乳房重建中心自成立以來，已在國內及國際專業整形外科醫學期刊SCI發表40篇與乳房重建相關學術論文。除此之外，更受邀參與英文教科書的編寫8篇，學術論文共計達48篇，秉持著臨床與學術研究並進成長的精神。
學術代表作：
國內論文
【摘要】
以自體組織進行乳房重建會有較為自然和美麗的外觀不論是根蒂性或是自由皮瓣。下腹部的組織通常是最常見的供應區，對於下腹部組織不足以作乳房重建，之前曾做過腹部整形術，下腹部有縱切疤痕，或是計劃懷孕的病人都是以下腹部皮瓣進行乳房重建的禁忌。
在這種狀況下，能夠提供大量的表皮與脂肪的臀部是另一種好的選擇。上臀動脈穿透枝皮瓣是由臀大肌皮瓣演化而來，它提供較長的血管長度且不致因切除部分臀大肌而導致肌肉無力的情形發生。自1999年至2002年，於長庚醫院共有七個病人以上臀動脈穿透枝皮瓣進行乳房重建。三個病人屬於延遲性，立即性重建的病人也有三個，另一個是波蘭氏症候群。皮瓣重量平均是425克。大小從9×20公分到10×28公分。血管平均長度是8公分。除了一個皮瓣失敗外其餘都存活。發生靜脈循環不良的一個病人之後有脂肪壞死與部分皮瓣喪失的現象。
大部分的病人對重建的乳房感到滿意。因此當下腹部不能作為乳房重建的供應區時，以上臀動脈穿透枝皮瓣進行乳房重建是另一個好的選擇。
【摘要】
BACKGROUND:
Breast reconstruction offers not only physical but also psychological rehabilitation. Autologous tissue transfer is a good option for breast reconstruction. The purpose of this study was to investigate the success rate, complications, and cosmetic outcomes following use of a muscle-sparing free transverse rectus abdominis myocutaneous (TRAM) flap for breast reconstruction.
METHODS:
Between August 1999 and February 2001, 15 consecutive patients underwent breast reconstruction using a muscle-sparing freeTRAM flap after a mastectomy. Ten patients received mastectomies and immediately underwent breast reconstruction using muscle-sparing freeTRAM flaps at Chang Gung Memorial Hospital. The remaining 5 patients first received a modified radical mastectomy and then underwent breastreconstruction.
RESULTS:
The mean age of patients was 43.9 (range, 32 to 50) years. Ten patients (67%) underwent immediate reconstructions, and 5 (23%) underwent delayed reconstructions. The overall success rate was 93.3%. Postoperative complications included 1 abdominal seroma and 1 small area of breast fat necrosis. Six of 10 patients with immediate reconstruction underwent both adjuvant chemotherapy and hormone therapy, while 3 patients received only chemotherapy. None of these adjuvant therapies were delayed by the reconstructive surgery. At a mean follow-up of 26.7 months, no local recurrence had been found, and 93% of patients were satisfied with the esthetic results.
CONCLUSIONS:
A muscle-sparing free TRAM flap is a good option for breast reconstruction. Both the success rate and patient satisfaction are high. The subsequent adjuvant therapy need not be delayed following immediate reconstruction.
【摘要】
因為擔心增加腫瘤復發的機會，皮膚保留乳房切除術合併立即重建乳房仍尚未廣泛的被病人接受。本研究主要的目的在探討以皮膚保留乳房切除術後立即以自由式深下腹動脈穿透枝皮瓣重建乳房的腫瘤安全性，併發症及結果。
2000年6月至2002年9月期間，在林口長庚醫院共有34位乳房癌病患接受皮膚保留乳房切除術後，立即以自由式深下腹動脈穿透枝皮瓣來重建乳房。平均年齡為44.3歲。AJCC病理腫瘤的分期分別為零期癌5例，第一期癌13例，第二期癌16例。成功率為百分之百。無腹部皮瓣壞死，但有2例(5.9%)胸部皮瓣部分壞死。2例(5.9%)乳房傷口感染及1例(2.9%)腹部肚臍傷口感染。4例(11.7%)於皮瓣外側部份脂肪壞死。在為期平均31.2個月的追蹤當中，有1例(2.9%)於術後20週後產生腫瘤復發，病患目前仍存活中。皮膚保留乳房切除術並不會增加局部腫瘤復發的風險，也不會增加本身胸部皮瓣壞死機率。以自由式深下腹動脈穿透枝皮瓣來重建乳房提供較少的供應區傷害，較佳的外觀及較少的併發症。合併皮膚保留乳房切除術及自由式深下腹動脈穿透枝皮瓣來重建乳房是一個不錯的選擇。
【摘要】
以自由皮瓣進行乳房重建時，使用內乳血管為接受區愈來愈普遍。尤其在延遲性重建時，常因放射線治療及術後疤痕組織造成胸背血管的傷害，內乳血管的角色更形重要。不過有關內乳血管的文獻報告多侷限於西方人，關於亞洲人的研究很少。因為大體解剖在台灣並不被普遍接受，我們利用術前彩色杜卜勒超音波及臨床手術來研究內乳血管的解剖位置及是否適合當作接受區血管。
自2000年3月至2001年10月，在長庚醫院共有44例自由皮辦乳房重建使用內乳血管為接受區，17例接受術前超音波評估。根據我們的研究，在第三肋骨下的內乳血管平均外徑3.0mm，適合顯微手術接合。此外亞洲人較少一側有兩條靜脈(13.6%)，左側的機率較高。總體的皮瓣存活率為97.7%。其中有兩位病人，內乳血管無法在術前以超音波偵測到，術中證實一例無血管，另一例則因血管太小無法進行可靠的血管接合。當內乳血管無法以術前超音波看到時，它並不適合作為接受區血管。
【摘要】
治無論在組織容量、大小和柔軟度方面，下腹部皮瓣組織是自體組織重建乳房的第一選擇。雖然在亞洲女生中乳房過度增生並不常見，但對某些須重建卻擁有對側過大乳房的病人，要做到對稱且令人滿意的乳房重建，對整形外科醫師而言仍是很大的挑戰。
從2000年3月到2005年4月間，有7位乳房重建病人對側乳房過大，其中二人分二期手術，其他5人中有4人同時接受深下腹動脈穿通枝皮瓣重建和對側乳房縮小手術，另一人接受淺下腹動脈穿通枝皮瓣乳房重建和對側乳房縮小手術。這五位同時做乳房重建和對側乳房縮小的病人平均年齡48歲（38-67歲），都是延遲性的重建，且自由皮瓣都成功存活。另外對側乳房縮小後並沒有胸壁皮膚壞死和感染，平均開刀時間10.5小時（9-12小時）。在平均12個月（3-36個月）的追蹤治療，對側縮小後的乳房都和自由皮瓣重建後的乳房呈現對稱且令人滿意的乳房，其中4位病人穿C罩杯，另一人穿D罩杯的胸罩。其中二位病人雙側乳房疤痕有過度增生的現象，但病人都能接受，五位病人都有很好的滿意度。
總之，同時以深下腹動脈通枝或淺下腹動脈皮瓣作乳房重建，和對側乳房縮小手術，對於需乳房重建且對側乳房過大的病人可提供令人在功能上及外觀上滿意的效果，且非常少發生供應區的後遺症，雖然麻醉時間長，且要擁有顯微手術的技巧，但初步結果是肯定的。
【摘要】
