technique. Arch Surg 56:570,1948 6. Fell GE: Forced respiration. JAMA 16:325, 1891 7. Graham EA, Singer JJ: Successful removal of an entire lung for carcinoma of the bronchus. JAMA 101:1371, 1933 8. Meadows JA 111, Stauts BA, Pairolero PC, et al: Effect of resection of the sternum and manubrium in conjunction with muscle transposition on pulmonary function. Mayo Clin Proc 60:604, 1985 9. Miller JI, et al: Single stage complete muscle flap closure of the post pneumonectomy empyema space: A new method and possible solution to a disturbing complication. Ann Thorac Surg 38:227, 1984 10. O'Dwyer J: Fifty cases of croup in private practice treated by intubation of the larynx, with a description of the method and of the dangers incident thereto. NY Med Rec 32:557, 1887 11. O'Dwyer J: His methods of work on intubation; the measure of his success; the interest of both to young graduates. NY Med Rec 65:561, 1904
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12. Pairolero PC, Arnold PG: Thoracic wall defects: Surgical management of 205 consecutive patients. Mayo Clin Proc 61:557, 1986 13. Tansini I: Sopra il mio nuovo process0 di amputazione della mammella. Gazzetta Medico Italia 57:141, 1906 14. Watson WL, James AG: Fascia lata grafts for chest wall defects. J Thorac Surg 16:399, 1947
Address veprint vequests to Craig H. Johnson, MD Divisions of Plastic Surgery and Hand Surgery Mayo Clinic 200 First Street SW Rochester, MN 55905
1055-3207/97 $0.00
+ .20
CHEST WALL RECONSTRUCTION P. G. Arnold, MD, and Craig H. Johnson, MD
The need to reconstruct the chest wall usually arises out of the management of trauma, tumor (primary or recurrent), infection, or radiation injury. Many patients, approximately 25% in our practice, have multiple combinations of the aforementioned indications for chest wall reconstruction, requiring significant preoperative planning and a secondary plan for closure should initial efforts fail to achieve a healed wound. Frequently, as is the case at our institution, the thoracic surgeon and plastic surgeon work in concert to manage these problems successfully. Consideration must be given to the status of the pleural cavity, skeletal support requirements, and soft-tissue coverage. It is generally agreed that an airtight seal at the time of closure is necessary to generate an intrathoracic negative pressure. The critical first step in management of chest wall problems and ultimate reconstruction is the initial resection and dkbridement. Even the most elegant of reconstructions is doomed to failure if residual tumor or radiation damaged tissue is left behind. Our ability to achieve complete eradication of involved tissue is aided by a team approach. The extirpative surgeon can resect aggressively without compromising the wound bed owing to concerns of closure. The plastic surgeon can plan from the outset to provide abundant, vascularized tissue for wound closure. Essentially, we have progressed to the point where resection margins, especially in radiation damaged wounds, are carried out to the extent and limits of the vascular tissue available for wound healing.
From the Divisions of Plastic Surgery (PGA, CHJ) and Hand Surgery (CHJ), Mayo Clinic and Mayo Foundation, Rochester, Minnesota
SURGICAL ONCOLOGY CLINICS OF NORTH AMERICA VOLUME 6 NUMBER 1. JANUARY 1997
91
92
ARNOLD & JOHNSON
HISTORY
Many of the techniques for, and principles behind, chest wall reconstruction actually have been present and within the armamentarium of the surgeon for more than 100 years. The latissimus dorsi musculocutaneous flap was described nearly 100 years in 1906 for coverage of the anterior chest wall. Intrathoracic muscle transposition for control of bronchopleural fistula was described in 1911.l Other early modalities used for reconstructive techniques included the use of fascia lata and rib grafts as struts.5,l4 In the past several decades, these techniques and modalities have been refined, and more definitive management algorithms have been developed. Adjunctive and critical care supportive measures have further enhanced our ability to manage chest wall abnormalities. The development of positive pressure ventilation in conjunction with the importance of upper airway control provides major advances in control of the physiology of the cardiorespiratory tract in the perioperative and postoperative period.6, With the advent of the first successful pneumonectomy in ,~ pulmonary surgery and chest wall resection can the early 1 9 3 0 ~major be undertaken safely. The dawn of the musculocutaneous flap has been considered one of the foremost milestones in the long history of reconstructive surgery inasmuch as before this development all reconstructive flaps were limited by a lengthwidth ratio. As such, the development and refinement of the chest wall flaps along with their relative vascular leashes provided significant advances in the reconstructive management.
