12. Nakajima (1995). Arterial anatomy of mammary gland. Asthetic Plast.Surg 27: 393.
the nipple - areola complex. Plast.Reconstr. ^^ Wuringer (1998). Nerve and vessel Surg. 96: 843. supplying logamentous suspension of the 13. Van Deventer (2004). The blood suplly mammary gland. Plast. Reconstr. Surg, to the nipple-areola complex of the human 30: 363.
Summary
THE ARTERIAL BLOOD SUPPLY TO MAMMARY GLAND AND NIPPLE AREOLA COMPLEX
Our study aim to discuss the blood supply of the mammary gland and the nipple areola complex in Vietnamese cadavers. The results show that, in dry dissected specimens, tree types of vessels were identified that have the potential to carry blood to the mammary gland and NAC: lateral thoracic artery, internal thoracic artery, superficiel thoracic artery. In the first group, the lateral thoracic artery consist to the main artert with a diameter of 2.21 ± 0.97 mm and the secondary artery with a diameter of 1.63 ± 0.27 mm. The blood branch supplying to NAC derived from the lateral thoracic artery (34.55%) and from secondery artery (38.18%). Their branchs to NAC were focused on external haft of the areola. CONCLUSIONS: The blood supply for the mammary gland and NAC derived from different vessels, this rich blood supply allows for a variety of reduction techniques, ensuring the viability ofthe skin flaps after surger.
Keyword: lateral thoracic artery, internal thoracic artery, superficiel thoracic artery, nipple areola complex
SU" DUNG VAT C U 6 N G LI^N MACH XUYEN OQNG MACH NGl/C LUNG TRONG TAO HJNH KHUYET P H A N M ^ M C 6 NGg'C:
NHAN BA TRU'ONG HOP LAM SANG
Nguydn Dinh Minh\ Trln Thilt Sen^
^Bgnh viin Saint Paul Hi A/p/, 'Trw&ng Dgi hgc YHi NQI
Vat cudng iiin mach xuydn ddng mgch nggc Iwng la mdt chit lidu mdi duxyc dp dgng tmng phiu thudt t^o hinh. Nghidn cdu duxyc thgc hidn nhim md td qui trinh phiu thudt vat cudng liin mach xuydn ddng mach nguc Iwng vd ddnh gid mdt sd wu diim cua vat cudng liin mach xuydn ddng mach nggc Iwng tmng tao hlnh vung c6 nggx;. Kit qua cho thiy vgt cudng liin mach xuydn ddng mgch nggc Iwng cd cudng mach td 10 em din 15 cm, kieh thwde vat ddi Id 12 cm din 16 cm, chiiu rdng vat td 7 cm din 8 cm, pham vi xoay cua vat tdi da Id 36 cm d cdc vung nggc ddi bdn vd cd cung bdn. Thdnh phin vat bao gdm da vd mdt phin ca nim theo cudng m^ct).
Tit cd ede tnrdng hgp diu eho kit qud thim my tdt Tw dd ed thi kit ludn. phiu tich vat cudng liin mach xuyen ddng mach nggc Iwng khdng khd khdn vd vat ed thi sd dgng di che phu cdc khuyit phin mim vung ed ngiyc.
Tip khda: nhanh xuyen dfng mgch nggc lung, vgt cudng liln, khuyet phin mem
I. DAT V A N 0 £ cudng mgch nudi la nhanh xuydn tip dfng mgch I nggc lung gin day mdi dugc Angrigiani va CS Vgt da ca lung rpng cudng mgch liln dugc ||n dau tien dua vao dp dgng tren Idm sang I.Tasini phat hifn va su- dgng tip nam 1896, (1995). Tip dd din nay, vgt da dga trdn nhanh nhung vgt da khdng kem ca lung rpng vdi xuyen dpng mgch nggc lung dugc cdc tac gia
khai thac chu yeu dudi dgng vgt vi phiu, trai Igi vgt da cudng mach lien it duge chu y vd dp dgng tren lam sang. Nhti-ng uu dilm nhu sii-c sdng cua vgt cao, tinh hang djnh cua cudng mgch nggc lung, dp dai ciia cudng mgch ciing vdi nhanh xuyen kha ldn, thanh phin cua vgt ed t h i kit hgp vdi mpt phan ca lung to, kha ndng xoay vat den nhti-ng vimg xa so vdi lung... da ldm cho vgt cudng lien mgch xuyen dfng mgch nggc lung (MXDMNL) trd thdnh mft chit lifu hip din cac phiu thugt vien tgo hinh. Lan dau tien tai Vift Nam, vgt da cudng liln MXDMNL da dugc chiing tdi dp dgng thanh edng tren ba bfnh nhin cd cac khuyet phin mem d vimg nggc cd trong thdi gian vira qua. Mge dii ddy chi Id nhu-ng kit qua budc dau nhung dieu nay cung md ra mdt hudng nghien ciPU ve mdt logi chit lieu tgo hinh mdi cd chat lugng vd hifu qua cao.