隨著發現從遠方轉移類似的組織取代原組織的能力，顯微手術已經改革了重建的策略。而利用內乳靜脈做為顯微靜脈接合仍然是乳房重建中最大的挑戰之一，本篇文章的目的在於研究乳房重建中利用Microvascular Anastomotic Coupler System接合內乳靜脈的成果。2003年3月至2005年12月期間，利用7個自由式深下腹動脈穿透枝皮瓣來重建乳房，5例(71.4%)為延遲性重建，2例(28.6%)為立即性重建，6例是用來治療乳房切除術後胸部缺陷，1例是用來覆蓋燙傷後疤痕攣縮，在這7例重建中，使用Microvascular Anastomotic Coupler System來做靜脈接合，沒有病人有短期或是長期的異物反應，有著相對容易使用，節省時間並且較少技術依賴性的優點。Microvascular Anastomotic Coupler System是值得信賴的因為其有高通暢性以及低併發症率，它值得被推薦在乳房重建中，用來接合內乳靜脈。
國外論文
【摘要】
Nipple reconstruction is usually the final stage of breast reconstruction and there are over 50 articles that describe different techniques. The majority of methods use local soft tissue as local flaps but they face the disadvantage of reduction in nipple projection after the initial two months. This is particularly troublesome in Asian females who may have wider nipples with prominent projection but small areola surface area. We developed a method to correct this problem using cartilage graft harvested during the initial breast reconstruction operation and banked beneath the skin flap. Using the modified 'top hat' flap, we found that no excess soft tissue is required to compensate for the reduction. We have used this method in 25 cases of nipple reconstruction and have obtained satisfactory result in projection.
【摘要】
From March 2000 to June 2002, 74 deep inferior epigastric perforator (DIEP) flaps were performed in 73 female patients for oncological post-mastectomy breast reconstruction in Chang Gung Memorial Hospital. The mean age was 44.2 years and mean body weight was 56.6 kg. Twenty-five breast reconstructions were immediate and 49 were delayed. The average size of the flap was 30.1x12.0 cm and the mean number of perforators was 2.2. The average weight of the harvested flap was 595 g and 85.6% (mean: 509 g) of the flap was used for shaping the new breast mound. Zone IV was not discarded, except in one case. Total flap failure and donor site morbidity was not encountered. Only one flap was revised due to venous congestion (1.4%) and successfully salvaged. Partial flap loss occurred in two patients (2.7%). Fat necrosis was detected in 10 cases (13.5%) and sizes ranged from 2x2 to 4x5 cm. The numbers of perforators and the percentage of the used flap weight/total flapweight were not related to the complications. The free DIEP flap and inclusion of zone IV is a reliable and valuable method of breast reconstruction and provides superior aesthetic outcomes.
【摘要】
BACKGROUND:
Every year many patients diagnosed with breast cancer are subjected to mastectomy. Some of them choose to undergo breastreconstruction to restore their body image. Immediate or delayed reconstruction is possible, depending on medical, financial, and emotional considerations. High success rate and cost-effectiveness are two important factors that may guide decision making in the management plan. The objective of this study was to compare the resource costs and success rates of immediate and delayed breast reconstructions using either deep inferior epigastric perforator (DIEP) or superficial inferior epigastric artery (SIEA) flaps. The resource cost is referred to as the cost of operation and hospitalization.
METHODS:
From September of 2000 through August of 2001, 42 patients underwent immediate (n = 21) or delayed (n = 21) unilateral breastreconstruction using either a DIEP (n = 30) or SIEA (n = 12) flap by one surgeon.
RESULTS:
There were no statistical differences in resource costs, success, and complication rates between DIEP and SIEA flaps in both theimmediate and delayed breast reconstruction groups.
CONCLUSIONS:
Using either a DIEP or SIEA flap as the autologous tissue, delayed breast reconstruction is as cost-effective as immediatereconstruction.
