乳头肥大缩小整形的新方法

目的　介绍一种具有较好外形及功能的乳头肥大缩小整形的新方法。方法　局部麻醉下按设计线切除肥大的乳头顶部多余的皮肤及皮下组织 ,注意不要伤及乳腺管 (特别是对未哺乳的患者 ) ,在皮下分离乳头基底部组织 ,对皮下组织肥厚者可切除部分皮下组织。结果　为 17例双侧乳头肥大者行乳头缩小整形术 ,均取得满意效果。结论　这种新方法可以使乳头肥大且两侧形态、大小各异的乳头缩小 ,形成符合美学标准的乳头 ,满足了患者的要求 ,并且愈合快、肿胀轻 ,不破坏乳头的感觉及血运 ,术后不影响哺乳     

Residual breast tissue after robot-assisted nipple sparing mastectomy

IntroductionWhile the long-term oncologic safety of robot-assisted nipple sparing mastectomy (RNSM) remains to be elucidated, histologically detected residual breast tissue (RBT) can be a surrogate for oncologically sound mastectomy. The objective of this study is to determine the presence of RBT after RNSM.MethodsBetween August 2019–January 2020, we completed 5 cadaveric RNSMs. Full thickness biopsies from the mastectomy skin flap were obtained from predefined locations radially around the mastectomy skin envelop and nipple areolar complex to histologically evaluate for RBT.ResultsThe first case was not technically feasible due to inability to obtain adequate insufflation. Five mastectomy flaps were analyzable. The average mastectomy flap thickness was 2.3 mm (range 2–3 mm) and the average specimen weight was 382.72 g (range 146.9–558.3 g). Of 70 total biopsies, RBT was detected in 11 (15.7%) biopsies. Most common location for RBT was in the nipple-areolar complex, with no RBT detected from the peripheral skin flaps.ConclusionsIn this cadaveric study, RNSM is feasible leaving minimal RBT on the mastectomy flap. The most common location for RBT is in the periareolar location consistent with previous published findings after open NSM. Clinical studies are underway to evaluate the safety of RNSM.     

Lessons learned from 416 cases of nipple discharge of the breast

Background

For patients with nipple discharge (ND), surgical duct excision is often required to exclude underlying malignancy. Our objective was to define clinical predictors of malignancy and examine the utility of common preoperative studies.

Study design

We retrospectively identified 475 patients presenting with a chief complaint of ND from 1995 to 2005; 416 (88%) were eligible for review.

Results

Following standard evaluation (clinical breast examiation/mammogram/ultrasound), 129 of 416 (31%) were considered to have physiological ND and were managed expectantly, whereas 287 of 416 (69%) underwent further evaluation (cytology/ductography/magnetic resonance imaging) followed by biopsy ± surgery. Clinical features associated with pathological ND included bloody ND (adjusted odds ratio 3.7) and spontaneous ND (adjusted OR 3.2). Biopsy/surgery identified a causative lesion in 259 of 287 (90%), of which 37% were either malignant (n = 65) or high-risk (n = 30) lesions. The sole clinical predictor of malignant/high-risk lesion was a palpable mass (adjusted odds ratio 4.3). Preoperative evaluation identified 76 of 95 (80%) malignant/high-risk lesions, whereas 19 of 95 (20%) were identified by duct excision alone.

Conclusions

Although clinical stratification alone reliably identified patients with pathological ND, neither the clinical characteristics nor preoperative studies can reliably distinguish between benign and malignant pathology. Surgical duct excision remains the gold standard to exclude underlying malignancy.     

