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Sternal wound dehiscence complicated by macromastia: report of two cases with discussion of literature
Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, e362ee364
CASE REPORT
Sternal wound dehiscence complicated by macromastia: report of two cases with discussion of literature A. Roshan*, A. Kotwal, M. Riaz, P.R.W. Stanley Department of Plastic Surgery, Castle Hill Hospital, Cottingham, Hull, UK Received 6 August 2007; accepted 2 February 2008
KEYWORDS Macromastia; Sternal dehiscence; Pectoralis major flap
Summary Sternal wound dehiscence complicated by macromastia can be difficult to treat by standard musculocutaneous flaps alone. We present our experience with two cases of sternal wound dehiscence complicated by macromastia, and their subsequent healing with a combination of reduction mammoplasty and local musculocutaneous flaps. Reduction mammoplasty is a useful adjunctive procedure in patients with macromastia complicating sternal wound dehiscence. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Sternal wound dehiscence is a recognised complication following median sternotomy for cardiac surgery, with a reported incidence of 1.1e2.3%.1e4 In the obese [with body mass index (BMI) > 30], the incidence of sternal dehiscence can reach 6.5%.5 This complication is associated with high morbidity and can sometime have fatal consequences with the resultant mediastinitis.1e5 Described treatment involves radical debridement and soft tissue cover, usually with flaps including pectoralis major, rectus abdominis, omentum or latissimus dorsi.6e11 The management can
* Corresponding author. Address: MRCS, Department of Plastic Surgery, Castle Hill Hospital, Cottingham, HU16 5JQ, UK. Tel. þ44 7787771362. E-mail address: [email protected] (A. Roshan).
sometimes be complicated in women by the presence of hugely enlarged breasts which produce laterally directed force on the wound edges.12,13 This can lead to recurrent breakdown of the wound in spite of tension-free closures. We present two cases of sternal wound dehiscence associated with macromastia and their management.
Case report 1 A 76-year-old woman underwent aortic valve replacement and coronary artery bypass (CABG) using the internal mammary artery. She weighed 118.6 kg and had a height of 1.63 m with a BMI of 44. She was a chronic smoker. Comorbidity included hypertension and diabetes mellitus. She developed a wound infection with bacteroides,
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.02.019
Sternal wound dehiscence complicated by macromastia peptostreptococcus and pseudomonas. This resulted in the sternum being exposed with the sternal wires visible at the base of the wound. Six weeks after the original operation she underwent radical debridement of the wound, removal of the sternal wires and resurfacing of the wound with a pedicled transverse rectus abdominis (TRAM) flap. The TRAM flap was used because the width of the defect was too large for a vertical rectus abdominis (VRAM) flap. The wound dehisced at the edges because of the massive lateral tension from the enlarged breasts. This subsequently became contaminated with methicillin-resistant Staphylococcus aureus (MRSA). Further attempts at debridement and closure were unsuccessful. After eradicating MRSA, she had further debridement and advancement of bilateral pectoralis major muscular flaps. At the same time a bilateral breast reduction was performed using a Wise pattern excision and free nipple grafts. 1156 g of tissue was removed from the right breast and 925 g from the left. She had an uneventful recovery apart from a small wound breakdown in the upper part of the wound that healed secondarily in a month (Figure 1).
Case report 2 A 73-year-old woman underwent aortic valve replacement and CABG using the left internal mammary artery. She weighed 92 kg, had a height of 1.62 m and a BMI of 35. She was an ex-smoker. Co-morbidity included hypertension and gigantomastia. She developed a wound infection that was treated with debridement, antibiotics and vacuum therapy. Microbiological examination of the wound revealed mixed skin and faecal flora. In view of our previous experience with sternal dehiscence we decided to perform breast reduction at the time of the definitive surgery. The patient was appropriately counselled. She underwent radical debridement of the wound, removal of the sternal wires, bilateral pectoralis major advancement flaps and Wise pattern bilateral breast reduction with free nipple grafts. 1900 g of tissue was removed from the right breast and 1450 g from the left. The patient made an uneventful recovery and the wound healed in 2 weeks (Figure 2).
