MDCTA指导下的腹部皮瓣乳房再造术式选择

目的：评价MDCTA对腹部皮瓣乳房再造术术式选择的指导意义。方法：2006年10月～2008年12月,应用螺旋CT血管造影对拟采用腹部皮瓣进行乳房再造的34例患者进行术前腹部血管造影,并依据造影结果进行手术方式选择及术前设计。选取该时间段之前,MDCTA尚未采用时的58例腹部游离皮瓣乳房再造的病例设立对照组,比较两组间不同手术方式的采用率,DIEP皮瓣的穿支血管保留数目,同一手术方式的手术时间,以及术后皮瓣坏死的发生率。结果：手术方式的选择：实验组中SIEA为5.9%,DIEP为64.7%,TRAM为11.8%,双蒂联合皮瓣为17.6%;对照组中SIEA为0,DIEP为41.4%,TRAM为15.5%,双蒂联合皮瓣为43.1%。采用卡方检验对两组患者手术方式采用率进行对比,其中SIEA采用率,DIEP采用率和TRAM采用率具有统计学意义,联合皮瓣采用率两组数据无明显差别。实验组DIEP皮瓣保留穿支血管的平均数目为：（1.73±0.70）支,对照组为（2.75±1.15）支,P=0.01〈0.05两组比较差异有统计学意义。实验组DIEP皮瓣平均手术时间为（7.23±1.42）h,对照组DIEP皮瓣平均手术时间为（10.67±1.74）h;实验组TRAM皮瓣平均手术时间为（4.72±1.53）h,对照组TRAM皮瓣平均手术时间为（6.64±1.83）h;实验组联合皮瓣平均手术时间为（10.36±1.16）h,对照组联合皮瓣平均手术时间为（12.83±1.35）。经独立样本t检验,P值均小于0.05,四组数据差异皆有统计学意义。实验组皮瓣并发症发生率为：8.8%。对照组的皮瓣坏死率为13.7%,经卡方检验两组比较差异有统计学意义。结论：在MDCTA指导下,我们可以更合理地制定乳房再造的手术方式,简化手术步骤,节省手术时间,提高手术安全性,降低手术风险。     

320排螺旋CT血管造影和三维重建在阴股沟穿支皮瓣临床设计中的应用

目的：以320排螺旋CT血管造影和三维重建为基础,尝试在临床为阴股沟穿支皮瓣血管蒂的术前设计提供体表定位方法.方法：对18名需运用阴股沟穿支皮瓣行会阴部再造的实验组患者,术前进行320排螺旋CT血管造影和三维重建,并通过影像学资料为阴股沟穿支皮瓣血管蒂提供体表定位,从而进一步指导手术.同时设置对照组,包括20名运用阴股沟穿支皮瓣行会阴部再造患者,未使用CT血管造影技术.结果：两组共38名患者皮瓣完全存活,实验组手术时间较对照组明显缩短（P＜0.0001）,术后并发症实验组明显减少（P＜0.05）.皮瓣外观形态满意,生理功能接近正常.结论：320排螺旋CT血管造影及三维重建为阴股沟穿支皮瓣血管蒂的术前体表定位提供了一种可靠、有效的方法.     

术前CT血管造影在腹壁下动脉穿支皮瓣乳房再造的应用现状和展望

目的总结CT血管造影(computed tomographic angiography,CTA)在腹壁下动脉穿支(deep inferior epigastric artery perforator,DIEP)皮瓣乳房再造中的应用进展,并简要分析其应用前景。方法查阅近年来国内外有关CTA在DIEP皮瓣乳房再造中应用的相关文献,并进行分析和总结。结果术前CTA对胸腹壁的血管解剖结构可进行精确评估,在腹部供区可精确定位穿支,识别优势穿支;在胸部受区可指导探查胸廓内动脉肋间隙以及胸廓内动脉穿支分支的选择;参照对侧乳房大小进行腹部皮瓣容积重建,精确预构腹部皮瓣的大小,对手术方案的制定以及手术安全性的提高均有着至关重要的作用。结论术前CTA在DIEP皮瓣乳房再造领域的供区穿支定位、受区血管选择以及乳房容积评估方面具有巨大的应用潜力。     

