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。     

皮瓣转移结合负压抽吸治疗乳腺癌术后上肢淋巴水肿

目的 探讨一种治疗乳腺癌根治术后上肢淋巴水肿的手术方法。方法 2001～2002年我们采用侧胸壁皮瓣或背阔肌肌皮瓣转移结合上肢负压抽吸治疗10例单侧乳腺癌根治术后上肢淋巴水肿患者。结果 术后所有患者上肢周径均有不同程度减小，核素淋巴管造影显示淋巴回流有显著改善。术后随访3～18个月，疗效稳定。结论 皮瓣转移结合负压抽吸可以有效地治疗乳腺癌根治术后淋巴水肿。     

手动负压抽吸联合血管化淋巴结移植治疗继发性下肢淋巴水肿的疗效分析

目的 探讨手动负压抽吸联合血管化淋巴结移植治疗继发性下肢淋巴水肿的临床疗效。方法 回顾性分析2018年11月至2021年11月接受联合治疗的12例妇科恶性肿瘤术后继发性下肢淋巴水肿患者的临床资料。患肢大腿采用手动负压抽吸减容,同时取锁骨上血管化淋巴结移植至患侧小腿。比较治疗前后患肢周径变化;记录治疗前后丹毒发作情况及生活质量的改变。结果 患肢大腿抽取脂肪组织500～1 200 mL,平均（917±196） mL。术后患肢周径明显减小（P<0.05）。治疗后随访期间所有患者均无丹毒发作,主观症状均较术前明显好转。结论 手动负压抽吸联合血管化淋巴结移植治疗下肢淋巴水肿疗效确切,值得推广。     

Improvement of upper extremity lymphedema after delayed breast reconstruction with an extended latissimus dorsi myocutaneous flap

Lymphedema is a common complication after mastectomy in breast cancer patients. Many treatment options are available, but no treatment results in a complete cure. We report a case of lymphedema that occurred after modified radical mastectomy in a breast cancer patient who showed objective improvement after delayed breast reconstruction with an latissimus dorsi myocutaneous flap. A 41-year-old female patient with left breast cancer had undergone modified radical mastectomy with axillary lymph node dissection and postoperative radiotherapy 12 years previously. Four years after surgery, lymphedema developed and increased in aggravation despite conservative treatment. Eight years after the first operation, the patient underwent delayed breast reconstruction using the extended latissimus dorsi myocutaneous flap method. After reconstruction, the patient's lymphedema symptoms showed dramatic improvement by subjective measures including tissue softness and feeling of lightness, and by objective measures of about 7 mL per a week, resulting in near normal ranges of volume. At a postoperative follow-up after 3 years, no recurrence was observed. Delayed breast reconstruction with extended latissimus dorsi myocutaneous flaps may be helpful to patients with lymphedema after mastectomy. This may be a good option for patients who are worried about the possibility of the occurrence or aggravation of secondary lymphedema.     

Appraisal of myocutaneous flapping for treatment of postmastectomy lymphedema. Case report

Two patients with severe postmastectomy lymphedema of the upper extremity were treated with myocutaneous flapping, using latissimus dorsi muscle. Complete disappearance of edema was achieved by 11 months postoperatively in one case and 50% reduction by 8 months in the other case. The satisfactory results commend the procedure, which has yet to gain global acceptance.     

背阔肌肌皮瓣移转治疗乳癌根治术后上肢淋巴水肿

目的　减轻乳癌根治术及放疗后上肢淋巴水肿。方法　采用带蒂背阔肌肌皮瓣移转一期完成治疗乳癌根治术加根治量放疗后所致上肢严重淋巴水肿伴胸壁放射性溃疡、上肢上举受限 12例。结果　肌皮瓣成活良好 ,上肢淋巴水肿明显减轻 (消肿率达 5 1%～ 67% ) ,上举功能明显改善 (达 10 0～ 110度 ) ,随访 1～ 3年未见复发。结论　本手术简单、省时、安全、有效 ,不仅能减轻肢体淋巴水肿 ,还可修复胸壁塌陷畸形 ,解除腋部瘢痕牵扯 ,改善上肢上举功能 ,因此 ,不失为一种可行的治疗乳癌根治术后继发上肢淋巴水肿的方法。     

Use of pedicled latissimus dorsi myocutaneous flap to reconstruct the upper limb with large soft tissue defects

