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Ann Thorac Surg 1995;60:1372-1375
© 1995 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Soft-Tissue Reconstruction in Thoracic Surgery

Royal Brompton Hospital, London, United Kingdom

Accepted for publication June 9, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Reconstructive techniques using omental and myocutaneous flaps are widely used in the treatment of infected sternotomy wounds. To illustrate their wider role in thoracic reconstruction, we have retrospectively reviewed our experience over the last 5 years.

Methods. We used complex omental and myocutaneous flaps in 30 patients: 19 men and 11 women with a mean age of 53 ± 4 years (range, 43 to 75 years). In 18 patients, these techniques were used to provide soft-tissue cover after chest wall resection, and in 12 cases complex myocutaneous flaps were used to obliterate chronic intrathoracic cavities. Rectus muscle was used in 11 of 24 muscle flaps, and omentum was used in 12 cases. There were 23 rotational flaps and seven free myocutaneous flaps with microvascular anastomosis.

Results. There were no operative deaths, and there were three complications. In 2 patients with infected lesions, loss of the free flap required subsequent revision. In 1 patient, infection developed underneath a prosthesis, which was treated with drainage and rib resection. In all other cases, the primary aim of the operation was achieved without complications.

Conclusions. The vascularity of the omentum should encourage its wider use, especially when infection exists preoperatively. Excellent results can be achieved when using the rectus muscle as a complex myocutaneous flap. The use of free flaps should be reserved for difficult cases and used only in the absence of infection.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The use of myocutaneous flaps in the treatment of sternal infection after coronary bypass operation is well established [1]. With the advantages of not only rotational but also free flaps, a wider range of applications in thoracic surgery was created. Large chest wall lesions with muscle and skin involvement have always been a difficult problem. The use of synthetic prostheses as skeletal support was only partially beneficial because of their limited applications and associated morbidity [2]. Myocutaneous flaps and skin grafts have been used more frequently in association with these prostheses to overcome these difficulties.

Equally important is the use of these flaps in treatment of bronchopleural fistula (BPF) and chronic intrathoracic residual spaces. Schede thoracoplasty is a major operation with high morbidity and deleterious effects on cosmetic appearance. The use of omental with or without muscle flaps can increase the chances of closing the BPF and simultaneously filling the residual space [3].

In this report, we retrospectively review our cases of chest wall reconstruction and intrathoracic residual space filling in which reconstructive techniques using omental or myocutaneous flaps were used.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Over a period of 5 years, from January 1989 to December 1993, omental with or without myocutaneous flaps were used in 30 patients. There were 19 men and 11 women, with a mean age of 53 ± 4 years (range, 43 to 75 years). The flaps were used to reconstruct chest wall defects in 18 patients. The pathologic diagnosis was primary chest wall malignancy in 9 and chest wall invasion by adjacent primary tumor in 7 patients. Chest wall malignancies included chondrosarcoma (2 patients), fibrosarcoma (2), neural sarcoma (2), malignant fibrous histiocytoma (1), malignant schwannoma (1), and sinus histiocytoma (1). Metastatic invasion included breast carcinoma (5 patients) and 1 each with lung malignancy and melanoma.

Twelve of the 16 patients with malignancy had preoperative exposure to radiotherapy. One patient had chronic osteomyelitis of the sternum and in another, chest wall reconstruction was necessary to close a large fenestrum created to drain an empyema.

These reconstructive techniques were also used in a further 12 patients with residual intrathoracic spaces. Postpneumonectomy space accounted for 8 cases, 3 of which were associated with established BPF and 1 with esophagopleural fistula. Postlobectomy space accounted for 2 cases, and 2 cases involved an infected plombage space.

