Muscle flap reconstruction of the post-lung resection space: clinical cases involving latissimus dorsi, serratus anterior, and pectoralis major

Background: Chronic empyema and bronchopleural fistula (BPF) are challenging complications after lung resection, often requiring surgical solutions when conservative treatments fail. This case report contributes to the literature by illustrating tailored use of different muscle flaps-including combined serratus anterior and latissimus dorsi, as well as pectoralis major-for definitive closure of chronic post-resection spaces. Case Description: . No BPF was detected. Definitive closure of the open window thoracostomy (OWT) was achieved 6 months post-lobectomy using combined serratus anterior and latissimus dorsi flaps, chosen to provide adequate bulk for a large lateral cavity. Case B: a 67-year-old male developed a late BPF (5 mm, right main bronchus stump) with empyema seven years after right pneumonectomy. Cultures were negative at the time of reconstruction. An OWT was closed via pectoralis major flap 14 months later, selected for its anterior reach and volume, appropriate for the upper thoracic defect. In both cases, infection resolution and thoracic stability were confirmed through clinical improvement, normalization of inflammatory markers, and follow-up computed tomography (CT) imaging. No postoperative complications occurred. At 18 months (Case A) and 12 months (Case B) follow-up, both patients remained recurrence-free with preserved shoulder function. Conclusions: These cases illustrate that successful outcomes in chronic post-resection empyema depend on flap choice tailored to cavity location, size, and prior surgery. Combining serratus anterior and latissimus dorsi provides sufficient bulk for extensive lateral cavities, while the pectoralis major is effective for anterior upper thoracic spaces, even in the setting of prior pneumonectomy and fistula. Careful patient selection and flap matching to defect characteristics are key to durable closure and functional preservation.