CME Abdominal Wall and Chest Wall Reconstruction Ghazi Althubaiti, M.D. Charles E. Butler, M.D. Houston, Texas
Learning Objectives: After studying this article, the participant should be able to: 1. Define the goals of abdominal wall and chest wall reconstruction. 2. Discuss the general principles of and the different surgical techniques for abdominal wall and chest wall reconstruction. 3. List the major advantages and disadvantages of synthetic and bioprosthetic mesh in abdominal and chest wall reconstruction. 4. Define the indications for and major factors to consider in chest wall skeletal stability reconstruction. 5. List the flaps commonly used for chest wall and abdominal wall reconstruction. Summary: Plastic surgeons commonly face reconstructive challenges in repairing the abdominal and chest walls. Reconstructive options in these two areas are rapidly expanding with the availability of new techniques and new products. The purpose of this article is to provide an updated summary of reconstruction of the abdominal and chest walls, focusing on commonly encountered problems. (Plast. Reconstr. Surg. 133: 688e, 2014.)
V
ideo, Supplemental Digital Content 1, which briefly highlights some of the important points of abdominal wall and chest reconstruction, is available in the “Related Videos” section of the full-text articles on PRSJournal.com or, for Ovid users, at http://links.lww.com/ PRS/A971.
ABDOMINAL WALL RECONSTRUCTION Ventral hernia repair and postoncologic reconstructive problems are some of the most commonly encountered abdominal wall challenges faced by plastic surgeons and are the focus of this section of the article. Because of space limitations, other abdominal wall reconstructive problems, such as congenital defects, traumatic defects, and open abdomen, are not discussed. General Principles The goals of abdominal wall reconstruction are to provide stable soft-tissue coverage, restore fascial integrity, prevent hernia, protect abdominal viscera, and restore function if possible. To minimize wound-related complications, the patient’s general medical condition (e.g., nutritional, cardiac, pulmonary) should be optimized preoperatively if feasible. From the Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center. Received for publication September 24, 2012; accepted November 1, 2012. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000086
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Ideally, abdominal wall reconstruction should be approached with a multidisciplinary team. In ventral hernia repair, for example, the surgeons who performed the laparotomy that resulted in the hernia are often involved, along with the reconstructive surgeons who will perform the abdominal wall reconstruction. The fascia and the soft-tissue envelope of the abdominal wall—including the skin—can be considered as two separate units. The “like-with-like” principle of reconstructive surgery should be followed in reconstructing these units if possible. Dead space should be eliminated as much as possible during reconstruction, and extensive undermining of the skin should be avoided. The surgeon should also choose a method of reconstruction that minimizes the chances of bowel adhesions, fistulization, and perforation. The musculofascia can be repaired by primary closure with or without component separation, fascial grafts, fascial components of tissue flaps, and synthetic or bioprosthetic mesh materials. Disclosure: The authors have no financial interests related to the content of this article. There was no external funding for this article.
Related Video content is available for this article. The videos can be found under the “Related Videos” section of the full-text article, or, for Ovid users, using the URL citations published in the article.
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Volume 133, Number 5 • Abdominal and Chest Wall Reconstruction
Video. Supplemental Digital Content 1, which briefly highlights some of the important points of abdominal wall and chest reconstruction, is available in the “Related Videos” section of the full-text articles on PRSJournal.com or, for Ovid users, at http:// links.lww.com/PRS/A971.
The surgeon should avoid undue tension on the fascial repair site and repair the fascia under physiologic tension to minimize the chance of early dehiscence and late hernia recurrence. Midline musculofascial defects may benefit from component separation, depending on the size and location of the defect. If the fascial defect is located laterally, which is often encountered following tumor resection, reconstruction of the fascia with synthetic or bioprosthetic mesh is often the best option. Stable skin coverage can be provided with primary closure of the skin, local or regional flaps, skin grafts, tissue expansion, and/or free tissue transfer. Flap selection will depend on the location, extent, and size of the defect. Preoperative Considerations Physical examination should be performed to assess the patient’s general condition, the abdominal wall integrity, the extent and location of any abdominal wall abnormalities, and the presence of scars that could become an obstacle to raising reliable tissue flaps. Routine laboratory tests and a nutritional workup are advised. Preoperative computed tomography to examine the defect characteristics and abdominal wall anatomy and vascularity is helpful for surgical planning. Operative Techniques Hernia Repair The most common abdominal wall defects faced by reconstructive surgeons are incisional
hernias. The incidence of incisional hernia is approximately 11 percent following midline laparotomy.1 One in three incisional hernias will cause symptoms, and approximately 4 percent of patients undergoing laparotomy will undergo an additional operation to repair an incisional hernia (Reference 2 Level of Evidence: Therapeutic, II).1,2 Patients with hernias are at risk of developing bowel-related complications such as enterocutaneous fistulas, obstruction, incarceration, and strangulation. Functional problems in hernia patients include poor respiratory effort, loss of abdominal domain, and weak abdominal musculature. Cosmetic problems are also frequent complaints from patients with abdominal hernias. Incisional hernias are notorious for their high recurrence rate after repair and for their high rate of surgical complications. One study found that the 5-year reoperation rate was 23.8 percent after the first hernia repair operation, 35.3 percent after the second, and 38.7 percent after the third (Level of Evidence: Therapeutic, III).3 The infection rate following ventral hernia repair is 4 to 16 percent.4 The risk significantly increases if the patient had a previous infection (41 percent versus 12 percent in one study).5 Following infection, the risk of hernia recurrence was reported to be approximately 80 percent in one study.6 Bowel-related complications such as adhesions, obstruction, erosion, and fistulization are other known complications of hernia repair, especially with the use of synthetic mesh. One study found that the risk of enterotomy or unplanned bowel resection in patients with previous synthetic mesh hernia repair was higher (20 percent versus 5 percent) than in patients who did not have mesh repairs for their hernias.7 Factors that may complicate hernia repair include the presence of multiple scars that could compromise skin vascularity, the presence of enterocutaneous fistulas or exposed mesh, the presence of extensive bowel adhesions, obesity, and chronic hernia with loss of domain. The Ventral Hernia Working Group developed a grading system for the risk of complications at the surgical site that categorizes patients into one of four groups.4 Table 1 summarizes the Ventral Hernia Working Group recommendations for whether to use mesh and what type to use in each group. The Ventral Hernia Working Group recommends the use of prosthetic material to reinforce the repair of all incisional ventral hernias regardless of whether the midline fascia can be reapproximated—unless there is a contraindication to use mesh, such as wound infection.4
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Plastic and Reconstructive Surgery • May 2014 Table 1. Ventral Hernia Working Group Grading System for Risk of Complications at the Surgical Site with Recommendation for Each Grade* Grade 1 2 3 4
Description The healthy patient with no contamination and no history of wound infection; the VHWG recommends the use of prosthetic material to reinforce the repair of all incisional ventral hernias, regardless of whether or not the midline fascia can be closed The patient who does not have wound contamination or infection but has one or more comorbidities that increase the risk of infection; the VHWG suggests that bioprosthetic material might have an advantage over synthetic material in these cases The patient who has violation of bowel or the presence of nearby stoma or infection; synthetic mesh is not recommended*; bioprosthetic mesh may be a good option The patient with infected synthetic mesh or septic dehiscence; no repair material should be used in the setting of gross uncontrolled contamination; the surgeon may consider a delayed repair
VHWG, Ventral Hernia Working Group. *Breuing K, Butler CE, Ferzoco S, et al. Incisional ventral hernias: Review of the literature and recommendations regarding the grading and technique of repair. Surgery 2010;148:544–558.
