保留乳头乳晕乳腺癌改良根治术一期游离腹壁下动脉穿支皮瓣乳房再造应用体会

目的实践保留乳头乳晕复合体（nipple—areolar complex,NAC）的乳腺癌改良根治术一期游离腹壁下动脉穿支皮瓣（free deep inferior epigastric perforator,free—DIEP）乳房再造的方法与临床应用。方法2005年6月至2009年5月对9例乳腺癌患者行保留NAC乳腺癌改良根治术,应用free—DIEP一期乳房再造。结果9例皮瓣均成活。随访半年以上,局部未见肿瘤复发,再造乳房对称,弹性好,无腹壁疝等并发症发生,患者满意。结论选择符合指征的乳腺癌患者,行保留NAC的改良根治术一期free—DIEP乳房再造安全可行。     

应用腹壁下动脉穿支皮瓣乳房再造的临床研究

目的探讨横行腹直肌肌皮瓣（TRAM瓣）行乳房再造的方法与效果。方法自2000年3月至2006年5月，应用腹壁下动脉穿支（DIEP）皮瓣对44位患者再造乳房，其中3例为双侧再造，17例为乳癌切除术后Ⅰ期即刻再造，27例为Ⅱ期延迟再造。所有患者都分别参加研究，没有患者退出。术后随访患者的腹壁功能、腹部供区满意度和再造乳房满意度，以及再造乳房自发感觉的恢复情况。结果患者的平均年龄38．6岁（28～50岁）。皮瓣的大小平均为11cm×26cm（其长10～12cm，宽15～33cm）。皮瓣血管蒂长度为9．3cm（7～12cm）。术后平均随访时间16个月（3～30个月）。皮瓣全部失活2例，皮瓣部分失活2例。腹部切缘坏死4例。腋窝血肿1例。术后腹壁检查未发现腹壁疝和腹膨出。所有患者日常活动均恢复。腹壁瘢痕直接影响患者对腹部供区的满意度。患者对再造乳房的满意度评分较高。95％的再造乳房有白发神经恢复，但是都未达到或接近正常。结论DIEP皮瓣游离移植是自体组织乳房再造的一种可靠方法。DIEP皮瓣具有和TRAM瓣相同的优点，同时通过保留腹直肌的完整性，又避免肌皮瓣的缺点。虽然解剖DIEP皮瓣技术难度更大，但是DIEP皮瓣减轻受区损伤，同时能再造更美的乳房。     

应用腹壁下动脉穿支皮瓣即刻乳房重建

目的总结乳腺癌切除同时应用腹壁下动脉穿支（DIEP）皮瓣行即刻乳房重建的手术经验,探讨DIEP皮瓣即刻乳房重建的适应证及优点。方法2003年4月-2009年6月,中国医学科学院肿瘤医院乳腺中心接受乳腺癌切除术患者21例（根治术6例,改良根治术15例）,术前应用多排螺旋CT（MDCT）血管造影及多普勒血流仪探明穿支位置,乳腺癌切除的同时,解剖腹壁下动脉穿支,形成腹壁下动脉穿支蒂皮瓣,与患侧胸背血管吻合,进行即刻乳房重建。结果术后随访6个月至6年。21例患者中,20例皮瓣全部存活,1例出现皮瓣远端1／3脂肪液化;胸部受区出现1例血肿;无腹壁膨隆、腹壁疝、切口脂肪液化等供区并发症;再造乳房外形满意,形态自然。结论乳腺癌切除同时,采用DIEP皮瓣进行即刻乳房重建,可以使患者免受乳房缺失的痛苦,同时具有受区组织条件好、皮瓣组织量丰富、供区损伤小及并发症少的优点,是一种理想的即刻乳房重建方法。     

