Biological mesh in chest wall reconstruction: state-of-the-art and our institutional experience

Introduction

Background

The thoracic wall, comprising a complex musculoskeletal structure, plays a pivotal role in maintaining structural integrity, providing stability for shoulder and upper arm movement, and safeguarding the vital organs within the chest. Additionally, it significantly contributes to normal respiratory function.

Chest-wall tumors encompass both benign and malignant entities. Managing these tumors remains a significant diagnostic and therapeutic challenge for thoracic surgeons. Nonetheless, recent substantial progress, particularly in surgical techniques and the use of prosthetic materials for reconstruction, has significantly improved long-term prognosis and survival rates (1,2). Surgical resection often stands as the optimal treatment strategy, offering the greatest chance of cure. En-bloc surgical excision, ensuring adequate margins of healthy tissue surrounding the tumor mass, is crucial in preventing local recurrence. Successful oncological resection of chest-wall tumors often necessitates reconstruction to reinstate both the structural and functional integrity of the thorax. Therefore, the primary goal is to restore anatomical defects ensuring protection of underlying organs and preventing lung herniation. This approach aims to minimize skeletal instability, paradoxical respiratory motion, respiratory failure, and the risk of infectious complications (3). Additionally, whenever possible, achieving satisfactory aesthetic results is also a desired outcome.

Presently, definitive guidelines or a consensus outlining the precise indications for chest-wall reconstruction are lacking. Consequently, various surgical procedures are frequently selected based on the discretion and expertise of individual surgeons (1). However, it is widely acknowledged that not all chest-wall defects necessitate immediate repair. In general, small defects (less than 5 cm) or resections involving fewer than three ribs typically do not require reconstructive interventions. In these instances, the surrounding soft tissue is usually considered sufficient to close the breach in the chest wall (4). Furthermore, defects in the subscapular and apico-posterior regions, up to 10 cm in size, may not necessitate reconstruction owing to the inherent support and structural integrity offered by the scapula and shoulder (5,6). Additionally, defects in the subscapular and apico-posterior regions, up to 10 cm in size, may not require reconstruction due to the sufficient support and structural integrity provided by the scapula and shoulder.

Consensus among many surgeons delineates specific indications for reconstruction following resection:

• Chest-wall defects larger than 5 cm in diameter or exceeding a total area of >100 cm². In these scenarios, consideration of body mass index and total body surface area is warranted, as the relative proportion of the chest wall defect may hold greater significance than its absolute size.
• Removal of >3 ribs from the anterior chest wall.
• Excision of >4 ribs from the posterior chest wall.

In cases involving posterior resections, including small defects, reconstruction below the fourth rib is recommended to prevent scapular entrapment (7).

While adhering to these recommendations is advisable, it is imperative to conduct individual patient assessments, taking into account factors such as the etiology, location and size of the chest defect, along with body mass index and total surface area. Therefore, surgeons should be receptive to a degree of variability in order to provide optimal reconstruction counsel to patients.

Rationale and knowledge gap

In practical terms, the method of chest-wall reconstruction depends on the extent of the resection, specifically discerning between partial- or full-thickness defects. For full-thickness resections, it is preferable to perform reconstructive procedures during the same surgery to restore skeletal integrity, protect vital organs, and maintain respiratory function. It is crucial not to limit the extent of resection due to apprehensions about reconstruction; hence, meticulous surgical planning involving multidisciplinary collaboration, including consultation with a plastic surgeon, is imperative. If the primary surgeon lacks expertise in chest-wall reconstruction, referral to specialized centers is advisable (6).

