Vascularized muscle flaps and reoperative approach for complicated, dehisced sternal wounds in children

Vascularized muscle flaps for treatment of mediastinitis and sternal wound dehiscence have become standard treatment practice, but triple-muscle flap reconstruction is reserved for the more complex wounds. The incisional approach for reoperation in such patients is controversial. We report an extremely ill infant, born at 38 weeks gestational age, who underwent an arterial switch procedure for transposition of the great arteries at 12 days of age. Sternal wound infection, dehiscence, mediastinitis, and extensive wound necrosis complicated the postoperative course. The cultured organism Enterobacter is a relatively rare cause for median sternotomy wound infection and was associated with massive postoperative hemorrhage. The infant underwent multiple debridements and at 2 months of age had reconstructive surgery with bilateral pectoralis major muscle advancement flaps combined with a rectus abdominis muscle flap. Three months postreconstruction the infant required reoperation to correct a stenosis at the site of the pulmonary artery anastomosis. This surgery was carried out through the previous median sternotomy scar because it was the safest, most direct approach and would also limit additional scarring. Long-term follow-up at 2 years of age shows a well-developed young boy with no limitations in growth and activity.