Introduction: The repair of complex chest wall defects presents a challenging problem for the reconstructive surgeon. Technical advances, such as the use of marlex mesh and methylmethacrylate for skeletal reconstruction and microsurgical tissue transfer, allow stable coverage of extensive composite chest wall defects. While the majority of such defects may be repaired with the use of local and regional musculocutaneous flaps, more complicated cases require increasingly sophisticated reconstructive techniques. This study reviews the experience at a single cancer center with chest wall reconstruction over a decade. Based on this clinical experience, a logical approach to the reconstruction of chest wall defects is presented.
Methods: A retrospective review of medical records was undertaken for each patient who underwent chest wall reconstruction from 1992 to 2002. Patient demographics and variables including pathologic diagnosis, extent of resection, size of defect, method of reconstruction, and outcome were evaluated.
Results: There was a total of 124 patients, 95 females and 29 males. The average age was 58 years (range 19-88 years). The most common diagnoses were breast cancer and sarcoma. The average area of the chest wall defect after resection was 225 cm2. 143 musculocutaneous or muscle flaps were performed for reconstruction of the chest wall. Eleven percent of patients underwent reconstruction with autologous free tissue transfer. 117 patients underwent a single operation. Seven patients (6%) required a second operation for salvage of a complication. The most commonly utilized free musculocutaneous flap was the rectus abdominis flap (71%). The most common pedicled flaps were the vertical rectus abdominis musculocutaneous flap (32%) and the latissimus dorsi musculocutaneous flap (30%). In 19 cases (15%), more than one flap was used simultaneously to complete the reconstruction. 84% of the patients achieved stable chest wall reconstruction with no complications. Five patients (4%) had partial (>10%) flap loss. The most common remaining post operative complications were: delayed wound healing (3% of patients), infection (2.5%), and hematoma (2.5%).
Conclusion: Immediate chest wall reconstruction is safe, reliable, and can most often be accomplished with one operation. A variety of flaps, both single and in combination, may be utilized to achieve definitive coverage of the chest wall after extirpative surgery. The reconstructive choice is dependent on factors such as size of defect, location on chest wall, and availability of tissue blood supply. Based on this single institutional experience over a decade, an algorithm with useful application in the clinical approach to chest wall reconstruction will be presented.
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