Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) 67, 634e639
Superior epigastric artery perforator flap for sternal osteomyelitis defect reconstruction* R. Wettstein a,*, M. Weisser b, D.J. Schaefer a, D.F. Kalbermatten a a Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital of Basel, Basel, Switzerland b Department of Infectious Diseases, University Hospital of Basel, Basel, Switzerland
Received 16 December 2013; accepted 26 January 2014
KEYWORDS Propeller flap; Infection control; Thoracic wall reconstruction; Sternum osteitis
Summary Sternal osteomyelitis after median sternotomy is associated with considerable morbidity and mortality. Combined with radical debridement, muscle and less frequently omentum flaps are used to reconstruct the resulting defects. In this study, we present our experience with the fasciocutaneous superior epigastric artery perforator (SEAP) flap for defect closure. After resection of the entire sternum, including the costochondral arches and the sternoclavicular joints, the repair of the defect was performed with the perforator flap without any re-stabilisation of the thoracic wall. A consecutive series of nine patients with a mean age of 69 6 years were reconstructed with the SEAP flap. The mortality rate was zero. One patient developed a mediastinal haematoma and required five re-interventions by the cardiothoracic surgeons and thereafter a revision to close a small-wound dehiscence at the tip of the flap. Another two patients developed partial necrosis of the flap that could be managed conservatively. One patient had a revision for a seroma on the donor site, resulting in a 100% closure rate of the defect; there were revisions in two out of nine patients. The underlying infection was controlled by debridement, antibiotic therapy and flap closure in all cases. The overall success of the procedure was satisfactory; however, the local complication rate was relatively high with three out of nine patients on the flap side and one of nine on the donor site. Major advantages of the perforator flap in this highly morbid patient cohort are that the operation is relatively quick, muscle tissue is spared and re-education facilitated. ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
*
This work has been presented at the 24th annual meeting of the European Association of Plastic Surgeons in Antalya, 23rde25th May 2013, and at the World Society for Reconstructive Microsurgery (WSRM) 2013 Congress in Chicago, IL, USA, 11the14th July 2013. * Corresponding author. Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Spitalstrasse 21, CH-4031 Basel, Switzerland. Tel.: þ41 61 556 5482; fax: þ41 61 265 7301. E-mail address: [email protected] (R. Wettstein).
1748-6815/$ - see front matter ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.01.037
Sternal osteomyelitis defect reconstruction
635
Ideally, defect reconstruction after thorough debridement of sternal osteomyelitis is a safe procedure with minimal donor-site morbidity permitting rapid recovery in this patient group presenting frequently in a poor general condition. Traditionally, muscle flaps, mainly pectoralis major turnover or advancement flaps,1 which may be sufficient in cases of sternal osteotomy wound dehiscence, have been used. In cases of recalcitrant osteomyelitis necessitating radical debridement that creates large defects after debridement, latissimus dorsi and vertical rectus abdominis muscle flaps or omental flaps have been used.2 Associated weakening of the abdominal wall by muscle harvest or opening of the abdominal cavity for harvest of the omentum or relatively long operation time with free flaps may be potential drawbacks of these procedures. Perforator flaps represent the most advanced method of tissue transfer in terms of applied anatomic and physiological principles. Basically, the use of a perforator flap maximally decreases donor-site morbidity and spares muscle tissue that is currently probably most frequently used for sternal defect closure. Theoretically, perforators such as superior epigastric artery perforator (SEAP) present an ideal source for fasciocutaneous flaps for sternal reconstruction. Previously, the use of this flap has been described for autologous breast volume augmentation after massive weight loss,3 tumour resection and radionecrosis,4e8 or after trauma.9 Of the total of 19 flaps described in the literature, only three were used for sternal osteomyelitis.10 The aim of the present study is to present the results obtained with a consecutive series of SEAP flaps for defect closure after radical sternectomy for recalcitrant osteomyelitis with an emphasis on infection control, local complications of the flap and the donor site and duration of post-flap hospital stay.
