British Journalof Plastic Surgery (1991), 44,243-246 0 1991 The Trustees of British Association of Plastic Surgeons
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“Supercharging” the rectus abdominis muscle to provide a single flap for cover of large mediastinal wound defects L. R. Pemia, H. L. Miller, R. Saltz and L. 0. Vasconez Department of Plastic Surgery, University of Aiabama at Birmingham, Alabama, USA SUMMARY. Mediastinitis continues to be a devastating complication of open heart surgery. Supercharging the rectus abdominis muscle through revascularisation of the deep inferior epigastric vessels in the neck adds another safety factor in the management of these diEcult problems. Large mediastinal wound defects that would usually require more than one muscle for cover can be covered adequately with this technique. Viability of the entire rectus abdominis is assured and permits use in its entirety. Details of the technique are presented as well as a review of the reconstructive options for mediastinal wound infections.
open wounds are susceptible to complications from erosion into the ascending aorta, septic thrombosis of coronary artery grafts and septic extension to coronrary grafts. Open management of mediastinitis with dressing changes and local wound irrigation, or the closed management advocated by Bryant et al. remained standard procedures until the late 1970s but morbidity and mortality remained high. A major advance was introduced by Jurkiewicz and Arnold (1977) who described early aggressive debridement and muscle transposition for closure of sternal wounds. They demonstrated that those patients in whom closed irrigation failed could often be salvaged by muscle transposition. Within a few years a number of authors began to advocate muscle or omental flaps for the more recalcitrant cases of mediastinitis, with various refinements (Arnold et al., 1984; Pairolero et al., 1984; Pearl and Dibbell, 1984; Majure et al., 1986). Recently, in a review of 211 cases of mediastinitis in which debridement and flap closure (muscle or omental) were utilised, Nahai et al. (1989) reported an overall 5.3% mortality rate, approximately a fourfold decrease compared to the open or closed management techniques cited above. In addition, he demonstrated superior primary therapy outcome and shorter hospital stays following therapy. We believe that in cases in which there is a compromised or questionable blood supply to the distal rectus muscle, particularly when the internal thoracic arteries have been used, microsurgical reinforcement of the inflow and outflow preserves the option of utilising other flap procedures if needed. We have performed this procedure on six patients to date.
Mediastinitis is a relatively rare but potentially serious complication of median stemotomy procedures. The incidence of wound infection after median stemotomy, including mediastinal sepsis, is approximately 2% (Arnold et al., 1984). Serry et al. (1980) reviewed over 4,000 median stemotomies for cardiac operations and found 74 sternal wound infections. He classified these 74 into three groups, based on the nature of the complications. The most serious group, characterised by sternal dehiscence and mediastinal sepsis, comprised less than 10% of the infected population (seven out of the 74 patients). These patients, however, required aggressive management and surgical intervention to arrest this complication; even so, five of these seven (71%) died. Historically, the technique of drainage and irrigation has been complemented with muscle coverage to obliterate the dead space and provide a salutory effect on the infectious process. We suggest an alternative option when using the rectus abdominis muscle. It involves reconnecting, by microvascular surgery, the divided deep inferior epigastric vessels to appropriate vessels in the lower neck, a procedure known as supercharging the rectus abdominis muscle. The advantage of this procedure lies largely in the fact that one single, large muscle covers the entire defect. Viability of the distal rectus abdominis is preserved with this type of transposition owing to the revascularisation of the deep inferior epigastric pedicle.