ObjectiveTo report the technique of reconstruction of large skin and soft tissue defects in the upper extremity using pedicled latissimus dorsi myocu-taneous flaps.MethodsSix patients with large skin and soft tissue defects were included in this report. There were 5 trauma patients and the rest one needed to receive plastic surgery for his extremity scar. All wounds were in the upper extremity. The sizes of defects ranged from 15 cmx6 cm to 30 cmx18 cm. Pedicled latissimus dorsi myocutaneous flaps were designed according to the defect area and raised with part of latissi-mus dorsi. The thoracodorsal artery and its perforators were carefully protected during surgery.ResultsAll flaps healed primarily without flap congestion, margin necrosis or infection. The skin donor sites either received split-thickness skin graft (3 cases, mostly from the anterior thigh) or was closed primarily (3 cases) and had minimal morbidity. Follow-up of 6-12 months showed that the contour of flap was aesthetic and the function of limb was excellent.ConclusionOur experience indicates that the pedicled latissimus dorsi myocutaneous flap is favorable for reconstruction of large skin and soft tissue defects in the upper extremity.     

皮下组织抽吸加弹力压迫治疗乳腺癌术后上肢淋巴水肿

目的 探讨乳腺癌术后上肢淋巴水肿的治疗方法。方法 2001年6月～2003年9月选择乳腺癌术后上肢淋巴水肿2年以上的患者11例，患侧上肢明显水肿，外观增粗，前臂中点周径与健侧平均相差4．4cm，上臂中点周径与健侧平均相差6.6cm，活动受限，其中2例有丹毒反复发作。利用肿胀吸脂技术，对其水肿的上肢进行皮下组织抽吸去除，术后弹力加压3个月后，改为每晚弹力加压，观察疗效。结果 经6～15个月随访，11例患者的上肢淋巴水肿明显减轻，外观缩小，平均上臂周径较术前减小4cm，无丹毒发生。结论 皮下组织抽吸加适时弹力压迫治疗乳腺癌术后上肢淋巴水肿，方法简便，近期有效。     

部分背阔肌皮瓣游离移植修复前臂背侧组织缺损并重建伸指功能

目的 报告应用部分背阔肌皮瓣游离移植修复前臂背侧复合组织缺损,并重建伸指功能的手术方法.方法 对11例因外伤致前臂背侧大面积复合组织缺损的患者,采用保留内侧部分背阔肌及胸背神经内侧支的部分背阔肌皮瓣游离移植修复,将皮瓣中胸背神经近端与受区桡神经深支或指总伸肌肌支缝合,背阔肌远端腱膜修复2～4指指总伸肌.皮瓣切取面积为21 cm×9 cm-27 cm×13 cm.结果 术后11例肌皮瓣全部存活,3例因皮瓣臃肿再次行皮瓣、肌皮瓣修整术,2例指伸肌腱松弛再次行肌腱紧缩术.术后2例失访,9例获得6个月至3年的随访,其中指伸肌力恢复至Ⅲ级2例、Ⅳ级6例、V级1例,肢体功能大部分恢复且外形满意.按中华医学会手外科学会上肢功能评定标准评定:优2例,良5例,可2例;优良率为77.8%.结论 应用游离部分背阔肌皮瓣修复前臂背侧复合组织缺损并重建伸指功能可取得较好的临床疗效,同时供区保留了部分背阔肌的功能.     

重度褥疮的临床治疗经验

目的 总结重度褥疮的临床治疗经验.方法 2007年8月至2011年6月,湖南省郴州市第一人民医院烧伤整形科收治21例重度褥疮患者,共43处Ⅲ～Ⅳ度褥疮创面,应用封闭负压引流技术,以及局部任意筋膜瓣、上位或下位臀大肌岛状肌皮瓣、下位臀大肌局部旋转肌皮瓣、股后皮神经营养血管皮瓣、阔筋膜张肌岛状肌皮瓣、游离背阔肌肌皮瓣和中厚皮片移植修复,配合翻身床,术后全程护理跟踪指导联合治疗.21例中有13例为多发性褥疮,其中有5处为Ⅲ度褥疮,以移植皮片封闭,3处非骶尾部Ⅲ度褥疮宽度＜2 cm,予扩创后直接拉拢缝合;8例为单个Ⅳ度褥疮.结果 21例43处创面均治愈,3例5处创面中有2处创面因引流不畅皮瓣下积液,重新放置引流管通畅引流后伤口愈合,另有3处创面皮瓣移植后伤口愈合不良,再次扩创二期缝合后伤口亦愈合,所有皮瓣(肌皮瓣)均成活良好.16例获2个月至2年2个月的随访,其中4例因出院后未按要求注意护理再次受压复发,其余均未复发.结论 综合应用封闭负压引流技术,多种皮瓣及移植皮片,配合翻身床及出院后护理跟踪指导,对重度褥疮进行治疗,能达到满意疗效.     