乳腺癌保乳手术的体会

目的　总结和探讨乳腺癌保乳手术保持乳房良好外形 ,在术前、术中和术后应注意的问题。方法　 3 7例患者接受了乳腺癌保乳手术。术后从乳头外观、双乳头水平差距、双乳头距同侧腋前线垂直距离之差距和瘢痕对乳房外形影响等四个方面的量化标准 ,评估保留乳房的外形美观效果。四项指标积分≥ 2 1分为优 ,13～ 2 0分为良 ,<13分为差。结果　术后保留乳房外形优良者 3 0例 ( 81.1% ) ,乳房外形较差者 7例 ( 18.9% )。常见问题是因切口瘢痕致乳房变形、乳头歪斜、乳头不自然挺立 ,以及与对侧乳头水平高度差距明显。结论　术前认真设计手术切口、术中注意术区皮瓣和保留乳腺组织的彻底游离以及切除、缝合技巧 ,术后切口包扎时注意避免压迫乳头等 ,将有助于保持保留乳房的外形美观效果     

乳头乳晕色素性病变切除的修复

目的探讨去除病变组织同时修复乳头乳晕组织缺损的方法。方法根据乳头缺损的范围，选择乳晕组织瓣。采用逆行设计法对缺损面积准确估计后，皮瓣按常规设计超出缺损面积的10％，使之旋转达乳头缺损区，局部推进皮瓣修复创面。结果本组10例患者，其中6例乳头乳晕均有部分色素痣，4例仅乳晕有色素痣。选用两个皮瓣进行修复。术后两侧对称，功能良好，效果满意。结论本方法可有效切除病变的同时，保持良好的外形，并保留乳头勃起功能。     

Quality of life after reduction mammaplasty

Reduction mammaplasty is a common procedure in plastic surgery. Patients seek the operation for neck and lower back pain, and social and emotional problems. The evaluation of health results based on the patient's opinion has become an important and reliable method for the analysis of alterations resulting from treatment. To evaluate the impact of plastic surgery on the quality of life of patients with mammary hypertrophy we used the SF‐36 standardised questionnaire in a prospective study of 44 patients preoperatively and three and six months postoperatively. There were significant improvements in seven of the eight aspects of the SF‐36 (physical function, physical role, pain, energy, social function, emotional role, and mental health). Only general health was unchanged.     

Postoperative analgesia after microsurgical breast reconstruction using liposomal bupivacaine (Exparel)

Conventional opioid‐based regimen for postoperative analgesia after autologous breast reconstruction can be associated with significant side effects. The purpose of this study was to assess the efficacy of an intraoperatively administered transversus abdominis plane (TAP) block with liposomal bupivacaine on postoperative narcotic use in patients undergoing microsurgical breast reconstruction with free abdominal flaps. Patients treated between December 2016 and June 2017 were included in the study. Parameters of interest were patient‐reported pain score, total narcotic use (in oral morphine equivalent [OME]) during the hospitalization, length of stay (LOS), and the need for patient‐controlled analgesia (PCA). Eighty‐two free abdominal flaps were transferred in 46 patients with a mean age of 47.6 years and a mean body mass index (BMI) of 28.1 kg/m². The average LOS was 3.5 days (range, 3‐5). Postoperatively, 42 patients (91.3%) did not require patient‐controlled analgesia (PCA). The mean time to first narcotic use after arrival on the nursing unit was 6 hours (range, 0‐19 hours). The mean total postoperative OME use was 123.2 mg (range, 0‐285 mg). However, analysis of OME use excluding the four patients requiring PCA revealed a mean OME use of 90.3 mg (range, 0‐167.5 mg). Liposomal bupivacaine provides for reliable, safe, and long‐acting postoperative analgesia and contributes to a reduction in postoperative narcotic intake. The use of liposomal bupivacaine shows great promise in improving the standard of care in postoperative analgesia in microsurgical breast reconstruction.     

乳腺癌保乳手术切缘问题

尽管外科医生普遍认为保乳手术切缘应该是没有肿瘤细胞的干净切缘,而肿瘤残留将可能增加局部复发概率,甚至增加病死率;但是由于保乳手术在各个国家地区的做法不同及切缘评估方法的差异,至今无保乳手术中有关安全切缘宽度的共识或指南。保乳手术应该保证切缘无瘤,否则肿瘤的残留将使得一个根治性的手术人为转变成为姑息手术及活检手术;将随后的辅助治疗人为转变成为解救治疗。     

