by M. Shuja Shafqat, MD (@shujashafqatmd)
Plastic surgeons are a versatile group and deal with a variety of different problems. Many do not realize this and even within the medical community, providers are unsure of exactly what plastic surgeons deal with. The last person you would expect to see after having a cardiac bypass or surgery for a lung tumor is a plastic surgeon. In this light, I share with you a review of an article from Plastic and Reconstructive Surgery: Global Open from March 2016 entitled “A Twelve Year Consecutive Case Experience in Thoracic Reconstruction” by Chen et al.
This article reviews records of 91 patients from the University of Madison, Wisconsin between 2001 and 2013 who underwent reconstruction of their chest, when they needed a cavity filled or wound closed with tissue moved from another area of the body. Most of the patients were male (67%) with an average age of 59 years old. Most of the patients had an issue inside their chest, termed intrathoracic (74%), rather than on the outside of their chest, called the chest wall (26%).
There were various reasons why patients needed chest reconstruction. Most commonly was due to infection inside the chest, called an empyema, or due to cancer. Another reason was for a fistula, or an abnormal connection between two spaces. In the chest reconstruction, this usually occurs between the airway and the space where the lung sits after it has been removed for cancer. This can also be made worse by radiation.
Once the area has been thoroughly cleaned of all dead tissue, healthy tissue must be put in its place. Most commonly in this article, muscles from the chest like the pectoralis major (15%) and the serratus anterior (34%), or the back like the latissimus dorsi (39%), are then transposed to close wounds, fill cavities, and cover over fistula repairs. If ribs are removed as part of the surgery, this is reconstructed with a mesh or rigid material to prevent issues with breathing. In this article, this was done in 12% of patients and was performed 100% of the time if > 5 ribs were removed.
On average, the patients undergoing intrathoracic reconstruction were on the ventilator much longer and were in the hospital longer than those having chest wall reconstruction. The average number of complications about 1 in every other patient (0.5), and only 4.9% required a return to the operating room. With regards to mortality, 3% died within 30 days. One year survival was 83% vs. 59% for chest wall vs. intrathoracic reconstruction respectively.
Overall this article is excellent and looks at a large series of patients needing chest reconstruction. They show that these surgeries can be performed safely for a variety of problems with relatively few complications. Moreover, it helps us as surgeons set expectations for patients and families with regards to how long they can expect to be on the ventilator, how long they may be in the hospital, or likelihood of survival for these complicated issues in very sick patients. Being informed is important for patients and families and this article gives us the tools to help that happen.