带蒂背阔肌皮瓣在乳房重建手术中的应用
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摘要
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。
With the development of breast cancer treatment mode and the changing attitudes of patients, reconstruction of the breast after mastectomy plays an important role in the interdisciplinary treatment concept of breast cancer. Because of the large area and the less variation of vessels pedicle of latissimus dorsi, it is considered to be an alternative flap for breast reconstruction. The latissimus dorsi flap can be used widely in breast reconstruction. Besides the implant-assisted latissimus dorsi(LDI) and autologous latissimus dorsi(ALD) flap breast reconstructions, the modified latissimus dorsi flap could be selected for various mastectomy. Compared with implant-assisted breast reconstruction, the latissimus dorsi flap can model a better mammary contour and receive better cosmetic outcomes on post-reconstruc-tion radiation. Compared with the transverse rectus abdominis myocutaneous(TRAM) flap, the latissimus dorsi flap has smaller scars and more rapid recovery. The improvement in postoperative donor area suturing techniques and auxiliary drug application greatly reduced the incidence of seroma. The Endoscopic technology avoids the donor scar. In clinical practice, statistical evaluation of aesthetic outcomes was impossible as an advantage in operation selection. This article summarized the control of complications and the further discussion of controversy.
With the development of breast cancer treatment mode and the changing attitudes of patients, reconstruction of the breast after mastectomy plays an important role in the interdisciplinary treatment concept of breast cancer. Because of the large area and the less variation of vessels pedicle of latissimus dorsi, it is considered to be an alternative flap for breast reconstruction. The latissimus dorsi flap can be used widely in breast reconstruction. Besides the implant-assisted latissimus dorsi(LDI) and autologous latissimus dorsi(ALD) flap breast reconstructions, the modified latissimus dorsi flap could be selected for various mastectomy. Compared with implant-assisted breast reconstruction, the latissimus dorsi flap can model a better mammary contour and receive better cosmetic outcomes on post-reconstruc-tion radiation. Compared with the transverse rectus abdominis myocutaneous(TRAM) flap, the latissimus dorsi flap has smaller scars and more rapid recovery. The improvement in postoperative donor area suturing techniques and auxiliary drug application greatly reduced the incidence of seroma. The Endoscopic technology avoids the donor scar. In clinical practice, statistical evaluation of aesthetic outcomes was impossible as an advantage in operation selection. This article summarized the control of complications and the further discussion of controversy.
引文
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[34]WELLISCH D K,SCHAIN W S,NOONE R B,et al.The psychological contribution of nipple addition in breast reconstruction[J].Plast Reconstr Surg,1987,80(5):699-704.
[35]JABOR M A,SHAYANI P,COLLINS D R Jr,et al.Nippleareola reconstruction:satisfaction and clinical determinants[J].Plast Reconstr Surg,2002,110(2):457-463,discussion 464-465.
[36]GERBER B,KRAUSE A,DIETERICH M,et al.The oncological safety of skin sparing mastectomy with conservation of the nipple areola complex and autologous reconstruction:an extended follow-up study[J].Ann Surg,2009,249(3):461-468.
[37]共识专家讨论组.保留乳头乳晕复合体乳房切除术的专家共识与争议[J].中国癌症杂志,2016,26(5):476-480.
[38]MUNHOZ A M,MONTAG E,FELS K W,et al.Outcome analysis of breast-conservation surgery and immediate latissimus dorsi flap reconstruction in patients with T1 to T2breast cancer[J].Plast Reconstr Surg,2005,116(3):741-752.
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[41]SCHROEGENDORFER K F,HACKER S,NICKL S,et al.Latissimus dorsi breast reconstruction:how much nerve resection is necessary to prevent postoperative muscle twitching?[J].Plast Reconstr Surg,2014(10):1125-1129.
[42]BRANFORD O A,KELEMEN N,HARTMANN C E,et al.Subfascial harvest of the extended latissimus dorsi myocutaneous flap in breast reconstruction:a comparative analysis of two techniques[J].Plast Reconstr Surg,2013,132(4):737-748.
