[The Reconstruction of Complex Thoracic Defects with Free Flaps and the Choice of the Appropriate Recipient Vessel]

Extensive thoracic wall defects can arise from the resection of malignant tumours or from sternal osteomyelitis following cardiac surgery. The aim of this study is to analyse the feasibility of reconstruction with free flaps, and considers recipient vessel conditions, surgical complications, and reconstructive outcomes.In this bicentric retrospective clinical study, all patients who underwent free flap transplantation for the reconstruction of an extensive thoracic wall defect between January 2013 and September 2024 were included. The objective was to evaluate surgical details and outcomes as well as surgical and medical complication rates. In a subgroup analysis, complications and outcomes of free flaps requiring the creation of suitable recipient vessels using an arteriovenous loop (AVL) were compared with those of free flaps that did not require additional vascular surgical procedures.A total of 107 patients (n = 66, 62% after cardiac surgery; n = 41, 38% after oncological surgery) underwent thoracic wall reconstruction with free myocutaneous tensor fasciae latae (TFL) flaps (n = 47; 44%), vastus lateralis (VL) flaps (n = 37; 35%), combined VL-anterior lateral thigh flaps (cVL-ALT) (n = 17; 16%) or cVL-TFL flaps (n = 2; 2%), anterior lateral thigh flaps (ALT, n = 2, 2%), and transverse rectus abdominis flaps (TRAM, n = 2, 2%). Of these reconstructions, 39 (36%) required simultaneous AVL creation. Postoperatively, six cases (6%) of pedicle thrombosis occurred. Complete flap necrosis occurred in three cases (3%) (VL flap, n = 2; cVL-ALT flap, n = 1), while partial flap necroses were observed in eight cases (8%) (TFL, n = 3; kVL-ALT, n = 2; VL, n = 2; TRAM, n = 1). Postoperative surgical complications showed no significant difference between reconstructions with or without the need for simultaneous AVL creation with respect to venous thrombosis (n = 0 vs. n = 3), arterial thrombosis (n = 2 vs. n = 1), partial flap necrosis (n = 3 vs. n = 5), and total flap necrosis (n = 0 vs. n = 3).This study demonstrates that reconstruction of extensive thoracic wall defects with free VL or TFL flaps is feasible with low complication rates, even when simultaneous AVL creation is required.