Thoracic and Cardiovascular Surgery SUPERFICIAL CHEST WALL MUSCULATURE

(Dr. Lat - online class, 2020)

THORAXIC ANATOMY

UPPER PART OF THE TRUNK

Boundaries:
 Diaphragm- inferiorly
 Thoracic inlet-superiorly
 Thoracic cage- between vital organs There are different muscles that play important role in respiration at
the same time as protection for the visceral organs of the chest.
Mediastinum- separates right and left hemithorax
BONY THORAX
Diaphragm is part of the peritoneal cavity. It is the most inferior  rigid, non collapsible frame
portion of the thorax. It is actually the division between the thorax  houses & protects thoracic organs
and abdominal cavity. Both part of thorax and abdominal cavity  composed of:
o 12 paired ribs
o 1-7 (true ribs),Complete loops between vertebrae
THORACIC INLET and sternum
 Limited by the body of the o 8-12 (false ribs), fail to reach the sternum
first thoracic vertebra o 11-12 (floating ribs), vertebral ribs, articulation is
posteriorly First pair of with their vertebra
ribs superiorly & o 8TH,9TH,10TH RIB- VERTEBROCOSTAL (Costal
 Costal cartilages cartilages articulates with adjacent rib cartilage)
anterolaterally o 3rd to 9th RIB- typical ribs (head, neck, shaft)
 Superior border of the  Sternum (flat bone), 15-20 cm (manubrium, body, xiphoid)
manubrium- anteriorly  multiple cartilages
As a surgeron, it is very hard to reach this area. Because what we can palpate  Clavicle
only is the level of 2nd thoracic vertebra. For you to reach this it means to say  thoracic vertebrae
you have gone all the way up to the vessels which is being protected by the
thoracic inlet Conventional Longitudinal Lines
1. Midsternal line- bisects the sternum, corresponds to midline
of back
2. Mammary Line- inner aspect of clavicle, passes thru nipple
3. Parasternal line- lies midway between the midsternal and
mammary lines
4. Anterior Axillary line- runs through the anterior axillary fold
5. Posterior Axillary line- passes through posterior axillary fold
6. Midaxillary line- dropped from the middle of the axillary
space
7. Scapular line- runs through the apex of the inferior angle of
the scapula
These longitudinal lines are important in describing certain lesions or when
describing where we enter. For example, if there is a midsternal line, usually
when you are doing midsternotomy, a midsternal incision is applied. When
you place a chest tube, it usually placed under anterior axillary line. You may
CERVICOAXILLARY CANAL also place a tube at the midaxillary line, which is between the anterior and
 Boundaries: posterior midaxillary line. When you are going to do thoracentesis, it usually
o First Rib- Inferiorly placed under the scapular line
o Clavicle- Superiorly
o Costoclavicular Ligament- MUSCLES OF THE THORAX
Medially  LATISSIMUS DORSI- largest muscle of the thorax, originates
 Structures That Pass thru the Canal from the lower six thoracic spinous process and lumbodorsal
o Subclavian Vein fiber
o Subclavian Artery  PECTORALIS MAJOR- arises from the sternum, clavicle and
o Brachial Plexus 1st 7 ribs, inserts on bicipital humeral groove
 SERRATUS ANTERIOR MUSCLE- in between pectoralis major
When asked to place a catheter either in the subclavian or jugular veins, and m. and latissimus dorsi m., originates from the 8th to 10th
you accidentally puncture the lining of the thoracic inlet, it will cause massive ribs, inserts on tip of scapula, can be used to cover bronchial
bleeding or even pneumothorax. stump, or muscle interpostition between trachea and
esophagus
 TRAPEZIUS- arises from the occipital bone and from the
spinous process of 7th cervical vertebra and all the thoracic
 vertebra, inserts on lateral aspect of clavicle, acromion FLEXIBLE BRONCHOSCOPY
process, spine of scapula
 EXTERNAL OBLIQUE- arises from 4th to 12th rib and inserts
on iliac crest
 RECTUS ABDOMINIS MUSCLE- originates at the pubic crest
and inserts 5th to 7th rib cartilages and xiphoid process

