The role of thoracoplasty in modern thoracic surgery: a narrative review with three illustrative cases

Introduction

Background

Thoracoplasty is defined as the surgical resection of ribs to reduce pleural space volume. The procedure may involve complete or partial rib resection, depending on the extent of disease and the desired degree of chest wall collapse. Descriptions of thoracoplasty date back to the late nineteenth century (1). Initially, it was developed as a primary treatment for chronic empyema, particularly of mycobacterial origin, with the goal of obliterating infected pleural spaces through passive chest wall collapse. With the advent of effective antimicrobial therapy and advances in thoracic surgical techniques, the use of thoracoplasty declined significantly (2,3). However, persistent pleural space infections, including those related to tuberculosis and postoperative complications, continue to present challenging clinical scenarios. In recent years, there has been renewed interest in thoracoplasty as a selective salvage procedure, particularly in patients who are not candidates for resection or in whom prior interventions have failed (4).

Rationale and knowledge gap

Thoracoplasty has historically been considered an aggressive and highly invasive procedure, and its use has largely declined in modern thoracic practice. As a result, familiarity with its indications and technical execution has diminished among contemporary surgeons. Despite this, the clinical scenarios for which thoracoplasty was originally developed remain relevant. Chronic empyema, bronchopleural fistula (BPF), and persistent pleural space following major pulmonary resection continue to represent challenging problems, particularly in patients with limited physiologic reserve or in those who have failed prior interventions. At the same time, the existing literature on thoracoplasty is fragmented, with most contemporary data limited to small case series and retrospective reports (2,3). There is a lack of a consolidated, clinically focused synthesis that integrates historical principles with modern techniques and outcomes. In addition, the role of thoracoplasty relative to alternative strategies, including muscle flap transposition, open window thoracostomy (OWT), and endobronchial interventions, remains incompletely defined.

Objective

The objective of this narrative review is to examine the historical evolution of thoracoplasty, summarize its current indications and operative techniques, and synthesize available evidence on clinical outcomes. Emphasis is placed on both traditional principles and modern adaptations, including integration with adjunctive techniques such as muscle and omental flap transposition. This manuscript also seeks to provide an updated perspective on multidisciplinary management approaches, aligning with advances in thoracic surgery and perioperative care. Ultimately, the goal is to support clinical decision making, improve patient selection, and optimize outcomes in patients with challenging pleural space pathology. We present this article in accordance with the Narrative Review reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1172/rc).

Methods

A comprehensive literature search was performed to identify studies addressing the role of thoracoplasty in thoracic surgery. Electronic databases including PubMed, Scopus, Web of Science, Cochrane Library, and Google Scholar were searched. An initial review of the topic was used to refine relevant search terms and better capture both historical and contemporary applications of thoracoplasty. The search strategy incorporated both Medical Subject Headings (MeSH) and free text terms. Relevant MeSH terms were identified and the final subset of Boolean search terminology selected to best identify current utilization of thoracoplasty (Table 1). Reference lists of selected articles and institutional library resources, including the University of Texas Moody Medical Library, were reviewed to identify additional relevant publications and obtain full text articles when necessary.

No strict date restrictions were applied to capture both historical and modern perspectives; however, emphasis was placed on contemporary literature published between 2000 and 2025. Studies published in English or Russian were included. Eligible publications comprised randomized controlled trials, observational studies, case series, systematic reviews, and expert opinion articles that addressed indications, techniques, or outcomes of thoracoplasty. Non-human studies, articles with insufficient methodological detail, and publications unrelated to thoracic surgical applications were excluded.

Data extraction focused on study characteristics, including design, patient population, clinical indications, operative techniques, adjunctive procedures, and reported outcomes such as morbidity, mortality, and functional results. Given the heterogeneity of available evidence and the narrative design of this review, findings were synthesized qualitatively to provide a comprehensive overview of current knowledge, identify gaps in the literature, and highlight evolving clinical applications.

Historical evolution of thoracoplasty

Early descriptions of thoracoplasty date to the late nineteenth century, with the first widely recognized technique attributed to Estlander in the 1870s (5). The procedure was often referenced as “The Operation of Estlander”, when performed, and consisted of the resection of multiple ribs, or decostalization, to allow for chronic empyema drainage and bring the chest wall in close opposition to limit the overall thoracic volume (1,5). Drainage was maintained through OWT or dependent drainage tracts, and procedures were often staged, with additional ribs resected over time depending on the degree of residual cavity. Patients were often left with significant chest wall deformities in order to achieve adequate collapse and obliteration of the infected space. This initial technique of decostalization served as the foundation for subsequent modifications.

Over time, the primary tracks of thoracoplasty modifications occurred—intrapleural and extrapleural thoracoplasty (Table 2) (6). In 1890, Schede expanded the procedure to include en bloc removal of the parietal pleura, intercostal muscles, and often portions of the endothoracic fascia, effectively converting the procedure into a more radical chest wall decortication (7). This allowed for more immediate collapse of the thoracic cavity but at the expense of increased morbidity (8). To further eliminate residual dead space, Roberts introduced a modification with filling of the cavity with a flap of parietal pleura and intercostal muscles (9). These techniques represented early attempts at what would later evolve into muscle flap transposition strategies (10). Parallel efforts focused on reducing morbidity through intercostal muscle and neurovascular-sparing modifications. Such advancements were aimed at prevention of unnecessary paresthesia and preserving vascular supply in hopes to facilitate more rapid regeneration and healing processes and eradication of the empyema cavity (10).

During the early to mid-twentieth century, thoracoplasty became a cornerstone in the management of pulmonary tuberculosis. Thoracoplasty was frequently compared with artificial pneumothorax as a form of collapse therapy, with the permanency of thoracoplasty maintaining the use of this procedure (11). The Alexander thoracoplasty was one of several staged extrapleural thoracoplasty techniques developed during the pre-antibiotic era for collapse therapy of pulmonary tuberculosis in the 1930s (12). The operation consists of sequential subperiosteal resection of the posterior ribs, typically proceeding from the apex downward in a staged fashion. Progressive loss of structural support allows the chest wall to collapse inward over time, resulting in gradual obliteration of the pleural space.

