Ⅰ、Ⅱ期乳腺癌即刻乳房重建153例临床分析

目的 探讨 Ⅰ、Ⅱ期乳腺癌的个性化手术方案。方法 回顾性分析2007年2月至2014年1月华中科技大学同济医学院附属同济医院整形外科收治的153例女性Ⅰ、Ⅱ期乳腺癌病人的临床资料,在病人保留乳房外形的要求下,行肿瘤切除或全乳切除+即刻乳房重建手术。结果 153例病人中,行保乳术+即刻乳房重建86例,包括带蒂远端腹直肌肌皮瓣乳房重建30例、带蒂背阔肌肌皮瓣乳房重建56例;保留皮肤的乳腺切除术+即刻乳房重建67例,包括带蒂远端腹直肌肌皮瓣乳房重建21例、带蒂背阔肌肌皮瓣及硅凝胶假体乳房重建43例、扩张器或假体乳房重建术3例。术后乳房形态优良率达93.5%。随访6～60个月,无局部复发及皮瓣坏死等严重并发症;5例发生脂肪液化,6例发生皮下血清肿,经换药引流后治愈;6例出现腹部隆起但无消化道症状;1例因脑转移死亡。结论 即刻乳房重建是Ⅰ、Ⅱ期乳腺癌病人安全理想的选择,个性化的手术方案及带蒂皮瓣技术适合推广。     

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。     

乳腺癌保乳术后背阔肌肌瓣转移修复乳房缺损28例

目的：探讨早期乳腺癌保乳术后乳房缺损的修复方法。方法：对28例早期乳腺癌保乳术患者应用带蒂背阔肌瓣一期修复乳腺缺损,术后给予辅助放化疗等综合治疗,评价其乳房外形及触感。结果：经过1.5～5年的随访,28例背阔肌肌瓣一期修复乳腺缺损区后全部成活,乳房外形和触感满意率均为89.3%。结论：保乳术后即刻背阔肌肌瓣修复乳房缺损的应用,扩大了保乳手术的适应证,同时得到良好的乳房美容效果。     

肿瘤整形术联合背阔肌肌皮瓣在中-小型外侧象限乳腺癌保乳重建中的应用体会

【摘要】〓目的〓探讨肿瘤整形技术联合背阔肌肌皮瓣在中-小型乳房外侧象限乳腺癌保乳重建中的美容效果。方法〓选择肿瘤位于乳房外侧象限的14例中-小型乳房乳腺癌患者,肿瘤距离乳头乳晕大于3 cm,保乳术后缺损体积超过20%的病人,采取肿瘤整形技术联合部分背阔肌肌皮瓣修复缺损。结果〓肿瘤直径中位大小3.2 cm(2.2~8.1 cm),切除中位体积为62.0 g(50.0~100.0 g),中位随访17(3.0~42.0)月,术后美容效果14例患者11例(79%)为优,3例(21%)为良,随访期间无1例复发及转移。结论〓肿瘤整形技术联合部分背阔肌皮瓣是一种安全有效修复保乳术后缺损的方法,特别适合肿瘤位于外侧象限,术后缺损体积超过20%的中-小型乳房。     

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.     

保留乳房外形的乳腺手术的临床应用研究

目的:探讨利用背阔肌皮瓣、腹直肌肌皮瓣(r ect us abdomi ni s myocut aneous f l ap,TRAM),假体或者联合使用开展保留乳房外形的乳腺手术的手术适应证,方式选择,手术并发症。方法:2007年5月至2009年2月行背阔肌皮瓣,腹直肌皮瓣,假体,以及联合使用的保留乳房外形的乳腺手术21例。观察指标包括手术方式的选择,手术时间,术后并发症以及美学效果。结果:背阔肌皮瓣改良保乳术12例,平均时间289mi n;腹直肌皮瓣改良保乳术4例,平均时间393 mi n。利用腹直肌和背阔肌皮瓣修复乳癌术后胸壁巨大缺损1例。Paget病利用腹直肌和背阔肌皮瓣行乳房再造术1例。乳癌术后行游离腹直肌皮瓣乳房再造术1例。保留皮肤乳头乳晕全切术后背阔肌乳房再造术1例。乳房全切后乳房即刻再造术1例。再造乳房有2例失败,其余乳房存活良好,手术并发症少。结论:利用自体组织或者假体行改良保乳术或者乳房再造术,操作时间不长,术后并发症少,美学效果好,基本不影响患者的后期治疗。     

