Reply: The Split Pectoralis Flap

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We thank the authors for their response to our 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 Postoperative hematomas are a special concern in the cardiovascular patient, as many of these patients require anticoagulation during the perioperative setting. At our institution, the postoperative heparin protocol includes bedrest for 2 days and the initiation of anticoagulation with heparin without a loading dose on postoperative day 1. Fortunately, we have not seen a high bleeding and hematoma rate using this protocol. Although it is true that this population is often anticoagulated before undergoing sternal reconstruction, in patients with prior biomechanical valves, the risk of perioperative thromboembolic events is low for short-term interruption of anticoagulation, specifically, when the drug regimen is stopped for 1 to 3 days preoperatively and 1 to 7 days postoperatively.2
Parisi et al. also bring up an outstanding point with regard to the blood supply of the pectoralis turnover flap in the absence of bilateral internal mammary arteries, because of their harvest for cardiac surgery.3 At our institution, it is rare for cardiovascular surgeons to use both arteries, as a higher sternal wound rate has been observed for patients with a history of bilateral internal mammary artery harvest when compared to unilateral harvest. In a randomized controlled study by Taggart et al. performed at 28 cardiac centers in seven countries, the rate of sternal wound complications was 3.5 percent in the bilateral internal mammary artery harvest group versus 1.9 percent in the unilateral internal mammary artery harvest group (p = 0.005).4 In a recent meta-analysis by Buttar et al., the incidence of deep sternal wound infection was significantly greater in the bilateral internal mammary artery harvest group (1.8 percent) compared with the unilateral harvest group (1.4 percent) (p = 0.0008).5 During our preoperative planning, if both internal mammary arteries have been harvested, we refrain from performing a split pectoris turnover flap, and instead perform a bilateral advancement. In addition, we use Doppler imaging to confirm the blood supply intraoperatively. If there is inadequate healthy tissue to fill the inferior dead space, we use the rectus abdominis or omental flaps for additional bulk. However, the use of these flaps adds abdominal donor-site morbidity.
Alternatively, the excellent technique described by Parisi et al. with staged reconstruction for sternal wounds using débridement and negative-pressure therapy followed by unilateral pectoralis advancement and rectus abdominis fascia for inferior sternal wound coverage can be used in these patients.3 When at least one internal mammary artery is available, the split pectoralis turnover flap eliminates the necessity of a second donor site, provides healthy vascularized tissue to enhance wound healing, and is a versatile option for inferior sternal wound coverage.
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