腹壁浅动脉蒂游离腹壁皮瓣乳房再造术的初步临床应用

目的 探讨采用腹壁浅动脉(superficial inferior epigastric artery,SIEA)蒂游离腹壁皮瓣乳房再造术方法 、特点及适应证.方法 术前采用多层螺旋CT(multipledetector-row computed tomography,MDCT)三维血管造影及多普勒血流探测仪检查SIEA的直径、走行及分布,于脐与阴阜上缘之间设计皮瓣,采用单蒂或双蒂SIEA,与胸廓内动,静脉吻合,腹部供区直接拉拢缝合.结果 4例乳房再造病例皮瓣全部存活,皮瓣和腹部供区无脂肪液化、坏死、切口裂开、腹壁薄弱及腹壁疝等并发症的出现,再造乳房外形效果满意.结论 SIEA蒂游离腹壁皮瓣与腹壁下动脉穿支皮瓣(DIEP),横行腹支肌肌(TRAM)皮瓣乳房再造术提供同样的腹部皮肤和组织量,但却减轻了对腹部功能和形态的损害,在做好充分的术前血管评估、严格把握适应证和熟练掌握显微外科技术的前提下,是一种可供选择的乳房再造方法.     

腹壁浅动脉蒂游离腹壁皮瓣乳房再造术的初步临床应用

目的 探讨采用腹壁浅动脉(superficial inferior epigastric artery,SIEA)蒂游离腹壁皮瓣乳房再造术方法 、特点及适应证.方法 术前采用多层螺旋CT(multipledetector-row computed tomography,MDCT)三维血管造影及多普勒血流探测仪检查SIEA的直径、走行及分布,于脐与阴阜上缘之间设计皮瓣,采用单蒂或双蒂SIEA,与胸廓内动,静脉吻合,腹部供区直接拉拢缝合.结果 4例乳房再造病例皮瓣全部存活,皮瓣和腹部供区无脂肪液化、坏死、切口裂开、腹壁薄弱及腹壁疝等并发症的出现,再造乳房外形效果满意.结论 SIEA蒂游离腹壁皮瓣与腹壁下动脉穿支皮瓣(DIEP),横行腹支肌肌(TRAM)皮瓣乳房再造术提供同样的腹部皮肤和组织量,但却减轻了对腹部功能和形态的损害,在做好充分的术前血管评估、严格把握适应证和熟练掌握显微外科技术的前提下,是一种可供选择的乳房再造方法.     

腹壁浅动脉蒂游离腹壁皮瓣乳房再造术的初步临床应用

目的 探讨采用腹壁浅动脉（superficial inferior epigastric artery,SIEA）蒂游离腹壁皮瓣乳房再造术方法 、特点及适应证.方法 术前采用多层螺旋CT（multipledetector-row computed tomography,MDCT）三维血管造影及多普勒血流探测仪检查SIEA的直径、走行及分布,于脐与阴阜上缘之间设计皮瓣,采用单蒂或双蒂SIEA,与胸廓内动,静脉吻合,腹部供区直接拉拢缝合.结果 4例乳房再造病例皮瓣全部存活,皮瓣和腹部供区无脂肪液化、坏死、切口裂开、腹壁薄弱及腹壁疝等并发症的出现,再造乳房外形效果满意.结论 SIEA蒂游离腹壁皮瓣与腹壁下动脉穿支皮瓣（DIEP）,横行腹支肌肌（TRAM）皮瓣乳房再造术提供同样的腹部皮肤和组织量,但却减轻了对腹部功能和形态的损害,在做好充分的术前血管评估、严格把握适应证和熟练掌握显微外科技术的前提下,是一种可供选择的乳房再造方法.     

腹壁下动脉穿支皮瓣血管磁共振血管成像研究及其在乳房再造中的应用

目的:腹壁下动脉穿支(Deep Inferior Epigastric Perforator,DIEP)皮瓣已经成为乳房再造的重要手段之一,本研究通过磁共振血管成像(magnetic resonance angiography,MRA)对腹壁下动脉穿支进行三维成像,研究其血管走形及穿支情况,并在临床中加以应用。方法:本研究中共11位单侧乳房缺如的女性患者,均为乳腺癌乳房切除术后,术前1周以内行腹部磁共振血管成像检查,根据血管三维成像的结果,术前在皮肤表面标记血管穿支的位置,与手术中实际寻找到的血管穿支点进行比较,得出定位准确率及定位距离误差。结果:术前MRA对腹壁下动脉穿支的三维成像与手术实际操作相比,血管穿支定位距离误差为(1.08±0.51)mm,定位腹壁下动脉血管的准确率为100%。结论:MRA应用于DIEP皮瓣是一种无创、有效、简便的辅助手段,有利于提高手术效率,减少手术时间及并发症的产生。     