History
The first description of the stemotomy incision for mediastinal and cardiac surgery was that of Julian and his associates (Julian et al., 1957). Shumacker and Mandelbaum (1963) described the use of mediastinal lavage and Bryant et al. (1969a, b) recommended surgical debridement and closed irrigation with an antibiotic solution to heal the sternal wound because
General considerations
The blood supply to the sternum has been experimentally investigated by Arnold (1972) by injection studies. 243
244 He concluded that, “The arterial blood supply of the adult human sternum is derived solely from its periosteal plexus fed by segmental sternal branches of the internal mammary artery”. Medial pectoralis fibres, in close apposition to the sternal periosteum, do not provide any significant blood supply to the sternum and there is an avascular area along the bone edge, off the midline. Arnold further concluded that the internal mammary artery (now generally termed the internal thoracic artery) divides into three groups of distributive branches with reliably well-defined origins and courses. However, terminal division of the internal thoracic artery shows a somewhat greater inter-individual variation in which “in about one specimen in eight, a branch may hug the lower border of the upper costal margin and be found below the diaphragm, separate from the musculophrenic artery 1, ... The rectus abdominis flap
The various options available for cover of large mediastinal wound defects have been well described by Jurkiewicz et al. (1980). The pectoralis major muscle, the rectus abdominis muscle and the omentum have been used singly or in combination. Each comprises well-vascularised tissue that is capable of adequate cover of the wound; each presents somewhat differing potential complications (Jurkiewicz and Arnold, 1977; Jurkiewicz et al., 1980). We would like to suggest that there is a compelling advantage to primary choice of the rectus abdominis muscle in that it preserves the possibility of other options in case of failure and that it is particularly amenable to supplementation of its blood supply (supercharging) in order to maintain viability that might otherwise be questionable. Supercharging of the rectus abdominis is not entirely unprecedented. Shaw (personal communication, 1989) has utilised this procedure on the rectus abdominis musculocutaneous flap for breast reconstruction. Transposition of the rectus abdominis normally provides adequate wound cover for the lower two thirds of large mediastinal wound defects. However, standard mobilisation procedures sometimes lead to ischaemia or venous congestion of the distal portion of the flap (Fig. 3), resulting in flap failure. In these cases the anastomosis of the deep inferior epigastric pedicle to blood vessels in the neck has proved to be a reliable procedure that allows successful coverage of very large mediastinal defects with only one muscle flap. Since 1986 we have successfully performed this procedure on six patients. In all cases, closure was successful. Two later succumbed to complications unrelated to the procedure. One patient suffered a rupture of the anastomotic suture line and a consequent massive haemorrhage from the root of the aorta, approximately 72 hours after the surgery. The other fatality occurred approximately 3 months after surgery in a diabetic elderly male who suffered a stroke and pneumonia. The mediastinal wound was fully healed at that time. One patient with previous laparotomy presented an asymptomatic ventral hernia.
British Journal of Plastic Surgery Operative technique
The operative technique involves two teams. One team thoroughly debrides the sternal wound (Fig. 1) while the second team exposes the rectus abdominis muscle from the xiphoid to the pubis. This exposure is accomplished through a paramedian incision that communicates with the sternal wound and leaves the fascia attached to the subcutaneous tissue and skin. After the first team completes the radical debridement and excision of all involved cartilage, it institutes an irrigation system to lavage the wound with copious amounts of warm saline (povidone iodine solution may be used if preferred). The lavage should be performed in a gentle fashion and care should be taken to avoid playing the jet on exposed vein grafts, pericardium or great vessels. These areas can be debrided gently with a tongue blade. Following completion of the lavage, the first team dissects the recipient vessels. The vessels of choice are the external jugular vein and any artery at the root of the neck. It should be noted, however, that we have obtained satisfactory results through anastomosing only the