Interdisciplinary thoraco-plastic surgery for chest wall reconstruction: a clinical practice review based on single-center quality control data

Abstract

Thoracic defects arise from a broad spectrum of causes, including tumours, congenital deformities, infections, and radiation-induced damage. Their surgical management is often challenging and typically requires close interdisciplinary cooperation, particularly between thoracic and plastic surgeons. This retrospective project included all patients who underwent thoracic wall resection and subsequent reconstruction at the University Hospital Basel between January 2013 and January 2025. During this 12-year period, 89 patients with chest, lung, pleura, and breast pathologies underwent thoracic reconstruction. The proportion of patients with an oncological diagnosis was 17% (n=15). Overall, there were 63 men (71%) and 26 women (29%). The mean age was 64±13 years. Pectoralis major flaps were used in 34 patients; latissimus dorsi (LD) flaps were used in 25 patients, with additional pectoralis major flaps in 2 patients and a combination of pectoralis flap reconstruction with a vertical rectus abdominis myocutaneous (VRAM) flap in 3 patients. Isolated VRAM reconstruction was performed in 4 patients, and in one patient, transverse rectus abdominis myocutaneous (TRAM) flap reconstruction was performed. In 2 patients, the serratus anterior muscle was used, and in one patient each, a vastus lateralis flap and an obliquus externus flap were applied for defect coverage. In 16 patients, the defect was covered plastically by local skin rotation. Chest wall reconstruction following extensive thoracic resection is safe and effective when guided by a structured, stepwise approach and close interdisciplinary collaboration.

Introduction

Thoracic defects arise from a broad spectrum of causes, including tumours, congenital deformities, infections, and radiation-induced damage. Advances in plastic and reconstructive surgery have significantly expanded options for the treatment of complex chest wall defects. Close collaboration between the ablative and reconstructive teams is essential to allow appropriate preoperative planning of the resection while at the same time considering the available reconstructive strategies. The optimal reconstructive approach depends on the location, depth, and configuration of the defect, with the ultimate goals of eliminating dead space and maintaining or restoring chest wall stability and reliable coverage. Methods for the safe restoration of thoracic wall function include the use of reliable synthetic and biological materials, metal-based skeletal support systems, and plastic surgery techniques that may include skin grafts, local or regional pedicled flaps, and free microsurgical chimeric flaps. In addition, the use of local flaps from the trunk allows the management of pleural cavity problems, such as the filling of postpneumonectomy empyema (PPE) spaces and the closure of bronchopleural fistulas (BPFs). In this article, we review and discuss our 12 years of experience with resection and reconstruction of the chest wall.

Paradigms of plastic surgical procedures on the thorax

Patients and methods

All patients who underwent thoracic wall resection and subsequent reconstruction at the University Hospital Basel between January 2013 and January 2025 were included. During this 12-year period, 89 patients with pathologies of the chest, lung, pleura, and breast underwent procedures for thoracic reconstruction. Overall, there were 63 men (71%) and 26 women (29%). The mean age of the patients was 64±13 years. The patient cohort was divided into six heterogeneous groups; these are summarized in Table 1. The proportion of patients with an oncological diagnosis was 17% (n=15). This quality control project was registered with the Ethikkommission Nordwest- und Zentralschweiz on 12 March 2026 under Registration No. 2026-00327. Individual consent was not needed for the retrospective descriptive analysis.

Table 1. Surgical indications for chest wall reconstruction (n=89).

Groups within the patient cohort	N (%)
1. Sternal osteomyelitis	35 (39)
2. Empyema or osteomyelitis of the sternoclavicular joint	18 (20)
3. Tumours of the lung or mediastinum with infiltration of the chest wall, or recurrence of breast cancer	15 (17)
4. Extensive chest wall infections with or without rib osteomyelitis	14 (16)
5. Pleural empyema with or without bronchial fistulas	5 (6)
6. Tracheo/broncho-oesophageal fistula	2 (2)

