gms | German Medical Science

43. Jahrestagung der Deutschen Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen e. V. (DGPRÄC), 17. Jahrestagung der Vereinigung der Deutschen Ästhetisch-Plastischen Chirurgen e. V. (VDÄPC)

13.09. - 15.09.2012, Bremen

Superiority of plastic surgical therapy in deep sternal wound

Meeting Abstract

  • presenting/speaker F. Simunovic - Universitätsklinikum Freiburg, Abteilung Plastische und Handchirurgie, Freiburg, Germany
  • G. Koulaxouzidis - Universitätsklinikum Freiburg, Abteilung Plastische und Handchirurgie, Freiburg, Germany
  • J. Thiele - Universitätsklinikum Freiburg, Abteilung Plastische und Handchirurgie, Freiburg, Germany
  • G.B. Stark - Universitätsklinikum Freiburg, Abteilung Plastische und Handchirurgie, Freiburg, Germany
  • N. Torio-Padron - Universitätsklinikum Freiburg, Abteilung Plastische und Handchirurgie, Freiburg, Germany

Deutsche Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen. Vereinigung der Deutschen Ästhetisch-Plastischen Chirurgen. 43. Jahrestagung der Deutschen Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen (DGPRÄC), 17. Jahrestagung der Vereinigung der Deutschen Ästhetisch-Plastischen Chirurgen (VDÄPC). Bremen, 13.-15.09.2012. Düsseldorf: German Medical Science GMS Publishing House; 2012. DocFV30

DOI: 10.3205/12dgpraec041, URN: urn:nbn:de:0183-12dgpraec0417

Veröffentlicht: 10. September 2012

© 2012 Simunovic et al.
Dieser Artikel ist ein Open Access-Artikel und steht unter den Creative Commons Lizenzbedingungen (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.de). Er darf vervielfältigt, verbreitet und öffentlich zugänglich gemacht werden, vorausgesetzt dass Autor und Quelle genannt werden.


Gliederung

Text

Introduction: Deep sternal wound infection (DSWI) is a grave complication of median sternotomy, associated with high morbidity, mortality and escalating treatment costs. In this study, we compared a plastic surgical therapeutic approach comprising of radical débridement and vascularised flap coverage with repeated débridements and vacuum-assisted closure (VAC) therapy, which is the current standard in many cardiac surgery clinics. We advocate the infraareolar pectoralis major myocutaneous island (PEC-MI) flap as flap of first choice for this indication.

Methods and patients: Seventy-three cases treated for DSWI between 1997 and 2009 were retrospectively reviewed. We compared the two groups according to duration of hospital stay and antibiotic therapy, as well as the incidence of treatment-associated complications and mortality. The most common risk factors for the development of DSWI were recorded. We analyse the choice of flaps and describe the surgical technique of the PEC-MI flap.

Results: Forty-six patients (62%) were treated with flap coverage and 27 (38%) with débridement and VAC therapy. The most common risk factors were hypertension (N=55, 77%), diabetes mellitus (N=31, 43%), obesity (N=30, 42%), renal failure (N=23, 32%), smoking (N=22, 31%), and chronic-obstructive pulmonary disease (N=19, 27%). Single internal mammary artery (IMA) was used during cardiac surgery in 33 (47%) cases, and both arteries were used in 13 (18%) cases. Patients treated with flap surgery had a significantly reduced duration of antibiotic therapy (34.5±31.14 vs. 66.41±47.96, P=0.0016) and hospital stay (31.55±26.93 vs.76±59.73 days, P<0.0001), as well as reduced mortality (N=5, 11% vs. N=9, 33%, P=0.128). Most commonly used flaps were the pectoralis major island flap (N=25), vertical rectus abdominis muscle flap (N=7), pectoralis major advancement flap (N=5) latissimus dorsi flap (N=4), pectoralis major turnover flap (N=4) and transverse rectus abdominis muscle flap (N=1). In 16 cases complications necessitating revision surgery occurred: 5 partial flap necrosis, 3 wound dehiscences, 4 haematoma and 4 infection recurrences.

Discussion: We show that primary plastic-surgical sternum coverage with a muscle flap for treatment of DSWI has several advantages over the conventional approach still used in many cardiac surgery units. Our flap of first choice is the infraareolar PEC-MI flap. Its muscle compartment provides highly vascularised tissue, which is used to completely obliterate the often substantial cavity created by extensive débridement, whereas the skin paddle enables low-tension skin closure, reducing the risk of dehiscence and skin necrosis. Thus, the need for skin grafting or mobilisation of the contralateral muscle is eliminated.