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Discussion Wound dehiscence after median sternotomy for coronary artery bypass surgery occurs in approximately 1e2% of cases. Though the incidence is low, because of the large number of patients undergoing this procedure, this complication is not uncommon. The methods for management of sternal wound dehiscence have changed over time and become increasingly successful. Earlier described treatment methods without muscle flaps included continous antibiotic irrigation, povidone-iodine irrigation and pedicled omental flaps.10,14,15 From the late 1970s, various muscle-based reconstructive options have been described including the VRAM flap, pectoralis muscle flaps and pedicled latissimus dorsi flaps.6,9 Muscle flap-based reconstructions have superior outcomes to wound catheter antibiotic irrigation and sternal re-wiring, especially in the setting of infection, as confirmed by Rand et al. in a prospective trial.16 Female sex has been found to be an independent risk factor for sternal complications following CABG (variable odds ratio 0.4, 95% confidence ratio 0.2e0.6).1 However, we do not know the correlation between breast size as a factor in the causation of the complication. The lower sternal wound has been shown to be the most unstable part of the median sternotomy from ultrasound and mechanical studies.17 The anatomic reasons for this include greater excursion of the lower thorax and abdomen during normal respiration, concentration of forces here with the attachment of ribs 7 to 10, the greater transverse and anterior-posterior dimensions of the lower versus upper thorax and the reduced thickness of the lower sternum in comparison with the manubrium. Macromastia produces further infero-lateral tension on a vertical sternotomy incision and this can lead to sternal wound dehiscence. Conservative management of the macromastia by binding the breasts in supportive bras may take a portion of the tension off the wound, but not be adequate to allow healing. Copeland12 and Fontaine13 have proposed pectoralis muscle flaps along with breast reduction mammoplasty for treating infected sternal wound dehiscence in patients with macromastia. This avoids the lateral tension on the sternal wound during closure and prevents further
Figure 1 A. Pre-operative marking in a 76-year-old with BMI of 44, for bilateral reduction mammoplasty with continuous suction device in situ. B Post operative result at 8 months following bilateral pectoralis major advancement flaps showing good healing.
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Figure 2 A Pre-operative sternal wound following CABG and aortic valve replacement in a 73-year-old with BMI of 35. B Three weeks post operative photograph following bilateral breast reduction and pectoralis major advancement flaps.
breakdown. We found this to be true in the cases of our two patients. The first patient had two previous failed attempts at closure. In the case of our second patient, after the initial debridement we decided to perform reduction mammoplasty right at the initial operation because of our previous experience with the first case. Our reduction mammoplasty was a simple amputative procedure and did not involve additional dissection in relation to the pectoralis advancement. Reduction mammoplasty is a useful adjunctive procedure in patients with macromastia complicating sternal wound dehiscence.
References 1. Stahle E, Tammelin A, Bergstrom R, et al. Sternal wound complicationseincidence, microbiology and risk factors. Eur J Cardiothorac Surg 1997;11:1146e53. 2. Loop FD, Lytle BW, Cosgrove DM, et al. Maxwell Chamberlain memorial paper. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg 1990;49:179e86. 3. Bryan AJ, Lamarra M, Angelini GD, et al. Median sternotomy wound dehiscence: a retrospective case control study of risk factors and outcome. J R Coll Surg Edinb 1992;37:305e8. 4. Parisian Mediastinitis Study Group. Risk factors for deep sternal wound infection after sternotomy: a prospective, multicenter study. J Thorac Cardiovasc Surg 1996;111:1200e7. 5. Molina JE, Lew RS, Hyland KJ. Postoperative sternal dehiscence in obese patients: incidence and prevention. Ann Thorac Surg 2004;78:912e7. 6. Jurkiewicz MJ, Bostwick J, Hester TR, et al. Infected median sternotomy wound. Successful treatment by muscle flaps. Ann Surg 1980;191:738e44.