【摘要】
BACKGROUND:
Large nipples, disproportionate to the small areola and breast size, are an ethnic characteristic frequently encountered among Asian female patients. Patients seek correction to improve cosmesis and alleviate psychological and physical discomfort. The authors present a new technique of nipple reduction and describe its potential advantages over other techniques.
METHODS:
Between March of 2003 and April of 2005, 34 nipple reductions were performed in 19 female patients (mean age, 40.5 +/- 5.6 years) using the modified top hat flap. The neonipple is designed to reduce the nipple diameter at the superior pole of the nipple while preserving the subdermal plexus. A crescent-shaped section of nipple skin below the proposed neonipple is excised, maintaining the integrity of the neonipple and the central nipple core. Two lateral wing flaps are elevated and trimmed to reduce both nipple height and diameter at the lateral walls of thenipple. The flaps of the neonipple are then sutured to the areola.
RESULTS:
Postoperative recovery was rapid and uneventful and no complications were encountered. The mean diameter of the hypertrophicnipple was 16.3 +/- 2.6 mm (range, 16 to 30 mm). The mean diameter of the neonipple was 7.9 +/- 1.7 mm (range, 5 to 11 mm), with an averagereduction of 8.4 +/- 1.6 mm (range, 5 to 20 mm). At 17.2 +/- 2.9 months of follow-up, the neonipple had a natural appearance, with less projection and an inconspicuous scar. There was no statistically significant difference on monofilament sensation testing (p = 0.5829) between reductionnipple and areola in 11 nipples of seven patients.
CONCLUSIONS:
The modified top hat flap requires minimal preoperative planning, is easy to perform, and yields reproducible results. This technique decreases both the diameter and height of any size nipple and can be modified to meet patient preferences. Because the continuity of the neonipple with the subdermal arterial plexus is maintained and the majority of the parenchymal elements are preserved, nipple sensation and circulation remain largely unaffected.
【摘要】
The long-term projection of nipple reconstruction is a challenge. Fifty-eight consecutive female patients underwent 58 nipple reconstructions withmodified top hat flap with cartilage graft following breast reconstruction in 54 autologous tissues and 4 implants, respectively. The average neonipple size was 11.5 mm initially and 8.5 mm at a mean follow-up of 44.9 months (range, 24-65 months), with a mean decrease in projection of 26.1%. Thirty-three patients achieved an excellent result, 20 patients a good result, 3 patients a fair result, and 2 patients a poor result, respectively. The complication rate was 12.1% (7 of 58 cases), and there was no statistically significant difference between the immediate and delayed groups; the revision rate was 8.6% (5 of 58 cases). The modified top hat flap with banked costal cartilage graft provides a sustainable solution to the gradual loss of nipple projection, with few complications.
【摘要】
With the rapid economic development of Southeast Asia, the demand for cosmetic surgery has increased rapidly. Breast augmentation is among the most frequently performed cosmetic procedures. However, breast augmentation still has "bad press" in Southeast Asia because of not so distant catastrophes caused by direct liquid silicone injection and "Amazing Gel" augmentations. Asian patients have special characteristics that need to be taken into consideration when performing breast augmentation. The patients are usually thin and small with proportionally smaller breasts. The areola is often small with a large nipple. Because of poor scar healing, incisions need to be hidden. The transaxillary approach is therefore favored. A frequently performed adjunctive procedure is nipple reduction. In this article, the authors present their preferred technique foraugmentation mammaplasty: endoscopically assisted subpectoral placement of smooth saline-filled implants via a transaxillary approach. Simultaneously, nipple reduction with the "modified top-hat flap" procedure is presented. Complications and their management are also discussed.
【摘要】
Most postmastectomy defects are reconstructed by use of lower abdominal-wall tissue either as a pedicled or free flap. However, there are some contraindications for using lower abdominal flaps in breast reconstruction, such as inadequate soft-tissue volume, previous abdominoplasty, lower paramedian or multiple abdominal scars, and plans for future pregnancy. In such situations, a gluteal flap has often been the second choice. However, the quality of the adipose tissue of gluteal flaps is inferior to that of lower abdominal flaps, the pedicle is short, and a two-team approach is not possible because creation of the gluteal flap requires that the patient's position be changed during the operation. In 2000, five cases ofbreast reconstructions were performed with anterolateral thigh flaps in the authors' institution. Two of them were secondary and three were immediate unilateral breast reconstructions. The mean weight of the specimen removed was 350 g in the three patients who underwent immediatereconstruction, and the mean weight of the entire anterolateral thigh flap was 410 g. Skin islands ranged in size from 4 x 8 cm to 7 x 22 cm, with the underlying fat pad ranging in size from 10 x 12 cm to 14 x 22 cm. The mean pedicle length was 11 cm (range, 7 to 15 cm). All flaps were completely successful, except for one that involved some fat necrosis. The quality of the skin and underlying fat and the pliability of theanterolateral thigh flap are much superior to those of gluteal flaps and are similar to those of lower abdominal flaps. In thin patients, more subcutaneous fat can be harvested by extending the flap under the skin. Use of a thigh flap allows a two-team approach with the patient in a supine position, and no change of patient position is required during the operation. However, the position of the scar may not be acceptable to some patients. Therefore, when an abdominal flap is unavailable or contraindicated, the creation of an anterolateral thigh flap for primary and secondary breast reconstruction is an alternative to the use of lower abdominal and gluteal tissues.
