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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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Hernández-Zamora RE, Sotelo-Carbajal J, Martínez-Maya G, García-Ledezma A, Román-Matus A, Torres-Salazar QL. Sternal dehiscence, a reconstructive challenge. Case report. Int J Surg Case Rep 2023; 111:108926. [PMID: 37804680 PMCID: PMC10569974 DOI: 10.1016/j.ijscr.2023.108926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 10/03/2023] [Indexed: 10/09/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Sternotomy is the main surgical procedure used to access the heart and great vessels. Among its most important complications is post-sternotomy dehiscence with an incidence of 10 %; the main risk factors for its occurrence are diabetes mellitus, obesity or chronic obstructive pulmonary disease. CASE PRESENTATION We present a clinical case of a 74-year-old male patient with sternal dehiscence secondary to sternotomy for myocardial revascularisation. CLINICAL DISCUSSION AND CONCLUSIONS Surgical dehiscence of sternotomy presents remarkable complexity and poses a significant challenge to the medical team. The therapeutic approach focuses on addressing the infection, removing the necrotic tissue and then covering the area with highly vascularised tissue. Surgical alternatives include the possibility of using a unilateral pectoralis muscle flap, an option that provides adequate sternal stability and leads to satisfactory functional and cosmetic results.
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Affiliation(s)
| | - Jorge Sotelo-Carbajal
- Hospital General Regional No.1 Instituto Mexicano del Seguro Social, Tijuana, Baja California, Mexico
| | - Gabriela Martínez-Maya
- Hospital General Regional No.1 "Vicente Guerrero" del Instituto Mexicano del Seguro Social, Acapulco de Juárez, Guerrero, Mexico
| | - Arnold García-Ledezma
- Hospital General Regional No.1 Instituto Mexicano del Seguro Social, Tijuana, Baja California, Mexico
| | - Alexis Román-Matus
- Hospital Regional "Dr. Manuel Cárdenas de la Vega" del Instituto de Seguridad Social al Servicio de los Trabajadores del Estado, Culiacán, Mexico
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Jiang X, Bu F, Xu Y, Jing Z, Jiao G, Li M, Rong X. Antibiotic-loaded bone cement combined with vacuum sealing drainage to treat deep sternal wound infection following cardiac surgery: the first case report. J Cardiothorac Surg 2021; 16:292. [PMID: 34629078 PMCID: PMC8504067 DOI: 10.1186/s13019-021-01673-x] [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: 07/04/2021] [Accepted: 09/25/2021] [Indexed: 11/18/2022] Open
Abstract
Background Deep sternal wound infection (DSWI) is a rare but serious complication after median sternotomy, and treatment success depends mainly on surgical experience. Here we first present a case of a patient successfully treated for antibiotic-loaded bone cement (ALBC) combined with vacuum sealing drainage (VSD) of DSWI. Case presentation This case report presented a patient who underwent open heart surgery, and suffered postoperatively from a DSWI associated with enterococcus cloacae. Focus debridement combined with ALBC filling and VSD was conducted in stage I. Appropriate antibiotics were started according to sensitivity to be continued for 2 weeks until the inflammatory markers decreased to normal. One month after the surgery, patient’s wound was almost healed and was discharged from hospital with a drainage tube. Two months after the stage I surgery procedure, the major step was removing the previous ALBC, and extensive debridement in stage II. The patient fully recovered without further surgical treatment. Conclusions The results of this case suggest that ALBC combined with VSD may be a viable and safe option for deep sternal wound reconstruction.
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Affiliation(s)
- Xia Jiang
- Department of Cardiovascular Surgery, Wuxi People's Hospital/Wuxi Affiliated Hospital of Nanjing Medical University, Wuxi, 214203, China
| | - Fanyu Bu
- Department of Chronic Wound, Wuxi Ninth People's Hospital Affiliated to Soochow University, Wuxi, 214062, China
| | - Yong Xu
- Department of Cardiovascular Surgery, Wuxi People's Hospital/Wuxi Affiliated Hospital of Nanjing Medical University, Wuxi, 214203, China
| | - Zhaohui Jing
- Department of Cardiovascular Surgery, Wuxi People's Hospital/Wuxi Affiliated Hospital of Nanjing Medical University, Wuxi, 214203, China
| | - Guoqing Jiao
- Department of Cardiovascular Surgery, Wuxi People's Hospital/Wuxi Affiliated Hospital of Nanjing Medical University, Wuxi, 214203, China
| | - Mingqiu Li
- Department of Cardiovascular Surgery, Wuxi People's Hospital/Wuxi Affiliated Hospital of Nanjing Medical University, Wuxi, 214203, China.
| | - Xiaosong Rong
- Department of Cardiovascular Surgery, Wuxi People's Hospital/Wuxi Affiliated Hospital of Nanjing Medical University, Wuxi, 214203, China.
