Chest Wall Reconstruction Techniques

Pleural Space. Photo © A.D.A.M.

Purpose:

Chest wall reconstruction is necessary when there is a defect in the thoracic or chest area. The most common cause of chest wall defects is an infected or unstable median sternotomy wound. A median sternotomy is a surgical procedure in which a vertical incision is made along the sternum (also known as the breastbone), after which the sternum is divided or cracked. This procedure provides access to the heart and lungs for surgical procedures.

Etiology:

Chest wall defects are grouped into two general categories: acquired and congenital.

Acquired:

  • Trauma
  • Tumor
  • Infection
  • Radiation

Congenital:

Goals:

The goals of reconstruction are to:

  • Remove unhealthy, devitalized tissue from the chest wall
  • Restore stability and structure to the chest wall
  • Obliterate any dead space (dead space is the empty space that results after removing part of the lung or the entire lung)
  • Provide durable coverage for the chest wall
  • Achieve aesthetic results

Anatomy:

The chest wall has three layers:

  • Outer layer: Soft tissue, which includes the skin, subcutaneous fat, and muscle
  • Middle layer: Skeleton, which includes the ribs, cartilage, and sternum
  • Inner layer: Pleural space, which is the space (cavity) between the skeleton and the lungs

    One, two, or all three layers may have to be reconstructed depending on the defect. The reconstructive sequence begins with the deepest tissues and proceeds to the most superficial -- pleural cavity, then skeletal framework, and finally soft tissue.

    Additionally, the type of reconstruction done will depend on the defect location on the chest wall.

    Reconstruction of the Inner Layer:

    • The goal of reconstructing the inner layer, also known as the parietal cavity, is to obtain an airtight pleural cavity.
    • This is done by filling the dead space to avoid it being filled with fluid and/or pus.

    Reconstruction of the Middle Layer:

    • The skeletal layer is considered the middle layer
    • This layer is needed to protect vital organs (heart, lungs, etc.) and to produce normal respiration
    • If four or more contiguous ribs have been removed or the defect is greater than five centimeters, the skeletal layer needs to be reconstructed
    • Reconstruction is done with the following options:

    Alloplastic reconstruction:

    • Mesh reinforced with methyl methacrylate
    • Bone grafts

      Autogenous reconstruction:

      Reconstruction of the Outer Layer:

      • The soft tissue (skin, subcutaneous tissue) is considered the outer layer
      • The defect of the soft tissue can be partial thickness (superficial wound) or it can be full thickness (deeper wound)

        Partial thickness wounds are reconstructed with:

        Full thickness wounds are reconstructed with:

        Sources:

        Din AM, Evans GRD. Chest Wall Reconstruction. In McCarthy JG, Galiano RD, Boutros SG, eds. Current Therapy in Plastic Surgery. Philadelphia: Saunders Elsevier, 2006.

        Janis JE. Chest Wall Reconstruction. In Janis JE (ed). Essentials of Plastic Surgery. St. Louis: Quality Medical Publishing inc., 2007.

        Chang RR. Thoracic Reconstruction. In Thorne CHM, Beasely RW, Aston SJ, Bartlett SP, Gurtner GC, Spear S, eds. Grabb and Smith’s Plastic Surgery, 6th ed. Philadelphia: Lippincott, 2007.

        Pectus Carinatum Medline Plus. Accessed April 2, 2011.

        Pomerantz J, Hoffman W. Chest Wall Defects. In Kryger, ZB, Sisco M (eds.). Practical Plastic Surgery. Austin, Texas: Landes Bioscience, 2007.

        http://www.microsurgeon.org/. Accessed April 2, 2011.

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