Narrative review: a multidisciplinary approach to chest wall reconstruction

Abstract

Background and Objective

Chest wall reconstruction (CWR) remains a surgical challenge for both thoracic and plastic surgeons owing to the physiologic and anatomic complexity of the region. Successful reconstruction re-establish chest wall integrity, obliterate dead space, preserve pulmonary function, and ensure robust soft tissue coverage. This narrative review discusses modern principles of CWR, including advances in biomaterials and surgical techniques, with an emphasis on the role of thoracoplastic collaboration.

Methods

A literature search was performed on PubMed for MeSH terms and keywords pertinent to CWR. Randomized controlled trials, retrospective studies, systematic reviews and case studies published from November 5, 1995 through November 5, 2025 were eligible for inclusion.

Key Content and Findings

New biomaterials have popularized hybrid and mesh-based approaches to skeletal fixation that preserve respiratory function and protect native tissue from implanted materials. Virtual surgical planning (VSP) and three-dimensional (3D) technology is increasingly used for operative planning and fabricating custom prostheses. While local pedicled flaps remain a mainstay of soft tissue reconstruction, advances in microsurgical tissue transfer have allowed for reconstruction of increasingly large and complex defects. Employing a thoracoplastic approach to CWR is vital to successfully reconstructing complex defects.

Conclusions

CWR remains an area of active innovation, and reconstructive approach varies widely by anatomic region, defect characteristics, and surgeon preference. The rise of new biomaterials and 3D printing holds immense promise for custom reconstructive approaches. Formalized thoracoplastic collaboration throughout the perioperative period is crucial to leveraging the expertise of both thoracic and plastic surgeons, particularly in highly complex cases.

Introduction

Chest wall reconstruction (CWR) remains a significant surgical challenge owing to the anatomic and functional complexity inherent to the chest and pleural space and the unpredictability of the final defect (1). Goals of reconstruction include re-establishing chest wall integrity, obliterating dead space, preserving pulmonary function, and ensuring robust soft tissue coverage. The pursuit of these goals has resulted in significant evolution in CWR since the first reported instance of composite resection and local flap closure in 1906 (2). Decades of advancements in surgical techniques and biomaterials have improved quality of life and functional outcomes for patients undergoing these major surgeries, even in the setting of exceptionally large chest wall defects (3-5). In the modern era, extirpative surgeons can pursue radical resection with confidence that the armamentarium of reconstructive approaches will allow for successful reconstructive outcomes (6). The increasing technical complexity of these operations in conjunction with ongoing advancements in biomaterials, three-dimensional (3D) printing, and surgical technique make multidisciplinary collaboration critical to delivering effective patient care (1,7). This narrative review will discuss current approaches to CWR and highlight recent advancements with a specific focus on the role of thoracoplastic collaboration. We present this article in accordance with the Narrative Review reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1781/rc).

Methods

A literature search on PubMed was performed for the MeSH terms and keywords identified in Table 1. Randomized controlled trials, retrospective studies, systematic reviews and case studies pertaining to reconstruction of composite chest wall defects published between November 5, 1995 and November 5, 2025 were eligible for inclusion; abstracts, theses, and correspondences were excluded from the search. Non-human and non-English language studies were also excluded. Resultant abstracts were then independently reviewed by two investigators (G.O. and D.D.). Qualifying manuscripts subsequently were selected for inclusion by study team consensus. A diagram of the literature review process is depicted in Figure 1.

Table 1. Search strategy.

