in thoracic surgery the vacuum assisted closure-device ( vac ; kci medical aps , ballerup , denmark ) , has shown promising results in the treatment of mediastinitis and thoracic instability in patients , who have undergone thoracotomy . this article describes an unprecedented employment of vac , promoting the recovery of a patient with flail chest following anterior thoracic wall resection for recurrent breast cancer and reconstruction with a gore - tex ( w. l. gore & associates inc . , a 44-years - old woman suffered from recurrent invasive oestrogen and progesterone receptor negative ductal carcinoma of the right breast . the course had encompassed subcutaneous lumpectomy , re - lumpectomy , subcutaneous mastectomy , lymph node dissection of the right axilla ( 1 metastatic lymph node out of 20 removed ) and adjuvant combined radio- and chemotherapy . the patient had undergone breast reconstruction with a latissimus dorsi island flap combined with silicone - gel prosthesis . fourteen months later , the patient was re - referred to our department with a painful local recurrence . computer assisted tomography ( cat ) and magnetic resonance imaging scans showed tumour infiltration around the upper 7 cm of the corpus sterni , ending close to the manubrium . no other foci were found by whole body positron emission tomography / cat - scans . the tumour was non - responsive to preoperative docetaxel ( taxotere , sanofi us , bridgewater , nj , usa ) treatment . tumor ablation was performed with wide excision margins guided by frozen section analysis and included a large anterior thoracic wall resection , including the cartilages of the left ribs nos . ii - iv , the caudal half of the manubrium , the corpus sterni , the xiphoid process and the anterior parts of the right ribs nos . the defect was reconstructed with a 2 mm polytetrafluoroethylene ( gore - tex ) patch and a combined musculocutaneous rectus femoris and tensor fasciae latae free flap with a 2020 cm skin paddle harvested from the right thigh . end - to - end microsurgical vascular microanastomoses were made to the left internal mammary vessels . the primary donor defect was covered with a meshed split - thickness skin graft harvested from the opposite thigh . figure 2reconstructed thoracic defect with rectus femoris / tensor fasciae latae - flap on day 8 . reconstructed thoracic defect with rectus femoris / tensor fasciae latae - flap on day 8 . prophylactic cefuroxim , dextrans , acetylsalicylic acid and low dose low molecular heparin was administered perioperatively . apart from reoperation of a simple haematoma between the gore - tex membrane and the flap on the 6 day , the postoperative course was marked by insufficient respiration . the pleural drains were removed on days 7 and 8 . phasing out of the ventilator was impossible due to the thoracic instability . some , but insufficient weaning progress was made during the first 5 days post - operatively . the reoperation set back the weaning process substantially ( figure 3 ) . on day 8 , external stabilisation of the thoracic wall was achieved with a vac device : a polyurethane foam under an airtight adhesive drape , placed on top of the flap , extending 5 cm beyond the borders of the flap . a hydrocolloid cast ( duoderm , convatec inc . , skillman , nj , usa ) protected the suture lines . continuous negative pressure of 125 mmhg was applied ( figure 4 ) . ps , pressure support ; peep / cpap , positive end - expiratory pressure / continuous positive airway pressure ; fio2 , fraction of inspired oxygen ; vac , vacuum assisted closure ; icu , intensive care unit . respiratory support during post - operative period . ps , pressure support ; peep / cpap , positive end - expiratory pressure / continuous positive airway pressure ; fio2 , fraction of inspired oxygen ; vac , vacuum assisted closure ; icu , intensive care unit . the vac was discontinued and the patient was discharged from the intensive care unit ( icu ) . the patient initially had a full recovery , with no subsequent respiratory problems and an uncomplicated healing of the transplants and all donor sites . the tracheal tube was removed on day 22 and the patient was discharged from the hospital on day 33 . unfortunately , the patient developed another locoregional recurrence with pulmonary and hepatic dissemination only two months later and was referred to palliative chemotherapy . flail chest , with the paradoxical respiratory movement of a segment of the thoracic wall , is a well - known adverse effect of sternotomy , cardiopulmonary resuscitation , costal fractures , and chest wall resection . reconstruction of defects in the thoracic wall is a familiar challenge to plastic and thoracic surgeons , and different