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General Thoracic and Cardiovascular Surgery

Published in:

01-06-2019 | Original Article

Z-plasty as an alternative choice for the treatment of recurrent local sternal wound infections

Authors: Emre Kubat, Malik Abacı, Celal Selçuk Ünal

Published in: General Thoracic and Cardiovascular Surgery | Issue 6/2019

Abstract

Objective

Sternal wound infections after sternotomy are associated with high morbidity, high mortality, and prolonged hospital stay. The recurrence rate of sternal wound infections after single-stage closure is greater than expected. The aim of the study is to present our results of a consecutive series of Z-plasty for the treatment of recurrent sternal wound infections.

Methods

Between March 2015 and March 2017, a total of 9 patients were referred to our clinic with a recurrent sternal wound infection due to sternotomy with or without osteomyelitis. All patients previously underwent one or more surgical procedures for sternal infection. Negative pressure wound therapy and several debridement methods were performed before reconstruction. Two triangular double-transposition fasciocutaneous flap techniques as Z-plasty under local anesthesia was performed for all of the patients.

Results

The flaps survived completely without any tissue loss. There were no major postoperative complications. One patient had recurrent infection after the flap procedure and was treated with antibiotic therapy. At 6 months of follow-up, all of the patients were able to return to normal activities of daily living with a high patient satisfaction rate.

Conclusions

Local sternal wound reconstruction is an effective, rapid, and simple with Z-plasty associated with low recurrence risk. We believe that Z-plasty can be used for recurrent local sternal wound infections as an alternative treatment option for selected patients without mechanical dehiscence.

Borger MA, Rao V, Weisel RD, Ivanov J, Cohen G, Scully HE, David TE. Deep sternal wound infection: risk factors and outcomes. Ann Thorac Surg. 1998;65(4):1050-6 (PubMed PMID: 9564926).CrossRefPubMed

Ridderstolpe L, Gill H, Granfeldt H, et al. Superficial and deep sternal wound complications: incidence, risk factors and mortality. Eur J Cardiothorac Surg. 2001;20:1168–75.CrossRefPubMed

Jones G, Jurkiewicz MJ, Bostwick J, Wood R, Bried JT, Culbertson J, et al. Management of the infected median sternotomy wound with muscle flaps. The Emory 20-year experience. Ann Surg. 1997;225(6):766–76.CrossRefPubMedPubMedCentral

Fleck TM, Koller R, Giovanoli P, et al. Primary or delayed closure for the treatment of poststernotomy wound infections? Ann Plast Surg. 2004;52:310–4.CrossRefPubMed

Sjogren J, Gustafsson R, Nilsson J, Malmsjo M, Ingemansson R. Clinical outcome after poststernotomy mediastinitis: vacuum-assisted closure versus conventional treatment. Ann Thorac Surg. 2005;79:2049–55.CrossRefPubMed

Immer FF, Durrer M, Mühlemann KS, Erni D, Gahl B, Carrel TP. Deep sternal wound infection after cardiac surgery: modality of treatment and outcome. Ann Thorac Surg. 2005;80:957–61.CrossRefPubMed

Juhl AA, Koudahl V, Damsgaard TE. Deep sternal wound infection after open heart surgery reconstructive options. Scand Cardiovasc J. 2012 Oct;46(5):254–61. https://doi.org/10.3109/14017431.2012.674549 (Review. PubMed PMID: 22404844).CrossRefPubMed

Koulaxouzidis G, Orhun A, Stavrakis T, Witzel C. Second intercostal internal mammary artery perforator (IMAP) fasciocutaneous flap as an alternative choice for the treatment of deep sternal wound infections (DSWI). J Plast Reconstr Aesthet Surg. 2015;68(9):1262–7. https://doi.org/10.1016/j.bjps.2015.05.019 (Epub 2015 May 29. PubMed PMID: 26113276).CrossRefPubMed

Anger J, Farsky PS, Almeida AF, Arnoni RT, Dantas DC. Use of the pectoralis major fasciocutaneous flap in the treatment of post sternotomy dehiscence: a new approach. Einstein (Sao Paulo). 2012;10(4):449–54 (English, Portuguese.PubMed PMID: 23386085).CrossRef

10.

Hudson DA. Some thoughts on choosing a Z-plasty: the Z made simple. Plast Reconstr Surg. 2000;106(3):665–71 (Review. PubMed PMID: 10987477).CrossRefPubMed

11.

Hundeshagen G, Zapata-Sirvent R, Goverman J, Branski LK. Tissue rearrangements: the power of the Z-Plasty. Clin Plast Surg. 2017;44(4):805–12. https://doi.org/10.1016/j.cps.2017.05.011 (Epub 2017 Jul 21. Review. PubMed PMID: 28888305).CrossRefPubMed

12.

Görgülü T, Olgun A. TG (Tri-Goniometry) technique: obtaining perfect angles in Z-plasty planning with a simple ruler. Burns. 2016;42(2):243–5. https://doi.org/10.1016/j.burns.2015.08.018 (Epub 2016 Jan 14. PubMed PMID: 26777447).CrossRefPubMed

13.

