术前CT血管造影在腹壁下动脉穿支皮瓣乳房再造的应用现状和展望

目的总结CT血管造影(computed tomographic angiography,CTA)在腹壁下动脉穿支(deep inferior epigastric artery perforator,DIEP)皮瓣乳房再造中的应用进展,并简要分析其应用前景。方法查阅近年来国内外有关CTA在DIEP皮瓣乳房再造中应用的相关文献,并进行分析和总结。结果术前CTA对胸腹壁的血管解剖结构可进行精确评估,在腹部供区可精确定位穿支,识别优势穿支;在胸部受区可指导探查胸廓内动脉肋间隙以及胸廓内动脉穿支分支的选择;参照对侧乳房大小进行腹部皮瓣容积重建,精确预构腹部皮瓣的大小,对手术方案的制定以及手术安全性的提高均有着至关重要的作用。结论术前CTA在DIEP皮瓣乳房再造领域的供区穿支定位、受区血管选择以及乳房容积评估方面具有巨大的应用潜力。     

腹壁下动脉穿支皮瓣在乳房重建的应用进展

腹壁下动脉穿支(DIEP)皮瓣是乳腺癌术后乳房重建的首选,但手术时间较长、技术要求较高、限制DIEP皮瓣推广。DIEP皮瓣在提高手术效率、减少并发症、皮瓣设计等方面取得较大进展,是乳房重建的研究热点。乳腺癌术后乳房重建需要乳腺外科及整形外科等多学科合作,DIEP皮瓣乳房重建技术发展较快有望广泛推广,手术规范尚未形成,有...     

三维心理护理在腹壁下动脉穿支皮瓣乳房再造患者治疗中的应用

目的:探讨三维心理护理在腹壁下动脉穿支(Deep Inferior Epigastric Perforator,DIEP)皮瓣乳房再造治疗中的应用。方法:乳腺癌术后希望进行乳房再造就诊患者为主要人群,通过在术前、术后及随访中,与其本人及家属,以医生和护士为沟通主体对其进行心理疏导。结果:本组患者32例,接受DIEP乳房再造者26例,手术效果满意,心理状态良好。结论:三维心理护理在DIEP皮瓣乳房再造治疗中起着辅助作用,对于患者的生活状态及术后康复有巨大影响,值得临床推广应用。     

CT血管成像技术在腹壁下动脉穿支皮瓣术前设计中的应用

目的 探讨CT血管成像(computed tomography angiography,CTA)技术在腹壁下动脉穿支(deep inferior epigastrie artery perforator,DIEAP)皮瓣术前设计中的应用. 方法 2007年1月至2008年3月,对13例拟行DIEAP皮瓣手术的患者术前应用CTA技术对腹壁下动脉进行检查,包括5例阴道先天性缺如、4例阴茎阴囊Paget's病、4例乳腺癌术后乳房缺损的患者,将获得的数据进行处理,包括多平面重组、最大密度投影以及容积显示.观察腹壁下动脉的走行、分支以及穿支位置,并将CTA图像结果与术中情况进行比较. 结果 CTA图像提供腹壁下动脉在肌肉内走行和穿支位置等有效信息,指导DIEAP皮瓣的术前设计,并在手术中得到验证. 结论 术前对腹壁下动脉进行CTA检查,可以有效地指导DIEAP皮瓣的术前设计.     

