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The use of Permacol® for chest wall reconstruction in a case of desmoid tumour resection
Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 406e408
CASE REPORT
The use of Permacol for chest wall reconstruction in a case of desmoid tumour resection Michael N. Mirzabeigi*, John H. Moore Jr, Gary A. Tuma Department of Surgery, Division of Plastic Surgery, Thomas Jefferson University Hospital, 840 Walnut Street e 15th Floor, Philadelphia, PA 19107, USA Received 24 November 2009; accepted 16 March 2010
KEYWORDS Chest wall reconstruction; Thoracic reconstruction; Permacol; Biologic materials; Desmoid tumour
Summary Desmoid tumour resection is a known, albeit rare, cause for chest wall reconstruction. Traditionally, musculocutaneous flaps and synthetic mesh materials have been employed for coverage over these potentially large thoracic defects. More recently, biologic mesh materials have become increasingly more prevalent in a multitude of surgical reconstructions. To date, the current literature describes the usage of select biologic materials, such as human cadaveric acellular dermal matrix, in chest wall reconstruction. One variation of the biologic materials, Permacol, has not been well described in the literature for chest wall reconstruction. Permacol is a porcine lyophilised acellular dermal collagen. We report the successful use of Permacol in a complex chest wall reconstruction following the resection of a large desmoid tumour. ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Case report A 39-year-old female presented with a 2-year history of pain on her left anterior chest wall. Upon primary medical consultation, it was believed that her pain, along her upper chest, was likely due to muscle strain. She began to
* Corresponding author. Tel.: þ1 412 352 1417; fax: þ1 215 625 6640. E-mail address: [email protected] (M.N. Mirzabeigi).
complain, not only of pain, but also of a mass along her first and second ribs. A biopsy of the rapidly growing mass revealed that the mass was, in fact, a low-grade spindle cell tumour compatible with desmoid fibromatosis. A wide local excision was performed by thoracic surgery with 3e4 cm margins in every direction. The excision included her first rib, second rib, left clavicle and the remaining anterior chest wall within the margins of the resection. A large defect remained, which spanned from the sternum to the anterior axillary line. A 40 cm2 Permacol (Tissue Science Laboratory, Covington, USA) patch was sewn into
1748-6815/$ - see front matter ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.03.043
The use of Permacol for chest wall reconstruction
407
place using 1/0 Polydiaxanone (PDS). Periosteal drilling was necessary to anchor the sutures. A rotational pectoralis major flap was used for coverage over the Permacol. Finally, the skin was closed over the muscle and drains. Postoperatively, the patient is doing well with a wellhealed chest; no sign of flail chest and only a mild bony deformity from her lack of clavicle. Future plans include a free fibula flap for clavicular reconstruction and fat grafting for soft tissue deformity if no recurrence is appreciated at 1 year (Figures 1e4).
Comment Desmoid tumours are rare connective-tissue tumours that can arise from fascia, aponeuroses and muscle striae. These low-grade malignant sarcomas often require large resection by the extirpative surgeon, thus leaving challenging defects for the plastic surgeon. Approximately 50% of desmoid tumours occur in the abdominal wall, whereas 8e10% occur in the chest wall. Interestingly, these tumours have been associated with a higher prevalence in young females.1,2 The need for chest wall reconstruction following the resection of a desmoid tumour has been cited in other large series of thoracic reconstructions.3,4 More common causes for chest wall reconstruction include radiation injury, infection, trauma, and various other neoplasms. The ideal thoracic reconstruction restores visceral protection and mechanic physiologic movement via an airtight seal with the pleural cavity. Common complications that follow these complex reconstructions include flail chest, paradoxical respiratory movement, pneumonia, pleural effusion, thoracic instability, infection, haematoma and seroma.5 Traditionally, local and free musculocutaneous flaps have been used for reconstruction. Unfortunately, autogenous repair with local- and free-flap coverage has been limited to the size and availability of flaps for repair. Furthermore, soft tissue flap coverage alone may provide inadequate structural support for large defects. Since the 1980s, prosthetic materials such as polypropylene mesh (PPM), polytetrafluoroethylene (PTFE) and polypropylene meshemethylmethacrylate composites have
Figure 1 Left-sided defect following resection of first rib, second rib, left clavicle, and anterior chest wall.