other words, the perforators were on the ipsilateral side in relation to the flap. The inframammary fold, that is, the lower border of the pectoralis muscle, served as the upper border of the flaps that were horizontally orientated in all cases resulting in a final flap rotation of 90 . Flap dissection started in the distal, lateral part of the flap in the plane above the muscle fascia, which was left intact, towards the previously identified pedicle. If there was more than one potential pedicle identified with the Doppler probe, flap preparation continued until the first (pivot point) perforator was identified. Fine perforator preparation was limited to the amount necessary to transpose the flap into the defect (Figure 1). The flaps could be easily rotated 90 into the defect and all donor sites could be primarily closed by a reverse abdominoplasty-type procedure. All patients received antibiotic treatment according to previous biopsy results or on an empirical basis with later adaptation as recommended by the infectious disease team. Drains were removed if output was 40%.2 However, the infectious problem may be solved with any flap tissue composition and seems to depend more on the wound preparation.2 An obvious advantage of this perforator flap is the decrease in donor-site morbidity, as there is no weakening of the pectoral and abdominal muscles and therefore in respiratory activity. The subcutaneous undermining in a reversed abdominoplasty fashion, however, can result in the typical complications, such as haematoma and seroma, which led to a reoperation in one case. The aesthetic outcome is usually not a major issue in this patient group; however, one patient required secondary flap contour correction. Ideally, the process of healing and recovery after a flap procedure is quick, and patients can be discharged early. In the present series, the mean duration of hospitalisation after the flap procedure was 42 days. This is significantly longer than previously reported and probably depends on multiple factors, such as general condition of the patients, the multiple reoperations in one patient, the duration of intravenous antibiotics recommended by the infectious disease team, as well as a delay in timely planning and limited availability of rehabilitation programmes that follow for most of these patients. One of the arguments against the use of fasciocutaneous flaps in the situation of sternal osteomyelitis is that the defect is relatively deep and that bulk is needed. In the present series, no tenting of the flap over a mediastinal cavity was observed and all flaps seemed to contour the defect nicely. Because all patients presented with a BMI >30 kg m2, we cannot comment whether this was the case in patients with a thinner subcutaneous tissue layer. The amount of soft-tissue laxity present and the defect size are probably more vital than the thickness of the subcutaneous layer. Infection is controlled by debridement, wound conditioning and antibiotic therapy for which the flap can be regarded as a transport vehicle. In purulent situations, neither a muscle nor a fasciocutaneous flap is indicated, but debridement and wound conditioning are indicated. Little is known about the importance of lymphatic drainage of flaps. Obviously, in completely mobilised perforator flaps, there is a paucity of lymphatic drainage that may be problematic. In conclusion, local fasciocutaneous flaps for reconstruction of sternal osteomyelitis defects present an ideal option with complete muscle preservation and consequently no weakening of the respiratory forces. Even though the precise territory that can safely be included in the SEAP flap is currently not known, the limited number of cases and anatomic studies published in the literature and intraoperative estimation permit to obtain a relatively safe result with an acceptable rate of complications and complete control of infection.
Conflict of interest/funding None of the authors has any conflict of interest or funding.
Sternal osteomyelitis defect reconstruction
References 1. Schmid DW, Orasch-Jo ¨rg C, Wettstein R, Kalbermatten DF, Todorov A, Pierer G. Successful therapy for a patient with an infected ascending aortic graft and sternal osteomyelitis without graft removal. Eplasty 2008;8:43e. 2. Wettstein R, Erni D, Berdat P, Rothenfluh D, Banic A. Radical sternectomy and primary musculocutaneous flap reconstruction to control sternal osteitis. J Thorac Cardiovasc Surg 2002; 123:1185e90. 3. Szychta P, Anderson WD. Islanded pedicled superior epigastric artery perforator flaps for bilateral breast augmentation with mastopexy after massive weight loss. J Plast Reconstr Aesthet Surg 2011;64:1677e81. 4. Hamdi M, Van Landuyt K, Ulens S, Van Hedent E, Roche N, Monstrey S. Clinical applications of the superior epigastric artery perforator (SEAP) flap: anatomical studies and preoperative perforator mapping with multidetector CT. J Plast Reconstr Aesthet Surg 2009;62:1127e34. 5. Uemura T. Superior epigastric artery perforator flap: preliminary report. Plast Reconstr Surg 2007;120:1ee5e. 6. Woo KJ, Pyon JK, Lim SY, Mun G-H, Bang SI, Oh KS. Deep superior epigastric artery perforator “propeller” flap for abdominal wall reconstruction: a case report. J Plast Reconstr Aesthet Surg 2010;63:1223e6. 7. Ziegler K, Schmidt M, Huemer GM. A pedicled superior epigastric artery perforator (SEAP-) propeller flap for 2-cavity reconstruction after oncologic rib resection. Microsurgery 2011;31:335e6. 8. Oni G, Sharma R, Rao R, Unger J, Saint-Cyr M. Bilateral superior epigastric pedicle perforator flaps for total chest wall coverage. J Plast Reconstr Aesthet Surg 2011;64:1104e7.
