乳腺癌术后一期乳房再造

背景与目的：乳房再造使乳腺癌全乳切除患者重获完整的乳房外形。本文介绍乳腺癌术后应用带蒂背阔肌肌皮瓣联合或不联合假体和带蒂横向腹直肌肌皮瓣（TRAM）行一期乳房再造的经验，并探讨适合中国乳腺癌患者的乳房再造方式。方法：2000年1月-2005年7月，74例乳腺癌患者乳房切除后，应用背阔肌肌皮瓣或带蒂TRAM行一期乳房再造。结果：再造手术均取得成功，背阔肌肌皮瓣再造62例（83．8％），其中联合假体13例、带蒂TRAM再造12例、联合假体1例。经过2～66个月随访，局部区域复发率4．1％。患者满意度高，可接受度96％。而且这两种自体再造方式在是否需要联合假体上没有差别（P=0．440）。结论：乳腺癌术后一期乳房再造能同时满足肿瘤治疗和形体美容的要求，提高患者生活质量，背阔肌肌皮瓣再造对中国女性适用性好，值得推广。     

乳腺癌术后修复重建的临床经验

目的 探讨国人乳腺癌术后修复重建的经验。方法 回顾性分析2009年11月至2011年1月海南省农垦总医院收治的15例乳腺癌术后自体组织修复重建患者的临床资料。结果 15例手术患者中,即刻修复5例（4例为即刻修复临床Ⅳ期乳癌术后胸壁创面）,延期修复10例。单纯应用背阔肌肌皮瓣带蒂转移3例（2例为即刻修复保乳术后局部缺损）,背阔肌肌皮瓣带蒂转移加乳房假体3例,乳腺瓣修复保乳术后局部缺损1例,内窥镜辅助背阔肌肌瓣带蒂转移修复保乳术后乳腺局部缺损1例,组织扩张术行局部皮瓣转移2例。随访2～15个月,皮瓣全部成活,创面愈合良好,形态满意。结论 自体组织修复保乳术后的局部缺损对于乳房普遍较小的中国患者实用方便,设计灵活,可同时修复腋窝缺损,不影响放疗和化疗的及时进行,具有良好的应用前景。     

带蒂侧胸动脉穿支皮瓣在乳房肿瘤整形保乳术中的应用进展

穿支皮瓣是乳房肿瘤整形保乳术中不可或缺的一部分,近年来一组由胸背动脉穿支皮瓣、肋间外侧动脉穿支皮瓣以及胸外侧动脉穿支皮瓣所构成的带蒂侧胸动脉穿支皮瓣成为自体乳房部分重建的新选择。与传统皮瓣相比,带蒂侧胸动脉穿支皮瓣操作更简单、术后供区并发症发生率更低,美学效果也更好。本文综述了带蒂侧胸动脉穿支皮瓣在乳房肿瘤整形保乳术中的应用进展,主要包括带蒂侧胸动脉穿支皮瓣的解剖、手术步骤以及优势和局限性。     

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。     

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.     

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。     

部分筋膜法TRAM皮瓣在乳腺癌根治即刻乳房重建中的应用

目的:探讨采用保留部分前鞘的下腹部横行腹直肌肌皮瓣(TRAM)即刻乳房重建在乳腺癌根治中的应用及效果.方法:对接受乳腺癌根治术的14例患者(Ⅰ、Ⅱ期9例,Ⅲ期5例),于根治术即刻采用保留部分前鞘的TRAM皮瓣重建乳房.所有患者术后均常规行放化疗或内分泌治疗.结果:本组14例皮辩均成活,无并发症.随访2～26个月,未见肿瘤复发和转移,未见腹壁疝和腹壁膨出发生.重建乳房外形可,与健侧对称性可,弹性好,患者自我满意度高.结论:部分筋膜法TRAM皮瓣即刻再造重建,可保持传统TRAM皮瓣手术的效果并降低术后腹壁并发症的发生率.放化疗和内分泌治疗不影响皮瓣的成活.     

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.     

乳腺切除术后全乳再造37例临床研究

目的探讨带血管蒂转移皮瓣在乳腺癌术后乳房再造中的安全性和整形效果。方法2004年3月—2010年6月,对37例乳腺肿瘤患者,行乳房切除术后带蒂背阔肌或TRAM皮瓣乳房再造。其中Ⅰ期再造34例,Ⅱ期再造3例;对其中15例TRAM皮瓣再造的供区下腹部应用涤纶补片加强腹壁。结果1例TRAM皮瓣小部分坏死,6例Ⅰ期再造术后乳房本体皮肤坏死。3例背阔肌皮瓣再造发生背部皮下血清肿;3例TRAM皮瓣下腹中段脂肪液化,无腹壁膨隆或腹壁疝发生。随访2月—72月,1例肿瘤局部复发,1例肝转移。乳房外观评价,总体可接受度94.59％。 结论背阔肌或TRAM带血管蒂转移皮瓣再造是乳房切除术后行全乳再造的有效和安全的方法,应用涤纶补片加强腹壁可以有效预防腹壁软弱和腹壁疝形成。     

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.     

