Choice of flap for the management of deep sternal wound infection--an anatomical classification

The use of flaps for management of deep sternal wound complications: A systematic review and meta-analysis

BACKGROUND

Many options are available for reconstruction after deep sternal wound infections. However, these options have not been critically appraised. The aim of this systematic review and meta-analysis was to assess the existing evidence on sternal rewiring versus flap reconstruction and pectoralis major muscle flaps (PMFs) versus greater omental flaps (GOFs).

METHODS

A systematic review and meta-analysis was performed. CENTRAL, MEDLINE and EMBASE were searched. Outcomes of interest included mortality, treatment failure and length of hospital stay (LOS).

RESULTS

Fourteen studies were included. Nine studies compared flaps to rewiring, reporting on 618 patients. Patients treated with flaps had significantly lower mortality compared with patient treated with rewiring (Risk ratio [RR] 0.42, 95% confidence interval [CI]: 0.23-0.77, P < 0.01). Flap patients had significantly lower treatment failure compared with those who were treated with rewiring (RR 0.22, 95% CI: 0.14-0.37, P < 0.01). No statistically significant differences were observed in LOS between patients treated with flaps compared those treated with rewiring (standard mean difference -0.84, 95% CI: -1.91 to 0.24, P = 0.13). Five studies compared PMF with GOF, reporting on 599 patients. No statistically significant differences were found in mortality (RR 0.63, 95% CI: 0.24-1.68, P = 0.36), LOS (standard mean difference -14.52, 95% CI: -42.00 to 12.96, P = 0.30) or treatment failure (RR 1.37, 95% CI: 0.31-6.07, P = 0.68) in patients treated with PMF compared with patients treated with GOF.

CONCLUSIONS

Flap-based reconstruction demonstrated improved mortality and treatment outcomes compared to sternal rewiring. However, no significant differences were observed in outcomes between the PMF- and GOF-based reconstructions.

Healthcare costs and outcomes associated with surgical site infections after coronary artery bypass grafting surgeries in Oman

BACKGROUND

Surgical site infection (SSI) after coronary artery bypass graft (CABG) surgeries is considered a key indicator of the quality of healthcare services.

OBJECTIVE

This study aimed to estimate the healthcare outcomes associated with SSIs after CABG surgeries in Oman in terms of mortality rate, case-fatality rate, LOS, readmission rate and healthcare costs.

METHODS

The nested case-control study design was used based on retrospective data, which was conducted from 2016 to 2017. The case group encompassed all CABG patients with confirmed SSIs within 30 days of the surgery (n = 104) while controls were CABG patients without SSIs (n = 404).

RESULTS

Forty-four (42.3%) of the SSI patients were readmitted to the hospital compared to eight (2%) of the control group (p < .001). Patients in the case group had a longer LOS (M = 24.4, SD = 44.6 days) compared to those in the control group (M = 11, SD = 21 days, p = .003). The mean healthcare costs of cases (M = Omani Rial [OMR] 3823, SD = OMR 2516) were significantly greater than controls (M = OMR 3154, SD = OMR 1415, p = .010).

CONCLUSION

Results from this study can be baseline data for formulating new hypotheses and testing the causal relationship between SSIs after CABG surgeries and the readmission rate, LOS and health care costs.Key messagesSurgical Site Infections (SSIs) are still a major complication after cardiac surgeries in Oman.SSIs after cardiac surgeries are associated with substantially increased healthcare costs and length of stay.SSIs after cardiac surgeries are associated with negative outcomes such as mortality and case-fatality rates.

Review on risk factors, classification, and treatment of sternal wound infection

Sternal wound infection (SWI) is the most common complication of the median sternal incision. The treatment time is long, and the reconstruction is difficult, which causes challenges for surgeons. Plastic surgeons were often involved too late in such clinical scenarios when previous empirical treatments failed and the wound damage was relatively serious. Accurate diagnosis and risk factors against sternal wound infection need to be in focus. Classification of different types of sternotomy complications post-cardiac surgery is important for specific categorization and management. Not familiar with this kind of special and complex wound, objectively increasing the difficulty of wound reconstruction. The purpose of this comprehensive review is to review the literature, introduce various SWI risk factors related to wound nonunion, various classification characteristics, advantages and disadvantages of various wound reconstruction strategies, to help clinicians understand the pathophysiological characteristics of the disease and choose a better treatment method.

