女性乳房手术预防乳头乳晕坏死的血供研究

目的研究女性乳头乳晕的动脉血供特点，为乳腺手术时避免乳头乳晕坏死提供解剖依据。方法对13具女性尸体26个乳房标本的乳头乳晕血管进行斛剖学观察。结果乳头乳晕动脉血供主要由胸外侧动脉分支及胸廓内动脉穿支供应：胸廓内动脉第2～4肋间血管穿支与胸外侧动脉的乳头乳晕支分别从乳晕上、内方和外上方经腺体小叶之间到达乳头乳晕基底部，然后在乳腺导管问上行供应乳头乳晕；胸廓内动脉肋间穿支和胸外侧动脉分支的浅层腺体穿支在皮下形成广泛吻合，特别是在乳晕下形成动脉网，由此网发出分支供应乳头乳晕；肋间动脉穿支与胸肩峰动脉末见有分支供应乳头乳晕。结论保留乳头的乳腺癌根治术时，为了避免乳头乳晕坏死，应注意保护乳晕下动脉网，这时的皮瓣厚度不能小于0．5cm。乳房缩小整形术时，应以乳房内上或外上象限腺体作为腺蒂，并且注意保留乳腺后方至少1．5cm厚的腺体，以保证胸廓内动脉第2～4肋间穿支或胸外侧动脉乳头乳晕支对乳头乳晕的血液供应。     

改良真皮帽双环法行乳房缩小整形术

目的：灵活应用真皮帽双环法行乳房缩小成形。方法：采用传统的双环法设计切口，外下象限辅助S形切口线，保留乳晕周围较大面积完整的真皮帽，切除乳房外下象限腺体组织，设计外上及内下两个腺体组织瓣交错连接固定成形，乳晕周围内外环真皮荷包缝合，修整乳晕周围及外象限多余皮肤，切口呈环形，辅助切口瘢痕较小。结果：术后三月随访，新乳房的大小和形态．乳头乳晕的位置和形态均满意，除具有良好的感觉及勃起功能外，还保留了泌乳功能。结论：用组织瓣旋转固定的改良真皮帽双环法行乳房缩小成形，手术操作简单，组织瓣及乳头乳晕供血丰富，组织损伤小，值得推广。     

小切口重度巨乳缩小术的临床应用

目的探讨一种切口瘢痕较小的乳房缩小整形术在巨乳治疗中的应用。方法去除乳晕周围皮肤的表皮，切除乳房下方梯形区域内的皮肤和乳腺组织，再以荷包缝合形成新乳晕，手术后仅在乳房下半留有一条垂直短小瘢痕。结果以该术式共治疗9例，效果良好，外观较满意，乳头血运、感觉良好，切口较隐蔽，并能够切除乳腺所有象限的肿物。结论该方法对于重度巨乳和合并有肿瘤的县乳的手术整复有其显著优点，值得推广。     

保留乳头乳晕感觉功能的改良双环法巨乳缩小术

目的 探讨改良双环法巨乳缩小整形手术的方法,以提高疗效,减少手术并发症.方法 以乳头为中心做近似双同心圆切口,滚轴取皮刀去除两同心圆之间的表皮,切除外环以外,包括外上象限、内上象限、内下象限肥大的腺体组织,保留外下象限和中央的乳腺组织,以便保持第4肋间神经对乳头乳晕的支配和充足的血供.将去表皮的真皮帽边缘与乳腺基部的筋膜紧密缝合固定在胸壁上,重塑乳房外形.以可吸收线荷包式缝合外环皮下组织,收紧荷包缝线将外环切口缩小到与内环相近,直接缝合切口.结果 本组患者31例,术后乳房形态自然挺拔、质感柔软;乳头乳晕对称,感觉正常;瘢痕隐蔽并且有效地保留了乳房的泌乳功能.结论 本法术后乳房形态良好,功能正常,是一种较理想的巨乳缩小整形方法.     

