Reoperative Aesthetic & Reconstructive Plastic Surgery

1526
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Not all recurrent wounds, uid collections, and dehiscences require intervention.
Indications for reoperation may be clear-cut, absolute or relative, and are subject to
debate. If support or protection of vital organs is inadequate to maintain acceptable
homeostasis, surgery is mandatory. However, in some cases a patient’s general con-
dition or risk factors can be so adverse that a more conservative approach is advised.
For example, a nutritionally depleted, catabolic patient with multiple organ failure
is an unfavorable, if not unacceptable, operative candidate. Such a patient can vir-
tually always be managed safely during a period of preoperative preparation.
PATIENT EXAMPLES
This patient, referred for reoperative chest and abdominal reconstruction, had nu-
merous complications after coronary artery bypass surgery. After reconstruction
with multiple aps, he continued to have a healed but unstable sternal wound and
abdominal hernias.The patient was ambulatory but severely depressed and in poor
nutritional condition. He was discharged for a period of aggressive outpatient nu-
tritional and psychiatric care. If reoperative thoracic or abdominal wall reconstruc-
tion had been performed, this patient would almost certainly have tolerated the
procedure poorly.

This 350-pound (159 kg) woman with marked macromastia was a poor candidate
for reoperative surgery. She refused a transfusion for religious reasons despite a
hematocrit level of 16 after a coronary artery bypass. She was also in poor nutri-
tional balance, with greatly depleted protein stores.
Despite this information, a sternal wound reconstruction was performed using bi-
lateral advancement pectoralis major myocutaneous and unilateral rectus abdominis
muscle aps. She manifested poor wound healing postoperatively. Despite all at-
tempts to avoid the inevitable dehiscence of the central intermammary segment
of the incision, the widely undermined submammary-pectoral cutaneous advance-
ment flaps ultimately dehisced, resulting in a massive, extensively undermined
wound that never healed. Without adequate nutritional support, transfusion, and
avoidance of the tension effects of widely undermined mammary-pectoral aps,
this patient was unlikely to recover under any circumstances.
Restraint is also advised when planning treatment for a patient with advanced sys-
temic malignancy who will not derive signi cant palliation from repeated attempts
at advanced tumor resection or prolonged treatment of complications resulting
from these procedures. The decision as to when to operate and “when to say no”
depends on a comprehensive analysis of the clinical situation.
In this chapter we will discuss the major problems encountered in reoperative tho-
racic surgery and the decision-making process crucial to planning and executing
that surgery. We will review the treatment of chest wall defects in the setting of
multiple failed debridements and/or failed prior ap reconstructions. We will also
address secondary chest wall reconstructions for multiply recurrent malignancy and
problems of unsuccessful prior treatment of congenital chest wall anomalies.
1527
Chapter 40
Reoperative Surgery of the Chest Wall

1528
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
ANATOMIC AND PHYSIOLOGIC CONSIDERATIONS
Reconstructive surgery of the thorax requires that the surgeon possess
a thorough knowledge of three-dimensional thoracic anatomy and car-
diopulmonary physiology, with careful attention to the special prob-
lems of that body region.
Assessing the risk to and preserving the function of the underlying organs are im-
portant considerations. In thoracic reoperation, it is particularly dangerous to as-
sume that the anatomy and the physiologic processes contained within the thorax
remain as they were at the time of the previous intervention—even when interop-
erative intervals are short.The potential for changes in these vital functions from the
time of primary intervention must be considered. Life-threatening manifestations
of cardiopulmonary abnormalities often develop as a result of the stress of reoper-
ation when they might otherwise remain subclinical or compensated.
Speci cally, the patient’s cardiac status must have adequate reserve for any major op-
eration. Patients undergoing thoracic operations can have a myriad of congenital or
acquired cardiopulmonary problems. However, in most cases—especially after suc-
cessful coronary revascularization or other cardiac reconstruction—the heart’s func-
tion or vulnerability to dysfunction may be signi cantly improved over the preop-
erative state. Consultation with colleagues in cardiology and the performance of
studies suggested by them to assess these potential problems can now be frequently
performed noninvasively.
At times the planned reoperation may be expected to further restrict or otherwise
interfere with cardiopulmonary function.Ventricular aneurysm, recurrent or per-
sistent tumor or infection, or refractory pulmonary air leak can each lead to further
compromise of the heart, lungs, or supporting structures.Wound closure can occa-
sionally add a small but critical degree of cardiovascular restriction in patients with
low output or cyanotic states.
The reoperative thoracic reconstructive surgeon must be concerned with locating
and exposing these troubled vital organs. Overzealous resection or debridement
can lead to intraoperative calamities or short- or long-term morbidity and, ulti-
mately, mortality from hemorrhage or cardiac or pulmonary insuf ciency. Overly
conservative debridement, resection, and reconstruction, however, will inevitably
subject the patient to yet another recurrent or persistent problem with its own in-
herent morbidity and mortality. Surgical therapy is thus executed, striking a balance
between multiple competing factors.

TIMING
If performed at the wrong time, even the best operation can be doomed
to failure.
This statement is especially true for patients requiring cardiothoracic interventions.
As a group these patients have limited reserve and cannot tolerate poorly timed
interventions. Taking the extra time to provide alimentation to such a patient, re-
duce the bacterial burden within the wound, improve uid balance or pulmonary
toilet, or evaluate and optimize other general medical problems can make the crit-
ical difference in preventing complications and achieving a satisfactory result. Be-
cause thoracic reoperation is performed for chronic, persistent, or multiply recur-
rent wounds or problems, there is no excuse for proceeding before all such issues
are addressed. A thorough investigation and understanding of prior interventions are
also required before an appropriate plan can be executed.
Occasionally, emergency situations such as exposed vascular or prosthetic suture
lines threaten hemorrhage and precipitate the need for prompt intervention or de-
nitive reconstruction. However, this circumstance is actually less common than
many think, because proper debridement, reduction of contamination, and preven-
tion of desiccation usually preclude such complications. In our experience, such
hemorrhage occurs more commonly as a result of preventable mechanical erosion
of the heart by irregular bony margins. Earlier intervention may also be mandated
by the presence of exposed, irradiated vital organs, which heal poorly and are in-
tolerable of even minor insults.
Consideration of the patient’s psychosocial situation is often neglected in the tim-
ing of intervention. In select cases, de nitive resection and/or reconstruction can be
performed semielectively (that is, not emergently), if not electively. In this situa-
tion, the interval before surgery can be used to enlist the patient’s full cooperation.
Thus improved efforts at pulmonary toilet, ambulation, and general mobilization
can be more easily achieved.
PATIENT EVALUATION
The assessment and planning phases are crucial aspects of all reconstructive surger-
ies, particularly reoperative chest wall reconstruction.
Many questions must be answered preoperatively to ensure satisfactory
results.The most crucial questions to be answered are these: W hat op-
erations and treatments have been performed and by whom? W hy have
previous treatments failed? W hy has the problem recurred or persisted?
1529
Chapter 40
Reoperative Surgery of the Chest Wall

1530
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Reviewing prior operative and radiotherapy summaries, discussing operative nd-
ings and previous surgery with the primary surgeons, and carefully examining the
patient to document previous incisions and operations are invaluable for addressing
these questions. It is important to inventory even previously violated or used aps
because they may be of use when properly reelevated and readvanced or trans-
posed. In addition, a list of unviolated reconstructive donor units can be generated
in this manner for use in reoperation. A careful patient examination and records
analysis will pinpoint the likely causes of recurrence or persistence of the patient’s
problem, or at least guide the way for reoperation in the previously operated eld.
Recurrent wound complications, sinuses, or stulas most commonly result from in-
adequate identi cation and resection of involved bone, cartilage, soft tissues, foreign
body, or tumor. The second most likely cause of local failure is inadequate soft tis-
sue reconstruction in terms of donor bulk, vascularity, inset, or drainage.These po-
tential causes and sites of recurrence must be sought rst in the records and patient
review and then determined after appropriate preoperative analysis and planning.
The patient’s general health status must also be assessed so that other disease processes
such as diabetes mellitus, conditions requiring immunosuppressive therapy, and nu-
tritional de cits can be adequately managed. A complete evaluation of the patient’s
pulmonary and cardiac function must be made before thoracic intervention. It can-
not be taken for granted that coronary artery bypass grafts, for example, remain
patent. A number of noninvasive studies are now available to ascertain the adequacy
of cardiopulmonary function. Occasionally, cardiac catheterization can be of help
in verifying graft patency and/or proximity of the graft to the wound that requires
debridement. Although most patients can be treated without cardiac catheteriza-
tion, sometimes biplane arteriographic views of bypass grafts, especially of the inter-
nal mammary artery, will help to avoid injury to this structure if it remains patent.
Arteriography can also con rm the integrity of the internal mammary–superior
epigastric axis supplying the rectus abdominis or pectoralis major turnover ap.
PATIENT EXAMPLES
This 64-year-old woman was
referred for treatment 6 weeks
after a coronary artery bypass
graft with left internal mam-
mary artery and multiple saphe-
nous vein grafts. She had previ-
ously undergone classic right
radical mastectomy for carci-
noma of the breast followed by
right thoracic radiation therapy.

