Residency · Residency · Cardiothoracic Surgery
Chest Wall Resection and Reconstruction
Introduction
Chest wall resection and reconstruction encompasses the surgical management of primary and secondary chest wall tumors, radiation necrosis, and complex chest wall defects. These procedures require an understanding of chest wall anatomy, oncologic principles, and reconstructive techniques to restore structural integrity, protect intrathoracic organs, and preserve respiratory mechanics. Multidisciplinary collaboration between thoracic surgery, plastic surgery, and orthopedic surgery is often essential.
Anatomy of the Chest Wall
The chest wall consists of 12 pairs of ribs, costal cartilages, the sternum, thoracic vertebrae, intercostal muscles, and overlying soft tissue. Blood supply derives from the internal mammary arteries, intercostal arteries (branches of the thoracic aorta), thoracodorsal artery, and lateral thoracic artery. Innervation comes from the intercostal nerves (ventral rami of T1-T11) and the subcostal nerve (T12). The chest wall provides rigid support for respiratory mechanics, and loss of more than 5 cm of chest wall or more than 3-4 ribs typically requires prosthetic reconstruction to prevent paradoxical motion.
Indications for Chest Wall Resection
Primary Chest Wall Tumors
Benign tumors include osteochondroma (the most common benign rib tumor), fibrous dysplasia, chondroma, and desmoid tumors. Malignant tumors include chondrosarcoma (the most common primary malignant chest wall tumor), osteosarcoma, Ewing sarcoma, solitary plasmacytoma, and malignant fibrous histiocytoma. Soft tissue sarcomas arise from intercostal muscles, fascia, or connective tissue.
Secondary (Metastatic) Involvement
Secondary involvement includes direct invasion from lung cancer (T3 tumors involving the chest wall), breast cancer invading the chest wall, and metastatic disease to ribs and sternum (particularly from renal cell carcinoma and thyroid carcinoma).
Non-Neoplastic Indications
Non-neoplastic indications include radiation necrosis of the chest wall, chronic osteomyelitis of the ribs or sternum, chest wall defects from trauma, and flail chest reconstruction.
Preoperative Evaluation
Cross-sectional imaging with CT chest with IV contrast provides bony and soft tissue detail, while MRI offers superior soft tissue characterization and assessment of neurovascular involvement. PET-CT stages malignant tumors and assesses for distant metastases. Core needle biopsy is preferred over incisional biopsy, with the biopsy tract planned within the planned resection field. Pulmonary function testing assesses respiratory reserve, especially for large resections. 3D CT reconstruction aids in planning the extent of resection and prosthetic reconstruction.
Surgical Technique
Principles of Resection
Wide en bloc resection with a margin of 2-4 cm circumferentially is required for malignant tumors. At least one uninvolved rib above and below the tumor should be included. Involved lung parenchyma, pericardium, or diaphragm is resected en bloc if necessary. Frozen section margins are obtained intraoperatively. For benign tumors, marginal excision with a 1-2 cm margin is typically sufficient.
Reconstruction Principles
Small defects (less than 5 cm) or those covered by the scapula posteriorly may not require prosthetic reconstruction. Larger defects require rigid or semi-rigid reconstruction to prevent paradoxical chest wall motion (flail) and protect underlying organs. Reconstruction goals include structural stability, airtight closure, soft tissue coverage, and acceptable cosmesis.
| Prosthetic Material | Properties | Best Indication | Advantages | Limitations |
|---|---|---|---|---|
| PTFE/Gore-Tex (2 mm dual-mesh) | Airtight, waterproof | Most common; anterior/lateral defects | Watertight seal; easy to handle | No rigidity; not for large bony defects |
| Polypropylene mesh (Marlex) | Strong, porous | Moderate defects with soft tissue coverage | Tissue ingrowth; strong fixation | Not airtight; requires flap coverage |
| Methylmethacrylate sandwich | Rigid (mesh-PMMA-mesh) | Large bony defects requiring rigidity | Custom-molded; excellent stability | Contraindicated in contaminated fields |
| Titanium rib plating (MatrixRIB) | Anatomic rigid fixation | Rib fractures, chest wall stabilization | Anatomic reconstruction; locking plates | Cost; hardware prominence |
| 3D-printed titanium | Patient-specific custom | Complex or large defects | Precise anatomic fit | Expensive; requires planning time |
Prosthetic Materials
PTFE/Gore-Tex patches (2 mm dual-mesh) provide an airtight, waterproof barrier and are the most commonly used prosthetic. Polypropylene mesh (Marlex) is strong but requires soft tissue coverage and allows tissue ingrowth. The methylmethacrylate sandwich (mesh-methylmethacrylate-mesh) provides rigid reconstruction for large bony defects and is custom-molded intraoperatively. Titanium rib plating systems (MatrixRIB, STRATOS) provide anatomic rib reconstruction with locking plates and screws. 3D-printed titanium implants are custom prostheses designed from preoperative CT data, representing an emerging technology for complex reconstructions.