Mesh or No Mesh? Prospective randomized studies have demonstrated that the use of mesh reduces hernia recurrence by approximately one half compared with primary suture repair at 3 years (24 percent versus 43 percent)6 and 10 years (32 percent versus 63 percent) of follow-up.2 Defects 2 cm in diameter or less may be suitable for primary suture repair, although the Ventral Hernia Working Group suggests that these small hernias may still benefit from the use of mesh.4 One study reported that even for small ventral incisional hernias, the recurrence rate is 67 percent following suture repair versus 17 percent after mesh repair.2 Mesh is used to either reinforce or bridge fascial defects. When the fascial edges of the hernia can be brought together with or without component separation, an overlay (or underlay) of mesh can be used to reinforce the primary suture repair. Reinforcement is recommended for repair of all ventral incisional hernias.4 When all or part of the fascial defect cannot be closed primarily, mesh is used to bridge (i.e., span) the defect. In general, this technique is associated with a higher rate of complications and recurrence than reinforcement with mesh.4 Mesh bridging is generally used when component separation is not feasible or fails to coapt the fascial edges.4 Bridging may be the only option for very
large fascial defects. Mesh placement choices are summarized in Table 2. The two main types of mesh currently used are synthetic and bioprosthetic. Advantages and disadvantages of synthetic and bioprosthetic meshes are summarized in Table 3.6,8–28 Most surgeons are more familiar with synthetic meshes, which are durable and reliable but are generally contraindicated in contaminated and infected fields. Bioprosthetic materials are preferred over synthetic materials for use in contaminated fields and should be strongly considered when the defect has bacterial contamination. In a study of bioprosthetic mesh, complex hernia repair in contaminated fields was successfully achieved in 80 percent of patients, with no mesh explantation at 1 year (Level of Evidence: Therapeutic, IV).18 No large studies have compared the outcomes of synthetic versus bioprosthetic mesh in ventral hernia repair. One study found a significant decrease in the recurrence rate after primary repair of medium-size hernias were reinforced with an overlay of human acellular dermal matrix mesh (median follow-up, 15 months).29 Human acellular dermal matrix was one of the first available bioprosthetic meshes and was previously commonly used for ventral hernia repair; however, because of high rates
Table 2. Methods of Mesh Placement in Ventral Hernia Repair Method Overlay Underlay Interpositional
Description The mesh material is sutured ventral to the primary repair or fascial edges, with no contact with viscera The mesh material is sutured dorsal to the primary repair or fascial edges; less risk of mesh exposure if skin wound dehiscence occurs; the Ventral Hernia Working Group’s preferred method*; mesh can be placed in the intraperitoneal, preperitoneal, or retrorectus plane The mesh material is sutured to the fascial edges (bridging) with minimal overlap; not generally recommended because of a high hernia recurrence rate*
*Breuing K, Butler CE, Ferzoco S, et al. Incisional ventral hernias: Review of the literature and recommendations regarding the grading and technique of repair. Surgery 2010;148:544–558.
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Volume 133, Number 5 • Abdominal and Chest Wall Reconstruction Table 3. Advantages and Disadvantages of Synthetic and Bioprosthetic Meshes Mesh
Advantages
Disadvantages
Synthetic
• Reduced hernia recurrence rate compared to primary closure6 • Inert • Strength maintained after implantation • Relatively inexpensive
• Risk of visceral adhesions, bowel erosion, fistulas, and obstruction8–10 • Remains as a foreign body (no tissue remodeling) • Infection or exposure often requires removal • Implantation in contaminated field associated with high rate of infection8 • Radiation can theoretically increase the risk of complications such as bowel adhesion and extrusion11,12 • May be contraindicated for use in contaminated wounds
Bioprosthetic
• May be more resistant to mesh infection*13–15 • Documented revascularization*16 • Often does not need to be removed when exposed to or contaminated with bacteria17,18 • Less risk of adhesion to bowel*19,20 • Can be used in high-risk surgical fields and can placed directly over bowel20–22
• Relatively expensive compared with synthetic23 • Some materials may stretch over time24–26 • Variable recipient host responses (encapsulation and resorption) have been reported for some types*27 • High incidence of hernia recurrence (up to 80 percent) and seroma reported for some types23,26,28 • Long-term data not available for most materials
*As demonstrated in an animal model.
of bulges and hernia recurrence, its use is now limited.25,30 Xenogeneic acellular dermal matrix (porcine and bovine) appears to be more durable and promising. In a recent study, porcine acellular dermis was found to be a useful durable adjunct to component separation in reconstructing the abdominal wall in 41 patients, with no mesh explantation or hernia recurrence during the relatively short follow-up period (194 to 1017 days).31 Component Separation When it is difficult to coapt the abdominal fascia edges in the midline without undue tension, component separation should be considered. Component separation facilitates reapproximation of the musculofascia toward the midline to allow primary closure of central abdominal wall musculofascial defects, such as hernias or resection defects. In component separation, the external oblique aponeurosis is released just lateral to the linea semilunaris; this allows significant medial advancement of the rectus abdominis complex attached to the internal oblique and transversalis muscles without denervating or devascularizing the abdominal musculature. The original component separation technique also includes releasing the posterior rectus sheath. The amount of medial advancement per side with component separation has been reported as 5 cm in the epigastrium, 10 cm at the waistline, and 3 cm in the suprapubic area (Level of Evidence: Therapeutic, IV).32 Component separation provides dynamic innervated abdominal wall reconstruction without a distant donor-site deficit.32,33 It allows primary
fascial closure even in contaminated fields in which the use of synthetic materials is not recommended.34 The component separation technique and its modifications have been shown to help reduce hernia recurrence in difficult and recurrent hernias.34–36 Previous violation of the rectus abdominis complex with a visceral stoma, scar, or resection is generally not a contraindication for the use of component separation (Level of Evidence: Risk, II).37 Modifications of component separation include endoscopic or laparoscopic techniques, periumbilical perforator–preservation techniques, and minimally invasive techniques30,38–42 such as minimally invasive component separation with inlay bioprosthetic mesh, which uses tunnel incisions for external oblique aponeurosis release (Level of Evidence: Therapeutic, IV).38 The main aims of these modified techniques are minimizing the subcutaneous dead space that can result from extensive tissue undermining and improving vascularity to the overlying skin by preserving the integrity of the rectus abdominis myocutaneous perforators. Some of the techniques used to perform component separation are illustrated in Figure 1. The hernia recurrence rate following repair with component separation but no mesh was reported to be 22.8 percent in a study of 158 patients with a mean follow-up of 10 months.30 However, among 18 patients in whom component separation was reinforced with soft synthetic mesh, in the same article, there were no recurrences during the mean follow-up of 13 months. In a recent review, open component separation without mesh
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Plastic and Reconstructive Surgery • May 2014 of paramedian skin vascularity and reduction in subcutaneous dead space with minimally invasive component separation with inlay bioprosthetic mesh. Furthermore, despite larger hernia defects in the minimally invasive component separation with inlay bioprosthetic mesh group, the latter study found a nonsignificantly lower incidence of hernia recurrence and bulge with minimally invasive component separation with inlay bioprosthetic mesh than with open component separation (Level of Evidence: Therapeutic, III).44
Fig. 1. Methods of component separation. (Above) Normal anatomy is shown in a cut section through the abdominal wall above the arcuate line. Dotted line represents the semilunar line. (Second row) Open component separation. All of the skin perforators from the deep inferior epigastric system are divided to allow exposure of the semilunar line (arrow). (Third row) Perforator-preserving component separation. One or more skin perforators from the deep epigastric system are preserved to minimize skin undermining and maintain better skin perfusion. The semilunar line is accessed through a tunnel. (Below) Endoscopic component separation. Perforators are preserved and dead space is minimized.
repair was associated with a higher hernia recurrence rate (27 percent at 27 months’ mean followup) than open component separation with mesh repair (16.7 percent at 33 months’ mean followup).43 Laparoscopic and open component separations are associated with similar hernia recurrence rates.43 In a recent study, Butler’s minimally invasive component separation with inlay bioprosthetic mesh (MICSIB)38 technique resulted in fewer wound-healing complications, including skin dehiscence, than did open component separation (14 percent versus 32 percent) when used for complex abdominal wall reconstructions.44 These findings are likely attributable to the preservation
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Composite Defects Timing of Reconstruction Most composite defects (those including musculofascia and overlying fat and skin) are repaired in an immediate, single-stage fashion unless the patient is unstable or there is significant bacterial contamination in the tissue. In these cases, several serial débridements are performed and definitive reconstruction is delayed. Common methods used to gain time until the definitive reconstruction can be performed include wound dressing changes and negative-pressure wound therapy.45 Lower Abdomen Defects For defects of the lower abdomen, soft-tissue coverage can be provided with thigh-based pedicled flaps if primary skin closure with local tissue is not possible. For midline fascial defects, component separation is less useful in the lower abdomen than in the central abdomen. Therefore, if the fascia cannot be closed primarily without undue tension, formal fascial reconstruction with mesh is advised. If there are no fascial edges to secure the mesh to, the surgeon may elect to secure the mesh to bone with polypropylene sutures through drill holes in the ribs, lumbosacral spine, and/or pelvis.46 Even if a soft-tissue flap is used for reconstruction, mesh repair is preferable to using the fascial component of the flap to patch the defect. Mesh repair may be more reliable than the fascia of a tissue flap, as it places less tension on the flap inset that might potentially compromise vascularity. Furthermore, the fascial component of soft-tissue flaps may be less reliable than implantable mesh, potentially resulting in failure or laxity of the repair.46 Upper Abdomen Defects For lateral upper abdomen defects, if primary closure of the skin with local tissue is not possible, soft-tissue coverage can be provided with flaps based on the upper trunk (e.g., latissimus dorsi, serratus). For fascial reconstruction, the same principles outlined for lower abdominal defects are followed.
