Sternotomy Wound Closure: Equivalent Results with Less Surgery

BACKGROUND: Mediastinitis after a median sternotomy can be life-threatening. The advent of pedicle flap–based treatment has resulted in an improvement in both morbidity and mortality. However, significant morbidities can still occur following the use of flaps for sternal closure, particularly in patients with comorbidities. To minimize an extensive surgical dissection, we modified our approach to reconstruction using a modified subpectoral approach, leaving the overlying skin attached. This technique focuses primarily on controlling wound tension rather than on maximal muscle coverage. This study is a retrospective review of 58 consecutive patients treated with this approach, by a single surgeon. METHODS: Fifty-eight consecutive patients treated between 2008 and 2019 were included. All patients received the same procedure regardless of the degree of illness, the extent of tissue loss, and the size of sternal defect. Treatment included thorough debridement, with total sternectomy (if required); limited dissection of the pectoralis major muscle off the chest wall to the level of the pectoralis minor without skin and subcutaneous undermining; no release of the insertion of the pectoralis or use of the rectus abdominis; and midline closure over drains connected to wall suction to obliterate dead space. RESULTS: Reoperations were required in 7 patients (12%). Of these, only 4 (6.9%) were related to continued sternal osteomyelitis. The other reoperations were for hematoma evacuation, breast fat necrosis, and skin necrosis. There were no operative mortalities. CONCLUSION: Chest closure using minimal dissection and tension release is safe, efficient, and associated with a complication rate equivalent to more extensive procedures reported in the literature despite significant comorbidities.