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Bigdeli AK, Falkner F, Schmidt VJ, Thomas B, Engel H, Reichenberger M, Germann G, Gazyakan E, Kneser U. Free Flap Reconstruction of Sternal Defects after Cardiac Surgery: An Algorithmic Approach for Dealing with Sparse Recipient Vessels. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5722. [PMID: 38596583 PMCID: PMC11003506 DOI: 10.1097/gox.0000000000005722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 01/31/2024] [Indexed: 04/11/2024]
Abstract
Background Sparsity of recipient vessels poses a challenge for microsurgical free flap reconstruction of sternal defects following deep sternal wound infection after cardiac surgery. Methods From January 2013, a standardized algorithm for dealing with sparse recipient vessels was strictly followed. In this retrospective study including 75 patients, we compared operative details, surgical complications, and reconstructive outcomes of patients treated according to this algorithm (group A: January 2013-May 2021; n = 46) with a historical control group (group B: January 2000-December 2012, n = 29). Results The left internal mammary artery had been harvested for arterial bypass grafting in 40 of 46 cases (87%) in group A and in all cases in group B. The right internal mammary artery (RIMA) and right internal mammary vein (RIMV) were the first choice as recipient vessels. In case of unsuitability of the RIMV, a right cephalic vein (CV) turndown was used for venous outflow. If both RIMA and RIMV proved insufficient, a single-stage arterio-venous loop (AVL) between the CV and subclavian artery (CV-SA AVL), CV and thoracoacromial artery (CV-TA AVL), or subclavian artery and subclavian vein (SA-SV AVL) was established. The algorithmic approach significantly reduced partial flap necrosis [group A: n = 3 (7%) versus group b: n = 7 (24%); P = 0.04], and overall operation time [group A: 360 ± 88 min versus group B: 415 ± 80 min; P = 0.01]. Conclusions Standardized approaches improve clinical outcomes in microsurgical free flap sternal reconstruction after cardiac surgery.
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Affiliation(s)
- Amir K. Bigdeli
- From the Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
- Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Florian Falkner
- From the Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
- Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Volker J. Schmidt
- Department of Hand, Plastic and Reconstructive Surgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Benjamin Thomas
- From the Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
- Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Holger Engel
- ETHIANUM—Clinic for Plastic and Reconstructive Surgery, Aesthetic and Preventive Medicine at Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias Reichenberger
- ETHIANUM—Clinic for Plastic and Reconstructive Surgery, Aesthetic and Preventive Medicine at Heidelberg University Hospital, Heidelberg, Germany
| | - Günter Germann
- ETHIANUM—Clinic for Plastic and Reconstructive Surgery, Aesthetic and Preventive Medicine at Heidelberg University Hospital, Heidelberg, Germany
| | - Emre Gazyakan
- From the Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
- Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ulrich Kneser
- From the Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
- Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
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Ernert C, Kielstein H, Azatyan A, Prantl L, Kehrer A. Extended arc of rotation of Latissimus Dorsi Musculocutaneous Flap providing well-vascularized tissue for reconstruction of complete defects of the sternum: An anatomical study of flap pedicle modification. Clin Hemorheol Microcirc 2024; 86:225-236. [PMID: 37742631 DOI: 10.3233/ch-238115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
BACKGROUND Deep sternal wound infections (DSWI) following cardiothoracic surgery represent a life quality endangering sequelae and may lead to sternal osteomyelitis. Radical debridement followed by Negative Pressure Wound Therapy (NPWT) may achieve infection control, provide angiogenesis, and improve respiratory function. When stable wound conditions have been established a sustainable plastic surgical flap reconstruction should be undertaken. OBJECTIVE This study analyses a method to simplify defect coverage with a single Latissimus Dorsi Myocutaneous Flap (LDMF). METHODS Preparation of 20 LDMF in ten fresh frozen cadavers was conducted. Surgical steps to increase pedicle length were evaluated. The common surgical preparation of LDMF was compared with additional transection of the Circumflex Scapular Artery (CSA). RESULTS Alteration of the surgical preparation of LDMF by sacrificing the CSA may provide highly valuable well-vascularized muscle tissue above the sensitive area of the Xiphisternum. All defects could be completely reconstructed with a single LDMF. The gain in length of flap tissue in the inferior third of the sternum was 3.86±0.9 cm (range 2.2 to 8 cm). CONCLUSIONS By sacrificing the CSA in harvesting the LDMF a promising gain in length, perfusion and volume may be achieved to cover big sternal defects with a single flap.
