Flap Reconstruction for Deep Sternal
Wound Infections: Factors Influencing
Morbidity and Mortality
William Piwnica-Worms, BA, Saïd C. Azoury, MD, Geoffrey Kozak, MD,
Shelby Nathan, MS, John T. Stranix, MD, David Colen, MD, Sammy Othman, BA,
Prashanth Vallabhajosyula, MD, Joseph Serletti, MD, and Stephen Kovach, MD
GENERAL THORACIC
Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania; and Division of
Cardiothoracic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
Background. Deep sternal wound infections (DSWI)
often require flap reconstruction to obliterate dead space
and provide healthy soft tissue coverage. A better un-
derstanding of risk factors for complications after DSWI
flap reconstruction may improve operative management.
Methods. A retrospective study (2007-2018) was con-
ducted of all patients with DSWI after cardiothoracic
procedure referred to a single reconstructive surgeon for
flap reconstruction. Patient and operative factors were
reviewed, including procedure types and outcomes. Pre-
dictors of morbidity and mortality rates were analyzed.
Results. A total of 119 patients requiring flap recon-
struction for DSWI met inclusion criteria. Unilateral
(49.6%) or bilateral (40.3%) pectoralis muscle flaps were
performed most frequently, followed by vertical rectus
abdominis myocutaneous (VRAM) (4.2%), omental
(4.2%), and omental/pectoralis flap combination (1.7%).
Superficial surgical site infection (SSI) was the predomi-
nant postoperative complication (17.6%). Debridement/
revisional procedures were required in 19 patients (16%),
and flap failure occurred in 5 (4.2%). Overall 30-day
D eep sternal wound infection (DSWI) after a median
sternotomy is a serious complication, estimated to
occur in 1.5% to 2.5% of patients after open cardiac pro-
cedure.1-4 Whereas superficial wound infections are
contained to the suprasternal skin, subcutaneous tissue,
and fascia, DSWI involves deeper structures, including
the sternum or mediastinum. DSWI portends significant
morbidity and mortality, with mortality rates ranging
from 1.0% to 36%.5-9 Historically treated with
debridement and open packing or with drains and anti-
biotic lavage, this devastating complication is managed
more recently with consultation of plastic surgery for a
Accepted for publication Dec 4, 2019.
Presented at the Thirty-sixth Annual Meeting of the European Association
of Plastic Surgeons, Helsinki, Finland, May 23-24, 2019.
Address correspondence to Dr Azoury, Division of Plastic Surgery, Uni-
versity of Pennsylvania Health System, 3400 Civic Center Blvd, Philadel-
phia, PA 19104; email: said.azoury@pennmedicine.upenn.edu.
Ó 2020 by The Society of Thoracic Surgeons
Published by Elsevier Inc.
mortality was 15.1%. End-stage renal disease (P [ .002),
congestive heart failure (P [ .049), low albumin (P [
.004), cardiopulmonary bypass time (P [ .0001), need for
open chest (P [ .020), and high American Society of
Anesthesiologists Physical Status Classification (P [
.003) were associated with higher mortality. By multi-
variate analysis, multidrug resistance was predictive of
any postoperative complication (odds ratio [OR], 5.6; 95%
confidence interval [CI], 1.3-23.2; P [ .018), VRAM was
predictive of SSI (OR, 9.6; 95% CI, 1.4-66.4; P [ .022), and
end-stage renal disease (OR, 8.57; 95% CI, 1.06-69.1; P [
.044) was predictive of higher mortality.
Conclusions. Pectoralis muscle flaps are the workhorse
for complex sternal wound coverage, but complications
after flap reconstruction for DSWIs remain high. In
particular, end-stage renal disease, VRAM reconstruction,
and multidrug-resistant infection may predict a compli-
cated postoperative course in these patients.
(Ann Thorac Surg 2020;109:1584-90)
Ó 2020 by The Society of Thoracic Surgeons
collaborative approach to d ebridement, followed by
muscle flap closure. The paradigm shift to early flap
coverage occurred after the early work of Jurkiewicz and
colleagues10 in 1980, which showed a significant reduc-
tion in mortality from as high as 40% to 8$ to 21% with the
use of a muscle flap.8,11-15
Use of unilateral or bilateral pectoralis major flaps re-
mains the most common reconstruction performed due to
the muscle’s proximity to the wound and versatility as a
turnover or advancement flap.13,16 Vertical rectus
abdominis myocutaneous (VRAM), omental, or a combi-
nation of these remain viable alternatives, but surgical
decision making ultimately depends on past surgical
history, potential donor sites, and the dimension and
tissue character of the defect remaining after
debridement. Despite adoption of early d ebridement and