带蒂横行腹直肌肌皮瓣联合腹壁下动脉穿支皮瓣乳房再造适应证的探讨

目的探讨带蒂横行腹直肌肌皮瓣(TRAM)+腹壁下动脉穿支(DIEP)联合皮瓣适应证选择标准的临床应用价值。方法回顾性分析2008年1月至2022年4月, 中国医学科学院整形外科医院乳房整形科和乳腺综合整形科采用双蒂下腹部皮瓣行乳腺癌术后延期乳房再造的患者资料。根据不同血供来源将患者分为TRAM+DIEP联合皮瓣组和双蒂DIEP皮瓣组, 比较2组的自体乳房再造特点。TRAM+DIEP联合皮瓣组适应证选择标准:胸部受区无法提供2组吻合血管, 腹部供区无优势腹壁下穿支吻合血管, 既往行腹部吸脂手术或剥离范围较大、瘢痕较重的腹部手术, 无法耐受长时间手术或具有显微外科手术的高风险因素。根据数据资料性质, 采用独立样本t检验、秩和检验、卡方检验、Fisher确切概率法分析2组患者的年龄、身体质量指数(BMI)、乳腺癌手术距乳房再造手术时间、放疗史、化疗史、吸烟史、下腹部手术史、高血压史、原手术切口类型、切取皮瓣长度及宽度、手术时间、住院时间、术前及术后情况、术后并发症等, P<0.05为差异具有统计学意义。结果共纳入54例女性患者, 均为单侧乳房再造, 平均年龄42.2岁(30～59岁),...     

利用腹壁浅动静脉超灌注回流挽救腹壁下动脉穿支皮瓣罕见血运不良的乳房再造1例

在腹壁下动脉穿支皮瓣乳房再造中, 非血管蒂原因如深浅静脉系统之间缺乏有效连通所致的皮瓣弥漫性淤血十分罕见。该文报道了1例乳腺癌术后行腹壁下动脉穿支皮瓣乳房再造的32岁女性, 影像学提示双侧腹部均缺乏优势的腹壁下动脉穿支, 且深浅静脉系统间缺乏交通。术中提前解剖腹壁浅动静脉备用, 术中行吲哚菁绿血管造影提示皮瓣动脉灌注不足和静脉淤血, 利用预留的腹壁浅动静脉进行超灌注回流成功挽救了皮瓣, 最大限度地保留了该年轻患者的腹壁功能。     

高频彩超结合超声造影技术在穿支皮瓣术前设计及评估中的应用

目的 应用高频超声及超声造影增强技术(CEUS),定位并检查穿支血管,为皮瓣手术的方案设计和操作提供准确依据 方法 2011年12月至2012年7月对我科49例拟行穿支皮瓣手术患者,在高频彩超基础上运用CEUS行术前探测:皮瓣供区做穿支血管出肌点定位和血管三维重建,测量血管管径及峰值流速；皮瓣受区探测有无血管硬化,有无炎症、脓腔及液性坏死.根据穿支血管直径和峰值流速,结合血管三维图像,首选直径粗、峰值流速快、血管走行平直的穿支血管,设计并切取皮瓣. 结果 49例患者,43例在拟切取皮瓣的49个区域共找到117支穿支,平均每个区域找到2.39个穿支,除6例12个第四腰动脉穿支皮瓣术前探测的30个穿支血管因不需要显露、术中未证实外,其余87个穿支血管均在术中得到证实,所有皮瓣均成活.6例患者根据术前探测结果,认为不适合做穿支皮瓣,改行其他手术,疗效良好.结论 高频彩超能准确定位穿支血管并了解受区情况,结合CEUS可以获得更清晰连续的二维图像和三维立体图像,是提高穿支皮瓣手术准确性和成功率的有效手段.     

3D CT angiography of abdominal wall vascular perforators to plan DIEAP flaps

PURPOSE: Since the first report of TRAM flap reconstruction, there have been numerous studies to reduce complications of elective breast reconstruction. Current methods of preoperative perforator localization can be time-consuming, inaccurate, and imprecise. Thus, we sought to evaluate ultra-high resolution 3D CT angiography for the preoperative mapping of DIEAP flap perforating vessels. METHODS: We reviewed all perforator-based breast reconstructions performed over a 5-month period. Candidates for DIEAP flap reconstruction were sent for a focused CT scan of the abdominal wall, using the 64 slice multi-detector CT scanner. RESULTS: This article presents our first 23 flaps in 17 patients with preoperative ultra-high resolution 3D CT angiography. The reconstruction plan changed in three patients (18%). There was one take-back for venous congestion, but no partial or total flap loss. CONCLUSIONS: Preoperative perforator flap planning for breast reconstruction utilizing 3D CT angiogram is safe, easy to read, and can change the operative plan.     

