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The Use of Biomaterials for Chest Wall Reconstruction 30 Years After Radical Surgery and Radiation
The Use of Biomaterials for Chest Wall Reconstruction 30 Years After Radical Surgery and Radiation Gaetano Rocco, MD, FRCSEd, Stefano Mori, MD, Flavio Fazioli, MD, Antonello La Rocca, MD, Nicola Martucci, MD, and Sergio Setola, MD Division of Thoracic Surgery, Department of Thoracic Surgery and Oncology, Service of Reconstructive Surgery, Service of Orthopedic Surgery, and Department of Radiodiagnostics, National Cancer Institute, Pascale Foundation, Naples, Italy
The combination of titanium plates and acellular collagen matrix was used to restore anterior chest wall integrity in a 68-year-old woman more than 30 years after a Halsted mastectomy and radiation treatment. A vertical rectus abdominis muscle flap was used for myocutaneous coverage of the reconstructed chest wall. Partial necrosis of the flap caused prolonged exposure of the collagen matrix and the titanium plates, which were then covered with a free skin graft. Long-term results were satisfactory
despite continued infection treated with vacuum-assisted closure and surgical debridement. Recently introduced materials for chest wall reconstruction may offer resilience to infection, tolerability, and stability, and their use may be contemplated when the potential for local morbidity is high.
R
wall. Prolonged vacuum-assisted closure and subsequent surgical debridement and application of dressings were necessary to control infection (Fig 3). Four months after the primary operation, a trapezius flap was rotated to cover the wound and complete flap integrity and a free skin flap was harvested from the right thigh and sutured over the donor site. The myocutaneous coverage finally showed excellent healing 6 months after operation.
eoperation and reconstruction on a previously irradiated chest wall can be challenging because of the increased risk for local morbidity. This case report challenges traditional dogma that foreign material needs to be removed in the presence of infection.
Technique A 68-year-old female patient was referred to our department for a recurrent breast carcinoma after a left Halsted procedure followed by chemoradiotherapy more than 30 years earlier (Fig 1). A previous open cholecystectomy with a Kocher incision had divided the right superior epigastric artery. Doppler ultrasonography demonstrated reduced flow in the left thoracodorsal artery and patency of the left internal thoracic artery and left superior epigastric artery. Full-thickness chest wall resection was performed, leaving a defect that measured 175 cm3. The anterolateral segments of the second and third ribs were resected and stabilized with 2 titanium plates (Synthes, Solothurn, Switzerland). The plates were tailored to duplicate the physiologic rib contour, and an acellular porcine collagen prosthesis (Permacol, Covidien, Mansfield, MA) was sutured between the 2 plates to mimic the intercostal space (Fig 2). The reconstructed chest wall was covered with a vertical left rectus abdominis myocutaneous flap. Postoperatively, the uppermost portion of the flap necrosed, thereby exposing the reconstructed chest Accepted for publication Aug 1, 2012. Address correspondence to Dr Rocco, Division of Thoracic Surgery, Department of Thoracic Surgery and Oncology, National Cancer Institute, Pascale Foundation, Via Semmola 81 80131, Naples, Italy; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2012;94:e109 –10) © 2012 by The Society of Thoracic Surgeons
Comment Biomimesis can be described as the attempt at duplicating chest wall shape once extended defects are created [1]. Chest wall restoration requires respect of the local anatomy, preservation of function, selection of adequate reconstructive materials, and the integration of multidisciplinary efforts [1]. Although biomimesis can be easily achieved during first-time operations in previously intact areas, reoperations on irradiated chest wall present several issues when a reconstructive strategy is planned. In this setting, we used a combination of cryopreserved fascia lata and stabilizing plates for repair of a lateral chest wall defect [2]. Anterior defects may require a rigid material such as methylmethacrylate or polytetrafluoroethylene, which are still used for most indications alone or in combination with titanium plates [3, 4]. However, incorporation into the host and resilience to infection play a major role in permitting restoration of chest wall integrity and function. Titanium plates, which can be contoured, are increasingly being used for the structural
Dr Rocco discloses a financial relationship with Synthes.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.08.029
e110
HOW TO DO IT ROCCO ET AL BIOMATERIALS FOR CHEST WALL RECONSTRUCTION
Ann Thorac Surg 2012;94:e109 –10
Fig 1. (A, B) Chest computed tomographic views demonstrating the recurrence of breast cancer (arrows) after radical mastectomy and radiation in 1979.
Fig 2. (A) Intraoperative view of the titanium plate and acellular collagen matrix reconstruction. (B) Postoperative computed tomographic scan showing the lack of pulmonary volume loss and the adaptation to the chest wall contour with an acceptable outcome.
