改良乳房下真皮乳腺单蒂瓣巨乳缩小术

目的为了进一步保证巨乳缩小术后乳头乳晕的血供和感觉，减少手术并发症。方法设计应用乳房下真皮单蒂瓣，并保留部分乳腺组织的垂直乳腺蒂，及切除的乳腺组织位于乳房下方两侧的巨乳缩小术，自１９９４年１月至１９９５年１１月，为６７例（１３２侧）巨乳患者在法国斯德拉斯堡欧洲美容整形诊所进行治疗。结果术后全部患者无乳头乳晕并发症，感觉正常。结论结合乳腺垂直蒂和乳房下真皮单蒂瓣的改良巨乳缩小术，不但可以确保乳头乳晕的血供，且可减少感觉损伤，降低手术并发症，及提供良好形态。     

改良乳房下真皮乳腺单蒂瓣巨乳缩小术

目的为了进一步保证巨乳缩小术后乳头乳晕的血供和感觉,减少手术并发症。方法设计应用乳房下真皮单蒂瓣,并保留部分乳腺组织的垂直乳腺蒂,及切除的乳腺组织位于乳房下方两侧的巨乳缩小术,自1994年1月至1995年11月,为67例(132侧)巨乳患者在法国斯德拉斯堡欧洲美容整形诊所进行治疗。结果术后全部患者无乳头乳晕并发症,感觉正常。结论结合乳腺垂直蒂和乳房下真皮单蒂瓣的改良巨乳缩小术,不但可以确保乳头乳晕的血供,且可减少感觉损伤,降低手术并发症,及提供良好形态。     

乳房外上真皮乳腺单蒂瓣巨乳和垂乳缩小整复术

目的　探讨乳房缩小美容术保持乳头乳晕血运感觉的方法。方法　采用宋氏巨乳缩小术方法设计切口,以乳头乳晕上方及外侧真皮乳腺单蒂供应乳头乳晕血运和神经支配,完成乳腺整形。１９９６ 年１ 月～１９９８ 年１２ 月对１８ 例３０ 侧巨乳和１２ 例２２ 侧垂乳进行手术。结果　新乳房外形满意,乳头乳晕血运感觉保留好。结论　该法切口瘢痕小、乳头乳晕血运感觉良好,适合于不同轻重程度的巨乳垂乳,可作为乳房肥大或松垂的重要手术方法     

复合组织下蒂法乳房缩小整形术25例

目的：回顾性总结复合组织下蒂法乳房缩小整形术25例病例资料,探讨复合组织下蒂法乳房缩小整形术手术注意事项及其并发症防治。方法：从2003～2008年5年间,对25例女性乳房肥大患者分别进行手术治疗,方法采用复合组织下蒂法。通过对术中复合组织下蒂的修整及术后乳房外形、乳头乳晕复合体血运、术后瘢痕及乳房感觉等方面观察,分析复合组织下蒂法乳房缩小整形术的术中注意事项及术后并发症的防治策略。结果：25例患者均取得了较好的效果,无乳头乳晕复合体血运障碍发生。结论：复合组织下蒂法乳房缩小整形术是较好的乳房缩小术式,良好的术前设计及术中调整是确保手术成功的关键。     

双环中心蒂法乳房缩小术

目的 探讨双环中心蒂乳房缩小术矫治乳房肥大下垂的方法 和疗效.方法 采用环绕乳晕内、外的2个环形切口,形成以乳头为中心的中央真皮帽,楔形或双S形切除多余腺体组织,保留第4肋间神经走行的乳腺组织的完整性,塑形后用真皮帽固定塑形.自2009年4月至2012年5月,采取上述方法 治疗乳房肥大伴不同程度下垂患者12例(24侧).结果 本组患者12例,术后切口均Ⅰ期愈合,经随访3～24个月,乳房外形良好,瘢痕轻微,乳头-乳晕感觉良好.结论 双环中心蒂乳房缩小术设计、操作简单,术后可确保乳头-乳晕的血供和感觉,是矫治乳房肥大下垂的有效方法.     

