游离下腹部皮瓣的分型及在乳房再造中的应用

Classification of free lower abdominal flap and its application in breast reconstruction

目的探讨下腹部游离皮瓣形式分类、制备策略及在乳房再造中的应用效果。方法收集2015年9月至2020年1月湖南省肿瘤医院和山东中医药大学附属医院行游离下腹部皮瓣移植即刻或延期乳房再造的乳腺癌患者资料进行回顾性分析。术中根据穿支实际情况制备以下4种形式的下腹部皮瓣进行乳房再造:(1)游离全段腹直肌肌皮瓣;(2)携带内侧或外侧部分腹直肌的游离腹直肌肌皮瓣;(3)携带中间部分腹直肌的游离腹直肌肌皮瓣;(4)游离腹壁下动脉穿支(DIEP)皮瓣。统计分析各类下腹部皮瓣的术中情况(皮瓣质量、血管蒂长度、制备时间等)、再造乳房外观及并发症情况。计量资料采用x±s表示。结果共纳入181例乳腺癌患者,其中Ⅰ期111例,Ⅱ期70例,患者年龄(38.5±4.8)岁(25~64岁)。共制备197侧游离下腹部皮瓣。其中,制备游离全段腹直肌肌皮瓣12侧(6.1%),皮瓣质量为(355.8±16.4)g,血管蒂长度为(5.7±0.8)cm,制备时间为(37.4±2.5)min;携带内侧或外侧部分腹直肌的腹直肌肌皮瓣41侧(20.8%),皮瓣质量为(357.4±20.5)g,血管蒂长度为(6.9±0.6)cm,制备时间为(45.9±4.9)min;携带中间部分腹直肌的腹直肌肌皮瓣68侧(34.5%),皮瓣质量为(362.6±24.7)g,血管蒂长度为(7.2±0.3)cm,制备时间为(49.4±6.3)min;游离DIEP皮瓣76侧(38.6%),皮瓣质量为(368.4±24.0)g,血管蒂长度为(9.8±0.4)cm,制备时间为(49.7±3.1)min。3例患者术后发生血肿,急诊探查清除血肿,所有皮瓣均完全成活。12例患者术后6~24个月行脂肪注射局部修整。随访14~60个月,平均37.1个月,未出现乳腺癌复发病例;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;采用全段腹直肌肌皮瓣和游离DIEP皮瓣的患者各有1例发生轻度腹壁疝,二次手术加强腹直肌前鞘后缓解。结论下腹部穿支血管的位置、大小、来源以及血管蒂的解剖情况变化较为复杂,必须根据实际情况采取相对最安全的皮瓣制备形式。DIEP皮瓣并不是游离下腹部皮瓣唯一的选择。

Objective To explore the classification and harvesting strategy of free lower abdominal flap.Methods From September of 2015 to January of 2020,the data of breast cancer patients who underwent immediate or delayed breast reconstruction with free lower abdominal flap transplantation in Hu’nan Cancer Hospital and the Affiliated Hospital of Shandong University of Traditional Chinese Medicine were collected and analyzed retrospectively.According to the actual situation of perforating branch,four types of lower abdominal flap were prepared:(1)free full segment rectus abdominis flap;(2)free rectus abdominis flap with medial or lateral segment of rectus abdominis muscle;(3)free rectus abdominis flap with middle segment of rectus abdominis muscle;(4)free deep inferior epigastric artery perforator(DIEP)flap.The intraoperative conditions(flap weight,vascular pedicle length,harvesting time,etc.),appearance of reconstructed breast and complications of various lower abdominal flaps were statistically analyzed.Measurement data are expressed by Mean x±SD.Results A total of 181 patients with breast cancer were included,including 111 stage Ⅰ patients and 70 stage Ⅱ patients.The age of the patients was(38.5±4.8)years old(25-64 years old).A total of 197 free lower abdominal flaps were harvested.Twelve(6.1%)free full segment rectus abdominis flaps were harvested.The weight of the flap was(355.8±16.4)g,the average length of vascular pedicle was(5.7±0.8)cm,and the average harvesting time was(37.4±2.5)min.Forty-one(20.8%)rectus abdominis flaps with medial or lateral rectus abdominis muscle were harvested,the weight of the flap was(357.4±20.5)g,the average length of vascular pedicle was(6.9±0.6)cm,and the average harvesting time was(45.9±4.9)min.Sixty-eight(34.5%)rectus abdominis flaps with middle segment of rectus abdominis muscle were harvested,the weight of the flap was(362.6±24.7)g,the average length of vascular pedicle was(7.2±0.3)cm,the average harvesting time was(49.4±6.3)min.Seventy-six(38.6%)free deep inferior epigastric artery perforator flaps were harvested,the weight of the flap was(368.3±24.0)g,the average length of vascular pedicle was(9.8±0.4)cm,the average harvesting time was(49.7±3.1)min.Hematoma was noted in 3 cases after operation and removed by emergency operation.All the flaps survived completely.Twelve cases received fat lipofilling 6 to 24 months after operation.Patients were followed up for 14 to 60 months,with an average of 37.1 months,and no recurrence of breast cancer occurred.The reconstructed breasts had satisfactory appearance and texture without flap contracture and deformation.There was only linear scar left at the donor site,there was no significant functional deficit of the abdominal wall.Mild abdominal wall hernia occurred in one patient with full segment rectus abdominis flap and one patient with free DIEP flap,which was relieved by further strengthening the anterior sheath of rectus abdominis.Conclusions The location,size and source of perforating vessels in the lower abdomen and the anatomic variations of vascular pedicle are complex.The safest way of flap harvest must be adopted according to the actual situation.The DIEP flap is not the only choice of free lower abdominal flap.