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.     

乳腺癌切除术后扩张法即刻分期乳房再造术

目的 探讨于不去皮的乳腺癌切除术后以扩张法为媒介行即刻分期乳房再造术,以简化手术操作方法,有利于放疗的进行.方法 乳房再造分两期完成:Ⅰ期在乳房切除同时,于胸大肌后间隙置入圆形扩张器,并于术后4～12周扩张至满意体积;Ⅱ期手术取出扩张器后换置硅凝胶乳房假体,或行背阔肌肌皮瓣+硅凝胶乳房假体置入,或单纯扩大背阔肌肌皮瓣转移,或单纯腹壁下动脉穿支(DIEP)皮瓣转移完成乳房再造.结果 采用该技术进行即刻分期乳房再造术34例,平均完成乳房再造共需时间5.5个月.术后无假体外露、皮瓣坏死等并发症出现.术后随访6～18个月,患者对手术效果满意率97.1％.结论 即刻分期乳房再造,简化了即刻Ⅰ期再造的手术难度,避免了术后放疗对乳房假体的影响,无需修补胸部皮肤缺损,因而避免了乳房表面的“补丁”样形象,是一项理想的即刻乳房再造方法.     

乳癌术后不同乳房再造术式的临床应用

目的探讨适合乳癌术后各种乳房再造术式的适应证。方法对我院2003至2005年收治的44例、45只乳癌术后乳房再造的患者,根据不同情况分别采用扩张器/假体置入(5只)、背阔肌肌皮瓣 假体置入(13只)、背阔肌肌皮瓣(3只)、DIEP皮瓣(6只)、单蒂TRAM瓣(10只)及劈开的双蒂TRAM瓣(8只)等方法进行乳房再造,分析各手术方法的适应证。结果应用皮瓣乳房再造40只,皮瓣全部成活;1只应用扩张器/假体乳房再造术后,注射壶部表皮坏死;1只应用背阔肌 假体乳房再造术后半年出现假体破裂伴局部感染;1只应用DIEP乳房再造术后,出现皮瓣下积液;2只部分皮瓣坏死。术后随访3个月至半年,医生及患者对乳房形态均较满意。所有应用腹部皮瓣的患者均无腹壁疝发生。结论6种乳房再造技术基本满足了我国女性乳癌术后各个时期各种条件再造乳房的要求,整形外科技术的改进以及新材料的应用扩大了乳房再造的适应证。     

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。     

应用背阔肌与胸大肌联合肌瓣及假体置入即刻乳房再造

目的探讨经乳房外侧弧形切口皮下乳腺切除术后,带蒂转移背阔肌肌瓣,与胸大肌肌瓣形成联合肌瓣覆盖乳房假体,进行即刻乳房再造术的治疗效果。方法选择临床分期为Ⅰ期或Ⅱ期．肿瘤未侵及皮肤和胸肌的乳腺癌患者共30例,经乳房外侧弧形切口皮下切除乳腺腺体并清扫腋窝淋巴结,利用同一切口,切取背阔肌肌瓣带蒂转移,分离胸大肌下间隙,切断胸大肌下缘与胸壁附着处直至胸骨边缘,将转移的背阔肌肌瓣与胸大肌断缘缝合,组成联合肌瓣,形成宽大的包裹假体的腔隙．置入假体。结果30例再造乳房外形及手感良好,其中优22例（73．3％）,良8例（26．7％）。术后所有患者均随访半年以上,均无瘤生存。结论再造乳房形态美观,能够置入较大的假体,不增加背部的切口,适合于无淋巴结转移、对侧乳房无明显下垂的早期青年乳腺癌患者的即刻乳房再造。     

