保留乳头乳晕乳腺癌改良根治术后即刻扩展型背阔肌乳房再造术的临床应用

目的:探讨保留乳头乳晕乳腺癌改良根治术后即刻扩展型背阔肌乳房再造术的安全性与疗效。方法:回顾性分析蚌埠医学院第一附属医院肿瘤外科32例行保留乳头乳晕乳腺癌改良根治术后即刻扩展型背阔肌乳房再造术患者(观察组)和34例行传统乳腺癌改良根治术患者(对照组)临床资料,比较两组患者并发症、预后,并分析观察组重建乳房外形评分情况。结果:两组年龄、肿瘤大小、病理分期方面无统计学差异(均P0.05);观察组与对照组术后总并发症发生率差异无统计学意义(37.5%vs.32.4%,P0.05)。所有患者随访18~60个月,中位时间44个月,观察组局部复发2例,远处复发3例;对照组局部复发3例,远处转移3例,观察组与对照组3年无瘤生存率差异无统计学意义(87.5%vs.91.2%,P0.05)。观察组乳房外形评分优良率为90.6%。结论:保留乳头乳晕乳腺癌改良根治术后即刻扩展型背阔肌乳房再造术安全有效,重建的乳房外观满意,且不增加并发症与局部复发、远处转移风险。     

Skin-Sparing Mastectomy with Immediate Breast Reconstruction by a New Modification of Extended Latissimus Dorsi Myocutaneous Flap

Background  The introduction of skin-sparing mastectomy has revolutionized both breast cancer surgery and breast reconstruction. Latissimus dorsi myocutaneous flap is a versatile flap that is gaining renewed popularity with the development of flap modifications and the continued recognition of its reliability and safety. We report our results with a new modification of the extended latissimus dorsi flap after skin-sparing mastectomy for breast cancer. Methods  From January 2002 to January 2006, 140 patients of breast carcinoma had unilateral skin-sparing mastectomy and immediate breast reconstruction. A total of 132 cases of invasive duct carcinoma and eight cases of invasive lobular carcinoma are included. Age ranged from 27 to 53 (median, 40.5) years. Tumor stage was stage I in 22 cases, stage II in 100 cases, and stage III in 18 cases. We performed a new modification to the standard extended latissimus dorsi flap, which allowed us to obtain enough autologous tissue to reconstruct the relatively large breast of the Egyptian women without implant. The postoperative aesthetic results and donor side morbidity, including contour deformity and scaring, were examined. Results  We applied both an objective and subjective aesthetic result monitoring. Aesthetic grading results of breast reconstruction were excellent in 85, good in 42, fair in ten and poor in three cases. Both flap and donor site complications were minor. Patients were followed for a median of 32.4 (range, 12-48) months. During this period of follow-up, no episode of local or distant failure was observed. Conclusions  Skin-sparing mastectomy with immediate breast reconstruction using our new modification of extended latissimus dorsi flap allows single-stage, totally autologous reconstruction with satisfactory aesthetic results and low morbidity.     

背阔肌肌皮瓣联合假体在乳腺癌术后二期乳房再造中的应用

目的探讨背阔肌肌皮瓣联合假体植入在乳腺癌术后二期乳房再造术中的临床应用。方法 2009年至2013年,共8例乳腺癌术后年轻患者接受二期乳房再造手术。术前以排水法测定健侧乳房体积,根据患者健侧乳房形状、大小及背部组织情况,设计胸背部供区皮瓣,术中测量移植皮瓣的容积,然后根据健侧乳房和移植皮瓣的容积差,选择大小合适的乳房假体,将假体埋植于背阔肌-胸大肌后间隙,利用背阔肌肌皮瓣移植联合乳房硅胶假体进行二期乳房再造。结果本组患者术后随访6个月至4年,再造乳房外形较佳,效果满意,供区无明显并发症。结论对于年轻有生育要求的乳腺癌术后乳房缺失患者,健侧乳房较大,利用背阔肌肌皮瓣联合假体进行乳房再造,可取得良好的手术效果。     

乳癌根治一期乳房重建

报道1985年～1989年5月,为6例乳癌患者作根治术的同时,一期作带血管神经肌蒂背阔肌肌皮瓣移位重建乳房,全部取得成功。较详细介绍了手术设计及操作方法,讨论了在乳癌根治术同时行再造术的必要性,以及背阔肌肌皮瓣作为再造材料的优点。     

