Ann Thorac Surg 2008;86:1012-1015. doi:10.1016/j.athoracsur.2008.02.054
© 2008 The Society of Thoracic Surgeons
Case Reports
Reconstruction of Large Post-Sternotomy Wound With Bilateral "V-Y Fasciocutaneous Advancement Flaps"
Fatih Uygur, MD,
Celalettin Sever, MD*,
Ersin Ulkur, MD,
Bahattin Cel
koz, MD
Gülhane Military Medical Academy and Medical Faculty, Haydarpasha Training Hospital, Kadköy, 
stanbul, Turkey
Accepted for publication February 18, 2008.
* Address correspondence to Dr Sever, GATA Haydarpa
a E
itim Hastanesi. Plastik ve Rekonstrüktif Cerrahi Servisi. Selimiye, Mah. Tbbiye Cad., Kadköy, stanbul, 34668, Turkey (Email: drcsever{at}hotmail.com).
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Abstract
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Post-sternotomy wounds are highly dangerous complications after a median sternotomy. Many different methods have been described for reconstruction of post-sternotomy wounds. The treatment is multifactorial. The treatment depends on the severity of the wound and various patient factors. We evaluate a novel method for closure of sternal dehiscence of a patient who has multiple comorbid problems, including diabetes mellitus, hypertension, and chronic obstructive pulmonary disease. In our method, after debridement, the "bilateral V-Y fasciocutaneous advancement flaps" were used for reconstruction. This method presents a successful resolution of an infected median sternotomy wound. It is a simple, rapid, and effective procedure associated with low mortality, morbidity, and short hospital stay.
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Introduction
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Two well-described complications of the median sternotomy incisions are sternal wound infections and sternal dehiscence [1]. The morbidity and mortality of sternotomy wounds make therapy relatively challanging. Various methods of reconstruction have been described and effectively used for closure of sternal wounds due to trauma, tumor resection, and infection after sternotomy [2].
"Bilateral V-Y fasciocutaneous advancement flaps" is a useful method for closure of defects of the upper, lower extremities, and areas such as sacral defects [3], vulvovaginoperineal reconstruction after vulvar cancer resection [4], meningomyelocele defects [5], and excisional defects of pilonidal sinus [6]. Bilateral V-Y advancement flaps help to close a circular defect by advancing subcutaneous, pedicled triangular flaps. Good cosmetic and functional results can be obtained by using these flaps.
In this case, we are presenting a patient with a sternotomy defect closed by using the bilateral V-Y fasciocutaneous advancement flaps technique.
A 63-year-old woman with a history of coronary artery disease who had previously undergone coronary artery bypass grafting by using a left internal mammary artery graft was uneventfully discharged. One month after the surgery, the patient presented at the emergency room complaining of fever. An elevated white blood cell count in the total blood counts and a sternal wound with purulent collection was noticed. The sternal wound was explored by a local incision, pus exuded from the wound, and drainage was performed. Laboratory culture showed this pus to contain methicillin-resistant Staphylococcus aureus. Suitable antibiotic therapy was begun with the consultation of the infectious disease department. After 15 days of intensive nonsurgical treatment by frequent wound irrigation and antibiotic therapy with vancomycin (Fig 1), the necrotic tissues, chronic granulation tissue, and nonviable bone and cartilage were removed from the lower third of the sternum. The right pectoralis major muscle advancement flap was attempted to eliminate the sternal wound. Unfortunately, the level of contamination was still too high and the flap was under tension. After 8 days, the first attempt for reconstruction had failed.
The patient had large breasts and was morbidly obese with multiple comorbid problems, including diabetes mellitus, hypertension, and chronic obstructive pulmonary disease. It was also determined that adequate vascularized tissue was necessary to stabilize the sternum and provide durable soft tissue for coverage. The treatment course was selected after careful analysis of each factor. Musculocutaneous perforators above the right pectoralis major flap were preserved at the first reconstruction attempt. We decided to use bilateral V-Y fasciocutaneous advancement flaps without muscle flaps for closure.
The patient was placed in the supine position with the arms padded alongside the body. It was important not to place the arms on the arm boards because that would cause stretching of the breasts. The chest was cleaned from the neck to the umbilicus with Betadine scrub (Kansuk, Istanbul, Turkey). Surgery started with the excision of all wound edges, all the necrotic nonvitalized tissues, and necrotic sternal bone. The previous sternal wires were removed, and subsequently, the wound was lavaged with 2 L of warm normal saline.
