Innovative Technique of Chest Wall Reconstruction After Extensive Tumour Ablation Surgery

Abstract

Chest wall reconstruction is among one of the most challenging surgeries because the defect comprises multiple components and each needs to be reconstructed separately with like tissues. Chest wall reconstruction ranges from simple skin cover to complex bony and or mediastinal/precordial reconstruction. Various methods of reconstruction include autologous as well alloplastic techniques. Autologous techniques include regional or distant flaps with or without bone. Whereas alloplastic techniques include the placement of a variety of implant materials like titanium plate/mesh, stainless steel mesh, medpore and biocompatible 3D-printed models. we present this article where extensive resection was performed, aiming to complete removal of recurrent chest wall chondrosarcoma and defect included all components of chest wall including precordial lining. The reconstruction was performed by using combined autologous as well as alloplastic techniques using acrylic implant.

Introduction

The thorax is the region which separates the neck from the abdominal cavity. The thoracic wall/chest wall is divided into anterior, posterior and lateral chest walls. The chest wall consists of the skin on the outer surface, thoracic lining on the inner surface and bony framework in between, consisting of the thoracic vertebra, ribs and sternum. The thoracic cage protects the thoracic contents; hence, any defect or loss should necessarily be replaced by rigid as well as anatomical reconstruction [1].

Smaller defects can be left to heal by itself or primary closed. However bigger defects require reconstruction to prevent cosmetic as well physiologic complications.

Indications for the reconstruction of chest wall are as follows:

1. Thoracic wall defects more than 5 cm in diameter

2. Removal of more than two consecutive ribs

3. Defects with high risk of lung herniation

4. Defects with risk of respiratory compromise

5. Defects prone to produce chances of paradoxical motion of the chest wall, particularly anterolateral defects and full-thickness resections [2].

Since the chest wall is vital for integrity of the human body, surgeon should be careful for its reconstruction. The following goals should be met before deciding the technique of reconstruction.

The primary goals are to obliterate dead space, to restore chest wall integrity and rigidity, to preserve pulmonary mechanism, to protect intra-thoracic organs, to provide soft tissue coverage, to minimize deformity and to allow patients to receive adjuvant radiotherapy if indicated. Various secondary goals are to maximize the post-operative quality of life and to minimum donor site morbidity. Reconstructive technique should not hamper with subsequent treatments.

Hence, a multidisciplinary approach is of utmost importance with the involvement of thoracic cancer surgeons, plastic surgeons, neurosurgeons, medical and radiation oncologists etc.

The aim of chest wall reconstruction is to provide a stable soft tissue cover and rigid bony support, soft and pliable lining for gliding movement, to separate mediastinal and pleural cavities, respiratory functions and negative intra-thoracic pressure.

Various methods for chest wall reconstruction include local flaps, regional flaps and free flaps. For lager defects of the chest wall, free flaps are the only choice in order to provide optimum function. In many adverse conditions, free flap may not be possible like recurrent tumour with high grade; the possibility of recurrence; very large defect which require double free flap and hence increased operating time; the patient is not fit for prolonged surgery like advanced age and comorbidities; and lack of resources like microvascular setup and post-op ventilatory support.

Acrylic implants are being used for various surgeries like cranioplasty and dental procedures [3]. As acrylic implant is biocompatible, moldable, easily available, cost-effective, rigid and radio-opaque, we decided to use acrylic for chest wall reconstruction. In this patient, the bony defect was so extensive that even double barrel design of free fibula bone was not suitable for reconstruction. We customized acrylic implant to replace the entire anterolateral chest wall. On search of literature, we could not find any method which could provide reconstruction of pleura and large bony cage as well as cover, in small duration surgery and without introduction of free flap. This article will be helpful for the reconstruction of extensive chest wall defects in a quick manner without free flap surgery.

