Thoracoplasty

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Thoracoplasty

Definition

Thoracoplasty is a surgical procedure involving the resection of multiple ribs (and sometimes their associated periosteum and intercostal bundles) to permanently collapse a portion of the chest wall, thereby obliterating an underlying space in the pleural cavity or lung.

Historical Background

Thoracoplasty was the cornerstone of tuberculosis (TB) surgery in the pre-antibiotic era (late 19th – mid 20th century). It was first systematized by de Cérenville (1885) and later refined by Alexander, Sauerbruch, and Schede. The principle was to collapse cavitary TB lesions by removing the bony support of the chest wall, thereby allowing the lung to "rest" and the cavity to close. With the advent of effective anti-TB chemotherapy in the 1950s–60s, its use declined dramatically but was never fully abandoned.

Indications

Historical (Classical)

Pulmonary tuberculosis with large cavities unresponsive to collapse therapy (pneumothorax, pneumoperitoneum)
Empyema thoracis with rigid, unyielding chest wall (Schede thoracoplasty)

Contemporary

Indication	Details
Chronic empyema / bronchopleural fistula	Most common modern indication; obliterates the empyema space
Post-pneumonectomy space complications	Empyema or persistent space after pneumonectomy
Multidrug-resistant (MDR) / XDR tuberculosis	Adjunct to chemotherapy when cavities persist
Chest wall reconstruction	After tumor resection with significant chest wall defect
Thoracic scoliosis correction	Rib hump correction (costoplasty/thoracoplasty as component of spinal surgery)
Failed lung re-expansion	Residual pleural space after decortication or pulmonary resection

Classification / Types

1. Extrapleural Thoracoplasty (Classic / Alexander type)

Ribs resected outside the pleura; pleura left intact
Aims to collapse underlying lung/cavity
Usually performed in stages (2–3 sessions weeks apart) to avoid paradoxical respiration and respiratory failure
Typically involves ribs 1–7 (upper lobe collapse) or specific segments

2. Intrapleural / Schede Thoracoplasty

En-bloc resection of ribs, intercostal muscles, thickened parietal pleura, and sometimes the empyema wall
Designed to obliterate a chronic empyema cavity
More extensive; performed in a single stage

3. Tailoring / Limited Thoracoplasty

Resection of only 1–3 ribs over a specific space
Used after pulmonary resection to close residual apical spaces
Less morbidity than classic thoracoplasty

4. Thoracoplasty with Muscle Flap (Modified)

Combines rib resection with muscle transposition (latissimus dorsi, serratus anterior) to fill the dead space
Preferred in bronchopleural fistula with contaminated spaces

Surgical Technique (Classical Extrapleural)

Patient position: Lateral decubitus
Incision: Posterior paravertebral incision (over erector spinae)
Subperiosteal rib resection: Periosteum stripped, ribs excised in segments — typically starting at rib 1 (transverse process to costochondral junction)
Number of ribs: Varies (commonly 3–8); determined by the extent of the space to be obliterated
Staging: To prevent acute mediastinal shift and paradoxical motion, ribs may be resected in 2–3 sessions
Closure: Drain placement; muscles closed in layers

Complications

Immediate / Early

Paradoxical chest wall motion → respiratory failure (major risk when >4 ribs resected in one stage)
Hemorrhage
Pneumothorax / hemothorax
Wound infection

Late

Severe thoracic deformity (scoliosis, shoulder drop, rib crowding) — the most visible long-term consequence
Chronic pain
Brachial plexus injury (especially with 1st rib resection)
Intercostal neuralgia
Restrictive ventilatory defect — loss of chest wall compliance reduces total lung capacity (TLC) and FVC
Cor pulmonale (in severe cases with significant lung reduction)
Persistent or recurrent bronchopleural fistula

Postoperative Image

Below is a postoperative AP chest X-ray following thoracoplasty, showing titanium miniplates used for chest wall stabilization after reconstruction:

Post-thoracoplasty chest X-ray with titanium miniplates

AP chest X-ray (postoperative day 6): Four titanium miniplates at ribs 1, 2, 4, and 5 securing the reconstructed thoracic cage. Lung fields are clear; no effusion or pneumothorax.

Functional Consequences

Pulmonary function: Significant permanent reduction in FVC and FEV₁ (20–40% depending on extent); restrictive pattern on spirometry
Exercise tolerance: Reduced in proportion to extent of resection
Quality of life: Cosmetic deformity and shoulder asymmetry are common concerns; patients often adapt surprisingly well

Modern Perspective

Thoracoplasty is now a salvage procedure reserved for situations where:

The pleural space cannot be obliterated by other means (decortication, muscle flap alone)
Pulmonary re-expansion is impossible (trapped lung, destroyed lung)
MDR-TB cavities persist despite adequate chemotherapy

It is rarely performed in resource-rich settings but remains relevant in high-TB-burden countries and in the management of complex post-resection complications. Limited thoracoplasty (1–3 ribs) combined with myoplasty represents the contemporary approach, minimizing deformity while effectively obliterating the target space.

Key Comparisons: Thoracoplasty vs. Alternative Space-Obliteration Methods

Method	Best for	Advantage	Disadvantage
Thoracoplasty	Rigid chest, large space	Definitive obliteration	Deformity, lung restriction
Muscle flap (myoplasty)	Moderate space, BPF	Preserves chest wall	Limited by muscle availability
Decortication	Early empyema, re-expandable lung	Restores lung function	Fails if lung trapped
Clagett procedure	Post-pneumonectomy empyema	Open drainage then closure	Multi-stage, prolonged course
Eloesser flap	Palliative / poor surgical risk	Simple open drainage	Permanent opening

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