CTA预选胸廓内动脉肋间穿支为腹壁下动脉穿支皮瓣乳房重建的受区血管

目的:术前及术中评估中国人胸廓内动脉肋间穿支(internal mammary artery perforator, IMAP)解剖特点,探讨IMAP为腹壁下动脉穿支(deep inferior epigastric perforator, DIEP)皮瓣乳房重建受区血管的成功率。方法:对2016年1月至2018年12月连续98例DIEP皮瓣一期乳房重建病例进行分析,分为IMAP组32例,胸廓内动脉组66例。所有病人术前均行多普勒超声评估血管。自2017年1月起,73例同时术前行CT血管造影(computed tomographic angiography, CTA)评估血管。分析所有病人患侧IMAP分布位置和管径,以及作为受区血管的使用率。结果:98例病人中,IMAP 66例(67.3%)位于第二肋间,直径(1.33±0.66) mm,24例(24.5%)位于第三肋间,直径(0.86±0.28) mm,8例(8.2%)位于第四肋间,直径(0.65±0.15) mm。98例DIEP皮瓣重建病人中,32例(32.7%)使用IMAP作为受区血管,其中28例(87.5%)位于第二肋间,4例(12.5%)位于第三肋间。在病人特征和皮瓣并发症等方面,IMAP组与胸廓内动脉组差异无统计学意义。术前CTA和超声检查双重定位的73例病人中,29例(39.7%)使用IMAP,远高于仅行超声检查的12.0%(3/25)(P=0.01)。结论:IMAP是一种可靠的DIEP皮瓣一期乳房重建受区血管。术前CTA检查可提高IMAP的使用成功率。IMAP作为受区吻合血管可简化手术步骤、缩短手术时间、减少胸壁损伤、避免牺牲胸廓内血管主干。     

腹壁下动脉穿支皮瓣血管穿支及感觉神经的应用解剖

目的　为腹壁下动脉穿支 (deepinferiorepigastricperforator,DIEP)皮瓣感觉的修复提供解剖学依据。方法　对 9具 18侧常规防腐固定的成年女尸腹前外侧壁进行详细解剖学研究。结果　腹壁下动脉穿支主要位于腹直肌鞘区 ,平均每侧 17 5支 ,直径≥ 0 5mm者 7 8支 ,直径≥ 0 5mm者 9 7支 ,其中皮瓣上半部最多 ,内侧略多于外侧。DIEP皮瓣主要位于T9～T12神经节段范围内 ,5 6 2 %DIEP有感觉神经穿支伴行 ,而粗大DIEP的感觉神经伴行率高达 80 .9%。结论　切取以腹壁下动脉穿支为血供来源、以肋间神经感觉支为感觉支配的DIEP皮瓣时 ,穿支选择应以脐周外侧粗大神经血管束为首选。     

腹壁下动脉穿支皮瓣在乳房再造和胸壁溃疡修复中的应用

目的　在解剖学研究基础上 ,对以腹壁下动静脉为蒂的横行腹直肌 (TRAM)肌皮瓣的切取进行完善和改进 ,将其精确为腹壁下动脉穿支 (DIEP)皮瓣 ,从而提供一种更为理想的乳腺癌术后乳房再造和胸壁创面修复的皮瓣。方法　切取DIEP皮瓣 ,移植至胸壁受区 ,腹壁下动静脉分别与胸廓内动静脉相吻合 ,用于乳腺癌术后乳房再造和胸壁放射性溃疡的修复。结果　解剖学研究和临床观察发现自腹壁下动脉有粗大的肌皮穿支或皮支自血管主干发出 ,穿过腹直肌纤维直接进入皮瓣 ,因此 ,术中只剪开腹直肌前鞘 ,钝性分离腹壁下动静脉及其穿支周围的腹直肌纤维 ,无须离断腹直肌纤维 ,临床应用DIEP皮瓣再造乳房 4例 ,修复胸壁缺损 2例 ,皮瓣面积 (10cm×l2cm)— (12cm× 35cm) ,全部成活 ,效果满意。结论　DIEP皮瓣是对传统的TRAM皮瓣的一种技术改良 ,既保留了TRAM皮瓣血运丰富、组织量大、易于塑形的优点 ,尚可保持腹直肌的完整性 ,同期进行腹壁整形     