可扩张乳房假体加背阔肌肌皮瓣的乳房再造术

目的：报告应用带蒂背阔肌肌皮瓣转移术及可扩张的乳房假体（BECKER）置入,修复乳腺癌根治术后的胸壁畸形,同时再造乳房的手术方法。方法：根据乳腺癌病灶清除术后患者胸部的畸形状况,设计患侧带蒂背阔肌肌皮瓣的肌瓣长度、体积以及皮瓣的面积和形状,切取肌皮瓣后经腋部皮下隧道转移至胸前。用肌瓣修复胸前软组织缺损,皮瓣则用于弥补胸部皮肤的不足。肌瓣与胸壁间置入可扩张的乳房假体。术后经注射壶注水,逐步扩张至额定值。6个月后,可抽除注射壶并重建乳头,完成治疗。结果：自1999年以来,对各种乳腺癌术后患者行乳房再造术共26例,获得了满意效果。结论：应用带蒂背阔肌肌皮瓣转移术及可扩张的乳房假体置入,不仅可修复乳腺癌病灶清除术后的胸部软组织的缺损、锁骨下的凹陷畸形而且可重建乳房。该法具有创伤小、恢复快、再造乳房的外形及质感逼真等特点。     

保留乳头乳晕复合体的乳腺癌术后即刻乳房重建术

目的探讨乳腺癌患者行保留乳头乳晕的改良根治术后即刻扩展型背阔肌肌皮瓣乳房重建的效果。方法自2009年1月至2012年11月,对20例女性乳腺癌患者行保留乳头乳晕的乳腺癌改良根治术,术后即刻乳房重建,重建方式为应用扩展型背阔肌肌皮瓣,术后评价其再造效果。结果20例患者手术成功,恢复良好,术后5例皮下积液,局部处理后愈合;患者均获随访6~38个月,形态良好,肿瘤均无局部复发。结论乳腺癌切除术后应用同侧扩展型背阔肌肌皮瓣即刻乳房再造,可获得良好的乳房形态。     

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。     

乳房皮下切除与自体组织即刻乳房再造

目的探索乳房皮下切除与几种方法的乳房再造术，即腹直肌肌皮瓣或背阔肌肌皮瓣加乳房假体或局部皮瓣等即刻再造乳房的方法。方法选择乳腺导管内原位癌10例和巨大乳腺良性肿瘤5例，顺乳晕切口活检，病理检查确立诊断后，采用经乳腺切口行乳癌或巨大肿瘤的乳房皮下切除术，若乳癌或良性肿瘤体积较大，另于腋窝部加做顺腋下皱襞的附加切口，以便于取出切除的组织及切除乳腺的腋尾部，同时可以切取腋淋巴结行冰冻切片活检。然后，应用腹直肌肌皮瓣或背阔肌肌皮瓣加乳房假体或局部皮瓣即刻行再造乳房，充填乳房切除后的空间，仅以少量的肌皮瓣皮肤修复乳头、乳晕切除后的缺损，并在此转移皮瓣上再造乳头、乳晕。结果经过多专科协作共完成15例，随访结果良好，无肿瘤复发。此法再造的乳房易与健侧乳房对称，保留了原有乳房皮肤的良好感觉，外观形态自然，再造乳房瘢痕较少，且手术切口瘢痕隐蔽。结论在严格选择手术适应证防止乳腺癌复发的前提下，乳房皮下切除与即刻乳房再造法，对乳腺导管内原位癌和巨大乳腺良性肿瘤患者I期完成肿瘤切除和乳房再造术，具有积极有效的意义。     