Figure 2 Permacol sewn into place with 1-0 Polydiaxanone (PDS): periosteal drilling was utilised to anchor the suture material.
been used as alternatives to soft tissue flaps in thoracic reconstruction.4 Prosthetic materials for musculofascial trunk defects have been met with success despite distinct disadvantages and limitations. These materials can be subject to dislocation, infection, fistula, dense scarring, erosion, cracking and bleeding. In addition, these prosthetic materials are contraindicated in cases that involve concurrent infection or require direct contact with viscera. More recently, biologic meshes have begun to replace prosthetic materials. Biologic mesh is composed of human or animal decellularised dermis that is treated such that the native collagen, extracellular matrix and basement membrane remain intact but with negligible antigenicity.6,7 Biologics are believed to be superior for thoracic reconstruction because these materials provide the necessary support in the early postoperative period. The biologic materials are then resorbed, thus alleviating the risks of a permanent prosthesis, which are unnecessary for longterm support.8 Chest wall reconstruction with human cadaveric biologic mesh, such as AlloDerm (LifeCell Corp., Branchburg, NJ, USA), has been well described in the literature. Following implantation, this biologic material is
Figure 3 A rotational pectoralis major flap providing coverage over a Permacol patch.
408
M.N. Mirzabeigi et al. transverse rectus abdominis myocutaneous (TRAM) flap donor site repair has been previously criticised for poor tissue integration, chronic inflammation and sub-acute foreign body reaction.11 Early indications suggest that Permacol is a viable alternative to human cadaveric acellular dermis in the setting of chest wall reconstruction. We suggest a prospective series comparing the efficacy of various biologic meshes in chest wall reconstruction.
Conflict of interest None.
Funding None. Figure 4 Postoperatively, the patient has a well-healed chest; no sign of flail chest and only a mild bony deformity from her lack of clavicle.
revascularised and remodelled into autologous tissue. AlloDerm has been successfully implanted in cases involving contaminated fields and direct contact with viscera.6,7 Furthermore, the AlloDermefascia interface has been demonstrated to be almost twice as strong as the syntheticefascia interface.9 Aside from human cadaveric dermis, other biologics such as bovine derivatives, collagen coated polydioxanone (CCP) mesh, and chitin fibre-reinforced polycaprolactone (CFRP) have been incorporated into the thoracic wall.8,10 For the case described in this report, a porcine lyophilised acellular dermal collagen derivative, Permacol, was implemented. Permacol retains elastin upon processing and is chemically cross-linked for strength and durability.11 Chest wall reconstruction using Permacol, particularly in conjunction with a myocutaneous flap, has not been well described in the literature. In reconstructing this large thoracic defect, we opted to use both Permacol and a pectoralis flap based on the principles of lining, support and coverage. Permacol served to provide as the in situ pleural lining, owing to the fact that biologic materials are well noted to react favourably when in direct contact with viscera. With regard to support, the pectoralis flap was employed to further strengthen the repair as well as promote revascularisation of the biologic material. Finally, the pectoralis flap served as additional soft tissue coverage to minimise contour deformity. We report the successful use of Permacol for chest wall reconstruction. The use of Permacol for coverage of
References 1. Wilcken N, Tatterall MN. Endocrine therapy of desmoids tumors. Cancer 1991;68:1384e8. 2. Brodsky JT, Gordon MS, Hajdu SI, et al. Desmoid tumors of the chest wall. A locally recurrent problem. J Thorac Cardiovasc Surg 1992;104:900e3. 3. Deschamps C, Tirnaksiz BM, Darbandi R, et al. Early and longterm results of prosthetic chest wall reconstruction. J Thorac Surg 1999;117:588e92. 4. Weyant MJ, Bains MS, Venkatraman E, et al. Results of chest wall resection and reconstruction with and without rigid prosthesis. Ann Thorac Surg 2006;81:279e85. 5. Mansour KA, Thourani VH, Losken A, et al. Chest wall resections and reconstruction: a 25-year experience. Ann Thorac Surg 2002;73:1720e6. 6. Butler CE, Langstein HN, Kronowitz SJ. Pelvic, abdominal, and chest wall reconstruction with AlloDerm in patients at increased risk for mesh-related complications. Plast Reconstr Surg 2005;116:1263e75. 7. Butler CE, Prieto VG. Reduction of adhesions with composite AlloDerm/polypropylene mesh implants for abdominal wall reconstruction. Plast Reconstr Surg 2004;114:464e73. 8. Qin X, Tang H, Xu Z, et al. Chest wall reconstruction with two types of biodegradable polymer prostheses in dogs. Eur J Cardiothorac Surg 2008;34:870e4. 9. Holton LH, Chung T, Silverman RP, et al. Comparison of acellular dermal matrix and synthetic mesh for lateral chest wall reconstruction in a rabbit model. Plast Reconstr Surg 2007; 119:1238e46. 10. Wiegmann B, Zardo P, Dickgreber N, et al. Biological materials in chest wall reconstruction: initial experience with peri-guard repair patch. Eur J Cardiothorac Surg; 2009 [Epub ahead of print]. 11. Otterburn D, Losken A. The use of porcine acellular dermal material for TRAM flap donor-site closure. Plast Reconstr Surg 2009;123:74ee76e.
