Reconstruction of the Chest, Sternum, and Posterior Trunk Flashcards
1
Q
Anterior and lateral chest wall defects involving three or
more adjacent ribs or that are 5 cm in width or greater
will benefit from skeletal reconstruction.
A
T
2
Q
Posterior
defects and resections in previously irradiated chest walls
can tolerate a larger defect before skeletal reconstruction
is necessary
A
T
3
Q
Bioprosthetic mesh should be used for skeletal chest wall
reconstruction in patients at high risk for wound healing
complications, such as those with a history of radiation
A
T
4
Q
The pectoralis major muscle flap is the workhorse flap for
posterior and anterior chest wall reconstruction
A
F The pectoralis major muscle flap is the workhorse flap for
sternal and anterior chest wall reconstruction
5
Q
in cases of acute wound infection.spinal instrumentation should be removed
A
Unlike other clinical scenarios involving infection and
hardware, spinal instrumentation should be maintained at
all costs in cases of acute wound infection
6
Q
The paraspinal muscle advancement flap is the workhorse flap for midline posterior trunk wounds
A
T
7
Q
The paraspinous muscle advancement flap is an
adequate option at superior part of the spinal level only
A
F an adequate option at any spinal level
8
Q
Prophylactic spinal wound reconstruction is prudent in
high-risk situations like
A
such as large resections/instrumentations, patients with multiple previous spinal surgeries, or a
history or radiation, diabetes, obesity, or steroid use
9
Q
Defects of the chest wall and intrathoracic space can result from infection only
A
F Defects of the chest wall and intrathoracic space can result from
tumor resection, infection, radiation injury, or trauma
10
Q
sternal wounds are most frequently associated with infectious complications after cardiothoracic procedures, such as mediastinitis or sternal osteomyelitis
A
T
11
Q
Soft tissue reconstruction of the posterior trunk is
often related to tumor resection or infectious complications following spinal instrumentation
A
T
12
Q
The intercostal neurovascular bundle runs along the interior surface of
each rib, at the inferior border, between the internal and innermost
muscle fibers
A
T
13
Q
The majority of chest wall wounds are the result of either the
treatment or palliation of malignancy.
A
T
14
Q
The majority of chest wall lesions are caused by the hematogenous metastasis of solid tumors
A
minority ofchest wall lesions are caused by the hematogenous metastasis of solid tumors most commonly sarcoma, followed by renal
cell carcinoma, and gastrointestinal adenocarcinoma
15
Q
most common are locally invading tumors from adjacent structures, including
breast cancer, lung cancer, mediastinal tumors, and mesothelioma
A
T
16
Q
osteoradionecrosis of the skeletal
chest wall can emerge many years after the completion of radiation
therapy, necessitating wide debridement and reconstruction with
well-vascularized tissue
A
T
17
Q
standard lateral thoracotomy will divide
the latissimus dorsi muscle and a portion of the serratus anterior
A
T
18
Q
mediastinal defects after cardiac surgery, any reconstructive surgery
or debridement should be performed in a cardiac surgery operating
room,
A
T
19
Q
The goals of skeletal chest wall reconstruction
A
minimizing
paradoxical motion, aiding pulmonary mechanics, protecting underlying thoracic viscera, and maintaining a normal chest contour
20
Q
reconstruction has been shown to decrease postoperative mechanical ventilation and length of stay
A
T
21
Q
Posterior chest wall resections can typically tolerate a larger resection without the need for reconstruction why?
A
Given the additional stabilizing forces provided by the scapula and thoracic vertebrae.
22
Q
defects in previously irradiated
chest walls often do not require skeletal reconstruction why?
A
because the radiation-related fibrosis will decrease chest wall compliance, which in turn, decreases the likelihood of paradoxical motion
23
Q
The ideal thoracic skeletal reconstruction material
A
promotes tissue
ingrowth and is inert, malleable, and radiolucent
24
Q
biologic materials are preferred in clean defects with minimal risk for
complication (no history of radiation, few comorbidities, no current
or past infection, nonfungating tumor, etc.)