[43]Report on autologous fat transplantation.ASPRS Ad-Hoc Committee on New Procedures,September 30,1987[J].Plast Surg Nurs,1987,7(4):140-141.
[44]COLEMAN S R,SABOEIRO A P.Fat grafting to the breast revisited:safety and efficacy[J].Plast Reconstr Surg,2007,119(3):775-785.
[45]LOSKEN A,PINELL X A,SIKORO K,et al.Autologous fat grafting in secondary breast reconstruction[J].Ann Plast Surg,2011,66(5):518-522.
[46]SANTANELLI DI POMPEO F,LAPORTA R,SOROTOS M,et al.Latissimus dorsi flap for total autologous immediate breast reconstruction without implants[J].Plast Reconstr Surg,2014,134(6):871e-879e.
[47]NIDDAM J,VIDAL L,HERSANT B,et al.Primary fat grafting to the pectoralis muscle during latissimus dorsi breast reconstruction[J].Plast Reconstr Surg Glob Open,2016,4(11):e1059.
[48]THEKKINKATTIL D K,SALHAB M,MCMANUS P L.Feasibility of autologous fat transfer for replacement of implant volume in complicated implant-assisted latissimus dorsi flap breast reconstruction[J].Ann Plast Surg,2015,74(4):397-402.
[49]FIGUS A,MAZZOCCHI M,DESSY L A,et al.Treatment of muscular contraction deformities with botulinum toxin type A after latissimus dorsi flap and sub-pectoral implant breast reconstruction[J].J Plast Reconstr Aesthet Surg,2009,62(7):869-875.
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[2]COTLAR A M,DUBOSE J J,ROSE D M.History of surgery for breast cancer:radical to the sublime[J].Curr Surg,2003,60(3):329-337.
[3]胡卫东,赵传印.不同手术方式对早期乳腺癌患者疗效及生活质量的影响[J].社区医学杂志,2016,14(5):41-43.
[4]钟世镇,徐达传,丁自海.显微外科临床解剖学[M].山东科学技术出版社,山东,2000:125-130.
[5]王 炜.整形外科学[M].浙江科学技术出版社,浙江,1999:241-246.
[6]WEI F C,MARDINI S,孙家明.皮瓣与重建外科[M].人民卫生出版社,北京,2011:247.
[7]ANGRIGIANI C,GRILLI D,SIEBERT J.Latissimus dorsi musculocutaneous flap without muscle[J].Plast Reconstr Surg,1995,96(7):1608-1614.
[8]SCHWABEGGER A H,HARPF C,RAINER C.Musclesparing latissimus dorsi myocutaneous flap with maintenance of muscle innervation,function,and aesthetic appearance of the donor site[J].Plast Reconstr Surg,2003,111(4):1407-1411.
[9]姜专基,刘鸿雁,杜延泽,等.乳腺癌保留乳房手术后部分背阔肌脂肪瓣即刻乳房重建的临床应用价值[J/CD].中华乳腺病杂志(电子版),2011,5(2):151-160.
[10]GERMANN G,STEINAU H U.Breast reconstruction with the extended latissimus dorsi flap[J].Plast Reconstr Surg,1996,97(3):519-526.
[11]BAUMHOLTZ M A,AL-SHUNNAR B M,DABB R W.Boomerang flap reconstruction for the breast[J].Ann Plast Surg,2002,49(1):44-48
[12]G A R B AY J R,S A O U M A S,M A R S I G L I A H.Progress in immediate breast reconstruction with skin sparing mastectomy[J].Ann Chir Plast Esthet,2008,53(2):199-207.
[13]DURKAN B,AMERSI F,PHILLIPS E H,et al.Postmastectomy radiation of latissimus dorsi myocutaneous flap reconstruction is well tolerated in women with breast cancer[J].Am Surg,2012,78(10):1122-1127.
