Clugston P A, Lennox P A, Thompson R P
Department of Surgery, University of British Columbia, Vancouver, Canada.
Ann Plast Surg. 1998 Dec;41(6):623-8. doi: 10.1097/00000637-199812000-00007.
Transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction has become an increasingly common procedure in the 1990s. The original description of the procedure was that of an ipsilaterally based pedicled procedure. However, because of concerns about potential folding of the pedicle with possible compromise of the vascular supply, with full muscle harvest the contralateral flap soon became the flap of choice. Subsequently there have been several large clinical series of pedicled TRAM flaps reported showing a relatively high complication rate related to problems with flap vascularity. These findings resulted in many centers favoring free TRAM flap breast reconstruction, despite an increased resource utilization and negligible differences in complication rates. Ipsilateral pedicled TRAM flap breast reconstruction is not a commonly reported procedure, and is reserved for patients in whom scars preclude use of the contralateral pedicle. The ease of flap shaping and lack of tension on the pedicle is recognized by some, and the ipsilateral procedure has become the flap of choice for these surgeons. The authors hypothesized that ipsilateral TRAM flaps have less compromise of venous outflow as a result of the rotational tension effect of transposing the flap to the mastectomy site. To determine if the vascularity of the pedicled TRAM procedure is influenced by pedicle choice, an intraoperative clinical study was designed to compare intravascular pressures in the deep inferior epigastric artery and vein pedicle at various times from pedicle division to flap insetting. Ten consecutive ipsilateral TRAM flaps were compared with eight contralateral flaps. The deep inferior epigastric pedicle was cannulated with both an arterial and venous catheter, and pressures were monitored from the time of division of the inferior pedicle through to the time of flap insetting. The venous pressures of the contralateral flaps were significantly higher at flap rotation and flap insetting compared with the ipsilateral group (p = 0.014 and p = 0.022 respectively). Perfusion pressures showed a greater decrease in the contralateral group from the time of pedicle division to the point of flap rotation and flap insetting compared with the ipsilateral group (p = 0.081 and p = 0.055). The authors conclude that pedicle tension in contralateral TRAM flaps is more common and results in greater venous resistance and decreased perfusion pressures. Versatility in flap shaping, improved maintenance of the IMF, and lack of disruption of the natural xyphoid hollow gives ipsilateral TRAM flaps additional advantages.
横行腹直肌肌皮瓣（TRAM）乳房重建术在20世纪90年代已变得越来越常见。该手术最初的描述是基于同侧带蒂的手术方式。然而，由于担心蒂部可能折叠，进而影响血供，在完全切取肌肉时，对侧皮瓣很快成为首选。随后，有多个关于带蒂TRAM皮瓣的大型临床系列报道，显示与皮瓣血管问题相关的并发症发生率相对较高。这些发现使得许多中心倾向于采用游离TRAM皮瓣乳房重建术，尽管资源利用增加且并发症发生率差异可忽略不计。同侧带蒂TRAM皮瓣乳房重建术并非常见报道的手术方式，仅适用于因瘢痕而无法使用对侧蒂部的患者。一些人认识到该皮瓣塑形容易且蒂部无张力，同侧手术方式已成为这些外科医生的首选。作者推测，由于将皮瓣转移至乳房切除部位时的旋转张力作用，同侧TRAM皮瓣的静脉流出道受影响较小。为确定带蒂TRAM手术的血管情况是否受蒂部选择的影响，设计了一项术中临床研究，比较从蒂部分离到皮瓣植入不同时间点腹壁下深动脉和静脉蒂内的血管压力。将连续的10例同侧TRAM皮瓣与8例对侧皮瓣进行比较。腹壁下深蒂分别插入动脉和静脉导管，从下蒂分离时开始监测压力直至皮瓣植入。与同侧组相比，对侧皮瓣在皮瓣旋转和皮瓣植入时的静脉压力显著更高（分别为p = 0.014和p = 0.022）。与同侧组相比，对侧组从蒂部分离到皮瓣旋转和皮瓣植入时灌注压力下降更明显（分别为p = 0.081和p = 0.055）。作者得出结论，对侧TRAM皮瓣的蒂部张力更常见，导致更大的静脉阻力和灌注压力降低。皮瓣塑形的灵活性、更好地维持乳房下皱襞以及未破坏自然剑突下凹陷使同侧TRAM皮瓣具有更多优势。
