Surgical Science, 2011, 2, 331-334
doi:10.4236/ss.2011.26070 Published Online August 2011 (
Copyright © 2011 SciRes. SS
Titanium Rib Plate Technique for Huge Chest Wall
Yong Han Yoon
Department of Th oracic and Cardiovascular Surgery, Inha University College of Medicine, Incheon, Korea
Received February 9, 2011; revised April 6, 2011; accepted August 2, 2011
Chest wall reconstruction after en-bloc tumor resection is very important to preserve functional mobility and
to enhance the cosmetic effect. Because they are flexible and pliable, titanium plates are proposed to recon-
struct the chest wall, even though such chest wall reconstruction has been performed in only a few cases
worldwide. We present a case of a 49-year-old man with a chondrosarcoma arising from the left 1st rib, in-
vading the manubrium, clavicle, 2nd and 3rd ribs, and the anterior segment of the left upper lobe. After wide
resection, the chest wall was reconstructed using titanium rib plates and Marlex mesh—the Bovine pericar-
dium sandwich type. The patient tolerated the pain well, and fourteen months after surgery, the chest wall
was well preserved function mobility and improved pulmonary function test.
Keywords: Chest Wall Reconstruction, Titanium Plate, Chondrosarcoma
1. Introduction
Generally, chest wall defects larger than 5cm in size, in
any location, and those more than 10cm in size, posterior
or in close proximity to the scapula, must be recon-
structed [1]. LeRoux and Shama [2], proposed that the
ideal characteristics of a prosthetic material are rigidity
to invalidate paradoxical chest wall motion, inertness to
allow in-growth of fibrotic tissue and decrease the like
hood to the appropriate shape at the time of operation,
and radiolucency to allow radiographic follow-up the
underlying problem. Techniques have been developed
for thoracic reconstruction surgery that allows resection
of chondrosarcomas. Wide excision surgical treatment is
the best choice for chondrosarcoma, after which local-
ized recurrence is the most common problem. Titanium
plates have sufficient inertness to allow the in-growth of
fibrous tissue [3]. Because rigid titanium plates have
many advantages, we expect to use them widely for chest
wall reconstruction.
2. Method
Case Report
A 48-year-old man was referred for evaluation of chest
pain and a palpable chest wall mass. A chest computed
tomography (CT) scan showed a large mass involving
the left upper lobe, 1st rib, and chest wall, originating
from a well-defined 12.6 × 10.1 cm chondrosarcoma in
the anterior chest wall (Figures 1(a) and (b)). A local-
ized chest wall biopsy showed a spindle cell sarcoma.
The chest wall mass was resected. The wide excision
was performed and included soft tissue, partial manu-
brium, clavicle, the 1st-3rd ribs, and anterior segment of
the left upper lobe without any problems. The surgical
margin had to be free of tumor by frozen section before
the reconstructive procedure was attempted. Skeletal
reconstruction surgery was performed, including the
manubrium, clavicle, and 1st-4th ribs. We used a latis-
simus dorsi muscle flap associated with a split thickness
skin graft. The pathology results revealed a dedifferenti-
ated chondrosarcoma sarcoma, the 1st rib was a rhado-
myosarcoma and cell necrosis extension into the inter-
costal soft tissue invaded the lung parenchyma and
manubrium that was 16.0 × 11.0 × 11.0 cm in size. The
patient was discharged uneventfully on post-operative
day 24 and underwent radiotherapy.
3. Surgical Tech nique
Five rib plate surgery of the anterior chest wall was per-
formed after resection of thechest wall chondrosarcoma,
(a) (b)
Figure 1. (a) Chest computed tomography scan showing the huge mass involving left upper lobe, 1st rib and chest wall; (b)
chest computed tomography scan showing the huge mass involving left anterior chest wall with sternum and left upper lobe.
