组织扩张结合假体乳房重建的技术改进

doi:10.19723/j.issn.1671-167X.2020.01.027

摘要/Abstract

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

马建勋,夏有辰,李比,赵红梅,雷玉涛. 组织扩张结合假体乳房重建的技术改进[J]. 北京大学学报（医学版）, 2020, 52(1): 169-176.

Jian-xun MA,You-chen XIA,Bi LI,Hong-mei ZHAO,Yu-tao LEI. Techniques enhancement for tissue expander/implant two-stage breast reconstruction[J]. Journal of Peking University(Health Sciences), 2020, 52(1): 169-176.

图/表 12

表1

图1

图2

图3

图4

图5

表2

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	<0.001^*
Delayed reconstruction of post-operation
Contralateral/mL	240.1±63.8	0.392
Affected/mL	238.2±58.6	0.392
Bilateral difference/mL	10.3±7.5
Breasts asymmetry/%	4.2±2.6

表3

图6

图7

图8

图9

参考文献 30

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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%)

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%)