保留乳房手术及外侧组织瓣乳房成型治疗乳腺癌的应用体会

1997-2002年对18例早期原发乳腺癌(Tis-T2A)进行保留乳房 外侧组织瓣乳房成形术。结果 18例手术均获成功，切口Ⅰ期愈合，乳头无坏死。10例患者术后随访2年以上，均无肿瘤局部复发及转移。初步研究结果提示，应用外侧软组织皮瓣(lateral tissue flap，LTF)乳房成型，有良好临床效果和使用价值。     

保留乳房手术及外侧组织瓣乳房成型治疗乳腺癌的应用体会

1997-2 0 0 2年对 18例早期原发乳腺癌 (Tis T2 A)进行保留乳房 +外侧组织瓣乳房成形术。结果 18例手术均获成功 ,切口Ⅰ期愈合 ,乳头无坏死。 10例患者术后随访 2年以上 ,均无肿瘤局部复发及转移。初步研究结果提示 ,应用外侧软组织皮瓣 (lateraltissueflap ,LTF)乳房成型 ,有良好临床效果和使用价值。     

乳腺癌保留乳头乳晕改良根治术的临床应用价值

目的 探讨保留乳头乳晕的改良根治术在乳腺癌治疗中的可行性、肿瘤的根治性和美容效果.方法 选择初治乳腺癌患者96例,其中保留乳头乳晕的改良根治术(NSM)组共35例,改良根治术(MRM)组共61例.对两组患者术后并发症、外观评价、局部复发及远处转移情况进行比较.结果 术后并发症NSM组和MRM组差异无统计学意义(x2=3.140,P=0.061);外观评价NSM组优于MRM组(x2=82.786,P=0.000);随访48～ 84个月,平均随访63个月,两组患者均无局部复发,NSM组发生远处转移2例(5.7％),MRM组远处转移3例(4.9％),两组远处转移率差异无统计学意义(x2=0.029,P=0.866).结论 保留乳头乳晕的改良根治术可以获得与改良根治术相同的治疗效果,术前患者容易接受,术后美容效果好,值得广泛推广.     

保留乳头乳晕乳房切除-重建术研究进展

保留乳头乳晕乳房切除-重建术是近年来乳腺癌外科治疗的新方向和热点问题。相比于传统改良根治术,保留乳头乳晕乳房切除-重建术保留乳腺癌患者形体上完整,弥补了患者乳房缺失的心理缺失。然而保留乳头乳晕乳房切除-重建术在乳腺癌外科治疗上的安全性一直广受争议,手术适应证也未完全明确,手术切口选择、切缘处理及重建方式选择失当导致的乳头坏死等问题也亟须进一步探讨。笔者将从以上几个角度探讨一下保留乳头乳晕乳房切除-重建术研究的最新进展。     

乳腺癌术后可扩张假体与自体组织乳房重建的临床比较

目的:探讨并比较分析保留皮肤乳腺切除术后,应用即刻可扩张假体植入乳房重建与即刻自体组织乳房重建的手术方法、效果及并发症.方法:60例患者行保留皮肤的乳腺改良根治术后乳房重建,其中可扩张假体植入重建43例,即刻自体组织重建17例.根据乳房的体积、形状、与对侧乳房的对称性比较及患者满意度,评价两种手术的效果.结果:随访12个月,可扩张假体乳房重建组到达良好以上为93％,自体组织重建组为86％,两种重建方法治疗效果差异无统计学意义.可扩张假体植入乳房重建安全可靠,手术效果好,并发症少.结论:可扩张假体植入即刻乳房重建扩大了假体植入乳房重建的手术适应证,是一种值得推广的手术方式.     

乳腺癌外科治疗的新理念：乳房肿瘤切除整复重建

乳腺癌的外科治疗一直在发展进步中,近年随着人们生活水平和生活质量的提高,乳腺癌患者对乳腺癌术后乳房形态恢复的要求也越来越高,采用各种整复重建技术对乳腺癌患者进行乳房手术后即刻重建在欧美国家得到了越来越普遍的关注与应用,由此催生了一个新的亚专科——乳房肿瘤切除整复重建外科（oncoplastic breast surgery）的出现[1-3]。这种治疗方式的应用不仅可以显著提高患者的生活质量,并且构成了乳腺癌综合治疗的一个重要组成部分。     

