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CASE REPORT – OPEN ACCESSInternational Journal of Surgery Case Reports 4 (2013) 669– 674

Contents lists available at SciVerse ScienceDirect

International Journal of Surgery Case Reports

journa l h om epage: www.elsev ier .com/ locate / i j scr

econstruction of chest wall chondrosarcoma with an anterolateralhigh free flap: An illustration of decision-making in chest walleconstruction

. Shahzada, K.Y. Wongb, J. Marakab, M. Di Candiab, A.S. Coonarc, C.M. Malatab,∗

University of Cambridge, School of Clinical Medicine, UKDepartment of Plastic and Reconstructive Surgery, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, UKDepartment of Cardiothoracic Surgery, Papworth Hospital, Cambridge University Hospitals NHS Foundation Trust, UK

a r t i c l e i n f o

rticle history:eceived 27 April 2013ccepted 8 May 2013vailable online 16 May 2013

eywords:hest wall reconstructionhondrosarcomanterolateral thigh free flaplap selectionespiratory functioneconstructive algorithm

a b s t r a c t

INTRODUCTION: Chondrosarcomas are the most common primary chest wall malignancy. The mainstayof treatment is radical resection, which often requires chest wall reconstruction. This presents numerouschallenges and more extensive defects mandate the use of microvascular free flaps. Selecting the mostappropriate flap is important to the outcome of the surgery.PRESENTATION OF CASE: A 71-year-old male presented with a large chondrocarcoma of the chest wall. Theplanned resection excluded use of the ipsilateral and contralateral pectoralis major flap because of sizeand reach limitations. The latissimus dorsi flap was deemed inappropriate on logistical grounds as wellas potential vascular compromise. The patient was too thin for reconstruction using an abdominal flap.Therefore, following radical tumour resection, the defect was reconstructed with a methyl methacrylatepolypropylene mesh plate for chest wall stability and an anterolateral thigh free flap in a single-stagejoint cardiothoracic and plastic surgical procedure. The flap was anastomosed to the contralateral internalmammary vessels as the ipsilateral mammary vessels had been resected.

DISCUSSION: The outcome was complete resection of the tumour, no significant impact on ventilationand acceptable cosmesis.CONCLUSION: This case demonstrates the complex decision making process required in chest wall recon-struction and the versatility of the ALT free flap. The ALT free flap ensured adequate skin cover, subsequentbulk, provided an excellent operative position, produced little loss of donor site function, and providedan acceptable cosmetic result.

© 2013 Surgical Associates Ltd. Published by Elsevier Ltd. Open access under CC BY-NC-ND license.

. Introduction

Chest wall neoplasms account for 5% of all thoracic tumours,1

ith the most common primary chest wall malignancy being chon-rosarcoma. Chondrosarcomas usually originate from the anteriorhest wall – from either the costochondral junctions or sternum.hey have a wide age range of presentation but typically occurn patients 30–60 years old. They are slightly more common in

ales, with a male to female ratio of 1.3:1. Chondrosarcomas canresent as painful or painless chest wall masses.2 At the time of pre-entation, 10% have pulmonary metastases.1 The overall five-yearurvival rates are greater than 60% but may be over 80% in patients

∗ Corresponding author at: Department of Plastic and Reconstructive Surgery,ddenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust,ambridge CB2 2QQ, UK. Tel.: +44 1223 586672; fax: +44 1223 257177.

E-mail addresses: cmalata@hotmail.com, charles.malata@addenbrookes.nhs.ukC.M. Malata).

210-2612 © 2013 Surgical Associ ates L td. Publi shed by Els evie r Ltd.ttp://dx.doi.org/10.1016/j.ijscr.2013.05.003

Open access under CC BY-

without metastases. Poor prognostic factors include an age over50 years, incomplete resection, synchronous metastases, and localrecurrence.2

It has been shown that radiotherapy or chemotherapy may notbe very effective in treating chondrosarcomas,3,4 particularly whenlow grade. The mainstay of treatment for chondrosarcomas, wherepossible, is complete excision sometimes with adjuvant therapy.In such cases, the primary aims of chest wall reconstruction areto ensure stability and good physiological functioning of the chestwall, as well as soft tissue closure of the defect. Good cosmesis isalso a consideration. Loco-regional flaps are often the first choicefor soft tissue coverage but due to the extensive resection oftenrequired part of the flap may be resected during tumour extirpa-tion and their vascularity is often compromised. Furthermore, ifthe flap blood supply is tenuous there may be necrosis at the dis-tal end and this can expose underlying organs leading to serious

complications. Sometimes these patients have had radiotherapymaking local flap options unreliable. For these reasons, some com-plex reconstructions require the use of microvascular free tissuetransfer flaps.5

NC-ND license.

