经腋窝单孔非溶脂全腔镜乳房皮下腺体切除联合假体乳房重建术的临床分析

Clinical analysis of axillary single-hole total breast subcutaneous gland resection combined with implant breast reconstruction

目的探讨经腋窝单孔非溶脂全腔镜乳房皮下腺体切除联合假体乳房重建术的手术方法和临床应用价值。方法回顾性分析2021年6月至2022年7月于烟台毓璜顶医院接受58例经腋窝单孔非溶脂全腔镜乳房皮下腺体切除联合假体乳房重建乳腺癌患者的病例资料。其中行胸肌后扩张器植入患者10例,胸肌前假体联合补片44例,胸肌后假体植入4例,对术中情况、术后并发症及术后外观改变进行统计,采用BREAST-Q量表对术后生活质量与满意度评分进行统计分析,对不同皮瓣厚度行胸肌前假体乳房重建的美容效果及满意度进行统计分析。结果58例患者术前临床分期:Tis期7例,Ⅰ期25例,Ⅱ期18例,Ⅲ期8例行新辅助化疗。单发肿瘤39例,多发肿瘤19例,肿瘤大小(2.2±0.5)cm,范围为0~4.5 cm。胸肌后扩张器组手术时间平均215min,术后引流管拔除时间平均12 d;胸肌前假体植入组手术时间平均160min,术后引流管拔除时间平均16 d;胸肌后假体组手术时间平均200min,术后引流管拔除时间平均10 d。术后波纹征8例(皮瓣厚度<1 cm的胸肌前假体植入),8例胸肌后扩张器假体乳房重建放疗后均出现不同程度的包膜挛缩及下皱襞向上移位,44例胸肌前假体植入均无术后运动畸形、胸壁疼痛及肩关节不适发生,所有行腔镜乳房重建患者术后生活质量及满意度均获得较高评分,尤其是皮瓣≥1 cm胸肌前组,随访3~16个月无复发及转移发生。结论单孔经腋窝充气法全腔镜乳房皮下腺体切除联合假体乳房重建术可通过较短的手术时间获得较好的根治效果和美容效果,患者术后生活质量和满意度均较高,腔镜下乳房皮下腺体切除联合胸肌前乳房重建不论在术后美容效果还是术后生活质量方面均具有更好的优势,但需选择合适的患者。

Objective To investigate the surgical method and clinical application value of trans-axillary endoscopic nipple sparing mastectomy combined with implant breast reconstruction.Methods From Jun.2021 to Jul.2022,the clinic-pathological data of 58 breast cancer patients who received single-port inflatable endoscopic nipple sparing mastectomy with immediate reconstruction using implant in Department of Breast Surgery,Yantai Yuhuangding Hospital,were retrospectively analyzed and followed up.Among them,there were 10 patients with postpectoral dilator placement,44 patients with prepectoral prosthesis using Ti-loop mesh,and 4 cases with postpectoral only prosthesis placement.Operation time,postoperative bleeding amount,postoperative drainage removal time,surgical complications,special appearance changes were analyzed.BREAST-Q scale was used for postoperative quality of life and satisfaction score,and the cosmetic effect and satisfaction of prepectoral prosthesis breast reconstruction with different flap thickness was statistically analyzed.Results Preoperative clinical stage of 58 patients:7 in Tis stage,25 in stageⅠ,18 in stageⅡ,and 8 in stageⅢall received neoadjuvant chemotherapy.In 39 single tumors and 19 multiple tumors,the tumor size was(2.2±0.5)cm,ranging from(0 to 4.5)cm.The mean operation time in the posterior chest dilator group was 215min;The mean drain removal time was 12 days;The operation time in the prepectoral prosthesis was 160min;The postoperative drain removal time was 16 days;The operation time in the postpectoral prosthesis was 200min,and the postoperative drain removal time was 10 days.Postoperative ripple signs occurred in 8 cases(anterior flap less than 1cm),8 cases had capsule contracture and upward displacement after breast reconstruction,and 44 cases had anterior implant insertion without postoperative movement deformity,chest wall pain and shoulder discomfort.All patients of endoscopic breast reconstruction had high score,especially the anterior flap greater than 1 cm group,and no recurrence in 3-16 months of metastasis occurred.Conclusions Single hole trans-axillary full endoscopic nipple sparing mastectomy combined with implant breast reconstruction can get better radical effect and cosmetic effect through a short operation time.Endoscopic nipple sparing mastectomy combined with prepectoral breast reconstruction have advantages in postoperative cosmetic effect and postoperative quality of life,but need to choose the appropriate patients.