The bony thorax with its overlying muscles and integument creates a cage that protects the relatively fragile heart, great vessels, lungs, esophagus, and large lymphatic vessels. 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. Technological advances in cardiac surgery include cardiopulmonary bypass, intraaortic 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 permitted more complex sternal and chest wall defects to be reconstructed successfully. In this chapter we focus on a multidisciplinary approach to reconstruction of the chest and highlight the three most common flaps used for large defects: the latissimus dorsi muscle, pectoralis major muscle, and omentum.
The chest wall has a robust blood supply provided anteriorly by the internal mammary vessels that are connected via intercostals to the aorta. Multiple other arteries, including the thoracoacromial trunk, transverse cervical artery, and thoracodorsal artery, provide the blood supply to muscles around the upper chest, back, and shoulders. Thorough understanding of the intricacies of the chest wall vasculature, including angiosomes, allows 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. This is generally performed with a variety of materials, including synthetic and biologic implants. An understanding of the biomaterial-tissue interface is critical to planning a 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 to ensure that the flap will survive after transfer. Because of the robust blood supply to the chest skin, many wounds can be closed using moderate tension without tissue 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 susceptibility to infection.
The reconstructive surgeon must carefully match the many possible solutions to a thoracic defect with the needs of the specific patient. Chest wall compliance is a function of age. Older patients have barrel chest development and stiffening of the costochondral junction. These patients often can tolerate more options for chest wall reconstruction than a younger patient, in whom movement may result in chest wall instability. Younger patients require careful attention to the donor site and ultimate functional and aesthetic outcome and can tolerate ...