Free extended anterolateral thigh myocutaneous flap versus combined pedicled pectoralis major-latissimus dorsi myocutaneous flaps in deep and extensive sternal wound reconstruction

BACKGROUND

The combined pedicled pectoralis major-latissimus dorsi (PM-LD) and free extended anterolateral thigh (ALT) myocutaneous flaps provide well-vascularized tissues for extensive sternal wound reconstruction. However, the outcomes and postoperative complications between the two surgical techniques are different. Thus, the aim of this study is to evaluate the feasibility of these two reconstructive options.

METHODS

This single-center, retrospective study was conducted between August 2011 and May 2019. Forty-four patients diagnosed with deep sternal wound infection (DSWI) and presented with grade four complications (sternal instability and necrotic bone tissue) were enrolled. Two reconstructive strategies, namely, combined pedicled PM-LD (n = 24) and free extended ALT (n = 20) myocutaneous flaps, were used according to the patients' hemodynamics. Data including age, gender, body mass index (BMI), hospital stay, follow-up, defect/flap size, number of surgical procedures before reconstruction, duration from the last debridement to flap coverage, comorbidities, and postoperative complications, were obtained for statistical analysis.

RESULTS

The mean defect size in the combined PM-LD myocutaneous flap group was 188.4 (5*17-10*23) cm² , and the mean flap size was 150.0 (8*12-15*15) cm² and 205.0 (8*15-10*25) cm² in PM and LD flap, respectively. The mean defect size in the free extended ALT myocutaneus flap group was 202.5 (6*16-10*21) cm² , and the mean flap size was 285.2 (9*30-12*25) cm² . No significant differences were observed between the free extended ALT and the combined pedicled PM-LD myocutaneous flaps in relation to age, gender, BMI, hospital days, follow-up, defect size, preoperative procedures, and comorbidities, except for the average operative time (443.2 ± 31.2 vs. 321.3 ± 54.3 mins, p = .048). The combined pedicled PM-LD myocutaneous flap had significantly more donor site complications, including seroma (21% vs. 0%, p = .030), bilateral nipple-areolar complex asymmetry (100% vs. 0%, p < .0001), and skin graft loss with infection (33% vs. 0%; p = .044) than the free extended ALT myocutaneous flap.

CONCLUSION

The free extended ALT and the combined pedicled PM-LD myocutaneous flaps were both feasible and effective options for sternal wound reconstruction. Our findings suggested that the free extended ALT myocutaneous flap may be a better alternative for a comprehensive and extensive reconstruction of sternal wounds. Further studies based on these findings can be conducted.

An Algorithmic Approach to the Surgical Management of Sternal Dehiscence: A Single-Center Experience

Background Deep sternal wound complications following sternotomy represent a complex challenge. Management can involve debridement, flap reconstruction, and rigid sternal fixation (RSF). We present our 11-year experience in the surgical treatment of deep sternal wound dehiscence using a standardized treatment algorithm.

Methods A retrospective review was conducted of all 134 cardiac patients who required operative debridement after median sternotomy at a single institution between October 2007 and March 2019. Demographics, perioperative covariates, and outcomes were recorded. Univariate and subgroup analyses were performed.

Results One-hundred twelve patients (83.5%) with a deep sternal dehiscence underwent flap closure and 56 (50%) RSF. Of the patients who underwent flap closure, 87.5% received pectoralis advancement flaps. A 30-day mortality following reconstruction was 3.9%. Median length of stay after initial debridement was 8 days (interquartile range: 5–15). Of patients with flaps, 54 (48%) required multiple debridements prior to closure, and 30 (27%) underwent reoperation after flap closure. Patients who needed only a single debridement were significantly less likely to have a complication requiring reoperation (N = 10/58 vs. 20/54, 17 vs. 37%, p = 0.02), undergo a second flap (N = 6/58 vs. 17/54, 10 vs. 32%, p < 0.001), or, if plated, require removal of sternal plates (N = 6/34 vs. 11/22, 18 vs. 50%, p = 0.02).

Conclusion Although sternal dehiscence remains a complex challenge, an aggressive treatment algorithm, including debridement, flap closure, and consideration of RSF, can achieve good long-term outcomes. In low-risk patients, RSF does not appear to increase the likelihood of reoperation. We hypothesize that earlier surgical intervention, before the development of systemic symptoms, may be associated with improved outcomes.

Pedicle flap reconstruction for treatment of infected median sternotomy wounds after cardiac surgery in overweight and obese patients: proposal of a management algorithm based on a case series analysis

Background

A relationship between obesity and adverse outcomes in patients with post-sternotomy wounds undergoing pedicle flap reconstruction is not well-documented. In this study, we present a single-centre retrospective case series analysis of early postoperative outcomes of patients with infected post-sternotomy wounds undergoing pedicle flap reconstruction. We also propose a management algorithm for such patients, based on BMI and wound width.

