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:

Tissue Expanders

1. Immediate first stage reconstruction of the bilateral breasts with tissue expanders (133S-MX-13-T) and Alloderm (8 x 16 cm).
2. Use of SPY indocyaine green fluorescence angiography.

Anesthesia:
General.

Drains:
15-French Blake drain x2 in right breast pocket.
15-French Blake drain x2 in left breast pocket.

45 y.o. female with biopsy proven left breast cancer. Given her imaging and pathology findings she was recommended to undergo bilateral mastectomy. I had a long discussion with the patient regarding the many options for breast reconstruction. The surgical options discussed included tissue expander-implant reconstruction, direct to implant reconstruction, latissimus-based reconstruction, abdominal-based free tissue transfer, and even thigh-based free tissue transfer. Given her lifestyle and body habitus, we felt that she would do very well with expander-based reconstruction followed by implants. We discussed the use of acellular dermal matrix in conjunction with a tissue expander for breast reconstruction, and she understands the higher complication rate that can be associated with it. However, I feel that it is a useful tool in our reconstruction. We discussed both prepectoral and subpectoral placement of the expanders. She understands the potential risks and complications, which Include but are not limited to infection, bleeding, fluid collections (e.g., seroma, hematoma), delayed wound healing, capsular contracture, implant rupture, implant malposition, loss of the implant due to infection or extrusion, wrinkling, rippling, asymmetry, undesired cosmetic result, scarring including hypertrophic scar or keloid, alteration of nipple areolar and/or breast sensation, chronic pain, implant breast illness, implant associated anaplastic large cell lymphoma, need for further surgery. We have talked about the need for drains along with their risks and benefits. We discussed postoperative restrictions. She also understands that adjuvant radiation, if needed, may change the overall cosmetic result and at that point may require soft tissue reconstruction with either a flap or even fat grafting. All her questions and concerns were addressed. Patient agreed to proceed with surgery and a consent form was signed. In the preoperative suite, all pre-operative markings were made with the patient in the standing position including the midline, the breast meridians, the inframammary folds, and the breast footprint on her chest wall.

Description Of The Procedure:
The patient was taken to the operating room and positioned supine on the operating table. Sequential compression devices were placed on both lower extremities for DVT prophylaxis. Antibiotics were administered intravenously within 1 hour of the skin incision for antimicrobial prophylaxis, and redosed appropriately during the case. All bony prominences were padded. After induction of general anesthesia, the chest area was prepped and draped in the usual sterile fashion.

Please refer to Dr. Tevis's operative note for full details of the bilateral mastectomy and left sentinel lymph node biopsy.

At the time that I was called into the operating room, the mastectomies and left sentinel lymph node biopsy had been completed. The chest was reprepped and redraped and a new clean set of instruments was used for our part. I proceeded with first stage tissue-expander reconstruction. I irrigated both breast pockets with triple antibiotic saline solution and hemostasis was confirmed. I then examined the mastectomy skin flaps. The SPY imaging device was brought into the field and the patient received ICG as per manufacturers guidelines in order to evaluate the viability of the breast flaps. The breast flaps perfused well based off the perforators and there was no clinical evidence of venous or arterial compromise. However, subpectoral placement of the tissue expanders was felt to be necessary due to the thickness of the flaps on both sides.

I began with the left side. I elevated the pectoralis major muscle by incising its lateral border and inferior attachments to the ribs. Its inferomedial origin was also divided. The pectoralis minor muscle was left attached to the chest wall. The perforators were controlled with cautery and small clips. Hemostasis was confirmed again after irrigating the pocket with triple antibiotic saline solution. The inframammary fold as marked in the preoperative area was transposed onto the chest wall with a marking pen. A sheet of thick Alloderm measuring 8 x 16 cm, which had been prepared as per manufacturers guidelines was then placed into the wound without touching the skin edges. I anchored the inferior edge of the Alloderm along the transposed inframammary and lateral breast border with interrupted 2-0 Vicryl sutures. Some of the sutures along the inframammary fold also helped to tack the mastectomy skin to the chest wall. The pocket was irrigated one more time with triple antibiotic saline solution, and gloves were exchanged. I selected an Allergan 133S-MX-13-T expander (with a 13 cm BD). This was soaked in triple antibiotic saline solution and I removed all the air from it. The expander was positioned into the breast pocket such that the inferior aspect of the base plate was positioned along the inframammary fold. The suture tabs were sutured to the chest wall with 3-0 Vicryl sutures. I then secured the inferior edge of the pectoralis major muscle to the superior edge of the Alloderm with interrupted 2-0 Vicryl suture. The wound was irrigated with triple antibiotic saline solution again and hemostasis was obtained with electrocautery. I placed two 15 Fr Blake drains in the subcutaneous pocket and brought them through separate stab incisions in the lateral aspect of the inframammary fold. Both drains were secured with a 3-0 nylon suture. I used the Magna-Finder to locate the port on the tissue expander and filled the expander with 100 cc of sterile saline. I reapproximated the mastectomy skin flaps using interrupted 2-0 Vicryl sutures for the fascial layer, interrupted 3-0 Monocryl sutures for the deep dermal layer, followed by a running 4-0 Monocryl suture in the subcuticular layer.

I then turned my attention to the right breast. I elevated the pectoralis major muscle by incising its lateral border and inferior attachments to the ribs. Its inferomedial origin was also divided. The pectoralis minor muscle was left attached to the chest wall. The perforators were controlled with cautery and small clips. Hemostasis was confirmed again after irrigating the pocket with triple antibiotic saline solution. The inframammary fold as marked in the preoperative area was transposed onto the chest wall with a marking pen. A sheet of thick Alloderm measuring 8 x 16 cm, which had been prepared as per manufacturers guidelines was then placed into the wound without touching the skin edges. I anchored the inferior edge of the Alloderm along the transposed inframammary and lateral breast border with interrupted 2-0 Vicryl sutures. Some of the sutures along the inframammary fold also helped to tack the mastectomy skin to the chest wall. The pocket was irrigated one more time with triple antibiotic saline solution, and gloves were exchanged. I selected an Allergan 133S-MX-13-T expander (with a 13 cm BD). This was soaked in triple antibiotic saline solution and I removed all the air from it. The expander was positioned into the breast pocket such that the inferior aspect of the base plate was positioned along the inframammary fold. The suture tabs were sutured to the chest wall with 3-0 Vicryl sutures. I then secured the inferior edge of the pectoralis major muscle to the superior edge of the Alloderm with interrupted 2-0 Vicryl suture. The wound was irrigated with triple antibiotic saline solution again and hemostasis was obtained with electrocautery. I placed two 15 Fr Blake drains in the subcutaneous pocket and brought them through separate stab incisions in the lateral aspect of the inframammary fold. Both drains were secured with a 3-0 nylon suture. I used the Magna-Finder to locate the port on the tissue expander and filled the expander with 100 cc of sterile saline. I reapproximated the mastectomy skin flaps using interrupted 2-0 Vicryl sutures for the fascial layer, interrupted 3-0 Monocryl sutures for the deep dermal layer, followed by a running 4-0 Monocryl suture in the subcuticular layer.

Biopatches and tegaderms were placed on the drains and dermabond applied to the incisions. She was placed into a surgical bra with fluffs. The patient was extubated by Anesthesia, and taken to the recovery room in stable condition.

Tourniquet: No
Drain: Yes
Sutures: Yes
Dressing: No