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Affiliation(s)
- Carsten Ernert
- Department of Plastic, Hand and Microsurgery, Ev. Waldkrankenhaus Spandau, Berlin, Germany
| | - Heike Kielstein
- Institute of Anatomy, Martin Luther University Halle Wittenberg, Halle, Germany
| | - Argine Azatyan
- Department of Plastic, Reconstructive and Breast Surgery, Görlitz Hospital, Görlitz, Germany
| | - Lukas Prantl
- Department of Plastic and Reconstructive Surgery, University Medical Center, Regensburg, Germany
| | - Andreas Kehrer
- Department of Plastic and Reconstructive Surgery, University Medical Center, Regensburg, Germany
- Division of Hand and Plastic Surgery, Ingolstadt Hospital, Ingolstadt, Germany
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3
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Ichimura N, Yamamoto N, Urata Y, Ikutomi S, Hibi H. A case of sternal osteomyelitis caused by defective wound healing after surgery of gingival cancer. IDCases 2023; 31:e01682. [PMID: 36654735 PMCID: PMC9841327 DOI: 10.1016/j.idcr.2023.e01682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 01/09/2023] Open
Affiliation(s)
- Norihisa Ichimura
- Department of Oral and Maxillofacial Surgery, Nagoya University Hospital, Nagoya, Japan,Correspondence to: Department of Oral and Maxillofacial Surgery, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan.
| | - Noriyuki Yamamoto
- Department of Oral and Maxillofacial Surgery, Kariya Toyota General Hospital, Kariya, Japan
| | - Yusuke Urata
- Department of Oral and Maxillofacial Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shohei Ikutomi
- Department of Oral and Maxillofacial Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hideharu Hibi
- Department of Oral and Maxillofacial Surgery, Nagoya University Hospital, Nagoya, Japan,Department of Oral and Maxillofacial Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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4
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Yu CM, Yu CM, Yao WT, Chen YF, Lee AL, Liu YC, Tu CP, Huang WC, Tung KY, Tsai MF. Efficacy and safety of pectoralis muscle flap combined rectus abdominis muscle sheath fasciocutaneous flap for reconstruction of sternal infection. Int Wound J 2022; 19:1829-1837. [PMID: 35289489 PMCID: PMC9615267 DOI: 10.1111/iwj.13788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/25/2022] [Accepted: 03/05/2022] [Indexed: 11/29/2022] Open
Abstract
Few studies have assessed the efficacy and safety of reconstruction of sternal infection using a pectoralis muscle flap combined with a rectus abdominis muscle (RAM) sheath fasciocutaneous flap. We report here our experience with this procedure to reconstruct the sternal defect in patients (n = 46) with a deep sternal wound infection (DSWI) after cardiac surgery. After wound reconstruction, the proportion of prolonged mechanical ventilation use and intensive care unit (ICU) stay were 17.4% (n = 8) and 21.7% (n = 10), respectively. The 30‐day all‐cause mortality was 15.2%; recurrence rate was 17.4%; postoperative complications were 15.2%; and median hospital stay was 31 (0‐157) days. Multivariate logistic regression analysis revealed that hypertension (β = 21.32, 95%CI 4.955‐37.68, P = .014), drainage‐tube use (β = 0.944, 95%CI 0.273‐1.614, P = .008), and prolonged intensive care unit stay (β = 53.65, 95%CI 31.353‐75.938, P < .001) were significantly correlated with hospital stay. In conclusion, a procedure including surgical debridement, sternal reconstruction with bilateral PM and RAM sheath flap, long‐term antibiotics, and adequate drainage is a beneficial technique in the reconstruction of deep sternal wound infection after cardiac surgery. Duration of drainage tube use may be as an index for a hospital stay or wound healing.
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Affiliation(s)
- Chieh-Ming Yu
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan
| | - Chia-Meng Yu
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan.,Burn Center, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Wen-Teng Yao
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan.,Burn Center, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Yu-Fan Chen
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan
| | - An-Li Lee
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan
| | - Ying-Chun Liu
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan.,Burn Center, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Chih-Peng Tu
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan
| | - Wen-Chen Huang
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan
| | - Kwang-Yi Tung
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan.,Burn Center, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Ming-Feng Tsai
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei City, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei, Taiwan.,Graduate Institute of Biomedical Informatics, Collage of Medical Science and Technology, Taipei Medical University, Taipei City, Taiwan
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5
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Abstract
SUMMARY Wounds have been one of the most prominent pathologies since the beginning of humanity. For the last 5 decades, a drastic improvement of healing has been observed, thanks to new medical devices based on fluid aspiration capacities and the development of negative pressure wound therapy. Negative-pressure wound therapy was initially designed for a double action, fluid aspiration and mechanical stimulation of wound edges by a foam. Successive technical evolutions of negative pressure wound therapy were declined since 1997 when Argenta and Morykwas first presented their solution. The adjunct of instillation in 2009 was considered as the first interactive dressing, allowing topical wound solutions to sequentially reach the wound, in alternance with negative pressure. Other devices based on the same principle were designed to prevent postoperative infections when placed over a suture after surgery. This long evolution could enhance the armamentarium of possible solutions, considerably reducing the wound healing time.
