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Scadiaia Joua o Suge 102: 913, 2013

Chest wall reConstruCtion ater onCologiCal

reseCtions

e. tk

Depatmet o Pastic Suge, Hesiki Uiesit Hospita, Hesiki, Fiad

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Ke ods: Chest a; ecostuctio; deects; tumo esectio; sacomas; ap ecostuctio; mesh

Coespodece:Ekki Tukiaie, M.D.Depatmet o Pastic SugeHesiki Uiesit HospitaP.O. Box 266FI - 00029 HUS, FiadEmai: ekki.tukiaie@hus.f

InTrODUCTIOn

Mode sugica techiques o maagig chest atumos deeoped i the 1960s ad 1970s (1). Theitoductio o eiabe, e methods o ap eco-stuctio, impoemets i itesie cae ad eha-biitatio hae ed to acceptabe mobidit ad mo-

tait ates. Eaie ecostuctios used adom

aps, ote esutig i ap ecosis ad compica-tios. Thaks to the eoutio o ap techiques, theopeatios ae oadas easie ad sae aoigmoe extesie esectios ad ecostuctios.

The coetioa optios icude the axia pattemusce, mocutaeous ad asciocutaeous pedicedaps, the beast ap, ad the ometa ap, hich ahae a eiabe bood supp. These emai the mai-sta o chest a deect ecostuctio ooig tu-mo esectio, iectio o adiatio ijuies. I di-eet seies, 7590% o chest a deects ae coeedith egioa o pediced mocutaeous aps (2, 3).

The adet o micosuge has made sige-stageecostuctio possibe aso i extesie ad moe

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10 E. Tukiainen

compex deects. The ea epots o ee ap e-costuctio o chest a deects used atissimusdosi o teso asciae atae aps. At peset otheap optios ae aso aaiabe. The use o micoas-cua aps is eiabe, ad i seected cases bette thaegioa o pediced optios. It has achieed a im-potat oe i the chest a suge i seectedcases.

THE CHEST wAll DEFECTS

The chest a deects ae usua the esut o a tu-mo esectio, iectio, adiatio o tauma. Theca be cassifed accodig to thei aatomica oca-tio. The ca be patia o o u thickess. Futhickess deects icudig a the tissue aes mustusua be ecostucted eiab ad immediate, iode to estoe the stabiit o the chest a, to po-tect ad coe the exposed ita ogas ad to aoea ecoe. I additio, postopeatie ocoogicatheap ote demads ueetu ecoe.

The goas o the ecostuctio ae adequate stabi-it i espiatio (peetio o paadoxica moe-met), ate- ad aitight cosue ad acceptabecosmetic appeaace.

The majoit o deects equiig ecostuctioesuts om tumo esectios. Chest a eopasmsae be cassifed as pima, oca iadig, admetastatic. The most commo pima maigaciesi the chest a ae the sot tissue ad boe saco-mas.

PrIMAry CHEST wAll TUMOrS

Pima chest a tumos accout o 5% o a tho-

acic eopasms ad 12% o a pima tumos (4).Chest a is the ocatio o 67% o a sacomas.About 45% o the pima maigat tumos aiseom sot tissues ad 55% appea i catiagious obo stuctues (5). Chodosacoma is the mostcommo pima chest a maigac. Chest ais aso a e-ko site o adiatio-iduced saco-mas (6).

Both o sot tissue ad boe sacomas a ide ocaesectio is the best teatmet i the tumo is esect-abe (7). I the ski ad subcutaeous tissues ae ad-heet o iftated, a u-thickess chest a esec-tio is ote idicated. Aso the peious biopseede tacts ad scas shoud be excised. It is esse-

tia to icude ide adica atea magis as e asa cea deep magi. This ote ecessitates a uthickess skeeta esectio icudig the paietapeua hich itse poides a good ocoogica ba-ie.

lOCAl rECUrrEnCE

loca ecuece is oe o the majo pobems i theteatmet o beast cace. Up to 20% o patiets hohae adica o modifed mastectom i sustai aoca ecuece. Occasioa, sma ecueces cabe excised eaig o a supefcia deect. Hoee,moe ote extesie esectio icudig boe ad

catiage (u-thickess esectio) is idicated de-madig coeage ith ascuaized tissue.

