几种巨乳缩小术并发症的meta分析及下蒂巨乳缩小术式临床改进研究

发布时间：2018-05-27 00:41

本文选题：垂直双蒂瓣法巨乳缩小术 + 下蒂瓣法巨乳缩小术　；参考：《安徽医科大学》2015年博士论文

【摘要】：目的：通过应用循证医学的meta分析方法,对下蒂瓣法、双环法和垂直双蒂瓣法等三种常用的巨乳缩小术式术后并发症进行综合评价分析,以期获得三种术式术后并发症发生情况的对比结果。方法：通过既定的检索策略对CNKI.万方数据库、维普数据库、PubMed、MEDLINE、 Cochrane图书馆数据库进行检索,纳入符合条件的文献对三种术式的术后并发症进行统计分析评价。使用固定效应模型,计算各项研究结果的危险比(RR)和95%置信区间(CI)。结果：共检索出相关文献41篇,最终11篇文献共291例患者符合条件并被纳入分析研究。分析结果显示,垂直双蒂瓣法较下蒂瓣法和双环法更容易发生术后乳头乳晕坏死(下蒂瓣法和双环法VS垂直双蒂瓣法,RR=3.27,95% CI:1.32-8.13, P=0.011)或感觉减退(下蒂瓣法和双环法VS垂直双蒂瓣法,RR=2.43,95% CI: 1.16-5.09, P=0.019);在术后并发症的合并分析中也得到了相似的结果(下蒂瓣法和双环法VS垂直双蒂瓣法,RR=3.63,95%CI：2.11-6.25,P=0.000；下蒂瓣法VS垂直双蒂瓣法,RR=3.64,95% CI:1.59-8.36, P=0.002;双环法VS垂直双蒂瓣法,RR=3.35,95% CI:1.72-6.54, P=0.000),差异均存在显著的统计学意义。而在下蒂瓣法与双环法术后并发症的比较中,没有发现显著的统计学意义(RR=1.11,95% CI:0.21-5.83, P=0.906)。结论：垂直双蒂瓣法术式相较下蒂瓣法和双环法,其术后并发症的发生率明显较高。而在下蒂瓣法与双环法术后并发症的比较中,没有发现显著的统计学差异。目的：研究成年女性乳房固定结构特征及乳头乳晕复合体的血供模式和神经支配、走向,为巨乳缩小术术式改进及获得良好手术效果提供解剖学依据。方法：对6具12侧成年女尸乳房标本进行大体解剖及显微解剖研究,观察乳房固定结构特征及支配乳头、乳晕区感觉的肋间神经皮支的分布、走向。另6具尸体完整切取前胸壁,注意保留锁骨下血管,于锁骨下动脉起始处插管灌注血管铸型剂,观察乳头乳晕复合体的深、浅两组血管构筑模式。结果：1.支配乳头、乳晕复合体的神经来自第3-5肋让神经的外侧皮支和前皮支,第4肋间神经外侧皮支和前皮支恒定地进入乳头、乳晕区,为支配乳头乳晕复合体感觉功能的主要神经分支。2.乳头乳晕复合体由深、浅两组血管供血。乳头乳晕深部动脉主要来源于胸郭内动脉和胸外侧动脉在胸肌筋膜浅面的穿支,是乳头乳晕重要的血供来源。供应乳头乳晕的浅层动脉由胸郭内动脉第2-4肋让穿支、胸外侧动脉乳头乳晕支和低位肋让动脉穿支组成,它们在乳晕外缘发出分支供应乳头乳晕。深浅两组血管在乳晕下汇集成乳头乳晕真皮下血管网。3.乳房固定支持结构特征：乳腺周缘韧带位于乳腺基底周缘,为一圈环绕乳腺基底如网袋状的结缔组织纤维,其下部及外侧纤维增厚致密,是乳腺的主要固定结构。此外,部分乳腺周缘韧带与浅筋膜相融合,对乳腺起辅助固定作用。结论：1.第4肋让神经外侧皮支和前皮支为支配乳头乳晕感觉的主要神经,其中外侧皮支因支配乳头乳晕范围大而更为重要。乳房缩小整形术中应注意保护第4肋让神经外侧皮支在乳腺腺体内的走行路径不受损伤,以保证乳头、乳晕区良好的感觉功能。2.乳头乳晕复合体具有多源性血供。由深浅两组供血系统,其供应血管主要由胸郭内动脉2-4肋间穿支、胸外侧动脉乳头乳晕支和低位肋让动脉穿支等组成。巨乳缩小手术中真皮腺体蒂的方向选择、组织剥离层次及多余腺体皮肤的切除都应考虑到乳头乳晕复合体的血供模式,以免造成乳头乳晕血运障碍。3.乳房固定支持结构由皮肤乳罩、浅筋膜和乳房周缘韧带组成,其中从乳腺腺体周缘穿出的乳房悬韧带最为重要。巨乳缩小手术应注意乳房支持固定结构的重建,避免继发乳房下垂等并发症的发生。目的：结合乳头乳晕复合体血供模式、神经支配及乳房固定结构的应用解剖学研究结果,对传统下蒂法巨乳缩小术存在的不足加以改进,形成一种具有更好的乳头乳晕血运和感觉功能,及能持久保持自然、挺拔乳房外形的巨乳缩小成形术式,并通过与传统下蒂法作比较评价其临床效果。方法：通过将传统下蒂瓣内外侧本应去除皮肤部分的真皮保留形成真皮帽,以及对乳腺蒂的设计进行改进等方法,形成下蒂法结合真皮帽巨乳缩小术式。并于2011年11月至2013年8月临床应用13例,通过对13例患者的临床资料进行回顾性分析,总结应用该技术的临床经验。并就临床症状、切除腺体重量、术后并发症及随访结果等方面与传统下蒂法巨乳缩小术进行对比,评价术式改进后的临床效果。以每侧乳房作为单个研究对象,其中传统下蒂法11例22侧。随访时间分别为术后1月及6月-1年两次。结果：两组24例乳房肥大患者术后症状均得到了明显的改善；所有患者术后乳房形态均基本对称,外形良好。(1)下蒂真皮帽组所有病例乳头、乳晕血供良好、感觉功能恢复满意,无乳头乳晕坏死发生；1例1侧术后出现血肿,经切开引流后伤口愈合;切口瘢痕增生1例(后期经抗瘢痕治疗后改善)；6-12月后所有病例均获得随访未见乳房下极过度饱满、乳房下垂发生,远期效果满意。(4)传统下蒂组：2例2侧乳晕表皮部分坏死经换药后瘢痕愈合,2例2侧血肿,经穿刺、加压包扎后好转；2例术后1月复诊时乳头感觉减退,其中一例术后6月随访时恢复正常,另一例术后8月随访时仍未完全恢复；3例术后1月随访见切口瘢痕增生后经局部注射药物好转；9例患者术后6-12月获得随访,其中2例出现乳房下极饱满伴乳房下垂。结论：下蒂结合真皮帽法巨乳缩小术式具有重建乳房血供更加可靠、术后乳头乳晕感觉功能恢复良好、乳房远期外形良好等优点。真皮悬吊技术为下真皮乳腺蒂复合组织瓣起到了很好的支撑、固定作用,加强了剩余腺体与胸肌筋膜的粘合力度,减小了切口张力,有效避免了单纯下蒂法乳房易下垂、切口瘢痕增生等并发症的发生,远期效果更为满意,是矫治中、重乳房肥大的有效方法。
[Abstract]:Objective: by using the meta analysis method of evidence-based medicine (EBM), the postoperative complications of three kinds of large mammaplasty with lower pedicle flap method, double ring method and vertical double pedicle flap method were synthetically evaluated and analyzed in order to obtain the comparison results of three kinds of postoperative complications. Method: the data of the CNKI. Wanfang Data by the established retrieval strategy. Library, VIP database, PubMed, MEDLINE, Cochrane library database were retrieved and included in the eligible literature to evaluate the postoperative complications of three kinds of surgical procedures. Using the fixed effect model, the risk ratio (RR) and the 95% confidence interval (CI) were calculated. Results: 41 articles were retrieved, and the final 11 articles were retrieved. The results showed that the vertical double pedicle flap was more likely to be more prone to postoperative nipple areolar necrosis (lower pedicle flap and double ring VS vertical double pedicle flap, RR=3.27,95% CI:1.32-8.13, P=0.011) or sensory hypothyroidism (lower pedicle flap and double ring VS vertical double pedicle flap), compared with the lower pedicle flap method and the double ring method. Method, RR=2.43,95% CI: 1.16-5.09, P=0.019); similar results were also obtained in the combined analysis of postoperative complications (lower pedicle flap and double ring VS vertical