乳腺切除术后即刻乳房再造术式的选择

乳腺切除术后即刻乳房再造与二期再造相比在术后效果、患者心理、住院时间以及所需费用等方面均具有明显优势.为乳腺癌术后患者选择一个合适的即刻乳房再造方式十分必要.本文对TRAM皮瓣、双蒂TRAM皮瓣、DIEP皮瓣、背阔肌肌皮瓣、扩张器/假体置入以及背阔肌肌皮瓣联合假体置入等各种即刻乳房再造术式的适应证与禁忌症进行综述.并从肿瘤学角度针对各种乳腺癌根治术如改良根治术、保留乳头、乳晕的乳腺切除术，以及保留皮肤的乳腺切除术、保乳手术后即刻乳房再造等术式的选择策略进行讨论.     

组织扩张器在乳腺癌术后乳房重建中的应用现状

乳腺癌的治疗已经从传统的根治术发展到了现今的保乳及乳房重建治疗。假体置入在乳腺癌即刻乳房重建中得到广泛应用,但部分患者术后需行放射治疗,增加了假体包膜挛缩的发生率,同时二期乳房再造患者形成胸壁瘢痕组织,影响假体置入乳房再造效果。软组织扩张器的应用很好地解决了上述问题,作者就软组织扩张器在乳腺癌术后乳房重建中的应用现状进行综述。     

乳腺癌术后即刻乳房修复和重建的临床研究

随着乳腺癌发病率逐年升高,以及人们对美的不断追求,人们在治疗乳腺癌疾病的同时,更加注意形体美和心理平衡方面的需求。乳房再造术则为这些患者带来了新的选择,达到了生理和心理的双重治疗。本研究回顾性分析了云南省乳腺癌临床研究中心1997年5月-2008年10月问行即刻乳房再造的71例乳腺癌临床资料,研究并评价乳腺癌术后即刻乳房再造的效果。     

组织扩张术在即刻乳房再造中的应用

目的改进即刻乳房再造的手术方法,将软组织扩张术应用于即刻乳房再造术中,避免再造乳房术后出现"补丁样"外观,并保留乳房再造的最佳条件。方法在乳腺癌切除后即刻于胸大肌后间隙置入圆形扩张器,并于术后8~12周注水扩张至理想体积。Ⅱ期再造手术采用硅凝胶乳房假体、背阔肌肌皮瓣+硅凝胶乳房假体、背阔肌肌皮瓣及DIEP皮瓣置换扩张器完成乳房再造。结果 2009年6月至2011年6月,采用该技术进行扩张法即刻乳房再造36例,平均完成乳房再造时间3.5个月。术后无假体外露、皮瓣坏死等并发症出现,也无原手术切口的延长或新手术切口增加。术后随访6~12个月,患者对手术效果满意率达97.2%。结论采用组织扩张法进行即刻乳房再造,可以保留最佳的乳房再造条件,避免了术后放疗对乳房假体的影响,可以避免由于采用皮瓣修补胸部皮肤缺损而出现的"补丁样"外观,是理想的即刻乳房再造方法之一。     

乳腺癌改良根治术后即刻乳房再造不同方法的临床应用

目的:探讨乳腺癌改良根治术后即刻乳房再造不同方法的适应证、手术方法及优缺点.方法:本组37例乳腺癌患者,分别采用横形腹直肌肌皮瓣带蒂转移、腹壁下动脉穿支皮瓣吻合血管游离移植、背阔肌肌皮瓣带蒂转移、单纯乳房假体置入以及不同方法相结合进行术后即刻乳房再造.结果:除2例单纯TRAM皮瓣患者近腋窝皮瓣局部坏死,1例TRAM+DIEP联合皮瓣患者下腹正中局部皮瓣脂肪液化外,余34例皮瓣全部成活,形态满意.随访5个月-10年,无腹部薄弱或腹壁疝等并发症,患者生活质量均得到提高.结论:乳腺癌术后即刻再造安全可行,不同的方法各有优缺点,应根据患者具体情况选择适合患者本人的方法进行乳房再造.     

