应用背阔肌与胸大肌联合肌瓣及假体置入即刻乳房再造

目的探讨经乳房外侧弧形切口皮下乳腺切除术后,带蒂转移背阔肌肌瓣,与胸大肌肌瓣形成联合肌瓣覆盖乳房假体,进行即刻乳房再造术的治疗效果。方法选择临床分期为Ⅰ期或Ⅱ期．肿瘤未侵及皮肤和胸肌的乳腺癌患者共30例,经乳房外侧弧形切口皮下切除乳腺腺体并清扫腋窝淋巴结,利用同一切口,切取背阔肌肌瓣带蒂转移,分离胸大肌下间隙,切断胸大肌下缘与胸壁附着处直至胸骨边缘,将转移的背阔肌肌瓣与胸大肌断缘缝合,组成联合肌瓣,形成宽大的包裹假体的腔隙．置入假体。结果30例再造乳房外形及手感良好,其中优22例（73．3％）,良8例（26．7％）。术后所有患者均随访半年以上,均无瘤生存。结论再造乳房形态美观,能够置入较大的假体,不增加背部的切口,适合于无淋巴结转移、对侧乳房无明显下垂的早期青年乳腺癌患者的即刻乳房再造。     

Combined use of the cephalic vein and pectoralis major muscle flap for secondary esophageal reconstruction

Secondary reconstruction of thoracic esophageal defects is a challenging problem for microsurgeons. Because of previous surgeries and coexisting disease, gastric pull‐up, and creation of a pedicled colon conduit are often impossible. Transfer of a supercharged pedicled jejunum flap or free jejunal interposition is usually the last resort; however, identifying appropriate recipient vessels and adequately covering the reconstructive conduit are often difficult. We performed secondary thoracic esophageal reconstruction with combined use of the cephalic vein as a recipient vein and the pectoralis major muscle flap for coverage in three patients. Two patients underwent transfer of a supercharged pedicled jejunum flap, and the other patient underwent free jejunal interposition. No wound complications occurred, and all patients could resume oral intake. The cephalic vein is a more reliable recipient vein than is the internal mammary vein. The skin graft‐covered pectoralis major muscle flap provides secure external coverage to prevent anastomotic leakage even in complicated cases. Combined use of the cephalic vein and the skin graft‐covered pectoralis major muscle flap is a versatile option for secondary thoracic esophageal reconstruction. © 2013 Wiley Periodicals, Inc. Microsurgery 34:319–323, 2014.     

Thoracodorsal artery perforator flap: a versatile alternative for various soft tissue defects

Thoracodorsal artery perforator (TDAP) flap is a relatively new member of the perforator flap family. The objective of this study is to describe the use of pedicled and free TDAP flaps for various soft tissue defects. Fifteen patients underwent soft tissue reconstruction using 16 TDAP flaps. Twelve pedicled flaps were used for axillary, breast, and shoulder regions. Four free flaps were used for cheek, popliteal, hand, and foot reconstruction. The flaps were harvested based on the perforators, which were preoperatively located at or close to a point 8 cm below the posterior axillary fold and 2 cm behind the lateral border of the latissimus dorsi muscle. Early, late, major, and minor complications were documented. In 13 of the 16 flaps, perforators from the thoracodorsal artery were found in the circle 3 cm in diameter, centered on the anatomic landmark. Three other perforators were found outside this circle. One flap loss was considered the only major complication. Minor complications occurred in 12.5% of flaps. Although the vascular anatomy can be variable, free and pedicled TDAP flap is a versatile option in soft tissue reconstruction.     

Primary reconstruction of head and neck cancer with anterior rib, osteomyocutaneous composite flap.

