Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Ludwig-Guttmann-Strasse 13, 67071 Heidelberg, Germany.
Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, Hand and Plastic Surgery, University of Heidelberg, Ludwig-Guttmann-Strasse 13, 67071 Heidelberg, Germany.
J Plast Reconstr Aesthet Surg. 2019 Apr;72(4):555-564. doi: 10.1016/j.bjps.2019.01.005. Epub 2019 Jan 11.
Though technically feasible, free tissue transfer carries the risk of perioperative morbidity and mortality in elderly patients. To minimize the operative treatment time and complication rates, we choose the rectus abdominis muscle (RAM) flap.
Between 2012 and 2017, 34 patients (mean age: 74±7 years, range: 65-89 years) with comorbidities underwent defect reconstruction with a free RAM flap. Recipient-sites were: lower extremity (65%), trunk (18%), upper extremity (12%), and head and neck (6%).
The ASA status was 2 in 11 patients, 3 in 21 patients, and 4 in 2 patients. Twenty patients (59%) received additional vascular surgery. Three patients (9%) underwent simultaneous restoration of fractures. The mean operative time (OT) was 325±75 min. There was no total flap loss. Partial flap loss occurred in one patient (3%). The incidence of surgical and medical complications was 32% and 38%: 11 patients experienced a total of 22 surgical complications, of which 15 were major (requiring additional surgery) and 7 minor (conservative treatment). One patient died postoperatively because of progressive respiratory failure. Prolonged OT was highly associated with hematoma formation requiring re-operation (p = 0.01). ASA status was a significant predictor for postoperative critical care monitoring (p = 0.03). Reconstruction was successful in 31 out of 34 patients (91%) during a mean follow-up time of 17.7 ± 8.8 months (range: 2-51 months).
The free RAM flap has proven as a reliable and efficient tool in the armamentarium of reconstructive microvascular surgeons with some advantages in the treatment of multimorbid patients older than 65 years.
尽管技术上可行，但游离组织移植会增加老年患者围手术期发病率和死亡率的风险。为了最大限度地减少手术治疗时间和并发症发生率，我们选择了腹直肌皮瓣（RAM）。
2012 年至 2017 年间，34 名患有合并症的患者（平均年龄：74±7 岁，范围：65-89 岁）接受了游离 RAM 皮瓣缺损重建。受区为：下肢（65%）、躯干（18%）、上肢（12%）和头颈部（6%）。
11 名患者的美国麻醉医师协会（ASA）分级为 2 级，21 名患者为 3 级，2 名患者为 4 级。20 名患者（59%）接受了额外的血管外科手术。3 名患者（9%）同时进行骨折修复。平均手术时间（OT）为 325±75 分钟。没有完全皮瓣坏死。1 名患者（3%）发生部分皮瓣坏死。手术和医疗并发症的发生率为 32%和 38%：11 名患者共发生 22 次手术并发症，其中 15 次为重大并发症（需要再次手术），7 次为轻微并发症（保守治疗）。1 名患者术后因进行性呼吸衰竭死亡。长时间的 OT 与需要再次手术的血肿形成高度相关（p=0.01）。ASA 状态是术后重症监护监测的显著预测因素（p=0.03）。34 名患者中有 31 名（91%）在平均 17.7±8.8 个月（范围：2-51 个月）的随访时间内重建成功。
游离 RAM 皮瓣已被证明是重建显微血管外科医生的可靠且有效的工具，在治疗 65 岁以上合并症较多的患者方面具有一些优势。