7. Ringelman PR, Vander Kolk CA, Cameron D, et al. Long-term results of flap reconstruction in median sternotomy wound infections. Plast Reconstr Surg 1994;93:1208e14. 8. Fansa H, Handstein S, Schneider W. Treatment of infected median sternotomy wounds with a myocutaneous latissimus dorsi muscle flap. Scand Cardiovasc J 1998;32:33e9. 9. Tizian C, Borst HG, Berger A. Treatment of total sternal necrosis using the latissimus dorsi muscle flap. Plast Reconstr Surg 1985;76:703e7. 10. Lee Jr AB, Schimert G, Shatkin S, et al. Total excision of the sternum and thoracic pedicle transposition of the greater omentum: useful stratagems in managing severe mediastinal infection following open-heart surgery. Surgery 1976;80: 433e6. 11. Jones G, Jurkiewicz MJ, Bostwick III J, et al. Management of the infected median sternotomy wound with muscle flaps. The Emory 20-year experience. Ann Surg 1997;225:766e76. 12. Copeland M, Senkowski C, Ergin A, et al. Macromastia as a factor in sternal wound dehiscence following cardiac surgery: management combining chest wall reconstruction and reduction mammaplasty. J Card Surg 1992;7:275e8. 13. Fontaine S, Devos S, Goldschmidt D. Reduction mammoplasty combined with pectoralis major muscle flaps for median sternotomy wound closure. Br J Plas Surg 1996;49:220e2. 14. Shumaker HB, Mandelbaum I. Continuous antibiotic irrigation in the treatment of infection. Arch Surg 1963;86:384e7. 15. Thurer RJ, Bognolo D, Vargas A, et al. The management of mediastinal infection following cardiac surgery: an experience utilizing continuous irrigation with povidone- iodine. J Cardiovasc Surg 1974;68:962e8. 16. Rand RP, Cochran RP, Aziz S, et al. Prospective trial of catheter irrigation and muscle flaps for sternal wound infection. Ann Thorac Surg 1998;65:1046e9. 17. Dasika UK, Trumble DR, Magovern JA. Lower sternal reinforcement improves the stability of sternal closure. Ann Thorac Surg 2003;75:1618e21.
CASE REPORT
Sternal wound dehiscence complicated by macromastia: report of two cases with discussion of literature A. Roshan*, A. Kotwal, M. Riaz, P.R.W. Stanley Department of Plastic Surgery, Castle Hill Hospital, Cottingham, Hull, UK Received 6 August 2007; accepted 2 February 2008
KEYWORDS Macromastia; Sternal dehiscence; Pectoralis major flap
Summary Sternal wound dehiscence complicated by macromastia can be difficult to treat by standard musculocutaneous flaps alone. We present our experience with two cases of sternal wound dehiscence complicated by macromastia, and their subsequent healing with a combination of reduction mammoplasty and local musculocutaneous flaps. Reduction mammoplasty is a useful adjunctive procedure in patients with macromastia complicating sternal wound dehiscence. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Sternal wound dehiscence is a recognised complication following median sternotomy for cardiac surgery, with a reported incidence of 1.1e2.3%.1e4 In the obese [with body mass index (BMI) > 30], the incidence of sternal dehiscence can reach 6.5%.5 This complication is associated with high morbidity and can sometime have fatal consequences with the resultant mediastinitis.1e5 Described treatment involves radical debridement and soft tissue cover, usually with flaps including pectoralis major, rectus abdominis, omentum or latissimus dorsi.6e11 The management can
* Corresponding author. Address: MRCS, Department of Plastic Surgery, Castle Hill Hospital, Cottingham, HU16 5JQ, UK. Tel. þ44 7787771362. E-mail address: [email protected] (A. Roshan).
sometimes be complicated in women by the presence of hugely enlarged breasts which produce laterally directed force on the wound edges.12,13 This can lead to recurrent breakdown of the wound in spite of tension-free closures. We present two cases of sternal wound dehiscence associated with macromastia and their management.