纤维乳管内视镜在乳头溢液性疾病诊治中的应用

目的 评价纤维乳管内视镜在乳头溢液疾病诊断及介入治疗中的价值.方法 2003年10月-2009年11月3280例乳头溢液患者进行了纤维乳管内视镜检查.对其中1018例乳管镜发现的占位病变患者及2例非占位病变患者进行了手术治疗;其余2260例非占位病变患者进行乳管镜下介入冲洗治疗.结果 血性溢液、单孔溢液、单乳溢液以及病变主要位于总乳管及Ⅰ～Ⅱ级乳管多提示是占位性病变;非血性溢液、多孔溢液、双乳溢液以及病变呈乳管内弥漫性分布多提示是非占位性病变.2260例介入冲洗治疗患者中,总治愈率为59.73％(1350/2260),总有效率为88.72％(2005/2260).结论对血性溢液、单孔溢液、单乳溢液以及病变主要位于总乳管及Ⅰ～Ⅱ级乳管者要考虑到占位性病变可能,利用纤维乳管镜对于非占位病变直接进行局部介入治疗效果明显.     

乳管镜诊断乳头溢液性疾病的后续治疗

目的探讨乳头溢液性疾病乳管镜诊断后的治疗措施。方法采用乳管镜对51例乳头溢液的病变导管进行观察、评估，并根据乳管镜下的不同表现特征实施治疗。乳头溢液性疾病的乳管镜下病变表现特征可分为隆起性病变和非隆起性病变，隆起性病变又分为结节状隆起和不规则隆起。本组结节状隆起29例，采取病灶局部切除23例，单纯乳腺切除6例；不规则隆起1例，病灶切除活检证实为乳腺癌后按恶性肿瘤的原则治疗；非隆起性病变21例，行乳管镜下冲洗治疗18例，3例有血性病变导管及其所属小叶切除术后石蜡切片病理诊断乳腺癌后按恶性肿瘤治疗。结果51例随访6～21个月，平均14个月，B超及胸片未见复发转移。结论乳管镜下的病变表现特征是乳头溢液性疾病制定治疗措施的重要依据。     

Reliability of plastic cups to measure breast volume

Abstract

Breast volume measurement is valuable in clinical practice, and various methods have been used. Nonetheless, no commonly accepted standard technique exists for clinical everyday use and there is no optimal method that is quick, cheap, minimally invasive, and acceptable for the patient and for the surgeon. Previously, a study has shown that the volume measured with plastic cups differed little from that measured from mastectomy specimens. The aim of the present study was to test the reliability of breast volume measurements with plastic cups as a tool to measure breast volume in everyday clinical practice. The plastic cups were designed by the senior author (AR) and comprise 14 cups from 125 millilitres (ml) to 2000 ml. Six raters measured 12 breasts on the same day. The results show that there is a certain variation between different raters, and that a certain rater seems to consistently measure slightly lower or higher volumes than the other raters. The Intra Class Correlation (ICC) coefficient of average measures between raters is 0.89, that is, the agreement between different raters is high. According to the Bland-Altman plot, the overall assessment of the comparisons of measurements between the different raters shows that the direction of the mean differences is close to zero. The limits of agreements of the differences were within ±56 ml. The coefficient of variation (CV) between different raters was 14%. Breast volume measurement with plastic cups is an easily usable quick and cheap way to measure breast volume in everyday clinical practice. The measurements have an acceptable reliability.     

Retention of a reconstructed nipple using a C-V flap with different layer thicknesses in the C-flap

Background: The C-V flap for nipple reconstruction is now one of standard surgical techniques. But decreased projection is still a problem. In recent years, it has been suggested that projection can be more easily maintained when raising of the C-flap is performed with a split thickness dermis. In this study, we examined whether decrease of projection can be prevented by raising of a C-flap with a split dermis rather than with full dermis.

Methods: A total of 49 consecutive patients who underwent reconstruction of a nipple using the C-V flap technique were enrolled. The patients included 22 who underwent surgery using a C-flap with a full thickness dermis (Group F), and 27 who underwent surgery with raising of a flap with a split thickness dermis (Group S). The size of the reconstructed nipple was measured at 2?weeks, 6?months and 1?year postoperatively for comparison between Groups F and S.

