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Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NYFiona and Stanley Druckenmiller Center for Lung Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY
Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NYFiona and Stanley Druckenmiller Center for Lung Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY
Address for reprints: Gaetano Rocco, MD, Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10060.
Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NYFiona and Stanley Druckenmiller Center for Lung Cancer Research, Memorial Sloan Kettering Cancer Center, New York, NY
The biosandwich technique is an effective, rigid, adaptable, and completely biocompatible reconstructive option for extensive defects in high-risk patients or complex settings.
An ideal reconstruction for extensive chest wall defects would restore the integrity and physiology of the chest wall while achieving patient-tailored cosmetic reconstruction (ie, biomimesis).
Extensive chest wall defects are usually covered with rigid prostheses, which include the risk of infection or fracture with subsequent need for material removal.
We present here a biocompatible sandwich technique for extensive anterior chest wall defects. The requirement for informed consent was waived by our institutional review board (IRB#18-391; October 17, 2022).
Technique
Chest wall resections are performed lege artis (Figure 1). The deeper layer of the reconstruction consists of biocompatible mesh, such as Vicryl (Johnson & Johnson), Permacol (Medtronic), or Phasix (BD). The prosthesis is anchored to surrounding skeletal tissues (ribs or sternum) with several long-term resorbable (eg, polydioxanone) or nonresorbable (eg, polypropylene) heavy sutures using a through-and-through or figure-of-8 configuration. If necessary, a recess is created to allow access to the thoracic artery and vein for free myocutaneous flap reconstruction. The superficial layer of the biosandwich is made of a titanium mesh, trimmed and shaped to the size of the defect, with a 1.5- to 2-cm overlap on each side. To distribute tensile strength on the titanium mesh and create escape routes from traction on the metallic mesh, the anchoring screws, gauged on the ribs or sternal thickness, are preferentially placed to anchor the cranial and caudal aspects of the mesh. Nonresorbable heavy sutures are used on the lateral aspects to minimize the risk of fracture. The edges of the titanium mesh are mechanically trimmed and embedded in Surgicel (Johnson & Johnson) to avoid tissue trauma. Finally, vancomycin powder is dispersed onto the biosandwich to reduce the risk of colonization.
Figure 1Overview of the biosandwich technique: A, Patient with full-thickness chest wall involvement of leiomyosarcoma. B, Resected specimen. C, Internal reconstruction with Phasix (BD) mesh after full-thickness chest wall resection. D, Rigid reconstruction with titanium mesh (Patient 1). E, Anterolateral thigh free-flap harvested to fill the soft-tissue defect. F, Postoperative result 4 weeks after surgery.
The construct is resurfaced with a soft tissue flap. A pedicled flap or free flap is used, depending on the size of the defect and availability of local tissue. The most commonly used recipient vessels for free tissue transfer in the chest are the internal thoracic, thoracodorsal and the transverse cervical vessels. Flap perfusion is verified by use of indocyanine green angiography and Doppler monitoring. Drains are placed between the myocutaneous flap and the titanium mesh.
Results
Among the 3 patients who underwent this procedure at our center during 2022, mean operating time was 421.7 minutes and mean defect size was 174.83 cm2 (Table 1). One patient had delayed healing of the anterolateral thigh flap that was successfully managed with debridement and reclosure. There was no perioperative mortality.
Table 1Overview of patients treated with the biosandwich technique
The biosandwich technique is an effective, rigid, entirely adjustable, and biocompatible solution for large complex defects in high-risk patients or patients with indications prone for postoperative complications (eg, redo surgery, heavy irradiation, or infectious processes).
The importance of a complete resection, as a determinant of survival, has been thoroughly investigated.
This has led to more-extensive and wider resections and, subsequently, the need for more-complex reconstructions. These reconstructions should be based on the principles of biomimesis to ensure functionality.
in designing patient-tailored reconstructions. For our biosandwich technique, we prefer to consider only biocompatible materials, owing to their specific characteristics regarding cytotoxicity and bacterial adhesion and their biomechanical properties.
Additionally, some of these materials are incorporated into the host surrounding osteomuscular structures, thereby contributing coverage of the chest wall defect. The external layer of the reconstruction, comprising a flexible and malleable titanium mesh that stiffens over time, provides added rigidity while restoring the chest wall configuration; soft tissue reconstructions, with regional pedicled flaps or free flaps, can compensate for tissue loss and reestablish cosmesis. The goal of soft tissue reconstruction is to provide durable coverage that is stable over time.
Because of the costs of the involved materials, the biosandwich technique may be preferentially used when larger and complex defects are reconstructed in specialized centers with dedicated thoracic and plastic surgery expertise.
The biosandwich technique is an effective solution for coverage of extensive chest wall defects in high-risk patients. The higher costs related to the biocompatible materials necessitate multidisciplinary decision making for such reconstructions.
This work was supported in part by National Institutes of Health/National Cancer Institute Cancer Center Support Grant No. P30CA008748.
Disclosures: The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
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