超声影像决定巨乳缩小术蒂的设计

背景与目的游离乳头移植法进行乳房缩小手术存在诸多弊端,例如乳头敏感度下降、泌乳功能丧失和勃起功能丧失等.为了避免上述风险,作者介绍一种以患者为基础的乳房缩小技术,依靠彩色多普勒超声仪来判断乳头-乳晕复合体的主要供应血管,然后根据供应血管的情况来设计真皮腺体蒂.方法本组共16例巨乳症患者,平均年龄41岁(23～60岁),术前使用5～13 MHz线阵探头多普勒超声仪来探明乳头-乳晕复合体的主要供应血管并根据其位置来设计蒂的保留,可选择上内侧蒂、上外侧蒂或内外侧蒂来完成乳房缩小手术.结果采用不同术式,保留胸廓内动脉穿支和胸外侧动脉穿支行乳房缩小手术.未发生乳头乳晕坏死.平均每侧乳房切除组织1795g(1320～2280g).结论使用超声检查进行个性化蒂的设计来治疗重度乳房肥大,而不是一概采用标准的设计方案,超声检查技术在治疗重度乳房肥大时可以作为外科医师的"向导".     

女性乳房神经分布解剖研究

目的：研究乳房的神经来源、走向及分布,为乳房整形美容手术提供依据,方法：对7具尸体13例乳房进行大体与显微解剖,并对乳头乳晕区神经分布进行组织学研究。结果：第2－6肋间神经的外侧皮支与前皮以都到达并支配乳房,未发现锁骨上神经分支到达乳房。肋间神经支分深、浅两支进入乳房、,走向呈“立体发散”模式到达乳房腺体及皮肤。乳头和乳晕区的神经主要来自于第3－5肋间神经的外侧皮支与前皮支,以第4肋间神经占主导地位,有少量神经伴随乳腺导管走行到达乳头。结论：乳房、乳头和乳晕的神经支配丰富且存在个体差异。     

乳房神经血管解剖学研究及在乳房缩小成形术中的意义

目的　探讨乳房的血供模式和神经支配走向 ,寻找适合各型乳房肥大的短小瘢痕乳房缩小成形术术式。方法　应用血管铸型、标本透明技术和大体解剖对 12具成年女性尸体的胸壁乳房血供模式和乳房的神经支配进行研究 ,并设计出改良的双环形切口乳房缩小成形术 ,用于 2 8例乳房肥大患者。结果　成年女性前胸壁软组织乳房或为两层血管构筑或为三层血管构筑 ,各层间均通过垂直穿支形成吻合并首先在胸肌筋膜表面形成致密的血管网 ,这些垂直穿支在乳房下部粗大 ,上部细小。乳头乳晕的神经支配以第 4肋间神经外侧皮支的深支为主 ,在下垂乳房于腺体内呈S形走行。 2 8例患者行乳房缩小成形术后外形满意 ,乳头乳晕完全成活 ,仅 1只乳房感觉减退或消失。结论　改良的双环形切口乳房缩小成形术是较为理想的术式 ,除具有原术式瘢痕不明显、乳房突出度好、效果持久等优点外 ,还最大限度地保留了剩余腺体的血供和乳头乳晕的神经支配     