Volume 133, Number 5 • Abdominal and Chest Wall Reconstruction The central upper abdomen remains a difficult area to reconstruct with pedicled flaps in general, as only the less reliable, less perfused distal part of trunk-based or thigh-based pedicled flaps tends to reach the upper abdomen. Free flaps are often needed for central upper abdominal defects and may require vein grafts or anastomosis to intraperitoneal vessels. Central fascial defects can be addressed in the same way as ventral hernia repair. Component separation and/or mesh (without a flap) provide a means for repairing midline defects in some cases. Flap Selection For abdominal wall defects that cannot be closed primarily or with a local flap, various regional flaps have been used to provide stable soft-tissue coverage. Defects in the lower abdomen can be closed with flaps from the thigh. Flaps that are based on the lateral circumflex femoral system can provide skin, muscle, and fascia, as needed. Lateral abdominal defects can be repaired with pedicled flaps from the abdomen or upper trunk. Table 4 summarizes key considerations in pedicled flap choice for abdominal wall reconstruction.47–54
The main indication for free flaps in abdominal wall reconstruction is extremely large defects or those located in the central upper abdomen where pedicled flaps cannot reach. Free flaps used to repair these defects include tensor fasciae latae flaps, anterolateral thigh flaps, other combined thigh flaps, groin flaps, and latissimus dorsi flaps.49,55,56 A paucity of reliable recipient vessels for free flaps in the abdominal wall is often encountered in patients who have had multiple operations and/or radiation therapy. Vein grafts or arteriovenous loops are helpful in this situation.46,57 Possible donor vessels include the femoral vessels and their branches the internal mammary, superior epigastric, inferior epigastric, and gastroepiploic vessels.46,57,58 Using intraabdominal vessels as recipient vessels requires creating a tunnel for the free flap’s vascular pedicle through the abdominal wall and/or mesh (if mesh is used); this increases the chance of hernia, pedicle compression, and thrombosis. Recipient vessel options that do not generally require vein grafts are the gastroepiploic and internal mammary vessels.
Table 4. Thigh-Based and Torso-Based Pedicled Flaps Used in Abdominal Wall Reconstruction Flap ALT flap
TFL flap
Rectus femoris flap
Combined thigh flaps
Rectus abdominis flap
Latissimus dorsi flap
Characteristics • Large surface area • Minimal donor-site morbidity • Generally will reach the periumbilical area but has been reported to reach up to the costal margin47 • Can reach the ipsilateral posterior superior iliac spine posteriorly and the contralateral fossa laterally47 • Associated fascia may not be reliable for fascial reconstruction47 • Large skin paddle (15 × 40 cm)48 • Skin can reach the periumbilical area, but distal skin necrosis is the main shortcoming when TFL is used in abdominal wall reconstruction48,49 • Adding rectus femoris muscle to TFL with their surrounding fascia allows coverage of larger defects but is still associated with skin necrosis50 • Can be transferred as a muscle flap, musculocutaneous flap, or part of a combined thigh flap based on the lateral circumflex femoral vessel • Provides a long cylindrical muscle, approximately 6 cm wide, and can support a 12 × 20-cm skin island • “Subtotal thigh” flap46 takes advantage of the versatile lateral circumflex femoral vessel system and can include rectus femoris, TFL, vastus lateralis, and/or ALT flap tissue • Nearly the entire abdominal wall skin can be reconstructed with bilateral pedicled subtotal thigh flaps46 • Fascial portion of these flaps can be used to repair fascial defects, but mesh is often preferred for reconstruction of the musculofascia, with soft-tissue flaps used for coverage; thigh fascia may be less reliable and can tear along its fibers46 • Skin paddle can be oriented vertically, horizontally, as an extended deep inferior epigastric artery flap (musculocutaneous flap with lateral skin extension based on the periumbilical perforators), or as a flag flap (skin from the upper abdomen with extensions to the inframammary fold and the anterior axillary line)51–54 • Useful for defects located at the periphery of the abdominal wall • Generally should be avoided for large abdominal wall defects when the donor site would add to the primary defect • Arc of rotation of the flap allows coverage of superolateral abdominal wall defects • Can be used as muscle or musculocutaneous flap
ALT, anterolateral thigh; TFL, tensor fasciae latae.
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Plastic and Reconstructive Surgery • May 2014 Tissue Expansion Tissue expansion of the abdominal wall can provide well-vascularized autologous skin, subcutaneous tissue, and/or abdominal fascia for the repair of large defects.,59–61 However, tissue expansion carries the risks of rupture, extrusion, infection, patient intolerance, and expander failure.
CHEST WALL RECONSTRUCTION There are generally four indications for chest wall reconstruction: resection of a tumor (primary or recurrent), radiation injury, trauma, and infection (Level of Evidence: Therapeutic, IV).62 Sternal wound dehiscence following sternotomy is also a commonly seen problem in plastic surgery and is often discussed as a separate entity from the other reconstructive problems. This part of the article focuses on intrathoracic reconstruction in bronchopleural fistula and empyema and chest wall reconstruction following tumor resection. Other aspects of chest wall reconstruction are discussed elsewhere in the literature. General Principles General principles for the treatment of chronic empyema and bronchopleural fistula, which often occur together, include drainage of the fluid collection, débridement of devitalized tissue, obliteration of the dead space, establishment of negative intrathoracic pressure, and administration of proper antibiotics.63 The bronchopleural fistula should be resected, the bronchus should be closed, and the repair should be reinforced with a well-vascularized tissue flap to reduce the chance of recurrent fistula.64 The severity of the case and the general condition of the patient determine whether definitive reconstruction can be performed in a single stage or will require multiple stages.63,65 The two major components of chest wall reconstruction following composite resection are reconstruction of chest wall stability and provision of reliable, well-vascularized soft-tissue coverage. Additional objectives, as described by Thomas and Brouchet,66 are to avoid lung hernia and paradoxical chest wall motion, counteract the contraction of the affected side of the thorax expected after surgery, prevent impaction of the scapula into the defect in cases of posterior chest wall resection, protect the underlying mediastinal organs, and maintain an aesthetically acceptable chest shape. Restoring a form of skeletal stability is often needed following major
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resection to reduce the negative impact on respiratory function. Preoperative Considerations The patient’s general medical condition and nutritional status should be optimized before surgery. In addition, the patient’s pulmonary function should be evaluated preoperatively (e.g., with spirometry) because the vast majority of patients undergoing major chest wall procedures will have some degree of postoperative respiratory dysfunction.67 Failed extubation and prolonged ventilator dependence could follow major chest wall surgery in patients with poor preoperative respiratory function. The plastic surgeon should communicate with the thoracic surgeon to develop a clear reconstructive plan. For intrathoracic reconstruction, the plastic surgeon should be familiar with bronchopleural fistula and empyema. Although bronchopleural fistula is sometimes treated in multiple stages, defects that follow composite chest wall resection are approached differently, with the aim of achieving reconstruction in a single operation. Preoperative (and intraoperative) planning will benefit from an algorithmic approach to the anticipated defect, evaluating the defect in layers from inside out, starting with the pleura, then the skeleton, and then the soft tissues. Resection of any of these components will create a unique problem that needs a specific form of reconstruction. Prosthetic materials are frequently needed to restore chest wall skeletal stability following resection. Operative Techniques Bronchopleural Fistula and Empyema Bronchopleural fistula and chronic empyema are two of the most common conditions necessitating reconstruction of the pleural space and often occur together. The incidence of postpneumonectomy stump fistula is 0 to 12 percent,68,69 although postpneumonectomy empyema has a reported incidence of 2.2 to 16 percent.70 The presence of untreated dead space and bronchopleural fistula following lobectomy or pneumonectomy will usually result in infection. The postoperative mortality rate of pneumonectomy increases to 25 percent if the course is complicated by empyema and to approximately 50 percent if bronchopleural fistula is present.71 Some of the classic techniques used to treat chronic empyema and/or bronchopleural fistula are summarized in Table 5.72–78
Volume 133, Number 5 • Abdominal and Chest Wall Reconstruction Table 5. Classic Surgical Techniques Used to Treat Chronic Empyema and Bronchopleural Fistula Technique/Procedure
Uses/Characteristics
Clagett procedure
Eloesser procedure (Fig. 3)
Thoracoplasty
• For treatment of postpneumonectomy empyema72 • Two stages73: First, establish open pleural drainage Second, fill pleural space with antibiotic solution and close • Can be repeated if first attempt fails • Reinforcing the bronchial stump with transposition of extrathoracic skeletal muscle (e.g., serratus anterior or latissimus dorsi) following the first stage of Clagett procedure successfully closes 85% of BPFs74 • For debilitated patients with chronic empyema in which extensive chest procedures and flap transfer would be poorly tolerated75 • One stage • Consists of resecting a segment of a rib in the posterior or posterolateral chest wall, creating a U-shaped soft-tissue flap, and suturing it to the pleura • Allows continuous drainage until the lung expands and reaches the chest wall, after which the wound closes automatically76 • Multiple ribs are selectively resected subperiosteally77 • Allows chest wall to collapse and reduce pleural dead space • Has become less popular in the past few decades, after the development of antituberculosis medications and widespread use of muscle transposition to fill pleural space78
BPF, bronchopleural fistula.