The anterior rib, osteomyocutaneous composite flap (AROCF) incorporating both vessels, supracostal and intercostal, has been harvested for primary reconstruction in advanced head and neck cancer patients. The adequacy of the periosteal circulation alone for the successful free osseous transfer has been well proved. The available length of the internal mammary vessels is sufficient for the successful microvascular anastomosis in the neck. This same AROCF can be used as a pedicled flap based on the pectoralis major musculo-vascular pedicle for successful primary reconstruction in cases in which it is deemed unsuitable for use as a free flap. This is possible because of the unique functional blood supply of the rib.     

Total mastectomy with axillary dissection: A modified radical mastectomy

A technic for total mastectomy with complete axillary dissection has been described. The procedure utilizes division of the pectoralis major muscle between its clavicular and sternal portions, perservation of its innervation, and reconstruction after completion of the dissection. The pectoralis minor muscle is resected. This modification facilitates a thorough axillary dissection, particularly at the apex, while preserving the cosmetic and functional benefits of the Patey operation.     

Combined use of free jejunum and pectoralis major muscle flap with skin graft for reconstruction after salvage total pharyngolaryngectomy

Salvage total pharyngolaryngectomy after failed organ‐preserving therapy often results in composite defects involving the alimentary tract, trachea, and neck skin. This retrospective study examined combined use of the free jejunum flap and the pectoralis major muscle flap with skin graft for such a complex reconstruction. We reviewed 11 patients who underwent free jejunum transfer for alimentary reconstruction and pedicled pectoralis major muscle flap transfer with a skin graft on the muscle for simultaneous neck skin resurfacing after salvage total pharyngolaryngectomy from 2005 through 2010. The operative morbidity rate was 27.3%. No pharyngocutaneous fistula developed in this series. Oral intake could be resumed within 3 weeks after surgery in all patients. Seven of 11 patients had a functional tracheostoma with adequate stomal patency. Combined use of free jejunum and pectoralis major muscle flap with skin graft provided secure wound closure even for complicated cases. © 2012 Wiley Periodicals, Inc. Microsurgery, 2013.     

Endoscopic assisted harvest of the pedicled pectoralis major muscle flap.

The Pectoralis Major flap is a reliable and versatile flap for head and neck reconstruction. However, it is associated with donor site scarring on the anterior of the chest wall. Endoscopic assisted harvest of a pedicled pectoralis major muscle flap was performed on three patients for head and neck reconstruction. The average incision length was 4.5 cm, the average time taken to harvest the muscle was 37 min. All patients were discharged from hospital on the 5th to 8th postoperative day and one patient had a seroma. Endoscopic harvest of the pedicled Pectoralis major muscle flap minimises postoperative scarring.     

Total mastectomy with complete axillary dissection.

A technique for total mastectomy with complete axillary dissection, which uses division of the insertion of the sternal portion of the pectoralis major muscle, preservation of its innervation, reconstruction after completion of the dissection and resection of the pectoralis minor muscle has been evaluated for 115 consecutive procedures. This modification facilitates a thorough axillary dissection, while preserving the cosmetic and functional benefits of the Patey operation.     

A Case of Postmastectomy Defect Reconstructed Using a Laterothoracic Bilaterally Pedicled V-Y Advancement Flap

BACKGROUND: The reconstruction of major defects of the trunk is generally achieved by means of pedicled or free musculocutaneous flaps, but for less extensive defects, local flaps or skin grafts are currently used. The bilaterally pedicled V-Y advancement flap differs from the traditional V-Y advancement flap and was described for soft tissue reconstruction in the face. In our unit, the bilaterally pedicled V-Y advancement flap is the most used local flap for face reconstruction, and our aim was to use it in a different location. METHODS: In this case report we present a postmastectomy defect reconstructed with good results using the bilaterally pedicled V-Y advancement flap. RESULTS: The flap healed without further problems, and a good aesthetic result was obtained. CONCLUSION: The bilaterally pedicled V-Y advancement flap is reliable and easy to harvest, and not only for face reconstruction. Its versatility and plasticity allow its use for the reconstruction of many defects at varying locations.     