双环法及乳头乳晕内上蒂缩乳术治疗重度男子乳腺发育

目的 探讨双环法及乳头乳晕内上蒂缩乳术治疗重度男子乳腺发育症的效果.方法 双环法设计内外环切口,并去除两环间的内上方部分表皮,形成包含真皮、乳腺及皮下组织的乳头及乳晕蒂,切除两环间其余大部分皮肤、腺体及脂肪组织后,将乳头乳晕蒂部适度内旋并与肌膜固定,外环收拢后与内环对位缝合.结果 9例(18侧),除1例单侧乳头乳晕表层坏死外,其余均Ⅰ期愈合,双侧乳房对称、外形满意.结论 利用双环法及乳头乳晕内上蒂缩乳术,可有效治疗重度男子乳腺发育症,内上蒂可确保乳头乳晕血运,并避免后期乳房下垂.     

保留乳头乳晕感觉功能的改良双环法巨乳缩小术

目的探讨改良双环法巨乳缩小整形手术的方法，以提高疗效，减少手术并发症。方法以乳头为中心做近似双同心圆切口，滚轴取皮刀去除两同心圆之问的表皮，切除外环以外，包括外上象限、内上象限、内下象限肥大的腺体组织，保留外下象限和中央的乳腺组织，以便保持第4肋间神经对乳头乳晕的支配和充足的血供。将去表皮的真皮帽边缘与乳腺基部的筋膜紧密缝合固定在胸壁上，重塑乳房外形。以可吸收线荷包式缝合外环皮下组织，收紧荷包缝线将外环切口缩小到与内环相近，直接缝合切口。结果本组患者31例，术后乳房形态自然挺拔、质感柔软；乳头乳晕对称，感觉正常；瘢痕隐蔽并且有效地保留了乳房的泌乳功能。结论本法术后乳房形态良好，功能正常，是一种较理想的巨乳缩小整形方法。     

乳晕周围双切口巨乳缩小和乳房悬吊术

自１９９４年９月以来，对１１例乳房肥大及松垂患者施行了乳晕周围双切口乳房缩小及乳房悬吊术，其中７例正常体积的乳房下垂（中度），４例乳房下垂伴肥大。术中选择乳腺肿瘤的好发部位，乳腺的外上象限切除多余的乳腺组织，并形成以乳腺下极为蒂的内外侧乳腺组织瓣，内侧瓣向内翻转折叠缝合，固定在第三肋及肋间的胸大肌肌膜上。外侧瓣向上向内翻转，固定在第二肋骨骨膜上，皮肤切口做荷包缝合。缝合后所形成的局部皱褶多在３～４个月后自行逐渐变小、消失。本手术方法具有设计简单、血供可靠、乳腺组织固定确实、塑形好、乳头乳晕感觉正常、切口隐蔽及瘢痕不明显等优点。１１例手术均取得满意结果     

改良乳房下真皮乳腺单蒂瓣巨乳缩小术

目的为了进一步保证巨乳缩小术后乳头乳晕的血供和感觉,减少手术并发症。方法设计应用乳房下真皮单蒂瓣,并保留部分乳腺组织的垂直乳腺蒂,及切除的乳腺组织位于乳房下方两侧的巨乳缩小术,自1994年1月至1995年11月,为67例(132侧)巨乳患者在法国斯德拉斯堡欧洲美容整形诊所进行治疗。结果术后全部患者无乳头乳晕并发症,感觉正常。结论结合乳腺垂直蒂和乳房下真皮单蒂瓣的改良巨乳缩小术,不但可以确保乳头乳晕的血供,且可减少感觉损伤,降低手术并发症,及提供良好形态。     

乳腺基底蒂乳房缩小整形术

在乳房深部血供的解剖学研究基础上,设计了以乳腺基底部的腺体组织为蒂携带乳头、乳晕移位的乳房缩小整形术。通过10例20只乳房的临床应用,取得了满意效果。     

保留上部真皮蒂的改良双环法提升乳房下垂

目的:探讨保留上部真皮蒂的改良双环法乳房上提手术的方法及临床效果。方法:按常规定位新乳头乳晕点,设计乳房内外,根据乳房下垂程度设计外环,在原乳晕上方内外环之间设计3~4cm宽皮肤蒂,切除除真皮蒂外的内外环之间的皮肤,上部皮肤蒂去表皮,折叠缝合真皮蒂,提升乳头乳晕;剥离除真皮蒂以外的乳房皮下直至基底,荷包缝合内外环皮肤。结果:本组病例,乳房下垂得到矫正,无乳头乳晕坏死,乳房形态良好,切口瘢痕愈合良好。结论:真皮蒂的折叠缝合可以确实提升乳头乳晕,并且保证乳头乳晕的血供。     

