Alternative Bi-Pectoral Muscle Flaps for
Postoperative Sternotomy Mediastinitis
Periklis Tomos, Elias Lachanas, MD, Panagiotis O. Michail, and Alkiviadis Kostakis
Propedeutic Department of Surgery and Department of Surgery, Athens University, Medical School, Athens, Greece
Suppuration, mediastinitis, and disruption of median
sternotomy are all rare, but nevertheless severe compli-
cations. We propose a simple mobilization of the two
pectoralis major muscles for use as flaps to fill the sternal
defect without the need for humeral detachment or a
second cutaneous incision. These will be supplied from
both the thoracoacromial vessels and the perforating
C omplications of sternotomies have been managed with
FEATURE ARTICLES
various techniques. Jurkiewicz and colleagues [1] de-
scribed reconstruction of the defect using the pectoralis
major muscles as flaps. Subsequently, many authors have
described their experiences with this procedure or modifi-
cations of it [2], or have described the use of other muscles
as flaps. In this article we present an alternative approach
with the pectoralis muscles as flaps.
Technique
We applied the following technique in 14 patients (3 fe-
males, 11 males) all of whom had already undergone a
previous heart operation through a sternotomy (ie, 11
aortocoronary bypasses, 1 acute ascending aortic dissection,
1 mitral valve replacement, and 1 Bentall procedure. Our
patients belonged to various types (ie, 7 type V, 4 type III B,
2 type IVA, and 1 type III A (Oakley classification) [3].
Hospital mortality was zero. All our patients are still alive
and healthy, except for 1 female who died from colorectal
cancer.
Our management was comprised of two separate stages.
The first was performed under local anesthetic, which
consisted of reopening the wound and removing all of the
necrotic soft tissue, necrotic bone, cartilage, and wires.
When fistulous tracts were present, they were excised
together with their blind ends, which usually led to
abscesses.
During the next 3 to 5 days, wounds were medicated
twice daily, alternately using povidone iodine and NaCl
solution (15%).
The patient was then taken into the operating room for
the second stage of treatment, which was performed under
general anesthesia. The midline of the sternum
Accepted for publication Oct 28, 2004.
Address correspondence to Dr Tomos, 16A Parthenonos St, Paleo Faliro
175 62, Greece; e-mail: periklistomos@hotmail.com.
2006 by The Society of Thoracic Surgeons
Published by Elsevier Inc
arteries of the nongrafted internal mammary artery
(IMA). Our technique is quick and easy, giving excellent
results. Furthermore, by maintaining the perforating
branches, we also preserve the nongrafted IMA.
(Ann Thorac Surg 2006;81:754 5)
2006 by The Society of Thoracic Surgeons
was scraped to form a V because it is usually a source of
infection. In cases of severe mediastinitis, and when the
sternum was detached right from the start, the medulla was
scraped to eliminate any source of abscess. Subsequently
bi-pectoral musculofascial flaps were created. Both the
pectoralis major muscles were separated from the subcuta-
neous tissue and also from their chest wall insertions. From
the side where the IMA was used as a graft (IMAg), the
dissection proceeded laterally to the level of the anterior
axillary line. The humeral insertion and thoracoacromial
vessels were left intact, whereas at the contralateral muscle
flap, the mobilization was not as extensive, but was still
great enough to leave the anterior intercostal perforators
intact (Fig 1A) and permit the insertion of the medial end of
the muscle flap into the dead space.
Subsequently the medial ends of the flaps were sutured
with a single row of interrupted, half-buried, vertical mat-
tress stitches using polyglycolic acid suture (Dexon No. 2;
United States Surgical, Norwalk, CT), starting 2 cm laterally
to the medial end of the IMAg flap in an anteroposterior
direction, then proceeding to the contralateral IMAg flap, 2
cm laterally to its medial end, in an anteroposterior-anterior
direction, then back again, but this time 1 cm caudal in an
anteroposterior-anterior direction. Finally the wire passed
from the posterior to anterior surface of the ipsilateral IMAg
flap, which created an overlap of the flaps (Fig 1B, 1C) so
that the contralateral IMAg flap was buried in the V
scraped area and the ipsilateral IMAg was overlapping. All
these sutures passed right through the muscle. Next a large
diameter drainage tube (vacuum No. 18) was placed adja-
cent to the sternal defect. Immediately afterward, large
transfixion sutures were applied to prevent excessive lateral
tension. These were tied at the end of the operation.