Soft-tissue flaps are often used to reinforce the repair after closure of a fistula and/or to fill the intrathoracic dead space after drainage of a fluid collection. Flaps used in bronchopleural fistula closure include intercostal muscle,79
pericardial fat,80 diaphragm,81 extrathoracic muscle,73 omental,82 and free flaps.83 Pedicled flaps commonly used to fill intrathoracic dead space are described in Table 664,84–87 and illustrated in Figure 2.
Table 6. Soft-Tissue Flaps Used to Obliterate Intrathoracic Dead Space* Flap
Approximate Size (cm)
Blood Supply
Pectoralis major
15 × 23
• Thoracoacromial vessels • Internal mammary perforators
Serratus anterior
15 × 20
• Lateral thoracic vessels (axillary) • Serratus branches of thoracodorsal vessels
Latissimus dorsi
25 × 35
• Thoracodorsal vessels • Intercostal and lumbar perforating vessels
Rectus abdominis
25 × 6
• Deep inferior and superior epigastric vessels
Trapezius
34 × 18
Omentum
Variable
• Transverse cervical vessels • Occipital, dorsal scapular, and intercostal perforating vessels • Gastroepiploic vessels (right and left)
Common Uses/Characteristics • Used to fill the cephalad part of the thoracic cavity and sternal defects • Introduced through a resected segment of second, third, or fourth rib near the axilla • Use of this flap as island increases its excursion • Used for mediastinal and hilar coverage84 • Frequently intact following thoracotomy and conforms easily to the size and shape needed for hilar reconstruction64,84 • Introduced through a created defect of the second rib at midaxillary line84 • Can be combined with latissimus dorsi muscle flap for larger bulk • Used to fill the lateral, anterolateral, and posterior chest • Introduced through a window in the anterolateral chest (similar to serratus) • Releasing the humeral attachment increases the reach of the flap • Used for sternal (anterior) and caudad anterolateral chest defects • Usually passed over the epigastrium • Used for posterior and apical chest defects85,86 • Passed through a posterior thoracotomy defect • Used to fill the anterior mediastinum and anywhere else in the chest • Tunneled to the chest through superior midline abdominal incision over the ribs or through the diaphragm
*Adapted from Mathes SJ, Nahai F. Reconstructive Surgery: Principles, Anatomy, and Technique. St. Louis: Quality Medical Publishing; 1997.
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Fig. 2. (Left) Pedicled flaps commonly used to fill intrathoracic dead space: pectoralis major muscle (1), serratus anterior muscle (2), latissimus dorsi muscle (3), omental (4), and rectus abdominis muscle (5) flaps. (Right) The pectoralis major muscle flap is useful for filling upper chest defects. The latissimus dorsi muscle flap is more useful for filling lateral defects. The omental flap can be passed over the ribs or through the diaphragm.
These flaps can be introduced into the thoracic cavity through the original wound63 or through a new, separate thoracotomy.64 For single-stage treatment of empyema without a bronchopleural fistula, the empyema is drained, and the dead space is irrigated, filled with a muscle flap, and closed.63,75 If the patient is too ill to undergo an extended single-stage procedure or if the infection is longstanding and resistant, treatment may
Fig. 3. Eloesser procedure. A superiorly or inferiorly based (Thourani VH, Lancaster RT, Mansour KA, Miller JI Jr. Twenty-six years of experience with the modified Eloesser flap. Ann Thorac Surg. 2003;76:401–405; discussion 405) skin flap (as shown here) is created over the area of the chest that needs to be drained. A window is created in the chest wall by removing a segment from one or more ribs. The skin flap is sutured to the inside of the pleural cavity (to the diaphragm in this illustration) to create a pleurocutaneous fistula.
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begin with a drainage procedure, such as the Eloesser procedure (Table 5 and Fig. 3). When bronchopleural fistula is also present, it must be addressed as well. Defects from Tumor Resection Reconstruction of Chest Wall Stability Autologous tissues such as rib grafts and fascial grafts have been falling out of favor for restoration of chest wall stability since synthetic mesh was introduced.62 Semirigid chest wall reconstruction can be achieved by suturing synthetic or bioprosthetic mesh under tension to span the skeletal defect that follows tumor resection. Some authors also suggest the use of more rigid fixation with polymethylmethacrylate/polypropylene mesh for such defects.88 Polymethylmethacrylate reconstruction is frequently advocated to repair large anterior and anterolateral chest wall contour defects, whereas large defects in flat surfaces on the anterior and posterior aspect of the chest may be repaired with prosthetic mesh.89,90 The ideal prosthetic material features, as described by le Roux and Shama, include rigidity that reduces paradoxical movement, inertness that allows tissue ingrowth, malleability, and radiolucency that does not obstruct radiographic evidence of tumor relapse.91 Synthetic mesh in general may increase complication rates when it is placed directly over viscera or when the operative site has been irradiated or contaminated with bacteria.22 Table 7 describes commonly used synthetic materials in chest wall reconstruction.62,66,92–94 Synthetic mesh is contraindicated in contaminated wounds unless prolonged dependence on a ventilator will result from not using it.62 In
Volume 133, Number 5 • Abdominal and Chest Wall Reconstruction Table 7. Synthetic Materials Commonly Used for Chest Wall Reconstruction Material
Advantages
Polypropylene
• Inexpensive • Macroporous, allowing tissue ingrowth around fibers
PTFE
• Achieves watertight seal (microporous) • Easy to suture • Stretches to contour into wound • Durable93 • Commonly used to provide rigidity • Often used in combination with polypropylene mesh • Able to contour to match curved shape of the chest wall
PMMA
Disadvantages • Does not allow initial watertight seal; more difficult than PTFE to contour and tends to wrinkle with suturing62 • Contraindicated in contaminated wounds92 • Infection may require removal92 • More expensive than some other synthetic meshes94 • Negligible tissue ingrowth (microporous) • Contraindicated in contaminated wounds92 • Infection commonly requires removal • Exothermic reaction may cause thermal tissue injury • Difficult to mold • May fracture tissue at edges • Rigid, permits less dynamic chest wall reconstruction94 • Does not allow tissue ingrowth into PMMA itself • Tends to form seromas66
PFTE, polytetrafluoroethylene; PMMA, polymethylmethacrylate.
the latter situation, bioprosthetic mesh is an alternative. Many bioprosthetic meshes are available; these include human and xenogeneic acellular dermal matrices. Bioprosthetic meshes have been shown in animal models to allow tissue ingrowth,95 become incorporated and revascularized,95 and be valuable for wounds with a high risk of infection or complications. The main limitations are their high cost, unproven long-term stability in the chest wall, and theoretic risk of stretching or laxity with ongoing remodeling. Bioprosthetic mesh may be a good option for defects that have bacterial contamination and/or an increased risk of skin dehiscence with mesh exposure; the material tolerates cutaneous exposure without the need for explantation.18 Once the synthetic or bioprosthetic material is placed and secured to the edges of the defect, well-vascularized soft-tissue coverage should be provided to minimize the chance of exposure and infection. The use of prosthetic mesh sutured under tension to recreate semirigid chest wall stability
following repair of large defects has been shown to reduce ventilator dependence and hospital stay.96 However, the absolute need for rigid or semirigid skeletal stability reconstruction of the chest wall following resection has been challenged, particularly for smaller defects. Arnold and Pairolero reported that pulmonary function is not ultimately compromised following major chest wall resection, such as removal of the entire sternum, if reconstruction is performed without mesh.62 Furthermore, the resulting pulmonary insufficiency following chest wall resection is often less significant than that following trauma.97 Factors to be considered in making a decision about skeletal stability reconstruction are summarized in Table 8.92,97–102 Soft-Tissue Coverage For small, full-thickness defects of the chest wall, a thick soft-tissue flap can provide enough stability without the need for chest wall skeletal stability reconstruction. Otherwise, soft-tissue flaps are used in conjunction with synthetic or bioprosthetic materials to provide soft-tissue coverage
Table 8. Factors to Consider in Skeletal Stability Reconstruction Size of the defect
Location of the defect
Condition of the chest wall
• Some authors advocate skeletal reconstruction when the defect is four ribs or more98,99 • Others use the actual size of the defect and believe that defects more than 5 cm in diameter are more likely to benefit from prosthetic reconstruction92,100 • Soft tissue–only reconstruction is often considered adequate for smaller defects • Defects in the anterior (and anterolateral) chest wall require stability reconstruction more often than posterior chest wall because they more mobile and have stronger impact on the respiratory function101 • Prosthetic stability reconstruction is thought to be required less often in the posterior chest wall than in the anterolateral chest wall because the scapula and its surrounding muscle attachment provide more stability in the former • Small (
Learning Objectives: After studying this article, the participant should be able to: 1. Define the goals of abdominal wall and chest wall reconstruction. 2. Discuss the general principles of and the different surgical techniques for abdominal wall and chest wall reconstruction. 3. List the major advantages and disadvantages of synthetic and bioprosthetic mesh in abdominal and chest wall reconstruction. 4. Define the indications for and major factors to consider in chest wall skeletal stability reconstruction. 5. List the flaps commonly used for chest wall and abdominal wall reconstruction. Summary: Plastic surgeons commonly face reconstructive challenges in repairing the abdominal and chest walls. Reconstructive options in these two areas are rapidly expanding with the availability of new techniques and new products. The purpose of this article is to provide an updated summary of reconstruction of the abdominal and chest walls, focusing on commonly encountered problems. (Plast. Reconstr. Surg. 133: 688e, 2014.)