Poland综合征胸部畸形的整复

目的:探讨矫治Poland综合征胸部畸形的手术方法。方法:2006年8月至2012年8月,笔者对3例年龄分别为21岁、18岁和10岁的女性Poland综合征患者进行了胸部畸形的整复。3例患者均有胸肌发育不良及肋软骨部分缺如等畸形,但上肢形态和功能均未见异常。其中21岁患者行"右侧背阔肌肌瓣带蒂移植术及硅胶假体植入隆乳术",18岁患者行"水动力腹部脂肪抽吸术及左胸部自体脂肪移植术",10岁患儿行"左侧多余乳头切除术",待成年后来我科行患侧胸壁及乳房II期修复术。结果:术后密切随访,患者胸部凹陷畸形均得到不同程度的改善,手术效果持续时间长,患侧上肢及胸背部功能未受影响,提高了患者自信心和生活质量。结论:Poland综合征是一种涉及多部位、变异性较大的先天性畸形,应根据患者的自身特点制定个性化的手术方案,方可取得满意的治疗效果。     

Reconstruction of upper extremity large soft-tissue defects using pedicled latissimus dorsi muscle flaps--technique illustration and clinical outcomes

SUMMARY: Reconstruction of large soft-tissue defects of an upper extremity is very challenging due to the unavailability of expendable local muscle. Appropriate soft-tissue restoration is an essential component of such reconstruction treatment protocols, and often requires a vascularised flap to protect the exposed neurovascular and musculotendinous structures. The latissimus dorsi muscle makes an ideal pedicled flap because of its long neurovascular pedicle, large size, ease of mobilisation and expendability. Moreover, the flap provides well-vascularised tissue from a region far from the area of injury. This paper describes the technique for pedicle latissimus dorsi flap transfer and also reports the authors' experience of its application for the acute treatment of massive upper-extremity soft-tissue injuries. 20 patients with large soft-tissue defects over the upper extremity caused by trauma and infection underwent aggressive debridements and immediate soft-tissue reconstruction using a pedicled latissimus dorsi muscle flap. Successful reconstructions were achieved and primary healing of wounds occurred in all patients, with minor complications. The donor site morbidity was minimal. At a mean of 3.6 years' follow-up (range: 1.5-6 years), all functional results were good and the patients were satisfied with their outcomes.     

Erysipelas of the upper extremity following locoregional therapy for breast cancer

Cellulitis is a well-known complication of lymphedema of the lower extremities. Erysipelas of the upper extremity complicating breast cancer therapy has never been reported in the English-language literature. We describe seven breast cancer patients with erysipelas of the upper extremity. Five had a predisposing injury to the extremity. All patients responded very well to intravenous antibiotics without any sequelae. They had rapid resolution with typical desquamation. No long-term sequelae were seen except for mild increase of lymphedema. Erysipelas should be listed as a rare complication after locoregional therapy for breast cancer. Intravenous penicillin should be used as the initial therapy. Prevention of arm lymphedema and avoidance of any trauma to the arm are important prophylactic measures. Sentinel lymph node biopsy reduces the rate of axillary lymph node dissection and thus should reduce the incidence of lymphedema and erysipelas.     