MUSCLES OF RESPIRATION
 Primary Muscles
o Diaphragm – primary muscle
o Intercostal Muscles
 Secondary Muscles – in case where there is respiratory You can use it under local or general anesthesia. A flexible scope can be placed
under the nasal cavity or oral cavity. In cases of prolonged coughing,
depression, these muscles help in respiration
hemoptysis, and non-resolving pneumonia, bronchoscopys is indicated. One
o Sternocleidomastoid can examine the trachea, including the bronchus in order to examine if there
o Serratus posterior are any mucus plug, tracheal lesions, or tumors. At the same time, you
o Levatores Costarum perform biopsy, and you can do some palliative measure.
 Tertiary Muscles – For patients who are critically ill.
o Deltoid RIGID BRONCHOSCOPY
o Pectoralis
o Latissimus Dorsi
Very helpful when you are
GENERAL THORACIC PROCEDURES trying to remove any
foreign material. This can
THORACENTESIS only be done under
general anesthesia.

THORACOSCOPY

Same as laparoscopy in abdominal

cavity. Here you would like to
visualize the thoracic cavity. Done
under genetal anesthesia. You can
Common procedure to drain the fluid inside the pleural cavity. In a patient
do biopsy, resection and drainage in
who has pleural effusion, because of gravity all the fluid will stay on the most
dependent portion, which is just above the diaphragm. However, nowadays this procedure. One advantage is
with the advent of ultrasound, it is better to do thoracentesis under US faster recovery and less pain.
guidance. There is no better replacement in doing this procedure while
performing your complete physical examination. If there is any lagging,
especially in massive pleural effusion, that area affective you will not able to
visualize the rising and lowering of the chest wall. On palpation, there may be MEDIASTINOSCOPY
some form of warmth because of presence of inflammatory fluid. On
percussion there is dullness. On auscultation, there might be decrease or
absent breath sounds that affects the hemithorax

TUBE THORACOSTOMY

A procedure that examines mediastinal space. Rarely done to access any

enlarge lymph nodes in the mediastinum. Specially for lung cancer, when
you would like to do preoperative staging prior to your resection. One of the
problem in lung cancer surgery, there are times we would like to do a lung
In cases where there is massive pleural effusion. A tube is being inserted inside
resection, however due to presence of regional lymph node metastasis, that
the pleural space or thoracic cavity. If the patient is pediatric, you make use
would prevent us from doing lobectomy or even pneumonectomy. In
of 12F. If the adult patient has pneumothorax, usually a 28F would do.
essence, mediastinoscopy is done to prevent any unnecessary lung resection
However, if there is blood or purulent material, inside the chest cavity, you
can use a 36F or 40F, to prevent it from clotting.
THORACOTOMY Physical Examination
 anxiety, somnnolence, confusion, hypotension, tachycardia,
tachypnea, palpable or visible subcutaneous air in the neck,
chest, and face (All are nonspecific signs)
 pitch of voice is high, nasal quality from air dissecting in the
paranasal sinuses and posterior mediastinal fascial planes
 Absent breath sounds owing to the presence of
pneumothorax, or pleural fluid collections, perforated viscus,
hemothorax, empyema (severe conditions)
 wheezes, rales, ronchi may be a sign of severe inflammation
which implies a delay has occurred to the time of
A right sided posterolateral thoracotomy, and your target area is actually the presentation (severe condition result from delay of diagnosis)
left descending thoracic artery, definitely you cannot access because you are  Hamman’s crunch (crepitant sound heard at auscultation that
in the wrong area. Better to plan any elective procedure before opening the varies with heartbeat)
chest.  Ecchymosis, masses, and erythema may be present on the
face, neck, or torso
STERNOTOMY
Diagnostics
1. 1.Chest x-ray - pneumothorax, degree of
pneumomediastinum, presence of air-fluid levels; air is
This procedure is very frequently seen streaking the left heart border; air at the
common is by-pass graft. You junction of the diaphragm and left heart “V” sign is associated
cut through the midsternal with Boerhaave’s Syndrome
line. Accessing the heart, and 2. CT Scan – neck and chest. TO better visualize the origin
anterior mediastinum, it is
3. Triple Endoscopy (Bronchoscopy, Esophagoscopy,
best done under sternotomy.
Laryngoscopy)
4. Contrast-enhanced fluoroscopy

