Residency · Residency · Plastic Surgery

Chest Wall Reconstruction

Introduction

Chest wall defects arise from oncologic resection (most common), radiation necrosis, infection (mediastinitis, osteomyelitis), trauma, and congenital anomalies. Reconstruction must address both structural integrity (skeletal stability) and soft tissue coverage. Goals: restore chest wall rigidity to maintain respiratory mechanics, provide durable soft tissue coverage, obliterate dead space, and achieve acceptable aesthetic outcome. Multidisciplinary collaboration with thoracic surgery, surgical oncology, and pulmonology is essential.

Anatomy of the Chest Wall

Bony skeleton: sternum, 12 pairs of ribs, clavicle, scapula, thoracic vertebrae. Musculature: pectoralis major, serratus anterior, latissimus dorsi, rectus abdominis, external and internal obliques, intercostal muscles, trapezius. Ribs 1-7 (true ribs) articulate directly with the sternum via costal cartilages. Ribs 8-10 (false ribs) articulate indirectly; ribs 11-12 (floating ribs) have no sternal attachment.

Internal mammary artery (IMA): runs 1 cm lateral to the sternal border; supplies the anterior chest wall; important pedicle for pectoralis major and superior epigastric artery. Thoracodorsal artery: supplies the latissimus dorsi; originates from subscapular artery.

Indications for Reconstruction

Oncologic resection: primary chest wall tumors (chondrosarcoma, Ewing sarcoma, osteosarcoma), locally advanced breast cancer, lung cancer with chest wall invasion. Radiation necrosis: chronic wounds following radiation therapy; exposed bone, hardware, or lung. Sternal wound infection/dehiscence: most commonly after median sternotomy for cardiac surgery; deep sternal wound infection (DSWI) occurs in 1-3% of cardiac surgery patients. Trauma: flail chest, blast injuries, gunshot wounds with tissue loss. Congenital: pectus excavatum (rarely requires soft tissue reconstruction), Poland syndrome.

Evaluation and Preoperative Planning

CT chest with 3D reconstruction: defines defect size, identifies involved structures, evaluates underlying lung. Assess respiratory function: pulmonary function tests; patients with marginal reserve may not tolerate rigid reconstruction that limits chest wall compliance. Nutritional optimization: albumin, prealbumin, caloric supplementation. Radiation history: prior radiation impairs local tissue healing and limits flap options.

Assess available flap donor sites; prior surgeries (mastectomy, thoracotomy, CABG with IMA harvest) may have divided flap pedicles.

Skeletal Reconstruction

When is Skeletal Reconstruction Needed?

Defects >5 cm in diameter or involving >4 contiguous ribs generally require rigid reconstruction to prevent paradoxical chest wall motion (flail segment). Posterior defects covered by the scapula may not require skeletal reconstruction (scapula provides structural support). Small anterior and lateral defects may be covered with soft tissue alone if no flail segment. Sternal defects: reconstruction depends on extent; partial sternectomy may not require rigid fixation.

Materials for Skeletal Reconstruction

Mesh: polypropylene (Marlex), polytetrafluoroethylene (PTFE/Gore-Tex), composite mesh. Provides tension across the defect; prevents lung herniation. Not truly rigid; does not prevent paradoxical motion for very large defects. Methylmethacrylate (PMMA) sandwich: mesh-PMMA-mesh construct; provides rigid reconstruction.

Molded intraoperatively to match chest wall contour. Advantages: rigid, durable, custom-shaped. Disadvantages: exothermic reaction during curing (thermal injury), infection risk (biofilm), inability to obtain postoperative imaging (artifact). Titanium plates and bars: MatrixRIB system, STRATOS system.

Bridging rib plates screwed to remaining rib stumps. Advantages: anatomic reconstruction, MRI compatible, lower infection risk than PMMA. Disadvantages: cost, hardware prominence in thin patients. Allograft (cadaveric rib or bone): limited use; resorption over time. Autograft (rib, fibula): rarely used for chest wall; donor site morbidity.

<image>Illustration demonstrating chest wall reconstruction after oncologic resection. The left panel shows a full-thickness chest wall defect involving four contiguous ribs (ribs 5-8) on the left lateral chest wall after tumor resection, with the underlying lung visible through the defect. The middle panel shows skeletal reconstruction using a methylmethacrylate sandwich technique: two layers of polypropylene mesh with a rigid methylmethacrylate cement layer between them, contoured to match the curvature of the chest wall and secured to the remaining rib stumps with sutures through drill holes. The right panel shows soft tissue coverage with a pedicled latissimus dorsi myocutaneous flap rotated anteriorly from the back, with the thoracodorsal pedicle labeled. The flap muscle is shown directly overlying the mesh-cement construct, and the skin paddle covers the external defect. Labels identify the resected rib stumps, mesh-cement construct, latissimus dorsi muscle, thoracodorsal artery and vein, and skin paddle.</image>

Soft Tissue Coverage

Pectoralis Major Flap

Workhorse flap for sternal and anterior chest wall defects. Blood supply: dual — thoracoacromial artery (dominant pedicle) and IMA perforators (segmental). Can be advanced as a muscle or myocutaneous flap. Turnover flap: pectoralis elevated on IMA perforators, detached from the thoracoacromial pedicle, and turned over medially to cover sternal defects.

Bilateral pectoralis advancement: most common reconstruction for sternal dehiscence/infection. Limitations: prior IMA harvest (CABG) may compromise the turnover flap; prior mastectomy divides the pectoralis insertion.

