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

Results

A total of 25 patients who received latissimus dorsi flaps through reconstructive surgical procedures (8 female and 17 male patients, mean age: 75.28 years; range, 55–88 years) were included in our study. The proportion of patients with a survival rate of 1 year was 84.00% (21/25 patients), and the proportion of patients with a 2-year survival rate was 80.00% (20/25 patients). When the evaluation was completed, 11 of 25 patients had died. While 24% of the operated patients had 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) (Table 1 and Table 2; Figure 1). There was a strong correlation between low survival rates and the presence of postoperative complications (P < .00002) (Figure 2).

Figure 1.

Bar graphic Clavien-Dindo classification.

Figure 2.

Kaplan-Meier survival curve postoperative complications.

The following risk factors also showed a significant correlation for decreased postoperative survival rates: the presence of preexisting renal insufficiency (P = .022) and a positive history of smoking (P = .034) (Figure 3 and Figure 4). Concerning the latter, it did not matter whether the patient was an active smoker at the time of flap surgery or he or she had only been a smoker in the past. However, we could not demonstrate a correlation between the history of smoking and the occurrence of flap tissue necrosis or wound-healing delays (P = .791). While the presence of metabolic syndrome had a significant correlation with decreased survival rates (P = .004) (Figure 5), it did not have a correlation with the occurrence of complications (P = .842).

Figure 3.

Kaplan-Meier survival curve renal insufficiency.

Figure 4.

Kaplan-Meier survival curve smoking.

Figure 5.

Kaplan-Meier survival curve effect of metabolic syndrome.

No statistically significant correlation was found between the presence of obesity (grade I vs grade II vs grade III vs grade IV: 42.10 ± 30.07 months vs 37.22 ± 19.51 months vs 41.07 ± 21.83 months vs 38.30 ± 50.77 months, respectively; P = .396) and the survival rate. Patients with comorbidities lived for a shorter period than the patients without comorbidities (patients with diabetes: 36.65 ± 25.66 months vs patients without diabetes: 44.93 ± 17.51 months; patients with sternal osteitis: 38.70 ± 13.54 months vs patients without sternal osteitis: 45.59 ± 28.12 months), but the difference was not statistically significant (P = .891 and P = .78, respectively).

The average interval between sternotomy and latissimus flap surgery was 72.16 ± 72.73 days. Within this period, several debridements were performed (mean: 6.8 ± 5.92 debridements). Patients were sometimes later referred to the plastic surgery department and required to have flap surgery because of exposed ribs and instable breathing. Concerning this interval, no significant influence on the survival rates could be detected (P = .075). Patients who underwent flap surgery 72 to 152 days (group 2) after sternotomy lived longer than the patients who had the surgery before the 72nd day (group 1) and after the 152nd day of sternotomy (group 3) (group 1 vs group 2 vs group 3: 35.40 ± 24.10 months vs 61.33 ± 14.01 months vs 36.07 ± 3.33 months, respectively).

The average duration of flap surgery was 248 ± 86 minutes. Patients were categorized into 3 groups, based on surgery duration: 160 to 220 minutes (group 1; 12 patients), 221 to 280 minutes (group 2; 5 patients), and longer than 280 minutes (group 3; 8 patients). There was no significant difference concerning survival rates among these 3 groups. However, individuals in group 2 had the highest survival rate (group 1 vs group 2 vs group 3: 37.96 ± 6.82 months vs 77.00 ± 8.05 months vs 48.64 ± 9.26 months; P = .207).

The intraoperative application of norepinephrine did not have a significant influence on postoperative survival rates (P = .818). The subjective evaluation showed better results in early follow-up inpatient treatment after surgery (1.86 ± 1.03) than the late follow-up care in September 2017 (1.93 ± 1.21; 1.0 = very good, 5.0 = poor). We evaluated patient satisfaction and arrived at subjective scorings based on changes in the quality of the patients' lives and of their respiratory function. Three patients (12.00%) reported subjective postoperative alterations in breathing, and 2 of these 3 patients (66.67%) suffered from dyspnea. While taking deep breathing, one of these patients suffered pain due to discomfort in the medial ends of the clavicles. Consequently, he avoided taking deep inhalations, which further led to decreased respiration rate and physical resilience.

processing....