即刻乳房修复重建的临床分析
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摘要
研究背景：本项工作是在中国临床肿瘤学科学基金(CSCO-康莱特基金)的资助下，我院与中国医学科学院肿瘤医院等十家单位共同合作完成。2003．1-2007．3，共行即刻乳房修复重建34例。这项研究的目的是对即刻乳房重建结果进行全面评价，为我国在即刻乳房重建领域的研究提供有力的指导依据。
研究方法：我们参考国际公认的欧洲研究治疗癌症组织制定的癌症患者生活质量问卷调查条例(EORTC QLQ-C30)，及专为乳腺癌患者设计的生活质量随访表，包括乳腺癌化疗随访表和乳腺癌治疗功能评价(FACT-B)，通过与乳房重建专业人员的讨论和乳腺癌患者的广泛交流，结合我们的研究方向自行设计随访问卷调查表。随机选取同期40例延迟乳房重建的患者做对照组。本研究通过问卷和电话两种形式进行随访。随访内容包括：对重建结果的评价、生活质量问卷、心理影响、选择乳房重建的原因、乳房重建信息来源等方面。另外，我们用Hopwood等设计的体像评分表又对即刻乳房重建的患者进行问卷调查，进一步证实评价结果的科学性。
研究结果：4年共行即刻乳房修复重建34例，延迟乳房重建共64例，即刻组随访了21例，随访比率为61.76％，延迟组随访了40例，随访比率为62.5％。采用SPSS11.5软件包对数据进行统计分析处理，对于有序的分类变量采用了Wilcoxon秩和检验，对于无序的分类变量采用了卡方检验。分析手术时间与手术费用时，以手术方式为区组，采用了随机区组设计的方差分析。分析年龄因素采用成组t检验。分析手术方法分类与并发症、再造乳房接受程度的关系采用Fisher确切概率法。分析选择乳房重建原因采用的是单因素和多因素Logistic逐步回归分析方法。
1．两组对重建结果的评价没有统计学差别(P＞0.05)；即刻组满意度为85.7％，延迟组为92.5％；
2．生活质量的影响：
2．1两组在穿衣服方面没有统计学差异，但是即刻组有66.66％的人不受任何影响，延迟组仍然有32.5％的人不能穿暴露的衣服；
2．2患者重建乳房后对参加社会活动的影响，即刻组明显有优势，P＜0.05；
2．3两组在性生活方面没有统计学差异，即刻组性生活不受影响占52.38％，丈夫对重建乳房的满意率达61.9％；
3．心理影响：
3．1即刻组中有66.67％自信心不受影响；手术乳房重建后延迟组较即刻组的自信心明显增强(P＜0.05)；
3．2即刻组有52.38％认为重建的乳房是自体乳房，有47.62％认为手术结果到达预期期望值，如果重新选择有80.95％仍然会选择相同的外科治疗方法；
3．3即刻组表现出对癌症复发的担忧为42.86％；
4．在乳房重建信息来源方面两组表现出很大差异，即刻组主要来源于肿瘤医生，延迟组主要来源于网络、电视节目的宣传(P＜0.05)；
5．即刻组选择乳房重建的原因，主要是“不能接受失去乳房的心理障碍”和“恢复完整的身体”；
6．其它结果：1)无论是即刻组还是延迟组，患者更愿意将背阔肌重建的乳房看成自己的乳房；2)即刻组更愿意选择相对简单的手术方式；3)手术并发症及瘢痕直接影响患者对重建结果的满意度；4)即刻组在花费和手术时间上均明显少于延迟组(F=15.462，P＜0.01；F=10.25，P＜0.01)；
7．体像评分发现，对重建的乳房越满意体像评分越低。
研究结论：
1．早期乳腺癌行即刻乳房重建可以预防乳房切除后对患者心理和生活质量的影响。
2．即刻乳房修复重建术不仅常规用于早期乳腺癌的乳房再造，而且可以用于晚期乳腺癌及复发肿瘤大范围切除的创面修复。
3．即刻乳房重建的患者对结果要求更高。如果肿瘤情况允许，行SSM和保留NAC的乳腺癌改良根治术即刻乳房重建，效果较其它方法更理想，患者对重建乳房的满意度更具优势。因此，肿瘤科医生和整形外科医生的共同努力是提高患者的术后满意率的关键。
The clinical assessment of immediatebreast reconstruction
Background: We cooperated with Chinese academy of medical scienceoncology hospital and others center in promoting the immediate breastreconstruction from January of 2003 to March of 2007, with staking ofChinese Society ClinicalOnconlogy(CSCO) fund. During this period, 34cases were performed and evaluated to supply information for furtherclinical work.
