Each of the following is appropriate for managing acute suppurative mediastinitis except:

A. Alloplastic material and skin flaps.

DISCUSSION: Alloplastic materials may be nonreactive in the laboratory and biologically acceptable in other areas (artificial hips, breast prostheses). Their introduction into a contaminated wound, however, would more likely promote rather than reduce infection. Various meshes and other types of “protection” devices are not necessary. Skin flaps alone do not obliterate dead space and have not been shown either to reduce or resist infection. The rectus abdominis muscle is a superb source of readily available tissue that can be rotated into very large cavities. The nature of the muscle allows it to be “dressed into” irregular cavities. It has an excellent, easily movable skin territory overlying it, which can also be transferred if locally available skin is wanting. The omentum has the great ability to fit into the many irregularities of some defects. For appropriately selected cases it is excellent. The pectoralis major muscle flaps are the usual initial choice since they are in the operative field. When the musculotendinous insertion is released their mobility is often sufficient. Additionally, it avoids the need for abdominal incisions. The latissimus dorsi muscle as a flap is dependable and includes sternal defects in the scope of its arc of rotation. It requires rotating the patient on the operating table and thus is less readily available than the other flaps.