[14]MCKEOWN D J,HOGG F J,BROWN I M,et al.The timing of autologous latissimus dorsi breast reconstruction and effect of radiotherapy on outcome[J].J Plast Reconstr Aesthet Surg,2009,62(4):488-493.
[15]DALTREY I,THOMSON H,HUSSIEN M,et al.Randomized clinical trial of the effect of quilting latissimus dorsi flap donor site on seroma formation[J].Br J Surg,2006,93(7):825-830.
[16]MUNHOZ A M,MONTAG E,ARRUDA E,et al.Assessment of immediate conservative breast surgery reconstruction:a classification system of defects revisited and an algorithm for selecting the appropriate technique[J].Plast Reconstr Surg,2008,121(3):716-727.
[17]MUNHOZ A M,MONTAG E,FELS K W,et al.Outcome analysis of breast-conservation surgery and immediate latissimus dorsi flap reconstruction in patients with T1 to T2breast cancer[J].Plast Reconstr Surg,2005,116(3):741-752.
[18]CHA H G,KANG S G,SHIN H S,et al.Does fibrin sealant reduce seroma after immediate breast reconstruction utilizing a latissimus dorsi myocutaneous flap?[J].Arch Plast Surg,2012,39(5):504-508.
[19]GISQUET H,DELAY E,PARADOL P O,et al.Prevention of seroma by quilting suture after harvesting latissimus dorsi flap.The“Chippendale”technic[J].Ann Chir Plast Esthet,2010,55(2):97-103.
[20]DANCEY A L,CHEEMA M,THOMAS S S,et al.A prospective randomized trial of the efficacy of marginal quilting sutures and fibrin sealant in reducing the incidence of seromas in the extended latissimus dorsi donor site[J].Plast Reconstr Surg,2010,125(5):1309-1317.
[21]YANG Y,CHEN Y,QU J,et al.The use of OK-432 to prevent seroma in extended latissimus dorsi flap donor site after breast reconstruction[J].J Surg Res,2015,193(1):492-496.
[22]POMEL C,MISSANA M C,ATALLAH D,et al.Endoscopic muscular latissimus dorsi flap harvesting for immediate breast reconstruction after skin sparing mastectomy[J].Eur J Surg Oncol,2003,29(2):127-131.
[23]IGLESIAS M,GONZALEZ-CHAPA D R.Endoscopic latissimus dorsi muscle flap for breast reconstruction after skin-sparing total mastectomy:report of 14 cases[J].Aesth Plast Surg,2013,37(4):719-727.
[24]刘春生,孙建伟,赖明华,等.腔镜辅助下背阔肌肌瓣乳腺癌肿瘤扩大切除乳房重塑25例临床观察[J].中华肿瘤防治杂志,2013,20(17):1352-1355.
[25]CLEMENS M W,KRONOWITZ S,SELBER J C,et al.Robotic-assisted latissimus dorsi harvest in delayedimmediate breast reconstruction[J].Semin Plast Surg,2014,28(1):20-25.
[26]CHUNG J H,YOU H J,KIM H S,et al.A novel technique for robot assisted latissimus dorsi flap harvest[J].J Plast Reconstr Aesthet Surg,2015,68(7):966-972.
[27]DUGGAL C S,MADNI T,LOSKEN A.An outcome analysis of intraoperative angiography for postmastectomy breast reconstruction[J].Aesthet Surg J,2014,34(1):61-65.
[28]HARLESS C A,JACOBSON S R.Tailoring through technology:a retrospective review of a single surgeon’s experience with implant-based breast reconstruction before and after implementation of laser-assisted indocyanine green angiography[J].Breast J,2016,22(3):274-281.
[29]DIEP G K,HUI J Y,MARMOR S,et al.Postmastectomy reconstruction outcomes after intraoperative evaluation with indocyanine green angiography versus clinical assessment[J].Ann Surg Oncol,2016,23(12):4080-4085.