Methods: Thirty-four cases of mastectomy with immediate breastreconstruction (IBR)were studied. We consulted both the EuropeanOrganization for Research and Treatment of Cance(EORTC) Quality-of-lifeC30 (QLQ-C30) and the Functional Assessment of CancerTherapy-Breast(FACT-B), combining our situation to designquestionnaire. We also use the Body Image Scale to investigate patientsin order to make sure our outcomes.
Results: The outcomes were assessed both mailing questionnaire andtelephone to 34 patients of IBR, and we selected 67 patients of delayedbreast reconstruction(DBR) to comparison. 21 questionnaires of IBR(61.76percent)and 40 questionnaires of DBR(62.5 percent) were returned. Toconduct a statistical analysis, the Wilcoxon signed rank test, Fisher exacttests, two-sided t test, Spearman' s correlation, and factor analysisstatistics were used. Variables analyzed included patient' sage, cost, reasons for reconstruction, method and operation time ofreconstruction, and postoperative complications. Data analysis showedthat the treatment received by the two groups was similar in manyrespects. There was no statistical association a patient's satisfaction with the results (P＞0.05). The QL of IBR is less affected than DBR. With thesame method, cost of IBR is lower than DBR(F=15.462, P＜0.01); operation timeof IBR is shorter than DBR (F=10.25, P＜0.01). Patients preferred simpletechnique of reconstruction, and were satisfied with the results ofreconstruction with the method of LDF. The information for IBR was mainlypromoted by oncology surgeon and DBR by Internet and TV. The reason of IBRare psychological influence without breast and for herself. We have founda strong correlation between scar of reconstructive breast and overallaesthetic results. Although overall satisfaction with breastreconstruction is undoubtedly determined by multiple and complex clinical,emotional, and psychological factors, this study suggests thatpostoperative complications are a particularly important indicator ofdissatisfaction with reconstruction.
Conclusion:
1. Our results confirm that patients of IBR responses regardingsatisfaction with reconstruction will reflect smaller negativepsychological and quality-of-life aspects of mastectomy.
2. IBR can be used to repair the wound of recurrent sarcoma and laterbreast cancer.
3. As a result of the development of new techniques that use a skin-sparingapproach and nipple-areola-preserving envelope mastectomy with IBR,the aesthetic outcome of reconstruction can be improved. In order toimprove the satisfaction, oncology surgeon and plastic surgeon shouldcooperate to benefit patient a lot.
研究方法：我们参考国际公认的欧洲研究治疗癌症组织制定的癌症患者生活质量问卷调查条例(EORTC QLQ-C30)，及专为乳腺癌患者设计的生活质量随访表，包括乳腺癌化疗随访表和乳腺癌治疗功能评价(FACT-B)，通过与乳房重建专业人员的讨论和乳腺癌患者的广泛交流，结合我们的研究方向自行设计随访问卷调查表。随机选取同期40例延迟乳房重建的患者做对照组。本研究通过问卷和电话两种形式进行随访。随访内容包括：对重建结果的评价、生活质量问卷、心理影响、选择乳房重建的原因、乳房重建信息来源等方面。另外，我们用Hopwood等设计的体像评分表又对即刻乳房重建的患者进行问卷调查，进一步证实评价结果的科学性。
研究结果：4年共行即刻乳房修复重建34例，延迟乳房重建共64例，即刻组随访了21例，随访比率为61.76％，延迟组随访了40例，随访比率为62.5％。采用SPSS11.5软件包对数据进行统计分析处理，对于有序的分类变量采用了Wilcoxon秩和检验，对于无序的分类变量采用了卡方检验。分析手术时间与手术费用时，以手术方式为区组，采用了随机区组设计的方差分析。分析年龄因素采用成组t检验。分析手术方法分类与并发症、再造乳房接受程度的关系采用Fisher确切概率法。分析选择乳房重建原因采用的是单因素和多因素Logistic逐步回归分析方法。
1．两组对重建结果的评价没有统计学差别(P＞0.05)；即刻组满意度为85.7％，延迟组为92.5％；
2．生活质量的影响：
2．1两组在穿衣服方面没有统计学差异，但是即刻组有66.66％的人不受任何影响，延迟组仍然有32.5％的人不能穿暴露的衣服；
2．2患者重建乳房后对参加社会活动的影响，即刻组明显有优势，P＜0.05；
2．3两组在性生活方面没有统计学差异，即刻组性生活不受影响占52.38％，丈夫对重建乳房的满意率达61.9％；
3．心理影响：
3．1即刻组中有66.67％自信心不受影响；手术乳房重建后延迟组较即刻组的自信心明显增强(P＜0.05)；
3．2即刻组有52.38％认为重建的乳房是自体乳房，有47.62％认为手术结果到达预期期望值，如果重新选择有80.95％仍然会选择相同的外科治疗方法；
