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Ann Thorac Surg 2001;72:1419-1429
© 2001 The Society of Thoracic Surgeons

Review

A rational approach to wound difficulties after sternotomy: reconstruction and long-term results

Thomas J. Francel, MDa, Nicholas T. Kouchoukos, MDb

a Department of Surgery, St. Louis University, St. Louis, Missouri, USA
b St John’s Mercy Medical Center, St. Louis, Missouri, USA

Address reprint requests to Dr Francel, 621 S New Ballas Rd, Suite 1009B, St. Louis, MO 63141


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
One hundred fifty-one patients were reconstructed after median sternotomy 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.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
The midline sternotomy advocated with Julian in 1956 [1] allowed excellent exposure for cardiac surgery. The complication rate of severe infection after a midline sternotomy irrespective of the operative procedure is 1 percent to 4 percent [2–7]. Although the incidence is low, the high mortality rate (20 percent to 50 percent) and morbidity rate (approximately 50 percent) demands aggressive treatment of this potentially fatal complication [8, 9]. This report will use the experience of a single reconstructive surgeon to address treatment and reconstructive options as well as present long-term results. Many issues that develop in the postreconstructive period are addressed and long-term follow up is presented.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
One hundred fifty-one consecutive patients reconstructed by the author for sternal wound difficulties were entered prospectively over a 6-year period (1990–1996). These patients resulted from over 5,000 sternotomies performed by ten cardiac surgeons and represented approximately a 3 percent infection rate. The reconstruction patients had follow-up visits at 6 weeks and 6 months, and approximately 50% had a 1-year follow-up visit.

A retrospective study of 20 patients who had undergone sternal rewiring procedures at a single institution was also completed. These patients did not include delayed rewiring procedures for chests that were not previously closed because of mediastinal edema or the presence of a left ventricular assist device.

The one hundred fifty-one consecutive reconstruction patients and 20 patients undergoing sternal rewiring were reviewed for intraoperative data and postoperative recovery, including demographics, infecting organisms, flap reconstruction, postoperative hospitalization, and success rates. A successful recovery is defined as a healed sternotomy wound at the 6-week office visit. Our 1-year follow up revealed that 13 patients died within the first year after reconstruction and 6 of these patients did not leave the hospital after their initial cardiac procedure.

Follow-up questionnaires were mailed out to the patients in 1996. Forty percent of rewire patients and 46 percent of reconstruction patients returned the questionnaire. Questions prompted patient responses to confirm solid data and also subjective data (ie, chest pain and overall cosmesis). The patients were also questioned about whether they noted any weakness of the trunk. The long-term follow-up questionnaires also addressed issues such as the return to previous hobbies and employment.

Statistical analysis for significance used the {chi}2 test and Fisher’s exact test with significance for p values less than 0.05.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
The demographics of the 20 rewire patients and 151 reconstruction patients are presented in Table 1. The two populations are similar in age and both exhibit a male preponderance. There is a greater proportion of combined coronary artery bypass grafting and valve procedures in the reconstruction group (p = 0.04) but a larger percentage of rewire patients that had a previous sternotomy (p < 0.0001).


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  		Table 1. Patient Demographics

 
The comparative sternal operative data (Table 2) revealed that, more commonly, patients who were rewired had negative cultures (p < 0.0001). This results from a conscious decision to rewire patients with healthy bone stock and an intraoperative gram stain showing no organisms.


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  		Table 2. Operative Sternal Data

 
Seven rewire patients had closed irrigation with vancomycin (n = 5) or betadine (n = 2) initiated after positive cultures. Vancomycin is used in Staphylococcal infections and povidone iodine in mixed cultures. Two patients failed this therapy (one vancomycin and one povidone iodine) and underwent successful flap reconstruction. Five other patients failed rewiring attempts without irrigation and were reconstructed with local pedicle muscle flaps.

The patients that required debridement and reconstruction tended to present with symptoms later (after sternotomy) than the patients who required rewiring of their sternum. Although the average number of days from sternotomy to debridement was extended (average 76.5 days), 52 percent presented with symptoms less than 30 days after sternotomy. The extended average resulted in a few patients seen months or even years after sternotomy. Reconstruction patients (45%) cultured a predominance of staphylococcal as the offending bacteria.

Flap reconstructions were performed an average of 2.5 days after debridement (range, 0–10 days). Sixty-three patients (42 percent) were reconstructed at the time of the initial sternal exploration and debridement. This was completed because there was minimal contamination, unhealthy sternal bone, and no gross purulence. Fifty-nine patients (94 percent) reconstructed at the time of debridement had healed sternotomy wounds at 6-weeks follow up. Eighty-three patients (94 percent) undergoing delayed reconstruction had successful outcomes.

