侧胸切口完成游离下腹部皮瓣移植乳房再造的策略和技术要点

Strategies and technical points for breast reconstruction with free lower abdominal flap transplantation through lateral thoracic incision

目的探讨通过侧胸切口完成游离下腹部皮瓣移植乳房再造的的策略和技术要点。方法回顾性分析2022年10月至2023年3月于湖南省肿瘤医院采用侧胸切口完成游离下腹部皮瓣移植单侧乳房再造的患者资料。受区采用侧胸切口,对于乳腺癌初发早期或者保乳术后复发患者先行合适的乳腺癌根治性手术,对于乳腺癌乳房再造术后扩张器取出或者假体包膜挛缩患者先行假体、扩张器去除或者包膜松解术;之后于同一切口下完成游离下腹部皮瓣乳房再造术,术中根据患者实际情况依次完成受区血管制备、供区皮瓣制备、供受区血管吻合和乳房塑形。术后观察并发症情况,并随访评价再造乳房外观及供、受区切口愈合情况。结果共纳入15例女性患者,年龄24~57岁,平均42.3岁,其中初发早期乳腺癌9例,保乳术后复发2例,乳房再造术后扩张器取出2例,假体再造术后包膜挛缩2例。侧胸切口长度为7.5~11.2 cm,平均8.7 cm。6例切取携带3/4部分的下腹部皮瓣,采用单侧腹壁下血管蒂,皮瓣体积为19.0 cm×10.0 cm×4.5 cm~23.0 cm×13.0 cm×6.0 cm,质量280~510 g,平均370 g;9例切取整个下腹部皮瓣,采用双侧腹壁下血管蒂,皮瓣体积为27.0 cm×11.0 cm×5.0 cm~30.0 cm×14.0 cm×6.5 cm,质量420~730 g,平均530 g。受区血管选择胸背血管主干9例,胸背血管前锯肌支4例,胸背血管主干结合前锯肌支2例。术后1例患者皮瓣发生静脉危象,手术失败,其余14例患者皮瓣顺利成活。随访6~17个月,平均10.4个月,再造乳房外形可,质地满意,无皮瓣挛缩变形;皮瓣供区及乳房受区仅遗留线性瘢痕,腹壁及肩关节功能无明显影响。随访期间无肿瘤复发或转移。结论采用侧胸切口实施乳腺癌根治的相关手术时,可以同一切口完成游离下腹部皮瓣移植乳房再造术,手术效果满意,受区损伤进一步减小。

Objective To explore the strategies and technical points for breast reconstruction using free lower abdominal skin flap transplantation through lateral chest incision.Methods The data of patients who underwent unilateral breast reconstruction with free lower abdominal flap transplantation using lateral thoracic incision in Hunan Cancer Hospital from October 2022 to March 2023 were retrospectively analyzed.Lateral thoracic incision was used in the recipient area.Firstly suitable radical mastectomy was performed for patients with early onset of breast cancer or recurrence after breast-conserving surgery,and prosthetic dilator removal or breast capsule release was performed for patients with dilator removed or capsular contracture after breast cancer prosthesis reconstruction.After that,the free lower abdominal skin flap breast reconstruction was completed under the same incision.During the operation,blood vessel preparation in the recipient area,skin flap preparation in the donor area,blood vessel anastomosis and breast shaping were completed successively according to the actual situation of the patient.Postoperative observation of complications,follow-up evaluation of reconstructed breast appearance and donor site healing were carred out.Results A total of 15 female patients were included,aged range from 24 to 57 years old,with an average of 42.3 years old.There were 9 cases of early breast cancer,2 cases of breast cancer recurrence after breast conserving surgery,2 cases of breast cancer with dilator removed after breast reconstruction,and 2 cases of capsule contracture after breast cancer prosthesis reconstruction.The length of the lateral chest incision was 7.5-11.2 cm,with an average of 8.7 cm.Six cases were performed with 3/4 of the lower abdominal skin flaps,using a unilateral inferior abdominal vascular pedicle.The volume of the flaps ranged from 19.0 cm×10.0 cm×4.5 cm to 23.0 cm×13.0 cm×6.0 cm.The weight ranged from 280 to 510 g,with an average of 370 g.Nine cases were performed by cutting the entire lower abdominal skin flap and using bilateral inferior abdominal vascular pedicle.The volume of the skin flaps ranged from 27.0 cm×11.0 cm×5.0 cm to 30.0 cm×14.0 cm×6.5 cm.The weight ranged from 420 to 730 g,with an average of 530 g.Nine cases were selected as the main trunk of the thoracic and dorsal blood vessels,4 cases were selected as the anterior serratus branch of the thoracic and dorsal blood vessels,and 2 cases were selected as the main trunk of the thoracic and dorsal blood vessels combined with the anterior serratus branch.One flap experienced venous crisis and the surgery failed,while the remaining 14 flaps survived smoothly.Follow-up period was 6-17 months,with an average of 10.4 months.The reconstructed breast had a satisfactory appearance and texture,without skin flap contraction or deformation.The skin flap donor area and breast recipient area only had linear scars,and there was no significant impact on abdominal wall and shoulder joint function.There was no tumor recurrence or metastasis during follow-up.Conclusion When the side chest incision is used to perform the related operations of breast cancer radical resection,the free lower abdominal skin flap can be transplanted into the same incision for breast reconstruction.The effect is satisfactory,and the damage of the affected area is further reduced.