保留乳头乳晕复合体的乳房切除术中乳头乳晕的血供特点及其评估

摘要

保留乳头乳晕复合体(nipple-areola complex，NAC)的乳房切除术(nipple-areola complex- sparing mastectomy，NSM)在乳腺肿瘤领域的治疗已得到认可，其更好的美容效果也使得这种手术方式的应用日益普及。在手术技巧方面需要着重考虑术后乳头缺血、坏死造成的并发症。患者因素、重建方法以及切口的位置等的选择可以降低这种缺血坏死并发症的发生，而且NSM术中判断NAC的血供更为重要。首先，着重阐述了NAC血供的解剖特点及临床意义；其次，讨论了乳腺MRI检查明确NAC血流灌注分类的方法，包括动脉充盈期、静脉引流期及三维重建最大密度投影(maximal intensity projection，MIP)图像，可以在术前评估NAC的血管解剖并提供有价值的信息；最后，阐述了基于吲哚氰绿(indocyanine green，ICG)荧光成像在术中影像导航的应用，为外科医生提供了术中实时评估乳房皮肤和NAC血流灌注的方法，可以帮助医生检测缺血的情况并及时调整手术方案，降低NSM术后乳头缺血坏死的发生。%Nipple-areola complex (NAC)-sparing mastectomies (NSM) have gained acceptance in the ifeld of breast oncology. The superior aesthetic outcomes of NSM explain their increased use and rising popularity. Technical considerations and challenges of this procedure are centered on nipple ischemia and necrosis. Patient selection, reconstructive strategies and incision placement have lowered ischemic complication rates. An understanding of the NAC vascular anatomy is, therefore, clinically relevant beyond NSM. In this paper, the relevant clinical anatomy is described, mainly focusing on the anatomy of the NAC. This article also covers how to identify and classify the in vivo blood supply to the NAC using breast MRI exams which provide valuable information for assessing vascular anatomy of the NAC. This includes the arterial iflling phase, venous drainage phase and 3-dimensional reconstructed maximum intensity projection (MIP) images. Finally, the indocyanine green (ICG) and a specialized infrared camera-computer system provide surgeons with a practical tool to assess real-time breast skin and NAC perfusion. Intraoperative evaluation of skin perfusion allows surgeons to detect ischemia and modify the operative approach to reduce the risk of nipple ischemia and necrosis.