A brief description about chest wall defects and their reconstruction for plastic surgery residents

1. CHEST WALL
DEFECTS AND THEIR
RECONSTRUCTION
DR G SWAMY VIVEK
SENIOR RESIDENT
DEPT OF PLASTIC SURGERY
GMCH, GUWAHATI

3. HISTORY
 Tansini is credited with the first latissimus dorsi flap for reconstruction of a
mastectomy defect in 1896.
 Arnold and Pairolero in the 1970s and 1980s made substantial
contributions using several muscle flaps (including the external oblique,
pectoralis major, and latissimus dorsi) and omentum for chest wall
reconstruction.

4. CHEST WALL ANATOMY AND
FUNCTION
 Chest wall consists of muscle, cartilage and bone arranged in conical
fashion and consisting of an apex and base.

6.  The junction of the first thoracic vertebrae, the first ribs, and the
manubrium forms the apex or "thoracic outlet.“
 The base is formed by the diaphragm and its attachments to the inferior
ribs, the xiphoid process, and the spine.
 The anterior surface of the chest wall consists of the sternum and its
cartilaginous attachments to the anterior ribs.
 The chest wall is connected to the upper extremities anteriorly via the
sternoclavicular joint and posteriorly through the soft tissue attachments
of the scapulae.

7.  The arterial supply to the chest wall consists primarily of paired intercostal
arteries that originate from the aorta posteriorly, run through the
intercostal spaces, and join the internal mammary arteries.
 The secondary arterial supply originates from the subclavian and axillary
arteries via thoracoacromial, lateral thoracic, and thoracodorsal branches.
 The venous drainage parallels the arterial supply, however, in the posterior
mediastinum the intercostal veins terminate in the azygous system.

8.  Paired intercostal nerves corresponding to the anterior rami of the T1 to
T11 thoracic nerves travel with the neurovascular bundles in the intercostal
spaces and provide motor innervation to the intercostal muscles as well as
sensation to the overlying skin

9. FUNCTIONS OF CHEST WALL
 (1) sturdy protection of the thoracic viscera;
 (2) assistance with respiratory function via muscular contraction and
structural stability;
 (3) symmetric attachment of the upper extremity musculature and
stabilization of the shoulder joint; and
 (4) symmetric attachment of the breasts.

10. ETIOLOGY OF CHEST WALL DEFECTS
 Trauma
 Tumor
 Infection
 Radiation
 Congenital

11. TRAUMA TO CHEST WALL
 Fractures of three adjacent ribs in two or more places may result in a flail
chest and paradoxical motion, and may lead to respiratory compromise.
 Blast and electrical injuries may induce zones of injury not immediately
apparent in the acute setting and require close cardiac and respiratory
monitoring.

12. TREATMENT
 After stabilization of life-threatening injuries, patients with flail chest may
require operative stabilization of rib fractures.
 While the mainstay treatment of rib fractures is nonoperative, rib plating
systems are currently available for the stabilization of rib fractures in a flail
chest segment.
 Rigid fixation systems contain a standard plate and screws, as well as
intramedullary rods.
 In traumatic wounds, coverage after debridement of nonviable tissues is
approached similarly to infections and tumor defects.

15. TUMORS OF CHEST WALL
 Primary malignancies of the chest wall may be classified into eight main categories:
 muscular,
 vascular,
 fibrous and fibrohistiocytic,
 peripheral nerve,
 osseous and cartilaginous,
 adipose,
 hematologic, and
 cutaneous.
 The diversity of malignancies and attendant surgical extirpation may result in significant
defects. Reconstruction must also take into account postoperative oncologic therapy
such as radiation.

16. TREATMENT
 After extirpation of the tumor, the dimensions and components of the
chest wall requiring reconstruction are evaluated.
 Restoration of pleural cavity integrity as well as protection of intrathoracic
structures may be required.
 Defects involving four or more ribs or greater than 5cm in diameter require
skeletal reconstruction.

17.  An option for skeletal reconstruction includes the so-called
methylmethacrylate and synthetic mesh "sandwich." The
methylmethacrylate is molded into the desired shape of the defect, and
Marlex or Prolene mesh is placed on each side of the construct and
sutured together. The methylmethacrylate and mesh sandwich can be
sutured to the surrounding structures.
 Some patients experience pain with respiration since the
methylmethacrylate is much more rigid than the chest wall.
 This method of skeletal reconstruction provides protection to the
underlying cardiac and pulmonary structures and can be used for even
large defects in tandem with soft tissue flaps

19.  Posterior and superior chest wall defects may not affect ventilation as
much as anterior defects. In these cases, skeletal reconstruction may not
be necessary; therefore, a variety of other products, both synthetic and
biologic, may be appropriate.
 Synthetic products such as Gore-Tex, Marlex, and Prolene mesh may be
used for smaller lateral defects.
 Biological products, such as human allograft dermis and xenograft dermis,
offer other options for reconstruction where rigid stability is not
mandatory.

20. INFECTIONS OF CHEST WALL AND
THORAX
 Empyema and Bronchopleural Fistula
 A bronchopleural fistula and pleural empyema (pus in the pleural cavity)
are complications of pneumonectomy that carry significant morbidity and
mortality.
 As a first step, drainage of the infectious empyema is performed, and
depending on its severity, may necessitate a delay in the reconstruction.

21. TREATMENT
 Eloesser Flap.
 The Eloesser flap, originally described in 1935 for the drainage of
tuberculous empyemas, externalizes the empyema.
 A 2-inch random-patterned fasciocutanous flap is created on the chest
wall at the level of the empyema, a segment of rib is resected, and the flap
is sewn to the pleural lining.
 This allows for continual drainage of the empyema.

24.  Clagett Procedure.
 The clagett procedure involves creation of a window thoracotomy and the
packing of the wound with antibiotic-soaked dressings that are changed
every 48 hours.
 Once the pleural space contains healthy granulation tissue, the cavity is
completely filled with antibiotic solution and the chest wall is closed in
layers.

25.  Thoracoplasty.
 Obliteration of the pleural space is necessary if the remaining lung does
not fill the hemithorax.
 A postpneumonectomy syndrome of tracheal deviation, inspiratory stridor,
and exertional dyspnea may develop.
 While this procedure addressed the dead space from the pneumonectomy,
it was quite morbid and disfiguring.

26. Flap Transposition.
 Regional flap transposition is the preferred method to fill intrathroacic
dead space and to patch a bronchial stump.
 To seal off bronchopleural fistula, extrathoracic flaps are transposed
through a second thoracotomy and sewn to the bronchial stump.
 Often a 7 to 10cm segment of rib will require resection to allow passage
of the flap into the pleural space.

27. Adult Sternal Wounds
 The incidence of sternal wound infections is on the order of 0.4% to 5% of
all sternotomies performed.
 There is an increased risk of sternotomy infections associated with internal
mammary artery (IMA) harvest, diabetes mellitus, and multiple
reoperations.
 The risk of mediastinitis is particularly high when both internal mammary
arteries are harvested for coronary artery bypass grafting.
 This occurs because the sternum does not contain separate nutrient
vessels and relies solely on the segmental sternal branches of the IMA to
supply the periosteal plexus for its nutrients.
 When both IMAs are used, the sternal vascularity is decreased significantly
and is vulnerable to nonunion and infection.

28. CLASSIFICATION OF STERNAL
WOUNDS
 Class 1 infections: occur 1 to 3 days postoperatively and are manifested by
serous drainage, cultures are sterile.
 Class 2 infections: occur 1 to 3 weeks postoperatively are manifested by
purulent mediastinitis, cultures are positive for bacterial pathogens.
 Class 3 infections: occur months to years after initial surgery , are
manifested by a chronic draining sinus tract, cultures are positive for
pathogens.

29. Treatment
 Initial treatment consists of debridement.
 Class 1 infection re-wiring of the sternum.
 Class 2 and 3 infections require a thorough debridement, antibiotics, and
flap coverage.
 While it may be common to perform multiple debridements of the wound
prior to flap coverage it has been shown that a single-stage radical
debridement and concomitant flap coverage has a similar success rate.

