Ann Thorac Surg 2006;81:754-755
© 2006 The Society of Thoracic Surgeons
How to do it
Alternative Bi-Pectoral Muscle Flaps for Postoperative Sternotomy Mediastinitis
Periklis Tomos
a
,
*
,
Elias Lachanas, MD
a
,
Panagiotis O. Michail
b
,
Alkiviadis Kostakis
a
a Propedeutic Department of Surgery, Athens, Greece
b Department of Surgery, Athens University, Medical School, Athens, Greece
Accepted for publication October 28, 2004.
* Address correspondence to Dr Tomos, 16A Parthenonos St, Paleo Faliro 175 62, Greece (Email: periklistomos{at}hotmail.com).
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Abstract
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Suppuration, mediastinitis, and disruption of median sternotomy are all rare, but nevertheless severe complications. We propose a simple mobilization of the two pectoralis major muscles for use as flaps to fill the sternal defect without the need for humeral detachment or a second cutaneous incision. These will be supplied from both the thoracoacromial vessels and the perforating arteries of the nongrafted internal mammary artery (IMA). Our technique is quick and easy, giving excellent results. Furthermore, by maintaining the perforating branches, we also preserve the nongrafted IMA.
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Introduction
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Complications of sternotomies have been managed with various techniques. Jurkiewicz and colleagues [1] described reconstruction of the defect using the pectoralis major muscles as flaps. Subsequently, many authors have described their experiences with this procedure or modifications of it [2], or have described the use of other muscles as flaps. In this article we present an alternative approach with the pectoralis muscles as flaps.
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Technique
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We applied the following technique in 14 patients (3 females, 11 males) all of whom had already undergone a previous heart operation through a sternotomy (ie, 11 aortocoronary bypasses, 1 acute ascending aortic dissection, 1 mitral valve replacement, and 1 Bentall procedure. Our patients belonged to various types (ie, 7 type V, 4 type III B, 2 type IVA, and 1 type III A (Oakley classification) [3]. Hospital mortality was zero. All our patients are still alive and healthy, except for 1 female who died from colorectal cancer.
Our management was comprised of two separate stages. The first was performed under local anesthetic, which consisted of reopening the wound and removing all of the necrotic soft tissue, necrotic bone, cartilage, and wires. When fistulous tracts were present, they were excised together with their blind ends, which usually led to abscesses.
During the next 3 to 5 days, wounds were medicated twice daily, alternately using povidone iodine and NaCl solution (15%).
The patient was then taken into the operating room for the second stage of treatment, which was performed under general anesthesia. The midline of the sternum was scraped to form a "V" because it is usually a source of infection. In cases of severe mediastinitis, and when the sternum was detached right from the start, the medulla was scraped to eliminate any source of abscess. Subsequently bi-pectoral musculofascial flaps were created. Both the pectoralis major muscles were separated from the subcutaneous tissue and also from their chest wall insertions. From the side where the IMA was used as a graft (IMAg), the dissection proceeded laterally to the level of the anterior axillary line. The humeral insertion and thoracoacromial vessels were left intact, whereas at the contralateral muscle flap, the mobilization was not as extensive, but was still great enough to leave the anterior intercostal perforators intact (Fig 1A) and permit the insertion of the medial end of the muscle flap into the dead space.
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Fig 1. (A) Preservation of the anterior perforating artery. (B) Placement of the first single row of interrupted, half-buried, vertical mattress stitches. (C) All sutures in the first row have been placed. (D) The second row of simple stitches.
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Subsequently the medial ends of the flaps were sutured with a single row of interrupted, half-buried, vertical mattress stitches using polyglycolic acid suture (Dexon No. 2; United States Surgical, Norwalk, CT), starting 2 cm laterally to the medial end of the IMAg flap in an anteroposterior direction, then proceeding to the contralateral IMAg flap, 2 cm laterally to its medial end, in an anteroposterior-anterior direction, then back again, but this time 1 cm caudal in an anteroposterior-anterior direction. Finally the wire passed from the posterior to anterior surface of the ipsilateral IMAg flap, which created an overlap of the flaps (Fig 1B, 1C) so that the contralateral IMAg flap was buried in the "V" scraped area and the ipsilateral IMAg was overlapping. All these sutures passed right through the muscle. Next a large diameter drainage tube (vacuum No. 18) was placed adjacent to the sternal defect. Immediately afterward, large transfixion sutures were applied to prevent excessive lateral tension. These were tied at the end of the operation.
