Anterior Chest Wall Resection and Reconstruction

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Presentation transcript:

Anterior Chest Wall Resection and Reconstruction Gaetano Rocco, MD, FRCSEd, FETCS Operative Techniques in Thoracic and Cardiovascular Surgery Volume 18, Issue 1, Pages 32-41 (March 2013) DOI: 10.1053/j.optechstcvs.2013.02.002 Copyright © 2013 Elsevier Inc. Terms and Conditions

Figure 1 Partial-thickness resection. (A) A truncated cone is obtained while the resection is deepened down to the ribs. (B) The periosteum is removed from the ribs while the myocutaneous layers containing the tumor are elevated and divided on safe margins. Operative Techniques in Thoracic and Cardiovascular Surgery 2013 18, 32-41DOI: (10.1053/j.optechstcvs.2013.02.002) Copyright © 2013 Elsevier Inc. Terms and Conditions

Figure 2 Partial-thickness reconstruction. (A) A V–Y advancement myocutaneous flap is rotated to cover the anterior chest wall defect. The triangular skin island is based on the perforators from the underlying latissimus dorsi muscle, which is freed from the lumbosacral fascia and elevated up to the thoracodorsal pedicle. (B) If the wound can be closed primarily, only the latissimus dorsi flap is raised and tunneled to cover the anterior defect. Operative Techniques in Thoracic and Cardiovascular Surgery 2013 18, 32-41DOI: (10.1053/j.optechstcvs.2013.02.002) Copyright © 2013 Elsevier Inc. Terms and Conditions

Figure 3 Full-thickness resection. The intercostal space is entered flush to the superior edge of the uppermost rib to be removed, while the intercostal neurovascular pedicle is divided between ligatures; the costotomy is performed in line with the previous ones, making sure to keep the bone section at a safe margin from the tumor. Operative Techniques in Thoracic and Cardiovascular Surgery 2013 18, 32-41DOI: (10.1053/j.optechstcvs.2013.02.002) Copyright © 2013 Elsevier Inc. Terms and Conditions

Figure 4 Full-thickness reconstruction. (A) The defect after chest wall resection for recurrent left breast cancer after redo surgery and maximal radiation treatment. A combination of recently introduced materials is used for chest wall reconstruction. (B) An acellular collagen matrix patch is anchored to the edges of the defect. (C) In addition or alternately to the acellular collagen matrix, bridging titanium plates contoured as to mimic the anterior upper ribs can be used; the titanium plate is locked into the rib. A minimum of 3-4 screws are used on both sides to secure the plate in place. (D) A reabsorbable mesh is sutured over the titanium plates to preserve the overlying skin from friction-related damage. Operative Techniques in Thoracic and Cardiovascular Surgery 2013 18, 32-41DOI: (10.1053/j.optechstcvs.2013.02.002) Copyright © 2013 Elsevier Inc. Terms and Conditions

Figure 5 Total sternal resection. The arrow is directed toward the head of the patient. (A) A T-shaped incision is performed to gain access to the clavicles. (B) The entire sternum is elevated from the mediastinum. The manubrium is dissected free from the brachiocephalic vessels. The internal mammary pedicles are divided and the clavicles resected subperiosteally. Operative Techniques in Thoracic and Cardiovascular Surgery 2013 18, 32-41DOI: (10.1053/j.optechstcvs.2013.02.002) Copyright © 2013 Elsevier Inc. Terms and Conditions

Figure 6 Reconstruction after sternal resection with neocreated sternum (ie, iliac crest). (A) After wide re-resection, the cryopreserved homograft is shaped and fitted to replace the sternum. Two titanium screws lock the homograft into the manubrium. (B) MMM sandwiches are sutured bilaterally to cover the anterior defects on both hemithoraces. A sheet of marlex mesh is sutured to the osteomuscular chest wall as a first layer; then, the MMM is prepared and spread onto the marlex and an additional mesh is used to complete the “sandwich” and consolidate the repair. (C) Alternatively, titanium plates can be used to bridge the defect. An omental flap protects the mediastinum. Operative Techniques in Thoracic and Cardiovascular Surgery 2013 18, 32-41DOI: (10.1053/j.optechstcvs.2013.02.002) Copyright © 2013 Elsevier Inc. Terms and Conditions

Figure 7 Use of the omental wrap with titanium plates or cryopreserved homografts (ie, cryopreserved ribs) after sternectomy (see text). (A) An omental flap is raised through a limited midline laparotomy and passed behind the titanium plates to cover the mediastinum. (B) The omental flap is folded onto the titanium plates or the homograft, which is then “wrapped” into omentum. Operative Techniques in Thoracic and Cardiovascular Surgery 2013 18, 32-41DOI: (10.1053/j.optechstcvs.2013.02.002) Copyright © 2013 Elsevier Inc. Terms and Conditions

Figure 8 Reconstruction after partial sternectomy. Both pectoralis major muscles are elevated to cover the midline defect. No prostheses are needed. The medial edges of the muscles are approximated to provide solid coverage of the defect (“paletot” technique). Operative Techniques in Thoracic and Cardiovascular Surgery 2013 18, 32-41DOI: (10.1053/j.optechstcvs.2013.02.002) Copyright © 2013 Elsevier Inc. Terms and Conditions