A
F synthetic materials are preferred in clean defects with minimal risk for
complication
25
all synthetic materials carry a risk of infection of up to >>>
5%
26
Polyethylene Macroporous, permitting ingrowth
T
27
Polypropylene Double-knitted; flexible in two dimensions
T
28
polytetrafluoroethylene permitting tissue ingrowth
- Encapsulates; no tissue ingrowth
- Seroma formation
29
Methylmethacrylate disadvantage
* Cures by exothermic reaction, putting tissues at risk for thermal injury
* May fracture
* Rigidity is nonanatomic
* No tissue ingrowth
* Seroma formation
30
Bioprosthetic Can be used in irradiated wounds
T
31
Bioprosthetic Incorporates
into host tissues
T
32
Bioprosthetics will not maintain chest contour in large defects
T
33
Bioprosthetic Infection/ exposure does not necessitate removal
T
34
Titanium rib plating Anatomic design, recreating chest contour, and physiologic compliance Improved pulmonary function
T
35
Titanium rib plating disadvantage
■ Expensive
■ Long term durability unknown
■ Requires an underlay synthetic or biologic mesh for pleural reconstruction
■ Requires specialty instrumentation
■ Radiopaque
36
all patients with infection had coexistent necrosis
of the overlying skin flaps
T
37
recommend that any
synthetic construct should be covered with a well-vascularized tissue,
such as a muscle flap
T
38
A bioprosthetic mesh is often favored in patients at high risk for
wound healing complications
T Due to their ability to
incorporate into the patient and revascularize, these products have
been shown to be resistant to infection and to function well in the
irradiated defect
39
Bioprosthetic meshes are classified by the
source material-either xenograft or allograft
T
40
Initially Xenograft was most commonly used for chest wall reconstruction;
F Initially human dermal allograft was most commonly used for chest wall reconstruction;
41
more recent evidence suggests that porcine or bovine-derived material may be preferred for this application because of the
lower amount of elastin comparedto human dermis
T
42
decrease amount of elastin n bioprosthetics is preferred like xenograft
T The decreased
elastin content translates to a more anatomic, semirigid reconstruction, which better approximates normal chest wall biomechanics.
43
For large skeletal chest wall defects, synthetic
meshes only are unable to maintain the natural thoracic curvature
F For large skeletal chest wall defects, synthetic and bioprosthetic
meshes alone are unable to maintain the natural thoracic curvature
44
For large skeletal chest wall defects, sandwiching methylmethacrylate cement between two layers of porous synthetic mesh can be used
T
45
Methylmethacrylate is better than titanium rib plating
F Methylmethacrylate, however, has several disadvantages, including a tendency to fracture as well as an association with infection and seroma formation. Because of these shortcomings, titanium rib plating osteosynthesis systems are gaining in popularity
46
spanning rib plates, which are useful for oncologic defects.
T
47
titanium rib plating osteosynthesis systems decreased incidence of pneumonia, improved pulmonary function
T
48
Spanning
plate reconstructions have been associated with a low complication
rate, good cosmetic result, and superior pulmonary function
T
49
Rib spanning plates only can be used for reconstruction of the chest wall wiyh out any supplemented mesh
F Rib spanning plates should always be combined with a synthetic or
biologic mesh underlay for reconstruction of the parietal pleura
50
Rib spanning plates should be
covered anteriorly with a well-vascularized tissue, such as a muscle
flap, to protect against possible exposure
T
51
local flap may offer a superior cosmetic result,
but its applicability is limited to smaller wounds
T
52
If the underlying
rib, sternum, or hardware is exposed or if there is a history of radiation to the area, local random flaps can be used
F If the underlying
rib, sternum, or hardware is exposed or if there is a history of radiation to the area, skin grafts or local random flaps are unlikely to be
successful
53
the vascular supply of
a free flap tends to be more robust and reliable than that of a pedicled flap, translating to a lower incidence of partial flap loss
T
54
Certain connective tissue tumors like angiosarcoma treated primarily with radiation therapy
F angiosarcoma, may occur as a side effect of previous radiation
therapy, necessitating wide resection in an irradiated field
55
The avoidance
of synthetic materials in the irradiated chest wall is recommended
T
56
bioprosthetic mesh is better tolerated due to its ability to revascularize.