Andrews thoracoplasty, also referred to as thoracomediastinal plication or thoracopleuroplasty, was originally described for the management of tuberculous empyema associated with BPF and is designed to achieve definitive space obliteration in a single stage procedure (13). In contrast to conventional thoracoplasty and other space management strategies such as muscle flap transposition or OWT, this technique enables immediate closure without the need for prolonged staged treatment. It involves resection of the costal arches surrounding the infected cavity, meticulous debridement, and direct suturing of the external parietal plane to the mediastinal plane, thereby eliminating dead space. The extent of rib resection is tailored to cavity topography and in post pneumonectomy settings typically involves five to ten ribs. Development of thoracomediastinal plication marked a fundamental shift from passive collapse to active space obliteration through mobilization of mediastinal structures. The mediastinal pleura is incised, and meticulous dissection is used to mobilize the mediastinum, including the pericardium and adjacent pleural reflections. Once mobilized, the mediastinum is advanced laterally into the residual cavity. Interrupted nonabsorbable sutures are placed between the mediastinal pleura and the parietal pleura or chest wall, effectively imbricating the mediastinum and eliminating dead space. In larger or more complex cavities, this technique is frequently reinforced with vascularized tissue transfer, such as intercostal muscle or other regional flaps, to enhance durability and reduce the risk of persistent infection or recurrence. This approach offers several advantages over staged strategies, most notably the ability to achieve single stage definitive closure with rapid healing (14). Patients can be discharged with healed wounds, avoiding the need for prolonged management with OWT (15). Importantly, the presence of BPF does not appear to adversely affect early outcomes, with no statistically significant impact on mortality, duration of mechanical ventilation, intensive care unit stay, or overall length of hospitalization, supporting the robustness of mediastinal plication even in fistulous disease (14,15). Alternatively, techniques combining both lung resection and diaphragm for similar cases were also proposed around this timeframe with similar success (16-18).

Alexander and Andrews thoracoplasty differ fundamentally in both strategy and execution. Alexander relies on staged chest wall collapse from outside the pleura, whereas Andrews directly obliterates the cavity in one operation through rib resection plus mediastinal plication. From a modern perspective, Alexander is largely historical, while Andrews or modified thoracoplasty techniques still have a niche role in salvage of complex empyema with BPF, especially after pneumonectomy.

Semb thoracoplasty represents a subsequent refinement that seeks to achieve effective space obliteration in a single stage without the need for extensive mediastinal mobilization (19). By combining selective subperiosteal rib resection tailored to the cavity with direct debridement, it enables controlled chest wall collapse while limiting operative complexity and long-term deformity. The technique is typically performed through an extrapleural dissection. Apicolysis is an important component, with careful mobilization and release of the lung apex from the chest wall to facilitate selective collapse of the upper lobe and improve apposition to the chest wall. Rib resection is deliberately limited and targeted, most commonly involving ribs 1 through 5 or extending to rib 7 depending on cavity extent (3). Following debridement, the combination of reduced skeletal support and preserved soft tissue envelope promotes inward collapse of the chest wall and progressive obliteration of the residual space, and adjunctive vascularized tissue such as intercostal muscle may be used when additional reinforcement is required.

Thoracoplasty for treatment of pulmonary tuberculosis declined following the advent of anti-tuberculosis medications from the 1940s onward (20). Despite this decline, the underlying clinical problems persisted. Chronic empyema and pleural space complications continue to require definitive management, leading to renewed interest in thoracoplasty as a selective but important salvage procedure in modern thoracic surgery.

Current use of thoracoplasty

Clinical indications

Thoracoplasty is currently reserved as a salvage procedure (secondary or tertiary intervention) for obliteration of persistent infected pleural spaces when less invasive interventions, including muscle or omental flap transposition, OWT, vacuum-assisted closure (VAC) therapy, or endobronchial techniques, are inadequate or have failed (2). Failure of alternative approaches is primarily related to an inability to eliminate dead space or achieve durable closure in a hostile operative field. Muscle and omental flaps may be insufficient in the presence of large cavities or compromised vascular supply (21). Endobronchial techniques are limited to small fistulas and are often ineffective in the setting of ongoing infection or tissue necrosis (22,23). Similarly, repeated debridement or drainage alone does not address the underlying problem of persistent pleural space (2). Accordingly, thoracoplasty is most appropriate in patients with persistent pleural space, rigid cavity walls, and failure of prior reconstructive strategies who remain suitable candidates for major surgical intervention (2,3). The primary contemporary indication is postresectional empyema, with or without BPF, particularly after unsuccessful attempts at prior space obliteration (3). These conditions most commonly arise following pneumonectomy, bilobectomy, or complex pulmonary resections, where large residual pleural spaces, devascularized tissue, and ongoing contamination create an environment resistant to conventional management. Postpneumonectomy empyema with BPF represents a particularly challenging scenario. In this setting, thoracoplasty is often combined with muscle flap transposition to reinforce bronchial stump closure, especially when a modified Clagett approach has failed or is not feasible (3,24). Late onset empyema following pulmonary resection, often characterized by rigid cavity walls that prevent spontaneous obliteration, also represents an important indication (25).

Thoracoplasty remains relevant in chronic empyema without prior pulmonary resection, including chronic apical empyema, post-pneumonic empyema with persistent pleural space despite adequate drainage and debridement, and infections related to tuberculosis or atypical mycobacteria associated with cavitary disease (5,26). It may also be applied in the management of residual pulmonary cavities, including those associated with pulmonary aspergilloma or persistent cavitary tuberculosis in the setting of multidrug resistant disease (MRD) (27-30).

Contraindications and limitations relate primarily to the morbidity of the procedure and the availability of less invasive alternatives. Thoracoplasty is associated with potential complications including chronic pain, progressive scoliosis, and chest wall deformity, which preclude its use as a first line intervention. It should not be performed in the setting of uncontrolled active infection, as adequate source control must be achieved prior to definitive reconstruction. In addition, patients with severe debilitation or inability to tolerate major surgery are generally not appropriate candidates (2,3).

