Rancati Alberto, Angrigiani Claudio, Lamas Gonzalo, Rancati Agustin, Berrino Valeria, Barbosa Karen, Dorr Julio, Irigo Marcelo
Oncoplastic Program, Hospital de Clínicas José de San Martin, Universidad de Buenos Aires, Buenos Aires, Argentina.
Gland Surg. 2024 Aug 31;13(8):1552-1560. doi: 10.21037/gs-23-291. Epub 2024 Aug 28.
Breast cancer is among the most common cancers diagnosed in women, affecting one in eight women per year. Immediate implant-based breast reconstruction has emerged as the predominant approach for postmastectomy reconstruction, with a growing preference for the direct-to-implant (DTI) method over the traditional tissue expander technique. While conventionally, implants were typically positioned beneath the pectoralis major muscle, recent advancements have paved the way for implant placement above the muscle, in the prepectoral plane. Nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM) techniques can be combined with prepectoral breast reconstruction. The presence of sufficient fatty tissue coverage is considered one of the foremost independent factors influencing the success of immediate breast reconstruction and flap viability. DTI is a safe approach for prepectoral implant-based reconstruction with a number of advantages. However, careful patient selection and judicious assessment of flap perfusion help identify an appropriate subset of patients for prepectoral DTI reconstruction. Proposed breast tissue coverage classification (BTCC) and rigorous perfusion assessment techniques will aid to minimize postoperative complications and reconstruction failure. Based on the obtained range of coverage values (distance between the Cooper's ligaments and the skin) of preoperative digital mammogram evaluation, a three-type BTCC is as follows: Type 1: <1 cm (poor coverage), Type 2: between 1 and 2 cm (medium coverage), Type 3: >2 cm (good coverage). Prepectoral DTI reconstruction provides good results with complication rates similar to those of subpectoral techniques, eliminating breast animation. A meticulous surgical technique is essential to preserve the vascular network that guarantees the survival of the skin flap and nipple-areola complex (NAC). In the good coverage group (Type 3), an immediate DTI reconstruction could be safely performed. Aesthetic complications as rippling can occur if prepectoral implants are placed in Type 1 patients. Preoperative planning for prepectoral placement should not depend on breast volume, but on breast tissue coverage. Flap evaluation based on preoperative imaging measurements may be helpful when planning a conservative mastectomy. Patient selection, preoperative and intraoperative mastectomy flap evaluation, and modifications in implant technology play a critical role in this new and rapidly growing method for implant-based breast reconstruction.
乳腺癌是女性中最常见的诊断癌症之一，每年每八名女性中就有一人受其影响。即刻植入式乳房重建已成为乳房切除术后重建的主要方法，与传统的组织扩张器技术相比，直接植入（DTI）方法越来越受到青睐。传统上，植入物通常放置在胸大肌下方，但最近的进展为在胸肌前平面的肌肉上方放置植入物铺平了道路。保留乳头的乳房切除术（NSM）和保留皮肤的乳房切除术（SSM）技术可以与胸肌前乳房重建相结合。充足的脂肪组织覆盖被认为是影响即刻乳房重建成功和皮瓣存活的最重要独立因素之一。DTI是一种安全的胸肌前植入式重建方法，有许多优点。然而，仔细的患者选择和对皮瓣灌注的明智评估有助于确定适合胸肌前DTI重建的患者亚组。提议的乳房组织覆盖分类（BTCC）和严格的灌注评估技术将有助于减少术后并发症和重建失败。根据术前数字乳房X线摄影评估获得的覆盖值范围（库珀韧带与皮肤之间的距离），三种类型的BTCC如下：1型：<1厘米（覆盖差），2型：1至2厘米（中等覆盖），3型：>2厘米（良好覆盖）。胸肌前DTI重建效果良好，并发症发生率与胸肌下技术相似，消除了乳房活动。细致的手术技术对于保留保证皮瓣和乳头乳晕复合体（NAC）存活的血管网络至关重要。在良好覆盖组（3型）中，可以安全地进行即刻DTI重建。如果在1型患者中放置胸肌前植入物，可能会出现如波纹等美学并发症。胸肌前放置的术前规划不应取决于乳房体积，而应取决于乳房组织覆盖情况。在计划保乳乳房切除术时，基于术前影像学测量的皮瓣评估可能会有所帮助。患者选择、术前和术中乳房切除皮瓣评估以及植入技术的改进在这种新的且迅速发展的基于植入物的乳房重建方法中起着关键作用。