CASE REPORT
The use of Permacol for chest wall reconstruction in a case of desmoid tumour resection Michael N. Mirzabeigi*, John H. Moore Jr, Gary A. Tuma Department of Surgery, Division of Plastic Surgery, Thomas Jefferson University Hospital, 840 Walnut Street e 15th Floor, Philadelphia, PA 19107, USA Received 24 November 2009; accepted 16 March 2010
KEYWORDS Chest wall reconstruction; Thoracic reconstruction; Permacol; Biologic materials; Desmoid tumour
Summary Desmoid tumour resection is a known, albeit rare, cause for chest wall reconstruction. Traditionally, musculocutaneous flaps and synthetic mesh materials have been employed for coverage over these potentially large thoracic defects. More recently, biologic mesh materials have become increasingly more prevalent in a multitude of surgical reconstructions. To date, the current literature describes the usage of select biologic materials, such as human cadaveric acellular dermal matrix, in chest wall reconstruction. One variation of the biologic materials, Permacol, has not been well described in the literature for chest wall reconstruction. Permacol is a porcine lyophilised acellular dermal collagen. We report the successful use of Permacol in a complex chest wall reconstruction following the resection of a large desmoid tumour. ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Case report A 39-year-old female presented with a 2-year history of pain on her left anterior chest wall. Upon primary medical consultation, it was believed that her pain, along her upper chest, was likely due to muscle strain. She began to
* Corresponding author. Tel.: þ1 412 352 1417; fax: þ1 215 625 6640. E-mail address: [email protected] (M.N. Mirzabeigi).
complain, not only of pain, but also of a mass along her first and second ribs. A biopsy of the rapidly growing mass revealed that the mass was, in fact, a low-grade spindle cell tumour compatible with desmoid fibromatosis. A wide local excision was performed by thoracic surgery with 3e4 cm margins in every direction. The excision included her first rib, second rib, left clavicle and the remaining anterior chest wall within the margins of the resection. A large defect remained, which spanned from the sternum to the anterior axillary line. A 40 cm2 Permacol (Tissue Science Laboratory, Covington, USA) patch was sewn into
1748-6815/$ - see front matter ª 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2010.03.043
The use of Permacol for chest wall reconstruction
407
place using 1/0 Polydiaxanone (PDS). Periosteal drilling was necessary to anchor the sutures. A rotational pectoralis major flap was used for coverage over the Permacol. Finally, the skin was closed over the muscle and drains. Postoperatively, the patient is doing well with a wellhealed chest; no sign of flail chest and only a mild bony deformity from her lack of clavicle. Future plans include a free fibula flap for clavicular reconstruction and fat grafting for soft tissue deformity if no recurrence is appreciated at 1 year (Figures 1e4).
Comment Desmoid tumours are rare connective-tissue tumours that can arise from fascia, aponeuroses and muscle striae. These low-grade malignant sarcomas often require large resection by the extirpative surgeon, thus leaving challenging defects for the plastic surgeon. Approximately 50% of desmoid tumours occur in the abdominal wall, whereas 8e10% occur in the chest wall. Interestingly, these tumours have been associated with a higher prevalence in young females.1,2 The need for chest wall reconstruction following the resection of a desmoid tumour has been cited in other large series of thoracic reconstructions.3,4 More common causes for chest wall reconstruction include radiation injury, infection, trauma, and various other neoplasms. The ideal thoracic reconstruction restores visceral protection and mechanic physiologic movement via an airtight seal with the pleural cavity. Common complications that follow these complex reconstructions include flail chest, paradoxical respiratory movement, pneumonia, pleural effusion, thoracic instability, infection, haematoma and seroma.5 Traditionally, local and free musculocutaneous flaps have been used for reconstruction. Unfortunately, autogenous repair with local- and free-flap coverage has been limited to the size and availability of flaps for repair. Furthermore, soft tissue flap coverage alone may provide inadequate structural support for large defects. Since the 1980s, prosthetic materials such as polypropylene mesh (PPM), polytetrafluoroethylene (PTFE) and polypropylene meshemethylmethacrylate composites have
Figure 1 Left-sided defect following resection of first rib, second rib, left clavicle, and anterior chest wall.