Value of a scapular flap in the treatment of axillary hidradenitis. Apropos of a clinical case]

A severe case of axillary hidradenitis suppurativa, treated bilaterally by large excision followed by reconstruction with a pedicled scapular flap is presented. This reliable and thin fasciocutaneous flap provides good cover of large axillary defects with minimal donor site consequences. Its advantage is discussed versus the other surgical procedures used in this pathology for axillary reconstruction.     

Buttock reconstruction using a pedicled deep inferior epigastric perforator flap

Although deep inferior epigastric perforator (DIEP) flaps are mainly used for breast reconstruction as free flaps, they are also useful as pedicled island flaps. However, DIEP flaps have seldom been used for reconstructions in the lateral hip region. Furthermore, to the best of our knowledge, no report has been issued on the use of this flap for buttock reconstruction. The authors describe the successful use of a pedicled oblique DIEP flap for the reconstruction of a severe scar contracture in the buttock. The pedicled DIEP flap can be a useful option for the reconstruction of large buttock defects, and if a transverse DIEP flap is unavailable, an oblique DIEP flap should be considered an alternative.     

Treatment modalities for post-burn axillary contractures and the versatility of the scapular flap

Inappropriate treatment of axillary burns frequently results in adduction contractures. In this clinical study we have reviewed 32 patients with different types of axillary post-burn adduction contractures.We have used a variety of surgical treatments for reconstruction of axillary contracture releasing defects such as simple grafting, Z-plasties and locally pedicled flaps. Among these alternatives, we preferred to use scapular island flap most frequently. In addition to conventional harvest of this flap, extension of its pedicle up to the subscapular ramification by passing it through the triangular space allowed its transfer even to the anterior axillary line defects in a vertical orientation without pedicle kinking.In conclusion, the island scapular flap is a good choice for reconstruction of all types of axillary contracture, releasing defects with satisfactory results in terms of function and cosmesis.     

Reconstruction of the axilla with a posterior arm fasciocutaneous flap.

We present our experience with the use of the posterior arm fasciocutaneous flap in the reconstruction of 22 axillae in 17 patients. These patients all suffered from long-standing, severe hidradenitis suppurativa and this flap was used to reconstruct the axilla after surgical excision of the whole hair-bearing area of the axilla and the underlying axillary disease. In most cases, excision included all of the axillary contents up to the axillary vessels but excluded the apex of the axilla. Nineteen axillae were reconstructed with a pedicled flap. Three axillae were reconstructed more recently with an island flap. All reconstructions were achieved without flap complications.     

Some observations on 112 pectoralis major myocutaneous flaps

Our results of 112 pectoralis major flaps used alone or in combination have been reviewed. Also, other anatomic studies have been described which led to the development of a true island flap with a more mobile, less bulky pedicle. The use of the flap in full-thickness reconstruction by modification of the flap or bilateral flaps has been discussed. The place of the flap when used in combination with the deltopectoral and forehead flaps in the repair of major postexcisional defects has been illustrated.     

A comparison of ipsilateral pedicled TRAM flap with and without previous irradiation

Due to concerns for increased complications, there is reluctance to use the ipsilateral pedicled TRAM for breast reconstruction in the presence of previous chest wall irradiation. This study will assess whether the ipsilateral pedicled TRAM is a safe and effective option when the pedicle is part of the irradiation field. Consecutive cases of ipsilateral pedicled TRAM flap procedures from 1997-2003 were reviewed. Patients with and without previous irradiation were compared on several vascular indicators. There were 123 and 124 patients in the irradiated and nonirradiated groups, respectively. These groups were demographically similar, except the nonirradiated group was significantly older. The irradiated group had a significantly higher rate of minor wound problems related to mastectomy flap healing (8.9% versus 1.6%). All other flap vascular complications were equivalent. The ipsilateral pedicled TRAM flap is a safe and effective option for breast reconstruction in an irradiated field in terms of the pedicle to the flap.     