Items	Specification
Date of search	November 5, 2025†
Database searched	PubMed
Search terms used	((“chest wall”[tiab] OR “thoracic wall”[tiab] OR “sternum”[tiab] OR rib[tiab] OR ribs[tiab]) OR (“thoracic wall/surgery”[MeSH] OR “thoracic wall/anatomy and histology”[MeSH]) OR (“wall reconstruction”[tiab])) AND (“reconstruction”[tiab] OR “reconstructive surgery”[tiab] OR “reconstructive surgical procedures”[MeSH] OR “plastic surgery”[tiab] OR “soft tissue reconstruction”[tiab] OR “chest wall reconstruction”[tiab] OR “sternal reconstruction”[tiab] OR “thoracic wall reconstruction”[tiab] OR “resection and reconstruction”[tiab] OR “defect reconstruction”[tiab] OR “prosthetic reconstruction”[tiab]) AND (defect*[tiab] OR resection*[tiab] OR “full thickness”[tiab] OR “sternal wound”[tiab] OR “chest wall defect”[tiab] OR tumor*[tiab] OR neoplasm*[tiab] OR sarcoma*[tiab] OR cancer*[tiab]) AND( flap[tiab] OR “surgical flaps”[MeSH] OR “free flap”[tiab] OR “muscle flap”[tiab] OR “myocutaneous flap”[tiab] OR “latissimus dorsi”[tiab] OR “pectoralis major”[tiab] OR “rectus abdominis”[tiab] OR “titanium”[tiab] OR “titanium mesh”[tiab] OR “titanium plate”[tiab] OR “methyl methacrylate”[tiab] OR “surgical mesh”[tiab] OR “biologic mesh”[tiab] OR “acellular dermal matrix”[tiab] OR prosthes*[tiab] OR implant*[tiab] OR plate*[tiab] OR bar*[tiab]) AND English[lang] AND (“1995/11/05”[PDAT]: “2025/11/05”[PDAT]) NOT (“review”[Publication Type] OR “systematic review”[Publication Type] OR “meta-analysis”[Publication Type] OR “case reports”[Publication Type] OR “comment”[Publication Type] OR “editorial”[Publication Type] OR “letter”[Publication Type] OR “conference abstract”[Publication Type] OR “dissertation abstract”[Publication Type] OR “thesis”[tiab] OR “abstract”[ti])
Timeframe	November 5, 1995–November 5, 2025
Inclusion and exclusion criteria	Inclusion: studies specific to composite chest resection and reconstruction; article types included randomized controlled trials, reviews, and case studies. Exclusion: abstracts, correspondences
Selection process	Two authors (D.D. and G.O.) reviewed the resultant study abstracts to identify relevant articles given the above inclusion criteria

^†, search criteria were revised in full following initial submission on August 31, 2025. November 5, 2025 reflects the date of the initial search with our revised criteria.

Figure 1.

Flow chart depicting results of literature review.

Discussion

Principles of CWR

Successful CWR must balance regional anatomic and pathophysiologic complexity with defect-specific characteristics, such as size, functional impact, and history of prior interventions. There remains a lack of consensus regarding optimal approach for CWR and multiple algorithms have been proposed as decision-making aids (8-13). Recent studies demonstrating similar postoperative functional outcomes regardless of biomaterial used (biologic versus synthetic, rigid versus flexible) indicate that a high-quality, biomimetic reconstruction may be more important to reconstructive outcomes than the material itself (6,14,15). Ultimately, the reconstructive methods employed largely depend on surgeon preference, the location and extent of resection, available soft tissue coverage options, and complicating factors such as radiation or infection (9,16).

Resection and fixation

Despite subtle nuances between CWR algorithms and practices, all are based on similar underlying principles. It has long been accepted that chest wall defects requiring repair fit one or more of the following criteria: diameter exceeding 5 cm, surface area exceeding 100 cm², removal of three or more ribs from the anterior chest, removal of four or more ribs from the posterior chest, or location below the fourth rib posteriorly (17). Full resection of chest wall tumors is critical, with recommended margins of 2 cm for benign lesions and 4 cm for malignancies (18). Subsequent reconstruction focuses on restoring the skeletal structure of the chest wall, preserving respiratory mechanics, and providing an acceptable cosmetic outcome (2,3,7,9).

