Closure of a sternal defect with the rectus abdominis muscle after sacrifice of both internal mammary arteries.

Infections of the median sternotomy incision are relatively uncommon. Successful treatment of this serious complication consists of adequate surgical debridement and obliteration of mediastinal dead space using the pectoralis major muscle, or the rectus abdominis muscle or both. The recent use of internal mammary artery grafts has created a new problem in closure of defects involving the lower one-third of the sternum. Under these circumstances the use of the rectus abdominis muscle is believed to be contraindicated. To date omental transposition remains the only alternative in therapy. A case of sternal dehiscence after coronary artery bypass surgery is described. Bilateral internal mammary artery grafts were used. A rectus abdominis flap based primarily on the eighth anterior intercostal perforator was transposed into the defect. The wound healed uneventfully after initial loss of a 3-cm portion of the skin graft. Success of this flap based on intercostal perforators is postulated to be secondary to a "delay" phenomenon related to prior division of the dominant blood supply.