X-ray showing pneumo-

CARDIOTHORACIC TRAUMA mediastinum, at the level of
paricardiac border. You
1. Pneumomediastinum don’t see air under pleural
2. Flail Chest & Pulmonary Contusion cavity, but actually in the
3. Chest Wall Injury paricardiac spaces. Might be
perforated left bronchus
4. Blunt & Penetrating Trauma to the Heart & Great Vessels
5. Traumatic Airway Injuries
6. Traumatic Hemothorax
7. Esophageal Trauma
8. Pulmonary Injury
9. Diaphragmatic Injuries Treatment
1. 1.Rest
All or majority of the cardiothoracic trauma are life threatening
2. Antibiotics & analgesics
situations.
3. Chest tube thoracostomy – If there is an infection
4. Surgery
PNEUMOMEDIASTINUM
a. Stop ongoing contamination & inflammatory fluid
 implies that there has been a breech of an air-containing
b. Drain
mediastinal structure c. Debridement
 May be a stable incidental finding on radiographic study or d. Correct any distal obstruction
may be a progressively worsening clinical finding resulting in e. plan for nutritional support
hemodynamic collapse
 Originates from the respiratory tract, such as facial bones, FLAIL CHEST & PULMONARY CONTUSION
larynx, hypopharynx, trachea, main stem bronchi, esophagus
(Boerhaave’s syndrome) Diagnosis & Treatment
Very common in the ICU. Caused by traumatic intubation.  most serious chest wall injury encountered
 mechanically, it is the complete
History disruption of a portion of the
 spontaneous or effort-induced pneumomediastinum chest wall by segmental
(Hamman’s syndrome) fractures of two or more
 in children and adolescents asthma and pneumonia adjacent ribs (Meaning to say,
 substrenal pleuritic chest pain that may radiate to the neck or if you have only 1 rib fracture,
back you will not develop any flailing
 associated with low grade fever and mildly elevated WBC of the chest)
count
  paradoxical wall movement in a spontaneously breathing PENETRATING CHEST WOUND INJURIES
patient (When the patient inspire, part of the uninvolved ribs
will rise. But the part where there are rib fractures, it will Diagnosis
depress. In expiration, there will be depression of the  clinical presentation is tamponade or shock, either from
uninvolved ribs and rising of the fractured ribs) controlled hemorrhage with an intact pericardium
 Endotracheal intubation and positive-pressure ventilation  Beck’s Triad (hypotension, distant muffled heart sound,
may prevent altered chest wall movement jugular vein distention)
 Pain management (Thoracic epidural anesthesia, oral  Hemothorax
analgesics rarely effective for pain control in the acute phase)  cyanosis of the upper body
– morphine for pain control
 diffuse hemorrhage into the parenchyma resulting from blunt Pericardiocentesis
and penetrating trauma
 Hemoptysis is a common consequence of pulmonary
contusion
 Treatment of pulmonary contusion as an isolated injury is
conservative in nature (pulmonary toilet, incentive
spirometry, pneumonia surveillance)

Draining of fluid inside the pericardial sac. It is best done under ultrasound
guidance

