Immediate Reconstruction of Full-Thickness Chest Wall Defects

Transcription

1 Immediate Reconstruction of Full-Thickness Chest Wall Defects Arthur D. Boyd, M.D., William W. Shaw, M.D., Joseph G. McCarthy, M.D., Daniel C. Baker, M.D., Naresh K. Trehan, M.D., Anthony J. Acinapura, M.D., and Frank C. Spencer, M.D. ABSTRACT Twenty-one patients had full-thickness chest wall defects reconstructed at the New York University Medical Center in the last ten years. Marlex mesh provided chest wall stability in 5 patients. In 9 patients with s Marlex mesh was not required; a severe fibrotic reaction had obliterated the pleural space and prevented paradoxical motion. Partial sternal resections did not require Marlex stabilization, while a total sternectomy resulted in marked ventilatory insufficiency in a patient who would have benefited from the use of a stabilizing material. Random pattern s were used initially; more recently, axial pattern, myocutaneous, and myocutaneous free s were employed. Necrosis developed in 4 (36%) of the 11 patients with random pattern s, but was not seen with the newer techniques. Myocutaneous free s provided uncomplicated coverage of and stability to three large, potentially contaminated defects. It seems that with the currently available techniques and the methods of chest wall stabilization, immediate repair of all full-thickness chest wall defects is possible. Full-thickness chest wall defects secondary to resection of malignant tumors or areas of necrosis are encountered infrequently, but when they are, they require prompt, secure repair. The ideal reconstruction of such a defect would provide in one stage enough stability to the chest wall to allow for adequate, spontaneous ventilation and a secure, airtight cosmetically acceptable closure covered by integument. From the Departments of Thoracic Surgery and Plastic Surgery, New York University Medical Center, New York, NY. Presented at the Seventeenth Annual Meeting of The Society of Thoracic Surgeons, Jan 26-28,1981, Los Angeles, CA. Address reprint requests to Dr. Boyd, 530 First Ave, New York, NY Chest wall stability of large defects has been achieved through the use of ox fascia [l], fascia lata, periosteum, rib autografts [2], tantalum plate [3], fiberglass [4], and stainless steel mesh 151. More recently, Marlex mesh [61, either alone or in conjunction with methyl methacrylate and stainless steel mesh [l], has proved to be very effective in providing stability to the chest wall and currently is used by most thoracic surgeons. Secure closure of these full-thickness chest wall defects often has been difficult. In the past, random pattern s [7] usually were employed (Fig 1). These are s that have no intrinsic axial vascular supply paralleling their long axis and require multiple surgical procedures, especially if the length to width ratio exceeds 1 : 1 or 2 : 1 at the very most. If the defects were small and if the surrounding donor tissues were normal, advancement or rotation of a local usually permitted satisfactory coverage of these defects [8]. If, however, the defects were large or the surrounding tissues abnormal as a result of previous operation or therapy, local tissues were most often not adequate for coverage. Occasionally, in the absence of suitable local donor tissue, the opposite breast [9, 101 or greater omentum covered with split-thickness skin [ll, 121 was used successfully. In general, however, a random pattern of distant normal tissue was used [131. The use of such s was time consuming because it required several stages, was prone to complications, and often gave poor cosmetic results. In recent years, new concepts of skin blood supply have been developed and newer techniques based on these concepts permit one-stage reconstruction of almost all fullthickness chest wall defects. Axial pattern [7], myocutaneous L141, and myocutaneous free by The Society of Thoracic Surgeons