double pedicle flap, RR=3.63,95%CI:2.11-6.25, P=0.000, VS vertical double pedicle flap method with lower pedicle flap, RR=3.64,95% CI: 1.59-8.36, P=0.002; double ring method vertical double pedicle flap method) 72-6.54, P=0.000), there were significant statistical significance, but there was no significant statistical significance in the comparison of the complications between the lower pedicle flap method and the double ring procedure (RR=1.11,95% CI:0.21-5.83, P=0.906). Conclusion: the incidence of postoperative complications is higher than that of the lower pedicle flap method and the double ring method. There was no significant statistical difference between the lower pedicle flap method and the complications after the double ring procedure. Objective: To study the characteristics of the fixed structure of the mammary gland and the pattern of blood supply and the innervation of the nipple areola complex in adult women, and to provide the anatomical basis for the improvement of the operation of giant milk reduction and the good effect of the operation. Method: 6 Gross anatomy and microanatomy of 12 adult female adult female cadavers were carried out to observe the characteristics of the fixed structure of the breast and the distribution of the intercostal branch of the intercostal nerve at the control of the nipples and the sensation of the areola. The other 6 bodies were completely cut into the anterior chest wall, and the subclavian vessels were reserved and the vascular casting agent was intubated at the beginning of the subclavian artery to observe the milk. The deep and shallow two groups of vascular architecture patterns of the head areola complex. Results: 1. control the nipple, the nerve of the areola complex comes from the 3-5 rib to the lateral cutaneous branch and the anterior cutaneous branch of the nerve, the fourth intercostal cutaneous branch and the anterior cutaneous branch enter the nipple, the areola area, the main nerve branch of the.2. nipple that dominates the sensory function of the nipple corona complex. The areola complex is supplied by two groups of deep and shallow blood vessels. The deep artery of the papillary areola is mainly derived from the perforating branches of the internal thoracic and lateral thoracic arteries in the superficial thoracic fascia. It is an important source of blood supply for the nipple areola. The superficial artery of the nipple areola is supplied by the 2-4 rib of the internal thoracic artery, the nipple areola branch of the lateral thoracic artery and the low rib The artery perforator consists of the papillary areola that emits branches at the outer rim of the areola. The two groups of vessels in the areola of the mammary corola integrate with the subdermal vascular network of the nipple areola, which are located at the basal margin of the mammary gland at the basal margin of the mammary gland, which is a circle of connective tissue fibers surrounding the base of the mammary gland, such as a net bag like tissue, and the lower and lateral part of the.3.. The thickening and dense fiber is the main fixed structure of the mammary gland. In addition, some of the peripheral ligaments of the mammary gland are fused with the superficial fascia to assist the fixation of the mammary glands. Conclusion: 1. the fourth rib makes the lateral cutaneous branch of the nerve and the anterior cutaneous branch the main nerve to control the sensation of the nipple areola, and the lateral cutaneous branch is more important for the large area of the nipple areola. In the reduction of plastic surgery, attention should be paid to protecting the fourth ribs to make the lateral cutaneous branch of the nerve in the mammary glands undamaged, so as to ensure the nipple and the good sensory function of the areola area, the.2. papillary areola complex has multisource blood supply. The supply of blood vessels in the two groups is mainly through the 2-4 intercostal arteries of the internal thoracic artery and the