Principles of Chest Wall Reconstruction: Anatomy, Indications, & Reconstructive Options

Overview of Chest Wall Reconstruction

Chest wall reconstruction is a complex and multidisciplinary process required when the thoracic cage is compromised in structure or function. This can occur due to cancer resection, trauma, infection, congenital anomalies, or prior surgical complications.

Reconstruction aims to achieve four primary goals.

• Restore stability and support to the chest wall to prevent flail segments or paradoxical motion.
• Protect intrathoracic structures such as the lungs and mediastinum from external trauma or infection.
• Preserve respiratory mechanics, minimizing restrictive impairment.
• Provide soft-tissue coverage that is durable, vascularised, and resistant to infection, especially over exposed organs or prosthetic material.

Defect characteristics such as size, location, and depth guide reconstructive planning, along with patient comorbidities, prior treatment (e.g., radiation), and available reconstructive options. Flap selection is based on local anatomy, vascular pedicles, and donor site morbidity, while skeletal defects may require rigid reconstruction using prosthetic materials or titanium supports.

Early cases relied on muscle flaps such as the latissimus dorsi (Tansini, 1906), but modern approaches integrate advanced techniques including 3D printing, custom implants, and acellular dermal matrices. Successful outcomes rely on sound surgical planning, a biomimetic approach, and close collaboration with thoracic surgery, oncology, and intensive care teams.

Pre- and post-operative macroscopic presentation is illustrated below.

Anatomy of the Chest Wall

A full anatomical review is beyond scope, but a working knowledge of chest wall structures is essential for flap design and preserving respiratory function.

Musculature

Muscles are grouped based on their relation to the thoracic cage.

• Thoracic Cage Muscles: Intercostals, subcostals, and transversus thoracis support ventilation and structural integrity.
• Muscles Inserting onto the Cage: Pectoralis major/minor, serratus anterior, and scalenes are key for both function and reconstruction.

Respiratory roles include,

• Inspiratory: Diaphragm, scalenes, sternocleidomastoid.
• Expiratory: Abdominals, obliques.

Vascular Supply

• Arterial: Primarily from internal thoracic arteries; with input from posterior intercostals, lateral thoracic, and thoracoacromial branches.
• Venous: Mirrors arterial pathways; posterior drainage via the azygous system.

Nerve Supply

• Intercostal nerves (T1-T11): Innervate muscles and overlying skin; crucial to preserve when possible.

The arterial supply of the chest wall and their reconstructive role is summarised below.

Principles of Chest Wall Reconstruction

The aim of chest wall reconstruction is to restore both function and form—achieving biomimesis or anatomical mimicry of the native chest wall (Rocco, 2010). Restoring skeletal integrity prevents paradoxical movement, protects intrathoracic contents, and supports respiratory mechanics.

This is guided by fundamental reconstructive principles, each tailored to defect size, location, and patient physiology.

1. Anatomical and Structural Restoration: Respect native planes and geometry. Skeletal defects, especially anterior or large, require rigid or semi-rigid fixation to preserve chest mechanics and respiratory function.
2. Tissue Coverage and Organ Protection: Well-vascularised flaps (preferably locoregional) provide soft tissue coverage, eliminate dead space, and protect vital organs. Avoid rigidity that compromises lung or diaphragm movement.
3. Precision and Planning: Optimal outcomes depend on meticulous technique, multidisciplinary coordination, and thoughtful material selection, balancing function, aesthetics, and complication risk (Anikin, 2020). Advanced tools like 3D printing and NPWT can support complex reconstructions.

In 1906, Tansini pioneered chest wall reconstruction using a pedicled latissimus dorsi flap to repair an anterior thoracic defect (Tansini, 1906).

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Indications of Chest Wall Reconstruction

Reconstruction is required when the thoracic cage loses its structural integrity, stability, or soft tissue coverage, regardless of the underlying cause. These defects can arise from resection, trauma, infection, or prior surgery, and often demand a tailored approach based on anatomical and functional needs.

General Indications

• Defect Size >5 cm: Often requires skeletal reconstruction, particularly if full-thickness (Anikin, 2020).
• Loss of ≥4 Ribs: Associated with paradoxical chest movement and risk of lung herniation; rigid support may be required (Anikin, 2020).
• Sternal Resection: Especially involving the manubrium; reconstruction prevents anterior instability.
• Exposed Lung, Pleura, or Mediastinum: Necessitates robust flap coverage to protect vital organs.

The indications for stabilisation are summarised below.

Individualised Decision-Making

Indications should not be applied rigidly. Surgical judgment, patient factors, and resource availability all play a role. Expert variation in practice includes,

• Apicoposterior defects may be left unreconstructed if the scapula provides natural support (Deschamps, 1999).
• Cartilage-level resections (4–6 ribs) are sometimes managed conservatively without reconstruction (Deschamps, 1999).
• Some surgeons reconstruct nearly all defects to pre-empt instability or patient dissatisfaction (Hughes, 1997).

