Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 372e378

Choice of flap for the management of deep sternal

wound infection e an anatomical classification*
Aina V.H. Greig*, Jenny L.C. Geh, Vikas Khanduja, Mohammed Shibu

Department of Plastic and Reconstructive Surgery, Barts and The London NHS Trust, Royal London Hospital,
Whitechapel, London E1 1BB, UK

Received 9 January 2006; accepted 15 October 2006

KEYWORDS Summary Background: Infection of a median sternotomy wound is a rare albeit potentially
Sternotomy; fatal complication because of the risk of mediastinitis and deep sternal wound infection. Cur-
Dehiscence; rent treatment of deep sternal wound infection comprises antibiotics, debridement and trans-
Deep sternal position of muscle or omental flaps to fill the anterior mediastinal dead space.
wound infection Methods: A retrospective analysis of the deep sternal wound infections treated in our unit over
a nine-year period was performed.
Results: Out of the 11 903 consecutive coronary artery bypass graft procedures performed, 27
patients were referred to plastic surgery for management of deep sternal wound infection with
flaps. Wounds were classified based on their location on the sternum as type A (upper ), B
(lower ) or C (whole of sternum). Five patients had type A wounds, 12 type B wounds and
10 type C wounds. The mean age was 68 years and the M:F ratio was 20:7.
We describe guidelines for the choice of flap for sternal wound reconstruction, according to
the anatomical site of the wound dehiscence.
2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Else-
vier Ltd. All rights reserved.

Julian et al. first described median sternotomy in 1957 for
use in cardiac surgery.1 It allows good access to the medias-
tinum, but carries the risk of sternal wound dehiscence,
deep sternal wound infection and mediastinitis. Deep
* divided the presentation of infected sternotomy wounds
This paper was presented at the British Association of Plastic
Surgeons Summer Scientific Meeting, Newport, 2 July 2003. There
are no financial interests associated with this paper and no sources
of funding.
* Corresponding author. Royal London Hospital, Whitechapel,
London E1 1BB, UK.
E-mail address: aina.greig@virgin.net (A.V.H. Greig).
sternal wound infection is a rare but devastating complica-
tion, which carries a 50% mortality risk in early series.2 In
more recent series the incidence has reduced to 0.4e5.1%.3
Pairolero and Arnold based their classification of sternal
wounds on the timing of presentation of infection.4 They
into three categories. Type I wounds occur in the first
few days postoperatively and are characterised by serosan-
guinous drainage only without cellulitis, osteomyelitis or
costochondritis (Fig. 1a). These wounds are usually dealt
with by cardiothoracic surgeons and respond well to intra-
venous antibiotics, wound debridement with or without

1748-6815/$ - see front matter 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2006.10.005
Choice of flap for sternal reconstruction 373

Figure 1 (a) Pairolero and Arnold type I wound with serosanguinous drainage only without cellulitis, osteomyelitis or costochon-
dritis. (b) Type II wound with purulent drainage, cellulitis, mediastinal suppuration and positive cultures. (c) Type III wound with
chronic draining sinus tracts.

resuturing of the sternum. Direct closure with suction
drainage of the mediastinum is usually the only treatment
required. The suction is sufficient to obliterate the dead
space in the mediastinum.
Type II wounds occur within the first few weeks and are
characterised by purulent drainage, cellulitis, mediastinal
suppuration, and positive cultures (Fig. 1b). Frequently
there is associated fulminating mediastinitis and osteomye-
litis, although costochondritis is rare. Patients in this group
are best treated by drainage, debridement and immediate
or delayed flap closure with obliteration of the dead space.
Type III wounds occur months to years later and are
characterised by the presence of chronic draining sinus
tracts, localised cellulitis, osteomyelitis, costochondritis,
or retained foreign body but mediastinitis is rare
(Fig. 1c). Debridement, extensive resection of the sternum
and costal cartilages followed by flap obliteration of the
mediastinum are required. Type II and III wounds are usu-
ally referred to plastic surgeons for reconstruction. The
key in treating type II and III patients is the obliteration
of the dead space within the mediastinum.
The Pairolero and Arnold classification scheme does not
indicate the type of reconstruction necessary for the man-
agement of deep sternal wound infection and dehiscence.
374 A.V.H. Greig et al.