V
ideo, Supplemental Digital Content 1, which briefly highlights some of the important points of abdominal wall and chest reconstruction, is available in the “Related Videos” section of the full-text articles on PRSJournal.com or, for Ovid users, at http://links.lww.com/ PRS/A971.
ABDOMINAL WALL RECONSTRUCTION Ventral hernia repair and postoncologic reconstructive problems are some of the most commonly encountered abdominal wall challenges faced by plastic surgeons and are the focus of this section of the article. Because of space limitations, other abdominal wall reconstructive problems, such as congenital defects, traumatic defects, and open abdomen, are not discussed. General Principles The goals of abdominal wall reconstruction are to provide stable soft-tissue coverage, restore fascial integrity, prevent hernia, protect abdominal viscera, and restore function if possible. To minimize wound-related complications, the patient’s general medical condition (e.g., nutritional, cardiac, pulmonary) should be optimized preoperatively if feasible. From the Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center. Received for publication September 24, 2012; accepted November 1, 2012. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000086
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Ideally, abdominal wall reconstruction should be approached with a multidisciplinary team. In ventral hernia repair, for example, the surgeons who performed the laparotomy that resulted in the hernia are often involved, along with the reconstructive surgeons who will perform the abdominal wall reconstruction. The fascia and the soft-tissue envelope of the abdominal wall—including the skin—can be considered as two separate units. The “like-with-like” principle of reconstructive surgery should be followed in reconstructing these units if possible. Dead space should be eliminated as much as possible during reconstruction, and extensive undermining of the skin should be avoided. The surgeon should also choose a method of reconstruction that minimizes the chances of bowel adhesions, fistulization, and perforation. The musculofascia can be repaired by primary closure with or without component separation, fascial grafts, fascial components of tissue flaps, and synthetic or bioprosthetic mesh materials. Disclosure: The authors have no financial interests related to the content of this article. There was no external funding for this article.
Related Video content is available for this article. The videos can be found under the “Related Videos” section of the full-text article, or, for Ovid users, using the URL citations published in the article.
www.PRSJournal.com
Volume 133, Number 5 • Abdominal and Chest Wall Reconstruction
Video. Supplemental Digital Content 1, which briefly highlights some of the important points of abdominal wall and chest reconstruction, is available in the “Related Videos” section of the full-text articles on PRSJournal.com or, for Ovid users, at http:// links.lww.com/PRS/A971.
The surgeon should avoid undue tension on the fascial repair site and repair the fascia under physiologic tension to minimize the chance of early dehiscence and late hernia recurrence. Midline musculofascial defects may benefit from component separation, depending on the size and location of the defect. If the fascial defect is located laterally, which is often encountered following tumor resection, reconstruction of the fascia with synthetic or bioprosthetic mesh is often the best option. Stable skin coverage can be provided with primary closure of the skin, local or regional flaps, skin grafts, tissue expansion, and/or free tissue transfer. Flap selection will depend on the location, extent, and size of the defect. Preoperative Considerations Physical examination should be performed to assess the patient’s general condition, the abdominal wall integrity, the extent and location of any abdominal wall abnormalities, and the presence of scars that could become an obstacle to raising reliable tissue flaps. Routine laboratory tests and a nutritional workup are advised. Preoperative computed tomography to examine the defect characteristics and abdominal wall anatomy and vascularity is helpful for surgical planning. Operative Techniques Hernia Repair The most common abdominal wall defects faced by reconstructive surgeons are incisional
hernias. The incidence of incisional hernia is approximately 11 percent following midline laparotomy.1 One in three incisional hernias will cause symptoms, and approximately 4 percent of patients undergoing laparotomy will undergo an additional operation to repair an incisional hernia (Reference 2 Level of Evidence: Therapeutic, II).1,2 Patients with hernias are at risk of developing bowel-related complications such as enterocutaneous fistulas, obstruction, incarceration, and strangulation. Functional problems in hernia patients include poor respiratory effort, loss of abdominal domain, and weak abdominal musculature. Cosmetic problems are also frequent complaints from patients with abdominal hernias. Incisional hernias are notorious for their high recurrence rate after repair and for their high rate of surgical complications. One study found that the 5-year reoperation rate was 23.8 percent after the first hernia repair operation, 35.3 percent after the second, and 38.7 percent after the third (Level of Evidence: Therapeutic, III).3 The infection rate following ventral hernia repair is 4 to 16 percent.4 The risk significantly increases if the patient had a previous infection (41 percent versus 12 percent in one study).5 Following infection, the risk of hernia recurrence was reported to be approximately 80 percent in one study.6 Bowel-related complications such as adhesions, obstruction, erosion, and fistulization are other known complications of hernia repair, especially with the use of synthetic mesh. One study found that the risk of enterotomy or unplanned bowel resection in patients with previous synthetic mesh hernia repair was higher (20 percent versus 5 percent) than in patients who did not have mesh repairs for their hernias.7 Factors that may complicate hernia repair include the presence of multiple scars that could compromise skin vascularity, the presence of enterocutaneous fistulas or exposed mesh, the presence of extensive bowel adhesions, obesity, and chronic hernia with loss of domain. The Ventral Hernia Working Group developed a grading system for the risk of complications at the surgical site that categorizes patients into one of four groups.4 Table 1 summarizes the Ventral Hernia Working Group recommendations for whether to use mesh and what type to use in each group. The Ventral Hernia Working Group recommends the use of prosthetic material to reinforce the repair of all incisional ventral hernias regardless of whether the midline fascia can be reapproximated—unless there is a contraindication to use mesh, such as wound infection.4
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Plastic and Reconstructive Surgery • May 2014 Table 1. Ventral Hernia Working Group Grading System for Risk of Complications at the Surgical Site with Recommendation for Each Grade* Grade 1 2 3 4
Description The healthy patient with no contamination and no history of wound infection; the VHWG recommends the use of prosthetic material to reinforce the repair of all incisional ventral hernias, regardless of whether or not the midline fascia can be closed The patient who does not have wound contamination or infection but has one or more comorbidities that increase the risk of infection; the VHWG suggests that bioprosthetic material might have an advantage over synthetic material in these cases The patient who has violation of bowel or the presence of nearby stoma or infection; synthetic mesh is not recommended*; bioprosthetic mesh may be a good option The patient with infected synthetic mesh or septic dehiscence; no repair material should be used in the setting of gross uncontrolled contamination; the surgeon may consider a delayed repair
VHWG, Ventral Hernia Working Group. *Breuing K, Butler CE, Ferzoco S, et al. Incisional ventral hernias: Review of the literature and recommendations regarding the grading and technique of repair. Surgery 2010;148:544–558.