Case Report

A 68-year-old gentleman presented to us with complaints of huge swelling on the anterior chest wall since 2 years. He had similar swelling over the same site 5 years ago for which he was operated elsewhere and histopathology showed high-grade chondrosarcoma. On careful clinical examination, the swelling was found to be irregular, single, nontender, hard and fixed to the chest wall along with vertical scar of previous surgery on the anterior chest wall. Radiological confirmation was done by CT scan with 3D reconstruction and MRI. Lesion was found to be extensive involving bilateral chest wall, superiorly up to thoracic inlet, inferiorly up to costal margin and posteriorly up to the mediastinum (Fig. 1).

Fig. 1.

Clinical picture and CT chest with 3D reconstruction showing extensive bony involvement

Traditionally, in such cases, double free fibula flap is the only option which could provide a large amount of the bone as well as the skin. In this case, potential defect was so extensive that even double free fibula osteocutaneous flap was hardly able to meet the anatomic as well as physiologic demands. Considering advance patient’s age, high-grade recurrent tumour, extensive resection and large soft tissue and bony defect, we planned a surgery which could replace all the lost structures in a relatively short duration of operative time. We planned acrylic implant chest wall reconstruction. Cadaveric chest wall of adult male was used to take measurement and impression. Clinical measurements of patient’s chest wall were taken. A male cadaver was selected, whose chest wall size was corresponding to the patient’s chest wall. A wax model was prepared and carved to ascertain the perfect shape and size (Fig. 2). Recent techniques like 3-D printed models may also be used for reconstruction; however, it may not be available at small centres. We could not use 3-D printed images due to high cost.

Fig. 2.

Cadaveric chest wall impression and acrylic implant

After taking the impression acrylization was done, final de-waxing was performed to get chest wall acrylic implant of size 18 × 15 cm, which included the sternum, clavicle and part of the ribs on both sides and separate ribs. Resultant acrylic implant was imposed on the patient’s chest wall to ascertain adequacy.

The patient was operated under general anaesthesia after taking informed consent. Two-team approach was used for the surgery to minimize the operative time. Patient was laid supine on OT table, and adequate incision was made. Tumour excision with adequate free margin was done by thoracic surgeon, and reconstruction was done by plastic surgery team. Complete excision of tumour was achieved and specimen sent for histopathology. After excision, the resultant defect included exposed lung and precordium. The defect comprised of the pleura, pericardium, bilateral clavicle, entire sternum bilateral ribs and overlying muscle and skin (Fig. 3).

Fig. 3.

Complete excision with resultant defect and excised tumour

Reconstruction

A larger segment of fascia lata of size 15 × 15 cm was harvested and sutured tightly to provide airtight closure, which was confirmed by Valsalva maneuvre over the reconstructed lining acrylic implant which was placed and secured rigidly by using titanium miniplates and screws.

After completion of bony cage reconstruction and rigid fixation, the overlying musculocutaneous cover was done by right-sided pectoralis major myocutaneous flap and skin graft over the donor site. Chest drain was placed, and surgery was completed in 3.5 h (Fig. 4). Patient was extubated and recovered well, and post-operative period remained uneventful. Post-operative recovery was uneventful, and the patient’s respiratory parameters were within normal limit. Histopathological report showed chondroid neoplasm, disposed in lobules with intervening fibrous stroma. Lobules were formed by proliferating chondrocytes with 2–3 or more cells per lacunae. Individual cells displayed moderate nuclear pleomorphism with high nucleocytoplasmic ratio and scant cytoplasm; findings were suggestive of well-differentiated chondrosarcoma. Patient was discharged on the 12th post-operative day and followed up to weekly until 2 months and monthly until 8 months. No tumour recurrence was noted. Cosmetic outcome was good, without any obvious chest wall deformity or respiratory compromise and tumour recurrence.

Fig. 4.

Pleura and pericardium reconstruction by fascia lata, bony chest wall reconstruction by acrylic implant, skin cover by pectoralis major myocutaneous flap and delayed outcome

Discussion

Chest wall defects are not a very uncommon scenario with which reconstructive surgeons deal with. Increasing incidence of trauma and tumours is one of the most common factors associated with occurrence of chest wall defects.

Chest wall defects can broadly be classified as congenital and acquired defect. The common causes of congenital defects are pectus excavatum, pectus carinatum, Poland syndrome, dysplasias, sternal clefts, sternal hypoplasia etc., whereas the common causes of acquired defects are tumour, trauma, infections etc.