flap reconstruction for management of DSWI, no stan-
dardized treatment exists, largely due to the variability in
time to presentation, patient risk factors, and extent of the
infection.
0003-4975/$36.00
https://doi.org/10.1016/j.athoracsur.2019.12.014
Ann Thorac Surg
2020;109:1584-90
Abbreviations and Acronyms
ASA = American Society of
Anesthesiologists
CBT = cardiopulmonary bypass time
CAD = coronary artery disease
CHF = congestive heart failure
CI = confidence interval
COPD = chronic obstructive pulmonary
disease
DSWI = deep sternal wound infection
ESRD = end-stage renal disease
MDR = multidrug resistant
MI = myocardial infarction
No. = number
NPWT = negative pressure wound therapy
OR = odds ratio
SSI = surgical site infection
VRAM = vertical rectus abdominis
myocutaneous
Common serious complications contributing to high
morbidity after DSWI flap reconstruction include super-
ficial surgical site infection (SSI), dehiscence, hematoma,
and seroma.13 However, specific risk factors for post-
operative complications have not been clearly defined in
this population. A better understanding of these variables
as they relate to the cardiac procedure, flap choice, spe-
cific complications, and outcomes will aid plastic and
cardiothoracic surgeons in management decisions sur-
rounding this frequently devastating complication.
Patients and Methods
After approval from the University of Pennsylvania Insti-
tutional Review Board, a retrospective review (September
2007-August 2018) was performed of all patients referred
to a single plastic surgeon for reconstruction of DSWI after
cardiothoracic procedures. Only patients aged older than
18 years at the time of procedure were included in the
study. The study excluded patients with DSWI after a
noncardiac procedure, those with superficial chest wall
infections managed with local tissue rearrangement/com-
plex closure (ie, no muscle flap), and patients with inade-
quate follow-up, defined as lack of available
documentation after discharge.
Medical records were reviewed for patient de-
mographics and relevant risk factors. Variables and out-
comes related to the index cardiothoracic operation and
subsequent reconstructive procedure were analyzed. Pa-
tient presentation was defined as delayed if the plastic
surgery consult occurred more than 30 days after the
original cardiothoracic procedure.17 Flap reconstruction
was defined as delayed if the surgeon performed recon-
struction more than 20 days after the plastic surgery
consult.17 Use of negative pressure wound therapy as a
bridge to reconstruction was reviewed.
The type of reconstruction performed included unilat-
eral pectoralis major advancement flap, bilateral
PIWNICA-WORMS ET AL 1585
RECONSTRUCTION OF COMPLEX STERNAL WOUNDS
pectoralis major advancement flap, VRAM flap, omental
flap, or a combination of omental and pectoralis flap. The
size of DSWI defect (measured as the cross-sectional area
of the wound after d ebridement), operation length (mi-
nutes), and the number and type of drains placed were
analyzed.
Once consulted, the senior author reconstructive sur-
geon (S.K.), in collaboration with cardiothoracic surgery,
proceeds with operative therapy as soon as possible.
Sternal hardware/wires are removed at the time of
debridement before flap advancement. The reconstruc-
tive and cardiothoracic surgeons choose not to reestablish
GENERAL THORACIC
sternal fixation with wires/hardware given the risk of
colonization to the prosthetic material. They prefer to
primarily use pectoralis muscle flaps for defects where
the prosthetic aortic reconstruction does not need
coverage in the deeper mediastinum. Omental flaps are
preferred if vascularized tissue needs to be used to shield
and cover prosthetic aortic grafts or if the sternum needs
to be reclosed (Figure 1). Successful reconstruction was
defined as complete resolution of the tissue defect with no
further intervention necessary.
Reoperations were divided into flap salvage or com-
plete flap failure. Salvage was defined as d ebridement
and irrigation with preservation of the original flap, and
complete failure was defined as partial d ebridement of
the original flap with advancement of an additional flap to
achieve adequate coverage for wound closure.
Pearson c2 Fisher exact tests were used to analyze
categorical variables, and the t test and Wilcoxon rank
sum were used for continuous variables to assess for
significance between risk factors/flap choices and
morbidity and mortality. Multivariate analysis was per-
formed with a step-down logistic regression model to