横双蒂加中央蒂真皮帽乳房缩小成形术

目的　介绍横双蒂加中央蒂真皮帽乳房缩小成形术的方法,并探讨其疗效。　方法　对8例(16只)乳房肥大病人施行手术治疗, 采用以乳头为中心的中央蒂真皮帽乳房缩小成形术, 设计双同心圆切口, 保留第4肋间神经径路乳腺组织的完整性, 切除多余乳腺组织, 环形切口缩拢缝合。结果　本组单侧切除组织量平均为(310±150)g,术后第2d查乳头乳晕感觉良好,反射存在,乳头乳晕无坏死,除1例伤口裂开行2期缝合外,余均无感染、血肿等并发症。随访6 (3 ~9)个月,外形满意,切口瘢痕不明显。　结论　横双蒂加中央蒂真皮帽乳房缩小成形术设计合理,形态好,可确保乳头乳晕的感觉及功能。     

乳房血供及乳房缩小术的研究进展

目的总结近年来乳房血供及乳房缩小术式的研究进展。方法广泛查阅近年来有关乳房神经分布、血供、乳房缩小术式的发展和术后哺乳功能等情况的国内外文献,并结合临床经验进行分析总结。结果随着对乳房腺体及乳头乳晕复合体的神经分布与血供的解剖研究,乳房缩小术已形成了多种手术方式,各有优缺点,适应证亦不同。通过辅助检查技术的应用,术后乳头、乳晕坏死等严重并发症发生率明显降低;通过对切口与蒂部位置的选择、保留蒂部腺体量的程度、辅助吸脂技术的应用和缝合技术方面的改进,减轻了术后切口瘢痕,更好地保留了乳头乳晕感觉,获得了更为满意的乳房形态。行乳房缩小术后部分分娩患者具有一定哺乳功能。结论乳房缩小术需根据患者特点采用个性化手术方式。在如何更好地保留乳头、乳晕感觉,获得良好而持久的乳房形态,生育期妇女术后哺乳功能保留等方面有待进一步研究。     

内上腺体蒂乳房缩小成形术

目的 探讨一种能够保持乳房功能和形成良好外观的乳房缩小成形术。方法 根据乳房肥大的程度设计不同类型的皮肤切口，采用内上腺体蒂技术，切除外上方和下方过多的乳腺组织，将保留的乳腺组织重新塑形，切除多余的皮肤后缝合切口。结果 本组36例72侧乳房术后形态良好，无并发症，乳头乳晕感觉良好，效果满意。结论 内上腺体蒂技术是一种安全、有效的手术方法，能获得持久的塑形效果，通过选择不同类型的皮肤切口可以适用于各种程度乳房肥大的矫治。     

下蒂瓣法乳房缩小整形术的效果

目的探讨下蒂瓣法乳房缩小整形术治疗中重度乳房肥大症的方法及效果。方法2010年1月至2019年12月,南京医科大学附属妇产医院整形外科对19例女性患者(年龄18~54岁,平均36.2岁)38侧肥大乳房,以Robbins的垂直下蒂瓣术式为基础,结合乳房血供、神经等解剖学进展,进行乳晕设计、下蒂瓣位置等改进。结果19例38侧肥大乳房缩小整形手术均顺利完成,切口均一期愈合;无乳头乳晕血运障碍,乳头乳晕感觉正常,乳房外形效果满意。术中切除乳房组织量每侧385~1525 g,平均570 g。术后随访6个月至8年,术后的倒T形瘢痕,均未出现增生性瘢痕,除2例肤色较深术后瘢痕色素沉着比较明显外,其余17例效果均满意。1例患者术后双侧乳头乳晕位置偏高,其余18例患者对乳头乳晕位置及形态表示满意。结论该术式可切除乳房组织量较大,乳头乳晕复合体血供稳定,是治疗中重度乳房肥大症切实可行的方法。     

经腋窝单孔腔镜乳房缩小上提固定术1例报告北大核心CSCD

乳房下垂主要表现为乳头乳晕复合体位置的下降、乳房实质组织的下移及皮肤松弛。乳房下垂常与乳房肥大伴随。乳房缩小上提固定术是临床上最主要的矫正方式。乳房巨大或者下垂可以通过各种开放手术方式矫形[1]。然而,开放乳房缩小上提手术会不同程度给乳房留下正面瘢痕,损伤乳头乳晕的血运,造成乳头感觉障碍和哺乳困难等问题。     

Reduction mammaplasty by central pedicle flap with short submammary scar

Reduction mammaplasty was performed in 30 patients by combining the central pedicle flap method with the short submammary scar (3-S) technique to avoid the common drawbacks of currently popular dermoglandular procedures. Reduction was accomplished by using perforating vascular branches from the pectoralis major muscle and its fascia supplying the nipple and breast parenchyme instead of the subdermal plexus. The central vascular pedicle supplying the nipple-areola complex was preserved. Only the periphery of the breast parenchyme was resected circumferentially, with the exception of the inferolateral portion, so as not to injure the sensory nerve. The remaining breast parenchyme was preserved in an inverted cone shape. The nipple-areola complex was safely transposed with great freedom, and the amount of resection was accurately adjusted for symmetry. No cases of nipple-areola complex sensory change occurred postoperatively, and lactation is possible because of preservation of the lactiferous ducts. The length of postoperative scars was reduced by using the short submammary scar technique. We believe this combined method is ideal in patients requiring resections ranging from 200 to 600 g per breast with good skin elasticity and moderate degree of ptosis.Presented at the Sixth Asian Pacific Congress of the International Confederation for Plastic and Reconstructive Surgery, in Seoul, Korea, October 1993.     