Figure 2 Permacol sewn into place with 1-0 Polydiaxanone (PDS): periosteal drilling was utilised to anchor the suture material.
been used as alternatives to soft tissue flaps in thoracic reconstruction.4 Prosthetic materials for musculofascial trunk defects have been met with success despite distinct disadvantages and limitations. These materials can be subject to dislocation, infection, fistula, dense scarring, erosion, cracking and bleeding. In addition, these prosthetic materials are contraindicated in cases that involve concurrent infection or require direct contact with viscera. More recently, biologic meshes have begun to replace prosthetic materials. Biologic mesh is composed of human or animal decellularised dermis that is treated such that the native collagen, extracellular matrix and basement membrane remain intact but with negligible antigenicity.6,7 Biologics are believed to be superior for thoracic reconstruction because these materials provide the necessary support in the early postoperative period. The biologic materials are then resorbed, thus alleviating the risks of a permanent prosthesis, which are unnecessary for longterm support.8 Chest wall reconstruction with human cadaveric biologic mesh, such as AlloDerm (LifeCell Corp., Branchburg, NJ, USA), has been well described in the literature. Following implantation, this biologic material is
Figure 3 A rotational pectoralis major flap providing coverage over a Permacol patch.
408
M.N. Mirzabeigi et al. transverse rectus abdominis myocutaneous (TRAM) flap donor site repair has been previously criticised for poor tissue integration, chronic inflammation and sub-acute foreign body reaction.11 Early indications suggest that Permacol is a viable alternative to human cadaveric acellular dermis in the setting of chest wall reconstruction. We suggest a prospective series comparing the efficacy of various biologic meshes in chest wall reconstruction.
Conflict of interest None.
Funding None. Figure 4 Postoperatively, the patient has a well-healed chest; no sign of flail chest and only a mild bony deformity from her lack of clavicle.
revascularised and remodelled into autologous tissue. AlloDerm has been successfully implanted in cases involving contaminated fields and direct contact with viscera.6,7 Furthermore, the AlloDermefascia interface has been demonstrated to be almost twice as strong as the syntheticefascia interface.9 Aside from human cadaveric dermis, other biologics such as bovine derivatives, collagen coated polydioxanone (CCP) mesh, and chitin fibre-reinforced polycaprolactone (CFRP) have been incorporated into the thoracic wall.8,10 For the case described in this report, a porcine lyophilised acellular dermal collagen derivative, Permacol, was implemented. Permacol retains elastin upon processing and is chemically cross-linked for strength and durability.11 Chest wall reconstruction using Permacol, particularly in conjunction with a myocutaneous flap, has not been well described in the literature. In reconstructing this large thoracic defect, we opted to use both Permacol and a pectoralis flap based on the principles of lining, support and coverage. Permacol served to provide as the in situ pleural lining, owing to the fact that biologic materials are well noted to react favourably when in direct contact with viscera. With regard to support, the pectoralis flap was employed to further strengthen the repair as well as promote revascularisation of the biologic material. Finally, the pectoralis flap served as additional soft tissue coverage to minimise contour deformity. We report the successful use of Permacol for chest wall reconstruction. The use of Permacol for coverage of
References 1. Wilcken N, Tatterall MN. Endocrine therapy of desmoids tumors. Cancer 1991;68:1384e8. 2. Brodsky JT, Gordon MS, Hajdu SI, et al. Desmoid tumors of the chest wall. A locally recurrent problem. J Thorac Cardiovasc Surg 1992;104:900e3. 3. Deschamps C, Tirnaksiz BM, Darbandi R, et al. Early and longterm results of prosthetic chest wall reconstruction. J Thorac Surg 1999;117:588e92. 4. Weyant MJ, Bains MS, Venkatraman E, et al. Results of chest wall resection and reconstruction with and without rigid prosthesis. Ann Thorac Surg 2006;81:279e85. 5. Mansour KA, Thourani VH, Losken A, et al. Chest wall resections and reconstruction: a 25-year experience. Ann Thorac Surg 2002;73:1720e6. 6. Butler CE, Langstein HN, Kronowitz SJ. Pelvic, abdominal, and chest wall reconstruction with AlloDerm in patients at increased risk for mesh-related complications. Plast Reconstr Surg 2005;116:1263e75. 7. Butler CE, Prieto VG. Reduction of adhesions with composite AlloDerm/polypropylene mesh implants for abdominal wall reconstruction. Plast Reconstr Surg 2004;114:464e73. 8. Qin X, Tang H, Xu Z, et al. Chest wall reconstruction with two types of biodegradable polymer prostheses in dogs. Eur J Cardiothorac Surg 2008;34:870e4. 9. Holton LH, Chung T, Silverman RP, et al. Comparison of acellular dermal matrix and synthetic mesh for lateral chest wall reconstruction in a rabbit model. Plast Reconstr Surg 2007; 119:1238e46. 10. Wiegmann B, Zardo P, Dickgreber N, et al. Biological materials in chest wall reconstruction: initial experience with peri-guard repair patch. Eur J Cardiothorac Surg; 2009 [Epub ahead of print]. 11. Otterburn D, Losken A. The use of porcine acellular dermal material for TRAM flap donor-site closure. Plast Reconstr Surg 2009;123:74ee76e.