British Journal of Plastic Surgery (199 I), 44, 538-540
Chest wall reconstruction by a rectus abdominis myocutaneous composite flap attached with the external oblique fascia. Preliminary report K. Ueda, T. Inoue,
I. Tanaka,
M. Hatoko
Department of’PIastic and Reconstructioe Kamoda, Kawagoe, Japan
and T. Harashina
Surgery, Saitama Medical Centre, Saitama Medical School,
SUMMAR Y. A composite rectus abdominis myocutaneous flap incorporating the external oblique fascia has been used for reconstruction of large full thickness chest wall defects after resection of recurrent breast cancer in two cases.
Full thickness chest wall defects caused by excision of malignant tumours should be reconstructed with substantial airtight tissue to seal the pleural cavity. Many reports have been published on chest wall reconstruction by the rectus abdominis myocutaneous flap, but we feel there are definite advantages in using a composite flap made of a skin component from the contralateral side and the external oblique fascia from the ipsilateral side. By this method, the pleura is reconstructed with a fascial flap and the anterior rectus sheath and the ribs and intercostal muscles are replaced by the rectus abdominis muscle. The skin defect is repaired by the skin paddle. This method was applied to two cases of recurrent breast cancer, both successfully reconstructed by this technique.
The operation was performed in March 1989. Resection of the chest wall, including the right 4th and 5th ribs, was carried out. The defect measured 7 x 10 cm (Fig. 2A). A flap similar to that used in Case 1 (Fig. 2B) was used to repair the defect. The tip of the skin component was deepithelialised and was inserted into a subcutaneous pocket in the subclavicular region to correct the depression (Fig. 2C). A Marlex mesh was used to repair the abdominal muscular defect. Fatty necrosis occurred postoperatively at the tip of the skin portion but healed spontaneously (Fig. 2D). There was no further recurrence of the tumour.
Discussion Reconstruction of a full thickness defect of the chest wall must be airtight to avoid the development of a pneumothorax. Furthermore, the flap, which must withstand the repetitive and forceful respiratory movements, must be tension free and therefore well vascularised (Shaw et al., 1990). Our method has satisfied all the above conditions by reconstructing the chest wall with a three layered flap of skin, muscle and fascia. Such stability may also reduce the amount of paradoxical movement during spontaneous respiration. Another method of reconstructing the chest wall was reported by Kiyoizumi et al. (1989), using a double folded vertical rectus abdominis myocutaneous flap to achieve an airtight reconstruction. The skin paddle in our technique is designed in an oblique fashion adjacent to the umbilicus to include many perforators, as well as the anterior sheath of the rectus abdominis muscle. Moon et al. (1988) carried out injection studies on the superiorly based transverse rectus abdominis flap in cadavers. No vascular filling occurred below Scarpa’s fascia in the skin paddle on the contralateral side. In the transverse flap at the level of the umbilicus, vascular filling was noted in the subdermal plexus and fascia, even in the contralateral skin paddle. The adequacy of the vascular supply to the fascia was confirmed by us during surgery by the
Case 1 A 56-year-old woman after a radical mastectomy developed a chest wall recurrence. The tumour rapidly increased and reached 7 x 5 cm in size. A thoracic CT scan showed a tumour shadow infiltrating the ribs in the right chest wall. After electron beam radiotherapy the operation was performed (Fig. IA). The procedure involved excision of all the layers of the chest wall, including the right 3rd, 4th and 5th ribs (Fig. 1B). The size of the skin defect was 10 x 17 cm. The defect was reconstructed with a contralateral flap. The flap was designed to have a fascial component of anterior rectus sheath and external oblique fascia from the ipsilateral side and a skin component from the contralateral side (Figs lC, D). After elevating the flap, the external oblique fascia bled from the edges, thus confirming its viability. The flap was moved to the chest wall defect, the fascia was sutured to the pleural defect (Fig. I E) and the skin defect was reconstructed with the skin paddle (Fig. 1F). A Marlex mesh was used to repair the abdominal muscular defect. The appearance of the chest wall 6 months later is shown in Figure 1G. The patient is free of recurrence.
Case 2 A 47-year-old woman had a radical mastectomy in June 1984. A subcutaneous tumour with redness developed in the scar in September 1988. A CT scan suggested invasion of the ribs.
538
Chest W.111Reconstruction
by a Rectus Abdominis
Myocutaneous
Composite
Flap
539
Fig. 1 Figure l-Casr I. (A) Preoperative condition. (B) The full thickness chest wall defect. !C) The flap design. (D) The elevated flap. (E) The fascia sutured to the pleural defect. (F) The skin paddle in the immedtate postoperative period (G i The condition 6 months postoperatively.
British Journal of Plastic Surgery
540
Fig. 2
FIeure 2-Cuse co;dition
2.
