HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hans-Beat Ris Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Banic, A. Articles by Striffeler, H. Search for Related Content PubMed PubMed Citation Articles by Banic, A. Articles by Striffeler, H. Related Collections Related Article

Ann Thorac Surg 1995;60:1028-1032
© 1995 The Society of Thoracic Surgeons

---

Original Articles: Cardiovascular

Free Latissimus Dorsi Flap for Chest Wall Repair After Complete Resection of Infected Sternum

Departments of Plastic Surgery and Thoracic and Cardiovascular Surgery, University of Berne, Inselspital, Berne, Switzerland

Accepted for publication April 13, 1995.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. Radical debridement, followed by muscle flap cover, has significantly reduced morbidity and mortality of infected sternotomy wounds. The pectoralis major, rectus abdominis, and greater omentum flaps are most commonly used, whereas the latissimus dorsi muscle is rarely employed.

Methods. In 7 patients with persistent infection and necrosis of the sternum, radical and extensive debridement including the sternum, costochondral arches, manubrium and sternoclavicular joints was performed. A free latissimus dorsi flap was used for soft tissue reconstruction without additional stabilization of the chest wall.

Results. All flaps survived without revision of the anastomosis. In the follow-up period (22 months to 5 years) no recurrent infection was observed. Three patients died during the study period (3 to 24 months after operation) due to causes not related to sternum operation. No additional weakness, pain, or restricted movements of the shoulders due to missing sternum was observed.

Conclusions. Our findings suggest that the use of free latissimus dorsi flap after complete sternectomy for infection has several advantages: it provides abundant tissue to allow radical and extensive debridement, obliterates completely the dead space, and helps to control infection. Even without additional chest wall reconstruction it gives enough stability to allow pain-free normal daily activities.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
See also page 1032.

Mediastinitis after median sternotomy in cardiac surgery represents an infrequent but serious problem with a reported incidence ranging from 0.4% to 5.1% [1–3]. Many of the problems associated with the operation including long hospitalization and high mortality (resulting from open treatment with debridement and secondary healing) were dramatically reduced when Shumaker and Mandelbaum [4] introduced in 1963 closed-catheter irrigation of the mediastinum, followed by debridement and reclosure of the sternum. Wide debridement of bone and cartilage followed by flap cover, as described by Lee and co-workers [5] in 1976, represented a significant improvement in the technique. They transposed the greater omentum to obliterate the dead space. Subsequently Jurkiewicz and associates [6] first used a muscle flap for this purpose. By the use of this concept in the primary treatment, Jurkiewicz and associates reduced mortality from 18% to zero and significantly diminished morbidity and hospitalization time.

The pectoralis major muscle is most commonly used for reconstruction after sternum resection, followed by the rectus abdominis and greater omentum flaps. The pectoralis muscle, based on the dominant blood supply from the thoracoacromial vessels, extends over the upper two thirds of the sternum. If a wider resection is needed, both pectoralis major muscles have to be used. In case of an extensive sternectomy, however, the pectoralis muscles must be combined with the rectus abdominis or the greater omentum flaps [7–9].

The latissimus dorsi flap is rarely employed after sternectomy [10] and is often reserved as a back-up flap when other flaps cannot be used [11]. When taken as a pedicled flap, the bulky proximal part of the muscle remains under the pectoralis muscle, and only the thin, partly aponeurotic muscle reaches into the defect. Moreover, similar to the pectoralis muscle, it adequately covers the upper and central parts of the resected sternum but is of insufficient size to cover the distal part (Fig 1A) [12]. When the latissimus dorsi is transferred as a free flap, however, the whole muscle is used to fill the dead space and no additional muscle or omentum is needed (Fig 1B). In addition, the latissimus dorsi can be taken as a myocutaneous flap to ensure tension-free skin closure. In the current study we report on extensive sternectomy followed by free latissimus dorsi flap reconstruction in the same operation, performed in 7 patients. Early postoperative complications and late results (mean follow-up, 3 years 2 months) were evaluated.

