Rinker Brian
Lexington, Ky. From the Department of Surgery, Division of Plastic Surgery, University of Kentucky.
Plast Reconstr Surg. 2016 Feb;137(2):395-401. doi: 10.1097/01.prs.0000475744.10344.1e.
Skin-sparing mastectomy with immediate reconstruction can yield excellent aesthetic results, but high rates of mastectomy flap necrosis have been reported. A prospective cohort study was undertaken to compare three methods of assessing mastectomy flap viability following skin-sparing mastectomy and immediate reconstruction to determine which is most effective in reducing mastectomy flap necrosis.
The study group included 60 consecutive patients (99 breasts) undergoing skin-sparing mastectomy and immediate reconstruction with either tissue expanders (n = 39) or transverse rectus abdominis musculocutaneous flaps (n = 21). Mastectomy flap viability was assessed either visually (n = 20), with fluorescein dye and Wood's lamp imaging (n = 20), or by indocyanine green angiography (n = 20). Variation across groups was analyzed using analysis of variance for continuous variables and chi-square test for dichotomous variables.
The mean follow-up was 10 months. There were no significant differences in mean age, body mass index, medical history, smoking history, pathologic diagnosis, chemotherapy, or reconstruction type. Mastectomy flap necrosis was observed in eight of 30 breasts in the direct visualization group (27 percent), compared with 14 percent in the indocyanine green angiography group and 3 percent in the fluorescein group (p = 0.03). The reoperation rate in the direct visualization group was 20 percent, compared with 15 percent in the indocyanine green angiography group and 0 percent in the fluorescein group.
Fluorescein dye was associated with the lowest rate of complications after skin-sparing mastectomy, but indocyanine green angiography was also shown to reduce mastectomy flap necrosis compared with direct visualization. Routine imaging of mastectomy flap perfusion seems to be beneficial in skin-sparing mastectomy, but intravenous fluorescein may be as effective as more expensive modalities.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.
保留皮肤的乳房切除术并即刻重建可产生极佳的美学效果，但有报道称乳房切除皮瓣坏死率较高。进行了一项前瞻性队列研究，比较保留皮肤的乳房切除术并即刻重建后三种评估乳房切除皮瓣存活能力的方法，以确定哪种方法在降低乳房切除皮瓣坏死方面最有效。
研究组包括60例连续接受保留皮肤的乳房切除术并即刻重建的患者（99个乳房），其中使用组织扩张器的有39例，使用腹直肌肌皮瓣的有21例。通过肉眼观察（20例）、荧光素染料和伍德灯成像（20例）或吲哚菁绿血管造影（20例）评估乳房切除皮瓣的存活能力。连续变量采用方差分析，二分变量采用卡方检验分析组间差异。
平均随访10个月。平均年龄、体重指数、病史、吸烟史、病理诊断、化疗或重建类型方面无显著差异。直接观察组30个乳房中有8个发生乳房切除皮瓣坏死（27%），吲哚菁绿血管造影组为14%，荧光素组为3%（p = 0.03）。直接观察组的再次手术率为20%，吲哚菁绿血管造影组为15%，荧光素组为0%。
荧光素染料与保留皮肤的乳房切除术后最低的并发症发生率相关，但与直接观察相比，吲哚菁绿血管造影也显示可降低乳房切除皮瓣坏死率。乳房切除皮瓣灌注的常规成像在保留皮肤的乳房切除术中似乎有益，但静脉注射荧光素可能与更昂贵的方法效果相同。
临床问题/证据水平：治疗性，II级