Mesh or No Mesh? Prospective randomized studies have demonstrated that the use of mesh reduces hernia recurrence by approximately one half compared with primary suture repair at 3 years (24 percent versus 43 percent)6 and 10 years (32 percent versus 63 percent) of follow-up.2 Defects 2 cm in diameter or less may be suitable for primary suture repair, although the Ventral Hernia Working Group suggests that these small hernias may still benefit from the use of mesh.4 One study reported that even for small ventral incisional hernias, the recurrence rate is 67 percent following suture repair versus 17 percent after mesh repair.2 Mesh is used to either reinforce or bridge fascial defects. When the fascial edges of the hernia can be brought together with or without component separation, an overlay (or underlay) of mesh can be used to reinforce the primary suture repair. Reinforcement is recommended for repair of all ventral incisional hernias.4 When all or part of the fascial defect cannot be closed primarily, mesh is used to bridge (i.e., span) the defect. In general, this technique is associated with a higher rate of complications and recurrence than reinforcement with mesh.4 Mesh bridging is generally used when component separation is not feasible or fails to coapt the fascial edges.4 Bridging may be the only option for very
large fascial defects. Mesh placement choices are summarized in Table 2. The two main types of mesh currently used are synthetic and bioprosthetic. Advantages and disadvantages of synthetic and bioprosthetic meshes are summarized in Table 3.6,8–28 Most surgeons are more familiar with synthetic meshes, which are durable and reliable but are generally contraindicated in contaminated and infected fields. Bioprosthetic materials are preferred over synthetic materials for use in contaminated fields and should be strongly considered when the defect has bacterial contamination. In a study of bioprosthetic mesh, complex hernia repair in contaminated fields was successfully achieved in 80 percent of patients, with no mesh explantation at 1 year (Level of Evidence: Therapeutic, IV).18 No large studies have compared the outcomes of synthetic versus bioprosthetic mesh in ventral hernia repair. One study found a significant decrease in the recurrence rate after primary repair of medium-size hernias were reinforced with an overlay of human acellular dermal matrix mesh (median follow-up, 15 months).29 Human acellular dermal matrix was one of the first available bioprosthetic meshes and was previously commonly used for ventral hernia repair; however, because of high rates
Table 2. Methods of Mesh Placement in Ventral Hernia Repair Method Overlay Underlay Interpositional
Description The mesh material is sutured ventral to the primary repair or fascial edges, with no contact with viscera The mesh material is sutured dorsal to the primary repair or fascial edges; less risk of mesh exposure if skin wound dehiscence occurs; the Ventral Hernia Working Group’s preferred method*; mesh can be placed in the intraperitoneal, preperitoneal, or retrorectus plane The mesh material is sutured to the fascial edges (bridging) with minimal overlap; not generally recommended because of a high hernia recurrence rate*
*Breuing K, Butler CE, Ferzoco S, et al. Incisional ventral hernias: Review of the literature and recommendations regarding the grading and technique of repair. Surgery 2010;148:544–558.
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Volume 133, Number 5 • Abdominal and Chest Wall Reconstruction Table 3. Advantages and Disadvantages of Synthetic and Bioprosthetic Meshes Mesh
Advantages
Disadvantages
Synthetic
• Reduced hernia recurrence rate compared to primary closure6 • Inert • Strength maintained after implantation • Relatively inexpensive
• Risk of visceral adhesions, bowel erosion, fistulas, and obstruction8–10 • Remains as a foreign body (no tissue remodeling) • Infection or exposure often requires removal • Implantation in contaminated field associated with high rate of infection8 • Radiation can theoretically increase the risk of complications such as bowel adhesion and extrusion11,12 • May be contraindicated for use in contaminated wounds
Bioprosthetic
• May be more resistant to mesh infection*13–15 • Documented revascularization*16 • Often does not need to be removed when exposed to or contaminated with bacteria17,18 • Less risk of adhesion to bowel*19,20 • Can be used in high-risk surgical fields and can placed directly over bowel20–22
• Relatively expensive compared with synthetic23 • Some materials may stretch over time24–26 • Variable recipient host responses (encapsulation and resorption) have been reported for some types*27 • High incidence of hernia recurrence (up to 80 percent) and seroma reported for some types23,26,28 • Long-term data not available for most materials
*As demonstrated in an animal model.
of bulges and hernia recurrence, its use is now limited.25,30 Xenogeneic acellular dermal matrix (porcine and bovine) appears to be more durable and promising. In a recent study, porcine acellular dermis was found to be a useful durable adjunct to component separation in reconstructing the abdominal wall in 41 patients, with no mesh explantation or hernia recurrence during the relatively short follow-up period (194 to 1017 days).31 Component Separation When it is difficult to coapt the abdominal fascia edges in the midline without undue tension, component separation should be considered. Component separation facilitates reapproximation of the musculofascia toward the midline to allow primary closure of central abdominal wall musculofascial defects, such as hernias or resection defects. In component separation, the external oblique aponeurosis is released just lateral to the linea semilunaris; this allows significant medial advancement of the rectus abdominis complex attached to the internal oblique and transversalis muscles without denervating or devascularizing the abdominal musculature. The original component separation technique also includes releasing the posterior rectus sheath. The amount of medial advancement per side with component separation has been reported as 5 cm in the epigastrium, 10 cm at the waistline, and 3 cm in the suprapubic area (Level of Evidence: Therapeutic, IV).32 Component separation provides dynamic innervated abdominal wall reconstruction without a distant donor-site deficit.32,33 It allows primary
fascial closure even in contaminated fields in which the use of synthetic materials is not recommended.34 The component separation technique and its modifications have been shown to help reduce hernia recurrence in difficult and recurrent hernias.34–36 Previous violation of the rectus abdominis complex with a visceral stoma, scar, or resection is generally not a contraindication for the use of component separation (Level of Evidence: Risk, II).37 Modifications of component separation include endoscopic or laparoscopic techniques, periumbilical perforator–preservation techniques, and minimally invasive techniques30,38–42 such as minimally invasive component separation with inlay bioprosthetic mesh, which uses tunnel incisions for external oblique aponeurosis release (Level of Evidence: Therapeutic, IV).38 The main aims of these modified techniques are minimizing the subcutaneous dead space that can result from extensive tissue undermining and improving vascularity to the overlying skin by preserving the integrity of the rectus abdominis myocutaneous perforators. Some of the techniques used to perform component separation are illustrated in Figure 1. The hernia recurrence rate following repair with component separation but no mesh was reported to be 22.8 percent in a study of 158 patients with a mean follow-up of 10 months.30 However, among 18 patients in whom component separation was reinforced with soft synthetic mesh, in the same article, there were no recurrences during the mean follow-up of 13 months. In a recent review, open component separation without mesh
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Plastic and Reconstructive Surgery • May 2014 of paramedian skin vascularity and reduction in subcutaneous dead space with minimally invasive component separation with inlay bioprosthetic mesh. Furthermore, despite larger hernia defects in the minimally invasive component separation with inlay bioprosthetic mesh group, the latter study found a nonsignificantly lower incidence of hernia recurrence and bulge with minimally invasive component separation with inlay bioprosthetic mesh than with open component separation (Level of Evidence: Therapeutic, III).44
Fig. 1. Methods of component separation. (Above) Normal anatomy is shown in a cut section through the abdominal wall above the arcuate line. Dotted line represents the semilunar line. (Second row) Open component separation. All of the skin perforators from the deep inferior epigastric system are divided to allow exposure of the semilunar line (arrow). (Third row) Perforator-preserving component separation. One or more skin perforators from the deep epigastric system are preserved to minimize skin undermining and maintain better skin perfusion. The semilunar line is accessed through a tunnel. (Below) Endoscopic component separation. Perforators are preserved and dead space is minimized.
repair was associated with a higher hernia recurrence rate (27 percent at 27 months’ mean followup) than open component separation with mesh repair (16.7 percent at 33 months’ mean followup).43 Laparoscopic and open component separations are associated with similar hernia recurrence rates.43 In a recent study, Butler’s minimally invasive component separation with inlay bioprosthetic mesh (MICSIB)38 technique resulted in fewer wound-healing complications, including skin dehiscence, than did open component separation (14 percent versus 32 percent) when used for complex abdominal wall reconstructions.44 These findings are likely attributable to the preservation
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Composite Defects Timing of Reconstruction Most composite defects (those including musculofascia and overlying fat and skin) are repaired in an immediate, single-stage fashion unless the patient is unstable or there is significant bacterial contamination in the tissue. In these cases, several serial débridements are performed and definitive reconstruction is delayed. Common methods used to gain time until the definitive reconstruction can be performed include wound dressing changes and negative-pressure wound therapy.45 Lower Abdomen Defects For defects of the lower abdomen, soft-tissue coverage can be provided with thigh-based pedicled flaps if primary skin closure with local tissue is not possible. For midline fascial defects, component separation is less useful in the lower abdomen than in the central abdomen. Therefore, if the fascia cannot be closed primarily without undue tension, formal fascial reconstruction with mesh is advised. If there are no fascial edges to secure the mesh to, the surgeon may elect to secure the mesh to bone with polypropylene sutures through drill holes in the ribs, lumbosacral spine, and/or pelvis.46 Even if a soft-tissue flap is used for reconstruction, mesh repair is preferable to using the fascial component of the flap to patch the defect. Mesh repair may be more reliable than the fascia of a tissue flap, as it places less tension on the flap inset that might potentially compromise vascularity. Furthermore, the fascial component of soft-tissue flaps may be less reliable than implantable mesh, potentially resulting in failure or laxity of the repair.46 Upper Abdomen Defects For lateral upper abdomen defects, if primary closure of the skin with local tissue is not possible, soft-tissue coverage can be provided with flaps based on the upper trunk (e.g., latissimus dorsi, serratus). For fascial reconstruction, the same principles outlined for lower abdominal defects are followed.
