508 Ann Thorac Surg 46: , Nov Copyright by The Society of Thoracic Surgeons

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1 Current Techniques for Chest Wall Reconstruction: Expanded Possibilities for Treatment Robert J. McKenna, Jr., M.D., Clifton F. Mountain, M.D., Marion J. McMurtrey, M.D., David Larson, M.D., and Quentin R. Stiles, M.D. ABSTRACT Myocutaneous flaps and prosthetic materials have greatly facilitated reconstruction after massive chest wall resection. This series includes 112 such procedures. Latissimus dorsi, rectus abdominis, omental, pectoralis major, and contralateral breast flaps were used in 80 patients. Early in the series, 3 flaps were lost because of technical problems. Minor areas of incomplete healing that resolved completely with local wound care occurred in 16 of 80 flaps. Skeletal reconstruction was performed in 82 patients without complication. Marlex mesh was used for flat surfaces, and Marlex mesh with methyl methacrylate was used for the sternum and the curved surface of the lateral chest wall. These results have allowed an expansion of the indications for chest wall resection to include the curative treatment of primary chest wall tumors and palliative treatment for breast cancer patients with osteoradionecrosis, local recurrence (in select patients), chest wall infection, and tumors metastatic to the chest wall. Modem techniques in reconstruction and in particular the development of the myocutaneous flap have dramatically increased the ease with which large chest wall defects can be repaired [l-171. Major chest wall resection can, therefore, be undertaken not only in an attempt to cure a patient with a primary chest wall tumor, but also to palliate areas of osteoradionecrosis, local recurrence of breast cancer, and metastatic tumors. In this report we present our philosophy on chest wall reconstruction based on an experience with 112 chest wall resections. Material and Methods This study includes 103 consecutive patients who underwent chest wall resection between 1977 and 1985 at the University of Texas M. D. Anderson Hospital and Tumor Institute at Houston, and 9 additional patients operated on during 1985 and 1986 at the Hospital of the Good Samaritan and Los Angeles County-USC Medical Center. Sixty-one of these patients have been included From the Departments of Thoracic Surgery and Plastic Surgery, The University of Texas M. D. Anderson Hospital and Tumor Institute at Houston, Houston, TX, and the Hospital of the Good Samaritan and Los Angeles County-University of Southern California Medical Center, Los Angeles, CA. Resented at the Thirty-fourth Annual Meeting of the Southern Thoracic Surgical Association, Boca Raton, FL, Nov 5-7, Address reprint requests to Dr. Mountain, Department of Thoracic Surgery, The University of Texas M. D. Anderson Hospital, Box 109, Houston, TX in two previous reports [5,7]. There were 90 women and 22 men. The most common indication for operation was breast cancer (61 patients with locally recurrent tumor or radionecrosis with infection of the chest wall or both). Twenty-seven patients had sarcomas: seven fibrosarcomas, six osteosarcomas, four Ewing s sarcomas, three unclassified sarcomas, four malignant fibrous histiocytomas, one liposarcoma, one malignant schwannoma, and one hemangiopericytoma. Four of the seven fibrosarcomas were grade I (desmoid) tumors. Nine patients had benign lesions: osteomyelitis in 3, chondroma in 3, fibrous dysplasia in 1, aneurysmal bone cyst in 1, and osteochondroma in 1. There were 4 patients with melanoma, 4 with basal cell cancer, 3 with lung cancer, 3 with thyroid cancer, and 1 with a sternal infection. The disease process involved the skeletal structure of the chest wall in all 112 patients. In 7, the disease process involved only the sternum (1 with malignant fibrous histiocytoma, 1 with Ewing s sarcoma, 1 with an unclassified sarcoma, 3 with osteomyelitis, and 1 with metastatic breast cancer). In 20 patients, the disease process involved both the ribs and the sternum (breastcancer osteoradionecrosis, 17 patients; basal cell carcinoma, 2; and desmoid, 1 patient). In the remaining 85 patients, the ribs were the only bony elements involved. The soft tissue defect ranged in size from 20 to 450 cm2 (average, 168 cm ). Skeletal Reconstruction In 82 patients, the skeletal defect was repaired with the aid of a prosthetic material. Methyl methacrylate was used between two sheets of Marlex mesh to reconstruct sternal defects to maintain a normal contour around the lateral aspect of the chest wall in 8 patients [4, 141. Methyl methacrylate was not used when the patient was to receive irradiation in that area, although we are not aware of any specific contraindication to irradiating methyl methacrylate. Flat surfaces on the anterior or posterior aspect of the chest wall were reconstructed with Marlex mesh without methyl methacrylate in 56 patients or with Dexon mesh in 4 patients. The Marlex mesh was secured to the adjacent ribs and fascia with running No. 1 polypropylene suture. Perioperative antibiotic prophylaxis (a cephalosporin begun preoperatively and continued postoperatively until all tubes were out) was used following the standard guidelines. No prosthetic material was necessary to reconstruct the skeletal defect in 30 patients. An aneurysmal bone cyst in the first rib was resected in 1 patient. This area 508 Ann Thorac Surg 46: , Nov Copyright by The Society of Thoracic Surgeons