【摘要】
Local recurrence of cancer after mastectomy and immediate breast reconstruction is generally regarded as a poor prognostic indicator. This study was conducted to identify specific patterns of local recurrence following reconstruction and to determine their biological significance. The records of all patients who had undergone immediate breast reconstruction at The University of Texas M. D. Anderson Cancer Center between June 1, 1988, and December 31, 1998, were reviewed. The records of patients who had local tumor recurrence were then carefully analyzed. During this 10-year period, a local recurrence of cancer was found to have developed in 39 of 1694 patients (2.3 percent). Most recurrences were in the skin or subcutaneous tissue (n = 28; 72 percent), and the remainder were in the "chest wall" (n = 11; 28 percent), as defined by skeletal or muscular involvement. Transverse rectus abdominis myocutaneous flaps were used most often in both groups, but latissimus dorsi myocutaneous flaps and implant techniques were also used in some patients. Patients with subcutaneous tissue recurrence had an overall survival rate of 61 percent at follow-up of 80.8 months, compared with patients with chest wall recurrence, whose survival rate was 45 percent at similar follow-up. Metastases were less likely to develop in patients with subcutaneous tissue recurrence than in those with chest wall recurrence (57 percent versus 91 percent; p = 0.044); the former group also had a greater chance of remaining disease-free after treatment of the recurrence (39 percent versus 9 percent), respectively. Metastasis-free survival was higher in patients with subcutaneous tissue recurrence than with chest wallrecurrence (2-year and 5-year survival: 52 and 42 percent versus 24 and 24 percent; p = 0.04). In both groups, the time to detection of therecurrence was similar (subcutaneous tissue recurrence, 27.1 months, versus chest wall recurrence, 29.5 months). Distant disease did not develop in one patient only in the chest wall recurrence group; this patient remained disease-free at 70 months. From these results, it was concluded that (1) not all local recurrences are the same: patients with subcutaneous tissue recurrence have better survival rates, a decreased incidence of metastases, and a greater chance of remaining disease-free than do those with chest wall recurrence; (2) immediate breastreconstruction (although potentially, it can conceal chest wall recurrence) does not seem to delay the detection of chest wall recurrence; and (3) even if a chest wall recurrence develops, it is highly associated with metastatic disease, and the survival rate is not likely to have been influenced by earlier detection. These data support the continued use of immediate breast reconstruction without fear of concealing a recurrenceor influencing the oncologic outcome.
【摘要】
Breast reconstruction in female Poland anomaly remains a surgical challenge with variable chest wall deformity and nipple position. Pedicled latissimus dorsi myocutaneous flap with implant reconstruction may have several drawbacks and complications. Free deep inferior epigastric flap(DIEP) flap is a reliable option for postmastectomy breast reconstruction, but rarely reported in Poland anomaly. We presented a 52-year-oldPoland anomaly patient who underwent successful reconstruction for breast and chest wall deformity using DIEP flap. Preoperative ultrasound Doppler study for internal mammary vessels is recommended for microsurgical anastomosis. Care should be taken with regard to the flap inset and the location of the nipple areolar complex.
【摘要】
BACKGROUND:
Among various alternatives for autologous breast reconstruction, the superficial inferior epigastric artery abdominal flap provides the least donor-site morbidity, as dissection of the rectus abdominis sheath and muscle is not required. However, because of inconsistencies in the existence and size of the superficial inferior epigastric artery, its use is limited. In addition, whether the perfusion from the superficial system is adequate across the midline is still a question to be answered.
METHODS:
Over a period of 16 months, the authors performed a total of 44 breast reconstructions using either the deep inferior epigastric artery perforator flap (n = 30) or the superficial inferior epigastric artery flap (n = 14). In all cases, the superficial inferior epigastric artery system was explored first and used as the pedicle if the diameter of the available vessels was larger than 1 mm. If the vessels were unavailable or the diameters were smaller than 1 mm, the deep inferior epigastric artery and vein were used as the pedicle. The diameter of the superficial inferiorepigastric artery ranged between 0.8 and 3.0 mm, and the mean pedicle length was 6 cm. The superficial inferior epigastric artery was not available in 21 cases (48 percent), and in nine cases (20 percent) the diameter was smaller than 1 mm. In six cases where the superficial inferiorepigastric artery was judged to be appropriate, laser Doppler study was performed perioperatively to assess the perfusion of each zone (I through IV) from the deep and superficial systems consecutively. In all cases, the superficial and deep systems ipsilateral to the defect were dissected. During inset, zone IV was not discarded routinely, and 92.3 percent and 86.7 percent of the harvested superficial inferior epigastric artery flap anddeep inferior epigastric artery perforator flap, respectively, were used.
RESULTS:
The flap survival rates were 93 and 100 percent in the superficial inferior epigastric artery and deep inferior epigastric artery perforator groups, respectively. Adequate perfusion of all zones from the superficial system was documented by laser Doppler flowmetry, and the perfusion rates were comparable to the deep system.
CONCLUSIONS:
The entire abdominal adipocutaneous flap based on the unilateral superficial inferior epigastric artery is as reliable as one basedon the deep inferior epigastric artery perforator flap. As a result, initially, the superficial inferior epigastric artery flap should be explored, as it provides less donor-site morbidity. A sizable superficial artery and vein is sufficiently safe for microsurgical transfer, similar to the deep inferiorepigastric system.
