Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA.
Microsurgery. 2022 Feb;42(2):109-116. doi: 10.1002/micr.30845. Epub 2021 Dec 2.
Although rates of microvascular thrombosis following free-flap breast reconstruction are low, debate persists about the optimal methods to restore blood flow and prevent ensuing flap shrinkage or fibrosis. Here we evaluate our management of microvascular compromise, including both a review of our approach for restoring blood flow and addressing the ensuing inflammatory changes following ischemia reperfusion.
We conducted a retrospective review of autologous free tissue transfer breast reconstructions from 1/2010 to 1/2020. Patients who had flaps requiring take-back for salvage were identified. Management of microvascular compromise and ischemia reperfusion injury were recorded.
Of 2103 flaps were used in the breast reconstructions, 47 flaps required take-back for microvascular compromise (2.2%). Most flaps were either completely salvaged (n = 29, 61.7%) or partially salvaged (n = 5, 10.6%). Thirteen (27.7%) were a total flap loss, for an overall rate of 0.8% (including 3 flaps with no salvage attempt). Management of microvascular compromise most often included revision of the anastomosis (n = 33, 70.2%), thrombectomy (n = 27, 57.4%), tissue plasminogen activator administration (n = 26, 55.3%), and vein grafts (n = 18, 38.3%). Management of ischemia reperfusion included intraoperative steroids (n = 33, 70.2%), postoperative steroids (n = 17, 38.6%), and postoperative therapeutic anticoagulation (n = 27, 61.3%). Of 34 salvaged flaps, 5 (14.7%) had partial flap loss and/or fat necrosis on clinical examination at an average follow-up of 2.7 ± 2.8 years.
Salvage of microvascular compromise in autologous breast reconstruction should include restoration of blood flow and management of ischemia reperfusion injury. Attention to both is paramount for successful outcomes.
尽管游离皮瓣乳房重建术后发生微血管血栓的发生率较低，但关于恢复血流并预防随之而来的皮瓣收缩或纤维化的最佳方法仍存在争议。在这里，我们评估了我们对微血管受压的处理方法，包括对恢复血流和处理缺血再灌注后随之而来的炎症变化的方法进行了回顾。
我们对 2010 年 1 月至 2020 年 1 月期间的自体游离组织转移乳房重建进行了回顾性分析。确定了需要挽救的皮瓣。记录了微血管受压和缺血再灌注损伤的处理方法。
在 2103 个皮瓣中，有 47 个皮瓣因微血管受压需要挽救（2.2%）。大多数皮瓣要么完全挽救（n=29，61.7%），要么部分挽救（n=5，10.6%）。13 个（27.7%）是完全皮瓣坏死，总的皮瓣坏死率为 0.8%（包括 3 个未尝试挽救的皮瓣）。微血管受压的处理方法最常包括吻合口修正（n=33，70.2%）、血栓切除术（n=27，57.4%）、组织型纤溶酶原激活物给药（n=26，55.3%）和静脉移植（n=18，38.3%）。缺血再灌注的处理包括术中类固醇（n=33，70.2%）、术后类固醇（n=17，38.6%）和术后治疗性抗凝（n=27，61.3%）。在 34 个挽救的皮瓣中，有 5 个（14.7%）在平均 2.7±2.8 年的随访中出现临床检查部分皮瓣坏死和/或脂肪坏死。
自体乳房重建中微血管受压的挽救应包括恢复血流和处理缺血再灌注损伤。两者都应引起重视，才能取得良好的效果。