30.  Negative pressure wound therapy has provided another treatment
modality for sternal wounds

31. Pediatric Sternal Wounds
 Pediatric sternal wounds present some subtle differences.
 While the debridement of the wound should be thorough, excessive debridement of
the sternum and the costal cartilages should be avoided.
 Since ossification of the skeletal structures is not complete in a young pediatric patient,
over-resection of these structures may occur.
 Second, the pectoralis major muscle is smaller relative to the size of the patient and will
definitely not reach the lower half of the sternum.
 Furthermore, deviation of a pectoralis flap in a female patient may damage the
developing breast and inhibit breast development in the future.
 Finally, the pediatric omentum is thin and may not provide adequate bulk for sternal
coverage.
 The rectus abdominis muscle is a better option, especially in infants since this muscle is
relatively wide, thin, and long.

32. Congenital Chest Wall Defects
 Pectus Carinatum
 Pectus carinatum is a protrusion of the sternum secondary to a deformity
of the costal cartilages.
 Pectus Excavatum
 Pectus excavatum, a concavity of the sternum and adjacent costal
cartilages.

33. TREATMENT
 Indications for surgical correction of pectus deformities include
cardiopulmonary impairment and progression of the deformity with age.
 Correction of pectus carinatum involves bilateral resection of deformed
costal cartilages, osteotomy, and repositioning of the sternum with re
approximation of the distal sternum to the xyphoid.
 The pectoralis major muscles are reapproximated over the sternoplasty.
 A variation of this procedure, including pectoralis muscle splitting without
detachment, cartilage resection with bioabsorbable plating, and
postoperative external compression splinting has been described

35. TREATMENT
 Two options for surgical correction of pectus excavatum have been
described:
 In the "open" Ravitch procedure, deformed cartilages are removed, the
xyphosternal articulation is divided, and a transverse osteotomy of the
sternum is performed at the superior limit of the deformity. The corrected
position is maintained using autologous or synthetic mesh support.
 In the closed Nuss procedure, a convex metal bar is introduced under
thoracoscopic guidance across the chest in a substernal tunnel and rotated
to force the sternum anteriorly, the bar is left in place upto 5 years.

37. Poland Syndrome
 Poland syndrome is a rare condition occurring in 1:16,500 births as a
constellation of symptoms, including hypoplasia of the pectoralis major,
hypoplasia of the bone and cartilage of the ipsilateral upper extremity and
trunk, as well as hypoplasia/agenesis of the latissimus dorsi.
 In addition, hypoplasia or absence of the breast and nipple may be
present

39. Treatment.
 Reconstruction of the male chest has been described using customized
silicone implants.
 Reconstruction of the female breast is dependent upon the degree of
breast hypoplasia.
 An algorithm developed by Freitas et al., in 2007 suggests
 Use of silicone prosthetics versus tissue expander for mild cases.
 Use of silicone prosthetics for severe cases.
 use of implant/latissimus dorsi myocutaneous flap reconstruction for more
severe cases involving hypoplastic pectoralis muscle.

40.  The latissimus dorsi muscle flap helps recreate the anterior axillary fold,
which is deficient in these patients and is difficult to reconstruct otherwise.
 In the event of hypoplasia or absence of the latissimus dorsi muscle, free
tissue transfer techniques may be employed, including perforator flaps.
 More recently, fat transfer techniques have been applied to the correction
of the female breast deformity in Poland syndrome.

41. FLAP COVERAGE FOR CHEST WALL
RECONSTRUCTION

43. PECTORALIS MAJOR FLAP
 The pectoralis major muscle inserts onto the proximal Humerus and is
attached broadly to the anterior chest wall from the clavicle and ribs one
through six.
 It receives blood supply from the thoracoacromial vessels, branches of the
lateral thoracic artery, and from perforators of the internal mammary and
intercostal arteries.
 Motor innervation is from the medial and lateral pectoral nerves.
 The pectoralis major flap is the workhorse flap for sternal reconstruction
due to its Close proximity.
 This flap is commonly based on the thoracoacromial artery and rotated
toward the sternotomy defect.

46.  The insertion on the humerus can be divided to allow better mobilization.
 The limitation of this flap is the inability to cover the lower third of the
sternum.
 If the IMA on that side was not harvested, the pectoralis major muscle flap
can be based on the IMA perforators and used as a turnover flap, which
allows coverage of the lower sternum.
 As a turnover flap, the pectoralis major muscle can be split to provide
coverage to the superior and inferior sternum.
 For sternal dehiscence without a deep cavity, the two pectoralis major
muscles can simply be advanced to each other.

