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Free Flap Reconstruction of Sternal Defects after Cardiac Surgery: An Algorithmic Approach for Dealing with Sparse

Amir K Bigdeli1,2, Florian Falkner1,2, Volker J Schmidt3

  • 1From the Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Ludwigshafen, Germany.

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Summary

A standardized algorithm for microsurgical free flap sternal reconstruction significantly reduced flap necrosis and operation time. This approach improves outcomes for patients with sparse recipient vessels after cardiac surgery.

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Area of Science:

  • Microsurgery
  • Cardiovascular Surgery
  • Plastic Surgery
  • Wound Healing

Background:

  • Sternal defects after deep sternal wound infection (DSWI) post-cardiac surgery present reconstruction challenges due to sparse recipient vessels.
  • Microsurgical free flap reconstruction is a common method for addressing these complex defects.

Purpose of the Study:

  • To evaluate the efficacy of a standardized algorithm for managing sparse recipient vessels in microsurgical free flap sternal reconstruction.
  • To compare outcomes between patients treated with the algorithm and a historical control group.

Main Methods:

  • A retrospective study comparing 46 patients (Group A) treated with a standardized algorithm (Jan 2013-May 2021) against 29 historical controls (Group B, Jan 2000-Dec 2012).
  • The algorithm prioritized right internal mammary artery (RIMA) and vein (RIMV), utilizing cephalic vein (CV) or arterio-venous loops (AVL) when necessary.
  • Key outcomes included operative details, surgical complications (e.g., flap necrosis), and reconstructive success.

Main Results:

  • The algorithmic approach significantly decreased partial flap necrosis (7% in Group A vs. 24% in Group B, P=0.04).
  • Overall operation time was reduced with the algorithm (360±88 min in Group A vs. 415±80 min in Group B, P=0.01).
  • The algorithm facilitated the use of RIMA and RIMV, with CV turndown and AVL as alternative venous outflow or arterial inflow/outflow strategies.

Conclusions:

  • A standardized algorithm for microsurgical free flap sternal reconstruction effectively addresses challenges posed by sparse recipient vessels.
  • This systematic approach leads to improved clinical outcomes, including reduced flap necrosis and shorter operative times.
  • The findings support the adoption of standardized algorithms in managing complex sternal reconstructions post-cardiac surgery.