Temple Claire L F, Strom Eric A, Youssef Adel, Langstein Howard N
Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030-4009, USA.
Plast Reconstr Surg. 2005 Jan;115(1):105-13.
This study compared the use of the internal mammary and thoracodorsal recipient vessels in a uniform group of patients who underwent delayed TRAM flap reconstruction after radiotherapy, focusing on usability rates and outcomes. The authors identified 123 delayed TRAM flap patients who had undergone postmastectomy radiotherapy from a prospective database (1990 to 2001). Recipient vessel unusability rates were calculated on the basis of reports of inspection of a vessel, either by direct intraoperative dissection or by findings from color Doppler examination (internal mammary vessels only). Charts were reviewed for outcomes including flap loss, vascular complications, fat necrosis, and lymphedema; t-test and chi-square analyses were performed to compare outcomes and unusability rates, and multiple regression analysis was performed to determine factors influencing outcome. Of the 123 planned free TRAM flaps, 106 were completed as free flaps and 17 were performed as pedicled flaps because of unusable recipient vessels. Of the free flaps, 45 were anastomosed to the internal mammary vessels, 55 to the thoracodorsal vessels, and six to other vessels. The internal mammary and thoracodorsal groups did not differ significantly in body mass index, abdominal scars, smoking history, time delay between irradiation and TRAM flap reconstruction, or flap ischemia time. Radiation doses to the axilla (thoracodorsal), internal mammary chain, and supraclavicular fossa were similar between the groups. The internal mammary vessels were rejected in 11 (20 percent) of 56 cases, and the thoracodorsal vessels were rejected in 19 (26 percent) of 74 cases (p = 0.42). In cases with unusable internal mammary vessels, 46 percent (n = 5) had inadequate veins, 27 percent (n = 3) had inadequate arteries, and in 27 percent (n = 3) both vessels were inadequate. In the 19 cases with unusable thoracodorsal vessels, 84 percent (n = 16) were excessively scarred, 11 percent (n = 2) had inadequate vessels, and 5 percent (n = 1) were absent. Outcomes were similar regardless of recipient vessels used (internal mammary versus thoracodorsal): total flap loss, 0 percent versus 4 percent (p = 0.20); vascular complications, 6.7 percent versus 11 percent (p = 0.46); arm lymphedema, 4.4 percent versus 9 percent (p = 0.37); partial flap loss, 9 percent versus 6 percent (p = 0.54); and fat necrosis, 18 percent versus 15 percent (p = 0.69). Multivariate analysis revealed a trend for higher complication rates in smokers and with the use of the thoracodorsal vessels as the recipients. Overall, no discernible unusability or outcome differences were detected between the internal mammary and thoracodorsal groups.
本研究比较了在一组接受放疗后延迟进行横行腹直肌肌皮瓣（TRAM瓣）重建的患者中，胸廓内血管和胸背血管作为受区血管的使用情况，重点关注其可用率和手术效果。作者从一个前瞻性数据库（1990年至2001年）中识别出123例接受乳房切除术后放疗的延迟TRAM瓣患者。根据术中直接解剖或彩色多普勒检查（仅针对胸廓内血管）对血管的检查报告计算受区血管不可用率。查阅病历以了解包括皮瓣坏死、血管并发症、脂肪坏死和淋巴水肿等手术效果；进行t检验和卡方分析以比较手术效果和不可用率，并进行多元回归分析以确定影响手术效果的因素。在123例计划进行的游离TRAM瓣手术中，106例成功完成游离皮瓣手术，17例因受区血管不可用而改为带蒂皮瓣手术。在游离皮瓣手术中，45例与胸廓内血管吻合，55例与胸背血管吻合，6例与其他血管吻合。胸廓内血管组和胸背血管组在体重指数、腹部瘢痕、吸烟史放疗与TRAM瓣重建之间的时间间隔或皮瓣缺血时间方面无显著差异。两组腋窝（胸背）、胸廓内动脉链和锁骨上窝的放疗剂量相似。56例中有11例（20%）胸廓内血管不可用，74例中有19例（26%）胸背血管不可用（p = 0.42）。在胸廓内血管不可用的病例中，46%（n = 5）静脉不足，27%（n = 3）动脉不足，27%（n = 3）动静脉均不足。在19例胸背血管不可用的病例中，84%（n = 16）瘢痕过多，11%（n = 2）血管不足，5%（n = 1）血管缺如。无论使用何种受区血管（胸廓内血管与胸背血管），手术效果相似：皮瓣完全坏死率分别为0%和4%（p = 0.20）；血管并发症发生率分别为6.7%和11%（p = 0.46）；上肢淋巴水肿发生率分别为4.4%和9%（p = 0.37）；部分皮瓣坏死率分别为9%和6%（p = 0.54）；脂肪坏死率分别为18%和15%（p = 0.69）。多因素分析显示，吸烟者以及使用胸背血管作为受区血管时并发症发生率有升高趋势。总体而言，胸廓内血管组和胸背血管组在可察觉的不可用率或手术效果方面无差异。