Methods

We retrospectively analyzed all patients, who underwent pedicle flap reconstruction for major sternal wound infections after sternotomy for cardiac surgery in a tertiary hospital in Germany during a 5-year period. Exclusion criteria included patients younger than 18 years of age and patients with BMI < 18.5 kg/m². Patients were divided into 2 groups according to BMI: normal-weight (NW; BMI < 25 kg/m²) and overweight/obese (OB/OW; BMI > 25 kg/m²). Both groups were compared in terms of preoperative parameters and early postoperative outcomes. Preoperative parameters included demographics, wound bacteria and comorbidities. Postoperative outcomes included duration of surgery time (from incision to skin closure), transfusion requirement (during surgery and entire hospital stay), onset of flap and donor-site complications, length of stay and 30-day mortality. We employed the two-tailed t-test to compare continuous variables and the two-sided Fischer’s exact test to compare categorical variables. Statistical significance was set at p < 0.05.

Results

The total sample consisted of 48 patients. Overall mean BMI was 28.4 (6.1) kg/m². Mean age was 67 (12) years. The study group consisted of 28 patients with BMI > 25 kg/m², who were compared with 20 normal-weight patients. There was a significant difference amongst both groups regarding duration of surgery (120 vs. 174 min, p < 0.05). Donor-site complications requiring intervention were observed in 30% of patients in both groups. Flap-related complications were recorded in 16 (57%) cases in the study group and 7 cases in the control group (35%, p = 0.15).

Conclusions

We conclude that wound width and BMI can aid the decision-making process for patients with infected sternal wounds after cardiac surgery requiring pedicle flap reconstruction. However, in our case series analysis, OB/OW patients were not found to be at statistically significantly increased risk for worse postoperative outcomes, but were associated with a longer duration of surgery.

Prevention, Diagnosis and Management of Post-Surgical Mediastinitis in Adults Consensus Guidelines of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES)

This is a consensus document of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES). These three entities have brought together a multidisciplinary group of experts that includes anaesthesiologists, cardiac and cardiothoracic surgeons, clinical microbiologists, infectious diseases and intensive care specialists, internal medicine doctors and radiologists. Despite the clinical and economic consequences of sternal wound infections, to date, there are no specific guidelines for the prevention, diagnosis and management of mediastinitis based on a multidisciplinary consensus. The purpose of the present document is to provide evidence-based guidance on the most effective diagnosis and management of patients who have experienced or are at risk of developing a post-surgical mediastinitis infection in order to optimise patient outcomes and the process of care. The intended users of the document are health care providers who help patients make decisions regarding their treatment, aiming to optimise the benefits and minimise any harm as well as the workload.

The management of deep sternal wound infection: Literature review and reconstructive algorithm

Deep sternal wound infection (DSWI) is an important complication of open thoracic surgery, with a reported incidence of 0.5-6%. Given its association with increased morbidity, mortality, inpatient duration, financial burden, and re-operation rates, an aggressive approach to treatment is mandated. Flap reconstruction has become the standard of care, with studies demonstrating improved outcomes with reduced mortality and resource usage in patients undergoing early versus delayed flap reconstruction. Despite this, no evidence-based standard for the management of DSWI exists. We performed a thorough review of the literature to identify principles in management, using a PRISMA compliant methodology. Ovid-Embase, Medline and PubMed databases were searched for relevant papers using the search terms "deep sternal wound infection," and "post-sternotomy mediastinitis" to December 2019. Duplicates were removed, and the search narrowed to look at specific areas of interest i.e. negative pressure wound therapy, flap reconstruction, and rigid fixation. The reference list of included articles underwent full text review. No randomized controlled trials were identified. We review the current management techniques for patients with DSWI, and raise awareness for the need for further high quality studies, and a standardized national cardiothoracic-plastic surgery guideline to guide management. Based on our findings and the authors' own experience in this area, we provide evidence-based recommendations. We also propose a reconstructive algorithm.

Comparison of pedicled versus free flaps for reconstruction of extensive deep sternal wound defects following cardiac surgery: A retrospective study

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.