lateral thoracic artery. The papillary areola and the lower rib make the artery perforator and so on. The selection of the pedicle of the dermal gland in the operation of the mammillary reduction, the tissue exfoliation level and the excision of the excess gland skin should take into account the blood supply pattern of the nipple areola complex, so as to prevent the nipple areola from obstruction of the.3. breast fixed support structure from the skin mask, the superficial fascia and the milk. We should pay attention to the reconstruction of the fixed structure of breast support and avoid the occurrence of secondary breast ptosis. Objective: to combine the model of the blood supply of the papillary areola complex, the anatomic study of the innervation and the fixed structure of the breast. As a result, the shortcomings of the traditional pedicle method of mammaplasty were improved to form a giant mammaplasty formula with better nipple areola and sensory function, and to maintain the shape of breast, and to evaluate its clinical effect by comparing the traditional pedicle method. In the side, the dermis of the skin should be removed to form the dermal cap, and the design of the pedicle of the mammary gland should be improved. The method of combining the lower pedicle with the real skin cap giant milk reduction was formed. From November 2011 to August 2013, 13 cases were applied. The clinical data of 13 patients were analyzed retrospectively, and the clinical experience of the application of this technique was summarized. The clinical symptoms, the weight of the glandular removal, postoperative complications and follow-up results were compared with the traditional pedicle method of mammaplasty, and the clinical effects were evaluated. Each side of the breast was used as a single object of study, including 11 cases and 22 sides of the traditional pedicle method. The follow-up time was two times in January and June -1 years respectively. Results: two groups 2 The symptoms of 4 cases of breast hypertrophy were improved obviously. All the patients were basically symmetrical and well shaped after operation. (1) all the cases nipple in the lower pedicle dermal cap group, the corola blood supply was good, the sensory function recovered satisfactorily, no nipple areola necrosis occurred, 1 cases of 1 side postoperative hematoma, cut after incision and drainage, cut the wound healing; 1 cases of cicatricial hyperplasia (later improved after anti scar treatment); after 6-12 months, all cases were followed up with no overdue breast extreme plump, breast drooping, and long-term effect was satisfactory. (4) traditional pedicle group: 2 cases of 2 sides of the areola of the epidermis were healed after dressing, 2 cases of 2 side hematoma, puncture and compression bandage improved; 2 cases were performed. The papillary sensation decreased in January, one of them recovered in June after operation, and the other case was still not completely recovered in August. 3 cases were followed up in January, and 9 cases were followed up 6-12 months after surgery, and 2 cases had lower breast plump with breast drooping. The combination of the lower pedicle and the skin cap method has the advantages of reconstructing the breast blood supply more reliably, recovering the sensory function of the nipple and the areola well, and the good shape of the breast. The dermis suspension technique provides a good support for the composite tissue flap of the lower dermal mammary pedicle. The fixation effect strengthens the adhesion of the remaining glands to the pectoral fascia. It reduces the tension of the incision, effectively avoids the complications such as the easy drooping of the breasts and the scar hyperplasia of the incision, and the long-term effect is more satisfactory. It is an effective method for the correction of heavy breast hypertrophy.
【学位授予单位】：安徽医科大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R655.8

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