乳房假体重建手术中假体覆盖与人工材料的应用进展

乳腺癌术后乳房重建是乳腺癌综合治疗的重要组成部分。对于以假体为基础的乳房重建手术，利用胸壁肌肉覆盖假体有效增加了覆盖的强度和厚度，降低了伤口裂开、感染引起的假体外露，同时也减少了假体移位、包膜挛缩等术后并发症的发生。随着材料学的进步，人工材料（人工真皮/网片）作为胸大肌的延伸或替代覆盖假体，得到了越来越多的应用，特别是对于需要植入较大假体的病例，借助人工材料联合胸肌可“延伸”肌肉组织，无张力覆盖假体，可使重建乳房下皱襞更为饱满、自然。对于有条件保留一定皮瓣厚度的病例，采用人工材料完全包裹假体，经皮下植入完成胸肌前乳房重建，避免了胸肌损伤，保留了胸肌功能。因此，对于以假体为基础的乳房重建手术，正确选择假体植入层次、保证假体的有效覆盖、合理应用人工材料，才能减少术后相关并发症，提高重建乳房的美学效果。     

人工材料在乳腺癌假体乳房重建中应用进展

正乳房重建是乳腺癌外科治疗中不可或缺的组成部分,目前以假体为基础的乳房重建(implant-based breast reconstruction,IBBR)已成为主要的重建方式~([1])。19世纪80年代,IBBR开始应用于乳房切除的病人,由于术中将假体直接植入皮下,术后假体移位、皮瓣坏死、感染以及明显的包膜挛缩等并发症发生较多,一度影响了IBBR的开展~([2])。1982年,Radovan开拓了胸肌下假体植入的方式,利用胸大     

生物型外科补片在聚丙烯酰氨水凝胶注射隆乳术后并发症修复中的应用

目的：探讨生物型外科补片（生物补片）联合硅凝胶假体植入在修复聚丙烯酰胺水凝胶取出术后乳房继发畸形中的使用方法和效果。方法：聚丙烯酰胺水凝胶注射隆乳材料注射术后142例，术前均行彩色B超或MRI影像检查，明确注射物所在部位。术中采用乳晕下半环形切口，尽可能清除肉眼所见注射物、肉芽肿，以及被注射材料所侵蚀的组织，使用生物补片内垫增厚乳房下缘或侧壁较薄者局部组织，修补注射材料渗漏、移位形成的通道，重建乳房下皱襞，然后植入硅凝胶假体。对移位、渗漏范围较大者，先用生物补片修补渗漏、移位通道，半年后再植入乳房假体。结果：采用生物补片联合硅凝胶假体进行修复的142例患者的174只乳房，除1例1只乳房因术后感染需要取出假体及生物补片外，其余乳房外形均较满意，随访3-12个月，乳房无变形。结论：生物补片可以增厚乳房内壁，修补移位、渗漏通道，增加乳房下皱襞托举力，在修复聚丙烯酰氨水凝胶取出术后乳房继发畸中可以弥补单纯假体植入的不足，是-临床所需的理想修复材料。     

皮肤无细胞基质材料在乳房假体重建中的运用情况

目的了解皮肤无细胞基质材料在乳房假体重建中的应用情况及研究进展。方法查阅近年来有关皮肤无细胞基质材料在乳房假体重建中应用的相关文献并进行分析总结。结果皮肤无细胞基质材料广泛应用于乳房假体重建及乳房调整性手术,能精确控制乳房下皱襞及增强周围组织对假体的控制从而获得较好的重建效果,但是其是否会增加乳房假体重建术后的并发症发生率目前尚无统一的结论。结论皮肤无细胞基质材料辅助的假体重建能取得较为满意的重建效果,目前亟需大样本随机对照试验评估其运用的效果及风险。     

