局部kiss皮瓣在局部晚期乳腺癌术后胸壁软组织缺损修复中的初步应用

局部kiss皮瓣在局部晚期乳腺癌术后胸壁软组织缺损修复中的初步应用

薛兵建王新星李凯强解钧媛甘丽裴新红

本文来源：《中华整形外科杂志》2023年4月第39卷第4期

DOI:10. 3760 / cma.j.cn114453-20220725-00233

作者单位：郑州大学第一附属医院乳腺外科，郑州450052

通信作者：裴新红，Email: 1007542778@qq.com

引用本文

薛兵建, 王新星, 李凯强, 等. 局部kiss皮瓣在局部晚期乳腺癌术后胸壁软组织缺损修复中的初步应用 [J] . 中华整形外科杂志, 2023, 39(4) : 359-365. DOI: 10.3760/cma.j.cn114453-20220725-00233.

【摘要】

目的探讨局部kiss皮瓣在局部晚期乳腺癌(LABC)切除术后胸壁软组织缺损修复中的初步应用效果。

方法回顾性分析2020年6月至2021年7月郑州大学第一附属医院乳腺外科收治的LABC患者临床资料。所有患者均在新辅助化疗后行乳腺癌改良根治术，应用局部kiss皮瓣技术修复继发胸壁软组织缺损，术中于缺损下方和外上方设计2个局部邻位皮瓣(皮瓣A和皮瓣B)，将皮瓣分别掀起后转移、拼接，共同修复胸壁缺损，供区直接拉拢缝合。术后常规观察皮瓣血运，记录皮瓣存活情况，根据患者手术前后的病理结果给予辅助全身治疗，伤口愈合后开始辅助放疗，并定期复查。

结果共纳入5例女性LABC患者，年龄41~71岁，平均53.4岁，临床分期均为Ⅲ期(T3~4N2~3M0)。LABC术后胸壁缺损面积为12.0 cm×12.0 cm~22.0 cm×20.0 cm，切取的皮瓣A面积为7.0 cm×7.0 cm~14.0 cm×13.0 cm，皮瓣B面积为5.0 cm×4.0 cm~11.0 cm×7.0 cm。术后有1例患者皮瓣A远端出现部分坏死，其余4例皮瓣均全部成活；供区均恢复良好，未发生并发症。术后随访13~20个月，平均15.8个月，皮瓣修复效果满意，有1例未接受放疗的患者于术后4个月出现局部肿瘤复发，其余4例未见肿瘤复发和转移。

结论局部kiss皮瓣技术操作简单、修复效果满意，是一种可行、可靠的LABC切除术后胸壁软组织缺损修复方法。

【关键词】外科皮瓣；乳腺肿瘤；kiss皮瓣；胸壁软组织缺损；修复外科手术

基金项目：河南省医学科技攻关计划联合共建项目（LHGJ20210288）

Local kiss flap for chest wall soft tissue reconstruction following mastectomy for locally advanced breast cancer

Xue Bingjian, Wang Xinxing, Li Kaiqiang, Xie Junyuan, Gan Li, Pei Xinhong

Department of Breast Surgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China

Corresponding author: Pei Xinhong, Email: 1007542778@qq.com

【Abstract】

Objective To investigate preliminary results of chest wall reconstruction with local kiss flap following mastectomy for locally advanced breast cancer (LABC).

Methods Clinical data of the LABC patients receiving treatment at the Department of Breast Surgery, the First Affiliated Hospital of Zhengzhou University between June 2020 and July 2021 was retrospectively analyzed. All patients underwent modified radical mastectomy after neoadjuvant chemotherapy. And the local kiss flap was used for reconstruction of the secondary chest wall soft tissue defects. Two small local flaps were designed intraoperatively and harvested from inferior (flap A) and lateral (flap B) to the defect, respectively, resurfacing a large chest wall soft tissue defect side by side with primary closure of both two donor sites. The flap perfusion was routinely monitored postoperatively. Adjuvant systemic therapies were implemented based on both pre- and post-operative pathological results. And the adjuvant radiotherapy was started immediately after wound healed completely. All cases were followed up regularly.

Results A total of five female patients were included, with an average age of 53.4 (ranging from 41 to 71). Stage Ⅲ (T3-4N2-3M0) breast cancer was diagnosed in all cases. After mastectomy, chest wall soft tissue defect was presented in all cases, ranging from 12.0 cm × 12.0 cm to 22.0 cm × 20.0 cm. The flap A measured from 7.0 cm × 7.0 cm to 14.0 cm × 13.0 cm and the flap B from 5.0 cm × 4.0 cm to 11.0 cm × 7.0 cm. Only 1 flap A suffered tip necrosis and the remnant flaps survived totally. All donor sites recovered uneventfully and no donor-site morbidity was noted. The mean post-operative follow-up period was 15.8 months (ranging from 13 to 20 months). No tumor recurrence or metastasis was noted in all patients, except one patient, who did not receive radiotherapy, suffered local recurrence 4 months after surgery.

Conclusion Given its simplicity and satisfying results, the local kiss flap is a feasible and reliable reconstructive option for chest wall soft tissue defect reconstruction after mastectomy in selected LABC patients.

