Combined pectoralis and rectus abdominis flaps are associated with improved outcomes in sternal reconstruction

Published:October 13, 2022DOI:



      Mortality increases nearly 5-fold in the approximately 5% of patients who develop sternal wound complications after cardiothoracic surgery. Flap-based reconstruction can improve outcomes by providing well-vascularized soft tissue for potential space obliteration, antibiotic delivery, and wound coverage; however, reoperation and readmission rates remain high. This study used the high case volume at a tertiary referral center and a diverse range of reconstructive approaches to compare various types of flap reconstruction. Combined (pectoralis and rectus abdominis) flap reconstruction is hypothesized to decrease sternal wound complication–related adverse outcomes.


      A retrospective cohort study of consecutive adult patients treated for cardiothoracic surgery sternal wound complications between 2008 and 2018 was performed. Patient demographics, comorbidities, wound characteristics, surgical parameters, and perioperative data were collected. Multivariable regression modeling with stepwise forward selection was used to characterize predictive factors for sternal wound–related readmissions and reoperations.


      In total, 215 patients were assessed for sternal wound reconstruction. Patient mortality at 1 year was 12.4%. Flap selection was significantly associated with sternal wound–related readmissions (P = .017) and reoperations (P = .014). Multivariate regression demonstrated rectus abdominis flap reconstruction independently predicted increased readmissions (odds ratio 3.4, P = .008) and reoperations (odds ratio 2.9, P = .038). Combined pectoralis and rectus abdominis flap reconstruction independently predicted decreased readmissions overall (odds ratio 0.4, P = .031) and in the deep sternal wound subgroup (odds ratio 0.1, P = .033).