腋窝入路腔镜下乳腺癌皮下腺体切除联合胸肌前假体+补片Ⅰ期乳房重建的创新探索北大核心CSCD

目的探讨腋窝入路腔镜下乳腺癌皮下腺体切除联合胸肌前假体+补片Ⅰ期乳房重建的手术方法及早期效果。方法回顾性分析2021年3~5月我院收治的9例腋窝入路腔镜下乳腺癌皮下腺体切除联合胸肌前假体+补片Ⅰ期乳房重建女性患者的临床资料,年龄40.6(22~60)岁。统计患者手术时间、早期并发症,并采用BREAST-Q量表分析患者乳房重建前后社会心理健康、对乳房满意度以及胸部功能的差异。结果均为单发肿瘤,平均最大径2.4(0.6~4.7)cm;肿瘤距离乳头平均2.5(2~4)cm。术后临床分期:0期2例,Ⅰ期7例。平均手术时间161.1(125~201)min,平均术中出血量41.1 mL,平均住院时间1.5 d,其中日间患者5例,目前患者均获随访,中位随访时间1(1~2)个月。术后1例(11.1%)患者出现乳头轻度缺血所致去色素化;全组患者均未出现切口并发症、皮下气肿、乳房内血肿形成、感染、乳头乳晕坏死、皮瓣坏死、假体和(或)补片取出。随访期间未发现肿瘤复发或转移。与术前相比,术后1个月胸部功能有所降低,差异有统计学意义(P=0.001),而乳房及社会心理评分差异无统计学意义(P>0.05)。结论腋窝入路腔镜下乳腺癌皮下腺体切除联合胸肌前假体+补片Ⅰ期乳房重建创伤小、术后恢复快、手术时间短、早期并发症少、再乳房美容效果好,采用该技术行乳房重建可获得较高的近期满意度。     

保留乳头乳晕皮下腺体切除加假体联合补片乳房一期重建与保乳整形手术治疗乳腺癌比较的单中心回顾性研究

背景与目的 中国女性乳腺癌发病年龄早,保乳手术和乳腺切除术后乳房重建是避免乳腺癌患者失去乳房的合理选择。近年来保乳整形术式的推广使得小乳房患者保乳术后仍能维持较好外形。使用假体联合钛网补片（TiLoop Bra）的乳房重建技术相对简单,便于推广,也能在乳房全切后较好重塑乳房外形。本研究通过回顾性分析评估两种方法在手术效果与满足患者术后美观需求方面的优劣,以期为临床决策提供参考。方法 回顾性分析2019年1月—2021年10月在中南大学湘雅医院乳腺外科接受以上两种手术的早期乳腺癌患者资料,其中接受保乳整形手术（保乳组）与保留乳头乳晕皮下腺体切除加假体联合补片一期乳房重建手术（乳房重建组）的患者各40例。收集患者的基本临床病理特征信息,两组的手术时间、术后留置引流管时间、术后住院时间、住院费用以及手术相关并发症等信息,使用Breast-Q量表评估患者术后满意度。结果 保乳组在手术时间、术后留置引流管时间、术后住院时间以及住院费用上均明显优于乳房重建组（均P<0.001）。乳房重建组乳头麻木的发生率明显高于保乳组（P<0.001）;乳房重建组发生皮瓣坏死4例,保乳组无皮瓣坏死发生,但差异无统计学意义（P=0.079）;两组间血肿、切口感染、脂肪坏死和组织挛缩的发生率差异均无统计学意义（均P>0.05）。两组患者的心理健康、身体健康、性健康及对乳房外形的满意度差异均无统计学意义（均P>0.05）。结论 两种手术方式的美学效果相似。皮瓣坏死为假体联合补片一期乳房重建中的严重并发症,背阔肌肌皮瓣覆盖创面可作为补救治疗手段。满足保乳手术适应证的患者,应优先考虑保乳整形的手术方式;存在保乳手术禁忌证的患者,但有乳房外形要求的,合理评估后实施保留乳头乳晕腺体切除加假体联合补片一期乳房重建也是一个可选方案。     