【摘要】
Unilateral breast reconstruction after mastectomy provides the challenge of achieving symmetry with the opposite side. Reduction mastopexy is a common balancing procedure for the contralateral breast used to achieve pleasing and symmetrical breasts. Although symmetry is the ultimate goal, some women have a hypoplastic and/or ptotic contralateral breast, and the recreation of this shape would therefore not be desirable. From April of 2000 to April of 2005, a total of 158 patients underwent postmastectomy breast reconstruction using either free deep inferior epigastric perforator flaps (n = 142) or superficial inferior epigastric artery flaps (n = 16) at Chang Gung Memorial Hospital. Of the 158 patients, 19 (12.0 percent) underwent endoscope-assisted placement of implants into the contralateral breast at the same surgical stage to form a more pleasing breast mound. Mean patient age was 46.1 +/- 7.6 years. All patients had a slender body habitus, with small to medium-sized breasts. Saline-filled implants were placed in a submuscular position with the assistance of endoscopy. Five different incisions for access were used: transaxillary (n = 6), Port-A-Cath catheter scar (n = 4), inframammary (n = 1), biopsy scar (n = 1), and transmidline (n = 7). The success rate was 100 percent, with complete survival of the 19 flaps. In three patients, revision procedures were carried out at 12 to 44 months' follow-up because of implant leakage, capsular contracture, and nipple ptosis (one patient each). The remaining patients were highly satisfied with the cosmetic result, and symmetry was achieved, with soft, natural appearing breasts during the follow-up period of 29.2 +/- 16.9 months. The transmidline approach was superior to the other routes, because no additional scar was produced and access was easier. Contralateral breast augmentation at the same stage with deep inferior epigastric perforator or superficial inferior epigastric artery flap surgery can be performed with high success rates and poses no surgical risks or morbidity to patients. The combined procedure does not significantly extend the time of operation, and aesthetically pleasing results and symmetry can be achieved and sustained over the long term.
【摘要】
The Asian breast reconstruction patient is usually of lower mean age, lower body mass index (BMI), and has relatively small breasts. This study aimed to investigate the outcome of 1-stage immediate breast reconstruction using saline-filled implants in the Asian patients.Between April 2002 and July 2005, 30 patients underwent skin-sparing mastectomy and 1-stage immediate breast reconstruction with a saline-filled implant. Mean age was 42.9 years, with a mean BMI of 21.9 and a mean implant volume of 283 mL. The overall success rate was 96.6%, with 1 case of implantexposure secondary to chest skin necrosis. At mean follow-up of 21.5 months (range 6 to 40 months), 1 patient developed local recurrence (3.33%). Perfusion of the chest skin flap is reliable enough to allow 1-stage breast reconstruction with small saline-filled breast implants. We present this as an additional option for immediate breast reconstruction in thin women with small breasts.
【摘要】
The internal mammary lymph node is the second most frequent site of nodal metastasis. With an increase in breast free flap reconstruction utilization of the internal mammary vessels, identification of these internal mammary lymph node metastases will become more prevalent. A chart review documented 75 free transverse rectus abdominis myocutaneous flaps cases performed at Kaiser Bellflower from 1998 to 2004. Between March 2000 and January 2006 there were 157 autologous breast reconstructions (122 DIEP flaps, 10 GAP flaps, 15 SIEA flaps, 7 free transverse rectus abdominis flaps, and 1 SCIA flap) using internal mammary vessels as the recipient site at the Chang Gung Memorial Hospital. A literature review was conducted to survey the current protocols in the surgical, oncological, and radiological communities. A population of 232 patients with breast reconstruction via free flaps was identified. The age range was 29 to 65 years. With the exception of the five cases presented, no other incidence of positive internal mammary lymph nodes was identified. Failure to account for the status of the internal mammary lymph nodes may risk understaging and preclude appropriate treatment stratification. With more frequent utilization of the internal mammary vessels, discussions regarding breast reconstruction should take this new oncological focus into consideration.
【摘要】
Options for autologous reconstruction have been limited in some patients by previous abdominal surgeries, and by lack of adequate abdominal tissue. The anterolateral thigh (ALT) flap has previously been described as an alternate donor site for autologous breast reconstruction when abdominal tissue is unavailable or unsuitable.We describe our experience with a 41-year-old low body mass index (19.8 kg/m) patient with previous suction-assisted lipectomy underwent bilateral breast reconstruction using bilateral ALT flaps.At a follow-up of 2 years, the patient was delighted with her reconstructed breasts and despite her athletic build was able to fill a B cup bra.ALT flap has the advantages of a long pedicle, adequate soft adipose tissue, and also allowing supine positioning with a 2-team approach. The anterolateral flap is a credible alternative that may be considered for bilateral autologous breast reconstruction in selected patients.
【摘要】
BACKGROUND:
Restoring the continuity of lymphatic drainage by lymphaticovenous or lymphaticolymphatic anastomosis was observed in the short term to be patent but eventually occluded because the elevated interstitial pressure will cause obliteration of these tiny, thin-walled, low-pressure lumens. The purpose of this study was to evaluate the outcome of vascularized groin lymph node transfer using the wrist as a recipientsite in patients with postmastectomy upper extremity lymphedema.
METHODS:
Between January of 1997 and June of 2005, 13 consecutive patients with a mean age of 50.69 +/- 11.25 years underwentvascularized groin lymph node transfer for postmastectomy upper extremity lymphedema. A vascularized groin lymph node nourished by the superficial circumflex iliac vessels was harvested and transferred to the dorsal wrist of the lymphedematous limb. The superficial radial artery and the cephalic vein were used as the recipient vessels. Outcome was assessed by upper limb girth, incidence of cellulitis, and lymphoscintigraphy.
RESULTS:
All flaps survived, and one flap required reexploration, with successful salvage. No donor-site morbidity was encountered. At a mean follow-up of 56.31 +/- 27.12 months, the mean reduction rate (50.55 +/- 19.26 percent) of the lymphedematous limb was statistically significant between the preoperative and postoperative groups (p ＜ 0.01). The incidence of cellulitis was decreased in 11 patients. Postoperative lymphoscintigraphy indicated improved lymph drainage of the affected arm, revealing decreased lymph stasis and rapid lymphatic clearance. A hypothesis was proposed that the vascularized groin lymph node transfer might act as an internal pump and suction pathway for lymphatic clearance of lymphedematous limb.
CONCLUSIONS:
Vascularized groin lymph node transfer using the wrist as a recipient site is a novel and reliable procedure that significantly improves postmastectomy upper extremity lymphedema.
