Chest wall reconstruction is where rigid skeletal support and versatile soft tissue coverage meet — and where a wrong flap choice or a missed debridement step turns a small defect into a respiratory disaster.

In this episode of Plastics in Practice, we review the basics of chest wall reconstruction: the anatomy that drives every decision, when you actually need to rebuild the skeleton, how to classify and treat sternal wound infections, and how to pick the right flap based on the location and depth of the defect.

Key takeaways:

• Skeletal reconstruction is classically indicated for defects involving four or more ribs or greater than 5 cm in diameter — but posterior and superior defects often tolerate soft tissue coverage alone.¹
• Methylmethacrylate–mesh "sandwich" gives you rigid protection for large anterior defects, but its rigidity can cost you respiratory comfort.¹
• Pectoralis major is the workhorse for the upper and middle sternum; for the lower sternum, think IMA-perforator turnover flap or rectus abdominis (VRAM/TRAM).²
• Omentum is your bailout when local flaps fail — large surface area, thin, perfect for wrapping vascular grafts — but you're paying for it with a laparotomy.³
• Bilateral IMA harvest strips the sternum of its segmental blood supply and dramatically raises mediastinitis risk; sternal plating is reserved for high-risk re-operative patients.⁴
• Sternal wound infections are classified by timing: Class 1 (early, sterile), Class 2 (1–3 weeks, purulent mediastinitis), Class 3 (chronic draining sinus). Class 2 and 3 demand thorough debridement plus flap coverage.⁵
• Single-stage radical debridement with concurrent flap coverage has comparable success to staged debridement — pick based on the patient and the wound, not dogma.⁵

This content is for educational purposes only and is not medical advice.

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#PlasticSurgery #Residency #ChestWallReconstruction #ReconstructiveSurgery #SurgicalEducation #PlasticsInPractice #Mediastinitis #FlapSurgery

References:

1. Carey JN, Otake LR, Echo A, Lee GK. Chest Wall Reconstruction. In: Thorne CH, ed. Grabb and Smith's Plastic Surgery. 7th ed. Wolters Kluwer; 2014.
2. Coleman JJ 3rd, Bostwick J. Rectus abdominis muscle-musculocutaneous flap in chest-wall reconstruction. Surg Clin North Am. 1989 Oct;69(5):1007-1027.
3. Villa MT, Chang DW. Muscle and omental flaps for chest wall reconstruction. Thorac Surg Clin. 2010 Nov;20(4):543-550.
4. Arnold PG, Pairolero PC. Chest-wall reconstruction: an account of 500 consecutive patients. Plast Reconstr Surg. 1996 Oct;98(5):804-810.
5. Lee CH, Hsien JH, Tang YB, Chen HC. Reconstruction for sternal osteomyelitis at the lower third of sternum. J Plast Reconstr Aesthet Surg. 2010 Apr;63(4):633-641.