乳腺癌切除术后乳房再造

目的 探讨乳腺癌切除术后乳房再造的方法及时间.方法 总结30例不符合保乳条件的乳腺癌病例,乳房切除术后假体置人乳房再造16例,下腹部横行腹直肌肌皮瓣(TRAM瓣)乳房再造10例,背阔肌肌皮瓣乳房再造4例.其中即刻乳房再造27例,延期乳房再造3例.结果 16例假体置入乳房再造术后外观评价均为良,未出现术后并发症.10例TRAM瓣乳房再造术后发生皮瓣部分坏死2例,腹壁疝1例,术后外观评价7例为良.2例为较好,1例为差.4例背阔肌肌皮瓣再造术后外观评价为良.结论 乳房再造术是乳腺癌综合治疗不可忽视一部分,对于有强烈的保乳愿望,而又不符合保乳条件的患者,乳房再造术是一种较好的选择.即刻乳房再造优于延迟乳房再造.乳房再造的方法选择要因人而异.局部晚期乳腺癌患者可以选择性进行即刻乳房再造术.     

扩张后背阔肌肌皮瓣修复乳房瘢痕挛缩

目的探讨应用扩张后背阔肌皮瓣修复乳房瘢痕挛缩的手术方法。方法扩张I期手术切口选择在腋前线,将扩张器置入背阔肌深层,定期注水至超量扩张;Ⅱ期手术将乳房挛缩的瘢痕组织切除、松解达正常解剖位置,再将预扩张充分的背阔肌肌皮瓣形成岛状肌皮瓣转移覆盖皮肤缺损区,皮瓣设计应较创面扩大10％～15％,供瓣区拉拢缝合。结果本组共5例患者,术后皮瓣成活良好,移位的乳头、乳晕恢复到正常解剖位置,切口瘢痕不明显,效果满意。结论扩张后背阔肌肌皮瓣是修复乳房瘢痕挛缩畸形的较好方法。     

乳房再造术的临床研究

目的 回顾总结了乳癌根治术后应用单纯假体植入、Becker可扩张假体植入和带蒂腹部横形腹直肌肌皮瓣(TRAM)移植、扩大的背阔肌肌皮瓣(ELDF)移植乳房再造术的经验,探讨手术的适应征、方法和效果.方法 16例行保留皮肤的乳癌根治术一期假体植入乳房再造;13例行Becker可扩张假体植入一期乳房再造;4例行单蒂下腹部横形腹直肌肌皮瓣(TRAM)移植乳房再造手术,其中2例为一期再造,另2例为二期再造.应用Becker可扩张假体行二期乳房再造1例.扩大背阔肌肌皮瓣(ELDF)移植二期乳房再造1例.结果 手术效果满意,优良率超过90%.3例病人出现轻微并发症,其中1例皮瓣局灶坏死,一例出现保留的乳头乳晕部分坏死,1例出现血清肿.结论 单纯假体植入适用于瘦小病人,对侧乳房小且没有明显下垂.优点是不增加额外瘢痕,术后恢复快;可扩张假体植入乳房再造适用于乳房大或改良乳癌根治术的患者,此法结合了单纯假体植入法和组织扩张术乳房再造术的优点;TRAM和ELDF皮瓣移植乳房再造的优点是自体组织移植,安全、手术效果好.     

乳腺癌术后带蒂背阔肌皮瓣部分联合假体植入一期乳房再造

目的总结乳腺癌术后采用带蒂背阔肌肌瓣、肌皮瓣联合假体植入一期乳房再造的疗效。方法 2008年2月-2009年12月,对30例女性乳腺癌患者于病灶切除术后采用带蒂背阔肌肌瓣或肌皮瓣部分联合假体植入一期乳房再造。患者年龄20～42岁,平均34岁。导管原位癌4例,浸润性导管癌26例。临床分期:0期4例,Ⅰ期20例,ⅡA期6例。病程3周～1年,中位时间5.6个月。肌瓣切取范围为3 cm×3 cm～6 cm×5 cm,肌皮瓣切取范围为6 cm×5 cm～7 cm×4 cm。供区直接拉拢缝合。结果术后肌皮瓣及肌瓣均顺利成活,创面Ⅰ期愈合;供区切口均Ⅰ期愈合。术后3个月5例出现供区局限性积液,对症处理后愈合。患者均获随访,随访时间24～42个月,平均32个月。1例术后19个月肿瘤复发,其余肿瘤均无复发。术后24个月根据再造乳房外观评价标准:获优14例,良12例,一般4例。结论乳腺癌切除术后应用同侧背阔肌肌瓣、肌皮瓣即刻乳房再造可获得足够组织量,联合假体植入再造乳房形态良好。     

