Bilateral Pectoralis Major Muscle Flaps Research Articles

Antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management for sternal infection after midline sternotomy

IntroductionDeep sternal wound infection (DSWI) after midline sternotomy of cardiac surgery is a challenging complication that affects the outcome of surgery. This study aims to assess the clinical effectiveness of the antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management in the treatment of DSWI.MethodsWe retrospectively analyzed 5 patients with DSWI who underwent antibiotic-loaded bone cement combined with bilateral pectoralis major muscle flaps for chest wall reconstruction after sternotomy for cardiac surgery in a tertiary hospital in China from January 2020 to December 2021. The clinical and follow-up data were retrospectively analyzed.ResultsAll patients had no perioperative mortalities, no postoperative complications, 100% wound healing, and an average hospital stay length of 24 days. The follow-up periods were from 6 to 35 months (mean 19.6 months). None of the cases showed wound problems after initial reconstruction using antibiotic-loaded bone cement combined with bilateral pectoralis major muscle flaps.ConclusionsWe report our successful treatment of DSWI, using antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management. The clinical and follow-up results are favorable.

Bilateral Pectoralis Major Muscle Flaps in Treating Deep Sternal Wound Infection following CABG in Diabetic Patients: Two Case Reports.

Deep sternal wound infection (DSWI) is a life-threatening complication after cardiac operations, especially after coronary artery bypass grafting (CABG) in diabetic patients. Bilateral pectoralis major muscle flaps have been performed to treat DSWI. Two diabetic patients suffering from DSWI after CABG were treated by bilateral pectoralis major muscle flaps in our hospital. Both patients were discharged with full recovery. Satisfactory results can be obtained with bilateral pectoralis major muscle flaps following tissue debridement and drainage. This procedure should be performed when DSWI occurs in diabetic patients after CABG.

Treatment algorithm for post sternotomy wound infection - our experience.

Median sternotomy is the most commonly used approach in open cardiac surgery. As in any other surgery, surgical site infections are aknown phenomenon, but morbidity depends on the depth of infection. Superficial wound infections can be managed conservatively; however, deep sternal wound infections need an aggressive approach to prevent disastrous consequence like mediastinitis. Hence, this study was conducted with the aim to classify sternotomy wound infection and to develop atreatment algorithm for superficial and deep sternotomy wound infections. Between January 2016 to August 2021, 25 patients who had sternotomy wound infections were studied. These wound infections were classified as superficial or deep sternal wound infections. Superficial wound infections underwent treatment with diluted vinegar dressings and deep infections underwent treatment with bilateral pectoralis major muscle advancement flaps. Patients were followed up till the wounds healed completely without complications. Patient characteristics, comorbidities, duration of treatment and outcomes of treatment were analyzed. Superficial sternal wound infection patients responded favorably to diluted vinegar dressings and deep sternal wound infection patients to pectoralis major muscle advancement flaps. Average time duration of healing for superficial and deep wound infections was 66.2 days and 18 days respectively. None of the patients had an increased severity of infection or re-dehiscence following treatment and during follow-up. Relatively conservative approach using diluted vinegar (1% acetic acid) dressing for superficial sternal wound infections was efficacious, whereas aggressive debridement and bilateral pectoralis major advancement muscle flaps for deep sternal wound infections are necessary for favorable outcomes. However, more studies are needed to ascertain this treatment algorithm.

Vacuum-assisted closure vs. bilateral pectoralis major muscle flaps for deep sternal wounds infection.

