双侧游离股后内侧皮瓣移植再造乳房单侧的经验

目的探讨应用双侧游离股后内侧皮瓣再造单侧乳房中的技术要点和注意事项。方法收集2018年10月至2020年12月湖南省肿瘤医院肿瘤整形外科收治的乳腺癌改良根治术后行即刻或延期双侧游离股后内侧皮瓣移植再造一侧乳房患者的临床资料, 进行回顾性分析。根据血管蒂来源, 切取的股后内侧皮瓣包括6种类型:股动脉穿支皮瓣、股薄肌肌皮瓣、大收肌穿支皮瓣、半膜肌穿支皮瓣、股后皮神经营养血管穿支皮瓣、坐骨神经营养血管穿支皮瓣。血管吻合方式包括4种:(1)外增压方式1, 胸廓内血管近心端和远心端与两侧皮瓣血管蒂分别吻合;(2)外增压方式2,胸廓内血管和胸背血管与两侧皮瓣血管蒂分别吻合;(3)内增压方式, 胸廓内血管与一侧皮瓣血管蒂吻合, 皮瓣血管蒂分支与另一侧皮瓣血管蒂吻合;(4)外增压结合内增压方式, 胸廓内血管和2套皮瓣血管蒂灵活组合。两侧股后内侧皮瓣摆放方式包括3种:横行摆放、垂直摆放、斜行摆放。对术后皮瓣成活情况、再造乳房外形、供区瘢痕、对下肢功能的影响及乳腺癌复发情况进行随访。结果共纳入12例患者, 年龄(37.4±3.6)岁(27～47岁)。肿瘤均为单侧, 其中左侧7例, 右侧5例;即刻乳房再造8...     

大面积股内侧穿支皮瓣移植重建乳房的临床效果

目的:探讨以股薄肌皮瓣联合大收肌穿支皮瓣的股内侧皮瓣形式移植再造乳房的临床价值。方法:2016年12月至2019年2月,湖南省肿瘤医院肿瘤整形外科收治16例女性乳腺癌患者,年龄27~59岁,平均40.3岁。肿瘤均为单侧,左侧9例,右侧7例;直径1.5~4.5(2.9±0.3) cm;全部为一期病例。病理诊断浸润性导管癌...     

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。     

股前内侧穿支皮瓣游离移植修复手部创面

目的 探讨应用股前内侧穿支皮瓣游离移植修复手部创面的临床疗效.方法 2008年6月至2011年6月,应用股前内侧穿支皮瓣游离移植修复手部创面共15例,其中手掌侧创面5例,尺侧创面4例,虎口区创面1例,手背创面5例;缺损面积:6 cm×4cm～13cm×9 cm;其中11例与受区桡动脉、头静脉吻合,4例与尺动脉、贵要静脉吻合.供区直接缝合9例,部分植皮6例.结果 本组15例皮瓣全部存活,未出现血管危象.随访3～ 12个月,临床效果满意.结论 应用股前内侧穿支皮瓣游离移植修复手部(正)面,临床效果满意,值得推广应用.     

应用股前内侧穿支皮瓣修复足部创面

目的 探讨应用股前内侧穿支皮瓣游离移植修复足部创面的临床疗效.方法 应用股前内侧穿支皮瓣游离移植修复足部创面共7例,其中足背创面缺损4例,足跟创面2例,足底创面1例.缺损面积:6cm×4 cm～18cm×9 cm大小.其中5例穿支皮瓣吻接了股前皮神经支,供区创面直接缝合3例,游离植皮4例.结果 本组7例皮瓣全部成活,未出现血管危象.随访3～9个月,皮瓣质地良好,其中吻合皮神经的穿支皮瓣恢复了保护性感觉.供区功能无影响.结论 应用股前内侧穿支皮瓣游离移植修复足部创面,临床效果满意.     

