游离腹部皮瓣乳房重建的应用及研究进展

乳腺癌发病率居女性新发恶性肿瘤的第一位,外科治疗是重要的治疗手段之一。全乳切除术后乳房重建能在不影响肿瘤学安全性的前提下,提高患者的生存质量,其中,自体组织乳房重建因其特有的优势成为乳房重建的重要方式之一,而游离腹部皮瓣是自体组织乳房重建中最理想的材料。该研究将对游离腹部皮瓣乳房重建手术的临床应用、手术时机及并发症进行综述,旨在探讨游离腹部皮瓣乳房重建的应用及研究进展。     

乳房自体组织重建的研究进展

乳腺癌是全世界女性最常见的恶性肿瘤。这些患者必须面对手术治疗对其生活质量和身体外观的长期影响。因此,越来越多的患者亟需一种结合肿瘤治疗与乳房重建的方法来满足其对疾病的治疗和乳房外观的需求。在美国,20世纪80年代接受乳房切除术后即刻重建的患者只有不到20%。但近年来,越来越多的患者选择即刻重建。乳房自体组织重建因其美容效果好而成为了许多患者的首选方案,但其术前穿支血管的选择及术后并发症的发生仍是目前自体组织重建所面对的问题。本文就乳房重建技术中自体组织重建皮瓣的应用、相关并发症的发生及预防、皮瓣穿支血管的影像学评估及腔镜技术下乳房重建的研究进展进行了详细的总结。     

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。     

乳腺癌乳房整形外科应用现状与进展

 乳腺癌术后乳房重建已成为乳腺癌综合治疗不可或缺的一部分,旨在不影响乳腺癌预后的基础上,提高患者生活质量。虽然中国乳腺癌乳房整形外科起步较早,但近几年才逐渐进入快速发展时期,且与发达国家仍存在较大差距。乳腺癌术后乳房重建整形技术主要包括肿瘤保乳整形技术以及全乳切除术后乳房重建,而乳房重建又可分为自体皮瓣重建及植入物重建。同时,脂肪移植、生物材料等重建辅助技术也在快速发展。国内首个较为全面细致的乳房重建指南,乳腺肿瘤整形与乳房重建专家共识将于今年发布,对乳房整形重建问题进行全面探讨和分析。在遵循乳房重建共识和指南的基础上,积极完善专科医生培训体系,建立更广泛深入的学科合作,从而促进我国乳腺癌术后乳房整形与重建技术的发展。       

腹部皮瓣乳房重建术后并发症及危险因素分析

用于乳房重建的腹部皮瓣主要包括：横行腹直肌（transverse rectus abdominis myocutaneous，TRAM）肌皮瓣和腹壁下动脉穿支（deep inferior epigastric perforator，DIEP）皮瓣。应用腹部皮瓣进行乳房重建因携带组织量大，重建乳房形态自然、柔软，同时也起到腹壁整形的效果，应用非常广泛。但此类手术技术难度大，手术时间长，如果出现术后并发症将延长患者住院时间，影响手术效果。     

皮瓣在乳腺癌手术中的应用

乳腺癌发病率呈逐年上升趋势。乳腺癌术后乳房缺失及保留乳房术、乳房巨大肿瘤切除所致的腺体、胸壁缺损和畸形,对患者的生理和心理造成了极大的创伤,已经成为乳腺外科医师迫切需要解决的问题。皮瓣作为乳腺癌患者乳房重建和胸壁修复的重要材料,在临床上的应用日益广泛。本文通过回顾历年来皮瓣在乳腺癌手术中的应用情况,总结了各类皮瓣的特点、手术适应证,介绍了乳腺癌术中各类皮瓣的操作要点及术后监测指标,以便临床医师更加规范地将其运用于乳腺癌手术中。笔者认为,深入探讨皮瓣手术的适应证、方案设计以及操作技巧,能更好地促进乳房再造技术的发展,提高乳腺肿瘤患者术后的生活质量。     

应用腹壁下动脉穿支皮瓣即刻乳房重建

目的总结乳腺癌切除同时应用腹壁下动脉穿支（DIEP）皮瓣行即刻乳房重建的手术经验,探讨DIEP皮瓣即刻乳房重建的适应证及优点。方法2003年4月-2009年6月,中国医学科学院肿瘤医院乳腺中心接受乳腺癌切除术患者21例（根治术6例,改良根治术15例）,术前应用多排螺旋CT（MDCT）血管造影及多普勒血流仪探明穿支位置,乳腺癌切除的同时,解剖腹壁下动脉穿支,形成腹壁下动脉穿支蒂皮瓣,与患侧胸背血管吻合,进行即刻乳房重建。结果术后随访6个月至6年。21例患者中,20例皮瓣全部存活,1例出现皮瓣远端1／3脂肪液化;胸部受区出现1例血肿;无腹壁膨隆、腹壁疝、切口脂肪液化等供区并发症;再造乳房外形满意,形态自然。结论乳腺癌切除同时,采用DIEP皮瓣进行即刻乳房重建,可以使患者免受乳房缺失的痛苦,同时具有受区组织条件好、皮瓣组织量丰富、供区损伤小及并发症少的优点,是一种理想的即刻乳房重建方法。     

