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1、转移背阔肌肌皮瓣修复术在局部晚期乳腺癌手术中的应用.Contents局部晚期乳腺癌定义局部晚期乳腺癌定义局部晚期乳腺癌治疗现状局部晚期乳腺癌治疗现状背阔肌解剖学背阔肌解剖学背阔肌肌皮瓣修复术手术要点背阔肌肌皮瓣修复术手术要点注意事项及临床体会注意事项及临床体会.局部晚期乳腺癌治疗现状？.Impact of progression during neoadjuvant chemotherapy on surgical management of breast cancer.nMETHODS: We reviewed clinicopathological data on patients who
2、 received NCT for stage I-III breast cancer from 1994 to 2007. Chemotherapy regimens were anthracycline-and/or taxane-based as determined by the treating medical oncologist. nRESULTS: Of 1,928 patients who received NCT, 1,762 (91%) had a partial or complete response, 107 (6%) had stable disease (SD)
3、, and 59 (3%) progressed (PD) while receiving at least one regimen. Of the patients with progressive disease, 40 (68%) patients underwent mastectomy, 12 (20%) underwent BCT, and 7 (12%) did not undergo surgery. In patients who underwent mastectomy, only three (8%) were BCT candidates before progress
4、ion. Overall, disease progression changed the operative plan in 11 (0.5%) patients: 3 developed distant metastasis, 2 developed clinical lymphadenopathy, 3 required mastectomy instead of BCT, 2 became inoperable, and 1 required flap closure.nCONCLUSIONS: Disease progression while receiving NCT is in
5、frequent (3%), but early identification may allow for change to other, potentially beneficial, therapeutic interventions. Patients with breast cancer who receive NCT should be evaluated frequently for response to therapy. Overall, progression during NCT changes the surgical management in a small pro
6、portion of patients. Caudle AS et al. Ann Surg Oncol. 2011 Apr;18(4):932-8. .转移背阔肌肌皮瓣修复术适应症及禁忌症适应症：适应症：n乳房切除术后皮肤缺乳房切除术后皮肤缺损损n乳腺癌根治术后自体乳腺癌根治术后自体组织乳房重建组织乳房重建n保乳术后局部畸形保乳术后局部畸形n放疗后胸壁溃疡放疗后胸壁溃疡禁忌症禁忌症n开胸术后背阔肌被切开胸术后背阔肌被切断断n胸背血管受损者胸背血管受损者n上胸壁大面积皮肤缺上胸壁大面积皮肤缺损者损者. 背阔肌的解剖学基础.背阔肌解剖学n位于肩胛骨下方，三角形位于肩胛骨下方，三角形n发于发于T7
7、T12T7T12、腰骶椎和最、腰骶椎和最下面下面3434根肋骨，止于肱骨根肋骨，止于肱骨结节间沟结节间沟n供血来源于胸背动脉和内供血来源于胸背动脉和内乳动脉及肋间动脉的穿支乳动脉及肋间动脉的穿支n神经支配为胸背神经神经支配为胸背神经n功能：使肱骨内旋，上臂功能：使肱骨内旋，上臂的内收和外展的内收和外展.背阔肌肌皮瓣的应用n历史历史：BaudetBaudet (1976) (1976) 首先进行了游离移首先进行了游离移植的报道。以后临床广泛应用，成植的报道。以后临床广泛应用，成为最常用的游离皮瓣之一为最常用的游离皮瓣之一 n皮瓣特点皮瓣特点：血管分布恒定，蒂部管径在血管分布恒定，蒂部管径在1.5
8、2.0mm1.52.0mm。血管蒂长：血管蒂长：68cm68cm易于剥离和切取易于剥离和切取供区范围大：供区范围大：68cmX 1215cm68cmX 1215cm供区不遗留明显的功能障碍供区不遗留明显的功能障碍皮瓣血运丰富皮瓣血运丰富可形成单纯的肌瓣可形成单纯的肌瓣可用于进行肌肉功能的重建可用于进行肌肉功能的重建 n应用范围应用范围：带蒂移植：胸部、上肢的组织缺损，带蒂移植：胸部、上肢的组织缺损，屈肘功能重建，乳房再造等屈肘功能重建，乳房再造等游离移植：头、面、颈、四肢、躯游离移植：头、面、颈、四肢、躯干等部位均可应用干等部位均可应用 .1n术前先描画出手术切术前先描画出手术切口口n全麻下，
9、先仰卧位，全麻下，先仰卧位，行乳腺癌改良根治或行乳腺癌改良根治或根治术根治术n乳房切口彻底止血后乳房切口彻底止血后用湿大纱布覆盖并用用湿大纱布覆盖并用无菌手术膜隔离无菌手术膜隔离.2n再取侧卧位，在背阔再取侧卧位，在背阔肌表面按预先设计的肌表面按预先设计的梭形切口逐层切开梭形切口逐层切开n沿背阔肌前缘切取背沿背阔肌前缘切取背阔肌并向后方延续，阔肌并向后方延续，注意保护前锯肌及大注意保护前锯肌及大圆肌圆肌n注意保护血管蒂注意保护血管蒂n把肌皮瓣经皮下隧道把肌皮瓣经皮下隧道轻送到乳房创面轻送到乳房创面.3n再改为仰卧位，将转再改为仰卧位，将转移的肌皮瓣缝合固定移的肌皮瓣缝合固定于前胸壁切口并关闭于
10、前胸壁切口并关闭皮肤切口皮肤切口n切口轻度加压包扎切口轻度加压包扎n引流管负压吸引引流管负压吸引.手术技巧及注意事项.1.体位1.先仰卧位；先仰卧位；2.侧卧位；侧卧位；3.最后仰卧位最后仰卧位.2.保护胸背血管蒂胸背血管胸背血管胸外侧血管胸外侧血管.5.慎防误切大圆肌及前锯肌误切上述二肌肉会引起肩关节内收功能障碍误切上述二肌肉会引起肩关节内收功能障碍.临床体会临床体会.体会1.严格掌握适应症严格掌握适应症防止并发症发生防止并发症发生体会2 术后开始辅助放射治疗的时间选择术后开始辅助放射治疗的时间选择.summaryn局部晚期乳腺癌的治疗是以手术为主的多学科综合治疗局部晚期乳腺癌的治疗是以手术为主的多学科综合治疗n转移背阔肌肌皮瓣修复术是局部晚期乳腺癌切除术后修复皮肤缺损的转移背阔肌肌皮瓣修复术是局部晚期乳腺癌切除术后修复皮肤缺损的一种安全合适的手术方式一种安全合适的手术方式.
