Rib fractures indicate significant chest trauma and may be associated with intrathoracic and intra-abdominal injury. Fractures of three adjacent ribs in two or more places may result in a flail chest and paradoxical motion, and may lead to respiratory compromise. Blast and electrical injuries may induce zones of injury not immediately apparent in the acute setting and require close cardiac and respiratory monitoring.

Treatment. After stabilization of life-threatening injuries, patients with flail chest may require operative stabilization of rib fractures. While the mainstay treatment of rib fractures is nonoperative, rib plating systems are currently available for the stabilization of rib fractures in a flail chest segment. Rigid fixation systems contain a standard plate and screws, as well as intramedullary rods.

In traumatic wounds, coverage after debridement of nonviable tissues is approached similarly to infections and tumor defects (see below).

Primary malignancies of the chest wall may be classified into eight main categories: muscular, vascular, fibrous and fibrohistiocytic, peripheral nerve, osseous and cartilaginous, adipose, hematologic, and cutaneous. The diversity of malignancies and attendant surgical extirpation may result in significant defects. Reconstruction must also take into account postoperative oncologic therapy such as radiation.

Treatment. After extirpation of the tumor, the dimensions and components of the chest wall requiring reconstruction are evaluated. Restoration of pleural cavity integrity as well as protection of intrathoracic structures may be required. Classic teaching recommends skeletal reconstruction for defects involving four or more ribs or greater than 5 cm in diameter; however, this varies depending on the location of the defect.

An option for skeletal reconstruction includes the so-called methylmethacrylate and synthetic mesh “sandwich.” The methylmethacrylate is molded into the desired shape of the defect, and Marlex or Prolene mesh is placed on each side of the construct and sutured together. The methylmethacrylate and mesh sandwich can be sutured to the surrounding structures. Some patients experience pain with respiration since the methylmethacrylate is much more rigid than the chest wall. This method of skeletal reconstruction provides protection to the underlying cardiac and pulmonary structures and can be used for even large defects in tandem with soft tissue flaps (Figure 92.2).

Posterior and superior chest wall defects may not affect ventilation as much as anterior defects. In these cases, skeletal reconstruction may not be necessary; therefore, a variety of other products, both synthetic and biologic, may be appropriate. Synthetic products such as Gore-Tex, Marlex, and Prolene mesh may be used for smaller lateral defects. Synthetic mesh can be problematic in the lower chest wall since the mesh may come into contact with the intra-abdominal contents and lead to bowel adhesions or even fistulae (Chapter 93). Biological products, such as human allograft dermis and xenograft dermis, offer other options for reconstruction where rigid stability is not mandatory. They are not likely to cause adhesions with the viscera and may tolerate bacterial contamination better than a synthetic product since they may become revascularized by the surrounding host tissue. Although the discussion of biologic materials is beyond the scope of this chapter, surgeons have continued to expand applications in complex defects and wounds. Both biologic and synthetic mesh do not provide the same level of rigidity as methylmethacrylate or titanium mesh, but they do provide additional stability to the chest by spanning the defect.

Empyema and Bronchopleural Fistula. A bronchopleural fistula and pleural empyema (pus in the pleural cavity) are complications of pneumonectomy that carry significant morbidity and mortality. As a first step, drainage of the infectious empyema is performed, and depending on its severity, may necessitate a delay in the reconstruction. Often the thoracic surgeon manages the empyema and requests help from a plastic surgeon for the transfer of flaps to reinforce the bronchial stump closure or to obliterate the pleural cavity.