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。     

应用下腹部横行腹直肌岛状肌皮瓣行乳房再造2例

作者应用下腹部横行腹直肌岛状肌皮瓣行乳癌术后乳房再造术2例,并讨论了该皮瓣的血供特点。     

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。     

带蒂腹直肌肌皮瓣及背阔肌肌皮瓣乳房再造并发症的Meta分析

目的 比较运用横行带蒂腹直肌肌皮瓣（transverse rectus abdominis myocutaneous flap,TRAM flap）和背阔肌肌皮瓣（latissimus dorsi flap,LDF）进行I期乳房再造术的并发症（包括脂肪坏死率、肌皮瓣部分坏死率、肌皮瓣完全坏死率）,为临床决策提供依据.方法 在CNKI、SinoMed、PubMed、VIP、Cochrane等数据库和运用手工检索1992～2012年有关带蒂TRAM肌皮瓣及LDFI期乳房再造的中英文文献共1493篇.按照纳入与排除标准选择、提取资料和评价质量后,发现有47篇文献符合标准,采用RevMan 5.0软件进行M-H固定效应模型进行Meta分析.结果 有10篇文献同时包含带蒂TRAM肌皮瓣和LDF乳房再造并发症,所以用以比较两者的并发症的相关危险度（relative risk,RR）和95％置信区间（confidence interval,CI）.带蒂TRAM肌皮瓣的部分坏死率是LDF的1.7倍（RR值为1.72,95％CI为1.02～2.88）,脂肪坏死率（RR值为1.01,95％CI为0.60～1.72）和肌皮瓣完全坏死率（RR值为2.13,95％CI为0.82～5.54）,与LDF相比差异无统计学意义（P＞0.05）.结论 LDF与带蒂TRAM肌皮瓣乳房再造术相比,LDF乳房再造的肌皮瓣部分坏死并发症发生率较低,肌皮瓣完全坏死率与脂肪坏死率比较,差异无统计学意义（P＞0.05）.     

上,下蒂横形腹直肌肌皮瓣乳房再造的解剖学研究

目的 探讨上蒂横形腹直肌肌皮瓣乳房再造术后并发症产生的原因。方法 对２０侧成人尸体进行解剖观察。结果 发现主要是由于上蒂术式切断了该肌皮瓣的主要供血动脉－腹壁下动脉，仅靠腹避暑上、下动脉之间微薄的螺旋微动脉的吻合支供血，以致术后产生脂肪液化、边缘坏死等并发症。结论 腹壁下动、静脉是中、下腹部横形腹直肌肌皮瓣的直接供血动脉及回流静脉，即下蒂优于上蒂。     

下腹部腹直肌肌皮瓣血供的应用解剖

目的了解与下腹部腹直肌肌皮瓣相关的血管分布情况,促进乳腺癌根治术后下腹部肌皮瓣移位乳房再造手术的推广。方法采用福尔马林浸泡未超过6个月的成人尸体15具30侧。上起锁骨下、下至腹股沟韧带,两侧至腋中线的胸腹壁完整切下。腹壁下动静脉自髂外动静脉起始处离断。分别用红、蓝乳胶墨水经腹壁下和胸廓内动静脉灌注,使其分支、属支显影。结果腹壁上、下动脉起始处外径分别为1.87±0.28mm及2.25±0.32mm。腹壁下动脉的皮下穿支分布有向脐水平逐渐密集的趋势,弓状线以下穿支明显减少,Rand各个区均可见穿支出腹直肌前鞘,排列上外侧穿支距腹直肌前鞘外侧缘、、区分别平均为1.22、1.46、1.57cm;内侧穿支在距正中线、、区平均1.54、1.62、1.66cm。近脐的穿支管径较其他部位粗和密集。腹壁上动脉在与肋弓下缘交界附近发出一肋缘动脉,距肋弓1.25±0.37cm。发出肋缘动脉后67%的肋缘动脉比腹壁下动脉本干粗。肋缘动脉分支分布于腹直肌中、外侧2/3,且与肋间前动脉及营养膈肌的血管间有广泛吻合。胸廓内动脉在发出腹壁上动脉前后还分出一分支营养剑突水平的腹直肌。结论以腹壁上动脉为蒂的横形下腹部肌皮瓣切取过程中,脐以下、弓状线以上保留腹直肌前鞘内、外侧各1cm在腹壁上和区的全部前鞘在皮瓣上,能较好保护腹壁下动脉肌皮动脉不受损伤。将肋弓下2cm以上的腹直肌前鞘和腹直肌完全保留在皮瓣上可有效保护肋缘动脉。肋缘动脉不受损是肌皮瓣成活的重要保证。     