Seea coditios eated to beast cace ca eadto a idicatio o chest a esectio: oca ad-aced pima cace, oca ecuet cace, sec-oda tumos associated ith adiotheap (posta-diatio sacoma, Steat-Tees sdome) o osteo-adioecosis.

Maigat eopasms ca aso iade om adja-cet tissues o ogas. Beast cace, ug cace, me-diastia eopasms o mesotheioma ma ocaiade the chest a.

The chest a ma aso be a site o distat metas-tasis o aious maigacies. The atue ad pog-osis o these tumos i iuece the extet o e-sectio ad the ecostuctio.

Sometimes tumos o the shoude gide iadethe bachia, axia o subcaia esses ad eesad aso ioe the thoacic a. I these cases, aoequate amputatio ad chest a esectio mabe idicated (a exteded oequate amputatio).

PrEOPErATIvE EvAlUATIOn

Extesie u-thickess chest a esectio combiedith the ecostuctio is oe o the most chaegigpocedues i suge ith a high isk o mobiditad motait. Idiiduaized teatmet ad caeupaig ae idicated. Peopeatie eauatio is im-potat ad, i paticua, pumoa, cadiac adutitioa pobems shoud be idetifed adteated. Idea, smokig shoud be stopped 68 eekspio to majo suge. Peopeatie pumoa uc-tio has to be eauated, CT o the chest ad tuk,ad MrI o the tumo aea ad boe sca ae idi-

cated. Patiets ae usua teated postopeatie ithe itesie cae uit, hee ea extubatio adactie phsiotheap ae madato. Epidua bock-ade is used to coto the postopeatie pai.

CUrATIvE Or PAllIATIvE InTEnTIOn

Some o the patiets ith extesie chest a maig-acies ae ot cadidates o a cuatie esectio.The tumou ma aead be dissemiated hich pe-cudes the possibiit o a cuatie appoach. Ho-ee, the patiets ma sue om itese oca pai,beedig ad dischage, cotiuig tumo gothad maodou. Aothe idicatio o paiatie su-

ge ma be a uppe extemit hich is soe,paatic, paiu o iected. This kid o imb cadeeop a secoda maigac ate choic m-phoedema o adiatio theap. It is impotat topoide a sae ad quick ecoe.

SOFT TISSUE rECOnSTrUCTIOn

Sot tissue coeage ca be achieed ith the use oa diect cosue, ski gats, oca ski adacemet,the beast ap, the ometum ap, pediced mocuta-eous aps, peoato aps ad ee aps. These di-eet methods ca aso be used i aious combia-

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11Chest wall reconstruction ater oncological resections

tios. The choice o a ecostuctio method is basedo the ocatio ad size o the deect, aaiabiit othe oca ad pediced optios, peious opeatioso adiotheap ad the geea coditio ad pog-osis o the patiet .

Diect cosue is possibe i sma esectios, o itumos i hich ski ad subcutaeous tissue ca bepeseed ith a good bood o so that, o exam-pe, a mesh ca be sae coeed.

Ski gats ca be used o i the suace is suit-abe (musce, ascia, ometum) but ot o boe, ca-tiage o oeig a mesh. Peious adiatio theapma peet the heaig o ski gats.

lOCAl FlAPS

Breast fap

The beast ca be used as a ap to coe deects o-cated most i the midie. This method ca be usedi ede, mobid patiets. I these cases a shot op-eatio time is peeabe ad the ca accept the

aesthetic defciec. The icisio is paced i the i-amamma cease, it ca be exteded atea upto the ateio axia ie ad the beast is adacedto coe the deect. The pocedue ca be peomedi oe positio, the cicuatio o the beast is usuagood ad the opeatie isks ae modeate.

PEDIClED FlAPS

The egioa pediced muscua o muscuocutaeousaps hae bee the fst choice o sot tissue coe-age o the chest a deects. Faps such as the atis-simus dosi, etica ectus abdomiis (vrAM), otasese ectus abdomiis (TrAM), ad pectoais,

seatus ad extea obiquae musces hae beecommo empoed (8, 9, 10 ). Aso mutipe ocaad pediced aps ca be used i combiatios.

