Study Supports Nonrigid Fixation for Chest Wall Reconstruction

Dr. Hanna replied that the retrospective nature of the series did not allow pulmonary function testing, and that the thoracic surgery community views such testing as less than ideal after reconstruction of the chest wall. A better measure is home oxygen use or limitation of daily activities, neither of which were observed in the cohort.

Dr. Hanna agreed that mesh infection is a highly morbid situation, especially with methacrylate or metallic prostheses, and that one of the benefits of soft prostheses like Vicryl or Gore-Tex is that they are able to respond to antibiotics.

Dr. Gerald Larson of University Surgical Associates in Louisville, Ky., who was also invited to discuss the study, asked how closure was achieved when mesh and a flap were not used, and why mesh and a muscle flap weren’t used for all patients.

Dr. Hanna responded that the risk of surgical site infection kept them from closing all patients with mesh and a muscle flap. The ideal method for closure is to mobilize enough local muscle that is present in the chest wall to reapproximate the muscle, and to close with skin without having to rotate a pedicle flap. When this is impossible, the defect has to be filled, and most surgeons at his institution elect to use soft mesh for the larger defects.

"In 75% of the time, on top of the mesh, we still mobilize a subcutaneous flap to cover the mesh because of the theoretical perception that a flap on top of the mesh would provide a good oxygenated environment and would decrease the rate of infection," Dr. Hanna said. The risk of surgical site infection kept them from closing all patients with mesh and a muscle flap, he added.

Dr. Hanna and his coauthors reported no relevant conflicts of interest.