      Although few factors can be modified in this complex highly comorbid population with a challenging and rare surgical problem, consideration of a more surgically aggressive multiflap reconstructive approach may be justified to improve outcomes.
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        • van Gulik L.
        • Janssen L.I.
        • Ahlers S.J.
        • et al.
        Risk factors for chronic thoracic pain after cardiac surgery via sternotomy.
        Eur J Cardiothorac Surg. 2011; 40: 1309-1313
        • Gelijns A.C.
        • Moskowitz A.J.
        • Acker M.A.
        • et al.
        Management practices and major infections after cardiac surgery.
        J Am Coll Cardiol. 2014; 64: 372-381
        • Kozlow J.H.
        • Patel S.P.
        • Jejurikar S.
        • Pannucci C.J.
        • Cederna P.S.
        • Brown D.L.
        Complications after sternal reconstruction: a 16-y experience.
        J Surg Res. 2015; 194: 154-160
        • Risnes I.
        • Abdelnoor M.
        • Almdahl S.M.
        • Svennevig J.L.
        Mediastinitis after coronary artery bypass grafting risk factors and long-term survival.
        Ann Thorac Surg. 2010; 89: 1502-1509
        • Toumpoulis I.K.
        • Anagnostopoulos C.E.
        • Derose J.J.
        • Swistel D.G.
        The impact of deep sternal wound infection on long-term survival after coronary artery bypass grafting.
        Chest. 2005; 127: 464-471
        • Filsoufi F.
        • Castillo J.G.
        • Rahmanian P.B.
        • et al.
        Epidemiology of deep sternal wound infection in cardiac surgery.
        J Cardiothorac Vasc Anesth. 2009; 23: 488-494
        • Fowler V.G.
        • O'Brien S.M.
        • Muhlbaier L.H.
        • Corey G.R.
        • Ferguson T.B.
        • Peterson E.D.
        Clinical predictors of major infections after cardiac surgery.
        Circulation. 2005; 112: I358-I365
        • Kubota H.
        • Miyata H.
        • Motomura N.
        • et al.
        Deep sternal wound infection after cardiac surgery.
        J Cardiothorac Surg. 2013; 8: 132
        • Graf K.
        • Ott E.
        • Vonberg R.P.
        • Kuehn C.
        • Haverich A.
        • Chaberny I.F.
        Economic aspects of deep sternal wound infections.
        Eur J Cardiothorac Surg. 2010; 37: 893-896
        • Greco G.
        • Shi W.
        • Michler R.E.
        • et al.
        Costs associated with health care-associated infections in cardiac surgery.
        J Am Coll Cardiol. 2015; 65: 15-23
        • Sears E.D.
        • Wu L.
        • Waljee J.F.
        • Momoh A.O.
        • Zhong L.
        • Chung K.C.
        The impact of deep sternal wound infection on mortality and resource utilization: a population-based study.
        World J Surg. 2016; 40: 2673-2680
        • Nickl S.
        • Steindl J.
        • Langthaler D.
        • et al.
        First Experiences with incisional negative pressure wound therapy in a high-risk poststernotomy patient population treated with pectoralis major muscle flap for deep sternal wound infection.
        J Reconstr Microsurg. 2017; 34: 001-007
        • Jurkiewicz M.J.
        • Bostwick J.
        • Hester T.R.
        • Bishop J.B.
        • Craver J.
        Infected median sternotomy wound. Successful treatment by muscle flaps.
        Ann Surg. 1980; 191: 738-744
        • Lee C.H.
        • Hsien J.H.
        • Tang Y.B.
        • Chen H.C.
        Reconstruction for sternal osteomyelitis at the lower third of sternum.
        J Plast Reconstr Aesthet Surg. 2010; 63: 633-641
        • Weinzweig N.
        • Yetman R.
        Transposition of the greater omentum for recalcitrant median sternotomy wound infections.
        Ann Plast Surg. 1995; 34: 471-477
        • Patel N.V.
        • Woznick A.R.
        • Welsh K.S.
        • Bendick P.J.
        • Boura J.A.
        • Mucci S.J.
        Predictors of mortality after muscle flap advancement for deep sternal wound infections.
        Plast Reconstr Surg. 2009; 123: 132-138
        • Izaddoost S.
        • Withers E.H.
        Sternal reconstruction with omental and pectoralis flaps: a review of 415 consecutive cases.
        Ann Plast Surg. 2012; 69: 296-300
        • Taylor A.H.
        • Mitchell A.E.
        • Mitchell I.M.
        A 15-year study of the changing demographics and infection risk in a new UK cardiac surgery unit.
        Interact Cardiovasc Thorac Surg. 2012; 15: 390-394
        • ElBardissi A.W.
        • Aranki S.F.
        • Sheng S.
        • O’Brien S.M.
        • Greenberg C.C.
        • Gammie J.S.
        Trends in isolated coronary artery bypass grafting: an analysis of the Society of Thoracic Surgeons adult cardiac surgery database.
