带蒂腹直肌皮瓣修复胸壁肿瘤术后大面积复杂缺损血运障碍的原因分析

Causes of blood supply disorder in large complex defects after repair of chest wall tumours with pedicled rectus abdominis flap

目的探讨带蒂腹直肌皮瓣血运障碍的原因。方法2019年1月至2021年5月,湖南省肿瘤医院肿瘤整形外科采用带蒂腹直肌皮瓣联合游离腹壁下动脉穿支皮瓣移植修复胸壁肿瘤术后大面积复杂缺损的女性患者61例,年龄25~70(46.9±2.1)岁,其中局部晚期乳腺癌39例、乳腺癌复发12例、叶状细胞肉瘤6例、软组织肉瘤4例。根据游离腹壁下动脉穿支皮瓣血运重建顺序将患者分为2组:先吻合动脉再吻合伴行静脉组(A组)31例、先吻合静脉再吻合动脉组(B组)30例。分析两组患者带蒂腹直肌皮瓣血运障碍的主要原因。结果61例患者中,带蒂腹直肌皮瓣都出现即刻红紫花斑等血运障碍表现,进一步吻合游离腹壁下动脉穿支皮瓣血管蒂以达到增压目的。受区血管选择含胸廓内血管26例、胸肩峰血管15例、胸背血管9例、胸背血管前锯肌支7例、胸外侧动静脉4例。皮瓣长(29.1±0.6)cm,皮岛宽(12.9±0.6)cm。随访9~16个月,平均12.7个月。A组31例中有7例皮瓣血运在进一步吻合静脉之前就明显缓解,其余24例在进一步吻合静脉之后皮瓣血运才恢复正常,B组30例中有27例皮瓣血运在进一步吻合动脉之前就明显缓解,其余3例在进一步吻合动脉之后皮瓣血运才恢复正常。61例皮瓣均完全成活,重建胸壁外形可,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。结论带蒂腹直肌皮瓣血运障碍的主要原因是静脉回流障碍,为了确保皮瓣血运可靠,应当优先增加静脉回流。

ObjectiveTo explore the causes of blood supply disorder of the pedicled rectus abdominis flap.MethodsBetween January 2019 and May 2021,a cohort of 61 female patients,aged 25 to 70 years with a mean age of(46.9±2.1)years,underwent surgical repair for extensive thoracic wall defects at Hunan Province Cancer Hospital.These defects,resulting from thoracic wall tumor resection,were addressed using a combination of pedicled rectus abdominis myocutaneous flaps and free inferior abdominal artery perforator flaps.The patient cohort included 39 cases of locally advanced breast cancer,12 cases of recurrent breast cancer,6 cases of lobular cell sarcoma,and 4 cases of soft tissue sarcoma.The patients were divided into two groups according to the order of revascularization sequence of free inferior abdominal artery perforator flap:31 cases in the group of anastomosing the artery first and then the accompanying vein(group A),and 30 cases in the group of anastomosing the vein first and then the artery(group B).The main reasons for the blood supply disorders of the pedicled rectus abdominis flap were analysed in the two groups.ResultsIn all 61 patients,the pedicled rectus abdominis myocutaneous flap showed immediate red and purple plaques and other blood supply disorders.Further anastomosis of the free inferior abdominal wall artery perforating the flap vessel tip was conducted to achieve pressurization.The vascular selection for the recipient area included the intrathoracic vessels in 26 cases,the thoracic acromion vessels in 15 cases,the thoracodorsal vessels in 9 cases,the anterior serratus branch of the thoracodorsal vessels in 7 cases,and the lateral thoracic arteries and veins in 4 cases.The flap length measured(29.1±0.6)cm,while the width of the skin island was(12.9±0.6)cm.The follow-up period was from 9 to 16 months,with a mean of 12.7 months.In the Group A,the flap blood supply was significantly relieved before further anastomosing the vein in 7 cases,and the flap blood supply returned to normal in the other 24 cases after further anastomosing the vein.In the Group B,the flap blood supply was significantly relieved before further anastomosing the artery in 27 cases,and the flap blood supply returned to normal in the other 3 cases after further anastomosing the artery.61 flaps survived completely,the shape of reconstructed chest wall was satisfactory,and there was no flap contracture and deformation;only linear scar was left in the donor area of the flap,and there was no significant effect on the function of the abdominal wall.The patients were followed-up for 9-16 months,with an average of 12.7 months.ConclusionsThe main reason for the blood supply obstacle of the rectus abdominis flap is the venous return obstacle,in order to ensure the reliable blood supply of the flap,the venous return should be increased as a priority.