Subxiphoid Pericardial Window

Xray of px with pulmonary contusion

Surgical Repair Of Flail Chest

Done under local anesthesia. In
cases you have to do this
preocedure, an incision 2-3 cm is
done. You will gradually visualize
the pericardial sac. Once you open,
there will be fluid or blood coming
out from the pericardium

Indications: Patient is placed under mechanical ventilator, every time patient

ween from the ventilator the patient suddenly desaturates. Another, when Treatment
patient has open chest wall injury, definitely surgical fixation is indicated.  initial resuscitation should follow the standard prinicples
used in the care of all trauma patients (airway control,
CHEST WALL INJURY adequate ventilation, oxygenation, volume replacement)
 blunt chest wall trauma can produce various direct injuries to  Placement of chest tubes based on clinical findings and rapid
the chest wall such as sternum, clavicle, scapular fractures & x-ray examination should be commenced simultaneously
muscle hemorrhage  Rapid repair of the lacerated heart
 internal consequences include blunt cardiac injury,
pericardial tamponade, pericardial rupture, pulmonary Surgical Repair
contusion, tracheobronchial tears, great vessel injury,
diaphragmatic tears

Etiology And Diagnosis If the patient is going to undergo

 sternal fracture can be diagnosed clinically and radiologically emergency procedure just to
by a lateral chest x-ray control myocardial laceration, we
usually employ a left anterolateral
Treatment thoracotomy to the 4th intercostal
 Sternal Fracture - in the absence of cardiac injury, are space.
repaired for two reasons: pain control & cosmesis
 Anterior Rib Fracture - treated non-operatively, pain control,
Fixation is reserved for “flail chest” and ventilator When you are trying to repair the
dependency myocardium usually you make use of
 Sternal Chondral Separation - treated conservatively plus 3.0 or 4.0 polypropylene monofilament
nonabsorbable suture and you make
adequate pain control
use of pledgets. pledgets are important
when you are tightening your knot. If
you have no pledgets and you tighten
the knot, it will just cut through the
myocardium.
 Again, proximal and distal control. Sometimes, we may resect the clavicle just
You can also make us of bop cap or an alice forceps in case of lacerated atrium. to get a better exposure of injured subclavian vessels. If you have combined
Or a side biting vascular clamp partially occluding the aorta while repairing the orthopedic and vascular problem, the order of priority is address first the
injured area of the aorta bleeding. A clavicular fracture can wait but vascular injury cannot

Ventriculorrhaphy TRAUMATIC AIRWAY INJURY

Causes of Injury
1. Direct – direct compression against anterior vertebral bodies
of the cervical spine
2. Indirect – a sudden increase in intratracheal pressure against
a closed glottis may induce linear tears in the membranous
portion of the trachea (like vasalva maneuver)

Initial Treatment
 Orotracheal intubation with appropriate cervical spine
precautions and direct laryngoscopy
Central Vascular Injury
 Flexible bronchoscopy, while maintaining cervical spine
This tell us the importance of immobilization
proximal and distal control. For
example, you have injury to the neck Surgical Treatment
and you are suspecting a carotid  Cricothyroidotomy
injury. It is easier said than done to
apply digital control in the carotid.
 Fractures of thyroid cartilage may require titanium
The problem there, every time your miniplates, plates, or fine wires
remove the finger on the opening,  Recurrent laryngeal nerve injury- no touch (some of the
definitely blood will come out. What accompanying injury in any laryngeal injury)
is emphasize in the picture is a  Injured trachea should be repaired without tracheostomy if
proximal control. You might have to possible
do a sternotomy and a proximal
control of the brachiocephalic artery.
If you will be doing a proximal control,
Resection Of Trachea
there will be less bleeding Remember that you can resect as
many as 4 tracheal rings if you are
going to do an end to end repair of
Same is true when you have a left the trachea with cervical incision.
carotid injury. You can actually do a
When you are repairing trachea,
proximal control at the 2 nd portion of make use of absorbable sutures
the arch of aorta which is your left and the knot should be outside the
common carotid artery, if you are lumen. If it is inside the lumen, it
suspecting any injury at the left side. may cause granulation making
If you are trying to control an upper tracheal stenosis in the future.
extremity bleeding, the proximal
control will be at the left subclavian Tracheal Repair
` artery, which is the 3rd portion of the
arch of aorta.

