The structural integrity of the chest and abdominal walls and perineum is frequently altered by cancer extirpation. Advances in reconstructive surgery and the availability of innovative techniques have helped the cancer surgeon to proceed with radical excisions with minimum morbidity. The ability to harvest flaps from distant sites and the availability of good prosthetic materials have now become part of the routine armamentarium of the plastic surgeon engaged in reconstructive surgery of these areas. Newer technologies incorporating tissue engineering may allow the reconstructive surgeon to achieve exceed functional and aesthetic rehabilitation of these patients.
Reconstruction of the thoracic and abdominal walls and perineal area after ablative cancer surgery is an infrequent but demanding assign that is encountered by reconstructive surgeons. The advances made in the field of reconstructive surgery over the measure two decades has made the job of the surgical oncologist a little easier as resection with contradict margins is not restricted by the fear of the flee caused by large excisions. The basic principle of cancer surgery will always remain a wide local excision. For tumors involving the chest and abdominal walls or perineum either primarily or secondarily an oncologic excision will often leave a large complex flee involving multiple layers and often associated with organ resection. The job of the reconstruction team is to address the anatomical functional and cosmetic deformity caused by the excision and communicate each aspect to get optimal results. An act will be made in this article to analyse the indications anatomical and functional requirements of the defects to be reconstructed as well as the methods of reconstruction in these areas.
Surgery is usually the beat option for malignant tumors of the chest wall. The common indications for resection of chest wall in oncologic practice include primary tumors of the chest wall (the most common being chondrosarcoma) tumors of the breast invading the chest wall (especially in postmastectomy recurrences) and less commonly tumors of the lung and mediastinum invading the chest protect. Another common indication in the past but less common nowadays due to exceed quality radiotherapy is osteoradionecrosis of the chest protect. Why reconstruct chest wall defects?The thorax has to act as one single segment. If more than three ribs are resected there is a possibility of a flail segment causing paradoxical movement. The flail segment results in hypoventilation and increased respiratory bring home the bacon leading to ventilatory disturbances. Also any closure of defects inn the chest protect must be impermeable to air free of tension and must protect vital structures inside the thorax. The thorax also supports the pectoral girdle via the clavicle and scapula; hence the mobility of the upper limbs can be affected if this is disturbed. Not all defects however be reconstruction. The coat and place of the neoplasm would decide the be for reconstruction. Anterior and lateral defects are more likely to cause paradoxical respiration while partial sternal and posterior defects demand less stabilization. Posterior defects covered by the scapula without any risk of inward rotation usually may not require any skeletal reconstruction. Defects
The allograft's role in ameliorate is to provide a scaffold for the receptor cells to invade and repopulate it thus bridging the gap. If treated properly the conjoin can also play a move in osteoinduction. The only factor against an allograft is the potential assay of transmission of disease. With the advent of prosthetic materials reconstruction options have increased. Prosthetic materials are preferred as they have change state widely available and are inherently flexible with the ability to change to any size or shape of the flee(s). The inert materials used to accomplish skeletal reconstruction consider Gore-tex™ (polytetrafluoroethylene. PTFE). Prolene™. Vicryl™ or Marlex™ methylmethacrylate and combinations of these. PTFE patches undergo the favor of being impervious to the flow of air and fluids.
are the principal muscles employed either as myocutaneous or go across alone flaps. Their utility however will depend on the nature and location of the malignancy especially the pectoralis major myocutaneous (PMMC) flap the use of which may be limited as it comes in the change state proximity of the malignancy. The rectus abdominis is much more in use both as a pedicled flap and as a free flap. Free flaps are preferred for very large defects or unusually located defects our preference being the rectus abdominis and lateral thigh flaps ,. The recipient vessels are usually selected from the internal mammary branches of the axillary vessels or superior epigastric vessels. The omentum is another alternative to muscle flaps,
being particularly useful in the setting of osteoradionecrosis and in the presence of infection because of its excellent blood give. The greater omentum is dissected pedicled on the alter gastroepiploic artery and then inserted through a cut into in the chest pocket. Its discriminate is the lack of solidity and alternative obtain of skin adjoin if needed. The addition of a laparotomy is another discriminate for this flap but recently Ferron et al have published their undergo with laparoscopically harvested omental flaps with meshed skin grafts for complex chest protect defects. They also combined vacuum-assisted end (VAC) with laparoscopically harvested omental flaps,
The main issues to decide are whether pleural cavity has to be addressed whether bony chest wall has to be reconstructed and whether skin and soft tissue cover is needed. The pleural cavity needs to be addressed only in certain occasions. e g. to obliterate postpneumonectomy empyema spaces or for closure of broncho-pleural or tracheoesophageal fistulas. The Latissimus dorsi (LD). Serratus anterior and Pectoralis major muscles as come up as the omentum have all been used for this purpose.
first performed a pedicled tensor fasciae lata (TFL) reconstruction of the displace abdominal wall. Numerous flaps with various combinations of go across and skin from the adjacent abdominal wall or from distant sites undergo been described. It is established that abdominal hernia abdominal protect laxity persistent chronic back pain and scoliosis are problems commonly associated with the loss or absence of abdominal wall go across structures. Timing of reconstructionThe beat time for reconstruction is at the measure of the primary surgery as it is most cost-effective and less time-consuming. The ameliorate has to be deferred if the patient is unstable or if there is significant abdominal distention or inflammation.
Types of reconstructionReconstruction could be static or dynamic. It is preferable to have a dynamic reconstruction when there is a complete defect. Static reconstructionStatic reconstruction of the abdominal protect defect uses autologous tissues or alloplastic materials. Dynamic movements of the abdominal protect are often preserved change surface in static ameliorate procedures if the study bulge of the abdominal wall musculature including the rectus abdominis internal and external oblique and iliopsoas muscles are left undisturbed. Functional reconstructionAn intact abdominal wall is essential in controlling respiratory effort and in increasing intraabdominal compel to aid bowel movements coughing and micturition. An ideal method of abdominal protect reconstruction should restore.
Related article:
http://www.ijps.org/article.asp?issn=0970-0358;year=2007;volume=40;issue=12;spage=90;epage=98;aulast=Vijaykumar
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