Twenty-nine percent of the reconstructed patients required a single muscle flap using either a unilateral pectoralis or a rectus abdominis muscle. One hundred patients (66 percent) required more than a single muscle with 73 patients undergoing bilateral pectoralis muscle flap reconstruction. Eighteen of these bilateral pectoralis muscle flaps remained inserted on the humerus and the muscle origins advanced and imbricated into shallow defects. Five omental flaps were used; four of these were for exposed great vessel grafts and one for coverage of a right ventricular repair. Two latissimus dorsi muscle flaps were used (one myocutaneous flap) in patients with contraindications to other donor flaps.

Postoperative hospitalization was similar for both the rewire patients (10 days) and the reconstruction patients (13 days). Forty-one percent of reconstruction patients and 30 percent of rewire patients went home on culture specific intravenous antibiotics (p = 0.34). There were seven failures after rewiring attempts and these patients had successful flap reconstructions. Nine patients failed reconstruction. This included six patients who died after reconstruction although the procedure successfully eliminated the septic mediastinal defect and the wounds were healed at the time of their death. The cause of death in these patients is recorded as respiratory arrest (n = 1), liver failure (n = 1), renal failure (n = 2), and ischemic bowel (n = 2). Three patients (2 percent) required a second flap procedure for initial flap failure and this included two infections with Candida.

Prospective follow ups revealed that 13 patients died within the first year after reconstruction (8.6 percent) (Table 3). More of these patients were infected with pseudomonas, gram negative, or mixed bacteria (69 percent) compared with patients infected with Staphylococcus aureus (28 percent). Our 30-day mortality was 4 percent. Seven patients left the hospital but succumbed prior to their 1-year follow-up visit. A slightly higher percentage of these patients went home on intravenous antibiotics but all were healed at the 6-week follow up.


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  		Table 3. 1-Year Mortalities After Reconstruction

 
Follow-up questionnaires were returned by over 40 percent of the patients (Table 4). It was interesting to note that the average age of the patients who returned the questionnaire was the same, and the number of patients who responded that they left the hospital on intravenous antibiotics was the same as the firm data from the discharge records in both study groups. We expected more complaints from the reconstruction patients regarding chest symptoms but were surprised to record that only 10 patients (14 percent) complained of incisional pain, clicking or rubbing, or pain while lying on their side. This compares favorably to the rewire patients in which 12 percent complained of incisional pain consistent with motion at the median sternotomy split. All were uniformly satisfied with the scar and overall cosmesis. Forty-seven percent of reconstruction patients complained of numbness in their chest compared to none of the rewire patients (p = 0.01). This is a result of undermining of the skin oftentimes to the anterior axillary line to primarily close the skin and fill the skin defect.


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  		Table 4. Follow-Up Data

 
Only 20 percent of reconstruction patients complained of shoulder or abdominal weakness. Seventy-five percent of rewire patients returned to their hobbies, and 89 percent of reconstruction patients had enough chest stability and strength to return hobbies such as golf, gardening, and knitting. Sixty-six percent of patients who were employed at the time of coronary artery bypass grafting and rewiring returned to their same jobs and 79 percent of reconstruction patients returned to similar employment. Three patients (1 rewire, 2 reconstruction) retired early, and 2 reconstruction patients considered themselves disabled because of their operation.


   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
The reconstructive options were chosen specifically for each individual patient based on available donor sites and size of the defect in the open mediastinum. The available donor sites included muscle, myocutaneous flaps, microvascular transfers, and omentum.

The muscle flaps used included the pectoralis major muscle based on either the thoracicoacromial axis off of the axillary artery [10–13] or the medial perforators from the internal mammary artery [14]. Our personal preference has been to rotate the pectoralis muscle on the thoracicoacromial vessel and use the widest medial part of the muscle to fill the defect. The turned over pectoralis muscle flap has been used less often because when the turnover is positioned into the mediastinal defect, the most inferior wound tends to be inadequately filled. Also loss of axillary fold with the turnover flap tends to be bothersome to the patient. The axillary fold can be maintained if a limited release is performed on a thoracicoacromial-based pectoralis major muscle flap at its insertion onto the humerus.

The rectus muscle may be rotated superiorly on the internal mammary artery [15, 16]. An absolute contraindication to its use includes previous subcostal incisions which render the muscle avascular if the inferior epigastric is ligated to rotate the muscle into position. A relative contraindication is a previous internal mammary artery harvest on the proposed donor muscle side. The ipsilateral rectus muscle may be used if there has been a delay between the internal mammary artery harvest and reconstruction (> 1 month) [17]. If the musculophrenic artery [18] and the ninth intercostal is maintained [19], then acute transfer of an ipsilateral rectus may be possible.

We used a latissimus dorsi muscle [20] only as a salvage procedure if other muscles have failed or are no longer available. Carrying the latissimus muscle across the superior chest into the mediastinum through a second and third lateral rib resection allows greater muscle bulk to reach the mediastinum.

A rectus myocutaneous flap was used when there was a relatively deep mediastinal defect or when elevation of chest wall skin flaps may be contraindicated. This was especially helpful in patients who had a previous mastectomy and radiation treatment, and therefore, the chest skin was thin and had become atrophied. Mobilization of radiation-damaged skin is dangerous and may lead to skin loss. A latissimus myocutaneous flap was used in a patient after bilateral IMA coronary artery bypass grafting and previous mediastinal radiation for plasma cell cytoma 15 years ago (Fig 1).



