扩张后背阔肌肌皮瓣修复乳房瘢痕挛缩

目的探讨应用扩张后背阔肌皮瓣修复乳房瘢痕挛缩的手术方法。方法扩张I期手术切口选择在腋前线,将扩张器置入背阔肌深层,定期注水至超量扩张;Ⅱ期手术将乳房挛缩的瘢痕组织切除、松解达正常解剖位置,再将预扩张充分的背阔肌肌皮瓣形成岛状肌皮瓣转移覆盖皮肤缺损区,皮瓣设计应较创面扩大10％～15％,供瓣区拉拢缝合。结果本组共5例患者,术后皮瓣成活良好,移位的乳头、乳晕恢复到正常解剖位置,切口瘢痕不明显,效果满意。结论扩张后背阔肌肌皮瓣是修复乳房瘢痕挛缩畸形的较好方法。     

乳腺癌根治术后二期岛状背阔肌肌皮瓣的乳房再造及腋前皱襞重建

目的 总结乳腺癌根治术后二期应用岛状背阔肌肌皮瓣加乳房假体行乳房再造术及腋前皱襞重建的手术方法及临床疗效.方法 2006年12月-2008年3月,收治11例乳腺癌根治术后1～4年胸壁严重缺损患者;年龄27～49岁.左侧3例,右侧8例.术中采用背阔肌止点离断的岛状背阔肌肌皮瓣旋转替代胸大肌,背阔肌肌瓣切取范围26cm×17 cm～31 cm×20 cm,皮瓣切取范围13 cm×6 cm～18 cm×8 cm.于肌瓣后间隙植入乳房假体,背阔肌前上缘固定于腋项及腋前线填补腋顶空虚并重建腋窝前皱襞.供区直接缝合.结果 术后再造乳房全部成活,供受区切口均Ⅰ期愈合.Ⅱ例均获随访,随访时间3～14个月.再造乳房外观自然,手感良好,重建的腋前皱襞与健侧基本对称,腋顶及腋前皱襞凹陷畸形基本纠正.结论 应用背阔肌止点离断的岛状背阔肌肌皮瓣加乳房假体行乳房再造及腋前皱襞重建是修复乳腺癌根治术后较严重缺损的较好方法之一.     

可扩张乳房假体加背阔肌肌皮瓣的乳房再造术

目的：报告应用带蒂背阔肌肌皮瓣转移术及可扩张的乳房假体（BECKER）置入,修复乳腺癌根治术后的胸壁畸形,同时再造乳房的手术方法。方法：根据乳腺癌病灶清除术后患者胸部的畸形状况,设计患侧带蒂背阔肌肌皮瓣的肌瓣长度、体积以及皮瓣的面积和形状,切取肌皮瓣后经腋部皮下隧道转移至胸前。用肌瓣修复胸前软组织缺损,皮瓣则用于弥补胸部皮肤的不足。肌瓣与胸壁间置入可扩张的乳房假体。术后经注射壶注水,逐步扩张至额定值。6个月后,可抽除注射壶并重建乳头,完成治疗。结果：自1999年以来,对各种乳腺癌术后患者行乳房再造术共26例,获得了满意效果。结论：应用带蒂背阔肌肌皮瓣转移术及可扩张的乳房假体置入,不仅可修复乳腺癌病灶清除术后的胸部软组织的缺损、锁骨下的凹陷畸形而且可重建乳房。该法具有创伤小、恢复快、再造乳房的外形及质感逼真等特点。     

背阔肌游离皮瓣修复面颈部瘢痕挛缩畸形

目的:研究背阔肌游离皮瓣在修复面颈部挛缩畸形中所起的重要作用。方法:10例面颈部瘢痕彻底松解后,采用游离的背阔肌肌皮瓣治疗,将胸背动静脉分别与面动静脉吻合,供瓣区采用中厚皮片移植,其中两例采用预扩张的背阔肌游离皮瓣进行修复。结果:9例背阔肌肌皮瓣游离移植后完全存活,1例背阔肌皮瓣远端部分坏死,术后患者的面颈部功能和外形得到明显的改善。结论:背阔肌游离皮瓣修复面颈部瘢痕挛缩畸形效果可靠。     