Skeletal reconstruction methods vary by anatomic area. Anterior regions can be divided into the sternum, anterolateral ribs, and costal margin. Complete sternectomy requires rigid reconstruction to stabilize the chest wall and protect mediastinal structures. The “sandwich” technique is often used in this setting, where the sternum is recreated with a rigid methyl methacrylate (MMA) or titanium prosthesis that is then placed between two layers of mesh to yield a well-integrated implant that preserves respiratory motion and prevents paradoxical breathing (3,19-23). This is a rapidly changing area, and leveraging 3D imaging to create custom titanium or high-density polymer sternal prostheses is likely to increase the options for CWR in the coming years (24). Large anterolateral defects also dramatically impact respiratory mechanics, and successful reconstruction must restore rib continuity, protect intrathoracic organs, and prevent lung herniation (25,26). Rigid vertical rib plating across rib levels for these defects should generally be avoided as it may impair chest mechanics and cause excessive strain on adjoining structures, resulting in prosthetic failure (27). Hybrid approaches consisting of rigid and non-rigid materials are of particular benefit in this area as meshes provide a protective barrier between rigid implants and adjacent skin and organs (20). Costal margin defects are uniquely challenging due to involvement of both the thoracic and abdominal cavities. Use of rigid implants in this region may cause discomfort or damage underlying organs, thus approaches utilizing rigid fixation for the upper costal margin and non-rigid mesh in the lower costal arch are preferred to reduce these complications (9,11,21).

Reconstruction of the posterior apical ribs is often less complex than anterior defects due to the limited role of this region in respiratory function and protection of visceral organs. Defects typically only require skeletal reconstruction if greater than 10 cm, with the exception of posterolateral defects that require reconstruction if the underlying scapular tip is at risk of impingement (2,25). Smaller defects can be reconstructed with mesh and soft tissue coverage (2,8,25,28).

The material selected for skeletal reconstruction must be biocompatible, able to tolerate function-related stress at the anatomical site, and appropriate for use in infected or irradiated areas, if applicable (9). Conventional synthetic materials include MMA cement, polypropylene, polyester, and polytetrafluoroethylene (PTFE) mesh. These offer excellent stability to the chest but carry infection risk in irradiated areas (9,11). Biologic meshes composed of acellular dermal matrices (ADM) or decellularized xenograft collagen scaffolds are used in settings where rigid fixation is not required as they carry lower infection risk and integrate with surrounding tissues through neovascularization, cellular ingrowth, and tissue remodeling (9,11,29). In the modern era, hybrid approaches that utilize rigid materials such as titanium plates or struts in combination with non-rigid materials are becoming increasingly common as they leverage the benefits of each biomaterial (2,11,19,20).

Soft tissue coverage

Similar to rigid fixation, soft tissue reconstruction of the chest wall varies widely and multiple reconstructive methods are often available for the same defect. A strong understanding of reconstructive options and relevant vascular and musculoskeletal anatomy is essential (26). Regional pedicled flaps are generally favored where available, as they offer reliable coverage without the increased intraoperative time or risk of thrombosis associated with microvascular reconstruction (6,8).

The latissimus dorsi, pectoralis major, rectus abdominis, and serratus anterior are well-established workhorse flaps for CWR (2,10,30,31). The latissimus dorsi is versatile and suitable for most anterior and anterolateral defects, with a broad arc of rotation and skin paddle measuring up to 20–35 cm (30). Its vascular pedicle is the thoracodorsal artery, which is prone to damage by thoracotomy or axillary incisions (10). For sternal coverage, the pectoralis major is often used, and the arc of rotation afforded by the thoracoacromial pedicle allows for reconstruction of supraclavicular and axillary defects as well (2,30). Historically, the rectus abdominis has been used to cover large anterior defects such as that from complete sternectomy. It is supplied by the deep superior or inferior epigastric artery and can be raised with a large skin paddle for cutaneous defects. While it does offer robust coverage, it confers substantial donor site morbidity yielding a significantly weakened abdominal wall. Furthermore, overlying skin may have poor contour in the setting of large body habitus resulting in poor cosmesis and tissue quality (25,30). This, coupled with advances in microsurgical technique, makes free flaps a more compelling option for large defects (4).

The omentum is also classically considered a workhorse flap, though it too has decreased in popularity for sternal reconstruction following the rise of microvascular reconstruction. It is based off the gastroepiploic arteries and provides coverage anywhere on the anterior chest wall (2). It remains an excellent choice in an infected or irradiated field owing to its richly vascularized tissue (10), and is also useful when flexible, pliable tissue is required to fill dead space or recipient vessels for microvascular anastomosis are unavailable. However, flap size is impossible to estimate, presenting a challenge for preoperative planning (25).

