A new method of anterior mediastinal tracheostomy following resection of cervical esophagus and the larynx: Report of a case

We report herein the case of a 52-year-old man for whom a split pectoralis major myocutaneous flap was applied at the time of extended radical surgery for esophageal carcinoma with tracheal involvement, to avoid the postoperative complications of anterior trachcostomy such as tracheal necrosis and rupture of the major vessels. Laryngopharyngectomy and extended resection of the proximal trachea was performed through a manubrectomy, leaving the tracheal remnant only 4 cm above the carina. A pectoralis major myocutaneous flap was split into two with one piece being wrapped around the trachea at the anterior mediastinal tracheostomy site, and the other being placed between the trachea and brachiocephafic artery. The postoperative course was uneventful and the patient was discharged from hospital on the 34th postoperative day. A split pectoralis major myocutaneous flap may be effective not only for filling the dead space between the trachea and brachiocephalic artery, but also for reducing tension at the tracheocutaneous anastomosis and protecting against circulatory damage at the mediastinal tracheostomy site to minimize stomal retraction.     

Unilateral pectoralis major muscle flap for the treatment of sternal wounds due to Ludwig's angina

Necrotising descending mediastinitis may rarely originate from Ludwig's angina, which is an infection of the submandibular space. The use of the bilateral pectoralis major muscle flap for the treatment of sternal wound dehiscence is common, but reports of the unilateral application of this flap are scarce. This study aims to report the use of the unilateral pectoralis major muscle flap for the treatment of sternotomy dehiscence in a patient with mediastinitis due to Ludwig's angina. A 21‐year‐old male patient underwent an exploratory cervicotomy and median sternotomy for drainage of a submandibular infection that extended to the anterior, retropharyngeal and mediastinal cervical spaces. The patient had dehiscence of the sternal wound, and the unilateral pectoralis major muscle flap was used for reconstruction of the defect. This flap was able to completely cover the area of dehiscence of the sternotomy, and the patient presented a good postoperative evolution, without complications. The reconstruction technique using the unilateral pectoralis major muscle flap was considered a good option for the treatment of sternotomy dehiscence. It is an adjuvant method in the treatment of infections such as mediastinitis and osteomyelitis of the sternum secondary to Ludwig's angina, allowing a stable coverage of the sternum.     

Anterior mediastinal tracheostomy with a latissimus dorsi musculocutaneous flap.

We describe the reconstruction of an anterior mediastinal tracheostomy with a latissimus dorsi musculocutaneous flap. This procedure is safer, more easily carried out, a more reliable means of creating an anterior mediastinal tracheostomy and is better suited for chest wound healing than previous methods. In addition, the appearance of the patient's chest after operation is cosmetically excellent.     

Dynamic stabilization of winging scapula by direct split pectoralis major transfer: a technical note

A new technique of split pectoralis major tendon transfer (sternal head) for symptomatic scapular winging is shown. Whereas other authors use a lengthening with autogenous grafts, we prefer a direct attachment of the split pectoralis major tendon. With the use of an anterior and a posterior incision, the tendon of the sternal head of the pectoralis major is mobilized and transferred directly to the inferior angle of the scapula. An anatomic study shows that the pectoralis major muscle usually seems to be suitable for this procedure. Direct transosseous fixation of the transferred split pectoralis major tendon appears to be an excellent operation for correcting winging scapula without the necessity of an autogenous graft and concern over stretching or tearing of the graft extension.     

Simple and reliable way in sternum wound coverage--tripedicle pectoralis major musculocutaneous flap

Objective: Sternotomy wound infection requires radically debridements and need secondary reconstruction of the resulting defect. Pectoralis major muscular or musculocutaneous flap is quite common in sternal wound closure. We modified the pectoralis major musculocutaneous flap design: bipedicle advancement cutaneous flap combined with thoracoacromial myocutaneous perforators, as a “tripedicle” fashion. We tried to utilize the cutaneous pedicle to provide a reliable skin coverage and decrease the wound dehiscence rate in lower one third sternal wound. Methods: Four patients undergoing median sternotomy surgery between 2004 and 2007 suffered from sternal wound infection and received tri‐pedicle pectoralis major musculocutaneous flaps transfer. Results: No skin paddle necrosis or wound dehiscence occurred in the postoperative course. Cosmetically and chest stability were satisfactory without complains about the daily activity. Conclusions: Tripedicle pectoralis major musculocutaneous flap is a simple and reliable technique to cover sternal wound defect necessitating resurfacing surgery. The blood supply to the skin paddle can be enriched by the superior and inferior cutaneous pedicle and the wound dehiscence rate is decreased with this technique. © 2008 Wiley‐Liss, Inc. Microsurgery, 2008.     

