Free Latissimus Dorsi Flap for Chest Wall Repair After Complete Resection of Infected Sternum

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1 Free Latissimus Dorsi Flap for Chest Wall Repair After Complete Resection of Infected Sternum Andrej anic, MD, PhD, Hans-eat Ris, MD, Dominique Erni, MD, and Heinz Striffeler, MD Departments of Plastic Surgery and Thoracic and Cardiovascular Surgery, University of erne, Inselspital, erne, Switzerland ackground. Radical debridement, followed by muscle flap cover, has significantly reduced morbidity and mortality of infected sternotomy wounds. The pectoralis major, rectus abdominis, and greater omentum flaps are most commonly used, whereas the latissimus dorsi muscle is rarely employed. Methods. In 7 patients with persistent infection and necrosis of the sternum, radical and extensive debridement including the sternum, costochondral arches, manubrium and sternoclavicular joints was performed. A free latissimus dorsi flap was used for soft tissue reconstruction without additional stabilization of the chest wall. Results. All flaps survived without revision of the anastomosis. In the follow-up period (22 months to 5 years) no recurrent infection was observed. Three patients died during the study period (3 to 24 months after operation) due to causes not related to sternum operation. No additional weakness, pain, or restricted movements of the shoulders due to missing sternum was observed. Conclusions. Our findings suggest that the use of free latissimus dorsi flap after complete sternectomy for infection has several advantages: it provides abundant tissue to allow radical and extensive debridement, obliterates completely the dead space, and helps to control infection. Even without additional chest wall reconstruction it gives enough stability to allow pain-free normal daily activities. (Ann Thorac Surg 1995;60: ) M ediastinitis after median sternotomy in cardiac surgery represents an infrequent but serious problem with a reported incidence ranging from 0.4% to 5.1% [1-3]. Many of the problems associated with the operation including long hospitalization and high mortality (resulting from open treatment with debridement and secondary healing) were dramatically reduced when Shumaker and Mandelbaum [4] introduced in 1963 closed-catheter irrigation of the mediastinum, followed by debridement and reclosure of the sternum. Wide debridement of bone and cartilage followed by flap cover, as described by Lee and co-workers I51 in 1976, represented a significant improvement in the technique. They transposed the greater omentum to obliterate the dead space. Subsequently Jurkiewicz and associates [6] first used a muscle flap for this purpose. y the use of this concept in the primary treatment, Jurkiewicz and associates reduced mortality from 18% to zero and significantly diminished morbidity and hospitalization time. The pectoralis major muscle is most commonly used for reconstruction after sternum resection, followed by' the rectus abdominis and greater omentum flaps. The pectoralis muscle, based on the dominant blood supply from the thoracoacromial vessels, extends over the upper two thirds of the sternum. If a wider resection is needed, both pectoralis major muscles have to be used. In case of an extensive sternectomy, however, the pectoralis mus- Accepted for publication April 13, 1995 Address reprint requests Io Dr anjo, Department oi Plastic and Reconstructive Surgery, Inselspital, 3010 erne, Switzerland. cles must be combined with the rectus abdominis or the greater omentum flaps [7-9]. The latissimus dorsi flap is rarely employed after sternectomy [101 and is often reserved as a back-up flap when other flaps cannot be used [11]. When taken as a pedicled flap, the bulky proximal part of the muscle remains under the pectoralis muscle, and only the thin, partly aponeurotic muscle reaches into the defect. Moreover, similar to the pectoralis muscle, it adequately covers the upper and central parts of the resected sternum but is of insufficient size to cover the distal part (Fig 1A) [121. When the latissimus dorsi is transferred as a free flap, however, the whole muscle is used to fill the dead space and no additional muscle or omentum is needed (Fig 1). In addition, the latissimus dorsi can be taken as a myocutaneous flap to ensure tension-free skin closure. in the current study we report on extensive sternectomy followed by free latissimus dorsi flap reconstruction in the same operation, performed in 7 patients. Early postoperative complications and late results (mean follow-up, 3 years 2 months) were evaluated. Patients and Methods [n our institution, about 500 median sternotomy incisions are performed annually for cardiac operations with a 1.1% incidence of sternal wound infections [13]. All patients with signs of infection in the sternal region after heart operation receive the following local treatment: initial debridement of the sternum and soft tissues, followed by restabilization of the bone and irrigation of 1995 by The Society of I horacic Surgc~,ns SSDI (95)00428-N

