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。     

乳腺癌术后单蒂横行腹直肌肌皮瓣乳房再造

目的：探讨下腹部单蒂横行腹直肌肌皮瓣（Transverse Rectus Abdomials Myocataneous，TRAM）在乳腺癌术后乳房再造中的应用。方法：2004～2007年，对13例乳腺癌患者应用对侧单蒂TRAM皮瓣进行乳房再造，其中Ⅰ期再造7例，Ⅱ期再造6例，乳腺癌根治术后1例，乳腺癌改良根治术后12例。1例Ⅱ期进行乳头乳晕再造。9例供区下腹部应用涤纶补片加强腹壁预防腹壁软弱和腹壁疝形成。结果：2例Ⅱ期再造术后TRAM皮瓣小部分坏死，1例Ⅱ期再造术后TRAM皮瓣部分皮下脂肪硬结伴部分液化，1例对侧下腹壁轻度膨隆不适，无腹壁疝。结论：乳腺癌术后应用单蒂TRAM皮瓣乳房再造术是一种较为有效、简单和安全的方法，应用涤纶补片加强腹壁可以有效预防腹壁软弱和腹壁疝形成。     

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。     

横行腹直肌肌皮瓣感觉神经的应用解剖

目的 观察Ｔ１１,Ｔ１２神经在腹直肌内及穿出前鞘后分布于下腹部皮肤的规律,分析横形腹直肌肌皮瓣（ｔｒａｎｓｖｅｒｓｅ ｒｅｃｔｕｓ ａｄｂｏｍｉｎｉｓ ｍｕｓｃｕｌｏｃｕｔａｎｅｏｕｓ ｆｌａｐ,ＴＲＡＭ）形成了与Ｔ１１,Ｔ１２神经相关的应用解剖学基础及手术要点。方法 在１１具２２侧常规防腐固定的成人尸体上,解剖并观察腹前外侧壁局部结构。结果 ＴＲＡＭ的皮神经来自Ｔ１１,Ｔ１２神经前支。其主干在腹     

伴有剖腹产史的单蒂横行腹直肌肌皮瓣乳房再造术

目的 探讨伴有剖宫产史的单蒂横行腹直肌肌皮瓣乳房再造术的手术方法、临床可行性及应用技术.方法 对9例剖宫产后不同时间的乳腺癌患者,在乳腺癌仿根治术后,采用即刻转移对侧单蒂横行腹直肌肌皮瓣进行乳房再造手术,腹壁横梭形皮瓣的上切口位于脐上l～2 cm,下切口于下腹壁纵行切口瘢痕的中下1/3,切取以对侧腹直肌为单蒂的下腹壁皮瓣,转移至胸壁缺损部位,修整塑造乳房外形.结果 9例乳房再造术患者转移的单蒂横行腹直肌肌皮瓣完全成活,再造乳房形态自然,外形逼真,无皮瓣坏死发生.2例保留乳头者发生乳头缺血,部分坏死脱落后愈合.结论 单蒂横行腹直肌肌皮瓣乳房再造术,对于有剖宫产史的乳腺癌患者并非绝对禁忌证,在做好术前充分评估的基础上,可以安全选择应用.     

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。     

乳腺癌术后横行腹直肌皮瓣乳房再造的适应证剖析

目的探讨乳腺癌术后下腹部横行腹直肌（transverse rectus abdominal myocutaneous,TRAM）皮瓣乳房再造术的适应证的选定,并进行临床剖析。方法对17例乳腺癌切除术后患者应用对侧单蒂TRAM皮瓣进行乳房再造,其中I期再造者7例,Ⅱ期再造10例,均为乳腺癌改良根治术后患者。9例Ⅱ期进行乳头、乳晕再造。12例供区下腹部应用涤纶补片加固腹壁以预防腹壁软弱和腹壁疝形成。由多学科诊疗小组对适应证选择,并进行总结和分析。结果17例经过5个月至6年的观察,2例Ⅱ期再造术后,TRAM皮瓣的皮肤发生小面积坏死,1例对侧下腹壁轻度膨隆,无腹壁疝,经过对症处理,17例均取得较好疗效。结论对于乳腺癌术后具有适应证的患者应用横行TRAM皮瓣乳房再造术是一种较为有效和安全的方法。严格选定适应证,是乳房再造成功的关键。     

单蒂横行腹直肌肌皮瓣乳房再造中Ⅳ区皮瓣的取舍

目的探讨单蒂横行腹直肌肌皮瓣乳房再造术中Ⅳ区皮瓣的取舍。方法通过16例实施单蒂横行腹直肌肌皮瓣乳房再造术，术中观察皮瓣的皮色、断面出血颜色，并利用近红外血氧监测仪测定皮瓣各区的组织血氧饱和度，决定Ⅳ区皮瓣的取舍。术后观察指标包括术后并发症及美学效果。结果16例中5例Ⅳ皮瓣的肤色正常、断面出血呈鲜红色而非暗红色、组织血氧饱和度不低于Ⅲ区组织血氧饱和度的95％。在接受了保留Ⅳ区皮瓣的单蒂横行腹直肌肌皮瓣乳房再造术后，再造乳房全部成活，无严重术后并发症，患者对再造乳房均很满意。结论近红外血氧无创检测有助于决定Ⅳ区皮瓣的取舍。有选择地实施保留Ⅳ区皮瓣的单蒂横行腹直肌肌皮瓣乳房再造术，可用于大面积胸壁缺损或乳腺尾叶的修复重建。     

