国外美容医学最新动态(八)

整形美容1接受放射治疗的乳癌患者用不同类型游离瓣重建乳房的效果对于乳腺癌患者手术治疗附加放射疗法可以减少局部复发率,并可提高存活率。关于乳癌切除后即时行自体组织重建乳房者,在切乳前或切乳后施行放疗的效果是否有差异,看法不一。现在,还不知道这类患者用不同类型的组织瓣(肌皮瓣或筋膜皮瓣)进行乳房重建,组织瓣对放疗的耐受性是否有差异。为此,本文作者进行了临床观察。     

不同方法乳房重建术的患者报告结局

乳腺癌术后乳房重建可以提高患者的自尊和健康相关的生活质量,重建方式有自体组织重建与假体重建。自体重建有不同自体组织;假体重建有一步法与二步法,假体植入物有不同类型,按重建时间分为即刻与延期重建;重建后可能需要放疗。不同重建材料、重建时机和术后放疗,都可能会对乳房重建患者的报告结局产生影响。本文就不同方法乳房重建术的患者报告结局的研究进展作一综述。     

国外美容医学最新动态(四)

<正>整形美容1预测自体组织乳房重建术静脉栓塞发生的因素静脉血栓形成,是选用自体组织进行乳房重建术可能发生的严重并发症。本文作者分析了患者的特质、重建乳房的术式、重建乳房的时机以及是否接受放射治疗或化学治疗等因素,对住院接受自体组织乳房重建者发生深静脉血栓/或肺栓塞的影响。作者查阅了2009~2010年美国的相关资料,并经统计学分析,发现,在住院接受自体组织乳     

乳腺癌术后即刻乳房重建肿瘤安全性探讨

即刻乳房重建在避免病人接受二次手术的同时，可以减轻病人失去乳房的心理创伤。但是，肿瘤外科医生在选择即刻乳房重建时必须保证肿瘤的安全性，术前细致的评估、术中足够完整的腺体切除是保证肿瘤安全性的前提。美国国家综合癌症网络（NCCN）指南明确指出，炎性乳腺癌是即刻乳房重建的禁忌证，此外，对于拟行术后放疗的病人也需慎重选择即刻乳房重建；尽管缺乏高级别循证医学证据，但现有的数据显示，即刻乳房重建并不影响术后辅助化疗的疗效，部分病人选择保留乳头乳晕的皮下腺体切除是安全可靠的，假体植入术后的淋巴瘤虽有报道，但发病率很低。因此，乳房切除术后即刻乳房重建在适宜的乳腺癌病人中是安全可靠的手术方式。     

延期-即刻乳房再造：方法及时机选择（摘要）

目的2002年，笔者应用一种分两期完成的“延期根Ⅱ刻乳房再造术”，对那些想要施行乳房再造术而又存在乳腺癌复发风险而必须接受放疗的乳腺癌术后患者，进行治疗。在临床应用中，接受这一疗法的患者不断增多。延期一即刻乳房再造术可取得良好的术后效果，并减少对扩张组织的浪费，在此，本文将着重探讨该技术的操作方法及时机选择。方法延期一即刻乳房再造术的Ⅰ期：保留皮肤的乳腺癌切除术巾，置入盐水扩张器，以保证乳房外层组织的立体外形。无须进行乳腺癌切除术后放疗治疗的患者直接进入Ⅱ期（最终的乳房再造术）：应在Ⅰ期后的2周内，避免拖延至开始化疗而造成乳房下垂外观，应保持乳房外层组织的立体外形。对于需要接受放疗的患者，在接受放疗前将扩张器抽瘪，以形成平整的胸壁使现代三束放疗光达到治疗效果。放疗完成后2周，充盈扩张器至失充盈前的体积。放疗结束3个月后．行保留皮肤的乳腺癌切除术后延期乳房再造术，除去扩张器，移植自体组织瓣进行修复。结论延期一即刻乳房再造术，对于保留皮肤的乳腺癌切除术后不需要放疗的患者来讲，其外观美学效果与即刻乳房再造相似；对于需要放疗的患者来讲，可避免放疗对即刻乳房再造术后效果的影响。     

放疗对乳腺癌术后假体和自体组织乳房再造影响的研究进展

乳房的完整性和美观性影响女性的生理及心理健康。乳腺癌乳房切除术后即刻乳房再造,能够显著增加女性的自信心及提高女性生活质量。放疗作为乳腺癌的一种常规治疗方式,能够降低乳腺癌局部复发率及无病生存率,然而放疗会增加乳腺癌术后即刻乳房再造的并发症发生率及乳房再造的失败率。目前,实施最多的两种乳房再造术为自体组织乳房再造和假体乳房再造。本文主要针对放疗对自体组织乳房再造及假体乳房再造影响的研究进展进行综述。     