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  		Fig 1. The defect after sternectomy following coronary artery bypass graft and prior radiation is extensive (A). A latissimus dorsi myocutaneous flap was rotated into position (B) because of unavailability of the chest and abdominal muscles.

 
The omentum has been harvested based on the right gastroepiploic vessel of the celiac axis [21–23]. It is mobilized as an isolated pedicle and tailored prior to rotation. Care must be taken to release areas after visualization of the vascular arcade and obtain as much length as possible. The diaphragm is partially split along the right inferior aspect of the pericardium above the left lobe of the liver. The omental flap is sutured into the diaphragm to prevent herniation back into the abdomen and this must be done without distortion of the pyloris and duodenum to avoid gastric outlet obstruction. It is thinned and draped along the right ventricle and used to fill the superior mediastinum.

The donor muscle for free flap transfers is usually the rectus abdominis muscle or the latissimus dorsi muscle. They are used to circumvent contraindications to their use as pedicle flaps. A rectus is most commonly used as a microvascular transfer if there has been bilateral subcostal incisions. The recipient vessels are usually in the neck although mediastinal vessels may be easily accessed to supply inflow and outflow.

The option for reconstruction depends upon a number of issues. Most important is the depth of the mediastinal defect (See Fig 4 in companion article [24]). The deeper the defect the more bulk that is needed for reconstruction. We have found that the more space filling flaps are the omentum, rectus abdominis myocutaneous flaps, and the rectus abdominis muscle flap. If the rectus muscle is used to fill deeper defects, then often a pectoralis muscle flap is included to fill the defect between the hemisternums. Less deep defects may be filled with either a rectus muscle alone or with a pectoralis muscle flap detached from the humerus to allow rotation into the defect. Defects involving only the depth of the sternal bone where the mediastinum is filled may usually be covered with bilateral sliding pectoralis major muscle flaps. Oftentimes, the humeral attachments may be maintained in these situations and a widened muscle origin imbricated into the shallow defect.

An internal mammary artery harvest renders the ipsilateral rectus muscle at risk if it is used for reconstruction. In general, the contralateral rectus is used. An ipsilateral rectus may be used if the superior inflow is maintained by the muscular phrenic vessels or the ninth intercostal vessels. Ipsilateral rectus muscles have also been used clinically after a delay.

Previous abdominal and chest surgeries may render a potential donor site avascular and other options must be examined. Subcostal incisions make the rectus muscles unavailable for pedicle transfers but they may be used as micro transfers. Perimedian incisions will interfere with the blood flow to the inferior rectus but the superior aspect of the rectus may still be used for inferior sternal defects. Any previous intraabdominal procedure may make the choice of omentum for reconstruction difficult or even unavailable. We have avoided the pectoralis muscle ipsilateral to previous mastectomy sites because of muscle atrophy. Also the pectoralis major muscle may not be the first choice for reconstruction because of the proximity of the thoracicoacromial vessels to the subclavicular hollow if a pacemaker or permanent defibrillator has been placed by a subclavian approach. The omentum is our first choice of reconstruction if there is exposed prosthetic material (Fig 2). It is more malleable and can be wrapped around the great vessels. It also maintains bulk to completely fill the dead space to allow primary healing of all areas. The omentum is also our reconstructive choice if the primary procedure has failed. It is also used if the mediastinum is purulent but reconstruction is urgently required (eg, a ruptured right ventricle).



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  		Fig 2. An aortic root graft infected with Candida species (A) is covered and wrapped with an omental pedicle flap (B).

 
The postoperative care of the reconstruction patient is critical. The most important intervention is cessation of mechanical ventilation. Earlier it was believed to help maintain physiologic stability but we found that the raw tissue did not heal as quickly, and drainage continued for extended periods postoperatively if the patient was maintained on a ventilator. If the patient is extubated soon after the muscle flaps are placed, there is: (1) less positive pressure, (2) less movement of the chest, and (3) rapid healing with minimal drainage tube output. Our patients have been watched overnight in the intensive care unit to maintain support for fluid shifts and cardiac monitoring and then moved to a monitored bed the next morning.

Shoulder activity should be limited if the pectoralis insertion onto the humerus has been maintained. This includes prohibiting the use of a walker, which is a common attempt in the early postoperative period before the patient’s strength returns. The patients should also log roll to the edge of the bed instead of pushing up on the bed railing. These limitations continue throughout the hospitalization and after discharge. At approximately 3 weeks, shoulder motion advances with postmastectomy exercises. From 4 to 6 weeks strength is developed and at 6 weeks all activities are allowed. A rectus muscle reconstruction requires limitations on bending and lifting for approximately 3 weeks. Latissimus dorsi reconstructions have limitations similar to patients undergoing pectoralis rotation flaps. Patients requiring omental pedicle flaps should be carefully followed for early gastric outlet obstruction and slow return of bowel function. An oral gastric or nasogastric tube is required for early postoperative gastric decompression.

