RADICAL FOREQUARTER AMPUTATION WITH HEMITHORACECTOMY AND FREE EXTENDED FOREARM FLAP - TECHNICAL AND PHYSIOLOGICAL CONSIDERATIONS

Background: A radical forequarter amputation with partial chest wall r esection (one to four ribs) has been reported for benign and malignant lesions involving the shoulder and chest wall region. Concerns about reconstruction and postoperative pulmonary function have previously li mited more extensive chest wall resections. The current report describ es the first case in which a complete unilateral anterior and posterio r chest wall resection and pneumonectomy (hemithoracectomy) accompany a forequarter amputation. A novel reconstructive technique used the fu ll circumference of the forearm tissue with an intact ulna as a free o sseomyocutaneous flap. Methods: In this case, a 21-year-old patient pr esented with an extensive recurrent desmoid tumor that involved the sh oulder, brachial plexus, subclavian vein, and chest wall from the late ral sternal border to the midportion of the scapula and down to the ei ghth rib. The operative technique involved removal of the entire right hemithorax from the midline sternum to the transverse process posteri orly, down to the ninth rib inferiorly. Due to the absence of a rigid hemithorax, the uninvolved ipsilateral lung was also removed. The fore arm flap was prepared before final separation of the specimen and divi sion of the subclavian vessels. Results: Postoperatively, the patient maintained excellent oxygenation without atelectasis or fever and was extubated on the 15th postoperative day. As expected after pneumonecto my, significant decreases from preoperative to immediate postoperative values were noted for the vital capacity (VC) (from 4.87 L to 1.29 L) , forced 1-s expiratory volume (FEV 1) (from 3.77 L to 1.02 L), and in spiratory capacity (IC) (3.33 1 to 0.99 1). Rehabilitation included a specially designed external prosthesis to provide cosmesis and prevent scoliosis. By the ]5th postoperative week the patient had returned to normal social and physical activities, with a gradual improvement in all respiratory parameters: VC 1.52 L, FEV 11. 29 L, IC 1.04 L. There has been no evidence of tumor recurrence at 1 year. Conclusions: This report provides evidence that a complete hemithoracectomy, pneumonecto my, and forequarter amputation can be safely performed for selective t umors involving the shoulder region with extensive chest wall invasion . Reconstruction may be achieved with an extended forearm osseomyocuta neous free flap with an excellent functional outcome.