乳腺癌术后乳房重建时机及术式选择

结合整形外科的理念和手段，在保证肿瘤安全性的前提下对乳腺癌病人进行乳房重建修复，成为乳腺外科领域重要的发展方向。乳房重建可以与全乳切除或部分乳房切除术同时进行，也可以延迟至完成辅助治疗后的适当时间进行，前者称为即刻乳房重建，后者称为延期乳房重建。临床上根据病人的疾病情况和自身的需求来确定重建时机。部分病人采用延迟-即刻乳房重建来降低辅助放疗给重建带来的不利影响，减少术后严重并发症的发生。从重建的技术手段来看，乳房重建有自体皮瓣乳房重建、假体乳房重建以及自体联合假体的乳房重建。植入物重建是即刻乳房重建中最常用的术式。在延期乳房重建中，更常采用自体皮瓣乳房重建或两步法的植入物重建术。     

国外美容医学最新动态(十)

1假体置入隆乳后有严重感染或伤口并发症者的长期效果观察因疾病接受乳房切除术后立即施行乳房假体置入的重建乳房患者,可能出现术后并发症,包括严重感染、伤口不愈等。某些对象可能因此需要取出假体和再次施行手术。对于此类患者,经过再次处置后长期效果资料很少。本文作者就     

乳腺癌术后自体组织即刻乳房重建与延期重建的疗效及其对患者相关生活质量的影响

目的探讨乳腺癌术后自体组织即刻乳房重建（IBR）与延期重建（DBR）的疗效及其对患者相关生活质量的影响。方法选取行择期乳腺癌根治手术患者106例,随机分为即刻组与延期组,每组各53例。即刻组于乳腺癌术后采用自体组织进行即刻乳房重建,延期组于乳腺癌术后1年再采用自体组织行乳房重建。术后6个月时．评价两组患者的临床疗效．包括重建乳房、腋窝、腋周及锁骨区域形态,以及上肢活动和术后并发症等,评价患者对重建乳房的状态的满意度;采用欧洲癌症研究治疗组织制定的生活质量问卷调查条例（EORTCQOL—C30）评价患者的相关生活质量,包括角色功能、情绪状态、社会功能评价。结果即刻组与延期组分别随访（8．4±1．2）个月、（8．1＋1．0）个月,随访率分别为96．23％、92．45％。两组患者术后重建乳房组织均成活,无肌皮瓣坏死、感染、血肿等术后并发症出现,乳房及供区切Vl均I期愈合。肉眼观双侧胸前壁基本对称,乳房外观自然,无明显包膜挛缩征象;重建的腋前皱璧与健侧基本对称,腋窝顶部与腋前皱璧凹陷畸形已纠正：锁骨下区域形态较术前明显改观;上肢活动无明显功能障碍。术后6个月时,即刻组患者对重建乳房的状态,包括总体满意度、外形满意度、对称满意度、瘢痕满意度均高于延期组,即刻组患者生活质量,包括角色功能、情绪状态、社会功能评价均高于延期组,差异均具有统计学意义（P〈0．05）。结论乳腺癌术后自体组织即刻乳房重建具有确切的临床效果．且患者对重建乳房的状态和相关生活质量均优于延期乳房重建。多数情况下,患者可选择即时手术,对于晚期需要大剂量放化疔者,则可待病情稳定后考虑行延期乳房再造。     

乳腺癌保守性乳房切除联合乳房重建的研究进展

目的 了解目前关于乳腺癌保守性乳房切除联合乳房重建的研究现状,为外科医生及乳腺癌患者手术方式的选择提供参考。方法 收集近年来国内外关于保守性乳腺切除联合乳房重建相关研究的文献并进行归纳总结。结果 目前保守性乳房切除术主要有保留乳头乳晕的乳房切除术、保留皮肤的乳房切除术及缩减皮肤的乳房切除术,这3种术式均安全、有效,手术并发症在可控范围内;联合乳房重建能获得较好的美容效果,能提高患者术后满意度及生存质量。结论 对乳腺癌患者进行充分的术前评估后,保守性乳房切除术为合适的乳腺癌患者提供了一种治疗选择,切除后根据患者乳房大小、下垂度及患者个人期望制定个体化重建方式,能使患者在治疗疾病的同时获得较高的生存质量。     

