Viewpoints Sternal Wound Reconstruction with Falciform and Omental Flaps for Chronic Sternal Osteomyelitis Heather A. Levites, BS Omer E. Kaymakcalan, MD Division of Plastic and Reconstructive Surgery Division of Thoracic Surgery Department of Surgery Health Sciences Center Stony Brook Medicine Stony Brook, N.Y. Brett T. Phillips, MD, MBA Division of Plastic, Maxillofacial, and Oral Surgery Department of Surgery Duke University Durham, N.C. Thomas V. Bilfinger, MD Alexander B. Dagum, MD Division of Plastic and Reconstructive Surgery Division of Thoracic Surgery Department of Surgery Health Sciences Center Stony Brook Medicine Stony Brook, N.Y.
Sir: nfections following a midline sternotomy are uncommon, potentially life-threatening complications. Conventional options for sternal wound reconstruction include pectoralis advancement or turnover flaps and rectus abdominis, latissimus dorsi, and omental flaps. To our knowledge, we present the first report of the use of an extraperitoneal pedicled falciform ligament flap. The flap was used, in part, to cover a chronic infected sternal wound. This falciform flap provides a useful alternative for coverage of small, central, upper abdominal or lower chest defect. A 71-year-old man presented to our institution 16 months after coronary artery bypass graft via a midline sternotomy with sternal osteomyelitis, abscess and sinus tracts extending onto the right second and third ribs. The patient’s postoperative course was previously complicated by recurrent infections treated with pro-
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Copyright © 2014 The Authors. Published by Lippincott Williams & Wilkins on behalf of The American Society of Plastic Surgeons. PRS Global Open is a publication of the American Society of Plastic Surgeons. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. Plast Reconstr Surg Glob Open 2014;2:e233; doi:10.1097/ GOX.0000000000000194; Published online 14 October 2014.
longed intravenous antibiotics and multiple surgical procedures including the prior use of pectoralis flaps. Following initial debridement of the infected sternum and ribs, definitive closure was performed. A falciform flap was elevated measuring 7.70 × 5.77 cm (area of 22.60 cm2) through a midline laparotomy by mobilizing its peritoneal attachments, leaving its pedicle intact, and then brought superiorly to assist in lower midline sternal coverage. The omental flap based on the left gastroepiploic vessels was elevated and used to cover the remaining sternum and rib defect (Fig. 1). The LifeCell SPY Elite system (LifeCell Corp., Branchburg, NJ) was used to confirm intraoperative viability of both flaps before closure (Fig. 2). The laparotomy incision was closed, leaving a small window for the omental and falciform pedicles. The flaps closed the dead space, the omentum covered the second and third rib defect, and superior sternum and the falciform ligament flap reached to the nipple line and covered the lower sternum. The sternal wound edges were undermined subpectorally and brought across the midline to cover the flaps. The patient had an uneventful postoperative course and at 6 months had returned to work as a heavy equipment operator. The use of falciform flaps intra-abdominally was first described in 19681 and have since been used in the repair of hepatic and bile duct injuries, perforated ulcers, hiatal defects, and pancreas surgery.2–4 It requires mobilization of its anterior abdominal wall attachment while leaving its proximal hepatic attachment intact. When mobilized adequately, it is 15–30 cm in length and can reach any surgical area in the upper abdomen. Potential complications include a hernia and those associated with a laparotomy. The left phrenic
Fig. 1. Intraoperative image of dissected omental and falciform ligament flaps.
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Fig. 2. A, Intraoperative image of falciform ligament pedicle with corresponding SPY ICG angiography image. B, ICG fluorescence increases from blue to red. C, Intraoperative image of omental pedicle with corresponding (D) laser angiography with indocyanine green.
and a liver middle segment artery branch provide the arterial supply, whereas venous drainage is achieved through the inferior phrenic vein. The falciform flap is fed through vessels located on the diaphragmatic surface of the liver (85%) or vessels located within the ligament, 1.5 cm above the liver (15%). In the former, separating the ligament from the liver may compromise blood supply, leading to flap failure.5 Reconstruction of lower sternal wounds or upper central abdominal defects can pose a challenge to plastic surgeons, in particular when the rectus abdominis muscle is not available. The extraperitoneal falciform flap provides for a previously undescribed reconstructive alternative. Correspondence to Heather A. Levites Division of Plastic and Reconstructive Surgery Department of Surgery Health Sciences Center T19-060 Stony Brook Medicine Stony Brook, NY 11794–8191 [email protected]
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DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors. REFERENCES
1. Ratziu O. [Plastic repair of partial lesions of principal bile duct by a pedicled flap of the falciform ligament of the liver]. Presse Med. 1968;76:1279–1280. 2. Fischer RP, Gervin AS. The use of falciform ligament in the repair of hepatic injuries. Surg Gynecol Obstet. 1985;161: 383–384. 3. Fry DE, Richardson JD, Flint LM Jr. Closure of an acute perforated peptic ulcer with the falciform ligament. Arch Surg. 1978;113:1209–1210. 4. Park AE, Hoogerboord CM, Sutton E. Use of the falciform ligament flap for closure of the esophageal hiatus in giant paraesophageal hernia. J Gastrointest Surg. 2012;16: 1417–1421. 5. Li XP, Xu DC, Tan HY, et al. Anatomical study on the morphology and blood supply of the falciform ligament and its clinical significance. Surg Radiol Anat. 2004;26: 106–109.
