Clinical application effects of the pedicled anterior intercostal artery perforator flap in breast reconstruction after breast-conserving surgery for breast cancer
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摘要:
目的 探讨带蒂肋间前动脉穿支皮瓣在乳腺癌保乳术后乳房重建中的临床应用效果。 方法 该研究为回顾性观察性研究。2023年1—12月, 西南医科大学附属医院乳腺外科收治16例符合入选标准的乳腺癌女性患者, 年龄（48±8）岁。采用带蒂肋间前动脉穿支皮瓣对患者进行保乳术后乳房重建：完整切除肿瘤组织后, 于乳房下皱襞设计“新月形”切口, 根据肿瘤位置及切除肿瘤后缺损面积切取带蒂肋间前动脉穿支皮瓣, 将皮瓣去表皮后进行对合、顺向或逆向旋转填充缺损。将供区创面逐层拉拢缝合。统计术中乳房组织损失量、手术时长、引流管留置时长、乳房切缘组织肿瘤阳性比例、乳房丢失比例, 以及术后皮瓣成活情况、并发症的发生比例。随访局部肿瘤复发或远处转移情况。末次随访时, 采用Ueda评分对保乳术后重建乳房进行美容评估, 应用Breast-Q量表2.0版对患者进行保乳术后乳房重建满意度及生活质量评估。 结果 该组患者术中乳房组织损失量为20~128（59±34）cm3, 手术时长为105~200（143±27）min, 引流管留置时长为3~7（4.6±1.0）d, 乳房切缘组织肿瘤阳性比例为1/16, 乳房丢失比例为0。术后, 患者移植皮瓣均成活。术后1例患者术区脂肪液化, 术后并发症发生比例为1/16。随访3~12（11±4）个月, 患者均未发生局部乳腺癌复发或远处转移。末次随访时, 患者保乳术后重建乳房美容评分结果：优秀者6例、良好者8例、尚可者2例, 优良比例为14/16。末次随访时, 患者保乳术后乳房重建满意度及生活质量评估中评分最高的是对外科医师的满意度, 评分为59~100（91±13）分；其次是胸部生理健康, 评分为60~100（77±14）分；随后依次为心理健康评分35~100（74±20）分、对乳房的满意度评分55~100（73±13）分、对获取信息的满意度评分53~100（70±14）分和性健康评分34~100（70±23）分。 结论 带蒂肋间前动脉穿支皮瓣用于乳腺癌保乳术后乳房重建安全、可靠, 能够取得较高的美容效果和患者满意度；该皮瓣设计简单、操作方便、可重复性强, 值得临床推广应用。 -
关键词:
- 乳腺肿瘤 /
- 穿支皮瓣 /
- 肋间前动脉穿支皮瓣 /
- 保乳术后乳房重建手术 /
- 创面修复
Abstract:Objective To investigate the clinical application effects of the pedicled anterior intercostal artery perforator flap in breast reconstruction after breast-conserving surgery for breast cancer. Methods This study was a retrospective observational study. From January to December 2023, 16 female breast cancer patients who met the inclusion criteria were hospitalized in the Department of Breast Surgery of the Affiliated Hospital of Southwest Medical University, with the age of (48±8) years. The pedicled anterior intercostal artery perforator flap was used for breast reconstruction of patients after breast-conserving surgery. After complete resection of tumor tissue, a "crescent-shaped" incision was designed at the inframammary fold. The pedicled anterior intercostal artery perforator flap was harvested based on the tumor location and the defect area after tumor removal. The flap was de-epithelialized, coapted, and rotated anterogradely or retrogradely to fill the defect. The donor site wound was closed with layered sutures. The following parameters were recorded: breast tissue loss volume during surgery, surgical duration, retention duration of the drainage tube, positive proportion of tumors in the breast incision margin tissue, breast loss ratio, flap survival, and incidence ratio of complications after operation. Patients were followed up for local recurrence or distant metastasis of tumor. At the last follow-up, the Ueda score was used to evaluate cosmetic outcomes of reconstructed breasts after breast-conserving surgery, and the Breast-Q scale version 2.0 was applied to assess patients' satisfaction and quality