Chest Wall Reconstruction
Skeletal reconstruction thresholds, mesh vs titanium vs 3D printing, and the muscle flap repertoire.
Indications
- Chest wall tumours — primary, secondary, or metastatic
- Traumatic chest wall injuries
- Congenital chest wall malformations
- Radiation necrosis of the chest wall
- Post-sternotomy wound complications and mediastinitis
- Osteomyelitis of ribs or sternum
Goals of reconstruction
- Protect vital structures — heart, great vessels, lung
- Maintain chest wall dynamics and ventilation mechanics
- Prevent dead space — reduces infection and fluid accumulation
- Provide durable, well-vascularised soft tissue cover
- Minimise deformity of shoulder and spine
- Facilitate post-operative adjuvant radiotherapy if required
Skeletal (bony) reconstruction
Skeletal reconstruction is required for: sternal defects (any size) · anterior chest wall resection of >4 ribs · posterior chest wall resection of >10 ribs · defect >5 cm diameter · risk of scapular entrapment. Without skeletal reconstruction in these situations: risk of cardiac/great vessel injury, lung herniation, flail chest, and respiratory failure.
| Material | Indication | Notes |
|---|---|---|
| Prolene mesh | Small defects | Flexible scaffolding; allows tissue ingrowth; inexpensive |
| PTFE (Gore-Tex) patch | Small–medium defects; infected fields | Impermeable; resistant to infection; no tissue ingrowth |
| PMMA (methylmethacrylate) composite with mesh | Large defects requiring contouring | Rigid; custom-moulded intraoperatively; good cosmesis; not MRI-compatible |
| Titanium plates / fixation system | Rib and sternal reconstruction | Custom-manufactured; strong; MRI-compatible; expensive |
| Rigid prosthesis | Sternal reconstruction; defects >25 cm diameter | Prevents paradoxical movement; essential for sternal stability |
| 3D-printed custom prosthesis | Complex defects; revision surgery | Precise contouring; reduced friction on adjacent ribs; more stable during respiration; better aesthetics; disadvantage: cost and availability |
Soft tissue reconstruction
Good soft tissue cover must be provided in all patients with a chest wall tissue defect — regardless of whether skeletal reconstruction is performed. Poorly vascularised wounds over prosthetic material lead to chronic infection, prosthesis exposure, and reconstruction failure.
For small defects with adequate surrounding tissue — no tension on closure.
For superficial defects with a healthy vascularised wound bed — granulating wounds after debridement.
Workhorse of chest wall reconstruction. Brings well-vascularised tissue to cover prosthetics, fill dead space, and resist infection.
For large defects or when regional flaps are unavailable (previous surgery, radiation). Requires microsurgical anastomosis.
Regional muscle flaps
| Muscle flap | Arterial pedicle | Primary use |
|---|---|---|
| Latissimus dorsi | Thoracodorsal artery (subscapular artery) | Posterior and lateral defects; largest volume flap available |
| Pectoralis major | Pectoral branch of thoracoacromial artery | Anterior chest wall; sternal wounds; post-sternotomy mediastinitis |
| Serratus anterior | Thoracodorsal artery (subscapular artery) | Lateral defects; used with latissimus dorsi for large defects |
| Trapezius | Transverse cervical artery | Posterior upper chest and neck defects |
| Rectus abdominis | Superior and inferior epigastric vessels | Lower chest wall; sternal defects; large volume |
| External oblique | Intercostal / deep / superficial circumflex iliac artery | Lower anterior chest wall |
Beyond chest wall reconstruction, regional muscle flaps are invaluable for: coverage of bronchopleural fistula · filling of infected pleural space (post-pneumonectomy empyema) · buttressing of bronchial stump after pneumonectomy · reinforcement of oesophageal anastomosis · coverage of mediastinitis wounds after cardiac surgery.
Planning principles
The surgeon performing the resection and the surgeon performing the reconstruction must agree on the plan before the first incision. The choice of flap determines which skin incisions are made for tumour resection — an incision that undermines a planned flap's blood supply, or that crosses the wrong territory, can make reconstruction impossible. Joint pre-operative planning is not optional.
Factors determining choice of reconstruction material:
- Size and location of the defect
- Previous radiotherapy (reduces vascularity — avoid prosthetics in irradiated fields where possible)
- Infection or contamination of the field
- Available donor sites (previous surgery may have divided pedicles)
- Patient's performance status and ability to tolerate a prolonged operation
- Need for post-operative radiotherapy
All clinical content should be verified against current guidelines before clinical application. This resource is intended for revision and educational purposes only.
Standard textbooks
- Shields TW, LoCicero J, Reed CE, Feins RH. General Thoracic Surgery. 7th ed. Lippincott Williams & Wilkins.
- Sellke FW, del Nido PJ, Swanson SJ. Sabiston & Spencer Surgery of the Chest. 9th ed. Elsevier.
- Pearson FG, et al. Thoracic Surgery. 3rd ed. Churchill Livingstone.