Deep sternal wound infection following cardiac surgery: A comparison of the monolateral with the bilateral pectoralis major flaps

Deep sternal wound infections are a serious complication following sternotomy for cardiothoracic surgery. "Conventional" treatment provides debridement and secondary closure or closed catheter irrigation. The combination of the Negative Pressure Therapy with flap coverages is an accepted technique and one or both Pectoralis Major muscles could be chosen. A multistep protocol was adopted. One hundred and sixty seven patients were treated with the combination of Negative Pressure Therapy with the Pectoralis Major muscle flap: 86 monolateral flap and 81 bilateral flap reconstruction. The main complications (hematoma, seroma, dehiscence, and re-infection), the need for re-intervention, mortality rates, Intensive Care Unit, and hospitalisation time were assessed. The mono-pectoralis group had fewer complications and need for revision, with a shorter hospital stay. A statistically significant difference emerged for the hematoma rate (P = .0079). Monolateral flap should to be preferred because with the same coverage effectiveness, it guarantees the saving of controlateral muscle with its functionality and the possibility of its use in case of failure. Furthermore, as the technique is less invasive, it can be reserved for more fragile patients.

Reconstruction of a deep sternal wound with exposed pericardium using an IMAP propeller flap: A case report

The results of this case suggest that the IMAP propeller flap may be a viable and safe option for deep sternal wound reconstruction with minimal donor-site morbidity.

Sternal Wound Reconstruction Made Simple

Sternal wounds and associated infections represent a complex reconstructive problem in a highly morbid patient population. Through strict adherence to excellent plastic surgical principles, this process can be simplified, allowing safe and effective wound closure. Emphasis is placed on thorough debridement, hardware removal, obtaining adequate tissue cultures, and finally, appropriate flap closure. In most cases, pectoralis major myocutaneous advancement flaps provide excellent coverage while eliminating dead space and providing sternal compression. Secondary flap options, such as the omental flap or rectus abdominis muscle, may occasionally be necessary. This article will provide an overview and simplified approach to sternal wound reconstruction.

Deep sternal wound infections: Evidence for prevention, treatment, and reconstructive surgery

Median sternotomy is the most popular approach in cardiac surgery. Post-sternotomy wound complications are rare, but the occurrence of a deep sternal wound infection (DSWI) is a catastrophic event associated with higher morbidity and mortality, longer hospital stays, and increased costs. A literature review was performed by searching PubMed from January 1996 to August 2017 according to the guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The following keywords were used in various combinations: DSWI, post-sternotomy complication, and sternal reconstruction. Thirty-nine papers were included in our qualitative analysis, in which each aspect of the DSWI-related care process was analyzed and compared to the actual standard of care. Plastic surgeons are often involved too late in such clinical scenarios, when previous empirical treatments have failed and a definitive reconstruction is needed. The aim of this comprehensive review was to create an up-to-date operative flowchart to prevent and properly treat sternal wound infection complications after median sternotomy.

Cadaveric evaluation of sternal reconstruction using the pectoralis muscle flap

BACKGROUND

Deep sternal wound infection is a significant complication of open cardiac surgery associated with increased mortality and morbidity. The use of muscle flaps, such as the pectoralis major advancement flap, in deep sternal wound infection reconstruction reduces hospital stay and mortality. However, the lower end of the sternum is remote from the vascular supply and cover is therefore problematic in many cases.

METHODS

This study aimed to determine the distance (cm) and surface area (cm² ) of sternum covered when the pectoralis major muscle is sequentially dissected from the sternocostal origin and humeral insertion using 10 cadaveric specimens.

RESULTS

The largest proportion of sternum was covered when both the origin and insertion were divided, allowing the flap to be islanded on its vascular pedicle. There was a statistically significant difference when the pectoralis major was divided from the origin and insertion compared to division of the origin alone (P < 0.01). The average area covered with sternocostal origin division alone was 55.43 cm² compared to 85.36 cm² after division of both the origin and insertion.

CONCLUSION

Division of both the sternocostal origin and humeral insertion of the pectoralis major muscle represents an effective means to increase sternal coverage. This study describes the average distance and area covered by sliding pectoralis major muscle advancement flaps. These measurements could better inform plastic surgeons when evaluating reconstructive options in sternal defects.

Z-plasty as an alternative choice for the treatment of recurrent local sternal wound infections

OBJECTIVE

Sternal wound infections after sternotomy are associated with high morbidity, high mortality, and prolonged hospital stay. The recurrence rate of sternal wound infections after single-stage closure is greater than expected. The aim of the study is to present our results of a consecutive series of Z-plasty for the treatment of recurrent sternal wound infections.

METHODS

Between March 2015 and March 2017, a total of 9 patients were referred to our clinic with a recurrent sternal wound infection due to sternotomy with or without osteomyelitis. All patients previously underwent one or more surgical procedures for sternal infection. Negative pressure wound therapy and several debridement methods were performed before reconstruction. Two triangular double-transposition fasciocutaneous flap techniques as Z-plasty under local anesthesia was performed for all of the patients.

