Chest Wall Reconstruction

Chest wall reconstruction is necessary when there is a defect in the thoracic or chest area. The most common cause of chest wall defects is an infected or unstable median sternotomy wound. A median sternotomy is a surgical procedure in which a vertical incision is made along the sternum (also known as the breastbone), after which the sternum is divided or cracked. This procedure provides access to the heart and lungs for surgical procedures.

Chest wall defects are grouped into two general categories: acquired and congenital.

Acquired:

• Trauma
• Tumor
• Infection
• Radiation

Congenital:

Poland Syndrome

Pectus Excavatum

Pectus Carinatum

The goals of reconstruction are to:

• Remove unhealthy, devitalized tissue from the chest wall
• Restore stability and structure to the chest wall
• Obliterate any dead space (dead space is the empty space that results after removing part of the lung or the entire lung)
• Provide durable coverage for the chest wall
• Achieve aesthetic results

The chest wall has three layers:

Outer layer: Soft tissue, which includes the skin, subcutaneous fat, and muscle

Middle layer: Skeleton, which includes the ribs, cartilage, and sternum

Inner layer: Pleural space, which is the space (cavity) between the skeleton and the lungs

One, two, or all three layers may have to be reconstructed depending on the defect. The reconstructive sequence begins with the deepest tissues and proceeds to the most superficial -- pleural cavity, then skeletal framework, and finally soft tissue.

Additionally, the type of reconstruction done will depend on the defect location on the chest wall.

• The goal of reconstructing the inner layer, also known as the parietal cavity, is to obtain an airtight pleural cavity.
• This is done by filling the dead space to avoid it being filled with fluid and/or pus.
• Dead space is filled by using muscle flaps (also known as locoregional flaps) in the region of the defect or using omentum:

Latissimus dorsi flap

Serratus anterior flap

Pectoralis major flap

Rectus abdominis flap

Omental flap

Alloplastic reconstruction:

Mesh reinforced with methyl methacrylate

Bone grafts

Autogenous reconstruction:

Latissimus dorsi flap

Serratus anterior flap

Pectoralis major flap

Rectus abdominis flap

Omental flap

• The soft tissue (skin, subcutaneous tissue) is considered the outer layer
• The defect of the soft tissue can be partial thickness (superficial wound) or it can be full thickness (deeper wound)

Partial thickness wounds are reconstructed with:

Split-thickness skin grafts or

Locoregional flaps

Full thickness wounds are reconstructed with:

Locoregional flaps

Free flaps in rare cases