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北京大学学报（医学版） ›› 2020, Vol. 52 ›› Issue (1): 169-176. doi: 10.19723/j.issn.1671-167X.2020.01.027

• 论著 • 上一篇    下一篇

组织扩张结合假体乳房重建的技术改进

马建勋1,夏有辰1,李比1,△(),赵红梅2,雷玉涛2   

  1. 1. 北京大学第三医院 成形外科, 北京　100191
    2. 北京大学第三医院 普通外科,北京　100191
  • 收稿日期:2019-04-11 出版日期:2020-02-18 发布日期:2020-02-20
  • 通讯作者: 李比 E-mail:libi0377@sina.com

Techniques enhancement for tissue expander/implant two-stage breast reconstruction

Jian-xun MA1,You-chen XIA1,Bi LI1,△(),Hong-mei ZHAO2,Yu-tao LEI2   

  1. 1. Department of Plastic Surgery, Peking University Third Hospital, Beijing 100191, China
    2. Department of General Surgery, Peking University Third Hospital, Beijing 100191, China
  • Received:2019-04-11 Online:2020-02-18 Published:2020-02-20
  • Contact: Bi LI E-mail:libi0377@sina.com

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摘要：

目的:探讨组织扩张-假体乳房重建中扩张器埋置、组织扩张、假体置换过程中技术细节的改进对于乳房重建效果的影响。方法:回顾分析2014年4月至2018年9月在北京大学第三医院行乳腺癌切除术后,接受即刻或延期扩张器-假体结合自体脂肪移植的68例乳房重建患者的相关信息,总结切口选择、扩张器埋置位置、扩张理念、包膜处理、假体选择方法及辅助重建技术的改进情况,并利用三维体表成像技术对重建效果进行客观评估。结果:即刻乳房重建者25例,延期重建者43例,组织扩张的中位周期为7.0(3.0, 20.0)个月,平均扩张注水量(372.8±87.2) mL,置换假体的中位体积为215(100, 395) mL,自体脂肪移植的中位次数为1(1, 3)次,平均脂肪移植的注射总量为(119.3±34.1) mL,术后随访的中位周期为7.0(4.0, 24.0)个月,2例患者出现的并发症均为扩张器渗漏,其中1例因继发感染行扩张器置换。即刻重建患者的术后双侧乳房体积比术前获得了更好的对称性(t=4.465,P<0.01),延期重建患者的术后双侧乳房体积比术前也获得了良好的对称性(t=0.867,P>0.1)。结论:通过横向切口的选择、扩张器埋置点的下移、胸壁软组织的快速扩张、包膜的张力释放、假体选择过程中试模(sizer)的应用并辅以自体脂肪注射移植,可以使组织扩张后的假体乳房重建达到良好的临床效果。

关键词: 组织扩张, 乳房成形术, 乳房植入物, 自体脂肪移植

Abstract:

Objective: To investigate the outcomes of breast reconstruction with employing improved techniques throughout the tissue expander/implant two-stage breast reconstructed process, which involved the tissue expander placement, the saline filling intraoperatively and postoperatively, the implant selection, and the permanent implant replacement. Methods: In this study, 68 patients who had been provi-ded immediate or delayed tissue expander/implant two-stage breast reconstruction with autologous fat injection post-mastectomy in Peking University Third Hospital from April 2014 to September 2018 were involved, and the relevant information was analyzed retrospectively. The enhancements of the techniques, involving the incision selection, the expander placement, the principle of expansion, the management of capsule, the prosthesis selection, and the assisted reconstruction method were summarized, and the reconstruction outcomes were evaluated objectively through three-dimensional surface imaging. Results: Among the 68 patients in this study, immediate reconstruction was conducted in 25 patients and 43 patients underwent delayed reconstruction. The median time of tissue expansion was 7.0 (3.0, 20.0) months, and the average volume of expansion was (372.8±87.2) mL. The median size of breast implant was 215 (100, 395) mL. The median number of injections for fat grafting was 1 (1, 3), and the average volume of fat grafting was (119.3±34.1) mL. The median follow-up time was 7.0 (4.0, 24.0) months. During the process of breast reconstruction, the tissue expander leakage was observed in two patients, and one of them underwent expander replacement due to the secondary infection. In the immediate reconstruction cases, the volume symmetry of bilateral breasts after reconstruction got even better than that before mastectomy (t=4.465, P<0.01). And in the delayed reconstruction cases, the volume between bilateral breasts also achieved good symmetry after reconstruction (t=0.867, P>0.1). Conclusion: Good results of tissue expander/implant two-stage breast reconstruction could be achieved through the techniques enhancement, which involved the preferred transverse incision, the downward placement of expander, the rapid expansion of chest soft tissue, the release of capsule tension, the application of sizer in prosthesis selection, and the assisted autologous fat grafting.