游离股内侧肌穿支皮瓣的解剖研究与临床应用

目的研究股内侧肌肌皮穿支解剖学特征,设计游离股内侧肌穿支皮瓣,为临床修复软组织缺损提供一种新的皮瓣。方法取6具自愿捐献的新鲜成人下肢标本,以氧化铅混合红色乳胶灌注,解剖股内侧肌肌皮穿支,并通过血管造影技术观测股内侧肌肌皮穿支的起源、走行、分布情况。根据解剖研究,于2009年6月-2011年8月,临床采用大小为14 cm×6 cm～20 cm×5 cm的股内侧肌穿支皮瓣修复4例足部皮肤软组织缺损,缺损范围8 cm×6 cm～12 cm×8 cm。结果股动脉恒定发出的股内侧肌动脉在内侧肌内下行至髌旁,终末支与旋股外侧动脉终末支吻合形成髌周血管网。沿途发出3～5支粗大肌皮穿支达深筋膜内,并浅出至股内侧肌表面皮肤,构成股内侧血管网。临床应用4例股内侧肌穿支皮瓣均成活,受区创面及供区切口均Ⅰ期愈合;患者均获随访,随访时间6～12个月,皮瓣色泽、质地良好,踝关节背伸、跖屈活动范围正常。结论游离股内侧肌穿支皮瓣切取简便,皮瓣供区隐蔽,质地优良,是理想的皮瓣供区。     

以双蒂腹壁下动脉穿支皮瓣再造乳房

目的 报道对有纵形剖腹产瘢痕的乳腺癌根治术后所造成的胸壁畸形，应用双蒂腹壁下动脉穿支皮瓣再造乳房的临床效果，从而说明胸廓内动脉远心端供血的可靠性。方法 应用游离的双侧腹壁下动静脉为蒂的腹壁下动脉穿支皮瓣与胸廓内动、静脉远近心断端分别进行端端吻合再造乳房4例。结果 临床应用4例，皮瓣全部成活，再造乳房的形态较满意。术后随访l0～26个月，无腹部薄弱或腹壁疝等并发症发生。结论 胸廓内动、静脉可提供远近心端两组可靠的受区血管。以双侧腹壁下动、静脉为蒂的横行腹壁下动脉穿支皮瓣，适用于乳腺癌根治术后的乳房再造，特别适用于有纵形剖腹产瘢痕及腹壁较薄者的整形修复。     

股臀区皮瓣乳房再造应用进展

目前,乳房再造方法大致有假体置入、局部皮瓣转移及游离皮瓣转移等[1].自1994年穿支皮瓣开始应用于乳房再造后,应用腹壁下动脉穿支皮瓣行乳房再造作为自体组织游离移植的经典术式,并在临床上得以广泛应用[2].但是,对于部分既往已有剖宫产、腹部吸脂等手术史或腹部脂肪量相对较少的患者来说,因其腹部供区条件所限,新供区的选择变得尤为迫切.近年来,股臀区皮瓣在应用自体组织乳房再造中表现活跃,笔者现对国内外该区域皮瓣应用于乳房再造的相关进展,进行综述.     

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。     

股前内侧穿支皮瓣修复手足创面的临床应用

目的探讨应用股前内侧穿支皮瓣游离移植修复手足创面的临床疗效。方法2008年6月-2009年9月,应用股前内侧穿支皮瓣游离移植修复手足创面12例,其中足部缺损7例,手部缺损5例。结果本组12例皮瓣全部成活,未出现血管危象。随访3～6月,临床效果满意。结论应用股前内侧穿支皮瓣游离移植修复手足创面是一种十分有效的方法,临床效果满意,值得推广应用。     

Anterolateral thigh flap salvage following failed deep inferior epigastric artery perforator breast reconstruction

The deep inferior epigastric artery perforator flap is an option for women desiring autologous tissue breast reconstruction. If this reconstruction fails, other autologous tissue flaps, including the gluteal artery perforator and latissimus dorsi flaps, may be used for salvage. The anterolateral thigh (ALT) flap offers adequate tissue volume for breast reconstruction, acceptable fat quality and a long vascular pedicle. Other advantages include obviating the need for intraoperative position changes and harvesting tissue outside of the radiation field. Two cases involving ALT flaps used in the setting of deep inferior epigastric artery perforator failure are presented with favourable results. A review of the anatomy of the ALT flap is included.     

