Ann Thorac Surg 1996;62:1837-1839
© 1996 The Society of Thoracic Surgeons
Case Report
Paraffin Plombage of the Chest Revisited
Wickii T. Vigneswaran, MD,
Sai S. Ramasastry, MD
Divisions of Cardiothoracic Surgery and Plastic and Reconstructive Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
Accepted for publication June 11, 1996.
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Abstract
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Complications related to previous thoracic plombage procedures are not uncommon. The management of these complications can be challenging. We present a patient who had a partial resection of the left upper lobe, a seven-rib thoracoplasty, and paraffin wax plombage 38 years previously, in whom a chest wall mass and a discharging sinus developed. She underwent excision and debridement of the paraffin wax mass followed by serratus anterior and latissimus dorsi pedicled muscle intrathoracic transposition. Follow-up at 2 years revealed excellent cosmetic and functional results.
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Introduction
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Operation was the primary mode of treatment for tuberculosis before the discovery of effective chemotherapy. There remains a group of patients at present who, decades ago, had operation as part of the treatment for tuberculosis [1]. These patients infrequently present many years later with complications related to the operation [2]. The optimal management of these complications may be complex and challenging. The most common complications are infections and migration of the plombage material. We report an elderly patient with plombage thoracoplasty in whom we used established techniques to manage migration of infected plombage material, with a successful long-term outcome.
An 83-year-old active woman presented with a large left-sided chest wall mass with extrusion of creamy material causing significant chest discomfort and continuous soiling of her clothes. At presentation she was afebrile and in atrial fibrillation with a ventricular rate of 70 beats/min. A 10 x 15-cm nontender, fluctuant mass was observed in the lateral aspect of the left chest wall with a cutaneous sinus discharging pasty material from the anterior aspect of the previous thoracotomy scar. Chest roentgenography confirmed the previous pulmonary resection, a seven-rib thoracoplasty, and a soft tissue mass in the left side (Fig 1
). The right side was unremarkable. Computed tomographic scan of the chest showed at 15 x 25-cm mass with a fluid level occupying most of the thoracic cavity in the left side. The mass appeared to necessitate through the overlying soft tissues to the cutaneous surface (Fig 2). After her cardiac function was optimized, an operative plan to remove this possibly infected mass was made.
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Fig 1. . Preoperative posteroanterior chest roentgenogram showing a left-sided seven-rib thoracoplasty with resection of the left upper lung. The right lung field is unremarkable.
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Fig 2. . Comparable section of the computed tomographic scan of the chest, preoperatively (A) and 1 year postoperatively (B). (A) The cystic cavity extends from the thoracic space to the cutaneous surface. Note the fluid level. (B) The corresponding space is occupied by the transposed muscle 1 year after the operation.
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A repeat lateral thoracotomy was performed, raising pedicled muscle flaps of latissimus dorsi and serratus anterior. The 15 x 20-cm encapsulated cystic mass was excised from the apex to the mid left chest cavity. The walls of the calcified residual cavity were debrided and then the cavity was packed with antibiotic-soaked cotton rolled bandage and the skin was approximated. The patient was returned to the operating room 48 hours later for further debridement of the cavity. After this the latissimus dorsi and serratus anterior muscles were transposed into the cavity on their vascular pedicles and the overlying soft tissues were closed in layers. The patient recovered without complications and was dismissed from the hospital on the fifth postoperative day after the closure. She remains well at 2 years postoperatively with a normal chest wall contour and excellent function of her left shoulder.