The efficacy of preoperative vascular mapping by MDCTA in selecting flap in abdominal flap breast reconstruction

Current methods of breast reconstruction using abdominal tissue include the transverse abdominal myocutaneous (TRAM) flap, deep inferior epigastric arterial perforator (DIEP) flap, superficial inferior epigastric arterial (SIEA) flap, and some other composite flaps. Because of the variant vascular anatomy in abdominal region, it is hard to choose an appropriate flap for a specific patient without accurate preoperative vascular mapping. This study was drawn to address the efficacy of preoperative vascular mapping by multidetector-row computed tomographic angiography (MDCTA) in selecting flap in abdominal flap breast reconstruction. A total of 34 breast reconstructions using abdominal flap from December 2006 to July 2009 were included. In all the patients included, MDCTA was performed preoperatively. Three indexes were obtained including choice of flaps, operation time, and flap complication rate. Then, these data were compared with the former data stored in the databank of our hospital from January 2004 to December 2006, before MDCTA was introduced in our center. Among the 34 patients, the flap selection was: SIEA flaps 11.8%, DIEP flaps 61.8%, TRAM flaps 11.8%, and bilateral flaps 14.7%. The correlate indexes from the data bank were as follows: SIEA flap 0; DIEP flaps 51.7%; TRAM flaps 32.8%; bilateral flaps 15.5%. p < 0.05 occurred between the comparison of SIEA, DIEP, and TRAM flap choice in the two groups. The operation time in the study group was as follows: SIEA flap (4.02 ± 0.46) hours, DIEP flap (6.23 ± 1.42) hours, TRAM flap (4.72 ± 1.53) hours, Bilateral flap (7.86 ± 1.16) hours; while the former correlate data were: DIEP (9.67 ± 1.74) hours, TRAM flap (6.64 ± 1.83) hours, bilateral flap (11.83 ± 1.35) (all the three comparison p < 0.05). The total flap complication rate was about 5.9% in the test group; while in the databank, it was 12.1% (p < 0.05). With the accurate mapping of vascular territory in abdomen by MDCTA, we could easily select a suitable abdominal flap for breast reconstruction, and we can also simplify the procedure to save operation time and make the process more safely.     

Does the preoperative imaging of perforators with CT angiography improve operative outcomes in breast reconstruction?

Background: Breast reconstruction is increasingly performed with the use of the abdominal wall donor site, with potential complications including donor site morbidity and impaired flap viability. As a tool for selecting the optimal perforators which will ultimately supply the flap, preoperative imaging with computed tomography angiography (CTA) has become increasingly popular. Potential benefits include reduced intramuscular dissection, with faster and safer dissection, reduced donor site morbidity and improved flap vascularity and survival. Despite the potential for improvements in operative outcome, any benefits are yet to be established. Methods: A cohort study of 104 breast reconstructions in 88 patients was conducted. All patients underwent breast reconstruction based on an abdominal wall free flap. Of these, 40 patients undergoing preoperative imaging with CTA and 48 patients not undergoing CTA were included, with all CTAs undertaken at a single institution. Length of operation, length of stay, and operative complications were assessed. An evaluation of operative stress was achieved with the use of visual analogue scales (VAS) administered to the surgeons. Results: The use of CTA was associated with decreased operating time (mean: 77 min for bilateral cases), significantly decreased complications related to flap viability (particularly partial flap loss), and a statistically significant reduction in donor site morbidity. Psychometric testing of surgeons revealed a statistically significant decrease in operative stress (41% decrease) with the use of preoperative CTA. Conclusion: The use of CTA for preoperative imaging in breast reconstruction is associated with improved operative outcomes. © 2008 Wiley‐Liss, Inc. Microsurgery, 2008.     

Preoperative computed tomography angiogram to predict patients with favorable anatomy for superficial inferior epigastric artery flap breast reconstruction