Reconstruction after mediastinal tracheostomy

Mediastinal tracheostomy has been associated with high morbidity and mortality, often due to skin necrosis, with resultant exposure of the great vessels and subsequent hemorrhage. During a 4 year period, 11 patients underwent mediastinal tracheostomy. Reconstruction included the use of a pectoralis major musculocutaneous flap to provide well-vascularized skin for anastomosis to the superior portion of the tracheostoma in nine patients. Whenever possible (eight patients), the trachea was transposed below the innominate artery to allow for slightly more mobility of the trachea and to remove the cartilaginous portion of the trachea from the artery. Among the eight elective operations reported herein, there were no postoperative deaths and only two minor wound-related complications. Among three patients who underwent emergency mediastinal tracheostomy, two patients died, one with an aneurysm of the innominate artery that ruptured several weeks postoperatively and the other with respiratory instability who could not be weaned from the respirator. These results suggest that use of the pectoralis major musculocutaneous flap and tracheal transposition decreases the risk of skin necrosis and resultant major vessel rupture. We advocate this approach in the reconstruction of the patient who requires mediastinal tracheostomy.     

Segmentally split pectoral girdle muscle flaps for chest-wall and intrathoracic reconstruction

The latissimus dorsi, pectoralis major, and serratus anterior provide the principal flaps for major chest-wall and intrathoracic reconstructions. Each of these muscles shows a philogenetically preserved internal metamerism that is expressed by a segmental morphology and neurovascular supply. This segmental anatomy creates multiple independent subunits in each muscle that can be surgically split and independently used. Surgically splitting these muscles permits flap refinements such as creating two flaps from one donor muscle and leaving independent subunits in situ to preserve donor motor function after flap transfer. The latissimus dorsi has a consistent proximal bifurcation of its neurovascular supply into a medial and lateral branch that permits dividing the muscle or skin-muscle unit into two independent flaps. The pectoralis major has three segmental neurovascular subunits, the clavicular, the sternocostal, and the external. These can be surgically split and independently transferred on vascular pedicles from the thoracoacromial, internal mammary, and lateral thoracic vessels. This provides a substantial degree of donor motor preservation, as shown by the pectoralis V-Y myoplasty for mediastinal reconstruction. The serratus arterial has a highly segmental morphology with multiple subunits corresponding to each of the first nine costovertebral units; it also can be surgically split. The resultant upper and lower groups can be further subdivided if needed. These flaps provide useful intrathoracic reconstruction with a substantial degree of donor motor preservation. Such technical refinements substantially increase each flap's versatility and lessens the donor cost for thoracic reconstruction.     

Congenital sternal cleft.

A cleft of the sternum is a rare congenital anomaly. We present a case of a sternal cleft in a 7-year-old boy. A split iliac bone graft covered with the sternocostal portion of a pectoralis major flap was used to reconstruct the defect.     

Muscle flap reconstruction for the treatment of major sternal wound infections after cardiac surgery: a 10-year analysis.

Infection of a median sternotomy wound is a rare though potentially fatal complication. Despite early diagnosis and proper treatment, prognosis is poor because of the chance of mediastinal spread of the infection and the poor physical state of these patients. Muscle repair is superior to more conservative surgical options such as sternal resuturing with mediastinal irrigation. During the last 10 years, complications--including sternal infections and dehiscences--have been encountered in 172/4725 median sternotomy wounds after cardiac surgery procedures (4%). Thirty-four patients (of whom 30 had acute sternal infections and four chronical sternal infections) underwent aggressive sternal debridement followed by muscle flap closure. Seventy-two muscle flaps were carried out, a pectoralis major bilateral muscle flap being the most common either alone or in combination with a rectus abdominis muscle flap. Five perioperative deaths (15%) were recorded. Of the 29 surviving patients, 25 patients (74%) were free of infection and four (12%) developed recurrence of the infection after a mean follow up of 3 years (range 49 days-8 years). We conclude that although muscle repair is not free of complications, it is reliable in reducing mediastinitis-related morbidity and mortality.     

