Clinical effects of combined tissue flap transplantation for repairing giant chest wall defects
Objective To investigate the clinical effects of combined tissue flap transplantation in repairing giant chest wall defects,Methods This study was a retrospective observational study.From August 2013 to December 2020,31 patients with chest wall tumor or radiation ulcer after radical resection of chest wall tumor and conformed to the inclusion criteria were admitted to the Department of Breast Oncoplastic Surgery of Hunan Cancer Hospital,including 12 males and 19 females,aged 25-71 years.After resection of tumor or ulcer and wound debridement,the area of secondary chest wall defect was 300-600 cm2 with length of 16-35 cm and width of 16-32 cm.According to the actual situation of the patients and the preoperative design,the chest wall defects were repaired with the flexible combination of perforator flaps and myocutaneous flaps from different donor sites,and the area of the combined tissue flap was 260-540 cm2 with length of 20-30 cm and width of 13-20 cm.Free posteromedial thigh perforator flap+free anterolateral thigh myocutaneous flap were used in 2 patients,free deep inferior epigastric artery perforator flap+free anterolateral thigh myocutaneous flap were used in 5 patients,free deep inferior epigastric artery perforator flap+pedicled rectus abdominis myocutaneous flap+free anterolateral thigh myocutaneous flap were used in 7 patients,free deep inferior epigastric artery perforator flap+pedicled rectus abdominis myocutaneous flap+pedicled latissimus dorsi myocutaneous flap were used in 2 patients,and bilateral free anterolateral thigh myocutaneous flaps were used in 15 patients.For the remaining small area of superficial tissue defect after being repaired by combined tissue flaps,skin graft was used to repair or delayed local flap transfering was performed after the tissue flaps survived and edema subsided.The appropriate blood vessels in the donor and recipient sites were selected for anastomosis to reconstruct the blood supply of tissue flaps.The wounds in the donor sites of tissue flaps that can be directly sutured were sutured directly;for those that cannot be sutured directly,the skin grafting or delayed suture was performed.The anastomosis of blood vessels in the recipient sites,operation length,and postoperative hospital stay were recorded.The survivals of tissue flaps and skin grafts,the shape and texture of reconstructed chest wall,the wound healing,scar formation,and function of donor sites of tissue flaps,and the scar formation of the donor sites of skin grafts were observed after operation.Tumor recurrence and death of recurrent patients were followed up after operation.Results The blood vessels in the recipient sites were anastomosed as follows:proximal internal thoracic vessels for 24 times,distal internal thoracic vessels for 12 times,trunk of thoracodorsal vessels for 4 times,anterior serratus branches of thoracodorsal vessels for 8 times,and thoracoacromial vessels for 12 times.The operation length was 6.0 to 8.5 hours,and the postoperative hospital stay was 9 to 21 days.Necrosis at the edge of partial tissue flaps occurred in 4 patients after operation,which healed after dressing change,and the tissue flaps and skin grafts of the other patients survived completely.The shape and texture of the reconstructed chest wall were good.Four patients had poor wound healing in the donor sites of abdominal tissue flaps,which healed after dressing change and local drainage.Only linear scar was left in the donor sites of all tissue flaps,and there was no obvious dysfunction in the donor sites of tissue flaps.Mild hypertrophic scar was left in the donor sites of skin grafts.During follow-up of 9 to 36 months after operation,6 patients had tumor recurrence,and the recurrence time was 5 to 20 months after operation.After comprehensive treatment for patients with tumor recurrence,3 patients died.Conclusions Transplantation of combined tissue flaps in repairing the giant chest wall defects can shorten the time of total operation and hospital stay,and avoid multiple operations.After operation,patients had good chest wall appearance,with reduced tumor recurrence in patients with chest wall tumor.
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