Patel A J K, Kulkarni M, O'Broin E S
Department of Plastic and Reconstructive Surgery, Addenbrooke's Hospital (Cambridge University Hospitals NHS Trust), Cambridge, UK.
J Plast Reconstr Aesthet Surg. 2009 Sep;62(9):1135-9. doi: 10.1016/j.bjps.2008.03.015. Epub 2008 Jun 30.
Autologous breast reconstruction following mastectomy is commonly achieved using the free Transverse Rectus Abdominis Myocutaneous (TRAM) flap. Since its first description, refinements and modifications have resulted in improved operative techniques and more aesthetically pleasing reconstructions. Pre-operative flap design, however, is a relatively new concept that has not received much attention in the literature. Patients who undergo breast reconstruction may have large, ptotic contralateral breasts. In these patients there is a tendency to raise a large abdominal flap in an attempt to achieve symmetry, or simply a larger breast. This has the potential to lead to tight closure of the abdomen and the risk of subsequent wound problems. Reconstructions that are too small or have inadequate ptosis commit the patient to contralateral breast surgery to achieve symmetry. Pre-operatively designing the flap, using a template created from the opposite breast, can help achieve a good match, often reducing the need for contralateral breast surgery. Even when contralateral breast reduction surgery is planned in advance, many of these patients still require, and prefer, a large reconstruction in order to achieve a well-proportioned result. We present a design template that addresses these particular issues and in the senior author's hands has proved to be a very effective technique. Our technique allows raising an abdominal flap of less vertical height than traditionally used (thus reducing the risk of tight abdominal closure) and incorporates an inverted V-shaped flap of skin from the inferior mastectomy skin flap into the reconstruction. This allows more flap tissue to be available to fill the upper poles of the reconstructed breast and at the same time produces good ptosis.
乳房切除术后的自体乳房重建通常采用游离腹直肌肌皮瓣（TRAM瓣）来完成。自首次描述以来，经过改进和改良，手术技术得到了提高，重建效果在美学上也更令人满意。然而，术前皮瓣设计是一个相对较新的概念，在文献中尚未受到太多关注。接受乳房重建的患者可能对侧乳房较大且下垂。在这些患者中，倾向于掀起较大的腹部皮瓣以试图实现对称，或者仅仅是获得更大的乳房。这有可能导致腹部闭合过紧以及后续伤口问题的风险。重建的乳房过小或下垂不足会使患者需要进行对侧乳房手术以实现对称。术前使用根据对侧乳房制作的模板来设计皮瓣，有助于实现良好的匹配，常常可减少对侧乳房手术的需求。即使预先计划了对侧乳房缩小手术，许多这类患者仍然需要并且更倾向于进行较大的重建，以获得比例协调的效果。我们提出一种设计模板，可解决这些特殊问题，并且在资深作者手中已证明是一种非常有效的技术。我们的技术允许掀起比传统方法垂直高度更小的腹部皮瓣（从而降低腹部闭合过紧的风险），并将来自乳房切除下方皮瓣的倒V形皮瓣纳入重建。这使得有更多的皮瓣组织可用于填充重建乳房的上极，同时产生良好的下垂效果。