T
57
despite an
adequate debridement and reconstruction, wounds in an irradiated
field are incredibly complex and continue to be prone to infection,
wound dehiscence, and soft tissue fibrosis.
T
58
Mediastinitis occurs in 0.25% to 5%
of patients after cardiac surgery
T
59
Pairolero and Arnold classified sternal
wound infections i
Type 1 infections
are defined by faint erythema and serosanguinous incisional drainage within the first few postoperative days. These wounds are typically sterile and not infected, therefore their classification as a type 1 infection is a misnomer
Type 2- infections occur
within the first few weeks and exhibit frankly purulent drainage
and significant cellulitis
A type 3 infection is indicative of a chronic
infection, due to osteomyelitis, costochondritis, or a retained foreign
body.
60
the type 1 wound is caused
by mechanical failure of the sternal wire closure; in the absence of
infection, these wounds can be treated effectively with conservative
debridement and irrigation
T
61
If the type 1 patient proceeds to a symptomatic sternal nonunion, as defined by pain or a bothersome click,
then the ineffective wires can be removed and the residual sternum
can be rigidly fixated with titanium plates
T
62
Patients presenting with signs and symptoms of mediastinitis should
have wound and blood cultures obtained
T
63
A CT scan of the chest can
be helpful for identifying drainable abscesses
T
64
If osteomyelitis is suspected, an MRI permits visualization of the extent of disease and is
useful for planning the debridement
T
65
type1, 2 and 3 infections require at least one significant debridement followed by a muscle flap wound reconstruction
F type 2 and 3 infections require at least one significant debridement
66
Ari adequate debridement is the cornerstone of the surgical management of mediastinitis
T
67
All hardware and
sternal wires should be removed in case of infection
T
68
The need for rigid sternal fixation is controversial
T
69
rigid skeletal fixation, such as titanium plating, reduces or
eliminates micromotion at the osteotomy site, thereby promoting
healing and decreasing infection
T
70
Titanium sternal plating systems
maybe best reserved for high-risk patients with multiple comorbidities contributing to poor healing
T
71
prophylactic sternal plating may reduce or even prevent
mediastinitis in high risk patients
T
72
Uni- or bilateral advancement pec major flaps can resurface the entire of the sternum baed on thoracodorsal
F Uni- or bilateral advancement flaps can resurface the superior two-thirds of the sternum based on the thoracoacromial
73
If the wound has a significant dead space component, or
involves the inferior third of the sternum, a turnover pectoralis flap
based on the internal mammary perforating vessels may be a better
option
T
74
A turnover flap is contraindicated if the internal mammary artery has been used for coronary revascularization.
T
75
In case of internal mammary art has been harvested for coronary surgery we cannot used the rectus muscle flap
F there are reports of
designing a superiorly-based rectus abdominis flap on the eighth
intercostal vessels when the internal mammary vessels have been
disrupted, doing so is not advisable if other flap options are available.
76
the omentum flap can be designed on the right gastroepiploic vessels only
F the omentum flap can be designed on either
the left or right gastroepiploic vessels and routed into the mediastinum either through the diaphragm or externally out through the
epigastric abdominal wall and into the chest
77
Disadvantages of the omentum flap are the possibility of an
epigastric or diaphragmatic hernia,
T
78
To minimize abdominal donor site morbidity, the omentum flap may
be elevated laparoscopically in select patients
T
79
,primary bone or soft tissue tumor are the most common indication for oncologic sternectomy
F metastatic
tumors are the most common indication for oncologic sternectomy
80
The pectoralis major muscleflap is a reliable option for soft tissue reconstruction unless there is a large cutaneous resection, in which case a free tissue transfer may be more appropriate
T
81
A bronchopleural fistula, often coexistent with an empyema,
T
82
the intrathoracic cavity is a bony, noncollapsible space. Therefore,
deep space infections are unlikely to resolve unless the cavity is either
collapsed down or filled with vascularized tissue
T
83
Intrathoracic deep space infection is treated by
thoracoplasty, in which multiple ribs were removed
to collapse of the chest wall, or through the creation of an Eloesser
flap
84
The omentum, latissimus dorsi, serratus anterior, rectus abdominis, and pectoralis major muscles are all options for filling the pleural
cavity with well-vascularized tissue
T
85
Flaps can also be transferred prophylactically in patients thought to be at high risk for bronchial stump
T
86
The latissimus, serratus,
and pectoralis muscles are transferred into the chest cavity through
the space created by removal of a rib to obliterate the pleura
T
87
rectus abdominis
muscle and omentum are passed into the chest through a surgically
created diaphragmatic window. to full the pleural spalce
T
88
The spinal cord ends at L3/ L4 and the dural sac terminates at S3
F The cord ends at Ll/ L2 and the dural sac terminates at S3
89
The paraspinal muscles are made up of three distinct muscle bellies-spinalis, longissimus, and iliocostalis-and travel the length of the spine
T
90
The trapezius muscle is the most
deep muscle in the midline posterior trunk
F The trapezius muscle is the most
superficial muscle in the midline posterior trunk
91
The trapezius extending from the occiput to the Tl2 spinous process
T
92
the trapezius overlaps
with the latissimus dorsi muscle from T7 to Tl2
T
93
The paraspinous muscles are immediately deep to the latissimus dorsi, except in the TlO-Ll location, where
the serratus posterior inferior muscle fibers may be found sandwiched
between the paraspinous and latissimus dorsi.
