Complex chest wall reconstruction after failure: a literature review

Background and objective: Primary and secondary chest wall tumors (bone, breast, and soft tissue), congenital defects, and chest wall osteoradionecrosis often require extensive full-thickness local excisions to guarantee safe oncological margins (in cases of tumors) and complex reconstruction to provide stabilization and good biomechanical results avoiding postoperative respiratory failure. Thus, a personalized approach is required when dealing with chest wall defects, and reconstruction is planned. This review summarizes failed chest wall reconstruction procedures, identifies causes of failure, and highlights principles for complex chest wall reconstruction post-failure. Methods: We performed a narrative review of the literature on PubMed, Scopus, ScienceDirect, and Google Scholar, including all the relevant studies published from 1970. Key content and findings: The available experiences in literature are only anecdotic and no current guidelines or rules exist on this topic, also given to its rarity. Proper pre-surgical planning and a multidisciplinary team (MDT) discussion are crucial for complex cases such as infections and radiation-induced chest ulcers after previous surgical treatment. Procedures should eventually include thoracic wall debridement, necrotic tissue excision, pulse-jet lavage, prosthesis removal, and vacuum assisted closure (VAC) therapy as a bridge for chest wall re-reconstruction. Sternotomy wounds require wire and prosthesis removal, and the use of meshes or bone allografts. This review aims to summarize experiences and highlight surgical and oncologic principles for complex chest wall reconstruction after failure. Conclusions: This review summarizes literature experiences to identify common key points for chest wall reconstruction after failure and to give some advice to surgeons managing this rare, challenging surgery.