Historically, indications for microvascular reconstruction have been limited to instances where locoregional options were insufficient or unavailable due to defect size, lack of local options in the setting of irradiated tissue or prior surgeries, or pedicle damage sustained during the resection (3,8,10,12,25). Common free flaps for CWR include the anterolateral thigh, deep inferior epigastric perforator, rectus muscle and latissimus dorsi muscle flaps. Common recipient vessels include the internal mammary, thoracodorsal, lateral thoracic, thyrocervical and axillary arteries. Locoregional and free flaps most frequently used in CWR are detailed in Figure 2, including the relevant vascular pedicles and recipient vessels.

Figure 2.

Tissue flaps and vasculature used in soft tissue reconstruction of the chest wall. [A] Internal mammary artery perforator flap; [B] pectoralis major muscle flap; [C] omental flap; [D] deep inferior epigastric artery perforator flap; [E] rectus abdominis muscle flap; [F] anterolateral thigh flap; [G] latissimus dorsi muscle flap; [H] thoracodorsal artery perforator flap; [I] trapezius muscle flap. Solid lines represent vascular pedicles; dashed lines represent common recipient vessels used for microsurgical anastomosis.

Innovation in CWR

Advancements in biomaterials

Continued innovation in CWR biomaterials reflects an ongoing search for the optimal reconstructive approach. In recent years, ADM has emerged as a favored option in CWR. Following implantation, native cells integrate into and revascularize the scaffold, forming a tissue layer that more closely approximates native tissue than synthetic alternatives. This ultimately results in a layer that offers stronger support for the pleural space and protection for thoracic organs relative to synthetic options while preserving pulmonary function and improving aesthetic results (32-34). Though ADM is expensive, long-term evaluations suggest it may be cost-effective, as it reduces postoperative infections and the associated need for reoperation, extended hospital stays, or readmission (33,34). Collectively, this evidence positions ADM as potentially superior to synthetic materials. While a consensus has not been achieved on the superiority of allograft versus xenograft options, each have demonstrated comparable efficacy at reconstructed sites and either is suitable for flap coverage (29,32,33).

Polyether ether ketone (PEEK), widely used in orthopedic, cranial, and maxillofacial reconstruction, has more recently been explored for thoracic applications. Huo et al. and Wang et al. utilized computerized tomography (CT)-based modeling software to simulate planned resections and fabricate patient-specific 3D PEEK implants of the sternum and ribs, secured with titanium screws. These studies found that PEEK prostheses provided favorable clinical outcomes, attributed to their ability to enhance structural support, sustain chest wall stability, and preserve long-term respiratory function (35,36).

Lastly, the introduction of the Strasbourg Thoracic Osteosynthesis (STRATOS) rib fixation system in 2014 marked an important shift in rigid CWR. Carvajal et al. reported higher rates of late-term complications associated with MMA compared with titanium plate systems, prompting their institution to transition away from MMA in favor of titanium-based fixation (37).

Incorporation of 3D technology

The rise of 3D printing has led to the development of custom titanium implants, MMA molds, and PEEK prostheses. Historically, MMA was challenging to use due to difficulty achieving precise anatomic contouring. The advent of 3D printing, however, has improved its utility as patient-specific implants can be derived from silicone molds generated from CT imaging. These are resource intensive in the preoperative period, typically requiring one day for printing, followed by 24 to 48 hours for curing and about 30 minutes for sterilization (38). Intraoperatively, however, casting MMA takes 15 minutes and implantation requires an additional 30 minutes. These durations are comparable to, or shorter than, traditional freehand techniques. Studies have demonstrated that patients undergoing CWR with 3D-assisted MMA models experience fewer postoperative symptoms, improved respiratory mechanics, and superior cosmetic outcomes compared to non-rigid reconstruction methods (38,39).