2 Ann Thorac Surg ANIC ET AL ;60: FREE FLAP FOR CHEST WALL REPAIR Fig l. A) Cadavcric dissection of the latissimus dorsi flap pedich'd in the ri~,,ht axilla. The proximal bulk of the musch' remains under the pectoralis real'or muscle, a,hcrcas, the thin, partly aponeurotic part reaches into the d~fi'ct, It ~overs well the upper amt central parts of the sternum but is insufficient in the distal part. () The muscle is positioned as in the frcc flap transfer. In such a case the whole musch' can be used to fill thc dead space and no additional ttllir h' or Otllctltum is tier'dolt o-ocr tiw distal part Of the stcrttltm. the substernal space with diluted povidone-iodine for 3 to 5 days. If infection persists, radical debridement and muscle flap cover are performed in the same operation. Seven consecutive patients with an average age of 65 years (range, 60 to 74 years) who had extensive osteomyelitis of the sternum, were operated on according to this principle over a period of 3 years. In these patients, a radical and extensive debridement that included sternum, costochondral arches, manubrium and sternoclavicular joints was performed. The overlying affected skin was generously resected. Recipient vessels for the anastomosis with the latissimus dorsi muscle were selected and prepared before the flap was taken. A free latissimus dorsi myocutaneous flap was performed in all patients. It was raised using conventional techniques [12]. The patient remained in the supine position (as was also the case for the debridement) with one shoulder and one hip elevated. The skin island was designed in the center of the muscle and parallel to its long axis. The superior thyroid artery and vein (4), internal mammary artery and external jugular vein (2) (Fig 2), and common carotid artery and external jugular vein (1) served as recipient vessels. All anastomoses were performed end-to-end except for the one to the common carotid artery, which was done end-to-side. The time needed to raise the flap was approximately 60 minutes, and an additional 30 minutes was required to complete the two microvascular anastomoses. lood loss during flap elevation and the microsurgical procedure was estimated to be about 500 ml. After the completion of the anastomoses the muscle was sutured to the ribs with its proximal part placed cranially. No synthetic material was used to replace the resected bone and cartilage. The skin island was of the same size as the excised skin over the sternum and was sutured into the defect without tension. The mediastihum and the space between the latissimus dorsi muscle and the skin were drained by the use of suction drains. After operation all patients were immediately extubated and were allowed to recover in the intensive care unit. The patients were mobilized on the first postoperative day and chest and lung physiotherapy was initiated. Antibiotic treatment was continued for two months. Anticoagulation therapy was administered for 3 months postoperatively. The mean follow-up time was 3 years 2 months (range, 22 to 60 months). Evaluation during this period included assessment of problems due to instability of the chest wall such as paradoxical chest movements, dyspnea and lung infections, mobility and strength of upper arm and shoulder region, pain or discomfort, and disability in daily activities and work. Three patients died between 3 months and 2 years after operation due to causes not related to sternum operation (two deaths were related to myocardial ischemia and one to malignant disease). Results All flaps survived without complication, and no revision of the microvascular anastomoses was needed. There was Fig 2. lntraoperative picture showing the defect after extensive debrmement q[ the sternum and the latissimus dorsi muscle after the completion of microvascular anastomoses to the internal mammary artery and external jugular vein (arrow').