双侧乳房重建118例单中心回顾性研究

目的 探讨双侧乳房重建手术的开展情况和影响因素。方法 对复旦大学附属肿瘤医院2000年1月至2019年12月间接受双侧乳房重建手术的病人资料进行回顾性分析,描述病人人口学、临床病理特征、双侧乳房重建手术规模、手术时机和方式,探讨双侧乳房重建手术方式选择过程中的影响因素。采用t检验、χ2检验以及Fisher检验进行显著性检验;利用单因素及多因素回归分析,对上述影响因素进行统计学检验。结果 2913例病人接受乳腺癌全乳切除术后乳房重建,其中双侧乳房重建病人共118例,占重建总数的4.05%。双侧乳腺癌病人82例,对侧乳房预防性切除的单侧乳腺癌病人31例,15例病人为一侧或双侧延期乳房重建。双侧即刻重建者103例,占87.3%,10例病人行单侧乳房延期重建,5例行双乳延期重建。双侧植入物重建97例（82.2%）,一侧植入物重建另一侧自体重建共9例（7.6%）,其余12例（10.2%）为双侧自体重建。乳房切除动机（治疗性/预防性）、双侧乳房切除时机（同时性/异时性）以及辅助放疗与双侧乳房重建方式选择相关。多因素分析发现,异时性双乳切除病人与术后需要行辅助放疗的病人更倾向于选择一侧或双侧自体重建。同时行双乳切除接受即刻植入物重建时,扩张器-假体两步法占比更高,达76.5%。和单侧乳房重建比较,双侧乳房重建术后非计划再次手术和重建失败的比例差异无统计学意义。结论 当前国内双侧乳房重建的占比虽然较低,但是面临潜在的增长趋势。乳腺癌多学科团队应制订合理的手术适应证,结合病人意愿,选择恰当的手术时机和方式,从而使临床决策更为规范。     

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??Immediate breast reconstruction using prosthesis after nipple-sparing mastectomy for breast diseases??a report of 10 cases ZHANG Ya-nan*, QIAN Hong-mei, YOU Cheng-zhong, et al. *Department of General Surgery, Zhongda Hospital, Southeast University, Nanjing 210009, China
Corresponding author: ZHANG Ya-nan, E-mail: zhangyanan79@126.com
Abstract Objective To investigate the indications, surgical methods, effects and feasibility of immediate breast reconstruction after nipple-sparing mastectomy. Methods The immediate breast reconstruction after nipple-sparing mastectomy was performed in 10 cases of breast disease from January 2009 to October 2010 in Zhongda Hospital of Southeast University. The effects of reconstructed breast were evaluated according to objective and subjective criteria. Postoperative complications were observed and therapeutic effects were followed up. Results All operations were successful. Two cases had slight complications in early postoperative stage and were cured quickly. The aesthetic outcome and the satisfactory rate were all 100% during 6—18 months follow-up. No recurrence and metastasis were founded in 7 cases. Conclusion The operation method of immediate breast reconstruction after nipple-sparing mastectomy is maneuverable and has excellent effect of aesthetics with no influence of the therapy of breast diseases.     

Better cosmetic results and comparable quality of life after skin-sparing mastectomy and immediate autologous breast reconstruction compared to breast conservative treatment.

Preoperative chemotherapy (PCT) can be used in large primary breast cancer to facilitate breast conservative surgery (BCS). Cosmetic results of BCS are influenced by the size of the residual tumour, relative to the size of the breast. After mastectomy, immediate breast reconstruction (IBR) with autologous tissue provides excellent cosmetic outcome and has proven to be safe in breast cancer patients. Besides improving overall and disease free survival, Quality of Life (QoL), body image and cosmetic outcome are also important issues after treatment for breast cancer.In this study, Health-Related-Quality of Life (HRQL) and body image were evaluated, in patients treated with PCT, followed by BCS, or skin-sparing mastectomy (SSM) and perforator-flap breast reconstruction. Additionally, clinical observers assessed cosmetic outcome.All participants were evaluated by the Medical Outcomes Study (MOS) 36-item Short Form Health Status Survey (SF-36, 36 items) and a study-specific questionnaire. An external panel evaluated standardised photographs of the breasts.For all patients, norm-based scores of physical and mental health state are comparable with the general population, except for vitality (VT) score, which is somewhat lower. No significant differences can be observed between both groups. The majority of the patients were satisfied with the appearance of their breasts.The cosmetic results, assessed by the clinical team, were significantly better for patients having IBR, compared to BCS. The mean score was 7.5/10 for IBR, versus 6.0/10 for BCS (p<0.0001).Breast conserving treatment or mastectomy with reconstruction may yield comparable results of QoL, but cosmetic outcome is better after SSM and perforator-flap reconstruction. Patients must be offered both options, and clinicians should stress that both are equally effective.     

