Chest wall reconstruction.

Chest wall defects are frequently encountered in all regions of the chest. Initial defect assessment includes evaluation of location, extent, and etiology of the defect. Reconstructive options include flap transposition, tissue expansion, and microvascular composite tissue transplantation. Partial thickness defects are readily covered with skin grafts if viable muscle is present in the wound base. Complex defects, particularly related to wound débridement for osteomyelitis or osteoradionecrosis, are covered with regional muscle or musculocutaneous flaps. Extensive full-thickness defects frequently require restoration of the bony defect. Split rib grafts are preferred for elective sterile extirpative defects. Complex defects with unfavorable wound environment (chronic open wound or osteoradionecrosis) may require use of Prolene mesh to maintain chest wall stability and to provide support for the overlying flap. Tissue expansion is useful for partial thickness defects in order to provide optimal contour and skin quality at the site of reconstruction and to avoid additional scars at distant donor sites (see Fig. 6). Microsurgical composite tissue transplantation will allow complex defect closure when regional muscle or musculocutaneous flaps are unavailable. With careful defect analysis in regard to reconstructive requirements, the surgeon may select appropriate options from the reconstructive triangle to accomplish safe chest wall reconstruction with optimal form and function.