Sir:
We read with great interest the article entitled “The Split Pectoralis Flap: Combining the Benefits of Pectoralis Major Advancement and Turnover Techniques in One Flap” (Plast Reconstr Surg. 2017;139:1474–1477).1 The authors performed a retrospective study in which they evaluated a new technique for the reconstruction of sternal wounds in which the pectoralis major flap was split and harvested as an advancement and turnover flap. The authors treated 11 patient with this technique, with few complications. In our opinion, this technique is very useful, especially to cover the distal part of the sternum. The risk of recurrence is high in these patients, and thus preserving the contralateral muscle flap permits having another choice for a second reconstruction. The advancement of a pectoralis flap does not permit total coverage of the inferior part of the sternum, which is the most common site for dehiscence after sternotomy, and does not fill the dead space.2 In our practice, to overcome this problem, we usually perform a monolateral advancement flap with mobilization of a rectus fascia flap.
Two main points of the article remain doubtful. First, these patients are usually anticoagulated, and thus splitting the muscle fibers can increase the risk of bleeding and hematoma formation, which reaches 20 percent in some clinical series.3 Furthermore, usually the internal mammary vessels are not present because of their use in previous cardiac surgery.
In our practice, we carry out a staged reconstruction,4 consisting of surgical débridement and negative-pressure therapy until negativization of microbiological specimens is achieved. Negative-pressure therapy led to early removal of infective material3,5 and helped to reduce dead space.4 Then, a monolateral advancement pectoralis major flap, including a piece of rectus fascia, is harvested for wound closure. We congratulate the authors on the newly described technique because it led to coverage of the entire sternum and full obliteration of the inferior dead space with reduction of the area for seroma formation and long-term wound stability.
DISCLOSURE
All authors have no potential conflict of interests and have not received any funding for this work. None of the authors received any funds or has any financial interests to disclose.
Paola Parisi, M.D.
Federico Lo Torto, M.D.
Bruno Carlesimo, M.D.
Diego Ribuffo, M.D.
Nicolò Scuderi, M.D.
Department of General and Plastic Surgery
Policlinico Umberto I
“Sapienza” University of Rome
Rome, Italy
REFERENCES
1. Brown RH, Sharabi SE, Kania KE, Hollier LH Jr, Izaddoost SA. The split pectoralis flap: Combining the benefits of pectoralis major advancement and turnover techniques in one flap. Plast Reconstr Surg. 2017;139:14741477.
2. Hultman CS, Culbertson JH, Jones GE, et al. Thoracic reconstruction with the omentum: Indications, complications, and results. Ann Plast Surg. 2001;46:242249.
3. Raja SG, Berg GA. Should vacuum-assisted closure therapy be routinely used for management of deep sternal wound infection after cardiac surgery? Interact Cardiovasc Thorac Surg. 2007;6:523527.
4. Carlesimo B, Lo Torto F, Rossi A, Marcasciano M, Ruggiero M. Long-term result of bilateral pectoralis major muscle advancement flap in median sternotomy wound infections. Eur Rev Med Pharmacol Sci. 2014;18:37673772.
5. Lo Torto F, Ruggiero M, Parisi P, Borab Z, Sergi M, Carlesimo B. The effectiveness of negative pressure therapy on infected wounds: Preliminary results. Int Wound J. doi: oai:research.unite.it:11575/95080 [Epub ahead of print].
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