Several options exist for chest-wall reconstruction and stabilization, encompassing soft-tissue coverage and the utilization of various prosthetic materials. At present, surgeons have access to diverse prosthetic materials for restoring the chest wall, such as synthetic, metallic, alloplastic, and biologic materials (4) for reconstructing chest wall defects. The optimal material for prosthetic chest-wall reconstruction should possess rigidity to prevent paradoxical movements, be adequately malleable, highly resistant to infection, biologically inert, radiolucent, and cost-effective (5). However, an ideal material has yet to be established, often necessitating a combination of materials since each prosthetic material carries its own specific advantages and disadvantages, and as of now, none have demonstrated unequivocal superiority over the others. Furthermore, the choice of reconstruction method frequently aligns with the preferences and proficiency of the surgeon (1,8,9).

According to a recent consensus study (10), flexible implants (generically known as “meshes”) meshes remain one of the most favored reconstruction techniques, utilized by approximately 82.5% of surgeons. Meshes offer advantages such as accessibility, cost-effectiveness, and ease of handling and storage. However, they often have drawbacks, including limited resistance to infections and occasional inadequacy in providing ample protection for vital organs. In the current setting, the bioprosthetic materials represent an evolution in chest-wall reconstruction that combines the rigidity and durability of non-absorbable synthetic materials with the ability for tissue integration and remodeling. However, to date, there has not been a comprehensive review of the literature that extensively covers biological meshes, specifically emphasizing surgical aspects, indications, and perioperative outcomes.

Objective

This article aims to comprehensively review the existing literature regarding the utilization of biological meshes in chest wall reconstruction, with a specific focus on detailing surgical techniques and outcomes. Additionally, we provide insights derived from the institutional experience at our center concerning the utilization of such materials.

Methods

We conducted an unsystematic narrative review of published articles pertaining to the use of biological meshes in chest wall reconstruction. Research was carried out by accessing the PubMed-MEDLINE database. The search was delimited using MeSH terms including ‘chest wall tumor’, ‘chest wall resection’, ‘chest wall reconstruction’, and ‘biological mesh’. Inclusion criteria encompassed papers written in either Spanish or English published between 2010 and 2024.

Biological meshes

Bioprosthetic materials have signified a substantial advancement in chest-wall reconstruction. Over the past two decades, various biological meshes have emerged, crafted from human (such as allografts like dermis, intestinal mucosa, or pericardium) or animal sources (xenografts derived from porcine or bovine tissues) (Table 1). Biological meshes typically encompass biological crosslinked collagen matrices, wherein cells, debris, and genetic materials have been meticulously removed. This resulting structure combines the sturdiness and endurance akin to non-absorbable synthetic materials, while also possessing the unique capability for tissue integration and remodeling. Contrary to synthetic materials, that may behave as foreign bodies, these decellularized biological meshes serve to establish a robust framework for tissue growth and healing, undergoing a gradual process of revascularization and remodeling facilitated by the body’s own tissues. In 2018, Adelman et al. (11) analyzed the tissue adherence and revascularization of bioprosthetic versus synthetic mesh in an experimental animal model. They found that the inflammatory and wound healing reactions to bioprosthetic mesh are fundamentally distinct from those elicited by synthetic mesh. These variances may result in diverse outcomes regarding the adherence and vascularization of the materials, ultimately impacting the effectiveness of hernia repair procedures.

Moreover, biological mesh demonstrates the capability to prompt the differentiation of mesenchymal stem cells within the bone marrow and stimulate fibroblast proliferation by up to two-thirds. In other terms, the matrix acts as a framework, encouraging the merging of connective tissue and facilitating its revascularization and repopulation by the patient’s cells. This ability for tissue integration and remodeling renders biological meshes particularly intriguing for pediatric reconstructions, as it has the potential to accommodate the patient’s growth and development. Reconstructing extensive chest wall defects in children can be difficult due to several reasons. Firstly, rigid prosthetic plates, which are intended to prevent paradoxical respiration, do not expand as the child grows. This lack of growth accommodation can lead to progressive chest and spinal deformities. Secondly, young children have a relatively larger thorax compared to their limbs, making extrathoracic soft tissue flaps potentially inadequate for proper reconstruction. Therefore, biologic mesh emerges as a secure and reliable alternative for pediatric patients undergoing chest wall reconstruction, surpassing both primary tissue repair and synthetic mesh options (12-16). In 2006, Smith et al. (16) conducted a study analyzing the outcomes of 26 growing children who underwent thoracic cage reconstruction using a biodegradable extracellular matrix patch derived from porcine. Over the follow-up period of 41 months thus far, there has been no need for the removal of the mesh for any reason, and it has not impeded the growth of the thoracic cage.