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. Case report

A 71-year-old male presented with a two-month history of ansymmetrical chest wall due to a large, slow-growing, painlessight-sided mass. The patient was a non-smoker, otherwise well

nd was a keen tennis player.

A chest CT scan (Fig. 1a) revealed features of a chondrosarcomahich impinged on the first and second ribs, manubrium, sternum

nd subclavian vessels. Abdominal and pelvic CT scans showed no

Fig. 1. (a) CT scan showing right-sided mass on

PEN ACCESSrgery Case Reports 4 (2013) 669– 674

evidence of metastatic disease. A pre-operative core biopsy of themass confirmed a grade 2 chondrosarcoma. The overlying skin wasfreely mobile (Fig. 1b).

The patient was reviewed at the sarcoma multi-disciplinaryteam (MDT) meeting, where surgery was recommended in prefer-

ence to primary radiotherapy or chemotherapy. He would requireskeletal and soft tissue reconstruction and thus he was referred tothe plastic surgery service. On assessment, a decision was made touse the contralateral anterolateral thigh (ALT) free flap. The advice

chest wall and (b) pre-operative photos.

CASE REPORT – OPEN ACCESSF. Shahzad et al. / International Journal of Surgery Case Reports 4 (2013) 669– 674 671

Fig. 2. (a) Incision for access to chest wall and post-excision and (b) left anterolateralt

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high flap donor site.

f an orthopaedic surgeon and a vascular surgeon was sought inase the patient needed further bony excision or resection of theubclavian vessels.

.1. Surgical details

After intubation with an endotracheal double-lumen tube, theatient was positioned in the oblique supine position in ordero allow adequate access for the resection both anteriorly andosteriorly. The patient was kept in this position throughout therocedure. Access was gained via a curvilinear incision jointly

greed by the plastic and cardiothoracic surgeons (Fig. 2a).

To avoid disruption of the sternoclavicular joint the manubriumas partly divided. An en bloc resection of the mass including most

f ribs 1–3 and part of the sternum was performed. The mass was

Fig. 3. (a) Resected tumour and (b) site of resection approaching subclavian vessels.

successfully dissected off the subclavian vessels (Fig. 3). Histologyof the excised mass revealed a 16 cm × 8 cm × 8 cm lobulated, wellcircumscribed cartilaginous tumour replacing the second rib. Therewas no infiltration of the pectoralis muscles anteriorly or the pleuraposteriorly and the resection margins were clear.

Simultaneously, a fasciocutaneous ALT free flap incorporatinga segment of the vastus lateralis muscle was harvested from thepatient’s left contralateral thigh (Fig. 2b).

The contralateral internal mammary recipient vessels wereexposed using a standard total rib-sparing technique.6 A methylmethacrylate polypropylene mesh sandwich was fabricated andsutured to the fifth rib inferiorly and the sternum medially. It wasfelt that this would provide a stable base and avoid any risk ofimpingement on the clavicle and subclavian vessels which mayhave occurred if it had been taken higher. The ALT flap was success-fully anastomosed to the internal mammary vessels end-to-end,with the flap pedicle positioned superficial to the sternum to enableeasy exposure in case of subsequent re-exploration.

2.2. Post-surgery

Post-operatively, he spent two days on the ICU and wasdischarged home on day 11. There were no significant respira-tory complications. He developed a small seroma under the flapdonor site, which was periodically aspirated. At six months post-operatively, he remains well and has an excellent range of shouldermovement. The cosmetic result was acceptable (Fig. 4).

3. Discussion of flap choice

Chest wall reconstruction has many challenges. It needs to bedurable, strong, airtight and must not be detrimental to ventilatory

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Fig. 4. Post-operative photos of chest wall.

echanics. Whether or not reconstructive surgery is indicatedepends on several factors; for instance, large tumours of thehest wall require large resections which cannot be closed directlynd hence need to be reconstructed.7 Rib resection may requireeconstructive surgery.8 Small defects do not need reconstruction.lternatives for skeletal reconstruction comprise biological orrtificial mesh sheets, cement and more recently artificial metalibs.9,10 Metal ribs may compromise future radiotherapy andhould only be used if there is great confidence regarding theargins. Previous radiotherapy compromises healing, whichay be improved by the use of nonadjacent flaps. The patient’s

ody habitus also plays a role in determining reconstructive flap

hoice.

This patient posed a number of challenges and provided a per-inent example of the decision-making process involved in flapelection. A local flap could not be used for this patient because

PEN ACCESSrgery Case Reports 4 (2013) 669– 674

the ipsilateral pectoralis major flap had to be resected with thetumour, while the contralateral pectoralis major was too short,whether used as an advancement or turnover flap, to sufficientlyfill the defect.