20例保留皮肤的乳腺癌全乳切除和即刻乳房再造

选择早期乳腺癌患者20例,行保留皮肤的乳腺癌改良根治术后即刻植入假体(14例)或背阔肌肌皮瓣(2例),或联合乳房再造(4例),部分保留乳头乳晕复合体.20例患者中,保留乳房皮肤及部分保留乳头乳晕,均未见局部复发.再造效果优6例,良12例,尚可2例,无严重变形病例.无严重并发症,均按时进行辅助治疗.保留乳房皮肤及乳头乳晕的乳腺癌全乳切除术局部复发率低,术中即刻假体、背阔肌肌皮瓣或联合乳房再造手术效果好,并发症少.     

乳腺癌术后即刻乳房重建的相关问题探讨

 乳腺癌术后乳房重建显著提高了患者的生活质量,已成为乳腺癌综合治疗的一个重要部分,但也暴露出一些盲目重建的问题。乳腺癌术后乳房重建的选择应综合考虑,即刻重建与保乳手术相比选保乳,即刻重建与延期重建相比尽量即刻再造乳房,假体重建与自体重建的选择也因人而异。总之,乳房重建应遵循根治基础上兼顾美容的原则。     

神经吻合术与乳腺癌术后即刻TRAM皮瓣乳房再造

目的：介绍乳腺癌术后应用下腹横型腹直肌肌皮瓣（TRAM皮瓣）即刻乳房再造的方法，并探讨神经吻合对再造乳房皮肤感觉恢复的疗效。方法：23例乳腺癌患者改良根治术后，Ⅰ期应用单蒂或双蒂横型腹直肌肌皮瓣（TRAM）行乳房再造，单蒂TRAM乳房再造18例，双蒂TRAM乳房再造4例，游离TRAM乳房再造1例，对4例患者进行了神经吻合术，对7例患者进行了血管吻合术。结果：再造手术均取得成功，经过2—72个月随访，无局部复发。行神经吻合的患者再造乳房皮肤感觉较没有行神经吻合者好，患者对再造乳房满意度高。结论：乳腺癌术后Ⅰ期乳房再造能同时满足肿瘤的治疗和形体美容的要求，并且神经吻合术可以一定程度恢复再造乳房皮肤感觉，提高生活质量。     

神经吻合术与乳腺癌术后即刻 TRAM 皮瓣乳房再造

目的：介绍乳腺癌术后应用下腹横型腹直肌肌皮瓣（TRAM皮瓣）即刻乳房再造的方法，并探讨神经吻合对再造乳房皮肤感觉恢复的疗效。方法：23例乳腺癌患者改良根治术后，Ⅰ期应用单蒂或双蒂横型腹直肌肌皮瓣（TRAM）行乳房再造，单蒂TRAM乳房再造18例，双蒂TRAM乳房再造4例，游离TRAM乳房再造1例，对4例患者进行了神经吻合术，对7例患者进行了血管吻合术。结果：再造手术均取得成功，经过2—72个月随访，无局部复发。行神经吻合的患者再造乳房皮肤感觉较没有行神经吻合者好，患者对再造乳房满意度高。结论：乳腺癌术后Ⅰ期乳房再造能同时满足肿瘤的治疗和形体美容的要求，并且神经吻合术可以一定程度恢复再造乳房皮肤感觉，提高生活质量。     

乳腺癌根治术后乳房再造方法的选择

乳腺癌术后所致的乳房缺失给患者带来的严重身心创伤以及由此造成的患者在抗肿瘤信心与能力方面的负面影响越来越受到肿瘤医师和整形外科医师的重视。乳房缺失常引起患者精神压抑、严重焦虑、夫妻生活失调以及社交活动受阻。目前由于乳腺癌综合治疗手段的进步，术后患者生存率大为提高，同时术式的不断改良（保留乳头、乳晕的乳癌改良根治术），为乳癌术后乳房再造，尤其是即刻乳房再造提供了更为有利的条件。     

