INTRODUCTION: Total and sub-total sternectomy oncological defects can result in large deficits in the chest wall, disrupting the biomechanics of respiration. Restoration of chest wall stability plays a crucial role in maintaining chest wall dynamics and allowing normal respiration. Current reconstructive algorithms for total and sub-total sternectomies favor a polymethylmethacrylate/polypropylene implant sandwich technique combined with an overlying soft tissue flap. We propose a novel approach of rigid reconstruction for large sternal defects using a longitudinally oriented double-barreled free fibula flap in association with titanium plates and local soft tissue coverage.
MATERIALS AND METHODS: A 31-year-old male underwent subtotal resection of the sternum sparing only the manubrium after he received a diagnosis of a 4.5cm x 1.6cm spindle-cell neoplasm. A free fibula flap was harvested in a double barrel fashion to best mimic the resected sternum. The fibula vascular pedicle was anastomosed to the internal mammary vessels at the right second rib space. Fixation of the ribs were performed using the Synthes-chest-wall-reconstruction 1.5mm titanium plates across the fibula flap and remaining rib segments bilaterally along the third, fourth and fifth ribs. Hardware coverage was obtained using bilateral pectoralis flap advancement.
RESULTS: Postoperative computed tomography scans of the chest at 5 and 7 months showed a stable, rigid chest wall with well-maintained alignment of the fibula flap and no evidence of hardware failure. Clinically, he continues to maintain painless and effortless respiration. No evidence of chest wall instability or paradoxical motion has been observed.
CONCLUSION: While the current standard is prosthetic rigid stabilization, our reconstructive approach was able to providing rigid support and protection while allowing articulation with adjacent ribs and preservation of chest wall mechanics. We present this case report to increase consideration for autologous rigid reconstruction in oncologic sternal resections in the young patient population.