Reconstructive procedures

The choice of flap for soft-tissue reconstruction was based on the size of the defect and on its location and depth. Where feasible, local flaps were used to repair soft-tissue defects because of their arc of rotation and defect size. Following these principles, pectoralis major flaps were used in 34 patients; latissimus dorsi (LD) flaps were used in 25 patients, with additional pectoralis major flaps in 2 patients and a combination of pectoralis flap reconstruction with a vertical rectus abdominis myocutaneous (VRAM) flap in 3 patients. Isolated VRAM reconstruction was performed in 4 patients, and in one patient, transverse rectus abdominis myocutaneous (TRAM) flap reconstruction was performed. In 2 patients, the serratus anterior muscle was used, and in one patient each, a vastus lateralis flap and an obliquus externus flap were applied for defect coverage. In 16 patients, the defect was covered plastically by local skin rotation. Skeletal reconstruction to restore chest wall stability was performed according to institutional experience using synthetic materials with metal plates and screws when indicated and was individualized to the defect.

Functional results

The patients underwent long-term outpatient follow-up. A favourable functional outcome was observed in 76 patients (86%), whereas certain functional limitations were recorded in 2 patients (2%). Follow-up data were unavailable for 11 patients (12%).

Complications

Complications were assessed using the Clavien-Dindo classification system (1). The most prevalent postoperative complication within 30 days of reconstruction was seroma (6 cases), followed by pleural empyema (4 cases) and local wound infection or disturbed wound healing (3 cases). Among late complications (those occurring after 30 days), osteomyelitis occurred most frequently (6 cases), followed by pleural empyema (3 cases) and local wound infection or disturbed wound healing (3 cases). Reoperation was performed in 6 patients who experienced early postoperative complications and in 12 patients who experienced late complications (Table 2). Furthermore, four patients underwent repeated surgery as a late complication. In cases of recurrent inflammatory disease, the initial measure consisted of surgical management of the infection via aggressive, repeated debridement and, typically, vacuum-assisted closure (VAC) therapy combined with systemic antibiotic therapy tailored to the antibiogram. In instances in which subsequent surgical intervention was performed, the preexisting muscle flaps were utilized; in only a single case was the initial muscle flap lost. In most cases, an additional flap was created to supplement the existing muscle flap, which was potentially reduced in size. The selection of muscle flap was determined by the extent of the (residual) defect; local muscle flaps or pedicled local muscle flap reconstructions were preferentially used, while free muscle flaps with microsurgical anastomosis to regional vessels were employed as a last resort.

Table 2. Surgery-related complications of grade II or higher according to the Clavien-Dindo classification, reoperations, and functional results.

Groups within the patient cohort	1	2	3	4	5	6	Total, n (%)
Patients	35	18	15	14	5	2	89 (100)
Early complications (in-hospital and 30-day follow-up period)	6	1	4	3	1	2	17 (19)
Failing flap			1				1 (2)
Impaired wound healing	2			1			3 (3)
Osteomyelitis	1			1			2 (2)
Partial flap necrosis	1						1 (2)
Pleural empyema			1		1	2	4 (4)
Seroma	2	1	2	1			6 (7)
Late complications	4	2	4	2	1		13 (15)
Failure of the osteosynthesis material	1						1 (2)
Impaired wound healing	1	1		1			3 (3)
Osteomyelitis	2	1	1	1	1		6 (7)
Pleural empyema			3				3 (3)
First Redosurgery	5	1	5	4	2	1	18 (20)
Early redosurgery	1		1	2	1	1	6 (7)
Late redosurgery	4	1	4	2	1		12 (13)
Functional results
Good functional results	26	17	15	14	4		76 (86)
Functional limitations	2						2 (2)
Unknown	7	1			1	2	11 (12)

The highest grade for each complication per patient was recorded, considering the hospitalization (including a 30-day follow-up period) and the late follow-up period separately. 1, sternal osteomyelitis; 2, empyema or osteomyelitis of the sternoclavicular joint; 3, tumours of the lung or mediastinum with infiltration of the chest wall, or recurrence of breast cancer; 4, extensive chest wall infections with or without rib osteomyelitis; 5, pleural empyema with or without bronchial fistulas; 6, tracheo/broncho-oesophageal fistula.

