upper ribs via their costal cartilage. Ribs 11 and 12 are called floating ribs as they have no anterior

connection. Rib 1 is unique in its shape as it is flat, short, and extremely curved. Ribs 2 through 10 have

a more standard configuration with the head containing articular facets for the vertebrae. After the neck

the tubercle contains the facet for the vertebral transverse process. The costal groove along the inferior

portion of the shaft houses the intercostal bundle, consisting of the nerve, artery, and vein (Fig. 80-2).

Because of this inferior placement, most chest wall procedures such as thoracostomy tube placement or

thoracentesis should be aimed at the superior aspect of the rib to avoid injury to this bundle.

There are three intercostal muscles, the external intercostal, the internal intercostal, and the

innermost intercostal muscle. The intercostal bundle lays just external to the innermost intercostal layer

(Fig. 80-3). On the inner aspect of the chest wall, the internal thoracic (mammary) artery and vein runs

between the innermost intercostal muscle and the transversus thoracis muscles which connect the ribs to

the lower half of the sternal body. The intercostal arteries have two sources, one posterior and one

anterior. Almost all the posterior arteries arise from the descending thoracic aorta, while the anterior

arteries branch off the internal thoracic artery. The intercostal nerve is a branch off the ventral ramus

after it joins the sympathetic trunk. The intercostal veins follow the arteries and posteriorly drain into

the azygos and hemiazygos veins. Lymphatic drainage from the posterior chest wall drains into the

thoracic duct on the left and into the right lymphatic duct on the right.

Figure 80-1. Skeletal support of the thorax. Anterior (A), and lateral (B), views. Note the anterior cartilaginous component of the

upper 10 ribs, the fused costal cartilages of ribs 7 through 10, the location of the sternomanubrial junction (angle of Louis) at the

level of the second rib, and the oblique course of the ribs laterally from posterior to anterior.

The muscles of the chest wall can be divided embryologically into those from the epimeres, such as

the deep back muscles, innervated by the dorsal rami, and those from the hypomeres, such as the

intercostals and rectus, innervated by the ventral rami. The musculature can also be classified based on

respiratory function, where the primary muscles of respiration are the intercostals and the diaphragm,

and the secondary, or accessory muscles are the sternocleidomastoid, scalenes, pectoralis, serratus, and

abdominal wall musculature. The major back muscles include the trapezius and latissimus dorsi (Fig. 80-

4). In normal breathing, the diaphragm performs a majority of the work with the intercostals supplying

about a quarter of the workload. In full inspiration, the pleura extend bilaterally down to the level of

the 11th and 12th ribs (Fig. 80-5).

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Figure 80-2. Anatomy of ribs 2 to 10 as viewed from above (A), and below (B).

Figure 80-3. Anatomy of the intercostal space. The major intercostal muscles are the external and internal. The neurovascular

bundle courses in the costal groove along the inferior aspect of the rib.

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Figure 80-4. Thoracic musculature. Anterior (A), and posterior (B), views.

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Figure 80-5. Topographic relations of the pleura to the chest wall. Laterally, the pleura extends to the level of the 11th to 12th

ribs. The anterior reflection of the mediastinal and costal pleurae forms the costomediastinal recess, whereas the reflections of the

costal and diaphragmatic pleurae form the costodiaphragmatic recess.

CHEST WALL NEOPLASMS

Chest wall tumors are very rare. Lesions may be divided into benign and malignant, and then further

subdivided into soft tissue versus bony/cartilaginous tumors (Table 80-1). Most malignant tumors of the

chest wall are either metastatic from carcinomas or sarcomas arising in other sites of the body, or from

local extension of lung cancers or breast cancers.1

Almost all lesions will present as a mass, as pain, or as a combination of both. Occasionally they will

be asymptomatic and be identified on imaging for cancer surveillance or other reasons.2 Fever can

occasionally be a presenting symptom in the setting of a systemic neoplastic process. Evaluation of

these lesions includes a thorough history and physical and appropriate imaging, which may begin with

plain radiographs, but should include three-dimensional imaging such as a CT scan and/or MRI. This

will allow for evaluation of the depth of the lesion, the relationship of the lesion to nerve and vascular

structures, and the pulmonary fields for possible metastases. Depending on the situation, PET scans may

also be useful.1 Prior films may help ascertain the rate of growth of the lesion.3

Surgical intervention depends on the type of lesion and the goal of surgery. Tumors that are suspected

metastases may require only a needle or an incisional biopsy to confirm the diagnosis. Lesions that are

possible primary tumors, whether benign or malignant, require excisional biopsies. Some low-grade

malignant tumors may be underdiagnosed and considered benign if the entire specimen is not removed

and examined. If a tumor is proven to be a primary malignant lesion, wide excision is required, with

margins upto 4 cm.3

BENIGN SOFT TISSUE TUMORS

These tumors include lipomas, fibromas, hemangiomas, and neurofibromas among others. These can be

removed by excisional biopsy and require no further treatment unless they recur. Inflammatory

osteomyelitis can mimic tumors by causing pain.