Radiation Therapy Following Postmastectomy Reconstruction: A Systematic Review

A lack of consistent data are available about optimizing cosmetic outcomes, reducing potential treatment-related toxicities, and defining important prognostic factors for women undergoing postmastectomy radiation therapy (PMRT) following breast reconstruction. A Medline search was conducted to summarize the latest data on the topic with a focus on both autologous and tissue expander/implant (E/I) reconstructions. Autologous tissue reconstructions (ATR) represent less than 20 % of all breast reconstructions and include several techniques. A multitude of small studies have suggested that ATR is associated with improved cosmetic outcomes and similar rates of complications compared with E/I reconstructions. With regards to ATRs, the addition of PMRT has been suggested but not definitively associated with a decrement in cosmetic outcome compared with patients not receiving radiation. Expander/implant-based reconstruction appears to be the most common form of breast reconstruction with large, prospective, and retrospective series demonstrating that 20–30 % of patients may require some type of revision/replacement with long-term follow-up based on large series from Memorial Sloan Kettering Cancer Center and the Cleveland Clinic. Whereas PMRT and the addition of regional irradiation has been traditionally associated with increased complications and worse outcomes with E/I reconstruction, recent data suggest that no difference in perioperative complications exists in patients receiving PMRT using modern techniques.     

Delayed autologous breast reconstruction after postmastectomy radiation therapy: is there an optimal time?

The optimal time for delayed autologous breast reconstruction after postmastectomy radiation therapy (PMRT) is unknown. Although most reconstructive surgeons recommend waiting for 6 months, this timing is arbitrary. A retrospective analysis was performed of 199 patients undergoing delayed autologous reconstruction; 100 patients had prior PMRT, whereas 99 patients had no previous radiation. Radiated patients had higher overall complications (40% vs. 20.2%, P = 0.0023), including wound dehiscence (11% vs. 3%, P = 0.049), and trended toward increased postsurgical infections (7% vs. 1%, P = 0.065). Logistic regression models of unequally distributed variables found radiation therapy to be the only independent risk factor for wound dehiscence (odds ratio, 3.97; P = 0.04). Mean follow-up for radiated and nonradiated patients was 33.3 months and 39.4 months, respectively. After PMRT, 17 patients were reconstructed within 6 months and 83 after 6 months. No significant differences in complications were observed between these groups. An alternate analysis examined 51 patients reconstructed within 12 months of PMRT and 49 patients reconstructed after; again, there were no differences in complications. As overall complications are similar in patients reconstructed early or late after PMRT, autologous breast reconstruction can potentially be performed earlier than is the current accepted practice.     

Postmastectomy radiotherapy: Indications and implications

BackgroundAlthough breast conservation surgery, when combined with radiotherapy, has been shown to provide excellent locoregional control for breast cancer, approximately one third of women with breast cancer require mastectomy. Many of these women are offered immediate reconstruction. Postmastectomy radiotherapy (PMRT) is indicated in some cases, but is associated with side-effects, including its impact on the reconstructed breast.ObjectiveTo review the pertinent issues surrounding PMRT, including patient selection for radiotherapy and the effect of radiotherapy on reconstructive decisions.MethodsA literature review was performed using the Medline database.ConclusionsPMRT is indicated in patients who are deemed to have a high risk of loco-regional recurrence. Although PMRT is strongly recommended for patients with four or more positive lymphnodes, other indications for PMRT remain controversial. Immediate reconstruction post mastectomy has been shown to have favorable outcomes. However, PMRT may increase the need for revision surgery post immediate reconstruction. There are few randomized trials looking at these key issues, and the evidence is largely derived from observational retrospective studies. Patients should be carefully counseled before a decision is made to proceed with immediate reconstruction, where there is a high chance that PMRT may be indicated.     

Accuracy of a multidisciplinary team-led discussion in predicting postmastectomy radiotherapy

Introduction

Immediate breast reconstruction (IBR) is performed increasingly following mastectomy for breast cancer. The literature suggests higher reconstructive failure and poorer cosmesis in the subgroup of patients receiving postmastectomy radiotherapy (PMRT) following IBR. We set out to determine the accuracy of a multidisciplinary team (MDT) discussion in predicting PMRT.

Methods

Preoperative MDT discussions were recorded prospectively over a 12-month period (from February 2011) in a symptomatic breast unit. The estimated need for PMRT was stratified into ‘PMRT not required’, ‘PMRT possibly required’, ‘PMRT probably required’ and ‘PMRT required’ groups.

