腹部游离皮脂肪筋膜瓣在保乳术缺损修复中的应用现状(1)
[摘要] 对于早期乳腺癌，肿瘤治疗的安全性与术后乳房外形的兼顾是医患双方共同追求的目标。目前，保乳手术乳房缺损的整复主要依靠乳腺肿瘤整形技术，即乳腺腺体移位法和自体组织瓣替代法。由于亚洲女性乳房体积整体偏小，肿瘤切除后的腺体缺损往往难以通过腺体移位弥补，应用自体组织填充缺损变形的乳房，可获得较好的美容效果。但既往尝试的背阔肌肌瓣、横行腹直肌肌皮瓣、腹壁下动脉穿支皮瓣等由于手术难度大，需专业显微外科技术而难以广泛开展。日本学者Kijima率先在临床上应用腹部游离脂肪皮瓣修复乳房缺损，术后美容效果好且手术操作简单，有望在临床上推广。但该术式目前开展时间尚短，仍需长期大样本量随访对其术后远期美容效果、并发症等进行科学评估。
[关键词] 乳腺癌;保乳手术;腹部游离脂肪皮瓣;整形技术
[中图分类号] R737.9 [文献标识码] A [文章编号] 1673-7210(2020)09(b)-0030-04
[Abstract] For early-stage breast cancer， both the safety of tumor treatment and the breast shape after surgery are the same goals pursued by doctors and patients. At present， the repairing of tissue defect after breast-conserving therapy mainly depends on oncoplastic breast surgery techniques， including glands displacement and autologous tissue breast replacement. Because the breast size of the Asian women are not big enough to undergo repairing by simple glands displacement after breast-conserving surgery， using an autologous tissue to fill up the defect can produce good cosmetic outcomes. However， the latissimus dorsi muscle flap， transverse rectus abdominis-myocutaneous flap， inferior abdominal artery perforator flap， and so on， which have been tried in the past， are difficult to carry out due to the difficulty of surgery and requirement of professional microsurgical techniques. Japanese scholar Kijima is the first one who use an autologous free dermal fat graft for breast defect tissue repair， which shows good cosmetic outcomes and simple to operating. This method is expected to be promoted clinically. Due to the short history of this operation， it still needs a long-term follow-up with large samples to scientifically evaluate the long-term postoperative cosmetic outcomes and complications.
[Key words] Breast cancer; Breast-conserving surgery; Abdominal free dermal fat graft; Plastic technique
隨着人群乳腺癌知识的普及、乳腺筛查的开展，临床上早期乳腺癌的比例逐步增加。国际上多项临床随机对照研究[1-3]表明，对于早期乳腺癌，保乳手术(局部扩大切除术)加放疗与改良根治术可以达到相同的预后。采用适当的乳房整形技术不仅可扩大肿瘤的切除范围，还能降低切缘阳性率，减少再次手术或全乳房切除的机会。目前，保乳手术乳房缺损的修复主要依靠乳腺肿瘤整形技术，即乳腺腺体移位法和自体组织瓣替代法，以达到肿瘤治疗效果与乳房外形的兼顾。Chan等[4]指出，切除腺体量达乳房体积的20%以上时，乳房会产生明显畸形。当采用腺体移位的方法难以达到满意修复效果时，自体组织修复成为一种有效的选择[5]，本文就腹部游离脂肪筋膜瓣在保乳手术中的应用进行综述。
1 保乳手术适应证
我国指南[6]提出，肿瘤大小属于T1和T2分期，且乳房有适当体积，肿瘤与乳房体积比例适当，术后能够保持良好的乳房外形的早期乳腺癌患者，如有意愿均可施行保乳。位于同一象限的多灶乳腺癌也可行保乳手术。
2 术后美容效果评价及影响因素
