Reconstruction of a massive thoracic defect: The use of anatomic rib-spanning plates

New York University Langone Medical Center, Institute of Reconstructive Plastic Surgery, 560 First Ave TCH 169, New York, NY 10016, USA.
Journal of Plastic Reconstructive & Aesthetic Surgery (Impact Factor: 1.42). 06/2012; 65(9):e253-6. DOI: 10.1016/j.bjps.2012.04.042
Source: PubMed


Larger thoracic defects require stable yet flexible reconstruction to prevent flail chest and debilitating respiratory impairment. We present the use of locking rib-spanning plates as a chest salvage procedure.
A 30-year-old male presented with a massive desmoid tumor in the posterolateral aspect of the chest wall. The mass measured 22 by 14 by 6 cm and involved the posterior third through seventh ribs. The patient underwent wide excision and reconstruction in layers with a porcine dermal substitute for the pleura, locking rib-spanning plates for structural support, and coverage with ipsilateral latissimus dorsi.
The patient tolerated the procedure without complication. He was extubated on postoperative day zero and has had an uneventful course.
Chest wall reconstruction with rib-spanning plates is an alternative method of reconstruction for large chest wall defects. This method limits the foreign body burden while providing rigid structural support. This technique also makes chest wall reconstruction possible in situations that might previously have been treated with pneumonectomy.

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    ABSTRACT: Technical note. In cases in which partial resection of the rib cage is accomplished with vertebrectomy, reconstruction of the chest wall may be challenging. That is because of lack of the anchor point which normally would be a proximal end of a rib or transverse process. We report a straightforward technique for chest wall reconstruction with the novel use of two systems of fixation commonly applied in spinal practice. The operation of a squamous cell carcinoma (Pancoast tumour) of the right lung infiltrating T2, T3 and T4 vertebrae was performed though T4 lateral thoracotomy. Posterior instrumentation with transpedicular screws T1-3-5 on the left and T1-5 on the right side was followed with the right upper lobectomy and hemivertebrectomy. The laminae and facet joints of T2-T4 vertebrae were removed on the side of the tumour. An osteotomy was performed medial to the pedicle at the lateral aspect of the dural sac on the side of the tumour. Proximal parts of four adjacent ribs were removed allowing radical en bloc resection with tumour-free margins. The distal end of each of four rib plates used (MatrixRib Precontoured Plate system) was attached to the proximal end of the rib. The proximal end of the plate was then attached to the rod of posterior fixation construct with the use of a flexible polyethylene terephthalate (PeT) band of the SILCâ„¢ fixation system. The other end of the PeT band was then passed through the top-loading clamp subsequently attached to the rod of the posterior fixation. The patient did not require additional procedures for chest wall reconstruction. On the 7-month follow-up, in chest CT he was found with satisfactory expansion of the remaining lung tissue with proper spinal alignment and anatomical shape of the rib cage. The reported technique can be applied for chest wall reconstruction in cases of total or subtotal vertebrectomy accomplished with the resection extending towards rib cage. It appears to be straightforward, safe and effective allowing good cosmetic and functional outcome.
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