带蒂穿支皮瓣在乳房再造术中的应用

与游离穿支皮瓣相比,带蒂穿支皮瓣分离技术更加简单,安全系数更高,而且供区畸形更小。近年来,应用带蒂穿支皮瓣技术已经成为乳房再造手术一种新的选择, 甚至是一些患者的首选方案。常用的带蒂穿支皮瓣有胸背动脉穿支皮瓣、肋间动脉穿支皮瓣(外侧肋间动脉穿支皮瓣、前侧肋间动脉穿支皮瓣)等,其他可用的选择包括前锯肌动脉穿支皮瓣,腹壁上动脉穿支皮瓣,胸外侧动脉穿支皮瓣等。为了提高手术设计的精确性,术前需要评估穿支血管的质量,并对其定位穿支。皮瓣的设计相比游离皮瓣手术而言,显得更加重要。虽然带蒂穿支皮瓣在乳房再造领域的作用尚不能取代游离皮瓣的金标准地位,但随着“损伤最小化”重建概念的日渐推广,带蒂穿支皮瓣将会成为乳房再造领域里的一种新的趋势。     

腹壁浅动脉(SIEA)皮瓣在乳房重建术中的应用

腹壁浅动脉(superficial inferior spigastric artery,SIEA)皮瓣乳房重建术是一种基于腹壁浅动脉系统的术式。由于术中不需切开腹直肌鞘以致破坏皮瓣深部腹部组织的完整,因此大大减少了术后供区并发症,同时取得良好的美容效果。文章综合近年来国外在此术式上的最新进展,就SIEA皮瓣的定义、解剖基础、手术方式、术后并发症进行综述。     

多模态超声检查对腹壁下动脉穿支皮瓣自体移植乳房再造术前血管评估研究

目的:探讨多模态超声对腹壁下动脉穿支(deep inferior epigastric perforator,DIEP)皮瓣血管检查有效性,并分析穿支血管的影响因素。方法:纳入2013年2月至2018年10月43例于天津医科大学肿瘤医院使用DIEP皮瓣进行乳房再造术的女性乳腺癌患者,对穿支血管行术前常规及彩色多普勒超声检查,并在超声造影增强状态下行三维重建,直观显示穿支血管的走行分布情况,同时体表标注投影位置。结果:43例患者腹壁下动脉穿支主要分布在脐周5 cm范围内,每侧2～5支,其中28例呈不对称分布。DIEP穿支血管管径与患者腹壁脂肪层厚度呈正相关(r=0.436,P<0.05);血管收缩期峰值血流速度与穿支血管管径呈正相关(r=0.448,P<0.05)。43例患者行超声造影检查后彩色血流信号均能显著增强,其中39例经三维重建后能清晰显示穿支血管与腹壁下动脉主干的关系,4例穿支血管显示欠连续。结论:多模态超声检查在乳腺癌患者DIEP乳房再造术前评估穿支血管具有重要的应用价值,腹壁脂肪层厚度对优势血管的选择有一定影响。     

带蒂侧胸动脉穿支皮瓣在乳房肿瘤整形保乳术中的应用进展

穿支皮瓣是乳房肿瘤整形保乳术中不可或缺的一部分,近年来一组由胸背动脉穿支皮瓣、肋间外侧动脉穿支皮瓣以及胸外侧动脉穿支皮瓣所构成的带蒂侧胸动脉穿支皮瓣成为自体乳房部分重建的新选择。与传统皮瓣相比,带蒂侧胸动脉穿支皮瓣操作更简单、术后供区并发症发生率更低,美学效果也更好。本文综述了带蒂侧胸动脉穿支皮瓣在乳房肿瘤整形保乳术中的应用进展,主要包括带蒂侧胸动脉穿支皮瓣的解剖、手术步骤以及优势和局限性。     

