Operative Technique in Plastic Surgery – Kevin C.Chung

Table 1 Cheng’s Grading and Related Management for Lymphedema
Grade Symptoms
Circumferential
difference (%)
Lymphoscintigraphy Management
0
Reversible
<9
Partial occlusion
CDP
I
Mild
10–19
Partial occlusion
LVA,
liposuction,
CDP
II
Moderate
20–29
Total occlusion
VLNT, LVA
III
Severe
30–39
Total occlusion
VLNT +
additional
procedure
IV
Very
severe
>40
Total occlusion
Charles
procedures
and VLNT
Circumferential difference: circumference of the affected limb subtracted from the circumference
of the healthy limb and divided by the circumference of the healthy limb, which is measured at
10 cm above and below the elbow. CDP, complex decongestive physiotherapy; LVA,
lymphaticovenous anastomosis; VLNT, vascularized lymph node transfer.
From Patel KM, Lin CY, Cheng MH. A prospective evaluation of lymphedema-specific quality-of-
life outcomes following vascularized lymph node transfer. Ann Surg Oncol. 2015;22(7):2424-
2430.
Table 2 Comparisons of Various Donor Sites of Lymph Node–Carrying Flaps
Cutaneous Lymph Node Flaps
Submental
Groin
Supraclavicular
Lateral
thoracic
Ome
flap
Number of
lymph node
+++
+++
+
++
+++
Artery/vein
size
+++
++
+
+++
++
Pedicle length
+++
++
++
+++
+
Reliability of
skin paddle
++++
+++
+
++
N/A
Ease of
harvest
+++
++
++
+
+++
Donor-site
scar
+++
+++
++
+++
+++

Advantages
Thin flap
with
concealed
donor scar,
reliable
pedicle
Reliable
pedicle
Concealed
donor scar
Thin flap
Lengthy
pedicle
Rich
lymp
node
Disadvantages
Risk of
marginal
mandibular
nerve
injury
Thick flap
Short
pedicle
Damage
thoracic duct
when the left
side is
selected, chest
wall numbness
Injury of
sentinel
lymph node
of upper
extremity,
sacrificing
the
thoracodorsal
nerve
Risk
panc
and
inter
blee
sma
of ve
++++, great; +++, good; ++, fair; +, poor.
■ The vascularized omentum flap contains numerous small lymph nodes and is
currently our second-line lymph node flap. Its vascular pedicle is as small as 2
to 3 mm in diameter, but it is short and thin walled for microvascular
anastomosis. Most of the lymph nodes can be found along the great curvature;
therefore, the flap can be elevated with only the tissues around the pedicle,
and most of them can be preserved in situ.
■ Compared with the cutaneous lymph node flaps, the omentum flap lacks a
skin paddle for replacing skin defects or flap monitoring after transfer.
■ Care should be taken to avoid compressing the pedicle vein at wound
closure.
T E C H N I Q U E S
■ Lymphaticovenous Anastomosis
■ Before surgery, patients were treated with ICG lymphography to confirm the
presence of functional lymphatic vessels.
■ Functional lymphatic vessels presenting as a linear pattern in ICG
lymphography are then selected and marked as the target for LVA. After ICG
mapping, the linear lymphatic vessels are marked, and an incision can be

transversely planned for 3 to 4 cm in length (TECH FIG 1A).
■ After incision, another distal subdermal injection with blue dye is then
performed, and lymphatic vessels can be identified accordingly under a
microscope.
■ A submental vein is then selected from the surrounding area. A good
subdermal recipient vein for LVA should present with less venous backflow
to prevent retrograde venous flow into the lymphatic vessels.
■ Anastomosis can be performed with end-to-end, end-to-side, or side-to-end
anastomosis, depending on the preference of the surgeon. The lymphatic
vessels are usually small in caliber (0.5–0.8-mm diameter) (TECH FIG 1B).

TECH FIG 1 • A. Before performing LVA, lymphatic
vessels are detected by ICG lymphangiography, and
the lymphatic vessels are marked. B. A lymphatic
vessel sized 0.5 mm is identified. C. The lymphatic
vessel is dissected. D. The technique of doing side-to-
end LVA with a 6-0 nylon as stent inside the lymphatic
vessel. E. Side-to-end LVA was performed. F. With the
same view under ICG evaluation mode, ICG can be
identified inside the lymphatic vessels, and the

recipient vein confirmed the patency of the
anastomosis.
■ To see the lumen clearly and promote better visualization and anastomosis,
an intravascular stent can be placed using 6-0 nylon suture under a
microscope with 40× magnification (TECH FIG 1C).
■ Multiple different techniques and methods of anastomosis have been used,
such as T-shaped anastomosis, diamond-shaped anastomosis, octopus-shaped
anastomosis, and ladder-shaped anastomosis. Many of these techniques were
designed to simultaneously use a limited recipient vein for anastomosis with
several lymphatic vessels.
■ The authors recommended a side-to-end anastomosis to allow drainage of
most of the lymphatic fluids from the same lymphatic vessel (TECH FIG
1D–F). Further large-scale series evaluating the outcomes of LVA are
necessary.
■ Vascularized Lymph Node Transfer
Donor Site
■ A lymph node flap can be selected among different donor sites. In general,
the authors prefer subcutaneous lymph nodes over omentum lymph nodes.
■ Subcutaneous lymph node flaps with a skin paddle are important for both
flap monitoring and extra skin for tension-free wound closure. However, if
the omentum lymph node flap is selected, a skin graft on the top of the flap
should be considered instead of burying the flap inside the subcutaneous
pocket to avoid compression of the pedicle vein.
■ In the example case, at the donor site, the midline of the neck and facial
artery and vein are identified and marked (TECH FIG 2A).
■ An incision is first made along the upper border of the flap and facial artery,
and the facial vein and marginal mandibular branch of facial nerve are
identified and carefully dissected out (TECH FIG 2B,C).
■ The pedicle of the flap is then divided (TECH FIG 2D) and the donor site
closed (TECH FIG 2E).

TECH FIG 2 • Example case of free submental lymph
node flap transfer to treat upper limb lymphedema. A.
Before surgery, the midline of the neck and facial
artery and vein were identified and marked. B. Incision
was first made along the upper border of the flap and
facial artery; facial vein and marginal mandibular
branch of facial nerve were identified and carefully
dissected out. C. Flap dissection was completed. Red
arrow showed the donor artery of the flap. D. The
pedicle of the flap was divided. Red arrow, artery; blue

arrow, vein; yellow arrow, lymph nodes. E. The donor
site was closed primarily.
Recipient Site
■ Recipient site selection is based on the severity of lymphedema.
■ The authors recommended transfer of the lymph node flap to the wrist in
advanced lymphedema. ICG lymphography with the lymphatic drainage
pattern can be a good reference for recipient site selection. The flap should
be placed distally if severe dermal backflow is present.
■ To use the wrist as the recipient site, the dorsal branch of radial artery in the
snuffbox is often selected as a recipient artery, and the cephalic vein is often
selected as a recipient vein.
■ A lazy S incision is transversely made along the dorsal crease of the wrist
(TECH FIG 3A).
■ Subcutaneous dissection is then carried out. The fibrotic tissue should be
removed to create a pocket with adequate space for a lymph node flap inset
and adequate space to compensate for swelling of the lymph node flap after
absorbing the lymphatic fluid inside the flap.
■ The recipient vessels should be well prepared with removal of all the fibrotic
adventitia to prevent restriction of blood flow from the fibrotic tissues.
■ Microvascular anastomosis is performed first, following with tension-free
flap inset and wound closure (TECH FIG 3B,C).
■ The flap often becomes engorged after it is transferred to lymphedema
recipient site because of transit of fluid into the lymph node in the first 7 days
following the operation.
■ Adequate pocket size for inset of the flap skin paddle will allow for tension-
free wound closure, and avoidance of pedicle vein compression is critical for
achieving an optimal result.