3．3即刻组表现出对癌症复发的担忧为42.86％；
4．在乳房重建信息来源方面两组表现出很大差异，即刻组主要来源于肿瘤医生，延迟组主要来源于网络、电视节目的宣传(P＜0.05)；
5．即刻组选择乳房重建的原因，主要是“不能接受失去乳房的心理障碍”和“恢复完整的身体”；
6．其它结果：1)无论是即刻组还是延迟组，患者更愿意将背阔肌重建的乳房看成自己的乳房；2)即刻组更愿意选择相对简单的手术方式；3)手术并发症及瘢痕直接影响患者对重建结果的满意度；4)即刻组在花费和手术时间上均明显少于延迟组(F=15.462，P＜0.01；F=10.25，P＜0.01)；
7．体像评分发现，对重建的乳房越满意体像评分越低。
研究结论：
1．早期乳腺癌行即刻乳房重建可以预防乳房切除后对患者心理和生活质量的影响。
2．即刻乳房修复重建术不仅常规用于早期乳腺癌的乳房再造，而且可以用于晚期乳腺癌及复发肿瘤大范围切除的创面修复。
3．即刻乳房重建的患者对结果要求更高。如果肿瘤情况允许，行SSM和保留NAC的乳腺癌改良根治术即刻乳房重建，效果较其它方法更理想，患者对重建乳房的满意度更具优势。因此，肿瘤科医生和整形外科医生的共同努力是提高患者的术后满意率的关键。
The clinical assessment of immediatebreast reconstruction
Background: We cooperated with Chinese academy of medical scienceoncology hospital and others center in promoting the immediate breastreconstruction from January of 2003 to March of 2007, with staking ofChinese Society ClinicalOnconlogy(CSCO) fund. During this period, 34cases were performed and evaluated to supply information for furtherclinical work.
Methods: Thirty-four cases of mastectomy with immediate breastreconstruction (IBR)were studied. We consulted both the EuropeanOrganization for Research and Treatment of Cance(EORTC) Quality-of-lifeC30 (QLQ-C30) and the Functional Assessment of CancerTherapy-Breast(FACT-B), combining our situation to designquestionnaire. We also use the Body Image Scale to investigate patientsin order to make sure our outcomes.
Results: The outcomes were assessed both mailing questionnaire andtelephone to 34 patients of IBR, and we selected 67 patients of delayedbreast reconstruction(DBR) to comparison. 21 questionnaires of IBR(61.76percent)and 40 questionnaires of DBR(62.5 percent) were returned. Toconduct a statistical analysis, the Wilcoxon signed rank test, Fisher exacttests, two-sided t test, Spearman' s correlation, and factor analysisstatistics were used. Variables analyzed included patient' sage, cost, reasons for reconstruction, method and operation time ofreconstruction, and postoperative complications. Data analysis showedthat the treatment received by the two groups was similar in manyrespects. There was no statistical association a patient's satisfaction with the results (P＞0.05). The QL of IBR is less affected than DBR. With thesame method, cost of IBR is lower than DBR(F=15.462, P＜0.01); operation timeof IBR is shorter than DBR (F=10.25, P＜0.01). Patients preferred simpletechnique of reconstruction, and were satisfied with the results ofreconstruction with the method of LDF. The information for IBR was mainlypromoted by oncology surgeon and DBR by Internet and TV. The reason of IBRare psychological influence without breast and for herself. We have founda strong correlation between scar of reconstructive breast and overallaesthetic results. Although overall satisfaction with breastreconstruction is undoubtedly determined by multiple and complex clinical,emotional, and psychological factors, this study suggests thatpostoperative complications are a particularly important indicator ofdissatisfaction with reconstruction.
Conclusion:
1. Our results confirm that patients of IBR responses regardingsatisfaction with reconstruction will reflect smaller negativepsychological and quality-of-life aspects of mastectomy.
2. IBR can be used to repair the wound of recurrent sarcoma and laterbreast cancer.
3. As a result of the development of new techniques that use a skin-sparingapproach and nipple-areola-preserving envelope mastectomy with IBR,the aesthetic outcome of reconstruction can be improved. In order toimprove the satisfaction, oncology surgeon and plastic surgeon shouldcooperate to benefit patient a lot.