Split pectoralis major flaps for mediastinal wound coverage: a 12-year experience

Poststernotomy mediastinitis is an infrequent but highly dangerous complication following median sternotomy. Typically, such wounds are debrided aggressively of necrotic and foreign materials with subsequent flap reconstruction. Between December 1989 and January 2002, 69 patients were referred to the University of Maryland division of plastic surgery for mediastinal wound coverage. A total of 105 flaps of various types were used. Fifty-eight percent of the patients received a single flap. Ninety percent of the flaps used were pectoralis major flaps, whereas only 10% of the flaps were rectus abdominis, latissimus dorsi, or omentum flaps. Ten patients (14.5%) required reoperation. The most common comorbidity was diabetes mellitus. Those patients with diabetes mellitus were 9.1 times more likely to require reoperation after their sternal reconstruction compared with nondiabetic patients (95% confidence interval, 2.1-40.4). Four patients (5.8%) died less than 30 days from their flap procedure. The flap of first choice used in this series is the pectoralis major turnover flap, which is harvested in its entirety and split in the direction of its muscle fibers. Taking the entire muscle allows better coverage of the lower portion of the incision, resulting in far less frequent need for abdominal flaps and their associated morbidity.     

Reconstruction of sternal defects with pectoralis major muscle flap

The earliest treatment of the median sternotomy defects was serial debridements and secondary healing. The muscle flaps that can be used in reconstruction of the presternal defects are pectoralis major muscle flap, rectus abdominis muscle flap, vertical rectus abdominis muscle flap, latissimus dorsi muscle flap with or without skin island, bipedicled pectoralis-rectus muscle flap, and external oblique muscle flap. Pectoralis major muscle flap can be used either as bilateral or unilateral rotation advancement flap, island flap, turnover flap, split turnover flap, and segmental muscle flap. Forty-eight patients with median sternotomy defects, who were treated with pectoralis major muscle flap, were included in this study. The complications were mortality, flap loss, flap dehiscence, persistent infection, and hematoma. The patients were evaluated in terms of functional loss after the operation by shoulder movement measurements. Various techniques of flap transfer can be used for the closure of a presternal defect; almost all presternal defects can be covered with the pectoralis major muscle in a single stage operation. In our opinion, the pectoralis major muscle flap should be the first choice of treatment for sternal defects.     

A more conservative technique for anterior mediastinal tracheostomy after sub-total resection of the trachea

Anterior mediastinal tracheostomy (AMT) is a rare but challenging operation associated with a high morbidity and mortality rate mainly related to the invasiveness of the procedure. In order to provide a more conservative technique with a lower risk of major postoperative complications, we proposed: (1) to reduce the extent of chest wall resection to only a trapezoidal segment of the manubrium; (2) to use a simple pedicle pectoralis major flap instead of myocutaneous or omental flaps; and (3) to perform a simple relocation of the residual trachea (RT) below the brachiocephalic artery instead of artery ligation, percutaneous stent placement or replacement by cadaveric allograft. This technique was used in a patient with cancer recurrence at the cervical stoma after total laryngectomy. Despite a short 2.5-cm RT, it was possible to perform AMT without any tension at the mediastinal stoma. Postoperative course showed only regressive minor complications. There was no late complication related to the procedure with a one-year follow-up. This more conservative technique for AMT could be used as an alternative to previously described procedures in order to reduce postoperative complications and mortality rate after sub-total resection of the trachea.     

Closure of a sternal defect with the rectus abdominis muscle after sacrifice of both internal mammary arteries

Infections of the median sternotomy incision are relatively uncommon. Successful treatment of this serious complication consists of adequate surgical debridement and obliteration of mediastinal dead space using the pectoralis major muscle, or the rectus abdominis muscle or both. The recent use of internal mammary artery grafts has created a new problem in closure of defects involving the lower one-third of the sternum. Under these circumstances the use of the rectus abdominis muscle is believed to be contraindicated. To date omental transposition remains the only alternative in therapy. A case of sternal dehiscence after coronary artery bypass surgery is described. Bilateral internal mammary artery grafts were used. A rectus abdominis flap based primarily on the eighth anterior intercostal perforator was transposed into the defect. The wound healed uneventfully after initial loss of a 3-cm portion of the skin graft. Success of this flap based on intercostal perforators is postulated to be secondary to a "delay" phenomenon related to prior division of the dominant blood supply.     