Sir: nfections following a midline sternotomy are uncommon, potentially life-threatening complications. Conventional options for sternal wound reconstruction include pectoralis advancement or turnover flaps and rectus abdominis, latissimus dorsi, and omental flaps. To our knowledge, we present the first report of the use of an extraperitoneal pedicled falciform ligament flap. The flap was used, in part, to cover a chronic infected sternal wound. This falciform flap provides a useful alternative for coverage of small, central, upper abdominal or lower chest defect. A 71-year-old man presented to our institution 16 months after coronary artery bypass graft via a midline sternotomy with sternal osteomyelitis, abscess and sinus tracts extending onto the right second and third ribs. The patient’s postoperative course was previously complicated by recurrent infections treated with pro-
I
Copyright © 2014 The Authors. Published by Lippincott Williams & Wilkins on behalf of The American Society of Plastic Surgeons. PRS Global Open is a publication of the American Society of Plastic Surgeons. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. Plast Reconstr Surg Glob Open 2014;2:e233; doi:10.1097/ GOX.0000000000000194; Published online 14 October 2014.
longed intravenous antibiotics and multiple surgical procedures including the prior use of pectoralis flaps. Following initial debridement of the infected sternum and ribs, definitive closure was performed. A falciform flap was elevated measuring 7.70 × 5.77 cm (area of 22.60 cm2) through a midline laparotomy by mobilizing its peritoneal attachments, leaving its pedicle intact, and then brought superiorly to assist in lower midline sternal coverage. The omental flap based on the left gastroepiploic vessels was elevated and used to cover the remaining sternum and rib defect (Fig. 1). The LifeCell SPY Elite system (LifeCell Corp., Branchburg, NJ) was used to confirm intraoperative viability of both flaps before closure (Fig. 2). The laparotomy incision was closed, leaving a small window for the omental and falciform pedicles. The flaps closed the dead space, the omentum covered the second and third rib defect, and superior sternum and the falciform ligament flap reached to the nipple line and covered the lower sternum. The sternal wound edges were undermined subpectorally and brought across the midline to cover the flaps. The patient had an uneventful postoperative course and at 6 months had returned to work as a heavy equipment operator. The use of falciform flaps intra-abdominally was first described in 19681 and have since been used in the repair of hepatic and bile duct injuries, perforated ulcers, hiatal defects, and pancreas surgery.2–4 It requires mobilization of its anterior abdominal wall attachment while leaving its proximal hepatic attachment intact. When mobilized adequately, it is 15–30 cm in length and can reach any surgical area in the upper abdomen. Potential complications include a hernia and those associated with a laparotomy. The left phrenic
Fig. 1. Intraoperative image of dissected omental and falciform ligament flaps.
www.PRSGlobalOpen.com 1
PRS Global Open • 2014
Fig. 2. A, Intraoperative image of falciform ligament pedicle with corresponding SPY ICG angiography image. B, ICG fluorescence increases from blue to red. C, Intraoperative image of omental pedicle with corresponding (D) laser angiography with indocyanine green.
and a liver middle segment artery branch provide the arterial supply, whereas venous drainage is achieved through the inferior phrenic vein. The falciform flap is fed through vessels located on the diaphragmatic surface of the liver (85%) or vessels located within the ligament, 1.5 cm above the liver (15%). In the former, separating the ligament from the liver may compromise blood supply, leading to flap failure.5 Reconstruction of lower sternal wounds or upper central abdominal defects can pose a challenge to plastic surgeons, in particular when the rectus abdominis muscle is not available. The extraperitoneal falciform flap provides for a previously undescribed reconstructive alternative. Correspondence to Heather A. Levites Division of Plastic and Reconstructive Surgery Department of Surgery Health Sciences Center T19-060 Stony Brook Medicine Stony Brook, NY 11794–8191 [email protected]
2
DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors. REFERENCES
1. Ratziu O. [Plastic repair of partial lesions of principal bile duct by a pedicled flap of the falciform ligament of the liver]. Presse Med. 1968;76:1279–1280. 2. Fischer RP, Gervin AS. The use of falciform ligament in the repair of hepatic injuries. Surg Gynecol Obstet. 1985;161: 383–384. 3. Fry DE, Richardson JD, Flint LM Jr. Closure of an acute perforated peptic ulcer with the falciform ligament. Arch Surg. 1978;113:1209–1210. 4. Park AE, Hoogerboord CM, Sutton E. Use of the falciform ligament flap for closure of the esophageal hiatus in giant paraesophageal hernia. J Gastrointest Surg. 2012;16: 1417–1421. 5. Li XP, Xu DC, Tan HY, et al. Anatomical study on the morphology and blood supply of the falciform ligament and its clinical significance. Surg Radiol Anat. 2004;26: 106–109.