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Comment
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Before the advent of effective chemotherapy, collapse thoracoplasty and plombage were used to treat tuberculosis, with the hope of inactivating the disease. In 1879, Eastlander first used the term thoracoplasty to denote removal of ribs to bring the chest wall down on the lung. Subsequently several techniques were developed including the one by Schede in 1890. He described a technique that included not only multiple rib resections but also the removal of periosteum, intercostal muscles, nerves, and parietal pleura. Because collapse thoracoplasty was considered cosmetically unacceptable, other surgeons used plombage thoracoplasty, introduced by Tuffier in 1891. Plombage maintained the chest contour while obliterating the cavity. The materials used were many and included omentum, fresh lipomas, plastic and Lucite balls, and paraffin wax. As early as 1899, Gersuny popularized the use of paraffin to replace lost tissue. The paraffin injection provokes characteristic granulomatous foreign body reaction. The tissue response develops slowly and is maximal at 3 months. Solid paraffin causes less reaction and, like silicone, it becomes encased in a pseudocapsule [3]. Yet, in some patients who had paraffin plombage decades ago, late complications develop. The most common complications are infection and migration of the plombage material through the chest wall, into the lung parenchyma or into the surrounding structures. Malignant neoplasm also has been reported in association with plombage thoracoplasty [2, 4, 5].
When the plombage material is infected, complete excision and debridement are required and the resulting cavity needs to be obliterated. This could be achieved by several means. One option is to collapse the cavity wall, if the surrounding tissues are pliable, by thoracoplasty. This, of course, results in deformity of the chest and sometimes is not possible due to the rigidity of the surrounding tissue. Another option is to fill the cavity with vascularized tissue. The large pedicled muscles of the chest wall are ideally suited for tissue transposition. Vascularized pedicled muscle has been successfully used to fill infected thoracic space [6, 7]. Its value has also been demonstrated in other situations after debridement of infected material [8]. This does not result in any significant functional loss of the shoulder, and often the chest wall contour is preserved.
In a patient with previous thoracotomy the latissimus dorsi muscle and the serratus anterior muscle may be partly devascularized. It is necessary to establish the pedicled muscles are vascularized before transposing to fill the space. A safe approach would be staging these procedures, as done in our patient, to establish that all pedicled tissues planned to be transposed have adequate blood supply. The staging additionally gives another opportunity to debride the infected space. If the muscle were observed to be devascularized, other muscles such as pectoralis major or rectus abdominis could be used on their vascular pedicle or the omentum, to fill the space.
We demonstrated in our patient pedicled muscle transposition is well tolerated in a chronically calcified infected space, even in the elderly, with no functional loss and an excellent cosmetic result. This technique should be part of the armamentarium of surgeons who treat patients returning with complications related to plombage thoracoplasty.
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Footnotes
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Presented at the Sixty-first Annual Meeting of the American College of Chest Physicians, New York, Oct 29–Nov 2, 1995.
Address reprint requests to Dr Vigneswaran, Division of Cardiothoracic Surgery, University of Illinois at Chicago, M/C 958, 840 South Wood, Chicago, IL 60612.
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References
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- Walkup HE, Murphy JD. Extrapleural pneumolysis with plombage. Am J Surg1979;78:245–50.
- Horowitz MD, Otero M, Thurer RJ, Bolooki H. Late complications of plombage. Ann Thorac Surg1992;53:803–6.
- Goldwyn RM. The paraffin story. Plast Reconstr Surg 1980;65:517–24.[Medline]
- Ashour M, Campbell IA, Umachandran V, Butchart EG. Late complications of plombage thoracoplasty. Thorax 1985;40:394–5.
- Wichmann M, Macha HN, Bas R, Zachgo W, Mikloweit P. Treating plombage complications. Techniques available? [Letter]. Chest 1994;105:1622.
- Pairolero PC, Arnold PG, Piehler JM. Intrathoracic transposition of extrathoracic skeletal muscle. J Thorac Cardiovasc Surg 1983;86:809–17.[Abstract]
- 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]
- Pairolero PC, Arnold PG. Intrathoracic transfer of flaps for fistulas, exposed prosthetic devices, and reinforcement of suture lines. Surg Clin North Am 1989;69:1047–59.[Medline]
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Abstract
Introduction