BackgroundDeep sternal wound infection (DSWI) is a life-threatening complication after cardiac surgery. The aim of this study was to retrospectively evaluate the outcomes of reconstructing infected poststernotomy wounds with either vacuum-assisted closure (VAC) after previous debridement or bilateral pectoralis major muscle flaps (BPMMFs).MethodsIn total, 565 patients with postoperative DSWI were enrolled in this study from January 1, 2014, to June 1, 2018. Of these patients, 247 received BPMMFs. To address the indicated biases, a 1:1 propensity score-matched cohort was created based on age, body mass index, preoperative diabetes mellitus, chronic obstructive pulmonary disease (COPD), internal thoracic artery grafting (ITAG), type of cardiac surgery, time before treatment for DSWI and wound classification. After matching, 132 patients who had similar risk profiles were enrolled in the study population (66 in the VAC group: 66 in the BPMMF group).ResultsAt 21.9±12.1 (median: 24, IQR: 14–28) months of follow-up, the survival rate was 93.9% in the BPMMF group and 74.4% in the VAC group (P<0.01). Compared with the VAC group, the BPMMF group had a significantly decreased length of hospital stay (P<0.01). At the spirometry assessment, the forced expiratory volume in the 1st second (FEV1), vital capacity (VC), and FEV1/VC ratio showed no significant differences in survival between the VAC group and BPMMF group.ConclusionsIn our study, compared with VAC therapy, BPMMFs guaranteed better early- and late-term outcomes, as shown by less length of hospital stay, a higher rate of long-term survival and unimpaired respiratory function.

Bilateral pectoralis major muscle flaps

Bilateral pectoralis major muscle flaps

Bilateral pectoralis major flaps for salvage of left ventricular assist device deep pocket infection

Current treatment for end-stage cardiac disease has benefitted greatly from the development of left ventricular assist devices (LVADs). However, as the prevalence of LVADs increased, so too did the number of patients with complications. The smaller size of the HeartMate III (HMIII) device allows for it to be placed completely intrathoracic. This requires a new reconstructive strategy when deep pocket infection and hardware exposure ensue. We report our first case of flap coverage of an exposed HMIII after deep pocket infection and discuss the reconstructive challenges associated with this fully intrathoracic device. A 31-year-old female with worsening postpartum non-ischemic cardiomyopathy was transferred to our facility in end-stage heart failure. She underwent complete sternal-sparing placement of a HMIII via bilateral anterior thoracotomies, and eventually developed a deep pocket infection with intrathoracic abscess. Plastic Surgery reconstructed the wounds using bilateral pectoralis major muscle flaps. The patient enjoyed an uneventful postoperative course and was discharged home 2 weeks later on intravenous antibiotics. HMIII devices are completely intrathoracic, occupying the pericardial space anteriorly, which can make an infection difficult to access. Wound location largely dictated which flaps would be acceptable for reconstruction following debridement. Close cooperation between cardiac and reconstructive surgeons will once again be paramount to evolving the surgical care of HMIII patients with deep pocket infection. Level of Evidence: Level V, therapeutic study.

Effective Combination of Different Surgical Strategies for Deep Sternal Wound Infection and Mediastinitis

Purpose: Timing and ideal reconstructive approach in deep sternal wound infection (DSWI) and mediastinitis still remain controversially debated. We present our own combined surgical strategy of bilateral pectoralis major muscle flap (BPMMF) or omental flap (OF) transposition.Methods: Between July 2010 and July 2016, poststernotomy patients with DSWI and mediastinitis underwent a secondary wound closure with modified BPMMF (Group A, center for disease control class (CDC)-II, n = 21; Group B, CDC-III, n = 20) or with OF (Group C, CDC-III, n = 19) following vacuum-assisted closure (VAC).Results: Significant risk factors for mediastinitis (CDC-III) were chronic obstructive pulmonary disease (COPD; p = 0.001), peripheral arterial disease (PAD; p = 0.012), cardiopulmonary bypass (CPB) time (p = 0.027), total operation time (p = 0.039), total intensive care unit (ICU) stay (p = 0.011), and blood transfusion (p = 0.049). Mean antibiotic therapy (18.4 ± 8.8[B] vs. 36.2 ± 24.4[C] days, p = 0.026) and length of hospitalization (25.2 ± 12.1[B] vs 53.8 ± 18.5 days[C], p = 0.053) were significantly longer in group C. In-hospital death was 3/19 (15.8%) in group C versus 0 in group B (p = 0.026). Frequency of recurrent mediastinitis was equal (p = 0.92); however, complications occurred more often in group C (31.6% vs. 0%, p = 0.031). The mean follow-up time was 111 ± 62 days.Conclusion: In younger (<70 years) patients without sternal bone necrosis, the BPMMF is superior to the OF technique with relatively low recurrence and mortality risks.

Sternal reconstruction of deep sternal wound infections following median sternotomy by single-stage muscle flaps transposition.

