关键词: 局部晚期乳腺癌, 　横行腹直肌皮瓣, 　腹壁下动脉穿支皮瓣, 　胸壁重建

Abstract: Objective　To explore the strategies of pedicle rectus abdominis myocutaneous flap combined with free inferior epigastric artery perforator flap transplantation for reconstruction of huge chest wall defect after local advanced breast cancer. Methods　From August 2007 to October 2018, 89 patients with locally advanced breast cancer who underwent secondary defect reconstruction with lower abdominal flap were selected. The area of secondary soft tissue defect was 25 cm×12 cm to 31 cm×16 cm. All were repaired with pedicled rectus abdominis flap combined with free inferior epigastric artery perforator flap. The flap size was 26 cm×12 cm to 35 cm×15 cm. All of them were large soft tissue defects left after radical mastectomy. The specific forms of combined flap were divided into two types: ① Contralateral pedicled rectus abdominis flap combined with ipsilateral free deep inferior epigastric artery perforator flap; ② Ipsilateral pedicled rectus abdominis flap com bined with contralateral free deep inferior epigastric artery perforator flap. The recipient vessels of free inferior epigastric artery perforator flap included internal mammary vessels, lateral thoracic arteries and veins, thoracoacromial vessels, thoracodorsal vessels, anterior serratus branches of thoracodorsal vessels and transverse jugular arteries and veins. In cases repaired with the second flap form, intrathoracic vessels cannot be selected as recipient vessels. Results　There were 57 cases repaired with the first flap form, of which 4 cases had marginal partial necrosis on the side of the pedicled rectus abdominis flap, and 32 cases repaired with the second flap form, of which 2 cases found that the pedicled rectus abdominis flap had no blood supply at all during the harvesting process, so they were replaced by free rectus abdominis flap combined with free deep inferior epigastric artery perforator flap, and 3 cases had marginal partial necrosis on the side of the pedicled rectus abdominis flap, after debridement, local advancement flap was used for repairing. The wounds of all other patients healed by first intention. All patients completed the later treatment smoothly. The postoperative follow-up ranged from 12 to 96 months, with an average of (29.5±0.3) months, and 11 patients lost the contact. Of the 78 patients who completed the follow-up, 4 patients had local tumor recurrence (5.1%), 4 patients had brain metastasis (5.1%), 3 patients had liver metastasis (3.8%), 6 patients had pulmonry metastasis (7.7%), and the rest recovered well with good flap appearance. The functional recovery was satisfactory, and the quality of life of patients was significantly improved. Conclusion　Combined abdominal flap transplantation is safe and helpful to control locally advanced breast cancer and improve the quality of life. Among them, the vascular anastomosis choice of the first flap form is more flexible, the blood supply of the flap is more reliable, and the second flap form is more time saving. The specific selection of the two methods needs to be determined according to the actual situation of patients.

Key words: Locally advanced breast cancer, 　Transverse rectus abdominis musculocutaneous flap, 　Deep inferior epigastric artery perforator flap, 　Chest wall reconstruction