Pedicled deep inferior epigastric perforator flap for lower abdominal defects and genital reconstructive surgery

The pedicled deep inferior epigastric perforator (DIEP) flap can be used successfully to reconstruct the lower abdominal, inguinal, and genital regions. This muscle-sparing technique offers many advantages, such as minimal donor-site morbidity, a wide arch of rotation, and more versatile flap design, and provides for easier reconstruction than free flaps. Four pedicled DIEP flap cases are described in this article. The flaps were used to reconstruct lower abdominal defects and groin defects and to perform a penile reconstruction. To the best of our knowledge, ours is the first report in the English literature to describe the use of a pedicled DIEP flap for penile reconstruction. The donor sites were closed directly, and morbidity in all cases was minimal.     

A new method of modified radical mastectomy for breast cancer

We have developed a new type of modified radical mastectomy, the method and clinical results of which are reported herein. In this operation, axillary dissection is performed by the following two approaches. Firstly, the axillary contents are dissected from the highest possible subclavicular point to the pectoralis minor muscle, after partially cutting the sternocostal origin of the pectoralis major muscle. The second approach is from the posterior aspect of the pectoralis minor muscle to the lateral portion of the latissimus dorsi muscle. Parasternal dissection can also be performed for stage II and IIIa cancers with a central or medial tumor. After lymph node dissection, the detached edge of the sternocostal origin of the pectoralis major muscle is resutured to cover the parasternal region. Thus, complete dissection of the axillary nodes is performed whilst preserving the pectoralis major and pectoralis minor muscles. Good clinical results were achieved with respect to radicality, cosmetic effects and function in 28 patients with stage I, II, and IIIa breast cancers who were followed up for between 5 to 8 years. This new operation may therefore be adopted for the majority of patients with Stage I, II, or IIIa cancers, unless massive infiltration into the pectoralis major muscle has occurred. Preservation of both the pectoralis major and pectoralis minor muscles results in a good cosmetic appearance, good functioning of the arm and easy reconstruction of the breast following mastectomy.     

Middle turbinate vascularized flap for skull base reconstruction after an expanded endonasal approach

Introduction  

The expanded endonasal approaches to the skull base are modular approaches that arise from the sphenoidal sinus. The reconstructive techniques in these approaches are key to avoid postoperative complications. Available flaps for reconstruction include the pedicled nasoseptal flap, the transpterygoid temporoparietal fascia flap, and the posterior pedicle inferior turbinate flap (PPITF), among others. Recently, the middle turbinate flap has been described in a cadaveric study. We report our preliminary experience in the use of this middle turbinate vascularized flap for skull base reconstruction after expanded endonasal approaches.     

A new method of modified radical mastectomy for breast cancer

We have developed a new type of modified radical mastectomy, the method and clinical results of which are reported herein. In this operation, axillary dissection is performed by the following two approaches. Firstly, the axillary contents are dissected from the highest possible subclavicular point to the pectoralis minor muscle, after partially cutting the sternocostal origin of the pectoralis major muscle. The second approach is from the posterior aspect of the pectoralis minor muscle to the lateral portion of the latissimus dorsi muscle. Parasternal dissection can also be performed for stage II and IIIa cancers with a central or medial tumor. After lymph node dissection, the detached edge of the sternocostal origin of the pectoralis major muscle is resutured to cover the parasternal region. Thus, complete dissection of the axillary nodes is performed whilst preserving the pectoralis major and pectoralis minor muscles. Good clinical results were achieved with respect to radicality, cosmetic effects and function in 28 patients with stage I, II and IIIa breast cancers who were followed up for between 5 to 8 years. This new operation may therefore be adopted for the majority of patients with Stage I, II, or IIIa cancers, unless massive infiltration into the pectoralis major muscle has occurred. Preservation of both the pectoralis major and pectoralis minor muscles results in a good cosmetic appearance, good functioning of the arm and easy reconstruction of the breast following mastectomy.