乳腺癌根治术后带蒂背阔肌皮瓣移植一期乳房再造

目的：总结应用带蒂背阔肌皮瓣移植进行乳腺癌改良根治术后Ⅰ期乳房再造的方法与疗效。方法：自2000年起,用带蒂背阔肌皮瓣移植方法对中青年妇女乳腺癌改良根治术后行Ⅰ期乳房再造38例。结果：全部病例的皮瓣及15例同时保留乳头病例的乳头均存活,无积液、感染、坏死等并发症,再造乳房外形美观。结论：用带蒂背阔肌皮瓣移植行乳腺癌术后Ⅰ期乳房再造是乳腺癌改良根治术后恢复乳房外形的一种理想的方法。     

双侧臂内侧穿支皮瓣移植即刻乳房再造1例

2021年6月15日, 湖南省肿瘤医院肿瘤整形外科收治1例43岁女性右侧乳腺癌患者。患者13年前曾接受左侧乳腺癌改良根治术, 6年前接受带蒂腹直肌肌皮瓣移植左侧乳房再造术。入院后行右侧乳腺癌改良根治术+双侧游离臂内侧穿支皮瓣移植右侧乳房再造术, 术中以同侧臂内侧皮瓣再造外侧半乳房, 尺侧上副血管蒂与胸外侧动脉近心端和胸外侧静脉远心端吻合, 以对侧臂内侧皮瓣再造内侧半乳房, 尺侧上副血管蒂与胸廓内血管吻合。完成血管吻合后见皮瓣通血良好, 两侧臂内侧皮瓣供区直接拉拢缝合。患者术后病程稳定, 皮瓣成活良好, 供区愈合良好。术后随访2个月, 皮瓣供区外观、功能好, 未见明显并发症, 再造乳房外形欠满意。本病例提示双侧游离臂内侧穿支皮瓣组合移植适合用于再造中小容量的乳房, 不足以用于大容量乳房再造。     

乳腺癌改良根治术后应用带蒂背阔肌皮瓣移植一期乳房再造

目的：介绍应用带蒂背阔肌皮瓣移植进行乳腺癌改良根治术后一期乳房再造的方法与疗效。方法：自2000年，用带蒂背阔肌皮瓣移植方法对中青年妇女乳腺癌改良根治术后行一期乳房再造20例。结果：全部病例的肌皮瓣及其中4例同时保留乳头病例的乳头均存活，无积液、感染、坏死等并发症，再造乳房外形美观。结论：用带蒂背阔肌皮瓣移植行乳腺癌术后一期乳房再造是乳腺癌改良根治术后恢复乳房外形的一种理想方法。     

颅底肿瘤切除后的颅底重建

报道１０例鼻窦恶性肿瘤侵犯颅底，颅底骨板切除后，用阔筋膜、带蒂帽状腱膜颅骨膜、额肌皮瓣修复。经３个月￣４年随访，术后无１例发生脑脊液漏、脑组织疝出及颅内感染。自下而上４年５例；术后３个月￣１年半，因肿瘤复发或转移死亡５例。     

人工血管复合皮瓣移植修复濒临截肢肢体

目的：报道急诊人工血管复合皮瓣移植修复濒临截肢肢体的临床效果。方法：采用Ｇｏｒｅ－Ｔｅｘ膨体泡沫聚四氯乙烯（ｅＰＴＦＥ）人工血管复合游离脐旁皮瓣、游离或带血管蒂的背阔肌皮瓣移植，修复上肢皮肤、软组织及肌肉缺损，同时重建前臂血管。结果：修复严重创伤上肢５例，游离脐旁皮瓣移植２例，游离背阔肌皮瓣移植２例，带血管蒂背阔肌皮瓣移植１例及采用直径５ｍｍｅＰＴＥＥ５条重建桡或尺动脉，皮瓣全部成活，肢体血运良好。经５～２０个月随访，所有经复合人工血管及皮瓣修肢体均得到保留及恢复基本功能。结论：采用人工血管复合皮瓣移植修复濒临截肢肢体，通过显微外科技术，可重建其活力及功能。     