自体组织即刻乳房重建和延迟乳房重建术后生活质量评价

目的评价自体组织即刻乳房重建和延迟乳房重建术后患者的生活质量。方法通过问卷和电话随访两种形式调查自体组织即刻乳房重建和延迟乳房重建的乳腺癌患者术后生活质量。生活质量问卷是欧洲癌症研究治疗组织制定的调查条例(EORTC QLQ-C30)及专用于乳腺癌的特异模块乳腺癌患者生命质量测定量表QLQ-BR23中文版。2005年1月-2009年10月,共随访到72例,即刻组31例,延迟组41例。结果即刻乳房重建对患者术后生活质量的影响在多方面优于延迟乳房重建。重建乳房对称性、角色功能、社会功能、情绪功能及上肢功能的评价即刻组显著高于延迟组（P<0.001和P<0.05）。结论自体组织即刻乳房重建患者术后生活质量优于延迟乳房重建患者,乳腺癌患者如果有乳房重建的要求,自体组织即刻乳房重建可以作为首选方法。     

51例乳腺癌患者术后游离腹壁皮瓣乳房重建的临床分析

背景与目的:随着乳腺癌患者预后的不断改善,全乳切除后接受乳房重建手术的患者比例正逐年增高。腹部游离皮瓣是目前应用最多的自体组织乳房重建方法。本研究旨在探讨游离腹壁皮瓣乳房重建在临床实践中的应用价值。方法:对2006年6月—2011年11月在复旦大学附属肿瘤医院接受游离腹壁皮瓣乳房重建的51例乳腺癌患者进行回顾性分析。在51例患者(1例患者为双乳重建,手术计52例次)中,行游离的横行腹直肌(free transverse rectus abdominis myocutaneous,F-TRAM)手术1例次,保留肌肉的F-TRAM19例次,DIEP 32例次。结果:手术成功49例(96.1%)。受区血管的选择:胸廓内血管42例次(80.8%);胸外侧血管1例次(1.9%);肩胛下血管9例次(17.3%)。穿支平均数量为2.31支(1～4支),平均手术时间为8.1 h(4.6～12 h),平均住院时间为20 d(10～39 d),术后平均住院时间为11 d(4～22 d)。在Ⅰ期重建的40例患者中(包括1例双侧Ⅰ期乳房重建),术后化疗有23例(57.5%),其手术距离首次化疗时间为15.6 d(7～33 d)。乳房重建术后乳头重建患者13例(25.5%)。随访1.2～38.5个月,中位随访7.5个月。全部皮瓣坏死2例(3.92%),皮瓣感染1例(1.96%),皮瓣下血肿1例(1.96%),部分脂肪坏死8例(15.69%),腹部并发症3例(5.88%)。患者总体满意度为8.5分。结论:游离腹壁乳房重建有较好的临床应用价值。血供佳,皮瓣组织量大,可以满足大部分患者的需求。术后供区并发症较少,患者对重建形体的满意度较高。但该术式需要较高的手术技巧、先进的手术设备及护理团队的配合。     

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。     

Association of the breast reconstruction modality with the development of postmastectomy lymphedema: A long-term follow-up study

BackgroundWhether the breast reconstruction modality could influence the long-term development of post-mastectomy lymphedema has been little investigated. The present study aimed to evaluate the potential association of the breast reconstruction method with the incidence of lymphedema over an extended follow-up period.MethodsPatients with breast cancer who underwent immediate reconstruction from 2008 to 2014 were reviewed. They were categorized into three groups according to the reconstruction method: tissue expander/implant, abdominal flaps, and latissimus dorsi (LD) muscle flaps. Differences in the cumulative incidence of lymphedema by the reconstruction method were analyzed, as well as their independent influence on the outcome. Further analyses were conducted with propensity-score matching for baseline characteristics.ResultsIn total, 664 cases were analyzed with a median follow-up of 83 months (402 prostheses, 180 abdominal flaps, and 82 LD flaps). The rate of axillary lymph node dissection was significantly higher in the LD flap group than in the other two groups. The 5-year cumulative incidences of lymphedema in the LD flap, abdominal flap, and prosthesis groups were 3.7%, 10.6%, and 10.9%, respectively. In multivariable analyses, compared to the use of the LD flap, that of tissue expander/implant and that of abdominal flaps were associated with increased risks of lymphedema. A similar association was observed in the propensity-score matching analysis. The use of abdominal flaps or prostheses was not associated with the outcomes.ConclusionsOur results suggest that the method of immediate breast reconstruction might be associated with the development of postmastectomy lymphedema.     

