改良带蒂股前外侧肌皮瓣修复腹壁肿瘤术后大面积全层缺损

目的探讨应用改良带蒂股前外侧肌皮瓣修复腹壁肿瘤术后大面积全层缺损的可行性和疗效。方法 2016年1月—2018年6月,采用改良带蒂股前外侧肌皮瓣修复5例腹壁肿瘤切除后大面积全层缺损。男3例,女2例;年龄32～65岁,平均43.7岁。腹壁纤维瘤3例,肉瘤2例。肿瘤切除后腹壁缺损范围为20 cm×12 cm～23 cm×16 cm。采用网片固定重建腹膜连续性,股外侧肌瓣封闭缺损,表面植皮联合股前外侧皮瓣修复腹壁皮肤软组织缺损。股外侧肌瓣切取范围为20 cm×12 cm～23 cm×16 cm,皮瓣切取范围为20 cm×8 cm～23 cm×10 cm。供区直接缝合。结果术后所有皮瓣和植皮均顺利成活,供受区创面均Ⅰ期愈合。患者均获随访,随访时间6～36个月,平均14.7个月。随访期间无肿瘤复发,皮瓣质地良好、外形不臃肿,腹壁外观、功能恢复满意,未见腹壁疝表现。供区外观影响小,下肢关节活动无影响。结论改良带蒂股前外侧肌皮瓣可用于修复腹壁肿瘤术后大面积全层缺损,不但减少了供区并发症,还可改善供、受区外形。     

修复上胸壁巨大肿瘤切除后缺损一例的早期效果

目的应用钛网、重建钢板及背阔肌带蒂肌皮瓣,修复上胸壁乳腺肉瘤样癌切除后巨大缺损1例,观察术后早期效果。方法于2006年2月收治1例56岁女性上胸壁乳腺肉瘤样癌患者,行肿瘤切除后缺损约20cm×15cm,钛网覆盖胸壁缺损,重建钢板连接双侧锁骨残端,右侧背阔肌带蒂肌皮瓣约20cm×15cm移位修复软组织缺损。结果患者术后3d脱呼吸机,反常呼吸较明显。2周皮瓣血运稳定后,用胸带固定胸廓,反常呼吸渐消失,皮瓣血供良好。复查胸片,钛网及重建钢板位置良好。术后1个月转入肿瘤科化疗。随访3个月,局部及全身无不适;双肩活动度前屈90°,外展90°;肿瘤未见复发。结论胸壁巨大缺损重建时应选择质地较硬的材料,重建钢板维持双侧锁骨的解剖位置,肩关节功能恢复好,背阔肌带蒂肌皮瓣可适当扩大切取。     

胸壁肿瘤切除后胸壁缺损的修复

目的探讨胸壁肿瘤切除后胸壁缺损的修复方法。方法 2011年5月至2018年5月共收治胸壁肿瘤患者31例,其中原发胸壁良性肿瘤6例,原发胸壁恶性肿瘤14例,转移性胸壁恶性肿瘤11例。胸壁缺损类型包括单纯骨性缺损16例,单纯软组织缺损4例,全层缺损11例。骨性胸壁缺损采用补片(7例)、Prolene网片(3例)、网格状钛合金钢板(17例)进行重建。胸壁软组织缺损采用直接对拢缝合(11例)、皮瓣修复(20例)。结果本组患者均顺利完成手术,术后呼吸功能良好,无反常呼吸运动。2例带蒂背阔肌肌皮瓣边缘部分坏死,1例带蒂腹直肌肌皮瓣远端部分坏死,1例游离腹壁下动脉穿支皮瓣边缘部分坏死,经换药后伤口均愈合。结论外科手术是胸壁肿瘤治疗的主要方法,术后的胸壁缺损按照大小、位置和复杂程度选择合适的材料进行修复,重建胸壁结构的稳定性及密闭性,是手术成功的关键。     