Results

Of 156 referrals included in the study, 76 patients (49%) underwent mastectomy: 61 simple mastectomy, 10 skin sparing mastectomy (SSM) and delayed-immediate breast reconstruction, 3 SSM and implant-based IBR, and 2 mastectomy IBR with an autologous flap. The IBR rate was therefore 19.7%. The proportion of patients who received PMRT was 14% (3/21) in the ‘PMRT not required’, 30% (7/23) in the ‘PMRT possibly required’, 65% (9/14) in the ‘PMRT probably required’ and 94% (17/18) in the ‘PMRT required’ groups. Assigning a linear numerical score (1–4) to these groups (higher score representing greater likelihood of receiving PMRT), the predicted need for PMRT correlated with the proportion of patients who ultimately received PMRT (linear regression r²=0.98, p=0.01).

Conclusions

This study has examined the factors influencing MDT discussions regarding IBR, demonstrating that the MDT is reasonably accurate at predicting need for PMRT. Whether such accuracy is clinically adequate and/or reproducible across units is debatable.     

Does post-mastectomy radiation therapy worsen outcomes in immediate autologous breast flap reconstruction? A systematic review and meta-analysis

BackgroundThere is great uncertainty regarding the practice of immediate autologous breast reconstruction (IBR) when post-mastectomy radiotherapy (PMRT) is indicated. Plastic surgery units differ in their treatment protocols, with some recommending delayed breast reconstruction (DBR) following PMRT. IBR offers significant cosmetic and psychosocial benefits; however, the morbidity of flap exposure to radiation remains unclear.ObjectiveThe aim of this review was to comprehensively analyze the existing literature comparing autologous flaps exposed to PMRT and flaps with no radiation exposure.MethodsA comprehensive search in MEDLINE, EMBASE and CENTRAL databases was conducted in November 2020. Primary studies comparing IBR with and without adjuvant PMRT were assessed for the following primary outcomes: clinical complications, observer-reported outcomes and patient-reported satisfaction rates. Meta-analysis was performed to obtain pooled risk ratios of individual complications.ResultsTwenty-one articles involving 3817 patients were included. Meta-analysis of pooled data gave risk ratios for fat necrosis (RR = 1.91, p < 0.00001), secondary surgery (RR = 1.62, p = 0.03) and volume loss (RR = 8.16, p < 0.00001) favoring unirradiated flaps, but no significant difference was observed in all other reported complications. The no-PMRT group scored significantly higher in observer-reported measures. However, self-reported aesthetic and general satisfaction rates were similar between groups.ConclusionIBR should be offered after mastectomy to patients requiring PMRT. The higher risks of fat necrosis and contracture appear to be less clinically relevant as corroborated by positive scores from patients developing these complications. Preoperative and intraoperative measures should be taken to further optimize reconstruction and mitigate post-radiation sequel. Careful management of patients’ expectations is also imperative.Level of Evidence: Level III     

Radiation effects on the cosmetic outcomes of immediate and delayed autologous breast reconstruction: an argument about timing.

OBJECTIVE: To conduct a systematic review to gather the available evidence on the optimum timing of the radiotherapy in relation to autologous breast reconstruction. MATERIAL AND METHODS: The data was extracted from scientific databases, and a manual follow-up of references. The studies were selected which included at least 20 patients with any method of autologous breast reconstruction who were treated with adjuvant radiotherapy either before or after their reconstruction, and had addressed the effects of radiotherapy on the cosmetic outcome in their results. The principal outcome was cosmetic appearance. Secondary outcomes were immediate and delayed complications. RESULTS: We could not find any randomised controlled trial on this topic. Ten studies were included, most were retrospective, heterogeneous in terms of control groups, radiation doses, follow-up duration, and outcome measurements. Two studies included no control groups, and four studies compared the outcomes of patients with radiotherapy either before (n=3) or after (n=1) autologous breast reconstruction. The overall incidence of complications was increased in patients with radiotherapy in three out of these four studies. Only four studies directly compared the outcomes of patients who received radiotherapy before with patients who received radiotherapy after autologous breast reconstruction and two out of these reported worse outcomes associated with post-reconstruction radiotherapy. CONCLUSIONS: Despite the paucity of the published data, the current evidence suggests that the radiation has a deleterious effect on autologous flap reconstruction. Until better methods of radiation delivery can be devised to minimise the long term radiation sequelae in the irradiated tissue, delayed reconstruction seems to be a safe option in most of the cases. However, the findings from these studies should be interpreted with great caution before generalising from their results.     

Tracking the aesthetic outcomes of prosthetic breast reconstructions that have complications

BACKGROUND:

Aesthetic results following breast reconstruction have been shown to be a major contributor to patient satisfaction. While many presume that complications after reconstruction impact final aesthetic results, little data exist to substantiate this putative relationship.

