Achieving urinary continence in cloacal exstrophy: The surgical cost

Introduction

Cloacal exstrophy (CE) is a severe midline congenital abnormality that requires numerous surgical corrections to achieve an acceptable quality of life. Candidates for urinary continence undergo multiple procedures, most often continent bladder diversions, to become socially dry. Here, the authors investigate the number of genitourinary interventions that patients with CE undergo to attain urinary continence.

Closure and augmentation of bladder exstrophy using rectus abdominis musculo-peritoneal flap

Background:

The aim of this study was to investigate the efficacy of the rectus abdominis myo-peritoneal flap (RAMP) technique for the closure and augmentation of small, non-elastic, non-compliant bladder exstrophies.

Materials and Methods:

The RAMP technique was used in three boys with bladder exstrophy who presented late with small, non-elastic, non-compliant bladder. The clinical outcome, imaging, cystoscopy, biochemical and microbiological studies were assessed during a follow-up of 36 months.

Results:

Bladder closure and augmentation was achieved in all patients without any complications. There were no urinary tract infections, metabolic problems or electrolyte disturbances and the kidney function remained normal in all patients. Radiography confirmed intact function and anatomy of the urinary tract and cystoscopy showed complete coverage of the inner peritoneal layer of RAMP with uroepithelium. No stone formation or mucous production was detected.

Conclusions:

The RAMP technique is a good alternative for closing bladder exstrophies and achieves an increase in bladder capacity and compliance. The technique is indicated in the closure of large bladder defects, bladder exstrophies with small, inelastic, non-compliant bladder remnants and failed primary closures.KEY WORDS: Augmentation of bladder, bladder exstrophy, rectus abdominis musculo-peritoneal flap     

An improved dual approach to post bariatric contouring — Staged liposuction and modified medial thigh lift: A case series

Objective:

Following massive weight loss (MWL) medial contouring of the thigh is frequently requested to improve appearance and function. Thigh lifting can be associated with significant complications. We present a case series of post bariatric patients undergoing thigh lift using staged the liposuction, a modified T incision and a buried de-epithelialised dermal flap.

Materials and Methods:

From January to December 2012, 21 consecutive patients underwent a modified medial thigh lift. A retrospective review of the case notes was performed to assess complications that occurred.

Results:

There were no major post-operative complications in terms of reoperation, hematoma, thromboembolism and no seromas. Seven patients, all of which were smokers had minor superficial wound healing complications. Aesthetic outcomes were satisfactory for all patients at a minimum follow-up of 6 months.

Conclusions:

The modified ‘T’ incision with staged liposuction is described. We have found the technique to be useful for a variety of different thighs. It is a reproducible method for contouring the medial thigh in MWL patients. In this series, our overall complications were low, and no seromas occurred.KEY WORDS: Combined liposuction, modified, thigh lift, buried dermal flap     

Management of recurrent post-prostatectomy incontinence after previous failed retrourethral male slings

Objective:

Our objective was to establish the feasibility of combining 2 minimally invasive procedures in patients with failed primary treatment (male sling) in post-prostatectomy incontinence (PPI) patients.

Methods:

From January 2007 to July 2008, 40 men with PPI were implanted with a suburethral tape (2 patients with Seratim, 3 with I-Stop and 35 with Advance). The median preoperative pad count was 4 (range 2–10). Prior to sling placement, 6 patients had undergone ProACT implantation. Of these, 4 patients required explantation due to balloon migration and 2 patients had their balloons kept in situ, with the balloons deflated.

Results:

Twenty-five patients were socially continent at this time. Fifteen patients (37.5%) did not improve or their improvement was not significant. These patients had a preoperative pad count between 7 and 10. Two of these patients had prostate adjustable continence therapy (ProACT) systems still in place. By gradually filling the balloons to 3 mL, both of these patients achieved complete continence, which was maintained at a mean follow-up of 8.5 months. Three patients with prior pelvic irradiation received an artificial urinary sphincter and achieved continence at mean follow-up of 8.3 months. The remaining 10 patients received a ProACT system in addition to the already implanted sling. After appropriate healing and filling of the balloons (average balloon volume 5 mL), all 10 patients reached complete continence; they were pad-free at a mean follow-up of 6 months (range 3–9).

Conclusions:

The combination of ProACT and a suburethral tape was demonstrated to be a possible treatment option in recurrent or persistent PPI.     

