Management of sternal wounds by limited debridement and partial bilateral pectoralis major myocutaneous advancement flaps in 25 patients: a less invasive approach.

PURPOSE: Because sternal wound complications after sternotomy can be life threatening and often occur in very sick patients, optimal management of these complications remains an important topic. To decrease postoperative morbidity and shorten the recovery period, the senior author (J.A.A.) sought a less invasive approach to sternal debridement and flap closure in carefully selected patients. The purpose of this study was to evaluate the effectiveness of this approach by obtaining specific outcomes data from a series of patients treated with this less invasive method. MATERIALS AND METHODS: Of the most recent 174 sternal wounds treated by the senior author, 25 underwent limited debridement and partial bilateral pectoralis major advancement flaps. The charts of these 25 patients were reviewed and analyzed. RESULTS: In the 25 patients who underwent limited debridement, there were no mortalities intraoperatively or during the 30-day postoperative period. Six patients (24%) experienced complications after debridement, including 1 recurrent sternal wound infection, 1 partial wound dehiscence, 1 seroma, 1 hematoma, and 1 wound edge necrosis requiring revision. Mean length of hospitalization after the procedure was 10 days, compared with 30 days (P = 0.0001) as previously reported with full debridement (Plast Reconstr Surg 2004; 114:676). Mean estimated intraoperative blood loss was reduced from 331 mL during full debridement to 93 mL (P < 0.0001) with limited debridement (Plast Reconstr Surg 2004; 114:676). There was no increase in postoperative morbidity (24 % vs 13 %, P = 0.2117). CONCLUSIONS: The authors advocate limited sternal debridement and partial bilateral pectoralis major myocutaneous advancement flaps in patients with limited wounds and partially or fully healed sternums. We demonstrate that the procedure is effective but less invasive than complete debridement, reduces operative time and blood loss, and shortens length of hospitalization.

Adenovirus-driven overexpression of proteinases in organ-cultured normal human corneas leads to diabetic-like changes.

Our previous data suggested the involvement of matrix metalloproteinase-10 (MMP-10) and cathepsin F (CTSF) in the basement membrane and integrin changes occurring in diabetic corneas. These markers were now examined in normal human organ-cultured corneas upon recombinant adenovirus (rAV)-driven transduction of MMP-10 and CTSF genes. Fifteen pairs of normal autopsy human corneas were used. One cornea of each pair was transduced with rAV expressing either CTSF or MMP-10 genes. 1-2 x 10(8) plaque forming units of rAV per cornea were added to cultures for 48 h with or without sildenafil citrate. The fellow cornea of each pair received control rAV with vector alone. After 6-10 days additional incubation without rAV, corneas were analyzed by Western blot or immunohistochemistry, or tested for healing of 5-mm circular epithelial wounds caused by topical application of n-heptanol. Sildenafil significantly increased epithelial transduction efficiency, apparently by stimulation of rAV endocytosis through caveolae. Corneas transduced with CTSF or MMP-10 genes or their combination had increased epithelial immunostaining of respective proteins compared to fellow control corneas. Staining for diabetic markers integrin alpha(3)beta(1), nidogen-1, nidogen-2, and laminin gamma2 chain became weaker and irregular upon proteinase transduction. Expression of phosphorylated Akt was decreased in proteinase-transduced corneas. Joint overexpression of both proteinases led to significantly slower corneal wound healing that became similar to that observed in diabetic corneas. The data suggest that MMP-10 and CTSF may be responsible for abnormal marker patterns and impaired wound healing in diabetic corneas. Inhibition of these proteinases in diabetic corneas may alleviate diabetic keratopathy symptoms.