2 338 The Annals of Thoracic Surgery Vol 32 No 4 October 1981 \ Supplied by branches of thoracodoraal a and v through underlying musc intercostal a Fig 2. An axial pattern is a single pedicle of skin and subcutaneous tissue with an intrinsic vascular supply paralleling its long axis. It can be used without the need for prior surgical delays. (a. = artery; v. = vein; 2, 3, 4 = ribs.) Fig 1. Random pattern having no intrinsic axial vascular supply and requiring surgical delays prior to use. (a. = artery; v. = vein.) s [151 all have their own intrinsic arterial and venous supplies permitting reliable onestage, cosmetically acceptable reconstruction of full-thickness chest wall defects. An axial pattern is a single pedicle of skin and subcutaneous tissue with a vascular supply paralleling its long axis, and it usually can be used without a prior delay in spite of its length being much greater than its width (Fig 2) [7]. In 1965 Bakamjian [16] described an axial pattern -the deltopectoral -and in the early 1970s McGregor and Jackson [17] wrote extensively on its use. Subsequently, the deltopectoral has been widely used for resurfacing chest wall defects. A myocutaneous [141 consists of skin and its underlying muscle through which the vascular supply of the skin is derived (Fig 3). Although the use of a latissimus dorsi myocutaneous was described by Tansini [18] in 1906, it is only in the last few years that the potentiality of these s has been recognized. Many broad muscles with reliable blood supplies permit the development of large s that can be used immediately. Pectoralis major (Fig 4) [19, 201, latissimus dorsi [21], and rectus abdominis myocutaneous s [221 have been used extensively to resurface chest wall defects. / /' r --- Cross Section of Flap Epid.rmisy Fig 3. Latissimus dorsi myocutaneous based on the thoracoabdominal vessels, branches of which extend through the muscle to supply the overlying skin. (a.v.n. = artery, vein, nerve.) Fig 4. Pectoralis major myocutaneous based on the pectoral branches of the thoracoabdominal vessels. (a. = artery; v. = vein.)

3 339 Boyd et al: Reconstruction of Chest Wall Defects \ 1. C.,"lC.l Skin '\i \ Fig 5. A tensor fascia lata myocutaneous free based on the lateral circumflex femoral vessels provides an excellent functional and cosmetic repair for full-thickness chest wall defects. (a. = artery; v. = vein; m = muscle.) With the recent development of microsurgical vascular techniques, it is only natural that myocutaneous free s should come into wide use [15, 231. They are myocutaneous s, which, with their pedicles and supplying vessels divided, are moved to a new location where their feeding vessels are anastomosed to appropriate local vessels (Fig 5). In the past ten years 21 patients have had full-thickness chest wall defects reconstructed at the New York University Medical Center. In the early years, random pattern s were used primarily; more recently, axial pattern, myocutaneous, and myocutaneous free s have been employed. Our experience with these patients provided us with the opportunity to compare these newer techniques with the older methods and forms the basis for the present report. Material and Methods Full-thickness chest wall resections were carried out on 21 patients at the New York University Medical Center in the past ten years (Tables 1,2). In 11 patients the resection was performed to remove a necrotic, which had resulted from ir of the chest wall following mastectomy. In 4 patients a primary tumor of the chest wall was.resected, and recurrent tumor was excised in 6. Chest Wall Resection In those 11 patients with s, all of the necrotic tissue including the skin, subcutaneous tissue, and involved bone and cartilage was excised back to healthy, bleeding tissue. In these patients, the underlying pleural space was obliterated. In the patients with primary malignant tumors of the chest wall, a wide, full-thickness excision of the chest wall through normal tissues was carried out. If the tumor arose from a rib, this rib was excised totally and involved ribs above and below were excised widely including a segment of normal