Incorporation of 3D technology to fabricate custom titanium implants is perhaps the area of most rapid evolution in CWR. These are transforming rigid fixation by reducing operative time, decreasing intraoperative blood loss, and improving postoperative pulmonary function (24,40,41). Smith et al. demonstrated that patient-specific 3D models generated from preoperative imaging required only 5.65 minutes of preoperative titanium plate shaping, with the plates achieving excellent fit and requiring minimal intraoperative modification (42). In addition to improving operative efficiency, 3D-printed titanium plates have been shown to exhibit enhanced biocompatibility and corrosion resistance while maintaining mechanical strength comparable to conventional rigid fixation systems (40). Studies have found that 3D-printed titanium plates are associated with reduced intraoperative bleeding, fewer postoperative complications, and decreased postoperative pain when compared with traditional fixation methods (43). The ability to design precise, anatomically contoured plates enables more dynamic CWR that better preserves pulmonary function postoperatively (44). Collectively, these findings suggest that 3D printing offers significant clinical advantages over traditional rigid fixation techniques. However, the benefits of custom 3D printed titanium plates is not without cost: custom plates for two ribs costs $1,200 and those for the sternum cost $1,300. This cost would be higher still for more complex models (45).

In highly complex reconstructions, multidisciplinary surgical teams are using advanced 3D imaging modalities and virtual surgical planning (VSP) technology to more precisely estimate defect size and define reconstructive options, resulting in improved surgical decision making, preoperative patient counseling, and postoperative outcomes (24,40). Similarly, detailed 3D-printed models are being used to enhance preoperative planning by allowing surgeons to conceptualize complex approaches, aiding in preservation of critical anatomy. They are also helpful as adjuncts to facilitate intraoperative decision-making and improve perioperative patient education, resulting in shorter operative times and higher patient satisfaction (24,40,41).

Evolving indications for microvascular reconstruction

Locoregional pedicled flaps have historically dominated soft tissue reconstruction, but recent advances in microsurgery have liberalized indications for microvascular reconstruction in favor of optimizing postoperative function and better preserving cosmesis (3,4,6,9,28,46). Though few studies directly compare pedicled and free flap reconstruction, microvascular reconstruction has proven effective for large defects with rates of postoperative complications such as infections, delayed wound healing, and flap necrosis similar to pedicled alternatives (23,47). Advantages of free flaps include decreased wound burden near the resection site and preservation of trunk muscles that structurally support the chest wall and aid in inspiration, resulting in faster functional recovery and improved long-term outcomes (4). They also often give superior aesthetic results as transferred tissue generally has more anatomically appropriate bulk and contour with relatively discreet donor site defects (4,6). Conventional concerns regarding microvascular reconstruction use include increased operative time, length of stay, and risk of flap loss due to thrombosis, but studies have thus far shown that free flap recipients have shorter lengths of stay with similar operative times and flap survival outcomes when compared to local flap recipients (4,6,46,47).

Thoracoplastic approach to CWR

Thoracic and plastic surgeons have long collaborated on the surgical management of extensive defects (48,49). The aforementioned advances in biomaterials and surgical techniques have broadened eligibility for CWR (6), and increased case complexity has driven a need for more intentional, codified multidisciplinary collaboration. Extirpative and reconstructive surgeons generally work very closely, as they are coupled in the pursuit of negative-margin resection and durable, functional repairs that minimize pathophysiological disruption (10,24,31,48). Cornerstones of a thoracoplastic approach include collaborative preoperative planning, dynamic intraoperative engagement from both teams throughout the resection and reconstruction phases, and close postoperative co-management.

In an era of increased case complexity, adopting a thoracoplastic approach to CWR has become an area of innovation, with many institutions endorsing structured operative approaches that balance extirpative and reconstructive principles (24,46,49). While options for regional and microsurgical soft tissue reconstruction abound in many patients, regional flaps and important recipient vessels for microvascular reconstruction can easily become injured during resection, thus significantly limiting reconstructive options during the index procedure as well as any subsequent reoperations (10,46). Improved collaboration has resulted in increased regional flap availability, enhanced operative efficiency, and adoption of more patient-centered reconstructive approaches while preserving strong functional outcomes (7,46,49,50).

