Large posterior chest wall defect reconstructed with a de-epithelised trans-thoracic TRAM flap

Extensive posterior chest wall defects, especially those closer to the midline of the trunk, pose surgical challenges in plastic surgery. In these cases, prior to tissue coverage, the status of the pleural cavity and skeletal support need to be addressed to obtain a functional and anatomical reconstruction. We recently operated upon a patient presenting with an aggressive ossifying fibromyxoid tumour located in the lower dorsal paraspinal region on the right side. After ablative surgery and intra-operative radiotherapy, a broad defect in the chest wall of 15 x 10 cm, including the proximal part of five posterior ribs, was presented. It required immediate bony frame reconstruction, which was resolved with a Goretex(R) patch wrapped with a de-epithelised myocutaneous pedicled transverse rectus abdominus myocutaneous (TRAM) flap, transposed through the right hemithorax. The patient was extubated 2 days after surgery and discharged in 10 days. We describe the use of an intra-thoracic TRAM flap to reach the posterior chest wall defects, and we propose its specific indication for reconstruction of extensive posterior chest wall defects when other options are unavailable. (C) 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.