Latissimus Dorsi Flap

Large, reliable muscle or myocutaneous flap. Blood supply: thoracodorsal artery (from subscapular system). Provides extensive coverage for lateral and posterior chest wall defects. Can cover large defects (up to 20 x 40 cm skin paddle).

Limitations: patient positioning (lateral decubitus); prior thoracotomy may have divided the thoracodorsal pedicle; seroma at donor site.

Rectus Abdominis Flap

Pedicled on the superior epigastric artery (continuation of IMA). Useful for lower sternal and epigastric defects. Limitations: cannot use if IMA was harvested for CABG; donor site abdominal wall weakness/hernia. Vertical rectus abdominis myocutaneous (VRAM) flap can reach the mid-sternum.

Omental Flap

Pedicled on the right or left gastroepiploic artery. Excellent for filling dead space in deep sternal wounds; highly vascularized and immunologically active. Delivered through an upper midline laparotomy or laparoscopically. Advantages: fills irregular cavities, excellent vascularity, promotes healing in infected fields. Disadvantages: laparotomy required, risk of abdominal complications (hernia, adhesions).

Free Flaps

Reserved for cases where pedicled options are exhausted or unavailable. ALT, DIEP, rectus abdominis, or latissimus dorsi free flaps. Recipient vessels: internal mammary, thoracodorsal, or thoracoacromial vessels.

Specific Clinical Scenarios

Deep Sternal Wound Infection (DSWI)

Classification (Pairolero and Arnold): Type I: within first days; no costochondritis; direct reclosure possible. Type II: 2-6 weeks; purulent drainage, cellulitis, mediastinitis, intact sternum; debridement + flap coverage. Type III: months to years; chronic draining sinus, sternal osteomyelitis; radical debridement of necrotic sternum and cartilage + flap coverage.

Treatment protocol: aggressive debridement of all necrotic bone and cartilage, irrigation, antibiotic therapy, and early flap coverage. Most common reconstruction: bilateral pectoralis major advancement flaps. VAC therapy as a bridge to flap closure if patient is unstable or wound is heavily contaminated.

Radiation-Induced Chest Wall Defects

Chronic, non-healing wounds from prior radiation (breast cancer, lung cancer). Radiated tissue is fibrotic, hypovascular, and hypoxic. Reconstruction requires well-vascularized tissue from outside the radiation field. Pedicled latissimus dorsi or free flap preferred. Irradiated bone (ribs, sternum) may require resection if osteonecrosis is present.

<image>Algorithm for chest wall reconstruction decision-making. The flowchart begins with assessment of defect characteristics at the top, branching into defect size and location. Small defects less than 5 cm or involving fewer than 4 ribs are directed to soft tissue coverage alone. Large defects greater than 5 cm or involving 4 or more ribs are directed to skeletal reconstruction plus soft tissue coverage. The skeletal reconstruction branch subdivides by location: anterior defects directed to mesh or mesh-methylmethacrylate sandwich, lateral defects directed to titanium rib plating or mesh-PMMA, and posterior defects covered by scapula noted as potentially not requiring skeletal reconstruction. The soft tissue branch subdivides by defect location: anterior and sternal defects directed to pectoralis major advancement or turnover flap, lateral defects directed to latissimus dorsi flap, lower sternal and epigastric defects directed to rectus abdominis VRAM flap, and deep cavitary sternal defects directed to omental flap. A final box notes free tissue transfer for cases where pedicled options are unavailable.</image>

Complications

Respiratory insufficiency: from paradoxical motion (inadequate skeletal reconstruction) or restrictive physiology (overly rigid reconstruction). Infection: mesh and PMMA are susceptible to biofilm; may require removal. Flap necrosis: partial or complete; risk increased in irradiated fields. Seroma: common at latissimus dorsi donor site (50-80%); managed with drains and compression.

Hernia: abdominal wall donor site morbidity after rectus harvest. Chronic pain: from mesh, hardware, or nerve entrapment. Hardware exposure: prominent titanium plates may erode through thin skin.

Key Clinical Pearls

Skeletal reconstruction is generally required when the defect exceeds 5 cm or involves more than 4 contiguous ribs; posterior defects under the scapula are an exception and often do not need rigid reconstruction. Bilateral pectoralis major advancement is the workhorse reconstruction for sternal wound infections after cardiac surgery; always verify IMA status before planning a pectoralis turnover or rectus abdominis flap, as prior CABG with IMA harvest divides these pedicles. In deep sternal wound infections, radical debridement of all necrotic bone and cartilage is essential before flap coverage; inadequate debridement leads to recurrent infection regardless of flap choice. The omental flap is uniquely suited for deep, irregular mediastinal dead space; its rich vascularity and immunologic properties make it particularly effective in infected fields. Preoperative CT with 3D reconstruction is essential for surgical planning; it defines defect dimensions, identifies vital structures, and helps select the appropriate skeletal reconstruction material and soft tissue flap.

References

• Arnold PG, Pairolero PC. Chest-wall reconstruction: an account of 500 consecutive patients. Plast Reconstr Surg. 1996;98(5):804-810.
• Mansour KA, Thourani VH, Losken A, et al. Chest wall resections and reconstruction: a 25-year experience. Ann Thorac Surg. 2002;73(6):1720-1726.
• Hameed A, Akhtar S, Naqvi A, Pervaiz Z. Reconstruction of complex chest wall defects by using polypropylene mesh and a pedicled latissimus dorsi flap: a 6-year experience. J Plast Reconstr Aesthet Surg. 2008;61(6):628-635.
• Voss B, Bauernschmitt R, Will A, et al. Sternal reconstruction with titanium plates in complicated cases. Eur J Cardiothorac Surg. 2008;34(1):139-145.

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