According to Gilli’s principles of reconstruction, all defects should be reconstructed with like tissues. A reconstructive surgeon should first define the defect in terms of site, size and component so that all components can be reconstructed with like tissue of adequate size [4].

The types of defects can broadly be categorized based either on components or thoracic cavity. Based on the components of the defects, defect can be cutaneous, muscular, osseous, pleural, combination of these, partial thickness, full thickness etc., whereas based on the involvement of the thoracic cavity, defects can be categorized as extra-thoracic defects, intra-thoracic defects and combination of both. Reconstructive procedures for chest wall defects can be done either as single-staged, where definitive reconstruction is done at the time of primary surgery or double-staged procedure, where the wound is covered temporarily and definitive reconstruction is done later. Single-staged reconstruction is an ideal method of reconstruction, unless there is a contraindication like doubtful margin of resection, unfit patient for prolonged general anaesthesia and lack of resources.

Reconstruction of the chest wall can be done as by autologous or alloplastic techniques or combination of both. For smaller defects, autologous techniques are a choice of reconstruction; however, for relatively larger and multi-component defects, combination techniques may provide good results. Full-thickness chest wall defects lack lining and bony framework as well cover. Hence, all three components should be replaced in order to provide optimum cosmesis and respiratory movement.

Ideal choice for reconstruction of chest wall lining is the tensor fascia lata (TFL) graft. TFL provides soft, smooth, pliable and non-fibrotic qualities to facilitate smooth movement of lung during respiration. TFL can be harvested easily, without significant donor site morbidity, and due to its toughness and high suture strength, it provides perfect seal for intra-thoracic contents.

Bony framework can be reconstructed by autologous cortical bone. Smaller defects can be reconstructed by avascular bone graft or titanium plates or polypropylene mesh, bone cement etc., whereas larger defects require vascularized bone graft. Vascularized free fibula is the ideal choice for such defects. We had previously used mesh with cement for the reconstruction but for smaller defects.

Kamran et al. conducted a study of chest wall reconstruction by using non-absorbable polypropylene meshes. They concluded that mesh reconstruction is a reliable tool for chest wall reconstruction for smaller defects. However, for larger defects, involving removal of four or more ribs, rigid bony reconstruction is a preferred method to avoid risk of herniation and paradoxical breathing [5].

Watanabe A et al. conducted study on the use of titanium implants in the reconstruction of chest wall defects after tumour ablation. They found titanium as a safe implant with successful outcomes. However, disadvantage with titanium implant is its high cost [6].

In this patient, we preferred tensor fascial lata over simple mesh, as is autologous, supple and without potential fibrosis. We have been using acrylic implant for cranioplasty and other head and neck reconstructions. In this patient, the preferred acrylic implant is over cement because in our experience, acrylic implant provided better strength, lesser chances of infection and implant extrusion.

The overlying skin cover can be reconstructed by various local, regional or free flaps. Options for flap include pectoralis major myocutaneous flap (PMMC), latissimus dorsi flap (LD), serratus anterior flap, transverse rectus abdominis flap (TRAM), thoraco-epigastric flap, omentum flap, free flaps etc. Among various free flaps, free fibula osteocutaneous flap, free anterolateral thigh flaps and free LD flaps are commonly used flaps [7–10].

Conclusion

Chest wall reconstruction is one of the most challenging reconstruction. Our technique of using acrylic implant with fascia lata and regional flap is an ideal option where free flap is not suitable.

Author Contribution

Sandhya Pandey was responsible for concept, manuscript writing and clinical management of the patient. Vijay Kumar assisted in surgical management. Vikas Sharma is responsible for formatting the revised manuscript. Shailendra Yadav assisted in surgical management.

Data Availability

Data related to this article is available in the record section of our institute.

Declarations

Consent to Participate

The authors certify that they have obtained all appropriate patient consent forms from patient. Consent for surgery, image, publication etc. are taken.

Conflict of Interest

The authors declare no competing interests.