T
94
Reconstruction of the midline posterior trunk wound is most
commonly related to spinal instrumentation and fusion.
T
95
In high-risk
patients, such as those with a history of multiple previous spine surgeries, radiation therapy to the spine, neoadjuvant chemotherapy,
obesity, or diabetes, the plastic surgeon may be asked to perform an
immediate muscle flap reconstruction at the time of the index surgery
T to protect the hardware and obliterate dead space-with the
intention of preventing a wound healing complication
96
The mainstay of bony fusion in spine surgery is a nonvascularized
particulate bone graft in conjunction with rigid fixation
T
97
spinal osseous defects >10 cm, up to 50% of patients fail to progress
to fusion
F spinal osseous defects >4 cm, up to 50% of patients fail to progress
to fusion
98
vascularized bone flaps can be a useful
adjunct in addition to the standard instrumentation and particulate
bone graft
T
99
Early
infections (<6 weeks from the index procedure) are usually adequately treated with antibiotics, aggressive surgical debridement,
and muscle flap reconstruction with the maintenance of the spinal
instrumentation
T
100
Chronic hardware infections of spinal instrumentatiuon, defined as a deep
space infection at least 6 months after hardware placement, are
difficult to effectively eradicate. In this situation, an MRI should
be obtained to evaluate for vertebral osteomyelitis. In addition
to debridement, the patient may require hardware removal and
replacement for definitive treatment.
T
101
Compared
to midline spine wounds, the reconstructive approach to the lateral
defect is more standard
T
102
The thoracodorsal vessels may be an option, but a vein graft or
arteriovenous loop is needed for posterior lateral defect
T
103
The plastic surgeon should be knowledgeable about the initial spine surgery
performed; if a laminectomy or partial/total vertebrectomy
T
104
the spinal cord and dura are vulnerable to injury during
the debridement
T
105
If the
wound can be adequately debrided with a single procedure, then it
should be fully closed over multiple drains, with the addition of a
well-vascularized muscle flap for dead space obliteration, protection
of the cord and hardware
T
106
Dressing of the spinal wound can be don in pedside
F Because of the proximity of the central
nervous system, in this scenario it is advisable to return to the operating room and perform all dressing changes under general anesthesia
107
Hardware maintains spinal stability,
protects the spinal cord, and acts to stabilize the wound.
T
108
Paraspinous Muscle Flaps the workhorse flaps for reconstruction of the lateral posterior trunk defects
F the workhorse flaps for reconstruction of midline posterior trunk
defects
109
The paraspinous muscles are perfused through a medial and lateral row of segmental perforating vessels from the lumbar, intercostal, or vertebral vessels,
T
110
The paraspinous muscles are type 2 flaps
Mathes and
Nahai type 4 flaps
111
the fascia is divided during paraspinal muscle harvesting
T
112
the anterior approach to the cervical spine is more
likely to have a wound-healing complication or infection
F Although more infrequent compared to the anterior
approach, the posterior approach to the cervical spine is more
likely to have a wound-healing complication or infection
113
In the posterior approach to cervical spine surgery the paraspinus muscle can be although it thin in this site
T
114
Trapezius muscle
flaps may also be used; however, they have a high seroma rate.