Tumour recurrence

Among the oncological patients, tumour recurrence was observed in three: two with breast cancer and one with locally advanced lung carcinoma. Reoperation was performed in all three of these patients, and the patients survived with good postoperative outcomes.

Mortality

Five of the 89 patients in the total cohort died because of advanced comorbidities. Two of these cases involved sternal osteomyelitis and mediastinitis with subsequent sepsis following cardiac surgery. One involved sternal osteomyelitis associated with extensive mediastinal recurrence of thymic carcinoma. Another involved a concomitant tracheoesophageal fistula, and one involved mediastinitis resulting from spontaneous oesophageal necrosis after aortic valve replacement.

Principles of chest wall reconstruction

Indications

Thoracic wall defects can be categorized by aetiology as tumour-related (primary or metastatic) or as induced by trauma, infection [e.g., sternal osteomyelitis (frequently poststernotomy)] or radiation.

Extensive oncologic resection of the chest often leads to chest wall instability or full-thickness defects, necessitating plastic surgical coverage.

1. Defects >5 cm in size require skeletal reconstruction.

2. Loss of ≥4 ribs often leads to paradoxical chest movement and a risk of lung herniation; in such cases, rigid support is strictly necessary to maintain respiratory mechanics and protect the internal organs.

3. Above all, sternal resection necessitates a stable reconstruction to ensure the anterior stability of the thoracic cage.

4. In individuals with exposed lung, pleura, or mediastinum, stable flap protection is needed.

Malignant tumours of the chest wall are most commonly metastatic; primary chest wall tumours are typically sarcomas (2). Sternal osteomyelitis after median sternotomy for cardiac surgery is a distinct and surgically challenging entity; postoperative mediastinitis or sternal osteomyelitis is reported in up to 5% of sternotomy procedures (Figure S1) (3-5). Another important indication for chest wall reconstruction is osteomyelitis or chronic inflammatory disease of the chest that especially frequently affects the sternoclavicular joint (SCJ) (6). These patients are usually multimorbid; after infection is eradicated, rapid and reliable coverage of the defect with well-vascularized tissue is prioritized (7). Myoplastic procedures play a key role in the management of bronchial stump insufficiencies after lung resection (8,9). The incidence of PPE ranges from 2% to 16% (10,11). Muscle flaps or other vascularized tissue are often transposed into the pleural cavity to seal persistent BPFs and obliterate dead spaces after empyema or to close persistent thoracostomy openings (Figure S2). Despite advances in the endoscopic and interventional closure of BPFs and tracheoesophageal fistulas, myoplastic closure with muscle flaps remains an important and reliable alternative (9,12). The typical pathological nosology and specific indications for chest wall reconstruction are shown in Table S1.

Preoperative planning

Preoperative planning is critical and must be individualized for each patient. The extent of the defect is usually assessed via CT or MRI (Figure S3). For free flaps and sometimes for pedicled or perforator-based flaps, Doppler or duplex ultrasonography and angiography can be used to evaluate vascular anatomy and map recipient vessels (13). For example, the use of one or both internal mammary arteries (IMAs) as bypass grafts significantly reduces the blood supply to the sternum and overlying soft tissues and prevents their use as axial vessels for pedicled flaps or as recipient vessels for free flaps. Alternative vascular systems, such as thoracodorsal or thoracoacromial arteries, must then be considered. LD flaps are currently among the most frequently used flaps; however, prior axillary lymphadenectomy can damage the thoracodorsal pedicle, and posterolateral thoracotomy may compromise the intramuscular vasculature. In these cases, flap perfusion may rely on the axillary pedicle or on paravertebral perforators located 4–6 cm lateral to the spinous processes. For TRAM or VRAM flaps, Kocher or other upper abdominal incisions (e.g., postcholecystectomy), prior laparotomies or subcostal scars may lead to atrophy of the superior epigastric vessels and limit their use; thus, alternative flap designs are needed. In patients with distant metastases and palliative indications, the safest, most reliable coverage with the shortest possible hospital stay should be selected.

