Chest drains
It is unusual to perform a radical repair without entering a pleural cavity. Theoretically one can get away without a chest drain as long as there is no air leak and the lung is well inflated at the end of the procedure. However, there is usually some blood loss into the pleura and I will place a basal drain into any pleural cavity I open. If I make only a small hole I tend to enlarge it to make sure the lung is fully inflated.

Suction drains
A 1/4 inch Redivac-style suction drain (Medinorm) is placed deep to the re-approximated muscle flaps and a second drain is placed sub-cutaneously.


After placing the chest drains and the first of the Redivacs, a stay suture is placed connecting the rectus abdominis flap with the two pectoral flaps. Each muscle corner is mattressed to prevent cutting through. Stay suture on muscles
The pectoral muscles are then apposed with a running Vicryl, tying to the stay suture before completing the pectoral/rectus limbs of the Mercedes insignia. Especially with the latter two limbs I try to pick up the deep tissues with alternate sutures to reduce the potential dead space.

Approximating muscle flaps (Quicktime movie 26 secs 2.3Mb)
Pectoral muscle approximation
The superficial drain is placed and the subcutaneous tissues closed with a running Vicryl. As the defect is rarely symmetrical the incision tends to pull one way or the other. I place an initial stay suture to help line up the cutaneous tissues with the aid of the previously placed skin markers. Again, to reduce dead space, I pick up the muscle fascia with alternate sutures.

The skin is closed with an undyed 3/0 Vicryl sub-cuticular suture with all knots buried.
Final result

Postoperative care
Routine postoperative analgesia, chest physiotherapy and drain care are employed. Patients are encouraged to mobilise the day after surgery. Chest drains can come out after 24 hours provided the patient can cough out any collected blood. The superficial Redivac drain can usually be removed after 24 hours but the deeper sub-muscular drain may need to stay 4-5 days till drainage settles.

Patients are usually discharged at 4-5 days. They are discouraged from contact sports for 6-12 months as the sternum does not have its normal supports. While school can be resumed after 2-3 weeks it is sometimes wise to keep boisterous boys away for longer to avoid aggressive play and the danger of a knock on the unstable anterior chest wall.

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