The role of thoracoplasty has also expanded into less conventional indications, reflecting its versatility as a salvage strategy. Modified thoracoplasty has been successfully applied in the management of chronic esophagopleural fistula with localized empyema refractory to prior intervention in the setting of Boerhaave syndrome (31). Although unconventional, this approach enabled definitive control in a patient with persistent sepsis and failed interventions over a prolonged course. Additional reported applications include reconstruction of complex chest wall defects with significant functional and cosmetic compromise, including cases with cardiac exposure (32).

Principles of management of pleural space disease

Successful management requires a structured, stepwise approach based on three core principles: control of sepsis, closure of BPF when present, and definitive obliteration of the residual pleural space (33). Initial management begins with prompt recognition and physiologic stabilization. Patients should undergo clinical assessment for sepsis, laboratory evaluation, cross sectional imaging, and bronchoscopy to assess bronchial stump integrity (34). Immediate source control is essential and typically includes chest tube drainage or operative washout, combined with broad spectrum antibiotics followed by culture directed therapy (35). In cases of loculated or complex empyema, minimally invasive debridement may be required. These measures aim to achieve adequate drainage and stabilization prior to definitive intervention (35). Subsequent management is guided by the presence of BPF and the ability of the lung to re expand. In patients without a fistula and with an expandable lung, continued drainage and decortication may be sufficient (33). However, persistent pleural space or non-expandable, entrapped lung necessitates additional intervention. When a BPF is present, management depends on its size and clinical impact (34). Small fistulas in stable patients may be managed with endobronchial techniques such as valve placement or sealants, whereas larger or refractory fistulas require surgical closure, typically reinforced with vascularized tissue such as intercostal muscle, pericardial fat pad, or omentum (36-38).

Role of thoracoplasty in definitive management

Thoracoplasty is selected when definitive control of pleural space disease cannot be achieved despite adequate infection control and prior reconstructive attempts. It is most appropriately considered in patients with large persistent residual pleural space, non-expandable or entrapped lung, and recurrent or refractory BPF (4). In these settings, rigid cavity walls, ongoing dead space, and compromised local tissue conditions prevent spontaneous resolution and limit the effectiveness of conventional approaches (2,3). The procedure is particularly valuable in patients with limited physiologic reserve or those who are not candidates for further pulmonary resection, as it allows definitive infection control without additional loss of functional lung parenchyma (4,24,25). When combined with adjunctive techniques such as muscle or omental flap transposition, thoracoplasty further enhances the likelihood of successful closure and long-term stability (30).

Thoracoplasty is considered only after specific prerequisites have been met. Adequate control of infection must first be achieved through drainage procedures. In unstable patients or those with uncontrolled infection, OWT or cavernostomy provide effective drainage and facilitate gradual control of sepsis. A persistent pleural cavity with rigid walls that prevent spontaneous obliteration is typically required (24,25). Careful patient selection remains essential, and candidates must be able to tolerate major surgery, although moderately debilitated patients may still be considered in selected clinical settings (5,26). Nutritional recovery and overall physiologic improvement should also be considered before definitive reconstruction. In complex or refractory cases, a staged approach is often required, allowing for initial infection control followed by delayed definitive reconstruction (33,35,38,39).

In modern practice, thoracoplasty is not a primary intervention but rather a definitive salvage option within a structured treatment algorithm, providing durable outcomes in patients with otherwise limited therapeutic options (Table 3). Definitive thoracoplasty alone is rarely used as a sole intervention in the modern era. It may be considered in selected patients with a relatively clean cavity following prolonged drainage, particularly when vascularized tissue flaps are unavailable or not feasible.

Surgical strategies and technical considerations

Modern surgical management of complex pleural space disease is based on three fundamental principles: volume reduction, elimination of dead space, and reinforcement with well vascularized tissue (2,3). Thoracoplasty is most effective when applied in a tailored, patient specific manner and integrated with adjunctive reconstructive techniques rather than used as an isolated procedure (25).

Extramusculoperiosteal thoracoplasty represents a modified, tissue preserving approach designed to achieve pleural space obliteration while minimizing chest wall deformity and preserving soft tissue integrity (25). A central principle of this technique is selective, tailored rib resection. In contrast to historical methods that relied on extensive chest wall resection, contemporary approaches emphasize removal of a limited number of ribs based on the size, location, and geometry of the residual cavity (24). The procedure is performed by elevating the chest wall musculature as an intact layer, allowing access to the ribs without division of major muscle groups. Subperiosteal rib resection is then carried out with preservation of the periosteum and surrounding soft tissues. Maintenance of the periosteal sleeve preserves structural continuity of the chest wall, facilitating inward displacement of the thoracic cage while reducing instability and deformity. Preservation of the muscular envelope also maintains vascular supply, enhances wound healing, and reduces postoperative pain and functional impairment. The extent of rib resection is individualized and dictated by cavity characteristics. Larger postpneumonectomy spaces generally require more extensive resection, averaging approximately 7.5 ribs, whereas post-lobectomy empyema typically requires more limited resection of 3 to 4 ribs (3). Intermediate extents are observed in other clinical scenarios, reflecting variability in cavity size and location. By combining limited rib resection with preservation of neurovascular structures and integration of reconstructive techniques, extramusculoperiosteal thoracoplasty achieves effective chest wall collapse and durable elimination of dead space while substantially reducing the morbidity historically associated with more radical thoracoplasty procedures (2).