Nutrition is especially important for adequate healing in a postoperative patient. Calorie counts are helpful and nutritional supplements may be required. In severe instances nutritional support (intravenous or gastrointestinal) may be beneficial to increase caloric intake. Vitamins (especially vitamin C) are helpful for wound healing. A patient on steroids may benefit from high doses of vitamin A to counter slow healing associated with exogenous steroid intake.

All patients are maintained on a culture-dependent intravenous antibiotic during the postoperative hospitalization. On discharge this is converted to appropriate oral antibiotics until the initial follow up (approximately 2 weeks). Antibiotics are discontinued at this time if healing is progressing. A sternal bone culture is routinely taken after debridement and prior to muscle flap coverage. The intraoperative bone cultures are a very important step in our treatment of a patient with poststernotomy infection. If this bone culture is positive, it is felt that bone debridement has not eliminated all of the infected bone and the patient is maintained on 6 weeks of intravenous antibiotics to treat for osteomyelitis. Any patient with prosthetic material in place (ie, vessel replacement, valve replacement) receives 6 weeks of intravenous antibiotics.

There are a few special concerns which should be addressed in the reconstruction patient. These include a perceived or real skin deficiency, wound healing difficulties in women, and prolonged signs of sepsis.

There is a perceived skin deficiency after sternal dehiscence, although no skin has been debrided. This is the result of disruption of the sternum and a larger chest circumference, therefore, the skin deficit is equal to the distance between the sternal edges. Sometimes this can be extreme. We find the available skin to be sufficient with adequate mobilization of the chest wall skin to the anterior axillary line. This does place skin closure under some tension, which may result in decreased blood flow and poor healing at the point of maximum tension. This tends to be the widest point of the sternal separation and is usually in the lower one third of the chest. Approximately 30% (Table 3) of postmediastinitis reconstructions have difficulty obtaining primary healing at the site. We have allowed the vast majority of these patients to heal secondarily (3 to 4 weeks) as long as the mediastinum is covered with healing muscle. If the mediastinum is open, a second muscle flap is performed, which was required in 2 patients (1 percent).

We reconstructed 4 patients because of the inability to wire the sternum closed secondary to mediastinal and lung edema. Multiple attempts at sternal closure in these patients caused cardiac decompensation because of inadequate volume within the chest cavity. These patients are not included in the series because they were not reconstructed secondary to an infectious etiology. They had a soft tissue deficiency and we successfully closed these patients with myocutaneous rectus abdominis pedicle flap rotations. The muscle protects the heart and mediastinum from the sternal edges and the subcutaneous tissue of the flap is situated between the sternal halves (Fig 3). The skin transferred with the flap is important as the chest wall skin does not need to be mobilized and therefore, further decreased chest volume. We were successful in obtaining primary healing in all 4 patients, and they showed rapid improvement in cardiac function (a decreased need for vasopressor agents) in the immediate postreconstruction period. Two patients requested removal of the cutaneous portion approximately 8 months after the initial reconstruction. The flap from these patients was markedly redundant after slow improvement of the mediastinal and chest edema. Removal of the cutaneous portion of the flaps with chest wall skin advancement obtained a healed midline scar in these two patients.



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  		Fig 3. A rectus myocutaneous flap was selected in this patient because of the depth of the mediastinal defect. On postoperative computed tomographic scan (A), the rectus muscle (R) and the overlying subcutaneous tissue has completely filled this deep defect and allows soft tissue healing between the sternal edges (S). The patient has a visible cutaneous portion (B) but few patients have requested excision of this at a later date.

 
Women have a higher number of wound healing difficulties in part due to the lateral traction of the breasts on the midline skin incision while the patient is supine in bed. We have placed women in elastic breast supports to decrease this lateral pull and have added support laterally by placing cotton rolls to force the breasts to the midline in women with larger breasts. The support bra must be worn in bed but may be removed while ambulating. We feel that preoperative breast reductions [25], as advocated by others, places the women at risk for cardiac injury by exposing them to anesthetic risks prior to coronary artery bypass grafting. Postcoronary artery bypass graft breast reductions may be contemplated but we have found this unnecessary [26].

Candida mediastinitis has been particularly difficult to irradicate. Once established, the associated morbidity and mortality is high [27]. It is usually recognized after failure of closed irrigation or long-term antibiotics used for a low grade bacterial infection. Although muscle flap reconstruction does well against most infections, we have used the omentum in these situations to take advantage of its inherent properties of angiogenesis and the abundance of leukocytes. Four patients treated by aggressive debridement, omental flap reconstruction, and long-term antifungal therapy have remained free of infection for at least 1 year after cessation of antifungalcides. This includes 6 weeks of intravenous amphoteracin B followed by 6 months of oral fungicidal.