应用游离腹部皮瓣行118例乳房重建术的单中心报告

背景与目的：随着诊疗技术的不断革新,乳腺癌的无病生存期和总生存率显著提高。为了改善患者术后的生活质量,越来越多的乳房重建技术被应用于临床。本文拟通过回顾复旦大学附属肿瘤医院乳腺外科118例游离腹部皮瓣乳房重建术的开展情况,介绍该术式的手术方法及结果,并就开展过程中的心得体会加以阐述。方法：收集2006年11月—2013年6月117例(1例接受双侧重建)接受全乳切除并进行即刻或延期游离腹部皮瓣乳房重建的患者进行即刻或延期游离腹部皮瓣乳房重建的临床资料,分析手术情况、围手术期并发症发生率及远期转归。结果：在上述观察期间共完成118例游离腹部皮瓣乳房重建术,平均手术时间7.72 h,平均热缺血时间78.74 min,平均血管吻合时间60.83 min。保留腹壁下深血管穿支平均为3支,胸廓内血管为首选的受区血管。术后发生血管危象10例,其中静脉血栓6例,静脉成角4例;解救成功7例,皮瓣全部坏死3例,成功率为97.46%。术后伤口感染发生率为7.00%,下腹部膨隆发生率为3.50%,无腹壁疝发生。手术距首疗程化疗的中位时间为19 d。中位随访12个月,1例出现远处转移,未发现局部复发。结论：游离腹部皮瓣乳房重建术可获得较佳的重建乳房外观,虽然该术式较为复杂,对术者要求高,存在学习曲线,但术式成功率高,术后并发症较少,不影响肿瘤安全性,值得推广。     

DIEP移植用于巨大外生性菜花样乳腺癌伴出血1例

腹壁下动脉穿支皮瓣(deep inferior epigastic perforator,DIEP)移植是Allen于1992年提出的自体乳房重建的新术式,将患者下腹部的脂肪皮瓣与供应皮瓣的动静脉血管移植修复缺损乳房,从而塑造一个美观且圆润的新乳房[1-3],因其有长久、美观、自然、并发症少等特点而成为乳房重建的金标准...     

DIEP皮瓣在乳腺癌术后一期乳房重建中的应用体会

目的:探讨腹壁下动脉穿支皮瓣(DIEP)+微血管吻合术在乳腺肿瘤术后一期乳房再造中的应用价值.方法:选择2007-4-25-2008-2-1收治11例乳腺肿瘤患者,其中保留乳房手术3例,保留或不保留乳头乳晕皮下全乳切除8例.所有患者术后即刻行腹壁下动脉穿支皮瓣+微血管吻合术,对缺损乳腺一期整形或再造.结果:11例乳腺肿瘤患者中,浸润性导管癌4例,浸润性小叶癌1例,导管内癌伴微小浸润3例,导管原位癌2例,恶性分叶状肿瘤1例.11例患者皮瓣全部成活,无脂肪液化、腹壁切口疝等并发症发生,美容效果满意.结论:腹壁下动脉穿支皮瓣+微血管吻合术是乳腺肿瘤术后一期再造的理想术式.中华肿瘤防治杂志,2009,16(1):66-68     

Secondary breast reconstruction after mastectomy using the DIEP flap

Introduction

Breast reconstruction is an important element in the successful therapy of breast cancer [1]. Thereby, autologous microvascular breast reconstruction has been shown to be a reliable technique. The use of a deep inferior epigastric perforator (DIEP) flap or a muscle-sparing (MS) free transverse rectus abdominis musculocutaneous (TRAM) flap is recognized in many centres as gold standard for reconstructive options [[2], [3], [4]]. Based on our experiences with 137 patients over a 5-year period we want to highlight the technical aspects of the free microsurgical autologous breast reconstruction using a DIEP flap.

