Cederna P S, Chang P, Pittet-Cuenod B M, Razaboni R M, Cram A E
Department of Surgery, University of Iowa College of Medicine, Iowa City, USA.
Plast Reconstr Surg. 1997 Jan;99(1):194-205. doi: 10.1097/00006534-199701000-00028.
The transverse rectus abdominis muscle (TRAM) flap has become the "gold standard" for autogenous breast tissue reconstruction. Complications are reported in 10 to 40 percent of patients undergoing this procedure, and many are related to soft-tissue necrosis secondary to ischemia. Various methods have been proposed to improve TRAM flap survival, including surgical delay of the flap. The beneficial effects of the delay phenomenon have been well established in laboratory studies and clinical evaluations. Many investigators agree that the delay phenomenon will enhance arterial inflow and venous outflow from the TRAM flap. No study has quantified the changes seen in the rectus abdominis muscle following a delay procedure. In this prospective, controlled, and blinded experiment, we evaluate the effect of a unilateral superficial inferior epigastric and deep inferior epigastric artery and vein ligation on the vascularity of the rectus abdominis muscles in rabbits. Thirty-eight rabbits underwent a left superficial inferior epigastric and deep inferior epigastric pedicle ligation as a delay procedure. The rectus abdominis muscle vasculature was then evaluated by lead oxide microangiography at 0, 5, 10, 15, 21, and 27 days following the delay procedure. Magnification (x 2) was used to count the number of vessels at the periphery of the deep inferior epigastric artery angiosomes in the microangiograms. An increase in the number of vessels from day 0 to day 27 was seen on both the ligated and nonligated sides in all the following: the number of large (> 0.5 mm) "choke" vessels and total number of vessels (all sizes) crossing the abdominal wall midline and the total number of vessels (all sizes) at the medial, superior, and lateral aspects of the right and left deep inferior epigastric artery angiosomes. A statistically significant increase in these vessels was not seen until day 21. The effect of the delay phenomenon was significantly greater on the ligated side compared with the nonligated side. The areas of the rectus abdominis muscles that were relatively more ischemic following left deep inferior epigastric pedicle ligation (medial aspect of the left deep inferior epigastric artery angiosome) showed greater increases in vascularity with the delay procedure than did areas of lesser ischemia (lateral aspect of the right deep inferior epigastric artery angiosome).
腹直肌横形肌皮瓣（TRAM瓣）已成为自体乳房组织重建的“金标准”。据报道，接受该手术的患者中有10%至40%会出现并发症，其中许多与缺血继发的软组织坏死有关。人们提出了各种方法来提高TRAM瓣的存活率，包括对皮瓣进行手术延迟处理。延迟现象的有益效果在实验室研究和临床评估中已得到充分证实。许多研究人员一致认为，延迟现象将增加TRAM瓣的动脉流入和静脉流出。尚无研究对延迟处理后腹直肌的变化进行量化。在这项前瞻性、对照性和盲法实验中，我们评估了单侧腹壁浅下动脉和腹壁深下动脉及静脉结扎对兔腹直肌血管分布的影响。38只兔子接受了左侧腹壁浅下动脉和腹壁深下动脉蒂结扎作为延迟处理。然后在延迟处理后的0、5、10、15、21和27天，通过氧化铅微血管造影术评估腹直肌的血管分布。使用放大倍数（×2）来计算微血管造影中腹壁深下动脉血管体周围的血管数量。在以下所有方面，结扎侧和未结扎侧从第0天到第27天血管数量均有增加：大的（>0.5毫米）“阻塞”血管数量、穿过腹壁中线的血管总数（所有大小）以及左右腹壁深下动脉血管体内侧、上方和外侧的血管总数（所有大小）。直到第21天，这些血管才出现统计学上的显著增加。与未结扎侧相比，延迟现象对结扎侧血管数量增加的影响显著更大。左侧腹壁深下动脉蒂结扎后相对缺血更严重的腹直肌区域（左侧腹壁深下动脉血管体的内侧），与缺血较轻的区域（右侧腹壁深下动脉血管体的外侧）相比，延迟处理后血管分布增加更为明显。
