Rivet Joshua J, Day Kristopher M, Rau Jeffrey F, Waldrop Jimmy L, Brzezienski Mark A
From the Department of Plastic Surgery, University of Tennessee College of Medicine, Chattanooga, TN.
Ann Plast Surg. 2019 Jun;82(6S Suppl 5):S394-S398. doi: 10.1097/SAP.0000000000001792.
Acellular dermal matrices (ADMs) are commonly used for immediate breast reconstruction after skin-sparing mastectomy (SSM). Regnault grades 2 and 3 ptotic breasts feature significant mastectomy flap redundancy that may be incorporated into the reconstruction. This allows surgeons to use patients' de-epithelialized inferior dermal pedicle instead of ADM.
All consecutive SSM patients with Regnault grade 2 or 3 ptosis who underwent Passot-type immediate breast reconstruction (IBBR) with tissue expanders (TEs) and de-epithelialized inferior dermal pedicle without an ADM were included. Patient data from the electronic medical record, clinical photographs, and a comparative cost analysis of ADM versus additional operative time are provided.
Thirty-eight patients with an average age of 52.7 years, weight 210.5 lb, and body mass index of 35.1 kg/m were treated (34 bilateral, 4 unilateral; 72 reconstructed breasts). Average mastectomy specimens weighed 962.8 g. Tissue expanders were filled to 265.0 mL (41.6% capacity) intraoperatively, and final implant volume averaged 710.9 ± 118.5 mL after an average of 628.6 ± 74.1-mL expansion. Operative times for Passot-type IBBR was 124.3 ± 37.7 versus 92.5 ± 27.9 minutes (P = 0.0001) for submuscular TE placement with ADM. The operative technique is described in detail. There were 8 TE explantations (21.1%) included: intractable infection (10.5%; n = 4), symptomatic capsular contracture (7.9%; n = 3), and spontaneous TE deflation (2.6%; n = 1). All but 3 patients (92.1%) successfully completed Passot reconstruction, with 2 patients declining salvage latissimus dorsi flap reconstruction and 1 patient lost to follow-up. Total cost savings in this case series was $89,724 ($2361 ± $3529/case).
Additional prospective comparison studies are needed to determine whether Passot-type IBBR results in higher complication rates than conventional IBBR with ADM in this challenging patient population. Passot-type IBR after SSM is safe, demonstrates acceptable rates of successful breast reconstruction, confers cost savings by obviating the use of ADM, and provides favorable aesthetic results.
脱细胞真皮基质（ADM）常用于保乳皮肤切除术后即刻乳房重建。Regnault 2级和3级下垂乳房的特点是乳房切除皮瓣有明显冗余，可纳入重建。这使外科医生能够使用患者的去上皮化下真皮蒂，而非ADM。
纳入所有接受了带组织扩张器（TE）的Passot式即刻乳房重建（IBBR）且使用去上皮化下真皮蒂而未使用ADM的连续Regnault 2级或3级下垂的保乳皮肤切除术患者。提供了电子病历中的患者数据、临床照片，以及ADM与额外手术时间的成本对比分析。
共治疗38例患者，平均年龄52.7岁，体重210.5磅，体重指数35.1kg/m²（34例双侧，4例单侧；72个乳房重建）。乳房切除标本平均重962.8克。术中TE充注至265.0mL（容量的41.6%），平均扩张628.6±74.1mL后，最终植入体体积平均为710.9±118.5mL。Passot式IBBR的手术时间为124.3±37.7分钟，而使用ADM的肌下TE植入手术时间为92.5±27.9分钟（P = 0.0001）。详细描述了手术技术。包括8例TE取出（21.1%）：顽固性感染（10.5%；n = 4）、有症状的包膜挛缩（7.9%；n = 3）和TE自发瘪陷（2.6%；n = 1）。除3例患者（92.1%）外，所有患者均成功完成Passot重建，2例患者拒绝挽救性背阔肌皮瓣重建，1例患者失访。本病例系列的总成本节省为89,724美元（2361±3529美元/例）。
需要更多前瞻性对比研究来确定在这一具有挑战性的患者群体中，Passot式IBBR是否比使用ADM的传统IBBR导致更高的并发症发生率。保乳皮肤切除术后的Passot式IBR是安全的，乳房重建成功率可接受，通过避免使用ADM节省了成本，并提供了良好的美学效果。