TECH FIG 3 • A. A lazy S incision was made along the
wrist to identify the recipient vessels. B. The flap was
transferred to the recipient site and anastomosis was
accomplished. C. Flap inset.
PEARLS AND PITFALLS
Imaging
■ Definitive diagnosis of lymphedema can be achieved using
lymphoscintigraphy.
■ ICG lymphography can be a good diagnostic and surgical guided
tool. The results of ICG lymphography are used to separate the
patients into LVA or VLNT groups. For LVA, it can provide good
intraoperative lymphatic mapping.
LYMPHATICOVENOUS ANASTOMOSIS
Technique
■ Do surgery only on patients presenting linear pattern of ICG
lymphography.
■ Selection of a small subdermal vein without venous reflux as a

recipient vein
■ Side-to-end anastomosis is recommended
■ Intravascular stent of lymphatic vessel using 6-0 nylon to prevent
back wall suture
■ Tension-free wound closure to prevent compression
Postoperative
care
■ Restriction of ambulation for 3 days
■ Compression garment is not recommended.
VASCULARIZED LYMPH NODE TRANSFER
Technique
■ Recipient site selection should be based on the lymphatic
obstruction; in general, distal transfer presents better results.
■ Subcutaneous lymph node flap is recommended to include its skin
paddle for tension-free wound closure and flap monitoring.
■ Be sure to release all the fibrosis and create a subcutaneous pocket
that is larger than enough for flap inset.
■ Release and adventitiectomy are important while preparing the
recipient vessels.
■ Tension-free flap inset and wound closure are important.
■ Never hesitate to use therapeutic dose of anticoagulants.
Postoperative
care
■ Intensive monitoring of the flap
■ Avoid ambulation for 7 days.
■ Prophylactic antibiotics for 7 days
POSTOPERATIVE CARE
Lymphaticovenous Anastomosis
■ After surgery, it is recommended that patients rest with limited ambulation for
the first 3 days.
■ Parenteral prophylactic antibiotics are given for 3 days.
■ Movement is gradually increased after the first postoperative day.
■ Compression garments are not required after surgery.
Vascularized Lymph Node Transfer
■ After surgery, patients are admitted to microsurgical intensive care unit for
postoperative monitoring of the flap.
■ Flaps are monitored using pencil Doppler detection of both artery and vein
every 2 hours.

■ Postoperative prophylactic antibiotics are given for 1 week.
■ The use of anticoagulants depends on intraoperative findings. The authors
found that there is a high tendency of thrombosis formation in lymphedema
surgery. Therefore, the use of therapeutic dose of anticoagulation is not
uncommon.
■ Patients are allowed to walk freely and move the upper extremity 1 week after
surgery.
■ Compression garments are not required after surgery.
OUTCOMES
Lymphaticovenous Anastomosis (FIG 3)
■ The largest series of LVA for upper extremity lymphedema was reported by
Chang and colleagues with significant improvement after LVA in 96% of
patients.
■ Constant improvement of volume reduction was observed from 33% 3 months
after surgery to 42% after 1 year.10
■ A better volume reduction after LVA was reported for earlier lymphedema
stage for upper extremity lymphedema.
■ The most important consideration in performing LVA is that it is difficult to
ensure a 100% patency rate after surgery.
■ Patency has been reported as low as 0% patency 3 weeks after surgery by
Puckett11 to 93% after 7 years of follow-up by Campisi et al.12
Vascularized Lymph Node Transfer (FIGS 4 to 6)
■ In patients with advanced stage lymphedema, it has been reported that VLNT
has better results than does LVA.5
■ A reduction rate of 39% was with 18 months of follow-up using distal
vascularized lymph node transfer.
■ With an average follow-up of 29 months, Brucker and colleague reported that
84% of the patients reported improvement of their lymphedema symptoms
after vascularized lymph node transfer.13
■ Although distal transfer of the flap often results in an unsightly skin paddle in
the beginning, revision surgery after the development of symptoms can
significantly improve the appearance.
■ It is not uncommon for patients to require some other additional procedure to
achieve better volume reduction and appearance after microsurgical

approaches. These procedures often include liposuction, wedge resection of
part of the proximal soft tissue, or debulking of the transferred skin flap.
Quality of Life After Lymphedema Microsurgery
■ VLNT helps to improve the patient-reported outcomes as soon as after the 1st
week of surgery.
■ By using health-related quality of life (HRQoL) merits, Patel and colleagues
prospectively evaluated patients undergoing vascularized lymph node transfer
for upper or lower extremity lymphedema and reported improvement regarding
the domains of function, body appearance, symptom, and mood in proportion
to the improvement of limb circumference.6
FIG 3 • A. This 60-year-old woman shown in TECH FIG 1
underwent mastectomy and chemotherapy for left
breast cancer and experienced BCRL. B. At 12-month
follow-up after LVA, she had reduction rates of 5% and
20% at the above-elbow level and below-elbow level,
respectively, in her left arm.

FIG 4 • This 56-year-old woman with left breast cancer
is pictured in TECH FIGS 2 and 3. She received skin-
sparing mastectomy and tissue expander reconstruction
followed by chemotherapy for breast cancer. A. Left
upper arm nonpitting edema presented 6 months after
surgery. B. At 30 months of follow-up, she presented
with reduction rates in her left arm lymphedema of 35%
and 20% at the above-elbow level and the below-elbow
level, respectively. C–E. Her donor-site scar was well
concealed, and there were no donor-site morbidities.

FIG 5 • This 79-year-old woman had a history of right
breast cancer after modified radical mastectomy,
radiotherapy, and chemotherapy. She started to
experience right upper arm swelling 6 months after
breast cancer treatment. She received vascularized
groin lymph node flap transfer 14 months after the first
presentation of lymphedema. A. Preoperative
appearance of the upper extremities. B. Vascularized
groin lymph node flap of 10 × 5 cm was designed on
her left groin area. C. Vascularized groin lymph node
flap was harvested based on the medial artery (red
arrow) and vein (blue arrow). D. At 24-month follow-up,
she had reduction rates of 30% and 35% in the upper
arm and forearm, respectively.