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6
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Falkner F, Thomas B, Haug V, Nagel SS, Vollbach FH, Kneser U, Bigdeli AK. Comparison of pedicled versus free flaps for reconstruction of extensive deep sternal wound defects following cardiac surgery: A retrospective study. Microsurgery 2021; 41:309-318. [PMID: 33780053 DOI: 10.1002/micr.30730] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/29/2021] [Accepted: 03/03/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Myocutaneous pedicled flaps are the method of choice for sternal reconstruction after deep sternal wound infection (DSWI) following cardiac surgery. We set out to investigate whether free flaps provide a superior alternative for particularly extended sternal defects. METHODS Between October 2008 and February 2020, 86 patients with DSWI underwent sternal reconstruction with myocutaneous flaps at our institution. Patients were retrospectively grouped into pedicled (A; n = 42) and free flaps (B, n = 44). The objective was to compare operative details, outcome variables, surgical as well as medical complication rates between both groups, retrospectively. Binary logistic regression analysis was applied to determine the effect of increasing defect size on flap necrosis. RESULTS Rates of partial flap necrosis (>5% of the skin island) were significant higher in pedicled flaps (n = 14), when compared to free flaps (n = 4) (OR: 5.0; 33 vs. 9%; p = .008). Increasing defect size was a significant risk factor for the incidence of partial flap necrosis of pedicled flaps (p = .012), resulting in a significant higher rate of additional surgeries (p = .036). Binary regression model revealed that the relative likelihood of pedicled flap necrosis increased by 2.7% with every extra square-centimeter of defect size. CONCLUSION To avoid an increased risk of partial flap necrosis, free flaps expand the limits of extensive sternal defect reconstruction with encouragingly low complication rates and proved to be a superior alternative to pedicled flaps in selected patients.
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Affiliation(s)
- Florian Falkner
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Benjamin Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Valentin Haug
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Sarah S Nagel
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Felix H Vollbach
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
| | - Amir K Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Heidelberg, Germany
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7
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Reconstruction of Oncologic Sternectomy Defects: Lessons Learned from 60 Cases at a Single Institution. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 7:e2351. [PMID: 31942367 PMCID: PMC6952121 DOI: 10.1097/gox.0000000000002351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 06/03/2019] [Indexed: 11/26/2022]
Abstract
Oncologic sternectomy results in complex defects where preoperative planning is paramount to achieve best reconstructive outcomes. Although pectoralis major muscle flap (PMF) is the workhorse for sternal soft tissue coverage, additional flaps can be required. Our purpose is to evaluate defects in which other flaps beside PMF were required to achieve optimal reconstruction.
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8
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Spindler N, Kade S, Spiegl U, Misfeld M, Josten C, Mohr FW, Borger M, Langer S. Deep sternal wound infection - latissimus dorsi flap is a reliable option for reconstruction of the thoracic wall. BMC Surg 2019; 19:173. [PMID: 31752814 PMCID: PMC6868737 DOI: 10.1186/s12893-019-0631-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/22/2019] [Indexed: 12/31/2022] Open
Abstract
Background At present, data describing patients’ long-term outcomes, quality of life, and survival after deep sternal wound infection are rarely available. The purpose of our study was to evaluate functional outcome and patient well-being after debridement and reconstruction of the sternal defect using a pedicled latissimus dorsi flap following deep sternal wound infection (DSWI). Methods This retrospective analysis reviewed 106 cases of DSWI after open-heart surgery treated between May 1, 2012, and May 31, 2015. The parameters of interest were demographic and medical data, including comorbidity and mortality. Follow-up consisted of physical examination of the patients using a specific shoulder assessment, including strength tests and measurements of pulmonary function. Results The population consisted of 69 (65%) male and 37 (35%) female patients. Their average age at the time of plastic surgery was 69 years (range: 35–85). The 30-day mortality was 20% (n = 21); after one-year, mortality was 47% (n = 50), and at follow-up, it was 54% (n = 58). Heart surgery was elective in 45 cases (42%), urgent in 31 cases (29%) and for emergency reasons in 30 cases (28%). The preoperative European System for Cardiac Operative Risk Evaluation (EuroSCORE) averaged 16.3 (range: 0.88–76.76). On the dynamometer assessment, a value of 181 Newton (N) (±97) could be achieved on the donor side, in contrast to 205 N (±91) on the contralateral side. The inspiratory vital capacity of the lung was reduced to an average of 70.58% (range: 26–118), and the forced expiratory volume in 1 s was decreased to an average of 69.85% (range: 38.2–118). Conclusions Given that only small adverse effects in shoulder function, strength, and pulmonary function were observed, the latissimus dorsi flap appears to be a safe and reliable option for the reconstruction of the sternal region after DSWI.