腹直肌-背阔肌肌皮瓣联合应用乳房再造术

目的　探索一种同时修复乳房和胸壁缺损的手术方法。方法　利用下腹部横行腹直肌肌皮瓣 (下简称TRAM皮瓣 )和部分背阔肌肌皮瓣 ,为乳癌术后患者行乳房再造及胸壁缺损修复。结果　 4例 8个皮瓣全部成活 ,再造乳房及胸壁缺损修复效果满意。结论　联合应用腹直肌—背阔肌肌皮瓣 ,可以同时完成乳房再造及胸壁缺损的修复 ,效果满意。     

剖宫产术后行横行腹直肌肌皮瓣乳房再造的应用策略

目的 探讨剖宫产后瘢痕者行横行腹直肌(transverse rectus abdominis myocutaneous,TRAM)肌皮瓣乳房再造的可行性和手术策略.方法 对12例有剖宫产史的乳腺癌患者实施TRAM肌皮瓣乳房再造术.所有患者的TRAM肌皮瓣应用危险因素评分均为0.5分,Ⅱ类.采用腹部倒梯形手术切口,切口上缘下距脐2～3 cm,对1例腹部纵切口瘢痕较长者采用腹直肌双蒂,其余均为患乳对侧腹直肌单蒂,并携带同侧腹直肌前鞘,对腹直肌和前鞘缺损以聚丙烯网片修补.结果 全部12例皮瓣成活,无腹部并发症发生,随访3～52个月,满意率达100％.结论 带剖宫产瘢痕者行TRAM肌皮瓣乳房再造需严格选择病例,并要求制定相应的手术策略.     

上、下蒂横形腹直肌肌皮瓣乳房再造的解剖学研究

目的探讨上蒂横形腹直肌肌皮瓣乳房再造术后并发症产生的原因。方法对２０侧成人尸体进行解剖观察。结果发现主要是由于上蒂术式切断了该肌皮瓣的主要供血动脉——腹壁下动脉，仅靠腹壁上、下动脉之间微薄的螺旋微动脉的吻合支供血，以致术后产生脂肪液化、边缘坏死等并发症。结论腹壁下动、静脉是中、下腹部横形腹直肌肌皮瓣的直接供血动脉及回流静脉，即下蒂优于上蒂。     

THE FREE TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP IN BREAST RECONSTRUCTION AFTER MASTECTOMY

Breast reconstruction after mastectomy by the transverse rectus abdominis myocutaneous (TRAM) flap technique is a widely accepted method which allows reconstruction without the need for an implanted silicone prosthesis. Even in suitable patients, deficiencies of the traditional technique, where the blood supply is based on anastomotic vessels in the superior part of the rectus abdominis muscle, may lead to complications. These include flap failure, fat necrosis which may mimic recurrence of breast carcinoma or sub-optimal cosmetic results. By transferring the same abdominal tissue as a free flap based on the inferior epigastric vessels, a more reliable blood supply and better cosmetic results can be obtained. This article reports a series of 14 flaps in 13 patients in whom an entirely free flap technique was used. No flap losses were recorded and the results are judged to be superior to the traditional technique.     

背阔肌皮瓣游离移植修复前臂重建功能

创伤致前臂屈肌或伸肌并皮肤广泛缺损,使患肢手部完全丧失功能,治疗上极为困难。我院从1987年开始应用吻合血管、神经的背阔肌肌皮瓣移植,修复前臂肌肉并广泛性皮肤缺损4例。术后随访6个月～3年,肌力恢复4级左右,外形和功能满意。 我们的方法是将背阔肌的腱性部分固定在肱骨内髁或外髁上,远端分成束,每一束与手指肌腱的远侧断端在张力下缝接。同时可应用肌腱移位重建1～2指功能以弥补背阔肌肌力的不足。对背阔肌修复前臂软组织缺损重建功能的优缺点、受区的准备、肌腱的处理等问题进行了讨论。     

乳癌根治一期乳房重建

报道1985年～1989年5月,为6例乳癌患者作根治术的同时,一期作带血管神经肌蒂背阔肌肌皮瓣移位重建乳房,全部取得成功。较详细介绍了手术设计及操作方法,讨论了在乳癌根治术同时行再造术的必要性,以及背阔肌肌皮瓣作为再造材料的优点。     

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.     

