Chang Edward I, Chang Eric I, Soto-Miranda Miguel A, Zhang Hong, Nosrati Naveed, Crosby Melissa A, Reece Gregory P, Robb Geoffrey L, Chang David W
From the Department of Plastic and Reconstructive Surgery, MD Anderson Cancer Center, Houston, TX.
Ann Plast Surg. 2016 Jan;77(1):67-71. doi: 10.1097/SAP.0000000000000263.
Loss of a breast free flap is a relatively rare but catastrophic occurrence. Our study aims to identify risk factors for flap loss and to assess whether different salvage techniques affect flap salvage. We performed a retrospective review of all breast free flaps performed at a single institution from 2000 to 2010. Overall, 2138 flaps were performed in 1608 patients (unilateral, 1120 and bilateral, 488) with 44 flap losses (2.1%). Age, body mass index, smoking, radiation, chemotherapy, and surgeon experience did not affect flap loss. Abdominal flaps based on a single perforator were at significantly higher risk for flap loss compared with flaps based on multiple perforators (P = 0.0007). Subgroup analysis of the subset of 166 compromised free flaps (flaps requiring a return to the operating room, an intraoperative anastomotic revision, or loss/partial loss of a free flap) demonstrated deep inferior epigastric perforator, and other flaps (superficial inferior epigastric artery and superior gluteal artery perforator) were significantly associated with flap loss [odds ratio (OR) 5.20; P = 0.03 and OR 6.91; P = 0.0004, respectively] compared with transverse rectus abdominis myocutaneous and muscle-sparing transverse rectus abdominis myocutaneous flaps. Although an intraoperative complication was not associated with a flap loss, the need for a reoperation was strongly predictive (P < 0.0001). Flap salvage was the highest within the first 24 hours (83.7%) and significantly less between days 1 and 3 (38.6%; P < 0.0001) and beyond 4 days (29.4%; P < 0.0001). Longer ischemia time was significantly associated with flap loss (P = 0.04). Salvage techniques (aspirin, heparinzation, thrombectomy, and thrombolytic) had no impact on flap salvage rates. Heparinization and thrombolytics were associated with higher loss rates (OR 3.40; P = 0.003 and OR 10.36; P < 0.0001, respectively). Free flap loss following breast reconstruction is multifactorial with higher losses in superficial inferior epigastric artery and gluteal flaps, single-perforator abdominal flaps, and longer ischemia times. Salvage rates are most successful within the first 24 hours, and the use of heparinization, aspirin, and thrombolytics does not improve salvage rates.
乳房游离皮瓣坏死是一种相对罕见但后果严重的情况。我们的研究旨在确定皮瓣坏死的风险因素，并评估不同的挽救技术是否会影响皮瓣挽救成功率。我们对2000年至2010年在一家机构进行的所有乳房游离皮瓣手术进行了回顾性研究。总体而言，1608例患者（单侧1120例，双侧488例）共进行了2138例皮瓣手术，其中44例皮瓣坏死（2.1%）。年龄、体重指数、吸烟、放疗、化疗和外科医生经验均不影响皮瓣坏死情况。与基于多穿支的皮瓣相比，基于单穿支的腹部皮瓣发生皮瓣坏死的风险显著更高（P = 0.0007）。对166例出现并发症的游离皮瓣（需要返回手术室、术中吻合口修复或游离皮瓣坏死/部分坏死的皮瓣）进行亚组分析显示，与腹直肌肌皮瓣和保留肌肉的腹直肌肌皮瓣相比，腹壁下深动脉穿支皮瓣及其他皮瓣（腹壁浅动脉穿支皮瓣和臀上动脉穿支皮瓣）与皮瓣坏死显著相关[比值比（OR）分别为5.20；P = 0.03和OR 6.91；P = 0.0004]。虽然术中并发症与皮瓣坏死无关，但再次手术的需求具有很强的预测性（P < 0.0001）。皮瓣挽救成功率在最初24小时内最高（83.7%），在第1天至第3天之间显著降低（38.6%；P < 0.0001），4天后更低（29.4%；P < 0.0001）。较长的缺血时间与皮瓣坏死显著相关（P = 0.04）。挽救技术（阿司匹林、肝素化、血栓切除术和溶栓）对皮瓣挽救成功率没有影响。肝素化和溶栓与更高的坏死率相关（OR分别为3.40；P = 0.003和OR 10.36；P < 0.0001）。乳房重建后游离皮瓣坏死是多因素导致的，腹壁浅动脉和臀瓣、单穿支腹部皮瓣以及较长缺血时间的皮瓣坏死率更高。挽救成功率在最初24小时内最高，使用肝素化、阿司匹林和溶栓并不能提高挽救成功率。