To assess clinical effectiveness of using bilateral pectoralis major or plus rectus abdominis muscle flaps in treating deep sternal wound infection (DSWI) following median sternotomy. Between January 2009 and December 2013, 19 patients with DSWI after median sternotomy for cardiac surgery were admitted to our hospital, including 14 males (73.7%) and 5 females (26.3%), aged 55±13 (18-78) years. According to the Pairolero classification of infected median sternotomies, 3 (15.8%) patients were type II, and the other 16 (84.2%) were type III. Surgical procedure consisted of adequate debridement of infected sternum, costal cartilage, granulation, steel wires, suture residues and other foreign substances. Sternal reconstruction used the bilateral pectoralis major or plus rectus abdominis muscle flaps to obliterate dead space. The drainage tubes were placed and connected to a negative pressure generator for adequate drainage. There were no intraoperative deaths. In 15 patients (78.9%), bilateral pectoral muscle flaps were mobilized sufficiently to cover and stabilize the defect created by wound debridement. 4 patients (21.0%) needed bilateral pectoral muscle flaps plus rectus abdominis muscle flaps because their pectoralis major muscle flaps could not reach the lowest portion of the wound. 2 patients (10.5%) presented with subcutaneous infection, and 3 patients (15.8%) had hematoma. They recovered following local debridement and medication. 17 patients (89.5%) were examined at follow-up 12 months later, all healed and having stable sternum. No patients showed infection recurrence during the follow-up period over 12 months. DSWI following median sternotomy may be effectively managed with adequate debridement of infected tissues and reconstruction with bilateral pectoralis major muscle or plus rectus abdominis muscle flap transposition.

From “Head to Heart

Sternal cleft is a rare anomaly and has been variously managed by using either autogenous tissue or synthetic materials for bony reconstruction. We report the reconstruction of sternal cleft in a 15-month-old child with a single-piece outer-table cranial bone graft that was harvested by splitting in situ. The reconstructed sternum was covered with bilateral pectoralis major advancement muscle flaps.

An Alternative Technique for Surgical Management of Poststernotomy Osteomyelitis and Reconstruction of the Sternal Defect

Introduction. Sternal osteomyelitis with or without mediastinal infection is a severe and rare complication of median sternotomy. In this paper, an alternative technique for the reconstruction of sternal defects with the use of bilateral pectoralis major pedicled muscle flaps is presented. Case presentation. A 70-year-old man with the diagnosis of poststernotomy osteomyelitis underwent reconstruction of his sternal defect with the use of bilateral pectoralis major muscle flaps. The patient had an uneventful recovery, and the physical examination revealed a normal range of motion for both upper limbs and sternal stability. Conclusion. The proposed technique incorporates a simple mobilization of the two pectoralis major muscles to be used as flaps to fill the sternal defect without the need for humeral detachment or a second cutaneous incision. Using this technique, a muscular implant is made that seals the dead space, which has no tension due to the presence of a second layer. Postoperative results are excellent, not only regarding infection and functionality but also from an aesthetic point of view.

Risk Factors and Management Approach for Deep Sternal Wound Infection After Cardiac Surgery at a Tertiary Medical Centre

Deep sternal wound infection (DSWI) is a rare but severe complication following cardiac surgery. Our study investigated the risk factors and treatment options for patients who developed DSWI at our institution between May 1988 and April 2008. Data was collected prospectively in a database and information on demographics reviewed retrospectively on 5649 patients who underwent cardiac surgery during this period. The incidence of DSWI was 34/5649 (0.6%). These patients were older (mean age 66.1 vs. 64.5), more likely to die (in hospital mortality 11.8% vs. non DSWI group 1.8%) and had longer hospital stays (DSWI group mean stay 25 days vs. non DSWI group 9 days). Using Fisher's exact test the risk predictors for DSWI determined at our institution included diabetes managed with oral medications (p=0.021), previous cardiac surgery (p=0.038), BMI≥30 (p=0.041), LVEF≤30 (p=0.010), IABP usage (p=0.028) and homologous blood usage (p<0.001). Most commonly bilateral pectoralis major muscle flap (BPMMF) was used for treatment of DSWI (11/30, 36.7%). Ultimately our data was comparable to published data in the literature on known risk predictors.

