Houston, Texas From the Department of Plastic Surgery, Baylor College of Medicine.
Plast Reconstr Surg. 2011 Nov;128(5):1039-1042. doi: 10.1097/PRS.0b013e31822b666b.
As techniques for breast reconstruction with autologous abdominal tissue have evolved, free transverse rectus abdominis myocutaneous flaps have persevered because of their superior reliability and minimal donor-site morbidity compared with muscle-sparing techniques. Further refinements are described in this article to maximize abdominal flap perfusion and ensure primary closure of the rectus fascia. It has been well documented that incorporating both the lateral and medial perforators provides maximal perfusion to all zones of the lower abdominal transverse skin flap. However, dissection and harvest of both sets of perforators requires disruption and/or sacrifice of abdominal wall tissues. The technique presented here was designed to use both the lateral and medial row perforators, and to minimize abdominal wall disruption. Deep inferior epigastric artery medial and lateral row perforators are selected for their diameter, proximity, and transverse orientation to each other. A transverse ellipse of fascia is incised to incorporate both perforators. The fascial incision is then extended inferiorly in a T configuration to allow for adequate exposure and harvest of the vascular pedicle and/or rectus abdominis, and primary closure. Limiting perforator selection to one row of inferior epigastric arteries diminishes perfusion to the abdominal flap. Furthermore, perforator and inferior epigastric artery dissection often results in fascial defects that are not amenable to primary closure. However, maximal abdominal flap perfusion and minimal donor-site morbidity can be achieved with the transverse dual-perforator fascia-sparing free transverse rectus abdominis myocutaneous flap technique and can be performed in most patients.
随着自体腹部组织进行乳房重建技术的发展，游离横形腹直肌肌皮瓣因其与保留肌肉技术相比具有更高的可靠性和更少的供区并发症，而得以保留。本文进一步详细介绍了一些技术，以最大限度地增加腹部皮瓣的灌注，并确保腹直肌筋膜的一期闭合。已经有充分的文献记载，包含外侧和内侧穿支可以为下腹部横形皮瓣的所有区域提供最大的灌注。然而，外侧和内侧穿支的解剖和采集需要破坏和/或牺牲腹壁组织。这里提出的技术旨在使用外侧和内侧穿支，并最大限度地减少腹壁的破坏。选择腹壁下动脉的内侧和外侧穿支是因为它们的直径、接近度和彼此的横向方向。横形切开筋膜以包含两个穿支。然后，筋膜切口向下呈 T 形扩展，以提供足够的暴露和血管蒂和/或腹直肌的采集，并进行一期闭合。将穿支选择限制在一条腹壁下动脉会减少腹部皮瓣的灌注。此外，穿支和腹壁下动脉的解剖通常会导致筋膜缺损，无法进行一期闭合。然而，通过横形双穿支筋膜保留游离横形腹直肌肌皮瓣技术可以实现最大的腹部皮瓣灌注和最小的供区并发症，并且可以在大多数患者中进行。
