by M. Shuja Shafqat, MD
The Reconstruction: Chest & Back section of The Resident Reader from PRS is a collection of 5 articles outlining important aspects of trunk reconstruction.
The first article, Abdominal Wall & Chest Wall Reconstruction, begins with a video summarizing the key points of the article. The paper reviews critical aspects of both abdominal and chest wall reconstruction. These include preoperative considerations, operative techniques, when to consider component separation, indications for chest wall skeletal stabilization, and flap selection for different anatomic subunits. The keystone of the article lies in the tables which are fundamental to this review. They outline hernia grades, methods of mesh placement, advantages and disadvantages of a number of flap choices and prosthetic materials, amongst other things. These tables quickly summarize the various options and help the reader keep them better organized in their mind. This is extremely useful in dealing with complex wounds that may have numerous solutions.
The next two articles, Chest Reconstruction I & II, divide wounds into anatomic location and whether respiratory function is affected or not. The first article begins with an overview followed by principles of skeletal stabilization and soft tissue coverage. They then outline considerations in anterior/mediastinal, anterolateral, and diaphragmatic defects that affect pulmonary mechanics. They also cover Poland syndrome and empyema/bronchopleural fistula. The second article begins by outlining scenarios in which posterior trunk and axillary wounds may occur, characteristics, and requirements of any reconstructive effort. Following is a description of soft tissue coverage principles and flap options in wounds of the upper and lower back, axilla, as a result of myelomeningocele or conjoined twin separation. The article concludes with a summary of flap choices in various anatomic locations. This method of categorizing chest wounds proves useful to the reader as the goals of reconstruction and the options are very different. The figures outline various cases and are tremendous in linking the textual descriptions with real life cases.
The fourth article, Management of Posterior Trunk Defects, starts with an introduction and step-wise algorithm for initial management of wounds. It then goes through an extensive list of 8 flaps, their anatomy, function, vascular supply, and various uses. They then discuss reconstruction of each anatomic subunit in the back. This paper is extremely valuable as it not only presents a great deal of information, but also provides two ways of conceptualizing these defects: one based on flap first, another on location first. This helps the reader to better organize their thought process regarding these wounds. The pictures are outstanding and complement the figures.
The final article, Trunk, Abdomen, and Pressure Sore Reconstruction, describes chest wall, posterior trunk, congenital deformity, abdominal wall, and pressure sore reconstruction. In addition, numerous flap options for pressure sore reconstruction are described for sacral, ischial, and trochanteric ulcers. The real pearl of this article are the two detailed videos that cover a variety of challenging cases and how they were managed using principles described in this and all the articles in this series. When using these principles, one can see that even difficult situations can become more clear.
All of the articles complement each other in many ways. They each provide something different to the reader looking for an algorithmic way to approach these common and complex wounds. This series is crucial and a must-read for the plastic surgeon in training.