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Alternative Bi-Pectoral Muscle Flaps for

Postoperative Sternotomy Mediastinitis


Periklis Tomos, Elias Lachanas, MD, Panagiotis O. Michail, and Alkiviadis Kostakis
Propedeutic Department of Surgery and Department of Surgery, Athens University, Medical School, Athens, Greece

Suppuration, mediastinitis, and disruption of median arteries of the nongrafted internal mammary artery
sternotomy are all rare, but nevertheless severe compli- (IMA). Our technique is quick and easy, giving excellent
cations. We propose a simple mobilization of the two results. Furthermore, by maintaining the perforating
pectoralis major muscles for use as flaps to fill the sternal branches, we also preserve the nongrafted IMA.
defect without the need for humeral detachment or a
second cutaneous incision. These will be supplied from (Ann Thorac Surg 2006;81:754 5)
both the thoracoacromial vessels and the perforating 2006 by The Society of Thoracic Surgeons

C omplications of sternotomies have been managed with was scraped to form a V because it is usually a source of
FEATURE ARTICLES

various techniques. Jurkiewicz and colleagues [1] de- infection. In cases of severe mediastinitis, and when the
scribed reconstruction of the defect using the pectoralis sternum was detached right from the start, the medulla was
major muscles as flaps. Subsequently, many authors have scraped to eliminate any source of abscess. Subsequently
described their experiences with this procedure or modifi- bi-pectoral musculofascial flaps were created. Both the
cations of it [2], or have described the use of other muscles pectoralis major muscles were separated from the subcuta-
as flaps. In this article we present an alternative approach neous tissue and also from their chest wall insertions. From
with the pectoralis muscles as flaps. the side where the IMA was used as a graft (IMAg), the
dissection proceeded laterally to the level of the anterior
axillary line. The humeral insertion and thoracoacromial
Technique vessels were left intact, whereas at the contralateral muscle
We applied the following technique in 14 patients (3 fe- flap, the mobilization was not as extensive, but was still
males, 11 males) all of whom had already undergone a great enough to leave the anterior intercostal perforators
intact (Fig 1A) and permit the insertion of the medial end of
previous heart operation through a sternotomy (ie, 11
the muscle flap into the dead space.
aortocoronary bypasses, 1 acute ascending aortic dissection,
Subsequently the medial ends of the flaps were sutured
1 mitral valve replacement, and 1 Bentall procedure. Our
with a single row of interrupted, half-buried, vertical mat-
patients belonged to various types (ie, 7 type V, 4 type III B,
tress stitches using polyglycolic acid suture (Dexon No. 2;
2 type IVA, and 1 type III A (Oakley classification) [3].
United States Surgical, Norwalk, CT), starting 2 cm laterally
Hospital mortality was zero. All our patients are still alive to the medial end of the IMAg flap in an anteroposterior
and healthy, except for 1 female who died from colorectal direction, then proceeding to the contralateral IMAg flap, 2
cancer. cm laterally to its medial end, in an anteroposterior-anterior
Our management was comprised of two separate stages. direction, then back again, but this time 1 cm caudal in an
The first was performed under local anesthetic, which anteroposterior-anterior direction. Finally the wire passed
consisted of reopening the wound and removing all of the from the posterior to anterior surface of the ipsilateral IMAg
necrotic soft tissue, necrotic bone, cartilage, and wires. flap, which created an overlap of the flaps (Fig 1B, 1C) so
When fistulous tracts were present, they were excised that the contralateral IMAg flap was buried in the V
together with their blind ends, which usually led to scraped area and the ipsilateral IMAg was overlapping. All
abscesses. these sutures passed right through the muscle. Next a large
During the next 3 to 5 days, wounds were medicated diameter drainage tube (vacuum No. 18) was placed adja-
twice daily, alternately using povidone iodine and NaCl cent to the sternal defect. Immediately afterward, large
solution (15%). transfixion sutures were applied to prevent excessive lateral
The patient was then taken into the operating room for tension. These were tied at the end of the operation.
the second stage of treatment, which was performed under While the assistant pushed on both sides of the soft
general anesthesia. The midline of the sternum tissue, the surgeon tied the mattress sutures before anchor-
ing a second row of simple stitches between the fasciae of
the two pectoralis muscles (Fig 1D), one of which was
Accepted for publication Oct 28, 2004. already overlapping. A new vacuum drainage tube was
Address correspondence to Dr Tomos, 16A Parthenonos St, Paleo Faliro placed in the subcutaneous tissue which was sutured, and
175 62, Greece; e-mail: periklistomos@hotmail.com. the skin was stapled.