In contrast to extramusculoperiosteal thoracoplasty, which remains strictly extrapleural and emphasizes preservation of the muscular envelope and soft tissues, the Lampl modification incorporates intentional entry into the pleural cavity to allow direct management of the infected space (4). Although both techniques employ subperiosteal rib resection, the Lampl approach includes incision of the periosteum and parietal pleura, enabling debridement, lavage, and direct assessment of residual cavity. This results in more immediate and controlled space obliteration, albeit with a higher degree of invasiveness. Ribs are resected in a defined sequence, typically from the upper to mid thoracic levels, with additional posterior resection as needed to achieve adequate volume reduction. A key feature of this technique is the mobilization of adjacent soft tissues, including the scapula and surrounding musculature, into the thoracic cavity to augment collapse. Preservation of critical muscular structures and avoidance of first rib resection help maintain shoulder girdle stability and limit functional impairment. When applied in accordance with the principles of contemporary osteoplastic techniques, it achieves effective space obliteration through controlled chest wall displacement rather than extensive rib excision, thereby preserving chest wall stability and reducing the risk of progressive scoliosis (4).

Building on extrapleural, tissue preserving strategies, further refinement has focused on reducing operative trauma while maintaining effective collapse. In this context, a minimally invasive osteoplastic thoracoplasty, as described by Krasnov, represents a modern extrapleural modification designed to achieve effective collapse with limited surgical exposure (40). The technique is performed through a short paravertebral incision, typically 4 to 5 cm, with limited division of the overlying musculature to preserve functional integrity. Subperiosteal rib resection is carried out in a targeted fashion, most commonly involving the upper ribs, followed by extrapleural pneumolysis to mobilize the lung and create a controlled collapse environment. A distinguishing feature of this approach is the formation of a “rib module,” in which the resected ribs are fixated to a lower rib using nonabsorbable sutures, generating a stable and sustained inward displacement of the thoracic cage. This results in selective concentric collapse of the affected lung segments without the need for extensive resection or external compression. In a prospective cohort, this approach was associated with significantly improved outcomes compared with conventional osteoplastic thoracoplasty, including higher rates of bacteriologic conversion [80.4% versus 69.3% at 12 months; odds ratio (OR) 1.84] and cavity closure (83.2% versus 70.0%; OR 2.13), as well as improved intermediate term clinical cure (88.5% versus 79.7%).

A minimally invasive alternative is the video assisted extrapleural thoracoplasty described by Giller, which applies the principles of thoracoplasty through a less invasive approach (41,42). The technique was developed for patients with cavitary disease in the upper lobe or S6 segment who have failed medical therapy and are not candidates for pulmonary resection. It is performed through a limited paravertebral incision with endoscopic assistance, allowing extrapleural mobilization of the ribs and surrounding soft tissues while preserving the overlying muscular envelope. Subperiosteal rib resection is then carried out under video guidance, typically involving the upper and mid thoracic ribs. The largest published series evaluating this approach included 208 patients treated between 1999 and 2017 (42). Efficacy was substantial, with an 88% success rate based on Laserson criteria and computed tomography confirmation of inactive disease, and 81% clinical improvement defined by sputum conversion, cavity closure, and absence of reactivation at 3 years. In multidrug-resistant (MDR) tuberculosis, success reached 77%, compared with approximately 55% reported globally with medical therapy alone. The safety profile was favorable, with no reported 30-day mortality, intraoperative complications in 7.2% of cases, and postoperative complications in 2.0%. In a cohort of 57 patients with bilateral cavitary MDR and extensively drug resistant (XDR) tuberculosis managed with tailored combinations of pulmonary resection, selective thoracoplasty, and endobronchial valve therapy, culture conversion rates at 20 to 36 months reached 95.5% in MDR and 65.7% in XDR disease, underscoring the effectiveness of multimodal surgical strategies in this high-risk population. Compared with traditional thoracoplasty, this minimally invasive approach offers clear functional advantages. In a reported case of bilateral application for XDR tuberculosis with 4-year follow up, patients experienced markedly less postoperative pain, no limitation in upper limb mobility, absence of significant chest wall deformity, and preserved functional status (43).

An alternative approach is the Sawamura technique, a recently reintroduced method that achieves pleural space obliteration without formal rib resection (44). Instead, the ribs are mobilized by stripping the periosteum and surrounding soft tissue attachments, allowing controlled inward displacement into the pleural cavity. This results in effective thoracic volume reduction while preserving the structural continuity of the chest wall. When combined with partial lung re expansion, the technique can facilitate complete elimination of residual pleural space. Early clinical experience demonstrates successful single stage treatment in complex empyema, with no residual effusions, preservation of chest wall contour, and maintained functional status at 6 month follow up (44).

Breast implant thoracoplasty represents an innovative modification aimed at preserving chest wall contour while achieving pleural space obliteration (45). In a reported case, placement of a breast implant was successfully used to fill a residual cavity following completion upper lobectomy for chronic Aspergillus infection, resulting in effective infection control without significant chest wall deformity. This approach directly addresses one of the principal limitations of traditional thoracoplasty, namely cosmetic distortion, although current experience remains limited and its broader applicability is yet to be defined (45).

In patients undergoing staged management with OWT, creation of the window should be performed with future reconstruction in mind. Preservation of the latissimus dorsi, serratus anterior, and other potential donor muscles is critical, as these structures may subsequently be required for thoracomyoplasty, bronchial stump reinforcement, or pleural space obliteration. Careful dissection along fascial planes and avoidance of unnecessary muscle division help maintain reconstructive options and may improve the likelihood of successful definitive closure.

Thoracomyoplasty represents an important evolution of thoracoplasty, combining rib resection with transposition of vascularized tissue to achieve both mechanical collapse and biologic obliteration of the pleural cavity (2,3,14). This approach is particularly valuable in large or complex cavities, as well as in the presence of BPF, where reinforcement of the bronchial stump is required (4,10). By integrating structural modification with tissue coverage, thoracomyoplasty improves durability of closure and reduces the risk of recurrent infection (26). Muscle and omental flaps play a critical role in modern surgical strategy (33,39). Commonly utilized muscle flaps include the latissimus dorsi, serratus anterior, and rectus abdominis, selected based on prior operations, vascular supply, and defect location (35). These flaps provide well vascularized tissue that enhances local immune response, promotes healing, and reinforces closure of fistulous tracts (29). Omental transposition offers an alternative option, particularly in reoperative fields or when local muscle flaps are unavailable, providing excellent vascularity and adaptability for filling complex cavities (36,46).