Debridement and wound conditioning

In cases in which there are chronic wounds or defects such as sternal osteomyelitis, radical debridement precedes any definitive reconstruction. All nonviable bone and cartilage, scar tissue and hypergranulation tissue should be removed. Fistula tracts must be completely excised (Figure S4A), as recurrent fistulas are a frequent result of inadequate debridement. Foreign material (cerclage wires and plates) must be removed whenever possible because of the high risk of persistent infection (4,14,15). Following debridement, VAC therapy is used to stimulate granulation, reduce the bacterial load, and define the actual size and depth of the defect (Figure S4B).

Goals of reconstruction

Reconstruction must (I) maintain or restore chest wall stability in a way that prevents flail segments or paradoxical motion; (II) preserve adequate respiratory mechanics and minimize restrictive impairment; (III) eliminate dead space and control infection; (IV) protect intrathoracic organs such as the lungs and mediastinum from trauma or infection; and (V) achieve airtight, tension-free and well-perfused soft-tissue coverage that is durable and resistant to infection, especially in cases involving exposed organs, implants or alloplastic material (2,16-18). These goals often necessitate pedicled or free flap procedures, sometimes combined with skeletal reconstruction using plates and meshes (9,19).

Resections of the sternoclavicular joint

The most frequent indication for SCJ resection is chronic infection or osteomyelitis. Treatment typically includes resection of the entire joint capsule, parts of the manubrium, and the medial clavicle; in selected cases the first sternocostal joint or first rib must be removed (Figure S5). Initial management consists of necrosectomy of all infected and nonvital bone and soft tissue, followed by VAC therapy until the wound is macroscopically clean and well granulated. Definitive coverage is then achieved using a pectoralis major advancement flap; this provides well-vascularized tissue to fill residual defects and reduce reinfection risk (20).

Extended anterior and lateral chest wall resections

Chest wall reconstruction after oncologic resection requires the restoration of both skeletal and soft-tissue components (2,21). Tumours may arise from intrathoracic structures and infiltrate the thoracic wall (e.g., T3 bronchial carcinoma) or originate in the bone (osteosarcoma or chondrosarcoma). Metastatic lesions (e.g., renal cell carcinoma), local recurrences after mastectomy and radiation-induced damage can involve the bone and cartilage of the ribs and sternum. In all these cases, wide oncologic margins are mandatory; this often requires resection of the involved ribs plus one uninvolved rib both cranially and caudally. Basic plastic surgical principles apply: small oval defects (up to palm size, ~5 cm) may be closed with advancement, transposition, or bilobed flaps, whereas larger full-thickness defects are best treated with pedicled axial muscle flaps (9,22). In complex cases involving multiple prior operations or compromised local vascularity, free microvascular flaps (e.g., contralateral LD or rectus abdominis flaps) may be needed. Figure S6, which is based on the surgical literature, illustrates common pedicled and microvascular flaps for thoracic wall defects (9,18).

Infections of the sternum

Sternal wound infection is an uncommon (1–6%) but potentially life-threatening complication; it occurs most frequently following cardiac surgery (4,5,23,24). A distinction must be made between superficial and deep sternal infections. Superficial infections involve the skin, subcutaneous tissue, and pectoral fascia. They are usually managed via wound opening, debridement, lavage, VAC, and administration of systemic antibiotics. Deep sternal infections/mediastinitis present with fever, sternal instability, purulent drainage, and pain. They require urgent surgical revision with debridement of necrotic bone and soft tissue, removal of cerclage wires, and excision of fistula tracts (often visualized using methylene blue). Partial or total sternectomy is reserved for cases of uncontrolled necrosis (3-5). The exposed heart or lungs must be protected from direct contact with VAC sponges using a silicone membrane to avoid vascular erosion (4,14,15). Once the infection is controlled, re-cerclage or plate osteosynthesis can be performed. Definitive coverage is achieved using muscle flaps (4,5,23). Pectoralis major muscle flaps are frequently used (Figure S7); rectus abdominis flaps are an option in cases in which there are lower sternal defects. The omentum majus represents an excellent filler for deep and irregular cavities (5,25).