        J Thorac Cardiovasc Surg. 2012; 143: 273-281
        • Bhupathiraju S.N.
        • Hu F.B.
        Epidemiology of obesity and diabetes and their cardiovascular complications.
        Circ Res. 2016; 118: 1723-1735
        • Kaul P.
        Sternal reconstruction after post-sternotomy mediastinitis.
        J Cardiothorac Surg. 2017; 12: 94
        • Piwnica-Worms W.
        • Azoury S.C.
        • Kozak G.
        • et al.
        Flap reconstruction for deep sternal wound infections: factors influencing morbidity and mortality.
        Ann Thorac Surg. 2020; 109: 1584-1590
        • Davison S.P.
        • Clemens M.W.
        • Armstrong D.
        • Newton E.D.
        • Swartz W.
        Sternotomy wounds: rectus flap versus modified pectoral reconstruction.
        Plast Reconstr Surg. 2007; 120: 929-934
        • Brandt C.
        • Alvarez J.M.
        First-line treatment of deep sternal infection by a plastic surgical approach: superior results compared with conventional cardiac surgical orthodoxy.
        Plast Reconstr Surg. 2002; 109: 2231-2237
        • Sears E.D.
        • Momoh A.O.
        • Chung K.C.
        • Lu Y.T.
        • Zhong L.
        • Waljee J.F.
        A national study of the impact of delayed flap timing for treatment of patients with deep sternal wound infection.
        Plast Reconstr Surg. 2017; 140: 390-400
        • Arnold P.G.
        • Pairolero P.C.
        Chest-wall reconstruction: an account of 500 consecutive patients.
        Plast Reconstr Surg. 1996; 98: 804-810
        • Cohen M.
        • Ramasastry S.S.
        Reconstruction of complex chest wall defects.
        Am J Surg. 1996; 172: 35-40
        • O’Keeffe N.
        • Concannon E.
        • Stanley A.
        • Dockery P.
        • McInerney N.
        • Kelly J.L.
        Cadaveric evaluation of sternal reconstruction using the pectoralis muscle flap.
        ANZ J Surg. 2019; 89: 945-949
        • Cala S.J.
        • Edyvean J.
        • Engel L.A.
        Chest wall and trunk muscle activity during inspiratory loading.
        J Appl Physiol (1985). 1992; 73: 2373-2381
        • Pairolero P.C.
        • Arnold P.G.
        Management of recalcitrant median sternotomy wounds.
        J Thorac Cardiovasc Surg. 1984; 88: 357-364
        • van Wingerden J.J.
        • Lapid O.
        • Boonstra P.W.
        • de Mol B.A.
        Muscle flaps or omental flap in the management of deep sternal wound infection.
        Interact Cardiovasc Thorac Surg. 2011; 13: 179-187
        • Falkner F.
        • Thomas B.
        • Haug V.
        • et al.
        Comparison of pedicled versus free flaps for reconstruction of extensive deep sternal wound defects following cardiac surgery: a retrospective study.
        Microsurgery. 2021; 41: 309-318
        • Taeger C.D.
        • Horch R.E.
        • Arkudas A.
        • et al.
        Combined free flaps with arteriovenous loops for reconstruction of extensive thoracic defects after sternal osteomyelitis.
        Microsurgery. 2016; 36: 121-127
        • Reichenberger M.A.
        • Harenberg P.S.
        • Pelzer M.
        • et al.
        Arteriovenous loops in microsurgical free tissue transfer in reconstruction of central sternal defects.
        J Thorac Cardiovasc Surg. 2010; 140: 1283-1287
        • Dornseifer U.
        • Kleeberger C.
        • Ehrl D.
        • Herter F.
        • Ninkovic M.
        • Iesalnieks I.
        Arteriovenous loop-independent free flap reconstruction of sternal defects after cardiac surgery.
        J Reconstr Microsurg. 2016; 32: 506-512
        • Ferris T.G.
        • Torchiana D.F.
        Public release of clinical outcomes data: online CABG report cards.
        N Engl J Med. 2010; 363: 1593-1595
        • Perrault L.P.
        • Kirkwood K.A.
        • Chang H.L.
        • et al.
        A prospective multi-institutional cohort study of mediastinal infections after cardiac operations.
        Ann Thorac Surg. 2018; 105: 461-468
        • Wu L.
        • Chung K.C.
        • Waljee J.F.
        • Momoh A.O.
        • Zhong L.
        • Sears E.D.
        A national study of the impact of initial débridement timing on outcomes for patients with deep sternal wound infection.
        Plast Reconstr Surg. 2016; 137: 414e-423e
        • Agarwal J.P.
        • Ogilvie M.
        • Wu L.C.
        • et al.
        Vacuum-assisted closure for sternal wounds: a first-line therapeutic management approach.
        Plast Reconstr Surg. 2005; 116 (discussion 1041–1033): 1035-1040
        • Raman J.
        • Straus D.
        • Song D.H.
        Rigid plate fixation of the sternum.
        Ann Thorac Surg. 2007; 84: 1056-1058