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，仅靠腹避暑上、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。     

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。     

横行腹直肌肌皮瓣血流动力学的超声多普勒研究

横行腹直肌肌皮瓣被广泛应用于乳腺癌根治术后乳房重建及其他部位的移植修复[1-2],而良好的腹壁下动脉血供是横行腹直肌肌皮瓣存活的关键,因此,术前了解该皮瓣主要供血动脉(腹壁下动脉)的位置及其走行具有重要意义.本研究采用彩色多普勒血流显像技术检测100名正常人的200条腹壁下动脉,以了解其走行和血流动力学参数,为横行腹直肌肌皮瓣的术前设计提供依据.     

腺苷促进猪横行腹直肌肌皮瓣成活的实验研究

目的　研究腺苷对猪横行腹直肌肌皮瓣成活率的影响。方法　横行腹直肌肌皮瓣以左侧腹壁下动脉为供血血管,肌蒂宽６ｃｍ ,皮瓣面积８ｃｍ ×３０ｃｍ 。２０ 头猪分为生理盐水对照组和１ｍｇ、２ｍｇ、５ｍｇ 腺苷注射实验组,掀起皮瓣前从腹壁上动脉注射不同剂量的腺苷和生理盐水。术后７ 天注射荧光素,以模片法记录腹直肌同侧皮瓣、对侧皮瓣和整个皮瓣的成活率。结果　２ｍｇ 和５ｍｇ 腺苷注射组,肌皮瓣成活率明显高于生理盐水对照组（Ｐ＜０－０５）。结论　小剂量术中局部使用腺苷可增加猪横行腹直肌肌皮瓣成活率     

腺苷促进猪横行腹直肌肌皮瓣成活的实验研究

目的研究腺苷对猪横行腹直肌肌皮瓣成活率的影响。方法横行腹直肌肌皮瓣以左侧腹壁下动脉为供血血管,肌蒂宽6cm,皮瓣面积8cm×30cm。20头猪分为生理盐水对照组和1mg、2mg、5mg 腺苷注射实验组,掀起皮瓣前从腹壁上动脉注射不同剂量的腺苷和生理盐水。术后7天注射荧光素,以模片法记录腹直肌同侧皮瓣、对侧皮瓣和整个皮瓣的成活率。结果 2mg 和5mg 腺苷注射组,肌皮瓣成活率明显高于生理盐水对照组(P<0.05)。结论小剂量术中局部使用腺苷可增加猪横行腹直肌肌皮瓣成活率。     

腹直肌蒂下腹横行岛状肌皮瓣乳房再造术

作者应用腹直肌蒂下腹横行岛状肌皮瓣行乳房再造７例、８个乳房，效果满意。该肌皮瓣以腹壁上动脉及其与腹壁下动脉的吻合支和伴行静脉为供血血管。由于该皮瓣组织量充足，故再造乳房外形丰满，皮瓣下一般不需植入假体。用本法行乳房再造手术操作简单，供区瘢痕荫蔽，不需吻合血管，安全性大，而且于再造乳房的同时可获腹部整形的美容效果。文中对该手术的方法、优缺点及适应证做了介绍。     

乳房再造术

乳房再造的方法较多,各有其适应证。最佳方案是根据患者本人的全身状况、主观要求、供区的条件及技术能力进行选择。 1.单侧腹直肌蒂腹部肌皮瓣转移法:含一侧腹壁上动、静脉。方法可靠,应为首选。 2.双侧腹直肌蒂部肌皮瓣转移法:含两侧腹壁上动、静脉,适合胸部受区组织缺损量大者。如胸壁放射性溃疡及复发性乳癌病灶切除时。     

下腹横行岛状肌皮瓣乳房再造术

应用腹直肌蒂下腹横行岛状肌皮瓣行乳房再造术8例、9个乳房,效果满意。该肌皮瓣以腹壁上动脉及其与腹壁下动脉的吻合支和伴行静脉为供血血管。由于该皮瓣组织量充足,故再造乳房外形丰满,皮瓣下一般不需植入假体。用本法手术操作简单,供区瘢痕隐蔽,不需吻合血管,安全性大,而且于再造乳房的同时可获得腹部整形的美容效果,不失为乳房再造的良好术式。文中对该手术的方法、优缺点及适应证做了介绍。     