Soft Tissue Flaps
The latissimus dorsi flap is the workhorse for lateral and posterolateral defects, with a reliable pedicle from the thoracodorsal artery. The pectoralis major flap provides advancement or turnover for anterior and sternal defects. The rectus abdominis flap (VRAM/TRAM), based on the superior epigastric artery, covers inferior chest wall and epigastric defects. The serratus anterior flap is useful for axillary and lateral chest wall defects. The omental flap excels at filling dead space and covering prosthetic material with its highly vascularized tissue. Free flaps including the anterolateral thigh (ALT), scapular, or other free tissue transfers are reserved for massive defects when pedicled options are insufficient.
Specific Clinical Scenarios
Lung Cancer Invading the Chest Wall (T3)
En bloc lobectomy with chest wall resection achieves 5-year survival of 25-40% with complete (R0) resection. Positive margins (R1/R2) significantly worsen prognosis. Neoadjuvant chemotherapy or chemoradiation may be considered for borderline resectable tumors.
Sternal Tumors
Partial or total sternectomy with reconstruction uses methylmethacrylate sandwich or titanium plating. Bilateral pectoralis major flaps provide soft tissue coverage. Careful preservation of internal mammary arteries, when possible, supports flap perfusion.
Chest Wall Sarcomas
Wide excision with negative margins is the primary treatment. Adjuvant radiation therapy is used for high-grade or close-margin sarcomas. The role of chemotherapy varies by histologic subtype, with responsiveness in Ewing sarcoma and less so in chondrosarcoma.
Postoperative Care
Pain management with thoracic epidural or paravertebral nerve blocks and multimodal analgesia is critical for respiratory mechanics. Pulmonary toilet with incentive spirometry, early mobilization, and aggressive chest physiotherapy reduces complications. Large resections may require prolonged ventilatory support. Wound care includes monitoring for seroma, infection, and prosthetic complications.
Key Clinical Pearls
Chondrosarcoma is the most common primary malignant chest wall tumor and is resistant to chemotherapy and radiation, making wide surgical excision the only curative treatment. Defects under the scapula are functionally protected, and prosthetic reconstruction may be unnecessary if the defect is entirely posterior and covered by the scapula. The methylmethacrylate sandwich technique provides rigid reconstruction but is contraindicated in contaminated fields due to infection risk. Core needle biopsy should be performed through skin that will be excised en bloc with the tumor; poorly placed biopsies can compromise the resection. 3D-printed titanium implants represent a promising frontier for anatomically precise, patient-specific chest wall reconstruction.
References
- Spicer JD, Shewale JB, Antonoff MB, et al. The influence of reconstructive technique on perioperative pulmonary and infectious outcomes following chest wall resection. Annals of Thoracic Surgery. 2016;102(5):1653-1659.
- Weyant MJ, Bains MS, Venkatraman E, et al. Results of chest wall resection and reconstruction with and without rigid prosthesis. Annals of Thoracic Surgery. 2006;81(1):279-285.
- Demondion P, Mercier O, Kolb F, Fadel E. Sternal replacement with a custom-made titanium plate after resection of a solitary breast cancer metastasis. Interactive Cardiovascular and Thoracic Surgery. 2014;18(1):145-147.
- Deschamps C, Tirnaksiz BM, Darbandi R, et al. Early and long-term results of prosthetic chest wall reconstruction. Journal of Thoracic and Cardiovascular Surgery. 1999;117(3):588-592.