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Ann Thorac Surg 2000;69:919-923
© 2000 The Society of Thoracic Surgeons

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Original Articles

Functional assessment of chest wall integrity after methylmethacrylate reconstruction

^a Department of Thoracic and Cardiovascular Surgery, University Hospital, University of Bern, Bern, Switzerland
^b Department of Radiology, University Hospital, University of Bern, Bern, Switzerland
^c Division of Reconstructive Surgery, University Hospital, University of Bern, Bern, Switzerland
^d Division of Pneumology, University Hospital, University of Bern, Bern, Switzerland

Address reprint requests to Dr Ris, Department of Surgery, University of Lausanne, CH 1011 Lausanne, Switzerland
e-mail: hris{at}chuv.hospvd.ch

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. All patients with extensive resection of the anterolateral chest wall and the sternum followed by reconstruction with methylmethacrylate substitutes were assessed prospectively 6 months after the operation to delineate chest wall integrity with pulmonary function and cine-magnetic resonance imaging.

Methods. Twenty-six patients underwent chest wall reconstruction by use of methylmethacrylate between 1994 and 1998 due to primary tumors in 35%, metastases in 27%, T3 lung cancer in 19%, and debridement for radionecrosis and osteomyelitis in 19% of patients. Three to eight ribs were resected and additional sternum resection was performed in 39% of patients.

Results. There was no 30-day mortality. All patients were extubated after the operation without need for reintubation. Prosthesis dislocation occurred in 1 patient and infection in 2 patients during follow-up. Nineteen patients (73%) suffered no restrictions of daily activities. Clinical examination revealed normal shoulder girdle function in 77% of patients. There was no significant difference between preoperative and postoperative FEV₁ (forced expiratory volume in 1 second) measurements in patients with lobectomy or wedge resections. Cine-magnetic resonance imaging revealed concordant chest wall movements during respiration in 92% of patients without paradoxical movements or implant dislocations being observed.

Conclusions. Large defects of the anterolateral chest wall and sternum can be reconstructed efficiently with methylmethacrylate substitutes with minimal morbidity and excellent cosmetic and functional outcome.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Chest wall resection may be necessary for a variety of reasons including malignancy, radionecrosis, infection, or trauma. Resections of the dorsoapical and posterior aspects of the chest wall usually do not require substitutes [1]. However, reconstruction of sufficient stability is warranted for large defects of the anterolateral chest wall and sternum to prevent flail chest and paradoxical, insufficient breathing, to protect underlying structures, and to offer a good functional and cosmetic result. A variety of different techniques have been proposed for this purpose [2–12]. In 1972, a sandwich of two layers of marlex mesh with a filler of methylmethacrylate was described [13] in these situations and has gained increasing acceptance as it satisfies the requirements for rigidity, protection, and chest wall remodelling [14–18]. However, the rigidity achieved with methylmethacrylate for chest wall reconstruction, highly desired in the early postoperative course, might adversely influence the late outcome due to stiffness of the chest wall and late pulmonary restriction. This prospective study investigates the impact of methylmethacrylate substitutes after extended anterolateral chest wall resection on chest wall integrity measured by clinical examination, pulmonary function tests, and cine-magnetic resonance imaging (MRI).

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
All patients requiring chest wall resection and reconstruction by use of methylmethacrylate substitutes were followed up in a prospective manner to delineate pulmonary function and chest wall integrity. Indications for methylmethacrylate reconstructions consisted of chest wall resections of the anterolateral chest wall with a minimum of three ribs involved or resections including the sternum. Resections of less than three ribs or those situated in the posterior or apical aspect of the chest wall were not included in this study because these defects were not reconstructed by methylmethacrylate.

Surgical technique
After completion of the resection, the skeletal chest wall defect was closed by use of a mersilene-methylmethacrylate-mersilene prosthesis. At the beginning of the study, the prosthesis was constructed on a back-table, according to the defect to be filled. Due to prosthesis dislocation in the third patient, we have subsequently modified our technique as follows. After resection of the chest wall, a mersilene mesh (polyethylen-terephthalat) with bidirectional elasticity was sutured under tension into the chest wall defect with nonresorbable interrupted sutures. The underlying lung was ventilated with positive end-expiratory pressure (PEEP) and normal tidal volumes to simulate the natural shape of chest wall to be replaced (Fig 1A). The viscosity of methylmethacrylate was also adapted to the modified technique and consisted of 40 g polymeric powder containing garamycin mixed with 30 mL liquid monomer instead of a mixture of 40 g powder and 20 mL liquid. This modification allowed a better handling of the methylmethacrylate for this purpose due to its lower viscosity and the longer time required for hardening. The methylmethacrylate was then distributed on the fixed mesh and modeled to the resection margins of the chest wall (Fig 1B). After sternal resection, holes were made in the spongiosa and filled with methylmethacrylate for better anchorage of the prosthesis. A second mersilene mesh was integrated in the methylmethacrylate (still in its viscous phase) and tightly fixed to the chest wall (Fig 1C). The lung was kept ventilated with PEEP at a normal tidal volume and the prosthesis was cooled with water during hardening to prevent heat injury to adjacent structures. Cooling was performed by irrigation of the prosthesis with cold NaCl solution during the polymerization phase. Soft tissue coverage was then performed by soft tissue adaptation or by use of pedicled or free myocutaneous flaps. Prophylactic antibiotics were given for 48 hours postoperatively and all patients received continuous peridural analgesia for 5 to 7 days after the operation.

