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The use of novel inferomedial fasciocutaneous breast flaps to reconstruct a sternal dehiscence with concomitant soft tissue loss
1762
The use of novel inferomedial fasciocutaneous breast flaps to reconstruct a sternal dehiscence with concomitant soft tissue loss* Dear Sir, Sternal dehiscence occurs in 0.3e5% of median sternotomy wounds.1 Dehiscence is associated with prolonged hospitalization and significant mortality.2 Risk factors predisposing patients to sternal dehiscence include those prone to infection (diabetes, immunosuppression), poor healing (smokers, vascular disease, malnutrition) and macromastia, due to distracting forces on the wound.3 The management of median sternotomy dehiscence includes targeting infection with antimicrobial medications and considering surgical debridement and V.A.C. therapy (trademarked by KCI, Inc) as an interim or adjuvant measure. Subsequent autologous vascularised flap reconstruction as standard treatment has lowered the mortality rate from post-sternotomy infection from 37.5% to 5%, and reduced the length of hospital stay compared with conservative management.2 We present the successful employment of an innovative partially de-epithelialised fasciocutaneous flap from each breast to reconstruct a lower sternal dehiscence with a soft tissue deficit. A concurrent bilateral breast reduction reduced the distracting force on the wound, and improved the patient’s quality of life. A 64 year-old lady was referred with a sternal dehiscence and 15 13 cm soft tissue deficit. Twenty-one days previously she had undergone a redo coronary artery bypass graft (CABG) using her right long saphenous vein, since both internal mammary arteries had been harvested in her first CABG, years earlier. She had sternal dehiscence five days post operatively, leading to 13 days’ empirical antibiotics and VAC therapy. Followed by unsuccessful surgical wire removal, and debridement, the sternal and soft tissue defect persisted. Her BMI was 34.2 (148 cm; 75 kg), and her medical history included hypertension, hypercholesterolaemia and type 2 diabetes mellitus. Her bra size was 44JJ (see Figure 1) and she had chronic lymphoedema to the left breast due to tissue dependency. She had no history of breast cancer, was a non-smoker and took multiple medications. Formal debridement and closure of the deficit with a bilateral breast reduction (BBR) was undertaken. The
Correspondence and communications
sternal area was debrided to healthy bone and soft tissue, and the infected wires removed. The nipple areolar complexes were removed as free nipple grafts. Bilateral fasciocutaneous flaps were raised from the inferomedial breasts, superficial to the mastectomy plane, to cover the median soft tissue defect. Two breast reduction pedicles were isolated and raised, superomedial and inferolateral in case one failed due to compromised blood supply. The redundant breast tissue was removed. The superomedial pedicle was proven viable for the breast reconstruction and the inferolateral pedicle removed. The inferomedial fasciocutaneous flaps were partially de-epithelialised and passed under a medial breast tissue bridge to fill the sternal and skin defect (see Figure 2). The superior aspect of the sternal defect was closed primarily. Over 5 kg of breast tissue was removed (2278 g right, 3021 g left). The nipples were secured onto a de-epithelialised bed. Three drains were inserted and antibiotics given for 48 hours. Her post-operative recovery was uneventful. The drains were removed at days one, three and eight. She was discharged eight days post-operatively, after a 60-day inpatient stay prior to BBR. Two weeks of antibiotics were required for mild left breast cellulitis (associated with the previous chronic lymphoedema). Her wounds healed well, with no dehiscence (see Figure 3).
*
This case has been presented at the Royal Society of Medicine Plastic Surgery Section lecture evening entitled: Chest Deformity & Reconstruction, 16th April 2013.
Figure 1 The patient at presentation, gigantomastia with a breast size of 44JJ, sternal soft tissue loss and dehiscence.