Percutaneous fixation with Schanz screws for displaced two- and three- part fractures of the proximal humerus in patients above fifty years of age

Purpose:

The aim of this study is to evaluate whether two 3.0 mm Schanz screws in two-part proximal humeral fractures (plus one additional Schanz screw or K wire in three-part fractures) can provide enough stability to allow early mobilization until healing occurs in elderly patients.

Settings and Design:

This prospective study was performed in the Orthopaedic Department of our University Hospital.

Patients and Methods:

We performed closed reduction and percutaneous pinning for thirty-three patients with proximal humerus fractures. Twenty-seven patients were available for the final follow-up. Of those 27 patients, 17 had two-part surgical neck fractures; while 10 had three-part fractures. For fixation, we used two 3.0 mm Schanz screws in patients with two-part fractures plus one additional Schanz screw or K wire in the 10 patients with three-part fractures.

Results:

The mean Constant score modified according to the age and sex was 89.8% (range: 77.3-97.2%). Fifteen patients had excellent results, 11 patients had good results, and one patient had a fair result.

Conclusion:

Closed reduction and percutaneous pinning with two Schanz screws for two-part surgical neck humeral fractures, plus an additional Schanz screw or K wire for three-part proximal humeral fractures is a useful and effective technique that provides enough stability to allow an early rehabilitation program till union occurs in elderly patients.

Level of Evidence:

IV; therapeutic study, case series.     

Microfracture of chondral lesions of the glenohumeral joint

Objective:

To determine if microfracture is successful in treating chondral lesions of the shoulder.

Design:

Case series.

Setting:

Tertiary referral practice.

Patients:

From June 2005 to November 2006, eight patients underwent shoulder arthroscopy with arthroscopic microfracture to treat full-thickness chondral lesions of less than 4 cm² size. The study group consisted of six men and two women. The mean age at surgery was 37 years (range: 27–55 years).One patient (12.5%) had an isolated chondral defect and seven patients (87.5%) had associated conditions treated simultaneously: two patients had arthroscopic subacromial decompressions, two had capsular plications for multidirectional instability, and three had anterior stabilization done (one with an associated superior labrum anterior to posterior repair and one with repair of a small rotator cuff tear). Five patients had humeral head defects and three had glenoid defects.

Intervention:

Microfracture.

Main outcome measures:

Constant score and Oxford score.

Results:

The mean follow-up period was 15.4 months, with a range of 12–27 months. The mean preoperative Constant score was 43.88 (range: 28–70) and at final follow-up the mean Constant score was 90.25 (range: 85–100); this difference was significant (P<0.005). The mean preoperative Oxford score was 25.75 (range: 12–37) and the mean postoperative Oxford score at final follow-up was 17 (range: 11–27); the difference was significant (P<0.005).There were no complications. Two patients underwent reoperation which allowed assessment of the lesion; in both cases the lesions showed good filling with fibrocartilage.

Conclusion:

Microfracture has been shown to be a reliable method of treatment for chondral lesions within the knee. We believe that this technique may also be applied to the shoulder; however, further study is required to assess its efficacy in this joint.

Level of evidence:

IV     

Posterior Reconstruction and Outcomes of Laparoscopic Radical Prostatectomy in a High-Risk Setting

Background and Objectives:

To detail the technique and evaluate the impact of a personal modified posterior reconstruction technique (PDR) on the outcomes of extrafascial laparoscopic radical prostatectomy (eLRP) in a consecutive series of 52 patients affected by high-risk prostate cancer (HRPCa).

Methods:

From October 2007 to March 2012, 52 patients underwent PDR during eLRP for HRPCa. Fifty-four patients who underwent eLRP for HRPCa with no PDR were considered as historical controls. Mean operative time (MOT), mean catheterization time (MCT), % continence and quality of life (QoL) at a scheduled follow-up, % anastomotic leakage, % adjuvant therapy were compared between the groups. Percentage of continence and QoL were prospectively assessed by self-administered validated questionnaires (ICI-Q-SF; SF-36) at 1, 3, 6, and12 months.

Results:

PDR was associated wither higher continence rates at 1 and 3 mo (P = .028, P = .006), a lower incidence of cystographic leakage (P = .002), and an increased adjuvant radiotherapy rate (P = .008). At 1- and 3-mo interval, in the PDR group, we found a higher number of patients reporting better general health, (P = .01, P = .03) reduced role limitations due to physical health, (P = .02, P = .001), and emotional problems (P = .001, P = .02).