Recent advances in microvascular autologous breast reconstruction after ablative tumor surgery

Breast cancer is a ubiquitous disease and one of the leading causes of death in women in western societies. With overall increasing survival rates, the number of patients who need post-mastectomy reconstruction is on the rise. Especially since its psychological benefits have been broadly recognized, breast reconstruction has become a key component of breast cancer treatment. Evolving from the early beginnings of breast reconstruction with synthetic implants in the 1960s, microsurgical tissue transfer is on the way to become the gold standard for post oncology restoration of the breast. Particularly since the advent of perforator based free flap surgery, free tissue transfer has become as safe option for breast reconstruction with low morbidity. The lower abdominal skin and subcutaneous fat tissue typically offer enough volume to create an aesthetically satisfying breast mound. Nowadays, the most commonly used flap from this donor site is the deep inferior epigastric artery perforator flap. If the lower abdomen is not available as a donor site, the gluteal area and thigh provide a number of flaps suitable for breast reconstruction. If the required breast volume is small, and there is enough tissue available on the upper medial thigh, then a transverse upper gracilis flap may be a practicable method to reconstruct the breast. In case of a higher amount of required volume, a gluteal artery perforator flap is the best choice. However, what is crucial in addition to selecting the best flap option for the individual patient is the timing of the operation. In patients with confirmed post-mastectomy radiation therapy, it is advisable to perform microvascular breast reconstruction only in a delayed fashion.     

Microvascular reconstruction of the breast

The growth of microsurgical procedures has led to significant technological, scientific, and clinical advances that have made these procedures safe, reliable, reproducible, and routine in most major medical centers. In many instances, free flap reconstruction has become the primary reconstructive method for many major defects, including breast reconstruction. The advantages of free flap breast reconstruction include better flap vascularity, broader patient selection, easier insetting of the flap, and decreased donor site morbidity. Free flap breast reconstruction can occur either at the time that the mastectomy is performed or as a delayed reconstruction following a previous mastectomy. Immediate reconstructions have the advantage of avoiding scar contracture and fibrosis within the mastectomy flaps and at the recipient vessel site. The most common recipient vessel sites are the thoracodorsal vessels and the internal mammary vessels. The thoracodorsal vessels are most frequently used in immediate reconstruction because they are partially exposed during the mastectomy procedure. The internal mammary vessels are used more frequently in delayed reconstructions, to avoid repeat surgery in the axilla. This recipient site also allows more medial placement of the reconstruction. Flap selections for free autogenous breast reconstruction include the transverse rectus abdominis myocutaneous (TRAM) flap, the superior gluteal myocutaneous flap, the inferior gluteal myocutaneous flap, the lateral thigh flap, and the deep circumflex iliac soft tissue flap (Rubens). The TRAM flap is most commonly used in free flap breast reconstruction. For patients with inadequate abdominal tissue or prior abdominal surgery, the superior gluteal flap is typically used. Both the TRAM flap and the superior gluteal flap can be designed as perforator flaps, preserving all of the involved muscle and, in the TRAM perforator, all the rectus fascia. These flaps are more technically demanding, with minimal impact on donor site function. The other flaps are less frequently used and limited to special patient circumstances. Free flap autogenous breast reconstruction provides a natural, long-lasting result with a high degree of patient satisfaction. Semin. Surg. Oncol. 19:264-271, 2000.     

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。     

Impact of insurance payer and socioeconomic status on type of autologous breast reconstruction

IntroductionAutologous breast reconstruction has evolved from more morbid procedures that sacrificed the abdominal muscle (the TRAM or transverse rectus abdominus muscle flap) to “perforator” flaps. Commercial insurers recognized the higher technical demand of perforator flaps by creating procedural codes with higher professional fees. This study examined whether procedure code discrepancies between insurance payers disproportionally incentivize perforator flaps among the commercially insured.MethodsAutologous breast reconstructions identified from the National Inpatient Sample (NIS) were subdivided into microvascular perforator (85.74, 85.75, 85.76), microvascular TRAM (85.73), and pedicled TRAM flaps (85.72). Demographics, comorbidities and access to care were compared. A logistic regression comparing microvascular reconstructions only was used to identify predictors for perforator flap reconstruction.ResultsA total of 66,968 cases of autologous breast reconstruction were identified. Perforator flaps were more likely among the commercially insured (p < 0.001) and higher insurance quartiles (p < 0.001).When comparing microvascular reconstruction, perforator flaps were 1.72 (p < 0.001) times more likely among the commercially insured. As compared to the lowest income quartile, the fourth quartile had an odds ratio of 1.36 (p < 0.001) for perforator flap reconstruction.ConclusionThe presence of a separate perforator flap billing code among the commercially insured may be exacerbating existing socioeconomic disparities in breast cancer reconstruction.     

