Plastics

PREOPERATIVE DIAGNOSIS:
Complex infected sternal dehiscence with missing segment inferiorly.
   PROCEDURES:
1. Bilateral pectoralis major flap and bilateral rectus abdominis flap reconstruction of deep sternal defect.
2. Complex secondary repair of sternotomy incision (28 cm length).
3. Placement of Prevena incision management system.
   DRAINS: 19-French round JP drain below the muscle flaps inferiorly where there was a sternal gap.
19-French round JP drain in the subcutaneous tissue laterally, one on each side.
    Risk:
I discussed the benefits and risks of chest wall reconstruction with the patient that include but are not limited to bleeding, infection, wound healing issues, fluid collection (seroma, hematoma, lymphocele), risk of injury to surrounding structures/organs/nerves/vessels, chronic pain, sensory deficits, motor weakness, partial or complete muscle flap loss, abnormal scarring (hypertrophic and keloid scarring), asymmetry, possible need for additional surgery, the risk of anesthesia, DVT/PE, MI, CVA and possible death.
    DESCRIPTION OF OPERATION: 
The patient was taken to the operating room, and placed supine on the operating room table. SCDs were placed onto the lower extremities for DVT prophylaxis. Antibiotics were given intravenously within 1 hour of the skin incision for antimicrobial prophylaxis. After successful smooth induction of general anesthesia, a surgical time out was performed, and the patient's identification, site, and procedure were verified. The chest and abdomen were prepped and draped in the usual sterile fashion.
  The Cardiac Surgery team proceeded with another washout and debridement of the wound along with plating of the superior aspect of the sternum. This will be dictated separately. Once plating was completed we took over for the soft tissue reconstruction. At that point the sternal wound overall looked to be quite clean, having undergone multiple debridements.  Some early granulation tissue was noted on the surfaces, and there was no clear necrotic tissue. The bony edges appeared well approximated superiorly having undergone plating. Inferiorly, the bony edges were clean but still quite separated, leaving a large central space, which was in close proximity with the underlying organs.
  Based on the unknown status of the internal mammary arteries, pectoralis major advancement flaps was felt to be required on both sides.  This was carried out initially on the left by first undermining the subcutaneous plane above the muscle all the way to the clavicle, inferior intercostal margin, and out to the lateral insertion of the pectoralis major. Then undermining was carried out beneath the muscle in the subpectoral plane.  Division of the muscle laterally was required, although it did not require a complete division of all elements, with some of the superiormost elements remaining intact. The humeral insertion was also preserved. Care was taken in the course of dissection to preserve the thoracoacromial pedicle.  Advancement was confirmed to easily be able to cover the superior and middle portions of the wound, although it was anticipated that the inferiormost portion would still be difficult to address with pectoralis major alone, given that a turnover flap design could not be carried out.  Accordingly, I felt that we should also add the rectus abdominis muscle to cover the lower portion of the defect.  In order to keep the soft tissues as solidly apposed as possible, the upper portion of the rectus abdominis muscle was elevated from its posterior sheath to facilitate centralization of the pectoral muscle without resection of the humeral insertion, keeping this in continuity with the lowest portion of the pectoralis major in a bipedicle flap design, with the rectus abdominis muscle based on the deep inferior epigastric vessels. An incision was accordingly made along the lateral aspect of the anterior rectus sheath, and dissected sufficiently far down to free up the muscle.  It was disinserted from its superiormost insertion and raised in a strip-like fashion as a bipedicle flap. Of note, the muscle on the left side was very thin and as a result was partially torn but it was more robust on the right side.  Identical procedures were performed on the right side, and both flaps were advanced medially to ensure we could fill the dead space inferiorly. The wound was irrigated again thoroughly using 50,000 units of bacitracin in 1L of normal saline and hemostasis was achieved. Inset of the 4 muscles was carried out by approximating through the center, overlapping the muscle over the bony edges in order to cover the plates and fill the underlying space. The flaps were fixated in place with interrupted 0 Vicryl sutures. Interrupted Lembert sutures were then utilizing using 0 Vicryl sutures to further approximate the muscles and imbricate them in order to obliterate the deep pectoral space inferiorly.  This was carried out over a 19-French round JP drain, which was brought out through a separate stab incision inferiorly.  Then, 19-French round JP drains were also placed into the lateral portions of the wound on each side and brought out through separate stab incisions inferiorly. All drains were secured with 3-0 silk sutures. Appropriate coverage of the plates, filling of the space and solid soft tissue repair was evident.
  Our attention was then turned to the large anterior skin and fatty tissue wound. The two sides could be advanced to contact it, despite a very large space between them, without seeming to produce excess tension. The skin edges were somewhat macerated and thus trimmed back to healthy bleeding tissue. Closure was carried out with interrupted 0 Vicryl sutures for the fascia. The skin was then approximated with interrupted 3-0 monocryl sutures for the deep dermis, followed by a running subcuticular 3-0 Stratafix monocryl suture. Drains were connected to bulb suction. A Prevena incision management system was then placed over the incision to assist with healing.

Sutures: Drain stitch 3-0 nylon x3, 0 vicryl pops (undyed) on CT1 drowned in a bowl of betadine for fascia, 3-0 monocryl deep dermal, 3-0 monocryl stratafix subcuticular.
Drains: 19-French round JP drain x3.
Irrigation: 50k baci in 1L
Dressing: Custom provena +/- ioban to pull over breasts like a bra. biopatch and tegaderm (sealed well) for drains. Abdominal binder at night to bind arms at night or when patient has waxing mental status.

Resident Notes: