乳房再造术的临床研究

目的 回顾总结了乳癌根治术后应用单纯假体植入、Becker可扩张假体植入和带蒂腹部横形腹直肌肌皮瓣(TRAM)移植、扩大的背阔肌肌皮瓣(ELDF)移植乳房再造术的经验,探讨手术的适应征、方法和效果.方法 16例行保留皮肤的乳癌根治术一期假体植入乳房再造;13例行Becker可扩张假体植入一期乳房再造;4例行单蒂下腹部横形腹直肌肌皮瓣(TRAM)移植乳房再造手术,其中2例为一期再造,另2例为二期再造.应用Becker可扩张假体行二期乳房再造1例.扩大背阔肌肌皮瓣(ELDF)移植二期乳房再造1例.结果 手术效果满意,优良率超过90%.3例病人出现轻微并发症,其中1例皮瓣局灶坏死,一例出现保留的乳头乳晕部分坏死,1例出现血清肿.结论 单纯假体植入适用于瘦小病人,对侧乳房小且没有明显下垂.优点是不增加额外瘢痕,术后恢复快;可扩张假体植入乳房再造适用于乳房大或改良乳癌根治术的患者,此法结合了单纯假体植入法和组织扩张术乳房再造术的优点;TRAM和ELDF皮瓣移植乳房再造的优点是自体组织移植,安全、手术效果好.     

乳癌术后的乳房再造

目的 探索乳癌根治术后3种不同乳房再造方法的最佳外观效果.方法 (1)乳癌切除Ⅱ期行扩大背阔肌肌皮瓣乳房再造.(2)乳癌切除即时腹直肌横行皮瓣乳房再造.(3)保留胸大肌乳癌切除,Ⅱ期乳房假体置入并行乳头、乳晕再造;对不保留胸大肌乳癌切除者,Ⅱ期皮肤扩张后乳房假体置入再造.结果 共计治疗12例,10例皮瓣全部成活,外观形态满意,优良率较高.2例不满意,其中1例扩张后,因局部皮肤皮下组织较薄,扩张程度不足,勉强置入140 ml乳房假体,外观形态明显偏小;另1例腹直肌肌皮瓣大部分坏死,经再次修复创面愈合,乳房再造失败.结论 乳房再造的方法选择得当,可使乳房形态更为自然.普通背阔肌皮瓣改用扩大的背阔肌皮瓣后,软组织量比前者增加1倍以上,使再造乳房与对侧相近.假体置入乳房成形后,Ⅱ期行单蒂乳头、乳晕再造,可给患者以心理和外观上的更多抚慰.     

乳腺癌改良根治一期乳房再造术后近期并发症的探讨

目的:探讨乳腺癌根治一期乳房再造术后近期发生的并发症及其原因.方法:收集本院2006年2月～2007年12月32例乳腺癌改良根治一期乳房再造病例.全组病例行乳房改良根治术乳房再造方法:一期行单蒂下腹部横行腹直肌肌皮瓣(TRAM)移植术3例,背阔肌肌皮瓣移植和假体植入6例,单纯假体植入术12例,乳房扩张假体植入术11例.结果:中位随访时间14个月,1例乳房局部血肿,1例术后10个月发生腹部切口疝:边缘局部坏死7例,乳头乳晕发生部分坏死2例,其中1例皮瓣坏死范围大导致假体露出.并发症的总发生率34.4%(11/32).结论:乳腺癌行改良根治性手术一期乳房再造术后并发症发发生率较高.乳癌改良根治手术时,要注意皮瓣及乳头乳晕区切除的宽度和剥离皮瓣的厚度:移植皮瓣时要注意移植的肌肉组织血运是否完整和有无遗留的微小血管未结扎;乳房再造术仅植入扩张器者,因局部张力小,对皮瓣血运影响小,并发症发生率低.     