This has to be repaired

The X-ray shows a clavicular fracture. or bolstered by a
One of the things we have to consider pleural flap covering
in clavicular fracture is a subclavian the defect
vessel injury. If you have a middle third
clavicular injury, suspect the presence
of subclavian vessel injury. You look for
the hard signs, look for hematoma at
the area.
`
TRAUMATIC HEMOTHORAX 5. Massive air leak or incomplete lung expansion despite
adequate drainage
 most commonly due to laceration of lung parenchyma or
6. Great vessel injury
chest vessels
7. Esophageal injury
 Standard treatment is a large caliber chest tube that allows
8. Diaphragmatic laceration
evacuation of blood, reduces risk of clotted hemothorax,
o If you conservatively manage the laceration, it will
provides for ongoing determination of the extent of thoracic
eventually result to diaphragmatic hernia.
bleeding
9. Traumatic septal injury or valvular injury
 Video-Assisted Thoracic Surgery
o Thoracotomy
ESOPHAGEAL TRAUMA
 Maybe caused by blunt chest trauma
 Maybe caused by penetrating trauma to the chest Types of injury:
 Collection of air in the pleural space (between lung & chest 1. 1.Endoscopic trauma- esophagoscopy, dilatation
wall) 2. Blunt traumatic injury- rupture, TEF
 Chest tube drainage is recommended, even for small 3. Barometric trauma- Boerhaave’s Syndrome
collection of air 4. Penetrating trauma
 When a large air-leak is present or re expansion of lung is 5. Caustic injury
incomplete, a tracheobronchial injury is suspected and 6. Foreign body
prompt fiberoptic bronchoscopy is performed Still, the most common cause is iatrogenic trauma.

TENSION PNEUMOTHORAX Reconstruction W/ Stomach

 Can also cause Beck’s triad

 distended neck veins
 deviated trachea
 absent breath sounds
 tympany to percussion
 Development of hypotension
This picture shows that one of the useful conduit of the esophagus is the
Immediate remedy is converting tension pneumothorax to simple
stomach itself. Specially those who have injury caused by caustic substances,
pneumothorax. You get an ordinary needle syringe, and puncture the chest
wherein you have necrotic esophagus. Gastric pull-up may be done.
wall usually at the 2nd intercostal space. While preparing necessary material,
you actually converted that pneuomothorax, preventing the complications of
the tension pneumothorax Gastric Pull-Up

PULMONARY INJURY

Pulmonary Tractotomy

A procedure wherein we tubeolorize (shape into tube-like) the stomach, and

that will past through the mediastinum and connect to the cervical portion of
` esophagus. As a conduit of neoespohagus. Don’t forget to do a pyloro
There are times you have to open the chest to control the bleeding, specially myotomy. This will open the pyloric end. One advantage of this is you only
for massive hemothorax. Doing this procedure, we open the pulmonary tract have one anastomosis. If there is some leak, it will manifest as erythema on
where bleeding is coming from. Individually identify the bleeding vessels. the neck area.
You may suture ligate it or do a stapler resection using JIA ringer stapler