The pectoralis major muscle in head and neck reconstruction

From June 1980 to June 1985 51 pectoralis major muscle flaps have been used for one-stage reconstruction of extensive defects in the head and neck following cancer surgery. The pectoralis major muscle was used as a myocutaneous flap on 28 occasions, as a muscle covered with split thickness skin on 17 occasions, and as a muscle-only flap six times. The muscle, in its various forms, was used for reconstruction of the pharyngooesophageal segment, the tongue, floor of the mouth and oropharynx, to replace the skin of the face and neck, and to provide a well vascularized recipient bed for a split-rib graft, used to replace a defect of the anterior arch of the mandible. Many of the problems associated with the use of a pectoralis major myocutaneous flap can be avoided by the judicious use of a muscle flap on its own or covered by a split thickness skin graft.     

Management of sternal wounds with pectoralis major musculocutaneous advancement flaps in patients with a history of chest wall irradiation

Although debridement and pectoralis major musculocutaneous advancement flap closure has proved to be an effective treatment of sternal wounds in the general population, the purpose of this study was to examine the use of these flaps in patients with previously irradiated chest walls. The authors examined 5 patients with a history of breast cancer and chest wall radiation therapy who developed poststernotomy wound complications that were treated with debridement and pectoralis major musculocutaneous advancement flaps. The average patient age was 76 years. Three patients had previously undergone a radical mastectomy and had only 1 pectoralis major muscle remaining. There were no intraoperative deaths. One patient died during the 30-day postoperative period. There were no hematomas, seromas, or dehiscences. One woman developed a postoperative wound infection. Functional and aesthetic results were excellent. This study demonstrates that early, aggressive sternal debridement and closure with pectoralis major musculocutaneous advancement flaps is effective in patients with a history of chest wall irradiation, including those who have had 1 pectoralis major muscle previously resected.     

Sternal resection and reconstruction for primary malignant tumors

BACKGROUND: Primary malignant sternal tumors (PMST) are locally aggressive and their optimal surgical management still continues to evolve. METHODS: From 1986 to 2002, 38 patients (25 females/13 males) underwent radical resection of PMST. This series included 33 sarcomas, 17 of which had been radiation-induced, 3 hematologic tumors, and 2 carcinomas. Seventeen were high-grade tumors. Nine patients had received preoperative chemotherapy. Twelve patients required extensive skin excision. Eight total, seven subtotal, and 23 partial sternectomies were performed. Resection was extended to the anterior chest-wall in 4 patients, lung in 4, brachiocephalic vein in 3, superior vena cava in 2, and pericardium in 1. In 36 patients, chest wall stability was obtained by Marlex (n = 21) or Vicryl (n = 2) mesh and polytetrafluoroethylene patch (n = 13), with methylmethacrylate reinforcement in 12 patients. Soft tissue coverage was done by the pectoralis major muscles with skin advancement in 25 patients, a myocutaneous flap in 11, a breast transposition in 1, and a skin flap in 1. Omentoplasty was performed in 3 patients. RESULTS: One patient died from pneumonia. Two patients needed a tracheostomy after total sternectomy. No flap-related complication was observed. Four local septic complications required removal of the composite prosthesis with reoperations. Local recurrence occurred in 9 patients, 7 patients having a repeat resection. Metastases developed in eight. The 5-year overall and disease-free survival was 66% and 53%, respectively. The histologic grade of sarcomas was a survival predictor (high grade versus others p = 0.035). CONCLUSIONS: Wide resection of PMST is necessary to minimize local recurrence. Large sternal defects are safely reconstructed with a musculocutaneous flap. We suggest that the use of methylmethacrylate should be limited to reconstruction after total sternectomy.     

