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doi:10.1510/mmcts.2005.001784
Chest wall and sternal resection and reconstruction
Sridhar Rathinam*, Pala B. Rajesh, Francis J. Collins
Regional Department of Thoracic Surgery, Birmingham Heartlands Hospital, Bordesley Green
East, Birmingham BS9 5SS, UK
Chest wall resection is performed for a variety of conditions and has been a complex
problem in the past due to intraoperative technical difficulties, surgical complications, and
respiratory failure. Advances in the fields of surgery and anaesthesia and the team effort of
the involved thoracic and plastic surgeons result in more aggressive resections with good
results. The surgical technique of sternal excision and reconstruction with a Marlex
methacrylate composite prosthesis as a part of chest wall resection and reconstruction
series is described here in this chapter.
Keywords: Chest wall resection; Sternal reconstruction; Tumour; Marlex methacrylate mesh

Introduction
Chest wall resection is performed for a variety of
conditions such as primary and secondary tumours of
the chest wall or the sternum, lung cancer, infections,
radio necrosis and trauma w1x.
Chest wall reconstruction has been a complex
problem in the past due to intraoperative technical
difficulties, surgical complications, and respiratory
failure caused by the chest wall instability and
paradoxical respiratory movements w2x. Advances in
the fields of surgery and anaesthesia and the team
effort of the involved thoracic and plastic surgeons
result in more aggressive resections. Nowadays
neither the size nor the position of the chest wall
defect limits surgical management, because resection
and reconstruction are performed in a single
operation that provides immediate chest wall stability
w1x.
Chest wall resection involves resection of the ribs,
sternum, costal cartilages and the accompanying soft
tissues and the reconstruction strategy depends on
the site and extent of the resected chest wall defect
w3x. Sternal resections and reconstructions have long

* Corresponding author: Tel.: q44-121-4242561; fax: q44-
1214240562.
E-mail: srathinam@rcsed.ac.uk
2007 European Association for Cardio-thoracic Surgery
been a challenge for surgeons, due to the difficulty in
making full-thickness resections without
compromising the stability and reconstruction of the
thoracic wall, but improvements in surgical techniques
now make it possible to perform even total
sternectomies with good results w4, 5, 6x.
Careful radiological investigation is necessary to
assess the extent of the tumour, as the mass evident
on examination is often part of a much larger tumour
invading the sternum. CT scans have become the
mainstay of imaging to evaluate the extent of the
tumour and search for pulmonary metastases w7x.
Highresolution scans and reconstructed images may
help assess the extent of the primary tumour,
particularly with respect to mediastinal invasion. MRI
scans are useful for assessment of mediastinal
invasion of the pericardium, heart, or great vessels.
Pulmonary function testing is important in patients
with chronic obstructive pulmonary disease, in the
elderly and in patients needing wider resection, as
this will have a bearing on the postoperative chest
wall mechanics and respiratory function.
Establishing a histological diagnosis is important and
this is performed by a core needle biopsy or an inci-
S. Rathinam et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2005.001784

sional biopsy, however, it should be borne in mind to
place the biopsy in a site where it will be excised
during the surgery.
Surgery is now considered the best therapeutic
choice in most cases of primary sternal tumours w6x.
Various prostheses are available for reconstruction of
sternum and anterior chest wall w8, 9x. If the defect is
small then a synthetic mesh is used to cover the
defect with soft tissue over it. However, if the defect is
large then a composite prosthesis is created with
methyl methacrylate and Marlex or PTFE mesh.
The surgical technique of sternal excision and
reconstruction with a Marlex methacrylate composite
prosthesis as a part of chest wall resection and
reconstruction series is described here in this chapter.
Procedure
Brief clinical history
A 26-year-old female presented with a swelling in the
front of her chest of one year duration with a recent
increase in size. She had intermittent pain on the
swelling on sneezing and coughing. She did not have
any loss of appetite or weight. She had a scar in the
front of her sternum and with a noticeable swelling
measuring 3 cm across which was quite tender on
deep palpation. The rest of her physical examination
was within normal limits.
Preoperative assessment
Accurate imaging is mandatory to evaluate the
resectability of chest wall conditions warranting
resection and reconstruction. CT scan is the mainstay
of imaging for chest wall conditions with the recent
threedimensional reconstruction giving the surgeon
more information in planning the operation. The CT-
scan of the thorax showing the tumour in the sternum
(Photo