4 340 The Annals of Thoracic Surgery Vol 32 No 4 October 1981 Table 1. Summary of Clinical Data on Patients Having Full-Thickness Chest Wall Defects Repaired with Random Pattern Flaps Patient Portion of Size of No., Age Chest Wall Defect Chest Wall (yr), Sex Diagnosis Resected (cm) Stability C 1 o s u r e Outcome LOCAL TISSUE 1. 58, F Ca (L breast); re- Sternum, partial; 10 X 8 Marlex currence (24 costal cartilages mo) 2, 3, , F Chondrosarcoma Ribs 7, 8, 9 12 X 6 Marlex (R 8th rib) 3. 63, M Recurrent Manubrium of 3 X 4 Flap only laryngeal Ca at sternum for tracheal stoma mediastinal tracheostomy 4. 49, M Rhabdomyo- Ribs 5, 6, 7, 8, 9 9 X 6 Marlex sarcoma (L chest wall) 5. 60, F Chondrosarcoma Total sternectomy 11 X 5 el- Flaps only of sternum lipse of skin 6. 58, F Ca (breast); recur- Ribs 2, 3, 4 and 8 X 6 Marlex rence (20 mo) lateral sternum DISTANT TISSUE Broad-based rotation Broad-based rotation Bipedicle advancement Bipedicle advancement Bilateral advancement s Broad-based rotation s Ca (48 mo) (60 mo) Flap necrosis; Ca (9 mo) sarcoma (12 mo) Respiratory insufficiency; on respirator 18 d; necrosis; infection; alive and well (9 yr) Ca (9 mo) 1. 63, F Ca (R breast); Ribs 2, 3, , F Ca (R breast); Ribs 3, 4 mastectomy; ir; 3. 49, F Ca (R breast); Ribs 3, , F Ca (L breast); Ribs 2, , F Ca (L breast); Ribs 3, 4 8 x 6 Flaps only 'Thoracoabdominal s (2 delays [necrosisl); abdominal transported to chest on forearm (necrosis) 7 x 5 Flap only Thoracoabdominal (3 delays) Multiple complications; necrosis; infection; Ca (24 mo) Distal necrosis of ; alive and well (8 yr) 6 x 5 Flap only Thoracoabdominal (2 delays) (6 yr) 5 x 5 Flap only,4bdominal transferred on died of Ca (38 forearm (4 delays) mo) 6 x 5 Flap only Thoracoabdominal (2 delays) (5 Yr) Ca = carcinoma.

5 341 Boyd et al: Reconstruction of Chest Wall Defects Table 2. Summary of Clinical Data on Patients Having Full-Thickness Chest Wall Defects Repaired with Newer Flap Techniques Patient Portion of Size of No., Age Chest Wall Defect Chest Wall (yr), Sex Diagnosis Resected (cm) Stability Closure Outcome TENSOR FASCIA LATA MYOCUTANEOUS FREE FLAPS 1. 55, F Ca (L breast); Ribs 2, 3, 4, 5; 15 x 20 mastectomy; ir- lateral sternum ; 2. 44, F Ca (L breast); Ribs 3, 4, 5; lat- 14 x 8 mastectomy; era1 sternum ; recurrence (breast) 3. 54, F Ca (R breast); Ribs 3, 4, 5 10 X 8 Fascia lata Fascia lata Fascia lata L free based on lateral femoral circumflex vessels anastomosed to transverse cervical vessels L free based on lateral femoral circumflex vessels anastomosed to thoracoabdominal artery and cephalic vein R free based on lateral femoral circumflex vessels anastomosed to transverse cervical vessels (20 mo) Ca (9 mo) (9 mo) PECTORALIS MAJOR MYOCUTANEOUS FLAPS 4. 63, F Ca (L breast); recurrence; ation 5. 53, M Basal cell Ca of neck & upper chest (7 yr duration) 6. 82, F Ca (R breast); 7. 66, M Recurrent adeno-ca of esophagus, xyphoid area Ribs 3, 4, 5, 6; 10 X 12 lateral sternum R clavicular head; R ribs, 1,2 manubrium of sternum 10 x 7 Ribs 2, 3; lateral 6 x 8 sternum Lower third of 10 X 8 sternum Flap only Flap only Flap only Flap only R pectoralis major myocutaneous R & L pectoralis major and R trapezius myocutaneous L pectoralis major myocutaneous L pectoralis major and R rectus abdominis myocutaneous Ca (5 mo) (12 mo) (12 mo) (3 mo) LATISSIMUS DORSI MYOCUTANEOUS FLAPS 8. 64, F Ca (R breast); Ribs 2, 3 6 X 8 Flap only R latissimus dorsi mastectomy; ir- myocutaneous ; radi- (30 mo) ation 9. 46, F Ca (L breast); Ribs 3, 4 4 X 8 Flap only Latissimus dorsi is- modified radi- land myocu- cal mastectomy; recurrent taneous (6 mo) Ca in incision AXIAL PATTERN FLAPS , M Recurrent squa- Ribs 3, 4, 5 12 X 8 Marlex mesh Deltopectoral axial mous cell Ca of pattern with R lateral chest random pattern (4% yr) wall segment at distal end: one delav Ca = carcinoma.