The atissimus dosi musce o muscuocutaeousaps ae eas to eeate, thei ac o otatio is idead the ae usua age ad ca be taioed to thedeect. Seatus ateio musce sips o the paa-scapua ap o scapua ap ca aso be icuded ithe ap. latissimus dosi ap coes ateio, ateaad posteio egios o the chest, ad aso deects othe uppe ha o the steum.

The pectoais majo musce ca be based o thethoacoacomia o itea mamma esses. It isthe okhose ap o ecostuctio o the uppe o

midde stea ad paastea egio. The pedicedectus abdomiis musce, o muscuocutaeous aps,vrAM o TrAM, ae used to coe the epigastic adstea aea ad the ateoatea chest a. Peioussuge o adiatio iju to the itea mammaesses ma pecude the use o the aps based othese esses. The tapezius musce o muscuocuta-eous ap ca poide coeage oe the posteiochest a aea. These aps ae based o the dosabach o the theoceica tuk.

Aso peoato aps such as thoacodosa atepeoato (TAP) ap o itecosta peoato apshae bee used i ecostuctio. The ca coesma ad modeate sized deects o the ateio ad

atea aspects ad ca be used i combiatio ithothe aps.

The omental fap

The ometum ca be used to coe ateio ad at-ea deects (11), but it i ot each the posteioaea o the chest a. The bood o is based o theight, et o both gastoepipoic esses. Usua thisap is e sot ad piabe, ad theeoe, i idedeects a mesh is ote used to gie a ecessa pat-om o the ap ad stabiit. The ometa ap isusua coeed ith ski gats. The haestig othe ometum ma aect espiatio postopeatie.Iectio o dehiscece i the abdomia oud eethe commoest compicatios, ad ate thee as aisk o a eta heia. The ap ca be sae diided612 moths ate the ecostuctio ad the abdom-ia ascia ae cosed.

FrEE FlAP rECOnSTrUCTIOnS

I seected cases, ee ap ecostuctio is idicated.The oca optios o ecostuctio ma hae beeaead used, o the ma be ueiabe due to eaiescas o adiotheap. The pedice o the ap mahae bee damaged b peious opeatios o adia-tio theap, o the ap size ma ot be adequate tocoe the hoe deect. I paticua, age ateiomidie deects extedig to the epigastium adage thoacoabdomia deects ma be difcut toecostuct ith pediced optios. Aso epeated at-ea thoacotomies ote damage the thoacodosaesses, so that atissimus o seatus musces ae otaaiabe to coe a deect o the atea chest a, ostea aea, o iside the chest cait (12, 13, 14). I

additio, the geea coditio ad pogosis o thepatiet must be take ito accout. The adatageso micoascua ecostuctio shoud outeigh thedisadatages such as oge opeatie time ad po-tetia aastomotic pobems.

Micoascua teso ascia atae ap (TFl) is oeo the odest aps to coe extesie deects. The TFlap is eas ad quick to haest both i the ateaad supie positios, ad the ap ca be age (20x35cm) ith a costat ad eiabe pedice. It aos ato-team appoach (15). The ap cotais a fmthick ascia, ad aso ectus emois musce ca beicuded i the ap i exta buk is eeded o ex-ampe to f the chest cait. The doo site i the

thigh has o iuece o espiato uctio.The ectus abdomiis mocutaeous (TrAM) aphas ma adatages ad it has aso bee equetused o chest a deects. The TrAM ap is a ei-abe ad age ap hich ca be used to coe chesta deects (16), ad i idicated, gie beast cotouat the same time. As a buk ap, it ca aso be usedas a fe i age itathoacic deects. I ma pa-tiets the TrAM ap ca poide age suace aea,but i thi patiets the size is ot as age. I additiothe ateio chest a deect ma icease, heTrAM doo site is cosed. The tight abdomia do-o site ma postopeatie adese aect espia-to uctio i thi, mobid patiets.