In selected cases, mediastinal mobilization techniques may be employed to further reduce pleural space. These approaches involve releasing and advancing mediastinal structures (heart, pericardium, great vessels) toward the affected hemithorax to help obliterate residual cavities, particularly in the setting of large or centrally located defects. When combined with thoracoplasty and tissue transposition, mediastinal mobilization can enhance space reduction and improve overall stability of the reconstruction (3).

In modern practice, these techniques are frequently combined in a patient specific manner. The choice of strategy depends on cavity size, presence of BPF, prior surgical interventions, and overall patient condition. This integrated approach allows for effective and durable management of complex pleural space disease while minimizing morbidity associated with more extensive historical procedures.

Outcomes and limitations

Contemporary series demonstrate that thoracoplasty is associated with acceptable morbidity and mortality when performed in appropriately selected patients following adequate infection control (Table 4). Reported operative mortality generally ranges from 0% to 5%, with success rates for pleural space obliteration between 77% and 91% (24,25,40,42,47), representing a substantial improvement compared with historical data and comparing favorably with overall surgical mortality for empyema management, which ranges from 0% to 10% (2).

Modern institutional series further support these findings (Table 5). Extramusculoperiosteal thoracoplasty is associated with mortality rates as low as 3.8%, with successful space obliteration in 73% to 77% and most patients achieving infection control (24,25). In postpneumonectomy empyema, staged management incorporating OWT yields mortality rates of approximately 5% (47). Similarly, thoracoplasty combined with intrathoracic muscle transposition demonstrates mortality rates near 5% (14), with some reports describing no operative mortality in selected post-lobectomy or nononcologic cases (25). These findings are consistent with current European Respiratory Society and European Society of Thoracic Surgeons guidelines, which cite operative mortality around 5% and success rates approaching 90% (2).

Large database analyses provide additional insight into perioperative outcomes. Contemporary National Surgical Quality Improvement Program data report mortality below 1% and overall major morbidity of approximately 23% (49). Complications such as respiratory failure, sepsis, and pneumonia occur in a minority of patients, while reoperation and readmission rates remain below 10%. Length of stay is typically modest, with a mean of approximately 6 days, and approximately 93% of patients are discharged home (49).

In selected high-risk populations, thoracoplasty may confer additional benefit. In patients with destructive tuberculosis following pneumonectomy, adjunctive delayed minimally invasive thoracoplasty has been associated with marked reductions in early complications, from 29% to 3%, elimination of hospital mortality, from 7.5% to 0%, and improved 5-year survival, from 85% to 94% (50).

Despite its historical reputation, modern thoracoplasty demonstrates improved functional and cosmetic outcomes. Chest wall deformity remains the most recognized sequela (2,3), but its clinical impact is generally limited, with most patients maintaining acceptable respiratory mechanics and preserved upper extremity function (25,50). In the extramusculoperiosteal series by Stefani et al., although some degree of chest wall deformity was present in all patients, it was severe in only a minority and did not significantly compromise functional status (24). Minimally invasive extrapleural techniques are associated with minimal deformity and preserved shoulder function (50), while osteoplastic approaches achieve controlled chest wall displacement with reduced structural distortion (14). Hybrid strategies incorporating tissue transposition further mitigate functional impairment. Mild shoulder impairment has been reported in approximately 6.6% of patients, and chronic thoracic sequelae in approximately 11.5% series (14,24,25).

Long term outcomes are influenced by the extent of rib resection, effectiveness of space obliteration, and underlying disease. More extensive resections are associated with an increased risk of secondary scoliosis and chest wall asymmetry, although clinically significant deformity is less common with modern techniques (51). Cosmetic outcomes remain variable and depend on resection extent, patient body habitus, and the use of adjunctive reconstruction (40,42,47).

Reintervention rates range from approximately 10% to 25%, reflecting the complexity of the underlying pathology rather than technical failure alone (3,24,25,47). Although most patients achieve durable pleural space obliteration, a subset requires additional procedures due to persistent infection, recurrent BPF, or incomplete cavity closure (47,49). BPF remains the leading cause of failure and reintervention, supporting the routine use of vascularized tissue reinforcement to improve durability of bronchial stump closure (3,52).

Incomplete obliteration of the pleural space is another key mechanism of failure, particularly in the presence of rigid cavity walls or when adjunctive filling procedures are not feasible. In contemporary extramusculoperiosteal series, thoracoplasty alone reduced cavity size in some patients, but residual space persisted when filling procedures could not be performed, with occasional recurrence of infection (24). Inadequate infection control prior to definitive intervention further contributes to failure, underscoring the importance of staged management with drainage, OWT, or cavernostomy before closure (24,25). Large residual cavities, particularly in postpneumonectomy spaces, may exceed the capacity of thoracoplasty alone and often require combined approaches with tissue transposition or staged reconstruction (25). Outcomes are further influenced by underlying infectious etiologies, particularly tuberculosis, including cases complicated by aspergilloma, as well as compromised vascular supply to residual tissues.

Management of failed thoracoplasty is guided by patient condition, residual cavity characteristics, and the presence of ongoing infection or fistula. A permanent OWT remains a reliable option for patients who are not candidates for further operative intervention or who have recurrent malignancy. In patients with adequate physiologic reserve and available tissue, additional muscle or omental flap transposition may be used to reinforce closure and obliterate residual space. A repeat Clagett type procedure represents another effective strategy in selected cases, while long-term suppressive antibiotic therapy may be used as an adjunct for sustained control of chronic infection (3,53).

These strategies reflect the fundamental principles underlying successful thoracoplasty. Adequate infection control before definitive intervention is essential and typically achieved through staged drainage and formation of a clean, granulated cavity. The extent of rib resection must be tailored to the residual space to ensure complete obliteration while preserving structural integrity. In complex cases, thoracoplasty should be combined with adjunctive reconstructive techniques such as muscle or omental flap transposition or delayed closure to reinforce bronchial stump integrity and eliminate residual dead space. Careful patient selection remains critical to achieving durable outcomes.