乳腺癌术后乳房重建手术与放疗间关系——基于中国110家医院横断面调查研究

目的 调查目前我国乳房重建手术开展现状,以及国内医生对放疗与乳房重建手术之间关系看法。方法 选取全国范围内110家乳腺癌年手术量>200例的医疗机构,以问卷调查形式开展研究,调查内容包括手术医师及其所在科室和医院的基本情况、2017年乳腺癌手术开展情况、各类型重建手术开展情况以及对放疗和重建手术关系的具体看法。结果 110家单位参与调研,96家(87.3%)单位已开展重建手术,植入物重建占总重建手术量的65.7%,自体重建占20.1%。对于可能需要术后放疗的患者,受访医院首选的手术方式为植入物重建,对于明确需要术后放疗和全乳切除术后接受过放疗的患者,首选自体组织重建。术后放疗是即刻乳房重建的阻碍因素,多数医院认为放疗对手术的影响不大。延期-即刻乳房重建的开展比例达到66%,86%的医院首选在放疗结束半年后更换假体。保乳术后复发的患者也可进行即刻重建,首选的手术方式为植入物重建。结论 我国乳房重建的比例开展较低,医生技术掌握仍有欠缺,在面对与放疗的冲突时,国内专科医生的选择与指南和共识尚存在出入,提示需要对医生进行更专业的培训,以进一步推动国内乳房重建事业的发展。     

Chronic postsurgical pain following breast reconstruction: a commentary and critique

In line with other major surgeries including breast cancer surgery (BCS), recent studies suggest a striking rate of chronic postsurgical pain (CPSP) following breast reconstruction. This commentary will critically examine evidence for the degree to which the prevalence of CPSP following breast reconstruction is directly attributable to reconstructive surgery. The discussion will trace similarities and distinctions between breast reconstruction and BCS in considering the risk for CPSP, and describe recent advances in the definition of CPSP, highlighting methodological limitations in the general investigation of CPSP, which also characterize the study of CPSP more specifically for breast reconstruction outcome. A convenience sample of relevant studies examining CPSP following breast reconstruction reveals inadequate evidence to support a serious concern for reconstruction-induced CPSP and further that these studies fail to adhere to recommended methodological standards to effectively isolate surgery as the etiology of persistent pain reported by women following reconstructive surgery. Suggestions for future exploration of problematic chronic pain after breast reconstruction are considered.     

乳腺肿瘤整形与乳房重建专家共识(2022年版)

随着乳腺肿瘤整形与乳房重建在国内新的临床应用趋势,更鉴于新的循证医学数据不断累积,中国抗癌协会乳腺癌专业委员会召集外科、整形、放疗、内科、病理等多学科专家,在《乳腺肿瘤整形与乳房重建专家共识(2018年版)》的基础上共同商讨制定了《乳腺肿瘤整形与乳房重建专家共识(2022年版)》,2022年版新增了腔镜乳房重建、胸肌前乳房重建及乳房重建的个案管理等内容,并将初版的保留乳头乳晕的全乳切除章节更名为保守性全乳切除,并做了大量内容补充及更新。共识也对胸肌前乳房重建、游离腹壁下动脉穿支皮瓣(deep inferior epigastric artery perforator flap,DIEP)手术等临床热点进行了详尽的阐述。相信本次更新会给各层级医院提高乳腺肿瘤整形及乳房重建临床水平,提升治疗规范化,优化治疗结局助力,最终提高患者满意度。     

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. 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.     

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.     

我国乳腺肿瘤整形外科的临床研究进展

乳腺癌是我国女性发病率最高的恶性肿瘤。随着乳腺癌综合治疗技术的进步和患者生存期的延长,为提高乳腺癌患者的生存质量,乳腺肿瘤整形外科受到越来越多的重视。乳腺肿瘤整形外科主要包括保乳整形和乳房重建两个技术体系。相较于西方发达国家,我国乳腺肿瘤整形外科虽起步较晚,但发展迅速,在很多领域都取得长足的进步。本文将就植入物乳房重建、自体组织乳房重建、脂肪移植乳房成形、内窥镜辅助乳房重建、乳头乳晕重建、患者报告结局评价等亚专科领域,对我国乳腺肿瘤整形外科的研究进展、当前学科发展的不足之处,及未来发展方向进行综述。     