Key words: Tissue expansion, Mammaplasty, Breast Implants, Autologous fat graft

中图分类号: 

  • R622

表1

68例乳癌术后乳房重建患者的基本情况"

Items Data
Age/years 37.6±9.1
BMI 21.6 (16.8, 28.7)
Clinical stage (breast cancer)
Stage 0 9 (13.2%)
StageⅠ 32 (47.1%)
StageⅡ 27 (39.7%)
Final pathology
Invasive ductal carcinoma 57 (83.8%)
Ductal carcinoma in situ 8 (11.8%)
Mucinous adenocarcinoma 2 (2.9%)
Large cell neuroendocrine carcinoma 1 (1.5%)
Affected side
Right 26 (38.2%)
Left 42 (61.8%)
Nipple-areola preserving
Yes 3 (4.4%)
No 65 (95.6%)
Axillary lymph node dissection
Yes 54 (79.4%)
No 14 (20.6%)
Chemotherapy
Yes 62 (91.2%)
No 6 (8.8%)
Radiation
Yes 7 (10.3%)
No 61 (89.7%)

图1

三维体表成像工作站(VECTRA-XT)"

图2

软组织扩张器埋置腔隙范围"

图3

组织扩张过程中双侧乳房对称性的判断"

图4

脂肪移植范围的术前设计"

图5

术中置入试模sizer辅助观察双侧乳房对称性"

表2

68例患者乳房重建的相关情况"

Items Data
Reconstruction timing
Immediate 25 (36.8%)
Delayed 43 (63.2%)
Volume injected for expansion/mL 372.8±87.2
Period of expansion/month 7.0 (3.0, 20.0)
Implant
Anatomical 58 (85.3%)
Round 10 (14.7%)
Volume/mL 215 (100, 395)
Numbers of fat grafting 1 (1, 3)
Volume of fat grafting/mL 119.3±34.1
Follow-up/month 7.0 (4.0, 24.0)
Recurrence or metastasis of tumor 0 (0)
Complication 2 (2.9%)

表3

三维体表成像的体积测量"

Items x?±s P
Immediate reconstruction
Affected/mL
Pre-operation 216.2±59.7
Post-operation 223.7±79.9
Contralateral/mL
Pre-operation 230.7±74.3
Post-operation 231.1±84.8
Bilateral difference/mL
Pre-operation 25.5±16.5
Post-operation 12.9±12.4
Breasts asymmetry/%
Pre-operation 11.1±6.4 <0.001*
Post-operation 5.3±4.3
Delayed reconstruction of post-operation
Contralateral/mL 240.1±63.8 0.392
Affected/mL 238.2±58.6
Bilateral difference/mL 10.3±7.5
Breasts asymmetry/% 4.2±2.6

图6

即刻乳房重建患者术前、术后的对比"

图7

延期乳房重建患者术前、术后的对比"

图8

扩张器的埋置位置"

图9

扩张器形态的球形变化"

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