带蒂背阔肌皮瓣在乳房重建手术中的应用

随着乳腺癌治疗模式的发展及患者观念的转变,乳房重建逐渐成为乳腺癌治疗的一部分。背阔肌因面积较大,且蒂部解剖变异较少,同时血供丰富可被改良成不同的皮瓣,因此被认为是良好的供瓣区。在乳房重建中,背阔肌肌皮瓣的应用较广,不仅可以使用全背阔肌或联合假体进行乳房重建,且可以根据不同的缺损范围选择合适的背阔肌皮瓣进行乳房缺损的修补。相比单纯植入物重建,背阔肌皮瓣可获得更为良好的乳房形态且对术后放疗影响较小;相比下腹部皮瓣,背阔肌皮瓣瘢痕较短,术后恢复较快。目前对于术后供区缝合方式的改进及辅助药物的应用,极大地降低了血清肿的发生率;腔镜技术的应用也避免了切取背阔肌皮瓣遗留的供区瘢痕。在临床应用中,背阔肌皮瓣行乳房重建患者满意率高,术后审美效果良好,是乳房重建中一种较为优势的手术方法。该研究总结了背阔肌皮瓣行乳房重建对并发症的控制并对近年来的手术中的问题作进一步探讨。     

保留皮肤的乳腺癌改良根治术后即刻乳房再造的临床应用

目的探讨保留皮肤的乳腺癌改良根治术后即刻再造乳房的适应证、方法、效果及可行性。方法2002年1月至2007年11月本院对94例乳腺癌患者行保留乳房皮肤皮下乳腺组织切除加腋窝淋巴结清扫术后，应用下腹部横行腹直肌肌皮瓣（transverse rectus abdominis myocutaneous flap，TRAM）、背阔肌肌皮瓣（latissimus dorsi myocutaneous flap，LDM）联合或不联合假体、单纯乳房假体植入4种方式即刻再造乳房。结果再造手术均取得成功。带蒂TRAM再造47例，LDM再造共42例（其中联合假体28例），单纯乳房假体植入5例。4例出现轻微术后并发症（4．25％）。经过3～67个月随访，局部区域复发率为0，再造乳房形态自然，效果满意，术后外观评价优良率97．87％。结论合理选择病例行保留皮肤或保留乳头乳晕乳腺癌改良根治术后即刻乳房再造是安全可靠的，切口隐蔽并能够保留原有乳房皮肤的感觉，从而获得最佳美容效果，值得广泛推广和应用。     

Transposition of myocutaneous flaps in breast reconstruction following radical mastectomy: latissimus dorsi vs. rectus abdominis flap

We evaluated two homogeneous groups of patients (20 each) who had undergone radical mastectomy and who underwent breast reconstruction in our department by transposition of a latissimus dorsi or of a rectus abdominis myocutaneous flap. The results achieved were very similar (in terms of postoperative hospitalization, complication rate, thoracic symmetry). We therefore believe that both these techniques should be considered as first choice in breast reconstruction following radical mastectomy. However, from the aesthetic viewpoint, the use of the latissimus dorsi is best suited to tall, slim patients, whereas the rectus abdominis allows us to obtain better results in patients of sturdy build, with a voluminous residual breast.     

即刻乳房再造在乳腺癌手术中的应用与探讨

目的探讨即刻乳房再造在乳腺癌手术中的应用价值。方法自2005年10月至2009年2月共完成了26例乳腺癌改良根治即刻乳房再造手术,其中10例为局部晚期乳腺癌。即刻腹直肌肌皮瓣乳房再造术12例,背阔肌肌皮瓣乳房再造术8例,保留乳头乳晕复合体皮下乳腺全切假体植入乳房再造术5例,保留乳头乳晕复合体皮下乳腺全切背阔肌肌皮瓣结合假体植入乳房再造术1例。结果全组手术切缘病理均达到阴性,皮瓣全部成活,无假体相关并发症,亦无腹壁疝发生。再造乳房形态满意,肌皮瓣再造乳房可以安全地耐受术后放疗,随访1～40个月无局部复发病例。结论即刻乳房再造手术从根本上改善了乳腺癌患者术后的生活质量,在局部晚期乳腺癌手术中,肌皮瓣乳房再造还可以为足够的切除范围提供安全保障,颇具临床应用价值。     