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.     

带蒂背阔肌皮瓣在乳房重建手术中的应用

随着乳腺癌治疗模式的发展及患者观念的转变,乳房重建逐渐成为乳腺癌治疗的一部分。背阔肌因面积较大,且蒂部解剖变异较少,同时血供丰富可被改良成不同的皮瓣,因此被认为是良好的供瓣区。在乳房重建中,背阔肌肌皮瓣的应用较广,不仅可以使用全背阔肌或联合假体进行乳房重建,且可以根据不同的缺损范围选择合适的背阔肌皮瓣进行乳房缺损的修补。相比单纯植入物重建,背阔肌皮瓣可获得更为良好的乳房形态且对术后放疗影响较小;相比下腹部皮瓣,背阔肌皮瓣瘢痕较短,术后恢复较快。目前对于术后供区缝合方式的改进及辅助药物的应用,极大地降低了血清肿的发生率;腔镜技术的应用也避免了切取背阔肌皮瓣遗留的供区瘢痕。在临床应用中,背阔肌皮瓣行乳房重建患者满意率高,术后审美效果良好,是乳房重建中一种较为优势的手术方法。该研究总结了背阔肌皮瓣行乳房重建对并发症的控制并对近年来的手术中的问题作进一步探讨。     

Mastectomy with immediate breast reconstruction after neoadjuvant chemotherapy and radiation therapy. A new option for patients with operable invasive breast cancer. Results of a 20 years single institution study

Purpose

To evaluate the feasability of immediate breast reconstruction (IBR) following mastectomy after neoadjuvant chemotherapy (NACT) and radiation therapy (RT) for operable invasive breast cancer (OIBC), in terms of incidence of local complications, locoregional control and survival.

Patients and methods

From 1990 to 2008, 210 patients were treated by NACT, RT and mastectomy with IBR for OIBC. One hundred and seven patients underwent a latissimus dorsi flap with implant (LDI), 56 patients a transverse rectus abdominis musculocutaneous (TRAM) flap, 25 an autologous latissimus dorsi flap (ALD) and 22, a retropectoral implant (RI) reconstruction.

Results

Forty-six (21.9%) early events were recorded: 20 necrosis, 9 surgical site infections and 6 haematomas, requiring further surgery in 23 patients. More necrosis were observed with TRAM flap reconstructions (p = 0.000004), requiring more surgical revision than LD reconstructions. Seromas represented 42% of early complications in LD reconstructions. Fifty-five patients presented with late complications (26.2%) with mainly implant complications (capsular contracture, infection, dislocation, deflation) (23.6%), requiring reintervention in 14 cases. There were more delayed surgical revisions in RI reconstructions (p = 0.0005). The 5 years overall and disease-free survival rates were respectively 86.7% and 75.6%. Sixty-four patients presented at least one recurrence (30.5%) with 5 local, 9 locoregional and 54 distant relapses.

Conclusion

This therapeutic sequence does not seem to increase the IBR morbidity nor alter disease-free and overall survival.     

Breast reconstruction with the TRAM flap: pedicled and free

BACKGROUND: Breast cancer is a ubiquitous disease affecting one in seven women. While breast conservation techniques are available for local control of the disease for many patients, not all patients are good candidates for these techniques. Mastectomy, therefore, remains a common method of breast cancer treatment. Methods of reconstruction include implant reconstruction and autogenous reconstruction. The advantages of autogenous reconstruction include the creation of a soft, ptotic breast mound, which tends to match a native contralateral breast both in and out of bra support. Autogenous reconstructions do not tend to change with time and usually do not require periodic revision as seen in implant reconstructions. METHODS: The most common method of autogenous reconstruction is the TRAM flap, either pedicled or free. The TRAM flap employs the redundant excess lower abdominal tissue typically removed during a cosmetic abdominoplasty. This tissue is brought to the mastectomy defect as a pedicled flap, passing subcutaneously from the upper abdomen and into the defect site. The pedicled flap is based upon the superior epigastric vessels. A free TRAM is harvested with the overlying muscle and the attached inferior epigastric vessels. This flap is completely separated from the abdomen and brought to the chest defect where it is anastomosed to either the thoracodorsal or internal mammary vessels. The donor defect within the abdominal wall is repaired with an inlay mesh with both the pedicled and free techniques. RESULTS: Patient selection criteria usually help determine which technique is used. The advantage of the free flap technique is improved blood supply to the skin island. The free flap, therefore, is used in patients at higher risk for partial flap loss with the pedicled technique. Such high-risk patients include smokers, the obese, patients with significant medical comorbidities, and patients with prior abdominal surgery. Patients without these risk factors can be expected to achieve good results with either the pedicled or free flap technique. CONCLUSION: Autogenous breast reconstruction with the TRAM flap achieves long lasting satisfactory results in most patients with the creation of a soft, naturally ptotic breast mound, which typically matches well a contralateral native breast.     