Assessment of Chest Wall Defects

A thorough evaluation informs timing, feasibility, and the overall strategy for reconstruction. It determines the need for skeletal support, flap selection, and perioperative planning.

Defect: Size, Location, and Depth

The reconstruction decision algorithm is strongly influenced by the size, location, and depth of the chest wall defect.

• Size: Large defects (>5 cm) often require skeletal reconstruction, especially if full thickness.
• Location
  • Anterolateral: Greater impact on respiratory mechanics due to lack of sternal or spinal support; structural restoration usually necessary.
  • Anterior: Suitable for pectoralis major or latissimus dorsi flaps.
  • Superoposterior: Often supported by the scapula; may not require skeletal stabilization.
• Depth
  • Partial-Thickness: May only require skin grafts.
  • Full-Thickness: Usually requires both skeletal and soft tissue reconstruction.

Surrounding Tissue

• Infection may necessitate staged reconstruction with initial debridement.
• Radiation impairs vascularity—flaps should be sourced from non-irradiated areas.
• Oncologic resection requires clear margins and reliable coverage.
• Dead space must be assessed and obliterated, especially when vital structures are exposed.

Patient Factors

• Assess overall suitability for surgery, cardiopulmonary and nutritional status are key.
• Comorbidities like diabetes or hypertension must be optimised preoperatively.
• Smoking cessation should occur at least 4 weeks before surgery.
• Review surgical history, including prior internal mammary artery harvest.
• Factor in adjuvant therapies, especially radiotherapy, which impacts flap selection.

The use of flaps for chest wall reconstruction is illustrated below.

Skeletal Reconstruction Options

The goal is to restore chest wall rigidity, prevent paradoxical motion, and protect intrathoracic organs. The ideal material should be strong enough to stabilise the defect, yet flexible enough to contour to complex anatomy. It must also be biocompatible, radiolucent, and inert to minimise complications (Losken, 2004).

There is no universal consensus on the best material (Momeni, 2016) Selection depends on,

• Defect size, location, and contamination
• Surgeon preference and experience
• Institutional resources (Momeni, 2016)

Alloplastic Materials

More commonly used due to their versatility and predictable performance. Each has specific indications and limitations, as summarised in the table below.

Autologous Materials

Now rarely used, autologous options include,

• Split rib grafts, iliac crest, fibula, and fascia.
• Limitations: increased donor-site morbidity, limited shaping, and unpredictable resorption.

Soft-Tissue Reconstruction of the Chest

Soft tissue reconstruction aims to provide robust, vascularised coverage of vital thoracic structures, particularly when skeletal reconstruction is not sufficient to restore protection or contour. Flap selection depends on defect location, size, prior surgeries, and available donor sites.

Commonly used flaps include,

• Pectoralis Major Flap
  • Ideal for anterior defects, especially post-sternotomy.
  • Reliable vascularity via thoracoacromial vessels.
  • Can be advanced, turned over, or islanded.
• Latissimus Dorsi Flap
  • Versatile muscle, suitable for anterolateral or posterior defects.
  • Large surface area, long pedicle (thoracodorsal vessels).
  • Can be used as a muscle or musculocutaneous flap.
• Rectus Abdominis Flap
  • Pedicled superiorly via superior epigastric artery.
  • Suitable for lower anterior chest wall defects.
  • Can be raised even if internal mammary arteries are sacrificed (via eighth subcostal artery) (Fernando 1988).
• External Oblique and Serratus Anterior Flaps
  • Useful for lateral and posterolateral defects.
  • External oblique has broad surface but less bulk.
  • Serratus anterior is thin, pliable, and based on thoracodorsal vessels.
• Omental Flap
  • Excellent vascularity and immune properties.
  • Best for infected or irradiated fields, mediastinal coverage, or irregular dead spaces.
  • Harvested via laparotomy or laparoscopy.

The use of these flaps for chest wall reconstruction is illustrated below.