Conclusions:

PDR is associated with a lower degree of anastomotic leakage, and it significantly enhances urinary continence at 1 and 3 mo. The increased adjuvant radiotherapy rate and quality of life after surgery observed with our technique suggest that in the high-risk setting an early functional recovery may substantially influence the oncologic outcome of eLRP.     

A novel and accurate technique of photographic wound measurement

Context:

Wound measurement is an important aspect of wound management. Though there are many techniques to measure wounds, most of them are either cumbersome or too expensive.

Aims:

To introduce a simple and accurate technique by which wounds can be accurately measured.

Settings and Design:

This is a comparative study of 10 patients whose wounds were measured by three techniques, i.e. ruler, graph and our technique.

Materials and Methods:

The graph method was taken as the control measurement. The extent of deviation in wound measurements with our method was compared with the standard technique. The statistical analysis used was ANOVA.

Results:

The ruler method was highly inaccurate and overestimated the wound size by nearly 50%. Our technique remained consistent and accurate with the percentage of over or underestimation being 2-4% in comparison with the graph method.

Conclusions:

This technique is simple and accurate and is an inexpensive and non-invasive method to accurately measure wounds.KEY WORDS: Digital planimetry, photography, wound measurement

You can’t manage what you can’t measureW. Edwards Deming

     

Is there a shortening of the urethral plate in complete penile disassembly used in epispadias repair,and what is its impact on the final outcomes?

Purpose

To assess the importance of shortening of the urethral plate that occurred with complete penile disassembly technique in epispadias repair and its impact on cosmetic and functional results (on urinary incontinence).

A modified two-incision technique for primary total hip arthroplasty

Background:

Minimally invasive surgery can be technically demanding but minimizes surgical trauma, pain and recovery. Two-incision minimally invasive surgery allows only intermittent visualization and may require fluoroscopy for implant positioning. We describe a modified technique for primary total hip arthroplasty, using two small incisions with a stepwise approach and adequate visualization to reliably and reproducibly perform the surgery without fluoroscopy.

Materials and Methods:

One hundred and two patients with an average age of 60 years underwent modified two-incision minimally invasive technique for primary THA without fluoroscopy. The M/L taper femoral stem (Zimmer, Warsaw, IN) and Trilogy (Zimmer) hemispherical titanium shell, with a highly cross-linked polyethylene liner, was used. Operative time, blood loss, postoperative hospital stay, radiographic outcomes and complications were recorded.

Results:

The mean operating time was 77 min. The mean blood loss was 335 cc. The mean hospital stay was 2.4 days. Mean cup abduction angle was 43.8°. Mean leg length discrepancy was 1.7 mm. Thirteen patients had lateral thigh numbness and two patients had wound complications that resolved without any treatment.

Conclusion:

A modified two-incision technique without fluoroscopy for primary total hip arthroplasty has the advantage of preserving muscles and tendons, shorter recovery and return to function with minimal complications. Provided that the surgeon has received appropriate training, primary total hip arthroplasty can be performed safely with the modified two-incision technique.     

Lip adhesion revisited: A technical note with review of literature

Context (Background):

Lip adhesion is a direct edge approximation without changing lip landmarks or disturbing tissue required for definitive closure. This converts a complete cleft into an incomplete cleft, facilitating and enhancing subsequent definitive lip and nose repair.

Aim:

The study aims to describe our technique of lip adhesion and its morbidity, and discuss the rationale for its use.

Settings and Design:

Retrospective follow-up study of complete clefts operated upon in the Bruges Cleft and Craniofacial Centre, at the supra regional teaching hospital AZ St. Jan, Bruges, between June 1, 1991 and May 1, 2009.

Methods and Material:

The group comprised 33 unilateral and 24 bilateral lip adhesion procedures. The medical files were reviewed for changes in surgical technique, morbidity, and complications and their treatment.

Results:

The lip adhesion procedure was performed at the age of two to eight weeks postnatal, and definitive lip closure, at the age of four to six months. In all cases, segment repositioning was further controlled by a palatal guidance plate. Wound dehiscence occurred in eight patients (14.0%), and three patients (5.3%) required reoperation.

Conclusions:

Although complications occurred, the beneficial effects of lip adhesion in combination with a guidance plate outweighed the risks for anatomical reconstruction of a platform for definitive lip and nose repair. Modifications are suggested to reduce these complications.     

