Nykiel Matthew, Hunter Cedric, Lee Gordon K
Stanford Plastic Surgery, Stanford, CA.
Ann Plast Surg. 2015 May;74 Suppl 1:S33-40. doi: 10.1097/SAP.0000000000000509.
Risk of abdominal free flaps complications and the risk of abdominal wound complications from surgery are significantly increased in patients with previous abdominal surgeries. Previous scars can limit the vascularized territories suitable for transfer and can lead to significant partial flap necrosis.
A retrospective review of abdominal free flap breast reconstructions performed by the senior author (GKL) over 5 years (2008-2013). Patients were grouped based on the presence or absence of abdominal scars and specific type/location of scar(s). In addition, we analyzed patient information. including demographics, body mass index, smoking history, comorbid conditions, and most importantly, surgical techniques to optimize vascular perfusion.
We identified 169 patients that underwent abdominal perforator free flap breast reconstruction. One hundred nine patients underwent previous abdominal surgery. Within this group, we had 2 complete flap losses, 5 major flap complications, 9 minor flap complications, and 9 donor site complications. Sixty patients had no previous abdominal surgery. Of these patients, we had no complete flap losses, 2 major flap complications, 1 minor flap complication, and 4 donor site complications. Patients with previous abdominal surgeries undergoing abdominal free flap breast reconstruction had a statistically significant higher rate of flap complications (P=0.02). Donor site wound healing complications were not statistically significant (P=0.5). The subgroup of patients that had both a previous intra-abdominal surgery scar and Pfannenstiel scar (21 patients) were at greatest risk for both free flap (19% of patients) and donor site wound healing (19% of patients) complications.
Abdominal scars increase the risk of complications to the free flap. Unlike previous studies, patients with abdominal scars do not appear to have a statistically significant increase for donor site complications. Using the data from our study, we developed an algorithm for abdominal flap harvest in patients with abdominal scars. The algorithm emphasizes the importance of bipedicled perforator flaps and supercharging/turbocharging when blood flow is required across scars or when a large volume of tissue is needed crossing the midline. In specific cases, where perforator viability is in question because of a previous abdominal surgical procedure, we recommend the inclusion of muscle (Muscle-Sparing-transverse rectus abdominis musculocutaneous vs transverse rectus abdominis musculocutaneous).
既往有腹部手术史的患者，腹部游离皮瓣并发症风险及手术导致的腹部伤口并发症风险显著增加。既往手术瘢痕会限制适合转移的血管化区域，并可能导致皮瓣出现明显的部分坏死。
对资深作者（GKL）在5年期间（2008 - 2013年）进行的腹部游离皮瓣乳房重建手术进行回顾性研究。根据有无腹部瘢痕及瘢痕的具体类型/位置对患者进行分组。此外，我们分析了患者信息，包括人口统计学资料、体重指数、吸烟史、合并症，最重要的是，分析了优化血管灌注的手术技术。
我们确定了169例行腹部穿支游离皮瓣乳房重建手术的患者。其中109例患者既往有腹部手术史。在这组患者中，有2例皮瓣完全坏死，5例严重皮瓣并发症，9例轻微皮瓣并发症，9例供区并发症。60例患者既往无腹部手术史。在这些患者中，无皮瓣完全坏死，2例严重皮瓣并发症，1例轻微皮瓣并发症，4例供区并发症。既往有腹部手术史的患者行腹部游离皮瓣乳房重建手术时，皮瓣并发症发生率在统计学上显著更高（P = 0.02）。供区伤口愈合并发症在统计学上无显著差异（P = 0.5）。既往有腹腔内手术瘢痕和耻骨上横切口瘢痕的患者亚组（21例患者）发生游离皮瓣并发症（19%的患者）和供区伤口愈合并发症（19%的患者）的风险最高。
腹部瘢痕会增加游离皮瓣的并发症风险。与既往研究不同，有腹部瘢痕的患者供区并发症在统计学上似乎没有显著增加。利用我们研究的数据，我们制定了一种针对有腹部瘢痕患者的腹部皮瓣切取算法。该算法强调了双蒂穿支皮瓣以及在需要跨越瘢痕的血流或需要大量组织跨越中线时进行增压/超速灌注的重要性。在因既往腹部手术导致穿支活力存疑的特定情况下，我们建议纳入肌肉（保留肌肉的腹直肌肌皮瓣与腹直肌肌皮瓣对比）。