While the assistant pushed on both sides of the soft tissue, the surgeon tied the mattress sutures before anchoring a second row of simple stitches between the fasciae of the two pectoralis muscles (Fig 1D), one of which was already overlapping. A new vacuum drainage tube was placed in the subcutaneous tissue which was sutured, and the skin was stapled.
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Comment
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Our technique has a number of advantages compared with other techniques described to date. First, after the skin and subcutaneous tissue are separated from the anterior pectoralis fascia of the muscles, the muscles are not divided and rotated [1], nor is there any need for a further cutaneous incision for a better approach to the humeral muscle extremity [3, 4]. To the contrary, we preserve the humeral insertion by mobilizing the muscles from their costal insertions, bringing them toward the midline and burying one of the two flaps in the sternal defect while the contralateral flap is folded over it. This kind of overlapping offers additional stability with respect to adaptation of the muscle. Second, we do not use foreign bodies to bring together the sides of the sternum; thus we do not use rewiring or polydioxanone sutures between the "outer cortex of the sternum" [5], and we do not use suturing of one of the flaps on the sternum resection line or on the cartilage [3] because the sternal defect is filled with viable tissue that is well supplied. Likewise, if part of the ribs or costal cartilage has been removed, this area is covered by the muscles themselves by simple apposition.
We believe in the aggressive "V" shaped sternectomy and the removal of infected cartilage, because failure of the reconstruction is directly related to persistent infection of bone and cartilage [6].
Blood supply in one of the two flaps is based both on the perforating arteries of the IMA and on the thoracoacromial artery, whereas the contralateral flap is based only on the thoracoacromial artery. This offers better viability and functionality of the flaps, contrary to Hugo and colleagues [2] who isolated and cauterized the anterior perforating arteries when they created myocutaneous flaps with the pectoralis muscles. In addition, Hugo and colleagues [2] were not interested in the dead space, whereas we fill this space using the sutures employed for burying one of the two flaps as previously described. By protecting and maintaining the perforating arteries, the IMA is also preserved for potential future use as a graft.
In conclusion, blood supply of the flaps is in no way compromised with our proposed technique because it respects both the perforating arteries (on one side) and the thoracoacromial arteries. Furthermore muscular detachment or co-mobilization of the rectus abdominis is not required, and at least one of the two IMAs remains intact for possible future use. By suturing the muscles, as proposed herein, a muscular implant is made. This seals the dead space, which has no tension due to the presence of a second layer. Early and later results are excellent, not only regarding infection and functionality, but also from an aesthetic point of view.
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Acknowledgments
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The authors would like to acknowledge the contribution of Danielle Bowler, translator and copy editor.
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References
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- Jurkiewicz MJ, Bostwick III J, Hester TR, Bishop JB, Craver J. Infected median sternotomy wound. Successful treatment by muscle flaps Ann Surg 1980;191:738-743.[Medline]
- Hugo NE, Sultan MR, Ascherman JA, 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]
- Reida M, El Oakley RM, Wright JE. Postoperative mediastinitisclassification and management. Ann Thorac Surg 1996;61:1030.[Abstract/Free Full Text]
- Jose R, Castello JR, Centella T, Garro L, et al. Muscle flap reconstruction for the treatment of major sternal wound infections after cardiac surgery10 year analysis. Scand J Plast Reconstr Hand Surg 1999;33:17-24.[Medline]
- Perkins DJ, Hunt JA, Pennington DJ, Stern HS. Secondary sternal repair following median sternotomy using interosseous absorbable sutures and pectoralis major myocutaneous advancement flaps Br J Plast Surg 1996;49:214-219.[Medline]
- Schroeyers P, Wellens F, Degrieck I, et al. Aggressive primary treatment for poststernotomy acute mediastinitisour experience with omental and muscle flaps surgery. Eur J Cardiothorac Surg 2001;20:743-746.[Abstract/Free Full Text]
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Abstract
Introduction