6 342 The Annals of Thoracic Surgery Vol 32 No 4 October 1981 rib above and below the lesion. If the sternum was involved, that segment of sternum plus a wide margin of normal bone was excised likewise. In the 1 patient with a chondrosarcoma of the sternum, the entire sternum and a large ellipse of overlying skin were removed. In the patients with recurrent tumors, a wide local excision of a full thickness of the chest wall was carried out. Chest Wall Stability In all of the patients with s of the chest, the pleural space was obliterated by a dense, fibrous reaction limiting paradoxical motion of the underlying intrathoracic structures with respiration. Marlex mesh stabilization, therefore, was not necessary among this group of patients. In those patients who had received no therapy and in whom more than two ribs were resected, Marlex mesh was used to give stability to the defect. Marlex mesh was not used in the patients having partial excision of the sternum or in the patient having a total sternectomy. Marlex mesh was used for chest wall stability in 2 patients having resection of primary chest wall tumors and in 3 with secondary tumors. Closure of the Chest Wall Defect RANDOM PATTERN FLAP. In 6 patients having resection of primary or secondary tumors of the chest wall who had not had previous operations or therapy, local tissue in the form of a broad-based rotation or advancement random pattern was used for immediate resurfacing of the defect. Often a split-thickness skin graft was needed to close the donor site from which these s were developed. If, however, the local tissues had been irradiated, as was the case with 5 patients seen early, distant normal tissue was generally needed for closure of the defects. These random pattern s required from two to four delays prior to their transfer. In 2 patients, the forearm was used to transfer abdominal random pattern s to the thoracic defect. AXIAL PATTERN FLAP. An axial pattern was used in 1 patient who had resection of a large recurrent squamous cell carcinoma of the right lateral chest wall. The resulting defect was repaired by a large sheet of Marlex mesh, covered with a deltopectoral. Because of the size of the chest wall defect, an attached, large random pattern component was employed at the distal end of this axial pattern. This random pattern portion required that a single delay be carried out prior to using the for closure of the large full-thickness chest wall defect. MYOCUTANEOUS FLAP. In 6 patients, pectoralis major, latissimus dorsi, and rectus abdominis myocutaneous s were used. In 2 of these patients, the defects were of such large size that more than one myocutaneous was needed to cover the defect. MYOCUTANEOUS FREE FLAP. Myocutaneous free s, which we recently have begun to use with increasing frequency, were employed in 3 patients in the present series. Free s were chosen because of the intense nature of the necrosis in these 3 patients who also had changes in the skin of the back overlying the latissimus dorsi muscles. The free s consisted of the tensor fascia lata muscle as well as a generous portion of fascia lata with overlying skin [23]. Epidermis was removed from the distal half of the, which was turned under, and the dermis was placed against the chest wall. The fascia lata was sutured carefully to the periosteum of the adjacent ribs and sternum and contributed to chest wall stability. The lateral circumflex femoral vessels on which the tensor fascia lata was based were anastomosed to the transverse cervical vessels in two instances and to the thoracoacromial artery and cephalic vein in the other patient. These anastomoses were performed using the operating microscope and 10-0 nylon suture material. Results Chest Wall Stability Chest wall stability proved to be satisfactory in 20 of the 21 patients. The patient having a total sternectomy in whom Marlex mesh was not used had severe ventilatory insufficiency postoperatively and required ventilatory support for eighteen days.

