Meme Kanserinde Total Mastektomi Sonrası Öz Doku İle Rekonstrüksiyon
Özet
Meme kanseri tedavisinde total mastektomi sonrası uygulanan öz doku (otolog) ile meme rekonstrüksiyonu, hastaların fiziksel ve psikolojik iyilik hallerini artıran ve uzun vadeli memnuniyet sağlayan önemli bir yöntemdir. Tarihsel süreçte pediküllü fleplerle başlayan bu cerrahi yaklaşım, zamanla kas koruyucu serbest TRAM fleplerine ve nihayetinde rektus abdominis kasını tamamen koruyarak donör alan hasarını en aza indiren derin inferior epigastrik perforatör (DIEP) flebine evrilerek günümüzde altın standart haline gelmiştir. Karın bölgesindeki deri ve yağ dokusu, doğal hacim ve şekillendirme kolaylığı sunması nedeniyle ilk tercih edilen donör bölgedir; ancak karın dokusu yetersiz olan veya daha önce ameliyat geçirmiş hastalar için gluteal bölge (SGAP, IGAP) ile uyluk bölgesi (TUG, PAP) alternatif donör sahalar olarak tanımlanmıştır. Ameliyat öncesi dönemde hastanın komorbiditeleri, sigara kullanımı ve radyoterapi öyküsü titizlikle değerlendirilmekte, rekonstrüksiyon zamanlaması acil veya gecikmeli olarak planlanmaktadır. Mikrocerrahi tekniklerdeki ilerlemeler sayesinde %95-98 gibi yüksek başarı oranlarına ulaşan serbest flep transferlerinde, internal mamarian damarlar sıklıkla alıcı damar olarak tercih edilmektedir. Otolog rekonstrüksiyon doğal ve kalıcı sonuçlar sağlasa da donör sahada yara izi, kontur deformitesi ve mikrocerrahi altyapı gereksinimi gibi faktörlerin cerrahi öncesinde dikkate alınması kritik önem taşımaktadır.
Autologous breast reconstruction following total mastectomy for breast cancer significantly enhances patients' physical and psychological well-being, yielding exceptional long-term satisfaction. Historically evolving from pedicled flaps to free TRAM techniques, the surgical field revolutionized with the introduction of the deep inferior epigastric perforator (DIEP) flap, which preserves the rectus abdominis muscle, minimizes donor-site morbidity, and currently represents the gold standard. The lower abdomen serves as the primary donor site due to its optimal tissue volume and exceptional pliability for breast shaping; however, for patients lacking abdominal fat or with prior abdominal surgeries, alternative sites such as the gluteal region (SGAP, IGAP) and thighs (TUG, PAP) are utilized. Preoperative planning requires strict management of patient comorbidities, smoking cessation, and careful scheduling around radiotherapy, which can dictate an immediate or delayed reconstructive approach. Driven by advancements in microvascular surgery, free flap transfers boast remarkable survival rates of 95-98%, predominantly utilizing the internal mammary vessels for anastomosis. Although autologous reconstruction delivers natural, permanent aesthetic results, it demands robust surgical infrastructure and requires careful consideration of potential donor-site complications, including scarring, contour deformities, and localized functional impairment.
Referanslar
Jonczyk MM, Jean J, Graham R, et al. Surgical trends in breast cancer: A rise in novel operative treatment options over a 12 year analysis. Breast Cancer Res Treat. 2019;173:267–274.
Hu ES, Pusic AL, Waljee JF: Patient-reported satisfaction with breast reconstruction during the long-term survivorship period. Plast Reconstr Surg, 2009; 124: 1–8.
American Society of Plastic Surgeons. 2019 plastic surgery statistics report. Available at https://www.plasticsurgery.org/ documents/News/Statistics/2019/plastic-surgery-statisticsreport-2019.pdf. Accessed February 13, 2021.
Teimourian B, Adham MN. Louis Ombredanne and the origin of muscle flap use for immediate breast mound reconstruction. Plast Reconstr Surg (1983) 72(6):905–10. doi:10.1097/00006534-198312000-00037.