应用腹壁下动脉穿支游离皮瓣移植乳房再造

目的 通过应用腹壁下动脉穿支游离皮瓣移植进行乳房再造的手术方法，总结应用该方法进行乳房再造的临床经验。方法 切取以腹壁下动静脉为蒂的穿支游离皮瓣，将腹壁下动静脉与胸廓内动静脉相吻合，进行乳房再造。结果 自2000年以来，临床应用腹壁下动脉穿支皮瓣再造乳房共15例，10例皮瓣100％成活，2例皮瓣远端局部皮肤坏死，1例皮瓣远端脂肪硬结，2例皮瓣完全坏死。随访6个月至1年，再造乳房外形满意，供区无腹壁疝、腹壁膨出、腹壁薄弱等并发症发生。结论 腹壁下动脉穿支游离皮瓣是下腹部横行腹直肌肌皮瓣(TRAM皮瓣)的技术改良与发展，该皮瓣具有血运丰富、组织量大、易于塑形、供区损伤小等优点，是一种安全可靠的乳房再造方法。     

乳癌根治应用游离下腹部腹直肌皮瓣Ⅰ期乳房再造

应用下腹部腹直肌肌皮瓣带蒂转移因腹壁上、下动、静脉间交通支吻合的形态与方式不同，在ＷｅｂｓｔｅｒⅣ区常发生皮瓣部分坏死。而采用吻合腹壁下动、静脉的ＴＲＡＭ皮瓣游离移植供血有保证，且血管粗大蒂长，手术易成功。它放置自由，裁剪容易，再造后外形好。其注意点应避免发生术后切口疝。ＴＲＡＭ皮瓣移植，一次手术，同时可达“乳癌根治、乳房再造、腹壁整形”的目的。     

双蒂腹部皮瓣单侧乳房再造的应用

目的探讨双蒂腹部皮瓣单侧乳房再造的临床效果。方法回顾分析2014年3月—2018年3月,19例接受双蒂腹部皮瓣单侧乳房再造女性患者的临床资料。患者年龄32～51岁,中位年龄45岁。一期乳房再造3例,二期16例。左侧7例,右侧12例。术中采取带蒂横行腹直肌肌皮瓣加对侧游离横行腹直肌肌皮瓣8例,带蒂横行腹直肌肌皮瓣加对侧腹壁下动脉穿支皮瓣3例,双侧腹壁下动脉穿支皮瓣7例,一侧保留部分肌肉的游离横行腹直肌肌皮瓣加对侧腹壁下穿支皮瓣1例。腹部皮瓣切取范围为24 cm×7 cm～43 cm×13 cm。供区直接缝合。结果术后1例发生皮瓣血管危象,经探查处理后缓解;1例腹部切口愈合不良,经清创后愈合。其余皮瓣均顺利成活,供区切口均Ⅰ期愈合。术后患者均获随访,随访时间4～42个月,中位时间12个月。术后4例行再造乳房修整术,2例因对侧乳房下垂行对侧乳房下垂矫正术。末次随访时采用BREAST-Q评分系统评价,腹部评分为(84.1±11.7)分,胸部评分为(86.5±8.9)分,乳房评分为(67.6±16.4)分。结论对于体型较纤瘦以及存在腹部切口瘢痕尤其是纵行切口的患者,双蒂腹部皮瓣能够提供充足组织量和良好血供,是一种较好的自体组织单侧乳房再造方法。     

皮瓣肌皮瓣移植修复感染性缺损创面

目的 报道应用皮瓣肌皮瓣修复感染性缺损创面的临床效果。方法 自1995年8月-2002年8月，应用带血管蒂或吻合血管皮瓣肌皮瓣移植术，修复组织缺损并化脓性感染创面53例，其中皮瓣38例，肌皮瓣15例。吻合血管的游离移植16例，带血管蒂岛状移植37例。结果 创口一期愈合44例，其中15例肌皮瓣移植者均一期愈合；二期愈合8例，皮瓣坏死l例。部分坏死3例，经换药后痊愈，其余皮瓣肌皮瓣全部成活。术后随访3个月-1年，修复效果满意。结论 应用皮瓣肌皮瓣修复感染性缺损创面可获得理想的临床效果。     

吻合窝外侧皮血管小腿后部皮瓣的临床应用

吻合窝外侧皮血管小腿后部皮瓣的临床应用李华涛于加平曾金鉴蔡茂季１９８２年柏树邻、李吉〔１〕提出小腿后部皮瓣，应用临床后取得很好效果。但多为带蒂移位术，也有学者提出可作游离移植〔２～４〕。我们自１９９３年２月起以窝外侧皮血管小腿后部皮瓣游离移植修复...     