One month postoperatively, she developed signs of an acute staphylococcal infec-
tion; the wound was subsequently drained and debrided surgically. The pectoralis
major muscle was absent because of the mastectomy, and it was unlikely that either
rectus abdominis muscle could be used in its entirety because of the harvest of the
left internal mammary artery for the coronary artery bypass and the possible injury
to the right internal mammary artery secondary to radiation therapy. The signi -
cant size of the left breast was also of concern because of the weight it placed on
the presternal region.The stress caused by the weight of the breast was considered
to be a risk for further wound healing problems with the unstable irradiated skin.
Extensive bony and cartilaginous involvement with copious purulent drainage em-
anating from the wound, and multiple sternal fractures were evident. Erythema-
tous and indurated skin margins were also visible. Given the intense brosis that had
occurred in the 6 weeks since the surgery, the cardiac surgeon believed it would be
helpful to obtain an arteriogram before sternal wound reconstruction to assess the
internal mammary artery–left anterior descending coronary artery bypass with re-
gard to patency and proximity to the wound.
1531
Chapter 40
Reoperative Surgery of the Chest Wall
Coronary angiograms were obtained before sternal wound reconstruction. Selec-
tive injections of the left internal mammary artery, which had been used to revas-
cularize the left anterior descending coronary artery, were performed.The antero-
posterior and sequential lateral views demonstrate an abrupt cut-off of ow in the
internal mammary–left anterior descending coronary artery revascularization. It
was consequently believed that this particular coronary artery revascularization had
not been successful and that intraoperative injury to the left internal mammary ar-
tery would not be as dangerous as if the bypass had been successful.The left inter-
nal mammary artery is in close proximity to the sternum as seen on lateral view (see
p. 1532).This vessel would be at risk of injury when resection of a densely brotic
mediastinum was performed for sternal debridement. Coincidentally, injection of
the right internal mammary artery demonstrated robust ow, with patency all the
way down to the superior epigastric artery.
Right and left internal mammary artery:
anteroposterior view

1532
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The ap was elevated; it appeared quite healthy, except for equivocal venous con-
gestion at the inferior most suprapubic rectus territory. Accordingly, the ap was in-
set without microvascular anastomoses. The equivocal venous congestion was
treated with leeches for 2 to 3 days.Their use did not appear necessary beyond this
point and the ap survived in its entirety.
Left internal mammary artery: sequential lateral views
Right internal mammary artery: selective injection
The operative plan was thus to avoid mobilizing the left pectoralis major muscle be-
cause it was considered to have insuf cient bulk, and because of concerns about the
effect that elevation and mobilization of the totally undermined, heavy left breast
would have on the wound. An extremely long, vertically oriented, right rectus ab-
dominis musculocutaneous ap was planned, realizing that the venous or arterial
circulation might require supplementation.The right rectus abdominis musculocu-
taneous ap was elevated, preserving a long inferior epigastric arteriovenous pedi-
cle for anastomosis to recipient vessels in the neck, if necessary.

1533
Chapter 40
Reoperative Surgery of the Chest Wall
Radiographic contrast injection studies proved bene cial in evaluating this 58-year-
old man who had multiple recurrent infections and a sinus tract infection after an
urgent coronary artery bypass graft.The midsternal sinus (above) demonstrated ap-
parent extension directly to underlying bone, where a smoldering sequestrum, in-
fected sternal wire segment, or other foreign body was presumed to account for the
Use of a rectus myocutaneous ap is not often necessary in sternal wound recon-
struction. However, in this case it provided the advantage of allowing further resec-
tion of the compromised right presternal cutaneous margin, and avoided the ten-
sion that elevation and mobilization of the pendulous left breast and pectoral region
would have placed on the wound.
The postoperative result is shown 3 months
later, with the patient having healed per
primum without complications.
Preoperative pulmonary evaluation and
therapy can minimize systemic and local
wound complications that might result
from pulmonary-related wound compli-
cations. An assessment of the likely reasons
for failure must be made. Evaluation of
posteroanterior and lateral chest radio-
graphs can help to locate certain foreign
bodies such as retained pacemaker wire
remnants or sternal wires that may be infected. Although it is usually not necessary,
it should be remembered that other radiographic and nuclear medicine studies such
as bone, indium, gallium, or CT scans, MRI, and sonograms can help with the pre-
operative determination of the extent of infection or exploration and debridement
that might be necessary.

1534
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
wound. Injection of a less prominent but recurrent left epigastric sinus opaci ed a
tract extending beneath the xyphoid to an inferior cardiac-diaphragmatic collec-
tion, as well as a more superior retrosternal-precardiac collection. Preoperative cul-
tures were also obtained so that the use of sensitivity-directed antibiotic therapy
could be ensured.
In recurrent benign processes of the chest wall, it must be determined whether the
problem or wound is probably going to be self-limited or to heal spontaneously in
a reasonable time frame. Factors that would make spontaneous wound healing more
protracted, if not unlikely, include exposed foreign body, exposed rib cartilage or
bone, radiation therapy, persistent signi cant air leak in the presence of obstructive
pulmonary disease, poor nutrition, high levels of contamination, a large residual
dead space or cavity, and a persistent in ammatory or malignant condition.
This 42-year-old woman presented with a nonhealing wound of the left antero-
lateral chest wall secondary to a recurrent infection lasting 4 years. She had under-
gone multiple procedures for the infection, including ultimately a mastectomy in an
unsuccessful attempt at a cure. Her past medical history was also signi cant for in-
flammatory bowel disease, which had been treated with steroids and other im-
munosuppressive agents.
The wound tracked down to underlying rib. The bone scan was positive for os-
teomyelitis in this area as well. Given the multiple previous drainage procedures, re-
sections, and soft tissue manipulations, we decided to attempt chest wall resection
and reconstruction to cure this wound.

The resection included segmental resection of the underlying rib and a 4 cm soft
tissue margin. The wound cavity was stained with methylene blue before resec-
tion. The wound was obturated with a pectoralis major muscle ap, and closure
was completed with cutaneous advancement aps.
1535
Chapter 40
Reoperative Surgery of the Chest Wall
Because of the chronic nature of the in-
fection, the patient was treated with a
6-week postoperative course of intra-
venous antibiotics.The healed wound is
demonstrated 6 months postoperatively.
With recurrent or persistent malignancy
the possibility of distant disease might
affect the indications or extent of plan-
ned resection. In this situation, before
a major reoperative reconstruction is at-
tempted,a full metastatic workup,usually consisting of an MRI or CT scan of appro-
priate body cavities, should be obtained.
A problem-oriented workup should also be performed as indicated to fully assess
the extent and course of bronchopleural stulas, empyema, or sinus tracts. If there
is any question regarding these parameters after reviewing suitable posteroante-
rior and lateral chest radiographs, the following tests can also be helpful: CT scan,
MRI, injection studies with both posteroanterior and lateral views, or injection
studies in conjunction with a CT. These injection studies help to assess the three-
dimensional anatomy of the wound, plan the execution of the reoperative proce-
dure, and ascertain the arcs of ap rotation. Occasionally a three-dimensional CT
scan or MRI can even more descriptively illustrate the anatomy of these entities and
provide information helpful in the preoperative evaluation of depression and pro-
trusion deformities.

1536
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
When injection studies are performed, the most appropriate contrast medium must
be selected by the radiologist for each study, particularly in cases in which the con-
trast material is likely to enter the tracheobronchial tree. In these cases, fat-soluble
contrast material is best tolerated by the tracheobronchial tree and least likely to
cause aspiration pneumonia.
W hen recurrent tumor occurs in proximity to major vessels (usually
the subclavian vessels), vascular examination and angiography are in-
dicated to detail the underlying vascular anatomy, ascertain the degree
of vascular disease, and make any necessary contingency plans for lo-
calizing, resetting, or bypassing involved vessels. In patients who have
undergone irradiation of multiple operations, these issues can be espe-
cially complicated and require special care.
PLANNING
When reoperative thoracic surgery is necessary, careful forethought and contin-
gency planning are important for maximizing the margin of safety. A multitude of
life-threatening contingencies may arise rapidly and without warning in the tho-
rax. Effective surgical planning requires that any operation and all imaginable con-
sequences and subsequent actions be envisioned in advance in a step-by-step man-
ner to ensure the success of the intervention. In this way intraoperative problems as
well as short- and long-term sequelae can be anticipated and management planned
accordingly.
A three-dimensional analysis of the wound, structures to be resected, aps avail-
able for reconstruction and their arcs of rotation, and vital organs that need to be
covered is important in this planning process. In postsurgical empyema or bron-
chopleural stula, for example, the hilum and the diaphragm may typically shift su-
periorly and laterally. This movement effectively elevates the pleural defect or
bronchial stump to a more superior (and usually more favorable) territory for cov-
erage.The diaphragm elevation effectively decreases the volume of the pleural cav-
ity and thus its demand for vascularized ll. Failure to appreciate the mediastinal hi-
lar shift makes injury during debridement more likely. The three-dimensional
appreciation of the intrathoracic wound is also invaluable in making counterinci-
sions or creating transcostal or transdiaphragmatic windows or tunnels to optimize
ap use or inset.
Resection of the soft tissue margins of the wound must also be planned.These must
be resected as completely as possible without injuring or jeopardizing vital organs.
Although true resection of the surfaces of the heart and great vessels is impractical,
the bacterial burden at these sites is greatly reduced by curettage of these surfaces,
gentle stripping of exudates and peels, and jet lavage. However, when infection of
synthetic-pledgeted sutures, overly prominent sternal wires, or vascular patches or
conduits occurs, the intimidating task of their resection, removal, or replacement

