Ann Thorac Surg 2005;79:163-167
© 2005 The Society of Thoracic Surgeons
Original article: Cardiovascular
Redo Submammary Incision for Median Sternotomy and Cardiac Repair
Jonah Odim, MD, PhD*,
Raj Vyas, BS,
Hillel Laks, MD,
Azie Alikhani, BA,
Umang Mehta, MD,
Kakra Hughes, MD
Division of Cardiothoracic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
Accepted for publication June 16, 2004.
Abbreviations and Acronyms
min = minute(s);
kg = kilogram;
hr = hour(s);
VSD = ventricular septal defect;
AR = aortic regurgitation;
AV = aortic valve;
ASD = atrial septal defect;
LA = left atrial;
TVR = tricuspid valve regurgitation;
PS = pulmonary stenosis;
PAB = pulmonary artery band;
RVOT = right ventricular outflow tract;
PAPVR = partial anomalous pulmonary venous return;
D-TGA = D-transposition of the great arteries;
IAA = interrupted aortic arch;
PA = pulmonary artery;
MV = mitral valve;
TOF = tetralogy of Fallot;
PFO = patent foramen ovale;
L-TGA = L-transposition of the great arteries;
LV-PA = left ventricule to pulmonary artery;
TV = tricuspid valve;
PDA = patent ductus arteriosus
* Address reprint requests to Dr Odim, Division of Cardiothoracic Surgery, David Geffen School of Medicine, 10833 Le Conte Ave, Los Angeles, CA 90095-1741 (E-mail: jodim{at}mednet.ucla.edu).
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Abstract
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BACKGROUND: Minimally invasive and cosmetically attractive approaches are fashionable in conducting cardiac operations.
METHODS: We reviewed retrospectively our experience in patients undergoing cardiac operations by means of redo submammary incisions.
RESULTS: Fifteen consecutive female patients with a mean age of 13.2 years (range, 0.7 to 44 years) underwent reoperation through a former submammary incision. Seventy-three percent (11 of 15) had median sternotomy, cardiopulmonary bypass, and cardiac repairs. The mean aortic cross-clamp and cardiopulmonary bypass times were 78 ± 49.7 minutes (range, 16 to 182 minutes) and 114.4 ± 66.4 minutes (range, 27 to 261 minutes), respectively. Twenty-seven percent (4 of 15) had off-pump procedures; 3 for pacemaker-related issues (1 a third time reentry) and 1 for removal of sternal wires. Mean time interval between the primary submammary incision and reoperation was 5.4 ± 5.6 years (range, 0.01 to 20 years). Mean first 24 hours Hemovac drainage was 3.2 ± 2.4 mL/kg (range, 0.4 to 8.5 mL/kg). Mean intensive care unit and hospital stays were 2.1 ± 1.7 days (range, 0.0 to 5 days) and 5.5 ± 3.6 days (range, 0.80 to 13 days), respectively. One patient exhibited a chylothorax requiring ligation of her thoracic duct. Another patient had an infected seroma requiring incision and drainage 2 months postoperatively. Skin necrosis and infection were absent in this group. Breast development and lactation were normal. The cosmetic results were satisfactory. There was no mortality.
CONCLUSIONS: Redo sternotomies performed through redo transverse submammary incisions are safe for cardiac repair and result in acceptable cosmetic and functional results.
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Introduction
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Recent advances in minimally invasive surgical techniques have focused on the cosmetic, traumatic, and psychological sequelae of surgical scars. For decades, the traditional vertical skin incision combined with median sternotomy has provided complete, efficient, and quick access to the cardiac operative field. However, the potential unsightly scar, especially in women, is conspicuous with normal female attire [1]. Because the vertical incision is made at right angles to the lines of Langer, the scar widens with time [2, 3]. The increased tension requires skin sutures be kept for at least 7 days, leading to potentially unattractive prominent suture marks.