RESULTS

The flaps survived completely without any tissue loss. There were no major postoperative complications. One patient had recurrent infection after the flap procedure and was treated with antibiotic therapy. At 6 months of follow-up, all of the patients were able to return to normal activities of daily living with a high patient satisfaction rate.

CONCLUSIONS

Local sternal wound reconstruction is an effective, rapid, and simple with Z-plasty associated with low recurrence risk. We believe that Z-plasty can be used for recurrent local sternal wound infections as an alternative treatment option for selected patients without mechanical dehiscence.

Reconstruction of infected trunk wounds with pedicled rectus abdominis musculocutaneous flaps: a retrospective case series

OBJECTIVE

To completely treat and cover extensively infected trunk defects, reconstruction should be performed using a sufficiently vascularised flap, such as a muscle or musculocutaneous flap after perfect debridement. These reconstructive surgeries are challenging in patients with severe comorbidities. In this case series, we describe extensively infected trunk defect reconstruction, in patients with severe comorbidities, using a pedicled rectus abdominis musculocutaneous flap and suggest an algorithm for reconstruction.

METHOD

Between March 2011 and March 2015, participating patients underwent reconstruction of extensively infected trunk defects using a pedicled rectus abdominis musculocutaneous flap. All patients had diabetes and hypertension, and several patients had severe comorbidities, including heart and renal failure. Bacterial cultures revealed that meticillin-resistant Staphylococcus aureus (MRSA) was present in seven patients (with concurrent Pseudomonas aeruginosa in two patients), multidrug-resistant Acinetobacter baumannii in one patient and Mycobacterium tuberculosis in two patients.

RESULTS

A total of 10 patients underwent the procedure. The pedicled rectus abdominis musculocutaneous flaps survived completely in all 10 patients. There were no complications related to the flaps, although two patients developed minor wound dehiscence, which may be due to their comorbidities. There were no signs of recurrent infection during the follow-up period in each case.

CONCLUSION

Reconstruction using the pedicled rectus abdominis musculocutaneous flap is a good treatment option for extensively infected three-dimensional trunk defects, even for patients with severe comorbidities.

Omentum flap as a salvage procedure in deep sternal wound infection

INTRODUCTION

Deep sternal wound infections (DSWIs) are rare but devastating complication after median sternotomy following cardiac surgery. Especially in the presence of artificial material or inadequate preliminary muscle flaps, the pedicled omentum flap is due to its immunological properties, the predetermined flap in salvage procedures.

METHODS

We treated 14 patients suffering a mediastinitis and open thorax using a pedicled omentoplasty as a salvage procedure because of persisting DSWIs. Omentoplasty was performed in combination with a split skin graft and the wound was closed by a vacuum-assisted therapy for 7 days. The patients' sex and comorbid risk factors supporting DSWIs as well as the postoperative complications were recorded.

RESULTS

Retrospective analysis of 14 patients (10 males and four females) after a follow-up time of 24 months was performed. The average age was 75 years (range: 67-83). Heart surgery took place electively in eight cases, in three cases urgently and three for emergency reasons. The preoperative Euro Score was 16 (range 3.51-42.58). We had no flap loss in any patients. The skin graft showed a full take in all patients. Two patients needed revision of an abdominal wound dehiscence after laparotomy and one patient developed hernia in the late outcome.

DISCUSSION

The greater omentum flap has, over many years, become an ideal partner in the coverage and treatment of DSWIs. Especially due to its immunologic capacity and amorphous structure, it has the ability to fill up cavities and cover infected artificial material so residual infections can be controlled.

Management of the extensive thoracic defects after deep sternal wound infection with the rectus abdominis myocutaneous flap: A retrospective case series

Deep sternal wound infection is a severe complication after open heart surgery. According to the different severity and dimensions of the deep sternal wound infection, the treatment method is different. In this study, we aimed to describe our experience with the rectus abdominis myocutaneous flap for large sternal wound management, especially when 1 or 2 internal mammary arteries were absent.Between October 2010 and January 2016, a retrospective review of 9 patients who suffered from the extensive thoracic defects after deep sternal wound infection was conducted. All of these sternal defects encompassed almost the full length of the sternum after debridement. Defect reconstruction was achieved by covering with a rectus abdominis myocutaneous flap. When the ipsilateral or bilateral internal mammary artery had been harvested previously, we took advantage of the inferior epigastric artery to provide additional blood supply to the rectus abdominis myocutaneous flap. Thus, this flap had a double blood supply.There was no recurrent infection in all 9 patients. Three patients received the rectus abdominis myocutaneous flap with a double blood supply. Flap complications occurred in 2 patients (22%). One patient who did not have the double blood supply flap suffered from necrosis on the distal part of the flap, which was then debrided and reconstructed with a split-skin graft. The other patient had a seroma at the abdomen donor site and was managed conservatively. None of the patients died during the hospital stay.This study suggests that the rectus abdominis myocutaneous flap may be a good choice to repair the entire length of sternal wound. When 1 or 2 internal mammary arteries have been harvested, the inferior epigastric artery can be anastomosed to the second intercostal artery or the internal mammary artery perforator to provide the rectus abdominis myocutaneous flap with a double blood supply.

