双侧同期腰动脉穿支皮瓣乳房再造术：围手术期结局评估安全性和可行性。
Bilateral Simultaneous Lumbar Artery Perforator Flaps in Breast Reconstruction: Perioperative Outcomes Addressing Safety and Feasibility.
机构信息
From the Department of Plastic Surgery, University of Texas Southwestern Medical Center.
出版信息
Plast Reconstr Surg. 2024 May 1;153(5):895e-901e. doi: 10.1097/PRS.0000000000010830. Epub 2023 Jun 19.
BACKGROUND
The lumbar artery perforator (LAP) flap has emerged as an excellent option for breast reconstruction, but its steep learning curve makes it less approachable. Furthermore, length of the operation, flap ischemia time, need for composite vascular grafts, complex microsurgery, multiple position changes, and general concern for safety has led experienced surgeons to stage bilateral reconstructions. In the authors' experience, simultaneous bilateral LAP flaps are feasible, but overall perioperative safety has not been fully explored.
METHODS
Thirty-one patients (62 flaps) underwent simultaneous bilateral LAP flaps and were included in the study (excluding stacked four-flaps and unilateral flaps). Patients underwent two position changes in the operating room: supine to prone and then supine again. A retrospective review of patient demographics, intraoperative details, and complications was performed.
RESULTS
The overall flap success rate was 96.8%. Five flaps were compromised postoperatively. The intraoperative anastomotic revision rate was 24.1% per flap (4.3% per anastomosis). The significant complication rate was 22.6%. The number of sustained hypothermic episodes and hypotensive episodes correlated with intraoperative arterial thrombosis ( P < 0.05). The number of hypotensive episodes and increased intraoperative fluid correlated with flap compromise ( P < 0.05). High body mass index correlated with overall complications ( P < 0.05). The presence of diabetes correlated with intraoperative arterial thrombosis ( P < 0.05).
CONCLUSIONS
Simultaneous bilateral LAP flaps can be performed safely with an experienced and trained microsurgical team. Hypothermia and hypotension negatively affect the initial anastomotic success. In this complex operation, a coordinated approach between the anesthesia and nursing team is paramount for patient safety.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
背景
腰动脉穿支（LAP）皮瓣已成为乳房重建的绝佳选择，但由于其陡峭的学习曲线，使得它不太容易掌握。此外，手术时间长、皮瓣缺血时间长、需要复合血管移植物、复杂的显微外科手术、多次体位改变以及对安全性的普遍关注，使得经验丰富的外科医生选择分期进行双侧重建。根据作者的经验，同时进行双侧 LAP 皮瓣是可行的，但总体围手术期安全性尚未得到充分探讨。
方法
31 名患者（62 个皮瓣）接受了同时进行的双侧 LAP 皮瓣手术，并纳入研究（不包括堆叠的四瓣和单侧皮瓣）。患者在手术室中进行了两次体位改变：从仰卧位到俯卧位，然后再次仰卧位。对患者的人口统计学资料、术中细节和并发症进行回顾性分析。
结果
总的皮瓣成功率为 96.8%。术后有 5 个皮瓣出现问题。每个皮瓣的术中吻合修正率为 24.1%（每个吻合口为 4.3%）。显著并发症发生率为 22.6%。持续低体温发作和低血压发作的次数与术中动脉血栓形成相关（P<0.05）。低血压发作次数和术中液体增加与皮瓣问题相关（P<0.05）。高身体质量指数与总体并发症相关（P<0.05）。糖尿病与术中动脉血栓形成相关（P<0.05）。
结论
有经验和训练有素的显微外科团队可以安全地进行双侧 LAP 皮瓣同时手术。低体温和低血压会对初始吻合的成功产生负面影响。在这种复杂的手术中，麻醉和护理团队之间的协调方法对患者的安全至关重要。
临床问题/证据水平：治疗性，IV 级。
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