Modified minimally invasive two-incision total hip arthroplasty using large diameter femoral head

Background:

Minimally invasive (MI) total hip arthroplasty (THA) is an alternative to standard THA, but has created much controversy among orthopedic surgeons. The authors modified the original minimally invasive two-incision THA technique and used large-diameter (32 mm, 36 mm) ceramic-on-ceramic articulation.

Materials and Methods:

One hundred and seventy patients that underwent unilateral MI two-incision THA were retrospectively reviewed, and surgical morbidity, functional recovery, radiological properties, and complications were assessed.

Results:

Mean Harris hip score (HHS) improved from 41.8 to 96.1 at last followup, and mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score from 66.2 to 26.9. The mean lateral opening angle of the acetabular component was 38.2° and the mean stem position was valgus 1.9°. There was an intraoperative femur fracture and one revision surgery due to stem subsidence. No patient had dislocation.

Conclusions:

Our data suggest that this modified technique combined with large ceramic femoral head is safe and reproducible in terms of achieving proper implant positioning and early functional recovery.     

Namaste (counterbalancing) technique: Overcoming warping in costal cartilage

Background:

Indian noses are broader and lack projection as compared to other populations, hence very often need augmentation, that too by large volume. Costal cartilage remains the material of choice in large volume augmentations and repair of complex primary and secondary nasal deformities. One major disadvantage of costal cartilage grafts (CCG) which offsets all other advantages is the tendency to warp and become distorted over a period of time. We propose a simple technique to overcome this menace of warping.

Materials and Methods:

We present the data of 51 patients of rhinoplasty done using CCG with counterbalancing technique over a period of 4 years.

Results:

No evidence of warping was found in any patient up to a maximum follow-up period of 4 years.

Conclusion:

Counterbalancing is a useful technique to overcome the problem of warping. It gives liberty to utilize even unbalanced cartilage safely to provide desired shape and use the cartilage without any wastage.KEY WORDS: Autogenous cartilage, costal cartilage graft, counterbalancing technique, rhinoplasty, warping     

Anatomic and mechanical considerations in restoring volume of the face with use of hyaluronic acid fillers with a novel layered technique

Context:

Facial fillers have revolutionized the field of cosmetic facial rejuvenation as it has become the prime sought – after rejuvenation procedure offering youthful, 3-dimensional look with minimal invasiveness. Fillers are expensive and need to be redone periodically hence a sound understanding of structural basis on which they are laid is important in reducing the quantity of filler required in each sitting as well as increasing the longevity of results.

Aim:

The aim of the following study is to analyse a novel method of facial filling “The pillars pyramids and tie beams (PPT)” technique and its advantages over the conventional methods.

Subjects and Methods:

A novel technique of injecting the facial fillers was employed on 67 patients visiting our clinic. These patients were followed-up for a period of 3 years.

Results:

We observed that the amount of filler material required in initial sitting remains the same, however the frequency of touch up visits is decreased and so is the amount of filler material required for follow-up injections.

Conclusion:

Facial contour remodelling is being revolutionised by the new filler materials for volume augmentation and no uniform consensus has been reached on the techniques currently used in clinical practice. We advocate this novel PPT technique of facial filling in facial rejuvenation to restore a youthful look as a primary goal.KEY WORDS: Aging face, facial fillers, facial rejuvenation, hyaluronic acid     

Bladder neck closure and suprapubic catheter placement as definitive management of neurogenic bladder

Objective

Surgical management for neurogenic bladder may require abandonment of the native urethra due to intractable urinary incontinence, irreparable urethral erosion, severe scarring from previous transurethral procedures, or urethrocutaneous fistula. In these patients, bladder neck closure (BNC) excludes the native urethra and provides continence while preserving the antireflux mechanism of the native ureters. This procedure is commonly combined with ileovesicostomy or continent catheterizable stoma, with or without augmentation enterocystoplasty. Alternatively, BNC can be paired with suprapubic catheter diversion. This strategy does not require a bowel segment, resulting in shorter operative times and less opportunity for bowel-related morbidity. The study purpose is to examine preoperative characteristics, indications, complications, and long-term maintenance of renal function of BNC patients.

Methods

A retrospective review of medical records of 35 patients who underwent BNC with suprapubic catheter placement from 1998 to 2007 by a single surgeon (LKL) was completed.

Results

Neurogenic bladder was attributable to spinal cord injury in 71%, 23% had multiple sclerosis, and 9% had cerebrovascular accident. Indications for BNC included severe urethral erosion in 80%, decubitus ulcer exacerbated by urinary incontinence in 34%, urethrocutaneous fistula in 11%, and other indications in 9%. The overall complication rate was 17%. All but two patients were continent at follow-up. Forty-nine per cent of patients had imaging available for review, none of which showed deterioration of the upper tracts.

