Algorithm for classification and treatment of poststernotomy wound infections

The treatment of sternal wound infection still carries a high mortality. Treatment preferences range from more conservative treatments that do not include flaps, to more aggressive reconstructions using different types of flaps, and these could be resolved and standardised using a proper classification with a treatment algorithm. We propose modification of the existing classification, with different proposals for treatment, stressing the importance of the radicality of debridement, and report our results in 31 patients, 24 of whom were well satisfied. Eleven were left with some pain in the chest wall, and eight each with some muscular weakness and less than adequate cosmesis. We would also like to recommend the omental flap as the first choice for selected cases. With our selective approach we have achieved good functional and aesthetic results with satisfied patients

The "dermal cage": a modification of the inferior pedicle breast reduction

In spite of more recent techniques for breast reduction, the inferior pedicle technique has proven to be enduring and still a very popular option in the plastic surgeon's armamentarium despite certain shortcomings. This technique is especially important for treating large breasts with a long sternal notch-to-nipple distance. The modifications we describe in this article overcome some of the main drawbacks of the standard inferior pedicle technique and make the procedure particularly effective when used on appropriately selected patients. This is achieved principally by the creation of a strong, durable, and internalized "dermal cage" that remains fixed to the chest wall in the upper part, as well as on both sides, to support the majority of the remaining breast tissue. This serves several purposes, including narrowing the breast thereby giving good projection and reduction of the N-IMF length of the inferior pedicle. Through suspension and fixation of the inferior pedicle to the chest wall, one can mitigate the effects of gravity on the inferior pedicle. The benefits of this include reduced tension on the T junction, thereby reducing the incidence of wound dehiscence in the immediate postoperative period, while reduction of tension on the nipple-areola complex reduces "bottoming" out over the long term. This process has been the main shortcoming of the inferior pedicle technique to date. The technique was used on 26 patients over a 7-year period with a mean long-term follow-up of 41 months. The results demonstrate the short- and long-term effectiveness of our own particular combination of modifications to previously described techniques and modifications of the inferior pedicle breast reduction. ----- LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266