T
115
If cutaneous coverage is necessary, the trapezius muscle flap can
be designed with a skin paddle
T
116
Thoracic Region Bilateral paraspinous muscle advancement
flaps are most commonly employed and should be considered a
first-line option
T
117
I case of Paraspinous muscle is not available LD flap can be used
T
118
If
the defect is along the inferior thoracic back or has a significant volumetric component, then a reverse latissimus dorsi flap-based on the
thoracic and lumbar perforating vessels-may be a better option
T
119
The omentum flap cannot used for thoracic reconstruction because it cannot reach the site
the omentum flap can be tunneled through the
retroperitoneum to fill dead space along the thoracic spine
120
The paraspinous muscles are the largest and most mobile in the
lumbar spine, making them ideally suited for reconstructions in
this area
T
121
Advancement of the LD flap can used to reconstruct the lumber area
F second-line option for this area is the reverse latissimus dorsi muscle or myocutaneous flap, based on the lumbar perforating vessels
122
Lumbar region reconstructions tend to have a
higher rate of minor wound healing complications (seroma, skin
edge separation, etc),
T owing to the more dependent location and
lordotic spinal curvature, which may allow for seroma accumulation
123
The liberal use of closed suction drains is encouraged to mitigate seromas.
T
124
the sacral and lumbosacral spine defects typically
require the obliteration of dead space for seroma and abscess prevention
and to reduce the chance of developing perineum! hernia
T
125
bridging bioprosthetic mesh can used safely in the sacral
defect to minimize perinea! bulge development
F this practice is
controversial and has been associated with a higher complication rate
126
Partial sacrectomies that are inferior to the sacroiliac joint useally at the S2 LEVEL
F S3
127
Partial sarecotomies are technically simpler from a reconstruction perspective because the entire resection and reconstruction can be performed from a prone, transperineal
approach
T
128
the superior gluteal vessels are not preserved in partial sarecotomies
F thesuperior gluteal vessels are preserved
129
Partial sarecotomies reconstructed with either V-Y or rotational fasciocutaneous advancement flaps or a superior gluteal perforator flap,
T
130
A sacrectomy that includes the sacroiliac joint and/or
the Sl or S2 level is much more complex
T
131
if one or both of the S2 nerve roots are resected,
then incontinence is likely.
T
132
A sacrectomy that includes the sacroiliac joint These resections require both
a supine, trans-abdominal approach as well as a prone, transperineal
approach.
T
133
Because of the laparotomy requirement,
trans-abdominal flaps based on the deep inferior epigastric vessels, such
as a VRAM, are a good option to obliterate dead space and resurface the
sacrum.
T
134
The free fibula flap is the flap of choice and a variety
of branches from the internal iliac artery and vein are often available for the sacroiliac joints reconstruction
T
135
Free fibula flaps will usually demonstrate radiographic signs of ossification at 12 months
F Free fibula flaps will usually demonstrate radiographic signs of ossification at 6 weeks whereas fibula bone grafts may
require 12 months or more for bony union
136
Acute hardware exposure is defined as occurring within 6 week of placement
F Acute hardware exposure is defined as occurring within 6 months
of placement whereas a chronic exposure occurs more than
6 months after
137
an acute exposure can be treated with
aggressive debridement, irrigation, muscle flap closure, and culture-directed antibiotics.
t
138
chronic exposure is more difficult
and requires removal of the exposed/involved hardware
T
139
hardware
encased in bone can be left in place
T
140
Sign of CSF leak
serous drain output
postural headache
Drainage can be sent to the lab to test for beta-transferrin,
141
a chronic occult CSF leak will
form a pseudomeningocele, which most often requires operative
repair.
T
142
drains should be
placed deep to the muscle flaps in the epidural space as well as
more superficially, between the skin and muscle closure.
T
143
When
laminectomies or vertebrectomies have been performed, the epidural drains are especially important because they help to drain
away the excess serosanguinous fluid
T
144
The superior gluteal vessels are
often ligated on the side of the sacrectomy,
T