应用带少许肌袖的背阔肌肌皮瓣修复下肢软组织缺损

目的探讨应用带少许肌袖的背阔肌肌皮瓣移植修复下肢软组织缺损的临床效果。方法2000年6月～2006年12月,应用带少许肌袖的背阔肌肌皮瓣移植修复8例下肢软组织缺损患者。男6例,女2例;年龄25～69岁。其中创面位于足跟3例,足背2例,胫前2例,右小腿鳞癌1例。软组织缺损范围10cm×7cm～18cm×12cm,皮瓣切取范围15cm×8cm～22cm×15cm。结果术后6例皮瓣成活;1例术后2h出现皮瓣血管危象,经探查重新吻合静脉,植皮后成活;1例胫前创面因骨髓炎感染,经引流后皮瓣成活。创面及供区均期愈合。8例患者获随访3～12个月。皮瓣外形满意,无臃肿。供区功能不受影响。结论应用带少许肌袖的背阔肌肌皮瓣移植是修复大面积肢体软组织缺损较为理想方法之一。     

带蒂股前外侧肌皮瓣修复腹壁肿瘤术后全层缺损

目的探讨带蒂股前外侧肌皮瓣修复腹壁肿瘤术后全层缺损的疗效。方法 2010年9月—2017年12月,收治18例腹壁肿瘤患者。男11例,女7例;年龄29~68岁,平均45.2岁。原发疾病:腹壁纤维瘤8例,肉瘤6例,结肠腺癌腹壁转移2例,恶性畸胎瘤2例。手术彻底切除肿瘤,遗留全层腹壁缺损范围为15 cm×6 cm~25 cm×22 cm;采用网片固定重建腹膜连续性,带蒂股前外侧肌皮瓣填充腔隙及修复皮肤软组织缺损;其中股外侧肌瓣切取范围为10 cm×8 cm~22 cm×10 cm,股前外侧皮瓣为14.0 cm×8.0 cm~21.0 cm×8.5 cm。其中2例大面积缺损采用双侧带蒂股前外侧肌皮瓣修复。供区均直接拉拢缝合。结果术后所有皮瓣顺利成活,创面Ⅰ期愈合;供区切口Ⅰ期愈合。患者均获随访,随访时间11~56个月,平均22.5个月。随访期间均无肿瘤复发,未见腹壁疝表现,皮瓣外观及腹部功能均满意。结论带蒂股前外侧肌皮瓣结合网片适用于修复腹壁肿瘤术后全层缺损。     

背阔肌肌皮瓣窗瓣修复头部大面积缺损

目的 探讨改良背阔肌肌皮瓣修复头部大面积缺损的临床疗效。方法 采用改良的游离背阔肌肌皮瓣移植修复头部大面积缺损患者6例,其中1例为慢性溃疡,5例为鳞状细胞癌;肿瘤扩大切除后形成的最大创面面积为20 cm×21 cm。相较于传统的背阔肌皮瓣切取后需要供区植皮覆盖创面的方法,改为肌瓣表面携带部分皮瓣作为观察窗的切取方法,皮瓣大小以供区能够拉拢缝合为宜。肌皮瓣切取最大面积为22 cm×23 cm,表面携带部分皮瓣形成观察窗,以便观察血供情况,其余肌瓣表面行植皮覆盖;侧胸背部皮瓣供区直接拉拢缝合。结果 6例患者的移植皮瓣均成活良好,修复效果满意。皮瓣供区伤口均一期愈合,仅遗留线性瘢痕。结论 采用改良的游离背阔肌肌皮瓣移植修复头部大面积缺损,可避免皮瓣供区植皮,减轻传统术式带来的皮瓣供区继发畸形。     