venous outflow; clinical judgment should be exercised regarding the decision of recipient vessels, considering all of the factors at the time of the procedure. After satisfactory vessels are identified, the rectus abdominis muscle is detached from the pubis, leaving the deep inferior epigastric vessels as long as possible. The tendinous origin of the rectus abdominis should be included with the muscle to aid in suturing. The muscle can then be transposed into the chest wound (Fig. 2). If the distal rectus shows clinical evidence of vascular compromise (Fig. 3), microvascular anastomosis is performed (Fig. 4). While one team performs the anastomosis, the second team closes the abdominal wound. Our experience has demonstrated that simultaneous performance of the microvascular anastomosis and wound closure is feasible and minimises the surgical time required. We estimate that, at worst, the procedure increased the operative time only moderately, approximately one hour beyond that which would have been required if two flaps had been necessary for total closure. Significant improvement in the colour of the distal one-third of the rectus muscle can be observed immediately after completion of the anastomosis (Fig. 4). The transposed muscle can then be covered with a thin meshed split thickness skin graft to supply greater eventual stability to the chest and direct observation of the flap. Finally, closed suction catheters should be placed under the muscle hap. Figures l-5 show the procedure from before to 7 months after the operation. It should be noted that supercharging the rectus abdominis muscle is not dependent on the availability of the internal thoracic artery. The rectus muscle can still be based on a superior epigastric artery because it is supplied by collaterals from the intercostals (Boyd et al., 1984; Nahai et al., 1989). In general, complications of the exposed rectus abdominis flap procedure are new. We believe that an
245
Supercharging the Rectus Abdominis Muscle
Fig. 2
Fig. 4
Fig. 5
Figure I-Mediastinal wound infection (preoperative). Fii 2-Rectus abdominis muscle Rap based on superior epigastric vessels. F@re 3-Flap showing vascular compromise. Figure &Deep inferior epigastric vessels anastomosed to neck vessels. Figme SHealed wound with skin graft covering muscle flap (7 months postoperatively).
246 even more reliable flap is produced when the microvascular anastomosis described above has been performed because the inferior epigastric pedicle alone can supply the entire muscle. In all of our cases we observed complete survival of the entire flap from xiphoid to sternal notch. Two elderly diabetic patients presented with dehiscence of the skin of the abdominal wound; both had had previous midline incisions. One patient had persistent sinus drainage from residual cartilage, which was noticed approximately 2 months after discharge from hospital. This complication was managed by re-exploration and exicision of the involved cartilage with transposition of pectoralis muscle flap. As described above, there were two deaths unrelated to the flap procedure; in both cases the flap was deemed successful. conclusions Microvascular anastomosis of the rectus abdominis flap (supercharging) provides a reliable and safe alternative to the use of omentum or multiple flaps for cover of large mediastinal wound defects. A major advantage of this technique over the available alternatives derives from the fact that all other options are retained in the case of further failure, whereas use of the omentum or multiple muscle flaps limits future repair options, Moreover, from our experiences to date, the technique appears feasible, safe and robust.
References Arnold, M. (1972). Surgical anatomy of sternal blood supply. Joumal ThorackCardiovascular Surgery, 64,596. Arnold, P. G., Daoielson, G. K. and Pairolero, P. C. (1984). Management of recalcitrant median stemotomy wounds. Jounal of Thoracic Cardiovascular Surgery, 88,357. Boyd, J. B., Taylor, G. I. and CorIett, R. (1984). The vascular
of
territories of the superior epigastric and deep inferior epigastric systems. Plastic and Reconstructive Surgery, 73,1. Bryant, L. R., Spencer, F. C. and Trinkle, J. K. (1969a). Treatment of median stemotomy infection by mediastinal irrigation with an antibiotic solution. Annals of Surgery, 169,914.
British Journal of Plastic Surgery Julian, D. C., Lopez-Belie, M., Dye, W. S. and Grove, W. J. (1957). The median sternal incision in intracardiac surgery with extracorporeal circulation. Surgery, 42,753. Jurkiewicz, M. J. and Arnold, P. G. (1977). The omentum: an account of its use in the reconstruction of the chest wall. Annals of Surgery, 185,548.