Table 80-1 Chest Wall Tumor Classification

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Figure 80-6. Osteochondroma of left second rib. The stippled calcification within the tumor and the intact cortex of the rib are

characteristic.

BENIGN BONY/CARTILAGINOUS TUMORS

About two-thirds of benign chest wall tumors are either osteochondromas, chondromas, or fibrous

dysplasia, with osteochondromas comprising almost 50% of all nonmalignant rib tumors.

Osteochondromas usually present as painless masses with a male-to-female predominance of 3:1. If the

lesion becomes painful it may indicate malignant degeneration.3 They are often found on routine

radiographic examinations for other reasons and have a characteristic appearance of a pedunculated

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bony prominence (Fig. 80-6).

Chondromas account for 15% of benign rib lesions and grow from the cartilage at the sternocostal

junction.1 They have an equal male-to-female incidence. Clinically and radiographically, it is impossible

to distinguish chondromas from chondrosarcomas. It can be difficult microscopically to distinguish

chondromas from low-grade chondrosarcomas as well. As a result, all chondromas must be treated as if

they are potentially malignant and require complete excision.3

Fibrous dysplasia arises in the lateral portion or shaft of the rib and can have a “soap bubble” or

“ground-glass” appearance on radiographs (Fig. 80-7). These lesions may become painful if they enlarge

and can result in rib fractures. Surgical excision is needed for diagnosis and symptom relief.4

Eosinophilic granulomas and osteoid osteomas are rare conditions that affect men more often. Patients

may have multiple granulomas, including the skull and may benefit from radiotherapy as opposed to

surgical resection. Osteomas may be symptomatic and if so, should be resected.

MALIGNANT SOFT TISSUE TUMORS

These lesions can range from melanomas to desmoid tumors to malignant fibrous histiocytomas (MFHs).

Sarcomas also arise in the soft tissue of the chest wall, but they comprise less than 10% of all sarcomas.2

Desmoid tumors are borderline lesions between a benign and malignant classification, and are

sometimes considered low-grade fibrosarcomas.1 Almost half of all desmoids occur in the chest wall and

shoulder where they can encapsulate the brachial plexus. They require wide local excision and have a

high rate of recurrence. If they encircle vital structures, they can be treated with radiotherapy after

surgical excision.3

Figure 80-7. Fibrous dysplasia of the rib. Note the characteristic expansion and thinning of the cortex (arrows) and the central

ground-glass appearance.

MFHs are the most common primary chest wall tumors. They are more frequent in men (2:1 ratio)

and generally occur after the age of 50. They are slow-growing, painless, and spread along the facial

planes or between muscle fibers. MFHs are unresponsive to other forms of therapy and require wide

local excision. Because of the lesion’s propensity for fascial plane infiltration, there is a high rate of

recurrence following resection and patients who have undergone resection have a 5-year survival of

under 40%.3 Rhabdomyosarcoma is the second most common soft tissue lesion of the chest wall and

usually occurs in children and younger adults. It grows rapidly from the striated muscle, but is usually

painless. It is treated with wide excision followed by radiation and chemotherapy with a reported 70%

survival at 5 years.3 A recent review of soft tissue sarcomas in the chest wall suggested that tumor size

greater or less than 5 cm correlates with overall prognosis. Also, low-grade tumors had a 100% 5-year

