穿支皮瓣乳房再造的进展

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综述窑窑doi:10.3969/j.issn.1673-0364.2019.02.014

穿支皮瓣乳房再造的进展杜星仪

揖提要铱

欧阳熠烨李成程刘春军

穿支皮瓣乳房再造具有供区损伤小尧美学效果长期稳定等诸多优点袁是乳房再造领域中极其重要的部分遥目前

常用于乳房再造的穿支皮瓣有腹壁下动脉穿支皮瓣尧股深动脉穿支皮瓣尧胸背动脉穿支皮瓣尧臀动脉穿支皮瓣和腰动脉穿支皮瓣等遥不同的穿支皮瓣在适应人群尧手术设计等方面有各自特点遥本文就常见的穿支皮瓣在乳房再造中的应用进展进行综述遥揖关键词铱

支皮瓣

乳房再造

腹壁下动脉穿支皮瓣

月

揖文章编号铱

股深动脉穿支皮瓣

胸背动脉穿支皮瓣

肋间动脉穿支皮瓣

臀动脉穿支皮瓣

揖中图分类号铱

腰动脉穿支皮瓣

员远苑猿原园猿远源渊圆园员怨冤园2原园115原园4

DUXingyi,OUYANGYiye,LIChengcheng,LIU

R622揖文献标识码铱

ResearchProgressofPerforatorFlapsinBreastReconstruction

Chunjun援TheEighthDepartmentofPlasticSurgery,PlasticSurgeryHospital,ChineseAcademyofMedicalScienceandPekingUnionMedicalCollege,Beijing100144,China.Correspondingauthor:LIUChunjun(E-mail:liuchunjun@psh.pumc.edu.cn).揖Summary铱

Perforatorflapisacrucialpartinthefieldofbreastreconstruction,ithasmanyadvantagessuchassmall

functionaldamageofdonorarea,long-termstableaestheticoutcomeandsoon.Besidedeepinferiorepigastricarteryperforatorflap,profundaarteryperforatorflap,thoracodorsalarteryperforatorflap,intercostalsarteryperforator,glutealarteryprogressoftheseperforatorflapsinbreastreconstructionwerereviewed.揖Keywords铱Perforatorflap;

Profundaarteryperforatorflap;

Breastreconstruction;

Glutealarteryperforator;Lumbararteryperforatorflap

乳腺癌是女性常见的恶性肿瘤袁根治切除是目前主要的治疗方法袁但会造成患者的形体畸形和巨大的心理创伤遥乳房重建能帮助患者重获自信袁提高生存质量遥同假体相比袁自体组织乳房重建有更持久的美学效果遥近年来袁对供区损伤较小的穿支皮瓣的应用日渐广泛遥穿支皮瓣指的是在肌皮瓣的基础上袁分离出肌肉组织袁仅以管径细小渊0.5~0.8mm冤的皮肤穿支血管供血的皮瓣袁属轴型血管的皮瓣范畴遥本文就常见的穿支皮瓣在乳房再造中的应用进展进行综述遥1影像学辅助检查

穿支血管的部位和管径具有易变性和不稳定性袁术前影像学检查可对穿支血管进行评估袁增加对术中解剖血管的了解遥术前影像学检查是否能缩短手术时间袁提高术后效果袁目

基金项目院首都卫生发展科研专项渊2016-2-4041冤遥

作者单位院100144北京市中国医学科学院北京协和医学院整形外科医院整形八科遥

通讯作者院刘春军渊E-mail院liuchunjun@psh.pumc.edu.cn冤遥

perforatorandlumbararteryperforatorflaparealsocommonlyusedinbreastreconstruction.Inthispaper,theresearch

Thoracodorsalarteryperforatorflap;

Deepinferiorepigastricarteryperforatorflap;

Intercostalsarteryperforator;

前尚有争议遥有研究认为袁术前是否应用CTA或超声多普勒并不会对手术时间有明显的影响袁手术时间的缩短可能更多依赖于经验的增加和技术的提高[1-2]曰但也有研究通过对相关文献的系统评价得出结论袁认为术前应用CTA能显著提高手术效率袁缩短手术时间袁并且能减少术后并发症[3-4]遥