引文
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50. Harcourt DM, Rumsey NJ. Psychological aspects of breast reconstruction: A review of the literature. J Adv Nurs. 2001, 35:477.
51．张作峰，董子迎，王惠君等．乳腺癌切除一期乳房再造．中国美容医学．2006，15：38-39．
52．王圣应，鲁智，程新德等．早期乳腺癌保留乳头乳晕复合体的改良根治术——Ⅰ期腹直肌肌度瓣重建乳房．癌症．2004，23：56-59．
53．姚成才，叶披德，郭耐强等．保留乳头乳晕复合体的皮下乳腺癌改良根治术后Ⅰ期假体乳房再造术的探讨．中华普通外科杂志．2006，21：683-684．
54．亓发芝，陈君雪，顾建英等．保留皮肤的乳腺癌改良根治术后即时乳房再造．实用美容整形外科杂志．2001，12：305-307．
55．狄根红、吴炅，亓发芝，中国癌症杂志，乳腺癌术后一期乳房再造，2006，16：257—261．
56．肖永红 何喜 赵光明．乳腺癌一期背阔肌瓣乳房再造术后生活质量的研究．中国综合临床，2006，22：16-18．
57．尹健 张学慧 张斌．即刻乳房再造与延期乳房再造的心理调查．中华整形外科杂志，2005，21：175-177．
58. Aaronson NK, Ahmedzai S, Bergman B, et al. for the European Organization on Research and Treatment of Cancer Study Group on Quality of Life. The European Organization for Research and Treatment of Cancer QLQ-C30:A Quality-of-Life Instrument for Use in International Clinical Trials in Oncology. J. Natl Cancer Inst. 1993, 85:365-376.
59. Brady MJ, Cella DF, Mo F, et al. Reliability and Validity of the Functional Assessment of Cancer Therapy-Breast Quality-of-Life Instrument. J. Clinical 0ncol, 1997, 15:974-986.
60. Hopwood P. The assessment of body image in cancer patients. Eur J Cancer 1993, 28A:276-281.
61. Hopwood P, Fletcher I, Lee A, et al.A body image scale for use with cancer patients. Eur J Cancer. 2001, 37:189.
62. Andrade WN, Semple JL. Patient Self-assessment of the cosmetic results of breast reconstruction. Plastic Reconstr Surg, 2006, 117:44-47.
63. Sarwer DB. Discussion:Patient Self-assessment of the cosmetic results of breast reconstruction. Plastic Reconstr Surg, 2006, 117:48.
64. Gerald G, Geeta K, Su-Ming T , et al. Evaluation of Outcome After Immediate Breast Reconstruction: Prospective Comparison of Four Methods. Plast Reconst Surg. 2005, 115(7) :1916-1919.
65. Lowery JC, Wilkins EG, Kuzon WM , et al. Evaluation of aesthetic results in breast reconstruction: An analysis of reliability. Ann Plast Surg. 1996, 36:601-607.
66. Gilboa D, Borenstein A, Floro S, et al. Emotional and psychosocial adjustment of women to breast reconstruction and detection of subgroups ant risk for psychological morbidity. Ann Plast Surg. 1990, 25:407-401.
67. Alice B. Kornblith, Jennifer Ligibel. Psychosocial and sexual functioning of survivors of breast cancer. Semin Oncol. 2003, 30:799-813.
68. Hopwood, Penelope . ORIGINAL ARTICLES: Discussion (David J. W. Keith, Mary B. Walker, Leslie G. Walker, et al. Women Who Wish Breast Reconstruction: Characteristics, Fears, and Hopes.2003 111(3), 1057-1059.
69. Rowland JH, Dioso J, Holland JC, et al. Breast reconstruction after mastectomy:who seeks it, who refuses? Plast Reconstr Surg 1995, 95:812-822.
70．韩炳生，朱红成，张雪鹏．背阔肌脂肪瓣一期乳房再造术的临床研究．肿瘤防治杂志2000，7：631-633．
71．尹健 张学慧 张斌．即刻乳房再造与延期乳房再造的心理调查．中华整形外科志．2005，21：175-177．
72. Reaby LL, Hort LK. Postmastectomy attitudes in women who wear external breas prostheses compared to those who have undergone breast reconstructions. J Behav Mde 1995, 18:55-67.
73. Randy SR, Julie CL, Jennifer D, et al. Quality of Life and Affective Distress in Women Seeking Immediate versus Delayed Breast Reconstruction after Mastectomy for Breast Cancer. Plast Reconstr Surg. 2005, 116(4): 993-1002.