下腹壁横行腹直肌肌皮瓣及腹壁下动脉穿支皮瓣乳房再造的相关肋间神经解剖学研究

目的　为开展保留感觉神经和部分腹直肌功能的下腹壁横行腹直肌肌皮瓣 (TRAM皮瓣 )及腹壁下动脉穿支皮瓣 (DIEP皮瓣 )乳房再造手术方法提供解剖学依据。方法　对 9具 18侧 10 %甲醛溶液防腐固定的成年女尸腹前外侧壁进行大体及显微解剖 ,观察T8～T12 肋间神经的走行及分布 ,重点解剖腹直肌区域内肋间神经分支。在 15例DIEP皮瓣乳房再造术中 ,观察肋间神经在腹直肌内的走行分布特点及其与腹壁下血管穿支的关系。结果　肋间神经在腹直肌外侧 1/3区域内穿入腹直肌 ,其运动支在腹直肌内有交通支形成 ,相邻神经可重叠支配节段性腹直肌。感觉神经支分为内侧穿支和外侧穿支 ,与腹壁下血管穿支形成血管神经束进入皮下组织。纯感觉神经蒂长为 (2 7.6± 12 .2 )mm。结论　在应用TRAM皮瓣和DIEP皮瓣进行乳房再造时 ,可以保留感觉神经蒂进行神经吻合以恢复乳房感觉功能 ;而在切取TRAM皮瓣时 ,保留外侧 1/3腹直肌不会导致术后肌肉失神经萎缩。     

腹壁下动脉穿支皮瓣在乳房再造和胸壁溃疡修复中的应用

目的　在解剖学研究基础上 ,对以腹壁下动静脉为蒂的横行腹直肌 (TRAM)肌皮瓣的切取进行完善和改进 ,将其精确为腹壁下动脉穿支 (DIEP)皮瓣 ,从而提供一种更为理想的乳腺癌术后乳房再造和胸壁创面修复的皮瓣。　方法切取DIEP皮瓣 ,移植至胸壁受区 ,腹壁下动静脉分别与胸廓内动静脉相吻合 ,用于乳腺癌术后乳房再造和胸壁放射性溃疡的修复。　结果　解剖学研究和临床观察发现自腹壁下动脉有粗大的肌皮穿支或皮支自血管主干发出 ,穿过腹直肌纤维直接进入皮瓣 ,因此 ,术中只剪开腹直肌前鞘 ,钝性分离腹壁下动静脉及其穿支周围的腹直肌纤维 ,无须离断腹直肌纤维 ,临床应用DIEP皮瓣再造乳房 4例 ,修复胸壁缺损 2例 ,皮瓣面积 (10cm× 12cm )～ (12cm× 35cm) ,全部成活 ,效果满意。　结论　DIEP皮瓣是对传统的TRAM皮瓣的一种技术改良 ,既保留了TRAM皮瓣血运丰富、组织量大、易于塑形的优点 ,尚可保持腹直肌的完整性 ,同期进行腹壁整形     

DIEP皮瓣在乳房再造中的应用

应用腹壁下动脉穿支(deep inferior epigastric perforator flap,DIEP)皮瓣行乳房再造是目前较受国内外整形医生推荐的自体组织重建乳房方法,它克服了许多以前常用于乳房再造皮瓣存在的缺点。现综述DIEP皮瓣应用于乳房再造的现状。     

Advances in the pre‐operative planning of deep inferior epigastric artery perforator flaps: Magnetic resonance angiography

Imaging of the abdominal wall vasculature prior to deep inferior epigastric artery (DIEA) perforator (DIEP) flaps has been shown to significantly improve surgical outcomes. Although computed tomography angiography (CTA) has been shown to be highly accurate, it is associated with radiation exposure, and as such modalities without radiation exposure have been sought. Magnetic resonance angiography (MRA) has been proposed as such an option. We conducted a pilot study comparing MRA with CTA and with operative findings in six consecutive patients undergoing DIEP flaps for breast reconstruction. The DIEA, superficial inferior epigastric artery (SIEA) and perforators were all assessed with each modality. We found that the DIEA and SIEA were accurately imaged with both CTA and MRA, but that while MRA could identify some major perforators, CTA was more accurate than MRA for perforator mapping. As such, while MRA does have a role in the imaging of DIEA perforators, CTA is still the preferred modality. On the basis of these findings, a larger study into the role for MRA in this setting is warranted. © 2008 Wiley‐Liss, Inc. Microsurgery, 2009.     