STERNAL RESECTIONS
Both primary and secondary, or recurrent, malignancies can develop within the region of the sternum, requiring major resection for oncologic control. In this situation, the thoracic surgeon and plastic surgeon are presented with several areas of concern. Previous writings in the literature have suggested that the physiologic insult resulting from sternal resection has depended on the extent of the skeletal components lost. Loss of the upper sternal body and adjacent ribs was believed to provide minimal physiologic deficit. In fact, the entire sternal body, xyphoid, and adjacent ribs could be resected with minimal compromise. It was, however, believed that loss of the manubrium and upper sternal body with adjacent ribs carried with it a more significant functional impact. Our own personal experience indicates that when necessary, resection of the entire sternum, including the manubrium and adjacent costochondral junction with adjoining cartilage, can be tolerated without signifi-
CHEST WALL RECONSTRUCTION
93
cant alteration in lifestyle. Previous studies show that the patient who has normal pulmonary function preoperatively can withstand this resection and, in general, show no significant change in postoperative pulmo.~ patients who have undergone sternal resection for nary f ~ n c t i o nOften, malignancy may have radiation therapy as adjunctive treatment, either preoperatively or postoperatively. We have found that the radiation fibrosis induced to the chest wall by the radiation treatment often provides significant structural stiffness, perhaps to reduce some of the flail condition resulting from significant rib and sternal resection. The pectoralis major muscles are well suited when attempting closure of sternal wounds after resection. The pectoralis major, mobilized on its thoracoacromial vascular leash, provides excellent coverage to defects of the anterior chest wall, particularly in the upper, central portion of the chest (Figs. 1 and 2). When the thoracoacromial neurovascular leash is preserved, the muscle remains not only viable but also functional. We prefer thoracoacromial axial perfusion over perforators of the internal mammary vessels for various reasons. When based on the internal mammary perforators, the muscles are placed at risk should a secondary midline incision be needed or should either primary or secondary surgery place the internal mammary artery at risk. Skin paddles can be designed on the pectoralis major, which are transposed easily to fill full-thickness defects of the anterior chest wall. We have not found a good solution nor a preponderance of need for structural reconstruction of the sternum. Indeed, the most significant comments from patients after wound closure after sternal resection appear to be aesthetic rather than functional, physiologic, or due to lack of wound healing. The search for the perfect solution to both the functional and aesthetic reconstruction of the midline anterior chest wall continues, but certainly pectoralis transposition has provided excellent results with respect to wound healing per se. Secondary methods of closure with anterior midline wounds include the use of rectus abdominis based on its superior epigastric artery perfusion. Omentum, transposed on the right gastroepiploic artery and veins, can be used as a salvage procedure should initial efforts with pectoralis transposition fail. Omental transposition is, however, our first choice for coverage in certain circumstances, especially radiation damaged beds and partial-thickness resections (Fig. 3). The external oblique muscle and musculocutaneous flap can provide coverage to the anterior and lateral chest wall to approximately the level of the inframammary fold. The donor site is closed in a V-Y fashion or grafted. The muscle can be split to address both diaphragmatic and chest wall defects.
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Figure 1. See legend on opposite page
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Figure 1 (Continued). A, A 23-year-old woman with one-year history of slowly enlarging mass located in the area of the right first rib and manubrium. 8, The mass clinically measures 5 x 9 cm (chondrosarcoma). C, lntraoperative specimen resection. D, Intraoperative view of chest wall defect with exposed lung. illustration continued on following page
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Figure 1 (Continued). E, Right pectoralis major mobilization. F, Two years postoperative healed wound.