早期乳腺癌保留乳头乳晕复合体的改良根治术--Ⅰ期腹直肌肌皮瓣重建乳房

背景与目的：改良根治术目前已成为早期乳腺癌主要外科治疗方法之一,但术后如何重建乳房及保留乳头乳晕复合体一直是争论的焦点。本研究探讨早期乳腺癌保留乳头乳晕复合体的改良根治术——Ⅰ期腹直肌肌皮瓣重建乳房的方法及临床应用。方法：对早期乳腺癌患者行皮下乳腺切除,腋窝淋巴结清除,腹直肌肌皮瓣Ⅰ期乳房再造,最大限度地保留乳房皮肤以及乳头乳晕复合体。结果：应用该方法治疗10例早期乳腺癌,术后随访24～48个月,所有病例均无肿瘤局部复发及远处转移,重建乳房外形良好,乳头乳晕区皮肤无坏死,皮肤无明显萎缩、变硬,半年后乳头感觉恢复,供区无腹壁疝形成。结论：保留乳头乳晕复合体的乳腺癌改良根治术——Ⅰ期腹直肌肌皮瓣重建乳房,外形效果良好,对早期乳腺癌要求保持乳房外形的患者可能是一种较好的治疗方法;因本研究例数较少,该技术的疗效有必要行更大样本的研究来证实。     

双旋转皮瓣应用于乳腺癌保留乳房治疗的临床研究

目的：研究拓宽乳腺癌保留乳房治疗的指征及改善术后美容效果的手术方法。方法：对65例临床T1-3N0-2M。乳腺癌患者行肿瘤切除＋全腋淋巴结清除术,达到切缘阴性,术中采用双旋转乳腺皮瓣进行乳腺整形,辅以放、化和（或）内分泌治疗。结果：65例清除腋窝淋巴结8～26枚／例,平均16枚／例,术后中位随访时间为68个月,均无局部复发,3、5、8年生存率分别为100％、91．67％和86．67％。保留乳房的美容效果满意率为95．38％。结论：采用双旋转乳腺皮瓣行乳腺癌保留乳房手术,可以拓宽乳腺癌保留乳房治疗的指征,提高术后美容效果的满意度,不降低肿瘤局部控制率及生存率。     

保留乳房天然结构的乳腺癌改良根治术后即刻乳房成形术的临床应用

目的探讨保留乳房天然结构的乳腺癌改良根治术后即刻自体组织乳房成形术在临床中的运用价值。方法乳腺癌患者12例,其中DCIS 6例,浸润性导管癌3例,小管癌1例,髓样癌1例,黏液癌1例;保留乳房皮肤的乳腺癌改良根治术9例,保留乳头乳晕复合体的乳腺癌改良根治术3例。全组均保留或重建乳房下皱襞,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背阔肌肌皮瓣即刻乳房成形。结果横行腹直肌肌皮瓣乳房成形术3例,背阔肌肌皮瓣乳房成形术9例,术后皮瓣均存活,皮瓣血管通畅,成形乳房外观良好。结论对早期乳腺癌患者行保留乳房天然结构的乳腺癌改良根治术后即刻自体组织乳房成形,切口隐蔽,成形乳房形态效果良好,可以获得较好的美容效果。     

乳腺癌改良根治术后自体肌皮瓣乳房重建21例

对21例乳腺癌采用不同部位的自体肌皮瓣移植，在改良根治术同期或术后Ⅱ期乳房重建，21例乳房重建均获成功，结果表明乳房重建以根治性手术同期腹直肌肌皮瓣移植重建较为理想，常用。     

吲哚菁绿血管造影在带蒂横行腹直肌皮瓣乳房重建术中的应用

目的探讨应用吲哚菁绿(ICG)血管造影指导带蒂横行腹直肌(TRAM)皮瓣乳房重建术中皮瓣修剪的可行性。 方法采用前瞻性研究方法,分析天津医科大学肿瘤医院和郑州大学附属郑州中心医院2015年1月至2017年6月收治的64例带蒂TRAM皮瓣乳房重建患者的临床资料。使用随机数字表法将患者分为造影组(34例)和对照组(30例)。造影组采用ICG血管造影指导TRAM皮瓣修剪,对照组采用传统经验修剪皮瓣。2组患者术后12 h皮瓣血供异常发生率、皮瓣相关并发症发生率及重建乳房术后外观评价等级的比较,均采用χ²检验,患者术后总体满意度评分比较采用t检验。 结果造影组患者未出现ICG血管造影相关并发症,并且,依据造影结果切除血流灌注不良的部分后,乳房塑形满意。造影组患者术后12 h皮瓣血供异常发生率为2.9% (1/34),对照组为13.3% (4/30),2组比较,差异无统计学意义(χ²＝1.165,P＝0.280);并且,造影组患者皮瓣相关并发症发生率为2.9%(1/34),对照组为10.0%(3/30),2组比较,差异也无统计学意义(χ²＝0.418,P＝0.518)。术后随访1年,造影组患者乳房外观评价为非常好者占97.1%(33/34),明显高于对照组的76.7%(23/30)(χ²＝4.338,P＝0.037);造影组与对照组患者总体满意度评分分别为(8.91±0.38)分和(8.47±0.57)分,2组比较,差异有统计学意义(t＝3.622, P＝0.001)。 结论吲哚菁绿血管造影能在术中动态显示带蒂TRAM皮瓣的血供范围,对指导皮瓣修剪有一定的帮助,有助于获得较好的乳房外观。     