乳腺癌乳房切除术后两种不同即刻再造方法的并发症和生存分析

目的 比较乳腺癌乳房切除术后两种不同即刻再造方法 的并发症和患者的生存情况.方法 选取女性乳腺癌患者128例,根据治疗方法 不同将患者分为带蒂横行腹直肌肌皮瓣组(腹直肌组)和带蒂横行背阔肌肌皮瓣组(背阔肌组),每组各64例.对两组患者的术后并发症发生情况、骨转移、全身多处转移、局部复发及死亡情况进行统计分析.结果 腹直肌组患者的术后并发症发生率和局部复发率均低于背阔肌组(P<0.05);两组患者的骨转移率、全身多处软组织转移率和病死率比较,差异无统计学意义(P>0.05).结论 乳腺癌乳房切除术后带蒂横行腹直肌肌皮瓣即刻乳房重建术较背阔肌临床效果好.     

即时扩展型背阔肌肌皮瓣乳房再造术常见失误及并发症探讨

目的探讨乳腺癌改良根治术后应用扩展型背阔肌肌皮瓣即时乳房再造的常见失误和并发症的处理。方法回顾41例行保留皮肤或保留乳头乳晕乳腺癌改良根治术后即时扩展型背阔肌肌皮瓣乳房再造病例,分析手术失误和并发症发生原因及预防处理措施。结果 41例乳房再造手术均获成功。术后情况:7例美容效果欠佳,18例血清肿,7例皮瓣坏死,3例干性皮肤坏死,2例翼状肩,2例乳头部分坏死,1例发生感染。结论乳腺癌术后应用扩展型背阔肌肌皮瓣即时乳房再造形态良好,并发症虽然较高,但严重并发症相对少,且可以有效预防或减少,适合中国女性,作为目前我国乳腺肿瘤治疗的一种有效补充手段,有一定临床应用价值。     

乳腺癌术后即时扩展型背阔肌肌皮瓣乳房重建27例分析

目的探讨乳腺癌改良根治术后应用扩展型背阔肌肌皮瓣即时乳房重建的疗效。方法对27例乳腺癌患者施行乳腺癌改良根治术（其中6例行保留皮肤的乳腺癌改良根治术,21例行保留乳头、乳晕的乳腺癌改良根治术）,术后即时切取包括背阔肌及其表面的脂肪和岛状皮肤、髂嵴上方脂肪、背阔肌前沿侧胸部脂肪和肩胛区脂肪构成扩展型背阔肌肌皮瓣,转移至胸壁重建乳房。结果27例即时乳房重建全部获得成功。切除乳房的组织量为180-330ml（平均215ml）,移植重建乳房的扩展型背阔肌肌皮瓣组织量为210-380ml（平均245ml）。24例术后辅助化疗,5例辅助放射治疗。随访6～24个月（中位随访12个月）,所有患者均生存,术后无一例局部复发、转移。美容效果：优17例,良6例,一般3例,差1例。结论乳腺癌患者行保留皮肤或乳头乳晕改良根治术后应用扩展型背阔肌肌皮瓣即时乳房重建形态良好,不影响术后辅助治疗和远期疗效,作为目前乳腺肿瘤治疗的一种有效补充手段,值得临床推广。     

IMMEDIATE BREAST RECONSTRUCTION WITH LATISSIMUS DORSI MUSCULOCUTANEOUS FLAP： A SUITABLE OPTION FOR CHINESE WOMEN AFTER MASTECTOMY

Objective： To discuss the suitable immediate breast reconstruction modalities for Chinese patients by comparing the pedicled transverse rectus abdominis myocytaneous flap （TRAM） reconstruction with latissimus dorsi myocytaneous flap （LTD） reconstruction plus implants or not after mastectomy due to breast cancer. Methods： From Jan. 2000 to Jul. 2005, 74 staged 0-II patients （mean age 39） were performed immediate breast reconstruction with autologous tissue either using LTD flaps or pedicled TRAM flaps with supplemental implants when necessary after mastectomy due to breast cancer and the charts were reviewed. Results： The age, marriage and menses status did not affect the selection of modalities and the need of implants. In 74 patients, 62 cases （83.8%） were performed LTD reconstruction with 13 implants and 12 cases received TRAM with 1 implant. The difference in need of implants or not between the two modalities had no statistical significance （P=0.442, Fisher＇ exact test）. Aesthetic results judged as good or fair were in 88% patients and the cosmetic effects between LTD and TRAM groups or implant and non-implant groups had no differences. All reconstructions were successful, with 4.1% cumulative locoregional recurrence and 100% overall survival by following up to 66 months （median 9 months）. The DFS and RFS between the two modalities had no significant differences by log rank test. Conclusion： Immediate autologous tissue reconstruction makes it possible to regain the natural and symmetric contour of breast without increased local recurrence. The LTD flap reconstruction is a suitable option for most Chinese women as well as the pedicled TRAM flap.     