Muc tieu:
1. Md ta qui trinh phau thuft vgt da cudng liln mgch xuyen ddng mach nguc lung.
2. Nhdn xet mot sd uu dilm ciia vat da cudng liln mach xuyen dong mach nguc lung trong phlu thudt tgo hinh vimg cd nguc.
II. 0 6 l TUONG VA PHUONG
P H A P1. Ddi tLPeng nghien ciPU
Ba benh nhan duge dilu tri tgi khoa Phiu thudt tgo hinh benh vien da khoa Xanh Pdn Ha Ndi tip thdng 9/2008 d i n thdng 2/2011. Nguyen nhdn gay khuyet phin mem Id do xa tri dilu tri ung thu (2 trudng hgp) va dieu tri u mau (1 trudng hgp). Kich thude cua cac tdn khuylt phin mem dao ddng tip 28 cm^ din 42 cm^ Tit ca cdc vgt da 6\roc su- dgng d dgng cudng lien vdi mgch nudi la MXDMNL.
2. Phueng phap nghien ciPU
Ky thuit phiu tich vat da cuong lien MXDMNL
Dudng di ciia eac ddng mach nggc lung va cac mgch xuyen 6\yac xac djnh sa bd trudc dd bang Doppler d m tay. Tren ca sd ciia mgch xuyen, thiet k l vgt da tuang irng vdi khuyet phin mim ciia bfnh nhan. Vgt da mam theo hudng di cua mach xuyen. Bfnh nhan 6^yac phiu thuat dudi vd cam toan than, nam nghieng
va tay dang 90 dp. Dudng rgch da nam d bd trudc cua ca lung rpng. Rgch da va td chiPC dudi da din ldp can ca. Tim bd trudc ca lung rpng, sau dd tien hanh tim dilm vdo da ciia cac mgch xuyen trong Idp dudi da. Vifc phiu tich dpng mgch nggc lung va cae nhdnh dpng mgch ngodi dugc thgc hifn d mft dudi ca lung rpng.
Tim cac mgch xuyen tach ra d tip nhanh dpng mgch va phiu tich mgch ra khdi khdi ca. Trong trudng hgp cd nhieu mgch xuydn va dudng kinh mgch qua nhd, ed the lay mgch cimg mpt bd ca xung quanh d l bao tdn cudng mgch. Khi phgm vi cua dao da ldn, cd the lly cimg mpt liic cac mgch xuyen cua cac nhanh dpng mgch ngoai va trong. Phiu tieh vd bao tdn cac nhanh thin kinh nggc lung chgy cimg mgch mau. Diing dao difn ludng cgc 6k ddt cac nhanh nhd chay vao ca. Qua trinh tach vgt da khdi can ca lung rong dyyqfc tiln hanh tip diu xa tdi ddu gan, tip bd trudc din bd sau. Cudng mach nggc lung dugc phiu tich cho den dogn nguyen uy, hay lay den ddng mgch dudi vai dk cd dugc cudng mach dii dai trong mpi trudng hgp.
Sau khi phiu tieh vgt ciing cudng mach nggc lung, tien hanh tao hinh cac khuylt phdn mem.
Tao mpt dudng him dudi da ndi tip hom nach tdi bd tdn thuang. Khau hai Idp toan bp vat vdi bd khuyet tdn vd dan luu. Vung cho vat dugc ddng trge tiep. Kit qua phiu thudt duge danh gia vao cac tieu chuln: vat sdng tdt tgi nai nhdn, nai cho vgt da khdng bj bien dgng vd chire ndng tgi nai tgo hinh phgc hdi tdt, tinh thim my ciia vat cho tao hinh dam bao.
