Philadelphia, Pa. From the Divisions of Plastic Surgery and Finance, Hospital of the University of Pennsylvania.
Plast Reconstr Surg. 2013 May;131(5):928-934. doi: 10.1097/PRS.0b013e3182865977.
Choosing a breast reconstructive modality after mastectomy is a critical step involving complex decisions. The authors provide outcomes data comparing two common reconstructive modalities to assist patients and surgeons in preoperative counseling and discussions.
A prospectively maintained database was queried identifying select patients undergoing expander/implant and abdominally based free flaps for breast reconstruction between 2005 and 2008. Variables evaluated included comorbidities, operations, time to reconstruction, complications, overall outcome, clinic visits, revisions, and costs.
One hundred forty-two patients received free flaps and 60 received expander/implants. Expander/implant patients required more procedures (p < 0.001) but had shorter overall hospital lengths of stay (p < 0.001). The two cohorts experienced a similar rate of revision (p = 0.17). Free flap patients elected to undergo nipple-areola reconstruction more frequently (p = 0.01) and were able to sooner (p < 0.0001). Patients undergoing expander/implant reconstruction had a higher rate of failure (7.3 versus 1.3 percent, p = 0.008). Free flap patients achieved a stable reconstruction significantly faster (p = 0.0005), with fewer visits (p = 0.02). Cost analysis demonstrated total cost trended toward significantly lower in the free flap cohort (p = 0.15). Reconstructive modality was the only independent factor associated with time to stable reconstruction and reconstructive failure (p < 0.001 and p = 0.05, respectively).
The authors' analysis revealed that free flap reconstructions required fewer procedures, had lower rates of complications and failures, had fewer clinic visits, and achieved a final, complete reconstruction faster than expander/implant reconstructions. Although autologous reconstruction is still not ideal for every patient, these findings can be used to enhance preoperative discussions when choosing a reconstructive modality.
CLINICAL QUESTION/LEVEL OF EVIDENCE: : Therapeutic, III.
在乳房切除术后选择乳房重建方式是一个涉及复杂决策的关键步骤。作者提供了比较两种常见重建方式的结果数据，以帮助患者和外科医生进行术前咨询和讨论。
前瞻性维护的数据库查询确定了 2005 年至 2008 年间接受扩张器/植入物和腹部游离皮瓣进行乳房重建的选定患者。评估的变量包括合并症、手术、重建时间、并发症、总体结果、就诊次数、修复和成本。
142 例患者接受游离皮瓣，60 例患者接受扩张器/植入物。扩张器/植入物患者需要更多的手术（p < 0.001），但总体住院时间更短（p < 0.001）。两组患者的修复率相似（p = 0.17）。游离皮瓣患者更频繁地选择进行乳头乳晕重建（p = 0.01），且时间更早（p < 0.0001）。接受扩张器/植入物重建的患者失败率较高（7.3%对 1.3%，p = 0.008）。游离皮瓣患者更快地实现稳定重建（p = 0.0005），就诊次数更少（p = 0.02）。成本分析表明，游离皮瓣组的总费用趋势明显较低（p = 0.15）。重建方式是唯一与稳定重建时间和重建失败相关的独立因素（p < 0.001 和 p = 0.05）。
作者的分析表明，游离皮瓣重建需要的手术更少，并发症和失败的发生率更低，就诊次数更少，并且比扩张器/植入物重建更快地实现最终、完整的重建。尽管自体重建并非适合每位患者，但这些发现可用于增强选择重建方式的术前讨论。
临床问题/证据水平：治疗性，III 级。