Correspondence and communications Sternal defects represent a common and serious complication of midline sternotomy incisions. This patient was pre-disposed to infection with her diabetes, poor wound healing due to vascular disease and suffered gigantomastia distracting her wound. Vascularised flap cover incorporating a BBR offered the most definitive option but was challenging since few of the usual options were possible: without IMAs, a rectus abdominis flap was risky; using pectoralis major would compromise the perforator supply to the medial breast tissue and skin for a BBR; an omental flap carried the morbidity of a laparotomy, and risked spreading mediastinal infection to the abdominal cavity. A BBR with a superomedial pedicle and bilateral inferomedial fasciocutaneous advancement flaps, designed from redundant tissue, was therefore designed. The breast reduction was initially based upon two pedicles in case one failed secondary to the poor IMA supply and concurrent inflammation of the medial chest. Ultimately the inferolateral pedicle was disposed of as part of the mastectomy. The local fasciocutaneous flaps to cover the sternal deficit were raised superficial to the mastectomy plane, ensuring that no breast tissue was hidden from surveillance, and that it was suitably thin for the sternal defect. Vascularised flap cover of defects post median sternotomy reduces hospital stay as compared with conservative management of sternal defects, as shown here.2 There are patients in whom formal flap cover may be precluded, especially the debilitated cardiac patient.4 In patients with exceptionally large breasts and a sternal dehiscence with a soft tissue deficit, a BBR with a local tunnelled fasciocutaneous flap provides a good reconstructive option. It is an effective and reproducible approach to close these sternal defects, whilst treating one of the underlying causes of the dehiscence.
Conflict of interest None.
1763
Figure 3
The result 6 months post-operatively.
Funding N/A.
Ethical approval N/A.
References 1. Losanoff JE, Richman BW, Jones JW. Disruption and infection of median sternotomy: a comprehensive review. Eur J Cardiothorac Surg 2002;21(5):831e9. 2. Singh K, Anderson E, Garrett Harper J. Overview and management of sternal wound infection. Semin Plast Surg 2011;25(1): 25e33. 3. Copeland M, Senkowski C, Ergin A, Lansman S. Macromastia as a factor in sternal wound dehiscence following cardiac surgery: management combining chest wall reconstruction and reduction mammoplasty. J Card Surg 1992;7(3):275e8. 4. Morsi AW, Kimble F, Quarmby C, Tucker A. The waist coat flap: a new technique for closure of infected median sternotomy wounds. Br Assoc Plast Surg 2004;57:728e32.
Lilli Coopera Caroline Paynea Plastic Surgery Department, Royal London Hospital, London E1 1BB, UK E-mail address: [email protected] ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.07.041
Figure 2 The redundant breast tissue is removed. The superomedial pedicle is proven viable, so the inferolateral pedicle is removed. The inferomedial pedicle is deepithelialised and passed under a medial breast tissue bridge to fill the sternal defect.
a
Both authors have substantially contributed to the conception, analysis, the interpretation of data and the drafting of the manuscript submission.
The use of novel inferomedial fasciocutaneous breast flaps to reconstruct a sternal dehiscence with concomitant soft tissue loss* Dear Sir, Sternal dehiscence occurs in 0.3e5% of median sternotomy wounds.1 Dehiscence is associated with prolonged hospitalization and significant mortality.2 Risk factors predisposing patients to sternal dehiscence include those prone to infection (diabetes, immunosuppression), poor healing (smokers, vascular disease, malnutrition) and macromastia, due to distracting forces on the wound.3 The management of median sternotomy dehiscence includes targeting infection with antimicrobial medications and considering surgical debridement and V.A.C. therapy (trademarked by KCI, Inc) as an interim or adjuvant measure. Subsequent autologous vascularised flap reconstruction as standard treatment has lowered the mortality rate from post-sternotomy infection from 37.5% to 5%, and reduced the length of hospital stay compared with conservative management.2 We present the successful employment of an innovative partially de-epithelialised fasciocutaneous flap from each breast to reconstruct a lower sternal dehiscence with a soft tissue deficit. A concurrent bilateral breast reduction reduced the distracting force on the wound, and improved the patient’s quality of life. A 64 year-old lady was referred with a sternal dehiscence and 15 13 cm soft tissue deficit. Twenty-one days previously she had undergone a redo coronary artery bypass graft (CABG) using her right long saphenous vein, since both internal mammary arteries had been harvested in her first CABG, years earlier. She had sternal dehiscence five days post operatively, leading to 13 days’ empirical antibiotics and VAC therapy. Followed by unsuccessful surgical wire removal, and debridement, the sternal and soft tissue defect persisted. Her BMI was 34.2 (148 cm; 75 kg), and her medical history included hypertension, hypercholesterolaemia and type 2 diabetes mellitus. Her bra size was 44JJ (see Figure 1) and she had chronic lymphoedema to the left breast due to tissue dependency. She had no history of breast cancer, was a non-smoker and took multiple medications. Formal debridement and closure of the deficit with a bilateral breast reduction (BBR) was undertaken. The
Correspondence and communications
sternal area was debrided to healthy bone and soft tissue, and the infected wires removed. The nipple areolar complexes were removed as free nipple grafts. Bilateral fasciocutaneous flaps were raised from the inferomedial breasts, superficial to the mastectomy plane, to cover the median soft tissue defect. Two breast reduction pedicles were isolated and raised, superomedial and inferolateral in case one failed due to compromised blood supply. The redundant breast tissue was removed. The superomedial pedicle was proven viable for the breast reconstruction and the inferolateral pedicle removed. The inferomedial fasciocutaneous flaps were partially de-epithelialised and passed under a medial breast tissue bridge to fill the sternal and skin defect (see Figure 2). The superior aspect of the sternal defect was closed primarily. Over 5 kg of breast tissue was removed (2278 g right, 3021 g left). The nipples were secured onto a de-epithelialised bed. Three drains were inserted and antibiotics given for 48 hours. Her post-operative recovery was uneventful. The drains were removed at days one, three and eight. She was discharged eight days post-operatively, after a 60-day inpatient stay prior to BBR. Two weeks of antibiotics were required for mild left breast cellulitis (associated with the previous chronic lymphoedema). Her wounds healed well, with no dehiscence (see Figure 3).