3 1030 ANIC El- AL Ann Thorac Surg FREE FLAP FOR CI lest WAI,I Rt PAIII 1995;60: A Fig 3. Computed tom,graphic scans showin.~ the latissi,lus dorsi myocutmleous flap in the upper part q( the reconstruction in inspiration (A) and in expiration (). no sign of recurrent sternal intection in any of the patients. Two patients had bronchitis approximately 1 year after reconstruction. In all 7 patients breathing and coughing produced a variable degree of paradoxical chest movement, mainly in the cranial half of the flap (Figs 3, 4). They all needed some external pressure on the flap to help expectoration, but only in the early postoperative phase. Only in the early postoperative phase did any patient complain of pain that could be related to chest wall reconstruction. Two patients, however, felt tightness and pressure in the reconstructed region for 8 to 12 months and 2 more at the final evaluation, but none was able to localize the discomfort precisely. Passive and active shoulder mobility and muscle strength was unchanged when compared with preoperative findings in all but 1 patient, who had a 20-degree restriction in abduction of both shoulders due to pain in the shoulder region. This patient complained of a moderate worsening, whereas the other 6 observed no deterioration in daily activities as compared with their preoperative condition. Comment Morbidity, mortality, and hospital stay have been significantly reduced since the introduction of radical debridement and the use of muscle flaps in severe infections of the sternum after open heart operations [6, 7]. The pectoralis major muscle is most widely used because it lies in the operating field and is easy to dissect. It can be either based on the perforators from the internal mammary artery as a turn-over flap or based on the thoracoacromial vessels and transposed as a rotation-advance- Fig 4. Picture c!f the patient standi~lg Lind in ti~r~ cd inspiration (A) and expiratioh (). The flap i> me:: ing with breathing mainly in the upper part ~!( the reconstruction, whih' the lower part, covering the heart, remains ahnost uncllanycd. A

4 Ann Thorac Surg ANIC ET AL ;60: FREE FLAP FOR CHEST De'ALL REPAIR ment flap. After extensive debridement, as performed in our patients, even two pectoralis flaps cannot adequately fill the cavity. The rectus abdominis or greater omentum has to be added to close the lower third of the defect [7-9]. However, abdominal wall-related complications can be significant when flaps from the abdomen are used [141. In our experience the free latissimus dorsi flap offers several advantages over other conventional flaps for the reconstruction of extensive defects after complete sternectomy. It is the largest expendable and easily accessible muscle [121, which can alone fill the defect adequately without the requirement of additional muscle or omentum. Furthermore, it can be taken as a myocutaneous flap with a skin island of the same size as the resected skin. This eliminates the tension on the skin suture and the need for additional release incisions or skin grafts. The abundant tissue available gives the surgeon freedom to radically and extensively debride the necrotic tissues and prevent recurrent infections. Except for the donor scar in the back, there is no further disfigurement of the chest or abdomen. The importance of muscle tissue in combating bone infection has been discussed previously [15-17]. The introduction of muscle flaps for the treatment of sternal infection has significantly reduced both morbidity and mortality in these patients [3, 6, 18]. In our patients with severe osteomyelitis, no recurrent infection was observed after the use of the latissimus dorsi muscle. In spite of meticulous and aggressive debridement, remnants of devitalized tissues remain in a contaminated field. We believe that it is very, important that the soft and bulky muscle completely fills the cavity and obliterates the dead space. Well-vascularized muscle comes into close contact with debrided structures, brings vascularitv to the tissues, and prevents bacterial growth. Free flaps have previously been used for chest reconstruction [19, 20] and for