本文選題：垂直雙蒂瓣法巨乳縮小術(shù) + 下蒂瓣法巨乳縮小術(shù)��； 參考：《安徽醫(yī)科大學(xué)》2015年博士論文

【摘要】：目的：通過應(yīng)用循證醫(yī)學(xué)的meta分析方法,對下蒂瓣法、雙環(huán)法和垂直雙蒂瓣法等三種常用的巨乳縮小術(shù)式術(shù)后并發(fā)癥進(jìn)行綜合評價(jià)分析,以期獲得三種術(shù)式術(shù)后并發(fā)癥發(fā)生情況的對比結(jié)果。方法：通過既定的檢索策略對CNKI.萬方數(shù)據(jù)庫、維普數(shù)據(jù)庫、PubMed、MEDLINE、 Cochrane圖書館數(shù)據(jù)庫進(jìn)行檢索,納入符合條件的文獻(xiàn)對三種術(shù)式的術(shù)后并發(fā)癥進(jìn)行統(tǒng)計(jì)分析評價(jià)。使用固定效應(yīng)模型,計(jì)算各項(xiàng)研究結(jié)果的危險(xiǎn)比(RR)和95%置信區(qū)間(CI)。結(jié)果：共檢索出相關(guān)文獻(xiàn)41篇,最終11篇文獻(xiàn)共291例患者符合條件并被納入分析研究。分析結(jié)果顯示,垂直雙蒂瓣法較下蒂瓣法和雙環(huán)法更容易發(fā)生術(shù)后乳頭乳暈壞死(下蒂瓣法和雙環(huán)法VS垂直雙蒂瓣法,RR=3.27,95% CI:1.32-8.13, P=0.011)或感覺減退(下蒂瓣法和雙環(huán)法VS垂直雙蒂瓣法,RR=2.43,95% CI: 1.16-5.09, P=0.019);在術(shù)后并發(fā)癥的合并分析中也得到了相似的結(jié)果(下蒂瓣法和雙環(huán)法VS垂直雙蒂瓣法,RR=3.63,95%CI：2.11-6.25,P=0.000；下蒂瓣法VS垂直雙蒂瓣法,RR=3.64,95% CI:1.59-8.36, P=0.002;雙環(huán)法VS垂直雙蒂瓣法,RR=3.35,95% CI:1.72-6.54, P=0.000),差異均存在顯著的統(tǒng)計(jì)學(xué)意義。而在下蒂瓣法與雙環(huán)法術(shù)后并發(fā)癥的比較中,沒有發(fā)現(xiàn)顯著的統(tǒng)計(jì)學(xué)意義(RR=1.11,95% CI:0.21-5.83, P=0.906)。結(jié)論：垂直雙蒂瓣法術(shù)式相較下蒂瓣法和雙環(huán)法,其術(shù)后并發(fā)癥的發(fā)生率明顯較高。而在下蒂瓣法與雙環(huán)法術(shù)后并發(fā)癥的比較中,沒有發(fā)現(xiàn)顯著的統(tǒng)計(jì)學(xué)差異。目的：研究成年女性乳房固定結(jié)構(gòu)特征及乳頭乳暈復(fù)合體的血供模式和神經(jīng)支配、走向,為巨乳縮小術(shù)術(shù)式改進(jìn)及獲得良好手術(shù)效果提供解剖學(xué)依據(jù)。方法：對6具12側(cè)成年女尸乳房標(biāo)本進(jìn)行大體解剖及顯微解剖研究,觀察乳房固定結(jié)構(gòu)特征及支配乳頭、乳暈區(qū)感覺的肋間神經(jīng)皮支的分布、走向。另6具尸體完整切取前胸壁,注意保留鎖骨下血管,于鎖骨下動脈起始處插管灌注血管鑄型劑,觀察乳頭乳暈復(fù)合體的深、淺兩組血管構(gòu)筑模式。結(jié)果：1.支配乳頭、乳暈復(fù)合體的神經(jīng)來自第3-5肋讓神經(jīng)的外側(cè)皮支和前皮支,第4肋間神經(jīng)外側(cè)皮支和前皮支恒定地進(jìn)入乳頭、乳暈區(qū),為支配乳頭乳暈復(fù)合體感覺功能的主要神經(jīng)分支。2.乳頭乳暈復(fù)合體由深、淺兩組血管供血。乳頭乳暈深部動脈主要來源于胸郭內(nèi)動脈和胸外側(cè)動脈在胸肌筋膜淺面的穿支,是乳頭乳暈重要的血供來源。供應(yīng)乳頭乳暈的淺層動脈由胸郭內(nèi)動脈第2-4肋讓穿支、胸外側(cè)動脈乳頭乳暈支和低位肋讓動脈穿支組成,它們在乳暈外緣發(fā)出分支供應(yīng)乳頭乳暈。深淺兩組血管在乳暈下匯集成乳頭乳暈真皮下血管網(wǎng)。3.乳房固定支持結(jié)構(gòu)特征：乳腺周緣韌帶位于乳腺基底周緣,為一圈環(huán)繞乳腺基底如網(wǎng)袋狀的結(jié)締組織纖維,其下部及外側(cè)纖維增厚致密,是乳腺的主要固定結(jié)構(gòu)。此外,部分乳腺周緣韌帶與淺筋膜相融合,對乳腺起輔助固定作用。結(jié)論：1.