of life with breast reconstruction after breast-conserving surgery. Results The breast tissue loss volume during surgery in this group of patients was 20-128 (59±34) cm3, the surgical duration was 105-200 (143±27) min, the retention duration of the drainage tube was 3-7 (4.6±1.0) d, and the positive proportion of tumors in the breast incision margin tissue was 1/16, with breast loss ratio of 0. After the surgery, the patient's transplanted flaps all survived. One patient had postoperative fat liquefaction in the surgical area, and the incidence ratio of postoperative complications was 1/16. The patients were followed up for 3-12 (11±4) months, and no local breast cancer recurrence or distant metastasis occurred. At the last follow-up, the cosmetic score of breast reconstruction after breast-conserving surgery were excellent in 6 cases, good in 8 cases, and fair in 2 cases, with an excellent and good ratio of 14/16. At the last follow-up, the highest score in the evaluation of patients' satisfaction with breast reconstruction and quality of life after breast-conserving surgery was the satisfaction with the surgeons, with a score of 59-100 (91±13), followed respectively by physiological health of the chest with a score of 60-100 (77±14), psychological health with a score of 35-100 (74±20), breast satisfaction with a score of 55-100 (73±13), satisfaction with information acquisition with a score of 53-100 (70±14), and sexual health with a score of 34-100 (70±23). Conclusions The pedicled anterior intercostal artery perforator flap is safe and reliable for breast reconstruction after breast-conserving surgery for breast cancer, and can achieve high cosmetic effects and patient satisfaction. This flap is simple in design, easy to operate and highly reproducible, and is worthy of clinical promotion and application. 本文亮点(1) 带蒂肋间前动脉穿支皮瓣设计多样, 获取简单, 血供可靠。使用该皮瓣进行乳腺癌保乳术后缺损的修复属于容积替代, 相较于容积移位, 能够修复更大的组织缺损并保持良好的乳房外形。(2) 带蒂肋间前动脉穿支皮瓣切口隐蔽, 能够取得良好的美学效果, 尤其适用于亚洲人群中小体积乳房保乳术后的乳房重建, 对中国女性乳腺癌保乳率的提高大有裨益。 -
参考文献
(40) [1] Treatment of early-stage breast cancer[J]. JAMA, 1991, 265(3): 391-395. DOI: 10.1001/jama.1991.03460030097037 .[2] Gradishar WJ, Moran MS, Abraham J, et al. Breast cancer, version 3.2024, NCCN clinical practice guidelines in oncology[J]. J Natl Compr Canc Netw, 2024, 22(5): 331-357. DOI: 10.6004/jnccn.2024.0035. [3] Chan SWW, Cheung C, Chan A, et al. Surgical options for Chinese patients with early invasive breast cancer: data from the Hong Kong Breast Cancer Registry[J]. Asian J Surg, 2017, 40(6): 444-452. DOI: 10.1016/j.asjsur.2016.02.003. [4] Lei S, Zheng R, Zhang S, et al. Global patterns of breast cancer incidence and mortality: a population ‐ based cancer registry data analysis from 2000 to 2020[J]. Cancer Commun (Lond), 2021, 41(11): 1183-1194. DOI: 10.1002/cac2.12207. [5] Lim LY, Ho PJ, Liu J, et al. Determinants of breast size in Asian women[J]. Sci Rep, 2018, 8(1): 1201. DOI: 10.1038/s41598-018-19437-4. [6] Tay MRJ, Wong CJ, Aw HZ. Prevalence and associations of axillary web syndrome in Asian women after breast cancer surgery undergoing a community-based cancer rehabilitation program[J]. BMC Cancer, 2021, 21(1): 1019. DOI: 10.1186/s12885-021-08762-z. [7] 殷竹鸣, 尹健. 