Lohana Parkash, Button Jane, Young David, Hart Andrew, Weiler-Mithoff Eva
Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, UK.
Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, UK.
J Plast Reconstr Aesthet Surg. 2019 Jul;72(7):1060-1066. doi: 10.1016/j.bjps.2019.01.013. Epub 2019 Jan 14.
The impact of unilateral extended autologous latissimus dorsi (EALD) flap harvest and axillary surgery on shoulder function has been well described, but the impact of bilateral EALD flap harvest has not been clearly defined nor is it clear whether reconstructions should be synchronous or staged.
In this prospective observational study, patients undergoing bilateral EALD breast reconstruction (February 2003-December 2009) completed the disability, arm, shoulder and hand (DASH) questionnaire preoperatively and at five post-operative timepoints. Intensive shoulder physiotherapy was offered to those whose DASH score was >30 at 6 weeks or >20 at 12 weeks post-operatively.
Sixty patients underwent bilateral EALD flap breast reconstruction (51 synchronous, 9 metachronous). Patients with pre-existing shoulder pathology (n = 1) and those who failed to return any post-operative DASH questionnaire (n = 10) were excluded from initial DASH analysis. However, these eleven patients were included in a separate analysis as an intention-to-treat analysis. Statistical analysis was performed using non-parametric, Friedman test and multiple comparison model. Forty-nine patients' DASH scores were analysed. DASH score initially increased after surgery and then returned to functionally normal within 3-6 months (median DASH: preoperative = 1 vs 6 weeks post-operation = 26, p = <0.001; vs 3 months = 19, p = <0.001; vs 6 months = 13, p = <0.001); thereafter, the scores remained less than 12 (p = <0.001). Median DASH score after synchronous reconstruction was not higher than that after metachronous reconstructions, although the metachronous sample size was small.
With appropriate patient selection and intensive physiotherapy, bilateral EALD breast reconstruction does not appear to cause significant long-term impairment of shoulder function, and patients can now be counselled about the likely timecourse of shoulder recovery. There seems no reason to stage bilateral reconstruction to reduce shoulder morbidity.
单侧背阔肌肌皮瓣（EALD）切取及腋窝手术对肩部功能的影响已有详尽描述，但双侧EALD瓣切取的影响尚未明确界定，且重建应同期进行还是分期进行也不明确。
在这项前瞻性观察研究中，接受双侧EALD乳房重建术的患者（2003年2月至2009年12月）在术前及术后五个时间点完成了残疾、手臂、肩部和手部（DASH）问卷调查。对术后6周DASH评分>30或术后12周DASH评分>20的患者提供强化肩部物理治疗。
60例患者接受了双侧EALD瓣乳房重建术（51例同期，9例分期）。初始DASH分析排除了术前存在肩部病变的患者（n = 1）以及未返回任何术后DASH问卷的患者（n = 10）。然而，这11例患者作为意向性治疗分析纳入单独分析。采用非参数Friedman检验和多重比较模型进行统计分析。分析了49例患者的DASH评分。DASH评分术后最初升高，然后在3 - 6个月内恢复到功能正常水平（DASH中位数：术前 = 1 vs术后6周 = 26，p = <0.001；vs术后3个月 = 19，p = <0.001；vs术后6个月 = 13，p = <0.001）；此后，评分保持低于12（p = <0.001）。同期重建后的DASH中位数评分不高于分期重建后的评分，尽管分期重建的样本量较小。
通过适当的患者选择和强化物理治疗，双侧EALD乳房重建似乎不会导致肩部功能的显著长期损害，现在可以告知患者肩部恢复的可能时间进程。似乎没有理由分期进行双侧重建以降低肩部发病率。