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Affiliation(s)
- Nick Spindler
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
| | - Stefanie Kade
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Ulrich Spiegl
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Martin Misfeld
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Christoph Josten
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Friedrich-Wilhelm Mohr
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Michael Borger
- Department of Cardiac Surgery, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Stefan Langer
- Department of Orthopedic Surgery, Traumatology and Plastic Surgery, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
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9
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Extensively Drug-Resistant Pseudomonas aeruginosa Sternal Osteomyelitis. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2018. [DOI: 10.1097/ipc.0000000000000559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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11
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Infraareolar pectoralis major myocutaneous island flap as treatment of first choice for deep sternal wound infection. J Plast Reconstr Aesthet Surg 2012; 66:187-92. [PMID: 23102609 DOI: 10.1016/j.bjps.2012.09.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 09/19/2012] [Accepted: 09/21/2012] [Indexed: 11/24/2022]
Abstract
Deep sternal wound infection (DSWI) is a grave complication of median sternotomy, associated with high morbidity, mortality and escalating treatment costs. There is general consensus that optimal treatment comprises radical debridement followed by coverage with a vascularised flap. However, there is ongoing debate regarding the ideal operative procedure. We present our experience with the infraareolar pectoralis major island myocutaneous flap (PEC-MI flap) as treatment of first choice in DSWI. Following a retrospective chart review, data pertaining to patient demographics, type of cardiac surgery performed, prevalence of known DSWI risk factors, identified pathogens, duration of surgery, flap-related complications, duration of hospital stay and antibiotic therapy, as well as mortality were noted. Additionally, we describe the operative technique and review the relevant literature. Twenty-five patients underwent coverage with the PEC-MI flap in our department. The average age was 69.2 years. Nineteen patients underwent coronary artery bypass surgery, 10 valve replacement, two aortic replacement surgery and one pericardiectomy. In six cases, no internal mammary artery was used in cardiac surgery, in 11 cases one and in seven cases both internal mammary arteries were used. The average duration of surgery was 154.2 min and the average hospital stay was 28.4 days. Complications which required revision surgery were haematoma in three cases, one wound dehiscence and one recurrent infection. Two cases required coverage with an additional regional flap. The PEC-MI flap has been used as flap of first choice in our clinic for treatment of DSWI. It is sufficient to raise the flap unilaterally, and it does not require skin grafting. The combination of immunocompetent bulky muscle tissue used to obliterate the sternal cavity and the large skin paddle enabling a low-tension skin closure allows reliable and efficient treatment of this severe complication.
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12
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Clemens MW, Evans KK, Mardini S, Arnold PG. Introduction to chest wall reconstruction: anatomy and physiology of the chest and indications for chest wall reconstruction. Semin Plast Surg 2012; 25:5-15. [PMID: 22294938 DOI: 10.1055/s-0031-1275166] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The chest wall functions as a protective cage around the vital organs of the body, and significant disruption of its structure can have dire respiratory and circulatory consequences. The past several decades have seen a marked improvement in the management and reconstruction of complex chest wall defects. Widespread acceptance of muscle and musculocutaneous flaps such as the latissimus dorsi, pectoralis major, serratus anterior, and rectus abdominis has led to a sharp decrease in infections and mortality. Successful reconstructions are dependent upon a detailed knowledge of the functional anatomy and blood supply of the chest and the underlying pathophysiology of a particular disease process. This article will provide an overview of key principles and evidence-based approaches to chest wall reconstruction.
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13
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Sahasrabudhe P, Jagtap R, Waykole P, Panse N, Bhargava P, Patwardhan S. Our experience with pectoralis major flap for management of sternal dehiscence: A review of 25 cases. Indian J Plast Surg 2012; 44:405-13. [PMID: 22279272 PMCID: PMC3263267 DOI: 10.4103/0970-0358.90810] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective: To report our experience of the pectoralis major flap as the treatment modality for post coronary artery bypass sternal wound dehiscence. Materials and Methods: A retrospective study of 25 open heart surgery cases, performed between January 2006 and December 2010 at Deenanath Mangeshkar Hospital, Pune, was carried out. Unilateral or bilateral pectoralis major muscle flap by the double breasting technique using rectus extension was used in the management of these patients. The outcome was assessed on the basis of efficacy of flap surgery in achieving wound healing and post-surgery shoulder joint movements to evaluate donor site morbidity. The follow-up ranged from 5 months to 3.5 years. Results: Twenty-three (92%) patients were discharged with complete wound closure. One patient (4%) had wound dehiscence after flap surgery. One patient (4%) died in the hospital in the immediate postoperative period due to mediastinitis. No recurrent sternum infection has occurred till date in 24 patients (96%). For one patient (4%) who had wound dehiscence, daily dressing was done and wound healing was achieved with secondary intension. At follow-up, shoulder joint movements were normal in all the patients. Conclusions: The double breasting technique of the pectoralis major muscle flaps with rectus sheath extension is efficient in covering the entire length of the defect and can reduce the morbidity, without affecting the function of the shoulder joint.
