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破除 DIEP 皮瓣的迷思与介绍腹部穿支皮瓣交换（APEX）乳房重建技术：单外科医师回顾性研究。

Myth-Busting the DIEP Flap and an Introduction to the Abdominal Perforator Exchange (APEX) Breast Reconstruction Technique: A Single-Surgeon Retrospective Review.

机构信息

From the Center for Restorative Breast Surgery and the Tulane School of Public Health and Tropical Medicine.

出版信息

Plast Reconstr Surg. 2019 Apr;143(4):992-1008. doi: 10.1097/PRS.0000000000005484.

DOI:10.1097/PRS.0000000000005484
PMID:30730497
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC6445603/
Abstract

BACKGROUND

Anatomical variations in perforator arrangement may impair the surgeon's ability to effectively avoid rectus muscle transection without compromising flap perfusion in the deep inferior epigastric artery perforator (DIEP) flap.

METHODS

A single surgeon's experience was reviewed with consecutive patients undergoing bilateral abdominal perforator flap breast reconstruction over 6 years, incorporating flap standardization, pedicle disassembly, and algorithmic vascular rerouting when necessary. Unilateral reconstructions were excluded to allow for uniform comparison of operative times and donor-site outcomes. Three hundred sixty-four flaps in 182 patients were analyzed. Operative details and conversion rates from DIEP to abdominal perforator exchange ("APEX") arms of the algorithm were collected. Patients with standardized DIEP flaps served as the controlling comparison group, and outcomes were compared to those who underwent abdominal perforator exchange conversion.

RESULTS

The abdominal perforator exchange conversion rate from planned DIEP flap surgery was 41.5 percent. Mean additional operative time to use abdominal perforator exchange pedicle disassembly was 34 minutes per flap. Early postsurgical complications were of low incidence and similar among the groups. One abdominal perforator exchange flap failed, and there were no DIEP flap failures. One abdominal bulge occurred in the DIEP flap group. There were no abdominal hernias in either group. Fat necrosis rates (abdominal perforator exchange flap, 2.4 percent; DIEP flap, 3.4 percent) were significantly lower than that historically reported for both transverse rectus abdominis musculocutaneous and DIEP flaps.

CONCLUSIONS

This study revealed no added risk when using pedicle disassembly to spare muscle/nerve structure during abdominal perforator flap harvest. Abdominal bulge/hernia was nearly completely eliminated. Fat necrosis rates were extremely low, suggesting benefit to pedicle disassembly and vascular routing exchange when required.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

摘要

背景

穿支排列的解剖变异可能会削弱外科医生有效避免腹直肌横断的能力，而不影响腹壁下动脉穿支（DIEP）皮瓣的血流灌注。

方法

回顾性分析了一位外科医生在 6 年内连续进行双侧腹部穿支皮瓣乳房再造的经验，其中包括皮瓣标准化、蒂部解剖和必要时的血管重新布线算法。排除单侧重建以允许对手术时间和供区结果进行统一比较。分析了 182 例患者的 364 个皮瓣。收集了手术细节和从 DIEP 到算法的腹部穿支交换（“APEX”）臂的转换率。标准化 DIEP 皮瓣的患者作为对照比较组，将结果与接受腹部穿支交换转换的患者进行比较。

结果

计划行 DIEP 皮瓣手术的腹部穿支交换转换率为 41.5%。每皮瓣使用腹部穿支交换蒂部解剖的平均额外手术时间为 34 分钟。早期术后并发症发生率低，各组之间相似。1 例腹部穿支交换皮瓣失败，无 DIEP 皮瓣失败。DIEP 皮瓣组发生 1 例腹部膨出。两组均无腹壁疝。脂肪坏死率（腹部穿支交换皮瓣，2.4%；DIEP 皮瓣，3.4%）明显低于横形腹直肌肌皮瓣和 DIEP 皮瓣的历史报告。

结论

本研究表明，在腹部穿支皮瓣采集过程中使用蒂部解剖以保留肌肉/神经结构不会增加风险。腹部膨出/疝几乎完全消除。脂肪坏死率极低，提示在需要时进行蒂部解剖和血管重新布线交换有益。

临床问题/证据水平：治疗，III。

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