View larger version (132K): [in this window] [in a new window]   Fig 1. . (A) Cadaveric dissection of the latissimus dorsi flap pedicled in the right axilla. The proximal bulk of the muscle remains under the pectoralis major muscle, whereas, the thin, partly aponeurotic part reaches into the defect. It covers well the upper and central parts of the sternum but is insufficient in the distal part. (B) The muscle is positioned as in the free flap transfer. In such a case the whole muscle can be used to fill the dead space and no additional muscle or omentum is needed over the distal part of the sternum.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

Seven consecutive patients with an average age of 65 years (range, 60 to 74 years) who had extensive osteomyelitis of the sternum, were operated on according to this principle over a period of 3 years. In these patients, a radical and extensive debridement that included sternum, costochondral arches, manubrium and sternoclavicular joints was performed. The overlying affected skin was generously resected. Recipient vessels for the anastomosis with the latissimus dorsi muscle were selected and prepared before the flap was taken.

A free latissimus dorsi myocutaneous flap was performed in all patients. It was raised using conventional techniques [12]. The patient remained in the supine position (as was also the case for the debridement) with one shoulder and one hip elevated. The skin island was designed in the center of the muscle and parallel to its long axis. The superior thyroid artery and vein (4), internal mammary artery and external jugular vein (2) (Fig 2), and common carotid artery and external jugular vein (1) served as recipient vessels. All anastomoses were performed end-to-end except for the one to the common carotid artery, which was done end-to-side. The time needed to raise the flap was approximately 60 minutes, and an additional 30 minutes was required to complete the two microvascular anastomoses. Blood loss during flap elevation and the microsurgical procedure was estimated to be about 500 mL.

View larger version (136K): [in this window] [in a new window]   Fig 2. . Intraoperative picture showing the defect after extensive debridement of the sternum and the latissimus dorsi muscle after the completion of microvascular anastomoses to the internal mammary artery and external jugular vein (arrow).

After operation all patients were immediately extubated and were allowed to recover in the intensive care unit. The patients were mobilized on the first postoperative day and chest and lung physiotherapy was initiated. Antibiotic treatment was continued for two months. Anticoagulation therapy was administered for 3 months postoperatively.

The mean follow-up time was 3 years 2 months (range, 22 to 60 months). Evaluation during this period included assessment of problems due to instability of the chest wall such as paradoxical chest movements, dyspnea and lung infections, mobility and strength of upper arm and shoulder region, pain or discomfort, and disability in daily activities and work. Three patients died between 3 months and 2 years after operation due to causes not related to sternum operation (two deaths were related to myocardial ischemia and one to malignant disease).

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
All flaps survived without complication, and no revision of the microvascular anastomoses was needed. There was no sign of recurrent sternal infection in any of the patients. Two patients had bronchitis approximately 1 year after reconstruction.

In all 7 patients breathing and coughing produced a variable degree of paradoxical chest movement, mainly in the cranial half of the flap (Figs 3, 4). They all needed some external pressure on the flap to help expectoration, but only in the early postoperative phase. Only in the early postoperative phase did any patient complain of pain that could be related to chest wall reconstruction. Two patients, however, felt tightness and pressure in the reconstructed region for 8 to 12 months and 2 more at the final evaluation, but none was able to localize the discomfort precisely.

View larger version (246K): [in this window] [in a new window]   Fig 3. . Computed tomographic scans showing the latissimus dorsi myocutaneous flap in the upper part of the reconstruction in inspiration (A) and in expiration (B).