must be pursued if cure is to be achieved. Grafts of biologic origin are more likely
to tolerate infection than synthetic ones. Such homografts or heterografts typically
respond favorably to adequate cleansing or debridement of the wound and ap
coverage without replacement.
The surgeon must bring three-dimensional planning into play when
considering the effects of bony-cartilaginous debridement for sternal
wound reconstruction.
The antibacterial bene ts of ridding the wound of contaminated or desiccated bone
and cartilage have been well described. No cartilage should be left exposed in the
wound because it is a frequent source of smoldering chondritis.A less frequently rec-
ognized favorable effect of this debridement is its creation of a shallower, less acutely
concave mediastinal wound.This effect also decreases the volume of wound requir-
ing vascularized ll.With the reduction of the anteroposterior height of the lateral
wound margins, the reach of the pectoralis major or latissimus dorsi muscle is in-
creased as it is advanced medially into the wound.Similarly,there is no bow-stringing
of taut muscle aps draped across the potential space of a steeply concave wound.
The short- and long-term cardiorespiratory effects of any required skeletal, car-
diac, pulmonary, or prosthetic resection must be anticipated. How likely is the pro-
posed operation to make the patient a cardiac or respiratory cripple? Will any re-
sultant vital organ compromise likely be transient or permanent? Will the procedure
interfere with subsequent growth? To what other problems will the patient be
prone as a result of the operation? An assessment of such problems in advance al-
lows the surgeon to minimize risks.
The amount of bony resection required must be analyzed relative to the maximum
amount that can be tolerated. Risk factors that increase the chances of infection, ex-
posure, or necrosis of bone grafts or prosthetic materials include the presence of
contamination, prior or planned radiation, and questionable soft tissue coverage.
Exposure of the skeletal reconstruction or prosthetic mesh at the site of thoracic
skeletal resection to a pulmonary air leak—especially in the presence of anticipated,
continued positive pressure ventilation—also renders bony reconstruction suscep-
tible to postoperative complications or failure. At times, rib grafts in certain loca-
tions may compress ap circulation or the ap pedicle.
W hen bony reconstruction is planned, it must be remembered that
harvesting multiple rib grafts—especially if split-rib grafts are not used
to stabilize the donor site—can result in paradoxical motion at the
donor site, an effect that may outweigh the bene ts of stabilizing the
area of resection.
Most patients can tolerate segments of two to three rib resections without replace-
ment, if necessary. Taut prosthetic mesh or an allogeneic dermis graft helps to sta-
bilize these segments without bone graft replacement. If aps are not adequately
1537
Chapter 40
Reoperative Surgery of the Chest Wall

1538
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
mechanically supported without the presence of mesh, and if support is the only in-
dication for the placement of mesh, absorbable mesh (for example,Vicryl) may be
used if contamination is a concern. Defects larger than two to three ribs can be
tolerated in some patients, especially in certain areas such as beneath the scapula.
Most adult patients also can tolerate the total absence of a sternum, if necessary.
Adults with pulmonary compromise, and children whose thoracic musculoskeletons
are virtually all cartilaginous, tend to have greater difficulty with respiratory
recuperation when larger skeletal defects are created.
When bony reconstruction is elected, bone stabilization is crucial in establishing an
adequate union. Maximizing contact at the junction of the bone graft to the mar-
gins of bony resection, and the use of rigid stabilization, can help. This is often a
cause of failure of primary reconstructions in situations such as pectus deformities.
PLANNING CHEST WALL R ECONSTRUCTION
FOR THE PEDIATRIC PATIENT
Chest wall reconstruction in the pediatric population requires other special general
considerations. Some patients with congenital heart disease may have persistent low
output or cyanotic disease that may not have been corrected at the time of chest
wall reconstruction.These patients require highly specialized perioperative critical
care. They often will require future cardiothoracic surgical interventions. Consid-
eration and analysis of future operative interventions, the possible surgical incisions
required for these future procedures, and the need to reenter any reconstructed site
must be performed in the planning of such procedures.
The analysis must include verifying that all tissues to be used in the current recon-
struction, and as many as possible that might be used in possible future corrective
procedures or reconstructions, have an adequate vascular supply. Foresight is manda-
tory in considering the issue of future growth in the pediatric population. Primary
thoracic musculoskeletal deformities are often present in this population. Recon-
structive procedures can additionally adversely affect the growth of the muscu-
loskeleton as well as the breast. Minimizing bony debridement, restoring the mus-
culoskeleton as anatomically as practical, and avoiding dissection beyond the
minimum required can help to minimize subsequent secondary growth deformi-
ties. Special care should be taken in the prepectoral or subcutaneous plane, espe-
cially in young women, because disturbance of breast growth can be severe, dra-
matic, and dis guring, even with minimal interventions in the early years of life.
GOALS OF TREATMENT
The goal of treatment in reoperative chest wall reconstruction, as with all of recon-
structive surgery, is the restoration of function and form. Because the function of

this body region is to facilitate and protect a multitude of vital processes, returning
the chest wall to a functional state is the highest priority. Although the goal of such
procedures should be to anatomically restore normal form as well, this cannot be
obtained in all cases.
In the pediatric age group subsequent operations, especially breast reconstructive
procedures or correction of progressive thoracic skeletal deformities, may become
necessary in the future. Long-term follow-up must be performed for surveillance
of such problems. In certain secondary deformities, early intervention can facilitate
the ease of their treatment.
STERNAL WOUNDS
Sternal wound reconstructions may fail in the early or late postoperative phase.
Early complications typically present as a wound separation, dehiscence, or early
septic complications. Late problems arise from recurrent infection, often manifest-
ing themselves as one or more sinus tracts.
Early wound separations after sternal wound reconstruction may be multifactorial.
However, they are usually caused by inadequate debridement leading to infection
or persistent chondritis, unevenly debrided bony or cartilaginous margins causing
mechanical trauma to the suture line, poor soft tissue coverage of the bony and
cartilaginous margins, or inadequate attention to the details of achieving an ade-
quate, meticulous, layered soft tissue coverage. Inadequate hemostasis, suction
drainage, or pulmonary toilet with resultant excessive coughing can contribute to
local factors and wound separations.
STERNAL DEBRIDEMENT AND DELAYED PRIMARY CLOSURE
In select cases of early sternal wound infection, several authors have employed de-
bridement and delayed primary closure with sternal reapproximation. Surgical de-
bridement is performed within 24 hours of wound infection and the open chest
undergoes dressing changes until the wound yields negative tissue cultures and gran-
ulation tissue settles in.The chest is primarily closed with sternal reapproximation.
Authors note that hemorrhage or substantial bone loss is a contraindication for this
salvage procedure. The patients who were successfully closed using this technique
featured uncomplicated infections and were, presumably, otherwise healthy.
This method of sternal wound reoperation is not widespread, and we would advo-
cate caution in wounds with large tissue de cits, and in patients with signi cant co-
morbidities.The elimination of dead space is not addressed with this operation and
the chest remains open on average for 10 to 14 days.
1539
Chapter 40
Reoperative Surgery of the Chest Wall

1540
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
PATIENT EXAMPLES
This 68-year-old man with a prior history of chronic obstructive pulmonary dis-
ease experienced episodes of severe coughing postoperatively after coronary artery
bypass graft, which resulted in the dehiscence and fragmentation of the sternum by
the sternal wires. He was returned to the operating room at that time for (1) de-
bridement of the involved bony-cartilaginous margins, and (2) reconstruction of
the wound with bilateral pectoralis major and unilateral rectus abdominis muscle
aps and cutaneous advancement aps.Two to three weeks postoperatively, during
recurrent ts of coughing, a segment of the left sternal margin and associated costal
prominences disrupted the incision as seen above.
The entire undermined subcutaneous space communicated with this wound.The
wound would not close in a stable fashion in any reasonable time interval.The pa-
tient was returned to the operating room for complete debridement-resection of
the residual sternal and costal margins, and salvage reconstruction with a greater
omental ap and skin grafts. At the time of surgery the undermined spaces were
vigorously curetted and jet lavaged. The omental ap was secured to the dermal
margins, and multiple suction catheters were used to adequately evacuate the sub-
cutaneous space.

Tracheostomy placement in a patient who has had sternal wound reconstruction
can occasionally lead to a recurrent wound secondary to disruption of the layered
closure by subcutaneous emphysema.This elderly obese patient with diabetes had
undergone sternal wound reconstruction with bilateral pectoralis major aps and a
rectus abdominis ap for mediastinitis, which had developed after coronary artery
bypass surgery. She also had acute systemic
herpes and systemic candidiasis. She required
tracheostomy for refractory pulmonary fail-
ure. Despite waiting 1 month after sternal
wound reconstruction to perform the tra-
cheostomy, and taking precautions to place
the tracheostomy as high as possible, massive
subcutaneous emphysema developed in the
entire pectoral region on both sides. Ulti-
mately the wound had to be reopened and
packed, thus representing a late cause for fail-
ure of the sternal wound reconstruction.The
patient did not survive.
The soft tissue planes can take a great deal of time to heal in a secure manner, es-
pecially in debilitated, immunosuppressed, or malnourished patients.Thus the op-
erating surgeon must continue to carefully supervise all treatments for a long inter-
val postoperatively.
PREOPERATIVE PREPARATION
The following precautions should be taken when performing mediastinal reoper-
ation. First, antithrombotic intermittent compression garments are placed on at
least one if not two extremities. Even if the lower extremities must remain draped
into the operative eld for other purposes, placement of such a garment on one of
1541
Chapter 40
Reoperative Surgery of the Chest Wall
At the 3-week postoperative visit, the heal-
ing omental ap and skin graft were healing
well.There were no complications from this
salvage procedure.