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12 E. Tukiainen

Fiet oeam ap. Ate oequate amputatiothe oud ca be usua diect cosed usig thestadad posteio ap. Hoee, i some cases theextet o the tumo demads esectio o sot tissueso ibs so that cosue ithout a ecostuctio is im-possibe. I these cases the amputated extemit capoide a ee ap (17, 18). I the oeam ad distauppe am ae ot aected, a fet oeam ap (itha pedice up to the dista bachia esses) ca be dis-sected. Usua the adius is excised, ad the ua cabe peseed i the ap, ad ate osteotom adpate fxatio, it ca gie stabiit ad poide co-tou o the shoude.

CHEST wAll STABIlITy

The aps used o ecostuctio gie some stabiito thei o depedig o thei compositio adthickess. Teso ascia atae ith a stog ascia isathe stabe, ad it ca be sutued ike a mesh to thedeect. Aso a thick muscuocutaeous ap (atissi-

mus dosi ap, vrAM, TrAM) is quite stabe aoei smae deects. Hoee, the ometum ap o athi musce ap ae ote too sot ad piabe. Theae commo used ith a mesh to gie patom adstabiit o the ap.

I paticua, the ooig deect ocatios ae atthe isk o heiatio o paadoxica beathig: totao subtota stea esectio icudig seea ibsbiatea, high atea esectio (moe tha 34 ibs),o exteded oequate amputatio ith esectio o3 o moe ibs. I these cases, the patiets ae poeto hae espiato pobems, i the stabiit is otadequate as ea as duig the immediate postop-eatie peiod (15). Istabiit o ee sight paa-

doxica moemet is bette toeated, he the deectis ocated i the oe atea aea o both i the chestad the abdomia a.

vaious autoogous mateias such as ee demisaps, ascia atae, fbua o ib gats hae bee usedto stabiize the chest a (19). The ae usua etoeated but ma aoe be eithe too accid o e-soe duig time. Cuet, popopee o Ma-ex mesh, potetauooethee (Goetex) ae usedo stabiizatio ad peetio o heiatio (20, 21).Fot patiets udegoig a chest a ecostuctioith mesh ad ap ecoeed sigifcat bette(shote time o espiato suppot ad shote hos-pita sta) compaed to those haig o aps eco-

stuctio (20).To get exta stabiit, ib gats hae bee used, too.with oe o to ib gats supeimposed a age de-ect coeed ith mesh ca be diided ito smaedeects ith adequate stabiit ad moemet. Macetes hae used methmethacate embeddedbetee to aes o mesh (23). The igid aeashoud be about 12 cm smae i diamete com-paed ith the deect size. This aos the sad-iched mesh to be secue fxed to the deect aeaig the had methmethacate potio about 1cm aa om the bo deect ad sti poidepope coexit ad igidit ith sight moemet(Fig. 1 AD).

I the thoaco-abdomia cases, the ieo-ateadiaphagm ote oms a baie ad shoud be e-sected aog ith the tumo. It is impotat to eco-stuct the missig potio o the diaphagm ith asimia-sized mesh ad sutue it to the oigia posi-tio o the diaphagmatic muscua isetio i odeto maitai pope peua cait size ad adequateespiato phsioog (15).

PrOGnOSIS

The pogosis o chest a tumos has become betteduig the ast decades. Fo the pima chest asacomas the fe-ea oea ad disease-ee su-ias ee 66% ad 47%, espectie (24). Faoabepogostic aiabes o suia icuded age beo50 eas, bo tumo, chodosacoma, ad o gadesot tissue sacoma (7). Micoscopica cea magiscoud be achieed i 80% o the pima sacomasad 64% o the ecueces. The chaces o oca co-to ee oe ate sugica teatmet o ecuet

sacoma compaed to pima sacomas (25 ). Aso ioca ecuet mamma cace the chest a e-sectio ad ecostuctio has easoabe og temsuia ad it has poe to be sae ad eectiepocedue ith acceptabe mobidit (22, 26)

rEFErEnCES

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02. Chag rr, Mehaa BJ, HU Qy et a: recostuctio o com-pex ocoogic chest a deect: a 10-ea expeiece. APast Sug 2004;52:471479

03. loske A, Thouai vH, Caso Gw et a: A ecostuctieagoithm o pastic suge ooig extesie chest aesectio. B J Past Sug 2004;57:295302

