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Ann Thorac Surg 1998;66:959-960
© 1998 The Society of Thoracic Surgeons

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How to Do It

Advancement flaps to treat superficial wound infections after cardiac operations

^a Cardiac Surgery Unit, Hôpital Européen de Paris, Paris, France

Accepted for publication May 11, 1998.

Address reprint requests to Dr Rescigno, 24 Rue Briant, 92260 Fontenay aux Roses, France
e-mail: (grescigno{at}aol.com)

	Abstract

Top Abstract Introduction Surgical technique Comment References

 
The management of superficial sternal wound infections is not well-codified. In case of large necrosis or tissue defect we use a two-stage approach, consisting of a first surgical debridement, followed a few days later by wound closure by means of two lateral advancement flaps. We have used this technique with good cosmetic results and shorter hospital stays.

	Introduction

Top Abstract Introduction Surgical technique Comment References

 
Postoperative wound infections represent a rare but severe complication of cardiac operations. Incidence can vary between 0.2% and 5%. Mediastinitis, the most severe form, can be associated with significant mortality. Treatment of deep sternal wound infections is well established. Some authors have shown that a prompt diagnosis followed by surgical debridement and closure can dramatically reduce mortality [1, 2]. Superficial sternal wound infections (SSWIs) are less severe, but they can significantly prolong the hospital stay. The incidence of this complication varies between 0.03% [3] and 1.18% [4]. The treatment of SSWI is less well codified. Many surgeons perform incision and packing, followed by serial wound dressing changes, thus allowing a secondary intention healing. This approach is effective when no tissue defect is present. In case of a wide tissue loss (eg, an infective necrotic process), the cosmetic results of this approach are disappointing. Since 1990 we have treated these more severe infections by an alternative approach: no attempt is done to close the wound; a wide resection of necrotic tissues is performed, followed by daily dressing changes; then, after sterilization of the wound, the defect is closed by advancing the skin and subcutaneous tissues of the anterior thoracic wall. This technique allows excellent cosmetic results, while reducing hospital stay and costs. Here we describe, in detail, the surgical technique.

	Surgical technique

Top Abstract Introduction Surgical technique Comment References

 
An SSWI is diagnosed in the presence of localized wound redness, discharge, or dehiscence. No sternal or substernal involvement should be present. A positive bacterial culture is also required. Very limited infections can be treated by simple incision and packing; in contrast, if the infected zone is quite large, or if a wide tissue defect exists, then we use a two-stage procedure:

First stage
The first stage consists of a large surgical debridement of all the devascularized tissue. The wound is then packed and daily dressing changes are performed. The wound is washed with povidone-iodine solution (Betadine; Purdue Frederick, Norwalk, CT) and subsequently filled with iodoformic gauze. This phase usually lasts from 4 to 7 days.

Second stage
When wound cultures are sterile, the patient is returned to the operating room. Depending on the size of the tissue defect, subcutaneous tissues are undermined from the thoracic cage structures on both sides (Fig 1). Care should be paid to remain as near to the rib plane as possible. This allows one to create a thick, mobile, cutaneous and subcutaneous flap to avoid underperfusion and necrosis. This dissection is performed by means of electrocautery. Dissection is interrupted when the two lateral flaps reach the midline without traction (Fig 2). The inferior insertion of the pectoralis muscle can be a part of the flap if needed. The advancement flaps of both sides should generally be as large as the tissue defect to avoid any tension on the suture line. Afterward, three to four high-suction small-diameter bulb drains (Uniredon; Fandre Laboratory, Ludres, France) are positioned to collect any possible discharge; these devices allow a perfect collapse of the tissue to the thoracic cage. The wound is closed by separate Vicryl 1-0 stitches (Ethicon, Inc, Somerville, NJ); a continuous Vicryl 2-0 suture is performed more superficially. Multiple monofilament stitches are used to close the skin. Drain effusion is cultured daily; if sterile, the drains can be removed after 3 to 4 days.

View larger version (35K): [in this window] [in a new window]   Fig 1. A full-thickness flap is undermined on both sides by means of an electric scalpel. Dissection should be directly on the chest wall.

View larger version (47K): [in this window] [in a new window]   Fig 2. Advancement flaps are sutured at the median line.