1542
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
the upper extremities can help to reduce the incidence of pulmonary embolism.
Cleansing and draping large areas of the body will help to prepare for any number
of contingencies. An adequate lower extremity donor site should be available for
harvesting vein grafts if replacement of a coronary artery bypass graft becomes nec-
essary. Similarly, access to the groin should be available for cannulation of the
femoral vessels if emergency extracorporeal circulatory support needs to be insti-
tuted.This precaution is important in the reoperative situation because dense me-
diastinal brosis from prior procedures makes inadvertent injury to the heart or
great vessels more likely.
The thigh can also be used to obtain fascia lata or deepithelialized full-thickness skin
grafts for use as an out ow tract patch or autologous pledget material if an indwelling
infected synthetic patch is to be replaced, or a cardiac suture line is to be reinforced.
A skin graft may also be needed from the thigh if cutaneous advancement aps are
not used to complete the closure.This is especially true when the greater omentum
is used.The entire abdomen is included in the operative eld and prepared,giving ac-
cess to both rectus abdominis muscles as well as the greater omentum.
When all of the pectoralis major and rectus abdominis muscles have been violated
or rendered unusable and the omentum is not suitable, the latissimus dorsi muscles
are available for coverage of the sternal region. If it seems likely that this contin-
gency will arise, it is advisable to prepare the back, staple or suture sterile drapes
along the posterior midline, then place the patient in the supine position on ster-
ile sheets placed over a beanbag before preparing and draping the anterior thorax
for debridement or resection.This preparation will obviate the need to turn the pa-
tient for redraping during a prolonged and complex operation and will also facili-
tate stable positioning of the patient in the appropriate lateral decubitus position.
Next the appropriate body regions are prepared and draped, and culture-directed
antibiotic doses are given intravenously before initiating the operation. Suitable
anesthesia is achieved with the appropriate monitoring lines and devices.
The degree of anticipated resection is assessed, and the desired incisions are outlined
with methylene blue. If feasible, any sinus tracts are injected with methylene blue
via a syringe and small catheter. In ltration with dilute epinephrine-containing so-
lutions into the region of the incisions can often help to minimize bleeding in the
super cial planes and to precisely visualize the location of the sinus tracts or other
areas of abnormal anatomy.
TECHNIQUE
The dissection proceeds rst with the elevation of any previously used cutaneous
flaps to allow wide exposure. Next, any previously used muscles are reelevated
anatomically to preserve their maximal bulk so that they may be reused if possible.
Previously used pectoralis major aps may have been advanced and sutured in the
midline.It is often dif cult to anatomically dissect them from each other where they
overlap or are secured. If both aps have been advanced, it works well to divide

them in the midline and re ect the soft tissues to their respective lateral direction.
Review of prior operative notes or discussions with the previous surgeons should
help to determine the pedicle on which each previously elevated ap was raised.
If reexploration is performed for a staged cardiac procedure in the setting of prior
chest wall reconstruction, reelevation or dissection of the aps from the heart and
great vessels does not have a prohibitive risk. In some cases it is much more straight-
forward than expected, even when extensive cardiac procedures or the placement
of large amounts of synthetic material is necessary. Alternatively, the procedure may
be performed via a previously unoperated alternative route.
1543
Chapter 40
Reoperative Surgery of the Chest Wall
Alternate Surgical Approaches for Cardiothoracic Procedures
Surgical Incision
Procedures Feasible Via a Given Incision
Sternotomy
All cardiac procedures
Select systemic-pulmonary shunts
Pericardial window
Pericardiectomy
Pulmonary band
Right pneumonectomy
Left pneumonectomy
Left upper lobectomy
Right upper lobectomy
Right middle lobectomy
Right anterior/anterolateral thoracotomy
Atrial septal defect repair
Mitral valve replacement
Tricuspid valve replacement
Anomalous pulmonary venous return repair
Select systemic-pulmonary venous return
Select esophageal procedures
Right upper lobectomy
Right middle lobectomy
Right lower lobectomy
Right lateral/posterolateral thoracotomy
Any pulmonary procedure
Select esophageal procedures
Left anterior/anterolateral thoracotomy
Repeat coronary artery bypass graft
Select systemic-pulmonary shunts
Pulmonary band
Pericardial window
Left upper lobectomy
Left lower lobectomy
Left posterior/posterolateral thoracotomy
Repeat coronary artery bypass graft
Patent ductus arteriosus ligation
Aortic coarctation
Vascular rings
Left upper lobectomy
Left lower lobectomy
Combined bilateral thoracotomy
Any cardiac procedure
Any pulmonary procedure

1544
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
PATIENT EXAMPLES
The well-healed sternotomy was reopened without dif culty and demonstrated
the lack of dense adhesions to the posterior sternum.The omentum remained pli-
able and was easily manipulated within the former abscess cavity.The omentum was
partially elevated and re ected to allow cannulation for cardiopulmonary bypass.
The procedure was completed without incident and the omentum was returned to
the cavity for closure.
This 12-year-old girl is seen 4 months after omental obturation of a retrosternal ab-
scess cavity that had occurred as a complication of right ventricular out ow tract
patch repair with a biologic patch. Her cardiac condition required that she be re-
turned to the operating room for reexploration and revision of the cardiac recon-
struction.

Another example of reexploration for a staged cardiac procedure is illustrated by
this 30-year-old man who presented with high fever and a suprasternal abscess 2
weeks after the replacement of a prosthetic pulmonary valve and the placement of
a right ventricular out ow tract patch for complex congenital anomalies. He had
undergone multiple previous surgical procedures since infancy.
1545
Chapter 40
Reoperative Surgery of the Chest Wall
The upper sternotomy incision was incised and the abscess was drained. It tracked
around the sternal notch superiorly and seemed to track further beneath the ster-
num.The entire sternotomy incision was reopened, and the sternal wires were re-
moved to allow inspection of the retrosternal space. The suprasternal cavity was
found to communicate with a large abscess cavity on the surface of the right ven-
tricular out ow tract bioprosthetic patch behind the left hemisternum, which is
seen being lifted by the retractors.

1546
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Because of the patient’s systemic toxicity and extensive suppuration found locally,
he was treated with several days of topical wound care and culture-speci c antibi-
otics. He was returned to the operating room for further debridement and ap re-
construction.The rake is seen retracting the portion of the sternum behind which
the xed, uncollapsed abscess cavity was located. After limited debridement of the
sternal margins and debridement and curettage of the abscess cavity, heart, and great
vessels, the wound was extensively jet lavaged with a dilute hypochlorite solution.
To obturate the unyielding abscess cavity with well-vascularized tissue, the left pec-
toralis major muscle was elevated on its dominant thoracoacromial pedicle (shown
retracted by suture). The insertion was divided to achieve greater mobility.To deliver
the muscle to the mediastinal abscess cavity and still allow reapproximation of the
uninvolved sternum, a costal window or tunnel was created by resecting three costal
cartilages on the left (malleable retractor traverses costal window). With cautious dissec-
tion, violation of the left pleura and the left internal mammary artery was avoided.

The muscle was secured to the costal window margins, placing the sutures in such
a way as to advance the muscle into the defect and hold it in place in the cavity.The
sternal wires were then placed and tied. Note the pectoralis major muscle entering
the costal window in the patient’s upper left thorax.
1547
Chapter 40
Reoperative Surgery of the Chest Wall
Four months later, he returned with a healed wound ready to undergo the next car-
diac procedure.

1548
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
He was later returned to the operating room, where the previous bilateral thoracot-
omy, sternotomy, and left pectoral ap tendon (axillary) release incisions are out-
lined. The sternotomy was opened and the muscle ap was taken down unevent-
fully. A large Dacron superior vena cava–right atrial shunt and, behind it, a main
pulmonary artery–left pulmonary artery shunt were placed. The muscle and ster-
num were closed over them without dif culty. There was no evidence of persis-
tent uid collection or cavity found at this reexploration. Healing proceeded with-
out dif culty despite the complex nature of this reconstructive effort.
If sinus tracts exist, they are circumscribed with separate counterincisions if they are
not in proximity to the primary incision. Otherwise excisional extensions of the
primary incision will include these in the original incision.
After re ection of previously used aps from the problem site, the recurrent wound
or sinus is traced, with the help of the methylene blue–stained tissues, to its origin.
This origin is most commonly a smoldering, infected, or desiccated costal cartilage
or sternocostal remnant or a foreign body such as sternal wires, pledgeted sutures
or patches, or other synthetic prostheses or materials.The involved materials or tis-
sues are then resected in a methodical, thorough, and safe manner.
This eradication of the offending materials typically requires several techniques.
Progressing from “known” to “unknown” tissues is a safe principle of dissection
and usually is achieved by exposing an adjacent uninvolved segment of bone or
cartilage, and proceeding with subperiosteal or subperichondrial dissection along it.
In this manner the involved bone and cartilage can be fully removed from the un-
derlying vital structures without violating the healthy tissue.

