0007T1226/89/0042-0460/$10.00 Brir~shJournalqfPlasticSurger~(1989). 42.46&462 (Cl 1989 The Trustees of British Association of Plastic Surgeons

Case Report

Reconstruction of a large full thickness chest wall defect by a double-folded vertical rectus abdominis musculocutaneous flap

T. KIYOIZUMI, T. TAKESHITA and T. FUJINO

Department of Plastic and Reconstructive Surgery, Keio University Hospital, and Department of Surgery, Yamato Municipal Hospital, Tokyo, Japan

Summary-A case is reported in which a double-folded vertical rectus abdominis musculocutaneous flap was successfully transferred to cover a large full thickness chest wall defect after resection of recurrent breast cancer. A brief discussion on chest wall reconstruction is included.

Case report

A 43-year-old female with left recurrent breast cancer underwent a resection of the chest wall which included partial resection of the first, second and third ribs, left hemisternal resection and upper mediastinal dissection with partial resection of both parietal and visceral pleura (Figs 1 and 2). The size of the skeletal defect was 13 cm wide and 15 cm long. The pericardium was exposed. The visceral pleura was reconstructed with Marlex mesh (Fig. 3). A double-folded vertical rectus abdominis musculo- cutaneous flap was designed (Fig. 4) and the lower half of the flap was denuded with a dermatome (Fig. 5). After severing the rectus abdominis muscle, the flap was elevated and introduced to the left anterior chest through

a subcutaneous tunnel (Fig. 6). The denuded skin portion was folded into the thoracic cavity and sutured to the sternal periosteum or the intercostal muscle to seal the pleural cavity (Fig. 7). The remaining flap was sutured to the surrounding skin in two layers (Fig. 8).

The chest tube was removed on the 10th postoperative day, and the patient had an uneventful course until her discharge on the 14th postoperative day. She resumed her daily activities without any functional deficit (Fig. 9).

Fig. I Fig. 2

Figure l-Preoperative view of the patient with left recurrent breast cancer. Figure 2-Operative view of the chest wall defect extending to the left visceral pleura.

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DOUBLE-FOLDED VERTICAL RECTUS ABDOMINIS MUSCULOCUTANEOUS FLAP 461

Fig. 3 Fig. 4 Fig. 5

Fig. 6 Fig. 7 Fig. 8

Figure &Marlex mesh was applied to the defect of the visceral pleura. Figure &Design of double-folded vertical rectus abdominis M-C flap. Figure %Distal half of the flap was denuded. Figure 6-Flap was introduced to the chest wall defect through a subcutaneous tunnel. Figure 7-Denuded portion of the flap was sutured to the remaining intercostal muscles and the sternal periosteum. Figure &Immediate postoperative view.

Discussion external rigidity are the main purposes of recon- struction.

There are two principles of chest wall reconstruc- Various methods of achieving these aims have tion. The first is restoration of the anatomical defect been reported. In general, even if the defect and the second is compensation of the physiological involving pleura is extensive, a fasciocutaneous or deficit (Starzynski et al., 1969). In other words, musculocutaneous flap is sufficient to reconstruct atmospheric seal and visceral protection with the chest wall. The latissimus dorsi musculocuta-

462 BRITISH JOURNAL OF PLASTIC SURGERY

Fig. 9

Figure 9-Postoperative view at 3 months

neous flap (McGraw et al., 1978) the pectoralis major muscle flap (Arnold and Pairolero, 1979), the rectus abdominis musculocutaneous flap (Boyd et al., 1981) and the vertical abdominal fasciocuta- neous flap (Maruyama et al., 1985) have been used successfully, mostly in combination with Marlex mesh.

Regularly, the authors close a pleural defect with Marlex mesh and cover it with the muscular portion of the musculocutaneous flap followed by subdermal and skin sutures.

The extensive width of the pleural defect in this case (13 cm) precluded our use of the conventional rectus abdominis musculocutaneous flap to cover the Marlex mesh since the muscle was not wide enough. We also excluded the latissimus dorsi musculocutaneous flap as the thoracodorsal vessels were severed in the primary mastectomy. As hemisternectomy and upper mediastinal dissection with extensive pleural resection were also per- formed, protection of the heart and great vessels as well as closure of the pleural cavity became an important consideration.

We have used the double-folded technique to reconstruct a total cheek defect after radical maxillectomy, utilising a free latissimus dorsi musculocutaneous flap (Fujino et al., 1981). Using this concept, we developed this double-folded rectus abdominis musculocutaneous flap to reconstruct a rigid chest wall and close the pleural cavity. The flap was designed vertically so that necrosis of the distal portion could be prevented. The denuded portion was large enough to cover the pleural defect

and suture to the remaining intercostal muscles and the sternal periosteum.

The rest of the flap was folded to reconstruct the outer chest wall. The resulting coverage of the heart and great vessels is double-layered and provides excellent visceral protection.

Surgical intervention is sometimes indicated, even in recurrent breast cancer, as a palliative treatment in co-ordination with chemotherapy, radiotherapy and immunotherapy, thus improving the quality of daily life. These patients have often had a radical mastectomy which usually impairs the thoracodorsal vessels. The double-folded rectus abdominis musculocutaneous flap is a useful addi- tion to the methods available for reconstructing an extensive full thickness chest wall defect in recur- rent breast cancer or radionecrosis.

References

Arnold, P. G. and Pairolero, P. C. (1979). Use of the pectoralis major muscle flaps to repair defects of the anterior chest wall. Plastic and Reconstructive Surgery, 63,205.

Boyd, A. D., Shaw, W. W., McCarthy, J. G., Baker, D. C., Trehan, N. K., Acinapura, A. J. and Spencer, F. C. (1981). Immediate reconstruction of full-thickness chest wall defects. Annals of Thoracic Surgery, 32, 337.

Fujino, T., Mamyama, Y. and Inuyama, I. (1981). Double-folded myocutaneous flap to cover a total cheek defect. Journal of Maxillofacial Surgery, 9, 73.

Mamyama, Y., OhnIshi, K. and Chung, C. C. (1985). Vertical abdominal fasciocutaneous flaps in the reconstruction of chest wall defects. British Journalof Plastic Surgery, 38.230.

McGraw, J. B., Penix, J. 0. and Baker, J. W. (1978). Repair of the chest wall and spine with the latissimus dorsi myocuta- neous flap. Plastic and Reconstructive Surgery, 62, 197. _

Starzvnski. T. E.. Snvderman. R. K. and Beattie. E. J. (1969). Problems of major chest ‘wall reconstruction. Plastic a&i Reconstructive Surgery, 44, 525.

The Authors

Takashi Kiyoizumi, MD, Clinical Instructor. Department of Plastic and Reconstructive Surgery. Keio University Hospital, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan 160.

Toshio Takeskita, MD, General Surgeon, Department of Surgery, Yamato Municipal Hospital.

Toyomi Fujino, MD, FACS, Professor and Chief, Department of Plastic and Reconstructive Surgery, Keio University Hospital.

Requests for reprints to Dr Kiyoizumi.

Paper received 3 May 1988. Accepted 10 October 1988.