The incidence of post-median sternotomy wound com-

Table 1 Classification of sternal wounds according to
plications is increased with pneumonia, obesity, re-explo-
anatomical site
ration, use of the intra-aortic balloon pump, mediastinal
haematoma and diabetes.2,5 Patients with impaired lung Wound Site of No. of Recommended
function and a history of smoking6 and those undergoing type sternal wound patients flap for
cardiac valve operations7 are also at greater risk for post- reconstruction
sternotomy infections. Harvesting the left and right Type A Upper half 5 (19%) Pectoralis major
internal mammary arteries may also compromise sternal sternum
vascularity and predispose a patient to sternal infection e Type B Lower half 12 (44%) Combined pectoralis
an increased risk has been reported in some studies,5,8,9 sternum major and rectus
while no significant difference was seen in others.10,11 In- abdominis bipedicled
vestigations usually include: cultures of wound swabs, tis- flap
sue samples and sternal bone biopsies, chest radiograph Type C Whole sternum 10 (37%) Combined pectoralis
and CT scan to evaluate disease extent, bone necrosis major and rectus
and fluid collections. abdominis bipedicled
The treatment of deep sternal wound infection has flap
evolved over the last 50 years. Treatment historically was
conservative, with open drainage, debridement and pack-
ing. This often led to problems with graft exposure,
osteomyelitis and carried a 50% mortality. Shumaker and There were five type I, 19 type II and three type III
Mandelbaum revolutionised treatment by introducing cath- wounds according to the Pairolero and Arnold Classifica-
eter antibiotic irrigation in 1963.12 This reduced mortality tion.4 Using the anatomical classification, five patients
from 50 to 20%. However, the disadvantage of this approach (19%) had type A wounds in the upper half of the sternum.
was the risk of fatal haemorrhage because the catheter Twelve (44%) had type B wounds (lower half of sternum)
could erode major vessels. In 1976 Lee et al. introduced and 10 patients (37%) had type C wounds (involving the
the concept of flaps to reduce the dead space in the ante- whole sternum). This is summarised in Table 1. The major-
rior mediastinum, using the greater omentum.13 In 1980 ity of our patients had wounds in the lower half of the ster-
Jurkiewicz et al. introduced the concept of muscle and num, where necrosis happened more frequently.
myocutaneous flaps, which have become the standard Risk factors for deep sternal wound infection are
treatment for deep sternal wound infection.14 Current summarised in Table 2. Average time of presentation of
management involves debridement of devitalised infected sternal wound dehiscence post-CABG was 12 days (range
soft tissue and bone, culture-specific antibiotics, and 1e41 days). Average time to first wound debridement
a flap to fill wound cavity and achieve closure. The use of post-CABG was 26 days (range 3e180 days). Average time
flaps has reduced the mortality rate from post-sternotomy of referral to plastic surgery post-CABG was 32 days (range
mediastinitis to 8e15%.15e17 1e186 days). Average time of plastic surgical reconstruc-
tion post-CABG was 58 days (range 4e360 days). Average
Methods length of follow up was 20 months (range 1e65 months).
The flaps used to reconstruct patients with deep sternal
wound infection are shown in Table 3. In the early part of
A retrospective review was made of 27 patients referred to
the study, the pectoralis major or the rectus abdominis
the plastic surgery department out of 11 903 coronary
muscles alone were used. More recently, when the defect
artery bypass graft (CABG) procedures performed at Barts
was larger, the combined pectoralis major and rectus
and the London NHS Trust from 1 April 1995 to 31 March
abdominis bipedicled flap was used (Fig. 2a and b;
2004. The site of deep sternal wound infection was used in
Fig. 3aef). The greater omental flap was used in only one
planning the choice of flap for reconstruction. Type A
patient. One patient had a latissimus dorsi flap to the lower
wounds were in the upper half of the sternum. Type B in
half of the sternum.
the lower half of the sternum and type C wounds involved
Complications are summarised in Table 4. The partial