Volume 133, Number 5 • Abdominal and Chest Wall Reconstruction The central upper abdomen remains a difficult area to reconstruct with pedicled flaps in general, as only the less reliable, less perfused distal part of trunk-based or thigh-based pedicled flaps tends to reach the upper abdomen. Free flaps are often needed for central upper abdominal defects and may require vein grafts or anastomosis to intraperitoneal vessels. Central fascial defects can be addressed in the same way as ventral hernia repair. Component separation and/or mesh (without a flap) provide a means for repairing midline defects in some cases. Flap Selection For abdominal wall defects that cannot be closed primarily or with a local flap, various regional flaps have been used to provide stable soft-tissue coverage. Defects in the lower abdomen can be closed with flaps from the thigh. Flaps that are based on the lateral circumflex femoral system can provide skin, muscle, and fascia, as needed. Lateral abdominal defects can be repaired with pedicled flaps from the abdomen or upper trunk. Table 4 summarizes key considerations in pedicled flap choice for abdominal wall reconstruction.47–54
The main indication for free flaps in abdominal wall reconstruction is extremely large defects or those located in the central upper abdomen where pedicled flaps cannot reach. Free flaps used to repair these defects include tensor fasciae latae flaps, anterolateral thigh flaps, other combined thigh flaps, groin flaps, and latissimus dorsi flaps.49,55,56 A paucity of reliable recipient vessels for free flaps in the abdominal wall is often encountered in patients who have had multiple operations and/or radiation therapy. Vein grafts or arteriovenous loops are helpful in this situation.46,57 Possible donor vessels include the femoral vessels and their branches the internal mammary, superior epigastric, inferior epigastric, and gastroepiploic vessels.46,57,58 Using intraabdominal vessels as recipient vessels requires creating a tunnel for the free flap’s vascular pedicle through the abdominal wall and/or mesh (if mesh is used); this increases the chance of hernia, pedicle compression, and thrombosis. Recipient vessel options that do not generally require vein grafts are the gastroepiploic and internal mammary vessels.
Table 4. Thigh-Based and Torso-Based Pedicled Flaps Used in Abdominal Wall Reconstruction Flap ALT flap
TFL flap
Rectus femoris flap
Combined thigh flaps
Rectus abdominis flap
Latissimus dorsi flap
Characteristics • Large surface area • Minimal donor-site morbidity • Generally will reach the periumbilical area but has been reported to reach up to the costal margin47 • Can reach the ipsilateral posterior superior iliac spine posteriorly and the contralateral fossa laterally47 • Associated fascia may not be reliable for fascial reconstruction47 • Large skin paddle (15 × 40 cm)48 • Skin can reach the periumbilical area, but distal skin necrosis is the main shortcoming when TFL is used in abdominal wall reconstruction48,49 • Adding rectus femoris muscle to TFL with their surrounding fascia allows coverage of larger defects but is still associated with skin necrosis50 • Can be transferred as a muscle flap, musculocutaneous flap, or part of a combined thigh flap based on the lateral circumflex femoral vessel • Provides a long cylindrical muscle, approximately 6 cm wide, and can support a 12 × 20-cm skin island • “Subtotal thigh” flap46 takes advantage of the versatile lateral circumflex femoral vessel system and can include rectus femoris, TFL, vastus lateralis, and/or ALT flap tissue • Nearly the entire abdominal wall skin can be reconstructed with bilateral pedicled subtotal thigh flaps46 • Fascial portion of these flaps can be used to repair fascial defects, but mesh is often preferred for reconstruction of the musculofascia, with soft-tissue flaps used for coverage; thigh fascia may be less reliable and can tear along its fibers46 • Skin paddle can be oriented vertically, horizontally, as an extended deep inferior epigastric artery flap (musculocutaneous flap with lateral skin extension based on the periumbilical perforators), or as a flag flap (skin from the upper abdomen with extensions to the inframammary fold and the anterior axillary line)51–54 • Useful for defects located at the periphery of the abdominal wall • Generally should be avoided for large abdominal wall defects when the donor site would add to the primary defect • Arc of rotation of the flap allows coverage of superolateral abdominal wall defects • Can be used as muscle or musculocutaneous flap
ALT, anterolateral thigh; TFL, tensor fasciae latae.
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Plastic and Reconstructive Surgery • May 2014 Tissue Expansion Tissue expansion of the abdominal wall can provide well-vascularized autologous skin, subcutaneous tissue, and/or abdominal fascia for the repair of large defects.,59–61 However, tissue expansion carries the risks of rupture, extrusion, infection, patient intolerance, and expander failure.
CHEST WALL RECONSTRUCTION There are generally four indications for chest wall reconstruction: resection of a tumor (primary or recurrent), radiation injury, trauma, and infection (Level of Evidence: Therapeutic, IV).62 Sternal wound dehiscence following sternotomy is also a commonly seen problem in plastic surgery and is often discussed as a separate entity from the other reconstructive problems. This part of the article focuses on intrathoracic reconstruction in bronchopleural fistula and empyema and chest wall reconstruction following tumor resection. Other aspects of chest wall reconstruction are discussed elsewhere in the literature. General Principles General principles for the treatment of chronic empyema and bronchopleural fistula, which often occur together, include drainage of the fluid collection, débridement of devitalized tissue, obliteration of the dead space, establishment of negative intrathoracic pressure, and administration of proper antibiotics.63 The bronchopleural fistula should be resected, the bronchus should be closed, and the repair should be reinforced with a well-vascularized tissue flap to reduce the chance of recurrent fistula.64 The severity of the case and the general condition of the patient determine whether definitive reconstruction can be performed in a single stage or will require multiple stages.63,65 The two major components of chest wall reconstruction following composite resection are reconstruction of chest wall stability and provision of reliable, well-vascularized soft-tissue coverage. Additional objectives, as described by Thomas and Brouchet,66 are to avoid lung hernia and paradoxical chest wall motion, counteract the contraction of the affected side of the thorax expected after surgery, prevent impaction of the scapula into the defect in cases of posterior chest wall resection, protect the underlying mediastinal organs, and maintain an aesthetically acceptable chest shape. Restoring a form of skeletal stability is often needed following major
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resection to reduce the negative impact on respiratory function. Preoperative Considerations The patient’s general medical condition and nutritional status should be optimized before surgery. In addition, the patient’s pulmonary function should be evaluated preoperatively (e.g., with spirometry) because the vast majority of patients undergoing major chest wall procedures will have some degree of postoperative respiratory dysfunction.67 Failed extubation and prolonged ventilator dependence could follow major chest wall surgery in patients with poor preoperative respiratory function. The plastic surgeon should communicate with the thoracic surgeon to develop a clear reconstructive plan. For intrathoracic reconstruction, the plastic surgeon should be familiar with bronchopleural fistula and empyema. Although bronchopleural fistula is sometimes treated in multiple stages, defects that follow composite chest wall resection are approached differently, with the aim of achieving reconstruction in a single operation. Preoperative (and intraoperative) planning will benefit from an algorithmic approach to the anticipated defect, evaluating the defect in layers from inside out, starting with the pleura, then the skeleton, and then the soft tissues. Resection of any of these components will create a unique problem that needs a specific form of reconstruction. Prosthetic materials are frequently needed to restore chest wall skeletal stability following resection. Operative Techniques Bronchopleural Fistula and Empyema Bronchopleural fistula and chronic empyema are two of the most common conditions necessitating reconstruction of the pleural space and often occur together. The incidence of postpneumonectomy stump fistula is 0 to 12 percent,68,69 although postpneumonectomy empyema has a reported incidence of 2.2 to 16 percent.70 The presence of untreated dead space and bronchopleural fistula following lobectomy or pneumonectomy will usually result in infection. The postoperative mortality rate of pneumonectomy increases to 25 percent if the course is complicated by empyema and to approximately 50 percent if bronchopleural fistula is present.71 Some of the classic techniques used to treat chronic empyema and/or bronchopleural fistula are summarized in Table 5.72–78
Volume 133, Number 5 • Abdominal and Chest Wall Reconstruction Table 5. Classic Surgical Techniques Used to Treat Chronic Empyema and Bronchopleural Fistula Technique/Procedure
Uses/Characteristics
Clagett procedure
Eloesser procedure (Fig. 3)
Thoracoplasty
• For treatment of postpneumonectomy empyema72 • Two stages73: First, establish open pleural drainage Second, fill pleural space with antibiotic solution and close • Can be repeated if first attempt fails • Reinforcing the bronchial stump with transposition of extrathoracic skeletal muscle (e.g., serratus anterior or latissimus dorsi) following the first stage of Clagett procedure successfully closes 85% of BPFs74 • For debilitated patients with chronic empyema in which extensive chest procedures and flap transfer would be poorly tolerated75 • One stage • Consists of resecting a segment of a rib in the posterior or posterolateral chest wall, creating a U-shaped soft-tissue flap, and suturing it to the pleura • Allows continuous drainage until the lung expands and reaches the chest wall, after which the wound closes automatically76 • Multiple ribs are selectively resected subperiosteally77 • Allows chest wall to collapse and reduce pleural dead space • Has become less popular in the past few decades, after the development of antituberculosis medications and widespread use of muscle transposition to fill pleural space78
BPF, bronchopleural fistula.
