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Chest Wall Reconstruction with Creation of Neoribs Using Mesenchymal Cell Bone Allograft and Porcine Small Intestinal Submucosa

Bryant, Justin R. M.S.IV; Eid, Rola D.O.; Spann, James C. M.D.; Miller, Archibald S. III M.D.

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Plastic and Reconstructive Surgery: September 2010 - Volume 126 - Issue 3 - p 148e-149e
doi: 10.1097/PRS.0b013e3181e3b5ad
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Sir:

Chest-wall skeletal reconstruction has been undertaken with many materials, including autogenous and allogeneic tissue and synthetics, the history of which has been well chronicled by Arnold and Pairolero.1 Autogenous bone grafting provides a durable reconstruction using iliac crest, tibia, fibula, or ribs placed in contact with cancellous bone at the defect margin.2 Disadvantages including donor-site pain, instability, and limited tissue availability have resulted in the creation of various alternatives. Autogenous bone grafting has been infrequent because of availability of synthetic materials that provide an adequate result.1 Wound contamination, however, is a contraindication to synthetic material placement.1

A 48-year-old woman who presented following chemotherapy, radiation therapy, and bilateral mastectomy for inflammatory breast carcinoma developed a chronic chest wall radiation-induced ulcer with intermittent infections. Wound cultures indicating Fusarium and Scedosporium accompanied by systemic signs of infection 3 months before consultation precipitated the need for chest wall débridement. Preoperative computed tomographic studies demonstrated anterior chest wall soft-tissue infiltration but no fluid collection, abscess formation, or metastasis. At consultation, 6 years after mastectomy and radiation therapy, the patient presented with a wound extending from the second through fifth ribs surrounded by irradiated tissue. Treatment with voriconazole and amphotericin-B was performed before surgery.

En bloc resection included the second through fifth ribs near the sternocostal junction extending laterally to wound edge margins, resulting in a 15 × 15-cm defect. Pleural closure was performed using porcine-derived small intestinal submucosa extracellular matrix (CorMatrix ECM; CorMatrix Cardiovascular, Inc., Sunnyvale, Calif.) attached to the pleura and inner aspect of bordering ribs.

Chest wall rigidity was preserved through neorib construction using mesenchymal cell bone allograft (Osteocel; NuVasive, Inc., San Diego, Calif.) in a porcine-derived small intestinal submucosa sheath. Neoribs were shaped to conform with resected ribs and sutured to the periosteum and connective tissue (Fig. 1). A delayed pedicled transverse rectus abdominis musculocutaneous flap was then transposed.

Fig. 1.
Fig. 1.:
Neoribs formed from mesenchymal cell bone allograft and porcine-derived small intestinal submucosa sheath sutured in continuity with the chest wall.

At 2-month follow-up, the chest wall was stable and firm to palpation. Three-dimensional computed tomographic studies (Fig. 2) demonstrated bone formation in the neorib grafts.

Fig. 2.
Fig. 2.:
Three-dimensional computed tomographic scan demonstrating ossification of neoribs.

Small intestinal submucosa, an acellular collagen-based matrix, has been demonstrated as an alternative to synthetics in reconstruction of contaminated wounds. Small intestinal submucosa has shown infection rates lower than synthetic materials after abdominal wall defect repair in the setting of infected or potentially contaminated wounds in studies by Ueno et al.3

Autogenous bone grafts are the standard means of bone grafting, but disadvantages frequently preclude its use. Bone allograft use is limited by availability of a tissue bank with a bone graft donation program.4 Many commercially available bone graft substitutes provide the osteoconductive scaffold for bone growth and the osteoinductive growth factors for osteogenic activity; only cell-based and allograft substitutes contain progenitor cells necessary for osteogenesis.5

Cadaveric mesenchymal cell bone allograft is a commercially available alternative to bone autograft. Osteocel is a cadaveric allograft product containing adult mesenchymal cells in a cancellous bone matrix marketed primarily for spinal surgery. To our knowledge, the scenario described here is the first reported case of neorib creation from commercially available mesenchymal cell bone allograft and small intestinal submucosa in chest wall skeletal reconstruction.

Justin R. Bryant, M.S.IV

Oklahoma State University

Center for Health Sciences

Rola Eid, D.O.

Department of Surgery

Oklahoma State University Medical Center

James C. Spann, M.D.

CVT Surgery, Inc.

Archibald S. Miller, III, M.D.

Cosmetic and Reconstructive Surgery of Tulsa

Tulsa, Okla.

DISCLOSURE

The authors have no financial interest or commercial association with any of the subject matter mentioned in this article.

REFERENCES

1.Arnold PG, Pairolero PC. Chest-wall reconstruction: An account of 500 consecutive patients. Plast Reconstr Surg. 1996;98:804–810.
2.McCormack PM. Use of prosthetic materials in chest-wall reconstruction. Surg Clin North Am. 1989;69:965–975.
3.Ueno T, Clark L, Pickett LC, de la Fuente SG, Lawson DG, Pappas TN. Clinical application of porcine small intestinal submucosa in the management of infected or potentially contaminated abdominal defects. J Gastrointest Surg. 2004;8:109–112.
4.Aranda JL, Varela G, Benito P, de Juan A. Donor cryopreserved rib allografts for chest wall reconstruction. Interact Cardiovasc Thorac Surg. 2008;7:858–860.
5.Laurencin C, Khan Y, El-Amin SF. Bone graft substitutes. Expert Rev Med Devices. 2006;3:49–57.

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