急诊组织瓣移植(位)修复伴有严重血管损伤的上肢复杂性组织缺损

目的 介绍急诊组织瓣移植或移位一期修复伴有严重血管损伤的上肢复杂性组织缺损的手术疗效.方法 对10例伴有严重血管损伤的上肢复杂性组织缺损的患者,在修复血管重建肢体血运的同时,根据组织缺损需要采用皮瓣、肌皮瓣、骨皮瓣甚至组织瓣组合移植的方法急诊进行一期修复.其中上臂肱动、静脉长段缺损,合并肱二头肌及上臂内侧大面积皮肤缺损,血管修复后背阔肌皮瓣移位覆盖创面并重建屈肘功能3例;肘部血管损伤合并肘关节周围大面积皮肤撕脱缺损,血管修复后移植胸脐皮瓣覆盖创面2例;前臂尺、桡动脉损伤合并皮肤肌肉缺损,血管修复后移植股前外侧皮瓣覆盖创面3例;前臂尺桡动脉损伤并尺桡骨缺损,血管修复后移植腓骨皮瓣重建尺骨缺损,二期再移植腓骨皮瓣重建桡骨缺损1例;前臂尺、桡动脉损伤合并桡骨及大面积皮肤缺损,血管修复后股前外侧皮瓣加髂骨皮瓣组合移植1例.结果 术后10例患肢及移位组织瓣全部存活.术后随访3～6个月,3例上臂损伤患者,肘关节最大屈曲度为105,屈肘肌力为M_3～M_4地,手功能恢复基本正常;肘及前臂损伤的7例患者,肢体及移植皮瓣完全存活,骨皮瓣和腕部已达骨性愈合,并恢复部分手功能.结论 对严重血管损伤且合并有复杂组织缺损的上肢损伤,急诊在施行血管修复重建肢体血运的同时,采用组织瓣单独或组合移植一期有效覆盖创面,可提高复杂性患肢的成活率,并为二期功能重建术提供良好的软组织条件.     

组织瓣移位修复锁骨区创面

目的 探讨不同组织瓣移位修复锁骨区创面的方法和疗效。方法1994年～2000年先后对3例锁骨骨折内固定后钢板外露、锁骨骨髓炎和放射性锁骨区溃疡合并锁骨骨髓炎患者，分别采用翻转筋膜皮下组织瓣、胸大肌肌(皮)瓣和背阔肌肌皮瓣移位修复，观察其疗效，并在复习文献的基础上对组织瓣修复锁骨区创面的手术适应证及不同术式进行总结。结果3例移位的组织瓣全部成活，均经2个月～7年随访，受区外观满意。锁骨骨折愈合，锁骨骨髓炎及溃疡无复发。结论单纯锁骨区创面可用翻转筋膜皮下组织瓣修复，对合并锁骨骨髓炎者，胸大肌锁骨头旋转肌瓣和背阔肌肌(皮)瓣移位修复更合适。对于锁骨区放射性溃疡无法应用局部组织瓣时，采用背阔肌皮瓣是较为理想的选择。     

Closure of large orbital-maxillary defects with free latissimus dorsi myocutaneous flaps

The treatment of advanced cancer of the maxillary sinus often requires extensive ablation and orbital exenteration that results in large full-thickness defects of the upper cheek and orbital regions. Reconstruction of such defects with local flaps is usually difficult because of the need for a large flap. Several regional flaps such as the deltopectoral flap, the temporal flap, and the shoulder flap may be used, but these techniques frequently require surgery in stages and result in severe deformity of the donor site. The island pedicled, pectoralis major myocutaneous flap may be rotated up to the orbital region; however, the uncertain blood supply to the skin in the distal area of the pectoralis may cause unexpected marginal necrosis of the flap. Reconstruction of large orbital-maxillary defects can readily be accomplished in one stage using microsurgical free transfer of latissimus dorsi myocutaneous flaps. The thoracodorsal artery and vein that form the nutrient pedicle of the flap approaches 2 mm in external diameter and up to 10 cm in length, allowing greater versatility in head and neck reconstruction. The muscle may be used to fill the orbital and maxillary cavities and will accept a skin graft on its deep surface. The donor defect is closed primarily and the resulting scar is well concealed beneath the arm. If necessary, extremely large flaps may be transferred by harvesting the entire latissimus dorsi muscle and the overlying skin based on the thoracodorsal system.     