7 343 Boyd et al: Reconstruction of Chest Wall Defects Fig 6. Thoracoabdominal random pattern being prepared in a patient with a of the anterior chest wall. Fig 7. Random pattern covering a chest wall defect following resection of a. Chest Wall Closure Random pattern s of local tissue were used immediately for wound closure in 6 patients who had had no previous operation or therapy. Healing was excellent in 4 of them, and extensive necrosis developed in 2. One of these 2 also had a severe infection of the mediastinum. These latter 2 patients required prolonged hospitalization and numerous grafting procedures in order to close the defects. Among the 5 patients in the random pattern group who had received therapy, distant normal tissue was used (Figs 6, 7), and necrosis developed in 2. In 1 patient the distal 15% of the became necrotic, while in the other, necrosis was extensive and infection developed, resulting in a prolonged course of hospitalization. The 1 patient who received an axial pattern with a random pattern component at its distal end had an excellent cosmetic result with primary healing (Fig 8). Myocutaneous s were used to cover defects, with excellent functional and cosmetic re- sults in 6 patients. In 2 of the patients, the defects were of such large size that more than one was required for closure. In no instance was there any problem with wound healing or necrosis. The 3 patients given tensor fascia lata myocutaneous free s had primary healing and excellent cosmetic results. These s were suitable for coverage of extremely large defects as well as providing a marked degree of stability to the chest wall because of the presence of the vascularized fascia lata component of the (Figs 9, 10). Comment Closure of full-thickness chest wall defects in the past often tested the ingenuity of surgeons [ Flap techniques developed in recent years have made closure of these defects easier, more reliable, and cosmetically more attractive [15-17, 19-23]. Previously employed random pattern s, as demonstrated in this study and that of Stranc and co-workers [24], are prone to complications. Flap necrosis occurred in 4

8 344 The Annals of Thoracic Surgery Vol 32 No 4 October 1981 Fig 10. Tensor fascia lata myocutaneous free cowerage of the defect demonstrafed in Figure 9. Fig 8. Axial pattern w i t h a ralldom pattern cornponent attached to its distal end cowering a large chest wall defect. Fig 9. Extensive necrosis of the anterior chest wall secondary to therapy after mastectomy. (36%) of our 12 patients with random pattern s, 2 of whom also had severe infection. These complications were not seen when the newer techniques were used. Axial pattern, myocutaneous, and myocutaneous free s have other advantages over random pattern s. Each of the newer s has its own intrinsic vascular supply, which permits immediate use despite their length being greater than their breadth. Pectoralis major, latissimus dorsi, and rectus abdominis myocutaneous s are large and thick and, when used alone or in combination, can provide some stability to and coverage of almost any defect of the chest wall with great security. Tensor fascia lata free s are suitable for coverage of large chest wall defects with normal nonirradiated tissue, and their use should be considered in patients whose chest walls show extensive areas of severe change. The use of s with normal tissue and an excellent blood supply should be preferable to using a that has been heavily irradiated since better healing can be expected from the normal tissues. The reliability of myocutaneous free s might be questioned by those not familiar with current microvascular surgical techniques. At present, vascular anastomoses of 1to 1.5 mm

9 345 Boyd et al: Reconstruction of Chest Wall Defects vessels by experienced surgeons using the operating microscope and 10-0 nylon suture material are very reliable. In the last four years at the New York University Medical Center, more than 110 free s have been used with a success rate greater than 96%. In addition to the 3 patients who had full-thickness chest wall defects repaired in this series, 5 other patients had breast reconstruction with myocutaneous free s, and in none of these 8 patients did problems develop. With the report of Marlex mesh as a prosthesis to provide stability to large chest wall defects [6], the use of most other materials became obsolete. When the pleural space is obliterated by a dense fibrosis