Reconstruction of sternal defects after sternotomy with postoperative osteomyelitis, using a unilateral pectoralis major advancement muscle flap

Abstract

Background: The pectoralis major flap, which is usually harvested bilaterally, is considered a workhorse flap in the reconstruction of sternal defects. After a median sternotomy for open heart surgery, 1%-3% of patients develop deep infection and dehiscence of the sternal wound, some of which will eventually require reconstructive surgery. Our aim was to describe the clinical feasibility and associated complications of the unilateral pectoralis major advancement flap in the reconstruction of sternal defects.

Methods: A retrospective analysis of all adult patients who were operated on using a unilateral pectoralis major flap for reconstruction of the chest wall at the Linköping University Hospital during 2008-18 was made using data retrieved from medical records.

Results: Forty-three patients had reconstructions with unilateral pectoralis major flaps. Three flaps failed completely, and another 10 patients developed complications that required further operation. The factors that were independently associated with loss of the flaps and complications were: older age, male sex, the number of different antibiotics used, and a long duration of treatment with negative wound pressure. Fewer wound revisions before the reconstruction resulted in more complications. The factors that were independently associated with prolonged time to complete healing were emergency reoperation after the initial operation and complications after reconstruction.

Conclusion: The unilateral pectoralis major advancement flap has proved to be a useful technique in the reconstruction of most sternal defects after sternal wound infection in older patients. There is, however, need for a follow-up study on a larger number of procedures to evaluate the long-term outcome compared with other methods of sternal reconstruction.

Conflict of interest statement

The authors declare no competing interests.

Figures

Figure 1

Flowchart showing the selection of patients. ZZR30 is the ICD-10-SE procedure code for “reconstruction with a muscle flap”. A total of 45 reconstructions of sternal defects were done with muscle flap, 43 with a unilateral pectoralis muscle flap, one with bilateral pectoralis muscle flaps and one with another muscle flap.

Figure 2

Flowchart showing different times of admissions for patients who had open heart surgery and were later readmitted for revision surgery, treatment using negative wound pressure, and antibiotics, when they developed signs of sternal instability or sternal infection, or both. If reconstructive surgery was indicated, the necessary flap was revised. The last visit, when the antibiotic treatment could be ended, was classed as the end point for healing of the defect. NPWT = negative pressure wound therapy.

Figure 3

(A) Sternal wound with deep infection after cardiac surgery. (B). Sternal wound after debridement. (C) The left pectoralis major muscle being mobilized after dissection. (D) The pectoral flap sutured in place to cover the defect. (E) After skin closure.

Figure 4

A set of special long surgical instruments: long retractor, bipolar diathermy forceps, tweezers, straight and curved scissors.