2 509 McKenna et al: Chest Wall Reconstruction A B Fig 1. (A) A palliative chest wall resection including the right breast, a portion of the diaphragm, and ribs 4 through 7 removed this metastatic melanoma. (B) A rectus abdominis myocutaneous Pap filled the defect. was well protected by the clavicle anteriorly and the scapula posteriorly. In 3 patients, the costal margin was resected and the diaphragm was reattached to the fourth rib. In the remaining 26 patients, no prosthetic material was used because infected or radionecrotic tissue was resected. In these patients, a rectus abdominis or latissimus dorsi myocutaneous flap provided adequate stability for the chest wall. These defects were as large as an entire hemithorax with resection of all ribs from the first rib through the costal margin and from the sternum to the anterior axillary line. Skin and Soft Tissue Reconstruction Five different flaps were used for reconstruction in 80 patients. The skin could be closed primarily in the remaining 32. Omentum plus a skin graft was used in 13 patients, a pectoralis major myocutaneous flap in 9, and a contralateral breast flap in 7. Prosthetic material provided structural support for these flaps. In the last 4 years, the rectus abdominis (25 patients) and the latissimus dorsi (26 patients) myocutaneous flaps have be- come the method of choice for reconstruction because they offer greater strength, durability, and surface area than the other flaps and do not require a prosthetic material for structural support. The other flaps have been used only when these are not available (i.e., the feeding vessels were resected with removal of the disease process or the muscles were transected by previous operations, such as a posterolateral thoracotomy through the latissimus dorsi muscle or a transverse abdominal incision through the rectus abdominis). lllustrative Case Reports PATIENT 1. A 36-year-old woman was referred when metastatic melanoma in the right breast recurred after a local excision (Fig 1A). The tumor was fungating, infected, and fixed to the ribs. Bleeding from the tumor necessitated multiple transfusions. A metastatic evaluation, including computed tomography of the brain, chest, and abdomen, revealed only two small nodules in the lung that were consistent with metastases. The patient underwent palliative resection of the chest wall, including four ribs, and a portion of the diaphragm. A rectus abdominis myocutaneous flap was used for reconstruction (Fig 1B). The operation effectively palliated the chest wall pain and the need for transfusions. The patient died 1 year later of widespread melanoma. PATIENT 2. A 47-year-old woman underwent mastec-

3 510 The Annals of Thoracic Surgery Vol 46 No 5 November 1988 A Fig 2. (A) Complete resection of osteoradionecrosis of the left anterior chest required resection of four ribs and the overlying skin and soft tissue. (B) A latissimus dorsi myocutaneous Pap was used for reconstruction. tomy and was treated with 5,000 rads of external-beam irradiation for a breast carcinoma. Figure 2A shows the resulting ulceration and osteoradionecrosis of the left chest and Paget s disease of the right nipple. Because there was no evidence of metastatic disease, the patient underwent a right simple mastectomy and left chest wall resection. Figure 2B shows the chest wall after reconstruction with a latissimus dorsi myocutaneous flap. Results The average hospital stay for the 112 patients was 11.4 days. Deaths Four perioperative deaths occurred in the series. One patient who died underwent removal of the left anterior chest wall, including partial resection of four ribs. She had a benign course and was discharged in 7 days. As an outpatient, she sustained a fatal pulmonary embolism on postoperative day 33. Another patient was moribund preoperatively because of sepsis arising from an area of radionecrosis on the chest wall. On postoperative day 10, she died of bilateral pneumonia, respiratory failure, and a pulmonary embolus. One patient underwent an extensive left chest wall resection and en bloc pneumonectomy. He came off