Complex Chest Wall Reconstruction After Sarcoma Resection

SavageGlow · #1 ● 03-01-2023, 10:44 PM

A 24-year-old female was referred at our center with the diagnosis of malignant mesenchymal sarcoma of the right side of the neck that extends to right upper lung and anterior mediastinum. After careful evaluation, the oncosurgical team planned a wide local resection. The soft tissue sarcoma was removed with a 2 cm margin along with the upper lobe of the right lung. The first four ribs and the clavicle of the affected side were also removed (Figure 1).

A vascular team reconstructed the subclavian artery and vein using PTFE grafts. Then, the reconstructive team planned a fibula osteocutaneous flap for clavicle stabilization, reconstruction, and resurfacing of the neck and thorax region. The fibula was fixed with miniplates, medially to the sternum and laterally to the remnant of the right clavicle. The flap was vascularized by the anastomosis of superior thyroid artery with the peroneal artery, along with a venous drainage from the peroneal comitant veins to the left external jugular vein. In both anastomoses, an interposed vein graft was utilized. The ischemia time was 80 minutes. In order to obliterate the pulmonary dead space and to provide coverage of the PTFE grafts and thoracic resurfacing, an anterolateral thigh flap measuring 25 cm x 12 cm was harvested along with the left vastus lateralis muscle. The descending branch of lateral circumflex femoral artery and the right thoracodorsal artery were anastomosed in an end-to-end fashion. The venous drainage ran from the comitant veins of the descending branch of lateral circumflex femoral to the thoracodorsal pedicle. The ischemia time was 70 minutes. The donor sites were resurfaced with 10/1,000 inch skin thickness skin graft. The patient stood the operation well. Both flaps survived completely. There were no donor site complications. Radiogram at three months of follow-up showed clavicle reconstruction with the transferred fibula flap (Figure 2). The patient was followed up by cardiovascular surgery, pulmonology, and physical therapy specialists with good recovery at three months post-surgery.