Fig 3. (A) Chest roentgenogram showing satisfactory result despite the partial failure of the vertical right rectus abdominis myocutaneous flap. (B) Failure of the flap is shown by 3-dimensional processing with volume rendering with opacity curve values set to enhance soft tissue.
repair of chest wall defects; their combination with acellular collagen matrix, which fills the gaps between the titanium plates, contributes to stability and incorporation of the repair into surrounding native tissue [5, 6]. This single case report suggests that infection can be controlled without the need to remove hardware in the presence of titanium plates and acellular collagen matrix [7]. As an alternative, cryopreserved homografts can decisively contribute to achieve biomimesis even when used in combination with other reconstructive materials [8].
References 1. Rocco G. Chest wall resection and reconstruction according to the principles of biomimesis. Semin Thorac Cardiovasc Surg 2011;23:307–13. 2. Rocco G, Fazioli F, Cerra R, Salvi R. Composite reconstruction with cryopreserved fascia lata, single mandibular titanium plate, and polyglactin mesh after redo surgery and radiation
3.
4. 5.
6. 7. 8.
therapy for recurrent chest wall liposarcoma. J Thorac Cardiovasc Surg 2011;141:839 – 40. Berthet JP, Canaud L, D’Annoville T, Alric P, Marty-Ane CH. Titanium plates and Dualmesh: a modern combination for reconstructing very large chest wall defects. Ann Thorac Surg 2011;91:1709 –16. Lee TY, Estrera AL, Safi HJ, Khalil KG. Total sternal reconstruction using a titanium plate-supported methylmethacrylate sandwich. Ann Thorac Surg 2007;84:664 – 6. Rocco G, Fazioli F, La Manna C, et al. Omental flap and titanium plates provide structural stability and protection of the mediastinum after extensive sternocostal resection. Ann Thorac Surg 2010;90:e14 – 6. Iarussi T, Pardolesi A, Camplese P, Sacco R. Composite chest wall reconstruction using titanium plates and mesh preserves chest wall function. J Thorac Cardiovasc Surg 2010;140:476 –7. Rocco G, Serra L, Fazioli F, Mori S, et al. The use of Veritas collagen matrix to reconstruct the posterior chest wall after costovertebrectomy. Ann Thorac Surg 2011;92:e17– 8. Rocco G, Fazioli F, Scognamiglio F, et al. The combination of multiple materials in the creation of an artificial anterior chest cage after extensive demolition for recurrent chondrosarcoma. J Thorac Cardiovasc Surg 2007;133:1112– 4.
The combination of titanium plates and acellular collagen matrix was used to restore anterior chest wall integrity in a 68-year-old woman more than 30 years after a Halsted mastectomy and radiation treatment. A vertical rectus abdominis muscle flap was used for myocutaneous coverage of the reconstructed chest wall. Partial necrosis of the flap caused prolonged exposure of the collagen matrix and the titanium plates, which were then covered with a free skin graft. Long-term results were satisfactory
despite continued infection treated with vacuum-assisted closure and surgical debridement. Recently introduced materials for chest wall reconstruction may offer resilience to infection, tolerability, and stability, and their use may be contemplated when the potential for local morbidity is high.
R
wall. Prolonged vacuum-assisted closure and subsequent surgical debridement and application of dressings were necessary to control infection (Fig 3). Four months after the primary operation, a trapezius flap was rotated to cover the wound and complete flap integrity and a free skin flap was harvested from the right thigh and sutured over the donor site. The myocutaneous coverage finally showed excellent healing 6 months after operation.
eoperation and reconstruction on a previously irradiated chest wall can be challenging because of the increased risk for local morbidity. This case report challenges traditional dogma that foreign material needs to be removed in the presence of infection.