乳腺癌改良根治术后Ⅰ期带蒂背阔肌皮瓣乳房重建术

目的 探讨乳腺癌改良根治术后Ⅰ期行带蒂背阔肌皮瓣乳房重建的方法与疗效.方法 采用带蒂背阔肌皮瓣移植的方法对乳腺癌改良根治术后行Ⅰ期乳房再造12例,其中11例术中联合应用乳房假体行乳房重建.结果 全部患者的肌皮瓣均成活,除1例患者因术后包扎过紧而引起假体位置上移需调整外,其他患者术后无积液、感染、坏死等并发症,再造乳房外形美观.结论 乳腺癌术后Ⅰ期利用带蒂背阔肌皮瓣行乳房重建术,效果肯定,对于组织需求少的患者是一种理想的方法.     

扩大背阔肌肌皮瓣乳房再造

目的 介绍单纯应用扩大背阔肌肌皮瓣进行乳房再造方法.方法 将背阔肌周围脂肪组织分为5个区,切取背阔肌及周围脂肪组织,不应用乳房假体,进行即时或后期乳房再造.结果 应用该方法再造乳房95例,其中保留乳头乳晕改良根治术后即时再造24例,保留皮肤改良根治术后即时再造36例,改良根治术后即时再造26例,后期再造9例,其中1例为改良根治术后,其他8例为改良根治术后,再造乳房均形态良好.术后6例乳头部分坏死;14例胸部皮肤表皮脱落,自行愈合;2例背部供区部分坏死;背部顽固性血清肿2例,再次手术后愈合.结论 扩大背阔肌肌皮瓣乳房再造安全有效,再造乳房形态良好,尤其适用于中、小乳房的乳房再造.     

扩大背阔肌肌皮瓣乳房再造

目的　介绍单纯应用扩大背阔肌肌皮瓣进行乳房再造方法。方法　将背阔肌周围脂肪组织分为 5个区 ,在背部设计半月形皮肤切口 ,切取背阔肌及周围脂肪组织 ,不应用乳房假体 ,进行即时或后期乳房再造。结果　应用该方法乳房再造 35例 ,再造乳房形态良好。结论　扩大背阔肌肌皮瓣乳房再造 ,安全有效 ,再造乳房形态良好 ,是乳房再造的重要进展。     

PRIMARY RECONSTRUCTION AFTER EXTENSIVE CHEST WALL RESECTION

Background : Chest wall resection and reconstruction has been proven to be a safe surgical procedure. This is particularly useful for breast cancer patients with chest wall recurrences or for those who first present with locally advanced cancer in the chest wall where there is both a large soft tissue and bony defect that need repair. In addition, many of these patients have had irradiation or chemotherapy, which can significantly impair wound healing. Methods : Thirty-four patients underwent chest wall resection and primary reconstruction over an 8-year period. Results : Twenty-three patients had breast carcinomas and six had breast and chest wall sarcomas. Of the breast carcinoma patients, 12 had local recurrences and 11 presented with locally advanced primary disease. Bony resection of the chest wall was required in 16 (47%) cases. Thirty myocutaneous flaps (18 rectus abdominis, four pectoralis major, eight latissimus dorsi) and three omental flaps were used for reconstruction. One required a deltovertebral skin flap. Skeletal reconstruction was necessary in four cases. All except one (97%) achieved primary wound healing. There was one mortality (3%) and three patients required further surgery for complications that were related to the reconstruction. Post-resection metastases occurred in 13 (42%) patients and only 2 (6%) had local recurrences. The 2-year survival rate was 78% with a mean survival time of 25.5 months. Conclusions : Primary reconstruction for curative or palliative purposes is a useful and safe surgical procedure for patients with recurrent or locally advanced chest malignancies after extensive chest wall resection. Pedicled myocutaneous flap is the preferred option for skeletal and soft-tissue coverage.     