动态增强磁共振成像在评估女性乳房乳头乳晕血供的应用

目的探究动态增强磁共振成像(DCE-MRI)用于评估女性乳房乳头乳晕血供特点的可行性,为乳房整形手术提供乳头乳晕的血供参考。方法从2012年3月至2019年10月华中科技大学同济医学院附属同济医院影像数据库中收集女性乳腺DCE-MRI图像资料,选择未发现肿物的正常乳房的DCE-MRI图像进行研究。在西门子工作站将患者乳腺DCE-MRI图像通过图像减影获取乳房血管图像,分别对轴位、冠状位和矢状位的最大密度投影(MIP)图像进行评估,结合三维MIP图像识别所有供应乳头乳晕的血管。乳头乳晕的血供被划分为内上、内侧、内下、外上、外侧、外下、中央、上方和下方9个象限,对各个象限血管进行统计和分析,并测量血管至乳房皮肤表面投影的最大距离。采用SPSS 19.0软件进行统计分析,通过卡方检验分别比较左侧与右侧乳房的乳头乳晕复合体(NAC)血供象限分布构成比。计算血管到皮肤距离的平均值、标准差及95%置信区间,通过方差分析比较各象限血管至皮肤距离的差异。P<0.05为差异具有统计学意义。结果共收集到245例患者490只女性乳房DCE-MRI图像,其中97例患者97只乳房发现有乳腺肿物,其余393只为正常乳房(97例单侧乳房、148例双侧乳房),将其作为研究对象。患者年龄23~72岁,平均43.7岁。393只乳房(左侧200只、右侧193只)共发现有637条(左侧311条、右侧326条)乳头乳晕供应血管。在637条血管中,内上象限269条(42.2%),外上180条 (28.3%),内侧57条(8.9%),下方37条(5.8%),中央30条(4.7%),内下25条(3.9%),外下25条(3.9%),上方11条(1.7%),外侧3条(0.5%)。卡方检验表明左侧乳房和右侧乳房在NAC血供象限分布构成比差异无统计学意义(χ2 =6.4,P=0.602)。除中央象限血管以外,所有血管到皮肤表面投影最大距离的平均值为0.91 cm, 95%置信区间为0.86~0.96 cm。方差分析表明各象限供血血管到皮肤投影的最大距离,差异有统计学意义(F=11.4,P<0.001)。结论 DCE-MRI可以清晰地显示乳头乳晕的血供来源。乳头乳晕血供主要来源于内上象限和外上象限的血管,血管在皮下约1 cm深度走行。     

应用对侧胸廓内动脉穿支皮瓣修复乳腺癌术后高位放射性溃疡

目的探讨适合老年女性乳腺癌根治术后胸部高位放射性溃疡的整复方法。方法自2006年1月以来,共收治12例老年女性乳腺癌术后胸部高位放射性溃疡患者,年龄55~79岁,溃疡面积为8 cm×10 cm~13 cm×15 cm,最深者伴有肋骨和胸骨坏死,采用对侧胸廓内动脉第2~4肋间前穿支岛状皮瓣进行整复,皮瓣面积为10 cm×11 cm~14 cm×16 cm,伴有肋骨和胸骨坏死者同期清除死骨,并行钛板坚强内固定。结果 12例胸廓内动脉肋间前穿支岛状皮瓣均完全成活,随访6个月至4年,无再次溃疡发生。结论利用健侧乳房松垂皮肤形成的胸廓内动脉肋间前穿支岛状皮瓣血供恒定,且修复老年女性乳腺癌术后胸部高位放射性溃疡的效果良好,术区损伤小,是一种比较适宜的方法。     

女性乳头乳晕相关神经的解剖学研究

最近的研究表明[1],女性乳头-乳晕复合体的感觉对于泌乳、乳头勃起以及性体验都有特别重要的作用.乳房缩小术及一些经乳晕切口的手术容易损伤乳房的皮神经,造成乳头、乳晕感觉减退或丧失.因此.清晰地了解支配乳头-乳晕复合体的神经及其走行,对于合理应用外科技术,最大限度地保留乳头、乳晕的感觉是非常重要的.大部分学者认为,乳头、乳晕接受肋间神经前皮支和外侧皮支的共同支配,但对于具体哪一肋间神经起主要作用及其走行,则缺乏统一认识.     

早期乳腺癌经皮下乳腺切除假体乳房重建术后不同切口的效果比较

目的:探讨保留乳头乳晕复合体经皮下腺体切除即刻假体乳房重建术不同切口的临床效果。方法:回顾性分析2013年6月至2020年12月在首都医科大学附属北京同仁医院乳腺中心完成保留乳头乳晕复合体腺体切除即刻乳房重建术的92例患者的临床资料。患者均为女性,年龄（42.0±7.5）岁（范围：27~64岁）,原发肿瘤0期12例,Ⅰ...     

保留乳腺横膈内上蒂垂直切口瘢痕乳房缩小术

目的 探讨保留乳腺横膈内上蒂垂直切口瘢痕乳房缩小术的临床效果.方法 采用Lejour穹窿顶式手术设计,切除乳房下方多余的皮肤、腺体,将乳头和乳晕以内上方真皮、腺体组织蒂抬高到正常位置,术中保护乳腺中隔神经、血管蒂.采用不吸收缝线缝合乳房下极腺体,适度修薄乳房下部皮肤,以便于皮肤回缩,减轻瘢痕.结果 共行手术27例,53侧乳房,其中1例为单侧乳房缩小术,手术效果满意,乳房形态良好.术后6例8侧乳房切口部分裂开,均经换药后愈合,无1例发生乳头、乳晕坏死.结论 保留乳腺横膈的内上蒂垂直切口瘢痕巨乳缩小术效果良好,提高了乳头、乳晕移位的安全性.     