Jurkiewicz, M. J., Bostwick, J., Hester, R., Bishop, J. B. and Craver, J. (1980). Infected median stemotomy wounds successful treatment by muscle flaps. Annals ofsurgery, 191,738. Majure, J. A., Albin, R. E., O’LknmeU, R. S. aad m, T. J. (1986). Reconstruction of the infected median stemotomy wound. Annals of Thoracic Surgery, 42,9. Nabd, F., Rand, R. P., Hester, T. R., Bostwick, J. R. III and
Jurkiewicz, M. J. (1989). Primary treatment of the infected stemotomy wound with muscle flaps: a review of 211 consecutive cases. Plastic and Reconstructive Surgery, 84,434. Pairolero, P. C., Arnold, P. G. and Danielson, G. K. (1984). Management of recalcitrant median stemotomy wounds. Journal of Tboracic and Cardiovascular Surgery, 88,357. Pearl, S. N. and Dibbell, D. G. (1984). Reconstruction after median stemotomy. Surgery, Gynecology and Obstetrics, 159,47. Serry, C., Bleck, P. C., Javid, H., Hater, J. A., Goldin, M. D., Delaria, G. A. and Nqja6, H. (1980). Sternal wound complications. Management and results. Journal of Tboracic and Cardiovascular Surgery, @I,86 1. Shnmacker, H. B. Jr and Mandelbaum, I. (1963). Continuous antibiotic irrigation in the treatment of infection. Archives of Surgery, 86,384.
The Authors Luis R. Pernia, MD, Assistant Clinical Professor of Plastic Surgery, University of Alabama, Tuscaloosa, Alabama. Howard L. Miller, PkD, MPH, Professor, Department of Psychology, University of Alabama, Tuscaloosa, Alabama; Adjunct Professor of Public Health, University of Alabama at Birmingham. Renato S&z, MD, Assistant Professor, Department of Plastic Surgery, University of Alabama School of Medicine, Birmingham, Alabama Luis 0. Vasconez, MD, Professor and Chair, Department of Plastic Surgery, School of Medicine, University of Alabama at Birmingham Requests for reprints to: Dr Renato Saltz, 3201 Sharpsburg Circle, Birmingham, AL 35213, USA. Paper received 3 August 1989. Accepted 22 October 1990 after revision.
,_
“Supercharging” the rectus abdominis muscle to provide a single flap for cover of large mediastinal wound defects L. R. Pemia, H. L. Miller, R. Saltz and L. 0. Vasconez Department of Plastic Surgery, University of Aiabama at Birmingham, Alabama, USA SUMMARY. Mediastinitis continues to be a devastating complication of open heart surgery. Supercharging the rectus abdominis muscle through revascularisation of the deep inferior epigastric vessels in the neck adds another safety factor in the management of these diEcult problems. Large mediastinal wound defects that would usually require more than one muscle for cover can be covered adequately with this technique. Viability of the entire rectus abdominis is assured and permits use in its entirety. Details of the technique are presented as well as a review of the reconstructive options for mediastinal wound infections.
open wounds are susceptible to complications from erosion into the ascending aorta, septic thrombosis of coronary artery grafts and septic extension to coronrary grafts. Open management of mediastinitis with dressing changes and local wound irrigation, or the closed management advocated by Bryant et al. remained standard procedures until the late 1970s but morbidity and mortality remained high. A major advance was introduced by Jurkiewicz and Arnold (1977) who described early aggressive debridement and muscle transposition for closure of sternal wounds. They demonstrated that those patients in whom closed irrigation failed could often be salvaged by muscle transposition. Within a few years a number of authors began to advocate muscle or omental flaps for the more recalcitrant cases of mediastinitis, with various refinements (Arnold et al., 1984; Pairolero et al., 1984; Pearl and Dibbell, 1984; Majure et al., 1986). Recently, in a review of 211 cases of mediastinitis in which debridement and flap closure (muscle or omental) were utilised, Nahai et al. (1989) reported an overall 5.3% mortality rate, approximately a fourfold decrease compared to the open or closed management techniques cited above. In addition, he demonstrated superior primary therapy outcome and shorter hospital stays following therapy. We believe that in cases in which there is a compromised or questionable blood supply to the distal rectus muscle, particularly when the internal thoracic arteries have been used, microsurgical reinforcement of the inflow and outflow preserves the option of utilising other flap procedures if needed. We have performed this procedure on six patients to date.