639 9. Hallock GG. The superior epigastric rectus abdominis muscle perforator flap. Ann Plast Surg 2005;55:430e2. 10. Mah E, Rozen WM, Ashton MW, Flood S. Deep superior epigastric artery perforators: anatomical study and clinical application in sternal reconstruction. Plast Reconstr Surg 2009;123: 1719e23. 11. Boyd JA, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstr Surg 1984;73:1e16. 12. Tregaskiss AP, Goodwin AN, Acland RD. The cutaneous arteries of the anterior abdominal wall: a three-dimensional study. Plast Reconstr Surg 2007;120:442e50. 13. Rozen WM, Grinsell D, Koshima I, Ashton MW. Dominance between angiosome and perforator territories: a new anatomical model for the design of perforator flaps. Microsurgery 2010;26: 539e45. 14. Rozen WM, Ashton MW, Le Roux CM, Pan W-R, Corlett RJ. The perforator angiosome: a new concept in the design of deep inferior epigastric artery perforator flaps for breast reconstruction. Microsurgery 2010;30:1e7. 15. Sharma RK, Mehrotra S, Nanda V. The perforator “plus” flap: a simple nomenclature for locoregional perforator-based flaps. Plast Reconstr Surg 2005;116:1838e9. 16. Mehrotra S. Perforator-plus concept: adding versatility to traditional flaps. Plast Reconst Surg 2009;123:219ee20e. 17. Mehrotra S. Perforator-plus flaps: a new concept in traditional flap design. Plast Reconstr Surg 2007;119:590e8. 18. Mesic H, Kirkebu ˛en KA, Bains R. The importance of a skin bridge in peripheral tissue perfusion in perforator flaps. Plast Reconstr Surg 2012;129:428ee34e.
Superior epigastric artery perforator flap for sternal osteomyelitis defect reconstruction* R. Wettstein a,*, M. Weisser b, D.J. Schaefer a, D.F. Kalbermatten a a Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital of Basel, Basel, Switzerland b Department of Infectious Diseases, University Hospital of Basel, Basel, Switzerland
Received 16 December 2013; accepted 26 January 2014
KEYWORDS Propeller flap; Infection control; Thoracic wall reconstruction; Sternum osteitis
Summary Sternal osteomyelitis after median sternotomy is associated with considerable morbidity and mortality. Combined with radical debridement, muscle and less frequently omentum flaps are used to reconstruct the resulting defects. In this study, we present our experience with the fasciocutaneous superior epigastric artery perforator (SEAP) flap for defect closure. After resection of the entire sternum, including the costochondral arches and the sternoclavicular joints, the repair of the defect was performed with the perforator flap without any re-stabilisation of the thoracic wall. A consecutive series of nine patients with a mean age of 69 6 years were reconstructed with the SEAP flap. The mortality rate was zero. One patient developed a mediastinal haematoma and required five re-interventions by the cardiothoracic surgeons and thereafter a revision to close a small-wound dehiscence at the tip of the flap. Another two patients developed partial necrosis of the flap that could be managed conservatively. One patient had a revision for a seroma on the donor site, resulting in a 100% closure rate of the defect; there were revisions in two out of nine patients. The underlying infection was controlled by debridement, antibiotic therapy and flap closure in all cases. The overall success of the procedure was satisfactory; however, the local complication rate was relatively high with three out of nine patients on the flap side and one of nine on the donor site. Major advantages of the perforator flap in this highly morbid patient cohort are that the operation is relatively quick, muscle tissue is spared and re-education facilitated. ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
*
This work has been presented at the 24th annual meeting of the European Association of Plastic Surgeons in Antalya, 23rde25th May 2013, and at the World Society for Reconstructive Microsurgery (WSRM) 2013 Congress in Chicago, IL, USA, 11the14th July 2013. * Corresponding author. Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Spitalstrasse 21, CH-4031 Basel, Switzerland. Tel.: þ41 61 556 5482; fax: þ41 61 265 7301. E-mail address: [email protected] (R. Wettstein).