Choice of flaps for breast reconstruction

The optimal method for breast reconstruction should be safe, reliable, and accessible for every patient, and it should display little or no donor-site morbidity. After comparing mammary implants it has been found that autogenous breast reconstruction can create a ptotic, soft, symmetrical breast mound. The transverse rectus abdominis musculocutaneous flap (TRAM) remains the most popular method for autogenous reconstruction. Modern trends in breast reconstruction using the TRAM flap have promoted adequate blood supply to the flap while minimizing donor-site defects in the anterior abdominal wall. The pedicled TRAM flap remains one of the most frequently used flaps, but the indirect blood supply in this flap has required many modifications and refinements. Such modifications have included the bipedicled TRAM flap, the free TRAM flap, and the supercharged TRAM flap. To avoid donor-site morbidities, the muscle-sparing free TRAM, deep inferior epigastric perforator flap (DIEP), and superficial inferior epigastric artery (SIEA) flap were introduced. The DIEP perforator flap requires meticulous technique but offers proven reliability and a low rate of complications. As surgeons become more comfortable with harvesting DIEP flaps, the frequency of usage seems likely to increase. The latissimus dorsi musculocutaneous flap, gluteus maximus musculocutaneous flap, and others may be selected when these modifications of free TRAM flap are unavailable or unusable.     

乳腺癌保乳术中胸外侧筋膜皮瓣在乳房缺损修复中的应用

目的 探讨胸外侧筋膜皮瓣在乳腺癌保乳术中修复乳房缺损的应用效果.方法 回顾分析行乳腺癌保乳术的73例乳腺癌患者的临床资料,根据乳房修复方法进行分组,其中对照组35例采用背阔肌肌皮瓣移植,观察组38例采用胸外侧筋膜皮瓣移植,观察2组患者术中出血量、手术时间、术后乳房重建效果、复发率及并发症发生情况,并对患者满意度进行调查评估.结果 所有患者均成功完成手术,且术后均无肿瘤复发.2组患者手术时间、术中出血量比较,差异有统计学意义(P＜0.05);2组患者术后乳房外观比较差异无统计学意义(P＞0.05);患者对手术满意度评价,差异无统计学意义(P＞0.05);观察组术后并发症发生率低于对照组,组间差异有统计学意义(P＜0.05).结论 在乳腺癌病灶切除术中,利用胸外侧筋膜皮瓣填充乳房缺损部位能够明显缩短手术时间,降低术后并发症的发生率.     

带蒂腹直肌皮瓣在乳房重建手术中的应用

随着人民生活水平的提高和医学技术的发展,乳腺癌患者接受全乳切除术后对乳房重建的需求日益增长。带蒂腹直肌皮瓣(transverse rectus abdominis muscle,TRAM)手术是重要的自体组织乳房重建方法。该文就TRAM皮瓣的解剖与血供、TRAM手术的适应证和禁忌证、手术步骤以及并发症进行介绍,同时还对TRAM手术中的一些细节问题进行了探讨。TRAM术式作为自体组织乳房重建技术,不需要假体,从而避免了假体相关的并发症。另外相比于假体重建,自体组织重建的外形和柔软度都更接近于自然乳房,具有更好的重建效果。同时带蒂的TRAM术式不需要显微血管吻合技术和密切的术后皮瓣检测,容易被外科医师掌握并在更多的医学中心开展。因此TRAM皮瓣仍然具有一定的应用前景。     

Options for immediate breast reconstruction following skin-sparing mastectomy

Background  Skin-sparing mastectomy (SSM) is a type of breast cancer surgery presupposed as breast reconstruction surgery. Cosmetically, it is an extremely effective breast cancer operation because the greater part of the breast’s native skin and infra-mammary fold are conserved. All cases of SSM and immediate breast reconstruction performed by the senior author during the last five years were reviewed. as]Methods: There are three implant options for breast reconstruction, namely, deep inferior epigastric perforator (DIEP) flap, latissimus dorsi myocutaneous (LDM) flap, and breast implant, and one of these was used for reconstruction after comprehensive evaluation. Results  From 2001 to 2005, immediate reconstructions following SSM were performed on 124 cases (128 breasts) by the same surgeon. Partial necrosis of the breast skin occurred in 4 cases of SSM. The mean follow-up was 33.6 months. During the follow-up, there was local recurrence following surgery in 3 cases. The overall aesthetic results of immediate breast reconstruction after SSM are better than those after non-SSM. Conclusion  SSM preserves the native breast skin and infra-mammary fold, and is an extremely useful breast cancer surgery for breast reconstruction. SSM is an excellent breast cancer surgical technique. We think this procedure should be considered in more facilities conducting breast reconstruction in Japan.     