几种乳房再造术的临床应用体会

目的：探讨乳腺癌根治术后应用单纯假体植入、可扩张假体植入和带蒂腹部横形腹直肌肌皮瓣（TRAM）移植乳房再造的适应证、手术方法、手术效果。方法：本组共24例病例。14例乳腺癌患者行保留皮肤的乳腺癌根治术，Ⅰ期行假体植入乳房再造；6例采用改良乳腺癌根治可扩张假体植入Ⅰ期乳房再造；4例接受单蒂下腹部横形腹直肌肌皮瓣（TRAM）移植乳房再造手术，其中2例为Ⅰ期再造，另2例为Ⅱ期乳房再造。结果：手术效果较满意，2例出现轻微并发症，其中1例皮瓣局灶坏死，另1例出现乳头乳晕部分坏死。结论：单纯假体植入适用于乳房小，没有明显下垂的瘦小病人。优点是不增加额外瘢痕，术后恢复快；可扩张假体植入乳房再造适用于乳房大或改良乳腺癌根治术的患者，此法结合了单纯假体植入法和组织扩张的优点：TRAM皮瓣移植乳房再造的优点是自体组织移植，安全、手术效果好。     

腹直肌-背阔肌肌皮瓣联合应用乳房再造术

目的　探索一种同时修复乳房和胸壁缺损的手术方法。方法　利用下腹部横行腹直肌肌皮瓣 (下简称TRAM皮瓣 )和部分背阔肌肌皮瓣 ,为乳癌术后患者行乳房再造及胸壁缺损修复。结果　 4例 8个皮瓣全部成活 ,再造乳房及胸壁缺损修复效果满意。结论　联合应用腹直肌—背阔肌肌皮瓣 ,可以同时完成乳房再造及胸壁缺损的修复 ,效果满意。     

Correction of chest wall deformity after implant-based breast reconstruction using poly-L-lactic acid (Sculptra)

Abstract:  Implant-based breast reconstruction after mastectomy offers excellent cosmetic results in select individuals. However, this technique may result in a step-off between the implant and the soft tissue of the chest wall, which can be problematic in the extremely thin patient. Also, the removal of soft tissue can result in prominent ribs and visible intercostal spaces. A number of surgical options exist to correct these defects and include dermal grafts, flap reconstruction, and implant exchange. We present the case of a thin woman with a persistent "step-off" deformity and visible intercostal spaces after mastectomy and two-stage implant reconstruction. Placement of acellular cadaveric dermis (Alloderm) failed to improve the appearance of her chest wall. The authors utilized poly- l -lactic acid (Sculptra) for soft tissue augmentation of her chest wall with significant esthetic improvement. This novel use of poly- l -lactic acid offers a useful alternative to invasive surgical procedures to correct a soft tissue deformity of the chest wall. While poly- l -lactic acid has recently gained popularity for soft tissue augmentation of the face, to date, no reports in the literature exist describing its use in the correction of difficult chest wall defects after mastectomy and implant reconstruction. We maintain that poly- l -lactic acid may also be useful to improve a variety of soft tissue deformities of the breast.     

Deep inferior epigastric perforator flap for successful simultaneous breast and chest wall reconstruction in a Poland anomaly patient

Breast reconstruction in female Poland anomaly remains a surgical challenge with variable chest wall deformity and nipple position. Pedicled latissimus dorsi myocutaneous flap with implant reconstruction may have several drawbacks and complications. Free deep inferior epigastric flap (DIEP) flap is a reliable option for postmastectomy breast reconstruction, but rarely reported in Poland anomaly. We presented a 52-year-old Poland anomaly patient who underwent successful reconstruction for breast and chest wall deformity using DIEP flap. Preoperative ultrasound Doppler study for internal mammary vessels is recommended for microsurgical anastomosis. Care should be taken with regard to the flap inset and the location of the nipple areolar complex.     

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.