Willman and Hanlon [4] pioneered the transverse submammary skin incision for median sternotomy to minimize the cosmetic drawbacks of the vertical skin incision (Fig 1). Laks and Hammond [5] and Brutel de la Riviere and colleagues [6] further described this procedure as a cosmetically acceptable alternative to vertical skin incisions for median sternotomy. Despite the potential cosmetic advantages of the submammary approach, particular clinical considerations abound. Inasmuch as the dissection of the skin flaps takes longer to achieve, there is some increased risk of infection [6, 7] and ischemic or necrotic damage to the skin flaps, particularly the inferior one [5, 8]. Furthermore, there are reports of mild and transient clinical complications such as hematoma [5, 6, 9], seroma [10, 11], hypertrophic scar or keloid formation [3, 9–11], galactorrhea [9], mastodynia [9], and hypoesthesia [3, 5, 6, 8–11]. Areola sensitivity, important in eliciting a neurohormonal reflex for breast-feeding, is sometimes reduced but almost always restored within 6 months after surgery [12].
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Fig 1. The schema for the transverse submammary skin incision is shown with underlying median sternotomy. The extent of dissection of the superior (upper) and inferior (lower) flaps is demarcated by the shaded areas.
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Surprisingly, there are no reports on outcomes of reoperative (redo) submammary incision and redo sternotomy for cardiac repairs. In fact, some studies have deliberately excluded such redo cases from their analysis [10]. Other studies have concluded that the submammary approach should not be undertaken if the surgeon anticipates the need for a second-stage or redo case in the future [10]. This study sought to evaluate our experience with redo submammary incisions and median sternotomy for cardiac repairs.
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Patients and Methods
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Patients
From 1992 to 2001, 15 female patients with a mean age of 13.2 years (range, 0.7 to 44 years; Table 1) underwent a redo submammary incision for cardiac reoperation. The medical records and operative notes were reviewed. Follow-up was complete, and all patients were contacted by phone regarding the status of their submammary incision. During the study period, there was an increasing tendency to offer women with simple congenital heart defects and no important chest wall deformity or exposure to chest irradiation the option of a submammary skin incision and sternotomy for routine and elective cardiac repair. The primary submammary skin incision is not offered to female patients with important genetic syndromes (eg, trisomy 21) or complex congenital heart disease notable for multiple staged operations (eg, hypoplastic left heart syndrome). When faced with later reoperation, reentry options were limited to redo submammary incision to avoid, in our opinion, the worse cosmetic result of a cross-bearing scar.
Study Design
The study design was a consecutive cohort of patients undergoing reoperative submammary and sternotomy incisions for cardiac operation.
Technique of Redo Submammary Incision
The skin incision is made along the previous submammary scar. If the original scar is in the area of developed breast tissue, the redo incision should be made slightly below the original, making sure to follow the contour of the developed breast and avoid entry into breast tissue. (Fig 2). The skin flaps are carefully elevated superiorly and inferiorly, taking care neither to violate breast tissue nor the pectoralis major muscle (Figs 1, 2). The upper skin flap is mobilized superiorly to the level of the sternal notch. The lower skin flap is mobilized inferiorly beyond the xiphisternum. The linea alba is incised, and the sternum is carefully opened vertically and in the midline with an oscillating saw. Careful attention is paid to avoid injuring the skin flaps during this maneuver. A sternal retractor is placed to expose the mediastinum. After cardiac dissection, the patient is heparinized and cannulated for cardiopulmonary bypass. The cardiac repair is completed, the patient is weaned from cardiopulmonary bypass, the heart is decannulated, and meticulous hemostasis is achieved. Chest tube placement and sternal closure follow. The skin flaps are carefully irrigated and inspected for meticulous hemostasis. A small Hemovac drain (BARD, Covington, GA) is left in the space beneath the flaps and brought out lateral to the incision. The subcutaneous fascia is closed with interrupted sutures, and the skin is closed either with a subcuticular suture or a running fine nylon suture.