the ventilator without difficulty, and the wounds healed well. However, the tumor recurred rapidly during the postoperative period. The patient remained in the hospital for treatment with radiotherapy and chemotherapy, but died of progressive disease on postoperative day 44. Another patient had a rapidly growing radiation-induced osteosarcoma of the sternum. He remained in the hospital for care of a wound infection and low-grade mediastinitis. Rapid recurrence and progression of the tumor resulted in a hospital death six weeks postoperatively. B Wound Complications Minor wound complications (e.g., superficial loss of skin) that did not require further surgical intervention occurred in 16 (20%) of the 80 patients who underwent reconstruction with a flap. Four patients (5%) had major wound complications that required operative correction early in the series. In the first of these patients, a pectoralis major myocutaneous flap was closed under some tension, and the distal half of the flap became necrotic. Salvage was accomplished with a latissimus dorsi flap. In the second patient, a technical problem related to inset of a latissimus dorsi myocutaneous flap resulted in loss of the distal quarter of the flap. The resulting wound was repaired with a pectoralis major flap. In the third patient, venous congestion caused total loss of a rectus abdominis myocutaneous flap. A latissimus dorsi flap was then used for chest wall repair. The fourth patient underwent chest wall reconstruction with a rectus abdominis flap for extensive chest wall osteoradionecrosis. The flap was entirely viable, but healing was incomplete at the superolateral margin because of residual radionecrosis. This required further debridement and use of an omental flap and skin graft. Respirato y Complications Respiratory complications were infrequent. No patient had a clinically significant problem with flail chest, even when a very large chest wall defect was repaired with only a myocutaneous flap (i.e., without the additional support of a prosthetic material). Patients were routinely extubated the morning after the operation. All patients received aggressive pulmonary toilet, which included incentive spirometry, encouragement by the nurses to cough, and nebulizer treatments when necessary. Follow-up Follow-up ranged from 6 months to 9 years (mean, 4.2 years). There were no instances of late infection. Three patients with Marlex mesh had areas in the incisions where the prosthetic material became infected. This problem was handled with local debridement of the wounds.

4 511 McKenna et al: Chest Wall Reconstruction Comment Modern techniques in reconstruction have allowed expanded indications for chest wall resection [13] because large amounts of skin, soft tissue, and structural support are readily available to fill almost any size of defect in the chest wall. At present, myocutaneous flaps are the method of choice for chest wall reconstruction because they offer large amounts of skin and soft tissue, optimal cosmetic results, and adequate chest wall support without the need for any prosthetic material. The methods for obtaining tissue coverage and skin coverage in the last thirty years have also changed substantially [4]. Initially, random sections of skin and subcutaneous tissue were rotated into the wound. The rotation of skin and subcutaneous tissues from the upper abdomen onto the chest and the use of a contralateral breast flap are examples of this kind of flap. These are still useful to close small defects of skin and soft tissue where primary closure can be obtained after undermining. The major limitation of this method of reconstruction is the random nature of the blood supply. The potential for reconstruction changed dramatically when flaps were developed that brought their own wellestablished blood supply [5]. The omental flap, an early example of this type of flap, is occasionally still used, but it has three disadvantages: it requires a split-thickness skin graft for skin coverage, it has a less cosmetic appearance than other methods of reconstruction, and it has no inherent strength so that the chest wall must be supported with mesh. The myocutaneous flaps greatly facilitate chest wall reconstruction because they offer a large amount of soft tissue with attached skin, they are thick and durable, and they have their own reliable blood supply. The donor site can usually be closed primarily. If the donor site cannot be primarily closed, it can be covered with a skin graft temporarily. The use of tissue expanders can stretch the tissues adjacent to the donor site to allow subsequent primary closure. Prior irradiation of the feeding vessels of the myocutaneous flap does not contraindicate the use of that flap. This series included many women who