吻合血管的腹直肌双蒂皮瓣移植修复小儿足踝部创伤

１９９０年以来，根据腹直肌肌皮瓣血管蒂的解剖特点，应用腹壁上动静脉和腹壁下动静脉的双蒂腹直肌皮瓣修复小儿足踝部大面积皮肤缺损，伴一知名动脉长段缺损５例，其中皮瓣内含部分腹直肌前鞘期修复趾伸肌健、足内翻或外翻肌健２例，全部获得成功，术后１～２年检查证实皮瓣轴心动脉通畅，患足生长发育无障碍，足负重、行走功能正常。     

Extended TRAM flap: feasibility study on fresh human cadavers

The purpose of this study was to investigate the feasibility of a superiorly based TRAM flap for breast reconstruction with its superior border abutting the inframammary fold. This flap would have a primary blood supply from the superior epigastric vessels, similar to a free flap attached to the mammary system. This flap, however, would not require microsurgery. Instead, it would have its superior epigastric pedicle lengthened by partial rib resection. Donor site closure would be accomplished by reverse abdominoplasty and the donor scar hidden in the inframammary fold. The surgical anatomy of such an extended TRAM flap (eTRAM) was investigated by cannulation of the internal mammary artery (IMA) in 10 fresh human cadavers bilaterally, injection with latex, and then dissection throughout its intrathoracic course. At the level of the third intercostal space, the mean external diameters of the right and left IMA were found to be 2.5 mm and 2.3 mm, respectively. The diameter of the vessel decreased until the IMA bifurcated into the superior epigastric artery and the musculophrenic artery, usually at the sixth intercostal space. The superior epigastric artery, having a mean diameter of 1.6 mm at its origin, descended caudally behind the seventh costal cartilage and could be followed until it entered the posterior rectus sheath and the rectus abdominis muscle. On its downward course, it was not embedded in the diaphragm muscle and was easily separated without violation of the thoracic cavity. From this anatomic study, it seems to be possible to raise an eTRAM after partial rib resection. Some technical considerations of such a flap are discussed. This modification of the TRAM would be helpful to surgeons commonly performing pedicled TRAM flaps and might extend its applicability beyond breast reconstruction to chest wall, intrathoracic, and head and neck reconstruction.     

Free perforator crossover TRAM flap for breast reconstruction

Breast reconstruction using a transverse rectus abdominis musculocutaneous (TRAM) flap has become the preferred method of autogenous reconstruction for most surgeons. The vascular basis of both the superior and inferior vascular pedicles of this flap has been well documented. When a pedicled TRAM flap is based superiorly, the perfusion across the midline to zone 4 and sometimes zone 3 is, at best, variable. Augmentation of the blood supply of the contralateral side with various methods has been reported. The methods include the delay procedure, bipedicled flaps, supercharging, and turbo-charging. The deep inferior epigastric artery is the dominant blood supply, and a microsurgical free TRAM flap based inferiorly provides reliable perfusion, even to zone 4, which obviates the need for many of these maneuvers. It has also been demonstrated that the circulation across the midline in a TRAM flap is primarily by means of a subdermal plexus and that with a previous vertical midline abdominal scar there is virtually no midline crossover at any anastomotic level. Therefore, even with a free TRAM flap based on the dominant inferior pedicle, perfusion across a vertical midline scar is unreliable. As a result, many patients with a vertical midline scar have been denied the best autogenous reconstructive option. The authors present their experience with a free perforator crossover TRAM flap using a constant premuscular branch of the deep inferior epigastric artery and vein that provides many patients who have a previous midline scar with a genuine option for autogenous tissue breast reconstruction.     