Endothoracic infections and postpneumonectomy empyema

Approximately 10% of patients with pneumonia develop pleural empyema. PPE occurs in approximately 2–16% of pneumonectomies, with associated BPFs occurring in 60–80% of cases (10,11). In all cases with stump insufficiency, coverage with vascularized tissue is needed (Figure 1). Local options include intercostal and diaphragm flaps or pedicled pericardial fat flaps. The large surface area and high immunologic/lymphatic activity of the omentum flap make it also ideal for filling infected cavities and supporting closure of the BPF (8,9). Negative pressure wound therapy at approximately 125 mmHg is frequently combined with omental transposition to press the omentum against areas of insufficiency and accelerate adhesion and healing. This has been shown to largely prevent the need for extensive thoracoplasty in many cases (26). Intrathoracic structures (e.g., the central vessels, heart, and oesophagus) must be protected by silicone sheets to prevent bleeding or fistula formation. When an infection-free state has been achieved, the thoracostomy can be closed using muscle flaps (Figure 2).

Figure 1.

Closure of the open bronchial stump after left pneumonectomy with a serratus anterior muscle flap. (A) Serratus anterior muscle flap. (B) Open bronchial stump after a left-sided pneumonectomy. (C) Bronchial stump covered with a serratus anterior muscle flap.

Figure 2.

Closure of the left thoracic cavity due to chronic Aspergillus-associated pleural empyema after left pneumonectomy. (A) Chest X-ray of a patient with a bronchopleural fistula following left pneumonectomy. (B) Left intrapleural Aspergillus vegetations. (C) Closure of the thoracic cavity with muscle flaps after prolonged VAC therapy. VAC, vacuum-assisted closure.

Closure of chest wall defects using flap techniques

The reconstructive ladder

Defect reconstruction follows the principles of the reconstructive ladder (9,18,27). Table S2 provides a comprehensive overview of these findings.

Advancement and rotation flaps

Sliding and advancement flap techniques (V-Y flaps, rotation flaps, transposition flaps, and bilobed flaps) provide simple and effective reconstruction for small to moderate soft-tissue defects of the thoracic wall. Planning must take into account the size of the defect, the laxity of the tissue, and the quality of the surrounding skin. In irradiated or infected tissue, generous debridement and the introduction of healthy tissue are needed; in many such cases, the use of pedicled distant flaps or free flaps is essential.

Local flap reconstruction and direct closure

Local flaps and direct closure are appropriate where tension-free approximation of tissues is possible. When the ribs are exposed, particularly on the anterolateral chest wall, a mobilized pectoralis major muscle flap may provide a vascularized bed for subsequent skin grafting. With fewer perforators, the flap becomes more mobile and can be rotated up to 180°. Preoperative mapping with Doppler or duplex ultrasound helps identify and dynamically assess the perforators (28). Flaps based on intercostal perforators are planned parallel to the ribs.

Pedicled muscle flaps

Pedicled muscle flaps provide robust, well-vascularized tissue and have become a standard technique for sternal wound dehiscence and osteomyelitis since the 1980s (Figure 3). Commonly used flaps include LD, VRAM, and TRAM flaps. Donor site morbidity, particularly abdominal wall weakness with VRAM/TRAM, must be considered.

Figure 3.

Most common pedicled flap reconstructions for thoracic wall defects. (A) Myocutaneous latissimus dorsi flap. (B) One-side split pectoralis major muscle flap (turnover). (C) Bilateral partial pectoralis major muscle turnover flaps. (D) TRAM flap. (E) VRAM flap. Created in BioRender. Kuhtin, O. (2026). https://BioRender.com/z6axo57. TRAM, transverse rectus abdominis myocutaneous; VRAM, vertical rectus abdominis myocutaneous.