While the assistant pushed on both sides of the soft
tissue, the surgeon tied the mattress sutures before anchor-
ing a second row of simple stitches between the fasciae of
the two pectoralis muscles (Fig 1D), one of which was
already overlapping. A new vacuum drainage tube was
placed in the subcutaneous tissue which was sutured, and
the skin was stapled.
0003-4975/06/$32.00
doi:10.1016/j.athoracsur.2004.10.065
Ann Thorac Surg
2006;81:754 5
Comment
Our technique has a number of advantages compared with
other techniques described to date. First, after the skin and
subcutaneous tissue are separated from the anterior pecto-
ralis fascia of the muscles, the muscles are not divided and
rotated [1], nor is there any need for a further cutaneous
incision for a better approach to the humeral muscle ex-
tremity [3, 4]. To the contrary, we preserve the humeral
insertion by mobilizing the muscles from their costal inser-
tions, bringing them toward the midline and burying one of
the two flaps in the sternal defect while the contralateral
flap is folded over it. This kind of overlapping offers addi-
tional stability with respect to adaptation of the muscle.
Second, we do not use foreign bodies to bring together the
sides of the sternum; thus we do not use rewiring or
polydioxanone sutures between the outer cortex of the
sternum [5], and we do not use suturing of one of the flaps
on the sternum resection line or on the cartilage [3] because
the sternal defect is filled with viable tissue that is well
supplied. Likewise, if part of the ribs or costal cartilage has
been removed, this area is covered by the muscles them-
selves by simple apposition.
We believe in the aggressive V shaped sternectomy
and the removal of infected cartilage, because failure of the
reconstruction is directly related to persistent infection of
bone and cartilage [6].
Blood supply in one of the two flaps is based both on the
perforating arteries of the IMA and on the thoracoacromial
artery, whereas the contralateral flap is based only on the
thoracoacromial artery. This offers better viability and func-
tionality of the flaps, contrary to Hugo and colleagues [2]
who isolated and cauterized the anterior perforating arter-
ies when they created myocutaneous flaps with the pecto-
ralis muscles. In addition, Hugo and colleagues [2] were not
interested in the dead space, whereas we fill this space
using the sutures employed for burying one of the two flaps
as previously described. By protecting and maintaining the
HOW TO DO IT TOMOS ET AL 755
PECTORAL MUSCLES AS FLAPS
Fig 1. (A) Preservation of the anterior perfo-
rating artery. (B) Placement of the first single
row of interrupted, half-buried, vertical mat-
tress stitches. (C) All sutures in the first row
have been placed. (D) The second row of
simple stitches.
FEATURE ARTICLES
perforating arteries, the IMA is also preserved for potential
future use as a graft.
In conclusion, blood supply of the flaps is in no way
compromised with our proposed technique because it re-
spects both the perforating arteries (on one side) and the
thoracoacromial arteries. Furthermore muscular detach-
ment or co-mobilization of the rectus abdominis is not
required, and at least one of the two IMAs remains intact
for possible future use. By suturing the muscles, as pro-
posed herein, a muscular implant is made. This seals the
dead space, which has no tension due to the presence of a
second layer. Early and later results are excellent, not only
regarding infection and functionality, but also from an
aesthetic point of view.
The authors would like to acknowledge the contribution of
Danielle Bowler, translator and copy editor.
References
1. Jurkiewicz MJ, Bostwick J III, Hester TR, Bishop JB, Craver J.
Infected median sternotomy wound. Successful treatment by
muscle flaps. Ann Surg 1980;191:738 43.
2. Hugo NE, Sultan MR, Ascherman JA, et al. Single stage
management of 74 consecutive sternal wound complications
with pectoralis major myocutaneous advancement flaps. Plast
Reconstr Surg 1994;93:1433 41.
3. Reida M, El Oakley RM, Wright JE. Postoperative mediastinitis:
classification and management. Ann Thorac Surg 1996;61:1030.
4. Jose R, Castello JR, Centella T, Garro L, et al. Muscle flap
reconstruction for the treatment of major sternal wound
infections after cardiac surgery: 10 year analysis. Scand J Plast
Reconstr Hand Surg 1999;33:1724.
5. Perkins DJ, Hunt JA, Pennington DJ, Stern HS. Secondary
sternal repair following median sternotomy using interosse-
ous absorbable sutures and pectoralis major myocutaneous
advancement flaps. Br J Plast Surg 1996;49:214 9.
6. Schroeyers P, Wellens F, Degrieck I, et al. Aggressive primary
treatment for poststernotomy acute mediastinitis: our experi-
ence with omental and muscle flaps surgery. Eur J Cardio-
thorac Surg 2001;20:743 6.