Viability and sensation of the nipple-areolar complex after reduction mammaplasty

Reduction mammaplasty with nipple-areolar transposition on a medial pedicle was designed as an alternative to amputation and free nipple graft for women with severe mammary hypertrophy. The purpose of this study was to review the viability and sensory outcome of the nipple-areolar complex (NAC) in 72 women (133 breasts) after medial pedicle and inferior pedicle reduction mammaplasty between 1996 and 2000. The medial pedicle was used for 41 women (79 breasts) with moderate to severe mammary hypertrophy. An inferior pedicle was used for 31 women (54 breasts) with mild to moderate mammary hypertrophy. Mean follow-up for all patients was 25 months. Total sensation of the NAC was obtained in 68 of 79 breasts (86%) after medial pedicle reduction mammaplasty and in 50 of 54 breasts (92%) after inferior pedicle reduction mammaplasty. Total viability of the NAC occurred in 74 of 79 breasts (94%) after medial pedicle reduction mammaplasty and in 53 of 54 breasts (98%) after inferior pedicle reduction mammaplasty. Quantitative sensory testing of the NAC using the pressure-specified sensory device demonstrated that static and moving sensory thresholds of the NAC are lowest in the inferior pedicle group followed by the control group and the medial pedicle group. It can be concluded from this study that the medial and inferior pedicle techniques are capable of supporting vascularity and innervation to the NAC. The medial pedicle technique for severe mammary hypertrophy is a good alternative to free nipple grafting. The amount of breast tissue removed does not correlate with sensory outcome for both inferior and medial pedicle techniques. The pressure-specified sensory device is an excellent means of assessing sensory outcome.     

Nipple-sparing mastectomy: technique and results of 54 procedures

HYPOTHESIS: The rationale for removal of the nipple-areolar complex (NAC) during total mastectomy centers on long-standing concerns about possible neoplastic involvement of the NAC and its postoperative viability. Nipple-sparing mastectomy (NSM) combines a skin-sparing mastectomy with preservation of the NAC, intraoperative pathological assessment of the nipple tissue core, and immediate reconstruction, thereby permitting better cosmesis for patients undergoing total mastectomy. Neoplastic involvement of the NAC can be predicted before surgery and assessed during the operation, and sustained postoperative viability of the NAC is likely with appropriate surgical technique. RESULTS: Fifty-four NSMs with immediate reconstruction were attempted among 44 patients. Six NAC core specimens revealed neoplastic involvement on frozen section analysis, resulting in conversion to total mastectomies. Forty-five of the 48 completed NSMs maintained postoperative viability of the NAC; 3 NACs had partial loss. CONCLUSION: Nipple-sparing mastectomy is a reasonable option for carefully screened patients.     

保留乳头乳晕乳房切除术联合即刻乳房重建手术中乳头乳晕安全性保留预测模型的建立

目的 探讨保留乳头乳晕复合体乳房切除术（NSM）联合即刻乳房重建手术（IBR）手术中乳头乳晕复合体（NAC）安全性保留的相关危险因素,并建立预测模型。方法 回顾性分析2017年1月至2019年8月在复旦大学附属肿瘤医院乳腺外科行NSM联合IBR的474例病人的临床资料。依据乳头后方组织术后石蜡病检结果进行病例分组即NAC（+）组与NAC（-）组。分析两组病人的临床、影像及病理学特征,进行多因素分析,对独立预测指标赋值,计算不同分值的NAC阳性率,建立相应预测模型并验证。结果 474例病例中,NAC阳性率为13.71%（65/474）,单因素分析显示肿瘤位置、乳头溢液、乳头凹陷、NAC皮肤湿疹样改变、临床肿瘤大小、肿瘤至乳头距离（TND）、临床淋巴结状态、MG-乳头后方钙化、恶性特征钙化灶、合并原位癌成分、组织学类型、组织学分级、脉管癌栓、分子分型与NAC肿瘤阳性相关。多因素分析显示乳头血性溢液、乳头凹陷、NAC皮肤湿疹样改变、临床肿瘤大小、TND、临床淋巴结状态、脉管癌栓是NAC肿瘤阳性独立预测指标。建立NAC预测指数（Predictive Index of NAC,PI-NAC）预测模型提示,0～1分为NAC肿瘤累及低风险,2～4分为中风险,5分及以上为高风险。该模型内部验证ROC曲线AUC值0.85（95%CI 0.80-0.89）,具有较好预测效能。结论 乳头血性溢液、乳头凹陷、NAC皮肤湿疹样改变、临床肿瘤大小、TND、临床淋巴结状态、脉管癌栓是NAC受累的重要独立指标。预测模型有助于术前更好地评估NSM的肿瘤安全性。     