Mediastinitis is a relatively rare but potentially serious complication of median stemotomy procedures. The incidence of wound infection after median stemotomy, including mediastinal sepsis, is approximately 2% (Arnold et al., 1984). Serry et al. (1980) reviewed over 4,000 median stemotomies for cardiac operations and found 74 sternal wound infections. He classified these 74 into three groups, based on the nature of the complications. The most serious group, characterised by sternal dehiscence and mediastinal sepsis, comprised less than 10% of the infected population (seven out of the 74 patients). These patients, however, required aggressive management and surgical intervention to arrest this complication; even so, five of these seven (71%) died. Historically, the technique of drainage and irrigation has been complemented with muscle coverage to obliterate the dead space and provide a salutory effect on the infectious process. We suggest an alternative option when using the rectus abdominis muscle. It involves reconnecting, by microvascular surgery, the divided deep inferior epigastric vessels to appropriate vessels in the lower neck, a procedure known as supercharging the rectus abdominis muscle. The advantage of this procedure lies largely in the fact that one single, large muscle covers the entire defect. Viability of the distal rectus abdominis is preserved with this type of transposition owing to the revascularisation of the deep inferior epigastric pedicle.
History
The first description of the stemotomy incision for mediastinal and cardiac surgery was that of Julian and his associates (Julian et al., 1957). Shumacker and Mandelbaum (1963) described the use of mediastinal lavage and Bryant et al. (1969a, b) recommended surgical debridement and closed irrigation with an antibiotic solution to heal the sternal wound because
General considerations
The blood supply to the sternum has been experimentally investigated by Arnold (1972) by injection studies. 243
244 He concluded that, “The arterial blood supply of the adult human sternum is derived solely from its periosteal plexus fed by segmental sternal branches of the internal mammary artery”. Medial pectoralis fibres, in close apposition to the sternal periosteum, do not provide any significant blood supply to the sternum and there is an avascular area along the bone edge, off the midline. Arnold further concluded that the internal mammary artery (now generally termed the internal thoracic artery) divides into three groups of distributive branches with reliably well-defined origins and courses. However, terminal division of the internal thoracic artery shows a somewhat greater inter-individual variation in which “in about one specimen in eight, a branch may hug the lower border of the upper costal margin and be found below the diaphragm, separate from the musculophrenic artery 1, ... The rectus abdominis flap
The various options available for cover of large mediastinal wound defects have been well described by Jurkiewicz et al. (1980). The pectoralis major muscle, the rectus abdominis muscle and the omentum have been used singly or in combination. Each comprises well-vascularised tissue that is capable of adequate cover of the wound; each presents somewhat differing potential complications (Jurkiewicz and Arnold, 1977; Jurkiewicz et al., 1980). We would like to suggest that there is a compelling advantage to primary choice of the rectus abdominis muscle in that it preserves the possibility of other options in case of failure and that it is particularly amenable to supplementation of its blood supply (supercharging) in order to maintain viability that might otherwise be questionable. Supercharging of the rectus abdominis is not entirely unprecedented. Shaw (personal communication, 1989) has utilised this procedure on the rectus abdominis musculocutaneous flap for breast reconstruction. Transposition of the rectus abdominis normally provides adequate wound cover for the lower two thirds of large mediastinal wound defects. However, standard mobilisation procedures sometimes lead to ischaemia or venous congestion of the distal portion of the flap (Fig. 3), resulting in flap failure. In these cases the anastomosis of the deep inferior epigastric pedicle to blood vessels in the neck has proved to be a reliable procedure that allows successful coverage of very large mediastinal defects with only one muscle flap. Since 1986 we have successfully performed this procedure on six patients. In all cases, closure was successful. Two later succumbed to complications unrelated to the procedure. One patient suffered a rupture of the anastomotic suture line and a consequent massive haemorrhage from the root of the aorta, approximately 72 hours after the surgery. The other fatality occurred approximately 3 months after surgery in a diabetic elderly male who suffered a stroke and pneumonia. The mediastinal wound was fully healed at that time. One patient with previous laparotomy presented an asymptomatic ventral hernia.
