Surgical management of malignant chest wall tumors has evolved, similar to other areas of surgical oncology, into an ensemble of multispecialty, team-based care.1,2 In the United States, surgical oncologists often work closely with plastic surgeons to plan one-stage procedures, with two surgical teams, that include both the cancer resection and chest wall reconstruction. In the operating room, after excision of the tumor, the plastic surgeon then carefully analyzes the location, size, and extent of the resulting defect and then implements a reconstructive strategy to provide durable coverage that can withstand radiation and preserve the functions of the chest wall. Reconstruction of these defects may be challenging, although through applying fundamental principles of reconstruction, these cases are often gratifying for both surgeon and patient. We congratulate the authors for developing a tremendous practice of managing these difficult cases in a resource-constrained setting, where the clinical challenges to provide this level of care often are complicated from social and financial standpoints.

In this article, Sharma et al. described their experience with 181 cases of malignant chest wall tumors at All India Institute of Medical Sciences between 1999 and 2020.3 In this resource-constrained setting, approximately two thirds of patients had primary tumors, most commonly arising from the soft tissues; the remaining cases involved secondary tumors from the breast or lung. Rib resections were performed in approximately 60% of cases (median of 3.5 ribs), and when indicated, rigid reconstruction was commonly performed by using a methyl methacrylate mesh-bone cement sandwich technique. In the vast majority of cases, the authors advocate for soft tissue coverage using locoregional myocutaneous flaps. The authors reported low rates of postoperative complications and cancer recurrence patterns that varied according to the tumor histology, most often occurring in secondary tumors. The authors describe their algorithmic approach to reconstruction of chest wall defects, based on location, size, and number of ribs resected.

The chest wall is more than the sum of its parts. It serves numerous essential functions, including protection of the heart, lung, great vessels, and spine, as well as to provide a mechanically sound environment for respiration, the foundation for upper limb movement and support of the head and trunk.4,5,6 The algorithm used by Sharma et al. to chest wall reconstruction largely mirrors approaches that have been described by other authors.6,7,8,9 Importantly, this algorithm may be generalizable to a range of healthcare settings, including those in low- or middle-income countries and other settings where resources are constrained. The vasculature and design of myocutaneous flaps based on pectoralis major, rectus abdominis, and latissimus dorsi muscles are well-described and can be performed by most reconstructive surgeons with minimal difficulty. These flaps, on their own or combined with each other, will provide coverage for the vast majority of chest wall defects.

However, other clinical scenarios are worth considering from a reconstructive standpoint that may not fit nicely into the algorithm described by the study authors. These circumstances will often demand microvascular techniques.10

The first scenario is for tumors located in the lower back. In this area, the options for soft tissue coverage are less certain and may involve perforator flaps or microvascular free flap coverage utilizing vein grafts or perforator-to-perforator anastomoses. Second, patients with a cancer recurrence who previously underwent reconstruction and radiation may require microvascular free flap coverage to introduce well-vascularized, nonradiated tissues. Third, in circumstances where the source vessel of the standard myocutaneous flap used for coverage has been ligated, which may occur with axillary tumors. Again, for these scenarios, microsurgical techniques afford the reconstructive surgeon additional options. Finally, although not explicitly discussed by the authors and often overlooked, the omentum can be used to cover defects involving the sternum, axilla, and the anterolateral chest up to the root of the neck when based on the right gastroepiploic vessels.6

Performing complex reconstructive surgery in resource-constrained settings presents a myriad of challenges that significantly impact the surgical care and patient outcomes.11 One primary challenge stems from limited access to essential medical infrastructure and technology. These settings may lack advanced surgical equipment (e.g., microscopes), specialized instruments (e.g., microsurgical instruments), and imaging facilities required for intricate reconstructive procedures.12 Under these circumstances, surgeons may then face the daunting task of improvising with basic tools and adapting their techniques to work within the constraints of the available resources. This creates opportunities for innovation, which is the lifeblood of reconstructive surgery. The authors of this study should be commended on their one team approach in a resource-constrained setting to resection and reconstruction with both high rates of success and low complication rates.

Another challenge can be the scarcity of trained healthcare professionals in resource-constrained settings. Performing complex reconstructive surgery demands a high level of expertise and experience, which may be lacking in regions with limited access to medical education and training programs.12 Surgeons working in these settings may find themselves grappling with a shortage of skilled colleagues, an insufficient support system, and limited opportunities for continuous professional development. This shortage of qualified personnel not only hinders delivery of complex reconstructive procedures but also places additional stress on the existing healthcare workforce, potentially impacting patient safety and recovery. Addressing these challenges requires a multifaceted approach, including increased investment in medical infrastructure, training programs, and collaborative efforts to bring specialized surgical expertise to resource-constrained regions.

Although the authors did not report any flap losses, these complications will inevitably occur at centers managing these conditions. In those circumstances, escalating up the reconstructive ladder may necessitate the use of microsurgical techniques. To enhance collaboration with the goal of improving surgical care and capacity in regions with limited number of plastic surgeons, the Plastic Surgery Foundation founded the Surgeons in Humanitarian Alliance for Reconstructive, Research and Education (SHARE) program.13 This program supports trainees and surgeons from around the world through mentorship, in-person and virtual learning opportunities, and research in general reconstructive and microsurgery. ReSurge International is another program focused on training and capacity-building, with the objective to provide surgeons in low-income countries with skills needed to provide complex microsurgical reconstructive care.14 SHARE and ReSurge International are two separate examples of collaboration between surgeons in the United States and those in resource-limited settings to address this gap in care. Despite the inherent challenges of performing microsurgery in resource-limited settings, the challenges can be surmountable. In a systematic review of reconstructive microsurgical cases in Africa for various indications, the pooled flap survival rate for 1376 flaps between 1976 and 2020 was 89%.15

Surgical management of malignant chest wall tumors and chest wall reconstruction often is reduced to its individual components and studies focus on short-term clinical outcomes. However, the overarching goals should be to help the patient return to their normal activities, restoring their quality of life and providing reassurance against cancer recurrence. As the surgical techniques for reconstruction of these defects have become increasingly apparent, the next pressing challenge is dissemination of best-practices in reconstruction so that all patients with these malignancies may have equal access to care.