74. Fung KW, Lau Y, Fielding R, et al. The impact of mastectomy, breast-conserving treatment and immediate breast reconstruction on the quality of life Chinese women. A. N. Z. J. Surg. 2001, 71:202.
75. Cederna PS, Yates WR, Chang P, et al. Postmastectomy reconstruction: Comparative analysis of the psychosocial, functional, and cosmetic effects of transverse rectus abdominis musculocutaneous flap versus breast implant reconstruction. Ann. Plast. Surg. 1995,35: 458.
76. Wilkins EG, Cederna PS, Lowery Julie C, et al. Prospective Analysis of Psychosocial Outcomes in Breast Reconstruction: One-Year Postoperative Results from the Michigan Breast Reconstruction Outcome Study. Plast Reconst Surg. 2000,106(5):1014-1025.
77. Yitzchak R, Yehuda U, Rony M, et al. Aesthetic Results and Patient Satisfaction with Immediate Breast Reconstruction Using Tissue Expansion: A Follow-Up Study.1997, 99 (3):686-691.
78. White, C. A. Body image dimensions and cancer. Psychooncology 9: 183, 2000.
79. Rosenqvist S, Sandelin K,Wickman M. Patients' psychological and cosmetic experience after immediate breast reconstruction. Eur. J. Surg. Oncol. 1996,22: 262.
80. Joslyn SA. Radiation therapy and patient age in the survival from early stage breast cancer. Int. J. Radiat. Oncol. Biol. Phys. 1999,44:821.
81. Hopwood P, Lee A, Shenton A, et al. Clinical follow-up after bilateral risk reducing ( "prophylactic" ) mastectomy: Mental health and body image outcomes. Psychooncology. 2000, 9:462.
82. Noguchi M, Earashi M, Ohta N, et al. Mastectomy with and without immediate reconstruction using a muscu locutaneous flap. Am. J. Surg. 1993,166: 279.
83. Mizgala CL, Hartrampf CR, Bennett GK. Abdominal function after pedicled TRAM flap surgery. Clin Plast Surg. 1994, 21: 255.
84. Mizgala CL, Hartrampf CR, Bennett GK. Assessment of the abdominal wall after pedicled TRAM flap surgery: 5-to 7-year follow-up of 150 consecutive patients. Plast Reconstr Surg. 1994, 93: 988.
85. Jensen JA. Should improved mastectomy and reconstruction alter thepri marymanagement of breast cancer[j]?Entorial Plast Reconstr Surg, 1999, 103(4): 1308.
86．亓发芝，主编．乳房整形再造外科[M]．北京：人民卫生出版社．2001．138—143．
87. Kroll SS, Schusterman MA, Tadjali HE, et al. Risk of recurrence after treatment of early breast eancer with skin sparing mastectomy[J]. Anr Surg Onrg Oncol, 1997, 4(3): 193.
88. Downes KJ[Downes KJ, Glatt BS, Kanchwala SK, et al. Skin-sparing mastectomy and immediate reconstruction is an acceptable treatment option for patients with high-risk breast carcinoma[J].Cancer, 2005, 103(5):906-913.
89. Fersis N, Hoenig h, Relakis K, et al. Skin-sparing mastectomy and immediate breast reconstruction:incidence of recurrence in patients with invasive breast cancer[J].Breast, 2004, 13(6):488-493.
90. Cunnick GH, Mokbel K. Skin-sparing mastectomy. Am J Surg, 2004, 188:78-84.
91. Medina—Franco H, Vasconez LO, Fix Rj, et al. Factors associated with local recurrence after skin—sparing mastectomy and immediate breast reconstruction for invasive breast cancer. Ann Surg, 2002. 235(6):814-819.
92．王圣应，鲁智，程新德等，早期乳腺癌保留乳头乳晕复合体的改良根治术—Ⅰ期腹直肌肌皮瓣重建乳房．癌症，2004，23(1)：56—59．
93．刘立刚，武勇进，王亮等，保留乳房皮肤的乳腺切除与即刻乳房再造．中国修复 重建外科志. 2004,18:471-474
94. Miyako Takahashi, Ichiro Kai,Mitsuru Hisata, et al. The Association between breast surgeons' attitudes toward breast reconstruction and their reconstruction-related information-giving behaviors:A nationwide survey in Japan. Plast Reconst Surg. 2006,118:1507-1514.
95. Harcourt DM, Rumsey N J, Ambler NR, et al. The psychological effect of mastectomy with or without breast reconstruction: A prospective, multicenter study. Plast Reconstr Surg. 2003,111: 1060.