1549
Chapter 40
Reoperative Surgery of the Chest Wall
The use of various techniques to eliminate offending materials is effectively
demonstrated in the treatment of this 65-year-old man who was referred 14
months after a coronary artery bypass operation. He had been returned to the op-
erating room 2 hours postoperatively for retrieval of a surgical sponge. He was then
readmitted 2 to 3 weeks postoperatively with signs of what proved to be a staphy-
lococcal infection. He had undergone multiple surgical debridements and many
months of intravenous and oral antibiotic therapy.
In the setting of multiple previous surgical procedures in this area, the wound was
densely brotic, with the heart quite adherent to the anterior mediastinal struc-
tures. There was evidence of continuing smoldering infection of the margins of
the sternum, and it was believed that sternal resection carried signi cant morbid-

1550
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
ity because of cardiac adhesions. A faded, long, right subcostal incision was evi-
dence of a gastrectomy performed 20 years earlier. His past medical history was
also signi cant for psoriasis. Because of multiple prior operations and the uncertain
nature of the multiple previous episodes of sternal debridement, the decision was
made to widely resect the sternocostal region to give the best possible chance of
completely removing the smoldering bony and cartilaginous tissues, and give the
greatest chance of recovery.
A chronic nonhealing wound was evident at the site of the patient’s previous me-
dian sternotomy with signs of peripheral skin involvement with psoriasis.The heart
was adherent to the posterior sternum and costal cartilages.The underlying nearby
internal mammary artery conduit was used for bypass of the left anterior descend-
ing coronary artery (see arrow on inset, p. 1551).
At this operation the soft tissue wound was rst incised through skin, subcutaneous
tissues, and muscle over areas where the presence of bone and cartilage could be
con rmed by palpation.
Composite musculocutaneous aps were then elevated from the rib surfaces so that
these units were widely undermined and elevated from the underlying structures to
be further dissected and resected. The residual, central, full-thickness wound is
shown with the adjacent/continuous unroofed costal cartilages and sternum. The
retractors are holding the composite aps laterally to expose the costal cartilages for
piecemeal resection.
Sequential subperichondrial dissection of the costal cartilages was performed, with
care taken to closely adhere to the cartilage surface to maintain a safe plane of dis-
section, and thus avoid cardiac injury. In this manner all costal cartilages were re-

moved and the lateral sternocostal junctions and lateral sternum were safely delin-
eated so that the dissection could proceed most safely centripetally toward the area
of greatest fibrosis and danger. Once the costal cartilages on both sides have all been
resected, sternal dissection and resection can take place in a methodical manner
from each sternal margin until the entire sternum is progressively elevated and re-
sected on a piecemeal basis, if necessary.
Use of a ne elevator such as the Freer with rongeurs is invaluable in this tedious,
cautious subperiosteal sternal elevation. Once all the costal cartilages have been re-
sected subperichondrially and the bone has been removed subperiosteally, a clean
wound with fresh tissues devoid of sequestra and any other nidus for infection has
been exposed without injury to the heart. At this point no bridges have been
burned with regard to preservation of all ap units except for the additional divi-
sion of internal mammary perforators (which are often injured by previous de-
bridements or pectoralis major elevation), precluding the use of pectoral turnover
aps.The left internal mammary artery had already been used as a vascular conduit
for coronary bypass.
During debridement several fragments of bone and cartilage not contiguous with
the body of the sternum were detected.These fragments resulted because the ster-
nal margins were not sequentially debrided during a previous surgery. In reopera-
tive situations it is critical to detect and remove all questionable bone and cartilage
fragments. It is easy to not appreciate all of these free- oating, incompletely de-
brided fragments when multiple previous debridements by other surgeons have
been performed. Bony landmarks are also lost in these situations, making debride-
ment more dangerous with regard to cardiac injury.
1551
Chapter 40
Reoperative Surgery of the Chest Wall

1552
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
After curettage of the surfaces of the wound overlying the heart, and jet lavage ir-
rigation, the pectoralis major muscles were remobilized and the tendinous inser-
tions were released bilaterally. They were approximated to each other, and closure
was completed with mobilization and approximation of bilateral cutaneous ad-
vancement aps over multiple suction catheters.

1553
Chapter 40
Reoperative Surgery of the Chest Wall
At the 2-year follow-up visit, the wound was
well healed.
Another technique that can be useful in achieving the goal of successful healing is
to approach the involved tissues via internal or external counterincisions to facili-
tate safe exposure, as performed in this 58-year-old man. Seven years earlier he had
undergone an urgent coronary artery bypass graft, which had been complicated by
multiply recurrent infections and sinus tract formation. He was treated with mul-
tiple surgical debridements and ap reconstruction at another hospital. The most
recent procedure included reconstruction with bilateral pectoralis major myocuta-
neous advancement aps. He was also treated with long-term courses of parenteral
and oral antibiotics. At several of the prior surgical debridements, temporary pac-
ing wire fragments were removed.
Radiographic contrast injection studies of the midsternal sinus demonstrated exten-
sion of the wound directly to underlying bone where a smoldering sequestrum and
infected foreign body were thought to be the cause. A recurrent left epigastric sinus
was injected to opacify a tract extending beneath the xyphoid to an inferior cardiac-
diaphragmatic collection and a more superior retrosternal-precardiac collection.

1554
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
At reoperation for chest wall reconstruction, incisional scars were noted at the orig-
inal median sternotomy site, pectoral humeral tenotomy counterincision sites, and
multiple former chest tube sites.The left epigastric and the midsternal sinus tracts
were forcefully injected with methylene blue before surgery.
The entire sternotomy incision was opened through the underlying, previously ad-
vanced pectoralis major muscle aps to the periosteum. An excisional incision (be-
hind the forceps and clamp) was made around the ori ce of the left epigastric sinus
tract. The well-formed sinus tract was dissected until it could be drawn into the
main wound cavity. Dissection continued around this well-formed tract, following
it through the bone itself into brotic, treacherous planes between the heart and the
diaphragm, and between the sternum and the heart. Segments of the xyphisternum
were resected piecemeal to unroof the extension between the heart and the ster-
num. Staining of the tract and cavities with methylene blue helped to verify the ad-
equacy of the resection of the involved tissue.This long tract is shown held under
traction at the inferior aspect of the wound by the surgeon’s two forceps and clamp.

A close-up view of this inferior portion of the wound demonstrates the unroofed
sinus tract and reveals a long pacing wire that had been the focus of the multiply re-
current inferior component of the infections. After this wire was fully excised, the
surrounding diaphragmatic and inferior cardiac surfaces were curetted, with the
contiguous xyphoid being resected as well.
Attention was then turned to the superior of the two tracts, the ori ce of which
had already been excised with reincision of the sternotomy scar and kept in con-
tinuity with its deeper origins. Once it became obvious that the midsternal tract ex-
tended through the old manubrial portion of the sternal split, it became necessary
to remove a block of bone. If the sinus were arising from this segment of bone it-
self, segmental ostectomy of the manubrium would be curative. If this segment of
bone were not the origin of the infection, its removal would be required for ade-
quate exposure of any underlying extension of the tract.
To facilitate safe resection of the manubrium in the setting of multiple prior surgi-
cal debridements and dense retrosternal adhesions while preserving the encased si-
nus tract, the previously unviolated adjacent second and third costal cartilages were
subperichondrially resected bilaterally.Thus the manubrium could be progressively
elevated in a centripetal fashion from a more peripheral, safer, and better-de ned
1555
Chapter 40
Reoperative Surgery of the Chest Wall

1556
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
area. The vessel loops are seen passing beneath the subperichondrially dissected
cartilages just before segmental resection. The Kocher clamp is holding the
manubrial segment to be lifted subperiosteally from the underlying heart.
Once the manubrium was resected, the body of the sternum was split cautiously
with the oscillating saw. It became apparent that the tract continued relatively far
posteriorly alongside the heart through unusually dense brous tissue. Continued
attempts at following the blue-stained tract toward its origins were frustrated by
an inability to de ne a safe plane. It could be determined, however, that the tract
likely extended to the area in which troublesome bleeding had been encountered
at the atrial cannulation site during the original coronary artery bypass surgery.
This area had been controlled, according to the original operative note, with
Te on-pledgeted sutures. It seemed highly likely that these pledgets were the ori-
gin of the continued recurrent contamination.
To achieve safe access to this area, it was decided that an internal counterincision
would be helpful in establishing safe anatomic landmarks. Accordingly, the second
right intercostal space was opened into the previously unviolated right pleural space
(traditional right thoracotomy is an accepted approach for cannulating the atria
and cavae) via the existing wound.This was an internal thoracotomy of sorts, which
did indeed greatly improve and make safer the exposure of the area of concern in
the posterior pericardial sac, although it divided the right internal mammary artery.
Even with improved exposure, it was also believed that there was a signi cant risk
of hemorrhage, or possibly of the need to resect a segment of the atrium contain-
ing the offending foreign bodies. For this reason the right femoral artery (the aorta
was not readily accessible because of brosis) and the inferior right atrium were
cannulated for the contingency that rapid institution of cardiopulmonary bypass
and reinfusion of shed blood would be necessary. Furthermore, a patch of left fas-
cia lata was harvested for expeditious atrial resection and autologous patch repair,
if necessary.

Once the cannulas were in place and the internal thoracotomy provided improved
access, the blue-stained tract was followed tediously down to the area indicated by
the forceps near the former atrial cannulation site. At this site numerous blue-
stained Te on pledgets with associated debris and purulent drainage were located
and removed.
1557
Chapter 40
Reoperative Surgery of the Chest Wall
Any portion of the tract that could not be excised (that is, that part abutting the
heart) was curetted.The removed infected pledget material (right), and the excised
sinus tract and accompanying lengthy segment of pacing wire (left) are shown.The
margins of the residual body of the sternum that was split were pristine and clearly
uninvolved with infection. The wound was jet lavaged with dilute hypochlorite
solution in preparation for closure.