乳腺癌改良根治术同期乳房重建的安全性和患者满意度评价

目的观察乳腺癌改良根治术同期行背阔肌肌皮瓣乳房重建的临床效果,评价患者满意度。方法选择病理确诊的乳腺癌患者22例(重建组),行腺癌改良根治术并同期行背阔肌肌皮瓣乳房重建术;匹配同龄、同学历、同TNM肿瘤分期的非乳房重建患者22例作对照(对照组),以Harris标准评价重建乳房的美容效果。随访3年,观察癌组织局部复发转移情况;对患者术后6个月、12个月、24个月和36个月的满意度进行评价。结果两组3年均无肿瘤局部复发及远处转移。乳房重建组优、良、一般分别为14例、5例和3例,患者满意度高于对照组(P0.05),时间因素和分组因素无交互作用(P>0.05)。结论乳腺癌改良根治术同期行背阔肌肌皮瓣乳房重建,不但保证了肿瘤治疗的效果,而且患者的形体美,满意度高。     

乳腺癌全乳切除术后扩大背阔肌肌皮瓣乳房重建：附150例报告

目的：探讨改良根治术全乳切除联合一期扩大背阔肌肌皮瓣乳房再造术治疗乳腺癌的临床疗效。 方法：回顾性分析2008年3月—2013年3月行乳腺全切除的150例乳腺癌患者的临床资料,其中传统的改良根治术28例,保留皮肤的全乳切除术47例,保留乳头乳晕的全乳切除术75例,均同期行扩大背阔肌肌皮瓣乳房再造术。 结果：手术成功149例,失败1例。再造乳房外观评价“优良”率达91.27%（136/149）。术后发生乳头部分坏死4例,发生胸部皮肤挫伤、表皮脱落3例,未经特殊处理,自行愈合;出现背部血肿8例,其中6例经穿刺抽液愈合,1例经切除纤维囊愈合,1例经刮除窦道假膜愈合;切缘皮肤局部坏死2例,背部供区部分坏死2例,经二次手术愈合;移植物缺血坏死1例,给予切除处理。随访8~73个月（失访18例,失访前均无瘤生存）,骨转移2例,肺转移1例,锁骨上淋巴结转移1例,无局部复发患者。 结论：乳腺癌改良根治术乳腺全切除联合I期扩大背阔肌肌皮瓣乳房再造术,安全有效,尤其适用于中小体积乳房的患者。     

背阔肌皮瓣联合假体在乳腺癌患者Ⅰ期乳房重建中的临床应用

目的介绍背阔肌皮瓣联合假体应用于乳腺癌患者Ⅰ期乳房重建的临床经验。方法回顾性分析14例应用背阔肌皮瓣联合假体行乳腺癌术后Ⅰ期乳房重建病例的临床资料,其中患者平均年龄44.2(20~54)岁,Ⅰ期乳腺癌4例,Ⅱa期8例,Ⅱb期2例。经背部和腋部切口分别为6例和8例。结果手术后无皮瓣坏死;无伤口感染;供区血清肿5例(35.7%),均经穿刺抽液治愈。平均随访32.6(4~58)月,2例患者接受了放射治疗未发现不良后果,患者对再造乳房形态非常满意8例,满意5例,一般1例,无不满意患者,乳房美学评价按照Ueda标准均6分,优良率为100%。结论对于选择性的乳腺癌患者,乳房切除后背阔肌皮瓣联合假体Ⅰ期乳房重建是一种并发症少、手术效果良好的乳房重建方法 。     

早中期乳腺癌保留乳头乳晕改良根治术后离断背阔肌止点扩大肌皮瓣I期乳房再造术的临床效果

目的探讨早中期乳腺癌行保留乳头乳晕改良根治术后使用扩大背阔肌肌皮瓣I期乳房再造治疗的应用价值及临床效果。方法我院2009年11月至2012年10月期间收治的60例经临床穿刺活检病理明确诊断为早中期的乳腺癌患者按术式分为2组：乳房再造组（30例）,即保留乳头乳晕乳腺癌改良根治术后离断背阔肌止点扩大肌皮瓣I期乳房再造术;对照组（30例）,即行传统乳腺癌改良根治术。比较2组患者的术后并发症,近远期疗效,生活质量,复发转移情况。结果①对照组完全患侧乳房缺失;乳房再造组乳房再造术均获得成功,再造乳房美容效果评价优22例,良7例,一般1例。②2组患者术后皮下积液、皮瓣坏死及患肢活动受限情况比较差异无统计学意义（P〉0．05）;术后切口拆线时间、术区引流时间、住院时间及术后化疗开始时间差异均无统计学意义（P〉0．05）。③乳房再造组心理压力出现率及对第二性征不满意率明显低于对照组（P〈0．001）,乳房再造组社会交往适应率明显高于对照组（P〈0．001）。④2组患者随访12～38个月（平均25个月）,其中对照组有1例死亡,其余59例患者均未发现有局部复发和远处转移。结论从本组有限的数据初步看,乳腺癌根治术后离断背阔肌止点扩大肌皮瓣I期乳房再造术,可在根治肿瘤的基础上获得满意的乳房美容效果,使患者的生活质量明显提高,该术式术后并发症较少,不影响乳腺癌的术后辅助放化疗和近远期疗效。     

