The bony thorax with its overlying muscles and integument creates a cage that protects the relatively fragile heart, great vessels, lungs, esophagus, and large lymphatics. Disruption of the thorax by trauma, tumor, congenital anomaly, infection, or surgical intervention can have potentially lethal consequences. Advances in cardiac and thoracic surgery have enabled surgeons to operate safely within these cavities. Positive pressure ventilation with the use of selective tubes and bronchial blockers permits surgeons to open the pleural spaces and continue respiration while the pleural cavity is disrupted. Advances in cardiac surgery include cardiopulmonary bypass, intra-aortic balloon pumps, and ventricular assist devices that permit continued or augmented perfusion with oxygenated blood. These advances combined with a better understanding of biomaterials,1–3 tissue-engineered solutions, and advances in plastic and reconstructive surgery4–6 have allowed more complex sternal and chest wall defects to be successfully reconstructed. In this chapter we will focus our efforts on the multidisciplinary approach to reconstruction of the chest and highlight the three most common flaps used for large defects: the latissimus dorsi, pectoralis major, and omental flaps.
The chest wall has a robust blood supply provided anteriorly by the internal mammary vessels that arise from the subclavian artery and are connected via intercostals to the aorta. Multiple other arteries including the thoracoacromial trunk, transverse cervical artery, and the thoracodorsal artery provide the blood supply to muscles around the upper chest, back, and shoulders. A thorough understanding of the intricacies of the chest wall vasculature, including angiosomes, will allow the surgeon to design reliable flap coverage for most defects. Occasionally, if regional flaps are insufficient or unavailable, free tissue transfer may be necessary to close selected defects.
Large chest wall defects may benefit from a stable reconstruction of the ribs or rib cartilages to maintain adequate pulmonary function (see also Chapter 137). This is generally performed with a variety of materials including synthetic and biological implants. An understanding of the biomaterial/tissue interface is critical to the proper planning of any reconstructive operation. In addition, the stiffness of the biomaterial should optimally match that of the region being replaced to avoid stress concentrations at the junction between the biomaterial and normal tissue.
Meticulous surgical technique is essential in dissecting flaps and allowing them to survive when transferred. Because of the robust blood supply to the chest skin, many wounds can be closed with moderate tension without breakdown. Many chest wall reconstructive procedures occur before or after radiation therapy. Radiated tissues can be difficult to work with because of increased stiffness and their susceptibility to infection.
The reconstructive surgeon must carefully match the many possible solutions of a thoracic defect to the needs of the specific patient. Chest wall compliance is a function of age, with older patients developing stiffer costochondral junctions and barrel chests. ...