我国乳腺肿瘤整形外科的临床研究进展[J]. 中国肿瘤临床, 2020, 47(5): 245-248. DOI: 10.3969/j.issn.1000-8179.2020.05.110. [8] 邵鼎轶, 苏永辉, 修秉虬, 等. 中国110家中心乳腺癌保乳整形技术现况调查分析[J]. 中国实用外科杂志, 2019, 39(11): 1176-1180. DOI: 10.19538/j.cjps.issn1005-2208.2019.11.14. [9] Lim YX, Lim ZL, Ho PJ, et al. Breast cancer in Asia: incidence, mortality, early detection, mammography programs, and risk-based screening initiatives[J]. Cancers (Basel), 2022, 14(17): 4218. DOI: 10.3390/cancers14174218. [10] Haloua MH, Volders JH, Krekel NM, et al. Intraoperative ultrasound guidance in breast-conserving surgery improves cosmetic outcomes and patient satisfaction: results of a multicenter randomized controlled trial (COBALT)[J]. Ann Surg Oncol, 2016, 23(1): 30-37. DOI: 10.1245/s10434-015-4906-4. [11] Franca FC, de Oliveira-Junior I, Morgan AM, et al. Breast-conserving surgery with the geometric compensation/split reduction technique. Indications, oncologic safety and cosmesis. A cohort series and systematic review of the literature[J]. Surg Oncol, 2022, 44: 101839. DOI: 10.1016/j.suronc.2022.101839. [12] Al-Hilli Z, Wilkerson A. Breast surgery: management of postoperative complications following operations for breast cancer[J]. Surg Clin North Am, 2021, 101(5): 845-863. DOI: 10.1016/j.suc.2021.06.014. [13] Serra M, Li AQ, Cataliotti L, et al. Aesthetic results following breast cancer surgery: a prospective study on 6515 cases from ten Italian Senonetwork breast centers[J]. Eur J Surg Oncol, 2020, 46(10 Pt A): 1861-1866. DOI: 10.1016/j.ejso.2020.04.036. [14] Mennati M, Moeinafshar A, Rezaei N. Enhancing breast cancer surgery outcomes: a comprehensive review of oncoplastic techniques, surgical planning, and aesthetic considerations[J]. Crit Rev Oncol Hematol, 2025, 206: 104578. DOI: 10.1016/j.critrevonc.2024.104578. [15] Clough KB, Thomas SS, Fitoussi AD, et al. Reconstruction after conservative treatment for breast cancer: cosmetic sequelae classification revisited[J]. Plast Reconstr Surg, 2004, 114(7): 1743-1753. DOI: 10.1097/01.prs.0000142442.62956.78. [16] Clough KB, Lewis JS, Couturaud B, et al. Oncoplastic techniques allow extensive resections for breast-conserving therapy of breast carcinomas[J]. Ann Surg, 2003, 237(1): 26-34. DOI: 10.1097/00000658-200301000-00005. [17] Hamdi M, Van Landuyt K, de Frene B, et al. The versatility of the inter-costal artery perforator (ICAP) flaps[J]. J Plast Reconstr Aesthet Surg, 2006, 59(6): 644-652. DOI: 