乳癌术后乳房再造的时机选择

乳癌治疗方法的每一次改进都对乳房再造的时机与方法产生重大影响。这其中最为重要的就是放射治疗在乳癌治疗体系中所处地位的变化。     

应用背阔肌皮瓣及硅胶假体行乳癌术后乳房再造

乳腺癌是女性最常见的恶性肿瘤之一,近年来,其发病率明显增高,发病年龄更加年轻化。乳腺癌的手术治疗主要采用传统的根治性手术,切除患侧乳房及腋窝部的组织,严重影响了女性的曲线美,同时也给患者带来巨大的心理伤害。针对乳腺癌改良根治手术后的上述不足,笔者于2008年6月始至2011年初开展乳腺癌改良根治术后应用背阔肌皮瓣及硅胶假体即刻乳房再造手术8例,现总结报道如下。     

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。     

皮下乳癌改良根治术后同期假体植入乳房再造的手术配合

目的 探讨保留皮肤及乳头乳晕的皮下乳癌改良根治术后同期假体植入乳房再造的手术配合方法.方法 对12例患者先于局麻下行乳房肿块切除术,将肿块送快速病理检查,确诊为乳癌后即行全麻,由甲乳外科医生实施保留皮肤及乳头乳晕的皮下乳癌改良根治术后,再由整形科医生实施同期假体植入乳房再造术.术中密切与手术医生和麻醉医生配合,严密观察病情,严格督促各级人员的无菌操作.结果 12例手术均顺利完成,无并发症发生.结论 在乳房切除术后采用假体植入进行乳房重建,既满足肿瘤治疗又能保持患者的躯体形象要求,提高患者生活质量;术中良好的配合是手术顺利完成的保证.     

乳腺癌术后即时乳房再造

1990年3月至1994年3月,为7例乳腺癌术后用国产硅胶囊乳房假体充填进行即时乳房再造,均获成功,无手术并发症。经3个月至4年随访,手感柔软,双乳基本对称。对即时再造术的适应证、方法、时间的选择和注意事项进行了讨论。     

乳癌根治应用游离下腹部腹直肌皮瓣Ⅰ期乳房再造

应用下腹部腹直肌肌皮瓣带蒂转移因腹壁上、下动、静脉间交通支吻合的形态与方式不同，在ＷｅｂｓｔｅｒⅣ区常发生皮瓣部分坏死。而采用吻合腹壁下动、静脉的ＴＲＡＭ皮瓣游离移植供血有保证，且血管粗大蒂长，手术易成功。它放置自由，裁剪容易，再造后外形好。其注意点应避免发生术后切口疝。ＴＲＡＭ皮瓣移植，一次手术，同时可达“乳癌根治、乳房再造、腹壁整形”的目的。     

乳癌术后乳房再造的研究进展

传统乳腺肿瘤术后造成患者乳房残缺,使女性特征缺失,造成严重的心理负担,影响其社会交往,乃至家庭生活[1]。因而,乳房再造成为乳癌患者术后的迫切需要,这充分体现了现代的生物心理社会医学模式,是肿瘤治疗技术的发展与进步。笔者总结国内外乳房修复与重建外科的研究与实践,现综述如下。1再造乳房的标准一般来说,再造的乳房应以对侧乳房为标准来塑形。如果对侧乳房过大、过小或下垂,再造的乳房不能与其对称,则需要将对侧乳房施以巨乳缩小术、隆乳术或乳房固定术。中国女性完美胸围大小与身高的关系为:胸围÷身高(厘米)=(0.50~0.53)。2再造乳…     

乳腺癌手后即对乳房再造

１９９０年３月至１９９４年３月，为７例乳腺癌术后用国产硅胶囊乳房假体充填进行即时乳房再造，均获成功，无手术并发症。经３个月至４年随访，手感柔软，双乳基本对称。对即时再造术的适应证，方法，时间的选择和注意事项进行了讨论。     

硅凝胶乳房假体隆乳术后乳癌二例

硅凝胶假体作为隆乳材料应用以来，因其手感好，材料理化性质稳定，被广泛用于临床，自20世纪80年代引入我国。我科曾收治2例隆乳术后伴发乳癌的患者，现报道如下。     

乳腺癌切除术后乳房再造

目的 探讨乳腺癌切除术后乳房再造的方法及时间.方法 总结30例不符合保乳条件的乳腺癌病例,乳房切除术后假体置人乳房再造16例,下腹部横行腹直肌肌皮瓣(TRAM瓣)乳房再造10例,背阔肌肌皮瓣乳房再造4例.其中即刻乳房再造27例,延期乳房再造3例.结果 16例假体置入乳房再造术后外观评价均为良,未出现术后并发症.10例TRAM瓣乳房再造术后发生皮瓣部分坏死2例,腹壁疝1例,术后外观评价7例为良.2例为较好,1例为差.4例背阔肌肌皮瓣再造术后外观评价为良.结论 乳房再造术是乳腺癌综合治疗不可忽视一部分,对于有强烈的保乳愿望,而又不符合保乳条件的患者,乳房再造术是一种较好的选择.即刻乳房再造优于延迟乳房再造.乳房再造的方法选择要因人而异.局部晚期乳腺癌患者可以选择性进行即刻乳房再造术.     

