Kamali Parisa, Lee Michelle, Becherer Babette E, Wu Winona, Curiel Daniel, Tran Bao Ngoc N, Tobias Adam M, Lin Samuel J, Lee Bernard T
Boston, Mass.
From the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School.
Plast Reconstr Surg. 2017 Jul;140(1):19-24. doi: 10.1097/PRS.0000000000003413.
The purpose of this study was to evaluate perfusion-related complications in bilateral deep inferior epigastric perforator (DIEP) flap breast reconstruction based on perforator selection.
A retrospective review of a prospectively maintained database was performed on all patients undergoing bilateral DIEP flap reconstruction at a single institution between 2004 and 2014. The hemiflaps were separated into three cohorts based on perforator location: lateral row only, medial row only, and medial plus lateral rows. Postoperative flap-related complications were compared and analyzed.
There were 728 total hemiflaps: 263 (36.1 percent) based on the lateral row, 225 (30.9 percent) based on the medial row, and 240 (33.0 percent) based on both the medial and lateral rows. The groups were well matched by perforator number and flap weight. Fat necrosis occurrence was significantly higher in flaps based solely on the medial row versus lateral row perforators (24.5 percent versus 8.2 percent; p < 0.001). There was no statistically significant difference in fat necrosis between flaps based only on the lateral row versus flaps based on both the medial and lateral rows (8.2 percent versus 11.6 percent; p = 0.203). Generally, within the same row, increasing the number of perforators decreased the incidence of fat necrosis.
Perforator selection is critical for minimizing perfusion-related flap complications. In bilateral DIEP flaps, lateral row-based perforators result in significantly less fat necrosis than medial row-based perforators. The authors' data suggest that the addition of a lateral row perforator to a dominant medial row perforator may decrease the risk of fat necrosis.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
本研究旨在基于穿支选择评估双侧腹壁下深动脉穿支（DIEP）皮瓣乳房重建术中与灌注相关的并发症。
对2004年至2014年在单一机构接受双侧DIEP皮瓣重建的所有患者进行前瞻性维护数据库的回顾性分析。根据穿支位置将半侧皮瓣分为三组：仅外侧排、仅内侧排、内侧加外侧排。比较并分析术后皮瓣相关并发症。
共有728个半侧皮瓣：基于外侧排的有263个（36.1%），基于内侧排的有225个（30.9%），基于内侧和外侧排的有240个（33.0%）。各组在穿支数量和皮瓣重量方面匹配良好。仅基于内侧排穿支的皮瓣脂肪坏死发生率显著高于基于外侧排穿支的皮瓣（24.5%对8.2%；p<0.001）。仅基于外侧排的皮瓣与基于内侧和外侧排的皮瓣之间脂肪坏死无统计学显著差异（8.2%对11.6%；p=0.203）。一般来说，在同一排内，增加穿支数量可降低脂肪坏死发生率。
穿支选择对于将与灌注相关的皮瓣并发症降至最低至关重要。在双侧DIEP皮瓣中，基于外侧排的穿支导致的脂肪坏死明显少于基于内侧排的穿支。作者的数据表明，在主要的内侧排穿支基础上增加外侧排穿支可能会降低脂肪坏死风险。
临床问题/证据水平：治疗性，III级。