■ The improvement in the HRQoL appeared as soon as the first month, and the
improvement was continued and sustained during the 1 year of follow-up.
■ Gratzon evaluated the psychosocial outcome of vascularized lymph node
transfer using the LYMQoL prospectively and revealed early steady
improvements with respect to the function, appearance, mood, and
symptoms.14
■ Using Upper Limb Lymphedema Questionnaire 27, Brucker and colleagues
evaluated the quality of life after simultaneous breast reconstruction and
vascularized lymph node transfer with inspiring results.
■ With an average follow-up of 29 months, 84% of the patients reported
improvement of their lymphedema symptoms.13
FIG 6 • This 52-year-old woman had a history of right
breast cancer, stage II, after modified radical
mastectomy, chemotherapy, and radiotherapy and lung
metastasis after wedge resection of the tumor. She
presented with right upper arm lymphedema 1 year
after surgery and received vascularized submental
lymph node flap transfer 4 years after her first
presentation of lymphedema. A. Preoperative
appearance of bilateral upper extremities. B.
Vascularized submental lymph node flap of 8.5 × 2.5 cm

was designed. C. Vascularized submental lymph node
flap was harvested based on submental artery (red
arrow) and facial vein (blue arrow). Lymph nodes were
visualized during surgery (yellow arrow). D. At 18-
month follow-up, she had reduction rates of 35% and
42% at the above-elbow level and below-elbow level,
respectively.
■ Although the different groups continue to have different preferences for
recipient and donor-site selection, vascularized lymph node transfer seems to
work by different designs and combinations of breast reconstruction with an
abdominal flap.
COMPLICATIONS
■ Complications of LVA include obstruction of the anastomosis and venous
reflux into the lymphatics. To prevent this, the recipient vein should be a small
subdermal vein with limited backflow.
■ Common complications of vascularized lymph node transfer include early
thrombosis of the vein, partial or total loss of the skin paddle, and infection.
■ To ensure a safe flap transfer, inclusion of skin paddle for intensive monitoring
is recommended.
■ It seems that there is a higher incidence of thrombus formation in vascularized
lymph node transfer. To minimize this risk, therapeutic dose anticoagulation is
occasionally required.
REFERENCES
1. Lopez Penha TR, van Bodegraven J, Winkens B, et al. The quality of life in
long-term breast cancer survivors with breast cancer related lymphedema. Acta
Chir Belg. 2014;114(4):239-244.
2. McLaughlin SA, Wright MJ, Morris KT, et al. Prevalence of lymphedema in
women with breast cancer 5 years after sentinel lymph node biopsy or axillary
dissection: patient perceptions and precautionary behaviors. J Clin Oncol.
2008;26(32):5220-5226.
3. Mihara M, Hara H, Shibasaki J, et al. Indocyanine green lymphography and
lymphaticovenous anastomosis for generalized lymphatic dysplasia with
pleural effusion and ascites in neonates. Ann Vasc Surg. 2015;29(6):1111-1122.

4. Koshima I, Yamamoto T, Narushima M, et al. Perforator flaps and
supermicrosurgery. Clin Plast Surg. 2010;37(4):683-689, vii-iii.
5. Akita S, Mitsukawa N, Kuriyama M, et al. Comparison of vascularized
supraclavicular lymph node transfer and lymphaticovenular anastomosis for
advanced stage lower extremity lymphedema. Ann Plast Surg. 2015;74(5):573-
579.
6. Patel KM, Lin CY, Cheng MH. A prospective evaluation of lymphedema-
specific quality-of-life outcomes following vascularized lymph node transfer.
Ann Surg Oncol. 2015;22(7):2424-2430
7. Yan A, Avraham T, Zampell JC, et al. Mechanisms of lymphatic regeneration
after tissue transfer. PLoS One. 2011;6(2):e17201.
8. Patel KM, Chu SY, Huang JJ, et al. Preplanning vascularized lymph node
transfer with duplex ultrasonography: an evaluation of 3 donor sites. Plast
Reconstr Surg Glob Open. 2014;2(8):e193.
9. Cheng MH, Huang JJ, Wu CW, et al. The mechanism of vascularized lymph
node transfer for lymphedema: natural lymphaticovenous drainage. Plast
Reconstr Surg. 2014;133(2):192e-198e.
10. Chang DW, Suami H, Skoracki R. A prospective analysis of 100 consecutive
lymphovenous bypass cases for treatment of extremity lymphedema. Plast
Reconstr Surg. 2013;132(5):1305-1314.
11. Puckett CL. Microlymphatic surgery for lymphedema. Clin Plast Surg.
1983;10(1):133-138.
12. Campisi C, Bellini C, Campisi C, et al. Microsurgery for lymphedema:
clinical research and long-term results. Microsurgery. 2010;30(4):256-260.
13. De Brucker B, Zeltzer A, Seidenstuecker K, et al. Breast cancer-related
lymphedema: quality of life after lymph node transfer. Plast Reconstr Surg.
2016;137(6):1673-1680.
14. Gratzon A, Schultz J, Secrest K, et al. Clinical and psychosocial outcomes of
vascularized lymph node transfer for the treatment of upper extremity
lymphedema after breast cancer therapy. Ann Surg Oncol. 2017;24(6):1475-
1481.

PART 5
Trunk Reconstruction and Body
Contouring

(Trang không có chữ)

1
CHAPTER
Section I: Reconstruction
of the Chest Wall
Pectoralis Flap for Chest
Wall Reconstruction
Jeff J. Kim and David H. Song
DEFINITION
■ Chest wall defect: Most common etiologies include trauma, tumor resection,
osteoradionecrosis, deep sternal wound infections, and chronic empyemas.
■ Chest wall functions: Protection of visceral organs, support of respiratory
mechanics, and base scaffold for shoulder/upper limb
■ Basic defect management concepts: Adequate debridement of
infection/nonviable tissue, reconstruct to re-establish form and function,
replacing like with like whenever possible
■ Reconstructive goals:
■ Stabilize thoracic skeletal defect to return proper respiratory mechanics.
■ Obliterate intrathoracic dead space that may predispose to infection.
■ Protect vital intrathoracic structures.
■ Provide soft tissue coverage for closure.
■ Recreate aesthetic contour.
■ Defects requiring skeletal support to prevent paradoxical motion: 5 cm or
more in diameter or two or more rib resection anteriorly, twice as much for
lateral and posterior defect; radiated tissue can often tolerate larger defect due
to rigidity from fibrosis.
ANATOMY
■ Pectoralis major

■ Origin: Sternum, 1st to 6th costal cartilage, clavicle (FIG 1A,B)
■ Insertion: Lateral lip of bicipital groove of humerus
■ Innervation: Medial and lateral pectoral nerve from medial, lateral cord of
brachial plexus
■ Function: Adduction, extension, and medial rotation of shoulder
■ Borders: Superficial to pectoralis minor, superior and superficial to serratus
anterior, inferior to the subclavius; two heads converge laterally inferior to
deltoids; lateral border forms the anterior axillary fold/wall
■ Vascular anatomy (FIG 1C)
■ Mathes and Nahai classification: type V muscular flap—thoracoacromial
artery (dominant) and internal mammary perforators (secondary segmental)

Clavicle Clavicular head Intertubercular sulcus of the humerus - Body of sternum Sternocostal head Costal cartilage Superior thoracic artery Thoraco-acromial artery Lateral thoracic artery- Subscapular artery Pectoral branch of thoraco-acromial artery Internal mammary artery Perforating branches of internal mammary artery