早期乳腺癌术后即时乳房再造术临床分析

目的探讨早期乳癌改良根治术后即时乳房再造的可行性与方法.方法对我院2000年6月～2002年2月收治的21例早期乳腺癌患者行保留皮肤的乳腺癌改良根治术,即时应用单蒂横行下腹直肌肌皮瓣(TRAM flap)乳房再造.结果应用该方法治疗21例患者,术后20例患者双侧乳房形态基本对称,患者满意.全组无腹壁切口疝及TRAM皮瓣完全坏死.结论对于Ⅰ、Ⅱ期的早期乳癌患者,选择保留皮肤的乳腺癌改良根治术后TRAM皮瓣即时乳房再造术,能够满足肿瘤治疗和形体美容两方面的要求,是一种安全可行的治疗方法.     

Skin-sparing mastectomy and immediate reconstruction is an acceptable treatment option for patients with high-risk breast carcinoma

BACKGROUND: Skin-sparing mastectomy (SSM) followed by immediate reconstruction is an effective treatment option for patients with early-stage breast carcinoma, but its use in patients with more advanced disease is controversial. METHODS: A retrospective review was performed that included 38 consecutive patients with high-risk breast carcinoma who underwent SSM and immediate reconstruction (between July 1996 and January 2002). Tumor characteristics, type of reconstruction, margin status, timing of adjuvant therapy, postoperative complications, and incidence of recurrence were evaluated. RESULTS: High-risk patients (Stage IIA [n=4 patients] Stage IIB [n=23 patients] Stage IIIA [n=8 patients] and Stage IIIB [n=3 patients]) underwent immediate reconstruction after SSM with the use of a transverse rectus abdominis myocutaneous flap (n=31 patients), a latissimus dorsi myocutaneous flap plus an implant (n=3 patients), or tissue expanders with subsequent implant placement (n=4 patients). The median follow-up was 52.9 months (range, 27.5-92.0 months), and the median time to recurrence has not yet been reached at the time of last follow-up. The median interval from surgery to the initiation of postoperative adjuvant therapy was 38 days (range, 25-238 days). Local recurrence was seen in 1 patient (2.6%), systemic recurrence in was seen in 10 patients (26.3%), and both local and distant metastases in were seen in 2 other patients (5.3%). CONCLUSIONS: SSM with immediate reconstruction appeared to be an oncologically safe treatment option for high-risk patients with advanced stages of breast carcinoma. In addition to the aesthetic and psychological benefits of performing SSM with immediate reconstruction, local recurrence rates and disease-free survival were favorable when combined with the use of radiation therapy and adjuvant chemotherapy, as indicated.     

保留皮肤的乳腺癌改良根治术后即时乳房再造15例

目的探讨一种既达到肿瘤根治性切除,又保留乳房美观外形的乳房再造的手术方法。方法对早期乳腺癌,保留乳房皮肤,切除乳腺组织和腋窝淋巴结。应用下腹部横行腹直肌肌皮瓣或扩大背阔肌肌皮瓣即时乳房再造。结果应用下腹部横行腹直肌肌皮瓣乳房再造10例,扩大背阔肌肌皮瓣再造5例。优11例（73．3％）,良4例（26．7％）。结论保留皮肤乳腺癌根治术后即时乳房再造,切口隐蔽,再造乳房形态效果好。对早期乳腺癌患者是一种安全可行的治疗方法。     

乳腺癌保乳手术后背阔肌肌皮瓣乳房缺损修补12例临床分析

目的 探讨改善乳腺癌保乳手术后乳房美容效果的方法。方法 2006年1月至2007年10月，本科对12例年龄为34～55岁（平均39岁）的原发性乳腺癌患者进行了病灶局部扩大切除后即刻背阔肌肌皮瓣转移整形。然后对乳腺组织切除量、乳房的美容效果及术后并发症进行评估。结果 乳腺组织切除量为110～215g（平均150g）。术后乳房美容效果：优3例，良好6例，尚可3例，无外形差的病例。术后所有患者对乳房形态均满意，未发生严重并发症。结论 利用背阔肌肌皮瓣转移即刻修补乳房缺损，是改善保乳手术后乳房美容效果的一个好方法。     