British Journal of Plastic Surgery Operative technique
The operative technique involves two teams. One team thoroughly debrides the sternal wound (Fig. 1) while the second team exposes the rectus abdominis muscle from the xiphoid to the pubis. This exposure is accomplished through a paramedian incision that communicates with the sternal wound and leaves the fascia attached to the subcutaneous tissue and skin. After the first team completes the radical debridement and excision of all involved cartilage, it institutes an irrigation system to lavage the wound with copious amounts of warm saline (povidone iodine solution may be used if preferred). The lavage should be performed in a gentle fashion and care should be taken to avoid playing the jet on exposed vein grafts, pericardium or great vessels. These areas can be debrided gently with a tongue blade. Following completion of the lavage, the first team dissects the recipient vessels. The vessels of choice are the external jugular vein and any artery at the root of the neck. It should be noted, however, that we have obtained satisfactory results through anastomosing only the venous outflow; clinical judgment should be exercised regarding the decision of recipient vessels, considering all of the factors at the time of the procedure. After satisfactory vessels are identified, the rectus abdominis muscle is detached from the pubis, leaving the deep inferior epigastric vessels as long as possible. The tendinous origin of the rectus abdominis should be included with the muscle to aid in suturing. The muscle can then be transposed into the chest wound (Fig. 2). If the distal rectus shows clinical evidence of vascular compromise (Fig. 3), microvascular anastomosis is performed (Fig. 4). While one team performs the anastomosis, the second team closes the abdominal wound. Our experience has demonstrated that simultaneous performance of the microvascular anastomosis and wound closure is feasible and minimises the surgical time required. We estimate that, at worst, the procedure increased the operative time only moderately, approximately one hour beyond that which would have been required if two flaps had been necessary for total closure. Significant improvement in the colour of the distal one-third of the rectus muscle can be observed immediately after completion of the anastomosis (Fig. 4). The transposed muscle can then be covered with a thin meshed split thickness skin graft to supply greater eventual stability to the chest and direct observation of the flap. Finally, closed suction catheters should be placed under the muscle hap. Figures l-5 show the procedure from before to 7 months after the operation. It should be noted that supercharging the rectus abdominis muscle is not dependent on the availability of the internal thoracic artery. The rectus muscle can still be based on a superior epigastric artery because it is supplied by collaterals from the intercostals (Boyd et al., 1984; Nahai et al., 1989). In general, complications of the exposed rectus abdominis flap procedure are new. We believe that an
245
Supercharging the Rectus Abdominis Muscle
Fig. 2
Fig. 4
Fig. 5
Figure I-Mediastinal wound infection (preoperative). Fii 2-Rectus abdominis muscle Rap based on superior epigastric vessels. F@re 3-Flap showing vascular compromise. Figure &Deep inferior epigastric vessels anastomosed to neck vessels. Figme SHealed wound with skin graft covering muscle flap (7 months postoperatively).
246 even more reliable flap is produced when the microvascular anastomosis described above has been performed because the inferior epigastric pedicle alone can supply the entire muscle. In all of our cases we observed complete survival of the entire flap from xiphoid to sternal notch. Two elderly diabetic patients presented with dehiscence of the skin of the abdominal wound; both had had previous midline incisions. One patient had persistent sinus drainage from residual cartilage, which was noticed approximately 2 months after discharge from hospital. This complication was managed by re-exploration and exicision of the involved cartilage with transposition of pectoralis muscle flap. As described above, there were two deaths unrelated to the flap procedure; in both cases the flap was deemed successful. conclusions Microvascular anastomosis of the rectus abdominis flap (supercharging) provides a reliable and safe alternative to the use of omentum or multiple flaps for cover of large mediastinal wound defects. A major advantage of this technique over the available alternatives derives from the fact that all other options are retained in the case of further failure, whereas use of the omentum or multiple muscle flaps limits future repair options, Moreover, from our experiences to date, the technique appears feasible, safe and robust.