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survival rate versus a 69.2% survival in high-grade tumors. There was a trend toward improved survival

in patients who received a complete resection versus those left with residual disease, but it did not

achieve statistical significance due to small sample size.2

MALIGNANT BONY/ CARTILAGINOUS TUMORS

Chondrosarcomas are the most common primary malignant bony tumors, accounting for 20% to 30% of

lesions. These are well-differentiated tumors and on microscopic examination may be difficult to

distinguish from their benign counterparts. Local recurrence can occur after excision and if untreated,

distant metastases can develop.3 Osteogenic sarcomas are more common in the limbs, but also occur in

the ribs. Radiographs depict a characteristic “sunburst” pattern. These tend to grow quickly and often

have metastases at the time of initial presentation. Patient evaluation should include a CT scan and bone

scan to check for the presence of metastatic disease. Surgery with adjuvant chemotherapy is the

treatment of choice for local disease.5 Ewing sarcomas constitute 5% to 10% of chest wall tumors. They

occur in children and younger adults with a male-to-female ratio of 1.6:1. Symptoms include pain, fever,

and fatigue. Radiographs show a large soft tissue mass with bony destruction. Patients often present

with metastatic disease, and ultimately three-quarters of patients will develop metastases.

Multimodality treatment is the key to treatment. Survival may be less than 30% at 5 years in patients

with metastatic disease.6

Figure 80-8. Plasmacytoma of the left seventh rib, showing characteristic cortical destruction and relatively large soft tissue

component projecting into the chest.

Solitary plasmocytoma is a rare tumor of the plasma cells and can be part of a systemic disease in

multiple myeloma. Lesions can be painful and usually occur in men over the age of 50. X-ray findings

show cortical destruction of the rib (Fig. 80-8). In the setting of systemic disease, only a needle biopsy

may be needed, but if the lesion is small and symptomatic, resection can be offered. For larger lesions,

radiotherapy is the primary treatment.1

METASTATIC TUMORS

As discussed before, metastatic lesions can arise from a variety of other cancers, and treatment depends

on the primary histology, time to recurrence, and goals of intervention. For isolated metastases with a

long interval before recurrence, surgical resection may be warranted. Each case should be individualized

and discussed within a multidisciplinary team.

CHEST WALL RECONSTRUCTION

1 Chest wall defects can result from cancer, radiation, trauma, or infection.7 The goals of repair are to

protect the thoracic cavity, minimize complications of respiration due to a flail chest, and to provide

cosmetic coverage as needed. Surgical repair involves chest wall stabilization and soft tissue coverage.

Stabilization depends on the size and the location of the defect. Often, if the defect is small enough, no

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stabilization is needed. In larger defects, or when the patient has an intrinsic lung disease limiting their

ability to breathe, stabilization using prosthetic materials is warranted. Soft tissue coverage of the

defect can vary from mobilization of soft tissue edges, to muscle/omental pedicled flaps, to free muscle

flaps.8

Size and location generally determine the need for chest wall stabilization. Defects less than 5 cm

anywhere in the chest wall, or defects less than 10 cm in the posterior chest wall that are anterior to the

scapula do not usually need stabilization.7,9 An alternative criteria is to use the number of ribs resected,

and to avoid stabilization when a portion of three ribs or less have been removed.10 Techniques for

closure of the defect include utilizing absorbable vicryl mesh, used in the setting of infection or if small

defects are present. This approach does not provide any stabilization. More definitive repairs utilize

polytetrafluoroethylene (PTFE) or a polypropylene methylmethacrylate (PPM) sandwich mesh. PTFE is

a flexible, soft material, while the PPM sandwich mesh resembles a hardened piece of plaster between

two portions of woven mesh. Different surgeons prefer different approaches, but some of the benefits

cited for the PTFE repair include greater stretch and the ability to create a water tight seal.7 The PPM

sandwich repair on the other hand allows the ability to mold the prosthetic and provides a firmer

stabilization (Fig. 80-9).9 Mortality rates from chest wall reconstruction in the setting of cancer

resections have been reported at 4% in multiple series.7,9,10

Flap coverage of the soft tissue defect will almost always require the assistance of a plastic surgeon,

and they should be involved preoperatively in the planning of a chest wall resection and reconstruction.

The decision-making process for which flap to use depends on the location of the defect, the size of the

defect, the corresponding size of the flap, and its vascular source. Pectoralis major flaps are the most

common in the upper chest/neck region. Its blood source can be from the thoracoacromial artery or

from intercostal perforators from the internal thoracic arteries (Fig. 80-10). The latissimus dorsi flap is

also commonly used for large, ipsilateral defects. Its blood source is from the thoracodorsal artery or

from perforators from the posterior intercostal vessels. It has a large arc of rotation from the

thoracodorsal pedicle and can cover a wide area of the chest wall (Fig. 80-11). Also commonly used are

rectus abdominal muscle flaps in either a vertical (VRAM) or transverse (TRAM) orientation (Fig. 80-