Limited Bilateral Advancement of the Sternocostal Head of Pectoralis Major for Sternal Reconstruction: Preserving the Axillary Fold

The introduction of well-vascularized flaps for infected sternotomy wound reconstruction has improved mortality rates dramatically. Multiple variations of the pectoralis major flap have been described in this context. However, unresolved limitations of this flap include poor cosmesis and problematic coverage of the inferior third of the sternotomy wound. We describe an approach to address these issues. The humeral attachments are preserved and bilateral muscles are advanced in a limited fashion. The left sternocostal head is advanced medially and rotated anticlockwise, using this portion to fill the upper half of the sternum while the caudal portion of the right pectoralis muscle is used as a turnover flap at the lower half of the wound. In all 25 patients, the anterior axillary fold was preserved bilaterally and the infection completely resolved. Complications included 3 cases of hematoma, 2 cases of coagulopathy, and 1 late bone sequestrum (aseptic). Although the study had a limited sample size, we had a high rate of success and few complications. With the preservation of bilateral axillary folds, good cosmesis, and adequate wound coverage, we recommend this modification of the pectoralis major flap in even complicated cases of mediastinitis.

Endoscope-Assisted Pectoralis Major-Rectus Abdominis Bipedicle Muscle Flap for the Treatment of Poststernotomy Mediastinitis

INTRODUCTION

Various management strategies have been reported for sternal wound care; however, they exhibit limited effectiveness or are associated with severe complications. Furthermore, it is difficult for the standard pectoralis major (PM) muscle advance flap to reach the lower third of the sternum. This article examines using the PM-rectus abdominis (RA) bipedicle muscle flap to treat lower-third deep sternal wound infection.

METHODS

The outcomes of patients who received a PM-RA bipedicle muscle flap harvest at our institution between 1996 and 2014 were reviewed. The method involves performing a subfascial and subperiosteal dissection of the PM to elevate the muscle flap. Blunt dissection may be performed carefully under an endoscope. Endoscope visualization enables us to identify the critical structures lateral to the PM muscle. In addition, the connective tissue to the RA muscle was preserved. Continuity was carefully preserved from the pectoral-thoracoepigastric fascia to the anterior rectus sheath. The flap could then be transposed to fill the lower-third sternal tissue defect with ease.

RESULTS

A total of 12 patients, with a mean age of 71 years (45-89 years), were treated using an endoscope-assisted PM-RA bipedicle muscle flap harvest. Wound microbiology of the 12 patients revealed that 3 patients had methicillin-resistant Staphylococcus aureus, 4 had S. aureus, 1 had coagulase-negative Staphylococcus, 1 had Escherichia coli, 1 had Pseudomonas aeruginosa, 1 had Mycobacterium tuberculosis, and 1 had a mixed growth of organisms. One instance of recurrent sternal infection was identified among the patients. Moreover, 1 patient died from heart failure 5 weeks after surgery, but the coverage of the sternal wound was successful. Accidental injury to the surrounding neurovascular structure of the patients was avoided, and only 10 to 15 minutes was required to divide the PM muscle.

CONCLUSIONS

Performing this harvest method under endoscopic assistance has several advantages, such as preventing excess traction of the skin edge to diminish the skin slough. This method could be an effective alternative for harvesting the PM-RA bipedicle muscle flap to reconstruct the lower-third sternal wound.

The internal mammary artery perforator flap and its subtypes in the reconstruction of median sternotomy wounds

OBJECTIVE

To determine the feasibility of using the internal mammary artery perforator (IMAP) flap for superficial and deep sternal wound breakdowns.

METHODS

This was a retrospective case review of 9 patients with sternal wound dehiscence over an 18-month period between 2013 and 2015. Seven of the 9 patients received a single IMAP flap to cover full-length sternal wounds, including 4 with a fasciocutaneous flap and 3 with a musculocutaneous flap.

RESULTS

All of the patients were male, with a mean age of 68 years. The mean number of perforators was 1.3, with a mean perforator diameter of 1.5 mm. In all cases, the torsion angle was 80 degrees, with a translational pedicle movement of 1 to 2 cm. There were no instances of total flap failure and only 2 cases of partial flap necrosis, which were managed conservatively. One flap, performed when both internal mammary arteries had been harvested previously, showed complete survival.

