Objective To investigate the location of the artery correlated with rectus abdominis musculocutaneous flap in order to promote the reconstruction of the breast after radical mastectocy for breast cancer.Methods An anatomic study was carried out on 15 cadavers of 30 sides，which were immersed in paraformaldehyde less than six months. Whole thoraepigastrica wall was cutted, which scale was from subclavian as upper limit to inguinal ligament, the lower limit across left and right of middle axillary. Veins or arteriesof inferior epigastrica and internal thorax in hang were injected with red or blue ink to show all of vessel branches. Results The external diameters of both the superior epigastric arteries and inferior vessels were 1.87±0.28 mm and 2.25±0.32 mm respectively. The myocutaneous arteries from inferior abdomen vessels had an intensive horizontal distribution on hylum. The perforators significantly decreased but could be found to pass through anterior rectus sheath in Rand. The distances between lateral perforators and Ⅰ,Ⅱ and Ⅲ parts in external edge of anterior rectus sheath were 1.22, 1.46 and1.57 cm, respectively; and the distances between medial perforators and Ⅰ, Ⅱ, and Ⅲ parts at median line were 1.54, 1.62, 1.66 cm. Perforators were more thick and intensive near hylum than in other part. The subcostal arteries derived from inferior abdomen artery and 1.25±0.37 cm away from costal arch. Afterdividing into subcostal artery, the outer diameter of 67 percent of subcostal artery was bigger than that of inferior abdomen arteries. The branches of subcostalarteries were distributed at the 2/3 lateral rectus abdominis, forming an extenive choke anastomosis system with intercostal anterior artery and vessels supplied diaphragmatic muscle. The rectus abdominis at the level of xyphoid was supplied by a branch came from inferoir thorax artery, which diverged epigastric vessels at the same time.Conclusion During the process of makingthe inferior transverse rectus abdominis musculocutaneous flap base on superior epigastric vessels and superoir rectus abdobminis, reservation of pro-theca edge 1 cm of rectus abdominis can protect inferior abdomen artery from injury. Reservation of more than 2 cm pro-theca and rectus abdominis below costal arch at the flag will protect effectively subcostal artery from injury. No damage of subcostal arteries can influence the survival of musculocutaneous flap.
Objective To introduce the treatment experiences about the skin-sparing mastectomy and immediate breast reconstruction. Methods The skin-sparing mastectomy and immediate breast reconstruction by using transverse rectus abdominis myocutaneous （TRAM） flat were performed in 10 patients with early-stage breast cancer from May 2008 to December 2011 in our hospital. The patients’ data were retrospectively analyzed. Results There were postoperative complications after skin-sparing mastectomy and immediate breast reconstruction， including TRAM flat necrosis in 1 case， papillary necrosis in 1 case and fat necrosis in the reconstructed breast with oxter wound infection in 1 case. There was no incision hernia of abdominal wall or necrosis of all TRAM flat in any case. The patients’ satisfaction that evaluation for the breast shapes of reconstructed breasts was very satisfaction in 5 cases， part satisfaction in 4 cases， and dissatisfaction in 1 case， respectively. Conclusions Because of the minimal access approach and good breast shape， the skin-sparing mastectomy and immediate TRAM flat breast reconstruction is a safe and effective way for treating early-stage breast cancer.
ObjectiveTo review the application and research progress of autologous fat grafting in breast reconstruction.
MethodThe recent literature concerning the technique, postoperative outcome, or limitations of autologous fat grafting in breast reconstruction was extensively consulted and reviewed.
ResultsThere are several ways of breast reconstruction using autologous fat for patients who underwent mastectomy or breast conserving surgery. The complication incidence of fat grafting in breast reconstruction is low. Although the long-term outcome is unsteady, the aesthetic outcomes of autologous fat grafting can still reach a high satisfaction. However, the oncological safety of autologous fat grafting in women with breast cancer has not been fully proved.
ConclusionsThe remarkable progress has been made in the researches of autologous fat grafting, and it is an effective method in breast reconstructive surgery. Studies with high quality and longer follow-up data are urgently required to assess the oncological safety of autologous fat grafting.