FIG 1 • A. Muscular anatomy of anterior chest and
shoulder. B. Origin and insertions of the pectoralis
major. C. Vascular anatomy of blood supply to
pectoralis major.
■ Thoracoacromial artery arises from second portion of axillary artery deep to
pectoralis minor, travels laterally and merges superomedially to pectoralis
minor, and divides into four branches as it pierces the clavipectoral fascia.
The dominant branch to the sternocostal portion is the pectoral branch, which
courses deep to pectoralis major after piercing through the clavicopectoral
fascia medial to pectoralis minor before dividing into muscular and cutaneous
branches; clavicular branch arising lateral to pectoralis minor has much
shorter pedicle (1 cm) before exclusively supplying the clavicular head,
subclavius muscle, and soft tissue around the clavicle.
■ Internal mammary artery (IMA) provides reliable secondary segmental
pedicles through its perforating branches that pass through the intercostal
spaces 1 to 2 cm lateral to the sternal edge; usually three perforators provide
the muscle through the first to third intercostal space with branches coming
through first or second space being the most dominant.
■ Venous drainage: Muscle drains mainly via venae comitantes of the pedicles,
through pectoralis branch into the axillary vein, while overlying skin drains
through venules accompanying arterial perforators.
PATHOGENESIS
■ Most common etiology and mechanism of chest wall defects requiring
reconstructive interventions include injury from trauma, iatrogenic (radiation,
cardiothoracic surgery), infection, congenital deformity, and neoplasm.
NATURAL HISTORY
■ Tansini is often credited with first use of muscle flap in chest wall
reconstruction using latissimus dorsi.1
■ Jurkiewicz and others transposed the pectoralis major into the mediastinum
either based on the thoracoacromial pedicle or as a turnover flap based on
perforators of the IMA.2
■ Nahai introduced a modification of the turnover pectoralis major flap by
dividing the muscle medial to the thoracoacromial pedicle and using only the

medial two-thirds of the pectoralis major for definitive coverage of the
mediastinal wound.3
■ Tobin suggested the splitting of the pectoralis major muscle into sternocostal,
external, and clavicular segments and the preserving of the thoracoacromial
pedicle.4
■ Morain suggested the splitting of the pectoralis major muscle into segments
but leaving some of the segments intact to preserve muscle function for smaller
defects requiring only a small portion of muscle.5
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Preoperative evaluation for patients requiring pectoralis flap for chest wall
reconstruction is mostly based on history and physical examination.
■ History
■ Etiology, chronicity
■ Important to note history of radiation and history of surgery, including history
of coronary artery bypass grafting (CABG)/IMA harvest and other chest
incisions. Also important to note pulmonary function and history of chronic
obstructive pulmonary disease
■ Social: Smoking history
■ Physical examination
■ Important to note size, location, and tissue composition of defect
■ Soft tissue: Size and location
■ Skeletal: Number of ribs and size of skeletal defect
■ Intrathoracic: Size and volume of dead space
■ Respiratory mechanics: Skeletal stability, presence of paradoxical motion,
soft tissue compliance
■ Previous scars, radiation changes
IMAGING
■ Preoperative computed tomography (CT) is not absolutely necessarily from a
reconstructive standpoint, especially in wounds requiring further debridement
where final size and composition of defect will invariably change.
■ If a CT scan is available, however, it can provide some preoperative insight for
operative planning in some cases.
DIFFERENTIAL DIAGNOSIS
■ Trauma

■ Empyema
■ Poststernotomy mediastinitis
■ Osteoradionecrosis
■ Tumor resection of anterior chest wall
NONOPERATIVE MANAGEMENT
■ For small and superficial wounds or defects with no exposed vital structure or
functional defect, it may be possible and appropriate to manage using simple
wound care methods with either traditional wet to dry gauze dressings or
negative pressure wound therapy.
■ In cases of heavily contaminated or actively infected wounds (except deep
sternal infections), local wound care may be more appropriate initial method of
management to prepare the wound bed prior to proceeding with definitive
operative reconstruction.
SURGICAL MANAGEMENT
■ Pectoralis major offers large muscular flap with robust blood supply, with arc
of rotation based on thoracoacromial pedicle by allowing coverage of central,
supraclavicular, and axillary or lateral chest wall defects, as well as being able
to be transposed to an intrathoracic position for obliteration of dead space.
■ The pectoralis major is most commonly used as an advancement flap to cover
anterior chest wall defects in the upper part of the chest, classically for wounds
resulting from an infected median sternotomy after open heart surgery.6
■ This technique allows for repeat subsequent procedures through the midline
incision, including further debridement and costochondral resection, without
sacrificing viability of reconstruction.1
■ Turnover flap is based off its medial segmental blood supply from perforators
of IMA allows coverage of wounds extending further inferiorly or to the
contralateral side or to provide large bulk of healthy tissue to obliterate more
significant area of dead space.
■ Contraindications/disadvantages:
■ Low sternal and xiphoid defects may be out of reach for the pectoralis flap.
■ If IMA has been harvested for prior cardiac bypass procedure, secondary
perfusion through segmental pedicles off IMA would not be available for a
turnover flap.
■ Other surgical options:
■ Local flaps: Latissimus dorsi, rectus abdominis, serratus anterior, omentum

■ Free tissue transfer
Preoperative Planning
■ A good history and physical examination will usually suffice for preoperative
purposes, as final size and extent of defect will often not be established until
called on intraoperatively after resection/debridement.
■ Location, extent of defect, and availability of the pedicles (prior radiation,
surgery) will primarily dictate whether reconstruction will be based off
thoracoacromial vs internal mammaries, unilateral vs bilateral, or if at all.
■ If size and extent of defect will not be fully established until intraoperatively,
the surgeon should be prepared and comfortable to use alternative options,
including other local flaps or even free tissue transfers.
Positioning
■ The patient is positioned supine on the operating table.
■ The arm should be adducted to the side and secured via tucking it on the side
from which the flap is planned to be harvested (FIG 2).
■ This allows for ease of surgeon positioning and access, especially in case
humeral attachments need to be divided.
■ It also allows for physiologic advancement where the pectoralis major
muscle is not placed on passive stretch as in an abducted/arm out position.
■ The opposite arm should be out.
■ For ease of identifying landmarks, entire anterior chest surface should be
prepped and draped into the field, with clavicle and acromial process of the
scapula exposed superiorly and upper arm and midaxillary line laterally.

FIG 2 • Preoperative patient positioning: supine with
arm on operative side adducted (A) and tucked and the
other arm out (B).
Approach
■ Pedicle landmarks
■ Thoracoacromial pedicle originates at the cross section of line drawn from
the acromial process of the scapula to the xiphoid and perpendicular line
originating at the junction between middle and lateral third portion of the
clavicle (FIG 3).
■ Internal mammary perforators can be found piercing through within
intercostal spaces, about two fingerbreadths lateral from the costosternal
junction.
■ Incisions
■ Depending on location of defect/wound, a separate incision may not be
required to access around the muscle for necessary releases. Muscle can often
be completely released through the wound.
■ For small median sternotomy wounds, lateral counterincision can often be
helpful to more easily access insertion of the muscle at the anterior axillary

fold.
FIG 3 • Markings for thoracoacromial pedicle.
■ If not accessed through pre-existing wound, depending on the choice of
vascular pedicle, location of defect, and plan for inclusion of cutaneous skin
paddle, incisions may be varied.
• Most useful incision is often placed along the lateral border of the muscle,
with option to extend the incision curved inferomedially under the breast in
subpectoral groove or inframammary fold (IMF) on females (this incision
can be used for either pedicle and entire surface of the muscle can be
accessed).
■ Skin paddle
■ Design should be centered on a line drawn from tip of acromion to xiphoid
process (approximate course of pectoral branch of thoracoacromial pedicle)
on males or centered along the IMF for females.