Skin-sparing mastectomy and immediate reconstruction with a deep inferior epigastric perforator flap

BACKGROUND: It is important for breast reconstruction after mastectomy to recreate immediately good breast symmetry with an adequate amount of soft tissue. METHODS: Eight patients with breast cancer underwent skin-sparing mastectomy and immediate reconstruction with a deep inferior epigastric perforator flap. This operative technique, and the results, advantages, and disadvantages of the technique were assessed. RESULTS: Seven patients had stage IIA disease, and one patient had stage I disease. An arc-shaped incision was made just at the lateral border of the breast in all patients. Three patients had a separate periareolar incision, and one had a circumferential nipple incision. There was 100% flap survival, and good breast symmetry was achieved in all patients. No major perioperative complications occurred in this series. A small amount of fat necrosis occurred in one flap. One patient had slight abdominal bulging. Minor wound-healing problems at the lateral breast skin envelope occurred in two patients. CONCLUSION: These data indicate that skin-sparing mastectomy and immediate reconstruction with a DIEP flap is a reliable and safe technique. This method is a potentially useful surgical technique, which has achieved very promising results.     

Recent advances in microvascular autologous breast reconstruction after ablative tumor surgery

Breast cancer is a ubiquitous disease and one of the leading causes of death in women in western societies. With overall increasing survival rates, the number of patients who need post-mastectomy reconstruction is on the rise. Especially since its psychological benefits have been broadly recognized, breast reconstruction has become a key component of breast cancer treatment. Evolving from the early beginnings of breast reconstruction with synthetic implants in the 1960s, microsurgical tissue transfer is on the way to become the gold standard for post oncology restoration of the breast. Particularly since the advent of perforator based free flap surgery, free tissue transfer has become as safe option for breast reconstruction with low morbidity. The lower abdominal skin and subcutaneous fat tissue typically offer enough volume to create an aesthetically satisfying breast mound. Nowadays, the most commonly used flap from this donor site is the deep inferior epigastric artery perforator flap. If the lower abdomen is not available as a donor site, the gluteal area and thigh provide a number of flaps suitable for breast reconstruction. If the required breast volume is small, and there is enough tissue available on the upper medial thigh, then a transverse upper gracilis flap may be a practicable method to reconstruct the breast. In case of a higher amount of required volume, a gluteal artery perforator flap is the best choice. However, what is crucial in addition to selecting the best flap option for the individual patient is the timing of the operation. In patients with confirmed post-mastectomy radiation therapy, it is advisable to perform microvascular breast reconstruction only in a delayed fashion.     

Options for immediate breast reconstruction following skin-sparing mastectomy

Background  Skin-sparing mastectomy (SSM) is a type of breast cancer surgery presupposed as breast reconstruction surgery. Cosmetically, it is an extremely effective breast cancer operation because the greater part of the breast’s native skin and infra-mammary fold are conserved. All cases of SSM and immediate breast reconstruction performed by the senior author during the last five years were reviewed. as]Methods: There are three implant options for breast reconstruction, namely, deep inferior epigastric perforator (DIEP) flap, latissimus dorsi myocutaneous (LDM) flap, and breast implant, and one of these was used for reconstruction after comprehensive evaluation. Results  From 2001 to 2005, immediate reconstructions following SSM were performed on 124 cases (128 breasts) by the same surgeon. Partial necrosis of the breast skin occurred in 4 cases of SSM. The mean follow-up was 33.6 months. During the follow-up, there was local recurrence following surgery in 3 cases. The overall aesthetic results of immediate breast reconstruction after SSM are better than those after non-SSM. Conclusion  SSM preserves the native breast skin and infra-mammary fold, and is an extremely useful breast cancer surgery for breast reconstruction. SSM is an excellent breast cancer surgical technique. We think this procedure should be considered in more facilities conducting breast reconstruction in Japan.     