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Affiliation(s)
- Parag Sahasrabudhe
- Department of Plastic and Cosmetic Surgery, Deenanath Mangeshkar Hospital, B. J. Medical College and Sassoon Hospitals, Pune, India
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Sansone F, Mossetti C, Bruna MC, Oliaro A, Zingarelli E, Flocco R, del Ponte S, Casabona R. Transomental Titanium Plates for Sternal Osteomyelitis in Cardiac Surgery. J Card Surg 2011; 26:600-3. [DOI: 10.1111/j.1540-8191.2011.01336.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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15
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Reconstruction for sternal osteomyelitis at the lower third of sternum. J Plast Reconstr Aesthet Surg 2010; 63:633-41. [DOI: 10.1016/j.bjps.2009.01.057] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2008] [Revised: 12/24/2008] [Accepted: 01/30/2009] [Indexed: 11/22/2022]
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16
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Clarkson JHW, Probst F, Niranjan NS, Meuli C, Vogt P, Lidman D, Andersson LC. Our experience using the vertical rectus abdominis muscle flap for reconstruction in 12 patients with dehiscence of a median sternotomy wound and mediastinitis. ACTA ACUST UNITED AC 2009; 37:266-71. [PMID: 14649684 DOI: 10.1080/02844310310000455] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The vertical rectus abdominis (VRAM) flap has been used for reconstruction of sternal defects, particularly in the inferior third, since it was first described 20 years ago. We describe 12 patients with mediastinitis or chronic sternal osteomyelitis after sternotomy treated between 1994 and 1997, nine performed at the Royal Hospitals Trust, London. Sternal osteomyelitis and mediastinitis after median sternotomy is an uncommon (0.4%-8.4%) but often fatal condition. Vascularised pedicles are the treatment of choice, and VRAM flaps were used in all cases. We report good long-term outcome with a follow up of 2-5 years, and no long-term morbidity relating to the VRAM reconstruction. We had only one partial failure of a flap. The operations were largely done in hospitals away from the plastic surgical unit in extremely sick patients, which illustrates the importance of multidisciplinary management to reduce hospital stay, mortality, and morbidity. We argue that early involvement of plastic surgical specialists in the treatment of sternal dehiscence is essential to ensure a successful outcome.
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Riedel K, Kremer T, Hoffmann H, Pfannschmidt J, Reimer P, Dienemann H, Germann G, Sauerbier M. [Plastic surgical reconstruction of extensive thoracic wall defects after oncologic resection]. Chirurg 2008; 79:164-74. [PMID: 17786394 DOI: 10.1007/s00104-007-1382-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In defect reconstruction following radical oncologic resection of malignant chest wall tumors, adequate soft-tissue reconstruction must be achieved along with function, stability, integrity, and aesthetics of the chest wall. The purpose of this retrospective analysis was to evaluate the oncoplastic concept following radical resection of malignant chest wall infiltration with an interdisciplinary approach. Between 1999 and 2005, 36 consecutive patients (nine males, 27 females, mean age 55 years, range 20-78) were treated with resection for malignant tumors of the chest wall. Indications were locally recurrent breast carcinoma (patient n=22), thymoma (n=1), and desmoid tumor (n=1). Primary lesions of the chest wall were spinalioma (n=1), sarcoma (n=7), and non-small-cell lung cancer (n=2). There were distant metastases of colon and cervical cancer in one patient each. Soft-tissue reconstruction was carried out using primary closure (n=1), external oblique flap (n=1), pectoralis major myocutaneous flap (n=3), latissimus dorsi myocutaneous flap (n=18), vertical or transversal rectus abdominis myocutaneous flap (n=9), free tensor fascia lata- flap (n=6), trapezius flap (n=1), serratus flap (n=1), and one filet flap. In 15 reconstructive procedures microvascular techniques were used. An average of 3.4 ribs were resected. Stability of the chest wall was obtained with synthetic meshes. The latissimus dorsi flap is considered the flap of choice in chest wall reconstruction. However, alternatives such as pectoralis major flap, VRAM/TRAM flap, free TFL flap, and serratus flap must also be considered. Low mortality and morbidity rates allow tumor resection and chest wall reconstruction even in a palliative setting.