基于多学科综合治疗模式的胸壁肿瘤术后巨大复合组织缺损的修复策略

目的 探究胸壁肿瘤切除术后巨大复合组织缺损重建的策略。方法 自2007年1月至2021年1月,中国医学科学院北京协和医院整形美容外科对基于多学科综合治疗（multi-disciplinary team,MDT）模式胸壁肿瘤术后巨大复合组织缺损修复的23例患者,进行回顾性分析和总结。结果 在纳入的23例患者中,19例进行了骨性重建,其中8例钛网,11例钛棒。23例患者均接受了软组织重建,其中12例采用带蒂背阔肌肌皮瓣,4例采用带蒂腹直肌肌皮瓣,4例采用胸大肌肌皮瓣,2例采用局部皮瓣,1例采用游离股前外侧皮瓣。术后平均随访时间为（32.96±22.85）个月,11例恶性肿瘤患者因肿瘤转移死亡,另外7例恶性肿瘤患者及5例良性肿瘤患者存活。12例存活患者中,3例术后出现局部伤口愈合不良,采取扩大清创,二期局部皮瓣转移覆盖缺损区域,其余患者皮瓣完全成活。结论 胸壁肿瘤切除术后巨大复合组织缺损修补需要多学科协作,根据患者情况进行个性化治疗。修复的基本思路是分层重建,骨性重建采用钛棒、钛网,软组织修复重建则应用背阔肌皮瓣、腹直肌皮瓣等。     

扩大股前外侧肌皮瓣在超大面积胸壁缺损修复中的应用北大核心CSCD

目的 探讨扩大股前外侧肌皮瓣移植修复超大面积胸壁缺损的临床疗效。方法 2018年8月—2020年12月,采用扩大股前外侧肌皮瓣移植修复胸壁肿瘤术后超大面积复杂胸壁缺损患者12例。其中男4例,女8例;年龄28~72岁,平均54.9岁。叶状细胞肉瘤4例,软组织肉瘤2例,肺癌转移胸壁肿瘤1例,乳腺癌复发5例。患者曾行2~7次肿瘤切除手术;其中3例既往行下腹部皮瓣移植手术失败,余9例患者因消瘦不适合采用腹部作为皮瓣供区。创面彻底清创后继发胸壁缺损面积为300~600 cm2;切取皮瓣长(24.7±0.7)cm,皮岛宽(10.6±0.7)cm,股外侧肌瓣长(26.8±0.5)cm,宽(15.3±0.6)cm,血管蒂长度为(7.9±0.6)cm。结果 11例患者肌皮瓣完全成活,肌瓣表面植皮全部成活,供受区创面均Ⅰ期愈合;1例男性患者胸壁切口裂开,进一步采用大网膜联合皮片移植修复。12例患者重建胸壁外形可,质地满意,无皮瓣挛缩变形;皮瓣供区仅遗留线性瘢痕,取皮区轻度增生瘢痕,大腿功能无明显影响。所有患者均获随访,随访时间9~15个月,平均12.6个月。未见肿瘤复发患者。结论 扩大股前外侧肌皮瓣手术操作简便,有效修复面积明显增加,避免了多皮瓣移植,可作为超大面积胸壁缺损修复的挽救手段。     

胸背血管前锯肌支在胸壁缺损修复中的应用北大核心CSCD

目的 探讨胸背血管前锯肌支在胸壁缺损修复中的应用。方法 2018年10月—2021年3月,采用双侧游离下腹部皮瓣移植修复23例胸壁肿瘤术后大面积复杂缺损患者。患者均为女性;年龄23~71岁,平均48.5岁。局部晚期乳腺癌11例,叶状细胞肉瘤4例,软组织肉瘤3例,乳腺癌复发3例,胸壁放射性溃疡2例。肿瘤切除、创面清创后继发胸壁缺损范围为20 cm×10 cm~38 cm×14 cm;皮瓣切取范围25 cm×12 cm~38 cm×15 cm,血管蒂长度为9~12 cm,平均11.4 cm。14例单纯软组织缺损,采用皮瓣移植修复;5例肋骨缺损(<3根)合并软组织缺损,采用单纯网片联合皮瓣移植修复;4例胸壁全层缺损合并大范围肋骨缺损(>3根),采用“网片+骨水泥”方法坚强内固定联合皮瓣移植修复。所有患者均采用胸背血管前锯肌支作为受区血管,组合方式包括前锯肌支近心端+其他受区血管(13例)、前锯肌支近心端+远心端(6例)、2支前锯肌支近心端(4例)。结果 23例患者胸背血管主干均得以完整保留。所有患者均获随访,随访时间10~18个月,平均13.9个月。术后皮瓣完全成活,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。随访期间未见肿瘤复发。结论 胸背血管前锯肌支解剖恒定,对受区损伤小,可以为游离皮瓣移植修复重建胸壁提供可靠血供。     