经胸外侧单孔非吸脂腔镜技术在早期乳腺癌即刻乳房假体重建中的应用

目的 探讨经胸外侧单孔非吸脂腔镜技术在保留乳头乳晕复合体乳房切除(nipple sparing mastectomy, NSM)并即刻假体联合补片乳房重建术的应用效果。方法 回顾性分析2020年2月至2022年7月在我科采用经胸外侧单孔非吸脂腔镜技术行NSM并即刻假体联合补片乳房重建术的42例早期乳腺癌女性患者的临床资料，分析围手术期指标、术后并发症、重建乳房美学效果和近期肿瘤安全性。结果 42例患者均顺利完成腔镜NSM并即刻乳房重建术，其中该术式开展第1年完成手术12例，1年后完成30例，手术成功率100%。第1年手术组与1年后手术组患者手术时间、术中出血量、术后引流量比较差异均有统计学意义(P<0.001),但拔管时间、术后并发症率比较无统计学差异(P>0.05)。术后乳头乳晕复合体不同程度缺血5例(11.90%),切口愈合不良2例(4.76%),感染1例(2.38%),血清肿6例(14.29%),包膜挛缩5例(11.90%),假体丢失1例(2.38%)。42例患者重建乳房优良率为54.76%(23/42),其中第1年与1年后重建乳房者优良率比较无统计学差异(41.67...     

乳房重建中应用背阔肌肌皮瓣适应证及技术原则

无论是延迟乳房重建还是即刻乳房重建,均可以应用背阔肌肌皮瓣来进行。它既可以单独使用,也可结合假体同时应用于乳房重建。对于乳房切除、腋窝淋巴结清扫术后局部缺损较大的病人,背阔肌肌皮瓣结合乳房假体的乳房重建手术是一种非常好的选择。对于因为腹部手术、腹部疾病等问题,不能采用腹直肌肌皮瓣进行乳房重建的病人,首选背阔肌肌皮瓣重建乳房。但如果不能排除胸背动脉、肩胛下动脉以及背阔肌损伤可能则应该避免采用背阔肌肌皮瓣乳房重建。术前应对背阔肌肌皮瓣进行全面评估及仔细设计,术中谨慎操作,注意避免发生术中及术后并发症。     

乳腺癌术后Ⅰ期假体置入乳房重建的研究进展

假体置入重建的乳房形态较接近自然,手感好,置入手术操作简单,避免了自体组织移植造成的供区创伤及瘢痕,是目前国际上使用最广泛的乳房重建方式,美国Moffitt癌症中心约3/4的乳腺癌患者选择假体置入乳房重建[1].现将有关乳腺癌术后Ⅰ期假体置入乳房重建进展综述如下.一、Ⅰ期假体置入乳房重建的适应证与患者选择Ⅰ期假体置入重建主要适用于乳房体积较小(一般指体积小于400 ml、或A/B罩杯)[2]、下垂不明显、不宜行保乳手术,不能或不愿接受自体组织重建的患者[3].按肿瘤病理分期,Ⅰ期假体乳房重建主要适用于0期、Ⅰ期和Ⅱ期.肿瘤已侵犯肌层或胸壁,需要切除胸大肌或扩大根治术者,不宜行Ⅰ期假体置入乳房重建[4].目前,国内开展的乳腺癌根治术后Ⅰ期假体置入重建,大部分限于Ⅰ-Ⅱ期乳腺癌、无淋巴结转移、术后不进行放疗的患者,手术范围基本为乳腺全部切除及腋淋巴结清扫[5].此外,吸烟、肥胖、高血压以及超过65岁者都是影响手术的危险因素[6].     

非生物补片在乳房重建中的应用进展

目的对非生物补片在乳房重建中的应用进展作一综述。方法查阅近年国内外非生物补片在乳房重建中应用的相关研究,并总结分析。结果非生物补片可分为可降解和不可降解两类,前者产品类型多样,其降解速率与组织修复速率是否匹配会显著影响切口愈合和组织再生;后者代表产品为Ti LOOP,具有表面纳米Ti O2层和轻薄柔软特性优势,将其用于乳房重建术可获得较好疗效。非生物补片目前已逐渐用于临床乳房重建术中,起到包覆和固定假体作用;与生物补片相比,价格优势明显,术后总体效果较好。结论非生物补片用于乳房重建术时间较短,其有效性及疗效有待进一步观察。     

A network data-based survey and analysis of attention towards breast reconstruction after breast cancer surgery in Chinese and American populations

