组合组织瓣移植修复巨大胸壁缺损的临床效果

于峻懿; 宋达疆; 刘旭; 王志远; 李赞; 章一新; 周波; 吕春柳; 唐园园; 易亮; 罗振华; 杨丽仪

doi:10.3760/cma.j.cn501225-20231120-00199

组合组织瓣移植修复巨大胸壁缺损的临床效果

doi: 10.3760/cma.j.cn501225-20231120-00199

1.
湖南省肿瘤医院乳腺肿瘤整形外科,长沙　　410008
2.
湖南省肿瘤医院超声诊断中心,长沙　　410008
3.
上海交通大学医学院附属第九人民医院整复外科,上海　　200011
4.
江阴市人民医院乳腺甲状腺外科,江阴　　214400

基金项目:

湖南省卫生健康委员会科研项目 202209024847

湖南省自然科学基金科卫联合项目 2023JJ60334

详细信息

通讯作者:
宋达疆,Email：sdj41@163.com

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出版历程
- 收稿日期: 2023-11-20

Clinical effects of combined tissue flap transplantation for repairinggiant chest wall defects

1.
Department of Breast Oncoplastic Surgery, Hunan Cancer Hospital, Changsha 410008, China
2.
Ultrasonic Diagnostic Center, Hunan Cancer Hospital, Changsha 410008, China
3.
Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
4.
Department of Breast and Thyroid Surgery, Jiangyin People's Hospital, Jiangyin 214400, China

Funds:

Scientific Research Project of Health Commission of Hunan Province 202209024847

Science and Health Planning Project of Hunan Provincial Natural Science Foundation 2023JJ60334