带蒂背阔肌皮瓣在乳房重建手术中的应用

随着乳腺癌治疗模式的发展及患者观念的转变,乳房重建逐渐成为乳腺癌治疗的一部分。背阔肌因面积较大,且蒂部解剖变异较少,同时血供丰富可被改良成不同的皮瓣,因此被认为是良好的供瓣区。在乳房重建中,背阔肌肌皮瓣的应用较广,不仅可以使用全背阔肌或联合假体进行乳房重建,且可以根据不同的缺损范围选择合适的背阔肌皮瓣进行乳房缺损的修补。相比单纯植入物重建,背阔肌皮瓣可获得更为良好的乳房形态且对术后放疗影响较小;相比下腹部皮瓣,背阔肌皮瓣瘢痕较短,术后恢复较快。目前对于术后供区缝合方式的改进及辅助药物的应用,极大地降低了血清肿的发生率;腔镜技术的应用也避免了切取背阔肌皮瓣遗留的供区瘢痕。在临床应用中,背阔肌皮瓣行乳房重建患者满意率高,术后审美效果良好,是乳房重建中一种较为优势的手术方法。该研究总结了背阔肌皮瓣行乳房重建对并发症的控制并对近年来的手术中的问题作进一步探讨。     

带蒂腹直肌皮瓣在乳房重建手术中的应用

随着人民生活水平的提高和医学技术的发展,乳腺癌患者接受全乳切除术后对乳房重建的需求日益增长。带蒂腹直肌皮瓣(transverse rectus abdominis muscle,TRAM)手术是重要的自体组织乳房重建方法。该文就TRAM皮瓣的解剖与血供、TRAM手术的适应证和禁忌证、手术步骤以及并发症进行介绍,同时还对TRAM手术中的一些细节问题进行了探讨。TRAM术式作为自体组织乳房重建技术,不需要假体,从而避免了假体相关的并发症。另外相比于假体重建,自体组织重建的外形和柔软度都更接近于自然乳房,具有更好的重建效果。同时带蒂的TRAM术式不需要显微血管吻合技术和密切的术后皮瓣检测,容易被外科医师掌握并在更多的医学中心开展。因此TRAM皮瓣仍然具有一定的应用前景。     

Immediate breast reconstruction with latissimus dorsi flap for patients with local recurrence of breast cancer

BackgroundIpsilateral breast cancer recurrence (IBTR) occurs in about 7% of patients with primary invasive breast tumor. Salvage mastectomy and breast reconstruction are often discussed and latissimus dorsi (LD) flap is frequently proposed.MethodsWe retrospectively investigated 111 consecutive locally relapsing patients who underwent salvage mastectomy and immediate LD reconstruction. All included patients with IBTR previously underwent conserving surgery for BC, and received a postoperative irradiation. Primary endpoints were disease free survival and overall survival. Secondary endpoints were surgical complications and re-interventions.ResultsInvasive ductal cancer was the most frequent histotype (60.4%) of breast cancer reappearance. rpT1, rpT2 and rpT3 were observed respectively in 50.5%, 20,7% and 3,6% of the patients. rpTis occurred in 11,7% of cases. Positive axillary nodes were observed in 9,9% of patients at reappearance. Post-operative complication other than seroma occurred in 17,1% of patients, while seroma at the donor site was observed in 61.3% of cases. At 5-year after surgery overall survival was 92% (95% CI: 85%–96%) and disease free survival was 78% (95% CI: 69%–85%).ConclusionsImmediate latissimus dorsi flap reconstruction in selected patients with isolated breast tumor recurrence, which occurred after breast irradiation, provides an effective treatment with a satisfactory outcome.     

游离腹部皮瓣乳房重建的应用及研究进展

乳腺癌发病率居女性新发恶性肿瘤的第一位,外科治疗是重要的治疗手段之一。全乳切除术后乳房重建能在不影响肿瘤学安全性的前提下,提高患者的生存质量,其中,自体组织乳房重建因其特有的优势成为乳房重建的重要方式之一,而游离腹部皮瓣是自体组织乳房重建中最理想的材料。该研究将对游离腹部皮瓣乳房重建手术的临床应用、手术时机及并发症进行综述,旨在探讨游离腹部皮瓣乳房重建的应用及研究进展。