	Comment

Top Abstract Introduction Surgical technique Comment References

The incidence of SSWI is similar to that of deep sternal wound infection [2, 5]. Even though SSWIs are not life-threatening, they can significantly lengthen hospital stay. The policy of complete arterial revascularization using both internal thoracic arteries has increased the frequency of limited, superficial wound infections. In our experience, these infections are often situated at the lower part of the sternotomy wound.

The optimal treatment of this complication is not well codified. It is often based on the surgeon’s personal experience. Minor infections can be treated by drainage and packing. For larger infections, one of two options can be chosen: (1) Allowing a secondary intention healing can be performed safely if no tissue defect is present. In this case a few days of dressing changes will allow the closure of the wound. If a tissue defect exists, the secondary intention healing necessitates a significantly longer hospital stay; moreover, cosmetic results are disappointing. (2) Adoption of a two-stage approach is well-known in plastic surgery. However, it is rarely used for the treatment of poststernotomy infections.

During the last 6 years we have treated more than 30 patients with this simple but effective technique, with good results. There were neither recurrences nor any particular complication. In our opinion, the two-stage approach has many advantages:

1. Complete excision of the devascularized and necrotic tissues is mandatory to avoid any deep progression. Moreover, this accelerates the wound sterilization, thus allowing early closure.
   
2. Advancement flaps of the anterior thoracic wall work very properly and are seldom complicated by necrosis. This is true even in potentially hypoperfused flaps as after double internal thoracic artery harvesting.
   
3. The overall hospital stay is often reduced with respect to a secondary intention healing.
   
4. Aesthetic results are acceptable in these patients, who are often quite young (double internal thoracic artery use).
   

However, some points should be kept in mind to achieve the best results with this procedure:

1. Wound cultures should be negative before any final closure is attempted.
   
2. No-traction sliding is required for the advancement flaps.
   
3. These flaps must be "full-thickness" to avoid any postoperative necrosis.
   

In conclusion, we believe that this two-stage approach should be preferred to other techniques to treat SSWIs in case of large tissue necrosis or defects.

	References

Top Abstract Introduction Surgical technique Comment References

 

1. Durandy Y., Batisse A., Bourel P., Dibie A., Lemoine G., Lecompte Y. Mediastinal infection after cardiac operation—a simple closed technique. J Thorac Cardiovasc Surg 1989;97:282-285.[Abstract]
2. Bray P.W., Mahoney J.L., Anastakis D., Yao J.K. Sternotomy infections: sternal salvage and the importance of sternal stability. Can J Surg 1996;39:297-301.[Medline]
3. Nishida H., Rooters R.K., Soltanzadeh H., Thierman K.C., Schneider R.F., Kim W. Discriminate use of electrocautery on the median sternotomy incision. A 0.16 wound infection rate. J Thorac Cardiovasc Surg 1991;101:488-494.[Abstract]
4. Blanchard A., Hurni M., Ruchat P., Stumpe F., Fischer A., Sadeghi H. Incidence of deep and superficial sternal infection after open heart surgery—a ten-year retrospective study from 1981 to 1991. Eur J Cardiothorac Surg 1995;9:153-157.[Abstract]
5. The Parisian Mediastinitis Study Group. Risk factors for deep sternal wound infection after sternotomy: a prospective, multicenter study. J Thorac Cardiovasc Surg 1996;111:1200-1207.[Abstract/Free Full Text]

This article has been cited by other articles:

				G. Rescigno, M. S. Ballestrazzi, and S. Nazari Continuous high vacuum and primary skin closure in sternotomy wound infection Eur. J. Cardiothorac. Surg., March 1, 2001; 19(3): 375 - 375. [Full Text] [PDF]

				G. Rescigno Reply Ann. Thorac. Surg., May 1, 1999; 67(5): 1538 - 1538. [Full Text] [PDF]

				M. Massetti, G. Babatasi, and A. Khayat Advancement flaps for superficial sternal wound infection Ann. Thorac. Surg., May 1, 1999; 67(5): 1537 - 1538. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Giuseppe Rescigno Miguel Sousa Uva Richard Raffoul Marcio Scorsin Arrigo Lessana Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Rescigno, G. Articles by Lessana, A. Search for Related Content PubMed PubMed Citation Articles by Rescigno, G. Articles by Lessana, A.