A reconstructive algorithm for plastic surgery following extensive chest wall resection.

Chest wall reconstruction following extensive resection is greatly facilitated by the use of vascularised flaps and prosthetic material. Plastic surgeons are often asked to assist with coverage of large chest wall defects. However, in addition to soft tissue coverage, we need to address other important issues such as the status of the pleural cavity, and the requirement for skeletal support. The purpose of this report is to analyse our experience, provide a reconstructive algorithm following the ablative procedure and review the literature. Two hundred chest wall resections were performed from 1975 to 2000. Defect location was divided into anterior (n = 73) lateral (n = 36) anterior-lateral (n = 36) posterior-lateral (n = 19) posterior (n = 22) and forequarter (n = 14) Average number of ribs resected was four. One hundred and fifty-eight patients (79%) required chest wall reconstruction with either prosthetic material and/or flap closure. Mesh closure was required in 85 cases (43%), being highest for lateral defects (61%), and lowest for anterior defects (31%). Vascularised flaps were needed in 112 patients (56%), more common in anterior defects (79%), and less common for the posterior-lateral defects (26%). Inpatient complication rate was 27% (43/158) following reconstruction, with a mortality of 6% (10/158). Chest wall reconstruction is common following extensive resection. This includes management of the pleural cavity, skeletal support and soft tissue coverage. A better understanding of the respiratory mechanics and local thoracoabdominal anatomy is crucial for managing these complex defects. The need for skeletal support was more prevalent in lateral and posterior-lateral defects. Flap reconstruction was required more often to cover large anterior defects, with regional flaps predominating.

Thoracic reconstruction with the omentum: indications, complications, and results.

This study provides a retrospective analysis of 60 patients who underwent thoracic reconstruction with the omentum. Patients were identified by searching several databases to determine demographics, indications for surgery, operative technique, and postoperative course, including donor and recipient site morbidity. From January 1975 to May 2000, the authors harvested and transferred the omentum successfully (57 pedicled, 3 free) in 60 patients (mean age, 60 years; age range, 21-86 years) for sternal wound infections (N = 34), chest wall resections (N = 17), pectus deformities (N = 2), intrathoracic defects (N = 4), and breast reconstruction (N = 3). The omentum was used as a primary flap in 39 patients and as a salvage flap in 21 patients. Average operative time was 3.9 hours and average hospital stay was 34.3 days. Partial flap loss occurred in 7 patients, with no total flap failures. Morbidity included six abdominal wound infections and seven epigastric hernias. Mortality was 11.7%. The omentum can be harvested safely and used reliably to reconstruct varying thoracic wounds and defects. Specific indications from this series include osteoradionecrosis, chest wall tumors, massive sternal wounds, and refractory mediastinitis. Hultman CS, Culbertson JH, Jones GE, et al. Thoracic reconstruction with the omentum: indications, complications, and results.

Forehead reconstruction with a modified radial forearm flap: a case report.

Forehead reconstruction, using a radial forearm flap with opposing long arterial and venous pedicles, is presented. Advantages of this flap design are discussed.

The reverse lateral upper arm flap for elbow coverage.

Closure of soft tissue defects in the vicinity of the elbow has been attempted by numerous methods. The reverse lateral upper arm flap was conceived by applying concepts of previous work. Cadaver studies demonstrated the cutaneous territory and vascular anatomy of this region. The nature of the posterior recurrent radial artery and its perforators allows this fasciocutaneous flap to be perfused in a retrograde fashion. The flap can be used for covering various soft tissue defects around the elbow in a single stage with acceptable donor site morbidity. A case is presented in which the flap was used in a reverse flow fashion to cover an 8 X 11 cm acute cubital defect present after soft tissue release. Operative technique is discussed.

A dermal-fat flap for nipple reconstruction.

A refinement in technique for nipple reconstruction utilizing local tissue is described. The operation has been performed on 31 patients who have previously undergone the transverse abdominal island flap breast reconstruction. The longest follow-up is 12 months. Preliminary results appear excellent with desired nipple size and projection.