Chang Chang-Cheng, Huang Jung-Ju, Wu Chih-Wei, Craft Randall O, Liem Anita A May-Ling, Shen Jen-Hsiang, Cheng Ming-Huei
From the *Division of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chia Yi; †Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital; ‡College of Medicine, Chang Gung University, Taoyuan, Taiwan, Republic of China; and §Plastic and Reconstructive Surgery, Banner MD Anderson Cancer Center, Gilbert, AZ.
Ann Plast Surg. 2014 Sep;73 Suppl 1:S6-11. doi: 10.1097/SAP.0000000000000244.
Deep inferior epigastric perforator (DIEP) flaps have become broadly accepted for autologous breast reconstruction. Our aim was to analyze outcomes and describe technical strategies to improve survival when harvesting the entire DIEP flap with a midline scar.
We retrospectively reviewed charts from March of 2000 to November of 2007; 186 DIEP flaps in 183 patients were used for breast reconstruction, including 18 flaps (9.68%) in 17 patients with previous lower midline abdomen scars. The patients were classified into 3 groups. Group 1: hemi-DIEP flaps (n=5);. group 2: DIEP flaps that included tissue crossing the midline (n=10); and group 3: entire-DIEP flaps (with zone IV) (n=3).
Reexploration for venous congestion and partial flap loss were encountered in 1 patient in group 1. Average flap-used ratio was 68.75±8.95% in group 2. Three flaps developed partial loss and underwent subsequent debridement. In group 3, entire DIEP flaps were designed with higher, bilateral superficial inferior epigastric venous drainages and intraflap pedicle-to-pedicle anastomosis. The first 2 cases underwent partial flap loss and debridement. The third case of bipedicle anastomosis achieved complete flap survival.
The hemi-DIEP flap is a safer method for the patient with a lower abdominal midline scar but limits the reconstructive volume. Carefully evaluating the perfusion across midline scar intraoperatively is crucial for deciding how much contralateral tissue should be discarded. Double pedicles anastomosis is an assurance for using entire DIEP flap with lower midline scar.
腹壁下深动脉穿支（DIEP）皮瓣已被广泛用于自体乳房重建。我们的目的是分析手术效果，并描述在采用中线瘢痕切取整块DIEP皮瓣时提高皮瓣存活率的技术策略。
我们回顾性分析了2000年3月至2007年11月期间的病历；183例患者中的186例DIEP皮瓣用于乳房重建，其中17例有下腹部中线瘢痕的患者采用了18例皮瓣（9.68%）。患者被分为3组。第1组：半DIEP皮瓣（n = 5）；第2组：包含跨越中线组织的DIEP皮瓣（n = 10）；第3组：整块DIEP皮瓣（含IV区）（n = 3）。
第1组1例患者因静脉淤血和部分皮瓣坏死而进行了再次手术探查。第2组皮瓣平均利用率为68.75±8.95%。3例皮瓣出现部分坏死并随后进行了清创。在第3组中，整块DIEP皮瓣设计有更高的双侧腹壁浅下静脉引流和皮瓣内蒂对蒂吻合。前2例出现部分皮瓣坏死并进行了清创。第3例采用双蒂吻合的皮瓣完全存活。
对于有下腹部中线瘢痕的患者，半DIEP皮瓣是一种更安全的方法，但限制了重建容量。术中仔细评估中线瘢痕处的灌注情况对于决定应舍弃多少对侧组织至关重要。双蒂吻合是采用有下腹部中线瘢痕的整块DIEP皮瓣的保障。