Our experience with pectoralis major flap for management of sternal dehiscence: A review of 25 cases

Objective:To report our experience of the pectoralis major flap as the treatment modality for post coronary artery bypass sternal wound dehiscence.Materials and Methods:A retrospective study of 25 open heart surgery cases, performed between January 2006 and December 2010 at Deenanath Mangeshkar Hospital, Pune, was carried out. Unilateral or bilateral pectoralis major muscle flap by the double breasting technique using rectus extension was used in the management of these patients. The outcome was assessed on the basis of efficacy of flap surgery in achieving wound healing and post-surgery shoulder joint movements to evaluate donor site morbidity. The follow-up ranged from 5 months to 3.5 years.Results:Twenty-three (92%) patients were discharged with complete wound closure. One patient (4%) had wound dehiscence after flap surgery. One patient (4%) died in the hospital in the immediate postoperative period due to mediastinitis. No recurrent sternum infection has occurred till date in 24 patients (96%). For one patient (4%) who had wound dehiscence, daily dressing was done and wound healing was achieved with secondary intension. At follow-up, shoulder joint movements were normal in all the patients.Conclusions:The double breasting technique of the pectoralis major muscle flaps with rectus sheath extension is efficient in covering the entire length of the defect and can reduce the morbidity, without affecting the function of the shoulder joint.

Vacuum-assisted closure and bilateral pectoralis muscle flaps for different stages of mediastinitis after cardiac surgery

To assess the results of bilateral pectoralis major muscle flaps (BPMMF) and vacuum-assisted closure (VAC) at different stages of postcardiac surgery mediastinitis. Of 65 patients with a deep sternal wound infection (DSWI) after cardiac surgery, 33 with a stable sternum were treated with VAC (59.3 +/- 11.7 years of age) and 32 with an unstable sternum or osteomyelitis (63.3 +/- 9.8 years of age) were treated with early BPMMF and continuous irrigation. Delayed BPMMF reconstruction was necessary in six VAC patients. The overall incidence of DSWI was 1.04% within the study period. Deep sternal wound infection was diagnosed 15.9 +/- 10.8 days (range 5-62 days) after surgery. Diabetes was more common in the BPMMF group than in the VAC group (P = 0.046). Hospital mortality after treatment was 4.6% (n = 3) overall. Causes of death were septic multiorgan failure and respiratory failure. The infective pathogens were methicillin-resistant Staphylococcus aureus (MRSA; n = 2) and Acinetobacter species (n = 1). The median hospital stay was 29 days (range 15-110 days). After 6 months, only one recurrent sternal infection had occurred in the VAC group. Early BPMMF is an effective surgical treatment for DSWI in patients with an unstable sternum and osteomyelitis. VAC may be considered for patients without osteomyelitis but a stable sternum, or as adjuvant therapy in patients with comorbidity.

Composite chest wall reconstruction using titanium plates and mesh preserves chest wall function

