Reconstruction of Extensive Chest Wall Defects Using Light-Weight Condensed Polytetrafl uoroethylene Mesh – Case Reports

Introduction

Chest wall tumors are classified to benign and malignant tumors and primary and secondary metastases from other body organs. Despite the advances in modern cancer treatment, radical resection of chest wall tumors remains the standard treatment and may be curative. The success of this treatment is based on multidisciplinary team cooperation and each patient is discussed at the oncology indication commission before the surgical procedure. In the case of extensive defects with the necessity of resection of bones, it is always necessary to consider adequate stabilization of the thoracic wall and preservation of its integrity in addition to the closure of soft tissues [1].

The gold standard in these procedures is bridging plate osteosynthesis. With advances in modern medicine, advanced biomaterials are increasingly becoming routine in clinical practice, bringing new possibilities and applications [2]. We present three case studies of reconstruction of the chest wall defects using light-weight condensed polytetrafluoroethylene (cPTFE) Omyra® Mesh TX B. Braun in combination with flap surgery. We want to demonstrate the possibility of restoring the stability of the rib cage without bone transfer or bridging plate osteosynthesis with successful closure of the defect using various types of flaps.

Description of the cases

Case report 1

We present a 66-year-old woman with a histologically verified chondrosarcoma of the sternum without further dissemination according to magnetic resonance imaging (MRI) and scintigraphy scan. Radical resection of the xiphoid and corpus of the sternum was selected as the curative option by the oncology indication committee. The resection was performed with 10 cm margins around the tumor and the resulting defect was 22 × 20 cm wide. During the surgery a macroscopic inspection of the visible part of lungs, mediastinum and upper abdominal wall was performed with no signs of a tumor. Intra-operative frozen section consultation showed the tumor mass was fully removed. Mammary vessels were dissected as recipient vessels for further microanastomosis. Two chest drains Ch 24 were inserted and a Omyra® Mesh TX 22.5 × 30 cm was sutured into the defect with adequate tension by a chest surgeon. There were two small windows in the mesh created for the mammary vessels. The patient was turned into the prone position and free latissimus dorsi flap was elevated, detached and placed on the mesh to cover the defect (Figure 1). After the surgery the patient was transferred to the intensive care unit (ICU) with monitoring vital functions and viability of the flap. An X-ray examination was performed for evaluation of the position of the chest drains and for potential pneumothorax. The flap was covered by autologous split-thickness skin graft (STSG) transplantation a week after the surgery. There were no complications in healing of the flap observed and the patient fully recovered without any limitation 3 weeks after the surgery. The patient is registered in the oncological follow-up with regular check-ups (Figure 2).

Case report 2

We present a 71-year-old patient with secondary tumor of the left lateral chest wall. The patient underwent a resection of the left lower lung lobe for metastatic ductal carcinoma from the left breast 8 years ago. The tumor of the chest wall was histologically verified as a metastatic disease and the positron emission tomography/computed tomography (PET/CT) scan showed it is a solitary lesion in the range of two ribs. The oncology indication committee in cooperation with the chest surgeon recommended radical resection of the tumor mass with wide margins. The patient underwent a spirometry and internal examination prior to the surgery. During the surgery, the chest surgeon removed the tumor mass from the left lateral chest wall with wide margins in the range of four ribs and five intercostal spaces, respectively (Figure 3). A chest drain Ch 24 was inserted inside the pleural cavity and a Redon drain No. 14 was inserted inside the abdominal cavity in the subphrenic space. After the reinsertion of diaphragm, the original defect was approximately 15 × 20 cm wide and was covered by Omyra® Mesh TX 22.5 × 30 cm. The patient was positioned on the right side and a plastic surgeon closed the defect with latissimus muscle flap transposition with a skin island. The rest of the muscle was covered with a rotation flap from dorsolateral mobilization and transposition (Figure 4). In the post-operative period, the patient was monitored at the ICU with antibiotic prophylaxis and regular X-rays of the chest. The chest drain was set to passive drainage on the 5^th day after the surgery and was removed on the 7^th day. There were observed no complications in the healing of the flap and no overall complications in the post-operative period (Figure 5).