■ Skin paddle width of up to 8 cm can be expected to be closed primarily.
T E C H N I Q U E S
■ Harvest for Rotation-Advancement Flap
■ This flap is based off the primary thoracoacromial artery.
■ If accessed via medial sternal wound, skin incision can be extended
vertically as needed. If a myocutaneous flap is planned, the muscle can be
accessed superolaterally and inferomedially through the incision around the
skin paddle.
■ Identify the plane between the subcutaneous tissue of the chest wall and
the anterior surface of the pectoralis fascia.
■ Dissection should continue superolaterally toward the axilla until the entire
anterior surface of the muscle is exposed.
Raising the Muscle
■ Dissection of muscle off the chest along the medial insertion is generally
more difficult so it may be helpful to raise the muscle off starting at the
lateral edge, where the subpectoral plane is easier to identify.
■ It usually can be identified through blunt dissection just using the fingers
(placement of counter skin incision over this area laterally on the chest
surface may allow for easier access).
■ Submuscular dissection can then proceed medially freeing the inferior
attachment of the muscle along the rectus abdominis and external oblique
aponeurosis and then subsequently proceed superolaterally toward the
axilla/pedicle.
■ When dissecting the medial attachment of the muscle, care should be taken
to ligate the intercostals and internal mammary perforators
■ It is important to leave some perforators from muscle to overlying skin to
maximize healing potential of midline and to minimize postoperative
seroma formation.
■ As muscle is elevated toward superolaterally, care is to taken to find the right
plane to avoid elevating the pectoralis minor and leaving it intact in situ.
■ Blunt finger dissection can be performed along the anterior surface of
pectoralis minor, which will aid in identification of pectoralis minor branch

from the thoracoacromial artery, which should be divided closely to the
pectoralis minor muscle to avoid damaging the main pedicle (TECH FIG
1).
■ Usually dividing the medial attachment and lifting the muscle off the chest
wall thoracic cage is sufficient to mobilize the muscle to cover the
sternotomy defect medially, but further mobilization can be achieved by
releasing the clavicular attachments superiorly or dividing the sternocostal
head from clavicular head of the muscle.
■ As the clavicular head of the muscle is dissected off the clavicle working in
a medial to lateral direction, when approaching the lateral third of the
clavicle, care is taken as subclavian vein can be found just deep to this
landmark.
■ Staying on the anterior surface of clavicle during release/dissection of
muscle will minimize any risk of injuring critical structures.
■ Humeral insertion can also be released laterally for further mobilization
through separate incision near the humeral insertion at the lateral lip of
bicipital groove; however, this usually accentuates aesthetic distortion of
anterior axillary landmark.
Approaching the Pedicle
■ An Allis or Babcock is used to grab the thick head of the muscle that has
been freed of the clavicle, and careful dissection of the upper portion of the
muscle can proceed.
■ The thoracoacromial artery should be identified as it exits the subclavicular
space and enters the underside of the pectoralis major muscle.
■ All muscle lateral to the pedicle is expendable and should be divided to
maximize excursion and advancement of the flap medially.
■ Careful inspection of the pedicle reveals initial lateral course of the pedicle
prior to turning medially toward along fibers of the muscle. Careful
dissection of the pedicle proximal to this “elbow” level can allow for
straightening out of the vessel and maximize its length.

TECH FIG 1 • Rotation-advancement flap harvest.
Release of medial, inferior, and lateral insertion of
muscle while preserving thoracoacromial pedicle
attachment.
■ Harvest for Turnover Flap
■ This flap is based off perforating branches of internal mammary, often used
when inferior pole of sternal wound requires coverage.
■ Disadvantages include relying on secondary blood supply.
■ Entire anterior surface of the muscle should be dissected free off the
overlying subcutaneous tissue.
■ Raising of the muscle should begin laterally at the anterior axillary fold and
proceed medially. A counter skin incision over this area can be very helpful
for access.
■ As the muscle is divided superolaterally, the humeral insertion of the
pectoralis major muscle should be divided.
■ Modification can be made by dividing the muscle medial to the
thoracoacromial pedicle and using only the medial two-thirds muscle.
■ Humeral insertion and anterior axillary fold can be preserved by dividing
the muscle medial to it and anchoring the lateral portion of the muscle to
the chest wall to preserve function and minimize donor-site morbidity.7

■ Proceed to divide clavicular and inferior attachments, being mindful of the
subclavian vessels deep to the clavicle.
■ As medial attachment is approached, care should be taken to identify and
protect the perforating vessels from IMA, which will arise about 2 cm medial
to the costosternal junction.
■ No medial attachment beyond these vessels should be divided since the
vessels themselves limit medial transposition of the flap (TECH FIG 2).
TECH FIG 2 • Turnover flap. Thoracoacromial pedicle
is ligated to allow for turnover of the lateral portion of
the muscle medially. Medial blood supply from internal
mammary vessels is preserved.
■ Bilateral Advancement Flap
■ This flap is often used for larger sternotomy wounds to obliterate deeper
sternal dead space (TECH FIG 3A,B).
■ Superiorly, dissection ends just below level of the clavicle.
■ Laterally, elevation off the chest wall should be performed so just enough
muscle can be mobilized from either side to approximate the two muscles
together with minimum tension (usually between midclavicular to anterior
axillary line; TECH FIG 3C).

■ Humeral insertion, pedicle axis, innervation, and pectoralis minor should
all be left intact.
■ Inferiorly, dissection is continued deep to the muscle and deep to anterior
rectus fascia, until level of xiphoid.
■ The inferior insertion of the pectoralis major is elevated without detaching
the muscle from the superior portion of anterior rectus sheath. The rectus
muscle should be left intact (TECH FIG 3D,E).8
■ The wound is closed (TECH FIG 3F–H).
■ Three drains should be placed: one medial drain, two laterally (one under
each flap; TECH FIG 3I).6

TECH FIG 3 • Bilateral advancement of pectoralis
major. A. Design of flap. B. Large sternal wound
before debridement. C. Pectoralis major muscle
dissected off the chest wall after complete

debridement of sternum. D. Bilateral pectoralis major
muscle advancement showing minimal tension. E.
Raising the pectoralis major in conjunction with the
superior portion of the rectus abdominis muscle as
one single unit to close the xiphoid region. F.
Pectoralis major advancement closure complete. G.
Cross-sectional view of defect repair. H. Muscle layers
closed. I. Closure completed with two drains in place.
PEARLS AND PITFALLS
Drains
■ Placement of closed suction drains in spaces above and below the
pectoralis muscle is critical to avoid seromas. Drains will typically stay
in for up to 3 weeks. Care must be taken to avoid placing closed suction
drains directly over the right ventricle. Closed suction drains that are
well placed can also be set to continuous wall suction at −70 mm Hg or
less to assist in obliterating the dead space.
Flap
harvest
■ Muscle harvest can be extended to the insertion of the pectoralis major
into the humerus. For greater mobility, the humeral insertion can also be
detached and the entire muscle can be transferred based on the
thoracoacromial vessels with reliability.
Coverage
■ The inferior portion of the sternal wound is the most difficult to cover.
Developing the pectoralis major muscle in continuity with the superior
origin of the rectus abdominis muscle can create greater vascularized
coverage for the inferior most extent of the wound. This allows for an
entire unit of both pectoralis major muscle and the superior origin of the
rectus muscle to be advanced into the inferior sternal wound. Often, the
superior epigastric artery must be ligated to gain greater mobility. This
then allows for the entire unit to be based upon the thoracoacromial
system above and the deep inferior epigastric system below.
Turnover
flaps
■ Turnover flaps are based on the secondary blood supply from the
internal mammary system and thus are unreliable but can be used when
the internal mammary vessels on the respective side have not been
sacrificed. This maneuver mandates a close examination of the
vasculature and blood supply with the use of either pencil Doppler
probes or preoperative duplex.