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CHEST WALL
The need for reconstruction of the chest wall can present in any of the circumferential locations surrounding the thoracic cavity. Reconstructive efforts, therefore, are largely dictated by location and extent of missing elements as well as the status of the pleural cavity. With this in mind, several musculocutaneous units have been used for chest wall reconstruction. The latissimus dorsi muscle and musculocutaneous unit, based on its thoracodorsal neurovascular leash, provide some of the most reliable and durable reconstructive tissue available (Fig. 4). Nearly two thirds of the back can be transposed to the anterolateral chest with a high degree of reliability. Dorsal midline coverage of the back provides a particularly difficult problem, but often the latissimus muscle or musculocutaneous flap can be mobilized and advanced in a bilateral fashion toward the midline in order to manage these difficult problems. These problems, in our experience, usually occur as a result of neurosurgical resection for tumor. Occasionally, the trapezius muscle and myocutaneous unit have been used for coverage of dorsal upper midline chest wall wounds. It can be based on the transverse cervical branch of the thyrocervical trunk or used as a turnover flap based on paraspinal perforators. In the event of large surface area tissue demands, the serratus anterior muscle also may be carried with the latissimus dorsi on the thoracodorsal neurovascular leash to provide for extensive size requirements, but in our practice the most common use for the serratus anterior muscle is intrathoracic transposition. The decision to reconstruct the skeletal structure of the chest wall has been considered and debated for many years. It was previously believed that resection of more than a two-rib segmental unit could not be overcome by soft-tissue reconstruction alone and demanded skeletal stabilization. The decision whether to reconstruct the skeletal defect depends on the size and location of the full-thickness defect and the presence or absence of wound infection. Recent reviews at our institution spanning the past two decades have demonstrated, however, that the most common rib resection usually resulted in the loss of four ribs3 Most of these patients have not undergone reconstruction with skeletal support. Our current practice uses 2-mm-thick Gortex (W. F. Gore, Inc., Phoenix, AZ) sheeting, or Prolene (Ethicon, Inc., Sommerville, NJ) mesh, which is sutured tightly in a circumferential fashion around the skeletal defect to provide some substance of firm support. The role of the Gortex patch is not so much rigid support as it is maintenance of a watertight seal. This Gortex patch is then covered with a muscle or musculocutaneous unit to provide durable, well vascularized, thick, soft-tissue coverage (Fig. 5). Review of these patients from our institution has not demonstrated
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Figure 2. A, A 56-year-old woman with recurrent adenocarcinoma of the breast. This patient had previous breast reconstruction with transverse rectus abdominis myocutaneous flap. B, Tumor involvement of the chest wall including the 3rd to 6th ribs and the sternum necessitating a complete sternectomy. Manubrium was resected partially. C, lntraoperative specimen. D, Reconstruction of chest wall with 2-mm thin Gortex patch. E, Mobilization and coverage of Gortex patch with bilateral pectoralis major muscle transposition. illustration continued on opposite page
Figure 2 (Continued). illustration continued on following page
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Figure 2 (Continued). F, Completed wound closure in the operating room. G, Postoperative appearance of the wound at 9 months.
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any significant long-term difficulty with respect to pulmonary function, protection and maintenance of vital structures within the thoracic cage and mediastinum, or significant functional impairment with respect to activities of daily living.3,l2 Indeed, as has been stated with the sternum, the main complaint is of an aesthetic rather than functional nature. In those patients in whom infection is present and a large defect has been created in the chest wall with exposed pleural contents, consideration can be given to soft-tissue reconstruction alone. Should the specific pulmonary parameters indicate that the patient would be unduly compromised, or if the defect is larger than six ribs, consideration can be given to rib or split rib graft. We have had minimal experience with methyl methacrylate sandwich, although there have been reports of success at other centers.
INTRATHORACIC TRANSPOSITION
In the past, bronchopulmonary fistulae were commonly seen as sequellae of pneumonia in the preantibiotic era. Bronchopleural fistula usually presents as a postthoracic surgical complication, often after pulmonary resection for malignancy. Reconstructive endeavors useful for management of this difficult problem also can be used for management of patients with postpneumonectomy empyema. Current management at our institution includes reopening of the pleural space and vigorous irrigation with a jet lavage, meticulous debridement of all nonviable tissue, including fibrinous exudate and debris, and a prolonged period of open dressing changes. This often requires a prolonged stay in the intensive care unit with ventilatory support. Most patients, however, can be managed without tracheostomf; after a period of 1 to 2 weeks of frequent dressing changes, a healthy granulation bed appears within the depths of the pleural cavity, indicating timing for obliteration of the pleural space. During the initial surgical debridement, should a bronchopleural fistula be identified, the fistula is surgically closed, followed by intrathoracic muscle transposition in order to seal the repaired bronchus from the pleural space. We most often use the intrathoracic transposition of the serratus anterior muscle, usually delivered through a second thoracotomy by removing a 7- to 10-cm segment of rib at the second or third interspace so that the muscle and vascular leash can be passed through. We have found that attempts at passing the intrathoracic muscle transposition through the original thoracotomy, usually located at the unresected bed of the fifth or sixth rib, do not allow the muscle to reach the bronchus and often compromise the vascular leash. Thus, a second thoracotomy is necessary. Muscle is then tacked in circumferenText continued on page 109
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Figure 3. See legend on opposite page
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Figure 3 (Continued). A, A 58-year-old woman with radiation necrosis of the right anterior chest wall. This patient had previous right modified radical mastectomy. B, Photograph taken after radical debridement and transposition of the greater omentum. C, Postoperative dressing used for coverage of the greater omentum. D, Postoperative wound appearance at 9 months.