View larger version (58K): [in this window] [in a new window]   Fig 1. Chest wall reconstruction with methylmethacrylate substitute. (A) After resection of the chest wall, a mersilene mesh (polyethylen-terephthalat) with bidirectional elasticity was sutured under tension in the chest wall defect by use of nonresorbable interrupted sutures. (B) The methylmethacrylate was then distributed onto the fixed mesh and modeled to the resection margins of the chest wall. (C) A second mersilene mesh was integrated into the methylmethacrylate (still in its liquid phase) and tightly fixed to the chest wall. The lung was kept ventilated with positive end-expiratory pressure at a maximum tidal volume and the prosthesis was cooled with NaCl during the polymerization phase to prevent heat injury to adjacent structures.

Statistical analysis
Statistical analysis was performed by use of paired t test for comparison of preoperative and postoperative pulmonary function testing. A two-tailed hypothesis was applied and significance considered at p values less than 0.05.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Twenty-six patients underwent chest wall reconstruction with methylmethacrylate substitutes between January 1994 and April 1998. There were 16 men and 10 women with a mean age at operation of 53 years (range, 20 to 74 years). All patients had a 6-month follow-up.

The indications for chest wall reconstruction included primary tumors of the chest wall in 9 patients (35%), chest wall metastases in 7 (27%), debridement for chronic infections including radionecrosis in 5 (19%), and chest wall infiltration of lung cancer in 5 (19%). The number of resected ribs ranged from three to eight ribs with a mean of four ribs per specimen. Additional sternum resection was performed in 10 patients (39%), with 4 complete and 6 partial resections of the sternum. Concomitant pulmonary resections of involved lung included wedge resections in 3, lobectomy in 7, and pneumonectomy in 2 patients. Soft tissue reconstruction was performed by adaptation of the overlying tissue in 9, use of pedicled myocutaneous flaps in 13, and use of free myocutaneous latissimus dorsi flaps in 4 patients.

Postoperative course
There was no 30-day mortality. All patients were extubated after the operation without need for reintubation. The mean hospital stay was 24 days (range, 10 to 60 days). Prosthesis dislocation occurred in 1 patient within 48 hours after the operation requiring reoperation and prosthesis replacement. One patient developed pneumonia of the underlying lung requiring antibiotic therapy and 2 patients a fluid collection requiring ultrasound-guided percutaneous drainage. These fluid collections showed no evidence of infection. Transient plexus palsy was observed in 1 patient after chest wall reconstruction and latissimus muscle transfer, with complete recovery after 4 months. No soft tissue flap necrosis or wound dehiscence were observed during hospitalization.

Infection of prosthesis
Infection of prosthesis occurred in 2 patients (8%) 8 and 12 months after the operation, respectively. In 1 of these patients the prosthesis was inserted after chest wall resection for chronic osteomyelitis (Pseudomonas) and fistulation in the anterolateral chest wall including the sternum after chest wall trauma 20 years ago. Despite wide excision in healthy tissue and antibiotic administration for 8 weeks, graft infection occurred requiring removal of the prosthesis after a fruitless attempt of conservative therapy with antibiotics and drainage. After removal of the prosthesis, the chest wall defect was closed by a pedicled omentum flap covered by the preserved pedicled myocutaneous latissimus dorsi flap deriving from the first operation. Further wound healing was uneventful. The second patient had a left pneumonectomy due to NSCLC T3 N0 M0 invading the anterolateral chest wall. The patient was previously irradiated due to head and neck cancer 10 years ago and had sequelae of chest wall irradiation at the time of operation. In this patient, low-grade prosthesis infection developed 1 year after the operation requiring removal of the prosthesis (Staphylococcus aureus). A pedicled serratus anterior muscle flap was transferred into the pneumonectomy cavity and sutured from inside into the chest wall defect. Further chest wall cavity healing was uneventful but a marked winging scapula resulted in a chronic wound dehiscence requiring interposition of a pedicled contralateral myocutaneous latissimus dorsi flap.