应用腹壁下动脉穿支皮瓣乳房再造术的手术并发症分析和护理策略

［摘要］ 目的 探讨乳腺癌患者乳房根治切除同期应用腹壁下动脉穿支（DIEP）皮瓣乳房再造术围术期感染的预防控制及并发症观察的护理方法。方法 回顾分析我院2016年6月至2018年6月接受DIEP皮瓣乳房再造术的96例乳腺癌患者进行围手术期感染监控和并发症观察,及早采取有效的护理干预。结果 手术时间7.0±1.5 h,术后住院时间11.4±3.7 d,96例手术患者发生并发症17例,发生率为17.7%,其中4例切口感染,感染率为4.1%,经过实施综合护理,患者均痊愈出院。结论 乳腺癌患者乳房根治切除同期应用DIEP皮瓣乳房再造术的临床治疗风险与护理难度大,重视游离皮瓣移植术后血管危象的观察与处理、预防性应用抗生素是提高临床效果的重要因素。     

Successful breast reconstruction with a perforator to deep inferior epigastric perforator flap

The authors report their experience with deep inferior epigastric perforator (DIEP) flap breast reconstruction in which an unusual recipient site was used. Successful anastomosis between a suitable perforating vessel from the internal mammary axis and the deep inferior epigastric bundle was performed, and the advantages of this alternative recipient site (perforator to the DIEP flap) are examined.     

下腹部横行腹直肌肌皮瓣联合腹壁下动脉穿支皮瓣乳房再造术

目的 探讨应用下腹部腹直肌肌皮瓣联合腹壁下动脉穿支皮瓣行乳房再造的手术方法，并分析其适应证。方法 以健侧腹直肌为肌蒂、患侧腹壁下动、静脉穿支为吻合血管蒂形成下腹部横行腹直肌肌皮瓣与腹壁下动脉穿支联合皮瓣，将腹壁下动、静脉与患侧胸背血管或胸廓内血管相吻合，进行乳房再造。结果 自2003年以来，于临床应用17例，所有皮瓣皆成活，随访3～12个月，再造乳房外形满意。结论 下腹部腹直肌肌皮瓣联合腹壁下动脉穿支皮瓣，具有血运可靠、提供组织量丰富、塑形自由度大、供区损伤较小等优点，尤适宜需要移植体积多以及胸廓内血管受损的乳房再造患者。     

Dynamic infrared thermography

This article describes how dynamic infrared thermography (DIRT) can be used in autologous breast reconstruction with a deep inferior epigastric perforator flap. This noninvasive and noncontact technique for indirect monitoring of skin blood perfusion can be used in the preoperative planning and intraoperative evaluation of flap perfusion, as well as the postoperative monitoring of perfusion dynamics of DIEP flaps. DIRT provides valuable information on the perfusion physiology of perforators.     

A subfascial variant of the deep inferior epigastric artery demonstrated by preoperative multidetector computed tomographic angiography: A case report

Precise preoperative imaging by multidetector computed tomographic (MDCT) angiography for planning of deep inferior epigastric artery perforator (DIEP) flap dissection has been reported for enormous advantages in terms of reduced operative time and minimized flap‐related complications. This case report shows a particularly rare anatomical subfascia variant of deep inferior epigastric artery (DIEA) which can be preoperatively demonstrated by MDCT angiogram. Therefore, the intraoperative finding also confirms the radiologic data and results in meticulous flap harvesting during incision on anterior rectus sheath. Additionally, the authors emphasize on performing preoperative high quality imaging for DIEP intervention precisely for specific vulnerable course of subfascial plane DIEP, which is rare but tends to be at risk without foreknowing its exact course. © 2009 Wiley‐Liss, Inc. Microsurgery, 2010.     

