局部晚期乳腺癌切除术后巨大复杂创面的整形外科修复

Surgical reconstruction of complex and huge defect after locally advanced breast cancer ablation

目的总结应用整形外科技术治疗局部晚期乳腺癌的效果。方法回顾性分析2007年8月至2015年12月收治的246例局部晚期乳腺癌切除后继发缺损女性患者的临床资料。患者年龄34～70岁，平均43．7岁，继发软组织缺损面积为12cm×6cm～32cm×28cm，采用不同的皮瓣进行修复。246例中65例合并小面积单纯肋骨或胸骨缺损，采用网片＋皮瓣修复；112例为单纯软组织缺损，采用带蒂皮瓣或游离皮瓣修复；69例为胸壁全层缺损合并胸骨、心前区、大范围的肋骨缺损，采用“网片＋骨水泥＋网片”三明治的方法或者“网片＋骨水泥”方法坚强内固定，并以带蒂或游离皮瓣修复软组织。结果本组病例切取皮瓣面积为13cm×6cm～33cm×29cm。246例中3例单纯腹直肌带蒂皮瓣术后边缘部分坏死，其中2例清创后再采用局部推进皮瓣修复，1例采用游离股前外侧皮瓣移植修复；2例游离腹壁下动脉穿支皮瓣修复术后出现静脉危象，急诊手术探查发现均为血肿所致，清除血块后皮瓣顺利成活；2例游离腹壁下动脉穿支皮瓣修复术后胸壁基底创缘不愈合，进一步扩创后采用游离股前外侧皮瓣移植修复后愈合；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。220例患者获得随访，时间为9～96个月，平均（28．8±0．4）个月，其中52例患者局部肿瘤复发（23．6％），42例患者发生远处转移（19．1％），其余患者皮瓣外观、功能恢复良好，患者满意。结论应用整形外科技术对局部晚期乳腺癌切除后缺损进行修复重建，安全性高，有助于控制局部肿瘤病灶，可以提高患者生存质量。

Objective The purpose of this study is to review the single institutional experience in oncoplastic treatment of locally advanced breast cancer （LABC）.Methods This is a retrospective analysis of 246 female patients who underwent breast and chest wall reconstruction after LABC ablation in the department from August 2007 to December 2015.The mean age of the patients is 43.7 years old,range from 34 to 70 years old.The soft tissue defect size ranged from 12 cm ×6 cm to 32 cm ×28 cm,different flaps were chosen for reconstruction,flap size ranged from 13 cm × 6 cm to 33 cm × 29 cm.Simple rib defects or sternum defects occurred in 65 cases,using mesh repair and flap reconstruction;simple soft tissue defects were noted in 112 cases,pedicled flap or free flap was used;in 69 cases complicated composite chest wall defects involving multiple layers （soft tissue,ribs/sternum,and intrathoracic organs） were repaired with methylmethacrylate/polypropylene mesh sandwich prostheses.The breast and chest wall soft tissue defects were repaired with pedicled or free flap.Results In 3 cases with pedicled rectus abdominis flap partial necrosis was noted,local flap was used after further debridement in 2 cases,in the third case with extensive defect left,free anterolateral thigh flap was transferred for reconstruction.In 2 cases with free deep inferior epigastric artery perforator flap,postoperative venous congestion occurred.The reexploration procedure was carried out,edema was removed and the flap survived thoroughly.In 2 cases with free deep inferior epigastric artery perforator flap postoperative course margin dehiscence and chest wall basement partial necrosis was noted,free anterolateral thigh flap was transferred for reconstruction after thoroughly debridement,the wounds healed smoothly.All other wounds healed uneventfully,all flaps survived totally.The hospital stay time ranged from 12 days to 42 days,all patients received further therapy.The mean follow-up was 28.8 ± 0.4 months,with a range from 9 to 96 months.26 cases were lost for follow up,in the rest 220 cases,local tumor recurrence was noted in 52 cases,distant metastasis was noted in 42 cases,all other patients recovered well,the function and appearance of flaps were satisfactory,the life quality of patients improved notably.Conclusions Oncoplastic techniques are suitable and safe for LABC reconstruction,helpful for oncological local control,can improve patients life quality.