肋间神经营养血管穿支在下腹部皮瓣中的作用研究

Role of intercostal neurovascular perforator in lower abdominal flap

目的 探讨肋间神经营养血管穿支能否为下腹部皮瓣供血。方法 2017年6月—2020年12月,对39例下腹部优势穿支来源于肋间神经营养血管的女性患者,选择以腹壁下血管主干联合肋间神经营养血管穿支制备游离下腹部皮瓣再造乳房。患者年龄28~52岁,平均38.6岁。左侧16例,右侧23例。乳腺癌病程3~32个月,平均21.8个月。病理分期:Ⅱ期31例,Ⅲ期8例。其中,25例一期肿瘤切除及乳房再造,14例延期乳房再造。结果 术中32例制备一侧血管蒂下腹部皮瓣,均为腹壁下血管主干联合肋间神经营养血管穿支供血;7例制备两侧血管蒂下腹部皮瓣,其中4例为一侧腹壁下血管主干联合肋间神经营养血管穿支联合对侧传统腹壁下血管穿支供血,3例两侧均为腹壁下血管主干联合肋间神经营养血管穿支供血。以腹壁下血管主干联合肋间神经营养血管穿支供血皮瓣中,肋间神经营养血管穿支为一支型15侧、一支+网状型19侧、网状型8侧。皮瓣切取范围为26 cm×10 cm~31 cm×13 cm;厚2.5~5.5 cm,平均2.9 cm;血管蒂长度7.0~11.5 cm,平均9.2 cm;皮瓣质量350~420 g,平均390 g。术后皮瓣均完全成活,供、受区切口均Ⅰ期愈合。患者均获随访,随访时间14~35个月,平均25.4个月。再造乳房外形可,质地满意,无皮瓣挛缩变形。皮瓣供区仅遗留线性瘢痕,腹壁功能无明显影响。随访期间未见乳腺癌复发。结论 腹壁下动脉直接穿支血管不能为下腹部皮瓣提供可靠血供时,选择腹壁下血管主干联合肋间神经营养血管穿支可以确保皮瓣血运。

Objective To investigate if intercostal neurovascular perforator can nourish lower abdominal flap.Methods Between June 2017 and December 2020,in 39 female patients with predominant perforator originated from intercostal nerve nutrient vessels,main trunk of the deep inferior epigastric vessels was chosen to be the pedicle to harvest free lower abdominal flap for breast reconstruction.The age of the patients ranged from 28 to 52 years,with an average of38.6 years.There were 16 cases on the left and 23 cases on the right.The duration of breast cancer was 3-32 months,with an average of 21.8 months.Pathological stage was stageⅡin 31 cases and stage Ⅲ in 8 cases.Among them,25 cases were primary tumor resection and one stage breast reconstruction and 14 cases were delayed breast reconstruction.Results The lower abdominal flap pedicled with one side pedicle was harvested in 32 cases,all of which were supplied by the main trunk of the deep inferior epigastric vessel combined with the intercostal neurovascular perforator;7 cases were harvested with bilateral pedicled lower abdominal flaps,of which 4 cases were supplied by the main trunk of the deep inferior epigastric vessel combined with intercostal neurovascular perforator on one side and deep inferior epigastric artery perforator on the other side,and the other 3 cases were supplied by bilateral main trunk of the deep inferior epigastric vessel and the intercostal neurovascular perforator.In the flaps nourished with the main trunk of the deep inferior epigastric vessel combined with the intercostal neurovascular perforator,the intercostal neurovascular perforators were one branch type in 15 cases,one branch+reticular type in 19 sides,and reticular type in 8 sides.The size of flap ranged from 26 cm×10 cm to 31 cm×13 cm;the thickness was 2.5-5.5 cm(mean,2.9 cm);the vascular pedicle length was7.0-11.5 cm(mean,9.2 cm);the weight of the flap was 350-420 g(mean,390 g).All the flaps survived completely and the incisions at donor sites healed by first intention.All patients were followed up 14-35 months(mean,25.4 months).The shape,texture,and elasticity of reconstructed breasts were good and no flap contracture happened.Only linear scar left at the donor site,the function of abdomen was not affected.No local recurrence happened.Conclusion When the direct perforator of the deep inferior epigastric artery may not provide reliable blood supply for the lower abdominal flap,the intercostal neurovascular perforator with deep inferior epigastric vessels can ensure the blood supply of the free lower abdominal flap.