目前常见的影像学辅助检查有院多普勒超声尧CTA尧MRA

和吲哚菁绿荧光显像等遥多普勒超声因操作简便袁无侵入性操作而应用广泛袁除常规用于术前确定穿支血管的位置袁还可在术中应用以选取最佳的穿支血管遥但该技术也有一定局限性院较高的假阳性尧较长的操作时长以及对图像的解读差异等遥相比多普勒超声袁CTA不存在对图像的解读差异袁操作时间更短袁有更好的空间分辨率[5]遥除了评估穿支动脉袁Davis等[6]认为袁CTA在应用于DIEP皮瓣术前评估时袁能通过辨识异常静脉结构袁对术后可能产生的静脉淤血情况提供预判遥对于部分碘造影剂过敏及不接受电离辐射的患者来说袁CTA无法进行袁MRA在此时提供了良好的替代遥同CTA比较袁

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允ournalofTissueEngineeringandReconstructiveSurgery,April2019,Vol.15No.2MRA支血管虽及在其空经间过分的辨肌肉率上较组织能弱袁有但更有好更的好显示的对[7-8]比遥度吲哚袁所以菁对绿穿一种水溶性染料袁荧光显像的范围仅到深约1cm的组织袁在是

眼外科尧心胸外科等领域应用已久遥近年来袁吲哚菁绿显像在乳房重建中的应用日益广泛袁多用于术中对皮瓣灌注的评估袁但较少用于术前及术后遥术中使用吲哚菁绿显像袁虽然可能增加手术时间袁但通过术中显像辅助可对皮瓣进行剪裁袁能显著降低术后皮瓣局部坏死尧液化等并发症的发生[9-11]需要注意的是袁在使用术前影像学检查辅助评估穿遥

支血管的同时袁应对影像所涉及的结构有全面的了解遥多项研究提出袁术前影像学检查存在偶然发现其他疾病/癌症转移的可

能性[12-14]遥

2腹壁下动脉穿支皮瓣

perforator1994袁DIEP年袁腹冤皮壁瓣下首动次被脉穿用支于渊阅乳eep房再inferior造遥该epigastric皮瓣主要artery

是组织量大袁易于塑形袁克服了TRAM皮瓣对腹直肌的破坏优点

袁有效减弱了术后供区腹壁薄弱尧腹壁疝等并发症袁缩短了住院时间袁还可起到腹部整形的作用袁能明显提升患者术后生活质量[15-16]行腹DIEP直肌肌皮遥

皮瓣瓣与渊带fTRAM蒂横行冤比较腹直袁就肌肌腹壁皮并瓣发渊pTRAM症而言冤袁和TRAM游离横

皮瓣对腹直肌的破坏导致了腹壁膨出和腹壁疝的出现袁但保留肌肉的穿支皮瓣并不能完全消除腹壁并发症的出现袁腹壁肌肉失神经萎缩也会导致腹壁膨出和腹壁疝的出现fTRAM皮瓣袁DIEP皮瓣因为要将蒂彻底游离而曰相比

避免对相应肋间神经的损伤[17]遥就皮瓣的术后并发有症更大来说机袁会脂肪液化尧皮瓣部分坏死尧皮瓣完全坏死等袁DIEP皮瓣无论如是和pTRAM皮瓣还是fTRAM皮瓣相比袁在统计学上均无显著差异性遥从治疗费用来说袁DIEP皮瓣比济[18]瓣的遥坏死静脉遥瘀在血常是规DIEP吻合腹皮壁瓣深的静较为脉的严基重的并fTRAM皮瓣更为经础上袁发额症外增袁可导致加吻皮合腹壁浅静脉袁能更好的改善皮瓣的静脉回流[19-20]脉的游离会显著增加供区血清肿的发生率[21]遥但腹壁浅静了解决上述问题袁可选择旋髂浅静脉来遥代Bartlett替腹壁等[22]认为袁为浅静脉袁亦可很好地改善DIEP皮瓣的静脉回流遥3股深动脉穿支皮瓣