Case report 1 A 76-year-old woman underwent aortic valve replacement and coronary artery bypass (CABG) using the internal mammary artery. She weighed 118.6 kg and had a height of 1.63 m with a BMI of 44. She was a chronic smoker. Comorbidity included hypertension and diabetes mellitus. She developed a wound infection with bacteroides,
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.02.019
Sternal wound dehiscence complicated by macromastia peptostreptococcus and pseudomonas. This resulted in the sternum being exposed with the sternal wires visible at the base of the wound. Six weeks after the original operation she underwent radical debridement of the wound, removal of the sternal wires and resurfacing of the wound with a pedicled transverse rectus abdominis (TRAM) flap. The TRAM flap was used because the width of the defect was too large for a vertical rectus abdominis (VRAM) flap. The wound dehisced at the edges because of the massive lateral tension from the enlarged breasts. This subsequently became contaminated with methicillin-resistant Staphylococcus aureus (MRSA). Further attempts at debridement and closure were unsuccessful. After eradicating MRSA, she had further debridement and advancement of bilateral pectoralis major muscular flaps. At the same time a bilateral breast reduction was performed using a Wise pattern excision and free nipple grafts. 1156 g of tissue was removed from the right breast and 925 g from the left. She had an uneventful recovery apart from a small wound breakdown in the upper part of the wound that healed secondarily in a month (Figure 1).
Case report 2 A 73-year-old woman underwent aortic valve replacement and CABG using the left internal mammary artery. She weighed 92 kg, had a height of 1.62 m and a BMI of 35. She was an ex-smoker. Co-morbidity included hypertension and gigantomastia. She developed a wound infection that was treated with debridement, antibiotics and vacuum therapy. Microbiological examination of the wound revealed mixed skin and faecal flora. In view of our previous experience with sternal dehiscence we decided to perform breast reduction at the time of the definitive surgery. The patient was appropriately counselled. She underwent radical debridement of the wound, removal of the sternal wires, bilateral pectoralis major advancement flaps and Wise pattern bilateral breast reduction with free nipple grafts. 1900 g of tissue was removed from the right breast and 1450 g from the left. The patient made an uneventful recovery and the wound healed in 2 weeks (Figure 2).
e363
Discussion Wound dehiscence after median sternotomy for coronary artery bypass surgery occurs in approximately 1e2% of cases. Though the incidence is low, because of the large number of patients undergoing this procedure, this complication is not uncommon. The methods for management of sternal wound dehiscence have changed over time and become increasingly successful. Earlier described treatment methods without muscle flaps included continous antibiotic irrigation, povidone-iodine irrigation and pedicled omental flaps.10,14,15 From the late 1970s, various muscle-based reconstructive options have been described including the VRAM flap, pectoralis muscle flaps and pedicled latissimus dorsi flaps.6,9 Muscle flap-based reconstructions have superior outcomes to wound catheter antibiotic irrigation and sternal re-wiring, especially in the setting of infection, as confirmed by Rand et al. in a prospective trial.16 Female sex has been found to be an independent risk factor for sternal complications following CABG (variable odds ratio 0.4, 95% confidence ratio 0.2e0.6).1 However, we do not know the correlation between breast size as a factor in the causation of the complication. The lower sternal wound has been shown to be the most unstable part of the median sternotomy from ultrasound and mechanical studies.17 The anatomic reasons for this include greater excursion of the lower thorax and abdomen during normal respiration, concentration of forces here with the attachment of ribs 7 to 10, the greater transverse and anterior-posterior dimensions of the lower versus upper thorax and the reduced thickness of the lower sternum in comparison with the manubrium. Macromastia produces further infero-lateral tension on a vertical sternotomy incision and this can lead to sternal wound dehiscence. Conservative management of the macromastia by binding the breasts in supportive bras may take a portion of the tension off the wound, but not be adequate to allow healing. Copeland12 and Fontaine13 have proposed pectoralis muscle flaps along with breast reduction mammoplasty for treating infected sternal wound dehiscence in patients with macromastia. This avoids the lateral tension on the sternal wound during closure and prevents further
Figure 1 A. Pre-operative marking in a 76-year-old with BMI of 44, for bilateral reduction mammoplasty with continuous suction device in situ. B Post operative result at 8 months following bilateral pectoralis major advancement flaps showing good healing.