Custom-made approach to a patient with post-burn breast deformity

Second and third degree burns on breasts at preadolescent period may cause severe breast deformations. This deformation can be variable depending on severity and location of the burns, personal adolescent patterns, and treatment modality in acute burn period. A 21 year old female patient admitted to our department for her breast deformation due to burn contracture at the inferior pole of the right breast. On physical examination we defined that development of the volume of the right breast was equal to the left, and inferior pole of the right breast was flattened due to contracture, and nipple was projected to inferior. We found that inframammary crease of the right breast was 2 cm lower than that of left; andthe distance of nipple-inframamary crease was 4.7 cm while areola-inframmary crease was 2 cm. New nipple-areola complex level was identified according to left breast''s level. Medial and lateral lines were planned to merge inferiorly at 2 cm above inframmary crease in a plan similar to vertical mammaplasty. Superior pedicle carrying nipple areola was desepitelised. Lower parenchymal V flap was transposed superiorly and attached to the pectoral muscle. Inferior parts of the lateral and medial glandular flaps were excised to form new inframammary crease. The desired laxity of skin at the lower pole was obtained by performing a new Z- plasty between lateral and medial skin flaps. Breast symmetry was confirmed by postoperative objective measurements between left and right breasts. Patient''s satisfaction and aesthetic appearance levels were high. Breasts deformation patterns caused by burns, trauma and mass exsicion due to cancer could not be addressed with traditional defined techniques. Special deformations can be corrected by custom made plannings as we presented here.KEY WORDS: Burn, burn contracture, post-burn breast deformity     

Vertical Mammaplasty for Gigantomastia

A 48-year-old female patient presented with gigantomastia. The sternal notch-nipple distance was 55 cm for the right breast and 50 cm for the left. Vertical mammaplasty based on the superior pedicle was performed. The resected tissue weighed 3400 g for the right breast and 2800 g for the left breast. The outcome was excellent with respect to symmetry, shape, size, residual scars, and sensitivity of the nipple-areola complex. Longer pedicles or larger resections were not found in the literature on vertical mammaplasty applications. In our opinion, by using the vertical mammaplasty technique in gigantomastia it is possible to achieve a well-projecting shape and preserve NAC sensitivity.     

MRI visualization of the female pelvis in the plane of the tension-free vaginal tape (TVT) procedure

We evaluated the distances and angles of the major blood vessels from various pelvic structures in the plane of the tension-free vaginal tape (TVT) procedure in 19 pelvic MR imagies. The major blood vessels were the iliofemoral vessels. The mean distance of the left iliofemoral vessels from the midline was 5.7±0.4 cm, and 5.7±0.3 cm for the right vessels. The mean distance of the left sacral tuberosities from the midline was 5.5±0.4 cm, and 5.6±0.3 cm for the right vessels. The angle between the midurethra and the left iliofemoral vessels was 50.6±4.4 cm, and 49.6±4.0 cm for the right. A significant correlation was found between the distance of the right and left iliofemoral vessels from the midline and the distance of right and left sacral tuberosities from the midline (P<0.01, P<0.007). We suggest that palpation of the sacral tuberosities might indicate the location of the iliofemoral blood vessels.Abbreviations - TVT Tension-free vaginal tape - - MRI Magnetic resonance imagingEditorial Comment: The authors evaluated the distances and angles of the major pelvic blood vessels in the plane of the tension-free vaginal tape (TVT) procedure in 19 pelvic MR images. A statistically significant correlation was found between the distance of the iliofemoral vessels from the midline and the distance of the sacral tuberosities from the midline. The authors suggest that palpation of the sacral tuberosities might alert the surgeon to those patients at greater risk for iliofemoral vessel injury during the TVT procedure.The main concern with this study is that the pelvic MR images were obtained in the supine position whereas the TVT is performed in the lithotomy position, which may change the relations of pelvic blood vessels with reference to the urethra. Further studies are needed to evaluate the clinical significance of this interesting observation in reducing vascular injuries during the TVT procedure.     