Case report 3

The last case we present is a 51-year-old woman with secondary tumor of the rib cage 6 months after she underwent radical right medial lobectomy for an adenocarcinoma. The primary surgery was performed as a video-assisted thoracoscopic surgery (VATS). Histological examination confirmed moderately differentiated adenocarcinoma of the lung with no metastasis. Three months after the surgery the PET/CT scan showed suspicious recurrence lesion in the scar originated from the 6^th rib, which was later confirmed by a biopsy. An oncology indication committee recommended neoadjuvant systematic therapy with cisplatin/pemetrexed. During the surgery the chest surgeon removed the 6th rib with adjacent soft tissue with 10 cm margins, original scar and one rib above and beneath the tumor as a complex resection. The original defect size was approximately 20 × 25cm. The Omyra® Mesh TX 22.5 × 30 cm was implanted into the defect (Figure 6). For final closure we used a pedicled latissimus dorsi flap, which was not affected by the scar from previous surgeries (Figure 7). However, the range of the skin island was limited by the lack of soft tissue mobility and the rest of the defect was covered by autologous STSG transplantation.

In the post-operative period, the patient was monitored at the ICU with prophylactic antibiotics therapy with regular X-rays of the chest. There was observed a problem in the healing of the STSG which was infected. After debridement we applied Vacuum Assisted Closure (VAC) therapy and we performed a secondary STSG transplantation with a successful result. Further hospitalization was without complications and the patient fully recovered (Figure 8).

Discussion

Thoracic wall tumors represent a complex clinical problem. In most cases, the treatment of operable tumors should be primarily surgical. Wide surgical resection with sufficient margins of tumor resection gives the greatest chance of recovery or long-term survival [1,3]. Chest wall resection involves disrupting a number of heterogeneous tissue layers. The ribs, intercostal muscles, sternum, scapula and numerous soft tissues may be all removed. Such intervention often leaves a widespread defect revealing vital organs and could significantly reduce their function. The aim of the surgical procedure is therefore the reconstruction of both protective and functional properties of the thoracic wall. This involves maintaining negative intrathoracic pressure, elimination of paradoxical rib motion and rigid protection of vital organs [4,5].

The literature on chest wall resections is relatively extensive, but inconsistent. The optimal procedure is often based on the individual experience of the workplace, which is often limited due to the relatively rare indication for a resection procedure. The risks associated with large-scale surgeries are strongly dependent on the individual experience of the operating surgeon and the quality of subsequent postoperative care as well as availability of material and equipment [1].

When looking at complete reconstruction of the thoracic wall, we must respect all anatomical boundaries and tissues. The key action is the reconstruction and stabilization of the skeletal part of the chest wall to ensure stability [6]. Historically the most commonly used method has been osteosynthesis for bridging multiple rib or sternal defects. There are many materials from all sorts of types, such as steel, ceramics or titanium. The titanium material outperforms the others due to its biocompatibility, osseointegration, resistance to infection, high strength/weight ratio and low optical density. Osteosynthetic material allows very good and physiological rib movement, but its major disadvantage is the high incidence of osteosynthesis failure, either due to fracture or displacement of material [6,7]. Berthet et al. disclose an alarming 44% incidence of osteosynthetic material failure in thoracic wall reconstruction [8]. To ensure chest wall stability, Kalab et al. described the transplantation of allogenic bone graft in combination with titanium plates. He presented 10 cases of allograft of sternum or calva bone and in all of them he achieved excellent chest stability with respiratory sufficiency. However, in 40% there were healing problems of the soft tissue which needed additional re-suture [9].

Synthetic materials in the form of mesh or net used for reconstruction of the chest wall gained popularity in the past years. The spectrum of the different materials is very wide: methylmethacrylate, polyglactin, nylon, polytetrafluoroethylene, silastic, silicone, etc. Their biggest advantage is easy manipulation, sufficient fixation and often good incorporation into the tissues (it is variable according to the material used). Materials are usually easy to stretch and therefore any paradoxical movement is avoided. Most of them are porous, thus preventing the formation of seroma [6]. These materials are generally well tolerated and show good bio-integration properties. There are many specific materials on the market today, often with minimal clinical differences. Jedlička et al. described their experience with polypropylene and polyester covered with polyurethane, which are both very effective with no statistical differences [1]. Experience with synthetic polytetrafluoroethylene mesh shows very similar results [10].