Easy venous superdrainage in DIEP flap breast reconstruction through the intercostal branch

The deep inferior epigastric perforator (DIEP) flap has been shown to be a valid option for breast reconstruction, as it has certain advantages over the free TRAM flap, including lower morbidity in the donor area, conservation of abdominal wall function, and reduced postoperative pain. However, some cases of venous congestion in using the DIEP flap have been described. The authors present a case in which the venous return in a DIEP flap objectively (by measurement with a flux meter) presented a marked improvement (from 4 ml/min to 13.9 ml/min) after venous drainage was increased by means of the supplementary anastomosis of a comitant vein from the deep inferior epigastric pedicle to the intercostal branch of the internal mammary vein. The preservation of this branch is a simple and effective technique to improve the venous drainage of DIEP flaps, whether signs of congestion are present or not.     

Contralateral unaffected breast augmentation using zone IV as a SIEA flap during unilateral DIEP flap breast reconstruction

BackgroundContralateral breast augmentation during unilateral breast reconstruction is a good option for women with small breasts. In patients with adequate lower abdominal tissues, the deep inferior epigastric perforator (DIEP) flap is often the first choice for unilateral autologous breast reconstruction. We use Zone IV, which is usually excised owing to its insufficient blood circulation, as a superficial inferior epigastric artery (SIEA) flap for contralateral breast augmentation.MethodsBetween October 2004 and January 2016, 32 patients underwent unilateral breast reconstruction using a DIEP flap and an attempted simultaneous contralateral breast augmentation with an SIEA flap. The unilateral DIEP flap attached to the contralateral SIEA flap was split into two separate flaps after indocyanine green angiography. In all patients, ipsilateral internal mammary vessels were used as recipient vessels for DIEP flap breast reconstruction. The SIEA flap pedicle was anastomosed to several branches of the deep inferior epigastric vessels. The SIEA flap was inset beneath the contralateral breast through the midline.ResultsOf 32 patients, 27 underwent DIEP flap breast reconstruction and simultaneous unaffected breast augmentation using 25 SIEA or 2 superficial circumflex iliac artery perforator (SCIP) flaps. All DIEP flaps survived, and total necrosis occurred in one SIEA flap. The mean weight of the final inset for DIEP flap reconstruction and SIEA or SCIP flap augmentation was 416 g and 112 g, respectively.ConclusionsUnilateral DIEP flap breast reconstruction and contralateral SIEA flap breast augmentation may be safely performed with satisfactory results.     

Salvage of congested deep inferior epigastric perforator flap with a reverse flow venous anastomosis

The deep inferior epigastric perforator flap (DIEP) is an increasingly popular method for autologous breast reconstruction because of less abdominal wall donor-site morbidity. However, disadvantages with the DIEP flap are its greater technical difficulties for flap harvest and a greater incidence of venous congestion. We report a case of salvage of a congested DIEP flap with a superficial inferior epigastric vein (SIEV) to deep inferior epigastric vein reverse flow anastomosis. Drainage of both the superficial and deep system resulted in complete reversal of venous congestion and flap salvage. Preservation and use of the SIEV for venous augmentation via a reverse flow anastomosis is a novel and simple method for DIEP flap salvage of venous congestion.     

应用腹壁下动脉穿支皮瓣再造阴道

目的探讨应用腹壁下动脉穿支皮瓣再造阴道的优缺点。方法2004年1月~2005年5月,采用腹壁下动脉穿支(deepinferiorepigastricperforator,DIEP)皮瓣再造阴道5例,年龄19~40岁。先天性无阴道4例,阴道肿瘤1例。术前常规用超声多普勒检测DIEP,设计10cm×9cm~12cm×11cm的菱形皮瓣,将穿支点包括在皮瓣内。皮瓣切取后作内翻缝合成皮筒状,于腹股沟韧带与耻骨之间沿耻骨结节及耻骨上支内侧面,形成皮筒通过的隧道。将阴道皮筒经隧道移位至人工阴道腔隙或阴道肿瘤切除后的创面中再造阴道。结果5例阴道再造均获得成功,1例患者术后2周出现阴道后壁血肿,经清除血肿后愈合。腹壁供区无任何并发症发生。术后随访1~6个月,再造阴道质地柔软,宽敞,3例有性生活,患者感觉满意。结论应用DIEP皮瓣再造阴道是一种较理想的术式,对广泛的阴道肿瘤切除,由于需填充较多组织,仍是较好选择。