Chest Wall Reconstruction
The need for reconstructive techniques after chest wall resection is dependent on the lesion size and the extent of involvement of the overlying soft tissue or skin. During the period of 5 years, we have performed 125 chest wall resections, in which 18 patients (14.4%) required reconstructive procedures. The 16 patients with primary or secondary chest wall malignancy were subjected to extensive preoperative investigations including high-resolution computed tomographic scan to define the extent of the tissue involvement, the need for intrathoracic procedures such as pulmonary resection, and the absence of distant metastasis. The general condition of the patient were evaluated to plan intensive care unit space or elective ventilation and to ensure that curative resection was possible. All 18 chest wall reconstruction patients were seen preoperatively by the plastic surgeon to discuss thoracic access and the reconstructive technique. Technique was dictated by the site and extent of tissue involvement. The need of skeletal support using a prosthesis or skin cover with the flap or as a graft was also planned when visible. In 15 of 18 cases, skeletal reconstruction with a composite Marlex methylmethacrylate prosthesis was created using two layers of Marlex. The latissimus dorsi (LD) muscle was suitable for use in only six cases, and the pectoralis muscle was used in one case of complete sternotomy for chronic osteomyelitis.

The rectus muscle was used in nine cases and the omentum in two. The flaps were in the form of rotation or transposition in 13 cases and were free flaps in five. One free LD flap was based on the thoracodorsal vessels, and free rectus flaps were based on the internal mammary vessels in three and thoracodorsal vessels in one. Skin cover was necessary in 8 patients and was achieved as a rotational myocutaneous flap in 5. In the other 3, a split skin graft was performed.

All patients were treated with broad-spectrum antibiotics. Both the intercostal and redi-vac drains were inserted routinely and kept until their drainage decreased to less than 50 mL per 24 hours. The use of intensive care unit or elective ventilation was based on the patient's general condition.

Intrathoracic Space
The first-line treatment for early BPF was reexploration and revision of the bronchial stump. Suturing is performed with or without omental flap. For late post-resection empyema with or without fistula, intrathoracic drainage using the intercostal drain is performed. Additional rib resection or fenestration was performed when required. Schede thoracoplasty was the operation of choice for chronic intractable intrathoracic residual space. This was replaced with myocutaneous flap thoracoplasty to achieve better cosmetic and operative results. All patients with previous malignancy were investigated to ensure curative resection and absence of recurrence.

Selected fit patients who had been treated with intercostal tube drainage but who still had residual space were prepared with repeated tube changing and intracavity washing and removal of debris to achieve optimal sterility.

The patients with intrathoracic residual space were managed according to the underlying problem. In cases of early BPF, the stump was revised and resutured using three layers of continuous 3.0 Prolene (Ethicon, Somerville, NJ): two layers of continuous transverse horizontal matrix and a third layer of over and over suture. After checking the air leak, we buried or covered the new stump with omental flap. Late fistulas were managed initially with drainage and rib resection. The residual space was filled with a suitable size of myocutaneous or omental flap.

In 8 of 12 patients a myocutaneous flap was used, with pectoralis muscle in 3, rectus muscle in 2, and LD in another 3. These flaps were either rotational or transpositional except for two free LD flaps based on the thoracodorsal vessels. In five of these eight flaps, additional omentum was brought to the space, three of them to cover the associated BPF. Isolated rotational omental flap was used in four cases. All patients were treated with broad-spectrum antibiotics.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
In all cases of chest wall resection, the operative aim was achieved and the defect was satisfactorily covered with good functional integrity. All resections for malignant diseases were curative with good healthy margins. All infected spaces were filled with sufficient sizes of healthy tissue. There were no inoperable or compromised cases and no operative or hospital deaths. All patients were followed up for a mean of 38 months (range, 7 to 60 months).

In the chest wall reconstruction group, complications developed in 3 patients: one infection and two cases of devitalized free flaps. The first patient was a 69-year-old woman with fungating carcinoma of the breast who had received preoperative radiotherapy and had a history of pulmonary embolism, for which she was taking warfarin. Chest wall resection was constructed using prostheses and rotational rectus muscle and omental flaps, which were then covered with skin graft. Three weeks postoperatively, the patient experienced repeated cough and shortness of breath, and computed tomography results showed an infected collection under the prostheses. Tube drainage under general anesthesia was performed.

The first devitalized flap was a free flap of the contralateral LD muscle based on the thoracodorsal vessels. This was used in a 75-year-old man with malignant fibrous histiocytoma of the chest wall. Eight weeks postoperatively, the flap became infected and was removed; the residual defect healed with granulation tissue after conservative management.

