Gunnarsson Gudjon L, Bille Camilla, Reitsma Laurens C, Wamberg Peter, Thomsen Jørn Bo
Skien, Norway; and Odense/Vejle, Denmark.
From the Department of Plastic Surgery, Telemark Hospital; the Department of Plastic Surgery, Odense University Hospital; and the Section for Breast Surgery, Department of Surgery, Vejle Lillebaelt Hospital.
Plast Reconstr Surg. 2017 Sep;140(3):449-454. doi: 10.1097/PRS.0000000000003621.
Nipple-sparing mastectomy with simultaneous hammock technique direct-to-implant reconstruction is increasingly offered to patients opting for risk-reducing mastectomy. Despite this promising method, patients with macromastia and ptotic breasts remain a challenging group to treat satisfactorily and more often end up undergoing a difficult corrective procedure and experience an unacceptably high rate of failed reconstruction. The authors examined whether targeted preshaping mastopexy/reduction could prepare these patients for a successful nipple-sparing mastectomy/direct-to-implant reconstruction.
Patients seeking risk-reducing nipple-sparing mastectomy/direct-to-implant reconstruction at the authors' institutions deemed unfit for a one-stage procedure based on their previous experience were offered a targeted two-stage, risk-reducing mastopexy/reduction followed by a delayed secondary nipple-sparing mastectomy and direct-to-implant reconstruction. Patients were followed up at 3 weeks and 6 or 12 months.
Forty-four reconstructions were performed in 22 patients aged 43 years (range, 26 to 57 years). All 44 procedures were completed successfully without any failure or nipple-areola complex losses. Patients' median body mass index was 30 kg/m (range, 22 to 44 kg/m). Six patients were smokers and one had hypertension. Two patients underwent reoperation because of hematoma and fat necrosis.
The authors' results demonstrate that a targeted preshaping mastopexy/reduction followed by nipple-sparing mastectomy/direct-to-implant reconstruction can be safely planned in women who opt for a risk-reducing mastectomy and can be performed successfully with a 3- to 4-month time span between operations. On the basis of these results and the superior cosmetic outcome, the two-stage approach has become the authors' standard of care in all such settings.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
对于选择降低风险乳房切除术的患者，越来越多地采用保留乳头的乳房切除术并同时采用吊床技术直接植入式乳房重建术。尽管这种方法很有前景，但巨乳症和乳房下垂的患者仍然是一个具有挑战性的群体，难以得到令人满意的治疗，而且往往最终要经历困难的矫正手术，且重建失败率高得令人难以接受。作者研究了针对性的预塑形乳房上提术/缩小术是否能让这些患者成功进行保留乳头的乳房切除术/直接植入式乳房重建术。
在作者所在机构寻求降低风险的保留乳头乳房切除术/直接植入式乳房重建术的患者，根据作者以往经验，被认为不适合一期手术的，接受针对性的两阶段降低风险乳房上提术/缩小术，随后进行延迟的二期保留乳头乳房切除术和直接植入式乳房重建术。在3周以及6或12个月时对患者进行随访。
对22名年龄43岁（范围26至57岁）的患者进行了44次重建手术。所有44例手术均成功完成，无任何失败或乳头乳晕复合体丢失。患者的中位体重指数为30kg/m²（范围22至44kg/m²）。6名患者吸烟，1名患有高血压。2名患者因血肿和脂肪坏死接受了再次手术。
作者的结果表明，对于选择降低风险乳房切除术的女性，可以安全地计划先进行针对性的预塑形乳房上提术/缩小术，然后进行保留乳头乳房切除术/直接植入式乳房重建术，且两次手术之间间隔3至4个月即可成功完成。基于这些结果以及更好的美容效果，两阶段方法已成为作者在所有此类情况下的标准治疗方法。
临床问题/证据水平：治疗性，IV级。