【Key words】Surgical flaps; Breast neoplasms; Kiss flap; Thoracic wall soft-tissue defect; Reconstructive surgical procedures

Fund program: Medical Science and Technology Project of Henan Province (LHGJ20210288)

Disclosure of Conflicts of Interest: The authors have no financial interest to declare in relation to the content of this article.

Ethical Approval: This study was conducted in accordance with the Helsinki Declaration.

据全球癌症统计，女性乳腺癌已超过肺癌，成为发病率第一位的恶性肿瘤[1]。以手术为主联合全身治疗及放疗，是目前早期乳腺癌的主要治疗方法[2]。部分患者因病情延误，发展成为局部晚期乳腺癌(locally advanced breast cancer，LABC)。LABC一般指不可手术的Ⅲ期乳腺癌，包括较大的原发肿瘤(T3~4)、肿瘤侵犯皮肤和胸壁、广泛的区域淋巴结转移(N2~3)和炎性乳腺癌，但尚无远处转移[3]。推荐先行新辅助化疗使肿瘤降期以利于手术切除，并尽可能达到肿瘤切缘阴性，改善LABC患者的预后[2,4,5]。因扩大了切除范围，LABC术后常遗留较大的胸壁软组织缺损，无法直接关闭。其修复方法包括肌皮瓣、穿支皮瓣、局部皮瓣和皮片移植等，各有适应证和优缺点[6]。基于章一新等[7]介绍的kiss皮瓣技术，本研究设计局部kiss皮瓣修复LABC切除术后的胸壁软组织缺损，即通过转移2个较小的局部皮瓣共同修复一个较大的缺损，且供区可直接拉拢缝合，取得了良好的效果。

资料与方法

一、资料选择

回顾性分析2020年6月至2021年7月郑州大学第一附属医院乳腺外科收治的LABC患者的临床资料。纳入标准：(1)参考美国癌症联合委员会乳腺癌分期系统(第8版)[8]，通过病理确诊临床分期为Ⅲ期的乳腺癌患者；(2)乳腺癌术后遗留无法直接关闭的软组织缺损；(3)应用局部kiss皮瓣修复同一缺损。排除标准：(1)胸壁全层缺损；(2)有乳房再造意愿。本研究已参考赫尔辛基宣言。患者均签署知情同意书，同意将其资料和照片用于本研究。

二、治疗方法

(一)术前准备

术前完善患者全身检查，排除肿瘤远处转移。对乳房肿块及区域肿大淋巴结进行空芯针穿刺活检，明确病理诊断，并制定新辅助化疗方案。按计划完成全部周期的新辅助化疗，2周后进行乳腺癌手术治疗。

(二)乳腺癌改良根治术

患者取仰卧位，患侧上肢外展，肩部垫高约10 cm。全身麻醉后，根据新辅助化疗前肿瘤大小及侵犯皮肤的程度设计切除范围并标记，切口一般距离肿瘤边缘约2 cm，自肿瘤上方开始绕肿瘤周围切开皮肤至皮下脂肪层，用电刀沿浅筋膜浅层游离皮瓣至标记范围，注意保留适当的皮瓣厚度(约0.5 cm),避免损伤真皮下血管网。将患侧乳腺及胸大肌筋膜自内向外一并掀起并切除，清扫腋窝淋巴结至第Ⅲ水平，若术中第Ⅲ水平淋巴结暴露困难，则切除胸小肌以充分暴露。留取上、下、内、外皮肤切缘及基底切缘，与上述切除组织一并送检病理。

(三)局部kiss皮瓣修复术

根据胸壁缺损的大小及缺损下方和外侧皮肤的松弛程度设计皮瓣，在缺损下方设计皮瓣A，在缺损外侧设计皮瓣B，原则上皮瓣的长度不超过宽度的1.5倍。设计时可将类圆形的胸壁缺损视为2个类菱形的缺损，再遵循菱形皮瓣的设计原则[9]，分别设计皮瓣A和皮瓣B。根据缺损周围可转移的皮肤组织量，皮瓣A和皮瓣B可设计为相近大小或一大一小。

沿标记线切开皮肤至皮下组织，自深筋膜浅层分别掀起皮瓣A和B，此时2个皮瓣共用缺损外下方同一蒂部。继续沿深筋膜浅层向蒂部外侧、下方充分游离，如遇较粗大肉眼可见搏动的肋间血管穿支进入皮瓣蒂部，则予以保留，以增强皮瓣血供，并沿穿支逆向解剖，获取足够长度的血管蒂，以便皮瓣转移时不被牵拉。将上述2个局部皮瓣分别按各自的轴线顺时针或逆时针向缺损处旋转、拼接，即形成局部kiss皮瓣，共同覆盖缺损创面(图1)，沿其外缘和下缘各留置1根负压引流管，间断缝合切口。

三、术后处理

术后常规观察皮瓣血运，记录皮瓣存活情况。每3天对伤口进行换药，术后2~3周拆线，当引流量少于10 ml/d时拔除负压引流管。术后1周内限制患侧肩关节外展，术后1个月内避免上肢负重，拔除引流管后常规进行患侧上肢功能锻炼。根据患者手术前后的病理结果，给予辅助全身治疗。伤口痊愈后，及时开始辅助放疗。术后常规定期复查。

结　果

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