A case of total pelvic exenteration that closed the perineal wound with a rectus abdominis myocutaneous flap for lower rectum cancer with cutaneous fistula

The patient was a 60-year-old man with lower rectum cancer invading into the prostate gland and urinary bladder. The tumor expanded locally and made perineal cutaneous fistula. We performed a total pelvic exenteration with extended resection of perineal skin and subcutaneous tissue, followed by reconstruction using vertical rectus abdominis myocutaneous flap (VRAM flap). Although a mild pelvic abscess developed after the operation, it was controllable by drainage because the dead cavity of pelvis was relatively small due to the filing effect of VRAM flap. The VRAM flap is useful for both pelvic and perineal skin defects due to the extended resection of rectal cancer invading skin and pelvic organs.     

Autologous tissue reconstruction after mastectomy–A cross-sectional survey of 110 hospitals in China

BackgroundAutologous reconstruction after mastectomy became more and more popular, so this study aimed to obtain up-to-date and comprehensive data on autologous reconstruction in China.MethodsAn electronic questionnaire was sent to 110 hospitals, which were chosen depending on geographical distribution and hospital types. The questionnaire investigated the demographics, characteristics, breast cancer treatment and reconstruction situation of these hospitals through different modules. We only focused on the autologous breast reconstruction module data.Results96 hospitals have performed breast reconstruction surgery. The proportion of the hospital performing latissimus dorsi flap (LDF, N = 91), pedicle transverse rectus abdominis myocutaneous flap (pTRAM, N = 62), free abdominal flap (N = 43) and other kinds of flap decreased in sequence. Of the overall reconstruction cases, only 34.3% were autologous reconstruction and LDF was still the most popular option for autologous reconstruction. Related factors of hospital performing different procedures included years of performing breast reconstruction, breast surgical volume, and establishment of an independent plastic surgery department. Compared with LDF, abdominal breast reconstruction was associated with a higher flap necrosis rate.ConclusionsThis cross-sectional survey offers real-life autologous reconstruction information on a large population and covers the national surgical landscape in China. Autologous reconstruction is still an important part of breast reconstruction. Nevertheless, its low proportion and lower proportion of abdominal flap reconstruction in each institution, demonstrates that special training should be developed for breast surgeons and multidisciplinary cooperation would be promoted in the future.     

横行下腹直肌肌皮瓣乳房再造术

目的　介绍乳腺癌根治术后乳房再造方法。方法　应用横行下腹直肌肌皮瓣 (TRAMflap)进行乳房再造。结果　应用该方法治疗 2 2例 ,再造乳房形态良好。结论　TRAM皮瓣乳房再造术对乳腺癌根治术后患者是一种安全有效的治疗方法     

Mastectomy with immediate breast reconstruction after neoadjuvant chemotherapy and radiation therapy. A new option for patients with operable invasive breast cancer. Results of a 20 years single institution study

Purpose

To evaluate the feasability of immediate breast reconstruction (IBR) following mastectomy after neoadjuvant chemotherapy (NACT) and radiation therapy (RT) for operable invasive breast cancer (OIBC), in terms of incidence of local complications, locoregional control and survival.

Patients and methods

From 1990 to 2008, 210 patients were treated by NACT, RT and mastectomy with IBR for OIBC. One hundred and seven patients underwent a latissimus dorsi flap with implant (LDI), 56 patients a transverse rectus abdominis musculocutaneous (TRAM) flap, 25 an autologous latissimus dorsi flap (ALD) and 22, a retropectoral implant (RI) reconstruction.

Results

Forty-six (21.9%) early events were recorded: 20 necrosis, 9 surgical site infections and 6 haematomas, requiring further surgery in 23 patients. More necrosis were observed with TRAM flap reconstructions (p = 0.000004), requiring more surgical revision than LD reconstructions. Seromas represented 42% of early complications in LD reconstructions. Fifty-five patients presented with late complications (26.2%) with mainly implant complications (capsular contracture, infection, dislocation, deflation) (23.6%), requiring reintervention in 14 cases. There were more delayed surgical revisions in RI reconstructions (p = 0.0005). The 5 years overall and disease-free survival rates were respectively 86.7% and 75.6%. Sixty-four patients presented at least one recurrence (30.5%) with 5 local, 9 locoregional and 54 distant relapses.

Conclusion

This therapeutic sequence does not seem to increase the IBR morbidity nor alter disease-free and overall survival.