Additionally, owing to its aptitude for tissue integration, this material exhibits considerable resistance to infections (2,4) and it is advocated for reducing the risk of site complications associated with prostheses. Based on these properties, they may also provide a safer alternative to synthetic mesh for chest wall reconstruction in immunocompromised patients (17). Furthermore, biological meshes have been employed in scenarios where the operative field is exposed to irradiation and/or bacterial contamination (18,19) with excellent postoperative outcomes. Nonetheless, there remains an ongoing debate on this matter. On one hand, some authors advocate against their removal in cases of infections (20,21), suggesting their resilience even under such conditions. On the other hand, other authors (22) have reported instances of wound healing complications, such as hematomas or infections, among several patients. However, recent studies with approximately two-year follow-up periods have reported no postoperative complications and have demonstrated favorable functional outcomes (23,24).

Biological meshes may be used in combination with rigid prosthesis such us titanium bars or customized.

3D-printed titanium implant (25-27) and/or muscle flaps (28,29). Interestingly, Miller et al. (19) described a series of 25 patients who underwent chest wall stabilization or reconstruction with a bovine pericardium patch and an absorbable polylactic acid bar. After one year follow-up, three patients necessitated the extraction of their biomaterials. Prophylactic removal of two bovine pericardial patches occurred during the debridement of a partially necrotic muscle flap, while the removal of one polylactic acid bar was necessitated by an inflammatory reaction. Notably, none of the patients with an infected resection site required the removal of their biomaterial. Additionally, in 2019, Shah et al. (30) conducted an evaluation of outcomes in chest wall reconstruction utilizing methyl methacrylate (MMA). They presented the first successful case series of reconstruction employing biologic mesh as a component of the MMA sandwich prosthesis. Their findings suggest that MMA represents a safe and efficacious option for rigid reconstruction, whether employed independently or in conjunction with synthetic or biologic mesh materials.

After chest wall resection and rigid reconstruction, attention must turn to addressing the need for soft tissue coverage. While small full-thickness defects can typically be closed primarily, larger defects often require vascularized soft tissue flaps. These flaps serve multiple purposes, including controlling infection, obliterating dead space, and providing coverage for synthetic materials. Typically, regional pedicled muscle or myocutaneous flaps may be used to cover all defect locations. Free tissue transfer is generally reserved for situations where regional flaps are unavailable, insufficient, or have previously failed (31).

While the majority of articles in the literature focus on case reports (28,29,32-34) or small case series (18,19,26,27) in which biological meshes have been used alone or in combination with rigid prosthesis or muscle flaps, the multicenter study conducted by Gonfiotti et al. (23) is noteworthy, as it utilized prospectively recorded data from 105 patients who underwent chest wall reconstruction using a porcine-derived acellular cross-linked dermal matrix biological mesh. The study evaluated various outcomes, including preoperative data, type of resection and reconstruction, hospitalization, 30-day morbidity and mortality, as well as overall survival. Notably, surgical sites were categorized as high-risk for infection in 28 patients (26.7%) and infected in 16 patients (15.2%) preoperatively. Thirty-day morbidity was observed in 30.5% of cases (n=32 patients), with 14 patients (13.3%) experiencing postoperative complications directly related to chest wall surgical resection and/or reconstruction. However, there were no reports of 30-day mortality, while the 1- and 2-year mortalities were 8.4% and 16.8%, respectively. The study concluded that biological mesh remains a valuable option in chest wall reconstruction, even in cases involving infected or high-risk surgical sites, as it demonstrates low rates of early and late postoperative complications and exhibits excellent long-term stability.