Preoperative collaboration

Given the breadth of underlying etiology and presentation, a comprehensive preoperative assessment must be completed, including imaging and tissue biopsy, consistent with oncologic guidelines (18). The workup must also include evaluation of patients’ baseline cardiac, pulmonary and nutrition statuses with optimization of any modifiable risk factors (9,28). A thorough physical exam is essential in developing a plan for soft tissue coverage, as history of prior radiation therapy or surgeries may affect the zone of resection and significantly impact local tissue coverage options (10). For complex and extensive reconstructions, preoperative imaging must include high-resolution CT scan. Given their demonstrated efficacy with respect to surgical planning and patient education, surgical teams may consider supplementing this imaging with virtual 3D reconstructions and/or printed models on a case-by-case basis (24,40).

Following these evaluations, a multidisciplinary preoperative planning meeting should be held during which key data is collectively reviewed, a staged operative approach defined, and a postoperative protocol for monitoring established (51). Resecting surgeons should detail the extent and anticipated functional impact of the defect and preliminary surgical plan, including any implanted materials required, as this will directly inform the reconstructive approach (26). Likewise, plastic surgeons should discuss anticipated first, second, and even third-line reconstructive options, highlighting pertinent imaging findings and relevant vascular anatomy for each.

Intraoperative collaboration

Intraoperative collaboration between thoracic and plastic surgeons is dynamic and will vary with each case, but at minimum consists of shared input on patient positioning, incision design, and initial dissection (3,46). At induction, patient placement should be optimized to minimize intraoperative repositioning between case stages. In the setting of microvascular reconstruction, thoughtful positioning may allow for a two-team approach wherein resection and free flap harvest occur simultaneously, thus maximizing operative efficiency (3,4). Likewise, incision placement should be deliberate, allowing ample exposure for successful resection while maximizing preservation of neighboring soft tissue and locoregional flaps (46). This approach maintains reconstructive optionality while mitigating risk of wound healing complications and infection.

In complex cases, involvement of plastic surgery during initial dissection may be merited to maximize use of natural tissue planes. This avoids inadvertent damage to local flap pedicles or recipient vessels and minimizes sacrifice of muscles that support respiratory function and chest wall stability (46,47,49,52,53). Where vessels do need to be sacrificed, modifications to surgical technique, such as preferentially using clips for hemostasis to limit spread of thermal injury, help to preserve reconstructive options.

Postoperative monitoring

Postoperatively, close monitoring and clear communication from each surgical team is crucial to minimize complications and facilitate smooth recovery. It is essential that endpoints for safe discharge, including respiratory function and activity tolerance, are discussed and agreed upon by the entire treatment team, as postoperative recovery timeline will vary by extent of resection and reconstructive details. Furthermore, many patients will have range of motion limitations to minimize inadvertent firing of involved muscles or prevent obstruction of the vascular pedicle; these too must be agreed upon and clearly communicated to the patient and caregivers, with additional occupational or physical therapy support provided as needed.

For patients undergoing free flap reconstruction, postoperative monitoring includes hourly exams by skilled care teams during which a complete flap assessment is performed, including review of implanted doppler signals, flap turgor and capillary refill (52). This frequently necessitates intensive care unit (ICU)-level care per institutional protocols. In addition, large defects and/or anatomic nuances may require that patients remain intubated postoperatively with close monitoring during ventilator wean (4).

Benefits and challenges

Implementing thoracoplastic processes in CWR has been shown to improve intraoperative decision-making and outcomes (4,11,28,53). A two-team approach to incision planning and initial exposure is associated with reduced intraoperative blood transfusion volume, lower incidence of regional muscle sacrifice, and higher utilization of local flap options (28,46). Postoperatively, co-management has been associated with reduced risk of surgical site infection and wound dehiscence as well as faster functional recovery with decreased lengths of stay (4,46). While two studies associated a thoracoplastic approach with longer operative times, this was not found to have a negative impact on outcomes (28,46). Ultimately, each of these studies is limited by small sample size given the relative rarity of these cases and additional studies are required to investigate these early findings.

Conclusions

While CWR remains a complex surgical challenge, advances in biomaterials and refinement of surgical technique have made successful reconstruction of defects previously considered inoperable possible. Innovation in this area is ongoing, and customized materials such as 3D-printed biomimetic implants hold immense promise to further improve outcomes (18,54). Adopting a thoracoplastic approach to CWR positions thoracic and plastic surgeons to maximize functional outcomes and quality of life in patients with chest wall tumors.

Supplementary

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Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.