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Affiliation(s)
- K Riedel
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie-Schwerbrandverletztenzentrum, BG-Unfallklinik Ludwigshafen, Klinik für Plastische und Handchirurgie an der Universität Heidelberg, Ludwigshafen
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18
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Strecker T, Rösch J, Horch RE, Weyand M, Kneser U. Sternal wound infections following cardiac surgery: risk factor analysis and interdisciplinary treatment. Heart Surg Forum 2007; 10:E366-71. [PMID: 17855200 DOI: 10.1532/hsf98.20071079] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Sternal wound infections are a serious complication after cardiac surgery. Although a variety of treatment algorithms has been published, the ideal operative treatment of complicated median sternotomy wounds is the subject of ongoing controversy. METHODS In a retrospective review, 3016 consecutive open-heart surgery patients between January 2003 and June 2006 were evaluated: 65.6% underwent coronary artery bypass surgery (CABG), 16.3% cardiac valve replacement, 13.5% combined CABG and valve replacement, 2.8% aortic reconstruction or replacement, 0.6% artificial heart implantation, and 1.2% cardiac transplantation. RESULTS Sixty-three patients (2.1%) developed sternal wound infections. Fifty-six wounds were treated with débridement, irrigation, and re-wiring. Thirty-four patients were treated using vacuum-assisted closure therapy. Nineteen of these patients eventually required plastic surgical coverage with either rectus abdominis or pectoralis major flaps. Diabetes mellitus, rethoracotomy, duration of operation and, interestingly, the time of operation (morning versus afternoon) presented significant risk factors for development of sternal wound infections (P <.05). Three patients developed partial flap necrosis and required a second flap. Eventually, all defects were successfully reconstructed and there was no recurrent ostemyelitis noticed over the entire observation period (follow-up, 23 +/- 13 months). DISCUSSION Patients at risk for development of sternal wound infections may be preferably operated in the morning at first position. Vaccuum-assisted closure therapy acts as a link between radical débridement and definitive plastic coverage. The type of flap is individually chosen based on location of the defect and availability of certain vascular axis. The presented interdisciplinary approach with radical surgical débridement, application of subatmospheric pressure dressings, and early involvement of the plastic surgical team allows efficient treatment of infected median sternotomy wounds.
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Affiliation(s)
- Thomas Strecker
- Center of Cardiac Surgery, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany.
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19
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Davison SP, Clemens MW, Armstrong D, Newton ED, Swartz W. Sternotomy wounds: rectus flap versus modified pectoral reconstruction. Plast Reconstr Surg 2007; 120:929-934. [PMID: 17805121 DOI: 10.1097/01.prs.0000253443.09780.0f] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Infected sternotomy wounds occur in 0.5 to 8.4 percent of open heart operations. They are complex problems, with a mortality rate of 8.1 to 14.8 percent despite flap closure. For closure, the pectoralis major flap has had considerable success. However, in providing coverage to the lower third of the sternum, it may be deficient. Modifications to improve closure have included a rectus flap or an anterior rectus fascia extension to the pectoralis flap. METHODS This retrospective study of 130 consecutive sternotomy wounds compares 41 bilateral pectoralis major muscle flaps with a modified anterior rectus fascia extension against 56 rectus abdominis muscle flaps alone in addressing the lower third of the sternum following dehiscence. RESULTS Pectoralis flaps with rectus fascia extension and rectus flaps have similar success, postoperative course, and morbidity and mortality rates. The pectoralis flaps with rectus fascia extensions prevented superior dehiscence, but this modification does not eliminate dehiscence of the distal third of the sternum. CONCLUSIONS The rectus muscle alone proved superior in coverage to the inferior sternum. Sternal wounds should be covered preferentially by a pectoralis flap to cover a superior infection and by a rectus flap if the dehiscence is localized to the distal third.
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Affiliation(s)
- Steven P Davison
- Pittsburgh, Pa.; and Washington, D.C. From West Penn Hospital, Shadyside Hospital, and the Division of Plastic and Reconstructive Surgery, Georgetown University Medical Center
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20
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Tebala GD, Ciani R, Fonsi GB, Hadjiamiri H, Barone P, Di Pietrantonio P, Zumbo A. Laparoscopic Harvest of an Omental Flap to Reconstruct an Infected Sternotomy Wound. J Laparoendosc Adv Surg Tech A 2006; 16:141-5. [PMID: 16646705 DOI: 10.1089/lap.2006.16.141] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Sternotomy dehiscence is associated with a high mortality rate. In most cases this complication may be treated by simple debridement and antibiotic therapy, but sometimes it is necessary to fill the sternal defect with viable tissue. The greater omentum seems to be the ideal tissue to be transposed because of its malleability, good vascularization, and high lymphatic tissue content. The transposition of the greater omentum usually requires a midline laparotomy for the preparation of the flap, with significant laparotomy-related morbidity. Laparoscopic access may represent an effective alternative for preparing and transposing the omental flap. The key points of the laparoscopic technique are (1) the coloepiploic detachment, (2) the section of the anastomotic arterial branches between the Barkow's arcade and the gastroepiploic arcade, (3) the mobilization of the greater omentum pedicled on the right gastroepiploic artery, and (4) its transposition into the mediastinum, taking care to avoid twisting the gastric greater curvature and the flap itself.
