乳腺癌术后横行腹直肌皮瓣乳房再造的适应证剖析

目的探讨乳腺癌术后下腹部横行腹直肌（transverse rectus abdominal myocutaneous,TRAM）皮瓣乳房再造术的适应证的选定,并进行临床剖析。方法对17例乳腺癌切除术后患者应用对侧单蒂TRAM皮瓣进行乳房再造,其中I期再造者7例,Ⅱ期再造10例,均为乳腺癌改良根治术后患者。9例Ⅱ期进行乳头、乳晕再造。12例供区下腹部应用涤纶补片加固腹壁以预防腹壁软弱和腹壁疝形成。由多学科诊疗小组对适应证选择,并进行总结和分析。结果17例经过5个月至6年的观察,2例Ⅱ期再造术后,TRAM皮瓣的皮肤发生小面积坏死,1例对侧下腹壁轻度膨隆,无腹壁疝,经过对症处理,17例均取得较好疗效。结论对于乳腺癌术后具有适应证的患者应用横行TRAM皮瓣乳房再造术是一种较为有效和安全的方法。严格选定适应证,是乳房再造成功的关键。     

应用下腹部横行腹直肌肌皮瓣的乳房再造

目的 安全应用下腹部横形腹直肌肌皮瓣（TRAM）进行乳房再造。方法 总结42例乳房再造的经验,详尽介绍了病例选择,皮瓣设计和手术方法。结果 应用TRAM再造乳房42例,其中即时再造25例,后期再造17例;单蒂TRAM35例,双蒂TRAM7例,单蒂中有7例附加血管吻合。2例术后腹部供区皮瓣部分坏死,2例TRAM部分坏死,1例双蒂皮瓣术后腹壁疝形成。结论 附加血管吻合或选用双蒂肌皮瓣,以及肌肉内分离是减少并发症的重要措施。     

几种乳房再造术的临床应用体会

目的：探讨乳腺癌根治术后应用单纯假体植入、可扩张假体植入和带蒂腹部横形腹直肌肌皮瓣（TRAM）移植乳房再造的适应证、手术方法、手术效果。方法：本组共24例病例。14例乳腺癌患者行保留皮肤的乳腺癌根治术，Ⅰ期行假体植入乳房再造；6例采用改良乳腺癌根治可扩张假体植入Ⅰ期乳房再造；4例接受单蒂下腹部横形腹直肌肌皮瓣（TRAM）移植乳房再造手术，其中2例为Ⅰ期再造，另2例为Ⅱ期乳房再造。结果：手术效果较满意，2例出现轻微并发症，其中1例皮瓣局灶坏死，另1例出现乳头乳晕部分坏死。结论：单纯假体植入适用于乳房小，没有明显下垂的瘦小病人。优点是不增加额外瘢痕，术后恢复快；可扩张假体植入乳房再造适用于乳房大或改良乳腺癌根治术的患者，此法结合了单纯假体植入法和组织扩张的优点：TRAM皮瓣移植乳房再造的优点是自体组织移植，安全、手术效果好。     

即刻及延期乳房再造方法的选择

目的回顾总结乳腺癌根治术后应用单纯假体植入、Becker可扩张假体植入和单蒂腹部横形腹直肌肌皮瓣（TRAM）移植、扩大背阔肌肌皮瓣（ELDF）移植乳房再造术的经验,探讨手术的适应证、方法和效果。方法自2002年7月至2005年10月,共67例患者进行了乳腺癌根治术后乳房再造术。即刻乳房再造56例：单纯假体植入38例、Becker可扩张假体植入16例、单蒂TRAM移植2例。延期乳房再造11例：单蒂TRAM移植6例、ELDF移植4例、Becker可扩张假体植入1例。结果手术效果满意,优良率超过90％。5例患者出现轻微并发症：皮瓣局灶性坏死2例,保留的乳头乳晕部分坏死1例,血清肿2例。结论单纯假体植入用于即刻乳房再造,适用于乳房较小、行保留皮肤的乳腺癌根治术后的患者,不宜用于延期乳房再造;可扩张假体植入即刻乳房再造适用于乳房较大或改良乳腺癌根治术的患者,同时可扩张假体植入延期乳房再造可用于皮肤、肌肉保留较好的乳腺癌根治患者;TRAM和ELDF皮瓣移植乳房再造是自体组织移植,其安全性高,可用于即刻和延期乳房再造。     

