Analysis of Immediate versus Delayed Sternal Reconstruction with Pectoralis Major Advancement Versus Turnover Muscle Flaps

Kamel, George; Jacobson, Joshua; Rizzo, Amanda M.; Kinkhabwala, Corin; Lalezar, Frank D.; Draper, Lawrence B.; Tepper, Oren M.; Garfein, Evan S.; Weichman, Katie E.

doi:10.1055/s-0039-1688760

Cited by 9 publications

(4 citation statements)

References 20 publications

(30 reference statements)

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“…The redistribution of forces helps prevent dehiscence, reinfections, and fistulas, and is the main reason for reducing postoperative morbidity, mortality, and length of postoperative hospitalization compared with those reported in the literature. 3,[28][29][30][31]…”

Section: Discussionmentioning

confidence: 99%

The Modified Sternoplasty: A Novel Surgical Technique for Treating Mediastinitis

Kachel

Arazi

Grosman‐Rimon

et al. 2022

Plastic and Reconstructive Surgery - Global Open

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Deep sternal wound infection (DSWI), also known as post-sternotomy mediastinitis, is a potentially devastating complication following cardiac surgery, as it is associated with a significant increase in patient morbidity and mortality, prolonged hospitalization, and heavy economic burden. 1-3 DSWI is prevalent in 2% of patients following cardiac surgery and up to 8% in high-risk patients, with mortality rates as high as 40%-47% in the last 50 years 4-6 and significant impacts on patient outcomes. [7][8][9][10][11][12][13][14][15][16][17][18] Current treatment includes negative pressure wound therapy, which can serve both as an adjuvant therapy to treat DSWI as well as bridge these patients to final surgical closure. 19,20 In large and complicated sternal defect cases, surgical approaches may be warranted and include wound reconstruction by muscle flaps, most commonly through bilateral pectoralis muscle as sliding or "turn over" techniques, or by a rectus abdominus muscle or omental flap. [21][22][23][24] We present here the novel modified sternoplasty technique for treating severe DSWI following cardiac surgery, which involves a unique method for sternal reconstruction combined with the use of bilateral pectoralis muscle flaps. METHODSBetween September 2010 and January 2020, 68 patients following cardiac surgery (2.5% of patients, which is similar to levels reported globally) [7][8][9][10][11][12][13][14][15][16][17][18] developed DSWI according to the Center for Disease Control definitions, 25 with wide sternal dehiscence and total exposure of the heart and great vessels. These patients failed to heal with conservative treatment, and therefore underwent the modified sternoplasty surgery.

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Section: Discussionmentioning

confidence: 99%

The Modified Sternoplasty: A Novel Surgical Technique for Treating Mediastinitis

Kachel

Arazi

Grosman‐Rimon

et al. 2022

Plastic and Reconstructive Surgery - Global Open

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“…16 Multiple studies have demonstrated the benefit of early referral and reconstruction after diagnosis of a sternal wound, with decreased morbidity, Plastic and Reconstructive Surgery • August 2021 length of stay, mortality, and resource use. 2,5,17 However, these studies generally do not take into account the timing from cardiac surgery to sternal wound intervention. Many of our patients present initially with only drainage or a sternal click, but more than 60 percent have positive deep wound or bone cultures and more extensive findings on operative exploration.…”

Section: Discussionmentioning

confidence: 99%

An Outcomes Review of 330 Sternal Wound Reconstructions: Timing of Closure Does Make a Difference