assess the strongest independent predictive factors asso-
ciated with perioperative mortality. Results with a P of
less than .05 were considered to be statistically significant.
Analyses were performed using Stata IC 11.0 software
(StataCorp, College Station, TX).
Results
During the study period (September 2007-August 2018),
16,340 median sternotomies with cardiopulmonary
bypass were performed by the cardiac services at the 2
major teaching hospitals of Penn Medicine. Overall, 119
patients met inclusion criteria for the study. Patient de-
mographics and presternotomy comorbidities are sum-
marized in Table 1.
The type and distribution of antecedent cardiac pro-
cedures are summarized in Table 2. Average cardiopul-
monary bypass time (CBT) was 174
112 minutes.
Emergent cardiothoracic procedures was performed in 41
patients (34.5%). Redo sternotomy was performed in 24
patients (20.2%), and only 3 (2.5%) required a nonmidline
sternotomy. Unilateral internal mammary artery grafting
was performed in 60 patients (50.4%), and bilateral internal
mammary artery grafting was performed in 3 (2.5%).
Massive transfusions were required during the operation
in 7 patients (5.9%), and 18 (15.1%) required tracheostomy
 1586 PIWNICA-WORMS ET AL
RECONSTRUCTION OF COMPLEX STERNAL WOUNDS
GENERAL THORACIC
Figure 1. Reconstructive algorithm for deep sternal wound infections. (VRAM, vertical rectus abdominus myocutaneous.)
placement postoperatively. Negative pressure wound
therapy was used to bridge 15 patients (12.6%) to recon-
struction before the plastic surgery consultation.
The average area of chest wall defects was 114
84 cm2.
Most patients received unilateral or bilateral pectoralis
major flap coverage, with the remaining flap choices
performed less frequently (Table 2). Evidence of pros-
thetic aortic graft or valve infection was present in 10
patients (8.4%) at the time of reconstruction. On average,
debridement and flap reconstruction took 147
54 mi-
nutes. Jackson-Pratt drains were most commonly used
(83%), and Blake (12%) or a combination of both (5%)
were less commonly used.
Staphylococcus aureus (50%) was the most common
operative cultured microbe, followed by polymicrobial
(12%), Staphylococcus epidermidis (10%), Pseudomonas aeru-
ginosa (8%), Serratia marcescens (8%), Proteus mirabilis (6%),
vancomycin-resistant enterococcus (3%), and Mycobacte-
rium abscessus (3%). Of patients with multidrug-resistant
(MDR) organisms, at least one of the studied complica-
tions developed in 48%, compared with 13% in those with
non-MDR organisms (P ¼ .004). MDR was associated with
requiring reoperation (P ¼ .046) and hematoma (P ¼ .029).
Polymicrobial infections were associated with flap failure
(P ¼ .008), dehiscence (P ¼ .044), and seroma (P ¼ .003).
There were no intraoperative deaths. Overall periop-
erative 30-day all-cause mortality was 15.1% (n ¼ 18)
(Table 3). Only 2 of these 18 deaths were directly related
Ann Thorac Surg
2020;109:1584-90
to the DSWI. Both patients were bilateral lung transplant
recipients on immunosuppression with progressive
sepsis ultimately leading to multiorgan failure. Cause of
death in the remaining patients included multiorgan
failure in 4, cerebrovascular accident in 3, congestive
heart failure (CHF) in 3, renal failure in 2, and necrotic
bowel, unrelated colonic perforation, aortic aneurysm
rupture, and pulmonary infection in 1 patient each. The
most common complications are summarized in Table 3.
By univariable analysis, younger age (52 vs 65 years,
P ¼ .002), lower body mass index (24.7 vs 31.1 kg/m2, P ¼
.003), and no history of hypertension were associated with
postoperative hematoma. Low preoperative albumin (2.2
vs 2.9 g/dL, P ¼ .013) was associated with hematoma. A
history of diabetes was associated with lower rate of
postoperative seroma (P ¼ .01), and evidence of prosthetic
aortic graft or valve infection was associated with higher
rate of seroma (P ¼ .024), end-stage renal disease (ESRD)
(P ¼ .003), and need for open chest (P < .0001) were
significantly associated with flap failure, and chronic
obstructive pulmonary disease (COPD) significantly
associated with dehiscence (P ¼ .043). There was no sig-
nificant association between the type of cardiothoracic
procedure and postoperative complications (P > .1) or
death (P ¼ .827) (Table 4). Flap choice for reconstruction
was not associated with flap failure (P ¼ .089) or higher
mortality (P ¼ .624) (Table 4). Increasing severity of
American Society of Anesthesiologists Physical Status
Ann Thorac Surg PIWNICA-WORMS ET AL 1587
2020;109:1584-90 RECONSTRUCTION OF COMPLEX STERNAL WOUNDS