Conclusions

Our results suggest that BNC in conjunction with suprapubic catheter diversion provides an excellent chance at urethral continence with a reasonable complication rate.     

The expanded inframammary fold triangle: Improved results in large volume breast reductions

Context:

The inferior pedicle, Wise-pattern reduction mammaplasty is the most popular technique for breast reduction because of its reproducible results and reliability. However, complication rates in super obese patients or patients receiving large volume reductions are high, ranging from 35 to 78%. These complications include delayed healing, infection, seroma, nipple-areolar complex necrosis, fat necrosis and development of hypertrophic scars.

Aims:

This study aimed to determine whether a modification to the standard Wise-pattern reduction technique, an expanded inframammary fold skin triangle, produces improved outcomes in high-risk large volume breast reduction patients. We report that this modification leads to improved outcomes by decreasing wound complications and improving aesthetic appearance.

Settings and Design:

Twenty-two patients received the inferior pedicle Wise-pattern reduction mammaplasty, which was modified to include an 8 cm wide inferior pedicle. This pedicle was de-epithelialized and an 8 × 3 cm² triangle of skin was preserved at the inferior base to reduce tension at the triple point, inverted T-closure.

Materials and Methods:

A retrospective review was performed on all patients who underwent reduction mammaplasty with the expanded inframammary fold (eIMF) technique as well as all patients who received the standard wise pattern technique.

Statistical Analysis Used:

A student t-test was performed for both reduction populations using SPSS software package. Statistical significance was defined as P < 0.05.

Results:

The average patient age was 32.25 years old (range 18-59), average BMI was 35.0, and average tissue mass removed per breast was 1378.39 g. The modified technique was found to produce a statistically significant (P < 0.05) increase in the amount of breast tissue removed (693.96 g increase in the left and 571.21 g in the right) as well as a statistically significant (P < 0.05) reduction in dehiscence (75% reduction) and post-operative infection (44.10%).

Conclusions:

This method is an easily reproducible and reliable technique that produces a favourable cosmetic outcome with acceptable, sustainable results in high-risk reductions in obese patients.KEY WORDS: Inverted T-closure, breast reduction, Wise pattern mammaplasty     

Long-term results of bladder neck reconstruction for incontinence in children with classical bladder exstrophy or incontinent epispadias

In the paediatric section this month several important issues are addressed. The authors from Lyon describe the results of bladder neck reconstruction for incontinence in children with bladder exstrophy and incontinent epispadias. They indicate the unpredictability of bladder neck reconstruction and discuss the results of the other techniques used for urinary continence.

OBJECTIVE

To review the long‐term results of bladder neck reconstruction (BNR) in patients with classical bladder exstrophy or epispadias, and to review the concept of continence surgery in these two groups, stressing the difficulty in finding an adequate balance between urine storage (which implies high outlet resistance and low storage pressure) and complete bladder emptying (which implies low outlet resistance and a transient increase in bladder pressure); surgery cannot achieve ‘continence’ (which implies active mechanisms) but only ‘dryness’ (which implies passive mechanisms).

PATIENTS AND METHODS

Eighty patients with classical bladder exstrophy (52 male, 28 female) and 25 with incontinent epispadias (17 male, 18 female) had their bladder neck reconstructed after a Young‐Dees‐Leadbetter procedure, subsequently modified by Mollard. The treatment is detailed and results reviewed after a mean follow‐up of 11 years. All patients were treated and followed in the same institution.

RESULTS

In the exstrophy group, 36 (45%) patients presented with a dry interval of > 3 h, with urethral emptying after one BNR; 52 (65%) presented with recurrent urinary tract infections, 19 (24%) with urinary stones, 21 (26%) with dilated upper urinary tracts, 13 (16%) with bladder perforations and one with an adenocarcinoma of the bladder. Thirty‐eight patients (48%) required further surgery; 51% of all patients required an endoscopic procedure within 3 months after the BNR and 26% had endoscopic procedures for late (> 3 months) urine retention. In the epispadias group, 13 (52%) patients presented with a dry interval of > 3 h with urethral emptying after one BNR; 12 (48%) had recurrent urinary tract infections, five (20%) upper tract dilatation, two (8%) bladder stones, one (4%) bladder perforation and one an adenocarcinoma of the bowels after a ureterosigmoidostomy. Ten (40%) children required further surgery.