Before the implantation of the mesh, the tumor mass must by fully removed with no further signs of metastasis. Intra-operative frozen section consultation with macroscopic inspection of the surgical field should be considered as a standard procedure. Chest drains are usually inserted in the thoracic cavity before implanting the mesh. The mesh must be sutured into the defect with adequate tension and with light overlap of the margins.

An extensive chest wall defect in combination with the technique mentioned above requires a flap cover for final wound closure. The technique for the soft part of the reconstruction is very well described in the literature. The choice between muscular or musculocutaneous flaps depends on the size of the defect, its location on the thoracic wall, the angle of flap rotation, availability of vascular supply and also on the experience and preference of the plastic surgeon [11]. The most frequently used musculocutaneous pedicle flaps include pectoralis major, latissimus dorsi and rectus abdominis [12]. Many authors prefer reconstruction with the pectoralis muscle, especially in the anterior portion of the chest wall [13]. For reconstruction of extensive defects in the lateral portion of the chest wall latissimus dorsi is the best suited, as it is the largest muscle in the human body [14]. Omentoplasty can also be used as well vascularized tissue ideal for healing. Its rotation is offered especially in the case of resection involving the diaphragm and already established communication with the abdominal cavity [15].

All the flaps mentioned can also be used as free flaps in case of extensive defects or in case of an unfavorable location where the axis for the pedicle is not sufficient. The spectrum of free flaps that can be used is much wider, given the zero limitation of local tissue. Frequently used free flaps include the anterolateral thigh flap (ALT), latissimus dorsi flap, deep inferior epigastric artery perforator flap (DIEAP) and many others, that are dependent upon the preference of the surgeon [16].

After the surgery, it is necessary to monitor vital functions of the patient as well as the vitality of the flap. The patient is usually situated at the ICU for the first week after the surgery. The position of chest drains is regularly checked via X-rays and the drains are set to passive drainage on the 5^th day after the surgery and removed on the 7^th day. Prophylactic antibiotics are indicated for 1–2 weeks after the surgery if the patient is without complications. At our department, the plastic surgeon takes care of the patient from the reconstruction of the defect until the flap is fully healed and all the skin defects are covered with STSG transplantation. After that, the patient comes under the care of a chest surgeon with oncological follow up and regular check-ups. Plastic surgeon takes care of the flap and donor site during the follow-up. The whole process requires a good cooperation with the chest surgeon in case of any complications.

In the future, no radical change or innovation in reconstruction of the chest wall can be expected. There are several condensed polytetrafluoroethylene meshes on the market (Infinit® – Gore, MotifMESH® – ProxyBiomedical, Omyra® – B. Braun) and also expanded polytetrafluoroethylene meshes (Gore-Tex® Soft Tissue Patch – Gore, Gore Dualmesh®– Gore, Composix® – Bard, Teflon® EI – DuPont). In recent years, there has been an upswing in 3D printing and associated “tailor made” implants. However, even these materials require further reconstruction of soft tissues and their cost makes them unavailable for most patients [17].

Conclusion

The reconstruction of deep defects of the chest wall after a radical resection of a tumor is challenging even for an experienced plastic surgeon. Planning the surgery requires intensive multidisciplinary cooperation in order to maintain the oncological radicality and successful closure of the defect. Every case needs to be individually considered as there is big variability in the type of tumor and its localization. Synthetic biomaterials in the combination with flap surgery can provide an excellent chest stability with no need of bone grafting or bridging osteosynthesis. They can be considered as a safe choice due to the low rate of infections and great biocompatibility with surrounding tissues.

Role of authors: All authors listed above were members of the surgical team and have contributed equally to this article.

Declaration: The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The authors declare that this manuscript has not been published before and is not currently being considered for publication. The authors declare that the study was conducted in accordance with the Helsinki Declaration.

Alica Hokynková, MD

Department of Burns and Plastic Surgery

Faculty Hospital Brno

Jihlavská 20

625 00 Brno, Czech Republic

e-mail: alicah@post.cz, hokynkova.alica@fnbrno.cz

Submitted: 30. 08. 2020

Accepted: 09. 12. 2020