【原】假体乳房重建：使用改良顶帽皮瓣＋真皮移植重建乳头

　　采用假体重建乳房时，由于皮下脂肪组织较薄，故使乳头重建难度较高。

　　2017年2月7日，国际美容整形外科学会官方期刊《美容整形外科》在线发表韩国建阳大学医院、蔚山大学医院、首尔峨山医院的研究报告，对克服乳头重建困难的改良技术进行了回顾对比。

　　该回顾对比研究入组2011年4月～2014年12月假体重建乳房患者34例，其中A组21例采用改良顶帽皮瓣技术重建乳头，B组13例采用改良顶帽皮瓣技术＋狗耳状侧翼真皮卷起移植重建乳头。

　　术前，以对侧乳头乳晕复合体为参照，标记改良顶帽皮瓣，新乳头的设计高度（垂直长度）和周长（水平长度）应比对侧大10%。术中，经皮下表层分离皮瓣，同时应注意保留皮下血管网并避免暴露假体；缝合顶帽皮瓣及侧翼；切除两侧狗耳状侧翼以获取椭圆形真皮；缝合真皮末端并紧紧卷起，插入顶帽皮瓣后将其与顶部皮瓣缝合。术中及术后1年，测量重建乳头的最大垂直-水平长度。

图1、假体重建乳房患者改良顶帽皮瓣技术＋真皮移植重建乳头示意图

1. 患者站立位，以对侧乳头乳晕复合体为参照，标记改良顶帽皮瓣

2. 新乳头的设计高度（垂直长度）和周长（水平长度）应比对侧大10%

3. 经皮下表层分离皮瓣，同时应注意保留皮下血管网并避免暴露假体

4. 缝合顶帽皮瓣及侧翼

5. 切除两侧狗耳状侧翼以获取椭圆形真皮

6. 缝合真皮末端并紧紧卷起

7. 插入顶帽皮瓣，覆盖顶部皮瓣并将两者缝合

8. 术后重建乳头比先前的体积增加

图2、假体重建乳房患者改良顶帽皮瓣技术＋真皮移植重建乳头临床图

图3、假体重建乳房患者改良顶帽皮瓣技术重建乳头临床图

　　所有病例均无任何皮瓣坏死缺失等并发症。

　　术中测量A、B组重建乳头：

• 平均突起分别为：0.75±0.107cm、1.29±0.064cm（范围：0.5～0.9cm、1.2～1.4cm）

• 平均宽度分别为：0.90±0.184cm、1.43±0.076cm（范围：0.6～1.2cm、1.3～1.5cm）

• B组均显著大于A组（P值均＜0.001）

　　术后1年测量A、B组重建乳头：

• 平均突起分别为：0.42±0.053cm、0.85±0.077cm（范围：0.3～0.5cm、0.8～1.0cm）

• 平均宽度分别为：0.55±0.107cm、1.01±0.068cm（范围：0.4～0.7cm、0.9～1.1cm）

• B组均显著大于A组（P值均＜0.001）

　　术后1年与术中相比，A、B组重建乳头：

• 突起维持率分别为：56.82±6.256%、66.01±3.992%（范围：44.44～66.66%、61.53～71.42%）

• 宽度维持率分别为：62.11±9.185%、70.57±2.627%（范围：45.45～85.71%、66.66～73.33%）

• B组均显著大于A组（P值均＜0.001）

　　因此，对于假体重建乳房患者，改良顶帽皮瓣技术＋真皮卷起移植可以简单有效增加重建乳头体积，但是仍需大规模研究证实其可行性。

Aesthetic Plast Surg. 2017 Feb 7. [Epub ahead of print]

Augmentation of the Nipples Reconstructed with Modified Top-Hat Flap Using Dermal Grafts in Implant-Based Breast Reconstruction: A Comparative Study.

Kim H, Kim SI, Ha W, Yoon CS, Lee TJ, Kim KN.

Konyang University Hospital, University of Konyang College of Medicine, Myunggok Medical Research Center, Daejeon, Korea; Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea; Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

BACKGROUND: Nipple reconstruction in implant-based breast reconstruction remains challenging, as the remaining thin skin envelope results in a less projected neo-nipple with a reduced volume. This study presents a modified top-hat flap technique with rolled dermal grafts from the dog-ears of lateral wings for augmenting reconstructed nipples during implant-based breast reconstruction.

METHODS: Between April 2011 and December 2014, among 34 patients who underwent immediate post-mastectomy reconstruction with a direct silicone implant, nipple reconstruction was performed using the modified top-hat flap technique in only 21 patients (group A), whereas 13 patients underwent the modified top-hat flap technique with rolled dermal grafts from the dog-ears of lateral wings (group B). The projection and width of the neo-nipple were measured at the time of surgery and at 1 year post-surgery, respectively.

RESULTS: All modified top-hat flaps were successful without any complications. The mean nipple projections at the time of surgery were 0.75 ± 0.107 cm (range 0.5-0.9 cm) and 1.29 ± 0.064 cm (range 1.2-1.4 cm) in groups A and B, respectively (p < 0.001). The mean nipple widths at the time of surgery were 0.90 ± 0.184 cm (range 0.6-1.2 cm) and 1.43 ± 0.076 cm (range 1.3-1.5 cm) in groups A and B, respectively (p < 0.001). The maintenance of nipple projection and width was significantly increased in group B compared with group A.

CONCLUSION: The modified top-hat flap technique with rolled dermal grafts from the dog-ears of lateral wings is a useful and easy method to expand and augment the volume of reconstructed nipples in implant-based breast reconstruction.

LEVEL OF EVIDENCE: III.

KEYWORDS: Breast implant; Breast reconstruction; Dermis graft; Nipple reconstruction

PMID: 28175968

DOI: 10.1007/s00266-017-0806-2