intrathoracic repair [21]. Here we used them for anterior chest wall reconstruction after sternectomy for infection. Although microsurgical procedures were involved, the duration of operation and blood loss did not significantly differ from our reconstructions with three conventional flaps. In the current study all operations were performed by thoracic and plastic surgeons together. Time was saved because patients remained in the supine position, with one shoulder and one hip elevated, during the whole operation. A number of recipient vessels for the flap exist given the length (9 to 10 cm) of the vascular pedicle of the latissimus dorsi muscle. The internal mammary vessels are usually chosen because they are already exposed bv the extensive sternectomy. If they have already been used for cardiac operations, the superior thyroid vessels can easily be accessed. If neither are available, as was the case in 1 of our patients who previously underwent a thyroidectomy, an end-to-side anastomosis to the external carotid artery is performed. The performance of these anastomoses is easy, because the vessels are of large caliber (2 to 3 ram) and are easily accessible. However, when anastomoses are performed on short stumps of the internal mammary vessels, some difficulties can be encountered due to heart movements. Extensive sternal necrosis in our patients required extensive debridement, and no direct bone closure was possible. However, except for some paradoxical movements of the reconstruction during breathing and coughing, the flap provided sufficient, pain-free stability of the chest to allow normal daily activities. Kohman and coworkers [221 studied the functional results of muscle flap reconstruction after sternal debridement on lung function. They demonstrated that the pulmonary function did not differ from the control group of cardiac surgical patients despite missing bone stability. The use of foreign materials for stabilization of the sternum after osteomyelitis has often been discussed. Larson and McMurtrey [23] state that the use of synthetic materials in open and infected wounds adds significantly to the risk of infection and is unnecessary, because full-thickness chest wall defect reconstruction can be accomplished by the use of flap only. According to Pairolero and Arnold [24], the posterior chest wall and sternal defects require less stabilization than do anterior and lateral ones, and they believe that myocutaneous flaps without skeletal stabilization give sufficient stability even in large defects. Results of the current study suggest that there is no need for chest wall stabilization even in complete resections of the sternum, and we believe that the use of synthetic materials in infected wounds should be avoided. In conclusion, free latissimus dorsi flap alone provides sufficient material for reconstruction of defects after complete and extensive sternectomy for infection. The flap provides abundant tissue and allows the surgeon to perform a radical and extensive debridement. The muscle fills the defect well, obliterates completely the dead space, and helps to control infection. The flap gives enough stability to the chest even without reconstruction of the bone to allow pain-free normal daily activities. No weakness, pain, or restricted movements of the shoulder due to missing sternum were observed. References 1. Sarr MG, Gott VL, Townsend TR. Mediastinal infections after cardiac surgery. Ann Thorac Surg 1984;38: Prevosti LG, Subramainian VA, Rothaus KO, Dineen P. A comparison of the open and closed methods in the initial treatment of sternal wound infection. J Cardiovasc Surg 1989;30: Hugo NE, Sultan MR, Ascherman JA, Patsis MC, Smith CR, Rose EA. Single-stage management of 74 consecutive sternal wound complications with pectoralis major myocutaneous advancement flap. Plast Reconstr Surg 1994;93: Shumaker HJ, Mandelbaurn 1. Continuous antibiotic irrigation in the treatment of infection. Arch Surg 1963;86: Lee A, Schimert G, Shatkin S. Total excision of the sternum and thoracic pedicle transposition of the greater omentum. Surgery 1976;80: Jurkiewicz MJ, ostwick J II1, Hester R, ishop J, Craver J.