保乳术后美容效果的评价指标[7]：①双侧乳房的对称性;②乳房表面凹陷程度;③皮肤质地与弹性;④皮肤色泽;⑤乳头横向移位距离;⑥乳头纵向移位距离;⑦乳房顺应性差值;⑧切口瘢痕。文献报道[5]，乳腺癌保乳术后14%～35%的患者美容效果不佳。重建乳房的外观除两侧乳房的对称外，还包括乳房下皱襞、下垂度和前突度[8]，受肿瘤大小和位置、乳房的体积及下垂度、手术技巧、放射治疗的剂量和范围等多方面因素影响。因此，欲取得良好的重建效果，术前需进行充分的准备，完善相关检查，明确乳腺癌分期、是否需行新辅助治疗，对拟行保乳疗法的患者进行筛选。, 百拇医药(赵烨 赵菁 王亚军)
[关键词] 乳腺癌;保乳手术;腹部游离脂肪皮瓣;整形技术
[中图分类号] R737.9 [文献标识码] A [文章编号] 1673-7210(2020)09(b)-0030-04
[Abstract] For early-stage breast cancer， both the safety of tumor treatment and the breast shape after surgery are the same goals pursued by doctors and patients. At present， the repairing of tissue defect after breast-conserving therapy mainly depends on oncoplastic breast surgery techniques， including glands displacement and autologous tissue breast replacement. Because the breast size of the Asian women are not big enough to undergo repairing by simple glands displacement after breast-conserving surgery， using an autologous tissue to fill up the defect can produce good cosmetic outcomes. However， the latissimus dorsi muscle flap， transverse rectus abdominis-myocutaneous flap， inferior abdominal artery perforator flap， and so on， which have been tried in the past， are difficult to carry out due to the difficulty of surgery and requirement of professional microsurgical techniques. Japanese scholar Kijima is the first one who use an autologous free dermal fat graft for breast defect tissue repair， which shows good cosmetic outcomes and simple to operating. This method is expected to be promoted clinically. Due to the short history of this operation， it still needs a long-term follow-up with large samples to scientifically evaluate the long-term postoperative cosmetic outcomes and complications.
[Key words] Breast cancer; Breast-conserving surgery; Abdominal free dermal fat graft; Plastic technique
隨着人群乳腺癌知识的普及、乳腺筛查的开展，临床上早期乳腺癌的比例逐步增加。国际上多项临床随机对照研究[1-3]表明，对于早期乳腺癌，保乳手术(局部扩大切除术)加放疗与改良根治术可以达到相同的预后。采用适当的乳房整形技术不仅可扩大肿瘤的切除范围，还能降低切缘阳性率，减少再次手术或全乳房切除的机会。目前，保乳手术乳房缺损的修复主要依靠乳腺肿瘤整形技术，即乳腺腺体移位法和自体组织瓣替代法，以达到肿瘤治疗效果与乳房外形的兼顾。Chan等[4]指出，切除腺体量达乳房体积的20%以上时，乳房会产生明显畸形。当采用腺体移位的方法难以达到满意修复效果时，自体组织修复成为一种有效的选择[5]，本文就腹部游离脂肪筋膜瓣在保乳手术中的应用进行综述。
1 保乳手术适应证
我国指南[6]提出，肿瘤大小属于T1和T2分期，且乳房有适当体积，肿瘤与乳房体积比例适当，术后能够保持良好的乳房外形的早期乳腺癌患者，如有意愿均可施行保乳。位于同一象限的多灶乳腺癌也可行保乳手术。
2 术后美容效果评价及影响因素
保乳术后美容效果的评价指标[7]：①双侧乳房的对称性;②乳房表面凹陷程度;③皮肤质地与弹性;④皮肤色泽;⑤乳头横向移位距离;⑥乳头纵向移位距离;⑦乳房顺应性差值;⑧切口瘢痕。文献报道[5]，乳腺癌保乳术后14%～35%的患者美容效果不佳。重建乳房的外观除两侧乳房的对称外，还包括乳房下皱襞、下垂度和前突度[8]，受肿瘤大小和位置、乳房的体积及下垂度、手术技巧、放射治疗的剂量和范围等多方面因素影响。因此，欲取得良好的重建效果，术前需进行充分的准备，完善相关检查，明确乳腺癌分期、是否需行新辅助治疗，对拟行保乳疗法的患者进行筛选。, 百拇医药(赵烨 赵菁 王亚军)