1558
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The residual sternum was reapproximated with sternal wires. Wound cavities per-
sisted superiorly and inferiorly at the sites of the manubrial and xyphoid resections,
respectively. The superior cavity was obturated by segmental elevation and read-
vancement of the previously advanced upper left pectoralis major muscle (upper
forceps). The lower space was lled with an inferiorly based right rectus abdominis
muscle transposition ap (lower forceps). The remainder of the pectoralis major ap
was reapproximated in the midline as before, and advancement of the pectoral cu-
taneous advancement aps completed the closure. In light of the multiply recurrent
7-year history of infection, the patient was treated with a 6-week course of par-
enteral, culture-speci c antibiotics.
The patient is shown 6 months postopera-
tively. There were no short- or long-term
complications.

As this case illustrates, counterincisions are especially useful when foreign bodies
extend deep to the bone or cartilage and give rise to a recurrent pathologic con-
dition that must be eradicated. An example would include an internal intercostal
extension or counterincision beneath an already elevated cutaneous and/or muscle
ap at the site of a prior sternotomy. This maneuver allows the surgeon to alter-
nately approach an area that must be resected at the level of the atria, ventricles,
great vessels, or pulmonary hila at the site of prior procedures and resultant bro-
sis.The margin of resection is extended beyond what is grossly involved to ensure
cure of the persistent or recurrent problems that tend to present in this area. This
resection would include all cartilage of any rib involved or that becomes exposed
adjacent to the involved area, or during the surgical resection. Such exposed carti-
lages are very susceptible to recurrent desiccation, contamination, and/or drainage.
In this way the patient is more likely to be cured of the problem that led to reop-
eration.This philosophy of debridement also prevents exposure of cartilage or bone
in the event of subsequent dehiscence, or if drainage and packing of a new uid
collection become necessary.
After resectional debridement of involved and adjacent tissues, any vital organs bor-
dering the area of resection are lightly curetted if resection is not possible. If the si-
nus tract or recurrent infection appears to arise from infected synthetic patches,
vascular conduits, or other synthetic material, it is extremely dif cult to eradicate
such an infection solely with debridement and coverage unless the infected mate-
rial itself is removed and replaced with the patient on cardiopulmonary bypass if
necessary. As previously stated, biologic prostheses such as pericardial autografts,
homografts, or heterografts tolerate such contamination or infection better than
synthetic materials, and usually do not need to be replaced. If the indication for
the reoperation is dehiscence, inability to close the chest, or tumor as opposed to re-
current infection, such synthetic materials need not be removed.
If synthetic materials must be removed, replacement with autogenous materials is
desirable. Depending on the tissues needed, small fascial or muscular fragments can
be used for pledgets, whereas fascia lata or epithelialized dermal grafts can be used
as a synthetic patch. Pericardium may not be available in the reoperative situation
because of brosis.Vascular conduits are ideally replaced with homografts. If a syn-
thetic replacement is absolutely necessary, the less porous synthetic graft materials
are less likely to harbor or retain bacteria than the more porous materials.
After debridement is completed, jet lavage of the wound is performed using the
Water-pik or a large syringe and plastic catheter with dilute hypochlorite irrigant
to further reduce the wound bacterial count. At that point, previously used muscle
aps can be carefully elevated, readvanced, and effectively used to augment or com-
plete the soft tissue reconstruction.
1559
Chapter 40
Reoperative Surgery of the Chest Wall

1560
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
As with primary chest wall reconstruction, pectoralis major muscles and/or rectus
abdominis muscles are prime donor tissues for reconstruction of soft tissue de cits
resulting from debridement. As previously mentioned, the greater omentum can be
used as a new ap or a readvancement ap to help ll a defect with vascularized tis-
sue. The greater omentum is usually easily elevated from the mediastinal contents
with fewer adhesions than would otherwise have been expected.
Another source of pedicled tissue for this site includes the latissimus dorsi muscle,
as mentioned previously.Transposition of the latissimus dorsi muscle to the anterior
midline usually requires division of the tendinous insertion of the latissimus dorsi
muscle, if not skeletonization of the pedicle to deliver adequate bulk to the arc
lengths desired. It should be noted, however, that the attachment of the serratus
collateral vessel to the thoracodorsal pedicle is best preserved in the case of prior ax-
illary radiation, or if there is any concern about preservation of the thoracodorsal
pedicle when axillary dissection has been previously performed.
Once adequate vascularized tissue bulk has been delivered to the wound, all possi-
ble geometric combinations of ap inset are evaluated. When possible, the most
hearty, dependable, and robust portion of the ap should be placed in the area that
most critically needs coverage. The bony margins of resection are ideally covered
with well-perfused portions of the ap by interposing these portions between the
bony margins and cutaneous margins. This method of ap inset also prevents ex-
posure of bone or cartilage if uid collections must be drained, or if small dehis-
cences occur.
Once the aps are positioned as desired, sutures of absorbable material are placed to
secure the aps to stout adjacent tissue, such as periosteum, nearby muscle fascia, or
occasionally fellow flaps. This inset should maintain adequate tissue bulk in the
cavities created by the debridement or resection and prevent undue tension on the
aps. Before closure each tissue plane should be generously and aggressively evac-
uated and drained with large suction catheters exiting through distant separate stab
wounds. Closed systems with controlled suction are used for connection to drains
placed directly on the heart or great vessels. Otherwise drains in the submuscular or
subcutaneous planes are placed directly to wall suction.
When possible, it is desirable to use cutaneous advancement aps to complete skin
closure. Possible contraindications to extensive cutaneous advancement aps in-
clude the presence of pendulous breasts (which place undue tension on the suture
line);obesity and diabetes (which can contribute to ischemia of overlying breasts);
and prior surgical incisions.These incisions must be released (for example, with Z-
plasty), or at least considered in the placement of any new incisions and evaluated
in terms of possibilities for safe cutaneous ap elevation.

This 80-year-old woman had undergone urgent mitral valve replacement and had
been reexplored for bleeding. Postoperatively mediastinitis developed, resulting in
a sternal wound. She had multiple thoracic and abdominal incisions including a
left mastectomy scar and a right thoracotomy scar. She underwent sternal wound
reconstruction with a left rectus abdominis ap and a right pectoralis major mus-
cle advancement ap after extensive debridement. Closure was completed with bi-
lateral cutaneous advancement aps. Both cutaneous advancement aps required Z-
plasty releases of the prior thoracic incisions. Four weeks postoperatively the wound
was well-healed; the healed wound is shown 3 months postoperatively.
Care must be taken to ensure that the wound edges do not invert and that all cu-
taneous surfaces are well-apposed, making the closure airtight and watertight. Even
a 1 or 2 mm loss of incisional integrity early in the postoperative course can lead
to open communication with large subcutaneous or submuscular planes created in
the dissection. Such a small breach of the closure can be a cause of persistent con-
tamination, or can preclude adherence of the undersurface of aps to the tissues be-
neath. Occasionally, even this small technical indiscretion can result in the need to
pack the entire wound open, or in a signi cant complication or reconstructive fail-
ure. If the skin cannot be closed, alternatives include closure with musculocuta-
neous aps or skin grafts.
1561
Chapter 40
Reoperative Surgery of the Chest Wall

1562
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
THE WOUND VACUUM-ASSISTED
CLOSURE DEVICE
In 1993 Argenta and Morykas1 described the use of negative pressure for chronic
wounds and pressure sores.The underlying concept of negative pressure is the pro-
motion of granulation tissue through increased arterial dilatation. Additional ben-
e ts of the vacuum-assisted closure (VAC) device include removal of excess uid,
reduction of bacterial colonization, and fewer dressing changes. The net result is
quicker, more ef cacious wound healing.
The VAC system consists of a polyurethane foam segment that is tailored to the size
of the wound, an evacuation tube, adhesive dressing, and a vacuum device with
collection canister.
Since the advent of the VAC device, it has been applied in a myriad of clinical sit-
uations, including sternal wounds. A number of studies have endorsed the use of
VAC in sternal wounds to avoid debridements and cumbersome dressing changes.
Investigators have employed the VAC device as a primary modality of closure, a
bridge between debridement and nal closure, an adjunct to ap closure, or as a
stopgap measure when ap coverage breaks down.
INDICATIONS
There exists a subset of patients who are not optimally treated by concurrent de-
bridement and ap closure. These include patients with grossly infected wounds
(greater than 105 organisms/g of tissue), patients with substandard nutrition param-
eters, critically ill patients, and patients whose wound size precludes closure with
available ap options.
For example, in grossly contaminated wounds (type II or III), the reconstructive
surgeon must consider clinical factors before wound closure, including resolution
of fever, reduction of bacterial quantitative counts, resolution of C-reactive pro-
tein, or clinical stabilization. Furthermore, the patient must be able to suf ciently
recover from the septic insult of infection from a physiologic standpoint and be
ready to heal from the reconstructive insult.
In the past, these patients were treated with serial debridement and/or dressing
changes.These procedures have recently been replaced by VAC therapy in many in-
stitutions. Song et al compared the VAC system with twice-daily dressing changes
in 35 patients and found a shorter period between debridement and closure, fewer
dressing changes, and less surgery in the former group.

PATIENT EXAMPLE
1563
Chapter 40
Reoperative Surgery of the Chest Wall
This 67-year-old man with hypertension underwent replacement of a thoracic aor-
tic root aneurysm with Hemashield, and a three-vessel coronary artery bypass. On
postoperative day 10, pus was expressed through the median incision that was de-
brided that day in the operating room.The following day, the patient underwent -
nal debridement before pectoralis ap reconstruction on postoperative day 12.

1564
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
However, the wound could not be closed completely without tension;therefore the
open portion was packed initially and then lled using the VAC device.Three VAC
changes per week ensued for the next 6 weeks. The drainage was monitored and
the patient’s clinical course optimized. The wound edges contracted in at the end
of the 6 weeks without further intervention and he is now doing well 2 years post-
operatively.