10例保留皮肤的乳腺癌改良根治术后即时TRAM皮瓣乳房再造体会

目的 总结保留皮肤乳腺癌改良根治术后即时乳房再造方法的治疗体会.方法 笔者所在医院2008年5月至2011年12月期间对10例早期乳腺癌患者行保留大部分皮肤的改良根治术,同时应用下腹部腹直肌带蒂肌皮瓣(TRAM)行即时乳房再造,就该10例患者的临床资料进行回顾性分析.结果 10例患者中1例TRAM皮瓣部分坏死,1例乳头部分坏死,1例再造乳房乳尾部脂肪部分坏死伴腋下伤口感染;无腹壁切口疝发生,无全部TRAM皮瓣坏死病例.术后患者对再造乳房形态评价非常满意5例,比较满意4例,不满意1例.结论 保留皮肤的乳腺癌改良根治术后即时TRAM皮瓣乳房再造方法的切口小,再造乳房形态好,是一种安全有效的治疗早期乳腺癌患者的方法.     

保留部分前鞘的TRAM瓣在乳腺癌同期乳房再造中的应用

目的 对乳腺癌患者采用保留部分前鞘的下腹部横行腹直肌肌皮瓣(TRAM瓣)进行一期乳房再造,并探讨降低术后腹壁疝、腹壁膨出发生率的方法.方法 对2002至2004年接受乳腺癌根治术的16例患者(一、二期9例,三期7例),于根治术同期采用保留部分前鞘的TRAM瓣术式再造乳房.结果 本组16例再造乳房与对侧基本对称12例,不对称的4例中,3例为对侧乳房中度以上下垂,1例为再造乳房偏小.术后随访平均2年5个月,所有病例的TRAM瓣均存活,仅1例发生腹壁膨隆.结论 部分筋膜法TRAM瓣一期再造乳房,可保持传统TRAM瓣手术的效果并能降低术后腹壁并发症发生率.     

伴有剖腹产史的单蒂横行腹直肌肌皮瓣乳房再造术

目的 探讨伴有剖宫产史的单蒂横行腹直肌肌皮瓣乳房再造术的手术方法、临床可行性及应用技术.方法 对9例剖宫产后不同时间的乳腺癌患者,在乳腺癌仿根治术后,采用即刻转移对侧单蒂横行腹直肌肌皮瓣进行乳房再造手术,腹壁横梭形皮瓣的上切口位于脐上l～2 cm,下切口于下腹壁纵行切口瘢痕的中下1/3,切取以对侧腹直肌为单蒂的下腹壁皮瓣,转移至胸壁缺损部位,修整塑造乳房外形.结果 9例乳房再造术患者转移的单蒂横行腹直肌肌皮瓣完全成活,再造乳房形态自然,外形逼真,无皮瓣坏死发生.2例保留乳头者发生乳头缺血,部分坏死脱落后愈合.结论 单蒂横行腹直肌肌皮瓣乳房再造术,对于有剖宫产史的乳腺癌患者并非绝对禁忌证,在做好术前充分评估的基础上,可以安全选择应用.     

乳腺癌切除术后乳房再造

目的 探讨乳腺癌切除术后乳房再造的方法及时间.方法 总结30例不符合保乳条件的乳腺癌病例,乳房切除术后假体置人乳房再造16例,下腹部横行腹直肌肌皮瓣(TRAM瓣)乳房再造10例,背阔肌肌皮瓣乳房再造4例.其中即刻乳房再造27例,延期乳房再造3例.结果 16例假体置入乳房再造术后外观评价均为良,未出现术后并发症.10例TRAM瓣乳房再造术后发生皮瓣部分坏死2例,腹壁疝1例,术后外观评价7例为良.2例为较好,1例为差.4例背阔肌肌皮瓣再造术后外观评价为良.结论 乳房再造术是乳腺癌综合治疗不可忽视一部分,对于有强烈的保乳愿望,而又不符合保乳条件的患者,乳房再造术是一种较好的选择.即刻乳房再造优于延迟乳房再造.乳房再造的方法选择要因人而异.局部晚期乳腺癌患者可以选择性进行即刻乳房再造术.     

双蒂横行腹直肌肌皮瓣乳房再造术的临床应用

目的探讨乳腺癌根治术后双蒂横行腹直肌肌皮瓣(transverse rectus abdominis musculo-cutaneous flap,TRAM)乳房再造的手术方法及临床应用。方法对5例伴有剖腹产史的乳腺癌患者行双蒂TRAM瓣乳房再造术,术中切取双侧腹直肌作为转移皮瓣的蒂,转移至根治术后胸壁缺损处,塑造乳房外形,采用局部皮瓣再造乳头,游离皮瓣再造乳晕。结果4例患者再造乳房完全成活,形态自然,外形逼真,手感好;1例部分皮瓣坏死,面积3cm×2cm。结论双蒂TRAM瓣乳房再造术对有剖宫产史的乳腺癌患者是值得推荐的好方法,并非禁忌证。     