Levy

Altchek

McMillen

et al. 2021

Plastic &Amp; Reconstructive Surgery

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Background: Sternal wound infection and dehiscence following cardiac surgery remain difficult clinical problems with high morbidity. Older classification systems regarding timing to reconstruction do not take into account recent improvements in critical care, wound vacuum-assisted closure use, or next-generation antibiotic therapies, which may prolong time to reconstruction. Methods: Records of patients undergoing sternal wound reconstruction performed by the senior author (J.A.A.) from 1996 to 2018 at a high-volume cardiac surgery center were reviewed. Indications included sternal wound infection or dehiscence. All patients underwent single-stage removal of hardware, débridement, and flap closure. Patients were divided into two groups based on timing of wound closure after cardiac surgery: less than 30 days or greater than or equal to 30 days. Results: Of the 505 patients identified during the study period, 330 had sufficient data for analysis. Mean time to sternal wound surgery was 15.7 days in the early group compared to 64.4 days (p < 0.01) beyond 30 days. Postdébridement cultures were positive in 72 percent versus 62.5 percent of patients (p = 0.11), whereas rates of postoperative infection were significantly higher in the delayed group: 1.9 percent versus 9.5 percent (p < 0.01). Partial wound dehiscence rates were also higher after 30 days (1.9 percent versus 11.3 percent; p < 0.01), whereas total length of stay was decreased. Use of wound vacuum-assisted closure was significantly associated with reconstruction beyond 30 days (p < 0.01). Conclusions: Although performing sternal wound reconstruction more than 30 days after initial cardiac surgery was associated with a shorter overall hospital length of stay and higher extubation rates in the operating room, these patients also had elevated postoperative infection and wound complication rates. The authors thus recommend not delaying definitive surgical reconstruction when possible.

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“…Other investigators have demonstrated loss of shoulder function with disinsertion of the pectoralis muscle either as a turnover flap or as an advancement flap. 22 , 30 – 32 On the other hand, Kamel et al 23 showed that patients who had pectoralis advancement flaps had less tissue necrosis than those who had turnover flaps. Furthermore, the pectoralis turnover flap relies on blood supply from the internal mammary artery.…”

Section: Discussionmentioning

confidence: 99%

Sternotomy Wound Closure: Equivalent Results with Less Surgery

Atwez¹,

Friedman

Durkin

et al. 2020

Plastic and Reconstructive Surgery - Global Open

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Background: Mediastinitis after a median sternotomy can be life-threatening. The advent of pedicle flap–based treatment has resulted in an improvement in both morbidity and mortality. However, significant morbidities can still occur following the use of flaps for sternal closure, particularly in patients with comorbidities. To minimize an extensive surgical dissection, we modified our approach to reconstruction using a modified subpectoral approach, leaving the overlying skin attached. This technique focuses primarily on controlling wound tension rather than on maximal muscle coverage. This study is a retrospective review of 58 consecutive patients treated with this approach, by a single surgeon. Methods: Fifty-eight consecutive patients treated between 2008 and 2019 were included. All patients received the same procedure regardless of the degree of illness, the extent of tissue loss, and the size of sternal defect. Treatment included thorough debridement, with total sternectomy (if required); limited dissection of the pectoralis major muscle off the chest wall to the level of the pectoralis minor without skin and subcutaneous undermining; no release of the insertion of the pectoralis or use of the rectus abdominis; and midline closure over drains connected to wall suction to obliterate dead space. Results: Reoperations were required in 7 patients (12%). Of these, only 4 (6.9%) were related to continued sternal osteomyelitis. The other reoperations were for hematoma evacuation, breast fat necrosis, and skin necrosis. There were no operative mortalities. Conclusion: Chest closure using minimal dissection and tension release is safe, efficient, and associated with a complication rate equivalent to more extensive procedures reported in the literature despite significant comorbidities.

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Analysis of Immediate versus Delayed Sternal Reconstruction with Pectoralis Major Advancement Versus Turnover Muscle Flaps

Cited by 9 publications

References 20 publications

The Modified Sternoplasty: A Novel Surgical Technique for Treating Mediastinitis

The Modified Sternoplasty: A Novel Surgical Technique for Treating Mediastinitis

An Outcomes Review of 330 Sternal Wound Reconstructions: Timing of Closure Does Make a Difference

Sternotomy Wound Closure: Equivalent Results with Less Surgery

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