secondary to ir, when the defect is less than two ribs wide, or when only a portion of the sternum is resected, paradoxical respiration is usually not severe enough to require the use of Marlex mesh. If, however, there has been no therapy or if three or more ribs or the entire sternum has been resected, material to stabilize the chest wall should be used. Until recently this stabilization usually would have consisted of a sheet of Marlex mesh. In 1981 McCormack and colleagues I1 I reported the use of Marlex mesh in conjunction with methyl methacrylate and stainless steel mesh to provide a rigid prosthesis. Our experience with this technique is limited to 3 patients but seems to confirm their observations. We recommend this technique in the repair of large chest wall defects. The use of a foreign body, such as Marlex mesh, in the repair of a potentially contaminated defect of the chest wall is open to question since a foreign body might contribute to a wound infection and breakdown of the repair. In such a circumstance, viable tissue would seem preferable to Marlex. The fascia lata contained in a tensor fascia lata myocutaneous free is strong, as well as viable, having an extensive vascularity on both its deep and superficial surfaces. In all 3 of our patients who had this type of, bleeding from the edges of the fascia was noted following completion of the arterial anastomosis. With underturning of the distal half of the and securing the fascia lata to the edge of the defect, no paradoxical motion was noted in any of these three large defects, healing was uncomplicated in spite of potential contamination, and the cosmetic results were excellent. This experience suggests that a tensor fascia lata myocutaneous free is the best means of providing chest wall stability and coverage of large, potentially contaminated defects. Our experience with axial pattern, myocutaneous, and myocutaneous free s and with the use of Marlex mesh or viable fascia lata for stability leads us to conclude that in almost all instances, full-thickness chest wall defects can be reconstructed immediately. Patient and surgeon can expect an excellent functional and cosmetic result. References 1. 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, Rees TD, Converse JM: Surgical reconstruction of defects of the thoracic wall. Surg Gynecol Obstet 121:1066, Beardsley JM: Use of tantalum plate when resecting large areas of the chest wall. J Thorac Cardiovasc Surg 19:444, Hardin CE, Kittle F: Repair of surgical defects of the chest wall with fiberglass prosthesis. Ann Surg 22:139, Catton BH, Paulsen GA, Dykes J: Prosthesis following excision of chest wall tumor. J Thorac Surg 31:45, Graham J, Usher FC, Perry JL, et al: Marlex mesh as a prosthesis in the repair of thoracic wall defects. Ann Surg 151:469, McGregor IA, Morgan G: Axial and random pattern s. Br J Plast Surg 26:202, Korlof B, Nylen B, Olson P, et al: Resection of the thoracic wall and local repair for recurrence of mammary carcinoma. Br J Plast Surg 26:322, Maier HC: Surgical management of large defects of the thoracic wall. Surgery 22:169, Whalen WP: Coverage of thoracic wall defects by a split breast. Plast Reconstr Surg 12:64, Carberry DM, Ballantyne LWR Jr: Omental pedicle graft in closure of large anterior chest wall defects. NY State J Med 75:1705, Jacobs EW, Hoffman S, Kirschner P, Danese C: Reconstruction of large chest wall defect using greater omentum. Arch Surg 113:886, Campbell DA: Reconstruction of the anterior thoracic wall. J Thorac Cardiovasc Surg 19:456, 1950

10 346 The Annals of Thoracic Surgery Vol 32 No 4 October McCraw JB, Dibbell DG, Carroway JH: Clinical definition of independent myocutaneous vascular territories. Plast Reconstr Surg 60:341, Maxwell GP: Musculocutaneous free s. Clin Plast Surg 7:111, Bakamjian VY: A two stage method for pharyngo-esophageal reconstruction with a primary pectoral skin. Plast Reconstr Surg 36:173, McGregor IA, Jackson IT: The extended role of the deltopectoral. Br J Plast Surg 23:173, Tansini I: Sopra il mio nuovo process0 di amputazione della mammella. Riforma Medica (Palermo) 12:757, Arizan S: The pectoralis major myocutaneous. Plast Reconstr Surg 63:73, Arnold PG, Pairolero PC: Use of pectoralis major muscle to repair defects of the anterior chest wall. Plast Reconstr Surg 63:205, Bostwick J, Nahai F, Wallace JG, et al: Sixty latissimus dorsi s. Plast Reconstr Surg 63:31, Robbins TH: Rectus abdominis myocutaneous