Regional flaps which were considered included a transverserectus abdominis myocutaneous (TRAM), thoracodorsal artery per-forator (TAP), intercostal artery perforator (ICAP), and the greateromentum. The TRAM flap was not ideal as an abdominal walloperation sacrificing an important muscle, in combination withan extensive thoracotomy involving multiple rib resection andpartial sternectomy, would further compromise the patient’s ven-tilatory mechanics. The right internal mammary vessels had alsobeen sacrificed. Furthermore, the rectus abdominis flap would alsoweaken the abdominal wall and potentially lead to other compli-cations such as hernia formation.11 Besides the patient was thinso had insufficient abdominal laxity to enable the harvest of aTRAM flap. The ICAP flap, although it would spare the abdomi-nal musculature, relies on the presence of excess lateral truncaltissue, which the patient lacked. The greater omental flap wouldprovide sufficient coverage12 but requires a split skin graft aswell as a laparotomy and has no rigidity. A laparotomy wouldfurther compromise respiratory mechanics and has risks of intra-abdominal complications.13,14 The patient had insufficient bulk onhis back so the TAP flap was not feasible with or without muscle(Fig. 5).

Free flap options in this instance included the latissimus dorsi(LD), ALT, tensor fascia lata (TFL) and deep inferior epigastricperforator (DIEP). Practical considerations in free flap chest wallreconstruction need to include; where the anastomoses would bemade, the pedicle length, the volume of the flap, and the skin pad-dle size. The flap pedicle could not be anastomosed to vessels onthe same side of the chest as these had been either sacrificed dur-ing the tumour resection (internal mammary and thoracoacromialaxis) while attempting anastomoses to the subclavian vessels or itstributaries carried too high a risk of venous thrombosis followingthe substantial dissection trauma to it. The LD flap was a viableoption15 but the logistics of the positioning of the patient wouldprovide hindrance to the cardiothoracic and plastic surgeons oper-ating simultaneously. The tumour was large (Fig. 3a) and reachedthe subclavian vessels (Fig. 3b) so resection or blunt damage to thevessels further excluded an ipsilateral pedicled LD flap, due againto the high venous thrombosis risk.

Pre-operatively, a core biopsy performed through the skin man-dated the sacrifice of the surrounding skin (at least 5 cm margins)and any flap had to possess enough skin to replace what wasremoved during the tumour resection. An LD free flap wouldprovide insufficient skin coverage without resorting to split skingrafting of the donor site, a usually undesirable proposition inchest wall reconstruction because of patient positioning post-operatively, subsequent poor skin graft take and poor donor sitecosmesis. The TFL flap, although it does have many of the advan-tages of the ALT flap, is a short flap measuring 4–6 cm long,16

making it unsuitable. The DIEP free flap was excluded due to insuf-ficient abdominal bulk (Fig. 5).

The ALT free flap has been shown to be reliable in complex chestwall reconstructions with or without radiotherapy.5 It was the bestoption in our case as it provided ample skin and soft tissue as well asminimal donor site morbidity.17,18 There is little functional deficitwith this flap as the potentially damaged vastus lateralis functionsas a synagonist with the other three knee extensors, leading to littlefunctional loss. The ALT free flap has a large skin area which can beharvested even with the use of only a single major perforator.19,20

Additionally, the patient did not have to be turned during surgery asthe ALT flap is harvested in the supine position with simultaneousresection of the tumour. It is based on large vessels ensuring easiermicrovascular surgery.

CASE REPORT – OPEN ACCESSF. Shahzad et al. / International Journal of Surgery Case Reports 4 (2013) 669– 674 673

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. Conclusion

Herein, this case demonstrates the decision-making processnvolved in flap selection and further highlights the versatility ofhe ALT free flap. The challenges involved in chest wall reconstruc-ion, the flap options available, and the possibilities for recipientessels are outlined. The ALT free flap ensured adequate skin cover,ubsequent bulk, provided an excellent operative position, pro-uced little loss of donor site function, and provided an acceptableosmetic result.

onflicts of interest

None.

unding

None.

thical approval

Written informed consent was obtained from the patient for

ublication of this case report and accompanying images. A copyf the written consent is available for review by the Editor-in-Chieff this journal on request.

onstrating body habitus.

Author contributions

Shahzad F. collected the literature review, wrote case report, dis-cussion, selected figures, edited all sections throughout, preparedfor submission; Wong K.Y. wrote case report, discussion, edited allsections throughout; Maraka J. wrote abstract, introduction, con-clusion, edited all sections throughout; Di Candia M. contributed todiscussion; Coonar A.S. and Malata C.M. edited the paper.