Follow-up at 6 months
Seventy-three percent of patients were satisfied with the result and had no relevant restrictions of daily activities. Clinical examination revealed uneventful healing and normal shoulder girdle function in 77% of patients. Assessment of pulmonary function 6 months after the operation revealed no statistically significant difference between the preoperative and postoperative FEV₁ (forced expiratory volume in 1 second) values either in patients without lung resection or wedge resection (FEV₁ = 0.165 ± 0.442 L) or in patients undergoing lobectomy (FEV₁ = 0.145 ± 0.535 L). Assessment of the chest wall integrity by cine-MRI 6 months after the operation revealed concordant chest wall movements in 92% of patients during inspiration and expiration. Rigidness of the reconstructed chest wall was noted in 8% of patients, whereas paradoxical movements or implant dislocations were not observed in any patient.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Resection and reconstruction of large chest wall defects of the anterolateral chest wall including the sternum usually require a multidisciplinary approach to estimate the preoperative risk, to delineate the extent of resection required, and to provide low postoperative morbidity. The procedure itself is best performed as a team approach, including thoracic surgery for wide resections in healthy tissues of the chest wall and underlying structures and reconstruction of the skeletal part of the chest wall, and plastic surgery for reconstruction of the overlying soft tissue defect. This multidisciplinary approach has resulted in safe and durable procedures with low postoperative morbidity and mortality and acceptable functional results [2] for a variety of pathologies such as primary tumors of the chest wall or the sternum [18], lung cancer and metastases invading the chest, infections, radionecrosis, and trauma.

Large defects after resection of the anterolateral chest wall and sternum usually require stabilization of the chest wall in addition to soft tissue coverage. Resections of infected sternum after cardiac surgery can be treated successfully by resection and soft tissue coverage by muscle flaps alone [19], however, these patients usually require prolonged respirator support and intensive care due to chest wall instability. Several authors have shown that stabilization of the chest wall in addition to soft tissue coverage reduced ventilator dependence and overall hospital stay [20] and improved postoperative PaO₂ and pulmonary function compared with soft tissue coverage alone [21].

Various techniques have been used successfully for closure of chest wall defects. Since 1972, methylmethacrylate substitutes consisting of two layers of marlex mesh and a filler of methylmethacrylate have gained increasing popularity for bridging large anterolateral chest wall defects including the sternum [13–18] as it is believed that this technique fulfills the criteria of an ideal reconstruction providing enough stability for normal spontaneous breathing and coughing and cosmetic acceptability. Moreover, it allows an individual remodeling of virtually every skeletal chest wall defect according to the shape of the chest. The in situ application of methylmethacrylate while the lung is ventilated instead of constructing the prosthesis on the back-table enables a better configuration of the prosthesis according to the shape of the chest wall to be replaced, leading to better functional and cosmetic results and fewer substitute dislocations due to optimal anchorage of the prosthesis in the surrounding tissue. However, this modification requires consequent cooling of the prosthesis during the polymerization process by use of cold NaCl solution to prevent heat injury to adjacent tissues. We have not observed heat-related injury in our patients, even in cases in which a free latissimus dorsi flap was branched on the internal mammary vessels brought through the reconstructed chest wall after extended resection of the sternum and the anterior chest wall.

Our results confirm the usefulness of this technique. The 30-day mortality was 0 and immediate postoperative extubation was performed in all patients, although large resections of the anterolateral chest wall including the sternum with an average of four ribs were performed for various reasons, including chest wall infections. However, competent soft tissue coverage of the methylmethacrylate substitute is mandatory because tissue ingrowth is probably less efficient than in mesh substitutes. Two of 26 patients developed prosthesis infection requiring removal during follow-up, 1 after chest wall resection for chronic fistulating Staphylococcus aureus infection and 1 after en bloc resection of lung and chest wall for non-small cell lung cancer and postoperative irradiation of the chest involved. Although 4 of the 5 patients with methylmethacrylate substitutes for resections of chest wall infections had an uneventful course, methylmethacrylate substitutes should not be used if active infection is present at operation. Postoperative irradiation also seems to increase the risk of infections after methylmethacrylate replacement as reported by other authors [22].

Although the early postoperative course after chest wall resection and reconstruction with methylmethacrylate has been gratifying, concerns remain regarding the impact of this technique on long-term chest wall integrity and late restriction in view of the rigidity of this substitute and the literature has been scant in this respect. However, our results 6 months after the operation have not only shown satisfying cosmetic results and a good shoulder girdle function, but also low chest wall complaints and a good self assessment of the result. Moreover, pulmonary function testing revealed no significant deterioration of FEV₁ after the operation compared with preoperative values in patients without major resections and no significantly lower FEV₁ values after lobectomy than expected. Chest wall resection reconstructed by use of methylmethacrylate does not seem to impair pulmonary function per se. This could be explained by our findings derived from dynamic observation of the chest wall during inspiration and expiration by cine-MRI. This technique has not been used to date to assess the chest wall integrity after reconstructive procedures, although the appearance of methylmethacrylate substitutes has been studied on computed tomography and MRI [23, 24]. In fact, 92% of patients revealed concordant chest wall movements compared with the healthy side during respiration, and no patient revealed paradoxical movements or prosthesis dislocation 6 months after the operation.

Our results demonstrate that large defects of the anterolateral chest wall including the sternum can be reconstructed by use of methylmethacrylate with minimal morbidity and excellent cosmetic and functional outcome provided that attention is paid to technical details and competent soft tissue coverage. Resections of the chest wall reconstructed with methylmethacrylate substitutes did not result in impaired pulmonary function per se or in a rigid or paradoxically moving chest wall during respiration as measured by cine-MRI.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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