即刻及延期乳房再造方法的选择

目的回顾总结乳腺癌根治术后应用单纯假体植入、Becker可扩张假体植入和单蒂腹部横形腹直肌肌皮瓣（TRAM）移植、扩大背阔肌肌皮瓣（ELDF）移植乳房再造术的经验,探讨手术的适应证、方法和效果。方法自2002年7月至2005年10月,共67例患者进行了乳腺癌根治术后乳房再造术。即刻乳房再造56例：单纯假体植入38例、Becker可扩张假体植入16例、单蒂TRAM移植2例。延期乳房再造11例：单蒂TRAM移植6例、ELDF移植4例、Becker可扩张假体植入1例。结果手术效果满意,优良率超过90％。5例患者出现轻微并发症：皮瓣局灶性坏死2例,保留的乳头乳晕部分坏死1例,血清肿2例。结论单纯假体植入用于即刻乳房再造,适用于乳房较小、行保留皮肤的乳腺癌根治术后的患者,不宜用于延期乳房再造;可扩张假体植入即刻乳房再造适用于乳房较大或改良乳腺癌根治术的患者,同时可扩张假体植入延期乳房再造可用于皮肤、肌肉保留较好的乳腺癌根治患者;TRAM和ELDF皮瓣移植乳房再造是自体组织移植,其安全性高,可用于即刻和延期乳房再造。     

几种乳房再造术的临床应用体会

目的：探讨乳腺癌根治术后应用单纯假体植入、可扩张假体植入和带蒂腹部横形腹直肌肌皮瓣（TRAM）移植乳房再造的适应证、手术方法、手术效果。方法：本组共24例病例。14例乳腺癌患者行保留皮肤的乳腺癌根治术，Ⅰ期行假体植入乳房再造；6例采用改良乳腺癌根治可扩张假体植入Ⅰ期乳房再造；4例接受单蒂下腹部横形腹直肌肌皮瓣（TRAM）移植乳房再造手术，其中2例为Ⅰ期再造，另2例为Ⅱ期乳房再造。结果：手术效果较满意，2例出现轻微并发症，其中1例皮瓣局灶坏死，另1例出现乳头乳晕部分坏死。结论：单纯假体植入适用于乳房小，没有明显下垂的瘦小病人。优点是不增加额外瘢痕，术后恢复快；可扩张假体植入乳房再造适用于乳房大或改良乳腺癌根治术的患者，此法结合了单纯假体植入法和组织扩张的优点：TRAM皮瓣移植乳房再造的优点是自体组织移植，安全、手术效果好。     

扩张后假体置入乳房再造术的临床应用

目的 介绍扩张后假体置入乳房再造术在乳癌改良根治术后乳房缺损、单纯乳腺腺体切除及乳房不对称畸形患者中的应用.方法 将圆形扩张器埋置于胸大肌深面,超量注水30%～50%扩张后,维持3个月以上,二期将扩张器更换为乳房假体.结果 临床应用9例,13侧乳房,其中乳癌改良根治术后乳房缺损2例2侧,单纯乳腺腺体切除4例8侧,乳房不对称畸形3例3侧,最长随访2年,效果满意.结论 扩张后假体置入乳房再造可以使患者获得接近对侧乳房的形态和大小,且没有再造术附加供区的创伤.放疗会增加并发症的发生,需要放疗的患者慎用此法.     

保留乳头乳晕的乳房全切术后带蒂大网膜联合假体乳房一期重建23例

目的探讨保留乳头乳晕的乳房全切术后带蒂大网膜联合假体一期乳房重建的可行性和效果。 方法选择湖南省肿瘤医院乳腺二科2013年8月至2015年9月收治的0、Ⅰ、Ⅱ期乳腺癌患者23例,所有患者按肿瘤切除原则先行保留乳头乳晕的乳房全切术,取上腹部小切口游离带蒂大网膜联合凝胶假体植入胸大小肌之间行乳房一期重建。 结果23例大网膜组织瓣全部成活,随访3~25个月,无一例假体移位、破裂,重建乳房外观自然、柔软、形态良好,其中2例导管内癌患者因术后预留乳头乳晕部位皮肤较薄出现了乳头缺血,颜色变黑,随访3个月,未见坏死。随访期间未见一例复发。 结论保留乳头乳晕的改良根治术后带蒂大网膜联合假体一期乳房重建是一种安全可行且美容效果良好的手术方法。     

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.     