Further Reading

1. Rocco G. Chest wall surgery. Thorac Surg Clin 20:xiii, 2010 2. Rocco G: Overview on current and future materials for chest wall reconstruction. Thorac Surg Clin 20:559-562, 2010
2. Din AM, Evans GR. Chest wall reconstruction. In: McCarthy JB, Galiano RD, Boutros S, editors. Current therapy in plastic surgery. Philadelphia: Saunders; 2006. p. 362
3. Seder CW, Rocco G. Chest wall reconstruction after extended resection. J Thorac Dis 2016;8:S863-S871.
4. Ferraro P, Cugno S, Liberman M, et al. Principles of chest wall resection and reconstruction. Thorac Surg Clin 2010;20:465-73.
5. Mahabir RC, Butler CE. Stabilization of the chest wall: autologous and alloplastic reconstructions. Semin Plast Surg 2011;25:34-42.
6. Deschamps C, Tirnaksiz BM, Darbandi R, et al. Early and long-term results of prosthetic chest wall reconstruction. J Thorac Cardiovasc Surg 1999;117:588-91. 13.
7. Arnold PG, Pairolero PC. Chest wall reconstructions: an account of 500 consecutive cases. Plast Reconstr Surg 1996; 98(5):804
8. Rocco G. Chest wall resection and reconstruction according to the principles of biomimesis. Semin Thorac Cardiovasc Surg 2011;23:307-13.
9. Losken A, Thourani VH, Carlson GW, Jones GE, Culbertson JH, Miller JI, Mansour KA. A reconstructive algorithm for plastic surgery following extensive chest wall resection. Br J Plast Surg. 2004 Jun;57(4):295-302. doi: 10.1016/j.bjps.2004.02.004. PMID: 15145731.
10. Bostwick J, Nahai F, Wallace JG, et al. Sixty latissimus dorsi flaps. Plast Reconstr Surg 1979;63:31.
11. Tansini I. Sopra il mio processo di amputazione della mammella. Gazz Med Ital Torino 1906;57:141 [in Italian]
12. Deschamps C, Timaksiz BM, Darbandi R, et al. Early and long-term results of prosthetic chest wall reconstruction. J Thorac Cardiovasc Surg 1999;117:588.
13. Weyant MJ, Bains MS, Venkatraman E, et al. Results of chest wall resection and reconstruction with and without rigid prosthesis. Ann Thorac Surg 2006;81:279-85.
14. Losken A, Thourani VH, Carlson GW, Jones GE, Culbertson JH, Miller JI, Mansour KA. A reconstructive algorithm for plastic surgery following extensive chest wall resection. Br J Plast Surg. 2004 Jun;57(4):295-302. doi: 10.1016/j.bjps.2004.02.004. PMID: 15145731.
15. Jones G, Jurkiewicz MJ, Bostwick J, et al. Management of the infected median sternotomy wound with muscle flaps. The Emory 20-year experience. Ann Surg 1997;225:766.
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24. Minabe T, Harii K. Dorsal intercostal artery perforator flap: anatomical study and clinical applications. Plast Reconstr Surg. 2007 Sep;120(3):681-689. doi: 10.1097/01.prs.0000270309.33069.e5. PMID: 17700119.
25. Fernando B, Muszynski C, Mustoe T. Closure of a sternal defect with the rectus abdominis muscle after sacrifice of both internal mammary arteries. Ann Plast Surg. 1988 Nov;21(5):468-71. doi: 10.1097/00000637-198811000-00013. PMID: 2906793.
26. Momeni A, Kovach SJ. Important considerations in chest wall reconstruction. J Surg Oncol. 2016 Jun;113(8):913-22. doi: 10.1002/jso.24216. Epub 2016 Mar 9. PMID: 26969557.
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28. Deschamps C, Tirnaksiz BM, Darbandi R, Trastek VF, Allen MS, Miller DL, Arnold PG, Pairolero PC. Early and long-term results of prosthetic chest wall reconstruction. J Thorac Cardiovasc Surg. 1999 Mar;117(3):588-91; discussion 591-2. doi: 10.1016/s0022-5223(99)70339-9. PMID: 10047664.
29. le Roux BT, Shama DM. Resection of tumors of the chest wall. Curr Probl Surg. 1983 Jun;20(6):345-86. doi: 10.1016/s0011-3840(83)80007-0. PMID: 6851629.
30. Losken A, Thourani VH, Carlson GW, Jones GE, Culbertson JH, Miller JI, Mansour KA. A reconstructive algorithm for plastic surgery following extensive chest wall resection. Br J Plast Surg. 2004 Jun;57(4):295-302. doi: 10.1016/j.bjps.2004.02.004. PMID: 15145731.
31. Butler CE, Langstein HN, Kronowitz SJ. Pelvic, abdominal, and chest wall reconstruction with AlloDerm in patients at increased risk for mesh-related complications. Plast Reconstr Surg. 2005 Oct;116(5):1263-75; discussion 1276-7. doi: 10.1097/01.prs.0000181692.71901.bd. PMID: 16217466.
32. Mahabir RC, Butler CE. Stabilization of the chest wall: autologous and alloplastic reconstructions. Semin Plast Surg. 2011 Feb;25(1):34-42. doi: 10.1055/s-0031-1275169. PMID: 22294941; PMCID: PMC3140239.
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