Eur J Plast Surg (1996) 19:97-99 European ]~-~1~ a 0

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Chest wall reconstruction using pedicled extended serratus anterior myocutaneous flap combined with vascularized rib

T. Inoue, S. Ohba, A. Takamatus, T. Kitazawa, T. Harashina

Department of Plastic and Reconstructive Surgery, Saitama Medical Center, Saitama Medical School, Kawagoe, Japan

Abstract. An extended serratus anterior myocutaneous flap with a vascularized rib has been used, in two cases, for reconstruct ion of large ful l- thickness chest wall de- fects after resection of recurrent breast cancer. Us ing this method, the bony support and the soft tissue of the chest wall can be safely reconstructed.

Key words: Chest wall reconstruct ion - Serratus anteri- or myocutaneous flap - Vascularized rib

serratus anterior myocutaneous flap with a 6 cm segment of the vascularized seventh rib was elevated from the contralateral right chest wall. The flap included the seventh and eighth muscle slips with a 9x16 cm large skin paddle. The vascular pedicle was about 18 cm in length and the flap could easily be passed to the defect through a tunnel dissected under the pectoralis major muscle. The seventh rib was fixed to the remainder of the fourth fib and the sternum. The overlying skin defect was reconstructed with the skin paddle. The postoperative course was uneventful.

One year after surgery the patient is without recurrence, and the chest wall is satisfactory (Fig. 1).

A local recurrence of breast cancer on the chest wall should be treated by radical resection, if there are no me- tastasis. Many reconstructive techniques have been re- ported for the resul tant large ful l- thickness chest wall defect. Most of these cases can be reconstructed without bony support. If, however, the defect is located near the sternum, bony support is necessary. This situation has been handled us ing a serratus anterior myocutaneous flap (SA-MC flap) with a vascularized rib. This method was used successfully in two cases of recurrent breast cancer; it seems to have many advantages over previous- ly used methods.

Case reports

Case 1

A 74-year-old woman presented having had a radical mastectomy 14 years previously. During the past year, a recurrent tumor was noticed, this rapidly increased to reach a size of 4x4 cm. A radical full-thickness excision of the chest wall including the left third and fourth ribs was performed. The small part of the sternum was resected because of its proximity to the lesion. The resulting skin defect was 9x5 cm in size, and the length of bone required for re- construction of the rib and sternal defect was 5 cm. An extended

Correspondence to: T. Inoue, Department of Plastic and Recon- structive Surgery, Saitama Medical Center, Saitama Medical School, 1981, Kamoda, Tsujido, Kawagoe 350, Japan

Case 2

A 61-year-old female presented having had a radical mastectomy two years previously. She noticed a recurrence on the scar six months prior to consultation. The mass had grown to 3x4 cm in size. There was no evidence of metastasis, thus a full-thickness excision of the chest wall including the left third and fourth ribs was performed. The size of the resulting chest wall defect was 9x15 cm in size, and a right extended serratus anterior myocuta- neous flap with a vascularized seventh rib was used for the recon- struction. The flap contained the seventh and eighth muscle slips and had an 18 cm long vascular pedicle. The flap was easily passed to the defect through a tunnel dissected under the pectora- lis major muscle. The seventh rib was fixed to the remainder of the fourth rib and sternum, the skin defect was reconstructed with the skin paddle of the flap.

Healing was uneventful, and six months after surgery she is being treated with anti-cancer agents (Fig. 2).