ObjectiveTo explore the effectiveness of dual-pedicle abdominal flap for unilateral breast reconstruction.MethodsBetween March 2014 and March 2018, a clinical data of 19 female patients underwent dual-pedicle abdominal flap reconstruction because of unilateral mastectomy defect was reviewed retrospectively. The median age was 45 years (range, 32-51 years), including 3 immediate breast reconstruction and 16 delayed breast reconstruction, and left side in 7 cases and right side in 12 cases. Unilateral breast reconstruction were performed for 8 patients with unilateral pedicle transverse rectus abdominis musculocutaneous (TRAM) flap and contralateral free TRAM flap, for 3 patients with pedicle TRAM flap and contralateral deep inferior epigastric perforator (DIEP) flap, for 7 patients with bilateral DIEP flaps, for 1 patient with free muscle-sparing TRAM flap and contralateral DIEP flap. The size of abdominal flap ranged from 24 cm×7 cm to 43 cm×13 cm. The donor sites were closed directly.ResultsVascular crisis ocuurred in 1 flap and relieved after surgical exploration. The other flaps survived. Poor wound healing in abdominal incision occurred in 1 patient and was successfully treated with debridement. The other donor sites healed without any other complication. The patients were followed up with a median period of 12 months (range, 4-42 months). Four patients received reparative operation of their reconstructive breast, and 2 patients received mamopexy of the contralateral breast due to mastoptosis. The abdominal BREAST-Q score was 84.1±11.7, chest score was 86.5±8.9, and breast score was 67.6±16.4 at last follow-up.ConclusionThe dual-pedicle abdominal flap for unilateral breast reconstruction provides adequate soft tissue volume and good blood supply. It is a reliable and effective breast reconstructive method for patients who need large tissue volume to make symmetric with the contralateral breast, or slim patients with few tissue in the donor site, or patients with scars in the donor site, especially vertical abdominal scars.
ObjectiveTo explore the feasibil ity and rel iabil ity of rib-sparing technique for internal mammary vessels exposure and anastomosis in breast reconstruction and thoracic wall repair with deep inferior epigastric perforator (DIEP) flaps.
MethodsBetween November 2009 and September 2011, 11 female patients with post-mastectomy deformities were treated. The mean age was 42 years (range, 33-65 years). Of them, 10 patients underwent breast reconstruction with the DIEP flaps, and 1 patient received defect repair for chronic thoracic wall irradiated ulcer with the DIEP flap. The size of the flap ranged from 18 cm×9 cm to 28 cm×12 cm. Rib-sparing technique was applied in all these cases. The internal mammary vessels were exposed by dissection intercostal space and anastomosed with the deep inferior epigastric vessels. The donor sites were closed directly in all cases.
ResultsIn all cases, the rib-sparing technique for internal mammary vessels exposure and anastomosis was successfully performed. The mean time for internal mammary vessels exposure was 52 minutes (range, 38-65 minutes). The mean exposure length of the internal mammary vessels was 1.7 cm (range, 1.3-2.2 cm). All flaps survived completely postoperatively, and wounds and incisions at donor sites healed primarily. All patients were followed up 8-26 months (mean, 12 months). All patients were satisfied with the reconstructive outcomes. No collapse deformity or discomfort of the thoracic wall occurred.
ConclusionThe rib-sparing technique for internal mammary vessels exposure and anastomosis is a rel iable and reproducible approach to reconstruct the breast and repair the thoracic wall with DIEP flap, and it can reduce collapse deformity of the thoracic wall.
Objective To review the application progress, mechanism, application points, limitations, and oncological safety of external volume expansion (EVE) assisted autologous fat grafting for breast reconstruction and provide a reference for optimizing the design of EVE. Methods Based on the latest relevant articles, the basic experiments and clinical applications of EVE were summarized. ResultsEVE can reduce interstitial fluid pressure, increase blood supply, and promote adipogenic differentiation, thereby benefiting the survival of transplanted fat. EVE assisted autologous fat grafting in clinical practice can improve the retention rate of breast volume and the outcome of breast reconstruction, meanwhile it doesn’t increase the risk of local recurrence. But there is no standard parameters for application, and there are many complications and limitations. ConclusionEVE improves the survival of transplanted fat, but its complications and poor compliance are obvious, so it is urgent to further investigate customized products for breast reconstruction after breast cancer and establish relevant application guidelines.