Pectoralis major flaps

The pectoralis major flap is ideal for treating defects of the cranial and medial chest wall, especially postoperative sternal wound dehiscence and wound infections after median sternotomy. Smaller defects can sometimes be closed by mobilization along the sternal border, whereas larger defects may require detachment of the humeral insertion via axillary incisions to gain additional reach (9,29). The medial segments are partially perfused by perforators from the IMA, which may be sacrificed during dissection. The pectoralis major flap is suitable for defects of the upper and middle sternum (Figure 4) and for isolated sternal or parasternal metastases (5,29-31). With respect to residual apical empyema cavities, a deepithelialized myocutaneous pectoralis major flap can be passed into the pleural cavity through partial resection of the second or third rib, creating a muscle plug (10,11). Compared with thoracoplasty, continuous suction over approximately 14 days supports adhesion and healing with lower morbidity, even in previously irradiated areas.

Figure 4.

Closure of the thoracic defect after resection of the right SCJ. (A) Pectoralis flap with feeding vessels (thoracoacromial artery). (B) Surgical site. (C) Defect closure with muscle flap. (D) Final result. SCJ, sternoclavicular joint.

Latissimus dorsi flaps

Owing to its large size (up to ~20×40 cm), an LD flap can cover extensive defects of the upper anterior and posterior thoracic wall. It can be harvested as a musculocutaneous flap with a skin island or as a pure muscle flap (9,32), often combined with split-thickness skin grafting (Figure 5). Alternative supply via paravertebral perforators or retrograde flow through intercostal branches allows modified flap designs with shorter rotation arcs (9,33). In patients with prior thoracotomy or radiation, distal flap perfusion must be assessed intraoperatively, clinically and, if available, using indocyanine green (ICG) angiography. LD flaps are suitable for covering the anterior chest wall up to the sternum and for covering the clavicular region, the dorsal thorax, the nuchal area, and the thoracoabdominal junction (9,18,34).

Figure 5.

Latissimus dorsi flap. The left-sided thoracic defect was closed after a solitary chest wall metastasis of renal cell carcinoma was resected. (A) CT scan of the chest with solitary chest wall metastasis of renal cell carcinoma. (B) CT-based 3D reconstruction of the chest. (C) Patient with solitary chest wall metastasis of renal cell carcinoma. (D) Latissimus dorsi flap. (E) Closure of the left-sided thoracic defect with a latissimus dorsi flap following resection of a solitary chest wall metastasis. (F) Final result. CT, computed tomography.

Proximal pedicled rectus abdominis (TRAM/VRAM) flaps

TRAM/VRAM flaps can be elevated vertically, transversely, or in combination as “anchor flaps” for a raised skin island (Figure 6). It should be determined in advance whether a coronary bypass operation using the IMA has been performed or whether the arterial supply is limited because of sternal cerclage. As a result of the high donor site morbidity (abdominal wall weakening with bulges or hernia), TRAM/VRAM flap repairs should be used only in cases involving full-thickness lesions. However, coverage of extremely large wound cavities is achievable (9,19,35,36).

Figure 6.

TRAM flap performed on a patient with a radiation-induced ulcer that developed after surgery for breast cancer. (A) Radiation-induced ulcer that developed after surgery for breast cancer. (B) Chest wall defect after resection. (C) Chest wall reconstruction using a composite mesh. (D) TRAM flap elevation. (E) Covering with alloplastic material using the island-type pedicled TRAM flap. (F) Final result. TRAM, transverse rectus abdominis myocutaneous.

Omental flaps

The pedicled omentum majus flap is particularly valuable in cases involving sternal osteomyelitis and for filling residual pleural cavities and covering BPFs. The omentum is usually based on the left or right gastroepiploic vessels (5,37,38). After laparotomy, it is mobilized from the greater curvature and the transverse colon and transposed cranially into the thoracic cavity (Figure S8). The omentum provides excellent vascularity and high immunologic potential, making it ideal for postinfectious defects. The limitations associated with its use include the need for abdominal access, a risk of abdominal complications (hernia, wall weakness), and limited volume in cachectic patients. In obese patients or in patients who have previously undergone upper abdominal surgery, mobilization can be technically demanding and carries a risk of partial necrosis.