Hartrampf CR, Scheflan M, Siyah PW. Transvers abdominal ada flebi ile meme rekonstrüksiyonu. Plast Reconstr Surg (1982) 69(2):216–25. doi:10.1097/00006534-198202000-00006.
Arnez ZM, Smith RW, Eder E, Solinc M, Kersnic M. Breast reconstruction by the free lower transverse rectus abdominis musculocutaneous flap. Br J Plast Surg (1988) 41(5):500–5. doi:10.1016/0007-1226(88)90007-0.
Grotting JC, Urist MM, Maddox WA, Vasconez LO. Conventional TRAM flap versus free microsurgical TRAM flap for immediate breast reconstruction. Plast Reconstr Surg (1989
Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg (1994) 32(1):32–8. doi:10.1097/00000637-199401000-00007.
Blondeel PN, Boeckx WD. Refinements in free flap breast reconstruction: the free bilateral deep inferior epigastric perforator flap anastomosed to the internal mammary artery. Br J Plast Surg (1994) 47(7):495–501. doi:10.1016/0007-1226(94)90033-7.
Gurunluoglu R, Spanio S, Rainer C, Ninkovic M. Skin expansion before breast reconstruction with the superior gluteal artery perforator flap improves aesthetic outcome. Ann Plast Surg (2003) 50(5):475–9. doi:10.1097/01. SAP.0000041489.11933.03.
Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction with gluteal artery perforator flaps. J Plast Reconstr Aesthet Surg (2006) 59(6):614–21. doi:10.1016/j.bjps.2006.01.005.
Papp C, Windhofer C, Gruber S. Breast reconstruction with the fasciocutaneous infragluteal free flap (FCI). Ann Plast Surg (2007) 58(2):131–6. doi:10.1097/01.sap.0000237635.05337.a1.
Saad A, Sadeghi A, Allen RJ. The anatomic basis of the profunda femoris artery perforator flap: a new option for autologous breast reconstruction – a cadaveric and computer tomography angiogram study. J Reconstr Microsurg (2012) 28(6):381–6. doi:10.1055/s-0032-1313773.
Schoeller T, Huemer GM, Wechselberger G. The transverse musculocutaneous gracilis flap for breast reconstruction: guidelines for flap and patient selection. Plast Reconstr Surg (2008) 122(1):29–38. doi:10.1097/ PRS.0b013e318177436.
Nahabedian MY. Breast reconstruction: a review and rationale for patient selection. Plast Reconstr Surg 2009;124:55-62.
Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction using perforator flaps. J Surg Oncol. 2006;94:441-454.
Beckenstein MS, Grotting JC. Breast reconstruction with free-tissue transfer. Plast Reconstr Surg. 2001;108(5):1345-1353.
Zhao R, Tran BNN, Doval AF, Broadwater G, Buretta KJ, Orr JP, et al. A Multicenter Analysis Examining Patients Undergoing Conversion of Implant-based Breast Reconstruction to Abdominally based Free Tissue Transfer. J Reconstr Microsurg. 2018;34(09):685-691
O’Neill AC, Hayward V, Zhong T, Hofer SOP. Usability of the internal mammary recipient vessels in microvascular breast reconstruction. J. Plast. Reconstr. Aesthetic Surg. 2016;69(7):907-911.
Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg 1988;82:815-32500 .
Rozen WM, Ashton MW, Grinsell D. The branching pattern of the deep inferior epigastric artery revisited in-vivo: a new classification based on CT angiography. Clin Anat 2010; 23:87-92.
Holm C, Mayr M, Hofter E, et al. Perfusion zones of the DIEP flap revisited: a clinical study. Plast Reconstr Surg 2006;117: 37-43.
Rozen WM, Ashton MW, Le Roux CM, et al. The perforator angiosome: a new concept in the design of deep inferior epigastric artery perforator flaps for breast reconstruction. Microsurgery 2010;30:1.
