I cover the chest wall service at The Harefield Hospital . This is an internationally renowned centre for lung and heart transplantation as well as cardiac bypass surgery. I have experience in chest wall reconstruction after deep sternal wound infection (DSWI). I work closely with Cardiac, Thoracic and Transplant surgeons in these challenging cases.

How should Sternal wound infections be managed?

Early debridement of wounds with cardiothoracic colleagues is key as deep sternal wound infections are associated with significant morbidity. Wounds are temporised with vacuum-assisted closure (VAC) before definitive closure with flaps.

Metal work is removed, and devitalised tissue and bone is debrided. Reconstruction is best performed with locoregional flaps. Most defects can be reconstructed with pectoralis muscle flaps that are advanced to fill in the deadspace after sternal debridement. These flaps are either advanced or turned over depending on their blood supply

In larger defects tissue has to be taken from the abdomen either in the form of muscle (rectus abdomi-nis) or the fatty apron of tissue (greater omentum).

What are the evidence based recommendations for the management of sternal infections?

Patients benefit from plastic surgery consultation and reconstruction as early as possible. We suggest that a plastic surgeon should be present at the time of initial debridement following diagnosis of DSWI, as with best practice guidelines for management of open lower limb fractures.

The aim in management of DSWI should be for early flap closure. If flap coverage is not possible at initial debridement due to instability of the patient, then –and only then –should VAC be used alongside aggressive IV antibiotic therapy for interval wound therapy, with plan for delayed closure.

VAC dressing changes should be performed in theatre every 3–4 days, and flap coverage performed as soon as the patient is suitably stable.