Soft-tissue flaps are often used to reinforce the repair after closure of a fistula and/or to fill the intrathoracic dead space after drainage of a fluid collection. Flaps used in bronchopleural fistula closure include intercostal muscle,79
pericardial fat,80 diaphragm,81 extrathoracic muscle,73 omental,82 and free flaps.83 Pedicled flaps commonly used to fill intrathoracic dead space are described in Table 664,84–87 and illustrated in Figure 2.
Table 6. Soft-Tissue Flaps Used to Obliterate Intrathoracic Dead Space* Flap
Approximate Size (cm)
Blood Supply
Pectoralis major
15 × 23
• Thoracoacromial vessels • Internal mammary perforators
Serratus anterior
15 × 20
• Lateral thoracic vessels (axillary) • Serratus branches of thoracodorsal vessels
Latissimus dorsi
25 × 35
• Thoracodorsal vessels • Intercostal and lumbar perforating vessels
Rectus abdominis
25 × 6
• Deep inferior and superior epigastric vessels
Trapezius
34 × 18
Omentum
Variable
• Transverse cervical vessels • Occipital, dorsal scapular, and intercostal perforating vessels • Gastroepiploic vessels (right and left)
Common Uses/Characteristics • Used to fill the cephalad part of the thoracic cavity and sternal defects • Introduced through a resected segment of second, third, or fourth rib near the axilla • Use of this flap as island increases its excursion • Used for mediastinal and hilar coverage84 • Frequently intact following thoracotomy and conforms easily to the size and shape needed for hilar reconstruction64,84 • Introduced through a created defect of the second rib at midaxillary line84 • Can be combined with latissimus dorsi muscle flap for larger bulk • Used to fill the lateral, anterolateral, and posterior chest • Introduced through a window in the anterolateral chest (similar to serratus) • Releasing the humeral attachment increases the reach of the flap • Used for sternal (anterior) and caudad anterolateral chest defects • Usually passed over the epigastrium • Used for posterior and apical chest defects85,86 • Passed through a posterior thoracotomy defect • Used to fill the anterior mediastinum and anywhere else in the chest • Tunneled to the chest through superior midline abdominal incision over the ribs or through the diaphragm
*Adapted from Mathes SJ, Nahai F. Reconstructive Surgery: Principles, Anatomy, and Technique. St. Louis: Quality Medical Publishing; 1997.
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Fig. 2. (Left) Pedicled flaps commonly used to fill intrathoracic dead space: pectoralis major muscle (1), serratus anterior muscle (2), latissimus dorsi muscle (3), omental (4), and rectus abdominis muscle (5) flaps. (Right) The pectoralis major muscle flap is useful for filling upper chest defects. The latissimus dorsi muscle flap is more useful for filling lateral defects. The omental flap can be passed over the ribs or through the diaphragm.
These flaps can be introduced into the thoracic cavity through the original wound63 or through a new, separate thoracotomy.64 For single-stage treatment of empyema without a bronchopleural fistula, the empyema is drained, and the dead space is irrigated, filled with a muscle flap, and closed.63,75 If the patient is too ill to undergo an extended single-stage procedure or if the infection is longstanding and resistant, treatment may
Fig. 3. Eloesser procedure. A superiorly or inferiorly based (Thourani VH, Lancaster RT, Mansour KA, Miller JI Jr. Twenty-six years of experience with the modified Eloesser flap. Ann Thorac Surg. 2003;76:401–405; discussion 405) skin flap (as shown here) is created over the area of the chest that needs to be drained. A window is created in the chest wall by removing a segment from one or more ribs. The skin flap is sutured to the inside of the pleural cavity (to the diaphragm in this illustration) to create a pleurocutaneous fistula.
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begin with a drainage procedure, such as the Eloesser procedure (Table 5 and Fig. 3). When bronchopleural fistula is also present, it must be addressed as well. Defects from Tumor Resection Reconstruction of Chest Wall Stability Autologous tissues such as rib grafts and fascial grafts have been falling out of favor for restoration of chest wall stability since synthetic mesh was introduced.62 Semirigid chest wall reconstruction can be achieved by suturing synthetic or bioprosthetic mesh under tension to span the skeletal defect that follows tumor resection. Some authors also suggest the use of more rigid fixation with polymethylmethacrylate/polypropylene mesh for such defects.88 Polymethylmethacrylate reconstruction is frequently advocated to repair large anterior and anterolateral chest wall contour defects, whereas large defects in flat surfaces on the anterior and posterior aspect of the chest may be repaired with prosthetic mesh.89,90 The ideal prosthetic material features, as described by le Roux and Shama, include rigidity that reduces paradoxical movement, inertness that allows tissue ingrowth, malleability, and radiolucency that does not obstruct radiographic evidence of tumor relapse.91 Synthetic mesh in general may increase complication rates when it is placed directly over viscera or when the operative site has been irradiated or contaminated with bacteria.22 Table 7 describes commonly used synthetic materials in chest wall reconstruction.62,66,92–94 Synthetic mesh is contraindicated in contaminated wounds unless prolonged dependence on a ventilator will result from not using it.62 In
Volume 133, Number 5 • Abdominal and Chest Wall Reconstruction Table 7. Synthetic Materials Commonly Used for Chest Wall Reconstruction Material
Advantages
Polypropylene
• Inexpensive • Macroporous, allowing tissue ingrowth around fibers
PTFE
• Achieves watertight seal (microporous) • Easy to suture • Stretches to contour into wound • Durable93 • Commonly used to provide rigidity • Often used in combination with polypropylene mesh • Able to contour to match curved shape of the chest wall
PMMA
Disadvantages • Does not allow initial watertight seal; more difficult than PTFE to contour and tends to wrinkle with suturing62 • Contraindicated in contaminated wounds92 • Infection may require removal92 • More expensive than some other synthetic meshes94 • Negligible tissue ingrowth (microporous) • Contraindicated in contaminated wounds92 • Infection commonly requires removal • Exothermic reaction may cause thermal tissue injury • Difficult to mold • May fracture tissue at edges • Rigid, permits less dynamic chest wall reconstruction94 • Does not allow tissue ingrowth into PMMA itself • Tends to form seromas66
PFTE, polytetrafluoroethylene; PMMA, polymethylmethacrylate.
the latter situation, bioprosthetic mesh is an alternative. Many bioprosthetic meshes are available; these include human and xenogeneic acellular dermal matrices. Bioprosthetic meshes have been shown in animal models to allow tissue ingrowth,95 become incorporated and revascularized,95 and be valuable for wounds with a high risk of infection or complications. The main limitations are their high cost, unproven long-term stability in the chest wall, and theoretic risk of stretching or laxity with ongoing remodeling. Bioprosthetic mesh may be a good option for defects that have bacterial contamination and/or an increased risk of skin dehiscence with mesh exposure; the material tolerates cutaneous exposure without the need for explantation.18 Once the synthetic or bioprosthetic material is placed and secured to the edges of the defect, well-vascularized soft-tissue coverage should be provided to minimize the chance of exposure and infection. The use of prosthetic mesh sutured under tension to recreate semirigid chest wall stability
following repair of large defects has been shown to reduce ventilator dependence and hospital stay.96 However, the absolute need for rigid or semirigid skeletal stability reconstruction of the chest wall following resection has been challenged, particularly for smaller defects. Arnold and Pairolero reported that pulmonary function is not ultimately compromised following major chest wall resection, such as removal of the entire sternum, if reconstruction is performed without mesh.62 Furthermore, the resulting pulmonary insufficiency following chest wall resection is often less significant than that following trauma.97 Factors to be considered in making a decision about skeletal stability reconstruction are summarized in Table 8.92,97–102 Soft-Tissue Coverage For small, full-thickness defects of the chest wall, a thick soft-tissue flap can provide enough stability without the need for chest wall skeletal stability reconstruction. Otherwise, soft-tissue flaps are used in conjunction with synthetic or bioprosthetic materials to provide soft-tissue coverage
Table 8. Factors to Consider in Skeletal Stability Reconstruction Size of the defect
Location of the defect
Condition of the chest wall
• Some authors advocate skeletal reconstruction when the defect is four ribs or more98,99 • Others use the actual size of the defect and believe that defects more than 5 cm in diameter are more likely to benefit from prosthetic reconstruction92,100 • Soft tissue–only reconstruction is often considered adequate for smaller defects • Defects in the anterior (and anterolateral) chest wall require stability reconstruction more often than posterior chest wall because they more mobile and have stronger impact on the respiratory function101 • Prosthetic stability reconstruction is thought to be required less often in the posterior chest wall than in the anterolateral chest wall because the scapula and its surrounding muscle attachment provide more stability in the former • Small (