Table 1. Patient Demographics Table 3. Morbidity and Mortality

Factors Overall (n ¼ 119) Outcome No. (%) (n ¼ 119)

Age, y 64.4
12.3 Mortality 18 (15.1)

Body mass index, kg/m2 30.6
6.5 Reoperation
Preoperative albumin, g/dL 2.85
0.80 Salvage 19 (16.0)
Smoking status New flap 5 (4.2)
Never 55 (46) Surgical site infection 21 (17.6)
Former 39 (33) Dehiscence 18 (15.1)
Current 24 (20) Hematoma 8 (6.7)
ASA Physical Status Classification Seroma 6 (5.0)
III 72 (61)

GENERAL THORACIC
No., number.
IV 42 (35)
V 1 (1)
Male sex 74 (62) confidence interval [CI], 1.06-69.1; P ¼ .044), and VRAM
Hypertension 93 (78) reconstruction was an independent predictor of SSI (OR,
MI/CAD 70 (59)
9.6; 95% CI, 1.4-66.4; P ¼ .022). MDR infection was an
independent predictor of developing any postoperative
Diabetes mellitus 60 (50)
complication (OR, 5.6; 95% CI, 1.3-23.2; P ¼ .018).
Insulin-dependent 31 (26)
Congestive heart failure 60 (50)
Chronic kidney disease 41 (34)
End-stage renal failure 18 (15) Comment
COPD 24 (20) The aim of this study was to provide additional insight
Chronic steroids 7 (6) into factors that contribute to the ultimate success of flap
Nonsteroid immunosuppressive agents 8 (7) reconstruction for DSWI after median sternotomy at a
high-volume center. Treatment algorithms based on the
Data are presented as mean
SD or number (%).
acuity and wound characteristics currently exist but do
ASA, American Society of Anesthesiologists; CAD, coronary artery dis- not take into account patient comorbidities.18 This high-
ease; COPD, chronic obstructive pulmonary disease; MI, myocardial
infarction. volume cardiothoracic experience offers a unique op-
portunity to examine the potential influence of many
Classification was significantly associated with higher different cardiac cases on outcomes after reconstruction.
mortality rates (P ¼ .003), as were increased CBT (P ¼ Interestingly, the type of cardiac procedure was not
.0001), need for open chest (P ¼ .020), CHF (P ¼ .049), significantly correlated with major flap complications or
ESRD (P ¼ .002), and low preoperative albumin (2.3 vs 2.9 higher mortality. One may expect a potentially more
g/dL, P ¼ .004) (Table 4). complicated course for patients undergoing more
By multivariable analysis, ESRD was an independent complicated initial cardiac operations (eg, aortic root
predictor of higher mortality (odds ratio [OR], 8.57; 95% repair) or heart/lung transplantation on immunosup-
pressive medications. Instead, the 2 cardiothoracic vari-
Table 2. Procedure Distribution ables associated with increased mortality in this
Procedure No. (%) (n ¼ 119) population were increased CBT and the need for open
chest management, 2 variables that increase mediastinal
Antecedent cardiothoracic procedure exposure to potential contamination and subsequent
CABG 48 (40.3) infection. Even at a high-volume center, the 15.1% mor-
CABG þ valve replacement 23 (19.3) tality reported in the above study is comparable to what
Valve replacement 18 (15.1) has been previously reported (Table 5).5,6,9,12,13,19-22
Aortic root 13 (10.9) This study found that VRAM reconstruction poses an
Lung or cardiac transplant 7 (5.9) increased risk of SSI in patients undergoing reconstruc-
Other 10 (8.4) tion. In fact, postoperative complications occurred in all 5
Internal mammary artery use patients who underwent VRAM flap reconstruction: 3
Unilateral 60 (50.4) were complicated by SSI, 1 required a salvage procedure
Bilateral 3 (2.5) for a dehiscence, and a hematoma developed in 1.
Flap choice for reconstruction Although pectoralis muscle flaps were used most
Unilateral pectoralis major 59 (49.6) commonly in our series, VRAM flaps were likely used in
Bilateral pectoralis major 48 (40.3) patients with more challenging reconstructions or more
Vertical rectus abdominis 5 (4.2) complicated prereconstructive procedure courses that
Omental 5 (4.2) were not well captured. Such reasons included prior
Combined pectoralis/omental 2 (1.7)
pectoralis flap failure, significant d ebridement that
rendered the pectoralis muscle less favorable for use, or
CABG, coronary artery bypass grafting; No., number. defects located at the inferior aspect of the sternum.
 1588 PIWNICA-WORMS ET AL Ann Thorac Surg
RECONSTRUCTION OF COMPLEX STERNAL WOUNDS 2020;109:1584-90