1748-6815/$ - see front matter ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.01.037
Sternal osteomyelitis defect reconstruction
635
Ideally, defect reconstruction after thorough debridement of sternal osteomyelitis is a safe procedure with minimal donor-site morbidity permitting rapid recovery in this patient group presenting frequently in a poor general condition. Traditionally, muscle flaps, mainly pectoralis major turnover or advancement flaps,1 which may be sufficient in cases of sternal osteotomy wound dehiscence, have been used. In cases of recalcitrant osteomyelitis necessitating radical debridement that creates large defects after debridement, latissimus dorsi and vertical rectus abdominis muscle flaps or omental flaps have been used.2 Associated weakening of the abdominal wall by muscle harvest or opening of the abdominal cavity for harvest of the omentum or relatively long operation time with free flaps may be potential drawbacks of these procedures. Perforator flaps represent the most advanced method of tissue transfer in terms of applied anatomic and physiological principles. Basically, the use of a perforator flap maximally decreases donor-site morbidity and spares muscle tissue that is currently probably most frequently used for sternal defect closure. Theoretically, perforators such as superior epigastric artery perforator (SEAP) present an ideal source for fasciocutaneous flaps for sternal reconstruction. Previously, the use of this flap has been described for autologous breast volume augmentation after massive weight loss,3 tumour resection and radionecrosis,4e8 or after trauma.9 Of the total of 19 flaps described in the literature, only three were used for sternal osteomyelitis.10 The aim of the present study is to present the results obtained with a consecutive series of SEAP flaps for defect closure after radical sternectomy for recalcitrant osteomyelitis with an emphasis on infection control, local complications of the flap and the donor site and duration of post-flap hospital stay.
other words, the perforators were on the ipsilateral side in relation to the flap. The inframammary fold, that is, the lower border of the pectoralis muscle, served as the upper border of the flaps that were horizontally orientated in all cases resulting in a final flap rotation of 90 . Flap dissection started in the distal, lateral part of the flap in the plane above the muscle fascia, which was left intact, towards the previously identified pedicle. If there was more than one potential pedicle identified with the Doppler probe, flap preparation continued until the first (pivot point) perforator was identified. Fine perforator preparation was limited to the amount necessary to transpose the flap into the defect (Figure 1). The flaps could be easily rotated 90 into the defect and all donor sites could be primarily closed by a reverse abdominoplasty-type procedure. All patients received antibiotic treatment according to previous biopsy results or on an empirical basis with later adaptation as recommended by the infectious disease team. Drains were removed if output was 40%.2 However, the infectious problem may be solved with any flap tissue composition and seems to depend more on the wound preparation.2 An obvious advantage of this perforator flap is the decrease in donor-site morbidity, as there is no weakening of the pectoral and abdominal muscles and therefore in respiratory activity. The subcutaneous undermining in a reversed abdominoplasty fashion, however, can result in the typical complications, such as haematoma and seroma, which led to a reoperation in one case. The aesthetic outcome is usually not a major issue in this patient group; however, one patient required secondary flap contour correction. Ideally, the process of healing and recovery after a flap procedure is quick, and patients can be discharged early. In the present series, the mean duration of hospitalisation after the flap procedure was 42 days. This is significantly longer than previously reported and probably depends on multiple factors, such as general condition of the patients, the multiple reoperations in one patient, the duration of intravenous antibiotics recommended by the infectious disease team, as well as a delay in timely planning and limited availability of rehabilitation programmes that follow for most of these patients. One of the arguments against the use of fasciocutaneous flaps in the situation of sternal osteomyelitis is that the defect is relatively deep and that bulk is needed. In the present series, no tenting of the flap over a mediastinal cavity was observed and all flaps seemed to contour the defect nicely. Because all patients presented with a BMI >30 kg m2, we cannot comment whether this was the case in patients with a thinner subcutaneous tissue layer. The amount of soft-tissue laxity present and the defect size are probably more vital than the thickness of the subcutaneous layer. Infection is controlled by debridement, wound conditioning and antibiotic therapy for which the flap can be regarded as a transport vehicle. In purulent situations, neither a muscle nor a fasciocutaneous flap is indicated, but debridement and wound conditioning are indicated. Little is known about the importance of lymphatic drainage of flaps. Obviously, in completely mobilised perforator flaps, there is a paucity of lymphatic drainage that may be problematic. In conclusion, local fasciocutaneous flaps for reconstruction of sternal osteomyelitis defects present an ideal option with complete muscle preservation and consequently no weakening of the respiratory forces. Even though the precise territory that can safely be included in the SEAP flap is currently not known, the limited number of cases and anatomic studies published in the literature and intraoperative estimation permit to obtain a relatively safe result with an acceptable rate of complications and complete control of infection.