Blondeel PN. Discussion: Perfusion-related complications are similar for DIEP and muscle-sparing free TRAM flaps harvested on medial or lateral deep inferior epigastric artery branch perforators for breast reconstruction. Plast Reconstr Surg 2011;128:590e-2e.
Rubino C, Ramakrishnan V, Figus A, et al. Flap size/flow rate relationship in perforator flaps and its importance in DIEAP flap drainage. J Plast Reconstr Aesthet Surg 2009;62: 1666-70.
Hijjawi JB, Blondeel PN. Advancing deep inferior epigastric artery perforator flap breast reconstruction through multidetector row computed tomography: an evolution in preoperative imaging. J Reconstr Microsurg 2010;26:11-20.
Masia J, Navarro C, Clavero JA, et al. Noncontrast magnetic resonance imaging for preoperative perforator mapping. Clin Plast Surg 2011;38:253-61.
Blondeel PN. One hundred free DIEP flap breast reconstructions: a personal experience. Br J Plast Surg 1999;52:104-11.
Granzow JW, Levine JL, Chiu ES, et al. Breast reconstruction with the deep inferior epigastric perforator flap: history and an update on current technique. J Plast Reconstr Aesthet Surg 2006;59:571-9.
De Frene B, Van Landuyt K, Hamdi M, et al. Free DIEAP and SGAP flap breast reconstruction after abdominal/gluteal liposuction. J Plast Reconstr Aesthet Surg 2006;59:1031-6.
Shayan R, Rozen WM, Bernard S, et al. Perforator dilatation induced by body weight gain is not reversed by subsequent weight loss: implications for perforator flaps. Plast Reconstr Surg 2008;122:1765-72.
Antia NH, Buch VI. Transfer of an abdominal dermo-fat graft by direct anastomosis of blood vessels. Br J Plast Surg 1971;24:15-9.
Grotting JC. The free abdominoplasty flap for immediate breast reconstruction. Ann Plast Surg 1991;27:351-4.
Rozen WM, Chubb D, Grinsell D, et al. The variability of the Superficial Inferior Epigastric Artery (SIEA) and its angiosome: A clinical anatomical study. Microsurgery 2010;30:386-91.
Fujino T, Harasina T, Aoyagi F. Reconstruction for aplasia of the breast and pectoral region by microvascular transfer of a free flap from the buttock. Plast Reconstr Surg 1975;56: 178-81.
Le-Quang C. Secondary microsurgical reconstruction of the breast and free inferior gluteal flap. Ann Chir Plast Esthet 1992;37:723-41.
LoTempio MM, Allen RJ. Breast reconstruction with SGAP and IGAP flaps. Plast Reconstr Surg 2010;126:393-401.
Allen RJ, Levine JL, Granzow JW. The in-the-crease inferior gluteal artery perforator flap for breast reconstruction. Plast Reconstr Surg 2006;118:333-9.
Schoeller T, Wechselberger G. Breast reconstruction by the free transverse gracilis (TUG) flap. Br J Plast Surg 2004;57:481-2.
Yousif NJ, Matloub HS, Kolachalam R, et al. The transverse gracilis musculocutaneous flap. Ann Plast Surg 1992;29: 482-90.
Fattah A, Figus A, Mathur B, et al. The transverse myocutaneous gracilis flap: technical refinements. J Plast Reconstr Aesthet Surg 2010;63:305-13.
Schoeller T, Huemer GM, Wechselberger G. The transverse musculocutaneous gracilis flap for breast reconstruction: guidelines for flap and patient selection. Plast Reconstr Surg 2008;122:29-38.
Fansa H, Schirmer S, Warnecke IC, et al. The transverse myocutaneous gracilis muscle flap: a fast and reliable method for breas.
Hallock GG. Further experience with the medial circumflex femoral (GRACILIS) perforator free flap. J Reconstr Microsurg 2004;20:115-22.
Allen RJ, Haddock NT, Ahn CY, et al. Breast reconstruction with the profunda artery perforator flap. Plast Reconstr Surg 2012;129:16e-23e.
