Unfortunately, the rectus abdominis musculocutaneous (VRAM) flap chosen as a sole flap to meet our established criteria in seven patients was complicated by four late infections. This could represent a technical problem on our part as the rectus muscle was never taken below the arcuate line to preserve abdominal wall integrity which was never compromised. Thus the upper third of each sternal defect so closed was devoid of muscle, which we know provides inherent immunological benefits as opposed to dermis or fat alone . This flap choice must then be suspect as a single flap option for the subacute or chronic sternal wound in spite of perceived advantages in simplifying the extent of surgery for these usually very sick patients.Obviously, further insight is welcome to insure the best initial and long term treatment for the difficult sternal wounds. It is important that the risk of recurrence must be recognized as a not insignificant facet of this problem which must be dealt with appropriately.
ACKNOWLEDGEMENTS: The major care for these patients was provided by William S Hoffman MD and Terrill E Theman MD, Division of Cardiothoracic Surgery, St Luke’s Hospital, Bethlehem, Pennsylvania, to whom we are indebted. Safe online shopping for drugs: Birth Control Ortho Tri Cyclen buy here to make your drugs cheaper.