J Reconstr Microsurg 2019; 35(08): 602-608
DOI: 10.1055/s-0039-1688760
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

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

George N. Kamel
1   Division of Plastic Surgery, Montefiore Medical Center, Bronx, New York, United States
,
Joshua Jacobson
1   Division of Plastic Surgery, Montefiore Medical Center, Bronx, New York, United States
,
Amanda M. Rizzo
1   Division of Plastic Surgery, Montefiore Medical Center, Bronx, New York, United States
,
Corin Kinkhabwala
1   Division of Plastic Surgery, Montefiore Medical Center, Bronx, New York, United States
,
Frank Lalezar
1   Division of Plastic Surgery, Montefiore Medical Center, Bronx, New York, United States
,
Lawrence Draper
1   Division of Plastic Surgery, Montefiore Medical Center, Bronx, New York, United States
,
Oren M. Tepper
1   Division of Plastic Surgery, Montefiore Medical Center, Bronx, New York, United States
,
Evan S. Garfein
1   Division of Plastic Surgery, Montefiore Medical Center, Bronx, New York, United States
,
Katie E. Weichman
1   Division of Plastic Surgery, Montefiore Medical Center, Bronx, New York, United States
› Author Affiliations
Further Information

Publication History

07 December 2018

19 March 2019

Publication Date:
10 May 2019 (online)

Abstract

Background The pectoralis major muscle flap is a versatile reconstructive option for deep sternal wound infections (DSWI). The timing and surgical technique of bilateral pectoralis major muscle advancement flaps versus unilateral pectoralis major muscle turnover and unilateral pectoralis major muscle advancement flap on patient outcomes remain to be elucidated. The purpose of this investigation was to compare timing, immediate versus delayed reconstruction, and the surgical technique in patients with deep sternal wounds infections on patient outcomes.

Methods A retrospective review of patients who underwent sternal reconstruction with pectoralis major muscle was conducted. Patients diagnosed with DSWI after undergoing cardiac surgery were included for analysis. Patients were divided by flap timing and flap type for analyses. Bivariate tests were performed to compare patient clinical characteristics. Outcomes of interest were rates of postoperative complications, same admission mortality, reoperation, readmission, operating room time, and length of stay.

Results A total of 88 patients were included for analyses (n = 57 bilateral advancement, n = 31 unilateral advancement with unilateral turnover; n = 62 immediate, and n = 26 delayed). Baseline characteristics did not differ between groups of flap type or timing. When postoperative complication rates were compared, the rate of tissue necrosis was significantly greater in patients with unilateral advancement with unilateral turnover flaps (n = 6 [19.4%]) compared with bilateral advancement flaps (n = 2 [3.5%]; p = 0.021). Mortality during admission did not differ with respect to flap type but differed significantly with respect to flap timing (immediate n = 7 [11.3%], delayed n = 9 [34.6%]; p = 0.015). Length of stay differed significantly by both type and timing (type: bilateral advancement = 26.9 ± 22.6 days, unilateral turnover = 38.0 ± 26.7 days, p = 0.042; timing: immediate = 26.8 ± 22.1 days, delayed = 40.2 ± 27.8, p = 0.019).

Conclusion Patients who underwent pectoralis major muscle advancement flaps had lower incidence of tissue necrosis. Furthermore, the timing of immediate sternal reconstruction was associated with a decreased hospital length of stay.

