双血管蒂腹壁下动脉穿支皮瓣在乳房再造中的临床应用

Clinical application and planning strategy of bipedicled deep inferior epigastric perforator flaps in delayed breast reconstruction

目的:探讨双血管蒂腹壁下动脉穿支皮瓣在乳房再造手术中的的应用效果和手术适应证。方法:对2015年4月至2019年4月于中国医学科学院整形外科医院应用双血管蒂腹壁下动脉穿支皮瓣进行延期乳房再造患者的临床资料进行回顾分析。术前应用CT血管造影评估腹壁下动脉穿支条件,术中应用吲哚菁绿造影评估灌注范围,判断行双血管蒂腹壁下动脉穿支皮瓣的必要性。对患者基本信息、术前检查、手术方式、并发症、术后乳房形态及肿瘤是否复发等情况进行统计及总结。采用描述性方法进行统计分析。结果:共纳入31例乳腺癌切除术后乳房再造女性患者,年龄30~55岁,平均43.0岁。其中16例行放疗,9例既往手术史导致明显下腹部瘢痕,2例体质量指数低于20 kg/m^(2)。术中切取皮瓣20 cm×8 cm~20 cm×38 cm,手术时间(593±94)min。以双侧腹壁下血管穿支为蒂24例,以腹壁下血管穿支及对侧腹壁浅血管为蒂6例,以双侧腹壁浅血管为蒂1例。血管吻合方面,双血管蒂瓣内吻合6例,与2条受区血管分别吻合25例。31例皮瓣除1例皮瓣边缘坏死外其余全部成活,4例供区脂肪液化,经清创及换药处理后愈合。术后随访10个月至5年,平均13个月,所有患者双侧乳房对称性及外形满意,腹部供区外观良好,无腹部膨隆、腹壁疝等并发症,随访期间乳腺肿瘤无复发。结论:双血管蒂腹壁下动脉穿支皮瓣在提供丰富皮肤软组织的同时能够确保有效血供,可以获得良好的乳房形态。对于胸部组织缺损严重、腹部脂肪较少或下腹部中线瘢痕的延期乳房再造患者是兼具灵活性与可靠性的有效方法。

Objective Introducing clinical application,planning strategy,and surgical tips of bipedicled deep inferior epigastric perforator(DIEP)flaps in delayed breast reconstruction.Methods A retrospective study of patients who underwent delayed breast reconstruction using bipedicled DIEP flaps from April 2015 to April 2019 at the facility of the authors was carried out.Preoperative CT angiograph was performed for evaluation of deep inferior epigastric perforators.Intraoperative indocyanine green angiography was performed for real-time flap perfusion assessment.Baseline data,information of mastectomy and adjuvant therapy,surgical details,and follow-up records were reviewed and collected for statistical analysis.Results A total of 31 patients were enrolled,with years of 43.0 on average(range,30 to 55).Among them 16 patients received radiotherapy(51.6%),9 patients had lower abdominal scars due to previous surgery(29.0%),2 patients had body mass index(BMI)lower than 20 kg/m^(2)(6.5%).Measurements of flaps ranged from 20 cm×8 cm to 20 cm×38 cm.The operative time was 593±94 minutes.Of the 31 flaps enrolled,24 were DIEP/DIEP flaps,6 were DIEP/SIEA flaps,one was SIEA/SIEA flap.Intraflap anastomoses were performed in 6 flaps.The other 25 flaps were anastomosed to separate recipients.There was no flap loss encountered.Marginal necrosis of the flap happened in one patient,fat liquefaction of the donor site occurred in four patients,which was treated with conservative debridement.Patients were followed up for 13 months on average(range,10 to 60 months).No long-term complication was observed during the follow-up.All patients reported satisfying aesthetic outcomes.Conclusions Bipedicled DIEP flaps provide sufficient tissue quantity and reliable blood supply.Patients with severe breast deficiency,lacking lower abdominal fat,or having abdominal midline scars were appropriate to perform this type of flaps for delayed breast reconstruction.