Salibian Ara A, Frey Jordan D, Choi Mihye, Karp Nolan S
Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, New York, N.Y.
Plast Reconstr Surg Glob Open. 2016 Nov 23;4(11):e1139. doi: 10.1097/GOX.0000000000001139. eCollection 2016 Nov.
The availability of acellular dermal matrix (ADM) and synthetic mesh products has prompted plastic surgeons to revisit subcutaneous implant-based breast reconstruction. The literature is limited, however, with regards to evidence on patient selection, techniques, and outcomes.
A systematic review of the Medline and Cochrane databases was performed for original studies reporting breast reconstruction with ADM or mesh, and subcutaneous implant placement. Studies were analyzed for level of evidence, inclusion/exclusion criteria for subcutaneous reconstruction, reconstruction characteristics, and outcomes.
Six studies (186 reconstructions) were identified for review. The majority of studies (66.7%) were level IV evidence case series. Eighty percent of studies had contraindications for subcutaneous reconstruction, most commonly preoperative radiation, high body mass index, and active smoking. Forty percent of studies commenting on patient selection assessed mastectomy flap perfusion for subcutaneous reconstruction. Forty-five percent of reconstructions were direct-to-implant, 33.3% 2-stage, and 21.5% single-stage adjustable implant, with ADM utilized in 60.2% of reconstructions versus mesh. Pooled complication rates included: major infection 1.2%, seroma 2.9%, hematoma 2.3%, full nipple-areola complex necrosis 1.1%, partial nipple-areola complex necrosis 4.5%, major flap necrosis 1.8%, wound healing complication 2.3%, explantation 4.1%, and grade III/IV capsular contracture 1.2%.
Pooled short-term complication rates in subcutaneous alloplastic breast reconstruction with ADM or mesh are low in preliminary studies with selective patient populations, though techniques and outcomes are variable across studies. Larger comparative studies and better-defined selection criteria and outcomes reporting are needed to develop appropriate indications for performing subcutaneous implant-based reconstruction.
脱细胞真皮基质（ADM）和合成网片产品的出现促使整形外科医生重新审视基于皮下植入物的乳房重建。然而，关于患者选择、技术和结果的证据，相关文献有限。
对Medline和Cochrane数据库进行系统综述，以查找报告使用ADM或网片进行乳房重建以及皮下植入物放置的原始研究。分析研究的证据水平、皮下重建的纳入/排除标准、重建特征和结果。
共确定6项研究（186例重建手术）进行综述。大多数研究（66.7%）为IV级证据的病例系列。80%的研究有皮下重建的禁忌证，最常见的是术前放疗、高体重指数和当前吸烟。40%涉及患者选择的研究评估了乳房切除皮瓣灌注情况以用于皮下重建。45%的重建手术为直接植入式，33.3%为两阶段式，21.5%为单阶段可调节植入式，60.2%的重建手术使用ADM，而使用网片的占33.3%。汇总的并发症发生率包括：严重感染1.2%、血清肿2.9%、血肿2.3%、乳头乳晕复合体完全坏死1.1%、乳头乳晕复合体部分坏死4.5%、皮瓣严重坏死1.8%、伤口愈合并发症2.3%、取出植入物4.1%以及III/IV级包膜挛缩1.2%。
在针对特定患者群体的初步研究中，使用ADM或网片进行皮下异体乳房重建的汇总短期并发症发生率较低，不过各研究之间的技术和结果存在差异。需要开展更大规模的对比研究以及更明确的选择标准和结果报告，以确定进行基于皮下植入物重建的合适指征。