The next step was to make bilateral skin incisions beginning at the lowest and the highest point of the sternotomy wound, then continuing laterally. Superiorly and inferiorly, the incisions were stopped at the level of the infraareolar area. After creating bilateral "V"-shaped incisions, the bilateral V-Y fasciocutaneous advancement flaps over the pectoralis muscle and fascia were elevated as far as the midclavicular line from medial to lateral (Fig 2). The skin and subcutaneous tissue of the flaps were totally mobilized and were advanced to the sternal wound. To decrease operative time, bleeding, and the risk of tissue ischemia at the flap edges, flaps were dissected only as far laterally as needed to appose them with no tension in the midline. Separation of the flap from the underlying pectoralis muscle and fascia were carefully performed to preserve ensuring flap viability.
After the flaps were elavated bilaterally, intercostal nerve blocks were performed with 0.25% Bupivacain for postoperative analgesia. Subsequently, the flaps were advanced to the midline and opposed to each other without tension. Through small stab incisions, drains were placed under the flaps. The subcutaneous tissue of flaps were approximated. The skin was approximated in layers with 3-0 Vicryl (Johnson & Johnson International, Brussels, Belgium) along the subdermal level, and finally the skin was closed with 4-0 Prolene sutures (Ethicon, Somerville, NJ) and a stapler (Fig 3). Subsequently, Steri-Strips (3M Healthcare, St. Paul, MN) and dry gauze dressings were used.
After the operation, chest roentgenogram was obtained to check if a pneumothorax existed. For the first 6 weeks after the operation, the patient needed to avoid any activity that would place stress on the breasts. Drains were removed when output was consistently less than 25 cc per drains in a 24-hour period. The result of the intraoperative culture determined the choice and length of postoperative antibiotic therapy. The antibiotic therapy was completed according to the direction of the infectious disease consultant. After 2 weeks of intravenous antibiotics, the quantitative cultures of the patient was sterile. The patient was discharged. Oral antibiotics were given for 10 more days.
The operation was successful. The patient was followed-up for 1 year. No recurrent sternal wound, infection, or circulation problems were observed. There were no major or moderate complications. At the late postoperative period, the patient was very active in daily life (Fig 4).
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Comment
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Postoperative sternal wounds continue to be one of the biggest problems in cardiac surgery. Among the normal weight population, the incidence is estimated to be anywhere between 1% to 6% [7]. Morbidly obese and large-breasted women are at increased risk for sternal wound complications. The combination of obesity, malnutrition, osteoporosis, diabetes mellitus, and chronic obstructive pulmonary diseases represent increased risks of postoperative infections and wounds [8, 9].
Currently, the most common and acceptable methods used for sternal wound coverage are muscle flaps. The pectoralis major muscle plays a significant and pivotal role, particularly in covering wounds at the lower third of the sternum or xiphoid region [2, 7–10]. However, if the pectoralis muscle is unavailable, using omentum, rectus muscle, latissimus muscle, or a free flap may be acceptable alternatives [11, 12]. These techniques have also been recommended to cover sternal wounds, possibly together with the pectoral muscle.
Some surgeons use the pectoralis major muscle as a turnover flap for covering sternal wounds [8, 9]. This requires dividing the muscle's humeral insertion. This maneuver may result in an abnormally raised contour deformity of the anterior chest wall, causing tension on the skin closure. In addition to the risk of skin edge necrosis, partial or total breast necrosis are seen more often in such patients. This may be due to further devascularization of ischemic tissues [11]. Although the pedicled greater omentum flap has a rich blood supply, this flap may cause some laparotomy-associated complications, such as an abdominal wall hernia or peritonitis spread from the sternal wound infection. The latissimus dorsi muscle has been used to cover limited defects; as a microvascular flap, the full muscle provides the widest possible coverage. The rectus muscle can provide excellent coverage of sternal wounds, especially those involving the lower sternal region [10]. The rectus abdominis muscle receives blood supply from both the superior epigastric system and the inferior epigastric system. Division of the inferior system, necessary for muscle transfer, makes it imperative for the superior system to be patent. Sacrifice of one rectus muscle should offer functional limitations in the future. In addition, free tissue transfer would require an extended operating time, which is not advisable in this critical period. The risk of morbidity, including hematoma formation, increases with more complex procedures.
The other alternative is the breast musculocutaneous flap. This flap is a kind of pectoralis major myocutaneous flap including breast appendage. The flap can be elevated rapidly and can provide a successful closure. This flap may cause an unaesthetic appearence because of medial displacement of breast mound; in addition, there can be an injury of musculocutaneous perforators when performing the seperation of the pectoralis major muscle from the breast appendage [11].