胸外侧筋膜皮瓣在修复乳房局部缺损中的应用

目的:探讨在利用胸外侧筋膜皮瓣修复乳房局部缺损的效果和意义。方法:对因保乳手术或乳房再造术后皮瓣坏死造成乳房局部缺损患者设计三角胸外侧筋膜皮瓣进行组织填充修复。结果:共完成8例,7例为保乳手术后即刻,1例为TRAM手术后局部皮瓣坏死。平均手术时间3h,平均出血量300ml。术后未发生皮瓣坏死等并发症。术后平均随访时间19.5月,均未出现复发,美容效果均为优良,患者对乳房外形的自我感觉均为满意。结论:利用胸外侧筋膜皮瓣修复乳房局部缺损,尤其是对于乳房较小患者,效果满意,简单易行。     

Impact of immediate breast reconstruction on breast cancer recurrence and survival

The practise of Immediate Breast Reconstruction (IBR) following mastectomy for primary breast cancer is being increasingly adopted. Here the impact of IBR on disease progression and survival was assessed following treatment for invasive breast cancer. 1697 consecutive patients received surgical treatment for operable primary breast cancer between January 1996 and December 2007. Overall, 691 (41%) received mastectomy of whom 136 (20%) underwent IBR (82 Latissimus Dorsi, 54 Subpectoral).The effect of IBR on overall survival, local and distant recurrence was analysed in all patients studied and also separately within subgroups defined by Nottingham Prognostic Index (NPI) scores. The median follow up of patients studied was 55 months (range 16–148). There was no difference between IBR and mastectomy alone in survival (p = 0.176), time to distant metastasis (p = 0.783) or local recurrence (p = 0.505), either overall or within Nottingham Prognostic groups.     

保留乳头乳晕乳腺全切除术后Ⅰ期假体植入10例报告

目的探讨保留乳头乳晕的乳腺全切除术后Ⅰ期乳房重建的适应证、方法、效果及可行性。方法东南大学附属中大医院2009年1月到2010年10月对10例病人行保留乳头乳晕的乳腺全切术及Ⅰ期假体植入的乳房重建术,术后从客观和主观两个角度评价美容效果,观察其并发症及随访治疗效果。结果所有病人手术成功。术后早期,2例出现轻微并发症,予以对症治疗后痊愈。术后随访6～18个月,主、客观评价的优良率均为100%。其中7例乳腺癌病人局部无复发,远处无转移。结论保留乳头乳晕的乳腺全切术后Ⅰ期乳房重建术的手术操作简单易行,美容效果好,无严重并发症,且不影响乳腺疾病的治疗。     

Prophylactic mastectomy: the Rotterdam experience

The efficacy of prophylactic mastectomy (PM) depends on the ability to remove all breast tissue and a regular mastectomy is recommended. In our study population (n=112), 103 women (94%) have chosen for immediate breast reconstruction (IBR) with a silicone prosthesis placed in a subpectoral pocket. The median follow-up after IBR was 3.5 (range 1-7) years. These 103 patients underwent 193 PM with IBR: 90 bilateral and 13 unilateral. The median follow-up after IBR was 3.5 (range 1-7) years. In 163 IBRs (82%) no complications were observed. The most common late complication was capsular contracture, significantly more around prostheses placed in a previously irradiated area. No cases of breast cancer were found after PM at a mean follow-up of 2.9 years. After breast cancer a delayed ipsilateral PM and/or contralateral PM can be considered after a disease-free interval of 2 years, also taking into account the age of onset of the first breast cancer. The prognosis of breast cancer in BRCA2 mutation patients seems to be similar to that in sporadic cancer. The most striking result of PM is the decrease of anxiety of developing breast cancer and a negative impact on their sexual life. Therefore a time delay is necessary to allow women to fully address the issues involved in PM and IBR.     

Immediate Breast Reconstruction after mastectomy with polyurethane implants versus textured implants: A retrospective study with focus on capsular contracture