96. Andrade WN, Baxter N, Semple JL. Clinical determinants of patient satisfaction with breast reconstruction. Plast Reconstr Surg, 2001,107:46 -54.
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7. Rosenqvist S, Sandelin K, Wickman M. Patient's psychological and cosmetic experience after immediate breast reconstruction. Eur. J. Surg. Oncol. 1996, 22:262
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13. Collins ED. The National Utilization of Immediate and Early Delayed Breast Reconstruction and the Effect of Sociodemographic Factors; Amy K. Alderman, Laurence McMahon Jr., Edwin G. Wilkins.[ORIGINAL ARTICLES: Discussion].Plast Reconstr Surg. 2003, 111(2): 704-705.
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15．柏宏亮，李学诚，杨军，等．综合近年国内论文探讨我国乳房再造的发展趋势．中国美容医学，2003，12(3)：288-290．
16. Newman LA, Kuerer HM, Hunt KK, et al. Presentation, treatment, and outcome of local recurrence after skin-sparing mastectomy and immediate breast reconstruction. Ann Surg 0ncoi, 1998, 5(7):620-626.
17. Von Smitten K, Sundell B. The impact of adjuvant radiotherapy and cytotoxic chemotherapy on the outcome of immediate breast reconstruction by tissur expansion after mastectomy for breast cancer.Eur. J. Surg. Oncol. 1992, 18: 119.
18. Doran, C M; Wilson, C R; Doughty, J C; George, D W; Cooke, T G; Weiler-Mithoff, E Immediate breast reconstruction is not associated with a delay in the delivery of adjuvant chemotherapy. Breast Cancer Research & Treatment. 2001, 69(3):248.
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26. Spear SL, Ducic I, Low M, et al. The effect of radiation on pedicled TRAM flap breast reconstruction: Outcomes and implications. Plast. Reconstr. Surg. 2005,115: 84.
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28. Rogers NE, Allen RJ. Radiation effects on breast reconstruction with the deep inferior epigastric perforator flap. Plast Reconstr Surg, 2002,109:1919
29. Mosahebi A, Ramakrishnan V, Gittos M. Aesthetic Outcome of Different Techniques of Reconstruction following Nipple-Areola-Preserving Envelope Mastectomy with Immediate Reconstruction. Plast Reconstr Surg .2007; 119 (3): 796-803.
30. Mosahebi A, Ramakrishnan V, Gittos M, et al.Envelope mastectomy and immediate reconstruction (EMIR), improving outcome without oncological compromise. J. Plast. Reconstr. Aesthetic Surg. 2006 ,59: 1025.
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32. Futter CM, Weiler-Mithoff E, HagenS, et al. Do pre-operative abdominal exercises prevent post-operative donor site complications for women undergoing DIEP flap breast reconstruction? A two-centre, prospective randomised controlled trial. Br J Plast Surg. 2003;56:674 - 683.
33. Alderman AK, Wilkins EG, Lowery JC, et al. Determinants of patient satisfaction in postmastectomy breast reconstruction. Plast Reconstr Surg. 2000:106:769-776.
34. Schwabegger A, Ninkovic M, Brenner K, et al . Seroma as a common donor site morbidity after harvesting the latissimus dorsi flap: Observations on cause and prevention. Ann. Plast. Surg. 1997 ,38: 594.
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41. Al-Ghazal SK, Fallowfield L, Blarney RW. Does cosmetic outcome from treatment of primary breast cancer influence psychosocial morbidity? European Journal of Surgical Oncology. 1999;25:571-573.
42. Passik SD, Dugan W, McDonald MV, et al. Oncologists' recongnition of depression in their patients with cancer. J Clin Oncol. 1998,16:1594-1600.
43. Dean C, Chetty U, Forrest APM. Effents of immediate breast reconstruction on psychosocial morbidity after mastectomy. Lancet. 1983,1:459.
44. Rowland JH, Holland JC, Chaglassian T, et al. Psychological response to breast reconstruction :Expectations for and impact on postmastectomy functioning. Psychosomatics. 1993, 34:241.
45. Harcourt DM, Rumsey NJ, Ambler NR, et al.The psychological effect of mastectomy with or without breast reconstruction:A prospective, multicenter study. Plast Reconstr Surg. 2003,111:1060-1068.
46. Rowland JH, Desmond KA, Meyerowita BE, et al. Role of breast reconstruction surgery in physical and emotional outcomes among breast cancer survivors. J Natl Cancer Inst. 2000, 92:1422-1429.