Reconstruction W/ Colon
Indications For Emergency Room Thoracotomy
1. Acute pericardial tamponade unresponsive to cardiac You have at least 3 anastomoses. You
massage have one on the neck area, colonic-
2. Exsanguinating intrathoracic hemorrhage esophageal anastomosis, another one
3. Need for internal cardiac massage is colo-colonic anastomosis and last is
colo-jejunal anastomosis. The sigmoid
Indications For Urgent Thoracotomy has a rich blood supply, so that is the
1. Chest drainage of >1500ml initial or >200 ml/hour preferred segment of the colon. It has
2. Large unevacuated clotted hemothorax the arch of Riolan.
3. Developing cardiac tamponade
4. Chest wall defect
 PECTUS CARINATUM (PIGEON CHEST DEFORMITY)
DIAPHRAGMATIC INJURIES
 Characterized by protrusion of
Grade Injury Description the sternum caused by an upward
 I - Contusion curve in the lower costal
 II - Laceration <=2cm cartilages (4th to 8th)
 III - Laceration 2-10 cm  Symptoms include exertional
 IV - Laceration >10 cm dyspnea and cardiac arrhythmias
 V - Laceration >25 cm tissue loss
Pectus excavatum and pectum carinatum is confirmed with a lateral
Grades II – V are treated surgically. Grades II – IV can be repaired using suture X-ray film
repair by non-absorbable silk sutures. For contusion can be managed
medically or conservatively. For grade V, you cannot just do a repair, you have
to place a substitute. Such as polypropylene mesh to cover the defect.
POLAND’S SYNDROME
 Absence of the pectoralis major, absence
Diagnosis or hypoplasia of the pectoralis minor,
1. Chest x-ray – for long standing diaphragmatic injury absence of costal cartilages , hypoplasia of
2. Laparoscopy/ VATS - best diagnostic modality in diagnosing breast and subcutaneous tissue,
diaphragmatic injuries brachysyndactyly
 Several operative procedures have been
Diaphragmatic Repair described but it is generally considered
that the procedure advocated by Ravitch is
the preferred approach

CLASSIFICATION OF CHEST WALL TUMORS

BENIGN MALIGNANT
BONE Osteoid osteoma Osteosarcoma
Chondroma Ewing’s Sarcoma
Chondrosarcoma
FIBROUS Fibrous Dysplasia Malignant Fibrous
Histiocytoma
All are surgically repaired except grade I, where it can be managed medically CARTILAGE Enchondroma Plasmacytoma
or conservatively. Grades II – IV can be repaired using suture repair by non-
Osteochondroma Hemangiosarcoma
absorbable silk sutures. For grade V, you have to place a substitute. Such as
polypropylene mesh to cover the defect. MARROW Eosinophilic
Granuloma
CHEST WALL ABNORMALITIES VASCULAR Hemangioma Hemangiosarcoma
1. Depression Deformities/ Pectus Excavatum - most common ADIPOSE Lipoma Liposarcoma
2. Protrusion Deformities/ Pectus Carinatum MUSCLE Leiomyoma Rhabdomyosarcoma
3. Poland’s Syndrome Rhabdomyoma
4. Sternal Defects/Fissures NEURAL Neurofibroma Neurofibrosarcoma
Neurilemoma Neurofibrosarcoma
PECTUS EXCAVATUM Malignant
 Deformity of the costal cartrilages that Schwannoma
have formed congenitally in a concave FIBROUS Desmoid Fibrosarcoma
manner and thus depresses the sternum
 Most severe depression is found above
the xiphoid process Most common chest wall tumor is malignancy. This malignancy is a
 Heart is displaced to the left metastasic one. When we are talking about primary chest wall tumor, it
 Deformity is usually present at birth, it may be benign or malignant.
may occasionally not appear until weeks
or months later Features Of Primary Chest Wall Tumors
 The primary indication for correction is a cosmetic one 1. 50-60% are malignant
Ravitch Procedure for Pectus Excavatum 2. Age at presentation for benign tumors is 26 yrs
3. Age at presentation for malignant tumor is 40 yrs
Developed as treatment for the deformity. The 4. Male-to-female ratio is 2:1 (except for desmoid)
problem is that it is radical, because you excise all
5. Ribs are affected more than the sternum
the costal cartilages connecting to the sternum.
This is done extra-pleural. After excision, you 6. Tumors originate more often from soft tissues (two thirds)
fracture the sternum to elevate it. The problem is than from bone or cartilage (one third)
after excision, eventually the patient will develop
flailing of the chest Diagnosis & Evaluation
 Signs & Symptoms
One modification was done is to insert a titanium o Complete the history and PE
bar under a sternum to prevent it from collapsing  Non-invasive procedure
back. o Diagnostic Imaging
  Invasive procdure When you say wide excision, you have to attain negative margin. You
o Needle biopsy have to excise one normal rib above and below. The problem in wide
o Excisional biopsy excision is the closure because you will have a wide defect.
o Incisional Biopsy
EWING’S SARCOMA
SPECIFIC TUMORS  small round-cell sarcoma
 flat bones and midshaft of long bones
OSTEOCHONDROMA  17% of all primary malignant chest wall tumors
 Most common benign bone  seen among the adolescents
neoplasm; 50% of all benign rib  male>female
tumors  Radiographically: “onion-skin” appearance of the bony
 Originate from bony cortex of a surface (mimic osteogenic sarcoma, osteomyelitis)
rib and most often asymptomatic  Treatment- Initially chemotherapy followed by RT & or
 Microscopically: stippled surgery
calcification within the tumor

