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A Review Of 559 Sternal Wound Reconstructions At A Single Institution: Indications And Outcomes For Combining An Omental Flap With Bilateral Pectoralis Major Flaps In A Subset Of 17 Patients With Infections Extending Into The Deep Mediastinum
Kevin Kuonqui, B.A.1, David Janhofer, M.D.2, Jeffrey A. Ascherman, M.D.2
1Columbia University Vagelos College of Physicians and Surgeons, New York, NY USA. 2Division of Plastic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY USA.

Background: Sternal wound infection (SWI) and dehiscence following median sternotomy for cardiac surgery remain challenging clinical problems with high morbidity. Bilateral pectoralis major myocutaneous (PMM) flaps are excellent for most sternal wounds but do not reach deeper mediastinal recesses. The omental flap may be a useful adjunct for addressing these deeper mediastinal infections.
Methods: Records of 593 sternal wound reconstructions performed by a single surgeon (JAA) from 1996-2022 at a high-volume cardiac surgery center were reviewed. Common surgical indications were SWI and dehiscence. At the time of surgery, patients underwent sternal hardware removal, debridement, and closure with bilateral PMM flaps. Pedicled omental flaps were used as well when vascularized tissue was also required within the deeper mediastinum. Patients undergoing closure with both PMM and omental flaps were selected for analysis.
Results: Complete data were available for 559 sternal wound reconstructive procedures performed by the senior author during this period. Bilateral pectoralis and omental flaps were mobilized in 17/559 (3.04%) patients. Common initial cardiac surgery procedures included repair or replacement of diseased aortic roots (9/17; 52.94%), aortic valves (8/17; 47.06%), and mitral valves (6/17; 35.29). Mean age and BMI were 59.88 years and 29.37 kg/m2, respectively. Preoperative morbidity included culture-positive wound infection (12/17; 70.59%), dehiscence (15/17; 88.24%), wound drainage (11/17; 64.71%), sternal click/instability (6/17; 35.29%), and inability to close the chest following the original sternotomy due to hemodynamic instability (6/17; 35.29%). The mean ASA classification score was 3.56 0.51. Complications immediately preceding sternal surgery were common, with SIRS/sepsis in 10/17 (58.82%) patients, AKI in 9/17 (52.94%), and pneumonia in 4/17 (23.53%). Intraoperative deep mediastinal or bone cultures were positive in 8/17 (47.06%) patients, with Pseudomonas aeruginosa encountered most frequently (3/8; 37.5%). Post-operative complications included partial dehiscence (2/17; 11.76%), skin edge necrosis (1/17; 5.88%), seroma (1/17; 5.88%), abdominal hernia (1/17; 5.88%), and recurrent infection (3/17; 17.65%). Three patients (17.65%) died within 30 days of the sternal surgery.
Conclusions: Patients undergoing combined pectoralis major and omental flap closure frequently had a history of aortic root and valve disease, and other significant preoperative morbidities, as reflected in their elevated ASA class. However, post-operative complications after combined flap closure were relatively low. We thus found combined pectoralis major and omental flap reconstruction to be an effective intervention in patients with sternal wounds extending into the deep mediastinum.


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