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Figure 4. See legend on opposite page
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Figure 4 (Continued). A, Preoperative photograph of a 74-year-old woman with residual breast carcinoma after mastectomy involving the left anterior chest wall. B, After complete resection including the 7th, 8th, and 9th ribs (defect measured 15 x 20 cm). A 2-mm Gortex patch was secured. C, Immediate postoperative appearance after closure with latissimus dorsi myocutaneous flap. D, Postoperative appearance at 14 months.
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Figure 5. A, A 41-year-old woman with enlarging mass of the right anterior chest wall. B, Biopsy revealed desmoid tumor. C, After full-thickness chest wall resection and initial suture placement for securing 2-mm Gortex patch. illustration continued on opposite page
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Figure 5 (Continued). D, Gortex patch in position. E, Mobilization of right latissimus dorsi muscle. F, Muscle secured into position. illustration continued on following page
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Figure 5 (Continued). G, Appearance of wound at time of initial closure. H a n d I,Postoperative appearance at 4 months. J, Postoperative appearance at 7 years and after augmentation mammoplasty.
tial fashion over the hilar structures of the previously resected lung to achieve a sealed closure with viable, healthy tissue protecting the suture line from the contaminated pleural space. After repeated dkbridements and dressing changes over the next 1 to 2 weeks, determination is made for the timing of the closure. Although there are certain signs and conditions that one can look for to help guide in the timing of the closure, we cannot provide any firm guidelines on which to base this decision. Indeed, we often have remarked that we are uncertain as to the number of patients that we have waited too long to close, but we clearly know those whom we have closed too early. For obliteration of the pleural space, we prefer a Clagett type closure. Other authors have written about obliteration of the pleural space with multiple transposed muscle units from the chest wall.9 Our own experience leads us to believe that there is simply inadequate muscular tissue on the chest wall to obliterate the entire pleural space. In smaller wounds or postpneumonectomy empyema situations in which the volume of the cavity is minimal, this may be possible; but when obliterating the entire pleural space, we have found the Clagett procedure as the best and least destructive to the patient. Patients are returned to the operating room, where repeat cleaning and wound inspection is performed under general anesthesia. Should there be no evidence of ongoing purulence or contamination and the bronchopleural fistula has been
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controlled, the decision is made to close (Fig. 6). Antibiotic solution is then used to obliterate the pleural space entirely. We currently use Dabs solution based on a formula of 1 L normal saline combined with 80 mg of gentamicin, 500 mg of neomycin and 1 million U of polymyxin B. One must be certain that all air has been removed from the pleural cavity. Should there be any question of this, a cross-table lateral radiograph taken upon closure of the wound is often reassuring. The wound closure itself usually involves skin and subcutaneous tissue only because these patients often have inadequate muscle to achieve a multilayered closure. We do attempt to close as much of the chest wall and chest musculature as possible before skin closure with large, nonabsorbable sutures in a watertight fashion. We then use petroleum jelly gauze along the suture line itself to achieve a watertight closure. Fine suture approximates the dermal edges, and at 4 days after the operation, the large approximating nylon or Prolene suture is removed to prevent fistulization through the skin. Our past review of this technique and management of this difficult problem reveals a long-term success rate of 75% to 80% wound healing4However, we have yet to see the long-term successful management using the Clagett procedure in the patient who has the combination of radiation and fungal infection after contamination of the pleural space.
