应用腹壁下动脉穿支皮瓣乳房再造的临床研究

Deep inferior epigastric perforator flap for breast reconstruction

目的探讨横行腹直肌肌皮瓣(TRAM瓣)行乳房再造的方法与效果。方法自2000年3月至2006年5月,应用腹壁下动脉穿支(DIEP)皮瓣对44位患者再造乳房,其中3例为双侧再造,17例为乳癌切除术后Ⅰ期即刻再造,27例为Ⅱ期延迟再造。所有患者都分别参加研究,没有患者退出。术后随访患者的腹壁功能、腹部供区满意度和再造乳房满意度,以及再造乳房自发感觉的恢复情况。结果患者的平均年龄38.6岁(28～50岁)。皮瓣的大小平均为11 cm×26 cm(其长10～12 cm,宽15～33 cm)。皮瓣血管蒂长度为9.3 cm(7～12 cm)。术后平均随访时间16个月(3～30个月)。皮瓣全部失活2例,皮瓣部分失活2例。腹部切缘坏死4例。腋窝血肿1例。术后腹壁检查未发现腹壁疝和腹膨出。所有患者日常活动均恢复。腹壁瘢痕直接影响患者对腹部供区的满意度。患者对再造乳房的满意度评分较高。95%的再造乳房有自发神经恢复,但是都未达到或接近正常。结论 DIEP皮瓣游离移植是自体组织乳房再造的一种可靠方法。DIEP皮瓣具有和TRAM瓣相同的优点,同时通过保留腹直肌的完整性,又避免肌皮瓣的缺点。虽然解剖DIEP皮瓣技术难度更大,但是DIEP皮瓣减轻受区损伤,同时能再造更美的乳房。

Objective In the past decade, there has been increasing breast reconstruction after mastectomy. The ideal material for reconstruction of a breast is fat and skin. The Transverse Rectus Abdominis Myoeutaneous （TRAM） flap has been the gold standard for breast reconstruction recently. Abdominal wall function is a major concern for plastic surgeon in breast reconstruction with TRAM flaps. The deep infe- rior epigastric perforator （DIEP） free flap spares the whole rectus abdominis muscle, includes skin and fat only, therefore preserves adequate abdominal wall competence. Methods Between March, 2000 and May, 2005, a total of 47 breast reconstruction in 44 patients were performed by using the DIEP flap. 3 patients had bilateral procedures, 17 breast reconstructions were immediate and 27 were delayed. All patients were collected prospectively and no patients were excluded from this study. Abdomianl function, satisfaction with the donor site and reconstructed breast and the sensation recovery are assessed respecticvely in the follow-up. Results The average age of patients was 38.6 years （ range, 28 - 50 years）. The size of the flaps were ranged from 11 em x26 cm （Range height 10 - 12 cm, width 15 -33 era）. The mean length of vascular pediele was 9.3 cm （range, 7 - 12 cm）. The mean postoperative follow-up period was 16 months （range, 3 to 30 months）. Total flap loss and partial necrosis oceued in 2 flaps （4%） perspectively. Wound edge necrosis in abdoman oceured in 4 patients（9% ）. Axillary seroma oceurd in 1 patient. Postoperative abdominal wall examination did not reveal any hernia. All patients were able to resume their daily activities. Abdominal Scar directly affect the satisfaction with the whole abdominal wall. Patient satisfaction with the reconstructed breast rated high. Spotaneous sensation return in reconstructed breast is 95%, but no one is equivalen or apporximate to normal. Conclusions The data indicate that the free DIEP flap is a new reliable and safe technique for autologous breast reconstruction. This flap offers the patients the same advantages as the TRAM flap and discards the disadvantages of the myocutaneous flap by preserving the continuity of the rectus muscle. The DIEP flap reduces donor site morbidity and is able to provide an aesthetic refinement in breast reconstruction, despite the technically more difficult dissection.