POSTOPERATIVE CARE
■ Keeping drains up to 3 weeks leads to decrease in seroma rate. Any drains in
intrathoracic spaces should be put to low continuous wall suction to prevent
possible pneumothorax.
■ When wound dehiscence is encountered, wound irrigation and light gauze
packing can be employed along with negative pressure dressings.
Readvancement of the pectoralis myocutaneous unit can be considered once
the wound is in bacteriologic control and all necrotic or infected tissues are
removed.
■ Other shoulder girdle muscles will compensate for weakened abduction,
internal rotation, and flexion.
■ Starting 6 weeks, start consistent fair to moderate physical therapy for range
of motion, flexibility, and strengthening only. Thereafter, full range of motion
with resistance and weight training is allowed.
COMPLICATIONS
■ Seroma/hematoma
■ Skin/flap necrosis, wound dehiscence
■ Infection
■ Donor-site complications
■ Contour deformities
■ Impaired shoulder functions
REFERENCES
1. Bakri K, Mardini S, Evans KK, et al. Workhorse flaps in chest wall
reconstruction: the pectoralis major, latissimus dorsi, and rectus abdominis
flaps. Semin Plast Surg. 2011;25(1):43-54.
2. Jurkiewicz MJ, Bostwick J III, Hester TR, et al. Infected median sternotomy
wound: successful treatment by muscle flaps. Ann Surg. 1980;191(6):738-744.
3. Naha, F, Morales L Jr, Bone DK, et al. Pectoralis major muscle turnover flaps
for closure of the infected sternotomy wound with preservation of form and
function. Plast Reconstr Surg. 1982;70:471.
4. Tobin GR. Pectoralis maor segmental anatomy and segmentally split
pectoralis major flaps. Plast Reconstr Surg. 1985;75:814-824.
5. Morain WD, Colen LB, Hutchings JC. The segmental pectoralis major muscle
flap: a function-preserving procedure. Plast Reconstr Surg. 1985;75(6):825-

830.
6. Ascherman JA, Patel SM, Malhotra SM, Smith CR. Management of sternal
wounds with bilateral pectoralis major myocutaneous advancement flaps in
114 consecutively treated patients: refinements in technique and outcomes
analysis. Plast Reconstr Surg. 2004;114(3):676-683.
7. Arnold PG, Pairolero PC. Chest-wall reconstruction: an account of 500
consecutive patients. Plast Reconstr Surg. 1996;98:804-810.
8. Davidson SP, Clemens MW, Armstrong D, et al. Sternotomy wounds: rectus
flap versus modified pectoral reconstruction. Plast Reconstr Surg.
2007;120(4):929-934.

2
CHAPTER
Sternal Debridement and
Application of Muscle Flaps
Sean M. Fisher, Jeff J. Kim, and David H. Song
DEFINITION
■ Deep sternal wound infections (DSWIs) are a feared postoperative
complication of open heart surgery, with a reported global incidence of 0.25%
to 2.8%.1
■ Sternal infections may be classified based on the system popularized by
Pairolero and Arnold1–3:
• Type I: Demonstrate serosanguineous drainage without evidence of deep
soft tissue, bone, or cartilage involvement.
• Type II: Demonstrate purulent drainage, cellulitis, and mediastinal
suppuration.
• Type III: Osteomyelitis, costochondritis, and/or foreign bodies are
commonly present.
■ Alternative classification systems are based on the extent of damage to
underlying tissue or relative anatomic location of the wound.2
■ Sternal necrosis can result in critical-size defects in the thoracic wall with
exposure of underlying thoracic structures, necessitating the involvement of
reconstructive surgeons.
■ Sternal nonunion is defined as pain or clicking with objective measures of
instability lasting greater than 3 months, albeit in the absence of signs of
infection.4
ANATOMY
■ The thoracic cage has mechanical and protective properties, serving as an
attachment point for a number of chest wall muscles and acting as a key
protective barrier for thoracic organs.

■ The sternum acts as a cornerstone of the thoracic cage and is composed of the
manubrium, the body, and the xiphoid process.
■ Manubrium
• Superior most aspect of the sternum, helping anchor the pectoral girdle via
the sternoclavicular joints, and as the anterior aspect of the superior thoracic
aperture (FIG 1A)
• Sternal angle serves as a critical surface landmark, composed of the
manubrium angled posteriorly to the body at the manubriosternal joint.
• Contains articular surfaces at the superolateral aspect, allowing for
articulation with the left and right clavicle
• Facets inferior to the sternoclavicular joints represent the site of attachment
for the first costal cartilage, whereas demifacets at the inferolateral aspect
allow for articulation with the superior aspect of the second costal cartilage
(FIG 1B).
• Serves as the site of attachment for the sternocleidomastoid, pectoralis
major, sternohyoid, and sternothyroid muscles
■ Body
• Narrow, flat bone that is oriented longitudinally with palpable transverse
ridges
• Contains facets along the lateral aspect, allowing for articulation with the
3rd to 6th costal cartilages
• Demifacets at the superior and inferior aspect allow for shared articulation
between the 2nd and 7th costal cartilages with the adjacent sternal
components (see FIG 1B).
• Serves as the major attachment for the pectoralis major
■ Xiphoid process
• Inferior aspect of the sternum and demonstrates variable morphology
• Along with the body of the sternum, the xiphoid process articulates with the
7th costal cartilage via superolateral demifacets.
• Serves as an attachment point for the diaphragm and rectus abdominis
PATHOGENESIS
■ The primary insult in DSWIs may begin as a site of focal sternal osteomyelitis
without external evidence of infection when sternal fixation is inadequate or
may be due to skin breakdown with subsequent penetration of bacteria to
deeper layers.