PLEURAL SPACE PROBLEMS
The factors that predispose to recurrent fistula or empyema—inadequate de-
bridement of the wound margins, inadequate closure of fistula, residual inflam-
mation, malignancy, and prior radiation therapy—make reoperative reconstruction
of the pleural space more challenging. In the reoperative setting, ap donor units of-
ten have already been violated by the reconstructive needs in the primary recon-
struction, or by a prior thoracotomy, injury, illness, or radiation therapy.
Other indications for reoperation in chest wall reconstructive surgery involving the
pleural space include infection or dislodgment of previously placed Prolene mesh,
Prolene-methacrylate “sandwich,” and rib grafts. Reoperation can also be necessi-
tated by ap failure resulting from ischemia, undue tension, or poor ap design.
EMPYEMA
Empyema is de ned as a purulent collection within the pleural space. In the pre-
antibiotic era it was a common sequela of pneumonia.The development of antibi-
otics, however, has rendered this disease a much less common entity. Empyema now
more commonly presents as a thoracic surgical complication.Typical symptoms of
pleural empyema include pleuritic chest pain, fever, tachypnea, tachycardia, de-
creased respiratory excursions, cough, and friction rub.These symptoms might oc-
cur, as previously mentioned, in the setting of recent surgical or percutaneous vio-
lation of the pleural space;a bacterial, fungal, or tuberculous pneumonic process;or
endobronchial tumor or aspirated foreign body. Radiographs of the chest usually
demonstrate a pleural effusion or opaci cation, sometimes superimposed on a pul-
monic in ltrate.
Early intervention consisting of evacuation of the offending uid and antibiotic
treatment achieves lung expansion before brosis xes and permanently restricts
lung expansion.The morbidity of empyema is greatly increased when such a xed
cavity is established. These cavities sometimes may “point,” eroding the subcuta-
neous tissues and draining spontaneously (empyema necessitatis). An erosive process
may extend centrally into the bronchial tree, giving rise to a bronchopleural stula
with increased production of foul sputum and possibly an air uid level visible ra-
diographically.
It is critical not to mistake a pulmonary abscess for empyema because the former
is an intrapulmonary lesion and its treatment differs from that of empyema or bron-
chopleural stula. Chronic empyema typically occurs approximately 6 weeks after
the offending process begins and results in a brinous exudate or peel that restricts
simple rein ation or expansion of the lung that could otherwise be achieved with
thoracentesis or dependent tube thoracostomy. In the chronic phase the xed lung
and the abscess cavity require open drainage, often with rib resection, chronic drain
placement, and irrigation.
1565
Chapter 40
Reoperative Surgery of the Chest Wall

1566
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
At times, well-drained empyema may gradually and spontaneously diminish in size
and proceed to ultimate healing. Large empyema cavity size, residual malignancy,
large persistent air leak (bronchial stula), prior radiation therapy, inadequate de-
pendent drainage, ongoing contamination, and persistent malignancy hinder suc-
cessful spontaneous healing of such cavities. In these situations the cavity margins
become increasingly brotic and unyielding with a poor blood supply, which results
in prolonged unsuccessful courses of tube drainage or dressing changes.
FISTULA
Fistulous tracts between the tracheobronchial tree and the pleural space
(bronchopleural stula), skin (bronchocutaneous or pleurocutaneous
stula), or other adjacent structures (for example, bronchobiliary) may
develop as a result of not only aspiration pneumonia or surgical or
nonsurgical empyema, but also bacterial infection of a pulmonary in-
farct or traumatic or iatrogenic invasions of the pleural space.
These entities include transbronchial lung biopsy or pleural biopsy, errant thoracen-
tesis or thoracostomy tube insertion, and inadequate bronchial closure or healing af-
ter pulmonary resection.The risk factors for poor bronchial stump healing include
preoperative radiation therapy, residual bronchitis or carcinoma at the site of the
bronchial stump closure, or inadequate tissue for bronchial stump closure.
Surgical closure of the stulas is important for repair unless the air leak merely re-
sults from multiple small peripheral air leaks in a poorly drained cavity, which of-
ten will respond to improved pleural drainage. Otherwise the stulas must be closed
with thorough debridement or resection of abnormal tissue, meticulous dissection
of the stula tract, and elimination of the related cavity.
When the surgeon prepares to perform a thoracic reoperation for treatment of
empyema or bronchopleural stula, the treatment options include a combination of
resection and collapse of the chest wall with closure of any bronchial leak (by alter-
nate exposure if necessary) and obturation of the wound with as much vascularized
tissue as possible.Thus the size, geometric shape, and location of the cavity, as well
as the reconstructive units still available, help to determine which combination of
options is chosen for such treatment.
Thoracoplasty obliterates empyema cavities by collapsing the chest wall into the
cavity. Decortication or empyemectomy allows expansion of the restricted lung.
The cavity can also be obturated with well-vascularized tissue or flaps. Tho-
racoplasty, although effective in some cases, has the disadvantage of producing a se-
vere deformity and fails to recruit well-vascularized tissues to the cavity walls, par-
ticularly when they have been previously damaged by radiation therapy. However,
thoracoplasty is quite useful as an adjunct to muscle ap reconstruction because it

helps to achieve adequate exposure for reexploration, resectional debridement, s-
tula repair, ap tunneling, ap access and inset, and modest cavity size reduction.
Empyemectomy or decortication is tedious to perform and can result in signi cant
blood loss and multiple iatrogenic peripheral pulmonary air leaks. However, it does,
reduce contamination and allow lung expansion. In this way it is a valuable adjunct
to the obliteration of empyema cavities. Instillation of broad-spectrum antibiotic so-
lutions into such cavities (for example,Clagett procedure) has shortcomings—it can-
not neutralize unreasonable levels of bacterial contamination or achieve what aggres-
sive resectional debridement and vascularized tissue reconstruction can provide.
However, this technique can be an adjunctive maneuver in the staged closure of
large bronchopleural stulas or empyema cavities. In cases in which there is a pro-
found mismatch between cavity size and tissue available for reconstruction,a second-
stage closure of the large cavity can be achieved once stula closure is accomplished.
The preoperative analysis of the particular problem or problems culpable for the re-
current or persistent disease process will also determine the extent to which each
of these issues must be addressed. In cases of reoperation for chest wall malignancy,
an assessment of the extent of disease and the palliative versus curative nature of the
operation will determine the degree of aggressiveness that will characterize the
proposed operation.
In addition to surgical options reviewed before the planned procedure, thought
must be given to options for adjuvant treatments that are available such as external
beam or interstitial seed radiation therapy. Another consideration that may need to
be addressed, especially in instances of multiple reoperation and/or radiation ther-
apy for recurrent or persistent malignancy, is whether to replace or bypass involved
or threatened vascular structures.
Flaps available for reconstruction of defects in this region typically include the pec-
toralis major, latissimus dorsi, serratus anterior, trapezius, rectus abdominis, external
oblique, greater omentum, and free flaps. In reoperative cases, of course, one or
more of these units, in whole or in part, typically will have been rendered unusable.
In cases in which the extent of the defect resulting from the resection exceeds the
ability of available tissues to readily ll it, reconstruction with microvascular free
aps, or a combination of newer ap techniques and older techniques such as tho-
racoplasty or staged closure over instilled antibiotic solution, can be helpful.
PREOPERATIVE PREPARATION
The anesthesiologist must have a working knowledge of a number of relevant tech-
niques in addition to the usual general anesthetic and perioperative critical care. A
familiarity with the use of differential lung ventilation, double-lumen endotracheal
tubes, and high-frequency ventilation is necessary.
1567
Chapter 40
Reoperative Surgery of the Chest Wall

1568
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The double-lumen endotracheal tube is invaluable for differential lung ventilation.
With this device, exposure can be maximized by single-lung ventilation while an
operative intervention is proceeding within the contralateral pleural space. Fur-
thermore, intraoperative air leaks and cross-tracheal bacterial contamination of the
lungs can be minimized in this manner. Postoperatively, differential lung ventilation
may be maintained with this tube.

This modality is used to (1) prevent contamination caused by the spillage of secre-
tions from the abnormal to the normal lung, (2) differentially de ate the involved
lung to achieve improved exposure, or (3) help maintain adequate ventilation using
high-frequency ventilation while minimizing the escape of air through the prob-
lematic bronchial stula or bronchial closure.
Epidural catheter placement for postoperative analgesic administration helps to
minimize postoperative pain and splinting, thus preventing postoperative pul-
monary complications. At times the assistance of the perfusion team may be needed
to make partial or total cardiopulmonary bypass available, or to reinfuse shed blood
in select dif cult cases. Reinfusion of shed blood is to be avoided in a contami-
nated wound. Thus this technique is problematic in cases of empyema and bron-
chopleural reconstruction.
Appropriate patient positioning is critical to trouble-free reconstructive sequence.
Access to all necessary reaches of the thorax must be ensured for resection, de-
bridement, ap elevation, and inset. Use of the beanbag is invaluable to satisfactory
patient positioning when lateral decubitus positions are required intraoperatively. In
some operations it may be necessary to prepare for the possibility that multiple pa-
tient positions may be required at the same operative setting. In these cases appro-
priate cleansing of the patient, draping, and positioning must be performed to allow
intraoperative changes in the patient’s position with a minimum of encumbrances
or disruptions to the procedure.
Achieving this end requires that the anesthesiologist avoid placing intravenous or
arterial lines, or other monitoring devices at sites that may need to be used during
the procedure. It is preferable to prepare and expose entire extremities to allow the
following: (1) monitoring of hand perfusion when the subclavian-axillary axis is
involved; (2) determining availability of vein graft donor sites if vascular recon-
struction is a possibility; and (3) harvesting of skin grafts when necessary. In addi-
tion, the groin is left exposed and femoral pulses are veri ed to prepare for the
contingency that partial femoral bypass may need to be implemented.
When combinations of anterior, lateral, and/or posterior trunk exposure are nec-
essary, it is most helpful to prepare the areas that may be required during the sec-
ondary portions of the procedure, secure the drapes with staples or skin sutures, and
then turn the patient to the position that will be needed for the initiation of the
procedure.This preparation can be performed completely with the patient on the
beanbag so that turning of the patient can be accomplished intraoperatively with a
minimum of disruption or redraping. Care should be taken to secure the endotra-
cheal tube—if necessary, to a tooth—and suture sterile cardiogram leads and other
lines into place so that they will be maintained during the position change.
1569
Chapter 40
Reoperative Surgery of the Chest Wall