【摘要】
The aim of the present study was to scrutinize the evidence on the use of acupoint stimulation for managing therapy-related adverse events inbreast cancer. A comprehensive search was conducted on eight English and Chinese databases to identify clinical trials designed to examine theefficacy of acupressure, acupuncture, or acupoint stimulation (APS) for the management of adverse events due to treatments of breast cancer. Methodological quality of the trials was assessed using a modified Jadad scale. Using pre-determined keywords, 843 possibly relevant titles were identified. Eventually 26 papers, 18 in English and eight in Chinese, satisfied the inclusion criteria and entered the quality assessment stage. The 26 articles were published between 1999 and 2008. They assessed the application of acupoint stimulation on six disparate conditions related to anticancer therapies including vasomotor syndrome, chemotherapy-induced nausea and vomiting, lymphedema, post-operation pain, aromatase inhibitors-related joint pain and leukopenia. Modalities of acupoint stimulation used included traditional acupuncture, acupressure, electroacupuncture, and the use of magnetic device on acupuncture points. Overall, 23 trials (88%) reported positive outcomes on at least one of the conditions examined. However, only nine trials (35%) were of high quality; they had a modified Jadad score of 3 or above. Three high quality trials revealed that acupoint stimulation on P6 (NeiGuang) was beneficial to chemotherapy-induced nausea and vomiting. For other adverseevents, the quality of many of the trials identified was poor; no conclusive remarks can be made. Very few minor adverse events were observed, and only in five trials. APS, in particular acupressure on the P6 acupoint, appears beneficial in the management of chemotherapy-induced nausea and vomiting, especially in the acute phase. More well-designed trials using rigorous methodology are required to evaluate the effectiveness ofacupoint stimulation interventions on managing other distress symptoms.
【摘要】
Free tissue transfer is rarely used for cosmetic breast enlargement, but in certain cases of failed augmentation with implants, it may be a justifiable alternative. Our experience in treating bilateral capsular contracture with deep inferior epigastric perforators/superficial inferior epigastric artery flaps has been very favorable. Advantages include avoidance of implants and their related problems, more natural feel and shape, and ancillary abdominoplasty. Although the operation is substantially lengthier and more complicated than implant replacement, and the overall treatment cost much higher, we feel that surgeons who are skilled in perforator-based free tissue transfer should consider such procedures in the appropriate circumstances.
【摘要】
BACKGROUND:
Elevation of the deep inferior epigastric perforator (DIEP) flap interrupts its superficial venous system, and if drainage through the deep venous system is inadequate the flap may develop congestion. The purpose of this retrospective study was to determine the fate of the congested DIEP flap and to optimize the strategy for its salvage.
METHODS:
Thirty-two of 162 patients who underwent unilateral breast reconstruction with a DIEP flap developed venous congestion. For the purpose of outcome analysis, cases were retrospectively allocated to "observation-only" (group A, n = 11), postoperative salvage (group B, n = 7), and intraoperative salvage (group C, n = 14), and complications among the various groups were compared to determine the necessity and optimal timing of salvage intervention.
RESULTS:
Two flaps (1 in group A, another in group B) failed completely, giving a success rate 98.8%. The complication rate and hospital stay were significantly lower in group C than in group B (P = 0.03, P = 0.02). The rate of venous congestion requiring salvage procedures was 13%, with a salvage rate of 95%. Salvage procedures included venous augmentation with an additional recipient vein in 7 procedures, adding superficialinferior epigastric vein (SIEV) to DIEV in 11 procedures, and substituting with SIEV in 7 procedures. There was no statistical difference in flapsalvage rate using the SIEV between "augmentation" and "substitution."
CONCLUSIONS:
The salvage procedures for venous compromised DIEP flap are better performed intraoperatively rather than postoperatively to prevent further complications. The engorged SIEV could be incorporated by anastomosing to an additional recipient vein or adding to the DIEV-internal mammary vein axis or substituting for DIEV.
【摘要】
BACKGROUND:
Successful breast reconstruction includes the creation of a natural breast mound in addition to achieving maximal symmetry of both breasts. This study investigated the patients' outcome and satisfaction of simultaneous contralateral balancing reduction/mastopexy withunilateral breast reconstruction using free abdominal flaps.
METHODS:
Between March 2000 and September 2009, 22 of 288 patients underwent unilateral breast reconstructions using a free abdominal flap with simultaneous contralateral breast reduction/mastopexy (group A). The remaining 266 cases were used as the control group (group B). The ultimate cosmesis with the complete pre- and postoperative pictures was assessed. The survey for the quality of life using the Heden questionnaire was obtained from 16 patients in group A.
RESULTS:
All 22 flaps survived. Two deep inferior epigastric artery perforator flaps developed venous congestion and subsequent partial flap loss. The mean flap-used weight was 568 ± 128.6 g and 486 ± 158 g in group A and B, respectively (P ＜ 0.01). There were no complications resulted from the reduction/mastopexy. The mean reduced breast tissue was 173.6 ± 101 g (range, 85-355 g). The overall cosmetic scores in group A were higher than in the group B. Of 16 patients, 7 (43.8%) graded this technique as very advantageous and the remaining 9 patients (56.2%) as advantageous.
CONCLUSIONS:
Simultaneous contralateral balancing procedures including reduction/mastopexy in selected patients can be performed withunilateral breast reconstruction using free abdominal flaps with greater patient satisfaction, minimal increase in operative time, and no increase in complication rates.
【摘要】
BACKGROUND:
A lower abdominal midline scar is known to restrict the amount of tissue that can be included in a deep inferior epigastric perforator (DIEP) flap. However, reconstructive demands have occasionally led us to include substantial territory beyond the scar. The purpose of this study is to review our experience with such flaps and to determine whether a meaningful amount of tissue can be reliably harvested across amidline scar.