 
  • References

  • 1 Tang GH, Maganti M, Weisel RD, Borger MA. Prevention and management of deep sternal wound infection. Semin Thorac Cardiovasc Surg 2004; 16 (01) 62-69
  • 2 Parisian Mediastinitis Study Group. Risk factors for deep sternal wound infection after sternotomy: a prospective, multicenter study. J Thorac Cardiovasc Surg 1996; 111 (06) 1200-1207
  • 3 Pairolero PC, Arnold PG. Management of infected median sternotomy wounds. Ann Thorac Surg 1986; 42 (01) 1-2
  • 4 Julian OC, Lopez-Belio M, Dye WS, Javid H, Grove WJ. The median sternal incision in intracardiac surgery with extracorporeal circulation; a general evaluation of its use in heart surgery. Surgery 1957; 42 (04) 753-761
  • 5 Jurkiewicz MJ, Bostwick III J, Hester TR, Bishop JB, Craver J. Infected median sternotomy wound. Successful treatment by muscle flaps. Ann Surg 1980; 191 (06) 738-744
  • 6 Nahai F, Rand RP, Hester TR, Bostwick III J, Jurkiewicz MJ. Primary treatment of the infected sternotomy wound with muscle flaps: a review of 211 consecutive cases. Plast Reconstr Surg 1989; 84 (03) 434-441
  • 7 Li EN, Goldberg NH, Slezak S, Silverman RP. Split pectoralis major flaps for mediastinal wound coverage: a 12-year experience. Ann Plast Surg 2004; 53 (04) 334-337
  • 8 Spiess AM, Balakrishnan C, Gursel E. Fascial release of the pectoralis major: a technique used in pectoralis major muscle closure of the mediastinum in cases of mediastinitis. Plast Reconstr Surg 2007; 119 (02) 573-577
  • 9 Ascherman JA, Patel SM, Malhotra SM, Smith CR. Management of sternal wounds with bilateral pectoralis major myocutaneous advancement flaps in 114 consecutively treated patients: refinements in technique and outcomes analysis. Plast Reconstr Surg 2004; 114 (03) 676-683
  • 10 Kaul P. Sternal reconstruction after post-sternotomy mediastinitis. J Cardiothorac Surg 2017; 12 (01) 94
  • 11 Zahiri HR, Lumpkins K, Kelishadi S. , et al. Pectoralis major turnover versus advancement technique for sternal wound reconstruction. Ann Plast Surg 2013; 70 (02) 211-215
  • 12 Cabbabe EB, Cabbabe SW. Immediate versus delayed one-stage sternal débridement and pectoralis muscle flap reconstruction of deep sternal wound infections. Plast Reconstr Surg 2009; 123 (05) 1490-1494
  • 13 Gdalevitch P, Afilalo J, Lee C. Predictors of vacuum-assisted closure failure of sternotomy wounds. J Plast Reconstr Aesthet Surg 2010; 63 (01) 180-183
  • 14 Preminger BA, Yaghoobzadeh Y, Ascherman JA. Management of sternal wounds by limited debridement and partial bilateral pectoralis major myocutaneous advancement flaps in 25 patients: a less invasive approach. Ann Plast Surg 2014; 72 (04) 446-450
  • 15 Daigeler A, Simidjiiska-Belyaeva M, Drücke D. , et al. The versatility of the pedicled vertical rectus abdominis myocutaneous flap in oncologic patients. Langenbecks Arch Surg 2011; 396 (08) 1271-1279
  • 16 Kolbenschlag J, Hörner C, Sogorski A. , et al. Sternal Reconstruction with the Omental Flap-Acute and Late Complications, Predictors of Mortality, and Quality of Life. J Reconstr Microsurg 2018; 34 (05) 376-382
  • 17 van Wingerden JJ. Outcome following sternal reconstruction with the omental flap. J Reconstr Microsurg 2018 Doi: 10.1055/s-0038-1668136
  • 18 Lindsey JT. A retrospective analysis of 48 infected sternal wound closures: delayed closure decreases wound complications. Plast Reconstr Surg 2002; 109 (06) 1882-1885 , discussion 1886–1887
  • 19 Fleck TM, Koller R, Giovanoli P. , et al. Primary or delayed closure for the treatment of poststernotomy wound infections?. Ann Plast Surg 2004; 52 (03) 310-314
  • 20 Sears ED, Momoh AO, Chung KC, Lu YT, Zhong L, Waljee JF. A national study of the impact of delayed flap timing for treatment of patients with deep sternal wound infection. Plast Reconstr Surg 2017; 140 (02) 390-400
  • 21 Wu L, Chung KC, Waljee JF, Momoh AO, Zhong L, Sears ED. A national study of the impact of initial débridement timing on outcomes for patients with deep sternal wound infection. Plast Reconstr Surg 2016; 137 (02) 414e-423e
  • 22 Nickl S, Steindl J, Langthaler D. , et al. First experiences with incisional negative pressure wound therapy in a high-risk poststernotomy patient population treated with pectoralis major muscle flap for deep sternal wound infection. J Reconstr Microsurg 2018; 34 (01) 1-7