上唇方肌内眦头肌皮瓣在面中部缺损修复中的应用

介绍一种新的鼻唇沟皮瓣转移方式——上唇方肌内眦头肌皮瓣,简述该皮瓣的应用解剖、手术操作方法。应用该肌皮瓣,在9例病人中,分别修复下眼睑、眶下区、上唇、鼻尖部缺损,全部获得成功。     

肩胛,侧胸,背阔肌皮瓣联合移植术

目的：干肩胛、侧胸、胸背区联合切取多类型皮瓣进行移植，以解决巨长、巨宽和环形创面的一次成形修复。方法：先显露肩胛下动脉及其分枝，再按设计从周边向轴型血管方向“会师”切取皮瓣至腋后皱壁，切断背阔肌并暂时性切断大圆肌，皮瓣切取完毕。结果：临床应用４例，皮瓣全部成活，治愈创面。结论：肩胛、侧胸、背阔肌皮瓣的联合切取，可取面积大，可形成单叶巨宽、巨长，也可分叶，适用于复杂性创面的一次成形修复。     

聚丙烯补片预防游离腹直肌皮瓣术后切口疝的作用

目的 探讨聚丙烯补片（Prolene)预防游离腹直肌皮瓣术后切口疝发生的作用。方法 1999年11月9日-2000年10月22日对26例患者行游离腹直肌皮瓣移植术时,采用聚丙烯补片作腹直肌前鞘修补,分析聚丙烯补片植入后的组织反应及创口愈合情况,以及切口疝发生的情况。结果 25例患者腹部创口均Ⅰ期愈合,1例术后腹部创口出现局部积液,经保守治疗好转,未出现排异和感染等并发症,术后随访1-12个月,全部患者聚丙烯补片愈合良好,无排出或取出,腹部不适,切口疝及腹壁膨隆。结论 聚丙烯补片具有较好的生物相容性,其植入体内后不会发生排异和增加创口感染的机会,用于腹直肌前鞘的修补安全可靠,能有效预防游离腹直肌皮瓣术后切口疝的发生,值得进一步观察和应用。     

颈皮瓣在喉重建术中的应用

总结了１９８８年１１月～１９９４年４月，在喉癌切除术后，采用颈部皮瓣转移重建喉７８例的临床效果。术后３～６个月，全部患者作纤维喉镜及间接喉镜检查。发现植入的皮肤角化上皮变深，１例患者有毛发生长。经３个月～５年随访，均可用新喉进行发音、吞咽及呼吸。生存３年以上３２例，有２例复发死亡。术后６例发生喉瘘，２例喉瘢痕狭窄。讨论了术后并发症的发生原因及预防方法。认为，采用颈皮瓣转移重建喉是一种有效的手术方法     

MANDIBULAR RECONSTRUCTION WITH METAL PLATE AND MYOCUTANEOUS FLAP

The combination of myocutaneous flap with three dimensional, bendable reconstruction plate has provided very satisfactory results in restoration of mandibular defects following surgical resections in irradiated patients. Twenty–four cases have been treated and evaluated prospectively using this technique. Patients requiring postoperative irradiation were excluded from this study. Two groups were identified. Group A (n=20) required myocutaneous flap to resurface the soft tissue defect and Group B (n=4) were treated by primary closure. No failures were encountered in the group handled primarily with myocutaneous flap combined with an AO plate. One failure occurred in the group closed primarily. Nine (38%) of the patients have maintained their plate for over 1 year. Twelve (55%) have functioned for more than 9 months. Of the remaining three (7%), one failed and the other two have been in place for more than 5 months. The results of this study demonstrate that well–vascularized soft tissue bed in combination with stainless steel plate provides very satisfactory, functional, esthetic and reliable method in rehabilitation of mandibular defects primarily in irradiated patients.     

皮瓣游离移植修复再造唇缺损

1981年以来,我科应用吻合血管的前臂桡、尺侧(肌)皮瓣对17例唇缺损进行修复与再造,皮瓣全部成活。术后6个月～6年随访15例,外形及功能满意。讨论了唇缺损及合并鼻底、鼻翼、鼻小柱及牙槽嵴缺损的整复方法,认为游离前臂桡、尺侧(肌)皮瓣适于唇缺损的修复。