Vascularized appendicular lymph node transfer for treatment of extremity lymphedema: A case report

Vascularized lymph node transfer has demonstrated promising results for the treatment of extremity lymphedema. In an attempt to find the ideal donor site, several vascularized lymph nodes have been described. Each has a common goal of decreasing morbidity and avoiding iatrogenic lymphedema while obtaining good clinical results. Herein, we present the preliminary clinical outcomes of an intra‐abdominal lymph node flap option based on the appendicular artery and vein used for the treatment of extremity lymphedema. A 62 year‐old woman with moderate lower extremity lymphedema, on chronic antibiotics because of recurrent infections and unsatisfactory outcomes after conservative treatment underwent a vascularized appendicular lymph node (VALN) transfer. At a follow‐up of 6 months, the reduction rate of the limb circumference was 17.4%, 15.1%, 12.0% and 9% above the knee, below the knee, above the ankle and foot respectively. In addition, no further episodes of infection or other complications were reported after VALN transfer. Postoperative lymphoscintigraphy demonstrated that the VALN flap was able to improve the lymphatic drainage of the affected limb. According to our findings, the use of VALN transfer minimizes donor‐site morbidity, avoids iatrogenic lymphedema and may provide a strong clearance of infection because of the strong immunologic properties of the appendiceal lymphatic tissue in selected patients. Despite these promising results, further research with larger number of patients and longer follow‐ up is needed.     

The latissimus dorsi‐groin‐lymph node compound flap: A comprehensive technique with three features including skin coverage,restoration of motor function,and prevention of upper limb lymphedema

Reconstruction of complex upper extremity defects requires a need for multiple tissue components. The supercharged latissimus dorsi (LD)‐groin compound flap is an option that can provide a large skin paddle with simultaneous functional muscle transfer. It is necessary to supercharge the flap with the superficial circumflex iliac pedicle to ensure the viability of its groin extension. In this report, we present a case of a supercharged LD‐groin flap in combination with vascularized inguinal lymph nodes, which was used for upper limb reconstruction in a young male patient, following excision of high‐grade liposarcoma. Resection resulted in a 28 cm × 15 cm skin defect extending from the upper arm to the proximal forearm, also involving the triceps muscle, a segment of the ulnar nerve and the axillary lymph nodes. Restoration of triceps function was achieved with transfer of the innervated LD muscle. Part of the ulnar nerve was resected and repaired with sural nerve grafts. Post‐operatively, the flap survived fully with no partial necrosis, and no complications at both the recipient and donor sites. At 1‐year follow up, the patient had a well‐healed wound with good elbow extension (against resistance), no tumor recurrence, and no signs of lymphedema. We believe this comprehensive approach may represent a valuable technique, for not only the oncological reconstruction of upper extremity, but also for the prevention of lymphedema. © 2015 Wiley Periodicals, Inc. Microsurgery 36:689–694, 2016.     

Customized reconstruction with the free anterolateral thigh perforator flap

From April of 2003 through September of 2006, 70 free anterolateral thigh (ALT) flaps were transferred for reconstructing soft-tissue defects. The overall success rate was 96%. Among 70 free ALT flaps, 11 were elevated as cutaneous ALT septocutaneous vessel flaps. Fifty-seven were harvested as cutaneous ALT myocutaneous "true" perforator flaps. Two flaps were used as fasciocutaneous perforator flaps based on independent skin vessels. Fifty-four ALT flaps were used for lower extremity reconstruction, 11 flaps were used for upper extremity reconstruction, 3 flaps were used for trunk reconstruction, and 1 flap was used for head and neck reconstruction. Total flap failure occurred in 3 patients (4.28% of the flaps), and partial failure occurred in 5 patients (7.14% of the flaps). The three flaps that failed completely were reconstructed with a free radial forearm flap, a latissimus dorsi flap and skin grafting, respectively. Among the five flaps that failed partially, three were reconstructed with skin grafting, one with a sural flap, and one with primary closure. The free ALT flap has become the workhorse for covering defects in most clinical situations in our center. It is a reliable flap with consistent anatomy and a long, constant pedicle diameter. Its versatility, in which thickness and volume can be adjusted, leads to a perfect match for customized reconstruction of complex defects.     

Suction lipectomy in the management of limb lymphedema

We have been pleased overall with the results achieved using suction lipectomy in lymphedema patients. In appropriately selected patients, it is predictable and well-tolerated. It is, however, only palliative and temporary. It may be performed on a periodic basis. Compressive stockings are essential for success. Based on our experiences, we recommend suction lipectomy for mild temporary cases, specifically involving the upper extremity, and liposuction plus excisional debulking for more severe cases and for the lower extremity.