Report of three cases

The authors’ experience highlights the role of thoracoplasty as a salvage strategy in complex pleural space disease.

Case 1

A 57-year-old female with interstitial lung disease complicated by spontaneous pneumothorax, prolonged air leak, entrapped lung, and empyema after two failed interventions underwent right sided thoracomyoplasty with omental flap transposition. A muscle sparing thoracotomy was performed with partial resection of the second through fourth ribs, followed by intrathoracic transposition of omentum, serratus anterior, and intercostal muscle flaps (Figure 1). The postoperative course was favorable with complete obliteration of the pleural space. Despite this success, the patient remained ventilator dependent due to advanced pulmonary fibrosis and died 2 years later from progression of her underlying interstitial lung disease.

Figure 1 Chest computed tomography of Case 1 (57-year-old female). Preoperative axial (A) and coronal (B) images demonstrating a chronic right-sided hydropneumothorax with lung entrapment, characterized by a thickened visceral pleural rind and basilar loculated air fluid collections consistent with chronic empyema. The residual right upper lobe contains endobronchial valves. Yellow arrows indicate a tiny residual bronchial channel along the medial aspect of the anterior endobronchial valve extending toward the visceral pleura, suggestive of a possible bronchopleural fistula. Background findings include diffuse fibrotic lung disease with architectural distortion. Postoperative axial (C) and coronal (D) images demonstrating interval right chest wall resection with partial removal of the second through fourth ribs and obliteration of the pleural space by transposed vascularized tissue, including omentum, serratus anterior muscle, and intercostal muscle flaps. The prior pleural cavity is replaced by a collapsed chest wall with inward displacement of soft tissues, with a small amount of residual fluid and associated pleural thickening, consistent with treated empyema.

Case 2

A 74-year-old female with chronic cavitary Mycobacterium avium infection and chronic obstructive pulmonary disease, with prior right upper lobectomy in 2016 for benign pulmonary nodule, initially underwent S6 segmentectomy for resection of a large cavitary lesion. Her course was complicated by prolonged air leak and entrapped lung, necessitating reoperation. She subsequently underwent redo right thoracotomy with decortication, intrathoracic transposition of omentum and serratus anterior muscle flap, and modified osteoplastic thoracoplasty (Figure 2).

Figure 2 Chest computed tomography of Case 2 (74-year-old female). Preoperative axial (A) and coronal (B) images demonstrating a large cavitary lesion in superior segment of right lower lobe in a patient with previous right upper lobectomy for benign pulmonary nodule. The yellow arrow indicates extrathoracic extension of the pleural cavity through the lateral seventh and eighth intercostal spaces, resulting in a pleurocutaneous extension of the chronic empyema cavity. Postoperative axial (C) and coronal (D) images demonstrating interval right thoracoplasty with subperiosteal resection of the third through fifth ribs and decortication, with obliteration of the pleural space by transposed vascularized tissue, including pedicled omental and serratus anterior muscle flaps. The right hemithorax demonstrates marked reduction of the pleural cavity with inward displacement of the chest wall, with residual air and fluid within the pleural space. The remaining right lung shows stable collapse of the middle lobe with partial aeration of the lower lobe.

Case 3

A 32-year-old male with a pulmonary tuberculosis complicated by persistent left sided empyema, previously treated with video-assisted thoracoscopic surgery (VATS) at an outside institution, presented with disease progression. He underwent a left muscle sparing thoracotomy with modified osteoplastic thoracoplasty with resection of ribs seven through ten (Figure 3). The patient recovered well, with improvement in pain and functional status, and continues therapy for XDR tuberculosis without recurrence or additional complications.

Figure 3 Chest computed tomography of Case 3 (32-year-old male). Preoperative axial (A) and coronal (B) images demonstrating a moderate left-sided hydropneumothorax with entrapped lung. There is extensive rounded atelectasis involving the left upper and lower lobes, consistent with trapped lung. Diffuse pleural thickening with adjacent inflammatory fat stranding is present, compatible with chronic empyema. Postoperative axial (C) and coronal (D) images demonstrating interval left thoracoplasty with partial resection of the seventh through tenth ribs and total decortication, resulting in reduction of the pleural space with inward displacement of the chest wall. There is interval resolution in the air component of the hydropneumothorax with partial reexpansion of the left lung.

Collectively, these cases illustrate the versatility of thoracoplasty as part of a tailored, multimodal approach, with outcomes largely determined by underlying disease severity rather than technical limitations of the procedure.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent for publication of this article and accompanying images was not obtained from the patients or the relatives after all possible attempts were made. However, the accompanying images are fully de-identified and contain no patient-identifying information.

Future directions

Future progress in thoracoplasty will depend on continued refinement toward less invasive, more reconstructive, and patient specific strategies. Advances in minimally invasive and image guided techniques are expected to further reduce morbidity while preserving the effectiveness of space obliteration. Modern imaging and three-dimensional planning now enable more deliberate and precise application of thoracoplasty, allowing preoperative assessment of patient specific anatomy, anticipation of intraoperative challenges, and planning for adjunctive techniques, while also supporting more detailed and informed discussions with patients. Emerging applications of robotic surgery may further expand these capabilities by enhancing visualization, dexterity, and precision in confined extrapleural and intrathoracic spaces, potentially facilitating more controlled rib mobilization, debridement, and adjunctive reconstructive procedures (36). Integration of biologic and regenerative approaches, including improved vascularized tissue options and adjuncts that enhance healing in infected fields, may further expand indications and improve durability. Standardization of outcome reporting and development of prospective, multicenter data are needed to better define optimal patient selection and technique. Finally, maintaining training and technical familiarity with thoracoplasty within thoracic surgery programs will be essential to ensure that this complex but valuable procedure remains available for the management of challenging pleural space disease.