Although multiple techniques have been used to correct chest wall defect, the impact of these on chest wall function (chest wall mechanism/pulmonary function) is poorly studied.1Bibas B.J. Bibas R.A. Operative stabilization of flail chest using a prosthetic mesh and methylmethacrylate.Eur J Cardiothorac Surg. 2006; 29: 1064-1066Crossref PubMed Scopus (14) Google Scholar In our experience, composite chest wall reconstruction using titanium plates and mesh correct both the cosmetic and physiologic abnormalities.2Cicilioni Jr., O.J. Stieg 3rd, F.H. Papaniculaou G. Sternal wound reconstruction with transverse plate fixation.Plast Reconstr Surg. 2005; 115: 1297-1303Crossref PubMed Scopus (73) Google Scholar, 3Voss B. Bauernschmitt R. Will A. et al.Sternal reconstruction with titanium plates in complicated sternal dehiscence.Eur J Cardiothorac Surg. 2008; 34: 139-145Crossref PubMed Scopus (81) Google Scholar, 4Lee T.Y. Estrera A.L. Safi H.J. Khalil K.G. Total sternal reconstruction using a titanium plate-supported methyl methacrylate sandwich.Ann Thorac Surg. 2007; 84: 664-666Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Surgical reconstruction was performed in 13 patients using a Titanium Fixation System (Synthes, West Chester, Pa); Figure 1, A, consisting of titanium plates and self-tapping unlock screws. All plates can be joined by U-shaped release pins, which allows quick and easy surgical access in case of reoperations. There were 3 patients groups (Table 1). In groups A and B, rib reconstruction was performed with titanium plates and a dual-mesh patch was placed and fixed to the plates to avoid direct contact between prosthesis and lung parenchyma (Figure 1, B).Table 1Personal observationPatient (age)DiagnosisSurgical treatmentSurgical reconstructionPreoperative FEV1 (L)Postoperative FEV1 (L)Group A 1 (47 y)SarcomaV, VI, VIIV, VI2.672.80 (+4.8%) 2 (82 y)SarcomaV, VI, VIIV, VI2.962.78 (−6.1%) 3 (56 y)Metastasis from sarcomaV, VIV1.311.25 (−4.5%) 4 (58 y)TraumaVI, VIIVI, VII2.101.99 (−5.2%) 5 (71 y)TraumaIV, V, VIIV, VI1.641.65 (+0.6%)Group B 6 (54 y)NSCLCUpper lobectomy (III, IV, V)III, V2.491.97 (−20.9%) 7 (48 y)NSCLCUpper lobectomy (III, IV, V)III, V2.801.71 (−38.9%) 8 (64 y)NSCLC(clavicle, I, II, III)Clavicle, II1.420.98 (−30.9%) 9 (56 y)Malignant pleural mesotheliomaLeft extrapleural pneumonectomy (II, III, IV, V, VI)III, IV, VI2.611.36 (−47.8%)Group C 10 (65 y)InfectionTotal sternectomyManubrium and sternum1.491.55 (−4.0%) 11 (48 y)Renal metastasisSubtotal sternectomySternum—— 12 (49 y)FracturePartial sternectomySternum2.982.89 (−3.0%) 13 (69 y)FractureOsteosynthesisSternum——Group A, Rib resection; group B, lung and rib resection; group C, sternal resection; NSLC, non–small cell lung cancer; FEV1, forced expiratory volume in 1 second. Open table in a new tab Group A, Rib resection; group B, lung and rib resection; group C, sternal resection; NSLC, non–small cell lung cancer; FEV1, forced expiratory volume in 1 second. In group C, the first patient, in particular, received an en bloc sternectomy for sternum infection after cardiac surgery, and then 4 titanium plates were fixed to the clavicle and to both sides of the second, fourth, and fifth rib, respectively, successively covered with a titanium patch.5Iarussi T. Marolla A. Pardolesi A. Patea R.L. Camplese P. Sacco R. Sternectomy and sternum reconstruction for infection after cardiac surgery.Ann Thorac Surg. 2008; 86: 1680-1681Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar In all cases of sternum resection, a bilateral pectoralis major muscle flap was carried out to cover the prosthesis. There was no postoperative mortality. A subcutaneous seroma occurred in 2 patients and atrial fibrillation and prolonged air leakage in 1 patient. A 3-day stay in the intensive care unit was required for hemodynamic instability in a patient with malignant mesothelioma having extrapleural pneumonectomy and chest resection. All the other patients were extubated immediately at the end of the surgical procedures. Pre- and postoperative data showed a good preservation of respiratory function even after lung resection if compared with predictive values (Table 1). The reported technique leads to chest wall stability and physiologic mobility preservation, allowing quick patient mobilization and participation in respiratory rehabilitation programs. Plates can be easily shaped to replace removed ribs, even in cases of bad bone quality. In cases of large chest wall defect, stability can be obtained without rebuilding each rib removed. In cases of removal of 3 or 4 ribs, for example, chest cage stability can be obtained with reconstruction of 2 ribs. Data from our experience, even if consisting of few cases, support the practical utility of titanium plate application for rib and sternal reconstruction.

