Sue Gloria R, Long Chao, Lee Gordon K
From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA.
Ann Plast Surg. 2017 May;78(5 Suppl 4):S208-S211. doi: 10.1097/SAP.0000000000001045.
Mastectomy skin necrosis is a significant problem after breast reconstruction. This complication may lead to poor wound healing and need for implant removal, which may delay subsequent oncologic treatment. We sought to characterize factors associated with mastectomy skin necrosis and propose a management algorithm.
A retrospective review was performed on consecutive patients undergoing implant-based breast reconstruction by the senior author from 2006 through 2015. Patient-level factors including age, race, body mass index, history of hypertension, history of diabetes, history of smoking, and history of radiation were collected. Surgical factors including type of mastectomy, location of implant placement, and immediate versus delayed reconstruction were collected. The incidence and treatment of mastectomy skin necrosis were analyzed.
A total of 293 patients underwent either unilateral or bilateral implant-based breast reconstructions after mastectomy with a total of 471 reconstructed breasts. Mastectomy skin necrosis was observed in 8.1% of reconstructed breasts. Skin necrosis was not associated with age, hypertension, diabetes, prior radiation, or type of mastectomy. The incidence of skin necrosis was higher among smokers (17.9% vs 5.0%, P < 0.001), among patients with higher body mass index (11.4% vs 6.1%, P = 0.05), patients who underwent immediate reconstruction compared to delayed (9.6% vs 0%, P = 0.004), placement of expander under acellular dermal matrix compared with submuscular placement (12.0% vs 5.2%, P = 0.02), and use of higher initial expander fill volume compared with lower fill volume (11.4% vs 5.4%, P = 0.02).The median necrosis size was 8 cm. The median time to treatment was 15 days postoperatively. In 55% of patients minor necrosis was treated with clinic debridement, whereas 43% had larger areas of necrosis requiring operative debridement. The median size treated with clinic debridement was 5.5 cm, compared to 15 cm for operative debridement. All necrosis was treated in a timely fashion and did not delay adjuvant therapy.
Mastectomy skin necrosis occurred in 8.1% of breasts after implant-based reconstruction. Necrosis less than 10 cm can be treated successfully with local debridement in the clinic setting. Timely and appropriate treatment of skin necrosis with debridement and primary closure expedites wound healing and facilitates tissue expander breast reconstruction.
乳房切除术后皮肤坏死是乳房重建后的一个重要问题。这种并发症可能导致伤口愈合不良以及需要取出植入物，这可能会延迟后续的肿瘤治疗。我们试图确定与乳房切除术后皮肤坏死相关的因素，并提出一种管理算法。
对2006年至2015年由资深作者连续进行基于植入物的乳房重建的患者进行回顾性研究。收集患者层面的因素，包括年龄、种族、体重指数、高血压病史、糖尿病病史、吸烟史和放疗史。收集手术因素，包括乳房切除术的类型、植入物放置的位置以及即刻重建与延迟重建。分析乳房切除术后皮肤坏死的发生率和治疗情况。
共有293例患者在乳房切除术后进行了单侧或双侧基于植入物的乳房重建，共471个重建乳房。在8.1%的重建乳房中观察到乳房切除术后皮肤坏死。皮肤坏死与年龄、高血压、糖尿病、既往放疗或乳房切除术的类型无关。吸烟者中皮肤坏死的发生率较高（17.9%对5.0%，P<0.001），体重指数较高的患者中发生率较高（11.4%对6.1%，P = 0.05），与延迟重建相比，即刻重建的患者发生率较高（9.6%对0%，P = 0.004），与肌下放置相比，在脱细胞真皮基质下放置扩张器的患者发生率较高（12.0%对5.2%，P = 0.02），与较低的初始扩张器填充量相比，使用较高初始扩张器填充量的患者发生率较高（11.4%对5.4%，P = 0.02）。坏死的中位大小为8厘米。治疗的中位时间为术后15天。在55%的患者中，轻度坏死通过门诊清创治疗，而43%的患者有较大面积的坏死需要手术清创。门诊清创治疗的中位大小为5.5厘米，手术清创为15厘米。所有坏死均得到及时治疗，未延迟辅助治疗。
在基于植入物的重建术后，8.1%的乳房发生了乳房切除术后皮肤坏死。小于10厘米的坏死可在门诊环境中通过局部清创成功治疗。通过清创和一期缝合及时、适当地治疗皮肤坏死可加快伤口愈合，并促进组织扩张器乳房重建。