The second patient was a 60-year-old woman 4 years after mastectomy and radiotherapy who had gross lymphedema and an area of radionecrosis. The resected chest wall was reconstructed with prostheses and a free rectus myocutaneous flap based on the thoracodorsal vessels. When the flap was devitalized 24 hours postoperatively, it was successfully revised with a free omental flap based on the internal mammary vessels.

Despite the prolonged drainage (3 to 9 days), recurrent seroma was noted in 6 patients, and repeated aspiration under aseptic technique was performed. The actuarial 5-year survival of the 16 patients with malignant chest wall lesions was 62.3% (±2). All six late deaths were due to metastatic disease.

Among the 12 cases in which intrathoracic flaps were used, there were no complications and there was one late death in a patient with postpneumonectomy empyema. The pneumonectomy was for unstaged lung cancer resected elsewhere. Although there was evidence of macroscopic recurrence at the time of the operation, the operation was performed as a palliative procedure. Metastatic disease developed 3 months after operation, which led to the patient's death. There were no other deaths or recurrences of infection in the remaining 11 cases during the follow-up period, averaging 32 months (range, 4 to 58 months).

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The use of omental or myocutaneous flaps is well established in plastic surgery, as it allows more extensive resection with safety margins if necessary and gives satisfactory cosmetic and functional results. In chest wall reconstruction, skeletal support can be achieved by creating a prosthesis of two layers of Marlex with a layer of methylmethacrylate in between. Large lesions, for which the resection would involve both overlying muscle and skin, require the additional use of myocutaneous flap [4, 5]. The risk of skin necrosis, repeated seroma, and infection is low, and more satisfactory functional and cosmetic appearance can be achieved.

Among the 18 cases for which chest wall resection was needed, skeletal support was required in 15 patients (83%). This rigid ``shield'' prosthesis gives better support and reduces the need for prolonged mechanical ventilation, which would have been necessary otherwise [6].

As most of the soft-tissue lesions with or without skin involvement were due to direct invasion, there was limited use of the LD. This muscle was used in six cases, two of which were transposed contralateral muscle and one of which was a free flap of the contralateral side.

Large defects involving the anterolateral chest wall muscle limit the use of the serratus anterior muscle. The rectus muscle as a myocutaneous flap has the advantage of being able to cover large defects, besides the possible use of the overlying skin [7]. In our series, the rectus was used in nine cases, five with the overlying skin as rotation flaps.

The omentum is a healthy tissue with a rich blood supply [8] that makes a good cover for large prostheses and can easily accept a skin graft [9]. Pectoralis muscle, on the other hand, makes a good cover for sternal defects [1].

In cases of intrathoracic spaces, the presence of established BPF necessitates omental or muscle transposition. For cases of post-pneumonectomy, we advise that the stump be cleaned, transected, and sutured with omental cover. Myocutaneous flaps can be used to fill the space as a one-stage operation [10]. Long-term use of preoperative chest drainage is helpful to prevent the recurrence of empyema after the operation [11].

Rotation and transposition flaps were the main surgical procedure to fill an intrathoracic cavity. All rectus, pectoral, and LD muscles were equally useful [3], whereas the serratus anterior is too small to be used for filling large intrathoracic residual spaces.

The omentum alone can be sufficient to fill small spaces. We used it successfully in 2 patients: one after right upper lobectomy for cavitating lung lesion and one after left pneumonectomy with Schede thoracoplasty. The omentum also has the advantage of producing angiogenic factors [3]. We have used it frequently as a supplement when myocutaneous flaps were used to fill a residual infected space. This accelerates bronchial healing and has an antiinflammatory effect [12], while its transposition would involve the addition of a simple surgical procedure.

Preoperatively, the sterility of the space should be maximized and prophylactic antibiotics should be used routinely, guided by the available cultures.

The selection of patients preoperatively led to the absence of prolonged ventilation or respiratory insufficiency postoperatively. Death from recurrent malignancy occurred in 1 of our patients. Meticulous preoperative investigations for all malignant cases to exclude distant metastasis and to ensure a curative resection can reduce the incidence of such complications. The risk of infection after insertion of a prosthesis is common, especially in high-risk patients who have had preoperative radiotherapy or previous skin necrosis or infection. Simple drainage of the empyema with rib resection and intercostal tube drainage is usually sufficient to clear the infection. Excess serous discharge should be expected, and both the redi-vac and the intercostal drains should be retained until drainage decreases, which usually occurs within 5 to 7 days. Further seroma should be aspirated only if it is large, and using aseptic technique. Free flaps were used only in cases of technical difficulty with rotation flaps, and two of the seven free flaps (28%) became devitalized (one after 8 weeks and the second after 1 day). The reason for devitalization was poor blood flow, but we think that free flaps should be avoided when infection is a risk.