BackgroundCapsular contracture (CC) is the most common complication following Immediate Breast Reconstruction (IBR) with breast implants. Different implant surfaces were developed aiming to reduce the incidence of CC. We evaluated the incidence and degree of CC after Direct-to-Implant (DTI) IBR with insertion of textured (TE) or polyurethane (PU) covered implants.MethodsA retrospective review of consecutive patients treated at our Institution with mastectomy and one-stage IBR and implant reconstruction between 2013 and 2018, with or without post mastectomy radiation therapy (PMRT), was conducted. Immediate breast reconstruction was performed by implanting 186 PU covered implants and 172 TE implants.ResultsThree-hundred-twelve women underwent 358 DTI IBR with PU or TE implants, were analyzed with a median follow-up time of 2.3 years (range 1.0–3.0). The overall rate of CC Baker grade III and IV was 11.8% (95%CI: 8.4–16.3), while, after PU and TE implant placement it was 8.1% (95% CI: 4.1–15.7) and 15.8% (95% CI: 4.1–15.7) [p = 0.009]), respectively. Irradiated breasts developed CC more frequently rather than non-irradiated breasts (HR = 12.5, p < 0.001), and the relative risk was higher in the TE group compared with the PU group (HR = 0.3, p = 0.003).ConclusionsAfter mastectomy and one-stage IBR, the use of PU covered implants is associated with a lower incidence of CC compared to TE implants. This advantage is amplified several folds for patients who necessitate PMRT. Footnote: Capsular contracture (CC); Immediate Breast Reconstruction (IBR); Directto- Implant (DTI); Textured (TE); Polyurethane (PU); Post mastectomy radiation therapy (PMRT); Nipple Sparing mastectomy (NSM).     

乳腔镜辅助乳腺癌腺体切除假体植入一期成形17例报告

目的探讨在乳腔镜辅助下行皮下腺体切除、假体植入一期成形术治疗乳腺癌的手术方法、可行性及疗效。方法 2009年3月～2012年5月乳腺癌患者17例,均在乳腔镜辅助下行皮下腺体切除及腋窝淋巴结清扫,一期将假体植入胸大肌后方间隙。结果 17例乳腔镜辅助单侧乳腺腺体皮下切除、假体植入一期成形术均获成功。切除腺体组织切缘未见癌残留。按TNM分期:T1N0M0期5例,T1N1M0期1例,T2N0M0期9例,T2N1M0期2例。术后病理证实16例为浸润性导管癌,1例为小叶癌。腋窝淋巴结病理发现1例有1枚淋巴结阳性,2例3枚淋巴结阳性。17例均无皮下气肿、乳头及皮肤局部坏死情况。均在术后7～10 d拔除引流管,4例出现腋窝少量积液,穿刺抽吸加压包扎后好转,无其他并发症发生。17例均获随访,随访时间3～41个月,中位时间18个月,均无局部复发及远处转移,无患侧上肢水肿及功能障碍。术后外观评价:优9例,良6例,尚可1例;优良率达94.1%。结论乳腔镜辅助下行皮下腺体切除、假体植入一期成形术治疗乳腺癌,可减少手术创伤,安全可行,美容效果好。     

Trends in immediate breast reconstruction and radiation after mastectomy: A population study

In the last decade, there has been an increase in women undergoing immediate breast reconstruction (IBR) at the time of mastectomy. Recent literature suggests a shift in practice: Surgeons are becoming more comfortable with IBR in the setting of possible postoperative adjuvant radiotherapy, despite the known complications. This study sought to investigate, at a population level, the patient and surgeon characteristics associated with the use of IBR and which of these factors were predictive of adjuvant radiotherapy. This retrospective population‐based cohort study included all adult women who underwent mastectomy in the province of Ontario from 2007 to 2014. The Canadian Institute for Health Information (CIHI) administrative data base was used to generate patient demographic and clinical data. The Ontario Health Insurance Plan (OHIP) data base was used to elicit surgeon characteristics including clinical experience and volume of practice dedicated to breast surgery. Outcome variables included reconstruction concurrent with mastectomy, alloplastic vs autologous reconstruction, and use of radiation. A total of 25 861 patients underwent mastectomy and 2972 had IBR (11.5%). The rate of IBR after mastectomy increased over time from 7.2% in 2007 to 17.2% in 2014 (P < .001). There was also an increase in the proportion of patients with IBR who received radiation over the time period, from 19.4% in 2007 to 28.2% in 2014 (P = .003). In the first regression analysis, IBR was associated with younger patient age, residing in closer proximity to cancer clinics, absence of malignant breast disease (ie, prophylactic mastectomy), having a younger surgeon performing the mastectomy, and receiving care at a teaching hospital. A second analysis showed that patient variables predictive of radiation after IBR were a younger age and a more advanced cancer stage and no variables specific to surgeon or institution were predictive of radiation in patients with IBR. A significant increase in the rate of IBR as well as the use of radiation occurred over the 7‐year study period. Multiple patient and surgeon factors were associated with IBR. Variables associated with radiation in IBR were harder to predict. Given the increase in the use of radiation in IBR, further research is needed to look at long‐term outcomes in these patients at the population level.