interest-of-myocutaneous-plasty-after-extended-sternal-resection-2161-

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The thoracic wall has a major static and dynamic role in respiratory function, which explains the need for efficient repair after parietal resection. Thoracic wall reconstruction is commonly performed by using muscle flaps or prosthetic materials.

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Volume 8 • Issue 1 • 1000447 J Pulm Respir Med an open access journal ISSN: 2161-105X Journal of Pulmonary Respiratory Medicine ISSN: 2161-105X Journal of Pulmonary Respiratory Medicine Ayed et al. J Pulm Respir Med 2018 8:1 DOI: 10.4172/2161-105X.1000447 Case Report Open Access Interest of Myocutaneous Plasty after Extended Sternal Resection Ahmed Ben Ayed Abdessalem Hentati Walid Abid Iyadh Ghorbel and Khalil Nouri Department of Thoracic Surgery Respiratory Medicine Hedi Chaker University Hospital Sfax Tunisia Abstract Background: Thoracic wall reconstruction is commonly performed by using muscle faps or prosthetic materials. We try through this article to show the possibility of myoplasty in extended thoracic wall resections. Case report: A 33-year-old woman had been treated by chemo-radiotherapy for undifferentiated carcinoma of the nasopharyngeal type. The CT-scan completed by magnetic resonance showed a 10 cm sternal mass centered by the manubriosternal articulation with an infltration of left and right second sternocostal joints and intercostal muscles. The diagnosis of a single sternal metastasis of nasopharyngeal carcinoma was established. After the resection of anterior arc of right ribs from the frst to the third resection of internal right clavicle edge transverse sternotomy above xiphoid process resection of anterior arc of left ribs from the frst to the third resection of internal left clavicle edge sternal tumor and sternal body were removed en-bloc without a 2 cm residual extension which was marked by metallic clips. A myocutaneous plasty using pectoralis major and pectoralis minor muscles covered the chest wall defect after the release of the pectoralis major from its humeral attachment. The postoperative course was uneventful. Residual tumor was treated by radiotherapy with no disease recurrence sign for 3 years later. Conclusion: The choice of muscle to use depends on the location and the extent of the defect to be repaired. The knowledge of the anatomy of the muscles is essential to obtain a good quality fap. Corresponding author: Ahmed Ben Ayed Department of Thoracic Surgery Respiratory Medicine Hedi Chaker University Hospital Sfax Tunisia Tel: 21623935354 E-mail: ahmed.benayed.tunisiagmail.com Received January 21 2018 Accepted February 16 2018 Published February 23 2018 Citation: Ayed AB Hentati A Abid W Ghorbel I Nouri K 2018 Interest of Myocutaneous Plasty after Extended Sternal Resection. J Pulm Respir Med 8: 447. doi: 10.4172/2161-105X.1000447 Copyright: © 2018 Ayed AB et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License which permits unrestricted use distribution and reproduction in any medium provided the original author and source are credited. Keywords: Nasopharyngeal carcinoma Sternal resection Chest wall reconstruction Myocutaneous plasty Introduction Te thoracic wall has a major static and dynamic role in respiratory function which explains the need for efcient repair afer parietal resection. Toracic wall reconstruction is commonly performed by using muscle faps or prosthetic materials 12. Because the use of prosthetic materials can be impossible in certain situations we try through this article to show the possibility of myoplasty in extended thoracic wall resections. Case Report A 33-year-old woman had been treated by chemo-radiotherapy 2 years previously for undiferentiated carcinoma of the nasopharyngeal type UCNT classifed T4N1M0 with a complete remission. She was presented at our department with a presternal swelling measuring 10 cm diagnosed during the oncological follow-up as a single UCNT metastasis. Te CT-scan completed by magnetic resonance Figures 1A and 1B showed a 10 cm sternal mass cantered by the manubriosternal articulation with an infltration of lef and right second sternocostal joints and intercostal muscles. Te tumor had a contact with the aorta cross and the lef brachiocephalic veins without an encroachment signs. Te diagnosis of a single sternal metastasis of nasopharyngeal carcinoma NPC was established afer a percutaneous biopsy. Considering the age of the patient her good performance status and the unique metastasis the decision of a resection surgery followed by local radiotherapy was taken by a multidisciplinary meeting including thoracic surgeon plastic surgeon oncologist radiologist and radiotherapist to increase survival and to improve quality of life. Surgical resection Afer the resection of anterior arc of right ribs from the frst to the third resection of internal right clavicle edge transverse sternotomy above xiphoid process resection of anterior arc of lef ribs from the frst to the third resection of internal lef clavicle edge a 2 cm residual tumor extension was discovered sheathing the phrenic nerve encroaching the pulmonary artery trunk and the lef subclavian vein. Given the major surgical risk of a complete resection sternal tumor and sternal body were removed en-bloc without the 2 cm residual extension which was marked by metallic clips Figure 2A-2C. Wide enough margins were respected to eliminate other residual malignant tissue. A large anterior thoracic wall defect exposing mediastinum and medial portions of lungs needed an immediate reconstruction to cover sof tissue mediastinum lef and right pleural cavities and to preserve respiration mechanical forces. Reconstruction and result A Myocutaneous plasty using pectoralis major and pectoralis minor muscles covered the chest wall defect afer the release of the pectoralis major from its humeral attachment Figure 3A. Te postoperative course was uneventful except an anterior paradoxical respiration with no functional impact. Te patient was discharged on postoperative day 7. Tree months afer the operation the patient started strengthening her anterior chest wall and paradoxical respiration movements decreased Figure 3B. Residual tumor was treated by radiotherapy with no disease recurrence sign for 3 years later.