10.1016/j.bjps.2006.01.006. [18] Kollias V, Kollias J. Safety and efficacy of anterior intercostal artery perforator flaps in oncoplastic breast reconstruction [J]. ANZ J Surg, 2022, 92(5): 1184-1189. DOI: 10.1111/ans.17496. [19] Carrasco-López C, Julian Ibañez JF, Vilà J, et al. Anterior intercostal artery perforator flap in immediate breast reconstruction: anatomical study and clinical application [J]. Microsurgery, 2017, 37(6): 603-610. DOI: 10.1002/micr.30171. [20] Palmer JH, Taylor GI. The vascular territories of the anterior chest wall[J]. Br J Plast Surg, 1986, 39(3): 287-299. DOI: 10.1016/0007-1226(86)90037-8. [21] Angrigiani C, Rancati AO, Masia J, et al. Modified anterior intercostal artery perforator flap (AICAP) for autologous breast volume restoration after explantation[J]. J Plast Reconstr Aesthet Surg, 2021, 74(11): 2916-2924. DOI: 10.1016/j.bjps.2021.03.123. [22] Oki K, Murakami M, Tanuma K, et al. Anatomical study of pectoral intercostal perforators and clinical study of the pectoral intercostal perforator flap for hand reconstruction [J]. Plast Reconstr Surg, 2009, 123(6): 1789-1800. DOI: 10.1097/PRS.0b013e3181a65ac3. [23] 胡雅楠, 谢婷珺, 刘元波, 等. 吲哚菁绿血管造影辅助下设计切取扩张皮瓣整复瘢痕的临床效果[J]. 中华烧伤与创面修复杂志, 2025, 41(4): 341-347. DOI: 10.3760/cma.j.cn501225-20250108-00013. [24] 张丕红. 浅谈薄型穿支皮瓣切取与穿支血管探测和皮瓣血运评估[J]. 中华烧伤与创面修复杂志, 2023, 39(10): 911-918. DOI: 10.3760/cma.j.cn501225-20230812-00047. [25] Ueda S, Tamaki Y, Yano K, et al. Cosmetic outcome and patient satisfaction after skin-sparing mastectomy for breast cancer with immediate reconstruction of the breast [J]. Surgery, 2008, 143(3): 414-425. DOI: 10.1016/j.surg.2007.10.006. [26] 马雨薇, 修秉虬, 邵鼎轶, 等. 中文版Breast-Q信效度验证及其对于乳房满意度评估研究[J]. 中国实用外科杂志, 2021, 41(6): 681-686. DOI: 10.19538/j.cjps.issn1005-2208.2021.06.11. [27] 中国抗癌协会乳腺癌专业委员会, 中国医师协会外科医师分会乳腺外科医师委员会, 上海市抗癌协会乳腺癌专业委员会. 乳腺肿瘤整形与乳房重建专家共识(2022年版)[J]. 中国癌症杂志, 2022, 32(9): 836-924. DOI: 10.19401/j.cnki.1007-3639.2022.09.011. [28] Clough KB, Kaufman GJ, Nos C, et al. Improving breast cancer surgery: a classification and quadrant per quadrant atlas for oncoplastic surgery[J]. Ann Surg Oncol, 2010, 17(5): 1375-1391. DOI: 10.1245/s10434-009-0792-y. [29] Meshkin DH, Firriolo JM, Karp NS, et al. Management of complications following implant-based breast reconstruction: a narrative review[J]. Ann Transl Med, 2023, 11(12): 416. DOI: 10.21037/atm-23-1384. [30] Noguchi M, Morioka E, Yokoi-Noguchi M, et al. Oncoplastic breast surgery to prevent "Bird's beak" deformity in the breast: a comparative retrospective study[J]. Surg Today, 2024, 54(1): 14-22. DOI: 10.1007/s00595-023-02690-0. [31] Vindigni V, Marena F, Zanettin C, et al. Breast reconstruction: the oncoplastic approach[J]. J Clin Med, 2024, 13(16): 4718. DOI: 10.3390/jcm13164718. [32] Renouvel F, Nos C, Clough KB, et al. Preliminary outcome of breast