Another alternative used for sternal wound coverage are fasciocuaneous flaps. Some fasciocuaneous flaps can be transferred to the chest for sternal closure without sacrificing the muscle. Various techniques, such as extended deep inferior epigastric artery flaps have been well described in reconstructing sternal defects [13]. However, these techniques result in considerable morbidity of the patients. We consider that muscle flaps are the first option of treatment. We used pectoralis flap as the first option for our patient, but it failed. We offered our patient the choice between a latissimus dorsi muscle flap, rectus abdominus muscle flap, or the omentum flap, as alternatives. The patient did not accept these alternatives due to the comorbid factors. Thus, we subsequently chose this simple method. The use of V-Y plasty for tissue rearrangement is a core principle of plastic surgery, and any competent plastic surgeon may apply this technique to wound closure anywhere in the body.
Reconstruction of the chest defect is difficult and challenging, requiring chest stabilization, protection of underlying mediastinal structures, and cover. Multiple fasciocutaneous and muscle flaps had been used for the primary coverage of large sternal defects. The bilateral V-Y fasciocutaneous advancement flaps are safe, effective, and easy to perform. They can be elevated rapidly, and thus, the sternal wound can be easily covered. It can be advanced farther as a result of the character of the inframammarial fold area. We do not recommend this operation on nonobese male or female patients or for the patients who have dehisence of the upper portion of the sternal wound. This flap may only be designed for female patients who have big, heavy breasts. The donor site deformity seems to be acceptable, but it leads to synmastia. In this case report, we aimed to emphasize the bilateral V-Y fasciocutaneous advancement flaps, because sternal dehisence closure may be an effective and simple option associated with low mortality, morbidity, and a short hospital stay.
Due to a simple, rapid, and effective procedure associated with low mortality, morbidity, and short hospital stay, the bilateral V-Y fasciocutaneous advancement flaps method can be an alternative option for patients: (1) who have dehisence of the lower portion of the sternal wound; (2) when other muscle flaps option can not be use or have failed; (3) who have multiple comorbid problems, including diabetes mellitus, hypertension, and chronic obstructive pulmonary disease, to impede further major surgical procedures; (4) who are female; or (5) who have big breasts.
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References
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- Netscher DT, Eladoumikdachi F. Sternal wound debridement and muscle flap reconstruction:functional mplications Ann Plast Surg 2003;51:115-122.[Medline]
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- Lee PK, Choi MS, Ahn ST, et al. Gluteal fold V-Y advancement flap for vulvar and vaginal reconstruction: a new flap Plast Reconstr Surg 2006;118:401-406.[Medline]
- Komura Y, Yanai A, Koga Y, et al. Bilateral modified V-Y advancement flaps for cloing meningomyelocele defects Ann Plast Surg 2006;57:195-198.[Medline]
- Sungur N, Koçer U, Uysal A, et al. V-Y rotation advancement fasciocutaneous flap for excisional defects of pilonidal sinus Plast Reconstr Surg 2006;117:2448-2454.[Medline]
- Kiessling A-H, Isgro F, Weisse U, et al. Advanced sternal closure to prevent dehiscence in obese patients Ann Thorac Surg 2005;80:1537-1539.[Abstract/Free Full Text]
- Molina JE, Lew RS, Hyland KJ. Postoperative sternal dehiscence in obese patients: ncidence and prevention Ann Thorac Surg 2004;78:912-917.[Abstract/Free Full Text]
- Momin AU, Deshpande R, Potts J, et al. Incidence of sternal nfection in diabetic patients undergoing bilateral nternal thoracic artery grafting Ann Thorac Surg 2005;80:1765-1772discussion 1772.[Abstract/Free Full Text]
- Oh AK, Lechtman AN, Whetzel TP, Stevenson TR. The nfected median sternotomy wound management with the rectus abdominis musculocutaneous flap Ann Plast Surg 2004;52:367-370.[Medline]
- Hallock GG. The breast musculocutaneous flap for complete coverage of the median sternotomy wound Plast Reconstr Surg 2003;112:199-203.[Medline]
- Netscher DT, Eladoumikdachi F, Goodman CM. Rectus abdominis muscle flaps used successfully for median sternotomy wounds after psilateral nternal mammary artery ligation Ann Plast Surg 2001;47:223-228.[Medline]
- Sharma RK, Mehrotra S, Dhaliwal RS. Extended deep inferior epigastric arteryflaps Br J Plast Surg 2005;58:1004-1006.[Medline]
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Abstract
Introduction
