The Importance of Early Flap Coverage in Deep Sternal Wounds

Lo, Steven; Hutson, Kristian; Hallam, Marc-James; Soldin, Mark

doi:10.1097/sap.0b013e318284084b

Cited by 14 publications

(11 citation statements)

References 19 publications

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“…[19][20][21] These results indicate that early identification of patients who would benefit from a flap reconstruction could provide the patients with a shorter hospital stay and quicker recovery. In line with this observation, Lo et al 15) found that each day of delay for flap coverage significantly increased the risk of chronic infection. Furthermore, Cabbabe et al 16) found patients undergoing one step radical debridement with muscle flap coverage had significantly shorter hospital stay and lower mortality compared to patients with DSWI who were referred to flap coverage after undergoing extended management by the thoracic surgeons.…”

Section: Discussionmentioning

confidence: 48%

“…Little evidence exists in the literature regarding the specific timing of flap reconstruction after DSWI. 15) Although some authors have proposed immediate debridement and flap coverage as the superior procedure, 5,16) others advocate TNP therapy and rewiring. 17) Although TNP therapy has the big advantage of allowing the medical staff relatively easy access to evaluate the healing progress of the DSWI defect, a subset of patients will not heal in time using TNP therapy alone.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Deep Sternal Wound Infection after Open-Heart Surgery: A 13-Year Single Institution Analysis

Juhl

Hody

Videbaek

et al. 2017

ATCS

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Section: Discussionmentioning

confidence: 48%

Section: Discussionmentioning

confidence: 99%

Deep Sternal Wound Infection after Open-Heart Surgery: A 13-Year Single Institution Analysis

Juhl

Hody

Videbaek

et al. 2017

ATCS

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“…The second factor to impact outcome is the timing between recognition of a deep sternal infection and surgical intervention. 16 , 19 , 22 – 24 Lo et al 25 calculated that each day of delay from diagnosis to flap coverage increased the risk of chronic wound infection by a factor of 1.2/day. The third factor is the adequacy of debridement of all infected tissue and contaminated foreign bodies.…”

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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“…During the last decades, the treatment of sternal wound infections has evolved considerably leading to major improvements in both survival and morbidity [10]. There is, however, no consensus relating to the most suitable treatment strategy, timing and reconstructive technique [3,10,11]. Multiple treatment algorithms have been proposed in an attempt to standardize the management of this morbid complication but none has achieved widespread general acceptance [4,5,10,12,13].…”

Section: Introductionmentioning

confidence: 99%

“…The advancement flaps may not reach sufficiently to cover the defects in the most caudal third of the sternum. A direct closure of the skin is often attempted, although sometimes this can lead to unwanted tension and wound-healing problems[10,11,13]. With large defects, skin grafts have to be used leading to suboptimal cosmetic results[3,8].The rectus abdominis muscle flap may be used if the pectoralis major muscle flap is unavailable or when it has an insufficient reach to the most caudal third of the sternum.…”

mentioning

confidence: 99%

Modified internal mammary artery perforator flap in treatment of sternal wound complications

Myllykangas

Mustonen

Halonen

et al. 2018

Scandinavian Cardiovascular Journal

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Objectivs There are multiple treatment strategies and flap options to cover defects after deep sternal wound infections and other similar sternal defects. The choice of flap is made according to surgeons' preferences and the size and location of the defect. Our aim is to introduce a new option to cover these kinds of defects with an internal mammary artery perforator flap combined with a pectoralis major muscle flap mostly raised with a muscle-sparing technique. Design We treated 13 patients with a sternal defect after cardiothoracic operations with this technique between 2010-2016. Ten patients had a deep sternal wound infection, two had an infection of the prosthesis after carotico-subclavian bypass and one had a fragmented sternum. Nine patients were treated with an internal mammary artery perforator fasciocutaneous flap with a muscle-sparing pectoralis major muscle flap and four patients with an internal mammary artery perforator fasciocutaneous flap combined with a right pectoralis major muscle flap. Results Three patients (23%) experienced major complications and four patients (31%) had conservatively treated minor complications. There were no flap losses. Conclusion This combination of flaps is a suitable option for patients with large defects in whom direct skin closure is not possible. It can be utilized for defects comprising the entire vertical length of the sternum. These are local flaps with a short operation time and are therefore most suitable for patients with comorbidities in whom major surgery is not an option.

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The Importance of Early Flap Coverage in Deep Sternal Wounds

Abstract: This study suggests that chronic infection after flap reconstruction in DSWI is associated with late flap cover. We suggest the need for a consensus agreement on the combined care and early management of DSWI.

Cited by 14 publications

References 19 publications

Deep Sternal Wound Infection after Open-Heart Surgery: A 13-Year Single Institution Analysis

Deep Sternal Wound Infection after Open-Heart Surgery: A 13-Year Single Institution Analysis

Sternotomy Wound Closure: Equivalent Results with Less Surgery

Modified internal mammary artery perforator flap in treatment of sternal wound complications

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