Zhong Toni, Fletcher Glenn G, Brackstone Muriel, Frank Simon G, Hanrahan Renee, Miragias Vivian, Stevens Christiaan, Vesprini Danny, Vito Alyssa, Wright Frances C
Plastic and Reconstructive Surgery, University Health Network, Toronto, ON M5G 2C4, Canada.
Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada.
Curr Oncol. 2025 Jun 17;32(6):357. doi: 10.3390/curroncol32060357.
Several postmastectomy breast reconstruction techniques and procedures have been implemented, although with limited evaluation of benefits and adverse effects. We conducted a systematic review on the plane and timing of reconstruction, and on the use of nipple-sparing mastectomy, acellular dermal matrix, and autologous fat grafting as the evidence base for an updated clinical practice guideline on breast reconstruction for Ontario Health (Cancer Care Ontario). Both immediate and delayed reconstruction may be considered, with preferred timing depending on factors such as patient preferences, type of mastectomy, skin perfusion, comorbidities, pre-mastectomy breast size, and desired reconstructive breast size. Immediate reconstruction may provide greater psychological or quality of life benefits. In patients who are candidates for skin-sparing mastectomy and without clinical, radiological, and pathological indications of nipple-areolar complex involvement, nipple-sparing mastectomy is recommended provided it is technically feasible and acceptable aesthetic results can be achieved. Surgical factors including incision location are important to reduce necrosis by preserving blood supply and to minimize nerve damage. There is a role for both prepectoral and subpectoral implants; risks and benefits will vary, and decisions should be made during consultation between the patient and surgeons. In patients who are suitable candidates for implant reconstruction and have adequate mastectomy flap thickness and vascularity, prepectoral implants should be considered. Acellular dermal matrix (ADM) has led to an increased use of prepectoral reconstruction. ADM should not be used in case of poor mastectomy flap perfusion/ischemia that would otherwise be considered unsuitable for prepectoral reconstruction. Care should be taken in the selection and handling of acellular dermal matrix (ADM) to minimize risks of infection and seroma. Limited data from small studies suggest that prepectoral reconstruction without ADM may be feasible in some patients. Autologous fat grafting is recommended as a treatment for contour irregularities, rippling following implant-based reconstruction, and to improve tissue quality of the mastectomy flap after radiotherapy.
尽管对益处和不良反应的评估有限，但已经实施了几种乳房切除术后乳房重建技术和程序。我们对重建的平面和时机，以及保留乳头的乳房切除术、脱细胞真皮基质和自体脂肪移植的使用进行了系统评价，以此作为安大略省卫生厅（安大略癌症护理机构）乳房重建最新临床实践指南的证据基础。即刻重建和延迟重建均可考虑，具体的首选时机取决于患者偏好、乳房切除术类型、皮肤灌注情况、合并症、乳房切除术前乳房大小以及期望的重建乳房大小等因素。即刻重建可能会带来更大的心理益处或生活质量改善。对于适合保留皮肤乳房切除术且无乳头乳晕复合体受累的临床、放射学和病理学指征的患者，若技术上可行且能获得可接受的美学效果，则建议行保留乳头的乳房切除术。包括切口位置在内的手术因素对于通过保留血供减少坏死以及将神经损伤降至最低很重要。胸肌前和胸肌后植入物都有其作用；风险和益处会有所不同，应在患者与外科医生的会诊过程中做出决定。对于适合植入物重建且乳房切除皮瓣厚度和血运充足的患者，应考虑使用胸肌前植入物。脱细胞真皮基质（ADM）导致胸肌前重建的使用增加。若乳房切除皮瓣灌注不良/缺血，否则被认为不适合胸肌前重建，则不应使用ADM。在选择和处理脱细胞真皮基质（ADM）时应谨慎，以将感染和血清肿的风险降至最低。来自小型研究的有限数据表明，在一些患者中不使用ADM进行胸肌前重建可能是可行的。自体脂肪移植推荐用于治疗轮廓不规则、基于植入物的重建后出现的波纹，以及改善放疗后乳房切除皮瓣的组织质量。