In conclusion, the use of omental with or without myocutaneous flaps enabled us to resect safely the large chest wall defects and to fill post–pulmonary resection space infection. The extensive preoperative investigation in malignant cases and the use of intercostal tube drainage to improve sterility in infected cases should be required when myoplastic techniques are to be used to decrease the postoperative morbidity.

The rectus muscle has proved to be a good myocutaneous flap, especially in large defects involving the chest wall muscles and in large intrathoracic spaces; it can also carry healthy skin with it, giving a good cosmetic appearance. The use of free flaps should be limited to cases in which there is technical difficulty in using rotation or transposition flaps or the risk of infection is minimal. Omental pedicle as an isolated flap or in association with other muscular flaps has proved to be useful in both chest wall reconstruction and intrathoracic space infection.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Goldstraw, Royal Brompton Hospital, Sydeny St, London SW3 6NP, UK.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Pairolero PC, Arnold PG, Harris JB. Long-term results of pectoralis major muscle transposition for infected sternotomy wounds. Ann Surg 1991;213:583–9.[Medline]
2. Pairolero PC, Arnold PG. Thoracic wall defects: surgical management of 205 consecutive patients. Mayo Clin Proc 1986;61:557–63.[Medline]
3. Pairolero PC, Arnold PG, Trastek VF, Meland NB, Kay PP. Postpneumonectomy empyema, the role of intrathoracic muscle transposition. J Thorac Cardiovasc Surg 1990;99: 958–68.[Abstract]
4. McCormack PM. Use of prosthetic materials in chest-wall reconstruction: assets and liabilities. Surg Clin North Am 1989;69:965–6.[Medline]
5. McKenna RJ Jr, Mountain CF, McMurtrey MJ, Larson D, Stiles QR. Current techniques for chest wall reconstruction: expanded possibilities for treatment. Ann Thorac Surg 1988;46:508–12.[Abstract]
6. Nash AG, Tuson JRD, Andrews SM, Stacey-Clear A. Chest wall reconstruction after resection of recurrent breast tumours. Ann R Coll Surg Engl 1991;73:105–10.[Medline]
7. Miyamoto Y, Hattori T, Niimoto M, Toge T. Reconstruction of full thickness chest wall defects using rectus abdominis musculocutaneous flaps; a report of 15 cases. Ann Plast Surg 1986;16:90–6.[Medline]
8. Goldsmith HS, Griffith AL, Kupferman A, Catsinpoolas N. Lipid angiogenic factor from omentum. JAMA 1984;252:2034–6.[Abstract/Free Full Text]
9. Mathisen DJ, Grillo HC, Vlahakes GJ, Daggett WM. The omentum in the management of complicated cardiothoracic problems. J Thorac Cardiovasc Surg 1988;95:677–84.[Abstract]
10. Miller JI, Mansour KA, Nahai F, Jurkiewicz MJ, Hatcher CR. Single-stage complete muscle flap closure of the postpneumonectomy empyema space. A new method and possible solution to a disturbing complication. Ann Thorac Surg 1984;38:227–31.[Abstract]
11. De la Rocha AG, Robertson GA. Sealing the post pneumonectomy space: use of a pectoralis major myodermal flap. Ann Thorac Surg 1984;38:221–6.[Abstract]
12. Shimizu J, Odo M, Hayashi Y, et al. Evaluation of surgical treatment of the usefulness of the omental pedicle flap method. Eur J Cardiothorac Surg 1993;7:543–7.[Abstract]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): David K. Kaplan Peter Goldstraw Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Al-Kattan, K. M. Articles by Goldstraw, P. Search for Related Content PubMed PubMed Citation Articles by Al-Kattan, K. M. Articles by Goldstraw, P.