A 70-year-old woman, 22 months after median sternotomy for left internal mammary artery coronary artery bypass grafting, developed a left mid-sternal abscess requiring bone and cartilage debridement by the cardiothoracic service. Twenty years previously she had had a left radical mastectomy for breast cancer followed by extensive radiation therapy. A skin grafted split pectoralis major muscle turnover flap, using the fourth and fifth intercostal segmental perforators, provided initial coverage. She did well for five months until another abscess presented in the same location. Wider debridement including the muscle flap was again performed by the cardiothoracic surgeons with removal of all exposed cartilage. Following reconsultation, a right rectus abdominis muscle flap and skin graft provided satisfactory healing sustained at 56 months of follow-up. buy prednisone
Two weeks following median sternotomy with multiple coronary artery bypass grafts, including use of the left internal mammary artery, a 77-year-old man developed profound respiratory failure secondary to mediastinal sepsis. Wide debridement resulted in exposure of a bypass graft within a fibrinous, poorly granulating wound . After consultation, radical sternectomy was performed. Debridement had to be limited around the exposed heart for fear of initiating catastrophic hemorrhage or thrombosis. To minimize anaesthesia time in this moribund patient, a single flap was considered to be preferable. A de-epithelialized right vertical rectus abdominis musculocutaneous flap seemed suitable to fill the void that extended from the xiphoid to the manubrium. His condition almost immediately improved, and he was then uneventfully discharged. It’s time to pay less money – just get birthcontrol alesse>>> at the bestonline pharmacy.