自制生肌膏联合培氟沙星粉治疗压疮效果观察

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。     

乳腺癌术后乳房即刻再造152例报告

目的探讨乳癌根治术后即时应用单纯假体植入、可调式双囊假体植入和自体组织移植乳房再造术的适应证及疗效。方法101例在保留皮肤的乳腺癌改良根治术基础上于胸大肌下方植入Mentor假体再造乳房，39例在胸大肌下方植入Becker可调式假体再造乳房，10例用单蒂下腹部横行腹直肌肌皮瓣移植至乳房缺损区再造乳房。2例采用扩大的背阔肌肌皮瓣移植再造乳房。结果随访152例3—65个月，中位时间28个月，2例13个月后肿瘤局部复发，取出假体。术后乳房外观评价优良率达94％。结论单纯假体植入适用于乳房较小的患者，可调式假体植入乳房再造适用于乳房较大，或根治术时皮肤缺损较多的患者。     

Infection following breast reconstruction

Of 33 patients who underwent 49 breast implantations for reconstructive surgery, 8 (24%) patients developed implant infections. All 8 of these patients were among a subgroup of 15 having immediate breast reconstructions with tissue expander implants after simple or modified radical mastectomy (a 53% infection rate). The infection rate increased substantially when bilateral procedures involving implants were performed as opposed to unilateral implants. Nine implants were removed (an overall implant loss rate of 18%). Patients who underwent other breast reconstruction techniques (i.e., including immediate reconstruction with permanent implants or delayed reconstruction with or without tissue expanders) did not develop infection unless they had had simultaneous immediate reconstruction with a tissue expander in the contralateral breast. The most frequently isolated organism was the coagulase-negative staphylococcus. The study concludes that neither the tissue expander nor immediate reconstruction is a risk factor, but the combination may lead to an unacceptable infection rate, especially in the face of bilateral breast procedures.     

One-stage immediate breast reconstruction with implant following skin-sparing mastectomy in Asian patients

The Asian breast reconstruction patient is usually of lower mean age, lower body mass index (BMI), and has relatively small breasts. This study aimed to investigate the outcome of 1-stage immediate breast reconstruction using saline-filled implants in the Asian patients.Between April 2002 and July 2005, 30 patients underwent skin-sparing mastectomy and 1-stage immediate breast reconstruction with a saline-filled implant. Mean age was 42.9 years, with a mean BMI of 21.9 and a mean implant volume of 283 mL.The overall success rate was 96.6%, with 1 case of implant exposure secondary to chest skin necrosis. At mean follow-up of 21.5 months (range 6 to 40 months), 1 patient developed local recurrence (3.33%).Perfusion of the chest skin flap is reliable enough to allow 1-stage breast reconstruction with small saline-filled breast implants. We present this as an additional option for immediate breast reconstruction in thin women with small breasts.     

Subincisional muscular coverage of expander implants in immediate breast reconstruction with pectoralis flaps

Immediate breast reconstruction with expander implants is a safe, simple procedure that allows for a rapid physical and emotional postmastectomy recovery. When complications occur, the patient may be left with a prolonged reconstructive course. Such complications may result from thin mastectomy flaps and resulting marginal skin flap necrosis and implant exposure. Muscle coverage of the implant under the skin incision prevents such marginal necrosis of skin flap from becoming a factor in implant loss. This paper demonstrates a simple method for providing subincisional muscle coverage of expander implants with pectoralis muscle flaps. In this technique, a pocket is developed under the pectoralis muscle. The sternal origin of the pectoralis is released from the midsternal position to its inferior origin. The pectoralis muscle is then rotated inferior-laterally and sutured to the dermis of the underside of the inferior mastectomy skin flap, thereby providing subincisional muscle coverage of the expander implant. During a 5-year period, 42 patients between the ages of 36 and 61 underwent breast reconstruction utilizing this technique. In these patients, there were 4 instances of marginal necrosis. In each of these cases, the implants did not become exposed, and all patients completed the expansion process without significant delay and underwent subsequent implant exchange without incident. Five-year follow-up has shown good esthetic results in all patients.     