for breast reconstruction. Aust NZ J Surg 49:527, Hill HL, Nahai F, Vasconeg 10: The tensor fascia lata myocutaneous free. Plast Reconstr Surg 61:517, Stranc MF, Labanter H, Roy A: A review of 196 tubed pedicles. Br J Plast Surg 28:54, 1975 Discussion DR. NAEL MARTINI (New York, NY): I had the privilege of reviewing these papers in advance of this meeting and agree with both Drs. Eschapasse and Boyd on the feasibility and value of reconstruction of chest wall defects by the various techniques described. Only last year we presented to the Society our experience with chest wall reconstruction, both skeletal and cutaneous. In many patients with chest wall disease, the soft tissue components are not involved and can be spared. In such patients, the skeletal reconstruction is best handled with Marlex mesh prostheses for the smaller defects and by Marlex mesh combined with methyl methacrylate for the larger defects. In patients in whom full-thickness chest wall resection becomes necessary, the regional arterialized s are superior to any other form of cutaneous reconstruction. Also, the cosmetic results are excellent. As correctly described, the pectoralis major, latissimus dorsi, and rectus abdominis muscles provide excellent sources of myocutaneous s to cover full-thickness chest wall defects. We have had occasion to use myocutaneous s in 48 patients to date, and are completely satisfied with the results. The need for a vascular-free graft is rare. It is a tedious and time-consuming procedure that requires specific expertise and equipment, and its use is not warranted except in the rare and select instances when no other method is possible. It is also difficult to ob- tain adequate reconstruction of large defects without using prostheses. The concern that the use of Marlex mesh could be a potential source of infection is not warranted. In areas of necrosis it is essential to excise all irradiated skin underlying necrotic bone, so that all contaminated and potentially infected tissue is removed. When that is done, the risk of infection is extremely low. In our experience, as well as in that presented by Dr. Eschapasse, Marlex mesh and methyl methacrylate have not caused problems of infection. To date we have seen no instance of infection attributed to their use in more than 150 operations, and there has been no need to remove the pros thesis. Whereas resection and reconstruction of most chest wall tumors can be accomplished by the thoracic surgeon, the combined efforts and expertise of the plastic surgeon and the thoracic surgeon are invaluable in the successful reconstruction of fullthickness chest wall tumors. There is need for accurate planning by the combined team before such a procedure is undertaken. There is no mention in Dr. Boyd s paper of the use of intraoperative dyes, such as fluorescein, to make certain that the is viable at the time of its use. The main message to be derived from both papers is that patients with tumors involving the chest wall are amenable to treatment. The results are satisfactory in most patients, and survival is prolonged in some. I congratulate both Dr. Boyd and Dr. Eschapasse for their excellent and timely contributions. DR. ESCHAPASSE: I thank Dr. Martini very much for his kind remarks. I think that both methods of repair, with or without a prosthesis, have very specific indications. The muscle s or other repairs with autologous tissues are certainly the best materials when the size of the defect is small or when there is necrosis. But, when there is a large defect and no infection, the repair with a composite material made with Marlex and methyl methacrylate is an excellent method, which we have been using since I am happy to learn that Dr. Martini has had some experience with this material, even in some patients who have undergone ir. DR. BOYD: I think that there is no disagreement at all between our position and that of Dr. Martini and Dr. Eschapasse. We have a much smaller experience with methyl methacrylate and Marlex but have been very happy with both materials. One of our patients had a huge on the chest wall. The ir involved not only the anterior chest but the posterior chest. We felt very uncomfortable using a local myocutaneous to try to cover that defect, and used a myocutaneous free. The other 2 patients fell in that same general category. Under those conditions, we favor a myocutaneous free, but whenever possible, we favor a simple myocutaneous.