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Thoracic: Chest Wall: Surgical Technique| Volume 18, P164-167, April 2023

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Biosandwich technique for extensive chest wall reconstruction in patients with complex defects

Open AccessPublished:January 24, 2023DOI:https://doi.org/10.1016/j.xjtc.2023.01.013
      Figure thumbnail fx1
      The biosandwich technique for complex chest wall reconstructions.
      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).
      • Rocco G.
      Chest wall resection and reconstruction according to the principles of 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.
      • Rocco G.
      • Martucci N.
      • La Rocca A.
      • La Manna C.
      • De Luca G.
      • Fazioli F.
      • et al.
      Postoperative local morbidity and the use of vacuum-assisted closure after complex chest wall reconstructions with new and conventional materials.
      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 thumbnail gr1
      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
      CharacteristicPatient 1Patient 2Patient 3
      Age (y)516442
      SexFemaleFemaleFemale
      Smoking statusFormerNeverNever
      Smoking pack-years400
      ECOG performance status000
      Surgical indicationChondrosarcomaLeiomyosarcomaDesmoid
      Tumor size (cm)3.16.84.4
      Tumor locationAnteriorAnteriorAnterior
      Number of ribs resected044
      Sternal resectionYesNoNo
      Internal reconstructionPolyglactin meshPoly-4-hydroxy-butyrate meshAcellular dermal mesh
      Osseus reconstructionTitanium meshTitanium meshTitanium mesh
      Soft tissue reconstructionPedicledFreePedicled
      Myocutaneous flapPectoralAnterolateral thighVertical rectus abdominis
      Operating time (min)264679322
      Blood loss (mL)5035050
      Defect size (cm2)32.24390.25102
      Length of stay (d)4266
      30-d complicationsNoneDelayed wound healingNone
      ReadmissionNoNoNo
      30-d mortalityNoNoNo
      Total follow-up (d)717967
      ECOG, Eastern Cooperative Oncology Group.

      Discussion

      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.
      • Shewale J.B.
      • Mitchell K.G.
      • Nelson D.B.
      • Conley A.P.
      • Rice D.C.
      • Antonoff M.B.
      • et al.
      Predictors of survival after resection of primary sarcomas of the chest wall—a large, single-institution series.
      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.
      • Rocco G.
      Chest wall resection and reconstruction according to the principles of biomimesis.
      Despite advancements in materials and an abundance of reconstructive options, the 1 ideal reconstruction has not yet been developed.
      • Rocco G.
      Overview on current and future materials for chest wall reconstruction.
      In line with the most recent literature, we aim to extend beyond the current discussions of rigid vs flexible
      • Spicer J.D.
      • Shewale J.B.
      • Antonoff M.B.
      • Correa A.M.
      • Hofstetter W.B.
      • Rice D.C.
      • et al.
      The influence of reconstructive technique on perioperative pulmonary and infectious outcomes following chest wall resection.
      or synthetic vs biologic
      • Giordano S.
      • Garvey P.B.
      • Clemens M.W.
      • Baumann D.P.
      • Selber J.C.
      • Rice D.C.
      • et al.
      Synthetic mesh versus acellular dermal matrix for oncologic chest wall reconstruction: a comparative analysis.
      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.
      • Wiegmann B.
      • Korossis S.
      • Burgwitz K.
      • Hurschler C.
      • Fischer S.
      • Haverich A.
      • et al.
      In vitro comparison of biological and synthetic materials for skeletal chest wall reconstruction.
      • Huang L.Z.Y.
      • Elbourne A.
      • Shaw Z.L.
      • Cheeseman S.
      • Goff A.
      • Orrell-Trigg R.
      • et al.
      Dual-action silver functionalized nanostructured titanium against drug resistant bacterial and fungal species.
      • Mahmoudi P.
      • Akbarpour M.R.
      • Lakeh H.B.
      • Jing F.
      • Hadidi M.R.
      • Akhavan B.
      Antibacterial Ti–Cu implants: a critical review on mechanisms of action.
      Internal biocompatible meshes protect the underlying organs against infection while representing a first barrier against lung herniation.
      • Rocco G.
      • Martucci N.
      • La Rocca A.
      • La Manna C.
      • De Luca G.
      • Fazioli F.
      • et al.
      Postoperative local morbidity and the use of vacuum-assisted closure after complex chest wall reconstructions with new and conventional materials.
      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.
      • Miller D.L.
      • Force S.D.
      • Pickens A.
      • Fernandez F.G.
      • Luu T.
      • Mansour K.A.
      Chest wall reconstruction using biomaterials.

      Conclusions

      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.

      Supplementary Data

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