Use of tumescent mastectomy technique as a risk factor for native breast skin flap necrosis following immediate breast reconstruction

Background

Native breast skin flap necrosis is a complication that can result from ischemic injury following mastectomy and can compromise immediate breast reconstruction. The tumescent mastectomy technique has been advocated as a method of allowing sharp dissection with decreased blood loss and perioperative analgesia. This study was performed to determine whether the technique increases the risk for skin flap necrosis in an immediate breast reconstruction setting.

Methods

Three hundred eighty consecutive mastectomies with immediate reconstruction over a 6-year period were reviewed and divided into 2 cohorts for comparison: 100 tumescent and 280 nontumescent mastectomy cases. The incidence of minor and major skin flap necrosis was evaluated.

Results

The use of tumescent mastectomy (odds ratio [OR], 3.93; P < .001), prior radiation (OR, 3.19; P = .011), patient age (OR, 1.59; P = .006), and body mass index (OR, 1.11; P = .004) were significant risk factors for developing postoperative major native skin flap necrosis.

Conclusions

The use of the tumescent mastectomy technique appears to be associated with a substantial increase in the risk for postoperative major skin flap necrosis in an immediate breast reconstruction setting.     

Immediate or delayed breast reconstruction after mastectomy: what do women really want

Breast reconstruction, especially immediate reconstruction after mastectomy has increased over the last decades, at present being regularly offered in many centres worldwide. Despite obvious benefits and the evident oncological safety of primary breast reconstruction, the majority of women still receive a delayed procedure or even no reconstructive surgery. The objective of the present study was to determine the preference of women for breast reconstruction—immediate or delayed—and in the case of rejection of treatment to find out the reasons for this reluctance. In a prospective study a sample of 200 women—divided into two groups—were evaluated by an oral interview on the subject. The two-formed groups of participants consisted of randomly chosen women (n=100) and non-surgical nurses (n=100). The questionnaire surveyed personal data including marital status and educational level, as well as information about the preferred timing, the method of and the reasons for or against breast reconstruction. The evaluation of all data showed that 66% of the participants voted for additional surgery after mastectomy. Young age and high education level were significantly correlated (age r=0.56, P<0.01; education r=0.25, P<0.01) to the wish for reconstruction. The mean age of all participants was 39 years (range 20–69), with a significant difference between the two groups (P<0.01), the group of nurses being younger (mean age 35, range 20–62) and the other women being older (mean age 43, range 20–69). Concerning the timing of reconstruction, 21% of women elected to have an immediate and 27% a delayed operation. Yet, 52% could not come to a decision as to whether they should prefer a primary or secondary procedure. For the surgical procedure—autologous versus non-autologous tissue—about 23% of the participants could not decide spontaneously, while 40% preferred autologous tissue, 14% implants and 23% would choose a combination of both. The main reason in favour of reconstruction was that it would enhance the physical appearance (96%), whereas an important reason for general rejection was the fear of additional surgical risk (19%). For primary reconstruction, a high percentage of women also were highly concerned that reconstruction could mask cancer recurrence (62%). Although the majority of women—unaffected with breast cancer—are interested in breast reconstruction, more than half of them cannot decide spontaneously about the timing and mode of surgery, including the medical women. The collected data emphasize the urgent necessity to systematically inform women and the whole population about the options of breast reconstruction. Equally important is for the involved surgeons to know the individual wishes and fears of women unexpectedly confronted with the diagnosis of breast cancer in order to provide comprehensive preoperative counselling with respect to cancer therapy including breast reconstruction.     

Recent trends and predictors in immediate breast reconstruction after mastectomy in the United States

Introduction

Immediate breast reconstruction after mastectomy has increased in frequency during the past decade, but the socioeconomic and patient factors have yet to be fully identified.

Methods

Data were analyzed from the Nationwide Inpatient Sample from 1999 to 2003 using International Classification of Disease-9 codes to identify patients undergoing immediate breast reconstruction. Regression analyses were used to examine predictive variables for immediate breast reconstruction after mastectomy.

Results

Between 1999 and 2003, 469,832 patients underwent mastectomy. Immediate breast reconstruction occurred in 110,878 patients, yielding a 5-year average rate of 23.6% (range of 22.2% to 25.3%). Independent predictors of immediate breast reconstruction after mastectomy include private insurance, hospital in an urban location, teaching hospital, white race, hospital region in the south, age between the 3rd and 6th decades, and low number of comorbidities.

Conclusions

Immediate breast reconstruction after mastectomy is still not commonly performed in the United States. Socioeconomic and geographic factors play a significant role in whether patients undergo immediate reconstruction.     