应用游离腹部皮瓣行118例乳房重建术的单中心报告

背景与目的：随着诊疗技术的不断革新,乳腺癌的无病生存期和总生存率显著提高。为了改善患者术后的生活质量,越来越多的乳房重建技术被应用于临床。本文拟通过回顾复旦大学附属肿瘤医院乳腺外科118例游离腹部皮瓣乳房重建术的开展情况,介绍该术式的手术方法及结果,并就开展过程中的心得体会加以阐述。方法：收集2006年11月—2013年6月117例(1例接受双侧重建)接受全乳切除并进行即刻或延期游离腹部皮瓣乳房重建的患者进行即刻或延期游离腹部皮瓣乳房重建的临床资料,分析手术情况、围手术期并发症发生率及远期转归。结果：在上述观察期间共完成118例游离腹部皮瓣乳房重建术,平均手术时间7.72 h,平均热缺血时间78.74 min,平均血管吻合时间60.83 min。保留腹壁下深血管穿支平均为3支,胸廓内血管为首选的受区血管。术后发生血管危象10例,其中静脉血栓6例,静脉成角4例;解救成功7例,皮瓣全部坏死3例,成功率为97.46%。术后伤口感染发生率为7.00%,下腹部膨隆发生率为3.50%,无腹壁疝发生。手术距首疗程化疗的中位时间为19 d。中位随访12个月,1例出现远处转移,未发现局部复发。结论：游离腹部皮瓣乳房重建术可获得较佳的重建乳房外观,虽然该术式较为复杂,对术者要求高,存在学习曲线,但术式成功率高,术后并发症较少,不影响肿瘤安全性,值得推广。     

Breast reconstruction using perforator flaps

BACKGROUND: Perforator flaps allow the transfer of the patient's own skin and fat in a reliable manner with minimal donor-site morbidity. The deep inferior epigastric artery (DIEP) and superficial inferior epigastric artery (SIEA) flaps transfer the same tissue from the abdomen to the chest for breast reconstruction as the TRAM flap without sacrificing the rectus muscle or fascia. Gluteal artery perforator (GAP) flaps allow transfer of tissue from the buttock, also with minimal donor-site morbidity. INDICATIONS: Most women requiring tissue transfer to the chest for breast reconstruction or other reasons are candidates for perforator flaps. Absolute contraindications to perforator flap breast reconstruction include history of previous liposuction of the donor site or active smoking (within 1 month prior to surgery). ANATOMY AND TECHNIQUE: The DIEP flap is supplied by intramuscular perforators from the deep inferior epigastric artery and vein. The SIEA flap is based on the SIEA and vein, which arise from the common femoral artery and saphenous bulb. GAP flaps are based on perforators from either the superior or inferior gluteal artery. During flap harvest, these perforators are meticulously dissected free from the surrounding muscle which is spread in the direction of the muscle fibers and preserved intact. The pedicle is anastomosed to recipient vessels in the chest and the donor site is closed without the use of mesh or other materials. CONCLUSIONS: Perforator flaps allow the safe and reliable transfer of abdominal tissue for breast reconstruction.     

Microsurgical breast reconstruction

Breast cancer, the most common cancer diagnosed in American women, often necessitates mastectomy. Many studies have demonstrated improved quality of life and well-being after breast reconstruction. Numerous techniques are available for breast reconstruction including tissue expander implants and autologous tissues. Microsurgical tissue transfer involves the use of excess skin and fat (flaps) from a remote location to reconstruct the breast. Most often, tissues are transferred from the abdomen and buttocks. Less commonly, thigh flaps are used. These operations can provide durable, esthetic reconstructions. In addition, advances in microsurgical techniques have improved operative success rates to the range of 99%. The selection of an appropriate flap for microsurgical breast reconstruction is multifactorial and is based on patient and oncologic factors. These factors include patient comorbidities, body habitus/availability of donor tissues, cancer stage, and the need for postoperative adjuvant radiation therapy, as well as the risk of cancer in the contralateral breast. Appropriate choice of flap and surgical technique can minimize the risk of operative complications. Additionally, several large series have established that microsurgical breast reconstruction has no impact on survival, or locoregional/distant recurrence rates.     

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.