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Citation: Ayed AB Hentati A Abid W Ghorbel I Nouri K 2018 Interest of Myocutaneous Plasty after Extended Sternal Resection. J Pulm Respir Med 8: 447. doi: 10.4172/2161-105X.1000447 Page 2 of 3 Volume 8 • Issue 1 • 1000447 J Pulm Respir Med an open access journal ISSN: 2161-105X Discussion Indication and surgical resection Skeletal metastases of NPC occur in ribs and sternum in 7.8 of all skeletal metastases. Ma et al showed the impact of surgery associated or not to chemotherapy in solitary lung UCNT metastasis compared to radiotherapy or chemotherapy alone. Te resection increased survival rate to 60.7 at 3 years versus 56 with radiotherapy the mean progression-free survival to 80.5 months versus 37.8 months with radiotherapy and the mean overall survival to 82.4 months versus 49.6 months with radiotherapy. But solitary skeletal or sternal UCNT metastasis survival afer surgery is not studied in the literature. In our case the patient survived up to 24 months with a good quality of life afer surgical resection followed by radiotherapy. Reconstruction Pectoralis major fap was used the frst time in 1968 by Hueston to repair a loss of sternal substance. By transposing the muscle the Figure 1: A CT-scan and B MRI showed a 10 cm sternal mass centered by the manubriosternal articulation infltrating left and right second sternocostal joints and intercostal muscles with a contact with the aorta cross and the left brachiocephalic veins without an encroachment signs. Figure 2: A Resection of anterior arc of right ribs from the frst to the third resection of internal right clavicle edge transverse sternotomy above xiphoid process resection of anterior arc of left ribs from the frst to the third resection of internal left clavicle edge B Sternal tumor and sternal body were removed en-bloc without the 2 cm residual extension which was marked by metallic clips C Large anterior thoracic wall defect exposing mediastinum and medial portions of lungs. Figure 3: A Myoplasty using pectoralis major and pectoralis minor muscles covered the chest wall defect B Surgery scar 3 months after the operation.

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Citation: Ayed AB Hentati A Abid W Ghorbel I Nouri K 2018 Interest of Myocutaneous Plasty after Extended Sternal Resection. J Pulm Respir Med 8: 447. doi: 10.4172/2161-105X.1000447 Page 3 of 3 Volume 8 • Issue 1 • 1000447 J Pulm Respir Med an open access journal ISSN: 2161-105X skin can be easily closed without an important distortion of breasts. When a large bilateral pectoral fap is used the release of the muscle from its humeral attachment allows gaining in length and allows a better coverage of the chest wall defect. Indeed pectoralis major fap ofers a coverage characterized by its simple and immediate technique fexibility rigidity relatively resistance to infections and with acceptable esthetic results. Paradoxical respiration decreased afer the adherence between visceral pleura and muscle fap. Te chest wall reconstruction is indicated afer large resections following metastatic or contiguous neoplasm post radiotherapy necrosis infectious process trauma and congenital parietal defect. If there is a risk of contamination afer tumor necrosis or radiation tissue necrosis the use of prosthetic materials is not advisedv. We have also the experience to avoid prosthetic materials afer an R2 resection because of the risk of tumor graf. Terefore myocutaneous plasty is a possible solution when the use of prosthetic materials is impossible due to peroperative considerations such as infected or contaminated feld wich exposes to chronic infection or temporary closing before a second intervention 3-5. Other muscles can be used to repair the anterior chest wall defect: Latissmus Dorsi Rectus and Serratus are the most commonly used. A consolidation by a bone auto graf is an alternative to enhance the stability of the rib cage. Several prosthetic materials are actually available and can be used in this case such as meshes and plates. Conclusion Te use of muscle faps is a good alternative to repair parietal defects. Te choice of the muscle depends on the location and the extent of the defect to be repaired. Te knowledge of the anatomy of the muscles is essential to obtain a good quality fap. References 1. Losken A Thourani VH Carlson GW Jones GE Culbertson JH et al. 2004 Reconstructive algorithm for plastic surgery following extensive chest wall resection. Br J Plast Surg 57: 295-302. 2. Sham JS Cheung YK Chan FL Choy D 1990 Nasopharyngeal carcinoma: Pattern of skeletal metastases. Br J Radiol 63: 202-205. 3. Ma J Wen ZS Lin P Wang X Xie FY 2010 The results and prognosis of different treatment modalities for solitary metastatic lung tumor from nasopharyngeal carcinoma: A retrospective study of 105 cases. Chin J Cancer 29: 787-795. 4. Hwang K 2016 The origins of deltopectoral faps and the pectoralis major myocutaneous fap. J Craniofac Surg 27: 1845-1848. 5. Shields WT 2011 General thoracic surgery.

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