47. Brandberg Y,Malm M,Blomqvist L.A prospective and randomized study, " SVEA " , comparing effects of three methods for delayed breast reconstruction on quality life, patient-defined problem areas of life, and cosmetic result. Plast Reconst Surg, 2000,105:66-74.
48. Paula-JC B; Caroline S; Arthur-RV G, et al. Satisfaction with Prophylactic Mastectomy and Breast Reconstruction in Genetically Predisposed Women , 2006,117(6):1675-1682.
49. Jabor MA, Shayani P, Collins D, et al. Nipple-areola reconstruction:Satisfaction and clinical determinants. Plast Reconstr Surg. 2002,110:457.
50. Harcourt DM, Rumsey NJ. Psychological aspects of breast reconstruction: A review of the literature. J Adv Nurs. 2001, 35:477.
51．张作峰，董子迎，王惠君等．乳腺癌切除一期乳房再造．中国美容医学．2006，15：38-39．
52．王圣应，鲁智，程新德等．早期乳腺癌保留乳头乳晕复合体的改良根治术——Ⅰ期腹直肌肌度瓣重建乳房．癌症．2004，23：56-59．
53．姚成才，叶披德，郭耐强等．保留乳头乳晕复合体的皮下乳腺癌改良根治术后Ⅰ期假体乳房再造术的探讨．中华普通外科杂志．2006，21：683-684．
54．亓发芝，陈君雪，顾建英等．保留皮肤的乳腺癌改良根治术后即时乳房再造．实用美容整形外科杂志．2001，12：305-307．
55．狄根红、吴炅，亓发芝，中国癌症杂志，乳腺癌术后一期乳房再造，2006，16：257—261．
56．肖永红 何喜 赵光明．乳腺癌一期背阔肌瓣乳房再造术后生活质量的研究．中国综合临床，2006，22：16-18．
57．尹健 张学慧 张斌．即刻乳房再造与延期乳房再造的心理调查．中华整形外科杂志，2005，21：175-177．
58. Aaronson NK, Ahmedzai S, Bergman B, et al. for the European Organization on Research and Treatment of Cancer Study Group on Quality of Life. The European Organization for Research and Treatment of Cancer QLQ-C30:A Quality-of-Life Instrument for Use in International Clinical Trials in Oncology. J. Natl Cancer Inst. 1993, 85:365-376.
59. Brady MJ, Cella DF, Mo F, et al. Reliability and Validity of the Functional Assessment of Cancer Therapy-Breast Quality-of-Life Instrument. J. Clinical 0ncol, 1997, 15:974-986.
60. Hopwood P. The assessment of body image in cancer patients. Eur J Cancer 1993, 28A:276-281.
61. Hopwood P, Fletcher I, Lee A, et al.A body image scale for use with cancer patients. Eur J Cancer. 2001, 37:189.
62. Andrade WN, Semple JL. Patient Self-assessment of the cosmetic results of breast reconstruction. Plastic Reconstr Surg, 2006, 117:44-47.
63. Sarwer DB. Discussion:Patient Self-assessment of the cosmetic results of breast reconstruction. Plastic Reconstr Surg, 2006, 117:48.
64. Gerald G, Geeta K, Su-Ming T , et al. Evaluation of Outcome After Immediate Breast Reconstruction: Prospective Comparison of Four Methods. Plast Reconst Surg. 2005, 115(7) :1916-1919.
65. Lowery JC, Wilkins EG, Kuzon WM , et al. Evaluation of aesthetic results in breast reconstruction: An analysis of reliability. Ann Plast Surg. 1996, 36:601-607.
66. Gilboa D, Borenstein A, Floro S, et al. Emotional and psychosocial adjustment of women to breast reconstruction and detection of subgroups ant risk for psychological morbidity. Ann Plast Surg. 1990, 25:407-401.
67. Alice B. Kornblith, Jennifer Ligibel. Psychosocial and sexual functioning of survivors of breast cancer. Semin Oncol. 2003, 30:799-813.
68. Hopwood, Penelope . ORIGINAL ARTICLES: Discussion (David J. W. Keith, Mary B. Walker, Leslie G. Walker, et al. Women Who Wish Breast Reconstruction: Characteristics, Fears, and Hopes.2003 111(3), 1057-1059.
69. Rowland JH, Dioso J, Holland JC, et al. Breast reconstruction after mastectomy:who seeks it, who refuses? Plast Reconstr Surg 1995, 95:812-822.