Conclusions

Thoracoplasty remains a valuable salvage option for complex pleural space disease in carefully selected patients. Contemporary modifications have transformed it from a highly morbid historical procedure into a more tailored, reconstructive strategy with acceptable morbidity, reliable infection control, and preservation of function. When integrated with modern techniques such as tissue transposition and staged management, thoracoplasty provides durable solutions in scenarios where other approaches fail. Maintaining familiarity with its principles and execution is essential to ensure optimal management of challenging cases in modern thoracic surgery.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Thoracic Disease for the series “Complications in Anatomical Lung Resection: A Comprehensive Surgical Perspective”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1172/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1172/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1172/coif). The series “Complications in Anatomical Lung Resection: A Comprehensive Surgical Perspective” was commissioned by the editorial office without any funding or sponsorship. A.I.G. and R.V.P. served as the unpaid Guest Editors of the series. R.V.P. was a former expert witness for Steptoe & Johnson PLL as well as Bolus Law Office. R.V.P. is also a stock owner of Romtec and is part of the Executive Counsel of ECTSS and a member of various committees of TSDA, SAGES, STS and ACS. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent for publication of this article and accompanying images was not obtained from the patients or the relatives after all possible attempts were made. However, the accompanying images are fully de-identified and contain no patient-identifying information.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Gould AP. On four cases of Estlander’s operation, or thoracoplasty. Lancet 1888;131:261-3.
2. Bedawi EO, Ricciardi S, Hassan M, et al. ERS/ESTS statement on the management of pleural infection in adults. Eur Respir J 2023;61:2201062. [Crossref] [PubMed]
3. Shen KR, Bribriesco A, Crabtree T, et al. The American Association for Thoracic Surgery consensus guidelines for the management of empyema. J Thorac Cardiovasc Surg 2017;153:e129-46. [Crossref] [PubMed]
4. Kuhtin O, Veith M, Alghanem M, et al. Thoracoplasty-Current View on Indication and Technique. Thorac Cardiovasc Surg 2020;68:331-40. [Crossref] [PubMed]
5. Hopkins RA, Ungerleider RM, Staub EW, Young WG Jr. The modern use of thoracoplasty. Ann Thorac Surg 1985;40:181-7. [Crossref] [PubMed]
6. Hiramatsu M, Atsumi J, Shiraishi Y. Surgical Management of Mycobacterial Infections and Related Complex Pleural Space Problems: From History to Modern Day. Thorac Surg Clin 2022;32:337-48. [Crossref] [PubMed]
7. Miller JI Jr. The history of surgery of empyema, thoracoplasty, Eloesser flap, and muscle flap transposition. Chest Surg Clin N Am 2000;10:45-53. viii.
8. Ferguson AH. Thoracoplasty in America and visceral pleurectomy, with report of a case. JAMA 1897;28:56-62.
9. Roberts JE. The Treatment of Empyema. Postgrad Med J 1935;11:28.7-55.
10. Shiraishi Y. Surgical treatment of chronic empyema. Gen Thorac Cardiovasc Surg 2010;58:311-6. [Crossref] [PubMed]
11. Carter BN. Thoracoplasty as a method of treatment in pulmonary tuberculosis: report of fifty-three cases. Arch Surg 1931;22:289-306.
12. Weissberg D, Weissberg D. Late complications of collapse therapy for pulmonary tuberculosis. Chest 2001;120:847-51. [Crossref] [PubMed]
13. Andrews NC. Thoracomediastinal plication: a surgical technique for chronic empyema. J Thorac Cardiovasc Surg 1961;41:809-16.
14. Botianu AM, Botianu PV. Modified thoraco-mediastinal plication (Andrews thoracoplasty) for post-pneumonectomy empyema: experience with 30 consecutive cases. Interact Cardiovasc Thorac Surg 2013;16:173-7; discussion 177-8. [Crossref] [PubMed]
15. Icard P, Le Rochais JP, Rabut B, et al. Andrews thoracoplasty as a treatment of post-pneumonectomy empyema: experience in 23 cases. Ann Thorac Surg 1999;68:1159-63; discussion 1164. [Crossref] [PubMed]
16. Ogirenko AP. Surgical transposition of the diaphragm as a method of correcting the pleural cavity. Vestn Khir Im I I Grek 1967;99:113.
17. Severov VS, Averbakh MM, Kalinichev GA. Transposition of the diaphragm carried out simultaneously with lung resection for the elimination of a postresectional cavity (experimental study). Probl Tuberk 1967;45:58-62.
18. Glok RI. External respiration in patients with bronchiectasis following extensive resections of the lung combined with transposition of the diaphragm. Grudn Khir 1974;78-80.
19. Urbanowski ME, Ordonez AA, Ruiz-Bedoya CA, et al. Cavitary tuberculosis: the gateway of disease transmission. Lancet Infect Dis 2020;20:e117-28. [Crossref] [PubMed]
20. Barry CE. Lessons from seven decades of antituberculosis drug discovery. Curr Top Med Chem 2011;11:1216-25. [Crossref] [PubMed]
21. Shinohara S, Chikaishi Y, Kuwata T, et al. Benefits of using omental pedicle flap over muscle flap for closure of open window thoracotomy. J Thorac Dis 2016;8:1697-703. [Crossref] [PubMed]
22. Cardillo G, Carbone L, Carleo F, et al. The Rationale for Treatment of Postresectional Bronchopleural Fistula: Analysis of 52 Patients. Ann Thorac Surg 2015;100:251-7. [Crossref] [PubMed]
23. Sun W, Zhao B, Zhang H, et al. Bronchoscopic management of airway fistulas: a clinical analysis of 45 cases with integrated bioinformatic analysis. Ann Med 2025;57:2590197. [Crossref] [PubMed]