techniques are used to manage flail chest . the surgical means are various forms of internal fixation , while the predominant conservative approach is by means of analgesia , pulmonary toilet or continuous positive airway pressure . sporadic case reports describe an alternative conservative approach by use of continuous negative extrathoracic pressure ( cnep ) provided by a cuirass respirator : a modern , portable version of the iron lung . after an extensive anterior thoracic wall resection with soft prosthesis and free flap reconstruction , our patient developed flail chest . that topical negative pressure would stabilise the chest wall sufficiently to wean the patient from mechanical ventilation , a vac device was tentatively placed on top of the reconstructed area . the resulting thorax stability immediately decreased the patient 's need of respiratory support and on day 10 , a larger vac reduced the pressure support needed by 50% ( figure 3 ) . after 7 days of temporary external stabilisation , the ventilator and the vac could be discontinued . we chose a negative pressure of 125 mmhg , because this level is most commonly used , and results in optimal wound healing . in a porcine sternotomy model , it was found that maximum stability occurs at a low negative pressure of 50 to 100 mmhg . concern has been raised regarding possible adverse systemic haemodynamic effects of placing the vac in thoracic wall defects , but these appear to be minimal at 125 mmhg if muscle is interposed . the local effects of placing vac on top of a free musculo - cutaneous flap are not well addressed in literature . in this case , there was no adverse effect on flap survival ; on the contrary , the increased microcirculation in the flap and the recipient wound edges , induced by the vac , may facilitate the take of the flap . it is likely that the ability of vac in neutralizing paradoxical respiration can be ascribed to its structural stabilising effect , due to the continuous negative pressure applied to the polyurethane foam , the flail segment and the surrounding thoracic wall . the observed clinical correlation between vac application and weaning from the ventilator can not be established as causal with certainty in this case report . several factors such as pneumonia , establishment of a tracheostomy and spontaneous rehabilitation could have influenced the course of the patient 's recovery . the pneumonia was caused by an opportunistic pathogen in a vulnerable patient weakened by cancer , and tracheostomy was performed on day 11 , which is our institution 's standard of care when the need for invasive ventilation exceeds more than one week , and extubation is not likely to be achievable in the near future . nonetheless , the application of vac and the reduction in pressure support ( ps ) ( from 19 cm h2o to 6 cm h2o ) occurred before the tracheostomy . furthermore , the reduction in ps of 14 cm h2o was achieved in only two days , whereafter the patient 's pulmonary condition only improved ( figure 3 ) . despite these ameliorations the patient did n't wean until after 7 days , which could indicate that cause and effect might not be entirely coherent . nevertheless , it seems that vac aided in stabilising the flail chest , facilitated quicker weaning and early mobilization , thereby improving the clinical picture . some may argue that flail chest development should be avoided at the time of chest wall reconstruction . hameed et al . studied a series of chest wall reconstructions in 20 patients with some similarity to our case , in which none developed flail chest . we ascribe this difference in outcome to the fact that the resection was more extensive in our case . for structural reconstruction , hameed et al . chose a polypropylene mesh that was sometimes doubled to provide extra support , but the choice of prosthetic material ( polypropylene versus gore - tex ) should not per se affect the outcome . this case suggests how vac can help improve the thoracic stability and pulmonary function in a patient with flail chest , and potentially decrease the time spent in the icu . it demonstrates the success of using vac as an adjuvant to a one - stage procedure for anterior thoracic wall reconstruction , allowing sufficient temporary external fixation to aid elimination of paradoxical respiration without adverse effects on haemodynamics or flap healing . as in the few previous reports , this case illustrates how cnep can provide intermediate thoracic stability and render surgical stabilisation of flail chest needless . vac is easier to apply and adjust , it is lighter and therefore more tolerable for the patient . further investigation of the use of vac in the conservative management of flail chest is desirable .