Anatomic and clinical study of rectus abdominis musculocutaneous flaps based on the superior epigastric system: ipsilateral pedicled TRAM flap as a safe alternative

This anatomic and clinical study supports the use of the ipsilateral transverse rectus abdominis musculocutaneous (TRAM) flap over the contralateral TRAM flap for breast reconstruction. The costomarginal artery was constant in these dissections and supplied a vascular pedicle to the rectus abdominis muscle. Radiologic studies confirmed the communications between the costomarginal artery and the deep epigastric system, the same as between the costomarginal artery and the musculophrenic and intercostal arteries. The results of the clinical series confirmed the costomarginal artery as an alternative or adjuvant vascular pedicle of the deep superior epigastric artery in cases of potential lesion of the latter. The lack of pedicle tension because of the shorter distance to be transposed allowed a greater versatility in flap shaping and positively affected its aesthetic result. This fact made the authors change from the contralateral to the ipsilateral pedicled TRAM flap as the first option for autologous breast reconstruction because of vascular security.     

The "parasite" TRAM flap for autogenous tissue breast reconstruction in patients with vertical midabdominal scars.

Abdominal scars play an important role in risk factors in transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction. In particular, vertical midline scars are a difficult problem to solve. Traditional techniques include the use of a single hemiflap (which may be insufficient to achieve an adequate volume), the transfer of a double-pedicle flap (which causes major trauma to the abdominal wall), or more complicated procedures such as two free hemiflaps. Since 1991 the authors have used an innovative technique to improve vascularity in the contralateral side of a standard unipedicled TRAM flap. They call this flap the recharged TRAM flap. By means of their technique, the retrograde flow coming from the deep inferior epigastric vessels raised in continuity with a superiorly pedicled flap is used to "recharge" the contralateral rectus muscle harvested as a free flap. On the basis of hemodynamic studies, this procedure was carried out in patients with vertical midabdominal scars. This flap was named the parasite flap because the free unit survives on the vascular source of the pedicled unit-the superior epigastric artery supplying both flaps in a retrograde fashion. Sixteen patients with vertical midabdominal scars underwent this procedure. Total flap survival was observed in 15 patients. One patient developed a partial flap necrosis and 1 patient developed abdominal bulging on the pedicled side. According to the surgeons' evaluation, aesthetic outcome was considered to be good to excellent in all patients.     

THE FREE TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP IN BREAST RECONSTRUCTION AFTER MASTECTOMY

Breast reconstruction after mastectomy by the transverse rectus abdominis myocutaneous (TRAM) flap technique is a widely accepted method which allows reconstruction without the need for an implanted silicone prosthesis. Even in suitable patients, deficiencies of the traditional technique, where the blood supply is based on anastomotic vessels in the superior part of the rectus abdominis muscle, may lead to complications. These include flap failure, fat necrosis which may mimic recurrence of breast carcinoma or sub-optimal cosmetic results. By transferring the same abdominal tissue as a free flap based on the inferior epigastric vessels, a more reliable blood supply and better cosmetic results can be obtained. This article reports a series of 14 flaps in 13 patients in whom an entirely free flap technique was used. No flap losses were recorded and the results are judged to be superior to the traditional technique.     

The free transverse rectus abdominis myocutaneous flap in breast reconstruction after mastectomy.

Breast reconstruction after mastectomy by the transverse rectus abdominis myocutaneous (TRAM) flap technique is a widely accepted method which allows reconstruction without the need for an implanted silicone prosthesis. Even in suitable patients, deficiencies of the traditional technique, where the blood supply is based on anastomotic vessels in the superior part of the rectus abdominis muscle, may lead to complications. These include flap failure, fat necrosis which may mimic recurrence of breast carcinoma or sub-optimal cosmetic results. By transferring the same abdominal tissue as a free flap based on the inferior epigastric vessels, a more reliable blood supply and better cosmetic results can be obtained. This article reports a series of 14 flaps in 13 patients in whom an entirely free flap technique was used. No flap losses were recorded and the results are judged to be superior to the traditional technique.     

Clinical results and color-coded duplex ultrasound findings 4 years after conditioned TRAM flap-plasty