乳房再造术的临床研究

目的 回顾总结了乳癌根治术后应用单纯假体植入、Becker可扩张假体植入和带蒂腹部横形腹直肌肌皮瓣(TRAM)移植、扩大的背阔肌肌皮瓣(ELDF)移植乳房再造术的经验,探讨手术的适应征、方法和效果.方法 16例行保留皮肤的乳癌根治术一期假体植入乳房再造;13例行Becker可扩张假体植入一期乳房再造;4例行单蒂下腹部横形腹直肌肌皮瓣(TRAM)移植乳房再造手术,其中2例为一期再造,另2例为二期再造.应用Becker可扩张假体行二期乳房再造1例.扩大背阔肌肌皮瓣(ELDF)移植二期乳房再造1例.结果 手术效果满意,优良率超过90%.3例病人出现轻微并发症,其中1例皮瓣局灶坏死,一例出现保留的乳头乳晕部分坏死,1例出现血清肿.结论 单纯假体植入适用于瘦小病人,对侧乳房小且没有明显下垂.优点是不增加额外瘢痕,术后恢复快;可扩张假体植入乳房再造适用于乳房大或改良乳癌根治术的患者,此法结合了单纯假体植入法和组织扩张术乳房再造术的优点;TRAM和ELDF皮瓣移植乳房再造的优点是自体组织移植,安全、手术效果好.     

Feasibility of postmastectomy radiation therapy after TRAM flap breast reconstruction

Background: Postoperative radiotherapy (PORT) has been shown to decrease locoregional failure rates in high-risk breast cancer patients following modified radical mastectomy. However, there had not been a study evaluating the effect of PORT in patients after transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. Therefore, we evaluated flap viability, cosmetic results, and locoregional recurrence in patients who underwent TRAM flap reconstruction and PORT. Methods: The charts of patients who had undergone modified radical mastectomy with TRAM flap reconstruction and PORT at our institution were reviewed. Patients were examined in the clinic and interviewed by telephone to evaluate their perceptions of the cosmetic result. Results: PORT was delivered to 19 patients with TRAM flaps (3 pedicled and 16 free flaps) between 1988 and 1994. There were no TRAM flap losses as a result of either surgical or radiotherapy complications. Two patients developed fat necrosis, one with a pedicled and one with a free TRAM flap. Patients with pedicled TRAM flaps noted more volume loss in the breast after radiation therapy. Eighty-four percent of patients felt their overall cosmetic result was excellent or good; only one patient reported a poor cosmetic result. Local control was achieved in three of the four patients who received PORT for local recurrence. There was only one local recurrence among the 14 patients who received PORT because they were at high risk of local recurrence. Conclusions: These results suggest that PORT can be given safely to high-risk patients following TRAM flap breast reconstruction with excellent cosmetic results and good locoregional control.     

Breast reconstruction using gluteal inferior free flaps. 34 cases in 30 patients

Recent evolution of breast reconstruction favorised autologous tissues, without prosthesis. 34 gluteal inferior free flaps have been performed in 30 patients aged from 33 to 72 years for immediate reconstruction (6) or secondary reconstruction (28), unilateral (26) or bilateral (8 flaps); after complete mastectomy (21 included a bilateral one), partial mastectomy (3), sub-cutaneous mastectomy with skin-sparing mastectomy (3 bilateral cases), radical mastectomy with radiolesion (2), non efficient reconstruction using prosthesis (2). The myocutaneous flap vascularized by gluteal inferior artery was anastomosed on thoracodorsal pedicle or on humeral vein. Added procedures have been symmetrizations (21), flap modifications (21), nipple reconstruction (20). Thirty three flaps presented good survey. Cosmetic results were excellent in five cases, good in 21 cases, middle in eight cases. Flap disadvantages were: possible failure of microsurgery with vessel thrombosis and flap necrosis, long operative time (average five hours), variable quality of the skin flap and hypoesthesia of the posterior area of buttock. Flap advantages were: the suffisant volume (300 to 500 g), the simple procedure to raise the flap (after specific training) and discrete scar of the donor site. This flap seems to be a excellent method for autologous mammary versus TRAM flap or latissimus dorsi added fat flap.     

