1. Dr. Ashraf Ahmed Esmat
Prof. Cardio-thoracic Surgery
Cairo University

2. Background
 Chest wall defects continue to present a complicated
treatment scenario for thoracic and reconstructive
surgeons.
 The surgeon is eager to rid the patient of all possible
malignant, contaminated, or irradiated tissues while
leaving a defect that should be closed to maintain life
itself.
 A thorough knowledge of reconstructive techniques
with a clear operative plan is most desirable.

3. Background
Three tenets of surgical resection should be maintained
1. First, a sufficient amount of tissues must be resected
to dispose all devitalized tissues.
2. Second, a replacement must be found to restore the
rigid chest wall to prevent paradoxical motion during
respiration.
3. Third, healthy soft tissue coverage is essential to seal
the pleural space and prevent infection.

4. Background
 Anterior chest wall defects were defined as being located
between the sternum to the anterior axillary line.
 Lateral defects located between the anterior and posterior
axillary lines.
 Posterior defects as located between the spine and
posterior axillary line.
 There is some controversy to which chest wall defects to be
reconstructed but, generally, lesions less than 5 cm in size
in any location, and those up to 10 cm in size posteriorly do
not need reconstruction for functional reasons.

5. Background
Techniques of Reconstruction:
 Historically, bone, diced cartilage, metal sheets,
autogenous rib graft, fascia lata, Teflon, and
numerous other substances were used with minimal
success.
 the ideal characteristics of a prosthetic material: rigidity to
abolish paradoxical chest motion, inertness to allow in-
growth of fibrous tissue and decrease the likelihood of
infection, malleability so that it can be fashioned to
the appropriate shape at the time of operation,
and radiolucency to allow radiographic follow-up of the
underlying problem.

6. Background
Techniques of Reconstruction
 While some authors advocate Prolene or Marlex mesh,
others advocate the use of polytetrafluroethylene
(Gore-Tex) soft tissue patch reconstruction of all
defects.
 In cases where structural integrity is necessary for
preventing chest wall collapse, methyl methacrylate
sandwich, silicone, Teflon, or acrylic materials have
been utilized.

7. Background
Techniques of Reconstruction:
 Rigid reconstruction: Polypropylene mesh-
methylmethacrylate sandwich (PMM).
methylmethacrylate is applied within double layer of
mesh tailored to the size and contour of the defect.
we managed to create strips of the methylmethacrylate
that mimics the natural ribs.
 Non-rigid reconstruction using Polypropylene mesh
(PM) alone to reconstruct the chest wall.
 Soft tissue reconstruction using myocutaneous flaps
were used, in cases of radiation necrosis of chest wall.

8. Rigid Reconstruction(PMM)

9. Rigid Reconstruction(PMM)

10. Rigid Reconstruction(PMM)

11. Rigid Reconstruction(PMM)

12. Polpropylene Mesh only

13. Polypropylene Mesh

14. Soft tissue Reconstruction

15. Soft tissue Reconstruction

16. Patients & Methods
 We are presenting our experience in 28 patients who
underwent chest wall resection and reconstruction at Cairo
University hospitals from January 2007 to January 2011.
 Patients with fewer than two rib resections, routine pectus
resections, acute sternal infections after median
sternotomy for cardiac surgery were not included in the
present series.
 Patients' demographics, the location of the chest wall
defect, performance of lung resection if any, the type of
prosthesis and postoperative complications were recorded.

17. Results
Table 1: Pts’ Demography & Medical history
No. of Patients Percentage
• Age 32 – 65 years
• Sex (M/F) (18/10) (65.5%/34.5%)
• Hypertension 11 37.9%
• Diabetes Mellitus 7 24.1%
• COPD 2 6.8%
• Ischemic Heart 2 6.8%
Disease

18. Results
Table2: Indications for chest wall resection
Number of Percentage
patients
Bronchogenic 8 28.5 %
Carcinoma
Primary Chest 14 50 %
wall Tumor
Radiation 5 17.8 %
Necrosis
Breast Carcinoma 1 3.5%

19. Results
Table 3: Chest Wall Resection; Anatomic Defects
Number of Percentage
patients
Combined Lung/chest 8 28.5 %
wall resection
Rib Defects
Anterior 8 28.5 %
Lateral 11 39.2 %
Posterior 5 17.8 %
Sternal defects
Partial Sternectomy 4 14.2 %

20. Results
Table 4: Techniques of Reconstruction
Number of Percentage
patients
• Rigid 17 60.7%
Reconstruction
(PMM)
• Non rigid 6 21.4%
Reconstruction
(PM)
• Soft tissue 5 17.8%
Reconstruction only
Latissimus Dorsi 22 78.6%
Pectoralis Major 6 21.4%

21. Results
table 6: Surgical Complications
Number of Patients Percentage
Respiratory 4 14.2%
Complications
Atelectasis 2
Persistent Air-leak 2
Wound 3 10.7%
Complications
Wound Infection 2
Wound Seroma 1

22. Results
Factors associated with postoperative complications
were analyzed.
Multivariate analysis identified patient age, size of chest
wall defect, and lung resection to be significant
predictors of postoperative complications.

23. Conclusion
Chest wall resection and reconstruction with or without
prosthesis can be performed as a safe, effective one-
stage surgical procedure for a variety of major chest
wall defects.