双蒂横行腹直肌肌皮瓣在双侧乳腺癌术后即刻乳房重建中的应用

双侧乳腺癌同时进行双侧乳腺切除，术后胸部缺损严重，使患者身心遭受双重打击，极大影响其生活质量。随着自体组织移植乳房重建手术的日益成熟和发展，乳腺癌患者要求乳房重建者日渐增多。本科于2004年4月至2007年8月对3例双侧乳腺癌改良根治术后患者采用双蒂下腹部横行腹直肌肌皮瓣（transverse rectus abdominis myocutaneous flap，TRAM）行即刻双侧乳房重建，均获得成功，重建乳房效果满意。现报告如下。     

Optimizing pedicled transverse rectus abdominis muscle flap breast reconstruction

With improved detection and genetic screening for breast cancer, increasing numbers of patients are choosing mastectomy and immediate breast reconstruction. Advances in breast reconstruction and mastectomy techniques over the last 25 years have increased expectations for breast reconstruction. The purpose of this review is to describe the role of the pedicled transverse rectus abdominis muscle (TRAM) flap in modern breast reconstruction.The pedicled TRAM flap is the most common method of autologous breast reconstruction. TRAM flap reconstruction involves the transfer of lower abdominal skin and subcutaneous fat based on the superior epigastric vessels. Common risk factors for complications from pedicled TRAM flap reconstruction include smoking, obesity, and postoperative radiotherapy. Patients with these risk factors are often candidates for a vascular delay procedure whose purpose is to enhance the blood flow within the TRAM flap.Despite advances in free flap breast reconstruction, pedicled TRAM flap breast reconstruction remains an excellent option for unilateral breast reconstructions. Unlike microsurgical breast reconstruction, the pedicled TRAM flap does not require sophisticated postoperative monitoring and can be performed efficiently in any hospital setting. Furthermore, with the addition of a vascular delay procedure, pedicled TRAM reconstructions can be safely performed even in traditionally "high risk" patients.     

Role of rectus abdominis myocutaneous flap in surgery for breast cancer

Rectus abdominis myocutaneous flap has been used in four different therapeutic situations after mastectomy for breast cancer. These include (1) to obtain skin cover after radical mastectomy with liberal skin sacrifice for locally advanced cancer in 14 cases, (2) for skin cover to obtain primary wound healing in 10 cases treated by preoperative radiotherapy, (3) for delayed breast reconstruction in three patients and (4) for immediate postmastectomy breast reconstruction in 25 patients. Prosthesis was not used for breast reconstruction. The operative morbidity was minimal but 1-2 units of extra blood transfusion was required. Administration of adjuvant treatment, including chemotherapy and radiotherapy was not affected. Reconstruction was satisfactory.     

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。     

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.     

The acute effects of postoperative radiation therapy on the transverse rectus abdominis myocutaneous flap used in immediate breast reconstruction

Purpose: To analyze the acute effects of postoperative radiation therapy on the transverse rectus abdominis myocutaneous (TRAM) flap reconstruction following modified radical mastectomy for breast cancer.

Methods and Materials: Twenty-five consecutive patients were treated with postoperative radiation therapy after TRAM flap reconstruction between 1985 and 1999. The radiation records for these patients were retrospectively reviewed. Information regarding treatment techniques, timing, and dose was obtained and correlated with the extent of erythema, desquamation, and the need for treatment break.

Results: The median age was 48 years. The median dose of chest wall radiation was 5040 cGy. Additional boost doses were delivered in 13 patients. Twelve patients (48%) developed mild erythema in the treatment field during the course of treatment and 13 patients (52%) developed moderate (40%) or brisk (12%) erythema. Only 10 patients (40%) developed any kind of desquamation; 5 patients (20%) developed dry desquamation and another 5 patients (20%) developed moist desquamation. No patients required a break in the course of treatment because of acute side effects. None of the parameters evaluated (the use of chemotherapy prior to radiation, the interval between surgery and radiation, smoking, prior incidence of fat necrosis, the use of bolus during radiation, and the use of a boost) were predictive of an increased incidence of either the extent of erythema or the development of desquamation in the treatment field.

Conclusion: Postmastectomy radiation for TRAM flap reconstruction is well tolerated and is not associated with an increased incidence of acute side effects. Radiation technique and the use of preradiation chemotherapy do not appear to be correlated with an increased incidence of acute side effects.