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.     

The dissection of the rectus abdominis myocutaneous flap with complete preservation of the anterior rectus sheath.

Harvesting the rectus abdominis myocutaneous flap results in defects in both the rectus abdominis muscle and the anterior rectus sheath, which may be circumvented by dissecting a perforator flap (DIEP flap) instead. However, the latter is associated with a reduction in the number of myocutaneous perforators nourishing the flap, which has been hypothesised to lead to an increased risk of partial flap failure. We present a technical modification that maintains all the feeding perforators within the flap while fully preserving the anterior rectus sheath. The anterior rectus sheath is incised along a line connecting the perforators. A muscle cuff including all the feeding perforators was raised with the flap. This technique was used in 20 consecutive patients. Nine patients underwent free TRAM flap transfers for breast reconstruction (10 flaps), and 11 patients underwent thoracic-wall reconstruction with a superiorly based pedicled flap. The median follow-up was 11 months. One patient with a pedicled flap developed a partial failure that required surgical revision; all other flaps healed spontaneously. One patient in each subset had preoperative abdominal-wall laxity that was partly corrected after surgery; no abdominal bulging or hernia occurred in the other patients. Our results suggest that the technical modification presented here may enable the surgeon to dissect a rectus abdominis myocutaneous flap with maximal perforator-related flap perfusion and minimal donor-site morbidity. An advantage over the DIEP flap is that this technique is applicable to both free and pedicled flaps.     

游离肌皮瓣移植治疗难治性小腿和足部创伤后骨髓炎

目的 探讨游离肌皮瓣移植治疗难治性小腿和足部创伤后慢性骨髓炎的有效性.方法 2004年2月至2007年12月,应用游离肌皮瓣治疗小腿和足部创伤后慢性骨髓炎11例,男9例,女2例;年龄18～75岁,平均35岁;胫骨骨髓炎8例,跖骨骨髓炎3例.患者均接受过4～5次手术和长期抗生素治疗而骨髓炎仍然不愈.骨髓炎病程12～47个月,平均26个月.根据Cierny-Mader慢性骨髓炎分型:ⅢA型3例,ⅢBL型2例,ⅥA型4例,ⅥBL型2例.手术去除内固定,严格彻底清创后,即刻行游离肌皮瓣移植,9例行游离背阔肌肌皮瓣移植,2例行游离腹直肌肌皮瓣移植;6例清创后形成胫骨骨缺损造成局部不稳定者采用单边外固定架固定.结果 术后随访1.5～5年,平均3.5年.2例患者的游离肌皮瓣发生部分坏死,经清创、游离植皮后愈合,余9例未出现严重手术并发症.4例胫骨缺损范围较大的患者行二期植骨,其中1例松质骨植骨者,骨愈合时间5个月;2例为骨块嵌入植骨,骨愈合时间8个月和10个月;1例骨缺损长度为10cm者,行游离腓骨瓣移植,骨愈合时间4个月.余7例未植骨,骨愈合良好.结论 治疗难治性慢性骨髓炎的关键是严格地清除感染的骨质、死骨、炎性及瘢痕组织;游离肌皮瓣移植能以血运丰富的组织消灭死腔、覆盖创面,是治疗小腿和足部慢性骨髓炎的有效方法.     

Brustrekonstruktion mit gestielten Lappen

It is important for women with breast cancer undergoing mastectomy to make an informed decision about the options for breast reconstruction and to be provided with information about the techniques, advantages and disadvantages. After modified radical mastectomy breast reconstruction involves replacement of breast skin and volume and after skin-sparing mastectomy only the volume must be reconstructed. The most commonly used surgical techniques are expander implant reconstruction, latissimus dorsi myocutaneous flaps with or without implants and the use of lower abdominal tissue. Currently, the pedicled transverse rectus abdominis myocutaneous (TRAM) flap is the standard method for autologous breast reconstruction after mastectomy and thoracic wall irradiation. In recent years microsurgical perforator flaps have gained in popularity because of the lower morbidity.     

