A Review of 559 Sternal Wound Reconstructions at a Single Institution

Abstract

Background Sternal wound infection (SWI) and dehiscence after median sternotomy for cardiac surgery remain challenging clinical problems with high morbidity. Bilateral pectoralis major myocutaneous flaps are excellent for most sternal wounds but do not reach deeper mediastinal recesses. The omental flap may be a useful adjunct for addressing these deeper mediastinal infections. Methods Records of 598 sternal wound reconstructions performed by a single surgeon (J.A.A.) from 1996 to 2022 were reviewed. At the time of surgery, patients underwent sternal hardware removal, debridement, and closure with bilateral pectoralis major myocutaneous flaps. Pedicled omental flaps were also mobilized when additional vascularized tissue was required within the deeper mediastinum. Results Complete data were available for 559 sternal wound reconstructions performed by the senior author during this period. Bilateral pectoralis and omental flaps were mobilized in 17 of 559 (3.04%) patients. Common indications for initial cardiac surgery included repair or replacement of diseased aortic roots (9/17; 52.94%), aortic valves (8/17; 47.06%), and mitral valves (6/17; 35.29). Mean American Society of Anesthesiologists score was 3.56. Preoperative morbidity included culture-positive wound infection (12/17; 70.59%), dehiscence (15/17; 88.24%), wound drainage (11/17; 64.71%), and inability to close the chest after the original sternotomy because of hemodynamic instability (6/17; 35.29%). Intraoperative deep mediastinal or bone cultures were positive in 8 of 17 (47.06%) patients. Postoperative complications included partial dehiscence (2/17; 11.76%), skin edge necrosis (1/17; 5.88%), seroma (1/17; 5.88%), abdominal hernia (1/17; 5.88%), and recurrent infection (2/17; 11.76%). Three patients (17.65%) died within 30 days of the reconstruction surgery. Conclusions Patients undergoing combined pectoralis major and omental flap closure frequently had a history of aortic root and valve disease, and other significant preoperative morbidities. However, postoperative complication rates after combined flap closure were relatively low. Combined pectoralis major and omental flap reconstruction thus appears to be an effective intervention in patients with sternal wounds extending into the deep mediastinum.

Reconstruction of Complex Anterior Chest Wall Defects: The Lasagna Technique

“…Furthermore, the harvest of three different flaps determines a relevant increase in intraoperative time. The harvest of the bilateral pectoralis flap may cause some kind of morbidity, which is, however, usually well tolerated according both to the literature 15 , 28 and to our previous published experience. 24 – 26 , 29 , 30 …”

“…Furthermore, the harvest of three different flaps determines a relevant increase in intraoperative time. The harvest of the bilateral pectoralis flap may cause some kind of morbidity, which is, however, usually well tolerated according both to the literature 15,28 and to our previous published experience. [24][25][26]29,30 A limitation of this report is a short follow-up time, which did not allow us to analyze long-term results in terms of respiratory function.…”

“…Kuonqui et al demonstrated that the pectoralis flap in combination with the omental flap is an effective intervention in with sternal wounds. 15 According to the literature, adequate skeletal stability without rigid reconstruction may be achieved if a significant part of the sternum is preserved. 9 Expert consensus suggests that chest wall defects larger than 5 cm should be reconstructed with rigid implants.…”