三叶状下腹部腹直肌肌皮瓣乳房重建

目的用改善血供的下腹部横行腹直肌肌皮瓣(TRAMF)重建乳房。方法在通常以上部腹直肌为蒂的 TRAMF 的肌蒂表面附加一块脐旁三角形皮瓣,使共同组成三叶状,藉以增加肌皮穿支动脉的血供及肌皮瓣提供的组织量,便于乳房塑形和腋部瘢痕挛缩的充分松解修复,以及胸壁的放射性烧伤创面的修复。结果乳癌术后单侧乳房缺失伴胸壁放射性溃疡及腋部瘢痕挛缩6例,肌皮瓣完全成活者4倒,皮瓣最远端少量坏死及脂肪液化者2例。重建乳房外形良好,胸壁放射性烧伤创面修复及腋部瘢痕挛缩修复。结论本术式最适用于单侧乳房缺失伴放疗后有胸壁烧伤溃疡及腋窝瘢痕挛缩的病例。     

扩张背阔肌节段肌皮瓣治疗前胸部广泛瘢痕挛缩

目的探讨扩张背阔肌节段肌皮瓣在前胸部广泛瘢痕挛缩畸形中的应用价值。方法2010年10月至2012年10月,对8例（11侧）前胸部广泛瘢痕挛缩患者应用扩张背阔肌节段肌皮瓣进行修复。治疗分两期,Ⅰ期：术前超声定位胸背动脉外侧支肌皮穿支的体表投影,设计含有胸背动脉外侧支肌皮穿支的背阔肌前缘节段肌束的胸背部皮瓣,分离腔隙后,放置扩张器,扩张器注水4~6个月;Ⅱ期：胸部瘢痕松解、切除,乳腺组织复位,以胸背动脉主干或外侧支为蒂,背阔肌扩张节段肌皮瓣转移修复。结果所有皮瓣全部成活,供区可直接缝合。随访3~20个月,皮瓣质地柔软,色泽与胸部接近。术后患侧肩关节内收、内旋、后伸力量无明显减弱,背部无明显凹陷畸形,女性患者乳房形态满意。结论应用背阔肌节段肌皮瓣预扩张术修复前胸部广泛瘢痕挛缩畸形,是一种较为理想的治疗手段,值得推广。     

乳腺癌保乳术后乳房畸形修复手术的选择

目的 探讨保乳术后继发乳房畸形的原因及预防方法,以及根据乳房畸形的不同程度采用不同方法进行修复重建的治疗效果.方法 选择行乳腺癌保乳术后1年以上,化疗及放疗结束半年以上,无局部复发及远位转移,患侧乳房出现继发畸形,要求修复重建患者30例,对患侧乳房进行瘢痕切除、挛缩松解,并根据组织缺损的不同程度,选择不同的方法进行修复重建,7例应用局部乳腺瓣法,21例应用背阔肌肌皮瓣法,2例采用横行腹直肌肌皮瓣法.结果 术后乳房形态及手感良好,优23例(76.7％),良7例(23.3％).术后所有患者平均随访约2.5年,目前均处于无瘤生存状态.结论 保乳术后继发乳房畸形,可根据畸形不同程度,选择不同方法进行修复重建,修复重建后乳房形态良好.     

背阔肌肌皮瓣移植修复严重深度烧伤

目的总结高压电烧伤、热压伤创面适用背阔肌肌皮瓣进行修复的经验。方法26例严重深度烧伤创面,应用背阔肌肌皮瓣移植,其中岛状转位25例,游离移植1例。对上肢广泛电击伤及热压伤创面采用该肌皮瓣与侧胸皮瓣及髂腰部皮瓣联合移植修复,全跟腱坏死应用游离背阔肌肌皮瓣修复。结果皮瓣面积最大40cm×20cm,除1例皮瓣尖端坏死2cm,其余全部成活。跟腱的功能恢复满意。结论背阔肌肌皮瓣修复严重深度烧伤是一种理想的方法。     

三叶状下腹部腹直肌肌皮瓣乳房重建

目的用改善血供的下腹部横行腹直肌肌皮瓣（ＴＲＡＭＦ）重建乳房。方法在通常以上部腹直肌为蒂的ＴＲＡＭＦ的肌蒂表面附加一块脐旁三角形皮瓣,使共同组成三叶状,藉以增加肌皮穿支动脉的血供及肌皮瓣提供的组织量,便于乳房塑形和腋部瘢痕挛缩的充分松解修复,以及胸壁的放射性烧伤创面的修复。结果乳癌术后单侧乳房缺失伴胸壁放射性溃疡及腋部瘢痕挛缩６例,肌皮瓣完全成活者４例,皮瓣最远端少量坏死及脂肪液化者２例。重建乳房外形良好,胸壁放射性烧伤创面修复及腋部瘢痕挛缩修复。结论本术式最适用于单侧乳房缺失伴放疗后有胸壁烧伤溃疡及腋窝瘢痕挛缩的病例。     

