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Research Article|Articles in Press

The contribution of microvascular free flaps and pedicled flaps to successful chest wall surgery

Published:May 24, 2023DOI:https://doi.org/10.1016/j.jtcvs.2023.05.018
The contribution of microvascular free flaps and pedicled flaps to successful chest wall surgery
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      Abstract

      Objective

      Pedicled flaps (PFs) have historically served as the preferred option for reconstruction of large chest wall defects. More recently, the indications for microvascular free flaps (MVFFs) have increased, particularly for defects where PFs are inadequate or unavailable. We sought to compare oncologic and surgical outcomes between MVFFs and PFs in reconstructions of full-thickness chest wall defects.

      Methods

      We retrospectively identified all patients who underwent chest wall resection at our institution from 2000 to 2022. Patients were stratified by flap reconstruction. Endpoints were defect size, rate of complete resection, rate of local recurrence, and postoperative outcomes. Multivariable analysis was performed to identify factors associated with complications at 30 days.

      Results

      In total, 536 patients underwent chest wall resection, of whom 133 had flap reconstruction (MVFF, n=28; PF, n=105). The median (interquartile range) covered defect size was 172 cm2 (100-216 cm2) for MVFF patients versus 109 cm2 (75-148 cm2) for PF patients (p=0.004). The rate of R0 resection was high in both groups (MVFF, 93% [n=26]; PF, 86% [n=90]; p=0.5). The rate of local recurrence was 4% in MVFF patients (n=1) versus 12% in PF patients (n=13, p=0.3). Postoperative complications were not statistically different between groups (odds ratio for PF, 1.37 [95% CI, 0.39-5.14]; p=0.6). Operative time >400 min was associated with 30-day complications (odds ratio, 3.22 [95% CI, 1.10-9.93]; p=0.033).

      Conclusions

      Patients with MVFFs had larger defects, a high rate of complete resection, and a low rate of local recurrence. MVFFs are a valid option for chest wall reconstructions.

      Graphical abstract

      Figure thumbnail fx1
      Graphical Abstract

      Keywords

      Abbreviations:

      ALT (anterolateral thigh), ECOG (Eastern Cooperative Oncology Group), IQR (interquartile range), MVFF (microvascular free flap), OR (odds ratio), PF (pedicled flap)
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      Article info

      Publication history

      Accepted: May 9, 2023
      Received in revised form: April 25, 2023
      Received: March 13, 2023

      Publication stage

      In Press Journal Pre-Proof

      Footnotes

      James Huang: Writing – review & editing. Robert J. Downey: Writing – review & editing. Daniela Molena: Writing – review & editing. James M. Isbell: Writing – review & editing. Valerie W. Rusch: Writing – review & editing. Bernard J. Park: Writing – review & editing. Peter G. Cordeiro: Writing – review & editing. Smita Sihag: Writing – review & editing. Joseph H. Dayan: Writing – review & editing. Michelle R. Coriddi: Writing – review & editing. Joseph Disa: Writing – review & editing. Jonas A. Nelson: Writing – review & editing. Colleen M. McCarthy: Writing – review & editing. Babak Mehrara: Writing – review & editing. Barkat Ali: Writing – review & editing, Data curation. Carrie Stern: Writing – review & editing. Stijn Vanstraelen: Writing – review & editing, Writing – original draft, Investigation, Formal analysis, Data curation. Gaetano Rocco: Writing – review & editing, Writing – original draft, Supervision, Investigation, Formal analysis, Conceptualization. Farooq Shahzad: Writing – review & editing. David R. Jones: Writing – review & editing. Manjit S. Bains: Writing – review & editing. Evan Matros: Writing – review & editing. Robert J. Allen: Writing – review & editing. Prasad S. Adusumilli: Writing – review & editing. Joe Dycoco: Writing – review & editing, Data curation. Matthew J. Bott: Writing – review & editing

      Disclosures: Matthew J. Bott is a consultant for AstraZeneca. James M. Isbell has stock ownership in LumaCyte and is a consultant/advisory board member for Roche Genentech. Daniela Molena serves on a steering committee for AstraZeneca and as a consultant for Johnson & Johnson, Bristol Myers Squibb, Merck, and Genentech. Bernard J. Park has served as a proctor for Intuitive Surgical and as a consultant for COTA. Valerie W. Rusch reports grant support (institutional) from Genelux and Genentech, travel support from Intuitive Surgical, and travel support and payments from NIH/Coordinating Center for Clinical Trials. Babak Mehrara is a consultant for PureTech and Mediflix and receives royalty payments from PureTech. He is also the recipient of investigator-initiated awards from PureTech, Regeneron, and Pfizer. David R. Jones serves as a consultant for AstraZeneca and on a Clinical Trial Steering Committee for Merck. Gaetano Rocco has a financial relationship with Scanlan, AstraZeneca, and Medtronic. The other authors have no conflicts of interest to disclose.

      Financial Support: This work was supported, in part, by NIH/NCI Cancer Center Support Grant P30 CA008748.

      IRB/Consent: This study was approved by the Memorial Sloan Kettering Cancer Center institutional review board (#18-391; September 6, 2022). The requirement for informed consent was waived because of the retrospective nature of the study and the lack of identifiable patient information.

      Central picture legend: Anterolateral thigh reconstruction of previously operated and radiated breast recurrence.

      Central message

      Microvascular free flaps are a valid and safe reconstructive option for extensive chest wall resection to achieve adequate oncologic margins.

      Perspective statement

      Pedicled flaps have historically been preferred for the reconstruction of large chest wall defects. Our results suggest MVFFs can cover larger defects and achieve high rates of R0 resection, with comparable postoperative complications. Therefore, MVFFs can be considered a safe option for complex reconstructions and ensure adequate margins after extensive chest wall resection.

      Identification

      DOI: https://doi.org/10.1016/j.jtcvs.2023.05.018

      Copyright

      © 2023 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery

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