胸外侧筋膜皮瓣在修复乳房局部缺损中的应用

目的:探讨在利用胸外侧筋膜皮瓣修复乳房局部缺损的效果和意义。方法:对因保乳手术或乳房再造术后皮瓣坏死造成乳房局部缺损患者设计三角胸外侧筋膜皮瓣进行组织填充修复。结果:共完成8例,7例为保乳手术后即刻,1例为TRAM手术后局部皮瓣坏死。平均手术时间3h,平均出血量300ml。术后未发生皮瓣坏死等并发症。术后平均随访时间19.5月,均未出现复发,美容效果均为优良,患者对乳房外形的自我感觉均为满意。结论:利用胸外侧筋膜皮瓣修复乳房局部缺损,尤其是对于乳房较小患者,效果满意,简单易行。     

延期乳房再造中应用单蒂TRAM皮瓣移植重建自然形态的乳房

目的:探讨乳癌根治术后延期乳房再造中应用单蒂腹部横形腹直肌肌皮瓣(transverse rectus abdominis musculocu taneous,TRAM)重塑自然形态乳房的方法。方法:2004年7月～2007年10月,笔者应用单蒂TRAM皮瓣对15例患者进行延期乳房再造。于较正常侧高1～2cm的位置设计患侧新乳房下皱襞,切除范围为新乳房下皱襞与乳癌根治术后切口瘢痕之间的皮肤,TRAM皮瓣修复瘢痕切除后创面。结果:所有患者术后随访4～26个月,平均随访15.2个月,效果优10例,良3例,一般2例。2例患者出现TRAM皮瓣II区皮下脂肪坏死,经引流后愈合,1例患者乳房下皱襞较健侧低,二期修复后手术效果为优。结论:本组病例应用的技术有利于再造乳房呈现自然形态,避免明显补丁样畸形。     

The "banked" TRAM: a method to insure mastectomy skin-flap survival

BACKGROUND: Necrosis of the skin flaps after mastectomy can be a devastating complication following immediate breast reconstruction with a TRAM flap. Skin-flap loss compromises the aesthetic result and may necessitate revisional surgery. The authors wish to present a simple and effective method to insure mastectomy skin-flap survival. METHODS: Seven patients over the last 5 years were treated with immediate breast reconstruction with a TRAM flap after skin-sparing mastectomy and had evidence of skin-flap compromise intraoperatively. These patients had their TRAM flaps "banked" under the flaps and returned to the operating room within 72 hours for definitive debridement of the skin flaps, deepithelialization, and insetting of the TRAM. RESULTS: In all cases, there was 100% survival of the skin flaps after delayed insetting. There was no skin-flap loss. No patients required additional surgery for revision. CONCLUSIONS: The banked TRAM is a simple and effective method to insure mastectomy skin flap survival if there is a question of flap viability.     

带蒂横行腹直肌皮瓣转移即刻乳房重建术10例报告

目的 探讨乳腺癌乳房切除后,带蒂横行腹直肌肌皮瓣(transverse rectus abdominis musculo cutaneous flap,TRAM)即刻乳房重建的方法及临床效果.方法 对2007年3月至2008年6月间10例乳房切除的乳腺癌患者行即刻带蒂TRAM乳房重建术,其中采用双蒂TRAM 6例,单蒂TRAM 4例.术中均用聚丙烯补片修补腹壁缺损.结果 10例患者重建乳房完全成活.1例发生乳房转移皮瓣感染,1例发生腹壁切口缘皮肤坏死.重建乳房形态:优8例,良2例.随访3～15月,所有病例无局部复发和远处转移.结论 带蒂TRAM乳房重建术在重建缺损乳房的同时达到了腹壁整形的效果,是一种较好的乳房重建方法.     

IMMEDIATE BREAST RECONSTRUCTION IN CHINESE WOMEN USING THE TRANSVERSE RECTUS ABDOMlNlS MYOCUTANEOUS (TRAM) FLAP

Background: Total mastectomy remains the mainstay of operative treatment for breast cancer mainly because it is preferred by surgeons. The techniques and benefits of reconstructing the amputated breast have been well documented in the medical literature but there have been very few reports on this issue in Chinese women. Immediate breast reconstruction using the transverse rectus abdominis myocutaneous (TRAM) flap in Chinese women suffering from early breast cancer who require mastectomy is summarized. Methods: Since September 1991, the option of immediate breast reconstruction was offered to all patients less than 60 years of age suffering from early cancer (Tis, T1 or T2) who were not suitable for breast-conserving treatment or who preferred to have a mastectomy. The single-pedicled TRAM flap was used. Results: From September 1991 to September 1994, 27 reconstructions were performed. Partial flap loss occurred in four patients (15%). fat necrosis in three patients (11%) and abdominal bulging in one patient (4%). Operations performed by two teams simultaneously reduced operating time by 1.5 h without increasing the risk of complications. Twenty-one patients (78%) were satisfied or very satisfied with the outcome of reconstruction. Conclusions: The TRAM flap is a safisfactory method of breast reconstruction in Chinese women. A two-team approach can be employed safely to shorten operative time. Overall patient satisfaction was high.