After reconstruction and control of infection the patient usually progresses rapidly to discharge on postoperative days 5 to 10. Delayed extubation or prolonged signs of sepsis should demand evaluation. This includes early postoperative computed tomographic scans and laboratory values. The computed tomographic scan may reveal areas of undrained sepsis or other abnormalities. For example, we were perplexed by the ventilation requirements and blood pressure support needed by a recent patient. A chest computed tomography coincidentally revealed the patient had sustained bilateral adrenal hemorrhages during hospitalization and upon initiation of steroid replacement made a rapid recovery. Laboratory values in another patient helped diagnose acute postoperative cholecystitis and another nonresponsive patient had markedly elevated amonia levels. The laboratory values to consider include nutrition (albumin and prealbumin), renal function, and control of diabetes.

Some long-term problems to be considered are strength of the patients after transfer of muscle groups, risk of abdominal hernias, reexploration of the mediastinum, and pulmonary problems associated with nonunion of the sternum.

The underlying strength of patients after transfer of muscle groups has been evaluated. In general, there has been no reported loss of strength with regular activity because of an abundance of secondary muscle groups. This has been reported previously after the harvest of the latissimus dorsi muscle [28, 29]. Our follow-up questionnaire revealed that only 20 percent of patients reported a decrease in shoulder strength after pectoralis muscle flap rotation. This may have resulted because the strength requirements of the shoulders in the older age group tend to be less demanding. We avoided detaching the pectoralis muscle (or using the pectoralis muscle at all) in the younger patients (less than 50 years old) who required the continued ability to lift and for strength require especially in particular occupations. The rectus muscle has been our preferred donor muscle in these cases.

We have seen very few complications after pedicle rectus muscle flap reconstruction. Most of these were minor (seroma 1 percent, hematoma 3 percent, partial incision dehiscence in 1 percent). We had three abdominal hernias and two were in patients reconstructed with pectoralis muscles who had inadequate secondary closure of the superior linea alba division made at the time of the previous sternotomy. The third patient had a superior abdominal hernia after a left rectus transfer. There were no lower abdominal hernias after 51 rectus abdominis harvests. This success is due to lessons learned after transverse rectus abdominis myocutaneous breast reconstructions. Full technical maneuvers included: (1) separation componentplasty of the abdominal wall [30], (2) including the edge of the internal oblique to complete a 2-layer closure, and (3) a lateral release of the external obliques to obtain a muscle closure over the weakened posterior sheath inferior to the arcuate line [31].

We have reexplored the mediastinum of the four patients who had previously undergone muscle flap reconstruction at another institution. This included two pseudoaneurysms at a great vessel suture line and 1 patient that required mitral valve replacement 2 years after coronary artery bypass graft and muscle flap reconstruction. We have not encountered the need for a redo coronary artery bypass after muscle flap reconstruction. Theoretically, muscles may help with revascularization, but realistically, the patients are probably less inclined to pursue a redo coronary artery bypass graft unless their symptoms were lifestyle-limiting. This was confirmed by asking a handful of reconstruction patients if they would undergo re-coronary artery bypass graft if required. They all responded negatively unless the symptoms were debilitating.

Technically, we have found that exploration of the mediastinum after flap reconstruction is best started in the superior aspect. The skin is opened and the flap muscle fibers are identified. We have found a fairly good plane of dissection in the superior mediastinum directly underneath the muscle but away from the great vessels (Fig 4). Once underneath the muscle superiorly, the dissection is carried inferiorly over the great vessels and heart. This is the most difficult because it is less precise and there must be constant vigilance for coronary artery grafts. Retraction of the muscle away from the heart afforded by freeing the superior aspect of the muscle helps to identify the plane of dissection. The rectus abdominis muscle is retracted inferiorly and the pectoralis muscles are retracted laterally. In these situations, we have used hypothermic arrest and peripheral bypass to obtain the best control should the heart or great vessel be entered during the dissection.



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  		Fig 4. When the mediastinum is reexplored after muscle flap reconstruction, it is important to start in the superior mediastinum where the muscle flap (M) can be raised off the superior mediastinal structures and the hemisternum (S). We have found this plane to be particularly easy to identify, although the inferior plane directly over the heart is much more difficult to identify. Do not cut through the muscle or it will be devascularized.

 
Minimal pulmonary effects are recorded after sternotomy and wire reapproximation of the hemi-sternums [32–35]. More pulmonary problems were expected with a nonunion of the sternum. This does not appear to be the case after muscle flap reconstruction because the chest does not appear to act flail as anticipated [36, 37]. The sternal nonunion failed to contribute to decreasing pulmonary function in our series. We have been able to evaluate a number of patients’ pulmonary function as they progressed from preoperative coronary artery bypass graft to open sternums and healed 4 months after muscle reconstruction (Table 5). In general, the patients started off with some mild chronic obstructive pulmonary disease with 95 percent predicted, forced vital capacity, and decreased forced expiratory volume in one second (FEV1). The pulmonary function test markedly deteriorated to approximately 50 percent predicted when the sternum is left open, probably secondary to a flail component as well as pain. Three month follow ups revealed that these two parameters have returned to preoperative values. Two interesting patients underwent pulmonary artery endarterectomy for pulmonary hypertension secondary to multiple pulmonary embolisms. These patients do not have postdebridement pulmonary function tests because they were immediately reconstructed secondary to an exposed suture line on the pulmonary artery. Both of these patients showed improved pulmonary function tests and no need for supplemental oxygen on follow up with successful reduction of pulmonary hypertension.