47. RECTUS ABDOMINIS MUSCLE FLAP
 The rectus abdominis muscle flap is a potential option for sternal wound
coverage.
 For the purpose of chest wall reconstruction, the flap is based on the
superior epigastric artery, a continuation of the IMA, and can provide
coverage over the lower sternum.
 A skin paddle can be harvested with the muscle in the form of a VRAM flap
or a TRAM flap if additional volume or skin coverage is needed.
 In cases where the IMA has been harvested, the flap can still be transferred
on the eighth intercostal vessels from the musculophrenic artery.
 In this scenario, the skin paddle and the distal muscle may be unreliable.

51. OMENTUM FLAP
 The omentum is a large and versatile flap for sternal wound reconstruction. An upper
laparotomy incision is needed for access into the peritoneal cavity.
 After dividing the short gastric arteries, this flap can be based on the left or right
gastroepiploic artery; however, the left gastroepiploic artery offers the greatest flap
length.
 This flap has the benefit of having a large surface area and being relatively thin, which
allows it to be easily contoured.
 lt can easily cover the entire length of the sternal wound, wrap around vascular grafts in
the chest, fill any small cavity around the wound, and even can be skin grafted.
 Previous abdominal surgery limits the use of the flap due to adhesions.
 The drawbacks of the omentum flap include a possible epigastric hernia, bowel
obstruction, bowel adhesions, and the insult of a laparotomy on a sick patient.

56. LATISSIMUS DORSI MUSCLE FLAP
 The latissimus dorsi muscle is a broad, fan-shaped muscle that has
attachments to the back along the fascia of the paraspinous muscles, and
the lumbar fascia.
 It has insertions onto the proximal humerus and is involved in adduction
and internal rotation of the arm.
 Its blood supply is from the thoracodorsal artery, which originates from the
subscapular system, as well as thoracolumbar perforators.
 Motor innervation is from the thoracodorsal nerve, which runs along with
the blood supply.

59.  The latissimus dorsi muscle flap is not the first choice of flaps for sternal
wound reconstruction, but it may be used in occasional circumstances.
 The flap is based on the thoracodorsal artery from the subscapular system.
 The flap is harvested in the lateral or prone position, necessitating position
changes during surgery.
 While the distal portion of the flap may reach the sternum, the blood supply
may be tenuous.
 The latissimus dorsi muscle flap is best reserved for coverage of lateral or
anterolateral chest wall defects.
 Donor site morbidity can include shoulder dysfunction as well as unattractive
scarring

60. SERRATUS ANTERIOR
 Serratus anterior is a thin multi-pennate muscle lying deep along
anterolateral chest wall.
 It originates from the upper 8 or 9 ribs and insert on the ventral-medial
scapula.
 It functions to stabilize the scapula and move it forward on the chest wall
such as when throwing a punch.
 It has two dominant pedicles including the lateral thoracic and
thoracodorsal arteries.
 Division of the lateral thoracic pedicle will increase the arc posteriorly, and
similarly division of the thoracodorsal will increase arc anteriorly.

62.  The muscle will reach the midline of the anterior and posterior chest.
 More commonly, however it is used for intrathoracic coverage, again
requiring rib resection.
 An osteomyocutaneous flap may be harvested by preservation of the
muscular connections with underlying ribs.
 Donor site morbidity is related to winging of the scapula and can be
avoided if muscle is harvested segmentally and inferior 3 or 4 slips are
harvested.

63. EXTERNAL OBLIQUE
 External oblique is a broad, flat muscle that originates from the lateral
lower 8 ribs and inserts onto the iliac crest and linea semilunaris.
 It easily covers anterior chest wall defects as a rotational flap and has a
segmented blood supply from posterior intercoastal arteries, which enter
the muscle at the mid axillary line.
 It functions in situ as an important strength layer of abdominal wall, and
thus its harvest tends to be a second line option when the latissimus is not
available.
 A similar flap can be made with overlying soft tissue leaving the muscle
intact as well.

65. THANK YOU