Chest wall reconstruction by a rectus abdominis myocutaneous composite flap attached with the external oblique fascia. Preliminary report K. Ueda, T. Inoue,
I. Tanaka,
M. Hatoko
Department of’PIastic and Reconstructioe Kamoda, Kawagoe, Japan
and T. Harashina
Surgery, Saitama Medical Centre, Saitama Medical School,
SUMMAR Y. A composite rectus abdominis myocutaneous flap incorporating the external oblique fascia has been used for reconstruction of large full thickness chest wall defects after resection of recurrent breast cancer in two cases.
Full thickness chest wall defects caused by excision of malignant tumours should be reconstructed with substantial airtight tissue to seal the pleural cavity. Many reports have been published on chest wall reconstruction by the rectus abdominis myocutaneous flap, but we feel there are definite advantages in using a composite flap made of a skin component from the contralateral side and the external oblique fascia from the ipsilateral side. By this method, the pleura is reconstructed with a fascial flap and the anterior rectus sheath and the ribs and intercostal muscles are replaced by the rectus abdominis muscle. The skin defect is repaired by the skin paddle. This method was applied to two cases of recurrent breast cancer, both successfully reconstructed by this technique.
The operation was performed in March 1989. Resection of the chest wall, including the right 4th and 5th ribs, was carried out. The defect measured 7 x 10 cm (Fig. 2A). A flap similar to that used in Case 1 (Fig. 2B) was used to repair the defect. The tip of the skin component was deepithelialised and was inserted into a subcutaneous pocket in the subclavicular region to correct the depression (Fig. 2C). A Marlex mesh was used to repair the abdominal muscular defect. Fatty necrosis occurred postoperatively at the tip of the skin portion but healed spontaneously (Fig. 2D). There was no further recurrence of the tumour.
Discussion Reconstruction of a full thickness defect of the chest wall must be airtight to avoid the development of a pneumothorax. Furthermore, the flap, which must withstand the repetitive and forceful respiratory movements, must be tension free and therefore well vascularised (Shaw et al., 1990). Our method has satisfied all the above conditions by reconstructing the chest wall with a three layered flap of skin, muscle and fascia. Such stability may also reduce the amount of paradoxical movement during spontaneous respiration. Another method of reconstructing the chest wall was reported by Kiyoizumi et al. (1989), using a double folded vertical rectus abdominis myocutaneous flap to achieve an airtight reconstruction. The skin paddle in our technique is designed in an oblique fashion adjacent to the umbilicus to include many perforators, as well as the anterior sheath of the rectus abdominis muscle. Moon et al. (1988) carried out injection studies on the superiorly based transverse rectus abdominis flap in cadavers. No vascular filling occurred below Scarpa’s fascia in the skin paddle on the contralateral side. In the transverse flap at the level of the umbilicus, vascular filling was noted in the subdermal plexus and fascia, even in the contralateral skin paddle. The adequacy of the vascular supply to the fascia was confirmed by us during surgery by the
Case 1 A 56-year-old woman after a radical mastectomy developed a chest wall recurrence. The tumour rapidly increased and reached 7 x 5 cm in size. A thoracic CT scan showed a tumour shadow infiltrating the ribs in the right chest wall. After electron beam radiotherapy the operation was performed (Fig. IA). The procedure involved excision of all the layers of the chest wall, including the right 3rd, 4th and 5th ribs (Fig. 1B). The size of the skin defect was 10 x 17 cm. The defect was reconstructed with a contralateral flap. The flap was designed to have a fascial component of anterior rectus sheath and external oblique fascia from the ipsilateral side and a skin component from the contralateral side (Figs lC, D). After elevating the flap, the external oblique fascia bled from the edges, thus confirming its viability. The flap was moved to the chest wall defect, the fascia was sutured to the pleural defect (Fig. I E) and the skin defect was reconstructed with the skin paddle (Fig. 1F). A Marlex mesh was used to repair the abdominal muscular defect. The appearance of the chest wall 6 months later is shown in Figure 1G. The patient is free of recurrence.
Case 2 A 47-year-old woman had a radical mastectomy in June 1984. A subcutaneous tumour with redness developed in the scar in September 1988. A CT scan suggested invasion of the ribs.
538
Chest W.111Reconstruction
by a Rectus Abdominis
Myocutaneous
Composite
Flap
539
Fig. 1 Figure l-Casr I. (A) Preoperative condition. (B) The full thickness chest wall defect. !C) The flap design. (D) The elevated flap. (E) The fascia sutured to the pleural defect. (F) The skin paddle in the immedtate postoperative period (G i The condition 6 months postoperatively.
British Journal of Plastic Surgery
540
Fig. 2
FIeure 2-Cuse co;dition
2.
