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

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      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.


      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.


      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).


      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



      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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