保留乳头乳晕复合体乳癌术后即时扩展型背阔肌肌皮瓣乳房再造

目的:探讨保留乳头乳晕复合体的乳腺癌改良根治术后行即时以扩展型背阔肌肌皮瓣行乳房再造的安全性和手术技巧。方法:28例早期乳腺癌患者行保留乳头乳晕复合体乳腺癌改良根治术,术后即刻使用扩展型背阔肌肌皮瓣再造乳房。术中改进:注意保护乳房皮肤的感觉神经、保留胸背神经及二级分支,采取皮瓣翻转法乳房塑型,行腋窝填塞和腋前皱襞的重建以及切取皮瓣的组织量大于切除的20%～50%腺体量等。结果:28例即时乳房再造全部获得成功。随访12～36个月,均生存,无局部复发,其中1例术后10个月骨转移,1例2年后肺转移;美学效果:优18例,良6例,一般2例,差2例;再造乳房皮肤的感觉、乳头的竖起功能存在,自然下垂,外形对称,腋窝饱满,患侧肢体运动范围较常规改良根治术明显增大。结论:对于选择合适的病例,保留乳头乳晕复合体的乳腺癌改良根治术后应用即时扩展型背阔肌肌皮瓣再造术安全、有效,术中几点合理的技术改进可以明显提高再造乳房的质量和自然度。     

乳房重建中应用背阔肌肌皮瓣适应证及技术原则

无论是延迟乳房重建还是即刻乳房重建,均可以应用背阔肌肌皮瓣来进行。它既可以单独使用,也可结合假体同时应用于乳房重建。对于乳房切除、腋窝淋巴结清扫术后局部缺损较大的病人,背阔肌肌皮瓣结合乳房假体的乳房重建手术是一种非常好的选择。对于因为腹部手术、腹部疾病等问题,不能采用腹直肌肌皮瓣进行乳房重建的病人,首选背阔肌肌皮瓣重建乳房。但如果不能排除胸背动脉、肩胛下动脉以及背阔肌损伤可能则应该避免采用背阔肌肌皮瓣乳房重建。术前应对背阔肌肌皮瓣进行全面评估及仔细设计,术中谨慎操作,注意避免发生术中及术后并发症。     

Brustrekonstruktion mit gestielten Lappen

It is important for women with breast cancer undergoing mastectomy to make an informed decision about the options for breast reconstruction and to be provided with information about the techniques, advantages and disadvantages. After modified radical mastectomy breast reconstruction involves replacement of breast skin and volume and after skin-sparing mastectomy only the volume must be reconstructed. The most commonly used surgical techniques are expander implant reconstruction, latissimus dorsi myocutaneous flaps with or without implants and the use of lower abdominal tissue. Currently, the pedicled transverse rectus abdominis myocutaneous (TRAM) flap is the standard method for autologous breast reconstruction after mastectomy and thoracic wall irradiation. In recent years microsurgical perforator flaps have gained in popularity because of the lower morbidity.     

Mastectomy scar histopathology of limited clinical value

This study assesses whether the routine submission of mastectomy scars for histologic examination at the time of delayed breast reconstruction is useful. A retrospective review was performed of all delayed breast reconstructions for breast cancer performed by a single surgeon over a 5-year period from January 2000 to December 2004. One hundred eighty-eight patients underwent delayed breast reconstruction during this period, and of these, 133 scars (1 patient had bilateral scars excised) were submitted for histology where the reconstruction was performed by either transversus rectus abdominus muscle flap (TRAM) or latissimus dorsi myocutaneous flap (LDF) +/- implant. Fifty-six patients had reconstruction performed by tissue expander through the inframammary crease where the original mastectomy scar was not excised and were excluded from the study. One mastectomy scar specimen showed a 2-mm suspicious area of invasive ductal carcinoma consistent with same histopathology at the time of mastectomy. This study corroborates evidence that it is questionable whether routine histopathology of mastectomy scar at the time of delayed breast reconstruction should not be a standard practice.     