分叶带蒂腹直肌皮瓣修复巨大胸壁缺损的疗效观察

目的 探讨分叶带蒂腹直肌皮瓣修复巨大胸壁缺损的疗效。方法 2021年6月—2022年6月，采用分叶带蒂腹直肌皮瓣修复14例巨大胸壁缺损患者。男5例，女9例；年龄32～57岁，平均44.2岁。左侧8例，右侧6例。晚期乳腺癌5例，胸壁原发肿瘤5例，乳腺癌术后胸壁放射性骨坏死4例。胸壁软组织缺损范围为20 cm×16 cm～22 cm×22 cm。切取大小为26 cm×8 cm～35 cm×14 cm的双侧带蒂腹直肌皮瓣，根据胸壁缺损面积将其制备成面积基本相等的两个皮岛，转移至胸壁缺损区域后重新拼接，具体方式：7例低位对侧皮岛位置不变、高位同侧皮岛旋转90°，7例两侧皮岛均分别旋转90°后重新拼接。供区直接拉拢缝合。结果 术后14例皮瓣全部顺利成活，创面Ⅰ期愈合。供区切口均Ⅰ期愈合。患者均获随访，随访时间6～12个月，平均8.7个月。皮瓣外观、质地满意。供区仅遗留线性瘢痕，腹壁外观及活动无影响。所有肿瘤患者均未见局部复发；2例乳腺癌患者发生远处转移。结论 灵活设计并切取分叶带蒂腹直肌皮瓣可以最大程度确保皮瓣血运，充分利用皮瓣组织修复巨大胸壁缺损后可减少术后并发症的发生。     

Never say no to a damaged muscle: the applications of previously damaged pectoralis major and latissimus dorsi muscles for chest wall reconstruction

The nondamaged latissimus dorsi and pectoralis major muscles are widely reported in the literature as being the most frequently used for chest wall reconstruction. In this study, we report a series of 9 patients with full-thickness chest wall defects who underwent reconstruction with previously damaged latissimus dorsi or pectoralis major muscles. Nine patients underwent chest wall reconstruction over a period of 3 years using previously damaged latissimus dorsi or pectoralis major muscles. The thoracic defect was posttraumatic in 3 patients and post-tumor resection in 6 patients. Three patients had previous radiation therapy. In 8 cases, the full-thickness chest wall defects were completely closed. The only failure encountered was in one patient who had a long lasting fistula. The proximal based island flap that was inserted into the tract showed good vascular supply and viability; however, it did not solve the clinical problem. Keeping in mind the basic rule of medicine ("Primum Non Nocere") and a thorough knowledge of the surgical anatomy of these muscles are essential for the successful application of these previously damaged muscles for chest wall reconstruction.     

Efficiency of the combination of Mersilene-musculocutaneous flap in the reconstruction of full-thickness chest wall defects. A retrospective study of 14 cases

SUBJECT: The tumors of chest wall can be responsible of large full-thickness defects. The skeletal stabilization by different synthetic materials with numerous modalities of use and the superficial coverage of the defect by a musculocutaneous flap are the two imperatives parts of this reconstruction. PATIENTS AND METHODS: From January 1997 to January 2006, 14 patients, 10 males and 4 females, aged between 17 and 63 years old and suffering from full-thickness chest wall defects secondary to tumor resection have benefited from a simple reconstruction, wherever the defect, by a Mersilene Mesh and a muscular or musculocutaneous flap. These defects measured between 8 x 12 cm and 14 x 16 cm and were located in the anterior part of the chest in 3 cases, with resection of the upper half of the sternum and the internal part of both clavicles and the first three ribs, and in the lateral part of the chest in 11 cases with resection between 3 and 5 ribs. The histological diagnoses of these tumors were 3 chondrosarcomas, 3 sternum and 1 rib metastases, 2 desmoid tumors, 1 Ewing's sarcoma, 4 benign tumors. The flaps used were pedicled in 13 cases and based on the latissimus dorsi muscle, the serratus muscle and the pectoralis major muscle; in 1 case, the latissimus dorsi musculocutaneous flap was free. RESULTS: The skeletal stabilisation seems satisfying. There was no problems with the pulmonary function except in 4 cases where a dyspnea appears in sustained effort. No vascular complication on these flaps was noted. With a mean follow up of 46 months, there was no local recurrence of the malignant tumors. Two patients were deceased 1 year after surgery.0. CONCLUSION: The Mersilene mesh associated with a locoregional musculocutaneous flap represent a simple and efficient solution for the treatment of such defects.     