下腹壁横行腹直肌肌皮瓣及腹壁下动脉穿支皮瓣乳房再造的相关肋间神经解剖学研究

目的　为开展保留感觉神经和部分腹直肌功能的下腹壁横行腹直肌肌皮瓣 (TRAM皮瓣 )及腹壁下动脉穿支皮瓣 (DIEP皮瓣 )乳房再造手术方法提供解剖学依据。方法　对 9具 18侧 10 %甲醛溶液防腐固定的成年女尸腹前外侧壁进行大体及显微解剖 ,观察T8～T12 肋间神经的走行及分布 ,重点解剖腹直肌区域内肋间神经分支。在 15例DIEP皮瓣乳房再造术中 ,观察肋间神经在腹直肌内的走行分布特点及其与腹壁下血管穿支的关系。结果　肋间神经在腹直肌外侧 1/3区域内穿入腹直肌 ,其运动支在腹直肌内有交通支形成 ,相邻神经可重叠支配节段性腹直肌。感觉神经支分为内侧穿支和外侧穿支 ,与腹壁下血管穿支形成血管神经束进入皮下组织。纯感觉神经蒂长为 (2 7.6± 12 .2 )mm。结论　在应用TRAM皮瓣和DIEP皮瓣进行乳房再造时 ,可以保留感觉神经蒂进行神经吻合以恢复乳房感觉功能 ;而在切取TRAM皮瓣时 ,保留外侧 1/3腹直肌不会导致术后肌肉失神经萎缩。     

颈胸部真皮下血管网皮瓣的血供特点及临床应用

应用血管内带色乳胶灌注显微镜下解剖和组织切片直接透明方法对４２例成人颈胸区皮肤和皮下组织血管分布情况进行了观察。该区血供来源于如下皮动脉：胸锁乳突肌前、后缘支、乳突前后缘支、胸锁乳突肌穿支、颈横动脉皮支、胸肩峰动脉皮支和一、二肋间穿支。这些皮支在真皮下互相连接成网,通过血管网使单个皮动脉的供血区域大大扩展,远远超过解剖学分布范围。在组织切片上可见三层水平血管网：乳头下层血管网、真皮下血管网和皮下血管网。该区皮下血管网位置表浅,真皮下血管网密集分布,在皮瓣血液重新分配中起重要作用。应用颈胸部真皮下血管网皮瓣修复１２例面颈部不同原因引起皮肤缺损病人,除２例皮瓣尖端少量皮肤呈点状坏死外,均成活良好。     

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.     

Reduction mammaplasty with the modified round block technique in Chinese patients and its anatomy study

Background: Although reduction mammaplasty is one of the most common procedures in plastic surgery, it is associated with some serious complications, especially in cases of severe hypertrophy or advanced ptosis, including necrosis of the nipple and areola, absence of normal sensation of the nipple-areolar complex, and loss of lactational function for future nursing. A thorough understanding of the breast anatomy is vital for successful reduction mammaplasty. This article describes the blood supply and innervation of the breasts, and introduces a modified round block technique for reduction mammaplasty based on this anatomy.

Methods: Six adult female cadavers were used to assess the vasculature of the anterior thorax and the nerve distribution of the breasts according to vascular perfusion and autopsy. Based on this anatomical study, a modified round block technique was designed for reduction mammaplasty, which was performed in 40 Chinese patients with breast hypertrophy.

Results: Würinger’s horizontal septum was observed in all six cadavers. In the superficial layer, the main sources of blood are the second and third intercostal perforating branches of the internal thoracic artery, which run along the medial ligaments, and the branches of the lateral thoracic artery, which run along the lateral ligaments. In the deep layer, the main sources of blood are the fourth and fifth intercostal artery perforators, which run along Würinger’s horizontal septum. Innervation of the nipple-areolar complex is achieved mainly by the lateral branches of the fourth intercostal nerve, which also run along Würinger’s horizontal septum toward the nipple-areolar complex. The 40 patients with breast hypertrophy underwent successful reduction mammaplasty using our modified round block technique, except for one case, which developed necrosis of the nipple-areolar complex.

Conclusions: Reduction mammaplasty using our modified round block technique can maximally preserve the blood supply to the remaining gland as well as the innervation to the nipple-areolar complex, while maintaining the advantages of the traditional technique, such as an invisible scar and good projection.     