BackgroundBreast reconstruction is an effective technique to rebuild the appearance of the breasts in patients after mastectomy and improves the prognosis. The current study aimed to compare and analyze willingness for breast reconstruction after breast cancer between populations in China and the United States, from the perspective of social concern, using big data analysis. We also aimed to explore factors affecting surgical selection and to identify methods that can improve social cognition and acceptance of breast reconstruction.MethodsUsing Baidu and Google, two representative Internet search engines in China and the United States as research tools, and using big data search volume as the benchmark, we compared and analyzed breast reconstruction willingness and attention characteristics between Chinese and American people, based on search heat, geographical distribution, age and sex, keyword distribution, ethnic group, and social development degree.ResultsIn both the long-term and short-term, Chinese people paid more attention towards searching about breast cancer, but less attention to breast reconstruction after breast cancer surgery. However, in both the short-term and long-term, people from the United States paid more attention towards breast cancer and breast reconstruction with the help of the Internet, showing a synchronous change relationship. There was a large regional difference in the search volume for breast cancer among the Chinese population, while no significant regional differences were noted in the search volume for breast cancer in the United States. However, a large regional difference was observed in the search volume for breast reconstruction between the two countries; people in the coastal and economically developed areas paid more attention to it. Most people who paid attention to breast reconstruction in China were women aged 20–39 years, while the attention among men was low. Search keywords were also limited to breast cancer-related information. However, between Asians and European Americans, Americans paid more attention to breast cancer and were affected by regional development, religious beliefs, and health facilities.ConclusionAttention towards breast reconstruction after breast cancer was lower in the Chinese population than in the American population, and this difference was closely related to the level of regional development. There is insufficient information on breast reconstruction after breast cancer in recent Internet media. In addition to strengthening communication in clinics, media education is important to improve the cognitive level and social awareness of patients and their families, which is conducive to breast reconstruction.     

How Reliable Are Textured Implants Used in Breast Surgery? A Review of 510 Implants

Five hundred ten implants were used in 273 patients. The follow-up was between 3 months and 8 years. Four hundred nineteen prostheses were used for subglandular breast augmentation, 91 for subpectoral breast reconstruction. All the breasts were checked personally: 397 augmented breasts and 86 reconstructed breasts—94.7%. The objective criterion was the Baker classification: grades I and II, good result; and grades III and IV, poor result. Results were as follows: Baker I, 397 breasts; Baker II, 78 breasts (I + II, 98.3%); Baker III, 5 breasts; Baker IV, 3 breasts (III + IV, 1.7%). Three prostheses were removed after 3, 4, and 6 years because the textured surface was totally damaged. Two bilumen prostheses lost the saline fluid. The complication rate due to the implants was very low.     

TIGR® matrix surgical mesh – a two-year follow-up study and complication analysis in 65 immediate breast reconstructions

In recent years, it has become increasingly popular to use matrices, such as acellular dermal matrices, in implant-based breast reconstruction. To lower the cost and to avoid implanting biological material, the use of synthetic meshes has been proposed. This is the first study examining TIGR^® Mesh in a larger series of immediate breast reconstruction. The aims of the study were to examine complications and predictors for complications. All consecutive patients operated on with breast reconstruction with TIGR^® Matrix Surgical Mesh and tissue expanders (TEs) or permanent implant between March 2015 and September 2016 in our department were prospectively included. Exclusion criteria were ongoing smoking, BMI (kg/m²)?>?30, planned postoperative radiation, and inability to leave informed consent. Fifteen breasts (23%) were affected by complications within 30 d: four (6.2%) major complications and eleven (17%) minor complications. The major complications included two implant losses and one pulmonary embolism (PE). Predictors for a complication were age over 51 years, BMI over 24.5?kg/m², large resection weight, and the need for a wise pattern excision of skin. Four minor surgical complications occurred after 30 d (minimum follow-up 17 months). There were no implant losses. In addition, minor aesthetic corrections, such as dog-ear resection, were performed in 10 breasts. In conclusion, breast reconstruction with a TE in combination with TIGR^® Matrix Surgical Mesh can be performed with a low complication rate.     

