Plastic Surgery Research Council
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Presenter: Mark W Clemens, MD
Co-Authors: Garvey PB; Corkum JP; Baumann DP; Hofstetter W; Butler CE
MD Anderson Cancer Center

Background: Massive chest wall resections with significant loss of skeletal support can result in prolonged ventilator dependence and major respiratory impairment. Few case reports address these rare reconstructions. We review our institutional experience to evaluate which potential factors are predictive or protective for development of complications.

Methods: Patients information was prospectively entered into a departmental database and then retrospectively reviewed. All consecutive patients who underwent immediate reconstruction of massive thoracic neoplastic or oncologic-related defects (?5 ribs resected) between 1994 2011 were included.

Results: A total of 59 patients (median age 53) were included. Rib resections ranged from 5 to 10 ribs (mean defect area 298cm2, range 80-1036cm2). Types of rigid and semi-rigid reconstruction included use of permanent synthetic mesh (52.5%), polymethylmethacrylate with mesh (25.4%), bioprosthetic mesh (5.1%). Soft tissue reconstruction was required in 45.7%, composed of free tissue transfer in 6.8% and local muscle flaps in 39.0%. The overall complication rate was 61%; which was subdivided into pulmonary complications (48%), cardiac complications (12%), and wound complications (17%). On average, patients were ventilator dependent for 3.9 (SD +/- 8.8), required ICU monitoring for 4.9 days (SD +/- 8.7), and were discharged after 15.9 days (SD +/- 13.8). Mean follow-up was 36.0 months (SD +/- 38.0). The 90-day overall survival rate of patients after initial procedure was 89.4%; all deaths occurred within superior resections (p=.03). Mean reduction from preoperative to postoperative FEV1 and FVC were 6.8% and 5.3%, respectively.

Conclusions: Complex reconstruction of massive oncologic thoracic defects is associated with a high rate of complications. Surgeons should exercise caution when reconstructing posterolateral defects and those in elderly patients. Soft tissue coverage is required in over half of the cases with regional pedicled flaps used in the majority of the cases.

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