Breast Shaping by an Isolated Tissue Flap

Breast reshaping surgery for tuberous breast, breast reduction, and mastopexy procedures aim to keep the gained shape for a long time. In breast reduction, the surgeon must avoid loss of fullness in the upper pole, descent of the breast mass known as secondary dropout, and relapsed shape of the repaired tuberous breasts. As described in their clinical report, the authors use a caudally based thoracic wall flap to avoid these problems. The blood supply to the breast comes from two main sources: the mammary internal and lateral arteries. Because of vessels constantly perforating the pectoralis major muscle, it is possible to isolate a caudally based thoracic wall flap. These vessels originate from intercostal arteries as anteromedial intercostal perforators, and from the thoracoacromial artery as in the skin paddle of the pectoralis major muscle flap. This flap is long enough to reach every part of the breast where it is needed. Between January 2002 and June 2005, 64 patients underwent procedures in which the caudally based thoracic wall flap was used.     

Preservation of lateral thoracic artery to improve vascular supply of distal skin without compromising pedicle length in harvesting pectoralis major myocutaneous flap.

The pectoralis major myocutaneous (PM) flap is supplied by three arterial systems. The lower chest skin of the PM flap is mainly supplied by the branches of lateral thoracic artery and internal mammary artery. The conventional harvesting technique for head and neck reconstruction utilizes single arterial supply from the pectoral branch of thoracoacromial artery. The distal skin island of PM flap is therefore compromised and requires indirect blood supply by communicating vessels. In harvesting the PM flap, the pectoralis minor muscle is divided to preserve the lateral thoracic artery and its blood supply to the lateral distal skin island of PM flap without compromising the pedicle length for head and neck reconstruction. Six PM flaps were harvested for reconstruction of head and neck defects with preservation of both the pectoral artery and lateral thoracic artery. The focal pint of swing of all six flaps was at the same point just below the mid-point of clavicle for both pectoral artery and lateral thoracic artery. The flaps can reach the oral cavity, tonsil or hypopharynx without limitation and there is no flap necrosis. In conclusion, the lateral thoracic artery can be preserved without compromising the pedicle length of PM flap. It is a recommended technique to improve the blood supply to the distal skin of PM flap.     

Breast deformities: Anatomical and physiological cosiderations in plastic repair

Fixation of the breast is provided by the skin through multiple fibrous prolongations (Cooper's Ligament) into the gland and by the retro-mammary fascia which provides a suspensory ligament attached to the clavicula. A marked increase in the weight of the breast, from any cause, overtaxes this apparatus and produces ptosis.In mammary reconstruction, the transposed gland should be firmly attached to the pectoral fascia to simulate normal fixation. This is done by means of a circular row of non-absorbable sutures, which must not be permitted to involve large amounts of gland or fat.In reducing the gland, the central portion should be left intact to preserve the blood supply to the nipple and to retain such function as exists in the main central ducts. In glandular hypertrophy of the breast, a rare condition bordering on malignancy, the entire breast gland should be removed.Circulation in the breast is derived from: (1) the thoracic lateral, which supplies the external half and skin; (2) the internal mammary, which is the principal source of supply of the internal half, including the central portion of the gland and the nipple; and (3) several perforant branches of the intercostal arteries which also supply the deep and central portions of the gland.There is little anastomosis between these, so the main blood supply must be carefully preserved in each part.Since the thoracic lateral does not supply the nipple, the large amounts of glandular structure may be removed from the external quadrant without impairing the “take” of the transposed nipple. Great care must be taken in the excision of excessive fat and glandular structures in the area of the nipple and areola. Although the circular incision in the areola does not endanger the blood supply it should be superficial so as not to injure the underlying circular muscle fibers or interfere with the surrounding vascular plexus.As the blood supply comes through the deep portion of the gland, there is always risk of interfering with the blood supply when large quantities of fat and glandular tissue must be removed. The author employs a two stage procedure to minimize this risk. The nipple is transposed with most of the blood supply preserved and secondary resection is postponed until after the “take” of the central portion of the gland is complete.     