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Fig 2. (A) Primary incision was made before breast development. Redo incision was made 11.6 years later. In this patient, the redo incision was made slightly below the original, making sure to follow the contour of the developed breast and avoiding entry into the breast tissue. (B) The incision is made down to the fascia, and skin flaps are elevated superiorly and inferiorly. The sternum is carefully opened vertically and in the midline with an oscillating saw. Beware of injuring the skin flaps during this maneuver. (C) This 14-year-old girl, with l-transposition of the great arteries and dextrocardia, is undergoing replacement of a left ventricle–to–pulmonary artery conduit. The malleable retractor, which is attached to the crossbar of the sternal retractor, is shown retracting the upper skin flap, which is protected by a moist pad. Exposure of the upper ascending aorta is adequate. The aortic perfusion cannula is also shown. (D) The chest tube exit sites are placed laterally, below the level of incision. The tracts of the chest tubes pass parallel to the linea alba and are outside the space beneath the flaps. (E) A small Hemovac drain is left in the space beneath the flaps and brought out lateral to the incision. The subcutaneous fascia is closed with interrupted sutures, and the skin is closed either with a subcuticular suture or a running fine nylon suture. (F) The patient was discharged from hospital with this cosmetic result.
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Results
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A variety of intracardiac procedures were performed in this cohort of patients requiring redo submammary incision an average of 5.4 years after the initial operation (Table 1). The mean aortic cross-clamp and cardiopulmonary bypass times of 78 and 114.4 minutes were in keeping with custom despite slightly longer time for opening and closing (Table 1). The need for epicardial pacing lead or generator implantation or removal dominated the off-pump indications (Table 2).
There was neither early nor late mortality in this small group. The only two cases of observed morbidity were isolated cases of infected seroma and chylothorax. Both complications were minor and transient, resolving during the hospital stay. The patient with an infected seroma had primary submammary incision and sternotomy at the age of 12 years for pericardial patch ventricular septal defect closure and resection of subaortic stenosis. She underwent aortic valve repair for severe valvular regurgitation 2 years later through the same incision. Postoperatively, she experienced a seroma related to inadequate drainage of the submammary flaps that subsequently became infected by Staphylococcus aureus at the incision site.
The incidence of chylothorax was not related to the submammary skin incision but occurred after the cardiac operation in a 15-year-old girl with type B interrupted aortic arch. This child was initially palliated with aortic arch reconstruction and pulmonary artery banding. She subsequently underwent definitive repair with pericardial patch ventricular septal defect closure, debanding, and pericardial patch augmentation of the pulmonary arteries 1.5 years later. She had chylous pericardial effusion and chylothorax ultimately requiring thoracic duct ligation after the latter definitive operation.
The follow-up period in this study after redo submammary incision was a mean of 6.5 years (range, 2.5 to 10 years).
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Comment
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As cardiac surgery outcomes have improved, the incisional scar is often now the only reminder of the potentially forgotten or repressed experience of open heart surgery [13]. Recent advances in minimally invasive surgical techniques have focused on cosmetic and psychological sequelae of surgical incisions and scars [14–17]. Some have tried the transsternal crossbow incision, but this procedure enters both pleural spaces. The right lateral thoracotomy is also of limited use because it provides decreased access to the left ventricle and aorta. Other strategies require the use of femoral or peripheral cannulation for cardiopulmonary bypass or unfamiliar new tools (eg, computer-assistance or "robotic" techniques).
Although the partial vertical incision with partial median sternotomy [18] and the minimal transverse incision with low median sternotomy [19] are both gaining popularity for repair of congenital heart defects in the pediatric population, these procedures are limited to simple cases and still leave a scar that, unlike the submammary incision, is not wholly contained within the female bikini line.
With the advent of percutaneous device closure for atrial septal defects, an increasing number of patients are choosing this strategy over surgery. In addition, the option of a right anterior minithoracotomy is becoming popular for closure of septal defects and valvular operations at our institution.