CHONDROMA
 15% of all benign rib neoplasm
 arise in the costochondral junction,
anteriorly
 most common: 2nd & 3rd decade of life
 affects M:F
 present with a painful mass that has
been growing slowly for years
 radiography: expansile, medullary mass The only role of biopsy in Ewing Sarcoma is to establish diagnosis.
causes thinning of the cortex
OSTEOSARCOMA
 *clinically & radiographically it is impossible to differentiate it
 less common than chondrosarcoma
from chondrosarcoma
 10% of all primary malignant chest
FIBROUS DYSPLASIA wall tumors
 benign, cystic lesion, painless chest wall mass most  poor prognosis
commonly over posterior ribs; Malignant degeneration is  common among the male adolescent
unusual  Radiographically: “sunburst”
 Lesion show a central, fusiform, expanded mass radiologically appearance
with thinning of the cortex & absence of calcifications  Treatment- Induction chemotherapy
 fibrous replacement of the medullary cavity of the ribs followed by wide excision
 30% of all benign chest wall tumors  -5-year survival rate 15%
 Presents as a solitary mass in the lateral or posterior rib cage Chest Wall Resection
 Radiologic:
Choice of Muscle Flaps For Thoracic Reconstruction
o trabeculated, expansile
lesion with ground-glass, Pectoralis Major
“soap-bubble” center &  Dual blood supply: thoracoacromial/IMA
thinning of cortex  Uses: for sternal reconstruction
 Treatment is conservative  LATISSIMUS DORSI Blood supply: thoracodorsal artery
o Resection is curative & should be indicated to rule  Uses: Full thickness reconstruction of anterior lateral defects
out malignancy and for painful, enlarging lesions
Latissimus Dorsi
MALIGNANT RIB LESIONS  Blood supply: thoracodorsal artery
 Uses: Full thickness reconstruction of anterior lateral defects
CHONDROSARCOMA
Rectus Abdominis
 most common primary chest wall
 Dual blood supply: superior/inferior epigastrics
bone neoplasm
 Uses: across anterior chest wall
 1/3 (20%) of all primary malignant
bone lesions Omentum
 occurs primarily in costochondral  Blood supply: gastroepiploic arteries (GEA)
arches or sternum  Uses: useful in exposed, contaminated, necrotic chest wall
 during 3rd decade of life In cases wherein you have empyema or infected pleural spaces,
 Male > female your omentum can also be used to treat the infected pleural space.
 Radiographically: mottled type of calcification So you mightend up opening the diaphragm, harvest the omentum
 Treatment: Wide Excision and place it where the infected area is. The you have to close the
 *5-year survival rate- 64% defect you have created tightly to prevent from having
diaphragmatic hernia