To Fill or Cover: The Dead Space Dilemma in Flap Reconstruction of Sternotomy Wounds
Todd S. Lefkowitz, MD1, Adam R. Kolker, MD2, Jamie P. Levine, MD3, Keith M. Blechman, MD3.
1St. Vincent's Hospital and Medical Center, New York, NY, USA, 2Mount Sinai School of Medicine, New York, NY, USA, 3New York Universiy Medical Center, New York, NY, USA.
Background Numerous techniques have been described for the treatment of sternotomy wound dehiscence and deep sternal wound infections (DSWI). After gaining control of the wound with staged debridement, controversy exists with regard to how the mediastinal “dead space” is addressed. Muscle or omental flaps have been used after DSWI to obliterate the dead space completely, whereas composite pectoralis musculocutaneous flaps apposed over closed-suction drains are also commonly used. This study addresses outcomes of muscle or omental flap transposition (fill) compared with musculocutaneous advancement and closed suction drainage (coverage and contraction).
Methods: Sixty consecutive patients from two institutions who were treated for sterile and infected open post-sternotomy wounds with flap reconstruction were evaluated. Follow up ranged from 7 months to 60 months, mean 28 months. One group underwent reconstruction that completely obliterated the mediastinal space with pectoralis and/or rectus abdominis muscle flaps or with omental flaps (Group 1, n=30), and the second group were reconstructed with bilateral pectoralis major musculocutaneous advancement over closed suction drains within the mediastinum (Group 2, n=30). Data were reviewed retrospectively.
Results: Mortality was equal in each group (Group 1 7%, Group 2 7%). The incidence of pain and asymptomatic instability were also equal in the two groups (7% and 10% respectively). Postoperative superficial dehiscence (skin) was seen in 17% in Group 1, and in 7% in Group 2 (all treated successfully with local measures). Re-operation and additional flap surgery was required in 3% in Group 1, and in 7% in Group 2.
Conclusions: Despite a higher rate of superficial complications in the transposition flap “fill” group, of all major indicators examined, there was no significant difference in long term outcomes between flap reconstruction techniques that obliterate sternotomy wound dead space compared with musculocutaneous advancement techniques geared toward their coverage and contraction.