Nitric oxide may mediate nipple erection

The nipple is a specialized structure that can become erect by cold, sexual arousal, breast-feeding, or other tactile stimulations, which can induce the milk ejection reflex and sexual arousal because of intense sensory innervation. The studies that have been conducted thus far to identify the mechanism of nipple erection (NE) are not sufficient. It has been stated that NE occurs via activation of the sympathetic nervous system and smooth muscle contraction. The purposes of this study were to investigate the existence of nitric oxide synthase (NOS) in the nipple-areola complex (NAC) to explain the NE mechanism. Considering that smooth muscle relaxation might be effective in NE, endothelial and neuronal NOS expression and localization were investigated via immunohistochemical methods on sagittal sections from 17 human NACs. The results of this study indicate that eNOS is expressed in the vascular endothelium, ductal epithelium, and smooth muscles, whereas nNOS is expressed in the neural fibers, smooth muscles, ductal epithelium, and vascular endothelium in the NAC. Sinusoidal spaces with endothelial layers similar to those found in penile cavernosal tissue are not found in the NAC. Various mediators are known to affect the function of the NAC smooth muscles; however, this study demonstrates that enzymes (eNOS and nNOS) that synthesize nitric oxide are expressed in the NAC.     

携带Würinger水平中隔的内上方真皮腺体蒂乳房缩小成形术

目的 探索应用携带Würinger水平中隔的内上方真皮腺体蒂乳房缩小成形术治疗乳房肥大症的方法及疗效.方法 自2009年1月至今,对15例中、重度乳房肥大伴有下垂患者施行携带Würinger水平中隔的内上方真皮腺体蒂乳房缩小成形术.结果 15例单侧腺体组织切除量为（522.9±218.3）g,术后胸骨上凹至乳头距离为（21.7±1.74）cm,平均上提乳头8.5 cm（4～16 cm）.术后无血肿及乳头乳晕复合物坏死并发症发生.1例发生小段切口裂开（发生率6.7%）.13例获随访6～18个月,新乳头乳晕感觉良好,切口瘢痕细小,新乳房外形饱满挺拔.结论 携带Würinger水平中隔的内上方真皮腺体蒂乳房缩小成形术,具有新乳头乳晕血运和感觉良好、乳房形态满意及效果稳定的优点,可作为治疗中、重度乳房肥大伴下垂的可选术式之一.     

Avoiding free nipple grafts during reduction mammaplasty in patients with gigantomastia

Excessive breast hypertrophy or gigantomastia (>2000 g excision of tissue per breast) has traditionally been approached with breast amputation and free nipple grafting during reduction mammaplasty procedures. Disadvantages of free nipple grafts include loss of sensation, poor projection, uneven nipple-areolar complex pigmentation, and loss of lactation. We report our experiences utilizing the inferior pedicle technique of reduction mammaplasty with successful preservation of the nipple-areola complex for patients with gigantomastia. Between 2001 and 2003, 15 patients (ages 19--45) were identified with gigantomastia through review of pathology and operative reports. The inferior pedicle technique was performed in all cases by the attending staff assisted by plastic surgery residents. Patients were followed regularly from 1 week up to 1 year postoperatively. All patients reported relief from the physical sequelae of breast hypertrophy. One patient experienced bilateral partial nipple desquamation; she maintained sensation throughout and healed well with moist dressings. Otherwise, there were no complications and all patients achieved satisfactory esthetic outcomes. Our results suggest that inferior pedicle technique can be successfully performed in patients with gigantomastia. Breast amputation with free nipple grafting need not be considered standard practice for this patient population. Maintaining a wider pedicle base and meticulous intraoperative handling of the pedicle may contribute to the increased viability of the nipple-areolar complex during these cases.     