Table 2 summarizes main findings of the different series on chest wall reconstruction with biological mesh.

Furthermore, there are some comparative studies evaluating outcomes of biological and synthetic meshes that merit attention. In 2020, Giordano et al. (35) conducted a pioneering comparative study involving the use of acellular dermal matrix and synthetic meshes in chest-wall reconstruction. Their retrospective analysis encompassed a cohort of 146 patients who underwent this procedure, utilizing either acellular dermal matrix or synthetic meshes. The primary focus was assessing surgical-site complications. Their findings revealed a notably higher rate of surgical-site complications in the group treated with synthetic meshes compared to those who received acellular dermal matrix prostheses (32.6% vs. 15.7%; P=0.03). Furthermore, it was observed that in numerous cases of infection, the removal of bioprosthetic meshes was not deemed necessary.

More recently, Lampridis et al. (36) conducted a study to explore the utilization of bovine acellular dermal matrix in diaphragmatic and chest wall reconstruction, comparing its efficacy with synthetic meshes. The research involved sixty-six consecutive patients who underwent diaphragmatic and/or chest wall reconstruction at a single center. The study assessed outcomes such as surgical site complications, readmission rates, and reoperation incidence. Results indicated that patients in the synthetic mesh group experienced a significantly higher rate of surgical site complications compared to those in the biological mesh group (37.5% vs. 11.5%; P=0.03). Likewise, the readmission rate was notably higher in the synthetic mesh group (17.5% vs. 0%; P=0.04), attributed to causes such as pleural effusion, pneumothorax, empyema, and pneumonia. Within the study cohort, only one patient with a synthetic mesh required reoperation (P>0.99).

Given that previous studies compared heterogeneous cohorts of patients, in a recent study Vanstraelen et al. (37) compared postoperative outcomes between biologic and synthetic reconstructions following chest wall resection in a matched cohort. They enrolled a total of 438 patients undergoing prosthetic chest wall reconstruction, with 49 receiving biologic prostheses and 389 receiving synthetic prostheses. After comparing 46 pairs of patients, their findings led them to conclude that, based on their experience, surgical site complications requiring reoperation, pulmonary complications, and 30-day morbidity did not demonstrate significant differences between biologic and synthetic prostheses in chest wall reconstructions. They concluded that instead of solely concentrating on the search for an ideal prosthesis, there is a necessity for a patient-tailored strategy. This strategy should encompass both the selection of the prosthesis and the implementation of suitable myocutaneous coverage for extensive chest wall defects. Such an approach aims to mitigate surgical site complications effectively.

While it seems evident that biological mesh products offer advantages over synthetic mesh by lowering the risk of infection or rejection, it is important to highlight that the costs associated with biological meshes remain relatively high. Synthetic prostheses typically range from $500 to $3,000, while biologic prostheses range from $3,000 to $30,000, depending on their size (19). In 2015, the Canadian Agency for Drugs and Technologies in Health conducted a review to assess whether there was substantial evidence indicating the clinical and cost-effectiveness of biological meshes, justifying their extensive use in surgical practice. However, the report concluded that there was not enough evidence available to decisively determine the appropriate place for biological mesh products in therapy (38). Moreover, when assessing cost-effectiveness, it’s crucial to consider expenses associated with complications, reoperations, and multistage strategies. From our perspective, conducting a comprehensive cost-effectiveness analysis is crucial to fully elucidate this aspect. However, such an analysis necessitates a meticulously designed prospective protocol, which, to the best of our knowledge, has not yet been undertaken in the thoracic surgery field. However, Schneeberger et al. (39) compared this metric in ventral hernia repair and demonstrated that biosynthetic and biologic mesh emerged as the preferred option as long-term complication rates for synthetic mesh increased to 15.5% and 26.2%, respectively.