The present status of breast reconstruction following mastectomy in the female

During the last 10 years increased interest has developed in reconstruction of the female breast following mastectomy. A number of methods of reconstruction are now available. These are immediate reconstruction by means of a silicone implant, delayed reconstruction by means of a silicon implant, use of local flaps with the silicone implant, and use of distant tissue and movement of tissue by microvascular anastomosis.The simplest and most efficient procedure is the one-stage reconstruction which consists of insertion of a silicone prosthesis approximately 6 months following the mastectomy. This can be combined, when necessary, with an elevation and reduction of the remaining breast and the reconstruction at the same time of an areolar and nipple complex.Reconstruction of the female breast in no way jeopardizes the survival of the patients. In addition, it may bring the patient to the surgeon sooner since the knowledge of reconstruction helps to reduce the woman's fear of mutilization.     

A twelve-year experience with implant reconstruction after mastectomy for cancer

Demand by patients who have undergone mastectomy for a satisfactory reconstructive procedure led us to consider less traditional approaches to reconstruction. Once such approach using a preserved and grafted nipple and areola complex followed by a prosthetic implant has been used in 40 patients. The results have been good. Technical details, morphological and psychological results, and overall results are discussed.Deceased     

Reconstruction of the breast after mastectomy for carcinoma

During the last 5 years, 80 patients underwent reconstruction of the breast as a primary or secondary procedure after mastectomy for carcinoma. Breast mounds were reconstructed with the silicone breast implant. A Silastic implant corrected the infraclavicular axillary deformity after radical mastectomy. The nipple-areolar complex was created either with a nipple-areolar graft from the contralateral breast or with a labial free graft in a bilateral breast reconstruction. If the contralateral breast was large or ptotic, reduction mammoplasty or mastopexy was performed. Subcutaneous mastectomy or total mastectomy of the other breast with insertion of the silicone breast implant was the method of choice for a group of high-risk patients.     

Immediate autologous latissimus breast reconstruction after skin sparing mastectomy

A technique of immediate breast reconstruction, combining skin sparing mastectomy and autologous latissimus breast reconstruction, is presented. In this study, 50 patients underwent this procedure between May 1993 and May 1997. The most frequent indication (62%) was ductal carcinoma in situ (multifocal, high grade or larger than 3 cm). In 38% of cases, the patients had a contraindication to the TRAM flap; in the other cases (62%) the patients preferred the dorsal donor site to the abdominal site. Reduction of the contralateral breast was done in 20% of cases of unilateral reconstruction. The aesthetic results, evaluated by two others surgeons, were rated as very good in 88% of cases, good in 8% and poor in 4%. Study of patient satisfaction showed 84% of patients to be pleased, 12% satisfied and 4% poorly satisfied. Dorsal sequelae were rated as slight in 96% of cases, intermediate in 4% and marked in none. The main disadvantage was dorsal seroma which occurred in 62% of cases but was easily managed by repeated aspiration. No patient developed a local recurrence or distant metastases. This technique represents a significant advance in breast reconstruction, giving a breast of natural shape and consistency with no transverse scar or patch effect due to the flap. Received: 13 October 1997 / Accepted: 16 November 1998     

保留乳头乳晕乳腺癌改良根治术后即刻扩展型背阔肌乳房再造术的临床应用

目的:探讨保留乳头乳晕乳腺癌改良根治术后即刻扩展型背阔肌乳房再造术的安全性与疗效。方法:回顾性分析蚌埠医学院第一附属医院肿瘤外科32例行保留乳头乳晕乳腺癌改良根治术后即刻扩展型背阔肌乳房再造术患者(观察组)和34例行传统乳腺癌改良根治术患者(对照组)临床资料,比较两组患者并发症、预后,并分析观察组重建乳房外形评分情况。结果:两组年龄、肿瘤大小、病理分期方面无统计学差异(均P0.05);观察组与对照组术后总并发症发生率差异无统计学意义(37.5%vs.32.4%,P0.05)。所有患者随访18~60个月,中位时间44个月,观察组局部复发2例,远处复发3例;对照组局部复发3例,远处转移3例,观察组与对照组3年无瘤生存率差异无统计学意义(87.5%vs.91.2%,P0.05)。观察组乳房外形评分优良率为90.6%。结论:保留乳头乳晕乳腺癌改良根治术后即刻扩展型背阔肌乳房再造术安全有效,重建的乳房外观满意,且不增加并发症与局部复发、远处转移风险。     

Factors predictive of immediate breast reconstruction following mastectomy for invasive breast cancer in Australia

PurposeTo investigate person, cancer and treatment determinants of immediate breast reconstruction (IBR) in Australia.MethodsBi-variable and multi-variable analyses of the Quality Audit database.ResultsOf 12,707 invasive cancers treated by mastectomy circa 1998–2010, 8% had IBR. This proportion increased over time and reduced from 29% in women below 30 years to approximately 1% in those aged 70 years or more. Multiple regression indicated that other IBR predictors included: high socio-economic status; private health insurance; being asymptomatic; a metropolitan rather than inner regional treatment centre; higher surgeon case load; small tumour size; negative nodal status, positive progesterone receptor status; more cancer foci; multiple affected breast quadrants; synchronous bilateral cancer; not having neo-adjuvant chemotherapy, adjuvant radiotherapy or adjuvant hormone therapy; and receiving ovarian ablation.ConclusionsVariations in access to specialty services and other possible causes of variations in IBR rates need further investigation.