第4肋讓神經(jīng)外側(cè)皮支和前皮支為支配乳頭乳暈感覺的主要神經(jīng),其中外側(cè)皮支因支配乳頭乳暈范圍大而更為重要。乳房縮小整形術(shù)中應(yīng)注意保護(hù)第4肋讓神經(jīng)外側(cè)皮支在乳腺腺體內(nèi)的走行路徑不受損傷,以保證乳頭、乳暈區(qū)良好的感覺功能。2.乳頭乳暈復(fù)合體具有多源性血供。由深淺兩組供血系統(tǒng),其供應(yīng)血管主要由胸郭內(nèi)動脈2-4肋間穿支、胸外側(cè)動脈乳頭乳暈支和低位肋讓動脈穿支等組成。巨乳縮小手術(shù)中真皮腺體蒂的方向選擇、組織剝離層次及多余腺體皮膚的切除都應(yīng)考慮到乳頭乳暈復(fù)合體的血供模式,以免造成乳頭乳暈血運(yùn)障礙。3.乳房固定支持結(jié)構(gòu)由皮膚乳罩、淺筋膜和乳房周緣韌帶組成,其中從乳腺腺體周緣穿出的乳房懸韌帶最為重要。巨乳縮小手術(shù)應(yīng)注意乳房支持固定結(jié)構(gòu)的重建,避免繼發(fā)乳房下垂等并發(fā)癥的發(fā)生。目的：結(jié)合乳頭乳暈復(fù)合體血供模式、神經(jīng)支配及乳房固定結(jié)構(gòu)的應(yīng)用解剖學(xué)研究結(jié)果,對傳統(tǒng)下蒂法巨乳縮小術(shù)存在的不足加以改進(jìn),形成一種具有更好的乳頭乳暈血運(yùn)和感覺功能,及能持久保持自然、挺拔乳房外形的巨乳縮小成形術(shù)式,并通過與傳統(tǒng)下蒂法作比較評價(jià)其臨床效果。方法：通過將傳統(tǒng)下蒂瓣內(nèi)外側(cè)本應(yīng)去除皮膚部分的真皮保留形成真皮帽,以及對乳腺蒂的設(shè)計(jì)進(jìn)行改進(jìn)等方法,形成下蒂法結(jié)合真皮帽巨乳縮小術(shù)式。并于2011年11月至2013年8月臨床應(yīng)用13例,通過對13例患者的臨床資料進(jìn)行回顧性分析,總結(jié)應(yīng)用該技術(shù)的臨床經(jīng)驗(yàn)。并就臨床癥狀、切除腺體重量、術(shù)后并發(fā)癥及隨訪結(jié)果等方面與傳統(tǒng)下蒂法巨乳縮小術(shù)進(jìn)行對比,評價(jià)術(shù)式改進(jìn)后的臨床效果。以每側(cè)乳房作為單個(gè)研究對象,其中傳統(tǒng)下蒂法11例22側(cè)。隨訪時(shí)間分別為術(shù)后1月及6月-1年兩次。結(jié)果：兩組24例乳房肥大患者術(shù)后癥狀均得到了明顯的改善；所有患者術(shù)后乳房形態(tài)均基本對稱,外形良好。(1)下蒂真皮帽組所有病例乳頭、乳暈血供良好、感覺功能恢復(fù)滿意,無乳頭乳暈壞死發(fā)生；1例1側(cè)術(shù)后出現(xiàn)血腫,經(jīng)切開引流后傷口愈合;切口瘢痕增生1例(后期經(jīng)抗瘢痕治療后改善)；6-12月后所有病例均獲得隨訪未見乳房下極過度飽滿、乳房下垂發(fā)生,遠(yuǎn)期效果滿意。(4)傳統(tǒng)下蒂組：2例2側(cè)乳暈表皮部分壞死經(jīng)換藥后瘢痕愈合,2例2側(cè)血腫,經(jīng)穿刺、加壓包扎后好轉(zhuǎn)；2例術(shù)后1月復(fù)診時(shí)乳頭感覺減退,其中一例術(shù)后6月隨訪時(shí)恢復(fù)正常,另一例術(shù)后8月隨訪時(shí)仍未完全恢復(fù)；3例術(shù)后1月隨訪見切口瘢痕增生后經(jīng)局部注射藥物好轉(zhuǎn)；9例患者術(shù)后6-12月獲得隨訪,其中2例出現(xiàn)乳房下極飽滿伴乳房下垂。結(jié)論：下蒂結(jié)合真皮帽法巨乳縮小術(shù)式具有重建乳房血供更加可靠、術(shù)后乳頭乳暈感覺功能恢復(fù)良好、乳房遠(yuǎn)期外形良好等優(yōu)點(diǎn)。真皮懸吊技術(shù)為下真皮乳腺蒂復(fù)合組織瓣起到了很好的支撐、固定作用,加強(qiáng)了剩余腺體與胸肌筋膜的粘合力度,減小了切口張力,有效避免了單純下蒂法乳房易下垂、切口瘢痕增生等并發(fā)癥的發(fā)生,遠(yuǎn)期效果更為滿意,是矯治中、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.
【學(xué)位授予單位】：安徽醫(yī)科大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2015
【分類號】：R655.8

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