III. K^T QUA
1. Ca lam sang 1
Benh nhdn nO- 62 tudi, trudc dd 4 nam da dugc dieu trj phiu thuat bao tdn va xa trj vii trai do ung thu. Trudc khi nhdp vifn 4 thang, tgi cgc tren vii trai xuat hifn vlt loet kich thude 6 x 6 cm, chay djch hdi. Vlt md cu cgnh vlt loet xuat hien co keo. Vet loet lan rpng vd gay khd chju cho bfnh nhan. Mge tieu ciia phiu thuat eat bd rdng tdn thuang sau xa tri da bj viem loet man tinh, tgo hinh che phu khuyet da vd td chire dudi da eiia vii bing vgt da edn MXDMNL, tao sg can ddi cua ben vu phai bj phi dgi. Benh nhan duge chl djnh sip dgng vat da can mgch xuyen ddng mach nggc lung sau khi duge sieu am xac djnh
65
cudng mgch ndy. Kip phiu thuft thip nhit d t lpc viing loet rpng rdi, khuylt hdng thu dugc hinh vgt kfch thudc 20 x 8 cm. Kip thu- hai phiu tich vgt da cdn mgch xuydn d i n nguydn uy dpng mgch nggc lung. Kich thudc dao da 12 X 8cm, chieu ddi cudng mgch 10 cm (bao gdm chieu dai nhinh xuyen vd nhdnh ngodi dfng mgch nggc lung). Vgt d l ddng dugc chuyin din khuylt phin mim. Viing cho vgt ddng da trge tilp. Vgt sdng tdt vd liln
spo thi d i u tgi nai nhdn vgt. Sau dd 6 thdng bfnh nhdn duge tgo hinh thu gpn vii phai cho cdn ddi vdi vu trdi. Theo ddi sau md cho thiy, vgt sdng hodn todn, chit lugng vgt rit phii hgp v l mdu sic, df ddy, tfnh chit mim mai so vdi da Idnh xung quanh. Theo ddi xa sau 6 thdng cho thiy vgt khdng bj co keo, spo quanh vgit mim mgi. Spo tgi nai cho vgt nilm mgi, khdng qud phdt nhung cd sg biln ddi mdu s i c (hdng) kdo dai.
Hinh 1. v l t loet idu l i l n vii trai sau xg trj 4 nam d u ^ c che phii bdng dao da cd cudng tip nhanh xuyen mgch ngg'c \vmg 2. Ca lam sang 2
Bfnh nhdn ntp 42 tudi, dugc dilu tri xg tri khdi u mau vung dc trudc dd 19 nam. Vung da 6\jfac xa tri mit sic td, dau rat vd ngira. Luc nhdp vipn, spo vdi kich thudc 5 x 12 em vung trudc iPc cd tinh trang mat sic td da, da mdng, ranh gidi tdn thuang rd rang. Bfnh nhdn dugc chf djnh diing vgt cudng lien MXDMNL. Bfnh nhdn dugc phiu thudt dudi vd cam todn thdn.
Tdn thuang dugc d t bd rfng rdi sang hai ben vdi khoang each an todn Id 1 cm. Vgt dugc thiet k l theo chilu song song vdi bd trudc ca lung rpng vdi kich thudc 7 x 14 cm, cung xoay dugc thilt k l nim d dinh ndch. Rgch bd trudc vgt tim dugc mpt nhanh xuydn ca da xult phdt tu- nhanh ngodi cua mgch nggc lung, tuy
vgy nhdnh nay khd nhd, vi vgy lly dai ca xung quanh di kdm vdi nhanh xuyen d l dam bao an todn clp mau cho vgt. Cudng mgch dugc boc din dinh ndch, thit bd nhdnh trong ciia mgch nggc lung 6k tdng dp vuan xa cua vgt. Cudng mgch sau bdc vgt dai 15 em. Ldm mdng vgt so clp vimg ngogi vi xung quanh cudng mgch de vgt cd dp day thieh hgp vdi vimg trudc xuang ii-e. Tgo mpt dudng him tip hdm ndch din vting iPC 6k chuyin vgt tdi vimg tdn thuang. Nai cho vgt duge ddng trge tiep 2 Idp vd din luu bang sonde sd 14. Vgt sdng hodn todn, spo xung quanh vgt mim mgi, nai lly vgt ddng tn/c tiep de dang. Chit lugng vgt rit tdt, vgt mim mgi, hodn todn tuang ddng v l mdu sac vdi da viing thdnh trudc nggc vd cd dd ddy iy tudng.
"n
•T Ql
i
Hinh 2. Sfo sau xa tri dieu trj u mau 19 nam, v?t cuing lien MXDMNL vdi cuong mach kem dai cff lung rfng
ml
3. Ca lam sang 3
Benh nhdn nam gidi, 53 tudi, da duge xa tri ung thu niem mge mifng each dd 5 nam. Tdn thuang bao gdm hogi tu- lp xuang ham dudi, loet toan bp da vimg ma, xa hda da xung quanh.