Technique A 68-year-old female patient was referred to our department for a recurrent breast carcinoma after a left Halsted procedure followed by chemoradiotherapy more than 30 years earlier (Fig 1). A previous open cholecystectomy with a Kocher incision had divided the right superior epigastric artery. Doppler ultrasonography demonstrated reduced flow in the left thoracodorsal artery and patency of the left internal thoracic artery and left superior epigastric artery. Full-thickness chest wall resection was performed, leaving a defect that measured 175 cm3. The anterolateral segments of the second and third ribs were resected and stabilized with 2 titanium plates (Synthes, Solothurn, Switzerland). The plates were tailored to duplicate the physiologic rib contour, and an acellular porcine collagen prosthesis (Permacol, Covidien, Mansfield, MA) was sutured between the 2 plates to mimic the intercostal space (Fig 2). The reconstructed chest wall was covered with a vertical left rectus abdominis myocutaneous flap. Postoperatively, the uppermost portion of the flap necrosed, thereby exposing the reconstructed chest Accepted for publication Aug 1, 2012. Address correspondence to Dr Rocco, Division of Thoracic Surgery, Department of Thoracic Surgery and Oncology, National Cancer Institute, Pascale Foundation, Via Semmola 81 80131, Naples, Italy; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
(Ann Thorac Surg 2012;94:e109 –10) © 2012 by The Society of Thoracic Surgeons
Comment Biomimesis can be described as the attempt at duplicating chest wall shape once extended defects are created [1]. Chest wall restoration requires respect of the local anatomy, preservation of function, selection of adequate reconstructive materials, and the integration of multidisciplinary efforts [1]. Although biomimesis can be easily achieved during first-time operations in previously intact areas, reoperations on irradiated chest wall present several issues when a reconstructive strategy is planned. In this setting, we used a combination of cryopreserved fascia lata and stabilizing plates for repair of a lateral chest wall defect [2]. Anterior defects may require a rigid material such as methylmethacrylate or polytetrafluoroethylene, which are still used for most indications alone or in combination with titanium plates [3, 4]. However, incorporation into the host and resilience to infection play a major role in permitting restoration of chest wall integrity and function. Titanium plates, which can be contoured, are increasingly being used for the structural
Dr Rocco discloses a financial relationship with Synthes.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.08.029
e110
HOW TO DO IT ROCCO ET AL BIOMATERIALS FOR CHEST WALL RECONSTRUCTION
Ann Thorac Surg 2012;94:e109 –10
Fig 1. (A, B) Chest computed tomographic views demonstrating the recurrence of breast cancer (arrows) after radical mastectomy and radiation in 1979.
Fig 2. (A) Intraoperative view of the titanium plate and acellular collagen matrix reconstruction. (B) Postoperative computed tomographic scan showing the lack of pulmonary volume loss and the adaptation to the chest wall contour with an acceptable outcome.
Fig 3. (A) Chest roentgenogram showing satisfactory result despite the partial failure of the vertical right rectus abdominis myocutaneous flap. (B) Failure of the flap is shown by 3-dimensional processing with volume rendering with opacity curve values set to enhance soft tissue.
repair of chest wall defects; their combination with acellular collagen matrix, which fills the gaps between the titanium plates, contributes to stability and incorporation of the repair into surrounding native tissue [5, 6]. This single case report suggests that infection can be controlled without the need to remove hardware in the presence of titanium plates and acellular collagen matrix [7]. As an alternative, cryopreserved homografts can decisively contribute to achieve biomimesis even when used in combination with other reconstructive materials [8].
References 1. Rocco G. Chest wall resection and reconstruction according to the principles of biomimesis. Semin Thorac Cardiovasc Surg 2011;23:307–13. 2. Rocco G, Fazioli F, Cerra R, Salvi R. Composite reconstruction with cryopreserved fascia lata, single mandibular titanium plate, and polyglactin mesh after redo surgery and radiation
3.
4. 5.
6. 7. 8.
therapy for recurrent chest wall liposarcoma. J Thorac Cardiovasc Surg 2011;141:839 – 40. Berthet JP, Canaud L, D’Annoville T, Alric P, Marty-Ane CH. Titanium plates and Dualmesh: a modern combination for reconstructing very large chest wall defects. Ann Thorac Surg 2011;91:1709 –16. Lee TY, Estrera AL, Safi HJ, Khalil KG. Total sternal reconstruction using a titanium plate-supported methylmethacrylate sandwich. Ann Thorac Surg 2007;84:664 – 6. Rocco G, Fazioli F, La Manna C, et al. Omental flap and titanium plates provide structural stability and protection of the mediastinum after extensive sternocostal resection. Ann Thorac Surg 2010;90:e14 – 6. Iarussi T, Pardolesi A, Camplese P, Sacco R. Composite chest wall reconstruction using titanium plates and mesh preserves chest wall function. J Thorac Cardiovasc Surg 2010;140:476 –7. Rocco G, Serra L, Fazioli F, Mori S, et al. The use of Veritas collagen matrix to reconstruct the posterior chest wall after costovertebrectomy. Ann Thorac Surg 2011;92:e17– 8. Rocco G, Fazioli F, Scognamiglio F, et al. The combination of multiple materials in the creation of an artificial anterior chest cage after extensive demolition for recurrent chondrosarcoma. J Thorac Cardiovasc Surg 2007;133:1112– 4.