Aasi SZ. Z-plasty made simple. Dermatol Res Pract. 2010;2010:982623. https://doi.org/10.1155/2010/982623 (Epub 2011 Jun 26. PubMed PMID: 21789038; PubMed Central PMCID: PMC3123994).CrossRefPubMed

14.

Anger J, Dantas DC, Arnoni RT, Farsky PS. A new classification of post-sternotomy dehiscence. Rev Bras Cir Cardiovasc. 2015;30(1):114–8. https://doi.org/10.5935/1678-9741.20140033 (PubMed PMID: 25859875; PubMed Central PMCID: PMC4389524).CrossRefPubMedPubMedCentral

15.

Pairolero PC, Arnold PG. Management of recalcitrant median sternotomy wounds. J Thorac Cardiovasc Surg. 1984;88(3):357–64.PubMed

16.

El Oakley RM, Wright JE. Postoperative mediastinitis: classification and management. Ann Thorac Surg. 1996;61(3):1030–6.CrossRefPubMed

17.

Greig AV, Geh JL, Khanduja V, Shibu M. Choice of flap for the management of deep sternal wound infection—an anatomical classification. J Plast Reconstr Aesthet Surg. 2007;60(4):372–8.CrossRefPubMed

18.

Agarwal JP, Ogilvie M, Wu LC, Lohman RF, Gottlieb LJ, Franczyk M, Song DH. Vacuum-assisted closure for sternal wounds: a first-line therapeutic management approach. Plast Reconstr Surg. 2005;116(4):1035–40 (discussion 1041-3. PubMed PMID: 16163091).CrossRefPubMed

19.

Morisaki A, Hosono M, Murakami T, Sakaguchi M, Suehiro Y, Nishimura S, Sakon Y, Yasumizu D, Kawase T, Shibata T. Effect of negative pressure wound therapy followed by tissue flaps for deep sternal wound infection after cardiovascular surgery: propensity score matching analysis. Interact Cardiovasc Thorac Surg. 2016;23(3):397–402. https://doi.org/10.1093/icvts/ivw141 (Epub 2016 May 18. PubMed PMID: 27199380).CrossRefPubMed

20.

Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W. Vacuum assisted closure: a new method for wound control and treatment. Animal studies and basic foundation. Ann Plast Surg. 1997;38:553.CrossRefPubMed

21.

Bakri K, Mardini S, Evans KK, Carlsen BT, Arnold PG. Workhorse flaps in chest wall reconstruction: the pectoralis major, latissimus dorsi, and rectus abdominis flaps. Semin Plast Surg. 2011;25(1):43–54. https://doi.org/10.1055/s-0031-1275170 (PubMed PMID: 22294942; PubMed Central PMCID: PMC3140231).CrossRefPubMedPubMedCentral

22.

Juhl AA, Hody S, Videbaek TS, Damsgaard TE, Nielsen PH. Deep sternal wound infection after open-heart surgery: a 13-year single institution analysis. Ann Thorac Cardiovasc Surg. 2017. https://doi.org/10.5761/atcs.oa.16-00196 ([Epub ahead of print] PubMed PMID: 28163297).CrossRefPubMedPubMedCentral

23.

Eriksson J, Huljebrant I, Nettelblad H, Svedjeholm R. Functional impairment after treatment with pectoral muscle flaps because of deep sternal wound infection. Scand Cardiovasc J. 2011;45(3):174–80. https://doi.org/10.3109/14017431.2011.563318 (Epub 2011 Mar 15. PubMed PMID: 21405983).CrossRefPubMed

24.

Izaddoost S, Withers EH. Sternal reconstruction with omental and pectoralis flaps: a review of 415 consecutive cases. Ann Plast Surg. 2012;69(3):296–300. https://doi.org/10.1097/SAP.0b013e31822af843 (PubMed PMID: 22214791).CrossRefPubMed

25.

Wettstein R, Weisser M, Schaefer DJ, Kalbermatten DF. Superior epigastric artery perforator flap for sternal osteomyelitis defect reconstruction. J Plast Reconstr Aesthet Surg. 2014;67(5):634–9. https://doi.org/10.1016/j.bjps.2014.01.037 (Epub 2014 Feb 4. PubMed PMID: 24560800).CrossRefPubMed

26.

Calderon W, Chang N, Mathes SJ. Comparison of the effect of bacterial inoculation in musculocutaneous and fasciocutaneous flaps. Plast Reconstr Surg. 1986;77:5.CrossRef

Title: Z-plasty as an alternative choice for the treatment of recurrent local sternal wound infections
Authors: Emre Kubat
Malik Abacı
Celal Selçuk Ünal
Publication date: 01-06-2019
Publisher: Springer Singapore
Published in: General Thoracic and Cardiovascular Surgery / Issue 6/2019
Print ISSN: 1863-6705
Electronic ISSN: 1863-6713
DOI: https://doi.org/10.1007/s11748-018-1052-5

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Z-plasty as an alternative choice for the treatment of recurrent local sternal wound infections

Abstract

Objective

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Objective

Methods

Results

Conclusions

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