Benh nhdn da dugc d t doan xuang ham dudi, tgo hinh ehe phu khuylt phin mem ma vd niem mge mifng bang vgt diii trudc ngodi tg do. Tuy vay loet niem mge mifng keo dai la hogi tii- va nhiem trung dao da che phii ben ngodi. Khoang vimg d t dogn xuang hdm bj If vd chay djch keo ddi. Chf djnh su- dgng vgt da ea nhdnh NXOMNL nham su- dgng mpt chit lifu ed kha nang d p mau tdt, vO-a tgo hinh dpn khoang ao vimg ma, ham dudi vd che phii tdn thuang d ca mgt da cung nhu niem mge mifng. Qua sieu am Doppler xdc djnh 6w(yc 1 nhanh xuyen ciia nhdnh ngodi each dfnh hd ndch khoang 15 cm, tip vj tri mgch xuyen ndy vat vdi kfch thudc 16 X 7 em dugc thilt k l dga tren he mgch nggc lung. Tren phiu tieh phat hipn ra trong vgt cd 2 nhanh xuydn cho ra tip nhdnh ngoai, d l tang dp ddi ciia cudng mgch chiing tdi chi sii- dgng nhanh xuyen phia xa trung tam. Cudng mach dugc phau tieh kem mdt dai ca cd b l ngang 2 cm, mat khde d l tao hinh ddn viing xuang ham dudi, vgt dugc lly cimg mdt phan ca lung rpng eho mge dich nay. Cudng maeh dai 15 cm va dugc ludn qua dudng hdm dudi da vd vuan tdi ed, ma khdng bj cang. Tdn thuang vung niem mge 6ufac d t lpc rdng rai vd dugc tram bang ca lung rdng. Kit qua cho thay vat sdng hoan toan, khdng chay djch ra ngodi da hay trong khoang mieng. Chit lugng vgt khd tdt, benh nhdn vin de dang hogt dpng xoay cd khdng bj cang keo vgt
IV. BAN LUAN
Vgt da ca lung rdng la mdt chit lieu kinh diln da dugc u-ng dgng trong tgo hinh vii va che phu d c khuylt phin mem thanh nguc tip'thi ky 19, uu dilm ciia ky thuat la de lam, giai phiu cua ddng mgch nggc lung va ca lung rdng rat hang djnh. Nhugc dilm cua vat da ca lung rpng la phai hy sinh chipe nang ciia ca lung rpng, mdt ea Idn d viing lung lam giam lgc khep ciia canh tay cung nhu gay thieu hgt td chirc viing lung nai cho vat.
Vgt nhanh xuyen tip mach nggc lung lln dau tien dugc tac gia Angrigiani md ta dudi dgng Vgt da ea lung rpng khdng lay ca" [1], tip dd den nay da dugc su- dgng rpng rai ciing vdi cac vat mgch xuyen khac. Dga tren giai phiu hdng djnh cua dpng mgch nggc lung nhieu nghien ciPU da chl ra ring ludn tdn tgi nhanh xuyen tip nhanh xudng hoge nhdnh ngang ciia dpng mgch nggc lung [6, 7]. Trong nghien cii-u nay, tren mdi vat chung tdi diu tlm dugc it nhit mpt nhanh xuyen tip nhdnh xudng. Vifc sip dgng nhanh xuyen (cua nhanh xudng) edng xa trung tdm, thi cudng mgch cang dai. Nhu vdy, vdi each thiet ke tren vgt cd kha nang vuan xa han, cd thi su- dgng vat de tgo hinh viing trudc xuang iPC hoge tdi tang giti-a mat ma khdng gdy khd khan nao.
Trong qua trinh bdc vat, chimg tdi thay rang vifc bdc vgt nhanh xuyen cua dpng mach nggc lung ed thudn Igi han so vdi cac vgt mgch xuyen khac do mgch nggc lung kha hang djnh, ludn di song song vdi bd trudc ca nen viec tim nhanh xudng cung khd d l dang. Mat khac ca lung rpng kha mdng nen viec phiu tich dogn mach di trong ca khdng khd khan. Mpt dilm chu y khac khi bdc mach xuyen do la hlu nhu cae mach xuyen nay sau xuyen qua ca thudng di them mdt doan d mat tren ca rdi mdi vdo da, luu y nay giiip cac phau thuat vien tranh lam tdn thuang mgch do nhdn djnh nham la mgch nudi ca.
Vide lly ea kem theo cudng maeh da duge Hamdi dua ra trong ede trudng hgp mgch nhd hoac dap ylu. Cd 3 each lay ca kem theo cudng mach xuyen: lly dai ca 2 x 4 em, lly mpt phan ca hoac lly gin todn bp ca lung rdng tiiy vdo tinh trgng eg t h i ciia mach [2]. Trong nghien CLPU nay, cd mpt benh nhdn dugc lay kem theo dai ca 3 X 6 cm do mgch nhd, dap rat ylu. Bfnh nhan thip 3 dugc lly mpt nhdnh ca kem cudng mgch va mdt phan ea kem vgt de tang them dp day, kha nang dpn ciia vat.
