游离带感觉神经腹壁下动脉穿支皮瓣在乳房再造中的应用

目的 探讨游离带感觉神经腹壁下动脉穿支皮瓣移植再造乳房的方法和效果。方法 回顾性研究。纳入2015年10月—2017年12月湖南省肿瘤医院单侧早期(Ⅰ/Ⅱ期)乳腺癌患者12例,均为女性,年龄33～52 (37.4±3.5)岁。12例均行改良根治术,并应用带感觉神经腹壁下动脉穿支皮瓣行同期乳房再造术,皮瓣携带的肋间神经感觉支与受区肋间神经吻合,腹壁下血管与受区胸廓内血管或者胸背血管吻合。记录皮瓣长度、宽度、厚度及血管蒂情况,携带感觉神经长度及选择的受区血管和神经。随访再造乳房的感觉恢复情况,将乳房分为5个区,包括4个象限和中央区,对每区的压力觉和温度觉恢复情况进行记录。完成患者主观感觉的问卷调查,内容包括外形恢复、感觉恢复和满意度。结果 皮瓣长(32.3±0.4)cm、宽(12.7±1.6)cm、厚(3.8±0.4)cm,腹壁下血管蒂长度为(12.5±0.4)cm,动脉管径为(1.7±0.4)mm,伴行静脉管径为(2.2±0.7)mm,携带肋间神经感觉支长度为(2.3±0.4)cm。受区血管为胸廓内血管(7例)和胸背血管(5例)。所有受区神经为同侧第3肋间神经。所有皮瓣顺利成活,1例皮瓣供区发生脂肪液化,经换药后愈合,未见其他并发症。再造乳房外形圆润,弹性质地可,未见皮瓣发生溃疡;皮瓣供区仅遗留线性瘢痕,腹壁功能未见影响。12例患者均获随访12～38个月,平均19.6个月,未见乳腺癌复发情况。术后12个月调查患者的感觉恢复效果,12例(100%)带感觉神经腹壁下动脉穿支皮瓣再造乳房病例中,所有再造乳房至少有1区恢复了温度觉。患者对再造乳房外形及感觉恢复均满意。结论 游离带感觉神经腹壁下动脉穿支皮瓣与受区胸壁第3肋间神经吻合有助于乳腺癌术后乳房再造的感觉功能恢复。

Application of free innervated deep inferior epigastric artery perforator flap in breast reconstruction

Objective This study aimed to explore the clinical application methods and outcomes of innervated deep inferior epigastric artery perforator (DIEP) flap for breast reconstruction.Methods A retrospective analysis was conducted on 12 female patients with unilateral early breast cancer (clinical stage Ⅰ/Ⅱ) who were admitted from October 2015 to February 2017 in Hunan Cancer Hospital and received modified radical surgery and breast reconstruction by using the DIEP flap with sensory nerve repair (the sensory branch of intercostal nerve in the flap was coated with the third intercostal nerve). The patients' age ranged from 33 years to 52 years (mean age, 37.4±3.5 years). In all flap transplantations, the deep inferior epigastric vessels were anastomosed with internal mammary vessels or thoracodorsal vessels in the recipient sites. Each breast was subdivided into four quadrants. One central region with pressure, hot, and cold recognition was tested in every area. Each patient received a questionnaire asking for their subjective opinion about their breast shape outcome, return of sensation, erogenous sensation, and overall satisfaction.Results The flap had a length of (32.3±0.4)cm, width of (12.7±1.6)cm, and thickness of (3.8±0.4) cm. The length of pedicle was (12.5±0.4) cm, the outer diameter of artery pedicle was (1.7±0.4)mm, and the outer diameter of venae comitant was (2.2±0.7)mm. The length of sensory branch of intercostal nerve was (2.3±0.4)cm. The recipient vessels included internal mammary vessels (seven cases) and thoracodorsal vessel (five cases). All the recipient nerves are the third intercostal nerve. All flaps were successfully implanted. In one flap donor site, fat necrosis occurred and healed with dressing treatment. No other complications were noted. The reconstructed breasts' shape, texture, and elasticity were good, and no flap contracture deformation was noted. Only linear scar was left in the donor sites, and the abdominal function was not affected. All 12 patients were followed up for 12-38 months (averaged 19.6 months) with satisfying results. No local recurrence happened. At 12 months after breast reconstruction, the neurotization of the DIEP flap resulted in the recovery of sensibility. In all 12 cases (100%) of the DIEP flaps with sensory nerve repair, at least protective sensation was present in all five segments of the breast. Responses to cold or warm stimuli were still present.Conclusions DIEP flap neurotization using the third anterior intercostal nerve is an effective technique to increase the sensory recovery for patients undergoing breast reconstruction.