带蒂腹直肌皮瓣联合游离腹壁下动脉穿支皮瓣移植重建胸壁巨大缺损的手术策略  

Surgical strategy of huge chest wall defect reconstruction using pedicled rectus abdominis musculocutaneous flap combined with free deep inferior epigastric artery perforator flap

作　　者：宋达疆[1] 李赞[1] 章一新[2] SONG Dajiang;LI Zan;ZHANG Yixin(Department of Oncology Plastic Surgery,Hunan Cancer Hospital and Affiliated Cancer Hospital of Xiangya School of Medicine,Central South University,Changsha 410008,China;Department of Plastic and Reconstructive Surgery,Shanghai Ninth People’s Hospital,Shanghai Jiao Tong University School of Medicine,Shanghai 200011,China)

机构地区：[1]湖南省肿瘤医院肿瘤整形外科,湖南省长沙市410008 [2]上海交通大学医学院附属第九人民医院整复外科,上海市200011

出　　处：《组织工程与重建外科》2022年第5期386-392,共7页Journal of Tissue Engineering and Reconstructive Surgery

摘　　要：目的探讨应用带蒂腹直肌皮瓣联合游离腹壁下动脉穿支皮瓣移植重建局部晚期乳腺癌术后胸壁巨大缺损的手术策略。方法2007年8月至2018年10月,共收治病灶切除后继发缺损需行下腹部皮瓣移植修复的局部晚期乳腺癌女性患者89例,继发软组织缺损面积为25.0 cm×12.0 cm~31.0 cm×16.0 cm,全部采用带蒂腹直肌皮瓣联合游离腹壁下动脉穿支皮瓣进行修复,皮瓣面积为26.0 cm×12.0 cm~35.0cm×15.0 cm。本组患者均为乳腺癌扩大根治术后遗留的单纯大面积软组织缺损。联合皮瓣的具体形式分为两种:①对侧带蒂腹直肌皮瓣联合同侧游离腹壁下动脉穿支皮瓣;②同侧带蒂腹直肌皮瓣联合对侧游离腹壁下动脉穿支皮瓣。游离腹壁下动脉穿支皮瓣移植的受区血管选择包括胸廓内血管、胸外侧动静脉、胸肩峰血管、胸背血管、胸背血管前锯肌支和颈横动静脉。采用第二种皮瓣形式时不能选择胸廓内血管作为受区血管。结果采用第一种联合皮瓣形式57例,其中4例腹直肌带蒂皮瓣一侧术后发生边缘部分坏死;采用第二种联合皮瓣形式32例,其中2例在切取过程中发现带蒂腹直肌皮瓣完全没有血供,改为游离腹直肌皮瓣联合游离腹壁下动脉穿支皮瓣移植,3例腹直肌带蒂皮瓣一侧术后发生边缘部分坏死,清创后再采用局部推进皮瓣修复。其余患者伤口均一期愈合,皮瓣完全成活。所有患者顺利完成后期治疗,术后随访12~96个月,平均(29.5±0.3)个月,11例患者失访,完成随访的78例患者中有4例患者局部肿瘤复发(5.1%),4例患者发生脑部转移(5.1%),3例患者发生肝转移(3.8%),6例患者发生肺部转移(7.7%),其余患者恢复良好,皮瓣外观、功能恢复满意,患者生活质量明显提高。结论联合下腹部皮瓣移植安全性高,有助于控制局部晚期乳腺癌病灶,明显提高患者生存质量。其中第一种联合皮瓣形式移植血管吻合选择更加Objective To explore the strategies of pedicle rectus abdominis myocutaneous flap combined with free inferior epigastric artery perforator flap transplantation for reconstruction of huge chest wall defect after local advanced breast cancer.Methods From August 2007 to October 2018,89 patients with locally advanced breast cancer who underwent secondary defect reconstruction with lower abdominal flap were selected.The area of secondary soft tissue defect was 25 cm×12 cm to 31 cm×16 cm.All were repaired with pedicled rectus abdominis flap combined with free inferior epigastric artery perforator flap.The flap size was 26 cm×12 cm to 35 cm×15 cm.All of them were large soft tissue defects left after radical mastectomy.The specific forms of combined flap were divided into two types:①Contralateral pedicled rectus abdominis flap combined with ipsilateral free deep inferior epigastric artery perforator flap;②Ipsilateral pedicled rectus abdominis flap combined with contralateral free deep inferior epigastric artery perforator flap.The recipient vessels of free inferior epigastric artery perforator flap included internal mammary vessels,lateral thoracic arteries and veins,thoracoacromial vessels,thoracodorsal vessels,anterior serratus branches of thoracodorsal vessels and transverse jugular arteries and veins.In cases repaired with the second flap form,intrathoracic vessels cannot be selected as recipient vessels.Results There were 57 cases repaired with the first flap form,of which 4 cases had marginal partial necrosis on the side of the pedicled rectus abdominis flap,and 32 cases repaired with the second flap form,of which 2 cases found that the pedicled rectus abdominis flap had no blood supply at all during the harvesting process,so they were replaced by free rectus abdominis flap combined with free deep inferior epigastric artery perforator flap,and 3 cases had marginal partial necrosis on the side of the pedicled rectus abdominis flap,after debridement,local advancement flap was used for repairing.The wounds of

关 键 词：局部晚期乳腺癌 横行腹直肌皮瓣 腹壁下动脉穿支皮瓣 胸壁重建 

分 类 号：R622[医药卫生—整形外科]