Free microvascular flaps

When local vessels are compromised, vascular loops can be created (e.g., from cervical or pectoral vessels) and used to bring an adequate recipient vessel into proximity with the defect. Free tissue transfer is usually reserved for cases in which regional/pedicled flaps are not available, insufficient, or have failed. Table S3 summarizes the possible reconstructive procedures that can be used to repair existing chest wall defects.

Comment

Plastic-reconstructive procedures are now integral to the interdisciplinary management of extensive chest wall defects. Use of these procedures enables thoracic surgeons to perform adequate resections in situations that involve tumours or infection when the margins of the defect are clear without compromising the possibility of functional reconstruction. Interdisciplinary collaboration is critical for achieving optimal patient outcomes (9,18). Although primary closure of the defect without the use of synthetic material or flap coverage is possible in some situations, reconstruction is required for the vast majority of acquired thoracic and chest wall abnormalities. Reconstruction after extensive thoracic resection has proven safe and effective when three essential requirements are met. These are (I) adequate management of the pleural cavity, (II) restoration of skeletal stability where needed, and (III) reliable coverage of soft tissue with well-vascularized tissue. Our series focuses primarily on soft-tissue and skeletal reconstruction and highlights the observation that control of intrathoracic infection and closure of the pleural cavity are prerequisites for durable results. With respect to the management of the pleural cavity, muscle flaps and vascularized tissues are frequently transposed into the pleural space to obliterate empyema cavities and support the closure of bronchopleural and tracheoesophageal fistulas (11,39-41). These muscles can be easily mobilized through a 4–5 cm chest wall defect with one- or two-rib resection. The position is determined by the selected muscle and its major blood supply. The pleural cavity is typically treated using repeated irrigation, VAC therapy and systemic antibiotics. Once sterility is achieved, secondary closure is performed (11). To correct preexisting chest wall problems, a comprehensive analysis of the defect must include an analysis of respiratory mechanics. The restoration of skeletal stability is frequently required to protect the intrathoracic contents and sustain the mechanical forces that allow breathing. During the initial approach, the diaphragm and inspiratory accessory muscles should always be regarded as intact. Small (<5 cm) posterior defects, especially defects located under the scapula, may not necessitate rigid reconstruction, as the scapula provides adequate support. In irradiated chest walls, fibrosis may confer sufficient intrinsic stability, allowing reconstruction using soft tissue alone. Synthetic meshes and metal plates have largely replaced rigid alloplastic materials (17,18). Our experience with polypropylene-based materials [e.g., Prolene mesh (Ethicon Inc., Somerville, NJ, USA), occasionally doubled for additional strength] and temporary placement of Vicryl mesh (Ethicon Inc.) in contaminated fields has been favourable. For sternectomy, semirigid materials such as Codubix (TRICOMED S.A., Łódź, Poland) can provide necessary stability and protect the heart and great vessels (42-44). Soft-tissue reconstruction must ultimately (I) cover implants or exposed organs, (II) control infection, (III) close dead space, and (IV) provide durable, well-vascularized tissue. Flap introduction, supported by detailed anatomical work such as the Mathes and Nahai classification (45), has transformed chest wall reconstruction and made it possible to perform more radical ablative surgery with acceptable morbidity. Transfer of free tissue is rarely required and remains reserved for use in very complex or salvage situations. Table S4 illustrates the most significant principles of reconstructive surgery of the chest wall.

Conclusions

Chest wall reconstruction following extensive thoracic resection is safe and effective when a structured, stepwise approach is employed and there is close interdisciplinary collaboration. Thoracic surgeons should be familiar with the indications, basic principles, and common options for reconstructive plastic surgery of the chest wall, although complex planning and harvesting of flaps remain in the hands of plastic surgeons.

Supplementary

The article’s supplementary files as

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. This quality control project was registered with the Ethikkommission Nordwest- und Zentralschweiz on 12 March 2026 under Registration No. 2026-00327. Individual consent was not needed for the retrospective descriptive analysis.