Superficial inferior epigastric artery (SIEA) flap breast reconstruction has advantages over deep inferior epigastric perforator flap (DIEP) and muscle sparing transverse rectus abdominus myocutaneous flap (TRAM) reconstructions with less donor site morbidity and less complicated flap dissection. Not all patients have an adequate SIEA and superficial inferior epigastric vein (SIEV) to support free tissue breast reconstruction, and dissection of the SIEA in all patients can be time consuming. Preoperative computed tomography (CT) angiograms can be used to identify the SIEA and SIEV in patients planning to undergo free abdominal tissue breast reconstruction and direct more efficient dissection in patients with a large SIEA. Retrospective analysis of free abdominal tissue flap breast reconstruction from a single plastic surgeon was performed. All patients undergoing free abdominal tissue breast reconstruction had a preoperative CT angiogram using a protocol for the evaluation of the abdominal wall perforating arteries. CT scans were reviewed by the surgeon preoperatively and evaluated for the presence, caliber, and image quality of the SIEA and SIEV. All patients, regardless of CT angiogram findings, had operative dissection and evaluation of the SIEA and SIEV. A total of 177 free flaps were performed on 113 patients who underwent preoperative CT angiogram and free abdominal tissue breast reconstruction. Of them, 64 patients had bilateral breast reconstruction. Twelve SIEA flaps (10.6%) were performed on 12 patients. During preoperative CT angiographic evaluation, 49 patients (43%) were noted to have at least one visible SIEA, whereas only 24 of those patients (21%) were felt to have an SIEA of adequate caliber. No flaps were lost during the postoperative period. All 12 SIEA flaps performed had an adequate SIEA when observed on preoperative CT angiogram. Overall, 50% of patients found to have at least one adequate SIEA on CT angiogram had a single breast reconstructed with an SIEA flap. If the SIEA was not visualized on CT angiogram, no usable SIEA was found during surgery. Preoperative CT angiogram of the abdominal wall perforating arteries can help predict which patients may have adequate anatomy for an SIEA-based free flap. This information may help direct more efficient dissection of the abdominal flaps by selecting out patients who do not have an adequate SIEA.     

Three‐dimensional computed tomographic angiography to predict weight and volume of deep inferior epigastric artery perforator flap for breast reconstruction

Background: Three‐dimensional computed tomographic angiography (3D CTA) can be used preoperatively to evaluate the course and caliber of perforating blood vessels for abdominal free‐flap breast reconstruction. For postmastectomy breast reconstruction, many women inquire whether the abdominal tissue volume will match that of the breast to be removed. Therefore, our goal was to estimate preoperative volume and weight of the proposed flap and compare them with the actual volume and weight to determine if diagnostic imaging can accurately identify the amount of tissue that could potentially to be harvested. Methods: Preoperative 3D CTA was performed in 15 patients, who underwent breast reconstruction using the deep inferior epigastric artery perforator flap. Before each angiogram, stereotactic fiducials were placed on the planned flap outline. The radiologist reviewed each preoperative angiogram to estimate the volume, and thus, weight of the flap. These estimated weights were compared with the actual intraoperative weights. Results: The average estimated weight was 99.7% of the actual weight. The interquartile range (25th to 75th percentile), which represents the “middle half” of the patients, was 91–109%, indicating that half of the patients had an estimated weight within 9% of the actual weight; however, there was a large range (70–133%). Conclusion: 3D CTA with stereotactic fiducials allows surgeons to adequately estimate abdominal flap volume before surgery, potentially giving guidance in the amount of tissue that can be harvested from a patient's lower abdomen. © 2011 Wiley‐Liss, Inc. Microsurgery, 2011     

Preoperative planning of deep inferior epigastric artery perforator flap reconstruction with multislice-CT angiography: imaging findings and initial experience.

BACKGROUND: Autologous breast reconstruction with abdominal tissue is one of the best options after mastectomy. Reconstruction with deep inferior epigastric perforator (DIEAP) flaps requires a precise location and preoperative evaluation of perforating vessels. The objective of this report is to demonstrate the usefulness of multislice-CT (MSCT) angiography for preoperative planning in patients undergoing DIEAP flap reconstruction. METHODS: Six consecutive women were considered for breast reconstruction with DIEAP flaps after previous mastectomy for breast cancer. Preoperative MSCT angiography was performed to localise the arterial perforators. Axial images, multiplanar reconstructions (MPR) and 3D volume-rendered images were analysed. Findings were correlated with surgery. Initial experience and imaging findings will be described. RESULTS: Accurate identification of the main perforators was achieved in all six patients with a very satisfactory concordance between MSCT angiography and surgical findings. No unreported vessels were found. Location, course, anatomical variations and relations of the superficial inferior epigastric artery were reported. The very small perforators, were equally evaluated and described. CONCLUSIONS: Preoperative evaluation of perforator arteries with MSCT angiography is feasible in patients undergoing breast reconstruction. This technique provides a noninvasive global approach of the vascular anatomy and the entire anterior abdominal wall. However, more patients need to be evaluated in order to clarify the potential aspects pointed in this report.