Additionally, there exists a spectrum of prices among the biologic products, providing the opportunity to evaluate the value of the implant in relation to clinical outcomes in comparison to its cost. Concerning this idea, Byrge et al. (40) compared outcomes of two types of biological meshes (Strattice™ versus Permacol™) for ventral hernia repair by analyzing complications rates associated with each material, repair success, and cost difference over the two meshes. They found that Permacol™ use resulted in similar clinical outcomes with significant cost savings (median cost of $1,600 versus $8,940, P<0.001) when compared to Strattice™.

Based on these considerations, we may conclude that the selection of the mesh should be guided by a comprehensive consideration of both clinical outcomes and product cost.

Our institutional experience

Concerning the extent of chest wall resection for oncologic indications in our surgical procedures, we adhere to a protocol where a 3-cm free margin is maintained both anteriorly and posteriorly to the tumor and normal ribs situated above and below the lesion are consistently excised as part of the procedure. Additionally, we execute a skin incision that encompasses the area of the previous biopsy, any affected skin, and/or tissues previously exposed to radiation.

Regarding chest wall reconstruction, our policy dictates that defects smaller than 5 cm in any location and those measuring up to 10 cm in size posteriorly do not require prosthetic reconstruction. Patients necessitating extensive chest wall resection undergo discussion by a multidisciplinary panel including thoracic and plastic and reconstructive surgeons.

Based on our experience, the use of synthetic materials can pose various complications, notably infections, as they are considered foreign bodies. We have encountered numerous instances necessitating redo-surgeries involving the removal of infected synthetic meshes. Therefore, we have a preference for employing biological prosthetic material in chest-wall reconstruction. Nowadays, at our institution, the general indications for the utilization of biologic prostheses encompass critical wounds (e.g., in infectious environments or radionecrosis), noncritical wounds in patients with a history of radiation or redo surgery, oncologic etiologies requiring adjuvant therapies and defects lacking adequate myocutaneous coverage. Regarding patient selection, biological prostheses are recommended for immunosuppressed and fragile patients with the aim of avoiding surgical site complications. The ultimate decision rests with the thoracic surgeon and is informed by intraoperative findings, including the extent of the defect and the quality and availability of surrounding soft tissues. Importantly, biological meshes exhibit significant barriers to air and fluid, along with a heightened resistance to infections. For instance, when addressing significant anterior chest-wall defects, we often enhance the reconstruction by combining a biological prosthesis with rigid systems, such as titanium bars or three-dimensional custom-made titanium prostheses, along with a myocutaneous flap to reinforce structural integrity.

Among all the biological meshes currently available to us, the porcine dermal collagen matrix (Permacol™, Medtronic, Minneapolis, MN, USA) is our preferred choice. The mesh is composed of an acellular sheet made from porcine dermal collagen, with its elastin fibers retaining their original three-dimensional structure. Collagen fibers are cross-linked using diisocyanate, a process that involves bonding with lysine and hydroxylysine residues within the collagen fibers. This cross-linking enhances resistance to collagenases, potentially contributing to its long-term durability. This preference is attributed to its seamless integration into surrounding tissues, ease of placement, swift application, and effective fixation under tension to the defect edges.