[30]YANG J D,HUH J S,MIN Y S,et al.Physical and functional ability recovery patterns and quality of life after immediate autologouslatissimus dorsi breast reconstruction:a 1-year prospective observational study[J].Plast Reconstr Surg,2015,136(6):1146-1154.
[31]SAINT-CYR M,NAGARKAR P,SCHAVERIEN M,et al.The pedicled descending branch muscle-sparing latissimus dorsi flap for breast reconstruction[J].Plast Reconstr Surg,2009,123(1):13-24.
[32]LIU X,ZHOU L,PAN F,et al.Comparison of the postoperative incidence rate of capsular contracture among different breast implants:a cumulative meta-analysis[J].PLo S One,2015,10(2):e0116071.
[33]AJDIC D,ZOGHBI Y,GERTH D,et al.The relationship of bacterial biofilms and capsular contracture in breast implants[J].Aesthet Surg J,2016,36(3):297-309.
[34]WELLISCH D K,SCHAIN W S,NOONE R B,et al.The psychological contribution of nipple addition in breast reconstruction[J].Plast Reconstr Surg,1987,80(5):699-704.
[35]JABOR M A,SHAYANI P,COLLINS D R Jr,et al.Nippleareola reconstruction:satisfaction and clinical determinants[J].Plast Reconstr Surg,2002,110(2):457-463,discussion 464-465.
[36]GERBER B,KRAUSE A,DIETERICH M,et al.The oncological safety of skin sparing mastectomy with conservation of the nipple areola complex and autologous reconstruction:an extended follow-up study[J].Ann Surg,2009,249(3):461-468.
[37]共识专家讨论组.保留乳头乳晕复合体乳房切除术的专家共识与争议[J].中国癌症杂志,2016,26(5):476-480.
[38]MUNHOZ A M,MONTAG E,FELS K W,et al.Outcome analysis of breast-conservation surgery and immediate latissimus dorsi flap reconstruction in patients with T1 to T2breast cancer[J].Plast Reconstr Surg,2005,116(3):741-752.
[39]FIGUS A,MAZZOCCHI M,DESSY L A,et al.Treatment of muscular contraction deformities with botulinum toxin type A after latissimus dorsi flap and sub-pectoral implant breast reconstruction[J].J Plast Reconstr Aesthet Surg,2009,62(7):869-875.
[40]SZYCHTA P,BUTTERWORTH M,DIXON M,et al.Breast reconstruction with the denervated latissimus dorsi musculocutaneous flap[J].Breast,2013,22(5):667-672.
[41]SCHROEGENDORFER K F,HACKER S,NICKL S,et al.Latissimus dorsi breast reconstruction:how much nerve resection is necessary to prevent postoperative muscle twitching?[J].Plast Reconstr Surg,2014(10):1125-1129.
[42]BRANFORD O A,KELEMEN N,HARTMANN C E,et al.Subfascial harvest of the extended latissimus dorsi myocutaneous flap in breast reconstruction:a comparative analysis of two techniques[J].Plast Reconstr Surg,2013,132(4):737-748.
[43]Report on autologous fat transplantation.ASPRS Ad-Hoc Committee on New Procedures,September 30,1987[J].Plast Surg Nurs,1987,7(4):140-141.
[44]COLEMAN S R,SABOEIRO A P.Fat grafting to the breast revisited:safety and efficacy[J].Plast Reconstr Surg,2007,119(3):775-785.
[45]LOSKEN A,PINELL X A,SIKORO K,et al.Autologous fat grafting in secondary breast reconstruction[J].Ann Plast Surg,2011,66(5):518-522.
[46]SANTANELLI DI POMPEO F,LAPORTA R,SOROTOS M,et al.Latissimus dorsi flap for total autologous immediate breast reconstruction without implants[J].Plast Reconstr Surg,2014,134(6):871e-879e.
[47]NIDDAM J,VIDAL L,HERSANT B,et al.Primary fat grafting to the pectoralis muscle during latissimus dorsi breast reconstruction[J].Plast Reconstr Surg Glob Open,2016,4(11):e1059.
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