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  		Table 5. Pulmonary Function Testinga

 
One patient had severe chronic obstructive pulmonary disease prior to coronary artery bypass grafting. This patient subsequently required reconstruction for mediastinitis with a prolonged postoperative ventilatory dependence. Over the months postreconstruction, the patient had increasing oxygen dependence and increasing shortness of breath. The sternal nonunion was thought to be a contributing factor and a methylmethaculate neosternum was placed as stability. This did not improve his pulmonary function testing and he died with worsening chronic obstructive pulmonary disease.

Muscle and omental reconstructions for infected median sternotomy wounds are successful in approximately 90 percent of reported cases [38–40]. The initial success rate in this series was 94 percent. Through previous work we can use muscles to control infections. The muscle fills the dead space, delivers oxygen and antibiotics, and increases the polymorphonuclear cells available to fight infection [41–45]. This ability works in vivo as well as in the laboratory [46–51]. Six patients were considered failures as they died within 30 days of their procedure from multisystem failure without evidence of undrained ongoing mediastinal sepsis. Three patients required secondary flaps to obtain a healed wound. Therefore, 96 percent of the reconstruction patients could be successfully discharged from the hospital and obtained a healed wound at the 6-week postreconstruction follow-up visit.

A recent report reviewed the long-term results and functional outcome of flap reconstruction in poststernotomy wounds [52]. Although they reported success in obtaining a healed wound, they reported 51 percent of patients had persistent pain, 45 percent had sternal instability symptoms, 32 percent had shoulder weakness, 31 percent had abdominal wall weakness, and 85 percent had contour deformities. Fifty-two percent of patients did not return to work (which coincides with the percentage of patients with persistent pain) and only 36 percent returned to preoperative activities.

The results of our present study is in marked contrast to the previous report. As reported in Table 4, a minimal number of reconstruction patients recorded postoperative pain (8.6 percent) or symptoms of sternal instability (6 percent). Only 20 percent reported shoulder or abdominal weakness, and 95 percent were satisfied with the cosmesis. Ninety-eight percent returned to a previous hobby (eg, gardening) or sports (eg, golf, softball), and 79 percent returned to previous employment. To the best of our knowledge, only 2 of our patients required secondary stability procedures (one neosternum, one rewiring). This is more consistent with some earlier work [53]. The most common negative response was numbness of the chest skin (47 percent), which coincides with other personal experiences [54].

Our prospective single reconstructive surgeon study reports a much better sternal stability and return to work. This is a result of a more correct diagnosis of the defect and understanding the need to completely fill the dead space and allow for definitive healing tissue between the sternal edges. Aggressive debridement of the sternum has been beneficial to remove sources of ongoing infection, and large transfers of muscle bulk does not allow the remaining sternal bone to come in close proximity to cause pain. This is also confirmed by comparing preoperative and postoperative pulmonary function tests. If the sternum is open and the edges touch with every breath, then forced vital capacity and forced expiratory volumes are 50 percent of those predicted, secondary to pain and a flail component. Pulmonary function tests returned to preoperative values with good soft tissue reconstruction and healing between the sternal bone edges. The sternal stability and return of pulmonary function tests to preoperative levels corresponds to the results seen in 20 patients who had obtained sternal stability by rewiring procedures.

