不同形式横行腹直肌肌皮瓣在乳房再造和胸壁溃疡修复中的应用经验教训及对策

The clinical application of various forms of transverse rectus abdominis musculocutaneous flap in breast reconstruction and chest wall radiation ulcer repairment-Lessons learned and countermeasures

目的总结不同形式下腹部横行腹直肌肌皮瓣(TRAM)用于乳房再造和乳腺癌术后胸壁放射性溃疡修复的疗效和经验。方法本院自2008年1月至2016年2月,共收治61例患者,其中女58例,男3例,年龄39～57岁。其中乳腺癌根治术后一期乳房重建患者37例,术前均接受过多次化疗;乳腺癌术后放疗继发前胸壁放射性溃疡患者24例,均为乳腺癌根治术后辅以放疗后发生,病程12～56个月,长期换药保守治疗迁延不愈并有加重扩大趋势,伴有放射性骨损伤8例,范围涉及锁骨、肋骨及胸骨;胸膜损伤3例;肺损伤2例,合并有患侧臂丛神经损伤导致上肢功能障碍伴上肢淋巴水肿2例。采用单纯带蒂TRAM肌皮瓣(31例)、单纯游离TRAM肌皮瓣(3例)、带蒂TRAM肌皮瓣+腹壁浅静脉吻合(13例)和带蒂TRAM肌皮瓣联合对侧游离DIEP皮瓣移植(14例)。结果修复胸壁放射性溃疡皮瓣面积为22 cm×10 cm～38 cm×15 cm,乳房再造皮瓣面积为16 cm×10 cm～22 cm×13 cm。所有皮瓣供区直接拉拢缝合。3例单纯带蒂TRAM肌皮瓣出现皮瓣远端部分皮肤皮下组织坏死和脂肪液化,其中1例清创后直接拉拢闭合,另外2例清创后以游离股前外侧皮瓣移植修复,其余58例皮瓣均完全成活。术后随访12～108个月,溃疡及肿瘤无复发,重建乳房及胸壁外形功能满意。供瓣区仅遗留线性瘢痕,无腹壁疝形成。结论 TRAM肌皮瓣是乳房再造和修复胸壁放射性溃疡的首选皮瓣之一。根据所需皮瓣大小及皮瓣血运情况采用不同的TRAM肌皮瓣术式是保证手术成功的有效方法。

Objective To review outcome and experience in application of various forms of trans- verse rectus abdominis musculoeutaneous flap in breast reconstruction and chest wall radiation ulcer repairment. Methods From January 2008 to February 2016,61 cases （included 58 female patients and 3 male patients） were admitted, the age ranged from 39 to 57 years old. Among these cases, 37 cases received mastectomy and one-staged breast reconstructive operation and nmltiple chemotherapy preoperatively. The other 24 patients suffered from chest wall radiation ulcer, all occurred after mastectomy and radiotherapy, the course ranged from 12 to 56 months, all received long-time conservative therapy but the patient＇s condition worsened. Of those patients 8 cases suffered radioactive bone injury , involved clavicle, rib and sterum;3 cases suffered pleura injury; 2 cases suffered lung injury; 2 cases suffered brachial plexus injury and upper extremity lymphedema, resulted in upper extremity dysfunction. The patients were treated with pure pedi- cled transverse rectus abdominis musculocutaneous flap （TRAM） musculocutaneous flap in 31 cases, free TRAM musculocutaneous flap in 3 cases, pedicled TRAM musculocutaneous flap plus superficial inferior epigastric vein anastoinosis in 13 cases, and pedicled TRAM musculocutaneous flap combined with contra- lateral free deep inferior epigastric perforator （DIEP） flap in 14 cases. Results The area of flap for chest wall reconstruction ranged from 22 cm × 10 cm to 38 cm × 15 cm, the size of flap for breast reconstruction ranged from 16 cm × 10 cm to 22 cm×13 cm. The donor site was closed directly in all cases. Distal part necrosis and fat liquefaction were noted in 3 cases used pure pedicled TRAM musculocutaneous flap, in 1 case the defect was closed directly after radical debridement, in other 2 cases free anterolateral thigh flap was applied after debridement. All other 58 flaps survived uneventfully. All patients were followed up for 12 - 108 months with satisfied esthetic and functional results in reconstructed chest wall and breast. No local recurrence or ulcer happened. Only linear scar left in the donor sites, no hernia occurred. Conclusions Transverse rectus abdominis musculocutaneous flap is one of the first choice for breast reconstruction and chest wall radioactive ulcer. To ensure the operation success, it is efficient to apply different forms of trans- verse rectus abdominis musculocutaneous flap according to the flap size and blood supply.