Bilateral breast reconstruction with a pedicled transverse rectus abdominis myocutaneous flap after subcutaneous mastectomy for symptomatic injected breasts

Abstract

Breast deformities after augmentation with injectable materials carried out by uncertified medical personnel present challenging problems. Materials include liquid silicone, paraffin, polyacrylamide hydrogels, and unknown gels. They usually cause granulomatous reactions, erythema, pain, and even skin necrosis. Tender masses that cannot be differentiated from breast cancers are the major concern. This retrospective study presents the authors' experience in managing 10 symptomatic injected breasts in five patients during the past 8 years. Subcutaneous mastectomies were carried out using periareolar, inverted “T”, or inframammary approaches combined with breast reconstruction using bilateral pedicled transverse rectus abdominis myocutaneous (TRAM) flaps. All flaps survived well and gave a satisfactory cosmetic appearance. There was no major complication or late occurrence of breast cancers over the following 8 years. Injectable materials used for breast augmentation should be prohibited until more scientific data are available about the long-term effect of these materials in breast tissues. Once the injected breasts become symptomatic, subcutaneous mastectomy and reconstruction with bilateral pedicled TRAM flaps is a reasonable option for the patient.     

Filling materials in the repair and esthetic surgery of the breast. Historical notes

The biological and synthetic materials employed over the years for filling breasts after mastectomy or for congenital malformations are reviewed. At the start of the century, breast shape and volume were changed by adipose tissue grafts. In the 50s and 60s dermo-fibro-adipose grafts and later auto-grafts and grafts of the large epiploon were used. Synthetic materials have also developed, from early century attempts using paraffin injections to the discovery for industrial use of plastics. Following the first polyvinyl prostheses, Cronin developed silicon prostheses for medical purposes and in later years these went through numerous changes in form, volume and design up to the recent skin expanders. Polyurethane has also been used in attempts to reduce capsular retraction.     

Complications,risk factors,and patients-reported outcomes after skin-sparing mastectomy followed by breast reconstruction in women with BRCA mutations

Background: Women with a BRCA mutation have the option of undergoing prophylactic mastectomy and immediate breast reconstruction; however, the potential negative effects of reconstruction on women’s physical and psychological well-being are unclear. This study aimed to investigate complications, patient-reported pain, health-related quality-of-life (HRQoL) and satisfaction following reconstructive surgery at Oslo University Hospital between 2006 and 2013.

Methods: Data were collected retrospectively from the records of 238 patients. A cross-sectional survey was conducted to collect patient-reported HRQoL and satisfaction with outcome using the Short Form-12 questionnaires and Breast-Q. The self-administered Leeds assessment of neuropathic symptoms and signs was used to assess neuropathic pain.

Results: The majority of participants (89.5%) underwent implant-based breast reconstruction (IBBR); the remainder underwent autologous-tissue breast reconstruction (ATBR). Overall, 28.6% had complications within 30?days of surgery and 14.6% required resurgery because of complications. Women who underwent IBBR had a later onset of complications than those undergoing ATBR. Participants in the survey (n?=?175 of 219, response rate 79.9%) reported similar HRQoL to an age-matched general female population. Few (2.9%) reported neuropathic pain. Patients who underwent IBBR were significantly less satisfied with the reconstructed breast (p?=?.001) and overall outcome (p?=?.02) than those who underwent ATBR, but there were no significant differences in HRQoL scores between the two groups.

Conclusions: Overall, 28.6% of the women had complications within 30?days and 14.6% needed resurgery. Few had neuropathic pain. Women who underwent ATBR were more satisfied with the overall outcome than those who underwent IBBR.     