70．韩炳生，朱红成，张雪鹏．背阔肌脂肪瓣一期乳房再造术的临床研究．肿瘤防治杂志2000，7：631-633．
71．尹健 张学慧 张斌．即刻乳房再造与延期乳房再造的心理调查．中华整形外科志．2005，21：175-177．
72. Reaby LL, Hort LK. Postmastectomy attitudes in women who wear external breas prostheses compared to those who have undergone breast reconstructions. J Behav Mde 1995, 18:55-67.
73. Randy SR, Julie CL, Jennifer D, et al. Quality of Life and Affective Distress in Women Seeking Immediate versus Delayed Breast Reconstruction after Mastectomy for Breast Cancer. Plast Reconstr Surg. 2005, 116(4): 993-1002.
74. Fung KW, Lau Y, Fielding R, et al. The impact of mastectomy, breast-conserving treatment and immediate breast reconstruction on the quality of life Chinese women. A. N. Z. J. Surg. 2001, 71:202.
75. Cederna PS, Yates WR, Chang P, et al. Postmastectomy reconstruction: Comparative analysis of the psychosocial, functional, and cosmetic effects of transverse rectus abdominis musculocutaneous flap versus breast implant reconstruction. Ann. Plast. Surg. 1995,35: 458.
76. Wilkins EG, Cederna PS, Lowery Julie C, et al. Prospective Analysis of Psychosocial Outcomes in Breast Reconstruction: One-Year Postoperative Results from the Michigan Breast Reconstruction Outcome Study. Plast Reconst Surg. 2000,106(5):1014-1025.
77. Yitzchak R, Yehuda U, Rony M, et al. Aesthetic Results and Patient Satisfaction with Immediate Breast Reconstruction Using Tissue Expansion: A Follow-Up Study.1997, 99 (3):686-691.
78. White, C. A. Body image dimensions and cancer. Psychooncology 9: 183, 2000.
79. Rosenqvist S, Sandelin K,Wickman M. Patients' psychological and cosmetic experience after immediate breast reconstruction. Eur. J. Surg. Oncol. 1996,22: 262.
80. Joslyn SA. Radiation therapy and patient age in the survival from early stage breast cancer. Int. J. Radiat. Oncol. Biol. Phys. 1999,44:821.
81. Hopwood P, Lee A, Shenton A, et al. Clinical follow-up after bilateral risk reducing ( "prophylactic" ) mastectomy: Mental health and body image outcomes. Psychooncology. 2000, 9:462.
82. Noguchi M, Earashi M, Ohta N, et al. Mastectomy with and without immediate reconstruction using a muscu locutaneous flap. Am. J. Surg. 1993,166: 279.
83. Mizgala CL, Hartrampf CR, Bennett GK. Abdominal function after pedicled TRAM flap surgery. Clin Plast Surg. 1994, 21: 255.
84. Mizgala CL, Hartrampf CR, Bennett GK. Assessment of the abdominal wall after pedicled TRAM flap surgery: 5-to 7-year follow-up of 150 consecutive patients. Plast Reconstr Surg. 1994, 93: 988.
85. Jensen JA. Should improved mastectomy and reconstruction alter thepri marymanagement of breast cancer[j]?Entorial Plast Reconstr Surg, 1999, 103(4): 1308.
86．亓发芝，主编．乳房整形再造外科[M]．北京：人民卫生出版社．2001．138—143．
87. Kroll SS, Schusterman MA, Tadjali HE, et al. Risk of recurrence after treatment of early breast eancer with skin sparing mastectomy[J]. Anr Surg Onrg Oncol, 1997, 4(3): 193.
88. Downes KJ[Downes KJ, Glatt BS, Kanchwala SK, et al. Skin-sparing mastectomy and immediate reconstruction is an acceptable treatment option for patients with high-risk breast carcinoma[J].Cancer, 2005, 103(5):906-913.
89. Fersis N, Hoenig h, Relakis K, et al. Skin-sparing mastectomy and immediate breast reconstruction:incidence of recurrence in patients with invasive breast cancer[J].Breast, 2004, 13(6):488-493.
90. Cunnick GH, Mokbel K. Skin-sparing mastectomy. Am J Surg, 2004, 188:78-84.
91. Medina—Franco H, Vasconez LO, Fix Rj, et al. Factors associated with local recurrence after skin—sparing mastectomy and immediate breast reconstruction for invasive breast cancer. Ann Surg, 2002. 235(6):814-819.
92．王圣应，鲁智，程新德等，早期乳腺癌保留乳头乳晕复合体的改良根治术—Ⅰ期腹直肌肌皮瓣重建乳房．癌症，2004，23(1)：56—59．
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