RADIATION NECROSIS
Cancer patients who have received radiation treatments to the chest wall provide another challenging dilemma to thoracic and plastic surgeons. Although radiation therapy undoubtedly has provided much in the way of long-term survival in both primary and secondary treatment, when surrounding tissue succumbs to the effects of radiation, a significant wound problem can develop that may or may not be full thickness with respect to the chest wall. Radiation changes are ongoing and can progress to serious and even life-threatening difficulties. Considerations with respect to the irradiated wound include whether recurrent cancer is present, whether the radiation site involves partial-thckness or fullthickness loss, and whether some attempt can be made at reasonably ascertaining the boundaries of the irradiated wound, which often extend far beyond what initially appears to be the borders. An important aspect in management of these difficult problems includes complete and adequate resection of radiation damaged and nonviable tissue. Our current surgical approach is to resect virtually all tissue within the immediate area affected by the radiation that we can close safely with our transposed tissue. We prefer transposition of tissue
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from outside the irradiated field because total muscle necrosis can occur when irradiated muscles are used.2 For partial-thickness defects of the chest wall secondary to radiation injury, we prefer transposition of the greater omentum. Past reports in the literature have somewhat relegated the omentum to a secondary role for fear of the laparotomy incision required for its harvest and transposition. In the past, we have not been particularly impressed with postoperative difficulties after the upper midline incision required to mobilize and transpose the omentum. The risk of contamination of a second body cavity requires care in technique and a clean set of instruments. We actually find the omentum ideally suited for this problem, because it can cover a wide area with wellvascularized tissue. We suggest a delay of skin grafting until early granulation tissue has formed on the transposed omentum. Problems in the past have included dressing management while waiting the 72 to 96 hours required for an adequate bed to reliably accept a skin graft. Our current practice includes placement of an entire large, sterile, sticky plastic operating room drape over the entire chest wall wound (see Fig. 3C). This is used to cover a saline soaked gauze sponge that is in contact with the omentum. On the first postoperative day, the sterile drape is slit in the middle, and the dressing is changed to a Nugel (Johnson and Johnson, New Brunswick, NJ) type dressing, which is then changed on a daily basis. We have found the Nugel to provide excellent coverage and maintenance of an environment that allows proliferation of granulation tissue from the omentum, but it also is somewhat hydrophilic so that the wound does not become unduly macerated or soggy. We try to avoid prosthetic mesh if possible in the situation of radiation wounds, because many times these wounds are also colonized with bacteria. We find that most often the radiation fibrosis allows little, if any, pneumothorax to develop within the pleural space, and the lung often firmly adheres to the parietal pleura.
SUMMARY
Chest wall resection and reconstruction continue to provide a formidable challenge. Prolonged hospitalization of 2 to 3 weeks is often necessary, and patients at our institution have undergone an average of two operations to achieve final closure. However, in multiple reviews of the senior author's personal experience, 85% of patients alive 30 days after operation had a healed, asymptomatic chest wall. Most late deaths occur as a result of the underlying disease process, usually malignancy.
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Figure 6. A, A 70-year-old male patient with right empyema. The cavity has been drained, and after multiple debridements and prolonged course of dressing change, the wound is clean with a healthy granulation bed. 8,The right latissimus dorsi muscle is sutured to the inferior portion of the thoracotomy incision for partial closure. C, Wound appearance after Clagett procedure. D, Postoperative appearance of the wound at 2.5 years.
References 1. Abrashanoff: Plastiche Methode der Schiessung von Fistelgangen, welche von inneren Organen kommen. Zentralbl Chir 38:186, 1911 2. Arnold PG, Lovich SF, Pairolero PC: Muscle flaps in irradiated wounds: An account of 100 consecutive cases. Plast Reconstr Surg 93:324, 1994 3. Arnold PG, Pairolero PC: Chest wall reconstruction: An account of 500 consecutive patients. Plast Reconstr Surg 98:5, 1996 4. Arnold PG, Pairolero PC: Intrathoracic muscle flaps: A 10 year experience in the management of life threatening infections. Plast Reconstr Surg 84:92, 1989 5. Bisgard JD, Swenson SA Jr: Tumors of the sternum: Report of a case with special operative technique. Arch Surg 56:570,1948 6. Fell GE: Forced respiration. JAMA 16:325, 1891 7. Graham EA, Singer JJ: Successful removal of an entire lung for carcinoma of the bronchus. JAMA 101:1371, 1933 8. Meadows JA 111, Stauts BA, Pairolero PC, et al: Effect of resection of the sternum and manubrium in conjunction with muscle transposition on pulmonary function. Mayo Clin Proc 60:604, 1985 9. Miller JI, et al: Single stage complete muscle flap closure of the post pneumonectomy empyema space: A new method and possible solution to a disturbing complication. Ann Thorac Surg 38:227, 1984 10. O'Dwyer J: Fifty cases of croup in private practice treated by intubation of the larynx, with a description of the method and of the dangers incident thereto. NY Med Rec 32:557, 1887 11. O'Dwyer J: His methods of work on intubation; the measure of his success; the interest of both to young graduates. NY Med Rec 65:561, 1904
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12. Pairolero PC, Arnold PG: Thoracic wall defects: Surgical management of 205 consecutive patients. Mayo Clin Proc 61:557, 1986 13. Tansini I: Sopra il mio nuovo process0 di amputazione della mammella. Gazzetta Medico Italia 57:141, 1906 14. Watson WL, James AG: Fascia lata grafts for chest wall defects. J Thorac Surg 16:399, 1947
Address veprint vequests to Craig H. Johnson, MD Divisions of Plastic Surgery and Hand Surgery Mayo Clinic 200 First Street SW Rochester, MN 55905