View larger version (253K): [in this window] [in a new window]   Fig 4. . Picture of the patient standing and in forced inspiration (A) and expiration (B). The flap is moving with breathing mainly in the upper part of the reconstruction, while the lower part, covering the heart, remains almost unchanged.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Morbidity, mortality, and hospital stay have been significantly reduced since the introduction of radical debridement and the use of muscle flaps in severe infections of the sternum after open heart operations [6, 7]. The pectoralis major muscle is most widely used because it lies in the operating field and is easy to dissect. It can be either based on the perforators from the internal mammary artery as a turn-over flap or based on the thoracoacromial vessels and transposed as a rotation-advancement flap. After extensive debridement, as performed in our patients, even two pectoralis flaps cannot adequately fill the cavity. The rectus abdominis or greater omentum has to be added to close the lower third of the defect [7–9]. However, abdominal wall--related complications can be significant when flaps from the abdomen are used [14].

In our experience the free latissimus dorsi flap offers several advantages over other conventional flaps for the reconstruction of extensive defects after complete sternectomy. It is the largest expendable and easily accessible muscle [12], which can alone fill the defect adequately without the requirement of additional muscle or omentum. Furthermore, it can be taken as a myocutaneous flap with a skin island of the same size as the resected skin. This eliminates the tension on the skin suture and the need for additional release incisions or skin grafts. The abundant tissue available gives the surgeon freedom to radically and extensively debride the necrotic tissues and prevent recurrent infections. Except for the donor scar in the back, there is no further disfigurement of the chest or abdomen.

The importance of muscle tissue in combating bone infection has been discussed previously [15–17]. The introduction of muscle flaps for the treatment of sternal infection has significantly reduced both morbidity and mortality in these patients [3, 6, 18]. In our patients with severe osteomyelitis, no recurrent infection was observed after the use of the latissimus dorsi muscle. In spite of meticulous and aggressive debridement, remnants of devitalized tissues remain in a contaminated field. We believe that it is very important that the soft and bulky muscle completely fills the cavity and obliterates the dead space. Well-vascularized muscle comes into close contact with debrided structures, brings vascularity to the tissues, and prevents bacterial growth.

Free flaps have previously been used for chest reconstruction [19, 20] and for intrathoracic repair [21]. Here we used them for anterior chest wall reconstruction after sternectomy for infection. Although microsurgical procedures were involved, the duration of operation and blood loss did not significantly differ from our reconstructions with three conventional flaps. In the current study all operations were performed by thoracic and plastic surgeons together. Time was saved because patients remained in the supine position, with one shoulder and one hip elevated, during the whole operation.

A number of recipient vessels for the flap exist given the length (9 to 10 cm) of the vascular pedicle of the latissimus dorsi muscle. The internal mammary vessels are usually chosen because they are already exposed by the extensive sternectomy. If they have already been used for cardiac operations, the superior thyroid vessels can easily be accessed. If neither are available, as was the case in 1 of our patients who previously underwent a thyroidectomy, an end-to-side anastomosis to the external carotid artery is performed. The performance of these anastomoses is easy, because the vessels are of large caliber (2 to 3 mm) and are easily accessible. However, when anastomoses are performed on short stumps of the internal mammary vessels, some difficulties can be encountered due to heart movements.

Extensive sternal necrosis in our patients required extensive debridement, and no direct bone closure was possible. However, except for some paradoxical movements of the reconstruction during breathing and coughing, the flap provided sufficient, pain-free stability of the chest to allow normal daily activities. Kohman and co-workers [22] studied the functional results of muscle flap reconstruction after sternal debridement on lung function. They demonstrated that the pulmonary function did not differ from the control group of cardiac surgical patients despite missing bone stability.

The use of foreign materials for stabilization of the sternum after osteomyelitis has often been discussed. Larson and McMurtrey [23] state that the use of synthetic materials in open and infected wounds adds significantly to the risk of infection and is unnecessary, because full-thickness chest wall defect reconstruction can be accomplished by the use of flap only. According to Pairolero and Arnold [24], the posterior chest wall and sternal defects require less stabilization than do anterior and lateral ones, and they believe that myocutaneous flaps without skeletal stabilization give sufficient stability even in large defects. Results of the current study suggest that there is no need for chest wall stabilization even in complete resections of the sternum, and we believe that the use of synthetic materials in infected wounds should be avoided.