More Information

Corresponding author: Song Dajiang, Email: sdj41@163.com

摘要

摘要: 目的探讨组合组织瓣移植修复巨大胸壁缺损的临床效果。方法该研究为回顾性观察性研究。2013年8月—2020年12月,湖南省肿瘤医院乳腺肿瘤整形外科收治31例符合入选标准的胸壁肿瘤或胸壁肿瘤根治术后放射性溃疡患者,其中男12例、女19例,年龄25~71岁。行肿瘤/溃疡切除、创面清创后,继发胸壁缺损面积为300~600 cm²（长16~35 cm、宽16~32 cm）。按照患者的实际情况及术前设计,灵活采用不同供区穿支皮瓣、肌皮瓣组合修复胸壁缺损,组合组织瓣面积260~540 cm²（长20~30 cm、宽13~20 cm）,其中2例患者采用游离大腿后内侧穿支皮瓣+游离股前外侧肌皮瓣,5例患者采用游离腹壁下动脉穿支皮瓣+游离股前外侧肌皮瓣,7例患者采用游离腹壁下动脉穿支皮瓣+带蒂腹直肌肌皮瓣+游离股前外侧肌皮瓣,2例患者采用游离腹壁下动脉穿支皮瓣+带蒂腹直肌肌皮瓣+带蒂背阔肌肌皮瓣,15例患者采用双侧游离股前外侧肌皮瓣。对于组合组织瓣修复后剩余的小面积浅表组织缺损,采用皮片移植修复或于组织瓣成活、组织水肿消退后行延期局部皮瓣转移修复,选择合适的供受区血管进行吻合以重建组织瓣血运。将能直接缝合的组织瓣供区创面直接缝合,不能直接缝合者行皮片移植或延期缝合。记录受区血管吻合情况、手术耗时、术后住院天数。术后观察组织瓣、皮片成活情况,重建的胸壁外形和质地,组织瓣供区创面愈合情况、瘢痕形成情况、功能情况,供皮区瘢痕形成情况。术后随访肿瘤复发情况及复发患者死亡情况。结果受区吻合血管如下：胸廓内血管近心端24次、远心端12次,胸背血管主干4次,胸背血管前锯肌支8次,胸肩峰血管12次。手术耗时为6.0~8.5 h,术后住院天数为9~21 d。4例患者术后部分组织瓣边缘坏死,均采用换药处理后愈合；其余患者组织瓣及移植皮片均完全成活。重建的胸壁外形、质地良好。4例患者腹部组织瓣供区创面愈合不良,经换药和局部引流后愈合；所有组织瓣供区均仅遗留线性瘢痕,组织瓣供区均无明显功能障碍；供皮区轻度瘢痕增生。术后随访9~36个月,6例患者肿瘤复发,复发时间为术后5~20个月；对肿瘤复发患者行综合治疗后,其中3例患者死亡。结论组合组织瓣移植修复巨大胸壁缺损的总手术时长和住院时长缩短,避免多次手术,术后患者胸壁外形良好,胸壁肿瘤患者肿瘤复发减少。
- 穿支皮瓣 /
- 肌皮瓣 /
- 胸壁 /
- 肿瘤 /
- 创面修复
Abstract: Objective To investigate the clinical effects of combined tissue flap transplantation in repairing giant chest wall defects. Methods This study was a retrospective observational study. From August 2013 to December 2020, 31 patients with chest wall tumor or radiation ulcer after radical resection of chest wall tumor and conformed to the inclusion criteria were admitted to the Department of Breast Oncoplastic Surgery of Hunan Cancer Hospital, including 12 males and 19 females, aged 25-71 years. After resection of tumor or ulcer and wound debridement, the area of secondary chest wall defect was 300-600 cm² with length of 16-35 cm and width of 16-32 cm. According to the actual situation of the patients and the preoperative design, the chest wall defects were repaired with the flexible combination of perforator flaps and myocutaneous flaps from different donor sites, and the area of the combined tissue flap was 260-540 cm² with length of 20-30 cm and width of 13-20 cm. Free posteromedial thigh perforator flap+free anterolateral thigh myocutaneous flap were used in 2 patients, free deep inferior epigastric artery perforator flap+free anterolateral thigh myocutaneous flap were used in 5 patients, free deep inferior epigastric artery perforator flap+pedicled rectus abdominis myocutaneous flap+free anterolateral thigh myocutaneous flap were used in 7 patients, free deep inferior epigastric artery perforator flap+pedicled rectus abdominis myocutaneous flap+pedicled latissimus dorsi myocutaneous flap were used in 2 patients, and bilateral free anterolateral thigh myocutaneous flaps were used in 15 patients. For the remaining small area of superficial tissue defect after being repaired by combined tissue flaps, skin graft was used to repair or delayed local flap transfering was performed after the tissue flaps survived and edema subsided. The appropriate blood vessels in the donor and recipient sites were selected for anastomosis to reconstruct the blood supply of tissue flaps. The wounds in the donor sites of tissue flaps that can be directly sutured were sutured directly; for those that cannot be sutured directly, the skin grafting or delayed suture was performed. The anastomosis of blood vessels in the recipient sites, operation length, and postoperative hospital stay were recorded. The survivals of tissue flaps and skin grafts, the shape and texture of reconstructed chest wall, the wound healing, scar formation, and function of donor sites of tissue flaps, and the scar formation of the donor sites of skin grafts were observed after operation. Tumor recurrence and death of recurrent patients were followed up after operation. Results The blood vessels in the recipient sites were anastomosed as follows: proximal internal thoracic vessels for 24 times, distal internal thoracic vessels for 12 times, trunk of thoracodorsal vessels for 4 times, anterior serratus branches of thoracodorsal vessels for 8 times, and thoracoacromial vessels for 12 times. The operation length was 6.0 to 8.5 hours, and the postoperative hospital stay was 9 to 21 days. Necrosis at the edge of partial tissue flaps occurred in 4 patients after operation, which healed after dressing change, and the tissue flaps and skin grafts of the other patients survived completely. The shape and texture of the reconstructed chest wall were good. Four patients had poor wound healing in the donor sites of abdominal tissue flaps, which healed after dressing change and local drainage. Only linear scar was left in the donor sites of all tissue flaps, and there was no obvious dysfunction in the donor sites of tissue flaps. Mild hypertrophic scar was left in the donor sites of skin grafts. During follow-up of 9 to 36 months after operation, 6 patients had tumor recurrence, and the recurrence time was 5 to 20 months after operation. After comprehensive treatment for patients with tumor recurrence, 3 patients died. Conclusions Transplantation of combined tissue flaps in repairing the giant chest wall defects can shorten the time of total operation and hospital stay, and avoid multiple operations. After operation, patients had good chest wall appearance, with reduced tumor recurrence in patients with chest wall tumor.
- Perforator flap /
- Myocutaneous flap /
- Thoracic wall /
- Neoplasms /
- Wound repair
于峻懿：论文撰写、修改与校对；宋达疆：手术操作,论文撰写；刘旭、王志远：文献查询；李赞、章一新：研究设计与指导；周波、吕春柳、唐园园、易亮、罗振华、杨丽仪：数据整理与管理