背阔肌分区的解剖及临床应用

目的：从解剖和电生理探讨背阔肌分区的可行性及实用性,以便指导临床应用。方法（1）对10具成人尸体进行背阔肌内的血管和神经解剖,按主要血管,神经的分支分布,将背阔肌分区。（2）利用体表电极记录13例（25侧）健康成人背阔肌不同分区在肩关节运动中的肌电表现,将记录结果进行统计学处理。（3）应用外下区背阔肌岛状肌皮瓣支配范围,为10例行乳房再造,肘关节及胸壁瘢痕创面的修复。结果：（1）背阔肌内的主要血管神经分内,外侧两支,按内,外侧将背阔肌分成内上和外下二区。（2）二区在肩关节运动中的肌电表现不同。（3）分区应用背阔肌肌皮瓣行乳房再造,肘关节及胸部瘢痕创面修复均得满意效果。结论：背阔肌可以分为二区并可分开应用,外下区较内上区有肩关节运动中起的作用大。     

Delayed Breast Reconstruction with Latissimus Dorsi Flap

Background  The ideal method of breast reconstruction should be safe, reliable, and have minimal or no donor-site morbidity. We present our experience with the latissimus dorsi musculocutaneous flap for delayed breast reconstruction with immediate permanent implant insertion. Methods  The latissimus dorsi musculocutaneous flap was performed on patients who presented for delayed breast reconstruction. From 1999 to 2007, charts of patients were reviewed for age, type of mastectomy, history of chest wall irradiation, nipple-areola complex reconstruction, and complications at both the donor site and the reconstructed breast site. Results  The latissimus dorsi was used as a musculocutaneous flap in 33 patients who had breast cancer surgery. The mean age was 51.14 (range = 30–63) years. Nine patients (27%) asked for nipple-areola reconstruction. Three patients had major complications (9%), including infection, partial flap ischemia, and liponecrotic pseudocysts. Eight patients required revision. Seroma was the most common problem observed at the donor site. Conclusion  The latissimus dorsi flap provides adequate soft tissue with a reliable blood supply for the enhancement of missing tissue after mastectomy. It is a safe method for breast reconstruction and an excellent alternative flap for patients at high risk for abdominal flap complications.     

Physiological studies using laser Doppler flowmetry to compare blood flow to the zones of the free TRAM flap

The latissimus dorsi musculocutaneous island flap was once the standard for breast reconstruction. With the increased use of tissue expanders and the development of the transverse rectus abdominis musculocutaneous flap for autologous tissue breast reconstruction, use of the latissimus dorsi has decreased. To reassess the role of the latissimus dorsi musculocutaneous flap in breast reconstruction, a retrospective review was performed to evaluate women who had skin-sparing mastectomy followed by immediate reconstruction with a latissimus dorsi flap and permanent implants. The postoperative aesthetic results and donor site morbidity, including contour deformity and scarring, were examined. Satisfactory results were obtained in 17 of 18 patients. Complications were noted in 5 patients, and all were minor. Using the latissimus dorsi musculocutaneous flap and a permanent breast prosthesis for immediate reconstruction is successful because it provides sufficient muscular coverage of the implant. In addition, it provides a good aesthetic result using a single-stage procedure. Illustrative cases are presented.     

Pre-expanded Muscle-sparing Latissimus Dorsi Flaps for Reconstruction of Severe Scar Contractures on the Anterior Chest

ObjectiveTo investigate the utility of pre-expanded muscle-sparing latissimus dorsi flaps in the reconstruction of deformities secondary to severe scar contractures on the anterior chest.MethodsThe function of the latissimus dorsi was preserved with blood supply from the main or lateral branch of the thoracodorsal artery. The entire treatment period was divided into two stages, during which segmental latissimus dorsi flaps were pre-expanded in stage I and anterior chest scar deformities were reconstructed in stage II.During stage I, the musculocutaneous perforators arising from the lateral branch of the thoracodorsal artery were determined by ultrasound preoperatively; the flap design included the anterior segment of the latissimus dorsi supplied by the musculocutaneous perforators from the lateral branch; and a tissue expander was placed following flap dissection and then infused with saline intermittently for 4–6 months.In stage II, the chest scars were excised, and breast tissues were repositioned; the continuity of the medial branch of the thoracodorsal nerve to the muscle was preserved when reconstruction was performed using the segmental latissimus dorsi flaps supplied by the main or lateral branch of the thoracodorsal artery.ResultsFrom October 2010 to October 2019, 21 patients (on 24 sides) underwent reconstructive procedures for extensive scar contractures on the anterior chest. All flaps survived, and their donor sites were sutured directly. During a follow-up of 3 months to 8 years, the flaps became soft and exhibited color similar to that of the adjacent tissues. The limited neck and shoulder movements improved, and postoperatively, all female patients were satisfied with the shape of their breasts. Additionally, neither apparent weakening on the adduction, internal rotation, or extension strength of the shoulder joint on the affected side nor marked depression deformity in the back was observed.ConclusionPre-expanded muscle-sparing latissimus dorsi flaps with blood supply from the main or lateral branch of the thoracodorsal artery proved to be a desirable option for the reconstruction of extensive scar contractures on the anterior chest.     

