Engel Holger, Pelzer Michael, Sauerbier Michael, Germann Günther, Heitmann Christoph
Department of Hand, Plastic, and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Germany.
Microsurgery. 2007;27(5):481-6. doi: 10.1002/micr.20391.
Loco-regional flaps are the method of choice for chest wall reconstruction. However there is a selected group of patients who require free flap reconstruction, when all other options are used up. A small subgroup of these patients was identified where the commonly used recipient vessels (Internal mammary A. + V., Thoraco-dorsal A. + V.) were no longer available.
This group comprised 16 seriously ill patients in the period from 2000 to 2004. Underlying diseases were sternum osteomyelitis (10x), tumor (2x), and osteo-radionecrosis (4x). There were 10 women and 6 men with mean age 62.4 years. All patients were classified as ASA III and IV. Fourteen patients received a TFL flap, two patients a vertical rectus myocutaneous flap (VRAM). Recipient vessels were created with a temporary A-V loop between the cephalic vein and the thoraco-acromial artery (CTA-loop).
No flap was lost and two had to be revised successfully for thrombosis of the arterial anastomosis. Mean operation time was 6.1 (4.7-8.4) h. Average time for ventilatory support was 56 (4-338) h. Five patients died within 6 months postoperatively due their underlying advanced disease (n = 3) or multiple organ failure (n = 2).
The new concept of creating recipient vessels for free flap reconstruction of complex thoracic wall defects proved to be safe and reliable. The CTA loop allowed for unhurried flap dissection, best possible flap positioning, and straightforward end-end anastomoses in these seriously sick patients. The outcome with respect to complications and survival justifies the operative effort.
局部皮瓣是胸壁重建的首选方法。然而，有一部分特定患者在其他所有选择都用尽时需要进行游离皮瓣重建。在这些患者中，有一小部分患者常用的受区血管（胸廓内动静脉、胸背动静脉）已无法使用。
该组包括2000年至2004年期间的16例重症患者。基础疾病包括胸骨骨髓炎（10例）、肿瘤（2例）和放射性骨坏死（4例）。有10名女性和6名男性，平均年龄62.4岁。所有患者均被分类为ASA III级和IV级。14例患者接受了阔筋膜张肌皮瓣，2例患者接受了腹直肌肌皮瓣（VRAM）。通过在头静脉和胸肩峰动脉之间建立临时动静脉环（CTA环）来创建受区血管。
没有皮瓣丢失，2例因动脉吻合口血栓形成而成功进行了修复。平均手术时间为6.1（4.7 - 8.4）小时。通气支持的平均时间为56（4 - 338）小时。5例患者在术后6个月内死亡，原因是基础疾病晚期（3例）或多器官功能衰竭（2例）。
为复杂胸壁缺损游离皮瓣重建创建受区血管的新概念被证明是安全可靠的。CTA环使得在这些重症患者中能够从容地进行皮瓣解剖、尽可能好地进行皮瓣定位以及直接进行端端吻合。在并发症和生存方面的结果证明了手术努力的合理性。
