胸壁全层缺损的修复重建

RECONSTRUCTION OF FULL-THICKNESS CHEST WALL DEFECTS

目的探讨胸壁全层缺损的修复重建方法及疗效。方法 2006年1月-2010年12月,收治14例胸壁全层缺损患者。男8例,女6例;年龄23～65岁,平均42岁。恶性肿瘤切除术后继发胸壁全层缺损12例,乳腺癌术后继发放射性损伤1例,热压伤1例。缺损范围为8 cm×5 cm～26 cm×14 cm。所有患者均伴肋骨缺损(1～5根),3例伴胸骨缺损。术中10例患者应用涤纶网或聚四氟乙烯补片行骨性重建,4例未作骨性重建。分别采用双叶皮瓣、胸大肌肌皮瓣、背阔肌肌皮瓣、腹直肌肌皮瓣修复软组织缺损,皮瓣切取范围为10 cm×7 cm～25 cm×13 cm。供区直接拉拢缝合或游离植皮修复。结果术后2例发生创面愈合不良,经再次彻底清创、肌皮瓣修复和补充植皮后愈合;其余皮瓣均顺利成活,创面Ⅰ期愈合。术后患者均获随访,随访时间6～36个月,平均8个月。除1例骨肉瘤患者因肝转移于术后6个月死亡,其他肿瘤患者随访期间均无复发。热压伤患者未同期行胸壁骨性重建,术后5 d出现短暂轻度反常呼吸,其他患者术后胸廓稳定性良好,无明显反常呼吸及呼吸困难。结论根据胸壁缺损病因、面积和部位,单独或联合应用局部皮瓣或肌皮瓣进行胸壁软组织缺损修复,必要时应用人工材料行胸壁骨性重建,可有效修复严重胸壁全层缺损。

Objective To investigate the surgical techniques and effectiveness for reconstruction of severe full-thickness chest wall defects.Methods Between January 2006 and December 2010,14 patients with full-thickness chest wall defects were treated,including 12 cases caused by giant chest wall malignant tumor excision,1 case by thermocompression injury,and 1 case by radiation necrosis.There were 8 males and 6 females with an average age of 42 years（range,23-65 years）.The size of chest wall defects ranged from 8 cm × 5 cm to 26 cm × 14 cm.All patients complicated by rib defect（1-5 ribs）,and 3 cases by sternum defect.Thoracic skeleton reconstruction was performed with Vicryl mesh or polytetrafluroethylene mesh in 10 patients.Other 4 patients did not undergo thoracic skeleton reconstruction.The bilobed skin flaps,pectoralis major myocutaneous flap,latissimus dorsi myocutaneous flap,and rectus abdominis myocutaneous flap were utilized for repairing soft tissue defects.The size of the dissected flaps ranged from 10 cm × 7 cm to 25 cm × 13 cm.The donor sites were sutured directly or were repaired by free skin graft.Results Poor healing of incision occurred in 2 cases,which was cured after debridement,myocutaneous flap transfer,and skin graft.The other wounds healed by first intention.All patients were followed up 6-36 months（mean,8 months）.No tumor recurrence during follow-up,except 1 patient with osteosarcoma who died of liver matastasis at 6 months after operation.Transient slight paradoxical respiration occurred in 1 patient who did not undergo thoracic skeleton reconstruction at 5 days after operation.Integrity of chest wall in other patients was restored without paradoxical respiration and dyspnea.Conclusion Depending on the cause,the size,and the location of defect,single or combination flaps could be used to repair soft tissue defect,and thoracic skeleton reconstruction should be performed when defect is severe by means of synthetic materials.