Clinical effects of lobulated supercharged pedicled rectus abdominis myocutaneous flap for repairing huge chest wall wounds
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摘要:
目的 探讨分叶外增压带蒂腹直肌肌皮瓣修复巨大胸壁创面的临床效果。 方法 该研究为回顾性观察性研究。2020年1月—2023年6月,湖南省肿瘤医院收治9例符合入选标准的行肿瘤扩大根治术或肿瘤扩大切除术或病损切除术后遗留巨大胸壁创面的患者,其中男3例、女6例,年龄31~59岁,应用分叶外增压带蒂腹直肌肌皮瓣修复巨大胸壁创面。胸壁皮肤软组织缺损面积为19 cm×15 cm~25 cm×21 cm,肌皮瓣切取面积为25.0 cm×7.5 cm~32.0 cm×13.0 cm,将腹部供区使用聚丙烯网片修补腹直肌及其前鞘缺损后,直接缝合切口。观察术中肌皮瓣血运情况、外增压受区血管选择情况,术后肌皮瓣成活情况、供区切口愈合情况。随访重建的胸壁外形和质地、腹部供区瘢痕形成情况及对功能和外观的影响,肿瘤复发、转移情况。 结果 术中7例患者单侧肌皮瓣、2例患者双侧肌皮瓣血运不佳。实施肌皮瓣外增压时选择的受区血管为胸廓内血管者7例、胸背血管者2例、胸肩峰血管者2例。术后肌皮瓣全部成活。术后7例患者供区切口顺利愈合；2例患者由于切口张力过大导致局部裂开,经清创缝合后愈合。随访8~12个月,重建胸壁外形良好、质地柔软；腹部供区仅遗留线性瘢痕,对腹式呼吸无明显影响,腹部较美观；未见肿瘤局部复发情况；2例乳腺癌患者发生远处转移。 结论 分叶外增压带蒂腹直肌肌皮瓣能有效覆盖巨大胸壁创面,同时最大限度保证肌皮瓣血运,确保胸壁重建手术的成功。 Abstract:Objective To explore the clinical effects of lobulated supercharged pedicled rectus abdominis myocutaneous flap for repairing huge chest wall wounds. Methods This study was a retrospective observational study. From January 2020 to June 2023, 9 patients with huge chest wall wounds remained after extended radical tumor resection, extended tumor resection, or lesion resection and conformed to the inclusion criteria were admitted to Hunan Cancer Hospital, including 3 males and 6 females, aged 31-59 years. The lobulated supercharged pedicled rectus abdominis myocutaneous flap was used to repair the huge chest wall wounds. The area of chest wall skin and soft tissue defects ranged from 19 cm×15 cm to 25 cm×21 cm, and the area of the harvested myocutaneous flap ranged from 25.0 cm×7.5 cm to 32.0 cm×13.0 cm. After repairing the rectus abdominis muscle and its anterior sheath with a polypropylene mesh, the incision in the donor site was directly sutured. The blood supply of the myocutaneous flap and the selection of blood vessels in recipient area for supercharging during the surgery, the survival of the myocutaneous flap and the healing of the donor area incision after the surgery were observed. The appearance and texture of the reconstructed chest wall, the scar formation in the abdominal donor area, and their impacts on function and appearance, and the tumor recurrence and metastasis were followed up. Results The blood supply of the unilateral myocutaneous flap was poor in 7 patients, and that of the bilateral myocutaneous flaps was poor in 2 patients during the surgery. The recipient area vessels selected for supercharging of the myocutaneous flap were the internal thoracic vessels in 7 patients, the thoracodorsal vessels in 2 patients, and the thoracoacromial vessels in 2 patients. All the myocutaneous flaps survived after surgery. The donor area incisions of 7 patients healed smoothly after surgery; 2 patients had partial dehiscence in the incisions due to excessive incision tension, which healed after debridement and suturing. Follow-up for 8 to 12 months showed that the reconstructed chest wall had good appearance and soft texture; only a linear scar remained in the abdominal donor area, which had no obvious impact on abdominal breathing and the abdomen was aesthetically pleasing; no local tumor recurrence was observed; distant metastases occurred in 2 breast cancer patients. Conclusions The lobulated supercharged pedicled rectus abdominis myocutaneous flap can effectively cover huge chest wall wounds, while maximally ensuring the blood supply of the myocutaneous flap to the greatest extent and safeguarding the success of chest wall reconstruction surgery. -
Key words:
- Rectus abdominis /
- Myocutaneous flap /
- Thoracic wall /
- Breast neoplasms /
- Soft tissue neoplasms /
- Wound repair /
- Flap supercharge
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张鑫山：论文撰写、手术实施；于峻懿：论文修改、文献综述、经费支持；李赞：患者管理、研究指导；宋达疆：数据收集整理、手术设计与实施、经费支持所有作者声明不存在利益冲突
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参考文献
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图 1 对血运不佳的分叶带蒂腹直肌肌皮瓣行外增压的效果。1A.术中肌皮瓣制备完成；1B.术中经静脉行荧光造影,提示一侧皮瓣血运不佳；1C.将血运不佳侧肌皮瓣携带的腹壁下血管蒂与胸廓内血管吻合,行外增压；1D.荧光造影提示肌皮瓣血运恢复
图 2 分叶带蒂腹直肌肌皮瓣的重新拼接方式。2A.术中双侧分叶带蒂腹直肌肌皮瓣制备完毕；2B.位于低位的对侧带蒂腹直肌肌皮瓣位置不变,将同侧带蒂腹直肌肌皮瓣旋转90°；2C.将位于低位的对侧带蒂腹直肌肌皮瓣和高位的同侧带蒂腹直肌肌皮瓣都分别旋转90°后重新拼接
注：图中数字1、2、3分别代表右侧分叶肌皮瓣的外侧、内上侧、内下侧,数字4、5、6分别代表左侧分叶肌皮瓣的内上侧、内下侧、外侧
图 3 分叶外增压带蒂腹直肌肌皮瓣修复患者巨大胸壁创面的效果。3A.术前见胸壁肿瘤；3B.术中切除肿瘤病灶后继发胸壁巨大缺损,采用聚丙烯网片结合钛网修复胸壁骨性组织缺损；3C.术中完成双侧带蒂腹直肌肌皮瓣制备；3D.术中将双侧带蒂腹直肌肌皮瓣直接转移至胸壁缺损区域后,可见皮瓣扭转张力较大,难以有效覆盖胸壁缺损；3E.示意图显示直接整体转移双侧带蒂腹直肌肌皮瓣无法完整修复胸壁缺损；3F.术中将双侧带蒂腹直肌肌皮瓣制备成分叶带蒂腹直肌肌皮瓣；3G.示意图显示将双侧带蒂腹直肌肌皮瓣沿正中线完全切开；3H.示意图显示将分叶带蒂腹直肌肌皮瓣重新拼接；3I.术中将双侧分叶肌皮瓣重新拼接以完整修复缺损,对左侧肌皮瓣行外增压；3J.示意图显示分叶肌皮瓣拼接方式；3K.术中胸壁重建后正面观；3L.随访12个月,重建的胸壁外形较佳
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