24. Stefani A, Jouni R, Alifano M, et al. Thoracoplasty in the current practice of thoracic surgery: a single-institution 10-year experience. Ann Thorac Surg 2011;91:263-8. [Crossref] [PubMed]
25. Krassas A, Grima R, Bagan P, et al. Current indications and results for thoracoplasty and intrathoracic muscle transposition. Eur J Cardiothorac Surg 2010;37:1215-20. [Crossref] [PubMed]
26. Horrigan TP, Snow NJ. Thoracoplasty: current application to the infected pleural space. Ann Thorac Surg 1990;50:695-9. [Crossref] [PubMed]
27. Shankar SH, Kutty SV, Madan K, et al. Thoracoplasty for tuberculosis. Lung India 2025;42:53-4. [Crossref] [PubMed]
28. Dantis K, Dey CK, Phuli R, et al. Thoracoplasty: A Collapse Therapy for Extra-Pulmonary Drug-Resistant Tuberculosis with Persistent Bronchopleural Fistula and Empyema Cavity. Tanaffos 2024;23:304-7.
29. Grima R, Krassas A, Bagan P, et al. Treatment of complicated pulmonary aspergillomas with cavernostomy and muscle flap: interest of concomitant limited thoracoplasty. Eur J Cardiothorac Surg 2009;36:910-3. [Crossref] [PubMed]
30. Botianu PV, Dobrica AC, Butiurca A, et al. Complex space-filling procedures for intrathoracic infections - personal experience with 76 consecutive cases. Eur J Cardiothorac Surg 2010;37:478-81. [Crossref] [PubMed]
31. Zhu Q, Zhan J, Yao X, et al. Modified thoracoplasty for esophago-pleural fistula following Boerhaave syndrome: a case report. J Surg Case Rep 2025;2025:rjaf639. [Crossref] [PubMed]
32. Mishra B, Joshi MK, Tiwari R, et al. Complex chest wall wound managed by a novel technique of thoracoplasty. BMJ Case Rep 2019;12:e230782. [Crossref] [PubMed]
33. Gritsiuta AI, Stovall A, Petrov RV. Surgical strategies in the management of postoperative bronchopleural fistula: a narrative review. AME Surg J 2025;5:10.
34. Pechetov AA, Gritsiuta AY, Davydenko PI. Preoperative radiologic evaluation of bronchopleural fistula as preparation for transsternal main bronchial stump occlusion. Med Vizualizatsiya 2018;70-6.
35. Pechetov A, Gritsyuta A. Surgical treatment for chronic nonspecific pleural empyema after anatomical lung resection. Vrach 2018;29:51-4.
36. Fortich S, Franco-Mesa C, Den J, et al. Robotic Omental Flap Harvest for Complex Thoracic Defects: Case Series and Review of the Literature. Med Sci (Basel) 2025;13:264. [Crossref] [PubMed]
37. Gritsiuta AI, Bakhos CT, Abbas AE, et al. Transsternal Approach for Broncho-Pleural Fistula Closure After Right Pneumonectomy. Cureus 2023;15:e50397. [Crossref] [PubMed]
38. Pechetov AA, Gritsuta AY, Esakov YS, et al. Transsternal occlusion of the main bronchus stump in bronchopleural fistula and non-specific pleural empyema. Khirurgiia (Mosk) 2019;5-9.
39. Gritsiuta AY, Eguchi T, Jones DR, et al. A Stepwise Approach for Postlobectomy Bronchopleural Fistula. Oper Tech Thorac Cardiovasc Surg 2020;25:85-104. [Crossref] [PubMed]
40. Krasnov D, Krasnov V, Skvortsov D, et al. Thoracoplasty for Tuberculosis in the Twenty-first Century. Thorac Surg Clin 2017;27:99-111. [Crossref] [PubMed]
41. Giller DB, Giller GV, Giller BD, et al. Case of Video-Assisted Thoracoplasty Application in Pulmonary Tuberculosis Treatment. Ann Thorac Surg 2020;109:e95-8. [Crossref] [PubMed]
42. Giller DB, Giller BD, Giller GV, et al. Video-assisted thoracoplasty in pulmonary tuberculosis: a retrospective study. J Thorac Dis 2020;12:980-8. [Crossref] [PubMed]
43. Marfina GY, Vladimirov KB, Avetisian AO, et al. Bilateral cavitary multidrug- or extensively drug-resistant tuberculosis: role of surgery. Eur J Cardiothorac Surg 2018;53:618-24. [Crossref] [PubMed]
44. Kostopanagiotou K, Papagiannopoulos K, Szulc J, et al. Thoracoplasty Without Rib Resection by the Sawamura Technique: A Forgotten Technique for Effective Complex Pleural Empyema Management in a Single-Step. J Clin Med 2025;14:7673. [Crossref] [PubMed]
45. Khan H, Woo E, Alzetani A. Modified thoracoplasty using a breast implant to obliterate an infected pleural space: an alternative to traditional thoracoplasty. Ann Thorac Surg 2015;99:1418-20. [Crossref] [PubMed]
46. Giang NT, Dung LT, Hien NT, et al. Hemoptysis from complex pulmonary aspergilloma treated by cavernostomy and thoracoplasty. BMC Surg 2019;19:187. [Crossref] [PubMed]
47. Hysi I, Rousse N, Claret A, et al. Open window thoracostomy and thoracoplasty to manage 90 postpneumonectomy empyemas. Ann Thorac Surg 2011;92:1833-9. [Crossref] [PubMed]
48. Grégoire R, Deslauriers J, Beaulieu M, et al. Thoracoplasty: its forgotten role in the management of nontuberculous postpneumonectomy empyema. Can J Surg 1987;30:343-5.
49. Phillip R, Bettis A, Davenport D, et al. Thoracoplasty: Still relevant to current practice. Asian Cardiovasc Thorac Ann 2021;29:518-23. [Crossref] [PubMed]
50. Giller DB, Basangova VA, Kesaev OS, et al. Impact of delayed video-assisted thoracoscopic surgery on pneumonectomy outcomes in patients with tuberculosis. Innov Med Kubani 2025;10:24-32.
51. Bredin CP. Pulmonary function in long-term survivors of thoracoplasty. Chest 1989;95:18-20. [Crossref] [PubMed]
52. Borges N, Saha S. Thoracoplasty for Postpneumonectomy Empyema Associated with Bronchopleural Fistula: A Case Series. Int J Angiol 2015;24:151-4. [Crossref] [PubMed]
53. Corcoran JP, Wrightson JM, Belcher E, et al. Pleural infection: past, present, and future directions. Lancet Respir Med 2015;3:563-77. [Crossref] [PubMed]