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参考文献(30)

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图 1 游离大腿后内侧穿支皮瓣+游离股前外侧肌皮瓣移植修复1例患者胸壁巨大肿瘤切除术后的缺损。1A.胸壁巨大肿瘤切除前；1B.术中游离大腿后内侧穿支皮瓣和游离股前外侧肌皮瓣的设计；1C.术中完成大腿后内侧穿支皮瓣切取后；1D.术中完成股前外侧肌皮瓣切取后；1E.术中组合移植游离大腿后内侧穿支皮瓣修复胸壁缺损内侧示意图,股深动脉直接穿支血管蒂与胸廓内血管近心端吻合；1F.术中游离股前外侧肌皮瓣修复外侧胸壁缺损,其携带的旋股外侧动脉降支血管蒂与胸肩峰血管吻合；1G.术中组织瓣组合修复胸壁缺损后；1H.术中穿支皮瓣和肌皮瓣供区创面直接缝合后

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图 2 游离腹壁下动脉穿支皮瓣+带蒂腹直肌肌皮瓣+游离股前外侧肌皮瓣移植修复1例患者胸壁巨大肿瘤切除术后的缺损。2A.胸壁巨大肿瘤切除前；2B.术中胸壁巨大肿瘤切除后；2C.术中完成游离腹壁下动脉穿支皮瓣及带蒂腹直肌肌皮瓣的切取转移和血管吻合后；2D.术中采用游离腹壁下动脉穿支皮瓣+带蒂腹直肌肌皮瓣修复后,遗留外侧胸壁巨大缺损；2E.术中完成右侧股前外侧肌皮瓣切取；2F.术中完成胸壁缺损修复后；2G.术后7 d,组织瓣外观良好,无明显肿胀；2H.延期手术转移局部皮瓣完成残余创面修复后

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图 3 游离腹壁下动脉穿支皮瓣+带蒂腹直肌肌皮瓣+带蒂背阔肌肌皮瓣移植修复典型病例胸壁溃疡切除后的缺损。3A.术前见右侧胸壁大面积皮肤感染、破溃伴溃疡、窦道形成；3B.术中完成胸壁病灶扩大根治性切除术后遗留巨大胸壁全层缺损,制备游离腹壁下动脉穿支皮瓣+带蒂腹直肌肌皮瓣；3C.术中完成骨水泥填充和钛网植入,制备带蒂背阔肌肌皮瓣；3D.游离腹壁下动脉穿支皮瓣+带蒂腹直肌肌皮瓣转移后；3E.组织瓣转移及血管吻合示意图,游离右侧腹壁下动脉穿支皮瓣血管蒂与胸背血管前锯肌支吻合；3F.胸壁重建及腹部供区创面缝合后；3G.术后10 d出院时情况,所有组织瓣完全成活,胸壁外形和质地良好；3H.术后12个月随访,胸壁外形良好,腹部供区瘢痕增生不明显

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