Chest wall reconstruction for recurrent breast cancer

Some recurrences of breast cancer require wide chest wall resection as curative or palliative therapy. We report a retrospective review of 14 chest wall resections and reconstructions. The width of the anterior chest wall excision was 150 cm(2) (80 to 360 cm(2)). Two defects were full-thickness ones, with sternal or costal resection. The reconstruction required synthetic mesh covered by a latissimus dorsi musculocutaneous flap. The 12 other resections were superficial ones, and have been covered by a skin graft in 5 patients, and by a regional flap in 7 patients (5 latissimus dorsi, 1 DIEP, and 1 bilobed flap). Two patients had a chest wall irradiation after the surgical procedure. We have analysed the factors, which had influenced our choice of the type of reconstruction. The reconstruction is performed by a regional flap, most commonly a latissimus dorsi pedicled flap, in case of full-thickness defect, of nodular isolated recurrence, or when a radiation therapy is provided after the surgical procedure. The coverage is made by a skin graft in case of palliative excision, or of multiple nodular chest wall recurrence (which have a high risk of recurrence in the same form).     

Immediate Reconstruction of Full-Thickness Chest Wall Defects

Twenty-one patients had full-thickness chest wall defects reconstructed at the New York University Medical Center in the last ten years. Marlex mesh provided chest wall stability in 5 patients. In 9 patients with radiation ulcers Marlex mesh was not required; a severe fibrotic reaction had obliterated the pleural space and prevented paradoxical motion. Partial sternal resections did not require Marlex stabilization, while a total sternectomy resulted in marked ventilatory insufficiency in a patient who would have benefited from the use of a stabilizing material. Random pattern flaps were used initially; more recently, axial pattern, myocutaneous, and myocutaneous free flaps were employed. Necrosis developed in 4 (36%) of the 11 patients with random pattern flaps, but was not seen with the newer flap techniques. Myocutaneous free flaps provided uncomplicated coverage of and stability to three large, potentially contaminated defects. It seems that with the currently available flap techniques and the methods of chest wall stabilization, immediate repair of all full-thickness chest wall defects is possible.     

A free fibula autologous transfer for a full-thickness anterior chest wall defect

Large defects of the anterior chest wall lead to gross chest instability which can result in paradoxical respiration. Skeletal stabilization is an essential requirement in such cases. The current methods for achieving total or near total sternal reconstructions involve the use of alloplastic implant materials: prosthetic mesh with methyl methacrylate. In our experience, this method of reconstruction is often complicated by a persistent seroma and infection. A large full-thickness sternal defect was reconstructed by an osteotomized free fibula "Z" transfer and bilateral bipedicled pectoralis major myocutaneous flaps. This case highlights the use of vascularized autologous tissue for a complex full-thickness anterior chest wall reconstruction.     

胸三角皮瓣修复乳癌术后复发病灶及放射性溃疡

目的 探讨乳癌根治术后复发病灶及放射性溃疡的胸壁大块深度缺损修复方法.方法 采用对侧以第2、3肋间前胸穿支为血管蒂的岛状皮瓣修复乳癌根治术后局部复发病灶清除后缺损创面4例及放射性溃疡8例.结果 12例皮瓣全部成活,其中l例皮瓣远端表皮坏死经换药后痊愈.随访6个月～4年,伤口愈合稳定,外形恢复满意.结论 以第2、3肋间前胸穿支为血管蒂的岛状皮瓣是一期修复乳癌根治术后局部复发病灶的清除缺损创面及放射性溃疡简便易行的理想方法.     

