Chest Wound Reconstruction

Chest wall defects are among the most complex wounds in reconstructive surgery. They may expose the lungs, pleural space, ribs, and prosthetic material — and they occur in patients who have often already undergone major oncologic surgery, radiation, or infection. Successful reconstruction requires both reliable wound coverage and preservation of chest wall mechanics for breathing.^1,2

When Is Chest Wall Reconstruction Needed?

Reconstruction becomes necessary when the chest wall cannot heal on its own or when vital structures are exposed. Common scenarios include:

• Chest wall tumor resection: Primary chest wall sarcomas, breast cancer invading the chest wall, lung cancer with direct chest wall extension, and metastatic disease can all require resection of ribs, intercostal muscles, and overlying soft tissue. The resulting defect may be too large for primary closure and may involve resection of structural components that need to be replaced to stabilize breathing
• Radiation necrosis: Radiation to the breast, lung, or mediastinum can cause delayed chest wall necrosis — sometimes years after treatment — leading to painful, non-healing wounds with or without underlying rib osteonecrosis
• Infection and empyema: Chronic empyema (infected fluid in the pleural space), bronchopleural fistula, and post-pneumonectomy space infections can erode through the chest wall or require open drainage procedures (Eloesser flap, Clagett window) that ultimately need closure
• Exposed hardware or mesh: Titanium rib plates, sternal hardware, and synthetic mesh used for structural reconstruction can become exposed or infected, requiring flap coverage or hardware removal followed by reconstruction
• Wound dehiscence after thoracic surgery: Thoracotomy incisions, particularly in irradiated or immunocompromised patients, can fail to heal and require flap reconstruction

Goals of Reconstruction

A successful chest wall reconstruction must accomplish multiple objectives simultaneously:³

• Structural stability: If ribs or sternum have been resected, the chest wall must be stabilized with mesh, titanium plates, or rib substitutes to prevent paradoxical breathing
• Soft tissue coverage: Exposed structures — including hardware, mesh, bone, pleura, and lung — must be covered with well-vascularized tissue
• Dead space obliteration: Any residual cavity (particularly in empyema cases) must be filled with vascularized tissue to prevent persistent infection
• Donor site preservation: The chosen reconstruction method should minimize functional impact at the donor site

Pedicled Flap Options

For most chest wall defects, pedicled (locally transferred) flaps provide the first line of reconstruction. These flaps retain their original blood supply and are rotated or advanced into the defect.⁴

Pectoralis Major Flap

The pectoralis major is the workhorse flap for anterior chest wall and sternal defects. It can be used as a muscle-only or musculocutaneous flap and is based on the thoracoacromial artery. The muscle can be advanced medially to cover the sternum or rotated to cover anterior chest wall wounds. It is particularly useful after sternal wound infection and for lower neck defects.

Latissimus Dorsi Flap

The latissimus dorsi — based on the thoracodorsal vessels — is the largest muscle in the upper body and provides reliable coverage for posterior, lateral, and large anterior chest wall defects. It can reach most areas of the chest when mobilized as a pedicled flap and provides substantial bulk for dead space obliteration. This is the preferred flap for post-thoracotomy wound breakdowns and lateral chest wall defects after tumor resection.⁴

Rectus Abdominis Flap

The vertical rectus abdominis musculocutaneous (VRAM) flap provides a large skin paddle and muscle bulk, based on the superior epigastric vessels. It is particularly useful for inferior sternal defects and lower chest wall wounds where pectoralis coverage does not reach.

Omental Flap

The omentum — the fatty apron within the abdomen — can be brought up through the diaphragm or a laparotomy incision to fill pleural space infections, cover mediastinal hardware, or reconstruct irradiated wounds where conventional muscle flaps have insufficient vascularity. The omentum has potent anti-infective properties and rich vascularity, making it the preferred option for contaminated or heavily irradiated fields.⁵

Free Flap Reconstruction for Large Defects

When the local and regional donor sites have been exhausted — by prior surgery, radiation, or simply because the defect is too large — free tissue transfer provides a reliable solution. Free flaps bring in entirely new blood supply from distant body regions. The anterolateral thigh (ALT) free flap is the most commonly used option for large chest wall resurfacing, providing a large, versatile skin paddle that can be thinned or combined with underlying vastus lateralis muscle for additional bulk. The latissimus dorsi can also be transferred as a free flap if the ipsilateral pedicled version is unavailable.

Structural Reconstruction: Mesh and Rigid Fixation

When more than 2–3 ribs are resected — particularly in the anterior or lateral chest wall — structural reconstruction is required to prevent flail chest and paradoxical breathing. Options include:

• Synthetic mesh (polypropylene, PTFE): Provides immediate structural support and is useful in clean, non-irradiated fields
• Biological mesh (acellular dermal matrix): Better suited for contaminated or irradiated fields due to resistance to infection and ability to integrate with surrounding tissue
• Titanium rib plating systems: Rigid fixation systems can reconstruct the mechanical function of the rib cage, particularly after multiple rib resections
• Methylmethacrylate composite: A custom rigid plate can be fashioned at the time of surgery for structural reconstruction of large defects

Collaboration with Thoracic Surgery

Chest wall reconstruction is inherently a multidisciplinary undertaking. Dr. Lakhiani operates alongside thoracic surgeons for oncologic resections, and coordinates closely with thoracic surgery, cardiac surgery, and infectious disease when managing post-operative wound complications or empyema-related defects. This team approach ensures that the structural and infectious aspects of the problem are addressed simultaneously with the reconstructive plan.

Dr. Lakhiani's Approach

Dr. Lakhiani brings microsurgical expertise to chest reconstruction cases that require free tissue transfer, while maintaining proficiency in all pedicled flap options for simpler defects. His approach:

• Thorough preoperative assessment with CT imaging to plan the extent of resection and available donor sites
• Joint surgical planning with thoracic surgery to sequence resection and reconstruction in a single operation when possible
• Selection of the simplest reliable reconstruction — avoiding unnecessarily complex procedures when a pedicled flap will suffice
• Escalation to free tissue transfer when pedicled options are unavailable, depleted, or inadequate for defect size
• Postoperative respiratory monitoring and early mobilization protocols to protect the reconstruction and support lung function