Can Nipple-sparing Mastectomy and Immediate Breast Reconstruction with Modified Extended Latissimus Dorsi Muscular Flap Improve the Cosmetic and Functional Outcome among Patients with Breast Carcinoma?

Background Nipple–areola complex (NAC) preservation is a new revolution in breast cancer surgery and breast reconstruction, if reliability and safety are considered. The latissimus dorsi muscular flap is a versatile flap that is gaining renewed popularity for immediate breast reconstruction with development of modifications. We are introducing nipple-sparing mastectomy (NSM) for Egyptian patients with breast carcinoma and reporting our results with a new modification of the extended latissimus dorsi muscular flap. Methods Between July 2005 and August 2006; forty-one patients with stage I to III breast carcinoma had NSM and immediate breast reconstruction. We performed a new modification to the extended latissimus dorsi muscular flap that allowed us to obtain enough autologous tissue to reconstruct the breast without implant or back incision. The postoperative aesthetic results with specific view of the preserved NAC were evaluated. Results We applied both an objective and subjective aesthetic result to our monitoring. Aesthetic grading results of breast reconstruction were as follows: excellent in 31, good in 6, fair in 2, poor in 2. Both reconstructed breast and donor site complications were minor. Patients are followed for a median follow-up of 7.9 months (range: 4–11 months). In this short period of follow-up, no local recurrence or distant failure has been observed. Conclusions Nipple-sparing mastectomy with immediate breast reconstruction using modified extended latissimus dorsi muscular flap allows single-stage, totally autologous reconstruction with a satisfactory aesthetic result, low morbidity, and good quality of life.     

Bilateral breast reconstruction with the autologous latissimus dorsi flap (a retrospective study of 31 consecutive cases)

PURPOSE OF THE STUDY: The purpose of this study was to analyse the advantages, disadvantages and results of bilateral breast reconstruction by autologous latissimus dorsi flap. MATERIAL AND METHOD: Thirty-one two-stage consecutive bilateral breast reconstructions were performed by the same operator between 1993 and 2001. All the reconstructions, in immediate or delayed manner, were indicated after radical or skin sparing mastectomy for breast cancer. We used the autologous latissimus dorsi flap for all cases. The reconstruction of the second breast was always delayed of a few months to avoid back's complications. We reviewed the charts of these patients retrospectively. Preoperative data, postoperative complications, dorsal seroma occurrence, morphological results and patient's satisfaction were evaluated. Median follow-up was 22 months. RESULTS: The results confirm the procedure's reliability. Comparative rates of postoperative complications are not significantly different between first and contralateral breast reconstruction. Functional after-effects of bilateral latissimus dorsi harvesting are moderate. The aesthetics results have been judged as very good in 84% of cases and good in 16%. The satisfaction rate of the patients is high: 90,3% are pleased, 6,5% are satisfied and 3,2% are moderately satisfied. CONCLUSION: The autologous latissimus dorsi flap allows a two-stage bilateral breast reconstruction. This procedure is not indicated for simultaneous bilateral breast reconstruction; it is the main drawback of this technique. So we believe that this procedure is an excellent alternative in all the indications of sequential bilateral breast reconstructions.     

Clinical studies on reconstruction procedure of total layer chest wall resection

The results of clinical studies on 16 reconstruction procedure after total layer chest wall resection in 14 cases of malignant tumor of the chest wall were reported. The 14 cases consisted of two cases with recurrent primary chest wall tumor, two cases of primary breast cancer, seven cases of recurrent breast cancer, and others. The reconstruction procedure after total layer chest wall resection was conducted using only various myocutaneous flaps (eight cases using latissimus dorsi of the resected side, three cases using the abdominitis of the resected side, three cases using latissimus dorsi of the non-resected side, and two cases using a pectoralis major myocutaneous flap of the non-resected side). reconstruction only using a myocutaneous flap proved to be satisfactory for preventing early stage postoperative respiratory distress and maintaining the stability of the chest wall and respiratory function during prolonged observation. Namely, use of myocutaneous flap is the best approach of reconstruction the chest wall after total layer chest wall resection. We confirmed that reconstruction with latissimus dorsi myocutaneous free flap of the non-resected side with microvascular anastomosis of thoracodorsal vessels was useful for posterior chest wall tumors invading the latissimus dorsi muscle. Also, our results demonstrated the insertion of an omental flap under the myocutaneous flap was useful for cases with secondary chest wall infection or vascular damage caused by preoperative high dose irradiation.     

