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      Sternal Wound Reconstruction Made Simple

      review-article
      Author(s): , MD 1 , , MD 1 ,
      Publication date (Electronic):
      Journal: Plastic and Reconstructive Surgery Global Open
      Publisher: Wolters Kluwer Health

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          Summary:

          Sternal wounds and associated infections represent a complex reconstructive problem in a highly morbid patient population. Through strict adherence to excellent plastic surgical principles, this process can be simplified, allowing safe and effective wound closure. Emphasis is placed on thorough debridement, hardware removal, obtaining adequate tissue cultures, and finally, appropriate flap closure. In most cases, pectoralis major myocutaneous advancement flaps provide excellent coverage while eliminating dead space and providing sternal compression. Secondary flap options, such as the omental flap or rectus abdominis muscle, may occasionally be necessary. This article will provide an overview and simplified approach to sternal wound reconstruction.

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          Most cited references25

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          Poststernotomy mediastinitis: a review of conventional surgical treatments, vacuum-assisted closure therapy and presentation of the Lund University Hospital mediastinitis algorithm.

          Johan Sjögren, Malin Malmsjö, Ronny Gustafsson … (2006)
          Poststernotomy mediastinitis, also commonly called deep sternal wound infection, is one of the most feared complications in patients undergoing cardiac surgery. The overall incidence of poststernotomy mediastinitis is relatively low, between 1% and 3%, however, this complication is associated with a significant mortality, usually reported to vary between 10% and 25%. At the present time, there is no general consensus regarding the appropriate surgical approach to mediastinitis following open-heart surgery and a wide range of wound-healing strategies have been established for the treatment of poststernotomy mediastinitis during the era of modern cardiac surgery. Conventional forms of treatment usually involve surgical revision with open dressings or closed irrigation, or reconstruction with vascularized soft tissue flaps such as omentum or pectoral muscle. Unfortunately, procedure-related morbidity is relatively frequent when using conventional treatments and the long-term clinical outcome has been unsatisfying. Vacuum-assisted closure is a novel treatment with an ingenious mechanism. This wound-healing technique is based on the application of local negative pressure to a wound. During the application of negative pressure to a sternal wound several advantageous features from conventional surgical treatment are combined. Recent publications have demonstrated encouraging clinical results, however, observations are still rather limited and the underlying mechanisms are largely unknown. This review provides an overview of the etiology and common risk factors for deep sternal wound infections and presents the historical development of conventional therapies. We also discuss the current experiences with VAC therapy in poststernotomy mediastinitis and summarize the current knowledge on the mechanisms by which VAC therapy promotes wound healing. Finally, we suggest a structured algorithm for using VAC therapy for treatment of poststernotomy mediastinitis in clinical practice.
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            Sternal wound infection after cardiac surgery: incidence and risk factors according to clinical presentation.

            R Raffoul, L Armand-Lefevre, M-P Dilly … (2015)
            The incidence of surgical site infection (SSI) after cardiac surgery depends on the definition used. A distinction is generally made between mediastinitis, as defined by the US Centers for Disease Control and Prevention (CDC), and superficial SSI. Our objective was to decipher these entities in terms of presentation and risk factors. We performed a 7-year single centre analysis of prospective surveillance of patients with cardiac surgery via median sternotomy. SSI was defined as the need for reoperation due to infection. Among 7170 patients, 292 (4.1%) developed SSI, including 145 CDC-defined mediastinitis (CDC-positive SSI, 2.0%) and 147 superficial SSI without associated bloodstream infection (CDC-negative SSI, 2.1%). Median time to reoperation for CDC-negative SSI was 18 days (interquartile range, 14-26) and 16 (interquartile range, 11-24) for CDC-positive SSI (p 0.02). Microorganisms associated with CDC-negative SSI were mainly skin commensals (62/147, 41%) or originated in the digestive tract (62/147, 42%); only six were due to Staphylococcus aureus (4%), while CDC-positive SSI were mostly due to S. aureus (52/145, 36%) and germs from the digestive tract (52/145, 36%). Risk factors for SSI were older age, obesity, chronic obstructive bronchopneumonia, diabetes mellitus, critical preoperative state, postoperative vasopressive support, transfusion or prolonged ventilation and coronary artery bypass grafting, especially if using both internal thoracic arteries in female patients. The number of internal thoracic arteries used and factors affecting wound healing were primarily associated with CDC-negative SSI, whereas comorbidities and perioperative complications were mainly associated with CDC-positive SSI. These 2 entities differed in time to revision surgery, bacteriology and risk factors, suggesting a differing pathophysiology.
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              Overview and management of sternal wound infection.

              Kimberly A Singh, Erica Anderson, J Harper (2011)
              Sternal wound infection is a life-threatening complication after cardiac surgery associated with high morbidity and mortality. Past treatment options have included closed suction and continuous irrigation. Current paradigms in the management of sternal wound infection include surgical debridement, vacuum-assisted closure therapy, flap coverage, and sternal plating. We provide a general overview of sternal wound infection and treatment options for the plastic surgeon.
              Article 0 comments Cited 34 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Plast Reconstr Surg Glob Open
                Journal ID (iso-abbrev): Plast Reconstr Surg Glob Open
                Journal ID (publisher-id): GOX
                Title: Plastic and Reconstructive Surgery Global Open
                Publisher: Wolters Kluwer Health
                ISSN (Electronic): 2169-7574
                Publication date Collection: November 2019
                Publication date (Electronic): 27 November 2019
                Volume: 7
                Issue: 11
                Electronic Location Identifier: e2488
                Affiliations
                [1]From the Division of Plastic Surgery, Department of Surgery, Columbia University Medical Center, New York, N.Y.
                Author notes
                Jeffrey A. Ascherman, MD, Division of Plastic Surgery, Thomas S. Zimmer Professor of Reconstructive Surgery at CUMC, Columbia University College of Physicians & Surgeons, New York, NY, E-mail: jaa7@ 123456cumc.columbia.edu
                Article
                Accession ID: 00025
                DOI: 10.1097/GOX.0000000000002488
                PMC ID: 6908337
                PubMed ID: 31942289
                SO-VID: 3ae4f04b-4b0d-4982-8e0c-64ec6b81b9a7
                Copyright © Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

                History
                Date received : 1 June 2019
                Date accepted : 6 August 2019
                Categories
                Subject: Review Article
                Custom metadata
                OPEN-ACCESS TRUE

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