Combined Free Vascularized Iliac Osteocutaneous Flap and Pedicled Pectoralis Major Myocutaneous Flap for Reconstruction of Anterior Chest Wall Full-Thickness Defect

Large defects of the anterior chest wall lead to gross chest instability that can result in paradoxic respiration. Osteoradionecrosis of the lower sternum and multiple left ribs resulted in a huge, full-thickness defect of the left anterior chest wall in a 67-year-old woman. An iliac osteocutaneous flap (bone segment 3 × 14 cm) was harvested for reconstruction of the bone defect. The skin defect was covered by the skin paddle of the iliac osteocutaneous flap and a contralateral rotational pectoralis major muscle flap. Months postoperatively, the patient was physically active, the chest was stable, and the vascularized iliac bone was incorporated into the recipient bone. Large defects of the anterior chest wall lead to gross chest instability that can result in paradoxic respiration. Osteoradionecrosis of the lower sternum and multiple left ribs resulted in a huge, full-thickness defect of the left anterior chest wall in a 67-year-old woman. An iliac osteocutaneous flap (bone segment 3 × 14 cm) was harvested for reconstruction of the bone defect. The skin defect was covered by the skin paddle of the iliac osteocutaneous flap and a contralateral rotational pectoralis major muscle flap. Months postoperatively, the patient was physically active, the chest was stable, and the vascularized iliac bone was incorporated into the recipient bone. Large defects of the anterior chest wall lead to gross chest instability, which can result in paradoxic respiration. Indications for sternal reconstruction include infection, malignancy, trauma, congenital defects, and osteoradionecrosis. In current techniques, soft-tissue reconstruction alone using muscle flaps is usually sufficient for wound stabilization; however, reconstruction of the skeletal portion is occasionally necessary to prevent myocardial compression and flail chest [1Tukiainen E. Popov P. Asko-Seljavaara S. Microvascular reconstructions of full-thickness oncological chest wall defects.Ann Surg. 2003; 238 (discussion 801–2.): 794-801Crossref PubMed Scopus (49) Google Scholar]. In this report, we present a new technique for the reconstruction of large composite anterior chest wall defect. A 67-year-old woman had undergone a modified radical mastectomy and adjuvant radiochemotherapy for left breast cancer 20 years previously. In March 2009, an infective ulcer was noted at the left anterior chest wall. Analysis of an open biopsy specimen of the swelling proved it was not a recurrence of the cancer. A progressive increase in the size of the necrotic area was noted, and it involved the skin over the left sternal region. A bone scan and a computed tomography scan showed osteoradionecrosis of the lower sternum and multiple left ribs. An ablative excisional surgical procedure resulted in a composite defect of the left anterior chest wall and included a huge skin defect as well as sternum and multiple ribs deficiency (Fig 1). An iliac osteocutaneous flap (bone segment, 3 × 14 cm; skin paddle, 9 × 12 cm) based on the right circumflex iliac artery was harvested for reconstruction of the sternum and rib defects and the lower part of the skin defect. The right thoracodorsal artery was used as the recipient artery, and a vein harvested from right leg was used for a 30-cm graft. The cephalic vein was dissected down to the right cubital area (30 cm) and then turned over as the recipient vein (Figs 2 and 3) .Fig 3The skin paddle (9 × 12 cm) of the iliac osteocutaneous flap and the contralateral rotational pectoralis major muscle flap with skin grafting was used to cover the upper part of the skin defect (13 × 5 cm).View Large Image Figure ViewerDownload (PPT) A contralateral rotational pectoralis major muscle flap was also harvested to cover the upper part of the skin defect (13 × 5 cm; Fig 3). The donor site was closed with 2-0, 3-0 Dexon (Covidien, Mansfield, MA) and 4-0 nylon sutures. The patient required respiratory support after the operation but showed no evidence of respiratory distress after extubation. At 8 months postoperatively, the patient was physically active, the chest was stable, and the vascularized iliac bone was incorporated into the recipient bone (Fig 4). Full-thickness chest wall resection with reconstruction is still one of the most challenging operations today. The loss of effective chest wall rigidity can result in paradoxic respiration and lead to ineffective respiratory effort and respiratory embarrassment. Complications such as infection of the prosthetic material, mesh removal, or pulmonary distresses are frequently seen [2Arnold P.G. Pairolero P.C. Chest-wall reconstruction: an account of 500 consecutive patients.Plast Reconstr Surg. 1996; 98: 804-810Crossref PubMed Scopus (281) Google Scholar]. Muscular or myocutaneous flap coverage has been reported by many investigators as