游离皮瓣移植乳房再造手术并发血管危象的原因以及分类和分期特点探讨

Causes,classification and staging of vascular crisis in breast reconstruction with free skin flap transplantation

目的探讨并总结游离皮瓣移植乳房再造手术发生血管危象的发生原因、分类和分期特点。方法自2015年6月至2021年6月,湖南省肿瘤医院整形外科统计605例游离皮瓣移植乳房再造的患者,对血管危象的发生情况,并进一步总结归纳血管危象发生的具体原因、分类和分期特点。共纳入一期乳房再造412例,延期乳房再造193例;采用游离下腹部皮瓣547例,游离大腿后内侧皮瓣58例。根据皮瓣颜色、表面温度与周围正常皮肤温度差别以及可听式多普勒监测数据的变化,渐进性动脉血管危象分期:隐匿期,动脉供血障碍期,静脉回流受阻期,血栓形成期,皮瓣坏死期。渐进性静脉血管危象分期:隐匿期,静脉回流受阻期,静脉栓塞期,动脉供血障碍期,血栓形成期和皮瓣坏死期。结果共发生血管危象65例,其中急性动脉血管危象16例,急性静脉血管危象25例,均于术中及时处理并成功挽救。渐进性动脉血管危象10例,2例经及时处理皮瓣移植成功,其余8例失败,5例直接闭合创面,3例游离大腿后内侧皮瓣移植;渐进性静脉血管危象患者14例,5例及时处理皮瓣移植成功,其余9例皮瓣失败,7例行直接闭合创面,2例行游离大腿后内侧皮瓣移植。结论在游离皮瓣移植乳房再造手术中,对皮瓣血管危象进行分类和分期有助于判断血管危象发生的原因以及进展程度,有助于预测开展探查的意义以及成功率、皮瓣坏死的风险和术后效果。

Objective To explore and summarize the causes,classification and staging of vascular crisis in free flap transfer breast reconstruction.Methods From June 2015 to June 2021,a total of 605 cases of free flap transfer breast reconstruction were included in this group,including 412 cases of primary breast reconstruction and 193 cases of delayed breast reconstruction,the flap form included 547 cases of free lower abdominal flap and 58 cases of free posterior medial thigh flap.The occurrence of vascular crisis was counted,and the specific causes,classification and staging characteristics of vascular crisis were further summarized.According to the changes of skin flap color,the difference between flap surface temperature and normal skin temperature,and the changes of monitoring data of audible Doppler,the stages of progressive arterial crisis include:hidden stage,arterial blood supply disorder stage,venous reflux obstruction stage,thrombosis stage and flap necrosis stage.The stages of progressive venous crisis include:hidden stage,venous reflux obstruction stage,venous embolism stage,arterial blood supply disorder stage,thrombosis stage and flap necrosis stage.Results Vascular crisis occurred in65 cases of this group,including 16 cases of acute arterial vascular crisis and 25 cases of acute venous vascular crisis,all of which were treated in time and rescued successfully during the operation.There were 10 cases of progressive arterial vascular crisis,of which 2 cases were treated in time and successfully rescued.Total flap failure occurred in the other 8 cases,in 5 cases the wound was closed directly,in other 3 cases free posterior medial thigh flap was transferred for salvage.In 14 cases of progressive venous vascular crisis,the flaps in5 cases received successfully salvage,and the flaps in the other 9 cases totally failed.In 7 cases the wound was closed directly,in other2 cases free posterior medial thigh flap was transferred for salvage.Conclusion In breast reconstruction with free flap transplantation,classification and staging of vascular crisis of flap is helpful to discriminate the cause and progress of vascular crisis,and to predict the significance and success rate of re-exploration,the risk of flap necrosis and the postoperative effect.