OBJECTIVE:

To track and evaluate aesthetic outcomes following implant reconstructions with complications.

METHODS:

A chart review was conducted on a series of consecutive expander-implant breast reconstructions performed by the senior author between 2004 and 2012. Included patients completed their prosthetic reconstruction or converted to autologous methods and had a minimum follow-up period of 130 days. Four blinded members of the division of plastic surgery independently rated postoperative anterior photographs of patients’ breasts using a validated scoring scale with respect to five distinct aesthetic domains: breast mound volume, contour, placement, scarring and inframammary fold.

RESULTS:

Of the 172 patients who met the inclusion criteria, 36 experienced a complication. The tissue expander in one-half of these patients was salvaged and the remaining patients converted to autologous reconstruction. The average aesthetic scores for each domain did not differ significantly between patients who experienced a complication and retained their expander and those who did not experience a complication. Patients who converted to autologous tissue reconstruction after experiencing a complication had the highest aesthetic scores.

DISCUSSION:

The ability to obtain aesthetic results following a complication that were not statistically different from results in those without complications may reflect the surgeon’s refined attempt to salvage the initial implant reconstruction; in other circumstances, the improved cosmesis was achieved through conversion to an autologous tissue-based method.

CONCLUSION:

The present study quantitatively assessed the impact of complications on aesthetic outcomes following implant breast reconstruction. Continuance of prosthetic reconstruction and conversion to autologous reconstruction serve as viable options to obtain adequate aesthetic scores following a complication. Information gained from the present analysis will help manage patient expectations.     

Oncoplastic breast consortium recommendations for mastectomy and whole breast reconstruction in the setting of post-mastectomy radiation therapy

AimDemand for nipple- and skin- sparing mastectomy (NSM/SSM) with immediate breast reconstruction (BR) has increased at the same time as indications for post-mastectomy radiation therapy (PMRT) have broadened. The aim of the Oncoplastic Breast Consortium initiative was to address relevant questions arising with this clinically challenging scenario.MethodsA large global panel of oncologic, oncoplastic and reconstructive breast surgeons, patient advocates and radiation oncologists developed recommendations for clinical practice in an iterative process based on the principles of Delphi methodology.ResultsThe panel agreed that surgical technique for NSM/SSM should not be formally modified when PMRT is planned with preference for autologous over implant-based BR due to lower risk of long-term complications and support for immediate and delayed-immediate reconstructive approaches. Nevertheless, it was strongly believed that PMRT is not an absolute contraindication for implant-based or other types of BR, but no specific recommendations regarding implant positioning, use of mesh or timing were made due to absence of high-quality evidence. The panel endorsed use of patient-reported outcomes in clinical practice. It was acknowledged that the shape and size of reconstructed breasts can hinder radiotherapy planning and attention to details of PMRT techniques is important in determining aesthetic outcomes after immediate BR.ConclusionsThe panel endorsed the need for prospective, ideally randomised phase III studies and for surgical and radiation oncology teams to work together for determination of optimal sequencing and techniques for PMRT for each patient in the context of BR     

A comparison of patient-centered economic and clinical outcomes of post-mastectomy breast reconstruction between obese and non-obese patients

BackgroundThe objectives of this study were to compare, by patient obesity status, the contemporary utilization patterns of different reconstruction surgery types, understand postoperative complication profiles in the community setting, and analyze the financial impact on health care payers and patients.MethodsUsing data from the MarketScan Health Risk Assessment Database and Commercial Claims and Encounters Database, we identified breast cancer patients who received breast reconstruction surgery following mastectomy between 2009 and 2012. The Cochran-Armitage test was used to evaluate the utilization pattern of breast reconstruction surgery. Multivariable logistic regressions were used to estimate the association between obesity status and infectious, wound, and perfusion complications within one year of surgery. A generalized linear model was used to compare total, complication-related, and out-of-pocket costs.ResultsThe rate of TE/implant-based reconstruction increased significantly for non-obese patients but not for obese patients during the years analyzed, whereas autologous reconstruction decreased for both patient groups. Obesity was associated with higher odds of infectious, wound, and perfusion complications after TE/implant-based reconstruction, and higher odds of perfusion complications after autologous reconstruction. The adjusted total healthcare costs and out-of-pocket costs were similar for obese and non-obese patients for either type of breast reconstruction surgery.ConclusionsA greater likelihood of one-year complications arose from TE/implant-based vs autologous reconstruction surgery in obese patients. Given that out-of-pocket costs were independent of the type of reconstruction, greater emphasis should be placed on conveying the surgery-related complications to obese patients to aid in patient-based decision making with their plastic surgeons and oncologists.