New York, N.Y.; and New Haven, Conn.
From the Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center; and the Section of Plastic Surgery, Yale School of Medicine.
Plast Reconstr Surg. 2018 May;141(5):1086-1093. doi: 10.1097/PRS.0000000000004271.
Free flap monitoring in autologous reconstruction after nipple-sparing mastectomy remains controversial. The authors therefore examined outcomes in nipple-sparing mastectomy with buried free flap reconstruction versus free flap reconstruction incorporating a monitoring skin paddle.
Autologous free flap reconstructions with nipple-sparing mastectomy performed from 2006 to 2015 were identified. Demographics and operative results were analyzed and compared between buried flaps and those with a skin paddle for monitoring.
Two hundred twenty-one free flaps for nipple-sparing mastectomy reconstruction were identified: 50 buried flaps and 171 flaps incorporating a skin paddle. The most common flaps used were deep inferior epigastric perforator (64 percent), profunda artery perforator (12.1 percent), and muscle-sparing transverse rectus abdominis myocutaneous flaps (10.4 percent). Patients undergoing autologous reconstructions with a skin paddle had a significantly greater body mass index (p = 0.006). Mastectomy weight (p = 0.017) and flap weight (p < 0.0001) were significantly greater in flaps incorporating a skin paddle. Comparing outcomes, there were no significant differences in flap failure (2.0 percent versus 2.3 percent; p = 1.000) or percentage of flaps requiring return to the operating room (6.0 percent versus 4.7 percent; p = 0.715) between groups. Buried flaps had an absolute greater mean number of revision procedures per nipple-sparing mastectomy (0.82) compared with the skin paddle group (0.44); however, rates of revision procedures per nipple-sparing mastectomy were statistically equivalent between the groups (p = 0.296).
Although buried free flap reconstruction in nipple-sparing mastectomy has been shown to be safe and effective, the authors' technique has evolved to favor incorporating a skin paddle, which allows for clinical monitoring and can be removed at the time of secondary revision.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
在保乳手术后游离皮瓣监测仍然存在争议。因此，作者研究了保留乳头的乳房切除术结合游离皮瓣重建与游离皮瓣重建结合监测皮瓣的结果。
回顾性分析 2006 年至 2015 年间行保留乳头的乳房切除术的自体游离皮瓣重建病例。分析比较了带埋置皮瓣和带监测皮瓣的游离皮瓣重建的患者人口统计学和手术结果。
共确定了 221 例用于保留乳头的乳房切除术重建的游离皮瓣：50 例带埋置皮瓣，171 例带监测皮瓣。最常用的皮瓣是腹壁下动脉穿支皮瓣（64%）、旋股外侧动脉穿支皮瓣（12.1%）和横行腹直肌肌皮瓣（10.4%）。带监测皮瓣的患者体重指数显著更高（p = 0.006）。带监测皮瓣的患者乳房切除术重量（p = 0.017）和皮瓣重量（p < 0.0001）显著更大。比较结果，两组间皮瓣失败率（2.0%与 2.3%；p = 1.000）或需要返回手术室的皮瓣比例（6.0%与 4.7%；p = 0.715）均无显著差异。与带监测皮瓣组相比，带埋置皮瓣的每例保留乳头的乳房切除术平均需要更多的修复手术（0.82 次比 0.44 次）；然而，两组间每例保留乳头的乳房切除术的修复手术率无统计学差异（p = 0.296）。
尽管保乳术后游离皮瓣重建已被证明是安全有效的，但作者的技术已经发展到倾向于结合使用监测皮瓣，这允许进行临床监测，并可在二次修复时去除。
临床问题/证据水平：治疗性，III 级。