e364
A. Roshan et al.
Figure 2 A Pre-operative sternal wound following CABG and aortic valve replacement in a 73-year-old with BMI of 35. B Three weeks post operative photograph following bilateral breast reduction and pectoralis major advancement flaps.
breakdown. We found this to be true in the cases of our two patients. The first patient had two previous failed attempts at closure. In the case of our second patient, after the initial debridement we decided to perform reduction mammoplasty right at the initial operation because of our previous experience with the first case. Our reduction mammoplasty was a simple amputative procedure and did not involve additional dissection in relation to the pectoralis advancement. Reduction mammoplasty is a useful adjunctive procedure in patients with macromastia complicating sternal wound dehiscence.
References 1. Stahle E, Tammelin A, Bergstrom R, et al. Sternal wound complicationseincidence, microbiology and risk factors. Eur J Cardiothorac Surg 1997;11:1146e53. 2. Loop FD, Lytle BW, Cosgrove DM, et al. Maxwell Chamberlain memorial paper. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care. Ann Thorac Surg 1990;49:179e86. 3. Bryan AJ, Lamarra M, Angelini GD, et al. Median sternotomy wound dehiscence: a retrospective case control study of risk factors and outcome. J R Coll Surg Edinb 1992;37:305e8. 4. Parisian Mediastinitis Study Group. Risk factors for deep sternal wound infection after sternotomy: a prospective, multicenter study. J Thorac Cardiovasc Surg 1996;111:1200e7. 5. Molina JE, Lew RS, Hyland KJ. Postoperative sternal dehiscence in obese patients: incidence and prevention. Ann Thorac Surg 2004;78:912e7. 6. Jurkiewicz MJ, Bostwick J, Hester TR, et al. Infected median sternotomy wound. Successful treatment by muscle flaps. Ann Surg 1980;191:738e44.
7. Ringelman PR, Vander Kolk CA, Cameron D, et al. Long-term results of flap reconstruction in median sternotomy wound infections. Plast Reconstr Surg 1994;93:1208e14. 8. Fansa H, Handstein S, Schneider W. Treatment of infected median sternotomy wounds with a myocutaneous latissimus dorsi muscle flap. Scand Cardiovasc J 1998;32:33e9. 9. Tizian C, Borst HG, Berger A. Treatment of total sternal necrosis using the latissimus dorsi muscle flap. Plast Reconstr Surg 1985;76:703e7. 10. Lee Jr AB, Schimert G, Shatkin S, et al. Total excision of the sternum and thoracic pedicle transposition of the greater omentum: useful stratagems in managing severe mediastinal infection following open-heart surgery. Surgery 1976;80: 433e6. 11. Jones G, Jurkiewicz MJ, Bostwick III J, et al. Management of the infected median sternotomy wound with muscle flaps. The Emory 20-year experience. Ann Surg 1997;225:766e76. 12. Copeland M, Senkowski C, Ergin A, et al. Macromastia as a factor in sternal wound dehiscence following cardiac surgery: management combining chest wall reconstruction and reduction mammaplasty. J Card Surg 1992;7:275e8. 13. Fontaine S, Devos S, Goldschmidt D. Reduction mammoplasty combined with pectoralis major muscle flaps for median sternotomy wound closure. Br J Plas Surg 1996;49:220e2. 14. Shumaker HB, Mandelbaum I. Continuous antibiotic irrigation in the treatment of infection. Arch Surg 1963;86:384e7. 15. Thurer RJ, Bognolo D, Vargas A, et al. The management of mediastinal infection following cardiac surgery: an experience utilizing continuous irrigation with povidone- iodine. J Cardiovasc Surg 1974;68:962e8. 16. Rand RP, Cochran RP, Aziz S, et al. Prospective trial of catheter irrigation and muscle flaps for sternal wound infection. Ann Thorac Surg 1998;65:1046e9. 17. Dasika UK, Trumble DR, Magovern JA. Lower sternal reinforcement improves the stability of sternal closure. Ann Thorac Surg 2003;75:1618e21.