腹部历来被视为乳房重塑的理想供区袁但对于既往有剖宫产或腹部吸脂手术史的患者来说袁腹部供区并不理想遥股深动脉穿支渊孕rofundaarteryperforator袁PAP冤是股后肌皮瓣的衍生袁多用于修补压疮和会阴部缺损遥Allen等[23]于2012年首次报道将PAP皮瓣用于乳房重建遥皮瓣所需的穿支常在腹股沟皱襞下5cm左右尧距后中线3.8cm左右的位置恒定出现遥

同腹部皮瓣相比袁PAP皮瓣的组织量相对较小袁可较好地满足部分乳房切除术后创面修复的需求袁但难以满足乳房较大患者的重建需求遥后期使用脂肪度上弥补这一缺点[24-26]遥此外袁亦有多个移报植道等尝方法试通过可在皮一瓣定设程

计来改良PAP皮瓣袁以期获得更大的组织量袁包括联合使用部分股薄肌肌皮瓣的反L型皮瓣和三叶型皮瓣等[27-29]遥

4胸背动脉穿支皮瓣

胸背动脉穿支皮瓣渊栽horacodorsalarteryperforator袁TAP冤是背阔肌肌皮瓣衍生而来的遥TAP的穿支可来源于胸背动脉的降支或水平支袁其中最大的穿支多源自胸背动脉降支遥该穿支常平行于背阔肌前缘袁并在其内侧2cm左右走行袁通常有2~3支穿支伴行袁其中近端穿支常为其最大的穿支袁可于腋皱襞下方术后的修皮复瓣8cm[30-31]不择[32]遥但也有单用遥带处在肌肉找到遥

TAPTAP整形袁皮保组织瓣乳进术量行中较全袁小乳TAP袁常再造皮用的瓣于部报是告修分[33-34]复乳的理房切遥更想除

多选于TAP皮瓣的使用是将其联合假体或脱细胞真皮基质使用关TAP瓣使皮用瓣同遥袁从而背避免阔肌肌了显皮微瓣外科相似操作袁因其袁可在位置一邻近定程袁可度做上带缩蒂短皮

手术时间并减少并发症遥对于使用假体行即刻乳房再造的患者来说袁螺旋桨TAP皮瓣可提供良好的组织覆盖袁减少了后期包膜挛缩和放疗所致的假体暴露的发生率[35-36]是袁在切取皮瓣时袁皮瓣尖端部分可能由于跨越遥值了得猿注个意血管的体区而出现供血不良的情况袁适当的剪裁能减少后期皮瓣部分坏死的发生遥与腹部皮瓣患者的术后满意度比较袁TAP皮瓣的术后满意度相对较低袁术后存在乳房皮肤差异[37]遥

5肋间动脉穿支皮瓣

肋间动脉穿支渊陨ntercostalsarteryperforator袁ICAP冤均来自肋间后动脉袁肋间后动脉被分为椎骨段尧肋骨沟段尧肌内段和腹直肌段4段遥

自肋间后动脉椎骨段穿出的为肋间动脉背侧穿支sal渊阅or鄄

口径intercostals较大袁可用作artery游离perforator皮瓣袁当flap被用作袁DICAP带蒂冤袁穿DICAP支皮瓣皮时瓣袁动较脉短的蒂长度限制了其在躯体修复中的应用遥自肋间后动脉肋骨沟段穿出的为肋间动脉外侧穿支perforator轻易用于袁周LICAP边区冤袁域LICAP的重建皮[38]瓣的应用较渊蕴ateral多袁intercostals可旋转180artery毅袁能

易袁手术时间较短[39]侧穿支渊粤nteriorintercostals遥自肋间动袁此外袁皮瓣蒂部的分离较为容artery脉肌内perforator段穿出袁的AICAP为肋间动冤袁AICAP脉前多发于第5~6肋间袁常位于胸骨旁1~3cm遥Carrasco-L佼pez等[40]利用AICAP皮瓣进行部分乳房切除后的即刻再造袁结果显示袁患者术前术后的BREAST-Q评分基本持平袁证明AICAP皮瓣在部分乳房再造中具有较好的应用前景遥同TAP皮瓣类似袁AICAP皮瓣可在不改变乳房下皱襞位置的情况下使胸腹皮瓣完全插入乳房内袁是整形保乳术中的良好选择[41-42]前袁对ICAP皮瓣的应用多集中于4~8肋间的穿支袁这一遥区目域的穿支在获取较长的蒂的时候不可避免地会对肋下部分进行分离袁带来潜在的气胸危险遥Iida等[43]阐述了下肋部穿支的解剖袁提示了基于下肋部穿支的带蒂ICAP皮瓣和游离ICAP皮瓣在侧胸尧背部及腹股沟区的应用遥