had undergone radiotherapy for breast cancer. The radiation field for the internal mammary nodes includes the internal mammary artery, and the radiation field for the axilla includes the thoracodorsal artery. These are the feeding vessels for the rectus abdominis and latissimus dorsi myocutaneous flaps, respectively. The radiotherapy, however, did not compromise the viability of these flaps. The rectus abdominis myocutaneous flap is very useful for reconstructing the anterior chest, since it can cover nearly an entire hemithorax from the clavicle to the costal margin and from the sternum to the midaxillary line. Its blood supply is the superior epigastric artery from the internal mammary artery. After a sternum has been removed because of mediastinitis and osteomyelitis, a rectus abdominis myocutaneous flap can fill the defect and provide adequate structural stability with- out use of a prosthetic mesh, which could become infected. The latissimus dorsi myocutaneous flap is optimal for reconstructing the breast or chest wall defects in that location. Its blood supply is the thoracodorsal artery. It usually does not reach inferiorly to the costal margin, especially in the area of the xiphoid. It does not offer quite as much skin and subcutaneous tissue as the rectus abdominis flap. The pectoralis major myocutaneous flap is useful for covering smaller defects in the anterior hew'thorax, especially superiorly over the area of the manut ium and the clavicles when the muscle is mobilized wit preservation of the pectoral branch of the tho- -oacromial trunk [lo]. Alternatively, to fill a defect after sternectomy, the flap can be mobilized based on the perforating brdnches of the internal mammary artery. In contrast to the rectus abdominis and the latissimus dorsi flaps, it usually requires prosthetic material for structural support. It also requires a split-thickness skin graft to cover the donor site more often than the two flaps just mentioned. The omental flap [ll] also is still useful for chest wall reconstruction, although it offers a less satisfactory cosmetic result and requires structural support and a splitthickness skin graft. Therefore, this flap is generally used only if the other flaps are unavailable or unsuccessful. Methods for reestablishing structural support for the chest wall have changed substantially since 1969, when Starzynski and associates [lo] wrote: "Although the rare case of successful reconstruction after total sternal excision in one stage has been reported, this should be undertaken only with great circumspection-in highly selected patients of great vigor and with diffuse pleural adhesions." Numerous foreign materials, including metal sheets, stainless steel struts, Lucite, tantalum, Ivalon, and fiberglass cloth, have been used to stabilize bony defects of the chest wall. These materials are now used infrequently because their lack of pliability makes intraoperative manipulation to fit the exact defect difficult. In addition, they can be difficult to secure easily to the remaining chest wall, and they have a significant incidence of rejection by the host. Autologous materials, such as lyophilized dura, periosteum, fascia lata, and rib grafts, have also been used, but synthetic meshes that are well suited for chest wall reconstruction are readily available. Because it is strong and durable, Marlex, a nonabsorbable mesh, is often used to support the chest wall [2]. Marlex alone is used for flat surfaces on the anterior or posterior chest wall. A myocutaneous flap without Marlex can be used for these flat surfaces, especially if the resected tissue is infected; however, Marlex mesh improves the cosmetic result and decreases the flail movement of the chest. A "sandwich" of Marlex mesh and methyl methacrylate is used to reconstruct the sternum and to maintain the normal contour of the lateral chest wall [17]. A 1- to 2-cm cuff of Marlex is left around the

5 512 The Annals of Thoracic Surgery Vol 46 No 5 November 1988 methyl methacrylate to secure the sandwich to the adjacent ribs. Because the lateral thigh usually has about the same contour as the lateral chest wall, the Marlex and methyl methacrylate sandwich can be formed on the lateral thigh to be certain that it will have the right contour for the chest wall defect. The prosthesis should be made smaller than the defect. A prosthesis that is too large causes the patient additional pain and stiffness because it does not flex as the ribs do. When the costal margin and lower ribs are resected, the resulting defect need not be reconstructed with mesh. The diaphragm can be sutured to the lowest remaining rib. If the resection extends above the fifth rib, however, the diaphragm does not reach the remaining ribs and the resultant chest cavity would be too