Thus, we have reported excellent control of infection with a single flap procedure. This is true even when 51 percent of the patients required preoperative control of their diabetes. Although 6 patients died less than 30 days after their reconstruction, the follow-up 1-year mortality rate was only 8.6 percent. Follow-up office visits and patient questionnaires confirmed a stable sternum and excellent functional results (employment and pulmonary function testing) for the reconstruction patients.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. Julian O.C., Lopez-Belio M., Dye W.S., et al. The median sternal incision in intracardiac surgery with extracorporeal circulation: a general evaluation of its use in heart surgery. Surgery 1957;42:753.[Medline]
  2. Culliford A.T., Cunningham J.N., Jr, Zeff R.H., et al. Sternal and costochondral infections following open-heart surgery: a review of 2,594 cases. J Thorac Cardiovasc Surg 1976;72:714.[Abstract]
  3. Grmoljez P.F., Barner H.H., Willman V.L., et al. Major complications of median sternotomy. Am J Surg 1975;130:679.[Medline]
  4. Engelman R.M., Williams C.D., Gouge T.H., et al. Mediastinitis following open-heart surgery: Review of two years’ experience. Arch Surg 1973;107:772.[Abstract/Free Full Text]
  5. Loop F.D., Lytle B.W., Cosgrove D.M., et al. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg 1990;49:179-187.[Abstract]
  6. Kustal A., Ibrisim E., Catav Z., et al. Mediastinitis after open-heart surgery: analysis of risk factors and management. J Cardiovasc Surg 1991;32:38-41.[Medline]
  7. Smith J. Michael, Glaser R.S., Osborne B.J., et al. Sternal wound complications after open-heart surgery: results from 3524 consecutive operative procedures. Contemp Surg 1993;43:197-202.
  8. Grossi E.A., Culliford A.T., Krieger K.H., et al. A survey of 77 major infectious complications of median sternotomy: a review of 7,949 consecutive operative procedures. Ann Thorac Surg 1985;40:214-223.[Abstract]
  9. Serry C., Bleck P.C., Javid H., et al. Sternal wound complications: management and results. J Thorac Cardiovasc Surg 1980;80:861-867.[Abstract]
  10. Palmer J.H., Taylor G.I. The vascular territories of the anterior chest wall. Br J Plast Surg 1986;39:287-299.[Medline]
  11. Reid C.D., Taylor G.I. The vascular territory of the acromiothoracic axis. Br J Plast Surg 1984;37:194-212.[Medline]
  12. Hugo N.E., Sultan M.R., Ascherman J.A., et al. Single-stage management of 74 consecutive sternal wound complications with pectoralis major myocutaneous advancement flaps. Plast Reconstr Surg 1994;93:1433-1441.[Medline]
  13. Arnold P.G., Pairolero P.C. Use of pectoralis major muscle flaps to repair defects of anterior chest wall. Plast Reconstr Surg 1979;63:205-213.[Medline]
  14. Nahai F., Morales J., Bone D.K., Bostwick J. Pectoralis major muscle turnover flaps for closure of the infected sternotomy wound with preservation of form and function. Plast Reconstr Surg 1982;70:471-474.[Medline]
  15. Iacobucci J.J., Stevenson T.R., Hall J.D., Deeb G.M. Sternal osteomyelitis: treatment with rectus abdominis muscle. Br J Plast Surg 1989;42:452-459.[Medline]
  16. Majure J.A., Albin R.E., O’Donnell R.S., Arganese T.J. Reconstruction of the infected median sternotomy wound. Ann Thorac Surg 1986;42:9-12.[Abstract]
  17. Fernando B., Muszynski C., Mustoe T. Closure of a sternal defect with the rectus abdominis muscle after sacrifice of both internal mammary arteries. Ann Plast Surg 1988;21:468-471.[Medline]
  18. Francel T.J., Dufresne C.R., Baumgartner W.A., O’Kelley J. Anatomic and clinical considerations of an internal mammary artery harvest. Arch Surg 1992;127:1107-1111.[Abstract/Free Full Text]
  19. Miller L.B., Bostwick J., Hartrampf C.R., et al. The superiorly based rectus abdominis flap: predicting and enhancing its blood supply based on an anatomic and clinical study. Plast Reconstr Surg 1988;81:713-724.[Medline]
  20. Seyfer A.E., Graeber G.M. The use of a latissimus dorsi and pectoralis major musculotaneous flaps for chest wall reconstruction. Contemp Surg 1983;22:29-39.
  21. Colen L.B., Huntsman W.T., Morain W.D. The integrated approach to suppurative mediastinitis: rewiring the sternum over transposed omentum. Plast Reconstr Surg 1989;84:936-943.[Medline]
  22. Heath B.J., Bagnato V.J. Post sternotomy mediastinitis treated by omental transfer without postoperative irrigation or drainage. J Cardiovasc Surg 1987;94:355-360.
  23. Herrera H.R., Ginsburg M.E. The pectoralis major myocutaneous flap and omental transposition for closure of infected median sternotomy wounds. Plast Reconstr Surg 1982;70:465-470.[Medline]
  24. Francel T.J., Kouchoukos N.T. A rational approach to wound difficulties after sternotomy: the problem. Ann Thorac Surg 2001;72:1411-1418.[Abstract/Free Full Text]