04. lipta MJ, F wA: Maigat boe tumos o the chest a.Semi Thoac Cadioasc Sug 1999;11:278284

05. Icaboe M, Pastoio U: Sugica teatmet o the chest atumous. wod J Sug. 2001:25:218230

06. wikud T, Bomqist C, rt J et a: Postadiatio sacoma.Aasis o a atioide cace egist mateia. Cace1991;68:524531

07. Kachoo P, Pak PS, Sadha HS et a: Sige-istitutio, muti-discipia expeiece ith sugica esectio o pimachest a sacomas. J Thoac Oco. 2012;3:552558

08. Aod PG, Paioeo PC: Chest a ecostuctio. A ac-cout o 500 cosecutie patiets. Past recost Sug, 1996;98:804810

09. Masou KA, Thouai vH, loske A et a: Chest a esec-tios ad ecostuctios: a 25-ea expeiece. A Thoac

Sug 2002:73:1720172510. Mathes SJ: Chest a ecostuctio. Ci Past Sug 1995;22:

18719811. Hutma CS, Cubetso JH, Joes GE: Thoacic ecostuctio

ith the ometum: idicatios, compicatios ad esuts. APast Sug 2001;46:242248

12. Codeio PG, Satamaia E, Hidago D: The oe o micosu-ge i ecostuctio o ocoogica chest a deects. Pastrecost Sug 2001;108:19241930

13. Baic A, ris H, Ei D, Stiee H: Fee atissimus dosi apo chest a epai ate compete esectio o iected ste-um. A Thoac Sug 1995;60:10281032

14. Che HC, Tag yB, noodho MS, Chag CH: Micoascuaee musce ap o choic empema ith bochopeuafstua he majo oca musces hae bee diided: oe-stageopeatio ith pima oud cosue. A Past Sug 1990;24:510516

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13Chest wall reconstruction ater oncological resections

1A

1B

1C 1D

Fig. 1 AD. recostuctio ith a mesh, methacate ad micoascua TFl ap.

A: 32-ea-od ma ith high gade sacoma o the ateio chest a.B: resectio o the ateio chest a.C: recostuctio ith methmetacate cemet betee to aes o popopee meshes.D: Sot tissue coe ith micoascua TFl ap. no ecuece duig a 4-ea oo-up.

15. Tukiaie E, Popo P, Asko-Sejaaaa S: Micoascua eco-stuctio o u-thickess ocoogica chest a deects. ASug 2003;238:94802

16. Hidago DA, Sadaa EF, rusch vw: Fee ap chest a e-costuctio o ecuet beast cace ad adiatio uces.A Past Sug 1993;30:375380

17. Codeio PG, Cohe S, But M, Bea MF: The tota oa oeam muscuocutaeous ee ap o ecostuctio o extededoequate amputatio. A Past Sug 1998;40:388396

18. Kuh JA, wagma lD, loat JA et a: radica oequateamputatio ith hemithoacectom ad ee exteded oe-am ap. A Sug Oco 1994;1:353359

19. watso wl, James AG: Fascia atae gats o chest a de-ects. J Thoac Cadioasc Sug 1947;16:399406

20. Ko SS, wash G. ra B, Kig rC: risks ad beefts o us-ig Maex mesh i chest a ecostuctio. A Past Sug1993;31:303306

21. McComack PM: Use o posthetic mateias i chest a e-costuctio. Sug Ci noth Am 1989;69:96597622. Icaboe M, Pastoio U: Sugica teatmet o chest a

tumos. wod J Sug 2001;25:21823023. ladiois D, Mue M, Fue M et a: Fuctioa assessmet

o chest a itegit ate methmethacate ecostuc-tio. A Thoac Sug 2000;69:919923

24. woutes Mw, a Gee An, nieuehuis l et a: Outcomeate sugica esectios o ecuet chest a sacomas. J CiOco 2008;26:51135118

25. lidod AJ, Jahkoa TA, Tukiaie E: late esuts ooigap ecostuctio o chest a ecuet beast cace.J Past recost Aestet Sug 2013;66:165173

receied: Jaua 21, 2013