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保留乳头、乳晕的乳腺癌改良根治术后假体植入即刻乳房再造

时间:2006-11-26栏目:医药卫生论文

  保留乳头、乳晕的乳腺癌改良根治术后假体植入即刻乳房再造
  
  【摘要】  目的 探讨保留乳头、乳晕及部分乳房皮肤的乳腺癌改良根治术后假体植入即刻乳房再造的具体方法、术后效果及可行性。方法 筛选出病理及癌肿位置符合要求的5例Ⅰ、Ⅱ期的乳腺癌患者,实施乳头、乳晕及部分乳房皮肤保留的乳腺癌改良根治术,同时采用硅胶充填假体置入乳房重建,另行术后个体化综合治疗。结果 5例乳腺癌患者即时乳房再造全部成功,未出现皮瓣坏死,双侧乳房基本对称,乳房形态良好,患者心理状态及社会适应性较好。术后随访4——52个月,所有病例均无局部复发和远处转移。美容效果:良2例,中2例,差1例。结论 合理选择患者行保留乳头、乳晕及部分乳房皮肤的乳腺癌根治术后,即刻进行假体植入乳房再造,手术操作简便,安全可靠,两次手术一次完成,减轻患者心理压力和缺陷,减少患者痛苦和经济负担,易被接受,术后不影响乳腺癌的辅助治疗和远期疗效,适宜于在基层医院大力发展及广泛推广。
  
  【关键词】  乳腺癌改良根治术;假体植入;乳房再造
  
  [Abstract] Objective To investigate specific surgical methods and effect and feasibility of immediate breast reconstruction with prosthesis implant and after modified radical mastectomy of breast cancer with nipple-areolar complex preservation and partial skin-sparing.Methods From November 2006 to October 2010,5 breast cancer patients who meet the requirements received nipple-sparing modified radical mastectomy plus axillary lymph node dissection and immediate breast reconstruction with prosthesis implant, after individual comprehensive treatment.Results All reconstructions were successful. Breast form is good and the two sides seemed symmetrical and no skin flap necrosis.Patients psychological status and social adaptability is good. None patient of local recurrence and distant metastasis was found. Cosmetic effect: good in 2 cases, general in 2 cases, poor in 1 case.Conclution Immediate breast reconstruction with prosthesis implant after mastectomy of breast cancer with preservation of nipple-areolar complex and partial skin-sparing is safe and effective for early stage breast cancer patients. Breast reconstruction surgery is economical and can reduce patients' psychological pressure due to loss of the breast, and improve quality of life. Immediate breast reconstruction does not affect postoperative adjuvant therapy and long-term therapeutic effect. Breast reconstruction surgery has been gradually accepted by more and more early stage breast cancer patients. This method should be accepted for the basic hospital to develop and widely promoted.
  
  [Key words] Modified radical mastectomy of breast cancer; Prosthesis implantation;Breast reconstruction
  
  除外逐渐成熟的保留乳房手术,对于乳腺癌根治术后的患者,乳房再造是恢复乳腺美感和对称完整的惟一手段。近些年乳腺癌根治术后即刻乳房再造已逐渐被临床接受,相比根治术后二期乳房再造,具有更好的美学效果,即刻再造还能明显减少患者的经济负担。保留皮肤乳腺切除术(skin-sparing mastectomy,SSM)后应用自体组织移植或假体植入行即刻乳房再造(immediate breast reconstruction,IBR)是目前早期乳腺癌的外科治疗方法之一[1].假体植入乳房再造与自体组织移植乳房再造术式相比,优点在于手术简便、效果好、创伤小、术后恢复快[2].笔者自2006年11月-2010年10月对5例乳腺癌患者行改良根治术后,行假体植入即刻乳房再造术,获得满意效果。此外,依据患者个体进行术后综合治疗,为临床乳腺癌术后同期乳房再造提供了一定经验。现报告如下。
  
  1 资料与方法
  
  1.1 病例资料
  
  5例女性患者,年龄24——46岁,平均27岁。术前5例均行针吸细胞学确诊。肿瘤长径约1.5——2.5cm,5例距乳头距离均>3cm;肿瘤所在部位:外上象限3例,内上象限1例,外下象限1例;乳头无溢液、无内陷及歪斜等异常表现;乳晕及边缘皮肤无橘皮征、酒窝征等改变;按TNM分期分为T1cN0M03例,T2N0M02例。淋巴结状态:术前及术中均未扪及肿大淋巴结。术后保留的乳头乳晕区皮下组织及切除乳腺组织切缘病理检查未见癌细胞浸润,腋窝淋巴结病理检查阴性。
  
  1.2 手术适应证
  
  (1)患者有强烈的保留乳头、乳房再造的意愿。(2)肿瘤为单发,长径≤3cm,且与胸肌及表面皮肤无粘连。(3)肿瘤至乳晕边缘距离≥3cm.(4)乳头、乳晕部检查无癌浸润征象,乳头无内陷、溢血或溢液,乳头、乳晕皮肤无变硬、水肿、糜烂、溃疡等。(5)同侧腋窝无明显肿大、融合、固定的淋巴结。(6)钼靶片上无广泛的钙化点。肿瘤与乳头、乳晕之间无异常阴影相连[3].
  
  1.3 手术方法
  
  (1)乳房肿瘤手术:切口设计以术后瘢痕隐蔽、尽量保留皮肤、方便乳腺癌根治术为原则,但不违反肿瘤根治原则,行保留乳头、乳晕根治术。(2)即刻乳房再造:乳腺癌根治完成后,冲洗创面后更换手术器械及手术衣,应用假体植入。切开胸大肌、前锯肌筋膜,然后于胸大肌、前锯肌下分离形成腔穴。肌性腔穴的分离一般从第四肋骨表面开始。首先切开胸大肌、前锯肌筋膜,上胸部可用手指在胸大肌下钝性分离,其余部分直视下用电刀锐性分离。内侧分离至胸骨旁,下至乳房皱襞下2cm,外至腋前线与腋中线之间。腔穴形成后,仔细检查无出血后,放入假体,将胸大肌外侧缘与前锯肌前缘缝合,保证假体表面有完整的肌肉覆盖。术后置负压引流,缝合术口,胸带固定加压包扎2周。
  
  1.4 术后辅助治疗
  

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