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Address reprint requests to Gaetano Rocco, MD, FRCSEd, FETCS, Division of Thoracic Surgery, Department of Thoracic Surgery and Oncology, National Cancer Institute, Pascale Foundation, Via Semmola 81, 80131 Naples, Italy
Anterior chest wall resections may significantly alter the respiratory physiology depending on whether the entire sternum is involved, the size of the defect, and the type of reconstruction.
To this end, computed tomography image reconstruction and digital subtraction are increasingly becoming a mandatory adjunct to visualize the extent of the chest wall involvement with special attention to tumor margins. To complete preoperative evaluation of tumors infiltrating the full thickness of the chest wall, a video-assisted thoracoscopic assessment of the inner chest wall can be useful, especially when chest wall recurrences from breast cancer or residual tumor after chemotherapy are to be assessed. Because frozen section is not feasible on bone specimens, up to 4- to 5-cm tumor-free margins should be obtained.
Although the decision about reconstructive strategy should be individualized, it is common knowledge that the defect resulting from the removal of only one rib may not necessitate reconstruction. However, anterior one-rib defects (ie, rib 4 or 5) in selected patients may require covering (ie, young athletes) if there is a consistent risk for lung herniation.
For malignant primary chest wall tumors, the immediate adjacent ribs should be resected for the corresponding length of the infiltrated segment on tumor-free margins.
When the manubrium and one or both clavicles are involved, these can be removed without subsequent reconstruction, yielding acceptable shoulder girdle movement.
Time-honored materials for chest wall reconstruction (ie, polypropylene, polyglactin meshes, or methylmethracrylate sandwich [MMM] along with polytetrafluoroethylene [PTFE] patches) are still valuable options albeit new materials (ie, titanium plates, acellular collagen matrix meshes, and cryopreserved homografts) are increasingly being preferred due to resilience to infection and ready incorporation into the host tissues.
The skin resection should be kept at a safe margin (2-3 cm) from the macroscopically visible tumor edge. When the tumor is ulcerated, the cutaneous incision should be at the same distance from the inflamed area. In no instances, concerns regarding subsequent reconstruction should affect the decision on how much to resect. The muscle layers are divided along an oblique line directed away from the tumor so that the en-bloc specimen resembles a truncated cone (Fig. 1A; Video 1). If possible, subcutaneous fat tissue should be spared as reinforcement for subsequent primary or secondary closure. The dissection is started by scarifying the periosteum of the uninvolved ribs. In the event of multiple local recurrences or a previously radiated area, the costal plane is adhered to elevate the overlying (pectoralis) muscles (Fig. 1B; Video 1). Thereafter, the specimen is suspended caudocranially and divided laterally and medially to identify and divide main vascular supply.
Figure 1Partial-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.
In straightforward cases, primary closure is possible by subcutaneous undermining of the wound edges or by using plastic surgery techniques of skin approximation or skin grafts.
My preference goes to the V–Y advancement flap, which enables the surgeon to cover extensive anterolateral defects and permits adequate approximation of the donor wound edges.
Layer-to-layer suturing with polyglactin 2-0 or 3-0 sutures (ie, latissimus dorsi edges to surrounding muscle in the recipient area) is usually sufficient to maintain the flap in place without anchoring it to the underlying ribs.
Alternatively, when the skin is spared to permit a primary closure of the partial thickdness defect, a latissimus dorsi flap can be raised and rotated anteriorly (Fig. 2B; Video 1). Needless to say, these muscle or myocutaneous flaps can be also transposed to cover full-thickness defects.
Figure 2Partial-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.
The uppermost intercostal space is opened by electrocautery, keeping it in contact with the superior border of the highest rib to be removed (Fig. 3; Video 1). Once the lowest rib to be removed is identified, the intercostal space is opened by electrocautery along the superior border of the immediately inferior rib. Finger palpation or thoracoscopic exploration of the inner chest wall may contribute to the definition of the resection margins. The intercostal vessels are ligated and divided at the ribs both above and below the involved one or ones (Fig.3; Video 1). By performing anterior and posterior costotomies, bony segments of sufficient length to ensure tumor-free margins are resected along with the corresponding intercostal muscles (Fig. 3; Video 1).
Figure 3Full-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.
As a rule, a material with enough rigidity to ensure chest wall stability needs to be selected. In this setting, PTFE and MMM have proved to serve this purpose.
However, when PTFE is used for extensive anterior chest wall defects requiring rib resection up to the entire lateral aspect of the sternum, the reconstruction will be based on a series of sternal punches going through the sternum to accommodate the anchoring sutures for either the PTFE or the MMM
(Video 1). However, titanium plates in association with acellular collagen matrix or cryopreserved homografts could be a viable alternative for reoperations and heavily irradiated areas
(Fig. 4B, C; Video 1). Titanium plates can be molded to fit the rib contour and then cut to the desired length (Fig. 4C; Video 1). The plates are anchored to the bony ribs with titanium screws of increasing length as required by the rib thickness. Usually, 3-4 screws on each side represent sufficient warranty against fracture or dislocation, which in our experience occurred in only one patient, who required plate replacement with acellular collagen matrix patching. Bone drills are of utmost value to guide the precise insertion of the screw (Fig. 4C; Video 1).