Conflict of interest/funding None of the authors has any conflict of interest or funding.
Sternal osteomyelitis defect reconstruction
References 1. Schmid DW, Orasch-Jo ¨rg C, Wettstein R, Kalbermatten DF, Todorov A, Pierer G. Successful therapy for a patient with an infected ascending aortic graft and sternal osteomyelitis without graft removal. Eplasty 2008;8:43e. 2. Wettstein R, Erni D, Berdat P, Rothenfluh D, Banic A. Radical sternectomy and primary musculocutaneous flap reconstruction to control sternal osteitis. J Thorac Cardiovasc Surg 2002; 123:1185e90. 3. Szychta P, Anderson WD. Islanded pedicled superior epigastric artery perforator flaps for bilateral breast augmentation with mastopexy after massive weight loss. J Plast Reconstr Aesthet Surg 2011;64:1677e81. 4. Hamdi M, Van Landuyt K, Ulens S, Van Hedent E, Roche N, Monstrey S. Clinical applications of the superior epigastric artery perforator (SEAP) flap: anatomical studies and preoperative perforator mapping with multidetector CT. J Plast Reconstr Aesthet Surg 2009;62:1127e34. 5. Uemura T. Superior epigastric artery perforator flap: preliminary report. Plast Reconstr Surg 2007;120:1ee5e. 6. Woo KJ, Pyon JK, Lim SY, Mun G-H, Bang SI, Oh KS. Deep superior epigastric artery perforator “propeller” flap for abdominal wall reconstruction: a case report. J Plast Reconstr Aesthet Surg 2010;63:1223e6. 7. Ziegler K, Schmidt M, Huemer GM. A pedicled superior epigastric artery perforator (SEAP-) propeller flap for 2-cavity reconstruction after oncologic rib resection. Microsurgery 2011;31:335e6. 8. Oni G, Sharma R, Rao R, Unger J, Saint-Cyr M. Bilateral superior epigastric pedicle perforator flaps for total chest wall coverage. J Plast Reconstr Aesthet Surg 2011;64:1104e7.
639 9. Hallock GG. The superior epigastric rectus abdominis muscle perforator flap. Ann Plast Surg 2005;55:430e2. 10. Mah E, Rozen WM, Ashton MW, Flood S. Deep superior epigastric artery perforators: anatomical study and clinical application in sternal reconstruction. Plast Reconstr Surg 2009;123: 1719e23. 11. Boyd JA, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstr Surg 1984;73:1e16. 12. Tregaskiss AP, Goodwin AN, Acland RD. The cutaneous arteries of the anterior abdominal wall: a three-dimensional study. Plast Reconstr Surg 2007;120:442e50. 13. Rozen WM, Grinsell D, Koshima I, Ashton MW. Dominance between angiosome and perforator territories: a new anatomical model for the design of perforator flaps. Microsurgery 2010;26: 539e45. 14. Rozen WM, Ashton MW, Le Roux CM, Pan W-R, Corlett RJ. The perforator angiosome: a new concept in the design of deep inferior epigastric artery perforator flaps for breast reconstruction. Microsurgery 2010;30:1e7. 15. Sharma RK, Mehrotra S, Nanda V. The perforator “plus” flap: a simple nomenclature for locoregional perforator-based flaps. Plast Reconstr Surg 2005;116:1838e9. 16. Mehrotra S. Perforator-plus concept: adding versatility to traditional flaps. Plast Reconst Surg 2009;123:219ee20e. 17. Mehrotra S. Perforator-plus flaps: a new concept in traditional flap design. Plast Reconstr Surg 2007;119:590e8. 18. Mesic H, Kirkebu ˛en KA, Bains R. The importance of a skin bridge in peripheral tissue perfusion in perforator flaps. Plast Reconstr Surg 2012;129:428ee34e.