CONCLUSIONS

The IMAP flap has an advantage in its the ability to reconstruct the entire length of a sternotomy wound from the suprasternal notch to the xiphisternum with relatively minimal dissection and morbidity compared with more conventional flaps such as pectoralis major, rectus, and omental flaps. Nevertheless, caveats for its use remain, such as in patients with vasopressor therapy and the resulting subclavicular scar, which is unaesthetic in women. Overall, the IMAP flap is an attractive reconstructive tool specifically in stable male patients with noninfected sternotomy wound dehiscence with a defect width of up to 7 cm. In this patient subset, it is the ideal first-line reconstructive tool.

Treatment of Sternal Wound Infection Using a Free Myocutaneous Flap

Deep sternal wound infections are potentially life-threatening complications after cardiac operations because they can spread into the mediastinum and cause postoperative morbidity and mortality. We present a 65-year-old man with a history of coronary artery bypass grafting. A large sternal defect was left after debridement. After brief vacuum-assisted closure (VAC), a free myocutaneous flap of the anterolateral thigh (ALT) was used to fill the dead space. At the 9-month follow-up, the wound had healed completely without tissue loss or complications, and the patient returned to normal life. This was a successful treatment of a deep sternal wound with free flap coverage.

A new classification of post-sternotomy dehiscence

The dehiscence after median transesternal sternotomy used as surgical access for cardiac surgery is one of its complications and it increases the patient's morbidity and mortality. A variety of surgical techniques were recently described resulting to the need of a classification bringing a measure of objectivity to the management of these complex and dangerous wounds. The different related classifications are based in the primary causal infection, but recently the anatomical description of the wound including the deepness and the vertical extension showed to be more useful. We propose a new classification based only on the anatomical changes following sternotomy dehiscence and chronic wound formation separating it in four types according to the deepness and in two sub-groups according to the vertical extension based on the inferior insertion of the pectoralis major muscle.

Risk factors for complications after reconstructive surgery for sternal wound infection

Background

Although the utility of flaps for the treatment of sternal wound infections following median sternotomy has been reported for 30 years, there have been few reports on the risk factors for complications after reconstruction. The objective of this investigation was to identify factors related to complications after the reconstruction of sternal wound infections.

Methods

A retrospective analysis of 74 patients with reconstructive surgery after sternal wound infection over a 5-year period was performed. Clinical data including age, sex, body mass index (BMI), comorbidities, bacterial culture, previous cardiac surgery, wound depth, mortality rate, type of reconstructive procedure, and complication rate were collected.

Results

The patients' BMI ranged from 15.2 to 33.6 kg/m² (mean, 23.1±3.74 kg/m²). Wound closure complications after reconstructive surgery were observed in 36.5% of the cases. The mortality rate was 2.7%. Diabetes mellitus significantly affected the rate of wound closure complications (P=0.041). A significant difference in the number of complications was seen between Staphylococcus aureus (S. aureus) and coagulase-negative Staphylococci (P=0.011). There was a correlation between harvesting of the internal thoracic artery and postoperative complications (P=0.048). The complication rates of the pectoralis major flap, rectus abdominis flap, omentum flap, a combination of pectoralis major flap and rectus abdominis flap, and direct closure were 23.3%, 33.3%, 100%, 37.5%, and 35.7%, respectively.

Conclusions

Diabetes mellitus, S. aureus, harvesting of the internal thoracic artery, and omentum flap were significant factors for complications after reconstruction. The omentum flap volume may be related to the complications associated with the omentum flap transfer in the present study.

Pectoral muscle flap with V-Y skin paddle for covering sternal defects

Deep sternal wound infection (DSWI) after a cardiac operation is a rare but serious complication associated with significant morbidity and mortality. It can lead to wound dehiscence with sternal osteomyelitis and both bony and soft tissue residual defects. When the infection is eradicated, reconstruction of the thoracic wall remains the main challenge. Tissue used for covering the defect must be well nourished and sutures must be tension free. We present our unique modification of the method using the pectoral muscle axial flap with a V-Y skin paddle.

Immediate debridement and reconstruction with a pectoralis major muscle flap for poststernotomy mediastinitis

Background

Poststernotomy mediastinitis is a rare, but life-threatening complication, thus early diagnosis and proper management is essential for poststernotomy mediastinitis. The main treatment for mediastinitis is aggressive debridement. Several options exist for reconstruction of defects after debridement. The efficacy of immediate debridement and reconstruction with a pectoralis major muscle flap designed for the defect immediately after the diagnosis of poststernotomy mediastinitis is demonstrated.