Surgical Delay of the Nipple–Areolar Complex: A Powerful Technique to Maximize Nipple Viability Following Nipple-Sparing Mastectomy

Objectives

Nipple-sparing mastectomy (NSM) improves cosmetic outcome of mastectomy, but many patients are not candidates for this procedure because of concerns about nipple-areolar viability. Surgical delay is a technique that has been used for more than 400?years to improve survival of skin flaps. We used a surgical delay procedure to improve nipple viability in patients who were identified to be at high risk for nipple necrosis following NSM.

Methods

Patients at high risk for nipple necrosis following NSM underwent a surgical delay procedure 7?C21?days prior to mastectomy. Subareolar biopsy and sentinel node biopsy, if indicated, were performed at the time of the delay procedure. Nipple viability was assessed before and after NSM. If the subareolar biopsy revealed malignancy, the NAC was removed at the time of mastectomy.

Results

31 NAC in 20 patients underwent surgical delay. All of the NAC subjected to a surgical delay survived following the delay procedure. In 2 patients, the subareolar biopsy was positive and 3 NAC were removed at the time of mastectomy (1 for purposes of symmetry). Of the 28 delayed NAC left at the time of NSM, all survived the post-mastectomy course.

Conclusion

A procedure to surgically delay the NAC 7?C21?days prior to NSM is demonstrated to ensure viability of NAC in patients previously thought to be at high risk for nipple loss.     

Oncoplastic technics with nipple-areolar complex resection for the treatment of central breast cancers

Central breast cancer has long been an indication for mastectomy. Plastic surgical techniques adapted to cancer (oncoplastic surgery) have made it possible to offer breast cancer patients conservative surgery with resection of the nipple-areolar complex (NAC). We evaluated carcinologic results and cosmetic outcomes as a function of the oncoplastic technique used. We performed a retrospective study in 47 patients with central breast cancers undergoing breast-conserving with NAC resection. Carcinologic results were assessed by calculating local and metastatic recurrences rates. Cosmetic results were evaluated on four criteria assessed by the patient then by two surgeons. The mean age of the patients was 59.8 (44-84) years. The mean tumour diameter was 17.4 (6-39)mm. Histological involvement of the nipple is present in 53% of the cases. No local recurrence, neither death was observed at 4.5 years median follow-up. One patient had liver metastatic recurrence at 83 months. Cosmetic results were assessed in 33 patients. Round-block provided better aesthetic results: the shape of the breast was considered very good or satisfactory for 90% of the surgeons with the round-block technique and for 46% with transverse incision (P=0.02). Breast-conserving surgery is feasible in selected patients with T1 or T2 central breast cancers, with no impact on the risk of local recurrence. NAC resection is essential especially when the patients have clinical signs of nipple involvement. It provides satisfactory cosmetic results, especially with the round-block technique, possibly associated with nipple reconstruction using the "cat-design" technique developed by our team.     

Breast conservation surgery using nipple-areolar resection for central breast cancers

HYPOTHESIS: Resection of the nipple-areolar complex (NAC) for central breast cancers that involve the nipple or areola, with postoperative radiation therapy, adheres to the oncologic principles established for breast conservation surgery of other breast cancers. Good or excellent cosmetic results can be achieved. The rate of ipsilateral breast recurrence will be similar to that seen with peripheral breast cancers. The indications for breast conservation surgery can be safely extended to include patients with breast cancers that involve the NAC. DESIGN: Retrospective medical record review; follow-up patient questionnaire. SETTING: Community teaching hospital. PATIENTS: Fifteen patients, aged 46 to 88 years, whose central breast cancers involved the NAC precluding preservation of the NAC. INTERVENTIONS: Nipple-areolar complex resection, postoperative radiation therapy. MAIN OUTCOME MEASURES: Ipsilateral breast recurrence, survival, cosmesis. RESULTS: Ten patients had subareolar cancers that directly involved the nipple or areola; 5 patients had Paget disease of the nipple. Average tumor size was 1.6 cm (range, 0.2-3.5 cm). With a mean follow-up of 32 months (range, 4-109 months), there has been only 1 recurrence (7%), which was treated successfully by modified radical mastectomy. All 15 patients are alive and free of disease. Cosmetic results are satisfactory to excellent, as judged by both the patients and the surgeons. CONCLUSIONS: Nipple-areolar complex resection for central subareolar cancers that directly involve the NAC, as well as for Paget disease of the nipple, extends the indications for breast conservation in other areas of the breast, and with acceptable cosmesis.