References

1. Souza FF, De Angelo M, O’Regan K, Jagganathan J, Krajewski K, Ramaiya N.Malignant primary chest wall neoplasms: a pictorial review of imaging findings.Clinical Imaging 2013;37(February (1)):8–17.

2. Burt M. Primary malignant tumors of the chest wall. The Memorial Sloan-Kettering Cancer Center experience. Chest Surgery Clinics of North America1994;4(February (1)):137–54.

3. Dickey ID, Rose PS, Fuchs B, Wold LE, Okuno SH, Sim FH, et al. DedifferentiatedChondrosarcoma: the role of chemotherapy with updated outcomes. Journal ofBone and Joint Surgery 2004;86(November (11)):2412–8.

4. Harwood AR, Krajbich JI, Fornasier VL. Radiotherapy of chondrosarcoma of bone.Cancer 1980;45(11):2769–77.

5. Di Candia M, Wells FC, Malata CM. Anterolateral thigh free flap for complexcomposite central chest wall defect reconstruction with extrathoracic microvas-cular anastomoses. Plastic and Reconstructive Surgery 2010;126(November

lar abdominal flap breast reconstruction utilizing the “total rib preservation”technique for internal mammary vessel exposure. Annals of Plastic Surgery2011;66(January (1)):36–42.

– O6 al of Su

1

1

1

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CASE REPORT74 F. Shahzad et al. / International Journ

7. Mansour KA, Thourani VH, Losken A, Reeves JG, Miller Jr JI, Carlson GW, et al.Chest wall resections and reconstruction: a 25-year experience. Annals of Tho-racic Surgery 2002;73(June (6)):1720–5 [discussion 1725-1726].

8. Yokote K, Osada H. Indication and method of chest wall reconstruction, KyobuGeka. Japanese Journal of Thoracic Surgery 1996;49(January (1)):38–41.

9. Coonar AS, Qureshi N, Smith I, Wells FC, Reisberg E, Wihlm J-M. A novel tita-nium rib bridge system for chest wall reconstruction. Annals of Thoracic Surgery2009;87(May (5)):e46–8.

0. Coonar AS, Wihlm J-M, Wells FC, Qureshi N. Intermediate outcome and dynamiccomputerised tomography after chest wall reconstruction with the STRATOStitanium rib bridge system: video demonstration of preserved bucket-handlerib motion. Interactive Cardiovascular and Thoracic Surgery 2011;12(January(1)):80–1.

1. Beahm EK, Chang DW. Chest wall reconstruction and advanced disease. Seminarsin Plastic Surgery 2004;18(May (2)):117–29.

2. Das SK. The size of the human omentum and methods of lengthening it fortransplantation. British Journal of Plastic Surgery 1976;29(April (2)):170–4.

3. Hultman CS, Culbertson JH, Jones GE, Losken A, Kumar AV, Carlson GW, et al. Tho-racic reconstruction with the omentum: indications, complications, and results.Annals of Plastic Surgery 2001;46(March (3)):242–9.

1

2

PEN ACCESSrgery Case Reports 4 (2013) 669– 674

4. Jurkiewicz MJ, Arnold PG. The omentum: an account of its use in the reconstruc-tion of the chest wall. Annals of Surgery 1977;185(May (5)):548–54.

5. Hameed A, Akhtar S, Naqvi A, Pervaiz Z. Reconstruction of complex chestwall defects by using polypropylene mesh and a pedicled latissimus dorsiflap: a 6-year experience. Journal of Plastic, Reconstructive and Aesthetic Surgery2008;61(June (6)):628–35.

6. Sauerbier M, Dittler S, Kreutzer C. Microsurgical chest wall reconstruction afteroncologic resections. Seminars in Plastic Surgery 2011;25(February (1)):60–9.

7. Kuo Y-R, Yeh M-C, Shih H-S, Chen C-C, Lin P-Y, Chiang Y-C, et al. Versatilityof the anterolateral thigh flap with vascularized fascia lata for reconstructionof complex soft-tissue defects: clinical experience and functional assess-ment of the donor site. Plastic and Reconstructive Surgery 2009;124(July (1)):171–80.

8. Di Candia M, Lie K, Kumiponjera D, Simcock J, Cormack GC, Malata CM. Versatilityof the anterolateral thigh free flap: the four seasons flap. Eplasty 2012;12:e21.

9. Kimata Y, Uchiyama K, Ebihara S, Nakatsuka T, Harii K. Anatomic variations andtechnical problems of the anterolateral thigh flap: a report of 74 cases. Plasticand Reconstructive Surgery 1998;102(October (5)):1517–23.

0. Luo S, Raffoul W, Luo J, Luo L, Gao J, Chen L, et al. Anterolateral thigh flap: areview of 168 cases. Microsurgery 1999;19(5):232–8.