Latissimus Dorsi Flap in the Treatment of Thoracic Wall Defects After Medial Sternotomy

Adam Stepniewski, MD; Joelle Krahlisch, MD; Alexander Emmert, MD; Ahmad-Fawad Jebran, MD; Maximilian Schilderoth, MD; Helen Synn, MD; Gunther Felmerer, MD

Disclosures

ePlasty. 2020;20(e4) 

In This Article

Abstract and Introduction

Abstract

Background: This study aimed to describe the subjective and objective results of the latissimus dorsi muscle flap and propose it as a reconstructive option for postoperative thoracic defects.

Methods: A systematic search for cases with pedicle-based latissimus dorsi flaps performed after medial sternotomy was conducted, and all cases occurred between 2010 and August 2017. Preoperative, intraoperative, and postoperative factors were retrospectively analyzed and then the correlations between prognostic factors and outcomes of flap surgery were calculated. Furthermore, an evaluation of the subjective quality of life after flap surgery was performed using questionnaires.

Results: A total of 25 cases were identified (8 female and 17 male patients) with the mean age of 75.28 years (range, 55–88 years). The average survival rate was 39.63 ± 23.03 months. The proportion of patients with a survival rate of 1 year was 84.00% (21 patients), and the proportion of patients with a 2-year survival rate was 80.00% (20 patients). While 24% of all patients who had latissimus dorsi flap operations experienced no complications, 64% of them developed minor complications (non–life-threatening, Clavien-Dindo grades I-IIIb) and 12% of them developed major complications (life-threatening, Clavien-Dindo grades IV-V). There was a significant correlation between the low survival rate and risk factors such as a positive history of smoking (P = .034), renal insufficiency (P = .022), metabolic syndrome (P = .004), and the presence of postoperative complications (P < .00002). No significant correlation was observed between the survival rate and obesity (P = .396), hyperlipoproteinemia (P = .684), arterial hypertonia (P = .0450), diabetes (P = .891), cardiovascular comorbidities (P = .794), the interval between sternotomy and latissimus flap surgery (P = .075), the duration of flap surgery (P = .207), sternal osteitis (P = .78), and intraoperative application of norepinephrine (P = .818). We identified metabolic syndrome (hazard ratio: 6.27), renal insufficiency (hazard ratio: 3.935), and the presence of postoperative complications (hazard ratio: 2.965) as high-risk prognostic factors. The subjective evaluations revealed positive reports from the patients with an average score of 1.86 ± 1.03 (1.0 = very good; 5.0 = poor).

Conclusions: The majority of the patients with defects after median sternotomy were treated successfully with the latissimus dorsi flap. High survival rates, low rates of severe complications, and subjective scoring of improved life quality make this procedure relative safe and reliable. However, some prognostic risk factors limit the outcome, so these factors should be considered during surgical planning.

Introduction

The advances in medical care, as well as the prolonged life expectancy, nowadays have led to an increased number of elderly and multimorbid patients who need cardiothoracic treatment. This leads to an increasing number of postoperative complications, such as wound-healing disorder and sternal osteomyelitis, which can result in high postoperative morbidity and mortality.[1] The mortality rate of patients with postoperative sternal defects is up to 50%, if left untreated.[2,3]

Thoracic wall defects can cause a life-threatening problem, so the therapeutic concept should consider various mechanical and functional aspects. The defect has to be covered with healthy tissue to enhance the local perfusion, allowing the wound to heal. Simultaneously, the therapy needs to preserve vital mediastinal structures and to restore thorax stability for respiratory function.[3]

When designing their therapeutic plans, surgeons have to understand the anatomical and physiological aspects related to the defect of the thoracic cavity, and different surgical techniques can be applied to cover wounds in reconstructive surgical procedures.

This study aimed to describe the subjective and objective results of a single reconstructive procedure (latissimus dorsi muscle flap surgery) for thoracic defects, as this is one of the flap techniques commonly used for chest wall reconstruction. The preoperative, intraoperative, and postoperative factors affecting the outcome are identified along with their correlations to the survival rate. Furthermore, prognostic risk factors are evaluated.

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