Management of ASA III and IV Patients for Chest-Wall Reconstruction

The authors reported on their treatment of a small group of patients with recurrent cancer/osteoradionecrosis of the chest wall or sternum osteomyelitis. The patients qualified for this group by being ASA III or IV and having had multiple previous operations (El Oakley III to V). All patients needed a free flap as the alternative options of the reconstructive ladder were no longer available.

Between March 1997 and March 2004, 14 patients were operated on (cancer/osteoradionecrosis − 7; sternum osteomyelitis − 7). There were 11 females and 3 males with an average age of 61.9 years (range: 54-82 years). All patients received a free tensor fasciae latae (TFL) fflap.

No flap was lost. The anastomoses had to be revised in three cases with subsequent uneventful course. The operating time was 6.1 hr on average (range: 4.7 to 8.4 hr). The procedure was always performed by two teams and no repositioning was necessary. The postoperative ventilation time was 180.7 hr on average (range: 9–338 hr). The mean hospital stay was 51 days (range: 13–135 days). Five patients died within 6 months postoperatively due to their underlying chronic illness (3 ×) or multiple organ failure (2 ×).

The free TFL flap remains the flap of choice in these seriously ill patients with chest-wall reconstruction. It is reliable and easy to harvest without a noticeable donor-site morbidity. The semi-rigid layer of the fascia lata is an important component of the flap that provides additional structural support at the site of the chest-wall reconstruction. Within the latest five cases, the descending branch of the lateral circumflex femoral artery was included in the flap, and a combined TFL/ALT free flap was raised. This modification augments the blood flow to the former distal part of the TFL and helps overall flap survival. The authors also anastomose the flap to a loop that runs from the cephalic vein to the thoracoacromial artery. With this maneuver, the recipient vessels are readily available at the time of the anastomosis and positioning of the flap is much easier. Although five of 14 patients were lost within 6 months postoperatively, a persisting, fungating defect that is painful, infected, and bleeding is hardly an alternative for the patient's remaining life span.