组织工程与重建外科杂志圆园19年4月第15卷第2期

6臀上动脉穿支皮瓣及臀下动脉穿支皮瓣

臀上动脉穿支渊杂uperiorglutealarteryperforator袁SGAP冤皮瓣及臀下动脉穿支渊陨nferiorglutealarteryperforator袁IGAP冤具有相似的优点袁两者在腹部供区不理想的时候袁都可以提供大量组织用于乳房重建遥臀上动脉起源于髂内动脉袁其主干经梨状肌上缘穿臀中肌走行于臀大肌内袁沿途发出肌皮穿支支配相应区域的皮肤袁SGAP皮瓣的穿支主要位于大转子和髂后上棘连线的中1/3遥臀下动脉也起源于髂内动脉袁经梨状肌下孔穿臀中肌行于臀大肌内侧袁沿途发出的穿支支配相应区域的皮肤及皮下组织袁穿支多分布于臀大肌的中外下部率尧血SGAP清肿及皮血瓣同肿发DIEP遥

生率皮等瓣方相比面无袁明在皮显区别瓣[44]部遥分SGAP或全部皮坏死

临的无法避免的问题是术后双侧臀部的不对称遥与其类似瓣面

IGAP皮瓣术后臀下皱襞不对称也很难避免袁臀部脂肪填充袁及局部小皮瓣移植可在一定程度上缓解这种不对称[45-46]遥

7腰动脉穿支皮瓣

来自腰部的肌皮瓣和脂肪筋膜瓣一直都被用于压疮和下腰部缺损的修复遥相比于臀动脉穿支皮瓣时umbar袁不会有artery损臀perforator部外观袁手术袁LAP瘢痕能冤皮瓣被在内提供衣遮足袁腰动脉穿支渊蕴蔽够袁组织术后量乳的房同

的

触摸感较腹部皮瓣和臀部皮瓣更加接近真实的乳腺组织[47]腰动脉起源于腹主动脉降支袁在4个上腰椎体背面构成成对遥的分支袁上猿对行于竖脊肌和腰方肌之间袁最下员对行于腰方肌前遥通过CTA进行三维重建袁Bissell等[48]发现第员及第源对腰动脉的穿支决该问题皮的瓣面最主要临为措的恒施主定遥要袁另缺口外点径袁虽是皮及蒂然该瓣长皮蒂度最为理想LAP遥

瓣对供较短袁血管区外移观植影响是解

不大袁但部分病例需施行对侧后腰部位的吸脂手术袁以获得双侧的对称[49]遥

83D技术与皮瓣塑形

术前对乳房组织量和外形的评估袁能辅助术中对皮瓣的塑形袁使术后具有更好的美学效果及患者满意度遥CTA的应用能准确预估重建乳房所需的组织量袁从而使术前设计更加准确[50-51]模型的使遥用3D成技为术可能能更为[52-53]遥直目观地进行设计尧塑形袁也使得术中

门槛也越来越低袁Lacher等[54]前提袁出3D了模使型用构普建通所RGB-D需要的设照备相机进行三维重建的方法遥

穿支皮瓣乳房再造有着假体乳房再造无法替代的长期且稳定的美学效果遥随着影像学的发展袁以及对局部解剖理解的深入袁穿支皮瓣极大地减少了对供区的不必要的损伤遥同时袁手术机器人尧3D技术与VR技术等在显微外科领域的应用袁有望进一步降低手术创伤袁不断提高手术精细度袁从而使得皮瓣塑形的准确度不断提升袁获得更好的乳房重塑效果遥

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