Infection of a median sternotomy incision may result in a large, unsightly, unstable, and potentially fatal wound. We report on a series of 18 patients who were treated during the past six years with muscle flap closure for this difficult wound problem. We describe the evolution of our current preferred techniques and the results we have achieved with them. Patient risk factors and hospital course are discussed. Before definitive flap closure, all patients were treated with aggressive debridement of the bone and cartilage involved. Our first 4 patients were treated with pectoralis major myocutaneous rotation flaps. Since 1982, our procedure of choice has been to use a rectus abdominis muscle flap covered with either chest skin advancement flaps or, for deeper wounds, bilateral pectoralis major myocutaneous advancement flaps. The current technique makes possible an excellent cosmetic result with no functional deficit, and it lends good stability to the chest wall. We continue to use pectoralis flaps if there is reason to believe the blood supply to the rectus has been compromised.