Morphologic Study of Nipple-Areola Complex in 600 Breasts

To investigate the morphologic characteristics of the nipple-areola complex, the diameter of the nipple-areola complex and the height of the nipple in 300 adult women (600 breasts) were measured using micrometer calipers. Furthermore, the morphologic characteristics were classified into four types by visual observation. Mean diameter of the areola was 4.0 cm, mean diameter of the nipple was 1.3 cm, and mean height of the nipple was 0.9 cm. From the morphologic point of view, the elevated plateau type without constriction (IIs) was most commonly found, being present in 60.2% of breasts. Inverted nipples (III) were found in 3.5% and unclassified type (IV) such as multiple or divided nipples was found in 0.3%. Because women have become sensitive about the appearance of their breasts and there is increasing cosmetic interest following surgery for breast carcinoma, operations on the nipple-areola complex are now common. When a surgeon counsels a patient and designs a reconstruction method prior to operation, these data may be helpful.     

Safety zones for anterior abdominal wall entry during laparoscopy: a CT scan mapping of epigastric vessels

OBJECTIVE: To determine the efficacy of CT scan in mapping the superior and inferior epigastric vessels, relative to landmarks apparent at laparoscopy. SUMMARY BACKGROUND DATA: Trauma to abdominal wall blood vessels occurs in 0.2% to 2% of laparoscopic procedures. Both superficial and deep abdominal wall vessels are at risk. The superficial vessels may be located by transillumination; however, the deep epigastric vessels cannot be effectively located by transillumination and, thus, other techniques should be used to minimize the risk of injury to these vessels. METHODS: Abdominal and pelvic CT images of 100 patients were studied. The location of the superior and inferior epigastric vessels from the midline were determined at five levels, correlated with each other and with the patient age, body mass index, and history of midline laparotomy using Pearson's correlation coefficient and multivariate analysis. RESULTS: CT scan was successful in mapping the epigastric vessels in 95% of patients. At the xiphoid process level, the superior epigastric vessels (SEA) were 4.41 +/- 0.13 cm from the midline on the right and 4.53 +/- 0.14 cm on the left. Midway between xiphoid and umbilicus, the SEA were 5.50 +/- 0.16 cm on the right of the midline and 5.36 +/- 0.16 cm on the left. At the umbilicus, the epigastric vessels were 5.88 +/- 0.14 cm on the right and 5.55 +/- 0.13 on the left of the midline. Midway between the umbilicus and symphysis pubis, the inferior epigastric (IEA) were 5.32 +/- 0.12 cm on right and 5.25 +/- 0.11 cm on the left. At the symphysis pubis, the IEA were 7.47 +/- 0.10 cm on the right and 7.49 +/- 0.09 cm away from the midline on the left side. CONCLUSIONS: Epigastric vessels are usually located in the area between 4 and 8 cm from the midline. Staying away from this area will determine the safe zone of entry of the anterior abdominal wall.     

Mammographic distance as a predictor of nipple-areola complex involvement in breast cancer

BACKGROUND: Although involvement of the nipple-areola complex (NAC) occurs in a minority of patients with breast cancer, standard skin-sparing mastectomy requires its removal. To assist in patient selection for NAC preservation we evaluated NAC involvement and correlated this with preoperatively available clinical data. METHODS: Patients with invasive breast cancer or ductal carcinoma in situ undergoing mastectomy from 1998 to 2005 were reviewed retrospectively. The NAC had been evaluated with multiple thin sections. Pathologic data including NAC involvement were analyzed. The mammographic tumor distance from the nipple was measured in 2 standard views. RESULTS: There were 302 patients enrolled, of which 10% were noted to have NAC involvement. This correlated negatively with tumor distance from the nipple (P < .05). A logistic regression equation was derived from the data, with NAC involvement as the dependent variable and distance from the nipple as the independent variable. The equation predicted involvement of the NAC when the distance was less than 4.96 cm with a sensitivity of 82% and a negative predictive value of 97%. CONCLUSIONS: A majority of patients are candidates for NAC preservation. The mammographic distance between the tumor and the nipple is independently predictive of NAC involvement and is useful as an equation variable.     