乳癌术后的乳房再造

目的 探索乳癌根治术后3种不同乳房再造方法的最佳外观效果.方法 (1)乳癌切除Ⅱ期行扩大背阔肌肌皮瓣乳房再造.(2)乳癌切除即时腹直肌横行皮瓣乳房再造.(3)保留胸大肌乳癌切除,Ⅱ期乳房假体置入并行乳头、乳晕再造;对不保留胸大肌乳癌切除者,Ⅱ期皮肤扩张后乳房假体置入再造.结果 共计治疗12例,10例皮瓣全部成活,外观形态满意,优良率较高.2例不满意,其中1例扩张后,因局部皮肤皮下组织较薄,扩张程度不足,勉强置入140 ml乳房假体,外观形态明显偏小;另1例腹直肌肌皮瓣大部分坏死,经再次修复创面愈合,乳房再造失败.结论 乳房再造的方法选择得当,可使乳房形态更为自然.普通背阔肌皮瓣改用扩大的背阔肌皮瓣后,软组织量比前者增加1倍以上,使再造乳房与对侧相近.假体置入乳房成形后,Ⅱ期行单蒂乳头、乳晕再造,可给患者以心理和外观上的更多抚慰.     

Use of the extended V-Y latissimus dorsi myocutaneous flap for chest wall reconstruction in locally advanced breast cancer

The extended V-Y latissimus dorsi myocutaneous flap described by Micali and Carramaschi provides an innovative method of closing large anterior chest defects after resection of breast cancer. The technique provides robust chest wall coverage that is able to withstand immediate postoperative radiotherapy. The aim of this article is to confirm the usefulness of the flap's design and describe modifications to the technique. The modifications to technique include: a curvilinear design that recruited more skin for closure in patients with wounds extending laterally or superiorly, routine transposition of latissimus dorsi insertion inferio-medially onto the chest wall to maximize pedicle reach, and the use of small split skin grafts or delayed primary closure if there was tension in closing. Twelve patients who underwent resection of locally advanced breast cancer had immediate chest wall reconstruction with the extended V-Y latissimus dorsi musculocutaneous flap. The V to Y design of the flap's cutaneous island allowed primary closure of chest wound and donor defect. There were no instances of chest wound dehiscence. The chest wounds healed, allowing patients to undergo adjuvant radiotherapy in a mean time interval of 6 weeks after surgery.     

扩大背阔肌肌皮瓣乳房再造术后供区并发症的探讨

目的 探讨扩大背阔肌肌皮瓣再造乳房术后供区的并发症及其防治.方法 自1999年5月至2004年11月,为88例患者采用扩大背阔肌肌皮瓣再造乳房后,从主观和客观两方面分析供区并发症的发生原因以及术后功能情况的评估.结果 术后1例血肿,7例血清肿（其中2例有包囊形成）,5例轻度皮缘表皮脱落,1例干性皮肤坏死,2例翼状肩,无感染和瘢痕增生.术后功能无明显受限,不影响日常生活.结论 扩大背阔肌肌皮瓣乳房再造术后并发症主要是血清肿,严重并发症少,并可以防止或减少,患者容易接受,是值得在东方人中推广使用的乳房再造方法.     

胸大肌肌瓣转移术预防乳腺癌术后上肢淋巴水肿的临床研究

目的 探讨胸大肌肌瓣转移术对乳腺癌改良根治术后患侧上肢淋巴水肿的预防效果。方法 自2013年9月至2014年6月,将68例乳腺癌患者分成2组,35例行乳腺癌改良根治术+胸大肌肌瓣转移术(干预组),33例单纯行乳腺癌改良根治术(对照组),术后随访观察,分别在术后2周、1个月、3个月、6个月和9个月测量双侧臂围,判断有无上肢淋巴水肿的发生及程度。结果 随访结果表明,干预组和对照组相比,术后患侧上肢淋巴水肿发生率明显减少,差异具有统计学意义(P<0.05)。结论 乳腺癌改良根治术后行胸大肌肌瓣转移术,可显著减少乳腺癌术后患侧上肢淋巴水肿的发生率,提高患者的生活质量。