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21
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Abstract
The management of mediastinitis involves directing appropriate antibacterial therapy against the potential bacterial pathogens. The increased recovery of anaerobic bacteria from mediastinal infections has led to a greater appreciation of their role in this condition and to re-evaluation of the proper treatment of this condition. Mediastinitis caused by anaerobic bacteria generally emerges following perforation of the oesophagus, extension of retropharyngeal abscess, suppurative parotitis, cervical cellulitis or abscess of dental origin. The bacteria recovered from these infections are often of oral origin and involve mixed aerobic-anaerobic oral flora. The predominant anaerobic isolates include Bacteroides spp., Peptostreptococcus spp., pigmented Prevotella and Porphyromonas spp. and Fusobacterium spp. Treatment includes surgical intervention, antibacterial therapy and supportive measures. Appropriate management of mediastinal infections due to aerobic and anaerobic infections requires the administration of antibacterials that are effective against both the aerobic and anaerobic components of the infection. Selection of antibacterials for the treatment of mediastinitis is determined by bacteriological studies.
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Affiliation(s)
- Itzhak Brook
- Georgetown University School of Medicine, Washington, DC 20016, USA.
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Puma F, Fedeli C, Ottavi P, Porcaro G, Battista Fonsi G, Pardini A, Daddi G. Laparoscopic omental flap for the treatment of major sternal wound infection after cardiac surgery. J Thorac Cardiovasc Surg 2004; 126:1998-2002. [PMID: 14688718 DOI: 10.1016/s0022-5223(03)00709-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The ideal reconstructive procedure after sternal debridement is still a matter of debate. The omentum might be theoretically preferable for its favorable properties, but it is seldom used because it entails the added trauma of a laparotomy. METHODS Three female patients with severe osteomyelitis after myocardial revascularization underwent sternal debridement and filling of the defect with a laparoscopically prepared omental flap. Sternal wound closure was achieved as a single-stage procedure in 2 patients. The third patient had a poststernotomy septicemia and required a 2-stage procedure. The abdominal procedures were conducted through 3 operating 5-mm ports. Omental flaps were developed by complete separation from the transverse colon and lengthening by division of some anastomosing arteries between gastroepiploic vessels and Barkow's arcade. Thoracic transposition of the omentum was achieved through a 5-cm diaphragmatic incision. The flaps were able to reach the base of the neck and fill the sternal defect in all patients. RESULTS A smooth postoperative course was observed. Oral intake was started from day 2; sole oral nutrition was maintained from day 3 or 4. Optimal wound healing was observed with minimal or absent local discomfort. Minor transient paradoxical movements of the anterior chest wall disappeared within 1 month. Postoperative hospital stay was 9, 14, and 14 days, respectively. CONCLUSIONS Laparoscopic omentoplasty, compared with the open procedure, entails several advantages for the treatment of sternal osteomyelitis. The introduction of minimally invasive techniques may widen the indications for the use of the omentum in the treatment of major sternal wound infections.
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23
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Francel TJ, Kouchoukos NT. A rational approach to wound difficulties after sternotomy: reconstruction and long-term results. Ann Thorac Surg 2001; 72:1419-29. [PMID: 11603489 DOI: 10.1016/s0003-4975(00)02009-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
One hundred fifty-one patients were reconstructed after median stemotomy by a single plastic surgeon over a 6-year period. The treatment included immediate reconstruction (63 patients) and delayed reconstructions (88 patients). Ninety eight percent of the patients had definitive healing at 6 weeks with an overall 30-day mortality of 4 percent. The issues of long-term intravenous antibiotics, perceived skin deficiency, cardiac decompensation, Candida infections, and reexploration of a healed mediastinum after flap reconstruction are discussed. Follow up (4 months to 6 years) of patients treated with reconstruction compared favorably with patients treated with rewiring procedures (20 patients) in regard to strength, chest wall stability, pulmonary function testing, and functional return to hobbies and employment.
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Affiliation(s)
- T J Francel
- Department of Surgery, St. Louis University, and St John's Mercy Medical Center, Missouri, USA
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Fansa H, Handstein S, Schneider W. Treatment of infected median sternotomy wounds with a myocutaneous latissimus dorsi muscle flap. SCAND CARDIOVASC J 1998; 32:33-9. [PMID: 9536504 DOI: 10.1080/14017439850140328] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Infected sternotomy wounds, particularly if accompanied by osteomyelitis, mediastinitis or pericarditis, are associated with significant morbidity, prolonged hospitalization and a mortality of up to 50%. Until the introduction of muscle flaps, the therapy of choice was debridement and open granulation or catheter irrigation. From 1994 to 1996, 9 patients with infected median sternotomy wounds were treated with a single-stage radical debridement and wound closure with a pedicled myocutaneous latissimus dorsi muscle flap (LDM). One patient received, in addition, a rectus abdominis muscle turnover flap. Healing was uneventful in all cases, with no respiratory complications or chest-wall instability. Shoulder strength was also unaffected. Functional and aesthetic outcome was good. The LDM provides a safe flap with little donor site morbidity. Compared to the most local muscle flaps, an intact IMA is not required. At the same time, length and cost of hospital stay are decreased.