The Blood Supply to the Nipple-Areola Complex of the Human Mammary Gland

The main sources of blood supply to the breast are described in textbooks as the internal thoracic, lateral thoracic, and posterior intercostal arteries. Textbooks, however, do not describe the contribution of each to the nippie-areoia complex (NAC), nor do they describe the pattern of supply. To investigate this issue, 15 female cadavers were injected intraarterially with latex, and dissections were performed on 27 breasts.The results were as follows: In all the dissected breasts (27/27), the NAC received at least one or more vessels from the internal thoracic artery. In 20 of 27 dissected breasts, the NAC received vessels from the anterior intercostal arteries, In 19 of the 27 dissected breasts, the NAC received vessels from the lateral thoracic artery. Direct branches from the axillary artery supplied the NAC in 2 of the 27 breasts. The posterior intercostal arteries supplied the NAC in only 1 of the 27 dissected breasts. An underlying segmental pattern could be detected that can be explained by the embryological development. According to this study, the internal thoracic arteries are to be considered the main and constantly reliable source of blood supply to the NAC.     

Temporary banking of the nipple-areola complex in breast reconstruction following mastectomy for gigantomastia

IntroductionGigantomastia is a breast disorder characterized by exaggerated rapid growth of the breasts, generally bilaterally. In some severe cases, mastectomy is required to ensure safe delivery or control disease progression or recurrence. Subsequently, most patients want to undergo breast reconstruction, including the nipple-areola complex (NAC).Presentation of caseHere, we report our experience with temporary banking of the NAC in a patient who underwent mastectomy for severe Gigantomastia. Each NAC was temporarily transplanted into the axilla as banking tissue for NAC reconstruction at a later date. Although the color of the NAC was slightly lighter after reconstruction, it mainly kept its original color and texture in addition to medical tattooing technique. At present, there has been no recurrence and the patient is fully satisfied with her appearance.DiscussionIn this case, mastectomy was recommended because of an unbearable breast size that disturb a safety delivery, as well as respiratory and cardiac complications and skin ulcer control. Because the disease is not pathologically malignant, temporary preservation of NAC allows it to be safely used again for later nipple reconstruction.ConclusionTemporary banking of the nipple-areola complex in breast reconstruction following breast resection including NAC, would be one of good surgical options for benign breast tumors like gigantomastia.     

乳腺癌患者皮肤微转移灶的临床意义

目的 探讨检测乳腺癌患者皮肤微转移灶的临床意义。方法 从皮肤距肿瘤最近点及乳头乳晕复合体正中切面取材，分别进行常规病理及细胞角蛋白单抗免疫组织化学法（immunohistochemistry，IHC）检测60例乳腺癌患者标本。结果60例乳腺癌中，常规病理检测出有乳头乳晕复合体浸润的3例（占5，0％），IHC检测出7例（占11．7％），两者间有统计学意义（X^2=2.25，P〈0．05）；常规病理检查及IHC法均检测出4例有皮肤浸润（占6．7％），其中3例两种方法均证实皮肤和乳头乳晕复合体同时有癌浸润。结论 IHC对乳头乳晕复合体的微转移灶的检出率高于常规病理，皮肤及乳头的受累率较低，如无受累，可行保留皮肤的乳房切除术。     

Seventeen Years of Experience with Reduction Mammaplasty Avoiding a Vertical Scar

BACKGROUND: It is important to reshape the breast with the least scar possible. This has led us to develop a technique for large breasts where the vertical scar was eliminated. METHODS: The new nipple is positioned at 19-21 cm. The level of the new inframammary line (IML) is marked 6 cm below the new areola. All the area between the marked IML and the present sulcus is de-epithelialized. The upper flap is undermined beginning from the new IML. The tissue excision is performed medially and laterally leaving a central pedicle that also carries the nipple-areola complex (NAC). The dermoglandular pedicle is shaped conically with breast-shaping sutures. The NAC is passed under the upper apron flap through its new opening. RESULTS: We retrospectively reviewed 145 patients who were operated on over the past 17 years. The mean age of the patients was 41 years. The mean distance preoperatively from midclavicle to nipple was 35.3 cm. The average weight of breast tissue excised was 1073 g per side. Seventeen patients (11%) suffered from minor complications. CONCLUSION: This technique works especially well in breast reduction cases where a large mass excision is required. The horizontal scar is obvious only when the patient is lying down and cannot be seen by the patient herself. There is no risk of destroying the circular feature of the areola, which is pulled inferiorly by the vertical scar in the other techniques.