  25. Copeland M., Senkowski C., Ulcickas M., et al. Breast size as a risk factor for sternal wound complications following cardiac surgery. Arch Surg 1994;129:757-759.[Abstract/Free Full Text]
  26. Copeland M., Senkowski C., Ergin M.A., Lansman S. Macromastia as a factor in sternal wound dehiscence following cardiac surgery: management combining chest wall reconstruction and reduction mammoplasty. J Cardiac Surg 1992;7:275-278.[Medline]
  27. Glower D.D., Douglas J.M., Gaynor J.W., et al. Candida mediastinitis after a cardiac operation. Ann Thorac Surg 1990;49:157-163.[Abstract]
  28. Russell R.C., Pribaz J., Zook E.G., et al. Functional evaluation of latissimus dorsi donor site. Plast Reconstr Surg 1986;78:336-344.[Medline]
  29. Laitung J.K.G., Peck F. Shoulder function following the loss of the latissimus dorsi muscle. Br J Plast Surg 1985;38:375-379.[Medline]
  30. Ramirez O.M., Ruas E., Delton A.L. "Components separation" method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 1990;86:519-526.[Medline]
  31. Spear S.L., Walker R.K. The external oblique flap for reconstruction of the rectus sheath. Plast Reconstr Surg 1992;90:608-613.[Medline]
  32. Howatt W.F., Talner N.S., Sloan H., et al. Pulmonary function changes following repair of heart lesions with the aid of extracorporeal circulation. J Thorac Cardiovasc Surg 1962;43:649-657.[Medline]
  33. Braun S.R., Birnbaum M.L., Chopra P.S. Pre- and postoperative pulmonary function abnormalities in coronary artery revascularization surgery. Chest 1978;73:316-320.[Abstract/Free Full Text]
  34. Berrizbeitia L.D., Tessler S., Jacobowitz I.J., et al. Effect of sternotomy and coronary bypass surgery on postoperative pulmonary mechanics. Chest 1989;96(4):873-876.[Abstract/Free Full Text]
  35. Locke T.J., Griffiths T.L., Mould H., Gilbson G.J. Rib cage mechanics after median sternotomy. Thorax 1990;45:465-468.[Abstract/Free Full Text]
  36. Kohman L.J., Auchincloss H., Gilbert R., Beshara M. Functional results of muscle flap closure for sternal infection. Ann Thorac Surg 1991;52:102-106.[Abstract]
  37. Meadows J.A., Staats B.A., Pairolero P.C., Rodarte J.R., Arnold P.G. Effect of resection of the sternum and manubrium in conjunction with muscle transposition on pulmonary function. Mayo Clin Proc 1985;60:604-609.[Medline]
  38. Martin R.D. The management of infected median sternotomy wounds. Ann Plast Surg 1989;22:243-251.[Medline]
  39. Pearl S.N., Dibbell D.G. Reconstruction after median sternotomy infection. Surg Gyn & Obstetr 1984;159:47-52.
  40. Cohen M., Silverman N.A., Goldfaden D.M., Levitsky S. Reconstruction of infected median sternotomy wounds. Arch Surg 1987;122:323-327.[Abstract/Free Full Text]
  41. Mathes S.J., Feng L., Hunt T.K. Coverage of the infected wound. Ann Surg 1983;198:420-429.[Medline]
  42. Chang N., Mathes S.J. Comparison of the effect of bacterial inoculation in musculocutaneous and random-pattern flaps. Plast Reconstr Surg 1982;70:1-9.[Medline]
  43. Moelleken B.R.W., Mathes S.J., Amerhauser A., et al. An adverse wound environment activates leukocytes prematurely. Arch Surg 1991;126:225-230.[Abstract/Free Full Text]
  44. Russell R.C., Graham D.R., Feller A.M., et al. Experimental evaluation of the antibiotic carrying capacity of a muscle flap into a fibrotic cavity. Plast Reconstr Surg 1988;81:162-170.[Medline]
  45. Masem M., Greenber B.M., Hoffman C., et al. Comparative bacterial clearances of muscle and skin/subcutaneous tissues with and without dead bone: A laboratory study. Plast Reconstr Surg 1990;85:773-781.[Medline]
  46. Jurkiewicz M.J., Bostwick J., Hester T.R., et al. Infected median sternotomy wound: successful treatment by muscle flaps. Ann Surg 1980;191:738-744.[Medline]
  47. Scully H.E., Leclerc Y., Martin R.D., et al. Comparison between antibiotic irrigation and mobilization of pectoral muscle flaps in treatment of sternal infections. J Thorac Cardiovasc Surg 1985;90:523-531.[Abstract]
  48. Cohen M., Marschall M.A., Silverman N.A., Levitsky S. Chest wall reconstruction for infected median sternotomy wounds. Contemp Surg 1988;32:13-20.
  49. Pairolero P.C., Arnold P.G. Management of infected median sternotomy wounds. Ann Thorac Surg 1986;42:1-2.[Medline]
  50. Arnold P.G., Pairolero P.C. Chest wall reconstruction: experience with 100 consecutive patients. Ann Surg 1984;199:725-732.[Medline]
  51. Graeber G.M., Seyfer A.E., Wind G.G. Chest wall reconstruction: reconstruction of the dehisced median sternotomy. Surgical Rounds 1988;11:94-99.
  52. Ringelman P.R., Vander Kolk C.A., Cameron D., et al. Plast Reconstr Surg 1994;93:1208-1214.[Medline]
  53. Nahal F., Rand R.P., Hester T.R., et al. Primary treatment of the infected sternotomy wound with muscle flaps: a review of 211 consecutive cases. Plast Reconstr Surg 1989;84:434-441.[Medline]
  54. Morain W.D. Editorial. Full circle. Ann Plast Surg 1996;37:452.[Medline]



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