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Chest Wall Reconstruction

Chest Wall Reconstruction. A. ETIOLOGY OF DEFECTS OF THE CHEST WALL. Table 46-1. B. PREOPERATIVE EVALUATION. PE, history, radiographs, laboratory exam Dyspnea, wheezing, cough…must be evaluated. PFT Cardiovascular, renal risks…. C. CONSIDERATION FOR RECONSTRUCTION.

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Chest Wall Reconstruction

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  1. Chest Wall Reconstruction

  2. A. ETIOLOGY OF DEFECTS OF THE CHEST WALL Table 46-1

  3. B. PREOPERATIVE EVALUATION • PE, history, radiographs, laboratory exam • Dyspnea, wheezing, cough…must be evaluated. • PFT • Cardiovascular, renal risks…

  4. 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.

  5. 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.

  6. 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.

  7. 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.

  8. 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.

  9. E. SKELETAL RECONSTRUCTION • Reconstruction o the bony thorax is controversial. • All full-thickness skeletal defects have chest wall paradox, so reconstruction is indicated. • Defects less than 5 cm in greatest diameter are usually not reconstructed. • Posterior defects less than 10 cm in greatest diameter are usually not reconstructed.

  10. 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.

  11. 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.

  12. F. SOFT TISSUE RECONSTRUCTION Table 46-3

  13. F. SOFT TISSUE RECONSTRUCTION F-1 Muscle Transposition

  14. 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.

  15. 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.

  16. 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.

  17. 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.

  18. 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.

  19. 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.

  20. 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.

  21. 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.

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