Management of the extensive thoracic defects after deep sternal wound infection with the rectus abdominis myocutaneous flap

Abstract

Deep sternal wound infection is a severe complication after open heart surgery. According to the different severity and dimensions of the deep sternal wound infection, the treatment method is different. In this study, we aimed to describe our experience with the rectus abdominis myocutaneous flap for large sternal wound management, especially when 1 or 2 internal mammary arteries were absent.Between October 2010 and January 2016, a retrospective review of 9 patients who suffered from the extensive thoracic defects after deep sternal wound infection was conducted. All of these sternal defects encompassed almost the full length of the sternum after debridement. Defect reconstruction was achieved by covering with a rectus abdominis myocutaneous flap. When the ipsilateral or bilateral internal mammary artery had been harvested previously, we took advantage of the inferior epigastric artery to provide additional blood supply to the rectus abdominis myocutaneous flap. Thus, this flap had a double blood supply.There was no recurrent infection in all 9 patients. Three patients received the rectus abdominis myocutaneous flap with a double blood supply. Flap complications occurred in 2 patients (22%). One patient who did not have the double blood supply flap suffered from necrosis on the distal part of the flap, which was then debrided and reconstructed with a split-skin graft. The other patient had a seroma at the abdomen donor site and was managed conservatively. None of the patients died during the hospital stay.This study suggests that the rectus abdominis myocutaneous flap may be a good choice to repair the entire length of sternal wound. When 1 or 2 internal mammary arteries have been harvested, the inferior epigastric artery can be anastomosed to the second intercostal artery or the internal mammary artery perforator to provide the rectus abdominis myocutaneous flap with a double blood supply.

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

“… 50 Anastomosing the IEA to the intercostal artery or IMA perforator to create an RA flap with a dual blood supply in cases where either a single or both IMAs have been used for the bypass graft has also been described, with no reported complications of distal flap necrosis, and all flaps healing without recurrence of infection. 51 This study is limited however by the very small sample size, and therefore it is not possible to draw any strong conclusions from this data.…”

The Free Myocutaneous Tensor Fasciae Latae Flap—A Workhorse Flap for Sternal Defect Reconstruction: A Single-Center Experience

“…Hereby, the most prevalent reconstructive options usually comprise pedicled muscle flaps, as they provide well-vascularized tissue with enough bulk to fill the defect cavity. The pedicled VRAM flap, LD flap, and bilateral pectoralis major flap have been the method of choice for decades [ 5 , 6 , 8 ]. In this context, it is recommended to cover cranial sternal wounds with pectoralis major flaps, whereas VRAM flaps are of better use to cover caudal sternal wounds.…”

“…When both internal mammary arteries (IMAs) have been harvested for coronary-artery bypass grafts (CABG) or after previous local flap failure, reconstruction can be difficult. This is partially due to the fact that the arc of rotation of pedicled flaps is limited [ 5 , 6 ] and closure of defects, which include the entirety of the sternum, can be critical, putting the most distal part of the pedicled flap at risk of impaired perfusion [ 7 , 8 ]. To offer these multimorbid patients the best possible care and optimal long-term outcomes, we are increasingly using the free myocutaneous tensor fasciae latae (TFL) flap for extended deep sternal defect reconstruction.…”

Successful Reconstruction of a Lower Chest Wall Defect with Delayed Fungal Deep Sternal Wound Infection following a Blast Injury in South Korea: A Case Report

“…After serial surgical debridements, the lower third anterior chest wall defect was confirmed to be clean with skeletal stability. Therefore, we decided to cover the defect using a VRAM flap because it is a well-vascularized soft tissue flap suitable for controlling infection and obliterating dead space [11,13]. It is also a versatile and robust muscle flap that yields a considerable volume of local tissue with similar texture and appearance to the chest region [11].…”