Extended Pectoralis Major Turnover Flap For Deep Sternal Wound Reconstruction

反向胸大肌延長皮瓣的深胸骨傷口重建

蔣春福(David Chon-Fok Cheong) ； 吳至偉(Jerry Chih-Wei Wu)

《臺灣整形外科醫學會雜誌》 26卷4期 (2017/12) Pp. 377-386

摘要

Background: Sternal wound dehiscence is a rare but severe complication that occurs after patients undergo an open cardiac surgery; especially median sternotomy is used for incision. Superficial sternal wound can be treated with definite surgical debridement followed by appropriate wound dressing therapy. However, deep sternal wound is usually more complicated with significant soft tissue defect, which needs additional flap closure. Pectoralis major (PM) flap is a conventional muscle flap used for closure of anterior chest walls defect. In order to advance the pectoralis major flap, skeletonizing the thoracoacromial pedicle towards its origin is mandatory so that desired extended reach can be obtained. In some circumstances in which the long median sternotomy wound is encountered, pectoralis major flap is unable to reach the lower third of the sternal wound despite full undermining of the flap and disruption of its' insertion. Therefore, additional flap is necessary for the coverage of lower third sternal wound. Here, we designed an extended pectoralis major turnover flap for the coverage of deep sternal wound, which can totally obliterate the whole sternal wound as distal to the xiphoid area. Aim and Objectives: Propose a new design of pectoralis major turnover flap and compare its results with the traditional pedicle PM muscle advancement flap. Methods: The medical records of 13 patients who underwent sternal wound reconstruction with 18 pectoralis major flaps between 2010 to 2014 were reviewed. Patient's median age is 62 years old. Six of thirteen patients were women and seven were men. All of them received open cardiac surgery with a median sternotomy incision. Group 1 had 7 patients with their sternal wound reconstructed with traditional pedicled pectoralis major advancement flap. Group 2 had 6 patients with their sternal wound reconstructed with extended pectoralis major turnover flap. Therapeutic outcomes are compared between two groups. Results: The pectoralis major flap transfer success rate was 100% in both groups. There was no significant difference in terms of patient's gender, age, ASA, tobacco use, comorbidities and surgical complication rate between two groups. Group 2 had significant lesser number of flap transfer (1 versus 2, p=0.035) and less mean reconstruction time (162 versus 218 minutes, p=0.008) when compared with Group 1. Conclusion: The extended pectoralis major turnover muscle flap is advantageous with regard to less reconstruction time and numbers of flaps needed for sternal wound reconstruction compared with the traditional pedicled pectoralis major advancement flap transfer. It should be considered as one of the treatment modalities for wide and long sternal wound reconstruction provided the internal mammary artery is not absent.

關鍵字

deep sternal wound infection ； pectoralis major flap

並列摘要

背　景：胸骨傷口裂開是發生在患者進行開放性心臟手術後的一種罕見且嚴重的併發症；尤其是使用正中胸部切口。淺表胸骨傷口可以用確實的清創手術及適當的傷口照料進行治療。然而，深部胸骨傷口通常比較複雜，有顯著軟組織缺損，這需要額外的皮瓣覆蓋。胸大肌皮瓣是傳統的肌肉皮瓣用於前胸壁缺損的覆蓋。為了延伸胸大肌皮瓣，將支配它的血管與旁邊的組織朝著它的起源做分離，這樣可以使皮瓣達到適當的延伸。在遇到長的正中胸骨傷口情況下，儘管胸大肌皮瓣已完全掀起及切斷其肌肉的止點，亦無法延伸至胸骨傷口的下三分之一。因此，必需使用額外的皮瓣來覆蓋下三分之一胸骨傷口。在這裡，我們設計一個翻轉的胸大肌延長皮瓣用於深胸骨傷口的覆蓋，其可以完全覆蓋整個胸骨傷口，即使傷口遠端至劍突區域。目的及目標：提出一個新的翻轉胸大肌延長皮瓣，與傳統的胸大肌延長皮瓣比較其治療結果。材料及方法：從2010年至2014年，十三位患者進行了十八例的胸大肌皮瓣轉移用作胸骨傷口的重建，對他們的醫療記錄進行了審查。患者平均年齡為六十二歲。六名患者為女性，七是男性。他們都接受開放性心臟手術並使用胸骨正中切口。第一組有七例，使用傳統胸大肌延伸皮瓣重建胸骨傷口重建。第二組有六例，使用翻轉的胸大肌延長皮瓣進行修復胸骨傷口，比較兩組其治療效果。結　果：兩組的胸大肌皮瓣轉移成功率達100％。兩組病人的性別，年齡，麻醉分類，吸菸情形，慢性疾病和手術併發症發生率方面沒有顯著差異。第二組有顯著的較少皮瓣轉移（1：2，p=0.035）的數量，當與第一組相比，平均重建時間較少（162與218分鐘，p=0.008）。結　論：使用翻轉的胸大肌延長皮瓣與傳統的胸大肌延長皮瓣轉移相比，有較少的重建時間，及所需的皮瓣數目。若內乳動脈仍存在，翻轉胸大肌延長皮瓣可作為寬和長胸骨傷口重建的其中一種選擇。