Park Jin Sol, Jin Ung Sik
Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
Arch Plast Surg. 2024 Feb 7;51(1):52-61. doi: 10.1055/s-0043-1775591. eCollection 2024 Jan.
Although prepectoral implant-based breast reconstruction has recently gained popularity, dual-plane reconstruction is still a better option for patients with poor-quality mastectomy skin flaps. However, shoulder morbidity is aggravated by subpectoral reconstruction, especially in irradiated patients. This study aimed to demonstrate shoulder exercise improvement in subpectoral reconstruction by delayed prepectoral conversion with an acellular dermal matrix (ADM) inlay graft technique at the time of expander-to-implant exchange after irradiation. Patients with breast cancer treated for expander-to-implant exchange after subpectoral expander insertion and subsequent radiotherapy between January 2021 and June 2022 were enrolled. An ADM inlay graft was inserted between the pectoralis major muscle and the previously inserted ADM. The ADM was sutured partially overlapping the pectoralis muscle from the medial side with the transition part, to the muscle border at the lateral side. Perioperative shoulder joint active range-of-motion (ROM) for forward flexion, abduction, and external rotation was also evaluated. A total of 35 patients were enrolled in the study. Active shoulder ROM significantly improved from 163 degrees preoperatively to 176 degrees postoperatively in forward flexion, 153 to 175 degrees in abduction, and 69 to 84 degrees in external rotation. There was no difference in patient satisfaction regarding the final outcome between the conventional prepectoral reconstruction group and the study group. Shoulder exercises in irradiated patients who underwent subpectoral reconstruction were improved by delayed prepectoral conversion using an ADM inlay graft. It is recommended that subpectoral reconstruction not be ruled out due to concerns regarding muscle contracture and shoulder morbidity in radiation-planned patients with poor mastectomy skin flaps.
尽管胸前植入物乳房重建术近来颇受青睐，但对于乳房切除术后皮瓣质量欠佳的患者而言，双平面重建仍是更佳选择。然而，胸肌下重建会加重肩部病变，尤其是在接受过放疗的患者中。本研究旨在通过在放疗后扩张器更换为植入物时采用脱细胞真皮基质（ADM）镶嵌移植技术进行延迟胸前转换，来证明胸肌下重建中肩部运动功能的改善。
纳入2021年1月至2022年6月期间因胸肌下扩张器植入及后续放疗而接受扩张器更换为植入物治疗的乳腺癌患者。在胸大肌与先前植入的ADM之间插入一块ADM镶嵌移植物。ADM从内侧与过渡部分开始与胸肌部分重叠缝合，直至外侧的肌肉边缘。还评估了围手术期肩关节前屈、外展和外旋的主动活动范围（ROM）。
本研究共纳入35例患者。主动肩部ROM在前屈方面从术前的163°显著提高至术后的176°，在外展方面从153°提高至175°，在外旋方面从69°提高至84°。传统胸前重建组与研究组患者对最终结果的满意度无差异。
采用ADM镶嵌移植物进行延迟胸前转换可改善接受胸肌下重建的放疗患者的肩部运动功能。对于乳房切除术后皮瓣质量欠佳且计划接受放疗的患者，不应因担心肌肉挛缩和肩部病变而排除胸肌下重建。