应用下腹部横形腹直肌肌皮瓣再造乳房

应用下腹部横形腹直肌肌皮瓣进行４例乳房再造，其中２例为皮瓣带蒂转移，于乳癌根治切除术后即刻完成乳房再造；２例为血管吻合肌皮瓣游离移植，分别于根治术后２个月和５年进行乳房再造。术后游离皮瓣完全成活，带蒂皮瓣分别于术后２￣３周出现脂肪液化，经换药痊愈。４例乳房外形基本满意。随访１０个月￣１８个月，２例游离移植未见异常，１例带蒂转移二术后１年出现腹壁薄弱膨隆，另１例失访。     

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。     

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。     

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。     

Postmastectomy radiation therapy after TRAM flap breast reconstruction

Postmastectomy chest wall and nodal radiation therapy decreases local recurrence and improves disease-free and overall survival. Immediate transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction after mastectomy has become more common. We report on our experience of irradiating the chest wall and regional lymph nodes after a TRAM flap reconstruction and describe the acute side effects, flap viability, and cosmetic outcome. Between 1995 and 2000, 22 patients with a median age of 47 years (range 27-61 years) received chest wall radiotherapy following mastectomy and immediate pedicled TRAM flap reconstruction. The indication for radiotherapy included tumor size, involved lymph nodes, or positive margins. All patients received chemotherapy before radiotherapy and three patients also received concurrent chemotherapy. The median dose to the chest wall was 50.4 Gy in 28 fractions of 1.8 Gy using a 6 or 4 MV linear accelerator. The patients were all computed tomography (CT) planned in the treatment position. The patients were immobilized using an alpha cradle. Two tangent fields were used to deliver the dose. On alternating days, a customized bolus was applied to the chest wall that spared the central region where the subsequent nipple reconstruction would be performed. All 22 patients completed 90% of the prescribed chest wall radiotherapy dose. Sixty-six percent of the patients received treatment without any treatment breaks. Only 10% of the patients developed desquamation of the TRAM flap skin. Thirty percent developed grade II erythema of the TRAM flap. With median follow-up of 18 months, no TRAM flaps have been lost or required revision. This technique for delivery of radiotherapy to the chest wall in patients who have undergone a mastectomy and immediate TRAM flap reconstruction is well tolerated. The acute toxicity was manageable. There were no TRAM flap losses or revisions performed secondary to the radiotherapy.     

A transverse rectus abdominis myocutaneous (TRAM) flap for reconstruction of a large deformity in the buttock: A new indication for a TRAM flap

A rectus abdominis myocutaneous flap has been used to repair the abdominal wall, chest wall, sternum, breast, and groin. We describe a patient in whom a large deformity in the buttock caused by a road crash was repaired with a transverse rectus abdominis myocutaneous (TRAM) flap. Distally-based TRAM flaps provide a good and reliable way of reconstructing the buttock. Its advantages are a long arc of rotation and well-vascularised bulky tissue that serve as a partition and promote quick healing of the defect. However, the flap is not the first choice for traumatic and infected wounds where fatty tissue is not desired.     

A critical review of the TRAM flap for the mastectomy patient

The lower transverse rectus abdominis musculocutaneous (TRAM) flap is becoming more popular as a method of breast reconstruction due to its unique aesthetic results. Forty-five patients were reviewed. The complication rate was high (38%). There was 1 total flap loss and 7 patients (16%) with a partial flap loss. This occurred more frequently in smokers. There were 8 abdominal hernias (18%). Despite these problems 91% of patients were satisfied with their reconstructed breast. Rigid patient selection and a good operative technique reduced the complication rate of this major surgical procedure.     

保留部分腹直肌TRAM皮瓣的应用解剖及在乳房再造中的应用

目的 通过尸体解剖模拟保留部分腹直肌的横行腹直肌肌皮瓣( TRAM)手术,以探讨将其应用于临床乳房再造的可行性及效果.方法 对5具成年女性尸体标本(福建医科大学人体解剖学教研室提供),自腹壁上、下动脉起点处灌注医用红色乳胶后进行解剖,模拟操作保留部分腹直肌TRAM皮瓣手术,以外侧穿支为垂直线纵向分离腹直肌肌束,向上分离达腹直肌上端,保留外侧部分腹直肌,观察腹壁上、下动脉走行、分支以及吻合支情况,并以此为解剖学基础,于临床应用保留部分腹直肌的TRAM皮瓣进行乳房再造.结果 解剖结果表明,腹壁下动脉自腹股沟韧带外侧2/3与内侧1/3发自髂外动脉(9/10,90％)或股动脉(1/10,10％),其分支与腹壁上动脉在脐上方开始出现广泛的吻合,大部分集中于脐上第1个腱划下方2 cm与脐水平线之间.2009年9月至2010年9月,于临床应用8例,术后随访3个月至1年,2例术后皮瓣Ⅳ区部分皮下组织纤维化,2例术后皮瓣Ⅳ区皮缘小部分坏死,部分皮下脂肪硬结伴液化,通过后期清刨缝合后愈合,其余4例术后皮瓣未发生明显血运障碍等并发症.除1例再造乳房形态欠佳外,其余病例形态尚好,效果较满意.无供区下腹壁薄弱和腹壁疝形成.结论 保留部分腹直肌的TRAM皮瓣移植再造乳房是可行的,手术简单,所用时间短,且无下腹部供区并发症发生.