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.     

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。     

Complications in Post-mastectomy Immediate Breast Reconstruction: A Ten-year Analysis of Outcomes

IntroductionImmediate breast reconstruction offers cosmetic and psychological advantages post-mastectomy. There are various options of reconstruction, and this study aims to evaluate the associated complications.Patients and MethodsThis is a single-center retrospective study analyzing data from January 1, 2008 to December 31, 2017 for immediate breast reconstruction procedures post-mastectomy performed at an academic breast unit. Procedures included expander and implant insertion, latissimus dorsi, pedicle transverse rectus abdominis musculocutaneous (TRAM), free TRAM, and deep inferior epigastric perforator. Complications and reoperative complications (defined as those requiring a reoperation within the first 30-day period), and associated risk factors were investigated using separate logistic regressions, and odds ratios (ORs) were calculated.ResultsA total of 243 post-mastectomy immediate breast reconstruction procedures and complications rates were analyzed. The overall complication rate was 27.6%, comprised mainly of reconstruction-specific complications such as post-TRAM hernia or bulges, fat necrosis, and implant capsular contracture and leakage. The rate of reoperative complications was relatively low at 6.6%. The flap failure rate was similar between expander/implant reconstruction and autologous reconstruction methods at 3.3% and 5.6%, respectively (P = .60). Logistic regression identified significantly higher risks associated with diabetes mellitus (OR, 5.21; P = .022), obesity (OR, 5.80; P = .016), and free pedicle autologous reconstruction (OR, 3.975; P = .046) for reoperative complications.ConclusionDifferent methods of immediate breast reconstruction post-mastectomy are feasible and safe. However, patient variables and procedure choice should be taken into consideration when counseling patients on reconstructive options, as they are strong predictors for postoperative complications.     

保留皮肤的乳腺癌改良根治术后即刻乳房再造的临床应用

目的探讨保留皮肤的乳腺癌改良根治术后即刻再造乳房的适应证、方法、效果及可行性。方法2002年1月至2007年11月本院对94例乳腺癌患者行保留乳房皮肤皮下乳腺组织切除加腋窝淋巴结清扫术后，应用下腹部横行腹直肌肌皮瓣（transverse rectus abdominis myocutaneous flap，TRAM）、背阔肌肌皮瓣（latissimus dorsi myocutaneous flap，LDM）联合或不联合假体、单纯乳房假体植入4种方式即刻再造乳房。结果再造手术均取得成功。带蒂TRAM再造47例，LDM再造共42例（其中联合假体28例），单纯乳房假体植入5例。4例出现轻微术后并发症（4．25％）。经过3～67个月随访，局部区域复发率为0，再造乳房形态自然，效果满意，术后外观评价优良率97．87％。结论合理选择病例行保留皮肤或保留乳头乳晕乳腺癌改良根治术后即刻乳房再造是安全可靠的，切口隐蔽并能够保留原有乳房皮肤的感觉，从而获得最佳美容效果，值得广泛推广和应用。     

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。     

腹部皮瓣在乳房重建中的应用

乳腺癌已经成为严重危害女性身心健康的恶性肿瘤,其发病率高居榜首,且有年轻化的趋势。现阶段随着医疗的不断进步,人们越来越重视乳房的缺失对患者心理、形体造成的伤害,所以乳腺癌的外科治疗已经由传统的根治性手术朝着保乳、乳房重建的手术模式发展。国内外众多医疗机构针对乳房重建开展了大量研究和实践,根据重建填充物的不同,可以将乳房重建分为自体组织重建和植入物重建,而自体组织重建又可分为腹部皮瓣、背部皮瓣、腰部皮瓣、臀部皮瓣及腿部皮瓣,其中腹部皮瓣因其血供好、组织量够大、远期效果好且具有腹部塑型的作用被广泛用于乳房重建及胸壁缺损的修复。本文将应用腹部皮瓣进行乳房重建的技术要点和相关并发症进行总结,旨在探讨腹部皮瓣乳房重建的最新进展。