This video demonstrates management of a large anterior chest wall defect to illustrate principles of chest wall reconstruction. Following multidisciplinary assessment, this patient was planned for resection of a rhabdomyosarcoma of the right anterior chest wall with anticipated skeletal defects spanning six ribs and a soft tissue defect overlying the breast footprint. Preoperative imaging demonstrated no evidence or suggestion of pleural spread. Principles for planning this reconstruction include anticipate the defect location, size, and composition to plan skeletal and soft tissue reconstruction. Aim to restore respiratory function accounting for the anticipated disruption of the pleural cavity, skeletal resection, and respiratory muscle compromise. Select a soft tissue reconstructive option that maintains the residual muscles of respiration and can be optimized for primary healing at both the donor and recipient sites. The oncologic resection begins at the superior lateral margins with wide exposure and early control of the great vessels. It is essential to remain wide around the tumor and sequentially identify and control branches of the axillary and subclavian vessels for both vascular control and identification of potential recipients. At the medial margin, the internal mammary vessels are identified and protected. It is critical to be present during the oncologic resection to help identify and protect potential recipient branches off of the subclavian and axillary arteries. An extra one to two centimeters left on the stump of a vessel will dictate whether or not you have space for a microclamp and thus can define its suitability as a potential recipient. The specimen is shown following complete resection with negative pathologic margins. The final defect included the breast, anterior chest wall musculature overlying and including ribs two to seven, as well as anterior segments of the pleura and diaphragm. Restoration of respiratory function begins with repair of the diaphragm. The diaphragmatic defect was repaired with a biologic mesh, specifically a perforated xenograft acellular dermal matrix to span the muscular gap with eventual vascularized integration. Next, it is essential to restore the pleural cavity with a watertight closure to permit generation of negative intrathoracic pressure. Chest tubes are placed in the superior anterior space for air displacement and in the posterior inferior space for fluid displacement. The skeletal stability of the anterior chest wall is planned with a bi-layer of expanded polytetrafluoroethylene and polypropylene mesh. In clean non-contaminated cases, the composite Gore-Tex purling mesh is inset with permanent woven synthetic non-absorbable sutures. The Gore-Tex layer is placed deep against the viscera and the woven purling surface lies superficial to be in contact with the overlying soft tissue reconstruction. It is critical to inset the composite mesh under tension to the surrounding bony structures. With the arm adducted, the mesh was inset on the undersurface of the adjacent remaining sternum, ribs, and clavicle. Soft tissue reconstruction was completed with bilateral deep inferior gastric perforator free flaps. Interoperative ICG angiography is utilized to confirm adequate perfusion of the entire anterior abdomen. The DIP flap is a preferred choice because one of the largest vascular cutaneous flaps that allows for the preferential perforator and pedicle selection for optimal perfusion of the entire abdominal angiozone, preservation of all residual respiratory muscle function, and allows for primary closure of the donor site, avoiding the need for secondary intention healing of skin grafts. It is very important to minimize physiologic insult and avoid delays of adjuvant treatments by selecting a flap with optimal vascular supply, low risk of partial failure or dehiscence, and reliable primary healing at the recipient site.

chest wall reconstruction

rhabdomyosarcoma resection

multidisciplinary approach

biologic mesh repair

free flap surgery