肝外供血动脉栓塞在巨块型肝癌治疗中的价值

目的探讨经导管肝外供血动脉栓塞在治疗巨块型肝癌中的价值。方法对35例巨块型肝癌,首次行经导管肝动脉化疗栓塞术（TACE）,第2次及其后在肝动脉TACE基础上加行经右侧胸廓内动脉、右侧肋间动脉侧支供血动脉栓塞术。结果本组35例巨块型肝癌患者,发现肝外侧支49支,对46支使用微导管进行栓塞治疗,3支行超选择灌注化疗。初次TACE治疗时肝外血供多有膈下动脉参与,治疗过程中,随着肿瘤的增大或肝动脉的闭塞,胸廓内动脉、肋间动脉、胰十二支肠动脉弓等血管有可能参与。结论对肝外侧支血管应用微导管超选择栓塞或灌注化疗均能加强TACE在巨块型肝癌治疗中的作用,提高患者带瘤生存期。     

胸背动脉肌皮穿支皮瓣的解剖学研究与临床意义

目的探讨背阔肌肌皮穿支皮瓣的解剖学基础及临床应用的可行性。方法①在15具（30侧）防腐成人尸体标本上,对背阔肌及其主要血供进行巨微解剖学观察。②对1具（2侧）防腐成人尸体标本作背阔肌肌皮穿支皮瓣及肌瓣与穿支肌皮瓣分离的共蒂“扇形”瓣模拟手术。结果①在32侧标本中,共发现血管外径大于0．5mm的肌皮穿支102支,其中来自胸背动脉内侧支的穿支数为56支（占55％）,来自胸背动脉外侧支的穿支数为46支（占45％）。每侧标本内侧支平均发出1．9支（在1-3支之间变化）,外侧支平均发出1．8支（在1-3支之间变化）。②胸背动脉内、外侧支的肌皮穿支外径大于0．5mm的穿支血管主要集中在距神经血管窗下约8．5cm（变化在6．4-9．2cm之间）范围内。结论胸背动脉的肌皮穿支血管位置恒定,管径粗,蒂长,适宜制作成肌皮穿支肌皮瓣或“扇形”瓣。     

中晚期乳腺癌的血供特点及术前DSA造影下超选择性动脉插管灌注化疗栓塞的临床分析

目的 总结中晚期乳腺癌的血液供应来源和特点以及探索术前DSA造影下超选择性动脉插管灌注化疗栓塞的方法、疗效及临床应用价值.方法 选取我院2007年2月至2011年10月期间经穿刺活检病理证实的中晚期乳腺癌患者共60例,采用Seldinger方法,经股动脉穿刺插管后在DSA造影下明确肿瘤供血动脉分布,然后分别超选择性插管于靶血管内,将吡柔比星60 mg+紫杉醇120 mg二联化疗药物缓慢注入靶血管内,实施介入灌注化疗,最后使用明胶海绵颗粒栓塞肿瘤供血动脉.结果 60例患者经DSA造影共发现112条明确的供血动脉,其中单支供血8例;多支供血52例,主要以胸外侧动脉和(或)胸廓内动脉供血为主.完全缓解率为25.0％(15/60),部分缓解率为73.3％ (44/60),稳定率为1.7％ (1/60),无进展病例,总有效率为98.3％ (59/60).中位缓解期19个月,中位生存期40个月.结论 乳腺癌原发肿瘤的位置与供血动脉密切相关,肿瘤位于乳腺外侧主要由胸外侧动脉主导供血,肿瘤位于乳腺内侧主要由胸廓内动脉主导供血.乳腺癌术前DSA造影下超选择性供血动脉插管、靶血管区域实施灌注化疗和明胶海绵颗粒栓塞,可明显提高乳腺癌新辅助化疗的疗效、远期生存率及介入化疗栓塞治疗的针对性.     

The vascular territories of the anterior chest wall

A series of 31 fresh cadaver injection, dissection and radiographic studies were undertaken to define the vascular architecture of the anterior chest wall and to correlate the findings of previous writers in this area. The findings confirmed that the dominant supply to this region is from the internal thoracic artery which interconnects in all layers with the posterior intercostals, the lateral thoracic, the acromio-thoracic and the transverse cervical arteries. The dominant cutaneous perforators of these vessels are concentrated around the perimeter of the pectoralis major muscle, the costal margin and over the interdigitations of the serratus anterior muscle in the mid-axillary line. The clinical significance of these findings is discussed with particular reference to the design of various breast reduction procedures and the planning of flaps in this area. Of special note is the observation that the concentration of large perforators which exists along the inframammary crease arises from the anterior intercostal vessels in the fifth and sixth intercostal spaces.