References Arnold, M. (1972). Surgical anatomy of sternal blood supply. Joumal ThorackCardiovascular Surgery, 64,596. Arnold, P. G., Daoielson, G. K. and Pairolero, P. C. (1984). Management of recalcitrant median stemotomy wounds. Jounal of Thoracic Cardiovascular Surgery, 88,357. Boyd, J. B., Taylor, G. I. and CorIett, R. (1984). The vascular
of
territories of the superior epigastric and deep inferior epigastric systems. Plastic and Reconstructive Surgery, 73,1. Bryant, L. R., Spencer, F. C. and Trinkle, J. K. (1969a). Treatment of median stemotomy infection by mediastinal irrigation with an antibiotic solution. Annals of Surgery, 169,914.
British Journal of Plastic Surgery Julian, D. C., Lopez-Belie, M., Dye, W. S. and Grove, W. J. (1957). The median sternal incision in intracardiac surgery with extracorporeal circulation. Surgery, 42,753. Jurkiewicz, M. J. and Arnold, P. G. (1977). The omentum: an account of its use in the reconstruction of the chest wall. Annals of Surgery, 185,548.
Jurkiewicz, M. J., Bostwick, J., Hester, R., Bishop, J. B. and Craver, J. (1980). Infected median stemotomy wounds successful treatment by muscle flaps. Annals ofsurgery, 191,738. Majure, J. A., Albin, R. E., O’LknmeU, R. S. aad m, T. J. (1986). Reconstruction of the infected median stemotomy wound. Annals of Thoracic Surgery, 42,9. Nabd, F., Rand, R. P., Hester, T. R., Bostwick, J. R. III and
Jurkiewicz, M. J. (1989). Primary treatment of the infected stemotomy wound with muscle flaps: a review of 211 consecutive cases. Plastic and Reconstructive Surgery, 84,434. Pairolero, P. C., Arnold, P. G. and Danielson, G. K. (1984). Management of recalcitrant median stemotomy wounds. Journal of Tboracic and Cardiovascular Surgery, 88,357. Pearl, S. N. and Dibbell, D. G. (1984). Reconstruction after median stemotomy. Surgery, Gynecology and Obstetrics, 159,47. Serry, C., Bleck, P. C., Javid, H., Hater, J. A., Goldin, M. D., Delaria, G. A. and Nqja6, H. (1980). Sternal wound complications. Management and results. Journal of Tboracic and Cardiovascular Surgery, @I,86 1. Shnmacker, H. B. Jr and Mandelbaum, I. (1963). Continuous antibiotic irrigation in the treatment of infection. Archives of Surgery, 86,384.
The Authors Luis R. Pernia, MD, Assistant Clinical Professor of Plastic Surgery, University of Alabama, Tuscaloosa, Alabama. Howard L. Miller, PkD, MPH, Professor, Department of Psychology, University of Alabama, Tuscaloosa, Alabama; Adjunct Professor of Public Health, University of Alabama at Birmingham. Renato S&z, MD, Assistant Professor, Department of Plastic Surgery, University of Alabama School of Medicine, Birmingham, Alabama Luis 0. Vasconez, MD, Professor and Chair, Department of Plastic Surgery, School of Medicine, University of Alabama at Birmingham Requests for reprints to: Dr Renato Saltz, 3201 Sharpsburg Circle, Birmingham, AL 35213, USA. Paper received 3 August 1989. Accepted 22 October 1990 after revision.