Results: Partial necrosis of the C-flap end occurred in 4 subjects in only Group S. The decrease in projection after 1?year postoperatively in Group S was significantly lower than that in Group F. In contrast, the teat base size in Group F tended to be greater than that in Group S, suggesting a tendency for an expanded base using a flap with a full dermis.

Conclusions: Our results indicated that it is recommended to use a C-flap with a split dermis for cases with high projection of the nipple on the contralateral side.     

中国妇女乳房乳晕乳头比例的测定及相关因素分析

目的为塑造自然、匀称而具有美感的乳房提供参考和依据。方法对45例22~45岁、对自己乳房满意且无乳房手术史的女性志愿者,分别测量体重、身高、乳头直径、乳晕直径、胸乳线(乳头至胸骨切迹连线距离)、乳房内侧半径(乳头至乳房下皱襞内侧止点连线距离)、乳房外侧半径(乳头至乳房下皱襞外侧止点连线距离)、乳房下半径(乳头至乳房下皱襞最低点连线距离)。以乳房外侧半径长度作为乳房大小参考指标,由此计算和确定乳房、乳晕、乳头之间的比例,并对可能影响其变化的年龄、体重、身高等因素进行研究分析。结果该组样本显示中国妇女乳房与乳晕之比约为3.7∶1.0,乳晕乳头之比约为3.4∶1.0。体重、体重指数与乳房大小、乳晕乳头比例之间呈正相关,具有显著的统计学意义;而年龄、身高的影响在该样本中并未显现。结论乳房与乳晕、乳头间具有一定的合适比例,体重和肥胖可能是影响该比例关系的因素。乳房、乳晕、乳头比例的确定对东方妇女的乳房整形和再造具有美学价值,可被用于手术中对乳房大小的理想化设计和预测。     

Endoscopic plastic surgery: The endoscopic evaluation of implants after breast augmentation

There is an ongoing discussion about the possible connection of gel-filled silicone implants for breast augmentation and the development of connective tissue disease. In the absence of any proven link and irrespective of the difficulty to prove such a causality, these discussions lead to great concern for the hundreds of thousands of women who underwent breast augmentation with silicone gel implants. As a consequence there are voices that call for regular checks of the implants with regard to their integrity. All the external methods of judging an implant, including MRI, can—if at all—detect only marked lesions or ruptures. Direct visualization of the implant up to now has been the only safe method. Direct visualization can be carried out by reopening the previous incision or by endoscopic inspection. Endoscopic evaluation needs the dexterity of all endoscopic plastic surgery procedures, but with sufficient training and experience it is a very safe, quick, and highly compliant procedure for the patient and can be combined with endoscopic biopsies and other endoscopic operations such as capsulotomies.Presented at the 31 st Annual Meeting of the Austrian Society of Plastic, Aesthetic and Reconstructive Surgery, Zell am See, Austria, October 1993     

乳腺癌保乳及再造手术技巧与美学效果评价

乳腺癌是危害妇女健康的主要肿瘤。乳腺癌病人不仅要承受因癌症可能危及生命的威胁,还要承受因乳腺癌治疗失去一侧乳房的打击,这对病人躯体和心理均造成巨大的损害[1]。大量的研究表明乳腺癌保留乳房治疗和乳房切除加乳房再造均能改善病人因乳房切除引起形体破坏的     

复合组织下蒂法乳房缩小整形术25例

目的：回顾性总结复合组织下蒂法乳房缩小整形术25例病例资料,探讨复合组织下蒂法乳房缩小整形术手术注意事项及其并发症防治。方法：从2003～2008年5年间,对25例女性乳房肥大患者分别进行手术治疗,方法采用复合组织下蒂法。通过对术中复合组织下蒂的修整及术后乳房外形、乳头乳晕复合体血运、术后瘢痕及乳房感觉等方面观察,分析复合组织下蒂法乳房缩小整形术的术中注意事项及术后并发症的防治策略。结果：25例患者均取得了较好的效果,无乳头乳晕复合体血运障碍发生。结论：复合组织下蒂法乳房缩小整形术是较好的乳房缩小术式,良好的术前设计及术中调整是确保手术成功的关键。     