METHODS:
Within a series of 125 DIEP flaps harvested across the entire lower abdomen (zones I-IV), 11 contained a midline scar. These 11 cases were compared with the remaining 114 in terms of (1) the amount of tissue beyond the scar that could be retained with the flap based on intraoperative assessment of vascularity and (2) postoperative complications.
RESULTS:
A significantly smaller percentage of the flap volume could be retained in scarred abdomens (70% of the harvested ellipse [ie, 20%beyond the midline]) versus unscarred abdomens (83%; P = 0.01). Complications were more frequent in the flaps with scars (55% vs. 25%; P = 0.04), although most of these complications were easily manageable and acceptable outcomes were achieved in all 11 cases.
CONCLUSIONS:
The rate of complications is significantly higher when tissue across a midline scar is included in a DIEP flap. However, in our experience, these complications are relatively mild, and in most cases, a substantial amount of tissue beyond the midline can be used, thereby increasing the volume available for reconstruction without resorting to dual-supply procedures.
【摘要】
BACKGROUND:
Simultaneous contralateral augmentation is performed with unilateral breast reconstruction to achieve pleasing and symmetricbreast mounds. This prospective study investigated the outcome of simultaneous scarless contralateral augmentation with unilateral breast reconstruction using bilateral differentially split deep inferior epigastric perforator (DIEP) flaps.
METHODS:
Between August of 2009 and May of 2010, six patients with a mean age of 46.2 ± 7 years underwent unilateral breast reconstructionand simultaneous contralateral augmentation using bilateral differentially split DIEP flaps. The ipsilateral internal mammary vessels served as the recipient vessels for the reconstruction split flap. The pedicle of the augmentation split flap was anastomosed to that of the reconstruction splitflap in a flow-through manner. The augmentation split flap was inset through the midline with endoscopic assistance. The Modified BREAST-Q questionnaire was administered preoperatively and at the 1- and 3-month follow-up visits.
RESULTS:
All flaps survived, giving a success rate of 100 percent. One reconstruction split flap required reexploration and was salvaged successfully. Mean flap weights used for reconstruction and augmentation were 410 ± 145 and 192 ± 58 g, respectively. At a mean follow-up of 12.7 ± 3.6 months, all patients were satisfied with the outcome of both reconstructed and augmented breast mounds. There were statistical improvements in breast satisfaction (p = 0.004), psychosocial function (p = 0.000), and sexual well-being (p = 0.004) postoperatively, as assessed by the Modified BREAST-Q.
CONCLUSIONS:
Simultaneous scarless contralateral breast augmentation can be performed safely during unilateral breast reconstruction usingbilateral differentially split DIEP flaps with satisfactory outcome.
【摘要】
BACKGROUND:
Vascularized groin lymph node flap transfer is an emerging approach to the treatment of postmastectomy upper limblymphedema. The authors describe the pertinent flap anatomy, surgical technique including different recipient sites, and outcome of this technique.
METHODS:
Ten cadaveric dissections were performed to clarify the vascular supply of the superficial groin lymph nodes. Ten patients underwent vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema using the wrist (n=8) or elbow (n=2) as a recipient site. Ten patients who chose to undergo physical therapy were used as controls. Intraoperatively, indocyanine green was injected subcutaneously on the flap margin to observe the lymph drainage. Outcomes were assessed using improvement of circumferential differentiation, reduction rate, and decreased number of episodes of cellulitis.
RESULTS:
A mean 6.2±1.3 groin lymph nodes with consistent pedicles were identified in the cadaveric dissections. After indocyanine injection, the fluorescence was drained from the flap edge into the donor vein, followed by the recipient vein. At a mean follow-up of 39.1±15.7 months, the mean improvement of circumferential differentiation was 7.3±2.7 percent and the reduction rate was 40.4±16.1 percent in the vascularized groinlymph node group, which were statistically greater than those of the physical therapy group (1.7±4.6 percent and 8.3±34.7 percent, respectively; p＜0.01 and p=0.02, respectively).
CONCLUSIONS:
The superficial groin lymph nodes were confirmed as vascularized with reliable arterial perfusion. Vascularized groin lymph nodeflap transfer using the wrist or elbow as a recipient site is an efficacious approach to treating postmastectomy upper limb lymphedema.
【摘要】
Asian women are generally thin with smaller breasts. The objective was to investigate the outcomes for patients who underwent 2-stage breastreconstruction using subcutaneous expansion followed by subpectoral implantation. Between 2003 and 2008, 22 patients underwentsubcutaneous expansion and subsequent submuscular implantation for 23 breast reconstructions. Mean age was 44.6 ± 7.0 years. The outcomewas assessed with a pain visual analog scale, a questionnaire, and the cosmesis. Mean expansion volume was 350.3 ± 80.8 mL. Mean implant size was 306.7 ± 84.6 mL. The complication rate was 8.6%, 13.0% in first and second stages. Mean pain scale was 2 ± 1.4. At a mean follow-up of 42.5 ± 18 months, patient's satisfaction was 3.2 ± 0.9. Overall shape of the reconstructed breast was rated as 2.8 ± 0.5. Subcutaneousexpansion with subsequent subpectoral implantation is feasible and reliable in low body mass index, nonsmoking, nonradiated patients with small and projective breasts.
