Comparison of the Treatment of Sternal Infections by Flap Reconstruction Versus Rigid Transverse Titanium Plate Fixation by One Surgeon in One Hundred Forty Nine Consecutive Cases over Thirteen Years

Abstract

Figure 2. Same patient seen in Figure 1. This is the site of BCC exhibiting signifi cant regression after HHIT at the time of resection and local fl ap reconstruction. Segmental mandibulectomy was avoided in this patient. CONCLUSIONS:Although HHIT was not curative in our patient series, HHIT is a viable option for neoadjuvant treatment of extensive BCC that can decrease the morbidity of surgical treatment. For future patients, a combined HHIT and surgical treatment protocol is outlined. BACKGROUND:Large composite tissue defects exhibiting segmental bone losses often require vascularized osseous constructs/fl aps for defi nitive reconstruction. However, failed osseous fl aps due to poor perfusion can lead to signifi cant complications and morbidity. Our group will outline the application of indocyanine green (ICG) fl uorescence angiography within the operative setting to identify and objectively evaluate the bipartite perfusion pattern of vascularized osseous fl aps to reduce perfusion-related complications. METHODS:A retrospective review was completed on osseous and osteocutaneous bone flaps where intraoperative ICG angiography was used to assess their perfusion patterns. The types of fl aps, their success/failure rates, and perfusion-related complications were compiled and assessed. RESULTS:Over a 38-month period, 16 osseous free fl aps evaluated with intraoperative ICG angiography to assess their corresponding bipartite perfusion patterns. Osseous fl aps evaluated included 9 osteocutaneous fi bulas, 1 osteocutaneous fi bula revision, 2 osseous-only fi bulas, 2 scapular/parascapular with scapula bone, and 2 quadricep-based muscle flaps containing a vascularized femoral bone component. All fl ap reconstructions were successful, with the only perfusion-related complications being 1) a case of delayed partial skin fl ap loss, and 2) a successfully avoided near miss. The near miss consisted of a vascular pedicle compression secondary to mandibular hardware placement that was easily identifi ed via this tool and replaced to ensure adequate perfusion to the osseous fl ap. CONCLUSIONS:Intraoperative fl uorescence angiography is useful in angiosome mapping, aiding in fl ap design, assessing soft tissue fl ap perfusion, and evaluating vascular pedicle or perforator flow. Our group has successfully extended the application of this intraoperative tool to critically assess vascularized osseous constructs/flaps for confirmation of bipartite endosteal and periosteal blood fl ow in an effort to reduce adverse outcomes related to preventable perfusionrelated complications.BACKGROUND: Treatment of sternal infection with muscle fl aps has improved morbidity and mortality over the last thirty years. 1 Post reconstruction sequelae frequently include pain, paradoxical chest wall motion, and decreased pulmonary function. Ringelman et al demonstrated that patients reconstructed with muscle fl aps often had long term sequelae due to lack of sternal integrity. 2 We compared muscle fl ap reconstruction with reconstruction using the DePu...

The management of deep sternal wound infection: Literature review and reconstructive algorithm

“…Several other authors have similarly described good outcomes with the use of a simultaneous sternal plating and PM advancement flap approach, suggesting this method to be associated with earlier extubation, low incidence of recurrence, and high sternal integrity. 65 , 66 In a large 15-year review of 92 patients, Baillot et al. reported decreased perioperative mortality in patients treated with VAC followed by TSFS and pectoralis major flaps compared with isolated muscle flaps.…”