Ann Thorac Surg 2007;83:697
© 2007 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
Chest Wall Reconstruction in Full-Thickness Defect for Mastectomy and Irradiation
Andrea Droghetti, MDa,*,
Andrea Schiavini, MDa,
Piergiorgio Muriana, MSa,
Donatella Tomassoni, MDb,
Barbara Canneto, MDa,
Enrico Aitini, MDc,
Alfredo Scalzini, MDb,
Giovanni Muriana, MDa
a Thoracic Surgery Division, C. Poma Hospital, Mantova, Italy
b Infectious Disease Division, C. Poma Hospital, Mantova, Italy
c Medical Oncology and Hematology Division, C. Poma Hospital, Mantova, Italy
* Address correspondence to Dr Droghetti, C. Poma Hospital, Thoracic Surgery Division, Viale Albertoni 1, Mantova, 46100 Italy (Email: adroghetti{at}libero.it).
A 65-year-old woman was examined for a full-thickness chest ulcer after bilateral mastectomy at age 39, with resection and radiotherapy for left-side recurrence at age 52. Nine months later an ulcer appeared in a large radiodermatitis zone without any recurrent neoplastic disease. Many different medical treatments were tried without success, and after 13 years the defect had grown to the size of 14 x 13 cm (Fig 1). Chronic sepsis involved secondary amyloidosis with nephritic syndrome, chronic anaemia, malnutrition syndrome, and cachexia.
A computed tomographic scan showed a large defect of 12 cm on the left side of the chest with no anterior arches of III, IV, V, and VI ribs, no soft tissue and muscle, and external exposure of the heart and lung (Fig 2). Echo color doppler showed good blood flow in the right internal mammary artery. Previous removal of both pectoral major muscles, iatrogenic atrophy of both the latissimus dorsi, and closure of the left internal mammary artery after radiation meant that the only suitable muscle for a satisfactory flap was the right rectus abdominis.
We made an adequate debridement of infected and ischemic tissues including the thoracic skeleton with partial sternectomy as well as III to VI rib resection. The reconstruction was accomplished after 3 months of systemic and local therapy with a vertical rectus abdominis musculocutaneous flap. To avoid abdominal bulging or hernia in the donor site, a Prolene mesh (Ethicon, Somerville, NJ) was positioned and the skin was directly closed with umbilicus repositioning. After 1 year the woman returned to a normal lifestyle and did not need any more therapy (Fig 3).
This unusual case demonstrates that the choice of the best treatment must be based on the patient’s characteristics and not on the surgeon’s technical preferences.
