The chest, back, and shoulders are at once amongst the least challenging areas to repair—given the often ample tissue laxity, low-patient expectations for cosmesis, and lack of anatomic danger zones and cosmetic unit boundaries—and amongst the most challenging, since the rate of hypertrophic scar formation and the tension from repetitive actions of daily living are rather high.
Therefore, reconstruction of these areas affords the flexibility of a potpourri of treatment approaches while demanding a reconstructive technique aimed at assuring that the tension across the wound surface, both at the time of closure and in the perceived future, remains kept to a minimum. Anticipating patient activity levels is of the utmost importance, as wounds in these areas may appear to be under a mild degree of tension at the time of reconstruction, while the patient lays in a restricted position and in a controlled environment; that same patient, however, is likely to be quite active even in the immediate postoperative period and the tension across the nascent wound may increase exponentially. Therefore, designing a closure with an eye to the future and after gaining a modicum of appreciation of the patient’s activity level is absolutely critical, since the same wound may be closed utilizing a variety of suturing techniques depending on the anticipated degree of tension that it will need to withstand.
In general, every effort should be made to close wounds in a linear fashion. This allows for the greatest chance of healing with minimal scarring, obviates the risk of flap or graft necrosis, and is generally the most cost-effective approach.
For the most part, reconstruction of the skin and soft tissues on the trunk does not present any major challenges. Unlike the head and neck, there are few danger zones to avoid, and the relative thickness of the underlying tissue planes makes for a rather forgiving canvas on which to work.
A few areas deserve special mention—the nipple unit and umbilicus may both be thought of as cosmetic subunits of their own. As with facial reconstruction, it is important to appreciate that the eye is drawn to these subunits and that any compromise of their unity leads to a cosmetic impression of imbalance out of proportion to the actual size and nature of the scar. Therefore, every effort should be made to maintain the integrity of these subunit boundaries.
For the nipple and areola, defects in the periareolar zone should be confined to this area. This may be accomplished by the use of rotation flaps in the immediate periareolar area, which may take advantage of the ability to hide incision lines in the outer boundary of the areola. Similarly, transposition flaps, M-plasties, and other approaches to shift the Burow’s triangles may also be used to avoid extending the incision onto the areola.
For defects within the areola, every attempt should be made to confine the repair within the boundaries of the areola itself. In the event of complete loss of the nipple or areola, some basic suturing techniques may be useful in reconstructing these anatomic landmarks. For example, the circular appearance of the areola may be evoked by utilizing a purse-string suturing approach, and reconstruction of a lost nipple may be effected by performing an exaggerated purse-string approach leading to bunching of the central skin, creating a rudimentary nipple.
Similarly, the umbilicus should be thought of a unique subunit; defects or wounds in this area should ideally be repaired by localizing the scar line either within the umbilicus, or reconstructing a modified umbilicus in cases of larger defects.
Of note, an inverting approach is useful here in order to recreate the natural inversion of the skin at the boundaries of the umbilcus. This may be accomplished with either simple buried dermal sutures or inverting horizontal mattress sutures. The Lembert stitch, or its running variant, the Cushing suture, may also be used to effect dramatic wound inversion.
Meticulous attention to technique remains the fundamental building block of all of these approaches, as even the best-planned flap or most thought-out approach can be waylaid by leaving suture track marks or other residual evidence of past surgical repair.