Photo 1. CT scan demonstrating the sternal tumour.
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Photo 2. Reconstructed sagittal image of the sternum
demonstrating the tumour.
1) with the reconstructed sagittal image of the
sternum demonstrating the extent and thickness of
the tumour (Photo 2). The MRI confirmed that there
was no mediastinal infiltration (Photo 3).
Pulmonary function tests, cardiac evaluation are
important in assessing operative risk especially in
cases involving pulmonary resection as well.
Histology is established prior to the procedure either
by a trucut or incisional biopsy. If incisional biopsy is
performed the scar is placed in such a way it can be
excised with the specimen. Our patient had an
incision biopsy which was suggestive of a low grade
chondrosarcoma.
S. Rathinam et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2005.001784
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Photo 3. MRI scan showing the tumour and absence of any
mediastinal involvement.
Positioning of the patient
The patient is anaesthetised and ventilated with a
double-lumen endotracheal tube. An epidural catheter
is inserted for pain control in the perioperative period.
The patient is placed on the table in a supine position
with a roll between the scapulae and the chest is
prepared and draped.
Incision
The incision starts at the level of the manubriosternal
joint and extends inferiorly to the xiphisternum
excising an elliptical segment of skin incorporating the
biopsy scar. The subcutaneous tissues are then
dissected and divided using diathermy. The pectoral
muscles are dissected off as flaps from the costal
cartilages on both sides (Video 1).
The lesion is then identified, defined and the extent of
resection is assessed. The extent of the tumour is
delineated after dissection of the xiphisternum and
dissecting up to the costal cartilages (Video 2).
Division of the costal cartilages and sternum
The internal mammary arteries are identified, ligated
and divided on both sides (Video 3).
The costal cartilages are then divided giving adequate
tumour clearance of 5 cm. The intercostal cartilages
are divided with a sternal saw and care is taken to
identify, ligate and divide the intercostal vascular
bundle (Video 4). The sternum is then divided with the
sternal saw and scissors (Video 5).
Assessment of the defect and measurements
The resection results in a defect in the anterior chest
wall exposing the pericardium and right lung. The
defect in the anterior chest wall is then assessed for a
good clearance margin on all sides and the prosthesis
is sized. Our choice for reconstruction is a com-

Video 1. The incision is made from manubriosternal joint to
xiphisternum. The pectoral muscles are dissected with diathermy to
create flaps.

Video 2. The intercostal spaces are dissected and the mammary
artery is identified.

Video 3. The internal mammary arteries are transfixed and ligated.

Video 4. The intercostal spaces are defined and the costal cartilage
is divided with the sternal saw serially on both sides. The
intercostal vascular bundle is ligated and divided.
S. Rathinam et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2005.001784


Video 5. The sternal excision is completed by dividing the
xiphisternum with Mayo scissors. The divided distal mammary
artery is controlled and ligated.
posite Marlex methyl methacrylate prosthesis. The
Marlex mesh (MMCTSLink 138) is folded and placed
on the defect and assessed (Video 6).
The mesh is sewn as a double breast using nylon to
create the prosthesis. The Marlex mesh thus created
has a small gap to instill the methyl methacrylate. The
methyl methacrylate with gentamycin is stirred to a
paste-like consistency and instilled into the Marlex
pouch. It is carefully smoothed and uniformly spread
inside the pouch. The sandwich is moulded to suit the
contour of the anterior chest wall (Video 7).
Reconstruction of the defect
The sandwich is then fixed to the defect with
interrupted O/ vicryl sutures (MMCTSLink 38). After
plac-

Video 6. The defect in the sternum exposing the pericardium and
right lung is assessed. The mesh is placed on the defect to size the
defect and marking stitches are placed to define the extent.

Video 7. The prosthesis is prepared by sewing with nylon suture
with a small opening to inject methyl methacrylate. The prepared
prosthesis is moulded to shape after instilling the methyl
methacrylate.

Video 8. The defect is reconstructed with the prosthesis by placing
interrupted vicryl sutures in all corners.
Table 1. Results after sternal reconstruction.

Video 9. The prosthesis is secured by semi-continuous run of vicryl
after placing a redivac drain behind the prosthesis. The pectoral
muscles are then reattached to the costal cartilages and the
prosthesis, and sutured then in the midline to cover the prosthesis.
The subcutaneous tissue and skin are closed in layers.

Video 10. The resected tumour.

S. Rathinam et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2005.001784
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Photo 4. Postoperative CT scan demonstrating the neosternum.
ing the mesh into a satisfactory position, the edges
are secured with continuous runs of vicryl sutures to
the costal cartilages (Video 8).
Once the composite prosthesis is in place the pectoral
muscles are reattached to the costal cartilages and
the prosthesis. The pectoral muscles and presternal
fascia are sutured together in the midline to cover the
composite prosthesis. Redivac drains are positioned
in the mediastinum behind the neosternum and
behind the pectoral muscles. Both drains come out
through separate stab incisions; fixation is provided
by purse string suture. After securing haemostasis,
the subcutaneous layer is approximated with
continuous absorbable suture (1 vicryl), with the
closed suction drainage underneath. Skin is closed by
a running subcuticular suture using non-absorbable
material (4 0 prolene with beads - MMCTSLink 144)
(Video 9).
The resected specimen is measured and sent for
histological examination (Video 10). The histology
confirmed the diagnosis of a Grade I chondrosarcoma
of the sternum with complete excision margins. The
patient had a satisfactory cosmetic and function
outcome and the prosthesis was found to be sitting
well in a follow-up CT scan (Photo 4). Her
postoperative respiratory function was preserved with
an FEV1 of 3 l.
Results
The surgical results of sternal reconstruction are good
(Table 1). Though this procedure is surgically
demanding and technically challenging, good
cosmetic and functional results are achieved with
minimal operative mortality w5x. Morbidity includes
seroma, local infection, systemic sepsis and graft
necrosis and infection w10x. The long-term results in
these patients depend on the nature of the primary
lesion with five-year survival ranging from 46% to 66%
w11x.
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Author Patients Year published Operative mortality 5-Year survival Reference
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Lequaglie C 88 2002 1% 51% w4x
Mansour KA 56 2002 Not defined NA w9x
Incarbone M 52 1997 None 46% w5x
Martini N 40 1996 5% 1480% w6x
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