In conclusion, free latissimus dorsi flap alone provides sufficient material for reconstruction of defects after complete and extensive sternectomy for infection. The flap provides abundant tissue and allows the surgeon to perform a radical and extensive debridement. The muscle fills the defect well, obliterates completely the dead space, and helps to control infection. The flap gives enough stability to the chest even without reconstruction of the bone to allow pain-free normal daily activities. No weakness, pain, or restricted movements of the shoulder due to missing sternum were observed.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Address reprint requests to Dr Banic, Department of Plastic and Reconstructive Surgery, Inselspital, 3010 Berne, Switzerland.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

1. Sarr MG, Gott VL, Townsend TR. Mediastinal infections after cardiac surgery. Ann Thorac Surg 1984;38:415–23.[Abstract]
2. Prevosti LG, Subramainian VA, Rothaus KO, Dineen P. A comparison of the open and closed methods in the initial treatment of sternal wound infection. J Cardiovasc Surg 1989;30:757–63.[Medline]
3. Hugo NE, Sultan MR, Ascherman JA, Patsis MC, Smith CR, Rose EA. Single-stage management of 74 consecutive sternal wound complications with pectoralis major myocutaneous advancement flap. Plast Reconstr Surg 1994;93:1433–41.[Medline]
4. Shumaker HBJ, Mandelbaum I. Continuous antibiotic irrigation in the treatment of infection. Arch Surg 1963;86:384–7.[Abstract/Free Full Text]
5. Lee AB, Schimert G, Shatkin S. Total excision of the sternum and thoracic pedicle transposition of the greater omentum. Surgery 1976;80:433–6.[Medline]
6. Jurkiewicz MJ, Bostwick J III, Hester R, Bishop JB, Craver J. Infected median sternotomy wounds: successful treatment by muscle flaps. Ann Surg 1980;191:738–44.[Medline]
7. Herrera HR, Ginsburg ME. The pectoralis major myocutaneous flap and omental transposition for closure of infected median sternotomy wounds. Plast Reconstr Surg 1982;70:465–70.[Medline]
8. Pairolero PC, Arnold PG. Management of recalcitrant median sternotomy wounds. J Thorac Cardiovasc Surg 1984;88:357–64.[Abstract]
9. Nahai F, Rand RP, Hester TR, Bostwick J III, Jurkiewicz MJ. Primary treatment of the infected sternotomy wound with muscle flaps: a review of 211 consecutive cases. Plast Reconstr Surg 1989;84:434–41.[Medline]
10. Tizian C, Borst HG, Berger A. Treatment of total sternal necrosis using the latissimus dorsi muscle flap. Plast Reconstr Surg 1985;76:703–7.[Medline]
11. Miller JI, Nahai F. Repair of the dehisced median sternotomy incision. Surg Clin North Am 1989;69:1091–102.[Medline]
12. Moelleken BRW, Mathes SA, Chang N. Latissimus dorsi muscle-musculocutaneous flap in chest-wall reconstruction. Surg Clin North Am 1989;69:977–90.[Medline]
13. Gersbach P, Santiago JM, Banic A, Althaus U. Sternuminfekt: Spüldrainage oder Muskellappenplastik. Schweiz Med Wochenschr 1994;124(Suppl 58):33.
14. Ringelman PR, Vander Kolk CA, Cameron D, Baumgartner WA, Manson PN. Long-term results of flap reconstruction in median sternotomy wound infection. Plast Reconstr Surg 1994;93:1208–14.[Medline]
15. Banic A, Wulff K. Latissimus dorsi free flaps for total repair of extensive lower leg injuries in children. Plast Reconstr Surg 1987;79:769–75.[Medline]
16. Richards RR, McKee MD, Paitich B, Bertoia T. A comparison of the effects of skin coverage and muscle flap coverage on the early strength of union at the site of osteotomy after devascularization of a segment of canine tibia. J Bone Joint Surg Am 1991;73:1323–30.[Abstract/Free Full Text]
17. Mathes SJ, Alpert BS, Chang N. Use of the muscle flap in chronic osteomyelitis: experimental and clinical correlation. Plast Reconstr Surg 1982;69:815–28.[Medline]
18. Jeevanandam V, Smith CR, Rose EA, Malm JR, Hugo NE. Single-stage management of sternal wound infections. J Thorac Cardiovasc Surg 1990;99:256–63.[Abstract]
19. Hidalgo DA, Saldana EF, Rusch VW. Free flap chest wall reconstruction for recurrent breast cancer and radiation ulcers. Ann Plast Surg 1993;30:375–80.[Medline]
20. Hirase Y, Kojima T, Kinoshita Y, Bang HH, Sakaguchi T, Kijima M. Composite reconstruction for chest wall and scalp using multiple ribs-latissimus dorsi osteomyocutaneous flaps as pedicled and free flaps. Plast Reconstr Surg 1991;87:555–61.[Medline]
21. Hammond DC, Fisher J, Meland NB. Intrathoracic free flaps. Plast Reconstr Surg 1993;91:1259–64.[Medline]
22. Kohman LJ, Auchincloss JH, Gilbert R, Beshara M. Functional results of muscle flap closure for sternal infection. Ann Thorac Surg 1991;52:102–6.[Abstract]
23. Larson DL, McMurtrey MJ. Musculocutaneous flap reconstruction of chest-wall defects: an experience with 50 patients. Plast Reconstr Surg 1984;73:734–40.[Medline]
24. Pairolero PC, Arnold PG. Chest wall tumors. Experience with 100 consecutive patients. J Thorac Cardiovasc Surg 1985;90:367–72.[Abstract]