*
This case has been presented at the Royal Society of Medicine Plastic Surgery Section lecture evening entitled: Chest Deformity & Reconstruction, 16th April 2013.
Figure 1 The patient at presentation, gigantomastia with a breast size of 44JJ, sternal soft tissue loss and dehiscence.
Correspondence and communications Sternal defects represent a common and serious complication of midline sternotomy incisions. This patient was pre-disposed to infection with her diabetes, poor wound healing due to vascular disease and suffered gigantomastia distracting her wound. Vascularised flap cover incorporating a BBR offered the most definitive option but was challenging since few of the usual options were possible: without IMAs, a rectus abdominis flap was risky; using pectoralis major would compromise the perforator supply to the medial breast tissue and skin for a BBR; an omental flap carried the morbidity of a laparotomy, and risked spreading mediastinal infection to the abdominal cavity. A BBR with a superomedial pedicle and bilateral inferomedial fasciocutaneous advancement flaps, designed from redundant tissue, was therefore designed. The breast reduction was initially based upon two pedicles in case one failed secondary to the poor IMA supply and concurrent inflammation of the medial chest. Ultimately the inferolateral pedicle was disposed of as part of the mastectomy. The local fasciocutaneous flaps to cover the sternal deficit were raised superficial to the mastectomy plane, ensuring that no breast tissue was hidden from surveillance, and that it was suitably thin for the sternal defect. Vascularised flap cover of defects post median sternotomy reduces hospital stay as compared with conservative management of sternal defects, as shown here.2 There are patients in whom formal flap cover may be precluded, especially the debilitated cardiac patient.4 In patients with exceptionally large breasts and a sternal dehiscence with a soft tissue deficit, a BBR with a local tunnelled fasciocutaneous flap provides a good reconstructive option. It is an effective and reproducible approach to close these sternal defects, whilst treating one of the underlying causes of the dehiscence.
Conflict of interest None.
1763
Figure 3
The result 6 months post-operatively.
Funding N/A.
Ethical approval N/A.
References 1. Losanoff JE, Richman BW, Jones JW. Disruption and infection of median sternotomy: a comprehensive review. Eur J Cardiothorac Surg 2002;21(5):831e9. 2. Singh K, Anderson E, Garrett Harper J. Overview and management of sternal wound infection. Semin Plast Surg 2011;25(1): 25e33. 3. Copeland M, Senkowski C, Ergin A, Lansman S. Macromastia as a factor in sternal wound dehiscence following cardiac surgery: management combining chest wall reconstruction and reduction mammoplasty. J Card Surg 1992;7(3):275e8. 4. Morsi AW, Kimble F, Quarmby C, Tucker A. The waist coat flap: a new technique for closure of infected median sternotomy wounds. Br Assoc Plast Surg 2004;57:728e32.
Lilli Coopera Caroline Paynea Plastic Surgery Department, Royal London Hospital, London E1 1BB, UK E-mail address: [email protected] ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.07.041
Figure 2 The redundant breast tissue is removed. The superomedial pedicle is proven viable, so the inferolateral pedicle is removed. The inferomedial pedicle is deepithelialised and passed under a medial breast tissue bridge to fill the sternal defect.
a
Both authors have substantially contributed to the conception, analysis, the interpretation of data and the drafting of the manuscript submission.