12). External obliques can be used on the lower anterior chest wall, and the trapezius can be used in the

mid back.11 Omental flaps are extremely useful and versatile. They can be used to cover large defects or

to fill cavities, such as the pleural space in the setting of a bronchopleural fistula and empyema. The

omentum can be taken off of the right or left gastroepiploic artery, but using the right arterial source

allows a greater arc of rotation than from the left. The limitations of this flap are that it requires a

laparotomy, although laparoscopic techniques have been described,12 and that the size of the omentum

can be variable, and difficult to assess preoperatively (Fig. 80-13).11

CHEST WALL CONGENITAL ABNORMALITIES AND THORACIC

OUTLET SYNDROME

Pectus Excavatum and Pectus Carinatum

Chest wall deformities occur in 1/1,000 live births. They are five times more common in men than

women, and pectus excavatum is five times more common than pectus carinatum. Upto 6% of people

with these deformities will also have a connective tissue disorder. Scoliosis is frequently seen in this

population.13 Pectus excavatum appears as a sternal depression that can be off midline approximately

50% of the time. Pectus carinatum is the opposite, with a sternal protrusion, often described as a

“pigeon chest” deformity. Less common deformities include sternal clefts, which are incomplete fusions

of the sternum, and Poland syndrome, where there is an absence of a pectoralis muscle and underlying

bony support in the chest wall.

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Figure 80-9. Marlex methylmethacrylate sandwich technique for chest wall reconstruction. A: Upper anterior chest wall defect

resulting from resection of ribs two to five and a portion of sternum. B: Marlex methylmethacrylate prosthesis being sutured in

place. Heavy, nonabsorbable sutures either encircling the ribs or passed through the sternum are used to anchor the prosthesis in

place. Inset: Detail of prosthesis showing sandwich of hardened methylmethacrylate between two sheets of Marlex.

Figure 80-10. Pectoralis major muscle rotation flap. A: Mobilization of the flap by detaching the clavicular, sternal, and chest wall

origins as well as the insertion of the muscle on the greater tubercle of the humerus. The dominant blood supply, the

thoracoacromial artery, which arises from the axillary artery medial to the proximal border of the pectoralis minor muscle, is

shown on the left side where the pectoralis major muscle has been removed. B: Medial transposition of the muscle flap, preserving

the thoracoacromial neurovascular bundle.

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Figure 80-11. Latissimus dorsi muscle rotation flap for chest wall reconstruction. A: Posterior view showing detachment of the

origins of the muscle. The dominant blood supply, the thoracodorsal artery, is preserved. B: Anterior view showing the extent to

which the mobilized muscle reaches.

Figure 80-12. Rectus abdominis muscle rotation flap. Shown is the mobilization of the rectus abdominis muscle, which is based on

the superior epigastric artery (the continuation of the internal thoracic artery), and rotation of the muscle and overlying skin to fill

an anterior chest wall defect.

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Figure 80-13. The omentum can be used to cover large defects. Shown is an open sternal wound after débridement with failed

prior muscle flap (A), and wound 6 months after omental flap placement (B). (Reproduced with permission from Ghazi B, Carlson

G, Losken A. Use of the greater omentum for reconstruction of infected sternotomy wounds: a prognostic indicator. Ann Plast Surg

2008;60(2):169–173.)

Pectus excavatum is the most common of these deformities, and the techniques for surgical correction

have been evolving, including the Ravitch and Nuss procedures. Despite this, less than 15% of patients

undergo surgery.14 Most patients present as children with notable deformities. People can be

physiologically asymptomatic, but can also present with fatigue, limited stamina, and cardiopulmonary

limitations. The workup includes pulmonary function testing, echocardiography, and CT scans. The use

of CT scans has been debated in children as the radiation exposure poses a risk. Some advocate that CT

scans are needed to show the three-dimensional aspect of defect and can better reflect the right heart

compression. The pectus severity index (Haller index) can be calculated by dividing the inner thorax

width by the depth measured from the posterior aspect of the sternum to the anterior aspect of the

spine (Fig. 80-14). Normal values are 2 to 2.2, and repair is only recommended when the index is at

least greater than 3.1.13,15 The age of the patient at which repair should be performed is also somewhat

controversial, as some surgeons advocate waiting until after the age of 10, but many series have

reported on a large number of patients treated at a much younger age with good outcomes.14 There is a

growing experience with treating adults also, as some patients seek repair at a later age (Fig. 80-

15).16,17

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