Figure 2. Intra-operative view of chest wall reconstruction,
there was performed by double Marlex mesh-Bovine peri-
cardium and multiple titanium rib plate.
partial clavicle, 1st, 2nd, and 3rd ribs, and the segmentec-
tomy of the left upper lobe with severe adhesions be-
tween the chest walls mass and left upper lobe. We used
a double Marlex mesh-Bovine pericardium composite to
repair large defects involving the sternum and anter-
olateral chest wall that protect the underlying cardiovas-
cular structures. The prosthesis was sewn with inter-
rupted non-absorbable suture (2-0 Ethibond). Five rib
plates were inserted between the 1st, 2nd, 3rd, and 4th ribs,
clavicle and manubrium (Figure 2). After the skeletal
reconstruction was completed, the second phase of the
chest wall reconstruction was performed with an interpo-
sition of large muscle and skin flaps.
Postoperative Recovery
The patient was discharged uneventfully on post-opera-
tive day 24 and underwent radiotherapy (Figure 3). The
pulmonary function test results before and 4 months after
surgery showed the following: vital capacity, 2.60 and
2.72 liter; 67% and 65%; forced expiratory volume in 1
Figure 3. 3D chest wall computed tomography showing
reconstructed left upper thoracic cage by multiple prosthe-
sis and screw.
sec, 2.17 and 2.33 liter; 67% and 71%. Fourteen months
after surgery, the patient was doing well and had im-
proved pulmonary function tests.
4. Discussion
Synthetic mesh (Prolene mesh, Gore-Tex, or Marelx
mesh), methyl metacrylate, and a muscular flap are fre-
quently used for chest wall reconstruction. Even though
its safety has been studied and favorable results have
been obtained [4-6], these meshes are too weak for lat-
eral chest wall reconstruction [7]. Methyl methacrylate,
popular in United States, can create good chest wall sta-
bility, but some problems have been reported in the
Copyright © 2011 SciRes. SS
Y. H. YOON333
preparation and adaptation to the shape of the defect [1].
Coonar et al. have reported on the advan tages of titanium,
including a high strength-to-weight ratio, osseointegra-
tion, and less interference with computed tomography
than higher density metals have. A reduced rate of com-
puted tomographic artifacts allows for more accurate
three-dimensional reconstructions. Titanium is not fer-
romagnetic, so it can be used safely with magnetic reso-
nance imaging [8]. In 1997, Nomori et al. performed
chest wall reconstruction with a titanium hollow screw
plate in a patient with squamous cell carcinoma invading
the 2th-4th ribs [9]. The defected 3rd and 4th ribs were re-
constructed with rib-to-rib titanium plates. At that time,
meshes, such as PTFE patches, metal plates, and silastic
sheeting were popular with reconstructing huge chest
wall defects. We suspect those types of reconstructions
presented very challenging trials, since there were no
other published reports of titanium plate use in chest wall
reconstruction for more than 10 years. In the past 2 years,
a few excellent cases reports were published. Gonfiotti et al.
operated on a Ewing’s sarcoma patient: two STRATOS
(Strasburg Thoracic Osteosyntheses System; MedXpert,
Heitersheim, Germany) bars were fixed posteriorly to the
ribs, with the special clips, and anterioly to the edges of
the sternum, with metal wires [1]. Bille et al. operated on
a Ewing’s sarcoma patient with a Gore-tex mesh and
titanium rib prosthesis to reconstruc t the third, fourth and
fifth ribs (Stratos) [7]. Coonar et al. placed four STRATOS
titanium plates, fixed by clips to both sides of ribs. Dur-
ing the 21-month follow-up, there was no recurrence;
also demonstrated were the durability and resistance of
inserted titanium plates through scapular and elbow frac-
tures [8,10]. Iarussi et al. performed 13 chest wall recon-
structions using Synthes titanium plates (Synthes, West
Chester, Pa) but no details were published [11]; even
though they achieved chest cage stability, with only 1
titanium plate insertion in the resected area of the 2nd rib.
Just how this stability was achieved has not been dis-
Compared to other reported cases, our patient had a
very large mass; for that reason, extensive reconstruction
from the clavicle to the 3rd rib was performed. Instead of
screws and wires, simpler and more relevant material,
such as clips, likely make it easier to fix plates. We used
titanium plates for the first time for a large chest wall
construction, and we had no difficulty inserting the plates
and we easily understood how they work. We assume
that Titanium plates cause less severe adhesions than
other rigid and non-rigid prostheses. Titanium plate chest
wall reconstruction is not used worldwide but has been
performed in some European countries. To establish the
most effective and optimal procedure, long-term follow
up and multicenter studies will be necessary. Titanium
rib plate is suitable in chest wall reconstruction surgery
for large defect chest walls and facilitates a good quality
of life.
