Thoracic: Chest Wall
The contribution of microvascular free flaps and pedicled flaps to successful chest wall surgery

https://doi.org/10.1016/j.jtcvs.2023.05.018Get rights and content

Abstract

Objective

Pedicled flaps (PFs) have historically served as the preferred option for reconstruction of large chest wall defects. More recently, the indications for microvascular-free flaps (MVFFs) have increased, particularly for defects in which PFs are inadequate or unavailable. We sought to compare oncologic and surgical outcomes between MVFFs and PFs in reconstructions of full-thickness chest wall defects.

Methods

We retrospectively identified all patients who underwent chest wall resection at our institution from 2000 to 2022. Patients were stratified by flap reconstruction. End points were defect size, rate of complete resection, rate of local recurrence, and postoperative outcomes. Multivariable analysis was performed to identify factors associated with complications at 30 days.

Results

In total, 536 patients underwent chest wall resection, of whom 133 had flap reconstruction (MVFF, n = 28; PF, n = 105). The median (interquartile range) covered defect size was 172 cm2 (100-216 cm2) for patients receiving MVFF versus 109 cm2 (75-148 cm2) for patients receiving PF (P = .004). The rate of R0 resection was high in both groups (MVFF, 93% [n = 26]; PF, 86% [n = 90]; P = .5). The rate of local recurrence was 4% in MVFF patients (n = 1) versus 12% in PF patients (n = 13, P = .3). Postoperative complications were not statistically different between groups (odds ratio for PF, 1.37; 95% confidence interval, 0.39-5.14]; P = .6). Operative time >400 minutes was associated with 30-day complications (odds ratio, 3.22; 95% confidence interval, 1.10-9.93; P = .033).

Conclusions

Patients with MVFFs had larger defects, a high rate of complete resection, and a low rate of local recurrence. MVFFs are a valid option for chest wall reconstructions.

Section snippets

Study Population and Data Collection

We retrospectively reviewed all patients who underwent chest wall resection in the Thoracic Surgery Service at Memorial Sloan Kettering Cancer Center from January 1, 2000, to April 30, 2022. Patients who did not receive myocutaneous flap reconstruction were excluded (n = 403) (Figure E1). The remaining patients were stratified on the basis of the type of flap that was used for reconstruction (MVFF or PF). Data on demographic characteristics (age, sex, race, smoking status, Eastern Cooperative

Results

From January 1, 2000, to April 30, 2022, 536 patients underwent full-thickness chest wall resection at our institution. Myocutaneous flaps were used to reconstruct soft-tissue defects in 133 patients (25% of the total cohort), of whom 28 (21%) received MVFFs and 105 (79%) received PFs. Table 1 summarizes the indications for MVFF reconstruction in our cohort. Table 2 lists the demographic characteristics of the study patients. The patient population predominantly consisted of women (n = 102

Discussion

In this study, we sought to investigate the safety of MVFF in the setting of chest wall reconstruction after extensive resection (Figure 1). However, it has to be emphasized that the indications for MVFF differ from those for PF, as summarized in Table 1. MVFFs are selected for use in reconstructions after careful multidisciplinary planning that takes into consideration clinical information, medical history, performance status, defect size, the local condition of the surgical field, oncologic

References (35)

  • J.T.K. Salo et al.

    Health-related quality of life after oncological resection and reconstruction of the chest wall

    J Plast Reconstr Aesthetic Surg

    (2019)
  • B. Gansera et al.

    Quality of internal thoracic artery grafts after mediastinal irradiation

    Ann Thorac Surg

    (2007)
  • M.J. Weyant et al.

    Results of chest wall resection and reconstruction with and without rigid prosthesis

    Ann Thorac Surg

    (2006)
  • G. Marulli et al.

    Primary chest wall chondrosarcomas: results of surgical resection and analysis of prognostic factors

    Eur J Cardiothoracic Surg

    (2014)
  • E. Wakeam et al.

    Chest wall resection for recurrent breast cancer in the modern era

    Ann Surg

    (2018)
  • J.B. Shewale et al.

    Predictors of survival after resection of primary sarcomas of the chest wall—a large, single-institution series

    J Surg Oncol

    (2018)
  • A. Daigeler et al.

    Reconstruction of the thoracic wall-long-term follow-up including pulmonary function tests

    Langenbeck's Arch Surg

    (2009)
  • Cited by (0)

    This work was supported, in part, by National Institutes of Health/National Cancer Institute Cancer Center Support Grant P30 CA008748.

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