Dayan Joseph H, Allen Robert J
Division of Plastic & Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, N.Y.
Plast Reconstr Surg Glob Open. 2019 Oct 16;7(10):e2463. doi: 10.1097/GOX.0000000000002463. eCollection 2019 Oct.
Although the deep inferior epigastric artery perforator flap remains the gold standard for autologous breast reconstruction, many patients are not candidates for this surgery. A variety of thigh-based flaps have been used including the diagonal upper gracilis (DUG) flap, vertical upper gracilis flap, profunda artery perforator (PAP) flap, and lateral thigh perforator flap. However, each of these techniques has a unique set of benefits and drawbacks in terms of wound healing, donor site morbidity, and potential for lymphedema. We describe the first report of a sensate diagonal PAP flap for breast reconstruction: combining the benefits of the DUG (wider skin paddle and reliable wound healing) with the benefits of the PAP (muscle-sparing technique and greater distance from the lymphatic collectors). This was the authors' sentinel case in a woman with paraplegia and chronic leg swelling. Preoperative imaging, markings, and technical details are presented along with postoperative results. In the appropriately selected patient, this flap offers several advantages: a 2-team approach to reconstruction, ample tissue for breast reconstruction, potential neurotization for breast sensibility, wound closure in resting skin tension lines, and avoidance of the lymphatic drainage to the lower extremity. The diagonal PAP flap provides a muscle-sparing alternative to the DUG flap while minimizing the risk of lymphedema. Future studies are needed to assess the donor site morbidity of this flap; however, this case proves the safety and reliability of the diagonal PAP flap in our breast reconstruction population.
尽管腹壁下动脉穿支皮瓣仍是自体乳房重建的金标准，但许多患者并不适合进行这种手术。已经使用了多种基于大腿的皮瓣，包括斜行上股薄肌（DUG）皮瓣、垂直上股薄肌皮瓣、股深动脉穿支（PAP）皮瓣和大腿外侧穿支皮瓣。然而，就伤口愈合、供区并发症和淋巴水肿的可能性而言，这些技术中的每一种都有其独特的优缺点。我们报告了首例用于乳房重建的带感觉的斜行PAP皮瓣：将DUG皮瓣的优点（更宽的皮瓣和可靠的伤口愈合）与PAP皮瓣的优点（保留肌肉技术和离淋巴管更远）相结合。这是作者为一名截瘫和慢性腿部肿胀女性实施的首例此类手术。文中展示了术前影像学检查、标记以及技术细节和术后结果。在适当选择的患者中，这种皮瓣具有几个优点：采用双团队重建方法、有足够的组织用于乳房重建、有可能实现乳房感觉神经化、在静息皮肤张力线处关闭伤口以及避免淋巴引流至下肢。斜行PAP皮瓣为DUG皮瓣提供了一种保留肌肉的替代方案，同时将淋巴水肿的风险降至最低。需要进一步的研究来评估这种皮瓣的供区并发症；然而，该病例证明了斜行PAP皮瓣在我们乳房重建患者群体中的安全性和可靠性。
