From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center.
Plast Reconstr Surg. 2018 Aug;142(2):120e-125e. doi: 10.1097/PRS.0000000000004550.
Obesity has been viewed as a relative contraindication against autologous free flap breast reconstruction because of increased risks of complications, including flap loss.
The authors conducted a prospective analysis of obese patients undergoing autologous breast reconstruction.
Overall, 72 patients (average age, 48.5 years; average body mass index, 35.7 kg/m) underwent abdominal free flap breast reconstruction. There were 43 bilateral reconstructions and the remainder were unilateral (n = 115 flaps). There were 67 muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) flaps (58.3 percent), 44 deep inferior epigastric perforator (DIEP) flaps (38.2 percent), two free bipedicle DIEP flaps, one superficial inferior epigastric perforator flap, and one free TRAM flap. Forty-two patients (58.3 percent) had prior radiation, and 51 (70.8 percent) had prior chemotherapy. Forty-three patients (59.7 percent) underwent delayed reconstruction and 21 (29.2 percent) underwent immediate reconstruction. Eight patients (11.1 percent) had bilateral reconstruction, with one breast reconstructed in an immediate and the other in a delayed fashion. Half of the patients (n = 36) had mesh placed in an underlay fashion to reinforce the donor site. Regarding breast complications, there were 11 wound dehiscences, one hematoma, one infection, and two patients with mastectomy skin flap necrosis. Twelve patients had donor-site wound healing complications, there were four infections, and three patients developed a bulge/hernia. There were no flap losses. Comparison to historic controls demonstrated no significant differences in overall flap loss rates (p = 0.061) or donor-site bulge/hernia (p = 0.86).
Autologous abdominal free flaps can be performed safely in obese patients without increased risks for donor-site bulge/hernia or flap loss compared to nonobese patients; however, patients should be counseled carefully regarding the potential risks of complications.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
由于肥胖增加了并发症的风险，包括皮瓣坏死，因此肥胖被认为是自体游离皮瓣乳房再造的相对禁忌症。
作者对接受自体乳房再造的肥胖患者进行了前瞻性分析。
共有 72 例患者（平均年龄 48.5 岁；平均 BMI 为 35.7kg/m）接受了腹部游离皮瓣乳房再造。其中 43 例为双侧重建，其余为单侧（115 个皮瓣）。有 67 例肌皮保留横腹直肌肌皮瓣（TRAM）（58.3%），44 例腹壁下动脉穿支皮瓣（DIEP）（38.2%），2 例游离双蒂 DIEP 皮瓣，1 例腹壁浅动脉穿支皮瓣，1 例游离 TRAM 皮瓣。42 例（58.3%）患者有既往放疗史，51 例（70.8%）有化疗史。43 例（59.7%）患者行延迟重建，21 例（29.2%）行即刻重建。8 例（11.1%）患者行双侧重建，其中 1 例即刻重建，1 例延迟重建。一半的患者（n=36）在下方放置了网片以加强供区。关于乳房并发症，有 11 例伤口裂开，1 例血肿，1 例感染，2 例患者乳房皮瓣坏死。12 例供区伤口愈合并发症，4 例感染，3 例患者出现膨出/疝。没有皮瓣坏死。与历史对照相比，总皮瓣坏死率（p=0.061）或供区膨出/疝（p=0.86）无显著差异。
与非肥胖患者相比，自体腹部游离皮瓣在肥胖患者中安全可行，不会增加供区膨出/疝或皮瓣坏死的风险；然而，应仔细告知患者潜在并发症的风险。
临床问题/证据水平：治疗，IV。