Qua nghien cii-u, thay rang, hf thdng tTnh mgch hdi luu ciia vgt rat nhd, thudng Id 2 tTnh mach tiiy hanh, do vdy vide cang cudng vat se chic chan din din vide nghen tTnh mgch v l . Do vdy, cudng mach d n dugc bdc dai tdi da, trong trudng hgp d n thilt, nlu ede nhanh xuyen cua nhanh xudng dii nudi vgt, cd t h i cap eat nhanh 67
ngang d l giai phdng cudng vgt, trong trudng hgp nghien ciru ndy chilu ddi tip cung xoay din da cua ba vgt dao dfng tip 10 din 15 cm, du d l xoay vgt din tdn thuang md khdng cd sii-c cang. Han nO-a, vifc bdc tdch dudng him dudi da d n rpng rai vd d m mdu ky d l trdnh nghdn tTnh mgch.
V. K£T LUAN
Vgt dao cudng liln nhdnh xuydn tip dpng mgch nggc lung la mdt vgt cd tinh kha thi cao cho tgo hinh che phu khuylt phin mim thdnh nggc trudc. Vgt cd nhO-ng uu dilm vugt trfi so vdi vgt da ca lung rfng kinh diln do cd df mdng phil hgp, mim mgi, mdu sic tuang ddng vdi vdi vung tgo hinh, mft khde vife su- dgng vgt linh hogt va cd kha ndng vuan xa han nhd su- dgng mgch xuydn. Vifc giam thilu dugc cdc di chipng tgi nai lly vgt cung Id mft ylu td 6k vgt dugc su- dgng ngdy cdng phd biln.
TAI LIEU THAM KHAO
1. Angrigiani C, Grilli D, Siebert J (1995).
Latissimus dorsi musculocutaneous flap without muscle. Plast Reconstr Surg. 96:1608-1614.
2. Hamdi M, Van Landuyt K, Monstrey S, Blondeel P (2004). Pedicled perforator flaps in
breast reconstruction: a new concept. Br J Plast Surg; 57: 531-539.
3. Kim JT (2005). Two Options for Perforator Flaps in the Flank Donor Site: Latissimus Dorsi and Thoracodorsal Perforator Flaps. Plast Reconstr Sur.\ 115: 755.
4. Kim JT, Kim SK (2004) Hand resurfacing with the superthin latissimus dorsi perforator- based free flap. Plast Reconstr Surg;111(1):
366 370.
5. Lln CT Yang KC, Hsu KC, Liu WC, Chen JS, Chen LW (2009). Sensate thoracodorsal artery perforator flap: a focus on its preoperative design and harvesting technique. Plast Reconstr Surg.;123(1): 163-174.
6. Mun GH, Lee SJ, Jeon BJ (2008).
Perforatortopography ofthe thoracodorsal artery perforator flap. Plast Reconstr St/rg.;121 (2):
497 - 504.
7. Schaverien M, Saint-Cyr M, Arbique G, Brown SA, Rohrich RJ (2008). Three- and four-dimensional arterial and venous anatomies of the thoracodorsal artery perforator flap. Plast Reconstr Surg.•,^2^ (5): 1578-1587.
8. Uygur F, Kufahci Y, Sever C, Duman H (2009). Reconstruction of postbum thenar contractures using the free thoracodorsal artery perforator flap. Plast Reconstr Surg.;124(1):
217 221.
Summary
THORACODORSAL ARTERY PERFORATOR PEDICLED FLAPS IN
RECONSTRUCTION FOR T H E NECK
AND THORAX: 3 CLINICAL CASES
Thoracodorsal artery perforator pedicled flap (TDAPP) was used firstly in our practice of plastic surgery. The aim of this study is to report the 3 cases, to discribe our experience on technical procedures with TDAPP flaps in reconstruction. The results show that the pedicled TDAP flap was harvested in two cases with the lenght of vascular pedicle was from 10 to 15 cm. The flaps dimensions were from 7 to 20 cm. There were two flaps with a variable amount of muscle. A successful flap transfer was achieved in all patients. The donor sites of the perforator flaps was premary closure.
In conclusion, our results show that TDAPP flaps are safe and extremely versatile technique with a long pedicle and a large flap cutaneous territory.
Key word: thoracodorsal artery perforator, pedicled flap, soft tissue defect