股前外侧双叶穿支皮瓣修复手部创面

目的：探讨股前外侧双叶穿支皮瓣修复手部创面的方法和疗效。方法2011年1月-2012年10月对9例手部创面采用游离股前外侧双叶穿支皮瓣修复,其中手部两处创面7例,另2例为洞穿性缺损。急诊修复创面桥接血管重建患肢血供1例,延期修复创面8例。结果本组9例皮瓣全部成活,术后随访3～6个月,供区外观仅为线状瘢痕,功能无明显影响。2例手部洞穿性缺损修复后外观满意,功能欠佳;其余7例创面修复后皮瓣质地柔软,外观稍臃肿,功能满意。结论股前外侧双叶穿支皮瓣可一次修复手部两个创面或通过拼接修复一处较大创面,而供区常可以直接缝合,优点明显。     

穿支游离皮瓣修复头颈肿瘤术后缺损

目的 探索更为理想的穿支游离皮瓣修复技术，运用于头颈肿瘤术后缺损。方法 2003年12月-2005年5月用于头颈部手术缺损修复的穿支游离皮瓣共14例（股前外侧皮瓣8例，腹壁下深动脉穿支皮瓣6例）。其中10例为复发后挽救手术，12例曾行放疗（平均63．5Gy）。头颈部肿瘤手术缺损部位分别为舌体3例，颊黏膜3例，口咽壁3例，舌根2例，颅底、头皮以及中面部各1例。受区供吻合动脉主要是甲状腺上动脉和面动脉；静脉为颈内静脉。结果 13例穿支游离皮瓣成功（93％），有1例穿支皮瓣因吻合侧的颈内静脉血栓形成导致皮瓣坏死。受区未发现其它明显并发症。供区均直接缝合关闭并一期愈合，未发现腹壁疝和运动受限等手术并发症。结论 穿支游离皮瓣保留了供区的肌肉、筋膜和神经，将供区的并发症降到最低限度，是头颈部缺损修复新的可靠技术。     

Breast reconstruction with deep inferior epigastric perforator flaps

INTRODUCTION

Approximately 45,000 women are diagnosed with breast cancer in the UK each year. The success of screening and the introduction of adjuvant therapies have meant that prognosis is improving and an increasing number of patients are seeking reconstruction following mastectomy. The purpose of this study was to evaluate the deep inferior epigastric perforator (DIEP) flap reconstructions performed in Stoke Mandeville Hospital and, through analysis of complications, detail the evolution of the current care pathway.

METHODS

A retrospective analysis was performed of all the DIEP flap reconstructions performed by the senior author (MT) between July 2003 and December 2010.

RESULTS

Overall, 159 flaps were performed on 141 patients (including 36 bilateral flaps). The average patient age was 49 years (range: 28–70 years) and 13% of flaps were risk reducing for BRCA1/2. Twenty-six per cent of patients suffered one or more complication post-operatively, including systemic complications (pulmonary embolism 2%) and flap specific complications (partial flap necrosis 9%, reanastomosis 3%, fat necrosis 9%). Seventy-four per cent had further elective operations including nipple reconstruction (72%), contralateral breast reduction (36%) and scar revision (21%).

CONCLUSIONS

DIEP flaps are a safe and reliable option for breast reconstructions. This series illustrates the significant leaning curve, with complications, operative time and ischaemic time reducing through the series and post-operative haemoglobin increasing. The complications experienced in this series of 159 flaps with no total flap loss provide the framework for the evolution of the current care pathway including pre-operative imaging, peri-operative deep vein thrombosis prophylaxis and analgesia.     

