Pectoralis Major Flaps for Sternal Reconstruction: Multidisciplinary Considerations and Patient Outcomes

Sternal wounds following cardiothoracic surgery are a challenging surgical problem, and pectoralis muscle flaps are a mainstay for reconstruction. Multiple variations of this strategy exist, and this study seeks to characterize key decision factors and patient outcomes to increase accessibility of this technique to surgeons.

This is a retrospective cohort study of adult sternal wound patients at a tertiary referral center between 2010-2020. Patient demographics, comorbidities, wound characteristics, and perioperative data were collected. Multinomial logistic regression determined factors significantly associated with reconstructive technique. Binomial logistic regression was used to analyze 90-day readmission and reoperation for sternal wounds.

In total, 114 patients underwent reconstruction with pectoralis flaps. Bilateral advancement flaps were the most common strategy (64%) followed by bilateral advancement/turnover (15%), unilateral advancement (11%), unilateral turnover (8%), and bilateral turnover (2%). The absence of the internal mammary artery was significantly associated with bilateral vs unilateral pectoralis flap reconstruction ( P < 0.01). Deep space sternal wounds were most likely to be treated with a turnover flap component ( P < 0.001). Type of flap reconstruction was associated with sternal wound recurrence ( P < 0.03). However, multivariable logistic regression modeling identified coronary artery disease [odds ratio (OR) = 8.18, P < 0.02], prior cardiothoracic surgeries (OR = 2.95, P < 0.01), and discharge before plastic surgery consultation (OR = 3.73, P < 0.04) as significant predictors of 90-day readmission or reoperations for sternal wound recurrence.

Multiple configurations of the pectoralis major can be utilized for treating sternal wounds. The absence of the internal mammary artery is an important factor given its association with bilateral flap reconstruction, while the turnover pectoralis is more frequently used for deep space wounds. Internal mammary artery patency should be clearly communicated to improve multidisciplinary management of these challenging problems.