In summary, several studies have demonstrated the cosmetic benefit, excellent exposure, and positive outcomes of the submammary incision. Nevertheless, several complications—although generally mild and transient in severity—are reported, raising concern that a redo submammary incision might lead to increased morbidity. Despite the inherent limitations of a retrospective, nonrandom study of this size, our experience indicates that redo sternotomy performed by means of redo transverse submammary incisions is safe for cardiac reoperation and results in acceptable cosmetic and functional outcome even if execution liberates more sweat from the surgeon.
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References
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- Lista FR, Thomson HG. The fate of sternotomy scars in children J Plast Reconstr Surg 1988;91:35-39.
- Langer K. Zur Anatomie une Physiologie der Haut Sitzengsb Akad Wissensch Math-Naturw 1861;43:133-157.
- Deutinger M, Domanig E. Submammary skin incision for median sternotomy Ann Thorac Surg 1992;53:1023-1024.[Abstract]
- Willman VL, Hanlon CR. Median sternotomy using a transverse submammary skin incision Am J Surg 1960;100:779-781.
- Laks H, Hammond GL. A cosmetically acceptable incision for the median sternotomy J Thorac Cardiovasc Surg 1980;79:146-149.[Abstract]
- Brutel de la Riviere A, Brom GHM, Brom AG. Horizontal submammary skin incision for median sternotomy Ann Thorac Surg 1981;32:101-104.[Abstract]
- Laczkovics A, Krisch I, Miholic J, Klepetko W, Domanig E. A cosmetically advantageous approach to median sternotomy Wien Klin Wochenschr 1983;95:678-679.[Medline]
- Bedard P, Keon W, Brais M, Goldstein W. Submammary skin incision as a cosmetic approach to median sternotomy Ann Thorac Surg 1986;41:339-341.[Abstract]
- Martinez-Sanz R, Fleitas MG, de la Llana R, et al. Submammary median sternotomy J Cardiovasc Surg 1990;31:578-580.[Medline]
- Bentz ML, Dunn JM. The inframammary incision for median sternotomy in pediatrics J Card Surg 1987;2:499-502.[Medline]
- Ramirez Marroquin S, Rojas Pacheco AM, Herrera Alarcon V, et al. [Submammary skin incision for longitudinal medial sternotomy] Arch Inst Cardiol Mex 1996;66:434-440.[Medline]
- Peters F. Laktation und StillenBucherei des Frauenarztes, Band 26. Stuttgart: Enke Verlag; 1987.
- Brom AG. Discussion of Coto EO, Norwood WI, Lang P, Castaneda ARModified Senning operation for treatment of transposition of the great arteries. J Thorac Cardiovasc Surg 1979;78:721-729.[Abstract]
- Cosgrove DM, Sabik JF. Minimally invasive approach for aortic valve operations Ann Thorac Surg 1996;62:596-597.[Abstract/Free Full Text]
- Navia JL, Cosgrove DM. Minimally invasive mitral valve operations Ann Thorac Surg 1996;62:1542-1544.[Abstract/Free Full Text]
- Calafiore AM, Giammarco GD, Teodori G, et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass Ann Thorac Surg 1996;61:1658-1665.[Abstract/Free Full Text]
- Stevens JH, Burdon TA, Peters WS, et al. Port-access coronary artery bypass grafting: a proposed surgical method J Thorac Cardiovasc Surg 1996;111:567-573.[Abstract/Free Full Text]
- Wilson Jr WR, Ilbawi MN, DeLeon SY, Piccione Jr W, Tubeszewski K, Cutilletta AF. Partial median sternotomy for repair of heart defects: a cosmetic approach Ann Thorac Surg 1992;54:892-893.[Abstract]
- Chan CY, Chiu IS, Wu SJ, Hung CR. A minimal transverse incision with low median sternotomy for pediatric congenital heart surgery Eur J Cardiothorac Surg 2001;19:290-293.[Abstract/Free Full Text]
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Abstract
Introduction