CONCLUSION

We compared the present results for continence with those in other published series; most complications encountered were related to the obstructive pattern of bladder emptying and the abnormal bladder urodynamic behaviour caused by BNR. We consider that BNR is unpredictable and the roles of the other factors in urinary continence are discussed. Alternative procedures are detailed. The concept of continence surgery in exstrophy and incontinent epispadias is reviewed, stressing the importance of favouring bladder development and limiting obstructive patterns of bladder emptying that cause severe and recurrent complications.

     

Renal and functional outcomes following cystectomy and neobladder reconstruction

Background:

Orthotopic reconstruction following cystectomy has evolved in an attempt to restore anatomy and function to as close as possible to the preoperative state. We review the renal and functional outcomes of patients who underwent cystectomy and neobladder reconstruction at our institution.

Methods:

Between December 2003 and October 2007, 31 patients underwent cystectomy with Studer neobladder reconstruction at the Ottawa Hospital, Ottawa, Ontario, Canada. Follow-up data were obtained regarding renal function (serum creatinine, μmol/L), continence, urinary flow rates and post-void residual (PVR) at 3, 6 and 12 months after surgery. Change in creatinine from preoperative baseline was calculated and analyzed by student t-test to determine if there was a significant rise in creatinine.

Results:

There was a statistically significant increase in creatinine from preoperative baseline, with an average increase of 17.3 μmol/L, 21.8 μmol/L and 26.3 μmol/L at 3, 6 and 12 months, respectively. Six patients developed hydronephrosis. Excluding patients with hydronephrosis, there continued to be a statistically significant rise in creatinine with an average increase of 11.9 μmol/L, 14.7 μmol/L and 19.4 μmol/L at 3, 6 and 12 months, respectively. At 1 year, daytime continence was achieved by 89% of patients; 70% were continent at night.

Interpretation:

Orthotopic neobladders have excellent functional outcomes with low rates of incontinence, which improved throughout follow-up. A significant proportion of patients developed hydronephrosis, highlighting the need for close follow-up to prevent reversible renal deterioration. Creatinine increased during follow-up irrespective of the development of hydronephrosis, but the clinical significance is unknown.     

Bilateral Ureteral Tapering and Secondary Ureteroneocystostomy for Late Stenosis in a Patient with Bladder Extrophy

Objective

To report a case of severe hydronephrosis 20 years after bladder exstrophy (BE) repair, managed by bilateral ureteral tapering and secondary ureteroneocystostomy.

Case Presentation

A 21-year-old woman with a history of BE and ureteral reimplantation, presented with hematuria-dysuria syndrome and recurrent febrile urinary tract infections. After counselling, she elected to undergo bilateral ureteral tapering and second ureteroneocystostomy.

Conclusion

Hydronephrosis secondary to ureteralvesical stricture in BE patients can be successfully managed with ureteral reimplantation associated to ureteral tapering even after a prior reimplantation.Key Words: Bladder exstrophy, Hydronephrosis, Surgical technique     

Our experience with pectoralis major flap for management of sternal dehiscence: A review of 25 cases

Objective:

To report our experience of the pectoralis major flap as the treatment modality for post coronary artery bypass sternal wound dehiscence.

Materials and Methods:

A retrospective study of 25 open heart surgery cases, performed between January 2006 and December 2010 at Deenanath Mangeshkar Hospital, Pune, was carried out. Unilateral or bilateral pectoralis major muscle flap by the double breasting technique using rectus extension was used in the management of these patients. The outcome was assessed on the basis of efficacy of flap surgery in achieving wound healing and post-surgery shoulder joint movements to evaluate donor site morbidity. The follow-up ranged from 5 months to 3.5 years.

Results:

Twenty-three (92%) patients were discharged with complete wound closure. One patient (4%) had wound dehiscence after flap surgery. One patient (4%) died in the hospital in the immediate postoperative period due to mediastinitis. No recurrent sternum infection has occurred till date in 24 patients (96%). For one patient (4%) who had wound dehiscence, daily dressing was done and wound healing was achieved with secondary intension. At follow-up, shoulder joint movements were normal in all the patients.

Conclusions:

The double breasting technique of the pectoralis major muscle flaps with rectus sheath extension is efficient in covering the entire length of the defect and can reduce the morbidity, without affecting the function of the shoulder joint.KEY WORDS: Bilateral pectoralis major flaps, left internal mammary artery and right internal mammary artery, sternal dehiscence