Closure of infected sternal wounds with a unilateral rectus abdominis muscle flap in addition to bilateral pectoralis major myocutaneous advancement flaps

We have recently added to our regimen a unilateral rectus abdominis muscle flap to cover the lower sternum and adjacent soft tissues, in addition to bilateral pectoralis major myocutaneous advancement flaps for closure of infected sternal wounds. Twenty patients underwent this procedure for closure of infected sternal wounds after initial débridement at our institutions. There were no intraoperative deaths in this series, but three patients died of other medical conditions. Two patients developed hematomas and one developed recurrent sternal wound infection after surgery; two had superficial wound infections and five had minor wound problems (i.e., skin edge necrosis). All surviving patients (17/20, 85%) had healed sternal wounds with normal chest contour and there were no instances of flap necrosis, sternal wound dehiscence, or abdominal wall hernia during the follow-up (18–60 months). Based upon our experience, we recommend a unilateral rectus abdominis muscle flap in addition to bilateral pectoralis major myocutaneous advancement flaps for selected patients with infected sternal wounds. This approach provides reliable soft tissue coverage with acceptable morbidity and mortality in this high-risk patient population. Received: 29 July 1998 / Accepted: 1 March 1999     

Primary tubercolous osteomyelitis of the sternum.

We present an 82-year-old woman with anterior sternal pain diagnosed as primary mycobacterial osteomyelitis of the sternum. She was treated with simultaneous wide resection and reconstruction of the chest wall. On admission, computed tomographic scan showed a sclerotic sternal mass with soft tissue reaction. Mycobacterium tuberculosis was grown in initial culture. First-line antituberculous medication and local debridement failed. The successful result was achieved by extensive sternal and chondral resection followed by simultaneous bilateral pectoralis major muscle flap positioning.     

Two-stage management of sternal wound infection using bilateral pectoralis major advancement flap.

OBJECTIVE: To report our experience using two staged bilateral pectoralis major flap as the sole treatment modality for sternal wound infection. METHODS: A retrospective study of 9417 open-heart surgery cases performed between 1998 and 2003 at The Prince Charles Hospital. Sixty-eight patients were referred to the plastic surgical team for consideration of bilateral pectoralis major flap as the sole treatment modality for sternal wound infection. RESULTS: There was a trend for early referral for flap operation (median 10 days) (p=0.49). The median postoperative ventilation time and ICU stay were 1 and 2 days, respectively. The median hospital stay after flap operation was 15.5 days. One-year overall survival was 91%. Ninety-five per cent healed stable sternum was achieved with 100% failure in patients with chronically unstable sternum. Early referral appears to be an important factor in preventing osteomyelitis formation (p=0.05) with the longest recurrence at 10 months postoperatively. CONCLUSIONS: The key to the successful management of deep sternal wound infection is early referral for pectoralis major flap operation. Our approach is safe with good long-term outcomes. We recommend this approach in all severe deep sternal wound infection but not in patients with chronic unstable sternum.     

Deep sternal wound infection after open heart surgery: current treatment insights. A retrospective study of 36 cases

The aim of this study was to retrospectively evaluate the results of reconstructing infected post-sternotomy wounds, with either sternal plating and/or pectoralis major flap transposition or pedicled omentoplasty after previous vacuum-assisted closure (VAC) therapy. Between January 2005 and December 2010, 36 patients, suffering from deep sternal wound infection (DSWI) after coronary artery bypass grafting procedure, received (plastic) reconstructive surgery. All patients, treated in the Maastricht University Medical Centre (Departments of Plastic Surgery and Cardiothoracic Surgery), were selected for this study. For 22 patients, sternal refixation and reconstruction were obtained by sternal internal plate fixation combined with bilateral pectoralis major advancement flap. In 11 patients, a pedicled omentoplasty was performed, with or without split-skin graft and additional VAC therapy. Three patients only received a pectoralis plasty. We evaluated preoperative characteristics and post-operative course. Twenty-four patients (66.7%) had an uneventful post-operative course. Complications in the other patients included wound dehiscence, herniation of the donor site and infection of sternal plating material. Average sternal wound healing after sternal plating plus pectoralis plasty, pectoralis plasty and omentoplasty respectively accounted 7.7, 8.0 and 11.6 weeks. From our experience, we recommend VAC therapy plus delayed sternal plating and additional bilateral pectoralis major flap advancement as first repair option in case of DSWI. However, individual clinical conditions need to be taken into account when making a decision between the different available reconstructive options. Omentoplasty should be reserved for cases in which the sternum has recurrently fallen open after previous sternal plate refixation, or for cases in which the sternum defect is too extended.