5 1032 ANIC ET AL Ann Thorac Surg FREE FLAP FOR CIIESI WALl. RtPAIR 1995;60: Infected median sternotomy wounds: successful treatment by muscle flaps. Ann Surg 1980;191: Herrera HR, Ginsburg ME. The pectoralis major myocutaneous flap and omental transposition for closure of infected median sternotomy wounds. Plast Reconstr Surg 1982;70: , 8. Pairolero PC, Arnold PG. Management of recalcitrant median sternotomy wounds. J Thorac Cardiovasc Surg 1984;88: Nahai F, Rand RP, Hester TR, ostwick J 111, Jurkiewicz MJ. Prima D' treatment of the infected sternotomv wound with muscle flaps: a review of 211 consecutive cases. Plast Reconstr Surg 1989;84: Tizian C, orst HG, erger A. Treatment of total sternal necrosis using the latissimus dorsi muscle flap. Plast Reconstr Surg 1985;76: Miller Jl, Nahai F. Repair of the dehisced median sternotomv incision. Surg Clin North Am 1989;69: Moelleken RW, Mathes SA, Chang N. Latissimus dorsi muscle-musculocutaneous flap in chest-wall reconstruction. Surg Clin North Am 1989;69: Gersbach P, Santiago JM, anic A, Althaus U. Sternuminfekt: Sptildrainage oder Muskellappenplastik. Schweiz Med Wochenschr 1994;124(Suppl 58): Ringelman PR, Vander Kolk CA, Cameron D, aumgartner WA, Manson PN. Long-term results of flap reconstruction in median sternotomy wound infection. Plast Reconstr Surg 1994;93: anic A, Wulff K. Latissimus dorsi free flaps fur total repair of extensive lower leg injuries in children. Mast Reconstr Surg 1987;79: Richards RR, McKee MD, Paitich, ertoia T. A comparison of the el~ects of skin coverage and muscle flap coverage on the early strength of union at the site of osteotomy after devascularization of a segment of canine tibia. J one Joint Surg Am 1991;73: Mathes SJ, Alpert S, Chang N. Use of the muscle flap in chronic ostenmyelitis: experimental and clinical correlation. Plast Reconstr Surg 1982;69: Jeevanandam V, Smith CR, Rose EA, Maim JR, Hugo NE. Single-stage management of sternal wound infections. J Thorae Cardiovasc Surg 1990;99: Hidalgo DA, Saldana EF, Rusch VW. Free flap chest wall reconstruction for recurrent breast cancer and radiation ulcers. Ann Plast Surg 1993;30: Hirase Y, Kojima T, Kinoshita Y, ang HH, Sakaguchi T, Kijima M. Composite reconstruction for chest wall and scalp using multiple ribs-latissimus dorsi osteomyocutaneous flaps as pedicled and free flaps. Plast Reconstr Surg 1991;87: Hammond DC, Fisher J, Meland N. Intrathoracic free flaps. Plast Reconstr Surg 1993;91: Kohman LJ, Auchincloss JH, Gilbert R, eshara M. Functional results of muscle flap closure for sternal infection. Ann Thorac Surg 1991;52: Larsnn DL, McMurtrey MJ. Musculocutaneous flap reconstruction of chest-wall defects: an experience with 50 patients. Plast Reconstr Surg 1984;73: Pairolero PC, Arnold PG. Chest wall tumors. Experience with 100 consecutive patients. J Thorac Cardiovasc Surg 1985;90: INVITED COMMENTARY This article by anic and colleagues reports the use of a free musculocutaneous flap of the latissimus dorsi in 7 consecutive patients treated for median sternotomy wound infection. Free compound flaps revascularized bv microsurgical techniques are now commonplace. To my knowledge and the collective knowledge of my colleagues at Emory, however, this is the first report of such use of a free flap in patients with median sternotomv wound infection. One cannot gainsay the end result in the patients so treated by anic and colleagues. One is obliged, however, to question the indications for its use rather than conventional techniques using pectoralis major muscle. anic and colleagues not only resected skin but removed a considerable amount of it and performed debridement that included a total sternotomy, costochondral arches and sternoclavicular joints. Resection of skin is uncommon in our practice except in chronic cases with numerous and confluent sinus tracts. Adequate debridement is the hallmark of a successful outcome. Rarely have we had to resect to the degree of debridement employed by anic and colleagues. The use of the internal mammary artery to revascularize the heart clearly renders the sternum relatively ischemic. Debridement has to be more extensive on the left half if infected. In most cases, even in large defects, a left pectoralis major turnover or advancement on its major pedicle will provide the requisite muscle to obliterate dead space, Rarely is it necessary to resort to omentum or to rectus abdomen. Microsurgery, however ubiquitous, is still not for everyone, nor is it always the first and best option as implied in this article. Conventional regional muscle flaps have served our patients well when used for the treatment of median sternotomy wound infections. Mauricc ]. ]urkiewicz, MD Emo~, University 1327 Cl!fiton Rd NE Athmta, GA 30322