Kroll S S
Department of Plastic Surgery at The University of Texas M.D. Anderson Cancer Center, Houston 77030, USA.
Plast Reconstr Surg. 2000 Sep;106(3):576-83. doi: 10.1097/00006534-200009030-00008.
A series of 310 breasts reconstructed by a single surgeon using free transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flaps was reviewed to see if there were any differences in the incidence of fat necrosis and/or partial flap loss between the two techniques. During the study period, 279 breasts were reconstructed with free TRAM flaps and 31 breasts were reconstructed with DIEP flaps. In the breasts reconstructed with free TRAM flaps, the incidence of partial flap loss was 2.2 percent and the incidence of fat necrosis was 12.9 percent. The DIEP flaps were divided into two groups. For the first eight flaps, patients were selected using the same criteria normally used to choose patients for free TRAM flaps. In this unselected early group, the incidence of partial flap loss was 37.5 percent and the incidence of fat necrosis was 62.5 percent. Because of the high incidence of partial flap loss and fat necrosis in the first eight flaps, subsequent selection was modified to limit the use of DIEP flaps to patients who had at least one sufficiently large perforator in each flap (a palpable pulse and a vein at least 1 mm in diameter) and who did not require more than 70 percent of the flap to create a breast of adequate size. In this later (selected) group, fat necrosis (17.4 percent) and partial flap loss (8.7 percent) were reduced to a level only moderately higher than that found in the free TRAM flap group. From these data, it can be concluded that the incidence of partial flap loss and fat necrosis is higher in DIEP flaps than in free TRAM flaps, probably because the blood flow to the former flap is less robust. This difficulty can be circumvented to some extent, however, by careful patient selection. Factors that should be considered include tobacco use, size of the perforators (especially the vein), and (in unilateral reconstructions) the amount of flap tissue across the midline needed to create an adequately sized breast. If these factors are properly considered when planning the operation, fat necrosis and partial flap loss can be reduced to an acceptable level. For selected patients, the DIEP flap is an excellent technique that can obtain a successful, autologous tissue breast reconstruction with minimal donor-site morbidity. For patients who are not good candidates for reconstruction with this flap, the free TRAM flap remains a good alternative.
对由一位外科医生使用游离腹直肌肌皮瓣（TRAM）和腹壁下深动脉穿支皮瓣（DIEP）进行重建的310例乳房进行了回顾性研究，以观察这两种技术在脂肪坏死和/或部分皮瓣丢失发生率上是否存在差异。在研究期间，279例乳房采用游离TRAM皮瓣重建，31例乳房采用DIEP皮瓣重建。在采用游离TRAM皮瓣重建的乳房中，部分皮瓣丢失的发生率为2.2%，脂肪坏死的发生率为12.9%。DIEP皮瓣分为两组。对于最初的8例皮瓣，患者的选择标准与通常用于选择游离TRAM皮瓣患者的标准相同。在这个未经过筛选的早期组中，部分皮瓣丢失的发生率为37.5%，脂肪坏死的发生率为62.5%。由于最初8例皮瓣中部分皮瓣丢失和脂肪坏死的发生率较高，随后的选择标准进行了修改，将DIEP皮瓣的使用限制于每个皮瓣至少有一个足够大的穿支（可触及的脉搏和直径至少1毫米的静脉）且创建一个大小合适的乳房所需皮瓣不超过70%的患者。在这个后来的（经过筛选的）组中，脂肪坏死（17.4%）和部分皮瓣丢失（8.7%）降低到仅略高于游离TRAM皮瓣组的水平。从这些数据可以得出结论，DIEP皮瓣中部分皮瓣丢失和脂肪坏死的发生率高于游离TRAM皮瓣，可能是因为前者皮瓣的血流不够强劲。然而，通过仔细选择患者，这种困难在一定程度上可以得到规避。应考虑的因素包括吸烟情况、穿支的大小（尤其是静脉），以及（在单侧重建中）创建一个大小合适的乳房所需跨越中线皮瓣组织的量。如果在手术规划时适当考虑这些因素，脂肪坏死和部分皮瓣丢失可以降低到可接受的水平。对于经过筛选的患者来说，DIEP皮瓣是一种出色的技术，可以成功地进行自体组织乳房重建，且供区并发症最少。对于不适合用这种皮瓣进行重建的患者，游离TRAM皮瓣仍然是一个很好的选择。