the whole sternum. Each patients age, sex and co-morbid
loss of the latissimus dorsi flap occurred due to infection-
risk factors for sternal wound dehiscence (diabetes, ste-
induced necrosis and healed after a vacuum assisted clo-
roids, obesity, and use of internal mammary arteries) were
sure (VAC) dressing. The latissimus dorsi flap was difficult
recorded. The time of presentation of deep sternal wound
to perform because of the need to change the position of
infection, the time of referral to plastic surgery, number of
days after CABG that plastic surgical reconstruction was
performed and postoperative complications were recorded.
Table 2 Risk factors associated with deep sternal wound
infection
Results
Risk factor Incidence
Eleven thousand nine hundred and three CABGs were Use of internal mammary artery 23 (85%)
performed from 1 April 1995 to 31 March 2004 within the Diabetes 17 (63%)
Trust. Twenty-seven patients (0.2%) with deep sternal Steroid inhalers for COAD 9 (33%)
wound infection required reconstruction. The mean age Obesity 5 (18%)
was 68 years (range 43e83) and the M:F ratio was 20:7.
Choice of flap for sternal reconstruction
Table 3 Muscle flaps used in sternal wound reconstruction
Rectus abdominis Pectoralis major
Upper half 1 2
Lower half 6 1
Whole sternum 1 0
the patient during the procedure. Only the most distal part
of the muscle can be used for wounds in the lower half of
the sternum and this has a less reliable blood supply. The
partial loss of the omental flap occurred in the upper part
and was treated with dressings.
Wound microbiology showed that eight patients had
MRSA, eight had Staphylococcus aureus, six had coagu-
lase-negative staphylococcus and 11 had a mixed growth
of organisms. There were five deaths in the patient group
studied. One patient died 4 days postoperatively due to
a pulmonary embolus. The others died between 1 and 5
months postoperatively. The peri-operative mortality rate
(death within 30 days of surgery) was 3.7% in our series.
Discussion
Sternal dehiscence and sternal wound problems occur in
approximately 1e3% of patients following median ster-
notomy.18 The infected sternotomy wound can range in
severity from a superficial infection to full blown, life-
threatening mediastinitis. Superficial infection can be
managed with intravenous antibiotics, wound drainage,
debridement and closure, whereas a deep infection
requires extensive debridement and obliteration of the
infected mediastinal cavity with vascularised muscle or
omental flaps. The most popular classification for the se-
verity and deep extension of infection was that proposed
Figure 2 (a) Diagram of composite pectoralis major and rectus abdominis muscle flap, reproduced from Solomon and Granick,
1998.21 (b) Flap is inset into sternal defect.
375
Pectoralis rectus Latissimus dorsi Omentum
2 0 0
4 1 0
8 0 1
by Pairolero and Arnold in 1986.4 This classification does
not help with the choice of flap required as sternal
wounds were classified on the timing of presentation of
infection. Nahai et al. have proposed a classification for
selection of flaps based on the type of bypass graft:
either vein graft, unilateral or bilateral internal mammary
artery grafts.18
An anatomical classification aids the choice of flaps for
sternal wound reconstruction for Pairolero and Arnold type
II and III wounds. Wounds in the upper half of the sternum
were classified as type A. Wounds sited in the lower half of
the sternum were classified as type B and wounds involving
the whole sternum as type C. We feel this anatomical
classification will help with the choice of reconstruction of
sternal wounds (see Table 1). For type A wounds (upper half
of sternum), we recommend using the pectoralis major
muscle flap. For defects in the lower half and whole ster-
num, i.e. type B and C wounds, we recommend the com-
bined pectoralis major and rectus abdominis bipedicled
muscle flap.
The pectoralis major muscle flap can either be trans-
posed into the mediastinum based on either the thoracoa-
cromial pedicle as an advancement flap or as a turnover
flap based on perforators of the internal mammary ar-
tery.14,19 The superiorly based rectus abdominis muscle flap
has also been used for sternal wound reconstruction but it
is considered risky to use it when the ipsilateral internal
376 A.V.H. Greig et al.

