| Background:According to statistics of World Health Organization,breast cancer incidence of women has been increasing in the past decades and becoming the worldwide number one malignancy in women.The incidence rate of breast cancer in China accounted for the first of the female cancer incidence.Present,whether domestic or foreign,the treatment of breast cancer is generally combined with resection of the ipsilateral tumors and a mastectomy.Lack of breast severely affected patients with normal mental health and social interactions.The aim of modern breast reconstruction is to correct breast defects and chest wall deformity caused by breast cancer,so as to treat patients physically and psychologically Deep artery perforator flap(deep inferior epigastric perforator DIEP),as the improvement of traditional free transverse rectus abdominis muscle flap(transverse rectus abdominis musculocu taneous,TRAM),has become the technique of preferred autologous tissue breast reconstruction..Compared with traditional TRAM flap,DIEP flap breast reconstruction retains the rectus sheath,and most of the rectus abdominis,minimizing the occurrence of flap donor site complications.However,the limited number of perforators of the DIEP flap increases the free flap surgery complexity,the occurrence of flap fat liquefaction and necrosis.How to improve the survival rate of breast reconstruction DIEP flap under the premise to protect the integrity of the flap donor site is the currently new topic of plastic and reconstructive surgeryObjective:This study included human anatomy experiments,rat DIEP flap model building and molecular biology experiments,and clinical surgeon study,in order to unclose the feasibility of unilateral pedicle DIEP flap,as well as its application in clinical breast reconstructionMethod:1.Anatomical study:? Three fresh cadavers were included.The anatomy was conducted on DIEP flaps and the surrounding tissue to explore the perforating branches of DIEP flap;?Twenty patients were included.Ultrasound detection was performed in order for the number,location and the caliber of the perforating branches.We also observed the above data during the operation,and compared them with the ultrasound results.Vitro studies:40 SD rats were included averagely grouped to build 4 kinds of flap model:group A:unilateral single-pedicled flap;group B unilateral double-pedicled flap;C Group:Bilateral single-pedicled flap;D group random flap;?Distal epithelial tissue of the flap was collected 72h after the operation.Western Blot was used to detect HIF-la expression change;?Flap survival rate of each group was recorded one week after the operation 3.Clinical model built:Twenty patients were included and the preoperative and the intro-operative clinical data was collected and analyzed;?We used microvascular clip to block the vascular pedicle,and observe the color changes,skin temperature transcutaneous oxygen pressure changes;Study of clinical application:Clinical inclusion and exclusion criteria were built,and patients with breast defect were included.The patients were classified to two groups:Group ? unilateral pedicle DIEP flap breast reconstruction and Group ? bilateral pedicle DIEP flap breast reconstruction.Parametric(Student's t-test)and nonparametric(Mann-Whitney U test for non-paired data)tests were used to compare different values.The criteria for statistical significance was set at a value of p<0.05Results:1.Anatomical study:?The average length of the vascular pedicle from deep blood vessels under the DIEP flap was 11.8 cm(10.3?12.6cm),the average diameter of the artery of the beginning part was 1.75 mm(1.64?1.95mm).The number of perforating branches with the circumference over 1mm was 26 in all,and 8.6 for each body,mostly intensively located around the cullen site.?clinical observation revealed that average effective length of the vascular pedicle of the DIEP flap is 13.6 cm(10.8?15.1cm);the average diameter of the artery of the beginning part was 1.75 mm(1.59?1.91);The number of perforating branches with the circumference over 1mm was 8.8;The number of perforating branches with the circumference over 1mm was 5.7 in the Cullen site(8cm in diameter).?The examination results of ultrasound suggested the accuracy of preoperative ultrasound on the positioning more than 75%of perforators of the DIEP flap.In vitro studies:?Seven days after flap construction,the average flap survival rate of group A was 69.0±3.1%,necrosis was limited to the contralateral distal flap area;the average flap survival rate of group B was 85.6±4.5%,necrosis was limited to the contralateral distal flap area;the average flap survival rate of C group was 88.8 ± 4.4%,necrosis was limited to the bilateral distal flap area;the average flap survival rate of group D was 55.3 ± 6.8%.Analysis of variance prompt significant difference(P<0.05)in the four groups.Compared with the group A and group D,the flap survival rate of group C and group B was significantly increased(P<0.05).All the group revealed the expression of HIF-1a 72 hours after the flap operation.Group D(random flap group)expressed the highest level,followed by group A(unilateral single-pedicled flap group),then group B(unilateral double-pedicled flap group)and group C(bilateral single-pedicled flap group).Compared with group D and group A,the HIF-1a expression of group B and group C was lower.4.clinical study:According to the distance from the contralateral pedicle to the midline of the flap,20 patients with 40 unilateral flap pedicles were divided into two groups:group I(5?8.6 cm,N=17)and group ?(3.5?5cm,N=23);?Ten minutes after the pedicle blood supply interrupted,the skin temperature change and the transcutaneous oxygen pressure change of the flaps did not differ significantly between the two groups,except for the contralateral distal flap area(P<0.05);4.None of patients occurred the flaps fully necrosis and postoperative donor site incision hernia;There's no difference in second surgery,and partial flap necrosis between the two operation styles the patients undertaking flap unilateral single-pedicled DIEP flap breast reconstruction has a lower rate of fat liquefaction(P<0.05).Conclusion:?Cullen area perforators with a diameter over 1mm could be ideal pedicle choose for a DIEP flap.Preoperative ultrasound examination of the flap donor site could help to position and number the perforators of the DIEP flap,making the operation less time consumed for the surgeon;?In the DIEP flap study in rats,unilateral double pedicle DIEP flap enjoined a flap survival rate which was close to the traditional bilateral pedicle flap;?Clinically,the use of single side cullen area perforators as pedicle for DIEP flap could achieve a similar postoperative clinical results in the receival site,and probably less postoperative complication in the donor sites... |
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