Presented is a new technique in preoperative conditioning of the pedicled TRAM-flap employing an interventional-radiologic procedure, selective embolization of the deep inferior epigastric artery (DIEA). During a four year period in 40 patients with a mean age of 48.4 (31-66) years breast reconstruction was performed by a superiorly pedicled TRAM-flap following preoperative conditioning. 30 of 40 patients were eligible for follow-up one to five years postoperatively. The mean interval between embolization and surgery amounted to 3.6 months. In 25 of 30 cases embolization of the DIEA was performed bilaterally, in 5 of 30 cases unilaterally. 14 of 30 patients underwent preoperative radiotherapy for breast cancer. Applying CCDS the peak flow values were determined in the superior epigastric arteries (TRAM/contralateral side). Pre-embolization values (54.9 cm/s/55.8 cm/s), post-embolization values (57.2 cm/s/57.9 cm/s) and late postoperative values (61.0 cm/s/61.6 cm/s) proved a statistically significant effect of selective embolization on peak flow without relevant difference between TRAM and contralateral side (p < 0.05). Postoperative flap complications consisted of partial necrosis in 2 of 30, fat necrosis in 1 of 30, impaired would healing in 5 of 30 and postoperative bleeding in 2 of 30 cases. Abdominal would healing complications occurred in 5 of 30 cases, abdominal wall weakness was found in 8 of 30 and hernia formation in 4 of 30 cases. Corrective surgery was performed at the breast (TRAM-flap) in 22 of 30 and at the abdomen (donor site) in 9 of 30 cases. Patient acceptance concerning selective embolization and TRAM-flap surgery was very high. 29 of 30 patients confirmed that they would again choose this type of breast reconstruction. The pedicled TRAM-flap following preoperative conditioning by selective embolization of the DIEA constitutes a safe and reliable method of breast reconstruction with autogenous tissue. It is superior to the pedicled TRAM-flap without delay and offers definite advantages compared to alternative techniques of enhanced flap vascularization.     

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     

Catheter ablation of the inferior epigastric artery. An conservative method for conditioning the pedicled TRAM flap

The pedicled transverse rectus abdominis musculocutaneous (TRAM) flap is a recognized, reliable method of autogenous tissue breast reconstruction after mastectomy. However, the blood supply to the distal part of the flap is often precarious after ligation of the the main feeder, the inferior epigastric artery (AEI), at time of the operation. We describe our clinical experience with a new technique to augment the superior blood stream (superior epigastric artery, AES) by selective embolization of the inferior epigastric artery some weeks prior to plastic surgery. One hundred and eleven embolization procedures were performed until now. Technique of crossover and ipsilateral epigastric spiral embolization is described, requiring minimal time and material as an in- or outpatient procedure. The anatomical situation of the m. rectus abdominis blood supply is discussed as well as possible complications of the procedure.     

Initial experience with laparoscopic inferior epigastric vessel ligation for delayed transverse rectus abdominus musculocutaneous flap breast reconstruction

HYPOTHESIS: Transverse rectus abdominus musculocutaneous (TRAM) flap breast reconstruction provides excellent cosmetic results. Pedicle flap viability is greatly enhanced by prereconstruction inferior epigastric vessel ligation, which encourages collateral arterial flow (delayed TRAM). We report our initial experience with laparoscopic inferior epigastric vessel ligation. DESIGN: Prospective case series. SETTING: Tertiary academic center. PATIENTS: Female patients with breast cancer who chose pedicle TRAM reconstruction. INTERVENTIONS: Vessel ligations were performed 7 to 14 days prior to reconstruction. Abdominal access was achieved with a 3-mm umbilical trocar. A 5-mm trocar was placed lateral to the rectus sheath in the right lower quadrant. Five-millimeter Teflon clips were used to ligate the vessels near their origin. MAIN OUTCOME MEASURES: Complications of surgery and subsequent flap viability. RESULTS: From January 2001 to July 2006, 130 patients had laparoscopic inferior epigastric vessel ligation, of whom 123 patients had bilateral ligation. Additional procedures in conjunction with vessel ligation were performed in 38 patients (sentinel node biopsy [27], bilateral oophorectomy [7], liver biopsy [2], breast biopsy [1], and Nissen fundoplication [1]). Median operative time for those patients undergoing ligation only was 32.6 minutes (range, 14-121 minutes). The inferior epigastric vessels were not identified in 2 patients. Metastatic breast cancer involving the liver was found in 1 patient. There were no conversions or complications. Subsequent TRAM flap viability was excellent in most cases, with 1 complete flap necrosis in a high-risk, morbidly obese patient. CONCLUSION: Laparoscopic inferior epigastric vessel ligation for delayed TRAM flap breast reconstruction is a safe, effective procedure.