T. Roderick Hester

Infected median sternotomy wound. Successful treatment by muscle flaps.

The purpose of this paper is to present the experience at Emory University Hospital with the infected median sternotomy wound and to offer a treatment plan for those patients recalcitrant to the usual therapy of debridement and closed catheter irrigation with antimicrobial agents. When standard treatment fails, we proceed not only with the necessary thorough debridement to convert the wound to a relatively clean one but also concomitant closure by pectoralis major muscle flaps to completely obliterate dead space. Transposition flaps of rectus abdominus muscle or omentum are used when necessary to complete the closure. In the initial phase of this study, there were 3,239 patients who underwent open heart procedures through a median sternotomy approach in the years 1975 through 1978. In the 50 patients who had wound infections (1.54%), there were nine deaths. Three were thought to be unrelated to the sternal wound infection, four patients ruptured the ventricle or aortz, two patients died of generalized sepsis. Of these 50 patients, 22 responded to simple drainage; 28 had involvement of the mediastinum (0.86%). Of the 28 patients, 25 had debridement and closed mediastinal irrigation by catheter. Fourteen of these 25 did not respond. In these failing patients, 12 were treated by further debridement and closure by muscle flaps. Nine of these 12 were rescued. In the past nine months, an additional 1,052 patients had an open heart procedure. Of these, 11 had a median sternotomy infection. There have been no deaths in this latter group of patients, most of whom were treated by the muscle flap procedure. In addition to the improvement in mortality, morbidity has-been reduced substantially. This procedure provides for a rational approach that we have found to permit salvage of a high percentage of patients who failed conventional closed irrigation techniques.

Primary treatment of the infected sternotomy wound with muscle flaps: a review of 211 consecutive cases

Between 1978 and 1987, 15,595 median sternotomies were performed at Emory University Hospitals. Sternal wound infections developed in 246 patients (1.6 percent). Mediastinitis was present in 211 patients, while superficial infections were detected in the remaining 35 patients. Debridement and muscle or omental flap closure were performed in all instances of mediastinitis, with an overall mortality rate of 5.3 percent. The results of this treatment are reviewed, and the evolution of current therapeutic guidelines is described. When compared with closed-catheter irrigation and open granulation techniques, flap closure is shown to result in a fourfold decrease in mortality, an increased success of primary therapy, and a diminished length of hospitalization following treatment. This evidence supports the conclusion that debridement and flap closure should be considered the primary therapy for patients with poststernotomy mediastinitis.

Ten years experience with the free jejunal autograft

Retrospective analysis by chart review, personal interview, and physical examination identified 88 patients who received 96 jejunal free flaps over a 10 year period. Seventy-nine of these patients had cancer. There were 13 operative failures (13.5 percent) in 10 patients. Failures were attributed to arterial thrombosis in four instances, venous anastomotic problems in four instances, fistula and infection in the neck in one instance, carotid blowout in one instance, psychosis with avulsion in one instance, and an unknown cause in two instances. Seven second attempts at salvage of jejunal flaps were performed with five successes. There were five deaths in the perioperative period (6 percent). Of these, one was directly attributed to graft failure. The following eight abdominal complications required operation: wound dehiscence (four instances), small bowel obstruction (one instance), Mallory-Weiss tear (one instance), gastrostomy tube leak (one instance), and acute gastric dilatation (one instance). Complications in the neck included infection (six instances), infection requiring operation (three instances), hematoma (three instances), and suture line dehiscence (one instance). Fistulas developed in 28 patients (32 percent), 12 of whom required operative closure (43 percent). Significant stenosis developed in six patients, two of whom required operative revision. Of 79 patients treated for cancer, 34 died from progression of disease which recurred an average of 9.7 months postoperatively. Death ensued an average of 16.7 months postoperatively. Ten patients died with no evidence of disease. At last follow-up, 28 patients were alive without apparent disease. Twenty-six of these patients have good swallowing function. Significant palliation and a high rate of restoration of function are possible with the free jejunal autograft. Careful patient selection should markedly decrease operative morbidity and mortality.

Reconstruction of cervical esophagus, hypopharynx and oral cavity using free jejunal transfer

Experience with 22 cases of reconstruction of the cervical esophagus, hypopharynx and oral cavity using free jejunal transfer is presented. The method requires an experienced team with high technical competence, but the benefits related to rapid single-stage completion and low morbidity certainly justify its use.

The superiorly based rectus abdominis flap: predicting and enhancing its blood supply based on an anatomic and clinical study.

A detailed investigation of the blood supply of the superiorly based rectus abdominis muscle flap and the transverse rectus abdominis musculocutaneous flap was done to improve the understanding of variations in flap viability and to explain the survival of the flap after internal mammary artery division and radiation. The study involved dissections of the internal mammary and superior epigastric systems, evaluation of pertinent angiograms, and impressions from observations of the vascular anatomy correlated with flap survival in over 600 clinical dissections. There is a diffuse intrathoracic collateral network involving the internal mammary system, widi multiple branches and intercommunications on the same side, as well as across the midline. This enhances flap predictability and survival in some patients with internal mammary artery division or compromise. There is also a laterally based blood supply to the flap from the costomarginal artery at the costal margin which is sometimes well developed and may prevent flap compromise if preserved.

Lateral canthal anchoring.

LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Understand the principles involved in canthal support for patients undergoing cosmetic and reconstructive surgery. 2. Understand the variations in surgical techniques required to perform canthal anchoring in differing patients. 3. Describe the significance and techniques of canthal anchoring (canthoplasty and canthopexy) as they relate to cosmetic and reconstructive lower lid surgery. 4. Describe the effect of canthal anchoring on the function of the upper and lower lids and eyelid fissure shape. Any surgeon performing cosmetic or reconstructive surgery procedures on the lower lid or midface through the lower lid should be comfortable with canthal anchoring procedures. Appropriate canthal anchoring is effective in preventing postoperative lower-lid malposition, in ensuring eyelid closure, and in improving or maintaining proper eye shape. In many patients, a canthopexy (nonlysis canthal anchoring) is effective. However, in patients with significant horizontal laxity, cantholysis with appropriate lid shortening is required. It should be remembered that canthal anchoring, no matter how well performed, will not prevent severe lower-lid complications in cases of over-resection of lower-lid skin and of poorly performed midface procedures that do not support the lower lid and cheek.

Sternal resection and reconstruction

Twenty-one patients underwent sternal resection and reconstruction. Surgical indications included sternal infection in 9 patients, recurrent breast cancer in 6, metastatic carcinoma from an unknown primary in 2, pectus excavatum in 2, and osteogenic sarcoma and eosinophilic granuloma in 1 each. Management included partial sternectomy in 10 patients (group 1) and complete sternectomy in 11 (group 2). Chest wall reconstruction was by various flaps and mesh repairs. Blood transfusions averaged 2 units in group 1 versus 5.5 units in group 2 (p = 0.02). Average number of days until extubation was 2.6 in group 1 versus 7.3 in group 2 (p = 0.04). Average number of intensive care unit days was 4.4 for group 1 versus 9.4 for group 2 (p = 0.03). The number of days until discharge was 14 days for group 1 versus 20 days for group 2. Complications occurred in 40% of group 1 and 82% of group 2 patients. Overall mortality was 9.5%. Sternal resection and reconstruction, particularly complete sternal resections, are a major undertaking with substantial morbidity. Using a multidisciplinary approach (cardiothoracic, plastic and reconstructive, critical care medicine, and infectious disease) and aggressive pulmonary support, acceptable cosmetic and functional results are possible.

The role of muscle flaps in wound salvage after vascular graft infections: the Emory experience.

Background: The incidence of prosthetic graft infection is 1 to 6 percent, and the mortality rate of infected aortoiliac or aortofemoral bypass is 25 to 75 percent. The goal of this study was to report the use of muscle flaps in the management of patients presenting with infected vascular grafts. Methods: A total of 22 patients required 26 muscle flaps to cover 24 infected vascular grafts. Muscle flaps were used for local wound control in all patients regardless of the fate of the graft. The vascular surgeons elected for graft salvage in eight of the 24 grafts. All of the muscle flaps survived. Results: The average time interval between the bypass and infection was 371 days. One-month follow-up revealed an 88 percent salvage rate, but this decreased to 50 percent during the mean follow-up of 23 months. None of the patients originally managed with a salvaged graft lost a limb, and overall, 14 of 22 limbs in this series remained viable (64.0 percent). The mortality rate during the index hospitalization was 9 percent. In this series, suprainguinal grafts had a higher mortality rate. In addition, infection occurring more than 1 month postoperatively, culture-positive Pseudomonas and methicillin-resistant species, and exposure of the arterial-graft anastomosis were poor prognostic indicators of graft preservation. Conclusions: Management of infected vascular grafts remains a challenging problem. Muscle flap coverage should have a high priority, as the chance of a good outcome is highly favorable in early infections.

Prominent eye: operative management in lower lid and midfacial rejuvenation and the morphologic classification system.

The purpose of this study was to evaluate a standard method for the identification of eye prominence and to review operative modifications necessary in patients with prominent eyes. A Hertel exophthalmometer was used to define a classification system according to the degree of eye prominence. A total of 43 patients undergoing lower lid or midfacial rejuvenation were included in the study. Preoperative parameters, including vector analysis, laxity, scleral show, rotational deformity, lateral canthus-to-lateral orbital rim distance, lateral-to-medial canthal distance, and exophthalmometry measurement, were documented. Intraoperatively, techniques including horizontal shortening and lateral canthoplasty placement were documented. Postoperative evaluation included scleral show, rotational deformity, and lateral-to-medial canthal distance. The proposed morphologic classification system divided patients into four groups on the basis of their degree of prominence, as measured by exophthalmometry, defined as deep-set (<14 mm), normal (15 to 17 mm), moderately prominent (18 to 19 mm), and very prominent (>20 mm). Operative techniques were different between the groups, with correction of laxity in the deep-set eyes and accentuated overcorrection of scleral show in the prominent eyes. The use of an exophthalmometer to classify patients before blepharoplasty may help reduce the risk of complications by identifying high-risk patients.

Transorbital lower-lid and midface rejuvenation

The authors present a 3.5-year experience combining lower-lid and midface rejuvenation via a lower-lid blepharoplasty incision. The midface approach is subperiosteal and the vector of elevation is vertical. By using this method, improved, more natural results have been obtained in the midface and lower lid. The authors emphasize the risk of eyelid complications associated with this procedure, as well as prevention and management.