【Abstract】 Objective To discuss the aesthetic effect and appl ication of refined incisions in breast reconstructionfor breast cancer patients by the transverse rectus abdominis myocutaneous (TRAM) flap. Methods From January 2001 toOctober 2006, 77 cases with breast cancer were treated with TRAM flap to immediate breast recontruction. The patients were all femals, with an average age of 45 years (ranging from 26 years to 53 years). There were 39 cases of left breast and 38 cases of right breast. The disease course was from 1 day to 180 days. There were 11 cases of stage I , 60 cases of stage II and 6 cases of stage III, among which 34 cases were located in the upper outer quadrant, 15 in the lower outer quadrant, 22 in the upper inner quadrant and 6 in the lower inner quadrant. The size of tumors varied from 1 cm to 4 cm. As to the pathologic type, 60 cases were invasive ductal cancers, 12 ductal cancers in situ, 5 invasive lobular cancers; positive lymph node (number: 1-7) happened in 29 cases, while negative lymph node happened in 48 cases. Among the 77 cases, regular shuttle incisions were performed in 35 cases, and refined circle incisions were performed in 42 cases, which were 2 cm away from the breast tumor border. Axillary incision was necessary for the breast tumors located in upper inner, lower inner and upper outer quadrants in order to perform axillary mastectomy. Ten cases were ni pple-areola sparing. The shape, symmetry and incision scar of the reconstructed breast were evaluated and graded. Results There were 6 cases out of 77 cases of breast reconstruction in which partial necrosis happened and the necrosis rate was 7.79%. The time of follow-up was from 13 months to72 months, with an average of 39 months. No recurrence or matastasis happened in 76 cases, and distant metastasis happened only in 1 case. There were 40 cases out of 42 cases with refined incisions which were scored more than 3, and the satisfaction rate was 95.24%. There were 31 cases out of 35 cases with regular incisions which were scored more than 3, and the satisfaction rate was 88.57%. Conclusion The reasonable refined incision based on the location of the tumor is effective to improve the satisfaction rate for the shape of the reconstructed breast.
ObjectiveTo explore the clinical efficacy of immediate breast reconstruction with extended latissimus dorsi musculocutaneous flap after nipple and areola sparing modified radical mastectomy for patients with early-middle breast cancer.
MethodsSixty patients diagnosed with early-middle breast cancer by needle biopsy from November 2009 to October 2012 in this hospital were divided into two groups according to the surgical method.The breast reconstruction group (30 cases) were performed immediate breast reconstruction with extended latissimus dorsi musculocutaneous flap after nipple and areola sparing modified radical mastectomy, the control group (30 cases) were performed traditional modified radical mastectomy.The postoperative complications, clinical efficacy, quality of life, and recurrence and metastasis were compared in two groups.
Results①The ipsilateral breast was completely missing in the control group.The aesthetic effect in the breast reconstruction group was satisfactory including excellent in 22 patients, good in 7 patients, general in 1 patient.②The rates of flaps effusion, flap necrosis, and affectied limb activity limitation had no significant differences in two groups (P > 0.05).The wound healing time, operation area drainage time, hospital stay, and post-operative chemotherapy start time all had no significant differences in two groups (P > 0.05).③The frequency of psycho-logical pressure (inferiority/anxiety/fear) and rate of un-satisfaction of secondary sexual characteristics (body/curve) in the breast reconstruction group were lower than those in the control group (P < 0.001).The rate of social interaction fitness in the breast reconstruction group was higher than that in the control group (P < 0.001).④The following-up time was 12 to 38 months with an average 25 months, one case died because of brain metastasis in the control group, the rest 59 patients had no local recurrence and distant metastasis.
ConclusionsThe immediate breast reconstruction with exte-nded latissimus dorsi musculocutaneous flap after nipple and areola sparing modified radical mastectomy can cure cancer on the basis of satisfactory cosmetic results of breast, excellent quality of life of patients, and fewer surgical complica-tions.It does not affect postoperative adjuvant radiochemotherapy and short-and long-term efficacy for breast cancer.
Objective To explore the interaction of postmastectomy radiotherapy （PMRT） and breast reconstruction， and elucidate how to choose the type and timing of breast reconstruction. Method Literatures about PMRT and breast reconstruction were reviewed. Results PMRT might increase the incidence of complications and impair the cosmetic satisfaction of breast reconstruction. Breast reconstruction might also compromise the effect of PMRT. Conclusions In patients who will receive or have already received PMRT， the optimal approach is delayed autologous tissue reconstruction after PMRT. If PMRT appears likely but may not be required at the time of mastectomy，delayed-immediate reconstruction may be considered， or immediate autologous tissue reconstruction may be considered in case of patients awareness of the increased complications and impaired cosmetic outcomes from PMRT.
ObjectiveTo understand the application of acellular dermal matrix (ADM) in implant-based breast reconstruction.
MethodLiteratures on application of ADM in the implant-based breast reconstruction were reviewed.
ResultsADM was widely used in the implant-based breast reconstruction and revisionary breast surgery. ADM could help to achieve a better reconstruction outcome by precisely locating the inferior mammary fold and strengthening the local control of the implant. However, whether ADM might increase the postoperative complications was controversial.
ConclusionADM assisted implant-based breast reconstruction could achieve a better cosmetic outcome, but the large sample randomized controlled trial is needed to evaluate the application effect and risk of ADM.
