Mosahebi Afshin, Da Lio Andrew, Mehrara Babak J
Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
Ann Plast Surg. 2008 Jul;61(1):30-4. doi: 10.1097/SAP.0b013e318151f9fa.
Internal mammary vessels are commonly used in microvascular breast reconstruction. Most surgeons resect a portion of the rib to expose these vessels. This resection can lead to contour abnormalities in the chest wall that are difficult to correct. In addition, exposure of these vessels deep in the wound can be problematic. The purpose of this study was to evaluate our experience with a pectoralis major flap designed to improve exposure and fill in the defect created by rib resection. All consecutive patients who underwent autologous breast reconstruction using the internal mammary vessels as recipient vessels between 2000 and 2005 were identified. All procedures were performed by a single surgeon. In each case, a superiorly based flap within the pectoralis major muscle spanning the bottom of the second rib to the top of the fourth costal cartilage was raised. This "L"-shaped flap was reflected and a portion of the third rib cartilage was excised. At the conclusion of the microsurgical anastomosis the pectoralis major flap was repaired and used to cover the defect created by rib resection. Patient demographic, operative details, and postoperative complications were obtained from a prospectively maintained clinical database. Deformity around sternal border was evaluated from the patients' photographs. There were 99 autologous reconstructions in 90 patients. In 71 cases the internal mammary artery/vein were used as recipient vessels. There were no cases of microvascular thrombosis or flap loss. A portion of the third rib was excised in all patients who underwent microsurgical anastomoses to the internal mammary vessels. In 3 patients a portion of both the second and third ribs was removed because of branching of the internal mammary vein proximal to the level of the third rib. A contour deformity was noted in 4 patients (4.4%) after a mean follow-up of 27 months. Of the 4 patients with contour deformity, 2 had a portion of both the third and second costal cartilage removed because of venous branching above the level of the third rib cartilage. The modified pectoralis major L-shaped flap is a useful technique for safe and clear exposure of the internal mammary vessels. In addition, the use of this flap to cover the segment of resected rib cartilage can decrease the contour deformities associated with rib resection as compared with reported rates in the literature. Resection of multiple rib segments, though unavoidable at times because of anatomic considerations, may be associated with an increased rate of postoperative contour deformities.
胸廓内血管常用于微血管乳房重建。大多数外科医生会切除一部分肋骨以暴露这些血管。这种切除可能导致胸壁轮廓异常，难以矫正。此外，在伤口深处暴露这些血管可能会有问题。本研究的目的是评估我们使用胸大肌皮瓣的经验，该皮瓣旨在改善暴露并填补肋骨切除造成的缺损。确定了2000年至2005年间所有连续接受以胸廓内血管为受区血管的自体乳房重建的患者。所有手术均由一名外科医生进行。在每例手术中，掀起一块位于胸大肌内、以第二肋底部至第四肋软骨顶部为跨度的上蒂皮瓣。将这个“L”形皮瓣翻转，切除一部分第三肋软骨。在显微外科吻合结束时，修复胸大肌皮瓣并用于覆盖肋骨切除造成的缺损。从前瞻性维护的临床数据库中获取患者人口统计学资料、手术细节和术后并发症。从患者照片评估胸骨边缘周围的畸形情况。90例患者中有99例自体乳房重建。71例中胸廓内动脉/静脉用作受区血管。没有微血管血栓形成或皮瓣丢失的病例。所有接受与胸廓内血管显微外科吻合的患者均切除了一部分第三肋。3例患者因胸廓内静脉在第三肋水平近端分支而切除了第二和第三肋的一部分。平均随访27个月后，4例患者（4.4%）出现轮廓畸形。在4例有轮廓畸形的患者中，2例因第三肋软骨水平以上静脉分支而切除了第三和第二肋软骨的一部分。改良的胸大肌“L”形皮瓣是一种安全、清晰暴露胸廓内血管的有用技术。此外，与文献报道的发生率相比，使用该皮瓣覆盖切除的肋软骨段可减少与肋骨切除相关的轮廓畸形。尽管有时由于解剖学考虑不可避免地要切除多个肋骨段，但这可能与术后轮廓畸形发生率增加有关。