small for adequate lung expansion. A Marlex mesh and methyl methacrylate sandwich would, therefore, be used to ensure an adequate-sized chest cavity. The inferior margin of this sandwich should be higher than the normal costal margin or the patient will have difficulty bending. When ribs 1 through 4 are resected beneath the scapula, they need not be replaced with a mesh. When the resection extends down to ribs 5 and 6, a mesh should be placed to prevent the scapula from getting caught underneath the ribs inside the chest cavity. The ease of reconstruction has increased the indications for chest wall resection. Even very large primary chest wall tumors can be resected with confidence that closure can be obtained [12]. In addition, the low morbidity and mortality allow application of the procedure for palliation in patients who cannot be cured but have a reasonable life expectancy. In breast cancer [12], for example, although patients with local recurrence have a 94% incidence of distant metastases at 2 years [ll], chest wall-resection can be indicated to palliate local wounds for patients who are thought to have a life expectancy of at least a year. Generally, surgical intervention should be used only after treatment with chemotherapy and radiotherapy has failed. Other potential indications for full-thickness chest wall resection in patients with breast cancer include relief of local symptoms (e.g., pain or ulceration), removal of a site of sepsis, and resection of osteoradionecrosis. Radiotherapy is being used more frequently for patients with breast cancer and lymphoma. As more patients survive for longer periods following radiotherapy, increasing numbers of patients probably will be seen with late complications of irradiation. Osteoradionecrosis can occasionally be managed with local wound care, but this often fails. Any hope for surgical repair requires the removal of all radiation-damaged tissue. This often means large areas of chest wall must be resected and replaced. Because the tissue removed is often infected, prosthetic mesh is undesirable. Therefore, a myocutaneous flap offers an excellent method of reconstruction because it provides large amounts of healthy, durable tissue with its own blood supply. Also, these myocutaneous flaps provide adequate chest wall support without the need for a mesh. Occasionally, primary lung cancers grow to a large size and invade the chest wall before metastasizing. Resection of such tumors when there are no lymph node metastases offers patients a 30 to 40% chance of a 5-year survival [12]. The long-term survival rate for patients with tumors metastatic to the chest wall is poor, but chest wall resection in properly selected patients affords excellent palliation. References 1. Harrington SW: Surgical treatment of intrathoracic tumors and tumors of the chest wall. Arch Surg 14:406, Stelzer P, Gay WA Jr: Tumors of the chest wall. Surg Clin North Am 60:799, Ravitch MM, Hurwitz D, Wolmark N: Chest wall resection. Surg Rounds 3:15, Graeber GM, Snyder RJ, Fleming AW, et al: Initial and long-term results in the management of primary chest wall neoplasms. Ann Thorac Surg 34:644, Larson DL, McMurtrey MJ: Musculocutaneous flap reconstruction of chest wall defects: an experience with 50 patients. Plast Reconstr Surg 73:734, Larson DL, McMurtrey MJ, Howe HJ, Irish CE: Major chest wall reconstruction after chest wall irradiation. Cancer 49:1286, McKenna RJ Jr, McMurtrey MJ, Larson DL, Mountain CF: A perspective on chest wall resection in patients with breast cancer. Ann Thorac Surg 38482, Pairolero PC, Arnold PG: Thoracic wall defects: surgical management of 205 consecutive patients. Mayo Clin Proc 61:557, Boyd AD, Shaw WW, McCarthy JG, et al: Immediate reconstruction of full-thickness chest wall defects. Ann Thorac Surg 32336, Starzynski TE, Snyderman RK, Beattie EJ Jr: Problems of major chest wall reconstruction. Plast Reconstr Surg 44:525, Valagossa P, Bonadonna G, Veronesi U: Patterns of relapse and survival following radical mastectomy: analysis of 716 consecutive patients. Cancer 41:1170, McCaughan BC, Martini N, Bains MS, McCormack PM Chest wall invasion in carcinoma of the lung: therapeutic and prognostic implications. J Thorac Cardiovasc Surg 89836, Dingman RO, Argenta LC: Reconstruction of the chest wall. Ann Thorac Surg 32:202, Graham J, Usher F, Perry JL, Barkley H: Marlex mesh as a prosthesis in the repair of thoracic wall defects. Ann Surg 151:469, Jurkiewicz MJ, Arnold PG: The omentum: an account of its use in the reconstruction of the chest wall. Ann Surg 18538, LeRoux BT: Maintenance of chest wall stability. Thorax 19:397, McCormack P, Bains MS, Beattie EJ Jr, Martini N: New trends in skeletal reconstruction after resection of chest wall tumors. Ann Thorac Surg 31:45, 1981