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.