1570
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
In certain reoperative or complex operative procedures it may be necessary to have
virtually the entire thorax exposed at one time or another during the procedure. In
these cases it is feasible to prepare the patient circumferentially before the admin-
istration of the anesthetic. The patient is awake and standing during this prepara-
tion.The patient then reclines on a sterile sheet, beneath which a second impervi-
ous sheet has been placed. Next, another sterile sheet is placed over the patient,
and towel clips are used to secure the cuffs of the two sheets to each other at the
neck for the induction of anesthesia.The patient is then uncovered, with the super-
cial sheet being folded up to the anesthesiologist.
Transvenous (that is, jugular) catheters can be placed above the cuffed drapes at this
time. Sterile arterial lines can be inserted aseptically after preparation and draping.
In addition, a groin cloth is secured with sutures or clips. Any extremities that may
not require exposure during the operation, and that will not encumber the turn-
ing of the patient or intraoperative exposure if draped, can then be draped out of
the eld with appropriate cuffed sheets or stockinettes.
TECHNIQUE
At this point, with provisions for comprehensive exposure and monitoring exe-
cuted, the necessary antibiotics are administered and the operation commences. In
tumor cases the desired margin of resection is outlined and circumscribed with a
margin of 4 to 6 cm in the soft tissue and one to two ribs and interspaces beneath.
It is particularly useful to enter the underlying pleural space, if it is not obliterated
by adhesions from prior operations, early in the resection to assess the underlying
anatomy, pulmonary adhesions, or intrapleural or parenchymal spread of tumor.
The surgeon’s bidigital or bimanual examination can thus also facilitate an expedi-
tious, effective, and safe extirpation by “cutting down” toward the underlying hand
at each margin. At this point any central resectional adhesions or tumor involve-
ment can be evaluated, and if necessary, pulmonary resection can be performed
with improved exposure in an en bloc fashion.
Often in reoperations in this setting, adhesions to underlying lung or neurovascu-
lar structures necessitate careful dissection to and exposure of structures at the pe-
ripheral margin of resection, with the subsequent painstaking separation of the un-
derlying vital structures from the overlying tumor.When it seems evident that the
tumor invades the underlying structures, vascular resection with bypass or place-
ment of interstitial radioactive seeds may be indicated. It is advisable to examine the
specimen personally with the pathologist so that the complex three-dimensional
anatomy and orientation can be maintained and appropriate frozen section studies
can be obtained to further assess the diagnosis and adequacy of resection.

PATIENT EXAMPLES
1571
Chapter 40
Reoperative Surgery of the Chest Wall
Twenty- ve years earlier this 71-year-old woman underwent radical mastectomy
for carcinoma of the breast. She was without evidence of disease until an infracla-
vicular local recurrence was excised locally 2 years before referral. External beam
radiation therapy to the entire mastectomy site including the clavicular region was
administered.
For 2 months she had noticed a new 2.5 cm area of dense nodularity adherent to
the clavicle. Multiple 2 to 3 mm super cial nodules were also found overlying this
area.There was no evidence of other local, regional, or systemic disease.Vascular ex-
amination of both upper extremities was normal. The ipsilateral latissimus dorsi
muscle was innervated. Other than the clavicular mass, a CT scan of the chest and
arteriogram were unremarkable.The thoracodorsal artery was patent.
At operation the patient was placed on the beanbag. The chest, abdomen, back,
and the upper and lower extremities were prepared.The drapes were stapled to the
posterior midline of the trunk. In this manner the area of resection, latissimus dorsi,
rectus abdominis, and omental ap donor sites, and skin and vein graft donor sites
were all readily available without redraping. Furthermore, the right arm and axilla
availability allowed ongoing intraoperative vascular examination or upper extrem-
ity bypass contingencies.

1572
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
Wide resection of the recurrent breast carcinoma with claviculectomy was per-
formed, with a dif cult dissection of the subclavian vessels.The frozen section mar-
gins at the subclavian vessels were positive for tumor. Because of the dense radia-
tion brosis, the vessels were not excised. Instead, iodine 125 radioactive seeds were
implanted on the areas of positive margins.
The wound was then reconstructed with a right latissimus dorsi musculocutaneous
ap, preserving the serratus collateral vessels. Despite interval eschari cation of the
distal tip of the skin island in the setting of prior and ongoing radiation, the wound
healed well. The patient is doing well without clinical evidence of disease 3 years
later.

When possible, prior incisions should be used, speci cally thoracotomy incisions,
to unroof the musculoskeletal structures overlying the empyema cavity. A central
bony-cartilaginous window is made into the underlying defect, and an assessment
is made of the extent of the cavity and the number and extent of rib resections
that must be performed.
It is crucial to adequately expose the cavity just to and slightly beyond its margins
by adequately removing the overlying ribs. This maneuver allows adequate expo-
sure of the cavity for debridement and repair of any contamination, debris, or s-
tulas that may be present. Furthermore, it exposes the cavity adequately enough to
facilitate comfortable ap inset and to completely obturate the defect with vascu-
larized tissue and prevent the persistence of potential spaces beneath the bony mar-
gins of the wound.
This resection of bone and cartilage and unroo ng of the defect is performed in a
rib-by-rib piecemeal fashion with subperiosteal and subperichondrial dissections,
preserving the periosteal and intercostal aps above and below the old thoracot-
omy site. Likewise, the sites of prior division of the latissimus dorsi, serratus ante-
rior, and the pectoralis major muscles from prior thoracotomies are preferentially
reincised to preserve any remaining bulk of these muscles’ remnants for possible
reconstructive use as they are elevated for the debridement or resection.
Any exposed rib or clavicular margins, especially when they are cartilaginous, are
debrided beyond the wound margin so that they are adequately covered by sur-
rounding soft tissue because they are particularly prone to desiccation, smoldering
contamination, or radionecrosis. Any underlying granulations are curetted when
they are situated on vital organs, but the more peripheral wound surfaces are de n-
itively resected back to normal tissue to reduce contamination and to achieve bet-
ter potential for healing.
To successfully close any thoracic wound, the issue of bronchial stula or periph-
eral air leaks must be de nitively addressed. Otherwise, stula, infection, subcuta-
neous emphysema, and/or recurrent wound will usually occur. Severe obstructive
pulmonary disease will also predispose to recurrence of peripheral air leaks.
Fistulas of the large airways will seldom heal without de nitive dissection and re-
pair. In addition to inadequate primary technical closure of the airway, common
causes include persistent in ammation or infection at the bronchial margin, resid-
ual tumor, and residual foreign body, especially in the presence of contamination.
These problems must be ruled out at the time of closure.
1573
Chapter 40
Reoperative Surgery of the Chest Wall

1574
PART IV
R EOPERATIVE SURGERY OF THE BREAST AND CHEST WALL
The 20-year-old patient whose radiograph is shown above (left) had undergone
multiple procedures since birth for tricuspid atresia. The most recent operation,
which was performed by another surgeon, was a Blalock-Taussig (left subclavian to
pulmonary artery) shunt with Gore-Tex at the age of 15 years. The patient was
left with an initially asymptomatic left apical pleural cavity measuring approxi-
mately 10 by 8 cm on chest radiograph.The operative note of the last procedure re-
ported that there were numerous bloody adhesions and multiple air leaks encoun-
tered in the dif cult reoperative thoracotomy.
Although asymptomatic for a number of years, the patient recently had an increas-
ingly severe chronic cough with occasional episodes of hemoptysis and coughing
up of surgical hemoclips. Radiographically the cavity had diminished in size slightly
during the past 1 to 2 years. Based on these clinical and more recent radiographic
findings (an associated air bronchogram), the diagnosis was considered to be a
chronic bronchopleural stula.
The prior operations had been performed through a right anterior thoracotomy ex-
tending to the midsternum.This approach violated the right pectoralis major muscle
and the right internal mammary artery.Two other operations had previously been
performed via a posterolateral thoracotomy on the left that violated the latissimus
dorsi and serratus anterior muscles. A preoperative angiogram (right) revealed par-
tial proximal occlusion of the Gore-Tex subclavian–pulmonary artery bypass graft.
The decision was made to explore the left apical pleural cavity and to attempt to
debride and reconstruct it with vascularized tissue. At operation the left apical pleu-
ral cavity was exposed through the previous posterolateral thoracotomy.There was
dense adhesion formation, and the dissection that was required to expose the cav-
ity was quite dif cult, with continuous bleeding from multiple chest wall collateral
vessels and multiple small peripheral air leaks from the pulmonary dissection.