Sternotomy Wounds: Rectus Flap versus Modified Pectoral Reconstruction

Infected sternotomy wounds occur in 0.5 to 8.4 percent of open heart operations. They are complex problems, with a mortality rate of 8.1 to 14.8 percent despite flap closure. For closure, the pectoralis major flap has had considerable success. However, in providing coverage to the lower third of the sternum, it may be deficient. Modifications to improve closure have included a rectus flap or an anterior rectus fascia extension to the pectoralis flap. This retrospective study of 130 consecutive sternotomy wounds compares 41 bilateral pectoralis major muscle flaps with a modified anterior rectus fascia extension against 56 rectus abdominis muscle flaps alone in addressing the lower third of the sternum following dehiscence. Pectoralis flaps with rectus fascia extension and rectus flaps have similar success, postoperative course, and morbidity and mortality rates. The pectoralis flaps with rectus fascia extensions prevented superior dehiscence, but this modification does not eliminate dehiscence of the distal third of the sternum. The rectus muscle alone proved superior in coverage to the inferior sternum. Sternal wounds should be covered preferentially by a pectoralis flap to cover a superior infection and by a rectus flap if the dehiscence is localized to the distal third.

Off-Pump Repair of a Giant Pseudoaneurysm of a Distal Saphenous Vein Bypass Graft

Pseudoaneurysm of a saphenous vein bypass graft is a rare occurrence after coronary artery bypass grafting but may have lethal consequences. We treated a giant pseudoaneurysm of a saphenous vein graft to the right coronary artery in an 80-year-old male Jehovah's Witness who had undergone coronary artery bypass grafting 4 and a half years earlier. His history revealed a recurrent sternal wound infection. By using a venous patch to close the damaged graft, we were able to perform a successful surgical repair without the need for extracorporeal circulation.

Adjuvant treatment of deep sternal wound infection with collagenous gentamycin

Background. The treatment of deep sternal wound infections remains controversial. Currently advocated procedures carry the risk of reinfections. The significance of local antibiotic-releasing systems as an adjuvant therapy to avoid reinfections is the subject of the presented study.Methods. Forty-two patients with deep sternal wound complication were treated with radical wound debridement, sternal refixation, retrosternal suction drainage, bilateral pectoralis major muscle flaps, and placement of collagenous drug carrier loaded with gentamycin (Sulmycin Implant) underneath, above, and between the sternal edges.Results. No treatment failure and death were observed in our patients. Side effects after adjuvant treatment with collagenous gentamycin were not detected.Conclusions. The preliminary results of adjuvant therapy with collagenous gentamycin in combination with surgical debridement leads to excellent results in the treatment of early deep sternal wound infections with no death and no primary treatment failures. This technique is easy to perform, reliable, and safe. For final judgment controlled randomized trials are mandatory.

Primary repair of complete sternal cleft with pectoralis major muscle flaps

We report the successful coverage of a complete sternal cleft with exposed pericardium using bilateral pectoralis major muscle flaps in a newborn. The patient was transferred to our institution with nearly complete sternal aplasia, rectus diastasis, and only dessicated pericardium covering the visible heart. Complete closure without compromise of cardiac function was achieved at 2 days of age with bilateral pectoralis major muscle flaps and fasciocutaneous advancement flaps.

Immediate Muscle Flap Coverage for Repair of Cardiac Rupture Associated with Mediastinitis

Sternal wound infection with mediastinitis is a dreaded complication of cardiac surgery. Even more devastating is perforation of the heart or great vessels secondary to advanced mediastinitis. The exsanguinating hemorrhage and presence of extensive infection usually lead to a poor salvage rate in these patients. Citations in the English literature of successful management of cardiac rupture associated with mediastinitis are, as expected, scare. Recently, the capability for immediate muscle flap coverage in the repair of associated rupture of the heart secondary to active mediastinal infection has been discussed in two reports. This article presents another report, in which bilateral pectoralis major muscle flaps were used successfully in salvage of a patient who sustained rupture of the right ventricle after debridement of an extensively purulent sternal wound and mediastinum.

Use of Pectoralis Major Muscle Flaps to Repair Defects of Anterior Chest Wall

We closed defects of the anterior chest wall in 6 patients, using either unilateral or bilateral pectoralis major muscle flap transpositions. In 4 of these patients the defect was stabilized with autogenous rib grafts, and none of these had a flail chest. All of the transposed muscle flaps remained viable and innervated. The deformities and the functional disturbances resulting from the transpositions were minimal.