■ Presentation often demonstrates a highly variable time course, ranging from
days to years following cardiac surgery.2
■ In cases requiring surgical debridement, Gram-positive organisms, namely
Staphylococcus, have been found to be overwhelmingly responsible for
infection.5
■ In addition to male sex, conditions associated with patients’ habitual state have
been shown to be risk factors in the development of DSWIs and associated
morbidity and mortality.
■ Diabetes mellitus (DM), COPD, BMI over 30, chronic steroid use, and
smoking are known predictors of DSWI.
■ Bilateral internal mammary artery (IMA) grafting for CABG also increases
the risk of postoperative DSWI, as it may reduce sternal vascularity, and
should be avoided in those patients with DM and other high-risk
comorbidities.1,2
■ Sternal nonunion represents a similar, yet separate, diagnosis that may
necessitate sternal debridement as a treatment strategy.
■ Both intrinsic and extrinsic factors may contribute to an increased propensity
in developing sternal nonunion following median sternotomy or traumatic
injury.
■ Factors that are dependent on patients’ habitual state closely mimic those risk
factors associated with DSWI.
• These include DM, COPD, obesity, chronic steroid use, malnutrition, and
osteoporosis.4
■ Intraoperative technical errors, as well as postsurgical factors, may also play
a role in the development of sternal nonunion.4

FIG 1 • A. The sternum represents an anterior anchor
point for the pectoral girdle, attaching via the
sternoclavicular joint bilaterally. The superior thoracic
aperture, noted in red, houses the trachea, esophagus,
and thoracic duct, as well as a variety of nerves and
vessels. B. Lateral view of the sternum demonstrates
the manubrium, the body, and the xiphoid process with
corresponding facets and demifacets for articulation
with corresponding costal cartilage.
NATURAL HISTORY
■ Julian et al. first described the median sternotomy in 1957, which initially met
resistance due to reported rates of infection exceeding 5%.1
■ As the technique gained traction in open cardiac surgery, and advances were
made allowing for surgical intervention in patients with more extensive
comorbidities, DSWIs began being described with incidence ranging from 3%
to 5%1,6,7 and associated mortality as high as 50%.1,2
■ Classification of the wound often typifies the time course to presentation1,2:
■ Type I: Often presents within the first few days following surgery
■ Type II: Typically occurs a few weeks following surgery
■ Type III: Can occur months to years following surgery
■ A second classification system proposed by Jones et al. attempts to further
qualify the severity of the wound by addressing the extent of involvement in
underlying tissues8:

■ Type 1a: Superficial wound with skin and subcutaneous tissue dehiscence
■ Type 1b: Superficial wound with exposure of the sutured deep fascia
■ Type 2a: Deep wound with exposed bone and stable wired sternotomy
■ Type 2b: Deep wound with exposed bone and unstable wired sternotomy
■ Type 3a: Deep wound with exposed necrotic or fractured bone, unstable
sternotomy, and exposed heart
■ Type 3b: Type 2a, 2b, or 3a wound with septicemia
■ Marked improvement in outcomes has been demonstrated, due to the
utilization of myocutaneous flaps for reconstruction, with more recent
morbidity reported as low as 8% to 15%.1,2
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Surgical history, physical exam, and history of trauma are imperative in the
initial assessment of patients suspected of having a DSWI or sternal malunion,
as well as complaints of ongoing pain, sternal clicking, or subjective instability.
■ Signs of infection may vary based on the time of presentation in relation to
patients’ history of cardiac surgery, as laid out by Pairolero and Arnold.3
■ Physical examination
■ Inspect the skin for median sternotomy scar.
■ Assess whether evidence of DSWI is present such as erythema, purulent
discharge, fever, wound dehiscence, or frank necrotic tissue.
■ If an open wound is present, the extent of necrotic tissue should be assessed
by evaluating the viability of different flap options based on the expected
extent of excision.
■ Stability of the sternum can be assessed with direct palpation.
■ If sternal nonunion is suspected, clicking may be elicited with movement.
IMAGING
■ Computed tomography (CT) is the mainstay of imaging support when
suspicion of DSWI is high, allowing for the evaluation of the depth of
dehiscence as well as sternal nonunion5 (FIG 2A).
■ 99mTc-leukocyte imaging also has value in the early detection of DSWIs (FIG
2B).
NONOPERATIVE MANAGEMENT
■ Nonoperative management is based on the extent of the infection, evidence of
instability, and clinic signs of systemic infection.

■ Mainstay of nonoperative management includes long-term IV antibiotics and
incision and drainage of limited/superficial abscess collection, followed by
local wound care with frequent wet to dry gauzes, topical antibiotics, or
negative pressure wound therapy (NPWT).5
FIG 2 • A. Axial CT demonstrating fluid collection, as
indicated by the arrows, resulting in the separation of
the sternum into two distinct halves. B. 99mTc-leukocyte
scan taken at 4 hours (left) and 20 hours (right) after
leukocyte radiolabeling. Diffuse uptake of the distal
sternum is noted at 4 hours, with lateral extension at 20
hours. Surgical intervention confirmed infection in areas
noted to have enhanced signaling. 20 hours after
leukocyte radiolabeling. Diffuse uptake of the distal
sternum is noted at 4 hours, with lateral extension at 20
hours. Surgical intervention confirmed infection in areas
noted to have enhanced signaling.
SURGICAL MANAGEMENT
■ The need for surgical intervention is dependent on wound severity and may
include complete debridement of devitalized tissue, removal of preexisting

hardware, fixation of sternal fragments, partial or total sternectomy, and
eventual reconstruction utilizing myocutaneous flaps.2,8,9
■ Indications for sternal debridement include the presence of devitalized tissue,
positive Gram stains of parasternal fluid, and notable sternal instability.8,9
■ Timely surgical debridement has been shown to result in shorter hospital stays
and fewer postoperative hospitalizations.10
■ Depending on the extent of devitalized tissue and time course since median
sternotomy, either limited or complete debridement may be indicated.8,11
■ Single-stage intervention, with immediate flap coverage, has been shown to
reduce the duration of hospital stays.1,8,11
■ Serial stage approaches utilizing bridging NPWT may avoid the need for a
vascularized flap or reduce the total number of flaps needed.
■ Consideration for flap selection is based largely on:
■ Anatomic location/extent of the defect
■ Prior surgical history, including prior CABG requiring IMA grafting, as this
may prevent the use of pedicled flaps based on IMA perforators or the
utilization of the IMA as recipient vessels in free flap transfer
Preoperative Planning
■ Usually, a thorough history and physical examination are sufficient for
preoperative planning. Evaluation of imaging studies can sometimes help
elucidate less obvious infection and sternal nonunion.
■ Given the extent of defect, adequacy of debridement may not be known until
the time of the procedure. Surgeons should be prepared for all possibilities,
including the need for sternal fixation, definitive closure/reconstruction after
debridement, and various appropriate flap options given patients’ surgical
history (ie, previous IMA harvest for CABG) and location/size of defect.
Positioning
■ In general, the patient is placed supine on the operating table with arms
abducted and secured to an arm board.
■ If not already onboard, preoperative evaluation by cardiothoracic surgery
should be performed, and need for groin prep or possible cardiopulmonary
bypass should be discussed.
■ If latissimus dorsi flap is planned, the patient will need to be positioned in
lateral decubitus position and repositioned intraoperatively to supine once flap

is raised.
Approach
■ Sternal debridement should proceed from superficial to deep, carefully and
continually reassessing the viability of tissues at the margins as further
debridement is carried out.
■ Depending on the location and extent of the final wound/defect following
debridement, separate skin incisions/approaches frequently may be necessary
for accessing local/regional muscles to be used for reconstruction.
■ Approaches for access/harvest of specific flaps will be discussed in
subsequent respective chapters.
T E C H N I Q U E S
■ Sternal Debridement
■ Generous debridement of all devitalized tissue is imperative to avoid
complications and need for return to the OR for additional operations.
■ Debridement should start superficially with soft tissue, continually assessing
the viability of tissue at the margins and the need to continue further.
■ Marginal/questionable tissue should be as aggressively debrided as safely
possible down to clearly healthy, bleeding tissue.
■ When in doubt, tissue/bone cultures should be sent to help tailor
postoperative antibiotic regimen.
■ In case of bony involvement or suspected osteomyelitis, any prior hardware
should be removed before bone debridement is carried out using rongeurs
and curettes.
■ Sternal Fixation
■ Depending on the location/extent/etiology of sternal defect, a variety of
techniques have been described for fixation of fragments and nonunions.
■ Obliquely oriented sternal wiring, figure-of-eight peristernal wiring, and
parasternal wiring help by adding additional lateral support.
■ Steel banding, polymer tapes, and absorbable sutures can be used for repair

