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.
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.
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.
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. 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.
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.
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
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 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
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 repair was associated with a higher hernia recurrence rate (27 percent at 27 months’ mean follow-up) than open component separation with mesh repair (16.7 percent at 33 months’ mean follow-up).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 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
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.
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.
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.
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 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 resection to reduce the negative impact on respiratory function.
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.
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
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.
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 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 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
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 and skeletal stability, respectively. Table 9 summarizes the pedicled soft-tissue flaps commonly used in chest wall defect coverage.
The pectoralis major muscle flap when based on its thoracoacromial pedicle can reliably reach the entire anterior chest wall except the lower sternum.103 The muscle remains innervated and functional and allows secondary sternotomy.62 For lower chest wall defects, the muscle can be more efficiently transferred as a “split-turnover” with the release of its humeral insertion and its thoracoacromial pedicle.
The omental flap can easily reach inside the thorax and even to the neck.104 The omental flap has been used prophylactically to cover vascular anastomoses considered to be at high risk for failure, to treat established chest infection, and to cover prosthetic chest wall replacements after extensive chest wall resection.105 The omental flap is also indicated for large and deep sternal wounds106 and has compared favorably to muscle flaps in treating poststernotomy mediastinitis.107,108 This flap carries the risk of intraabdominal morbidity and hernia when transposed through a subcutaneous tunnel.
The latissimus dorsi flap can easily reach the lateral, posterior, and anterior chest including the anterior mediastinum. When the latissimus dorsi flap is transferred as a musculocutaneous flap, a large skin paddle can be transposed to the anterior aspect of the chest with high reliability.62 However, if the skin paddle is more than 8 to 10 cm in width, the donor site may need to be skin grafted. The serratus muscle is often combined with the latissimus dorsi muscle to create a larger flap to fill dead space.
The rectus abdominis flap can be transferred as a muscle or musculocutaneous flap, with vertical or transverse skin orientation, with the latter providing a larger (but less reliable) cutaneous flap from the lower abdomen.109 For sternal reconstruction, this flap is usually used as a muscle flap. Even following internal mammary vessel ligation, the rectus abdominis muscle may still be perfused through the musculophrenic artery and through the lower intercostal arteries, on which the flap can be based.110
Pedicled fasciocutaneous flaps from the upper abdomen/lower chest can be based either medially on the deep epigastric system perforators or laterally on the intercostal perforators and used to cover lower chest and breast defects. Davis et al.111 reported their experience in 35 patients who underwent breast, chest, mediastinal, or upper extremity reconstruction using medially based thoracoabdominal flaps up to 11 × 35 cm, with only three cases of partial flap necrosis (which was attributed to excessive flap length).111
The subscapular vascular system is very versatile, and multiple flaps can based on it to provide sufficient tissue to cover large chest wall defects.112 Chimeric scapular, parascapular, serratus muscle, and latissimus dorsi muscle flaps are commonly used to repair massive chest wall defects with success.
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