Table 4. Variables Associated With Perioperative Mortality Rates pectoralis flap coverage (Figure 1).23,24 These in-
dications provide particularly unique challenges for the
Death Survival
Factors (n ¼ 18) (n ¼ 101) P plastic surgeon. Given the increased risk of SSI after
VRAM reconstruction, intraoperative sterile technique,
Patient copious irrigation, and ensuring adequate d ebridement
Age, y 63.6
10.8 64.6
12.7 .38 should be emphasized. Postoperative management may
Body mass index, kg/m2 31.3
7.4 30.5
6.4 .69 require more frequent wound checks with an emphasis
Preoperative albumin, g/dL 2.32
0.61 2.95
0.80 .004 on sterile dressings and short-interval follow-up
Hemoglobin A1c, % 8.24
3.1 8.06
2.4 .88 checks.
Smoking status .21 The literature supports an association between preex-
Never 50 46 isting renal dysfunction and death after cardiac proced-
Former 44 31 ures as well as development of sternal wound infection.25-
GENERAL THORACIC

Current 6 23
28
After flap reconstruction in these same patients,
ASA Physical Status .003 azotemia has been shown to be associated with higher
Classification rates of mortality, and ESRD has been described as an
III 33 68 independent predictor of death.8,29 In this series, ESRD
IV 61 32 again was found to be an independent risk factor for
V 6 0 higher mortality. Given that ESRD has been shown to be
Male sex 56 64 .50 strongly associated with development of DSWI, flap fail-
Hypertension 67 81 .17 ure, and higher mortality, it is evident that these patients
MI/CAD 56 60 .72 pose a particularly difficult problem to both the cardio-
Diabetes mellitus 61 49 .34 thoracic and plastic surgeons. Knowing the significant
Insulin-dependent 45 54 .60 risk of ESRD may allow for better preoperative coun-
Congestive heart failure 72 47 .05
seling and perioperative management.
Culture data also had a significant impact on the rate of
Chronic kidney disease 50 32 .32
complications after reconstruction. Similar to previous
End-stage renal failure 39 11 .002
reports, different microbes had no association with mor-
COPD 33 18 .14
tality rates.8 MDR infection was an independent risk
Chronic steroids 11 5 .31
factor for developing at least 1 of the studied complica-
Nonsteroid 11 6 .44
tions. The shift in management from antibiotics to
immunosuppressive agents
debridement and early flap coverage has decreased the
Cardiothoracic surgery
rate at which these particularly virulent organisms
Type of cardiothoracic procedure .83
develop within DSWI. For those who present after a delay
Emergent procedures 41 33 .51
in care to tertiary care centers, complication rates remain
Internal mammary artery use .11
high, and therefore, proper antibiotic stewardship is
None 33 9 important. Early consultation of the infectious disease
Unilateral 67 85 team is paramount in the treatment algorithm of this
Bilateral 0 5 particularly challenging subset of the studied population.
Redo sternotomy 33 18 .14 Other risk factors for postoperative complications
Non-midline sternotomy 6 2 .36 after sternal wound reconstruction include COPD,
Cardiopulmonary bypass 275
135 152
96 .0001 CHF, and low preoperative albumin. In general, COPD
time, min is a major risk factor for sternal dehiscence after me-
Required massive transfusion 11 5 .31 dian sternotomy.30-32 Studies have shown that the
Need for open chest 33 12 .02 increased chest diameter in patients with COPD leads
Required tracheostomy 22 13 .31 to elevated chest wall tension, particularly at the lower
Management of DSWI part of the sternum.33 Increased rates of dehiscence
Bridged with NPWT 11 12 .92 among women and patients with COPD needing flap
Late presentation 29 34 .73 reconstruction after DSWI highlight the necessity for
Delayed reconstruction 0 3 .47 particularly stout closures in these populations. Other
Prosthetic graft involvement 6 9 .63 studies have found CHF to be associated with any
Type of reconstruction .62 complication after reconstruction for DSWI and low
albumin to be associated with higher mortality.16,29
Data are presented as the mean
SD or percentage of patients. CHF decreases perfusion to the valuable flap tissue,
ASA, American Society of Anesthesiologists; CAD, coronary artery dis- putting these patients at risk of further complications.
ease; COPD, chronic obstructive pulmonary disease; DSWI, deep sternal Low albumin is a marker of poor nutritional status, and
wound infection; MI, myocardial infarction; NPWT, negative pressure
wound therapy. adequate nutritional support is necessary before and
after surgical procedures.
VRAM is sometimes preferred over pectoralis flaps Our study has several limitations, including its
for DSWI involving the lower sternum due to its retrospective design. The high mortality rate may also
superior coverage or for reoperation after failed be reflective of the tertiary referral status of the
Ann Thorac Surg PIWNICA-WORMS ET AL 1589
2020;109:1584-90 RECONSTRUCTION OF COMPLEX STERNAL WOUNDS