Immediate breast reconstruction with anatomical permanent expandable implants after skin-sparing mastectomy: aesthetic and technical refinements

Use of anatomic permanent expandable implant after skin-sparing mastectomy (SSM) permits a 1-stage immediate breast reconstruction with an optimum breast shape. Preservation of most of the mammary skin after SSM on 1 side and anatomic prosthesis shape on the other makes breast reconstruction easier and enhances the quality of the esthetic results. The authors describe their experience with 40 immediate breast reconstructions after SSM performed over a period of 2 years explaining some technical details. The implant is placed in a submuscular pocket, or preferably, depending upon the condition of the muscles and skin flaps after mastectomy, in a submuscular-subfascial pocket. In this case, the undermining of the pocket is submuscular in its upper part under the major pectoralis muscle and subfascial in the lower part of the breast undermining the adipo-fascial tissues above the anterior serratus muscle. The submuscular dissection is done in continuity with the subfascial dissection to allow the complete closure of the soft tissues over the implant. In this case, the minor consistency of subfascial tissues compared with muscle in the inferior pole of the breast allows the easier and quicker distention of the soft tissue overlying the prosthesis during the inflation phase and ensures a good shape of the breast soon after surgery. Whenever possible, the mastectomy is performed through a periareolar skin incision that is closed with a purse-string suture. Finally, the authors discuss the indications of 2 different-shaped anatomic permanent expandable implants: full-height and short-height prostheses with different shape and fullness of the upper pole of the implant.     

脱细胞异体真皮辅助即刻乳房再造术的初步经验

目的 探索脱细胞异体真皮辅助即刻乳房重建手术的可行性,并对其早期临床效果作出评价.方法 回顾性分析2009年9月至2010年5月,北京协和医院整形外科10例施行脱细胞异体真皮辅助的乳房重建手术的乳腺癌患者的临床资料,其中2例接受假体植入手术,8例接受扩张器植入手术.脱细胞异体真皮覆盖假体或扩张器的下、外侧1/3部分,胸大肌覆盖剩余的2/3部分.结果 10例中虽有2例发生感染,2例伤口裂开,但无一例假体或扩张器因并发症取出.术后平均随访4个月,重建乳房外形比较满意.结论 脱细胞异体真皮辅助的即刻乳房再造术创伤较小,在严格把握适应证的前提下,可以取得较好的临床效果.

Abstract：

Objective To investigate the feasibility and therapeutic effect of acellular cadaveric dermis(ACD)-assisted immediate breast reconstruction. Methods From Sep. 2009 to May 2010, 10 cases received ACD-assisted immediate breast reconstruction. During the operation, the ACD was used to cover inferior and lateral portion of the implants in 2 cases and expanders in 8 cases. Results The patients were followed up for an average period of 4 months with satisfactory breast appearance. The complications included infection in 2 cases and dehiscence in 2 cases. But no implant or expander was taken out. Conclusions The ACD-assisted immediate breast reconstruction is a technically simple procedure with minimal morbidity. Satisfactory clinical outcome can be achieved with appropriate candidates.     

Management of exposed, infected implant-based breast reconstruction and strategies for salvage

Introduction

Complications of implant-based breast reconstruction are rare but mastectomy flap necrosis and peri-implant infection are the most frequent and remain an important cause of early implant failure. This study aimed to compare the results of three different management strategies employed to deal with these complications at our institution.

Patients and methods

A consecutive series of 71 infected/exposed prostheses in 68 patients over a 20-year period were analysed. Management strategies included explantation and delayed reconstruction, implant salvage and explantation and immediate autologous reconstruction.

Results

Only 19 of 45 (42%), managed with implant removal, went on to delayed reconstruction. Methods of delayed reconstruction were distributed equally between implant-only, implant and autologous tissue and autologous-only reconstructions. The implant was successfully salvaged in nine cases, but reducing the implant size or introducing new tissue as a flap increased the success from 45% to 53%. Three patients with infected implant-only breast reconstruction underwent explantation and immediate conversion to autologous-only reconstructions.

Conclusions

All the three interventions reviewed here have their place in the management of infected implant-based breast reconstructions. It is noteworthy that following implant removal, the likelihood of the patient proceeding to delayed reconstruction of any kind is similar to the likelihood of successful salvage (42% vs. 45%). This study population had high numbers of exposed implants in irradiated fields. Reducing implant size or introducing new tissue in the form of a flap increases the chances of successful implant salvage. In the presence of mild infection, removal of exposed/infected implants and immediate conversion to an autologous-only reconstruction can prove to be successful.