GOT YOU COVERED: BIOLOGIC MESH AND OMENTAL FLAP REPAIR OF NECROTIC CHEST WALL MASS
K Wempe, GP Wright
Spectrum Health Hospitals
Patient is 62 year old male who presented in June of 2019 to the surgical oncology office with a complex history of chest wall squamous cell carcinoma. The ulcerated mass extended into the sternum and had a singular metastatic axillary lymph node (Top left picture). Radiotherapy to the primary site and axilla was performed which was complicated by seve0re wound necrosis. This wound continued to necrose to expose sternum, multiple ribs, and eventually patient presented with severe acute bleed from an exposed chest wall vessel requiring intervention. At this presentation, imaging confirmed resolution of the metastatic lymph node but local recurrence adjacent to the open chest wound.
After conferring with cardiothoracic surgery, the patient underwent a radical resection of the involved skin, subcutaneous tissues, sternum, and the right second through sixth ribs (top right picture). To cover exposed intrathoracic organs, a biologic mesh was secured in an underlay fashion to the remaining ribs and associated soft tissue. This was covered with an omental flap that was brought into the chest through a small diaphragmatic defect (bottom left picture). The entire wound was treated with negative pressure wound vac therapy. His inpatient course included a prolonged surgical intensive unit stay with early tracheostomy.
Post-operatively, he had approximately 90% take of his omental flap. The superior most portion did necrose and required debridement. Six weeks following his initial operation, he retuned to the operating room for a split-thickness skin graft from his thigh. He was initially fitted for a chest guard due to lack of bony structures but was decannulated after a few weeks. He has since returned to normal function. The below pictures show his wound progression and ultimate healing. He is one year out from his operations without evidence of recurrence.
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