Methods

Between September 2009 and June 2011, 6 patients were referred to the Department of Plastic and Reconstructive Surgery and the Department of Thoracic and Cardiovascular Surgery of Ajou University Hospital for poststernotomy mediastinitis. All of the patients underwent extensive debridement and reconstruction with pectoralis major muscle flaps, advanced based on the pedicle of the thoracoacromial artery as soon as possible following diagnosis. A retrospective review of the 6 cases was performed to evaluate infection control, postoperative morbidity, and mortality.

Results

All patients had complete wound closures and reduced severity of infections based on the erythrocyte sedimentation rate and C-reactive protein levels and a reduction in poststernal fluid collection on computed tomography an average of 6 days postoperatively. A lack of growth of organisms in the wound culture was demonstrated after 3 weeks. There were no major wound morbidities, such as hematomas, but one minor complication required a skin graft caused by skin flap necrosis. No patient expired after definitive surgery.

Conclusions

Immediate debridement and reconstruction using a pectoralis major muscle flap is a safe technique for managing infections associated with poststernotomy mediastinitis, and is associated with minimal morbidity and mortality.

Sternal wound reconstruction: management in different cardiac populations

Poststernotomy mediastinitis is a feared complication for patients undergoing cardiac surgery associated with high rates of morbidity and mortality. Approximately 15% of patients will ultimately be readmitted for a recurrent sternal wound infection. The objective of this study is to review a large single surgeon experience with sternal wound patients managed with a variety of soft tissue flaps to assess mitigating factors, involved organisms, and treatment protocols as related to specific cardiac populations. Records for 136 sternal reconstruction patients treated from January 2000 to July 2007 were evaluated. Patients underwent a variety of cardiac surgeries including coronary artery bypass grafting (CABG), valve replacement, aortic reconstruction, heart transplantation, lung transplantation, and combinations of these procedures. A total of 39.2% of patients developed a sternal wound during the same admission as their cardiac surgery, at an average of 16.1 days. This rate was only 6% for CABG-only patients and rose to nearly 50% in heart transplant and CABG + valve patients. A total of 78.6% of heart transplant patients with a sternal wound had a history of ventricular assist device and 41% of all patients had at least 1 previous sternotomy. Thirteen patients (9.6%) had 1 or more recurrent infections requiring surgery; 50% occurring in transplant patients, most of whom had diabetes and/or renal insufficiency. The most common presenting symptom was drainage (n = 75, 55.6%) or wound dehiscence (n = 22, 16.3%). Twenty-five different organisms were identified; 26 patients (18.5%) had multiple organisms. Staphylococcus species were most common. Plastic surgery intervention occurred on average 109.2 days after cardiac surgery. CABG and CABG + valve patients most frequently received right pectoralis muscle turnover flaps or left pectoralis muscle advancement flaps. Ten heart transplant patients (37.0%) underwent omental flaps. The 30-day perioperative mortality rate was 13 patients (9.6%).

Vacuum-assisted closure and bilateral pectoralis muscle flaps for different stages of mediastinitis after cardiac surgery

PURPOSE

To assess the results of bilateral pectoralis major muscle flaps (BPMMF) and vacuum-assisted closure (VAC) at different stages of postcardiac surgery mediastinitis.

METHODS

Of 65 patients with a deep sternal wound infection (DSWI) after cardiac surgery, 33 with a stable sternum were treated with VAC (59.3 +/- 11.7 years of age) and 32 with an unstable sternum or osteomyelitis (63.3 +/- 9.8 years of age) were treated with early BPMMF and continuous irrigation. Delayed BPMMF reconstruction was necessary in six VAC patients.

RESULTS

The overall incidence of DSWI was 1.04% within the study period. Deep sternal wound infection was diagnosed 15.9 +/- 10.8 days (range 5-62 days) after surgery. Diabetes was more common in the BPMMF group than in the VAC group (P = 0.046). Hospital mortality after treatment was 4.6% (n = 3) overall. Causes of death were septic multiorgan failure and respiratory failure. The infective pathogens were methicillin-resistant Staphylococcus aureus (MRSA; n = 2) and Acinetobacter species (n = 1). The median hospital stay was 29 days (range 15-110 days). After 6 months, only one recurrent sternal infection had occurred in the VAC group.

CONCLUSIONS

Early BPMMF is an effective surgical treatment for DSWI in patients with an unstable sternum and osteomyelitis. VAC may be considered for patients without osteomyelitis but a stable sternum, or as adjuvant therapy in patients with comorbidity.