Transcript Chest Wall Reconstruction

Chest Wall Reconstruction
A. ETIOLOGY OF DEFECTS
OF THE CHEST WALL
Table 46-1
B. PREOPERATIVE
EVALUATION
1. PE, history, radiographs, laboratory exam
2. Dyspnea, wheezing, cough…must be
evaluated.
3. PFT
4. Cardiovascular, renal risks…
C. CONSIDERATION FOR
RECONSTRUCTION
1. The ability to close the chest wall defect is
the main consideration.
2. The reconstructed thorax must support
respiration and protect underlying organs.
3. Joint effort of CS and PS surgeons is
important.
4. Among considerations of factors, location
and size are the most important.
D. SPECIAL
CONSIDERATIONS
D-1 Radiation Injury
1. It is important to understand the extent of
radiation injury.
2. CT scan and MRI are useful to
demonstrate lung and mediastinum
condition.
3. Such information is more important than
presence or absence of distant metastases.
D. SPECIAL
CONSIDERATIONS
D-1 Radiation Injury
4. Knowledge of the presence of mediastinal
abscess or destroyed lung is critical.
5. If a history of bleeding of chest wall is
present, angiography is indicated.
6. Parasternal ulceration must be evaluated
carefully, because the erosion into the internal
mammary artery may be present.
D. SPECIAL
CONSIDERATIONS
D-2 Infected Median Sternotomy Wound
1. It is a life-threatening complication.
2. During debridement, subcutaneous space and
sternum must be opened and all foreign
materials must be removed.
3. All recesses dissected previously must be
explored.
4. It is important not to enter the pleural space if no
evidence of empyema is present.
D. SPECIAL
CONSIDERATIONS
D-2 Infected Median Sternotomy Wound
5. After debridement, wet dressing with
saline solution is performed.
6. The pectoralis major( PM ) muscle is ever
reported to obliterate the mediastinum.
E. SKELETAL
RECONSTRUCTION
1. Reconstruction o the bony thorax is
controversial.
2. All full-thickness skeletal defects have chest
wall paradox, so reconstruction is indicated.
3. Defects less than 5 cm in greatest diameter are
usually not reconstructed.
4. Posterior defects less than 10 cm in greatest
diameter are usually not reconstructed.
E. SKELETAL
RECONSTRUCTION
5. Fascia lata, ribs and prosthetic
material( meshes, metals, methyl
methacrylate…) can be used for
reconstruction.
6. Stability of a bony thorax is best
accomplished with prosthetic material such
as Prolene mesh or 2-mm polytetrafluoroethylen
soft tissue patch.
E. SKELETAL
RECONSTRUCTION
7. Soft tissue patch is superior because it
prevents movement of fluid and air across
the reconstructed chest wall.
8. If the wound is contaminated with previous
radiation necrosis or necrotic neoplasm,
prosthetic material is not advised. A
musculocutaneous flap is preferred.
F. SOFT TISSUE
RECONSTRUCTION
Table 46-3
F. SOFT TISSUE
RECONSTRUCTION
F-1 Muscle Transposition
F-1 Muscle Transposition
F-1-1. Lassitissmus Dorsi( LD ) Muscle
(1) It is the largest muscle of the thorax.
(2) It has thoracodorsal neurovascular leash
and coverage of lateral and central back,
anterolateral and central front of the
thorax.
(3) The donor site may need skin graft.
F-1 Muscle Transposition
F-1-2 Pectoralis Major( PM ) Muscle
(1) It is the second largest muscle of the
thorax.
(2) It has thoracoacromial neurovascular leash
and coverage of anterior chest wall.
(3) Generally, only the muscle is transposed
and the skin can be closed primarily.
F-1 Muscle Transposition
F-1-3 Rectus Abdominis Muscle
(1) It has the internal mammary neurovascular
leash and coverage of the lower steranal wound.
(2) The inferior epigastric vessels must be divided
for rotation to the chest wall.
(3) The donor site can be closed primarily.
(4) Angiography is indicated to check the patency of
internal mammary vessels.
F-1 Muscle Transposition
F-1-4 Serratus Anterior Muscle
(1) Its blood supply comes from the serratus
branch of the thoracodorsal vessels and
from the long thoracic vessels.
(2) It can used alone or with PM or LD
muscles.
(3) It is particularly used as an intrathoracic
flap.
F-1 Muscle Transposition
F-1-5 External Oblique Muscle
(1) It is most useful in defects of lower thorax
or upper abdomen.
(2) Its blood supply is form the lower thoracic
intercostal vessels.
(3) With the muscle, lower chest wall can be
closed with distorting the breast.
F-1 Muscle Transposition
F-1-6 Trapezius Muscle
(1) It is useful in defects of neck or
thoracic outlet but not useful for other
chest wall defect.
(2) Its blood supply is from the dorsal
scapular vessels.
F. SOFT TISSUE
RECONSTRUCTION
F-2 Omental Transposition
1. It is used for partial-thickness chest wall
defects, particularly in radiation induced
necrosis not involving tumor.
2. Blood supply is from the gastroepiploic
vessels.
3. It is not used for full-thickness defect
because of lacking structural stability.
F. SOFT TISSUE
RECONSTRUCTION
4. Lower sternal wound is best reconstructed
with a rectus abdominis muscle, but the
internal mammary artery is not patent or
the wound is large. Omental transposition
can be done.