A new method for using a silicone rod for permanent nipple projection after breast reconstruction procedures

Nipple-areola complex (NAC) is a unique part of the human body. Not only is it a functional structure, but it plays an aesthetic role as well. It offers the final touch to the convex shape of the breast. Its lack frequently leads to depression in patients. This paper describes the method used by the authors for reconstructing nipple mound projection in patients following an autologous breast reconstruction procedure.To reconstruct the nipple mound an adapted local C-V flap technique described by Losken was used, with a silicone rod to support the nipple. The new method is based on simple preparation of flaps, fixing the silicone rod at the nipple bottom and below the top, it is quick and efficient in terms of time and materials used.The procedure was conducted in 30 patients: 10 cases following LDf reconstruction and Becker prosthesis or expander prosthesis, 20 cases following body tissue reconstruction with TRAM flap (Transverse Rectus Abdominis Musculocutaneous flap). All the patients who had undergone the LDf procedure developed flap necrosis followed by rod removal. In the patients who had undergone TRAM flap reconstruction no necrosis or wound split was observed, healing progressed without complications. In this group durable nipple projection was achieved. The new method for reconstructing nipple projection may be applied both in simultaneous and staged procedures, only in patients who have undergone autologous breast reconstruction procedure.     

The location of contralateral breast cancers after radiation therapy

Radiation therapy following conservative surgery results in scattered radiation to the contralateral breast, with higher doses to the medial breast and lower doses laterally. The purpose of the current study is to determine whether the location of contralateral breast cancers developing following breast conserving surgery and radiation is indicative of radiation-induced malignancies. The charts of 1,755 patients treated with conservative surgery and radiation therapy between 1970 and 1998 were reviewed. Fifty-nine patients who developed a contralateral malignancy following conservative surgery and radiation therapy and who had complete information and documentation of the location of the second lesion served as the primary focus of the current study. The location of the contralateral malignancy was compared with the location of the primary tumors of the overall patient population. The location of breast cancers developing in the contralateral breast following breast conserving therapy and radiation was not consistent with radiation-induced malignancies. Specifically, there was not a preponderance of medially located tumors in patients developing contralateral breast cancers following radiation. There was a slight excess of central lesions that cannot be explained by higher doses of radiation. The location of breast cancers in the contralateral breast following conservative surgery and radiation is not indicative of radiation-induced lesions. These data should be reassuring to women considering breast conserving surgery and radiation.     

Nipple sensitivity and lactation in two methods of breast reduction

Two methods of breast reduction were performed between 1981 and 1986. One was wedge resection of the breast in which nipple and gland were disconnected. The other was the tangential and circumferential breast reduction, in which the nipple remained in continuity with the gland. For each method, there were 21 patients. The mean follow-up was 5 years and 9 months. In both groups, 8 patients had 11 children, but only the tangential reduction patients lactated. They also had better subjective nipple sensitivity whereas objectively the differences were rather small.     

The use of leeches for treatment of venous congestion of the nipple following breast surgery

The medicinal leech,Hirudo medicinalis, played a central role in the evolution of medieval and folk medicine. Today, for the first time in history, the leech actually has a real and valuable purpose in medicine as a useful adjunct for the plastic surgeon: It provides relief of venous congestions. For over 2000 years, leeches were needlessly applied for a multitude of maladies as an adjunct to blood-letting. Their use in Europe peaked between 1830 and 1850, however, shortages led to a subsequent decline in leech application. Today there is a real clinical use for leeches which had led to a resurgence in their use in plastic surgery. Plastic surgeons use leeches in microsurgery to salvage congested flaps, whose viability is uncertain due to venous congestion. We present our experience with two patients where leeches were used to treat isolated venous engorgement of the nipple following breast surgery. Leech therapy is painless, well tolerated, and does not result in significant scarring. Prompt initiation of treatment is mandatory and produces dramatic resolution of venous congestion.