Figure 3 (a) Planning of composite pectoralis major and rectus abdominis muscle flap after debridement of type II deep sternal
wound infection. Marks on the skin from deep tension sutures are visible along the wound edges. (b) The skin and subcutaneous flap
is raised above the pectoralis major muscle. (c) The bipedicled composite pectoralis major and rectus abdominis muscle flap is
raised and separated from the underlying perforators to allow movement of the muscle across into the sternal defect. (d) The com-
posite pectoralis major and rectus abdominis muscle flap is inset. (e) The wound is then closed in layers over suction drains. (f) One
month postoperatively with minor wound dehiscence inferiorly.

mammary artery has been used for coronary artery bypass pectoralis major flap is a safer option to reconstruct de-
grafting and is relatively contraindicated as the flap would fects of the upper half of the sternum and the risk of ab-
be based on this vascular pedicle.20 The increased use of dominal hernia which may complicate the rectus
the internal mammary artery for grafting means that the abdominis muscle donor site is avoided.
Choice of flap for sternal reconstruction
Table 4 Complications after reconstruction
Local complications
Haematoma 2 (7%) (both combined
pectoralis rectus flaps)
Minor skin necrosis 5 (18%) (four combined
in the inferior pectoralis rectus flaps
part of the wound and one omental flap)
Seroma 1 (3.7%) combined
pectoralis rectus flap
Discharging sinus 4 (15%) (two rectus
abdominis flaps, one
latissimus dorsi, one
combined pectoralis rectus
flaps)
Partial flap loss 2 (7%) (one latissimus
dorsi one omental flap)
Upper abdominal bulge 1 (3.7%) (rectus abdominis)
General complications
Chest infection 1 (7%) (combined
pectoralis rectus flaps)
The combined pectoralis major and rectus abdominis
bipedicled muscle flap is a robust flap which completely
covers the sternal defect.20 This bipedicled flap has a good
blood supply from both the thoracoacromial artery superi-
orly and from the deep inferior epigastric artery inferiorly.
If the ipsilateral internal mammary artery has been used for
the coronary bypass graft then the blood supply to the flap
will not have been compromised.
To raise the muscle flap, a large skin flap is first raised at
the level of the pectoralis fascia and the anterior sheath of
the rectus abdominis muscle.20,21 The skin flap is elevated
from the midline to the mid-axillary line and from the clav-
icle to the inferior costal margin. The plane deep to the pec-
toralis major muscle is developed from medial to lateral.
The anterior sheath of the rectus abdominis muscle is di-
vided medially and laterally along the superior aspect of
the muscle, and the rectus abdominis muscle is elevated
from the posterior rectus sheath. The attachments of the
pectoralis major and rectus abdominis muscles to the ribs
are elevated and the intervening fascia between the mus-
cles is left intact, leaving the muscle units in continuity.
The lateral border of the rectus abdominis is separated
from the costal margin. The superior epigastric, lateral
costomarginal and segmental intercostal vessels supplying
the rectus abdominis muscle can usually be preserved, but
they can be ligated and divided if they tether the flap.
The pectoralis major muscle lateral to the thoracoacromial
pedicle is then divided, preserving the anterior axillary fold.
The medial one-third of the attachment of pectoralis major
to the clavicle is divided to facilitate flap transposition. The
bipedicled muscle unit can then be inset into the sternal de-
fect without tension, obliterating the dead space. Drains
are placed deep to the flap in the mediastinum and beneath
the skin flap into the axilla. Primary closure of the skin and
subcutaneous tissues is then performed.
The flap has the advantage that it is not necessary to
extend the skin incision below the umbilicus and there is no
377
need to open the abdominal cavity in a sick patient, as with
an omental flap. Patients undergoing coronary artery
bypass grafting and requiring sternal wound reconstruction
often have a multitude of problems including diabetes,
shock, hypertension, steroid use and pulmonary failure.
The use of an omental flap carries with it the risk of
introducing infection into the abdominal cavity and further
sepsis. In our small series there were few complications
with the bipedicled composite pectoralis major and rectus
abdominis muscle flap (Table 4). None of the flaps failed.
There was minor skin necrosis in the inferior part of the
wound in four patients. There was one patient who had
a discharging sinus which would have been the result of in-
complete debridement of the costal cartilages. There was
one seroma and two patients who had a haematoma. This
compares well with complication rates in the previous liter-
ature. Solomon and Granick published a review of 16
patients where bipedicled muscle flaps were used for ster-
nal wound reconstruction over 3 years in 1994. There were
no mortalities and no flap failures. Complications included
one haematoma, one seroma, and two patients with minor
wound breakdown.20 Solomon and Granick then published
a review of 42 patients over 7 years who had bipedicled
muscle flaps for sternal wound repair. There were no
deaths, one flap failure, one persistent infection, one pneu-
mothorax and one hernia in this series.21
Arnold and Pairolero described their experience with 500
consecutive chest wall reconstructions over 18 years.22 Of
these patients, 275 had chest wall tumours, 142 had in-
fected median sternotomies, 119 had radiation necrosis
and 121 had combinations of all three. Four hundred and
seven patients underwent 611 flaps: 355 pectoralis major,
141 latissimus dorsi and 115 others, including 27 serratus
anterior, 18 rectus abdominis and 30 external oblique.
The omentum was transposed in 51 patients. Pectoralis
major muscles were the most frequently used in this series
and mainly used for defects of the anterior chest wall,
especially in the upper portion of the chest.
These large published series support the case for using
either pectoralis major or combined pectoralis major and
rectus abdominis flaps for sternal wound reconstruction. We
are aware of the fact that this is a small series upon which
to base our conclusions - however we found that a pedicled
pectoralis major flap was useful for defects in the upper
half of the sternum and the combined pectoralis major and
rectus abdominis muscle flap was useful for lower half and
whole sternal defects. Both flaps are reliable and have good
blood supplies and represent the safest choice available.
We recognise that there are other pedicled flaps that can be
useful, for example the omental flap and the latissimus
dorsi muscle flap, and perhaps they should be reserved for
use if the first choice flaps fail. Free tissue transfer could
also be considered in a salvage situation.
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