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。     

急诊显微外科修复肢体复杂组织缺损

目的：报道急诊复合组织游离移植和游离组织组合移植修复肢体复杂组织缺损的临床效果。方法：组织移植包括单侧背阔肌肌皮瓣游离移植、带蒂转移，废弃肢体复合组织瓣游离移植，带伸趾肌腱足背皮瓣游离移植，背阔肌肌皮瓣与腓骨组合移植，以及双侧背阔肌肌皮瓣组合移植等。结果：移植组织共３０例，其中完全成活２４例，部分皮肤坏死经换药后愈合５例，失败１例。经８～１８个月随访，所有经修复的肢体均保留或恢复了有用的功能。结论：急诊显微外科修复组织缺损是可行、安全和有效的。     

多种区域组织瓣在口腔颌面部缺损修复中的应用分析

目的:寻找口腔颌面部缺损的理想修复方法。方法:对97例口腔颌面部缺损,根据缺损部位、性质、范围,分别采用鼻唇沟皮瓣(6例),邻位滑行皮瓣(13例),Abbe瓣(4例),胸大肌肌皮瓣(17例),颈阔肌肌皮瓣(14例),下斜方肌肌皮瓣(4例),前臂皮瓣(13例),额瓣(6例),颞肌筋膜瓣修复(6例),舌瓣(11例),腓骨肌皮瓣(3例),观察修复效果。结果:97例区域组织瓣中,胸大肌肌皮瓣坏死1例,下斜方肌肌皮瓣尖端坏死1例,另1例胸大肌皮瓣术后放疗后坏死(术后4月),其余皮瓣存活,外形基本满意。所有患者均能进食,97%能正常饮食(食饭),其余可流质饮食。舌、腭、咽、口底肿物T3以上,术后语音轻度影响。结论:采用以上多种区域组织瓣修复口腔颌面部缺损,建议应尽可能采用邻近带蒂皮瓣;对于较大缺损修复主要是修复组织缺损,采用不同组织修复缺损,对进食、语音影响似区别不大,日后尚需作深入研究。     

胸大肌肌瓣转移术预防乳腺癌术后上肢淋巴水肿的临床研究

目的 探讨胸大肌肌瓣转移术对乳腺癌改良根治术后患侧上肢淋巴水肿的预防效果。方法 自2013年9月至2014年6月,将68例乳腺癌患者分成2组,35例行乳腺癌改良根治术+胸大肌肌瓣转移术(干预组),33例单纯行乳腺癌改良根治术(对照组),术后随访观察,分别在术后2周、1个月、3个月、6个月和9个月测量双侧臂围,判断有无上肢淋巴水肿的发生及程度。结果 随访结果表明,干预组和对照组相比,术后患侧上肢淋巴水肿发生率明显减少,差异具有统计学意义(P<0.05)。结论 乳腺癌改良根治术后行胸大肌肌瓣转移术,可显著减少乳腺癌术后患侧上肢淋巴水肿的发生率,提高患者的生活质量。     

Reconstruction of the mandible with autogenous bone following treatment for squamous carcinoma

In a series of 24 patients treated for squamous carcinoma of the oral cavity and oropharynx, 26 mandibular reconstructions using 27 grafts or flaps were performed. Reconstruction was immediate in 23 cases and delayed in three. There were five 'simple' bone grafts, 10 pedicled compound myocutaneous flaps, and 12 vascularized free compound flaps. Operative mortality was 12% and complication rate 65%, but 70% of the grafts survived till death or follow-up of the patients. Three 'simple' bone grafts failed and were removed. Three of five compound pectoralis major flaps failed along with one of five pedicled compound latissimus dorsi flaps. Only one vascularized free compound flap was lost. The major cause of graft failure was intra-oral suture line dehiscence exposing the bone to saliva. Under these circumstances, bone graft necrosis occurred when blood supply to the bone was poor--viz. 'simple' grafts and compound pectoralis major flaps. The vascularized free compound flaps were most reliable but the need for jaw preservation where possible and better patient selection are recognized.