cancer located at the lower quadrant treated with a thoracomammary flap[J]. Bull Cancer, 2008, 95(7): 773-778. DOI: 10.1684/bdc.2008.0636. [33] Aljarrah A, Nos C, Nasr R, et al. Updated follow-up of patients treated with the oncoplastic "Crescent" technique for breast cancer[J]. Breast, 2012, 21(4): 475-479. DOI: 10.1016/j.breast.2011.11.004. [34] Ng EE, French J, Hsu J, et al. Treatment of inferior pole breast cancer with the oncoplastic 'Crescent' technique: the Westmead experience[J]. ANZ J Surg, 2016, 86(1/2): 88-91. DOI: 10.1111/ans.13268. [35] 李利根, 柴家科. 肢体高压电烧伤软组织及血管损伤的影像学判断及临床意义[J]. 中华烧伤杂志, 2020, 36(11): 1009-1012. DOI: 10.3760/cma.j.cn501120-20190904-00371. [36] Adler N, Carmon E, Chapchay K, et al. Anterior intercostal artery perforator flap for immediate reconstruction following breast conservation surgery[J]. Microsurgery, 2023, 43(1): 20-26. DOI: 10.1002/micr.30884. [37] Hamdi M, Spano A, Landuyt KV, et al. The lateral intercostal artery perforators: anatomical study and clinical application in breast surgery[J]. Plast Reconstr Surg, 2008, 121(2): 389-396. DOI: 10.1097/01.prs.0000298317.65296.cf. [38] Wong C, Saint-Cyr M, Rasko Y, et al. Three- and four-dimensional arterial and venous perforasomes of the internal mammary artery perforator flap[J]. Plast Reconstr Surg, 2009, 124(6): 1759-1769. DOI: 10.1097/PRS.0b013e3181bf815f. [39] 司婧, 吴炅. 乳腺癌患者乳房重建术后满意度评估方法比较[J/OL]. 中华乳腺病杂志(电子版), 2017, 11(6): 361-364[2024-06-25]. http://zhrhbzz.paperopen.com/oa/darticle.aspx?type=view&id=20180401# . DOI:10.3877/cma.j.issn.1674-0807.2017.06.008 .[40] Berkane Y, Oubari H, van Dieren L, et al. Tissue engineering strategies for breast reconstruction: a literature review of current advances and future directions[J]. Ann Transl Med, 2024, 12(1): 15. DOI: 10.21037/atm-23-1724. -
图 1 AICAP解剖示意图及术中显露情况。1A.AICAP解剖示意图；1B.皮瓣内AICAP（黑色箭头指示）；1C.皮瓣外侧AICAP（黑色箭头指示）
注：AICAP为肋间前动脉穿支
Figure 1. Schematic diagram of the AICAP and its intraoperative exposure
图 2 采用不同方式转移带蒂肋间前动脉穿支皮瓣对不同位置乳腺肿瘤患者行保乳术后乳房重建。2A、2B、2C.分别显示肿瘤位于右侧乳房内下象限、左侧乳房内下象限、右侧乳房平乳晕区域, 图2A与2B中设计切口均位于乳房下皱襞；2D、2E、2F.分别为针对图2A、2B、2C各位置乳腺肿瘤的皮瓣转移方式, 图2D为以蒂部为支点进行逆向旋转填充缺损, 图2E为以蒂部为支点进行顺向旋转填充缺损, 图2F因残腔下方仍留有腺体瓣而将腺体瓣向上推移填充部分残腔后用带蒂皮瓣填充剩余残腔进行乳房重建
Figure 2. Breast reconstruction after breast-conserving surgery in patients with breast tumors at different locations using different methods of transferring pedicled anterior intercostal artery perforator flaps
图 3 采用带蒂肋间前动脉穿支皮瓣对肿瘤累及乳房下皱襞的乳腺癌患者行保乳术后乳房重建的效果。3A.术前左侧乳房外形；3B.术前皮瓣设计；3C.切除肿瘤及内侧下皱襞；3D.螺旋桨形式的肋间前动脉穿支皮瓣修复缺损并重建下皱襞；3E.术后3个月, 皮瓣愈合良好；3F.术后9个月, 形成新的下皱襞
Figure 3. Application effects of the pedicled anterior intercostal artery perforator flap in breast reconstruction after breast-conserving surgery in a breast cancer patient with tumor involving the inframammary fold
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