Latissimus dorsi muscle and its short perforator-based skin compound free flap

Some authors have described the latissimus dorsi muscle and its short perforator-based skin compound flap based on the same thoracodorsal vessels. This flap procedure involves separating the skin island from the underlying latissimus dorsi muscle and rotating the skin island over the musculocutaneous perforator emerging from the latissimus dorsi muscle. As with all surgical procedures, there are various advantages and disadvantages. However, to the best of the authors' knowledge, there are no reports on the use of the flap in a consecutive series.Between 1997 and 2005, the flap was used to reconstruct below-knee structures in 26 patients (23 males and 3 females) by the 2 senior authors at the Chonnam National University Medical School. The clinical outcomes of this procedure were evaluated.Satisfactory results were obtained in most patients. However, there were 2 marginal necroses in the excessively large skin flaps, 1 partial necrosis over the distal edge of a skin flap, and 1 total flap failure caused by infection. The marginally and partially necrotized skin flaps were treated successfully with split-thickness skin grafts. However, another flap procedure was required to cover the defect in the case of flap failure. The donor sites were closed primarily in all patients, and the skin flaps were rotated between 40 degrees and 180 degrees. This flap allows the surface of the latissimus dorsi musculocutaneous flap to be expanded without additional donor morbidity. In addition, the flap procedure is safe and easy to perform. Moreover, the flap provides sufficient flexibility, even though it has less independent flap mobility than the chimeric flap. Therefore, the flap may be a convenient and reliable alternative for the reconstruction of large and irregular-shaped wounds.     

Chest wall resection and reconstruction for locoregionally advanced or recurrent breast cancer

Ten patients, including 7 with local recurrent breast cancer, 2 with primary advanced cancer and 1 with radionecrosis, underwent chest wall resection and immediate reconstruction, using large pedicled skin flaps or musculocutaneous flaps. A rectus abdominis musculocutaneous flap was used in 4 cases and a latissimus dorsi musculocutaneous flap was used in 1 case. The postoperative course of all the patients was uneventful and there was no incidence of flail chest or respiratory failure. The postoperative performance status and also the quality of life were improved in 9 of the 10 patients. Eight of the 10 patients are presently alive with or without disease, the longest survival time thus far being 8 years.     

Chest wall resection and reconstruction for locoregionally advanced or recurrent breast cancer

Ten patients, including 7 with local recurrent breast cancer, 2 with primary advanced cancer and 1 with radionecrosis, underwent chest wall resection and immediate reconstruction, using large pedicled skin flaps or musculocutaneous flaps. A rectus abdominis musculocutaneous flap was used in 4 cases and a latissimus dorsi musculocutaneous flap was used in 1 case. The postoperative course of all the patients was uneventful and there was no incidence of flail chest or respiratory failure. The postoperative performance status and also the quality of life were improved in 9 of the 10 patients. Eight of the 10 patients are presently alive with or without disease, the longest survival time thus far being 8 years.     

Reconstruction of large chest wall defects using a combination of a contralateral latissimus dorsi and a rectus abdominis musculocutaneous flap.

A combination of a contralateral latissimus dorsi musculocutaneous flap and a rectus abdominis musculocutaneous flap used in the reconstruction of large chest wall defects is reported in three patients. This combination is an easy and reliable procedure, without microsurgery, for reconstructing large chest wall defects or deformities and is applicable to patients whose ipsilateral branches of the subclavicular and axillary vessels cannot be used, and to those who need reconstruction of the subclavicular area and axilla as well as the breast mound area.     

Reconstruction of postburn breast deformities

Postburn breast deformity is a sequela of severe scar contraction of the burned chest. During the past 3 years, 24 female patients with such deformities required reconstruction, the surgery was performed in our department. These patients, the types of the deformities and the techniques used for reconstruction have been reviewed. For mild deformities (10 patients) reconstructions with skin grafts and local skin flaps were found to be satisfactory. For deformities which affected the mammary development (14 patients), mammary prostheses directly or under the soft tissue obtained by skin expansion or musculocutaneous flaps were used. In three of our patients, reduction mammaplasty or mastopexy was needed to symmetrize the breasts.