the treatment of choice [2Arnold P.G. Pairolero P.C. Chest-wall reconstruction: an account of 500 consecutive patients.Plast Reconstr Surg. 1996; 98: 804-810Crossref PubMed Scopus (281) Google Scholar, 3Solomon M.P. Granick M.S. Bipedicle muscle flaps in sternal wound repair.Plast Reconstr Surg. 1998; 101: 356-603Crossref PubMed Scopus (42) Google Scholar]. In these reports, good results have been shown with both free flaps and transposition flap (tensor fascia latae flap, rectus abdominis flap, pectoralis major flap and latissimus dorsi flap with or without rib transfer) when ribs and sternal resection is needed. In addition to soft tissue reconstruction, skeletal reconstruction of the anterior chest wall might be more important when wide resection of the anterior chest cage is indicated. It is evident that stability is most crucial in the early postoperative period, when the patient is being extubated. In the past, skeletal stability of the chest wall has been successfully achieved by numerous nonvascularized bone grafts (autologous and heterologous) and prosthetic materials (wires, metal plates, and mesh) [4McCormack P.M. Use of prosthetic material in chest wall reconstruction.Surg Clin North Am. 1989; 69: 965-976PubMed Google Scholar]. In autologous bone grafts, nonvascularized bones such as ribs and fibula have been used for chest wall reconstruction. Synthetic prosthetic materials such as methyl methacrylate and Marlex mesh (Phillips, Bartlesville, OK) have also commonly been used for sternal reconstruction [5Gayer G. Yellin A. Apter S. Reconstruction of the sternum and chest wall with methyl methacrylate: CT and MRI appearance.Eur Radiol. 1998; 8: 239-243Crossref PubMed Scopus (9) Google Scholar]. However, severe foreign body reaction and deep infection are common sequelae and usually require removal of the implant. These materials have been noted to cause erosion of the ribs and adjacent structures when they are applied to the constantly moving chest wall [5Gayer G. Yellin A. Apter S. Reconstruction of the sternum and chest wall with methyl methacrylate: CT and MRI appearance.Eur Radiol. 1998; 8: 239-243Crossref PubMed Scopus (9) Google Scholar]. Free tissue transfer incorporated with vascularized bone graft was also considered a reliable option in composite sternum and anterior chest wall reconstruction [6Cordeiro P.G. Santamaria E. Hidalgo D. The role of microsurgery in reconstruction of oncologic chest wall defects.Plast Reconstr Surg. 2001; 108: 1924-1930Crossref PubMed Scopus (63) Google Scholar, 7Cunha D. Bhathena H. Kavarana N. A free fibula autologous transfer for a full-thickness anterior chest wall defect.Eur J Plast Surg. 2001; 24: 140-143Crossref Scopus (2) Google Scholar, 8Heller L. Huang W.C. Chen H.C. Lu C.T. Lin S.L. Vascularized iliac bone flap used for sternum reconstruction after resection of chondrosarcoma.Plast Reconstr Surg. 2002; 110: 1088-1091Crossref PubMed Scopus (11) Google Scholar]. The advantages of vascularized bone flap include good incorporation into the recipient bone, provision of vascular supply to a poorly healing wound (especially after radiotherapy treatment), strong resistance against infections, and avoidance of the possible disadvantage of using prosthetic materials. The free fibula transfer has been used widely for long bone and mandibular reconstructions [7Cunha D. Bhathena H. Kavarana N. A free fibula autologous transfer for a full-thickness anterior chest wall defect.Eur J Plast Surg. 2001; 24: 140-143Crossref Scopus (2) Google Scholar]. It can be osteotomized into multiple segments of differing lengths, and good vascularity of the bone segments is manifested. The vascularized iliac osteocutaneous flap can provide the amount of bony tissue needed for reconstruction of anterior chest bony defect and the skin paddle needed to cover the defect [8Heller L. Huang W.C. Chen H.C. Lu C.T. Lin S.L. Vascularized iliac bone flap used for sternum reconstruction after resection of chondrosarcoma.Plast Reconstr Surg. 2002; 110: 1088-1091Crossref PubMed Scopus (11) Google Scholar]. Osteotomy of the bone is not necessary because the curved iliac bone can simulate the curvature of the chest cage and thus avoid compression of the heart. In this patient, a 3- × 14-cm bony segment and a 9- × 12-cm skin paddle were harvested. The vascularized bone graft was used to bridge the gap well, with similar curvature to the contralateral anterior chest cage. The skin paddle was used to cover the lower part of the skin defect, and the contralateral rotational pectoralis major muscle flap was used close the upper part of skin defect. Although the internal mammary vessels were not available and a long venous graft was needed to achieve the recipient vessels, the flap survived well. Ventilatory support was required after the operation. After extubation, the patient maintained arterial blood gas levels within normal reference ranges and showed no evidence of respiratory distress.