组织工程与重建外科杂志

组织工程与重建外科杂志 ›› 2025, Vol. 21 ›› Issue (2): 113-.

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制备保留外侧腹直肌的带蒂横行腹直肌皮瓣的策略和技术要点

  

  • 出版日期:2025-04-01 发布日期:2025-05-13

The strategy and technical points of harvesting outer muscle-sparing pedicled transverse rectus abdominis musculocutaneous flaps

  • Online:2025-04-01 Published:2025-05-13

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摘要：

目的　探讨提高保留外侧腹直肌的带蒂横行腹直肌皮瓣（ms-TRAM）血运安全性的策略和技术要点。

方法　 2020年6月至2023年3月对47例女性乳腺癌患者采用不同形式的ms-TRAM皮瓣完成单侧自体乳房再造，包括31例即 刻乳房再造、3 例即刻-延期乳房再造和 13 例延期乳房再造。皮瓣具体形式包括 3 种，单侧保留外侧腹直肌的 msTRAM皮瓣联合传统带蒂腹直肌皮瓣移植（16侧），单侧保留外侧腹直肌的ms-TRAM皮瓣联合传统游离腹直肌皮瓣移 植（14侧），双侧保留外侧腹直肌的ms-TRAM皮瓣联合移植（17侧）。术中以荧光造影评估皮瓣血运不佳时额外吻合保 留外侧腹直肌的 ms-TRAM 皮瓣携带的腹壁下血管蒂。结果　24侧保留外侧腹直肌的 ms-TRAM 皮瓣血运不良，其中 21 例额外吻合保留外侧腹直肌的 ms-TRAM 皮瓣携带的腹壁下血管蒂后，所有皮瓣全部顺利成活，未见明显并发症。 另外3例未作特殊处理，其中2例部分坏死，切除坏死部分并保守换药后愈合，另外1例以带蒂背阔肌皮瓣补救。随访 12~36个月，平均 23.9个月，再造乳房外形可，质地满意，基本对称；皮瓣供区及乳房受区仅遗留线性瘢痕，腹壁功能无 明显影响。

结论　保留外侧腹直肌的ms-TRAM皮瓣受限于解剖缺陷，血运不稳定，额外吻合腹壁下血管蒂为皮瓣增压 可以确保血运安全。

关键词: 乳腺癌, 　腹直肌肌皮瓣, 　乳房再造

Abstract: Objective　To explore the strategy and technical points of harvesting outer muscle-sparing pedicled transverse rectus abdominis musculocutaneous （ms-TRAM） flaps to improve the blood safety. Methods　 From June 2020 to March 2023， 47 female patients with breast cancer were treated with different forms of ms-TRAM flaps to complete unilateral autologous breast reconstruction. Specifically， there were 31 cases of immediate breast reconstruction， 3 cases of immediate delayed breast reconstruction， and 13 cases of delayed breast reconstruction. There are three specific forms of skin flaps included： unilateral outer ms-TRAM flaps combined with traditional pedicled rectus abdominis musculocutaneous flaps （16 sides）， unilateral ms-TRAM flaps combined with free rectus abdominis musculocutaneous flaps transplantation （14 cases），and bilateral outer ms-TRAM flaps （17 cases）. Intraoperative fluorescence contrast was used to assess the inferior vascular pedicle carried by ms-TRAM flaps preserving the lateral rectus abdominis muscle when the flap was poorly vascularized. Results　 A total of 24 patients with lateral rectus abdominis muscle preserved had malvascularity， and 21 of them had additional anastomosis of subabdominal vascular pedicle carried by ms-TRAM flaps retaining lateral rectus abdominis muscle， preserving all the flaps successfully survived without obvious complications. The other 3 cases were not treated with special treatments， including 2 cases of partial necrosis， which healed after resection of the necrotic part and conservative dressing change， and 1 case was remedied with pedicle latissimus dorsi flap. After 12-36 months of follow-up， with an average of 23.9 months， the shape of the reconstructed breast was acceptable， the texture was satisfactory， and the basic symmetry was presented. Only linear scars were left in the donor area and the breast recipient area， and the abdominal wall function was not significantly affected. Conclusion　ms-TRAM with preservation of the lateral rectus abdominis muscle is limited by anatomical defects and unstable vascularization， and additional anastomosis of the subabdominal vascular pedicle pressurizes the flap to ensure safe vascularization.

Key words: Breast cancer, 　Rectus abdominis musculocutaneous flap, 　Breast reconstruction