Usually, titanium plates are placed with a 2:1 ratio compared to the number of resected ribs. If an acellular collagen matrix prosthesis is selected, the sternal Sweet puncher or a bone drill can be used to facilitate placement of the anchoring sutures (2-0, non-reabsorbable) around the perimeter of the prosthesis (Fig. 4B; Video 1).
A combination of titanium plates and acellular collagen matrix patch can be used; in this case, the central prosthesis is sutured to the plates to confer additional stability
(Fig. 4C). Alternatively, the titanium plates are applied without internal coverage material. If the wound cutaneous layer can be closed primarily, the titanium plates are covered with polyglactin meshes to avoid friction on the overlying skin (Fig. 4D; Video 1).
Figure 4Full-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.
If the sternum needs to be removed, the division of the bony rib starts laterally on the side opposite to the most severely involved by the sternal neoplasm. The width of lateral extension is dictated by the need for safe, tumor-free margins.
If the tumor infiltrates the body of the sternum symmetrically, the resection is started on the left side and then carried out counterclockwise to the level of the same contralateral rib (in a “U” fashion). In any case, the chondrocostal release is performed up to at least one intercostal space superior to the macroscopic appearance of the tumor.
The mammary vessels are routinely identified and divided. The intercostal pedicle is usually dissected through an extraperiosteal route. However, if the primary tumor is a chondrosarcoma, the periosteum should be included in the specimen because its lymphatics may represent a possible route for local recurrence and metastatic dissemination. As the separation of the sternum from the ribs continues, the specimen is suspended, thereby allowing for visualization of the mediastinum. The adhesions connecting the endothoracic fascia to the pericardial fat are divided. If the manubrium can be spared, it is prepared by blunt dissection and divided with a sternal saw immediately above the second chondrosternal joint. If the tumor involves the upper sternum, the sternotomy incision is carried laterally onto the clavicles configuring a T-shaped incision (Fig. 5A).
Finger dissection is needed to break retrosternal ligaments behind the manubrium. The mammary pedicles are usually divided at this point and the clavicles are resected as needed en bloc with the manubrium
Figure 5Total 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.
The selection of the reconstructive material depends on the size of the defect, on previous irradiation or surgery, on concurrent infection, and on whether the manubrium is preserved.
If the sternum is completely removed up to the clavicles, anterior chest wall stabilization can be achieved by means of PTFE or MMM prostheses. If the manubrium is spared, a neosternum is created by fitting a cryopreserved homograft, (ie, iliac crest
A drill or a sternal puncher is used to accommodate the non-reabsorbable sutures (2-0 polypropylene) anchoring the MMM sandwiches to the neosternum (Fig. 6A, B).
Other cryopreserved homografts can be used (ie, ribs; Video 1) to bridge the defect after sternectomy. Cryopreserved ribs are fixed to native lateral rib segments through either Kirschner wires or titanium plates. Cryopreserved homografts may require an omental, vascularized bed to facilitate vascular inosculation and progressive incorporation into the host. The same technique is used to protect the mediastinum when titanium plates are selected to bridge the poststernectomy defect (Fig. 6C; Video 1).
The omentum is preferably raised through an upper midline limited laparotomy and passed under and over the homografts or the titanium plates; alternatively, the omental flap can be split in 2 different layers (Fig. 7A, B; Video 1).
Omental flaps are secured to surrounding structures with polypropylene 2-0 sutures. A potential alternative to omental flaps is represented by the combination of titanium plates and acellular collagen matrix.
If the defect is in the lower sternum, rigid stabilization may not be necessary. In this case, it might be sufficient to raise the pectoralis major muscles bilaterally and approximate them on the central line, thus covering the defect with viable tissue (Fig. 8).
Figure 6Reconstruction 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.
Figure 7Use 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.
Figure 8Reconstruction 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).
Nowadays, a versatile, individualized approach to both primary and redo resections for anterior chest wall tumors is possible thanks to the introduction of improved materials for the subsequent reconstruction.
In this setting, time-honored prostheses should still be used when a primary resection is performed on neither a previously irradiated nor an infected surgical site.
Accordingly, an increasing number of reconstructive options for reconstruction after anterior chest wall resection are becoming available. In addition, multidisciplinary expertise should be sought in the event of complex reconstructions.
Therefore, in a fashion similar to the biomolecular revolution for lung cancer management, a “targeted” resection and reconstruction can be planned for patients with anterior chest wall tumors.
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