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Ann Thorac Surg 1999;67:1537-1538
© 1999 The Society of Thoracic Surgeons
a Thoracic and Cardiovascular Surgery Department, University Hospital, C.H.U. "Cote de Nacre", 14033 Caen, France
e-mail: massetti-m{at}chu-caen.fr
To the Editor
We would like to congratulate the group of Drs Rescigno and Lessana for their simple technique of advancement flaps for superficial wound infection [1]. The authors stress the sometimes difficult wound treatment, after a superficial sternal wound infection. This technique represents a modification of the well-known myocutaneous plastic procedures used to treat poststernotomy infection [2]. As reported in the second stage of their procedure [1], the dissected musculocutaneous pectoralis flap is advanced medially without cutting the lateral and humeral insertions of the muscle, and the superficial wound is closed directly with an excellent cosmetic result, while reducing hospital stay and costs.
Based on our experience, after sternitis or suppurative mediastinitis, sometimes the necrotic tissue debridement leads to a superficial wound defect, which is difficult to close directly. Plastic-surgical procedures using pectoralis and rectus abdominus permit a primary closure of superficial wounds through a medial sliding of the musculocutaneous flaps. A blunt dissection, including the muscles and subcutaneous tissue en bloc, is used to develop the plane deep to the thoracic (pectoralis major) or abdominal (rectus abdominus) muscles. It is particularly crucial not to perforate arteries from the internal mammary vessels, and care must be taken not to damage the superior deep epigastric pedicle, which emerges from beneath the costal margin to enter the muscle. Bilateral flaps are necessary to fill the midline dead space. Occasionally, in narrrower defects, a unilateral flap might be sufficient. The internal mammary arteries and sometimes the epigastric vessels are often used as bypass conduits. In these cases the perforated arteries and collaterals must be preserved to avoid hypoperfusion and necrosis.
These composite musculocutaneous units are advanced medially and sutured to each other in the midline with nonabsorbable separate sutures. Partial detachment of these muscles from the wall reduces the lateral pull on the sternal closure. Securing them together adds further support to the repair, which is stressed during respiration.
Rarely, when extensive debridement of necrotic and infected tissue leads to a large superficial defect, a simple preparation of the musculocutaneous flap, as described, is insufficient to permit a direct wound closure without tension and risk of dehiscence. In these cases the turn-over flaps have been used; the same muscles are divided from their insertions and folded medially to cover the midline defect. However, hematoma and seroma are common complications at the donor muscle site, and infection can extend because of the large dissection. In these circumstances we used a simple modification of the technique described by Rescigno and coworkers. After preparation of the musculocutaneous flap, three longitudinal, full-thickness contraincisions are made (Fig 1) to facilitate the medial sliding of the flap and the primary closure without tension. The contraincisions are left to secondary intention healing.
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