【摘要】
Studies have shown that having breast reconstruction has a positive influence on patient satisfaction and health-related quality of life (HRQoL) at the conclusion of treatment. However, no study has critically evaluated changes to these patient-reported outcomes during the process of undergoing breast reconstruction. This study was to prospectively evaluate changes to patient-centered metrics through the progression of breast reconstruction. An IRB-approved prospective, multi-institutional study was performed for all patients undergoing breast reconstruction between 2009 and 2011. The Breast-Q reconstruction questionnaire was used for evaluation of HRQoL and was administered at five intervals in the perioperative period. Longitudinal evaluation was performed to assess changes to HRQoL metrics during this perioperative interval. One hundred and ten patients were enrolled, and 100 patients (91.9 %) completed appropriate follow-up. Preoperative HRQoL scores were higher in patients electing to forgo reconstruction (P ＜ 0.004), while postoperative HRQoL scores consistently deteriorated at multiple time points following mastectomy as compared to reconstructed patients. On subgroup analysis, results indicated lower initial HRQoL scores in delayed reconstruction(P ＜ 0.05) as compared to immediate reconstruction. These scores did, however, merge at approximately 9 months postoperatively. Changes to HRQoL outcomes occur through progression of breast reconstruction. Within the first year of surgery, early decreases are mirrored by significant increases at later time points above baseline levels when evaluating most forms of reconstruction. Choosing against reconstruction will likely result in continued deterioration of HRQoL for patients undergoing cancer surgery, but steady improvements can be expected if delayedreconstruction is chosen.
【摘要】
High-volume hydrodissection of intramuscular perforators of deep inferior epigastric perforator (DIEP) flaps in Sprague-Dawley rats has previously demonstrated a significant reduction in dissection time while simultaneously increasing the safety of dissection. However, increasing volumes of fluid injected into the closed rectus compartment may have adverse consequences on perfusion to the overlying flap. A prospective experimental animal study was performed to define a safe upper limit of volume injection for high-volume hydrodissection. Eight Sprague-Dawley rats underwent bilateral "DIEP" flap dissections with varying volumes of fluid (1, 3, 6, and 9 mL) injected into the study side. The primary outcome measurement was overlying tissue perfusion, measured using laser Doppler imaging, at 6 separate time points during the flap harvest. Although no significant difference in perfusion was noted between study and control sides despite increasing volumes of injection, a trend toward significant altered perfusion was noted immediately after injection in the 9-mL study group. Six milliliters is defined as the safe upper limit volume of injection into the closed rectus compartment without significantly altering overlying flap perfusion in our Sprague-Dawley rats. Using volumetric analysis, these data translate to 425 mL as the safe upper limit for high-volume hydrodissection for a single average sized human rectus sheath during DIEP flap harvesting. The mechanical and potentially pharmacologic implications of these data in humans remain to be seen.
【摘要】
BACKGROUND:
Deep inferior epigastric perforator (DIEP) flaps have become broadly accepted for autologous breast reconstruction. Our aim was to analyze outcomes and describe technical strategies to improve survival when harvesting the entire DIEP flap with a midline scar.
METHODS:
We retrospectively reviewed charts from March of 2000 to November of 2007; 186 DIEP flaps in 183 patients were used for breastreconstruction, including 18 flaps (9.68%) in 17 patients with previous lower midline abdomen scars. The patients were classified into 3 groups. Group 1: hemi-DIEP flaps (n=5);. group 2: DIEP flaps that included tissue crossing the midline (n=10); and group 3: entire-DIEP flaps (with zone IV) (n=3).
RESULTS:
Reexploration for venous congestion and partial flap loss were encountered in 1 patient in group 1. Average flap-used ratio was 68.75±8.95% in group 2. Three flaps developed partial loss and underwent subsequent debridement. In group 3, entire DIEP flaps were designed with higher, bilateral superficial inferior epigastric venous drainages and intraflap pedicle-to-pedicle anastomosis. The first 2 cases underwent partial flap loss and debridement. The third case of bipedicle anastomosis achieved complete flap survival.
CONCLUSIONS:
The hemi-DIEP flap is a safer method for the patient with a lower abdominal midline scar but limits the reconstructive volume. Carefully evaluating the perfusion across midline scar intraoperatively is crucial for deciding how much contralateral tissue should be discarded. Double pedicles anastomosis is an assurance for using entire DIEP flap with lower midline scar.
【摘要】
BACKGROUND:
Economic, cultural, and regulatory phenomena may explain recent popularization of implant-based augmentation in Asia; but the collective Eastern experience remains limited. Asian surgeons and their patients rely on evidence-based medicine that originates elsewhere and may not be entirely relevant. Distinct anatomic and cultural features of Asian women warrant a tailored approach to breast augmentation. We explore the Asian experience with a thorough exploration of the recent literature.
METHODS:
A literature search was performed for articles written after 2000, of Asian women who underwent augmentation mammoplasty using MEDLINE, Embase, and Pubmed Databases. Technique and outcomes data were summarized.
RESULTS:
Twelve articles reported outcomes of 2089 women. Korea contributed most series (English language, 7), followed by China (3), Taiwan (1), and Japan (1). Silicone implants were used in 82.1% of women studied, and almost exclusively after 2009. More round (68.9%) than anatomic implants (31.1%) were placed. Non-inframammary (axillary, areolar, and umbilical) incisions were used in 96.9% of cases. Nearly all implants were positioned below the muscle or fascia; subglandular placement accounted for 1.1% of cases. Implant/nipple malposition (1.3%), capsular contracture (1.9%), hematoma (0.6%), and infection (0.2%) rates were reported in most series. Undesirable scarring was the most frequent complication (7.3%), but was reported only in 4 of 12 series.
CONCLUSIONS:
Studies of Asian women undergoing augmentation mammoplasty are limited, often with ill-defined outcomes and inadequate follow-up. As experience accumulates, an expanding literature relevant to Asian women will provide evidence-based guidelines that improve outcomes and patient satisfaction, and foster innovation.