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Bagheri R, Tashnizi MA, Haghi SZ, Salehi M, Rajabnejad A, Safa MHG, Vejdani M. Therapeutic Outcomes of Pectoralis Major Muscle Turnover Flap in Mediastinitis. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2015; 48:258-64. [PMID: 26290837 PMCID: PMC4541051 DOI: 10.5090/kjtcs.2015.48.4.258] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 06/08/2015] [Accepted: 06/11/2015] [Indexed: 11/25/2022]
Abstract
Background This study aimed to evaluate the therapeutic results and safety of pectoralis major muscle turnover flaps in the treatment of mediastinitis after coronary artery bypass grafting (CABG) procedures. Methods Data regarding 33 patients with post-CABG deep sternal wound infections (DSWIs) who underwent pectoralis major muscle turnover flap procedures in the Emam Reza and Ghaem Hospitals of Mashhad, Iran were reviewed in this study. For each patient, age, sex, hospital stay duration, remission, recurrence, and associated morbidity and mortality were evaluated. Results Of the 2,447 CABG procedures that were carried out during the time period encompassed by our study, DSWIs occurred in 61 patients (2.5%). Of these 61 patients, 33 patients (nine females [27.3%] and 24 males [72.7%]) with an average age of 63±4.54 years underwent pectoralis major muscle turnover flap placement. Symptoms of infection mainly occurred within the first 10 days after surgery (mean, 10.24±13.62 days). The most common risk factor for DSWIs was obesity (n=16, 48.4%) followed by diabetes mellitus (n=13, 39.4%). Bilateral and unilateral pectoralis major muscle turnover flaps were performed in 20 patients (60.6%) and 13 patients (39.4%), respectively. Complete remission was achieved in 25 patients (75.7%), with no recurrence in the follow-up period. Four patients (12.1%) needed reoperation. The mean hospitalization time was 11.69±6.516 days. Four patients (12.1%) died during the course of the study: three due to the postoperative complication of respiratory failure and one due to pulmonary thromboembolism. Conclusion Pectoralis major muscle turnover flaps are an optimal technique in the treatment of post-CABG mediastinitis. In addition to leading to favorable therapeutic results, this flap is associated with minimal morbidity and mortality, as well as a short hospitalization time.
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Affiliation(s)
- Reza Bagheri
- Department of Thoracic Surgery, Cardio-Thoracic Surgery and Transplant Research Center, Emam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences
| | - Mohammad Abbasi Tashnizi
- Department of Heart Surgery, Cardio-Thoracic Surgery and Transplant Research Center, Emam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences
| | - Seyed Ziaollah Haghi
- Department of Thoracic Surgery, Cardio-Thoracic Surgery and Transplant Research Center, Emam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences
| | - Maryam Salehi
- Department of Community Medicine, Mashhad University of Medical Sciences
| | | | | | - Mohammad Vejdani
- Department of General Surgery, Cardio-Thoracic Surgery and Transplant Research Center, Emam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences
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Microsurgical Reconstruction of a Huge Mediastinal Defect Using Thoracoacromial Vessels as Recipient Pedicle. Plast Reconstr Surg 2012; 129:1021e-1023e. [DOI: 10.1097/prs.0b013e31824f001f] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Chest wall reconstruction of severe mediastinitis with intercostal artery-based pedicled vertical rectus abdominis muscle flap with oblique-designed skin pedicle. Ann Plast Surg 2012; 67:269-71. [PMID: 21587058 DOI: 10.1097/sap.0b013e3181f77b8c] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Recurrent poststernotomy mediastinitis has significant morbidity and mortality. Reconstructive treatment begins with pectoral muscle or omental flaps. When these options are unavailable or inadequate, surgeons resort to internal mammary artery-based vertical rectus abdominis muscle flap. If the internal mammary artery is harvested for coronary artery bypass grafting, surgeons are reluctant to use the muscle for pedicled flap because of the elevated risks. However, recent reports suggest that if enough time passes for intercostal artery collaterals to develop, they would support the viability of the flap. Moreover, recent improvements in defining flap microvasculature and proposed surgical techniques have enabled us to further refine the procedure. Although it appears that the intercostal artery-based pedicled vertical rectus abdominis muscle flap with oblique-designed skin pedicle is safe and effective for chest wall reconstruction, potential for failure remains elevated until sample size accumulates.
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Ortak T, Uraloğlu M, Uysal AÇ, Orbay H, Tekin F, Şensöz Ö, Uraloğlu G. Reconstruction of sternal defects with pectoralis major muscle flap. EUROPEAN JOURNAL OF PLASTIC SURGERY 2007. [DOI: 10.1007/s00238-007-0194-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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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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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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Graeber GM, McClelland WT. Current concepts in the management and reconstruction of the dehisced median sternotomy. Semin Thorac Cardiovasc Surg 2004; 16:92-107. [PMID: 15366693 DOI: 10.1053/j.semtcvs.2004.01.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This review will delineate the underlying conditions that predispose patients to deep mediastinal infection and sternal dehiscence, discuss the principles of thorough debridement and preparation of the wound, and assess the appropriate options available for successful reconstruction.
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Affiliation(s)
- Geoffrey M Graeber
- Section of Thoracic and Cardiovascular Surgery, West Virginia University School of Medicine, Morgantown, WV, USA.
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