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J Thorac Cardiovasc Surg 2006;132:1475-1476
© 2006 The American Association for Thoracic Surgery
Brief Communication |
Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pa.
Received for publication July 31, 2006; accepted for publication August 7, 2006. * Address for reprints: Victor O. Morell, MD, Chief, Cardiothoracic Surgery, Children’s Hospital of Pittsburgh, Associate Professor of Surgery, University of Pittsburgh, Room 2820, 3705 Fifth Ave, Pittsburgh, PA 15213 (Email: victor.morell{at}chp.edu).
To improve the cosmetic result of the standard vertical median sternotomy incision, William and Hanlon1
in 1960 introduced the transverse submammary incision for median sternotomy. This operative approach has proved especially useful for female patients undergoing simple cardiac surgical procedures, resulting in a more esthetically pleasing scar. Although used in some centers, it has not gained worldwide popularity because of concerns related to potential wound complications, adequacy of surgical exposure, and access for reoperation. We have reviewed our experience with the submammary incision in more than 100 patients undergoing repair of simple and complex congenital heart lesions.
This was a retrospective analysis of 106 consecutive female patients undergoing cardiac surgical procedures through the submammary approach for congenital heart defects. Their ages, surgical procedures, reoperations, and wound complications were examined.
A transverse surgical incision, extending from anterior axillary line to anterior axillary line, was performed at the level of the inferior mammary crease when present, or alternatively at the level of the xiphisternal joint in younger patients. The superior skin flap was created with electrocautery to the level of the sternal notch. Once the sternum was divided and the sternal retractor was placed, the skin flap was retracted superiorly with a self-retaining retractor. At the time of wound closure, a subcutaneous drain was placed under the superior skin flap in all cases.
The mean patient age was 3.9 years (range 1 month–44 years). The surgical procedures, recorded in Table 1, included both simple and complex operations. There were no deaths in this group. Wound complications (Table 2) included seroma formation in 5 patients (4.5%), superficial wound infection in 2 patients (1.8%), hematoma formation in 1 patient (0.9%), and partial superior skin flap necrosis in 1 patient (0.9%). Five patients underwent reoperation through a previous transverse submammary incision with no wound complications.
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During the last decade, there has been a renewed interest in improving the cosmetic results of cardiac surgical incisions, especially in female patients. Our preference has been to offer the submammary incision to female patients to avoid the unattractive scar associated with the standard vertical median sternotomy incision.
Although first described more than 40 years ago, the use of the submammary incision in cardiac surgery is still associated with concerns regarding surgical exposure, wound complications, and breast development. As with others,2-5 we have found that this surgical approach provides excellent exposure of the mediastinum, thus allowing the repair of both simple and complex congenital heart lesions. Although only a small number of patients (n = 5) underwent reoperations through a reopened submammary incision, we found no increase incidence of wound complications in this group. This agrees with the findings of Odim and associates,2 who reported on a series of 15 patients undergoing cardiac operations through a reopened submammary incision with minimal complications.
We observed a low incidence of wound complications with this type of incision in our series. The most frequent problem noted was the development of a seroma underneath the superior skin flap. These cases were treated with the placement of a subcutaneous drain, which was then managed on an outpatient basis. One patient had a small area of skin necrosis develop in the central portion of the superior flap; this was thought to be related to excessive upward traction of the skin flap.
Although we did not assess breast development in our patient population, other centers3,5 have reported normal breast development and function after a submammary incision. An incision that avoids the breast tissue is an important factor in promoting normal, symmetric breast development.5 One of the concerns with this approach in neonates, infants, and young female patients is where to place the incision to avoid the breast tissue. For these patients, we have opted to place a horizontal incision at the level of the xiphisternal junction, which should be safely below the inferior mammary crease and sufficiently removed from breast tissue.
In conclusion, the submammary incision provides a sensible alternative to the standard vertical median sternotomy incision for female patients undergoing repair of a congenital cardiac lesion. It results in an esthetically located scar with a low incidence of wound complications.
References
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