of nonunions.
■ Plate-based systems, such as the SternaLock System (Biomet
Microfixation, Warsaw, IN), can be used when adequate bone stock is
available for secure purchase from adjacent sides.
• Requires close approximation of sternal halves using bone-reducing
forceps
• A variety of plate configurations can be used in conjunction with
monocortical, self-tapping screws to allow for adequate union of sternal
halves.
• Provides rigid fixation and minimizes recurrence of nonunion/sternal
wounds
■ Workhorse Muscle Flap Options for
Reconstruction
■ Detailed techniques of harvesting each flap will be discussed in their
respective chapters.
■ Pectoralis Major
■ Common choice of repair for ease of harvest and reliability of flap,
especially for defects involving the superior aspect of the sternum
■ Minimal functional donor-site morbidity especially compared to other
options such as the rectus abdominis flap
■ Can be used either as an advancement rotational flap based on the
thoracoacromial pedicle for superior defects or a turnover flap based on IMA
perforators for more distal and inferior defects, as well as for obliteration of
significant dead space in the midline
■ Secondary segmental blood supply may not be available in patients with
history of IMA harvest.
■ Latissimus Dorsi
■ Large, well-vascularized/reliable muscular flap is useful in the case of lateral
defects—may not reach anterior midline defects especially superiorly

■ Subscapular system can be used to harvest composite flap when concomitant
bony reconstruction is also desired.
■ Require intraoperative repositioning for harvest and inset
■ Rectus Abdominis
■ Good for inferior midline defects
■ Not available for patients with history of CABG and IMA harvest as
pedicled flap would likely require a rotational flap based off the superior
epigastric artery
■ More significant functional donor-site morbidity (eg, hernias) when
compared to pectoralis or latissimus flap
■ Omentum
■ Can be useful in extensive defects with significant dead space/volume
requirement for reconstruction as the omentum is able to conform to the
recesses of deep wounds.
■ Highly vascularized and has a high concentration of vascular endothelial
growth factor, promoting extensive angiogenesis
■ However, requires more invasive entry into the peritoneal cavity with risk of
spreading infection and postoperative ventral hernia formation
■ Use of omental flap for sternal defect reconstruction is largely of historical
importance prior to rise in use/availability of various myocutaneous options.
PEARLS AND PITFALLS
Debridement
■ Early and aggressive debridement is imperative in decreasing the
morbidity and mortality especially in DSWIs.
■ In most cases, cardiothoracic surgery will already be involved, but
if not, preoperative evaluation and intraoperative assistance/standby
should be arranged prior to performing any excisional debridement.
Antibiotics
■ Empiric therapy should consist of broad coverage against Gram-
positive cocci and Gram-negative bacilli with special consideration

for methicillin-resistant Staphylococcus aureus based on its
prevalence at individual institutions. Fluid and tissue cultures
should be obtained when possible, to help tailor appropriate
regimen.
Flap
selection
■ For most sternal wound/defects requiring reconstruction, pectoralis
major is a reasonable first choice given its ease of accessibility and
reliability as a muscular flap; latissimus dorsi and rectus abdominis
should be considered next if pectoralis is not
available/contraindicated.
Negative
pressure
Wound
therapy
■ In the absence of active infection or exposure of vital intrathoracic
structures, NPWT can often be used to temporize urgent need for
operative intervention.
■ Well-documented efficacy in reducing wound size and promoting
wound healing—can often reduce the complexity or all together
need for surgical intervention.7
POSTOPERATIVE CARE
■ After debridement without reconstruction
■ Frequent local wound care should be performed to keep wounds clean—wet
to dry gauze or topical ointment dressings should be changed 2 or 3 times a
day, whereas NPWT should be changed once every 2 to 3 days, especially if
there is question of residual infection.
■ Wound cultures should be followed/repeated as necessary to tailor antibiotic
regimen.
■ Depending on the presence of defect/exposure of critical structures that
ultimately needs to be addressed with reconstruction, activity should be
limited until repair is completed.
■ General considerations after reconstruction with muscle flap (flap-specific
postoperative care issues will be further discussed in respective chapters)
■ Drains: seroma is one of the most frequent complications following a large
muscle flap harvest.
• Conservative management regarding drain duration minimizes the chance of
postoperative seroma.
• Criterion of less than 25 mL per drain per day, for 2 successive days, is
often used, though some reports note that 3-week duration regardless of
output is associated with lower seroma rate.
■ Wound dehiscence:

• Requires wound irrigation and light gauze packing
• The presence of healthy, viable muscle tissue without evidence of vital
structure exposure allows for secondary wound closure.
• Consider supportive brassiere in those patients with large cup size breasts,
as this population has been shown to have a greater risk of wound
dehiscence following mediastinal operations.12
■ Activity:
• Four to six weeks of rest following procedure
• Consistent physical therapy for range of motion, flexibility, and
strengthening should be started to rehabilitate and compensate for the loss of
muscle function from donor site.
OUTCOMES
■ Immediate consideration of sternal debridement with single-stage flap
reconstruction has been shown to reduce morbidity and mortality when
compared to those who underwent sternal preservation therapy with attempted
rewiring.13
■ Reported mortality following immediate debridement has been reported as
0% to 1%, whereas mortality in those who underwent delayed debridement
ranges from 14% to 47%.12
■ No consensus as to whether single-stage intervention with immediate flap
coverage or delayed debridement with bridging NPWT results in improved
morbidity or mortality.
■ Jones et al. retrospectively reviewed 186 patients who had undergone sternal
wound reconstruction over a 20-year period.8
■ Flap closure complications (35), recurrent infection/wound dehiscence (24),
and reexploration/wound necrosis (11) were among the most common
complications noted.
■ Regression analysis showed that hypertension, smoking, previous
sternotomy, IMA harvest, and previous sternal reconstruction were
statistically significant risk factors in predicting outcomes.
■ Mortality was 9.1%, and those patients presenting with septicemia at the
time of diagnosis had a risk of death 11 times greater than those who were
not septic.
■ Both early surgical debridement and single-stage repair have been shown to
reduce the average hospital stay in patients with DSWI.8,10

COMPLICATIONS
■ Hematoma/seroma
■ Wound dehiscence
■ Delayed union or nonunion following sternal fixation
■ Partial or complete flap loss
■ Donor-site complications (loss of muscle function, contour deformity, ventral
hernia)
■ Recurrent wound infection
REFERENCES
1. Juhl AA, Koudahl V, Damsgaard TE. Deep sternal wound infection after open
heart surgery: reconstructive options. Scand Cardiovasc J. 2012;46:254-261.
2. Greig AVH, Geh JLC, Khanduja V, et al. Choice of flap for the management
of deep sternal wound infection: an anatomical classification. J Plast Reconstr
Aesthet Surg. 2007;60:372-378.
3. Pairolero PC, Arnold PG. Management of infected median sternotomy
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