Discussion

Many methods have been described for reconstruct ion of a ful l - thickness chest wall defect, these have inc luded the la t iss imus dorsi myocu taneous flap, rectus abdomin- is myocu taneous flap, and other pedicled or free flaps [1, 2, 4, 5]. Most authors have men t ioned that the ma in aim of chest wall reconst ruct ion is to create a stable and airtight structure. Previously we used a rectus abdomin- is myocu taneous composi te flap with the external obl ique fascia attached [5]. This was an excel lent meth- od for the inferolateral area of the chest wall reconstruc-

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Fig. la---e. Case 1. a The resulting chest wall defect after radical excision of recurrent breast cancer, b Right extended SA-MC flap with 6 cm length of seventh rib was transferred through the tunnel dissected under the pectoralis major muscle, e The seventh rib was fixed to the remaining fourth rib and sternum, the skin defect was reconstructed with the skin paddle, d Front view of the pa- tient one year after operation, e The donor site was closed primar- ily

Fig. 2a-d. Case 2. a A 61-year-old female with a recurrent breast cancer on the mastectomy scar underwent a radical full-thickness excision of the chest wall. b Right extended SA-MC flap with 7 cm length of seventh rib was transferred to the defect through the tunnel dissected under the pectoralis major muscle, e The front view of the chest wall six months after operation, d The donor site was closed primarily

t ion when bony suppor t was not required . If, however , the defec t is a round the s ternal area bony suppor t mus t be supp l i ed to c rea te a s table chest wall . Fa sc i a is not requi red , because the r e m a i n i n g p leu ra can a lways be c losed wi thou t tension.

The ex tended serratus anter ior myocu t aneous flap, deve loped by us in 1991, has been one o f the mos t use- ful f laps in head and neck recons t ruc t ion [3]. The f lap has a very long vascu la r ped ic l e and thus can usua l ly be e m p l o y e d as a ped i c l ed flap. In recons t ruc t ion fo l lowing a s tandard mas tec tomy, the thoracodorsa l ar tery and veins m a y have been sacr i f iced [2]. The serratus anter ior m yocu t aneous f lap on the cont ra la tera l hea l thy side is

therefore used for chest wal l recons t ruc t ion and is eas i ly t ransferred to the defec t through a tunnel fash ioned un- der the pec tora l i s ma jo r muscle .

The serratus anter ior musc le has a ma jo r advan tage in that it can be used to carry vascu la r ized ribs. It is easy to raise and can be used to recons t ruc t any defec t which re- quires bone, e.g. skull recons t ruc t ion [6]. Mos t chest wal l recons t ruc t ions do not need bone because a s table chest wal l can be recons t ruc ted with musc le or myocu ta - neous f laps wi th or wi thout pros thet ic mater ia ls . In the case of recons t ruc t ion a round the sternum, the card iac m o v e m e n t is c lear ly v is ib le and is a cause of anxie ty to the pat ients , and should be prevented. A single rib trans-

fer red into the center o f the defec t can create a chest wal l s t rong enough to abol i sh this p rob lem.

Because of the uncer ta in ty of b lood supply on the af- fec ted side, the contra la tera l compos i t e serratus f lap is used. This l imits its recons t ruc t ive abi l i ty and is its sole d isadvantage .

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5. Ueda K, Inoue T, Tanaka I e t al (1991) Chest wall reconstruc- tion by a rectus abdominis myocutaneous composite flap at- tached with the external oblique fascia. Preliminary report. Br J Plast Surg 44:538

6. Ueda K, Harashina T, Inoue T et al (1993) Micorsurgical scalp and skull reconstruction using serratus anterior myoosseous flap. Ann Plast Surg 31:10

References

1. Abbes M, Mateu P, Giordano P e t al (1991) Chest wall recon- struction after full thickness resection: an experience with 22 cases. Eur J Surg Oncol 17:342

2. Harashina T, Takayama S, Ikuta Y e t al (1983) Reconstruction of chest-wall radiation ulcer with free latissimus dorsi muscle flap and meshed skin graft. Plast Reconstr Surg 71:805

3. Inoue T, Ueda K, Hatoko M et al (1991) The pedicled extended serratus anterior myocutaneous flap for head and neck recon- struction. Br J Plast Surg 44:259

4. Larson DL, McMurtrey MJ (1984) Musculocutaneous flap re- construction of chest wall defects: an experience with 50 pa- tients. Plast Reconstr Surg 73:734

T, Inoue