Microvascular reconstructions of full-thickness oncological chest wall defects

OBJECTIVE: To evaluate the suitability of microvascular flaps for the reconstruction of extensive full-thickness defects of the chest wall. SUMMARY BACKGROUND DATA: Chest wall defects are conventionally reconstructed with pedicular musculocutaneous flaps or the omentum. Sometimes, however, these flaps have already been used, are not reliable due to previous operations or radiotherapy, or are of inadequate size. In such cases, microvascular flaps offer the only option for reconstruction. METHODS: From 1988 to 2001, 26 patients with full-thickness resections of the chest wall underwent reconstruction with microvascular flaps. There were 8 soft tissue sarcomas, 8 recurrent breast cancers, 5 chondrosarcomas, 2 desmoid tumors, 1 large cell pulmonary cancer metastasis, 1 renal cancer metastasis, and 1 bronchopleural fistula. The surgery comprised 5 extended forequarter amputations, 5 lateral resections, 8 thoracoabdominal resections, and 8 sternal resections. The mean diameter of a resection was 28 cm. The soft tissue defect was reconstructed with 16 tensor fasciae latae, 5 tensor fascia latae combined with rectus femoris, and 3 transversus rectus abdominis myocutaneous flaps. In 2 patients with a forequarter amputation, the remnant forearm was used as the osteomusculocutaneous free flap. RESULTS: There were no flap losses or perioperative mortality. Four patients needed tracheostomy owing to prolonged respiratory difficulties. The mean survival time for patients with sarcomas was 39 months and for those with recurrent breast cancer 18 months. CONCLUSIONS: Extensive chest wall resections are possible with acceptable results. In patients with breast cancer, the surgery may offer valuable palliation and in those with sarcomas it can be curative.     

Using the costal muscle flap with latissimus dorsi muscle to repair full-thickness anterior chest wall defects

Musculoosseous flaps with latissimus dorsi muscle are used for reconstruction of full-thickness anterior chest wall defects. The 11th and 12th ribs and the posterior parietal pleura are elevated with the latissimus dorsi muscle. The blood supply of the compound flap comes from the thoracodorsal pedicle and from perforating segmental vessels. The posterior thoracic wall island is transferred to the anterior chest wall defect to restore a skeletal plane and the transposed latissimus dorsi obliterates all the dead spaces that cannot be collapsed. The latissimus dorsi compound flap with the 11th and 12th ribs appears to be a "safe" procedure to reconstruct full-thickness anterior chest wall defects.     

Chest wall resection and reconstruction: a case series of 20 patients in Hospital Kuala Lumpur,Malaysia

Chest wall resection is defined as partial or full-thickness removal of the chest wall. Significant morbidity has been recorded, with documented respiratory failure as high as 27%. Medical records of all patients who had undergone chest wall resection and reconstruction were reviewed. Patients’ demographics, length of surgery, reconstruction method, size of tumor and chest wall defect, histopathological result, complications, duration of post-operative antibiotics, and hospital stay were assessed. From 1 April 2017 to 30 April 2019, a total of 20 patients underwent chest wall reconstructive surgery. The median age was 57 years, with 12 females and 8 males. Fourteen patients (70%) had malignant disease and 6 patients (30%) had benign disease. Nine patients underwent rigid reconstruction (titanium mesh for sternum and titanium plates for ribs), 6 patients had non-rigid reconstruction (with polypropylene or composite mesh), and 5 patients had primary closure. Nine patients (45%) required closure with myocutaneous flap. Complications were noted in 70% of patients. Patients who underwent primary closure had minor complications. In total, 66.7% of patients who had closure with either fasciocutaneous or myocutaneous flaps had threatened flap necrosis. Two patients developed pneumonia and 3 patients (15%) had respiratory failure requiring tracheostomy and prolonged ventilation. There was 1 mortality (5%) in this series. In conclusion, chest wall resections involving large defects require prudent clinical judgment and multidisciplinary assessments in determining the choice of chest wall reconstruction to improve outcomes.     

Chest wall reconstruction using pedicled extended serratus anterior myocutaneous flap combined with vascularized rib

An extended serratus anterior myocutaneous flap with a vascularized rib has been used, in two cases, for reconstruction of large full-thickness chest wall defects after resection of recurrent breast cancer. Using this method, the bony support and the soft tissue of the chest wall can be safely reconstructed.