Reconstructive surgery for foot and ankle defects in pediatric patients: Comparison between anterolateral thigh perforator flaps and deep inferior epigastric perforator flaps

BackgroundsDue to the delicate tissue, small blood vessels and incomplete development of interarticular ligaments, skin and soft-tissue defects of the foot and ankle in pediatric patients remain a challenge for orthopedic and plastic surgeons. Anterolateral thigh perforator (ALTP) flap and deep inferior epigastric perforator (DIEP) flap are the most commonly used flaps for the repair of lower-extremity soft-tissue defects. The literature contains a shortage of evidence involving the differences between ALTP and DIEP flaps in the reconstruction of young patients with complex foot and ankle defects. This study was designed to determine which type of flap is better for foot and ankle repair in pediatric patients.MethodsFrom January 2004 to January 2018, 79 children younger than 14 years treated with DIEP flap (41 cases) or ALTP flap (38 cases) for composite defects of the feet and ankles were retrospectively investigated. The two groups were homogeneous in terms of age, the location of the defect, etiology, and flap area. Complications, scarring, cosmetic appearance, flap sensory recovery, and functional outcome were analyzed, and statistical analysis was performed.ResultsThe ALTP group had shorter operation time (155.0 ± 12.0 min vs 212.2 ± 23.9 min), flap harvested time (39.6 ± 5.1 min vs 57.2 ± 10.4 min), and operative blood loss (143.4 ± 23.7 ml vs 170.7 ± 44.7 ml) than the DIEP group (P < 0.05). In short-term follow-up, ALTP group showed a lower flap necrosis rate (5.3% vs 24.4%) and vascular insufficiency rate (2.6% vs 19.5%) than DIEP group (P < 0.05). In long-term follow-up, ALTP group showed a lower late complication rate and better cosmetic, functional, scar outcomes than DIEP group (P < 0.05).ConclusionsThe study showed that an ALTP flap may brings better results than a DIEP flap in terms of short- and long-term complications, scarring, and morpho-functional outcomes for pediatric patients undergoing reconstruction of foot and ankle defects.     

游离股前外侧穿支皮瓣或隐动脉穿支皮瓣修复足踝部软组织缺损

目的 探讨利用游离股前外侧穿支皮瓣或隐动脉穿支皮瓣修复足踝部软组织缺损的效果及手术技术.方法 2006年8月至2012年4月,对足踝部软组织缺损患者25例,创面范围4.0cm×5.5 cm～11.0 cm×23.0 cm.其中,足背软组织缺损采用游离股前外侧穿支皮瓣修复20例,足底软组织缺损采用游离隐动脉穿支皮瓣修复5例.结果 术后25例皮瓣全部成活.术后随访3～ 50个月,平均(18.0±0.8)个月.皮瓣修复后外形大部满意,皮瓣末梢二点辨别觉为10～22 mm,股前外和隐动脉穿支皮瓣组术后3个月随访,恢复S2+以上感觉分别为13/20和5/5例.结论 股前外穿支皮瓣修复足背软组织缺损较合适,隐动脉穿支用于修复足底软组织缺损.避免受区二次手术整形,重视皮瓣供区处理.负压封闭引流技术对开放性损伤导致创面的皮瓣成活有明显促进作用.     

320排螺旋CT血管造影和三维重建在阴股沟穿支皮瓣临床设计中的应用

目的：以320排螺旋CT血管造影和三维重建为基础,尝试在临床为阴股沟穿支皮瓣血管蒂的术前设计提供体表定位方法.方法：对18名需运用阴股沟穿支皮瓣行会阴部再造的实验组患者,术前进行320排螺旋CT血管造影和三维重建,并通过影像学资料为阴股沟穿支皮瓣血管蒂提供体表定位,从而进一步指导手术.同时设置对照组,包括20名运用阴股沟穿支皮瓣行会阴部再造患者,未使用CT血管造影技术.结果：两组共38名患者皮瓣完全存活,实验组手术时间较对照组明显缩短（P＜0.0001）,术后并发症实验组明显减少（P＜0.05）.皮瓣外观形态满意,生理功能接近正常.结论：320排螺旋CT血管造影及三维重建为阴股沟穿支皮瓣血管蒂的术前体表定位提供了一种可靠、有效的方法.