Management for Postoperative Complications of Breast Augmentation by Injected Polyacrylamide Hydrogel

Polyacrylamide hydrogel, a new biomaterial, has been used for injected breast augmentation in China since 1997. A series of 30 patients with various complications after injected polyacrylamide hydrogel visited the author’s department. Most of these patients had undergone injection of both breasts. The average age of the patients was 27.6 years, and the time of consultation for the complications was from 3 to 36 months postopertively. Nearly all the patients had breast lumps and other common complications including breast pain, disfigurement, and infection. Ultrasound examination showed diffuse, irregular, anechoic zones of mammary tissue. Pathologic results indicated inflammatory cell infiltration and fibrous capsular formation. An open suction technique and partial mastectomies via periareolar incisions were performed for the all patients. Most of their symptoms were relieved after removal of the polyacrylamide hydrogel. Only one patient had undergone immediate breast reconstruction with implants, whereas five patients had received breast implants secondarily via an axillary incision. The authors conclude that polyacrylamide hydrogel should be prohibited for injected breast augmentation before more scientific data are available about the long effect of the gel in breast tissue.     

乳癌术后不同乳房再造术式的临床应用

目的探讨适合乳癌术后各种乳房再造术式的适应证。方法对我院2003至2005年收治的44例、45只乳癌术后乳房再造的患者,根据不同情况分别采用扩张器/假体置入(5只)、背阔肌肌皮瓣 假体置入(13只)、背阔肌肌皮瓣(3只)、DIEP皮瓣(6只)、单蒂TRAM瓣(10只)及劈开的双蒂TRAM瓣(8只)等方法进行乳房再造,分析各手术方法的适应证。结果应用皮瓣乳房再造40只,皮瓣全部成活;1只应用扩张器/假体乳房再造术后,注射壶部表皮坏死;1只应用背阔肌 假体乳房再造术后半年出现假体破裂伴局部感染;1只应用DIEP乳房再造术后,出现皮瓣下积液;2只部分皮瓣坏死。术后随访3个月至半年,医生及患者对乳房形态均较满意。所有应用腹部皮瓣的患者均无腹壁疝发生。结论6种乳房再造技术基本满足了我国女性乳癌术后各个时期各种条件再造乳房的要求,整形外科技术的改进以及新材料的应用扩大了乳房再造的适应证。     

自体乳房重建中皮瓣相关并发症影响因素分析及术中使用吲哚菁绿造影的经济学效益

目的探讨自体乳房重建中皮瓣相关并发症的影响因素,以及术中使用吲哚菁绿(indocyanine green,ICG)造影的经济学效益。方法回顾分析2013年7月-2018年6月收治的符合选择标准的150例自体乳房重建的乳房切除术后患者(152个乳房)。对年龄、体质量指数、术前新辅助化疗(neoadjuvant chemotherapy,NC)、胸部放疗史、合并糖尿病、供区手术史、胸壁重建、重建时机、皮瓣类型、术中ICG造影进行单因素分析,初步筛选单因素分析中有统计学意义的临床因素,纳入皮瓣相关并发症及皮瓣局部坏死的logistic多因素回归分析(逐步后退法)。根据以上多因素分析结果,将患者分为4组:ICG+NC组(A组)、ICG+非NC组(B组)、非ICG+NC组(C组)、非ICG+非NC组(D组),计算每组患者的人均额外治疗费用(ICG造影费用+处理皮瓣相关并发症的费用)。结果术后152个皮瓣均成活。共有33个皮瓣发生皮瓣相关并发症,包括22个皮瓣局部坏死、9个局部感染、5个血肿、5个单纯脂肪液化、2个吻合口血栓形成。单因素分析显示,术前NC、皮瓣类型及术中ICG造影是发生皮瓣相关并发症的影响因素(P<0.05)。多因素分析显示,术前NC、未使用ICG造影是发生皮瓣相关并发症的危险因素(P<0.05),也是发生皮瓣局部坏死的危险因素(P<0.05)。对于NC患者,术中使用ICG造影会大大节省人均额外治疗费用,A组较C组人均额外治疗费用少花费1378元。对于未行NC者,术中使用ICG造影会增加人均额外治疗费用,B组较D组人均额外治疗费用多花费747元。结论在自体乳房重建中,ICG造影可降低皮瓣相关并发症的发生率,尤其是皮瓣局部坏死发生率;而NC则相反。对于非NC患者,ICG造影的性价比不高,经济条件允许下可使用;但对于NC患者,ICG造影性价比较高,建议使用。