Table 5. Predictors of Morbidity and Mortality for Flap Reconstruction of Deep Sternal Would Infection After Median Sternotomy
Study
Authors, Design, Dates, Types of Morbidity and Outcome of
Journal, Year Cohort Size Flaps Used Mortality Interest Result

Cabbabe Retrospective, Bilateral pectoralis Dehiscence Predictors of Delayed

et al,19 Plast multicenter, major flaps (100%) (6.2%), morbidity and reconstruction associated
Reconstr single surgeon pressure sore mortality after with increased ventilator
Surg, 2009 1986-2008 (5.7%), immediate vs dependence, tracheotomy,
n ¼ 583 required skin delayed flap pressure sore, dehiscence,
graft (1.5%) reconstruction skin grafting, length of stay,
Mortality, 1.5% mortality
Patel et al,8 Retrospective, Bilateral pectoralis Seroma (1.6%), Predictors of ESRD, COPD, and mechanical
Plast single center, major (89.5%), hematoma morbidity and ventilation (per day) found

GENERAL THORACIC
Reconstr single surgeon unilateral (2.4%), SSI mortality to be independent
Surg, 2009 1997-2004 pectoralis major requiring following flap predictors of mortality
n ¼ 124 (9.7%), pectoralis debridement reconstruction
major and right (7.3%), flap
rectus abdominis failure (2.4%)
(0.8%) Mortality, 21%
Zahiri et al,16 Retrospective, Bilateral pectoralis Required Predictors of Diabetes mellitus, congestive
Ann Plast single center, advancement reoperation complications heart failure, and
Surg, 2012 multiple (20.8%), unilateral (18%), SSI after flap hypertension associated
surgeons pectoralis (17%), skin reconstruction with increased
1989-2010 advancement necrosis (4.7%), complications
n ¼ 106 (17.0%), bilateral flap necrosis
pectoralis turnover (3.8%),
(1.9%), unilateral dehiscence
pectoralis turnover (3.8%),
(23.6%), mixed hematoma
(turnover þ (2.8%)
advancement) Mortality, 2%
(29.2%), omental
(2.8%), latissimus
dorsi (0.9%), rectus
abdominis (0.9%),
other (2.8%)

COPD, chronic obstructive pulmonary disease; DSWI, deep sternal wound infection; ESRD, end-stage renal disease; SSI, surgical site infection.

medical center, and this could not be quantified in the References

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Given the complexity of these patients, establishing a
standardized management algorithm for DSWI is diffi-
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significantly between patients. A general schematic of the
our preference for the surgical management of these
wounds is provided in Figure 1.
Similarly, owing to the quality of and access to medical
records for patients early in the series and those pre-
senting from other hospitals, most comorbidities were
analyzed on a binary scale, not by severity. Hemoglobin
A1c values were only accessible in 34 of the 60 diabetic
patients (57%), and therefore, this study may not have
captured the effect of this variable on outcomes.
Although this study was underpowered, it may be
learned that patients who undergo more complicated
cardiac procedures, such as heart transplantation on
immunosuppressive medications, have a higher likeli-
hood of complications after reconstruction. Although this
is a large single-surgeon single-institutional study, a
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RECONSTRUCTION OF COMPLEX STERNAL WOUNDS
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