Comparisons between titanium plates and other meth-
ods for cost-effectiven ess, quality of life, convenience of
skill, recurrence rate, and mortality sh ould be analyzed in
near future.
5. Conclusions
Titanium rib plate is suitable in chest wall reconstru ction
surgery for huge defect chest walls and facilitates a good
quality of life.
6. Acknowledgements
This work was supported b y an Inha Univ ersity Research
7. References
[1] A. Gonfiotti, P. F. Santini, D. Campanacci, et al., “Malig-
nant Primary Chest-Wall Tumors: Techniques of Recon-
struction and Survival,” European Journal of Cardio-
Thoracic Su rgery , Vol. 38, No. 1, 2010, pp. 39-45.
[2] B. R. LeRoux and D. M. Shama, “Resection of Tumors of
the Chest Wall,” Current Problems in Surgery, Vol. 20,
No. 6, 1983, pp. 345-386.
[3] H. Horio, T. Ohtshka, Y. Kubota, T. Hasegwa, H. No-
mori, T. Naruke and K. Suemasu, “Large Chest Wall
Resconstruction Using Titanium Micromesh and Pedicled
Lastissimus Dorsi Muscularcutaneous Flap: Report of a
Case,” Surgery Today, Vol. 35, No. 1, 2005, pp. 73-75.
[4] N.C. Dang, S. Siegel and J. D. Philips, “Malignant Chest
Wall Tumors in Children and Young Adults,” Journal of
Pediatric Surgery, Vol. 34, No. 12, 1999, pp. 1773-1778.
[5] Mansour K. A., Thourani V. H., Losken A., Reeves J. G.,
Miller J. I. and Jones G. E., Chest wall resection and re-
construction: a 25-year experience. The Annals of Tho-
racic Surgery, Vol. 73, No. 6, 2002, pp. 1720-1725.
[6] P. G. Arnold and P. C. Pairolero, “Chest-Wall Recon-
struction: An Account of 500 Consecutive Patients,”
Plastic and Reconstructive Surgery, Vol. 98, No. 5, 1996,
pp. 804-810. doi:10.1097/00006534-199610000-00008
[7] A. Bille, M. Gisabella, L. Errico and P. Borasio, “A Suit-
able System of Reconstruction with Titanium Rib Pros-
thesis after Chest Wall Resection for Ewing Sarcoma,”
Interactive CardioVascular and Thoracic Surgery, Vol.
12, No. 2, 2011, pp. 293-296.
Copyright © 2011 SciRes. SS
Copyright © 2011 SciRes. SS
[8] A. S. Coonar, N. Qureshi, I. Smith, F. C. Wells and E.
Reisberg and J.-M. Wihl m, “A Novel Titanium Ri b Bridge
System for Chest Wall Reconstruction,” The Annals of
Thoracic Su rgery , Vol. 87, No. 5, 2009, pp. e46-e48.
[9] H. Nomori, H. Horio and T. Hasegawa, “Chest Wall Re-
construction Using Titanium Hollow Screw Reconstruc-
tion Plate,” The Journal of Thoracic and Cardiovascular
Surgery, Vol. 45, No. 1, 1997, pp. 35-37.
[10] A. S. Coonar, J. M. Wihlm, F. C. Wells and N. Qureshi,
“Intermediate Outcome and Dynamic Computerized To-
mography after Chest Wall Reconstruction with the
STRTOS Titanium Rib Bridge System: Videodemonstra-
tion of Preserved Bucket-Handle Rib Motion,” Interac-
tive CardioVascular and Thoracic Surgery, Vol. 12, 2011,
pp. 80-81. doi:10.1510/icvts.2010.249615
[11] T. Iarussi, A. Pardolesi, P. Camplese and R. Sacco,
“Composite Chest Wall Reconstruction Using Titanium
Plates and Mesh Preserves Chest Wall Function,” The
Journal of Thoracic and Cardiovascular Surgery, Vol.
140, No. 2, 2010, pp. 476-7.