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Affiliation(s)
- H Fansa
- Department of Plastic, Reconstructive and Handsurgery, Medical Faculty, Otto-von-Guericke-University, Magdeburg, Germany
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25
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Verheyden CN, Grothaus PC, Lynch DJ. Implantable cardioverter-defibrillator: another device to cover. Plast Reconstr Surg 1996; 97:944-51. [PMID: 8618997 DOI: 10.1097/00006534-199604001-00009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The implantable cardioverter-defibrillator is a mechanical device developed to manage patients with life-threatening arrhythmias when pharmacologic control has failed or produced unacceptable side effects. It is a significant amount of foreign material with a generator pack (volume 113 to 145 cc, weight 197 to 235 gm) and two or three leads and patches that are inserted into or placed on the heart. Although it has worked very well in preventing premature death, there have been complications associated with the device itself. The most significant of these has been exposure and/or infection. We present three patients who have experienced this problem. Improved coverage has been accomplished by burying the implant beneath the rectus abdominis muscle in situations where skin and subcutaneous tissue alone have proved inadequate. By dividing one or two tendinous inscriptions and the anterior limb of the internal oblique fascia, a musculofascial pocket is created to contain the generator and lead wires. This provided satisfactory coverage in two of our three patients. The single failure resulted from external trauma to the abdominal wall.
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Hallock GG. Management of the recurrent sternal wound infection. THE CANADIAN JOURNAL OF PLASTIC SURGERY = JOURNAL CANADIEN DE CHIRURGIE PLASTIQUE 1995. [DOI: 10.1177/229255039500300307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
After adequate sternal debridement or resection for the treatment of a sternal wound infection, muscle flap obliteration of the resulting void has become an accepted standard. Unfortunately, recurrence is not an inconsequential risk as evidenced in six (20.7%) of our patients over the last 10 years. Two of these patients required a second muscle flap transfer before obtaining a healed wound. Since the available regional options for appropriate vascularized flaps is limited, especially with the increased frequency in use of the internal mammary artery for coronary artery bypass grafting, great care must be observed in the selection process not just for closure of the initial wound, but in anticipation of untoward sequela. A schema prioritizing alternatives has been established, so as to maximize the benefit of our workhorse flaps, the pectoralis major or rectus abdominis muscles.
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Affiliation(s)
- Geoffrey G Hallock
- Division of Plastic Surgery, St Luke's Hospital, Bethlehelm, Pennsylvania, USA
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27
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Knudsen FW, Andersen M, Niebuhr U, Nielsen PL, Krag C. The role of the internal thoracic artery in the sternal blood supply. SCANDINAVIAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 1993; 27:3-8. [PMID: 8493494 DOI: 10.3109/14017439309099086] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The altered arterial supply to the sternum after use of the internal thoracic artery in coronary bypass surgery was studied by delineation of the sternal arterial system with plastic material and by injection of ink/barium contrast for radiography and microscopy. The study was performed on 17 anterior chest walls from human cadavers. The total arterial supply was charted before and after 'harvest' of the internal thoracic artery. The dominant blood supply to the sternum was found to be periosteal and derived almost exclusively from branches of the internal thoracic artery. Following harvest of that artery, the arterial supply to the upper part of the corpus sterni was compromised, and based only on sparse ramifications to the periosteal membrane from the thoracoacromial artery via branches from the pectoralis major muscle.
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Affiliation(s)
- F W Knudsen
- Department of Plastic Surgery, University Hospital, Gentofte, Denmark
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28
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De Varennes B, Tchervenkov CI, Kerrigan C, Dobell AR. Sternotomy after muscle flap repair of sternal osteomyelitis and mediastinitis. J Card Surg 1990; 5:190-2. [PMID: 2133842 DOI: 10.1111/j.1540-8191.1990.tb01037.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
A 61-year-old man who had undergone aortocoronary bypass developed sternal osteomyelitis and mediastinitis which required sternal debridement and muscle flap interposition. Two years later the midline incision was used for an orthotopic heart transplantation. No major technical difficulties were encountered at the time of transplantation.
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Affiliation(s)
- B De Varennes
- Division of Cardiovascular and Thoracic Surgery, McGill University, Montreal, Canada
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29
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Rauf KG, Matthews RN. Cover of pre-sternal defects. BRITISH JOURNAL OF PLASTIC SURGERY 1989; 42:725-6. [PMID: 2605411 DOI: 10.1016/0007-1226(89)90092-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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