双侧乳房重建的研究现状

乳房重建手术已逐渐发展为乳腺癌手术治疗中的一个重要手段。近些年,随着乳房重建手术数量的增加,双侧乳房重建手术（bilateral breast reconstruction,BBR）的比例也在不断提高,而预防性乳腺切除术和双侧乳腺癌发病率的增长是双侧乳房重建手术增加的主要原因。本文将就BBR的临床指征、重建方式、手术并发症和远期效果等方面进行综述。      

Breast conserving surgery with primary volume replacement using a lateral tissue flap

Breast conserving surgery (BCS) is now a standard surgical treatment for early breast cancer. The number of patients with tumors under 3 cm who underwent breast conserving surgery overtook the number of patients who underwent total mastectomy for the first time in Japan in 2003. We have been employing breast conserving surgery with primary reconstruction using a lateral tissue flap (LTF), and have performed breast conserving surgery for 266 patients from 1990 to 2002. The incidence of local relapse was 5.6%. Although we did not irradiate a low risk group of 101 patients, our method is not inferior to other reports in which all cases underwent irradiation. Primary reconstruction with LTF has three advantages. The first is that we can avoid poly-surgery for breast reconstruction. The second is that the volume of the graft is maintained longer than reconstruction with a musculo-cutaneous flap. The third is that patients can avoid allergic reactions or granulomas as seen with artificial prosthesies. In conclusion, breast conserving surgery with immediate volume replacement with a LTF is a reasonable surgical procedure and has the advantage of avoiding unnecessary surgical procedures for reconstruction and surgical invasion without delaying the diagnosis of local relapse. Moreover, an adequate assessment of risk can spare low risk groups irradiation.     

放疗及其时机对组织扩张器-假体植入乳房重建的影响及研究进展

随着放疗在乳腺癌治疗中的适应证不断扩大,越来越多的患者在乳房切除术后需要放疗,而伴随着乳房重建的开展,在治疗肿瘤获益的同时,放疗及其时机的选择又会给乳房重建带来影响,可能导致术后并发症和美容效果迥异。如何优化乳腺癌术后乳房重建与放疗等综合治疗的策略,尤其是乳房重建的技术和放疗时机选择等,已成为放疗科、乳腺外科和整形外科等多学科治疗共同关注的问题。本文旨在回顾和汇总该领域最新的高质量研究,从放疗及其时机选择对组织扩张器/假体乳房重建的影响、假体重建率及术后患者满意度等方面进行综述,以便学者了解与放疗和乳房重建相关的最新研究进展,帮助临床医师优化治疗方案。     

24例保留乳头乳晕乳腺癌术后即刻乳房重建的临床经验

目的:探讨保留乳头、乳晕及部分乳房皮肤的乳腺癌改良根治术后即刻采用不同的方法乳房重建的可行性。方法:筛选出病理符合要求的24例早期乳腺癌患者,行保留乳头、乳晕及部分皮肤的改良根治术,根据患者的要求,结合其身体、心理、经济等状况,特别是乳房的大小和需要切除的尺寸,选择适合该患者的手术方式即刻行乳房重建,采用硅胶充填假体置入乳房重建9 例,腹直肌肌皮瓣乳房重建3 例,背阔肌肌皮瓣和硅胶填充假体联合重建12例。术后根据客观标准和主观标准评价重建效果。结果:24例乳腺癌患者术后即刻乳房再造术后外观良好,双侧乳房基本对称。客观评价效果优良和尚好者23例（95.83%）,主观评价优良和尚好者24例（100%）,1 例术后部分乳头坏死、脱落。1 例术后出现血肿,于术后3 个月消失。术后给予常规化疗,随访5～48个月,除1 例患者术后2 年死于原发性肝癌,均无局部复发或远处转移。结论:对于早期乳腺癌行保留乳头、乳晕及部分乳房皮肤的乳腺癌改良根治术后即刻采用不同方法乳房再造,具有经济、整形效果好、显著减少患者乳房缺失造成的心理影响、提高生存质量等优点。术后不影响乳腺癌的辅助治疗和远期疗效,能同时满足肿瘤治疗和形体美容两个方面的要求,正逐渐被广大乳腺癌患者所接受。