Chest Wall Reconstruction

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Chest Wall Reconstruction
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A. ETIOLOGY OF DEFECTS OF THE CHEST WALL

• Table 46-1

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B. PREOPERATIVE EVALUATION

1. PE, history, radiographs, laboratory exam
2. Dyspnea, wheezing, coughmust be evaluated.
3. PFT
4. Cardiovascular, renal risks

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C. CONSIDERATION FOR RECONSTRUCTION

• The ability to close the chest wall defect is
• the main consideration.
• The reconstructed thorax must support respiration
  and protect underlying organs.
• Joint effort of CS and PS surgeons is important.
• Among considerations of factors, location and
  size are the most important.

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D. SPECIAL CONSIDERATIONS

• D-1 Radiation Injury
• It is important to understand the extent of
  radiation injury.
• CT scan and MRI are useful to demonstrate lung
  and mediastinum condition.
• Such information is more important than
• presence or absence of distant metastases.

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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.

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D. SPECIAL CONSIDERATIONS

• D-2 Infected Median Sternotomy Wound
• It is a life-threatening complication.
• During debridement, subcutaneous space and
  sternum must be opened and all foreign materials
  must be removed.
• All recesses dissected previously must be
  explored.
• It is important not to enter the pleural space if
  no evidence of empyema is present.

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D. SPECIAL CONSIDERATIONS

• D-2 Infected Median Sternotomy Wound
• After debridement, wet dressing with saline
  solution is performed.
• The pectoralis major( PM ) muscle is ever
  reported to obliterate the mediastinum.

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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.

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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.

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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.

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F. SOFT TISSUE RECONSTRUCTION

• Table 46-3

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F. SOFT TISSUE RECONSTRUCTION

• F-1 Muscle Transposition

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F-1 Muscle Transposition

• F-1-1. Lassitissmus Dorsi( LD ) Muscle
• It is the largest muscle of the thorax.
• It has thoracodorsal neurovascular leash and
  coverage of lateral and central back,
  anterolateral and central front of the thorax.
• The donor site may need skin graft.

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F-1 Muscle Transposition

• F-1-2 Pectoralis Major( PM ) Muscle
• 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.

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F-1 Muscle Transposition

• F-1-3 Rectus Abdominis Muscle
• 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.

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F-1 Muscle Transposition

• F-1-4 Serratus Anterior Muscle
• Its blood supply comes from the serratus branch
  of the thoracodorsal vessels and from the long
  thoracic vessels.
• It can used alone or with PM or LD muscles.
• It is particularly used as an intrathoracic flap.

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F-1 Muscle Transposition

• F-1-5 External Oblique Muscle
• It is most useful in defects of lower thorax or
  upper abdomen.
• Its blood supply is form the lower thoracic
  intercostal vessels.
• With the muscle, lower chest wall can be closed
  with distorting the breast.

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F-1 Muscle Transposition

• F-1-6 Trapezius Muscle
• 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.

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F. SOFT TISSUE RECONSTRUCTION

• F-2 Omental Transposition
• It is used for partial-thickness chest wall
• defects, particularly in radiation induced
  necrosis not involving tumor.
• Blood supply is from the gastroepiploic
• vessels.
• It is not used for full-thickness defect because
  of lacking structural stability.

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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.