This article has been cited by other articles:

				K. Athanassiadi, N. Theakos, G. Benakis, S. Kakaris, and I. Skottis Omental Transposition: the Final Solution for Major Sternal Wound Infection Asian Cardiovasc Thorac Ann, June 1, 2007; 15(3): 200 - 203. [Abstract] [Full Text] [PDF]

				S. A. Khan, M. K. Varshney, A. S. Hasan, A. Kumar, and V. Trikha Tuberculosis of the sternum: A CLINICAL STUDY J Bone Joint Surg Br, June 1, 2007; 89-B(6): 817 - 820. [Abstract] [Full Text] [PDF]

				R. Wettstein, D. Erni, P. Berdat, D. Rothenfluh, and A. Banic Radical sternectomy and primary musculocutaneous flap reconstruction to control sternal osteitis J. Thorac. Cardiovasc. Surg., June 1, 2002; 123(6): 1185 - 1190. [Abstract] [Full Text] [PDF]

				W. Raffoul, M. Dusmet, M. Landry, and H.-B. Ris A novel technique for the reconstruction of infected full-thickness chest wall defects Ann. Thorac. Surg., November 1, 2001; 72(5): 1720 - 1724. [Abstract] [Full Text] [PDF]

				D. Lardinois, M. Muller, M. Furrer, A. Banic, M. Gugger, T. Krueger, and H.-B. Ris Functional assessment of chest wall integrity after methylmethacrylate reconstruction Ann. Thorac. Surg., March 1, 2000; 69(3): 919 - 923. [Abstract] [Full Text] [PDF]

				H.-B. Ris, A. Banic, M. Furrer, M. Caversaccio, A. Cerny, and P. Zbaren Descending Necrotizing Mediastinitis: Surgical Treatment Via Clamshell Approach Ann. Thorac. Surg., December 1, 1996; 62(6): 1650 - 1654. [Abstract] [Full Text]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hans-Beat Ris Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Banic, A. Articles by Striffeler, H. Search for Related Content PubMed PubMed Citation Articles by Banic, A. Articles by Striffeler, H. Related Collections Related Article