侧胸带蒂胸外侧动脉穿支皮瓣的解剖观察及其在保乳术乳房重建中的临床应用

目的 探讨带蒂胸外侧动脉穿支皮瓣在乳腺癌保乳术后部分乳房重建中临床应用的解剖学基础及效果。方法 (1)取新鲜成人尸体标本8具,其中男6具、女2具,年龄28~71岁,平均39.5岁。标本经股动脉灌注加入氧化铅的红色凝胶后,在上至锁骨、下至第五肋、外至腋前线、内至胸骨旁的区域内,解剖观察两侧胸外侧动脉的位置、走行、分支以及与周围血管的吻合情况,对胸外侧穿支血管的来源进行系统分型,并测量胸外侧动脉穿支起始处外径及血管蒂长度。(2)纳入湖南省肿瘤医院2015年8月—2019年2月收治的12例Ⅰ期乳腺癌患者临床资料进行回顾性分析,患者均为女性,年龄14～52岁,平均43.2岁。其中浸润性导管癌8例,浸润性小叶癌4例;均为单侧发病,肿瘤位于乳房外上区域9例、外下区域3例。12例均行保乳术,术中于肿瘤切除后应用带蒂胸外侧动脉穿支皮瓣行部分乳房重建,术后观察皮瓣成活情况及重建后的乳房外形。结果 (1)8具16侧标本中,有15侧出现胸外侧动脉,从胸大肌和背阔肌之间穿出,其起始处外径0.7~0.9 mm,平均0.80 mm;血管蒂长6.8～10.4 cm,平均8.15 cm,与胸肩峰动脉、胸廓内动脉、胸背动脉和肋间动脉形成丰富的血管吻合。15侧胸外侧动脉按照其来源分为6型,分别来自胸肩峰动脉(8/15,Ⅰ型)、腋血管(4/15,Ⅱ型)、胸背血管(2/15,Ⅲ型)、肩胛下血管(1/15,Ⅳ型)、多源型(1/15,Ⅴ型);另有1侧胸外侧动脉缺如(Ⅵ型)。(2)本组12例患者切除肿瘤及乳腺组织质量为70～95 (80.0±5.7)g,切取的侧胸带蒂胸外侧动脉穿支皮瓣长10.5～13.5 (11.2±0.4) cm、宽4.5～7.5 (6.3±0.5)cm、厚3.0～4.5 (3.4±0.4) cm。术后2例发生皮瓣脂肪液化,1例伤口裂开,经过换药治疗均愈合。12例患者术后随访6～20个月,平均11.5个月。所有皮瓣均顺利成活,重建乳房外形可,质地柔软,侧胸皮瓣供区仅遗留线性瘢痕,肩关节功能无明显异常;无一例出现乳腺癌复发。结论 胸外侧动脉穿支来源多样,解剖位置较恒定,且供血范围大,带蒂胸外侧动脉穿支皮瓣对于乳腺癌保乳术后乳房外侧区域重建是一个有价值的选择方案。

Anatomical research of pedicled lateral thoracic artery perforator flap in breast reconstruction after breast-conserving surgery

Objective To explore the anatomical basis of pedicled lateral thoracic artery perforator flap in breast reconstruction after breast-conserving surgery.Methods(1)To observe and record the resources and distribution of lateral thoracic artery in 8 adult specimens.Eight fresh adult cadavers(16 sides),6 males,2 females,aged from 28 to 71 years,39.5 years on average.The specimens were perfused with red gel joining lead oxide via femoral artery.The occurrence rate,location,course,branch and vascular anastomosis of bilateral lateral thoracic arteries with peripheral blood vessels were dissected from the upper to the clavicle,the lower to the fifth rib,the outer to the axillary front,and the inner to the parasternum.The sources of the lateral thoracic perforator vessels were systematically classified.The outer diameter and pedicle length of the lateral thoracic artery were measured.(2)From August 2015 to February 2019,12 cases of early breast cancer patients received breast-conserving surgery and pedicled lateral thoracic artery perforator flap transfer breast reconstruction in Hunan Province Cancer Hospital.All patients were female.Age ranged from 14 to 52 years old(43.2 years old on average).Eight cases were invasive ductal carcinoma and 4 cases were invasive lobular carcinoma.The locations of the masses were the upper lateral quadrant(n=9),the lower lateral quadrant(n=3).Survival of the flap and the shape of the reconstructed breast were observed after operation.Results Lateral thoracic artery was observed in 15/16 sides of 8 specimens,pierced between the pectoralis major muscle and latissimus dorsi muscle,outer diameter average of 0.80 mm(0.7-0.9 mm);pedicle length average of 8.15 cm(6.8-10.4cm),had rich vascular anastomosis with the thoracoacromial artery,internal mammary artery,thoracodorsal artery and intercostal artery.Lateral thoracic artery was classified in 6 types,originated from thoracoacromial artery(8/15,typeⅠ),axillary artery(4/15,typeⅡ),thoracodorsal artery(2/15,typeⅢ),subscapular artery(1/15,typeⅣ),multi-resources(1/15,typeⅤ).In one specimen,lateral thoracic artery was absent(1/15,typeⅥ).The average weight of the mass of tumor and breast tissue was 70-95(80.0±5.7)g.Size of the flaps were 10.5-13.5(11.2±0.4)cm in length,4.5-7.5(6.3±0.5)cm in width,and 3.0-4.5(3.4±0.4)cm in thickness.Complications developed in 2 of the cases,fat necrosis in two and wound dehiscence in one,all healed smoothly with dressing treatment.All flaps survived.The reconstructed breasts'shape,texture and elasticity were good.There was no flap contracture deformation in all cases.Only linear scar left in the lateral thoracic donor sites.Function of shoulders were not affected.All 12 patients were followed up for 6 to 20 months(11.5 months on average)with satisfactory results.No recurrence of breast cancer happened.Conclusions The lateral thoracic artery perforator has variable resources,instant existence and extensive performance.The pedicled lateral thoracic artery perforator flap can be a useful,alternative and reliable technique in breast reconstruction after breast conserving surgery,especially in laterally located breast cancer.