2006 by The Society of Thoracic Surgeons 0003-4975/06/$32.00


Published by Elsevier Inc doi:10.1016/j.athoracsur.2004.10.065
Ann Thorac Surg HOW TO DO IT TOMOS ET AL 755
2006;81:754 5 PECTORAL MUSCLES AS FLAPS

Fig 1. (A) Preservation of the anterior perfo-


rating artery. (B) Placement of the first single
row of interrupted, half-buried, vertical mat-
tress stitches. (C) All sutures in the first row
have been placed. (D) The second row of
simple stitches.

FEATURE ARTICLES
Comment perforating arteries, the IMA is also preserved for potential
future use as a graft.
Our technique has a number of advantages compared with
In conclusion, blood supply of the flaps is in no way
other techniques described to date. First, after the skin and
compromised with our proposed technique because it re-
subcutaneous tissue are separated from the anterior pecto-
spects both the perforating arteries (on one side) and the
ralis fascia of the muscles, the muscles are not divided and
thoracoacromial arteries. Furthermore muscular detach-
rotated [1], nor is there any need for a further cutaneous
ment or co-mobilization of the rectus abdominis is not
incision for a better approach to the humeral muscle ex-
required, and at least one of the two IMAs remains intact
tremity [3, 4]. To the contrary, we preserve the humeral
for possible future use. By suturing the muscles, as pro-
insertion by mobilizing the muscles from their costal inser-
posed herein, a muscular implant is made. This seals the
tions, bringing them toward the midline and burying one of
dead space, which has no tension due to the presence of a
the two flaps in the sternal defect while the contralateral
second layer. Early and later results are excellent, not only
flap is folded over it. This kind of overlapping offers addi-
regarding infection and functionality, but also from an
tional stability with respect to adaptation of the muscle.
aesthetic point of view.
Second, we do not use foreign bodies to bring together the
sides of the sternum; thus we do not use rewiring or
polydioxanone sutures between the outer cortex of the The authors would like to acknowledge the contribution of
sternum [5], and we do not use suturing of one of the flaps Danielle Bowler, translator and copy editor.
on the sternum resection line or on the cartilage [3] because
the sternal defect is filled with viable tissue that is well References
supplied. Likewise, if part of the ribs or costal cartilage has
been removed, this area is covered by the muscles them- 1. Jurkiewicz MJ, Bostwick J III, Hester TR, Bishop JB, Craver J.
Infected median sternotomy wound. Successful treatment by
selves by simple apposition. muscle flaps. Ann Surg 1980;191:738 43.
We believe in the aggressive V shaped sternectomy 2. Hugo NE, Sultan MR, Ascherman JA, et al. Single stage
and the removal of infected cartilage, because failure of the management of 74 consecutive sternal wound complications
reconstruction is directly related to persistent infection of with pectoralis major myocutaneous advancement flaps. Plast
Reconstr Surg 1994;93:1433 41.
bone and cartilage [6]. 3. Reida M, El Oakley RM, Wright JE. Postoperative mediastinitis:
Blood supply in one of the two flaps is based both on the classification and management. Ann Thorac Surg 1996;61:1030.
perforating arteries of the IMA and on the thoracoacromial 4. Jose R, Castello JR, Centella T, Garro L, et al. Muscle flap
artery, whereas the contralateral flap is based only on the reconstruction for the treatment of major sternal wound
thoracoacromial artery. This offers better viability and func- infections after cardiac surgery: 10 year analysis. Scand J Plast
Reconstr Hand Surg 1999;33:1724.
tionality of the flaps, contrary to Hugo and colleagues [2] 5. Perkins DJ, Hunt JA, Pennington DJ, Stern HS. Secondary
who isolated and cauterized the anterior perforating arter- sternal repair following median sternotomy using interosse-
ies when they created myocutaneous flaps with the pecto- ous absorbable sutures and pectoralis major myocutaneous
ralis muscles. In addition, Hugo and colleagues [2] were not advancement flaps. Br J Plast Surg 1996;49:214 9.
6. Schroeyers P, Wellens F, Degrieck I, et al. Aggressive primary
interested in the dead space, whereas we fill this space treatment for poststernotomy acute mediastinitis: our experi-
using the sutures employed for burying one of the two flaps ence with omental and muscle flaps surgery. Eur J Cardio-
as previously described. By protecting and maintaining the thorac Surg 2001;20:743 6.