Between February 2019 and December 2023, 20 patients [12 women (60%); mean age, 56.8±15.3 years; range, 34–80 years] had a porcine-derived acellular cross-linked dermal matrix (Permacol™) implanted in our center. Main characteristics of these patients are detailed in Table 3. The indications for using biological mesh implant in chest wall repair/reconstruction were: primary chest wall tumor [n=8 (40%)], secondary chest wall tumor [n=9 (45%)], lung hernia [n=2 (10%)] and Paget’s disease [n=1 (5%)]. Eighteen (90%) patients received the device alone (Figure 1 and Video S1), whereas in two patients, biological mesh was associated with titanium bars or a customized 3D-printed titanium implant (Figure 2); 10 (50%) patients also underwent a myocutaneous flap. Chest wall defect was located as follows: anterior or anterolateral (14 cases) (Figure 3), lateral (4 cases), and posterior (2 cases). R0 resection was achieved in 14 out of 18 tumor resections (77.8%). Thirty-day morbidity was 26.3% (5 patients). The most represented adverse event was seroma (2 cases). Two patients required unplanned reoperation due to bleeding and flap dehiscence, respectively. Thirty-day mortality was nil. All patients reported adequate pain control at discharge, although 40% required transdermal fentanyl treatment in addition to the usual analgesic regimen of paracetamol and anti-inflammatories. Moreover, all patients demonstrated acceptable and satisfactory cosmetic results, and none necessitated a secondary intervention to enhance cosmetic outcomes. Mean follow-up extended until 29.5±18.95 months (range, 1–59 months). One patient was lost at follow-up after 7 months. Four patients developed long-term complications including flap lymphedema, capsulated seroma, and abdominal wall hernia. Additionally, one patient required the removal of the titanium prosthesis due to a skin defect with partial implant exposure.

Figure 1 A case of anterolateral ribs resection due to prostate cancer. The chest wall defect was reconstructed with the biological mesh alone.

Figure 2 A case of body sternal resection extended to bilateral anterior ribs. The chest wall defect was reconstructed with biological mesh, a 3D printed prosthesis, and muscle flap to cover the prosthetic material.

Figure 3 A case of anterior ribs resection due to recurrence of breast cancer. The image illustrates mesh placement and fixation with non-absorbable sutures. The chest wall defect was reconstructed with the biological mesh and a myocutaneous flap.

Strengths and limitations

This paper presents a Clinical Practice Review focusing on the technical intricacies involved in chest wall reconstruction with biological mesh. It has been crafted based on the author’s extensive experience, amalgamating empirical knowledge with the latest evidence gleaned from scientific publications. Its academic and educational emphasis, constitutes its primary strengths. Additionally, a descriptive analysis of our experience in the utilization of biological mesh (Permacol™) including long-term follow-up, has been reported. However, it is important to acknowledge its limitations, notably the paucity of robust evidence supporting its development and the relatively modest level of recommendations derived from it. Secondly, the study did not assess how the higher cost of a biologic mesh might influence clinical decisions, as a comprehensive cost-effectiveness analysis was beyond the scope of this investigation. Furthermore, data regarding the respiratory function of the patients were not provided, as they did not undergo preoperative or postoperative pulmonary function testing. Therefore, it is uncertain to what extent chest wall resection and reconstruction with the biological mesh may have impacted respiratory function. However, no instances of flail chest phenomenon leading to pulmonary insufficiency were detected during the postoperative period.

Conclusions

Contemporary, reconstructing the chest wall continues to pose a considerable challenge for thoracic surgeons, persisting despite ongoing technological advancements and the emergence of novel materials. We strongly advocate for the use of biological materials as a viable alternative, particularly in scenarios involving infected fields or patients at a heightened risk of infection. Furthermore, biological meshes exhibit favorable attributes such as promoting robust wound healing and ensuring long-term stability, with minimal complications during the post-operative phase. Notably, they have demonstrated safety in pediatric patients as well.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Alessandro Gonfiotti) for the series “Chest Wall Surgery” published in Shanghai Chest. The article has undergone external peer review.

Peer Review File: Available at https://shc.amegroups.com/article/view/10.21037/shc-24-5/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://shc.amegroups.com/article/view/10.21037/shc-24-5/coif). The series “Chest Wall Surgery” was commissioned by the editorial office without any funding or sponsorship. M.F.J. has a contract with Medtronic for advisory work and as a proctor with Intuitive. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Publication of the images included in the article was waived from patient consent according to the Salamanca University Hospital ethics committee/institutional review board.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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