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1 ORIGINAL ARTICLE Journal of Breast Cancer J Breast Cancer 2008; December 11 (4): DOI: /jbc 유방보존술시반대편대흉근유선이식술을이용한즉각적유방재건술 이승주ㆍ배영태ㆍ서형일ㆍ강태우 1 부산대학교의학대학원외과학교실, 1 메리놀병원외과 Immediate Breast Reconstruction with Contralateral Pectoralis Major Myomammary Flap for Breast Conserving Surgery Seung Ju Lee, Young Tae Bae, Hyong Il Seo, Tae Woo Kang 1 Department of Surgery, College of Medicine, Pusan National University, Busan; 1 Department of Surgery, Maryknoll General Hospital, Busan, Korea Purpose: There has been much reported data showing that breast reconstruction surgery does not result in reduced patient survival if the accepted principles of cancer surgery are closely followed. The proper reconstructive technique can be selected according to diverse factors, but breast size and the site of tumor are mostly important. The latissimus dorsi musculocutaneous flap (LDMCF) is one of the most commonly used techniques for early breast cancer patients who have small breasts. But, it has difficulties for supplying enough tissues to the widely excised tumor site. Especially for ptosis patients, reduction mammoplasty by itself is not enough to achieve symmetry of the breast. We suggest that the pectoralis major myomammary flap (PMMF) is a useful technique for the patients with ptosis. Methods: Seventeen patients with ptosis were treated with breast conserving surgery with PMMF reconstruction. A quadrantectomy rather than lumpectomy was performed through a planned skin incision, and axillary lymph node dissection was performed according to the results of sentinel lymph node biopsy. The PMMF is carefully harvested without perforating branch injury to the internal thoracic artery. Reconstruction was done via the PMMF through the medial tunnel between both breasts. Results: Among the seventeen patients, seroma occurred in two patients and no necrosis occurred at all. The cosmetic result was fair in 15 patients and poor in two patients, based on the four-point scoring system of breast cosmetics. Conclusion: After performing enough quadrantectomy to adhere to the accepted principles of cancer surgery, PMMF was quite useful to supply enough proper tissues for breast reconstructions, and especially for the ptosis patients. Key Words : Breast cancer, Ptosis, Pectoralis major myomammary flap 중심단어 : 유방암, 유방하수, 대흉근유선피판술 서 유방암환자의치료에있어유방보존술후유방재건술은이제 책임저자 : 배영태 부산광역시서구아미동 1가 10, 부산대학교병원외과 Tel: , Fax: bytae@pusan.ac.kr 접수일 : 2008년7월 25일게재승인일 : 2008년10월24일 *2008년한국유방암학회춘계학술대회에서구연되었음. * 본논문은부산대학교 2007년자유과제학술연구비 (2년) 의지원을받았음. 론 기본술식으로자리잡고있다.(1) 유방재건술의선택은대체로술자의능력과수술전환자의체형, 유방의크기, 종양의위치등에따른절제범위에의해결정될수있다.(2) 따라서유방재건술은어느한가지방법이일률적으로적용될수없으며가장적합한재건법은환자마다각기다를수밖에없다. 유방암환자의치료에있어흔히이용되는유방보존술후유방고정술 (mastopexy) 과축소유방성형술 (reduction mammoplasty) 은반대편유방과의대칭성을얻는데에어려움이있고미용적효과를얻기위해서는절제되는유방조직을최소화하는종괴절제술 (lumpectomy) 206

2 Contralateral Pectoralis Major Myomammary Flap for Breast Conserving Surgery 207 을시행하여야하는단점이있다. 안전한절제연에대한논란이많고절제연양성이수술후진단된경우라도재수술또는방사선치료를통하여동일한예후를얻을수있지만 (3) 국내의여건에서수술후절제연양성인경우수술전충분한설명에도불구하고환자의이해를구하기어려운실정이다. 따라서충분한절제연을확보한절제술시유방의대칭성과미용적효과를극대화하기위해서광배근피판술을이용하여유방재건을고려하여야한다. 광배근피판술은수술중환자의체위를변환시켜야하는불편함과수술시간의연장으로인한수술후합병증의증가를야기할수있다. 이와같이유방보존술후양측유방에축소유방성형술을시행한다면유방고정술이나병변부유방의축소유방성형술에서야기되는비대칭성의문제와광배근피판술시발생하는문제점을해결할수있을것으로생각한다. 이때정상유방의축소유방성형술시제거되는유방조직을이용할수있다면병변부유방의절제연을충분히확보가능하고미용적측면에서도우수한성적을거둘수있을것이다. 대흉근유선피판술 (pectoralis major myomammary cutaneous flap, PMMCF) 은흉곽결손을해결하기위해처음시도된술식이었으나이후유방하수가심한환자에서유방의재건방법으로제안되고있다.(4-6) 대흉근유선이식술 (pectoralis major myomammary flap, PMMF) 은 PMMCF를변형시킨방법으로내흉동맥천공지를공급혈관으로한대흉근을이용하여그상부의피부를제외한유방조직을포함하여수술부위유방으로이동시키는방법이다. 이에저자들은유방암환자에서유방하수의정도에관계없이유방보존술후즉각적유방재건술로대흉근유선이식술을시행한초기경험과성적을보고하여그활용방안을제안하고자한다. 방법 1. 연구대상 2007년 1월부터 2008년 1월까지본원외과에서유방암진단을받고유방보존술후즉각적 PMMF를시행받은 17 명의환자를대상으로병력기록지를바탕으로나이, 병기, 체질량지수 (body mass index, BMI), 수술시간, 재원기간, 합병증, 만족도등을후향적으로평가하였다. PMMF의시행은축소유방성형을계획 하였으나계획보다많은유방조직의절제로인하여광배근피판술이필요하였으나환자와환자보호자가거부한경우, 유방의과도한비대칭성이발생한경우와 Regnault 분류 (Table 1) 에서중등도이상의유방하수가있는환자에서시행하였다.(7) 모든환자에게수술전에다양한형태의유방재건술방법과결과를사진을통하여확인시켰고우선적으로술자가체형, 종양의크기와종양위치를고려하여추천하였고환자의선택한방법을가장중요하게고려하였다. 수술후성적의평가는 5개월째 Four Point Scoring System of Breast Cosmesis (Table 2) 에근간을두고이루어졌다.(8) 2. 수술방법 1) 유방암의수술 (Fig 1) 감시림프절생검을시행하고종양의위치를확인하여절제범위를정한후도안을따라피부절개를한다. 대체로종양으로부터절제연까지 1-2 cm의거리를두고절제술을시행하며그경계부에대한동결절편을시행하여추가절제여부를확인한다. 감시림프절검사결과에따라액와림프절곽청여부를결정한다. 이후환자의상체를 30 거상시켜병변부만의유방고정술또는축소유방성형술로발생할비대칭성의정도를확인한다. 양측유방의축소유방성형술이결정되면일반적으로적용되는방법으로도안하고그도안을따라병변부의유방에피부절개를시행하여축소유방성형술을시행하고이상태에서유방의결손부피를계측한다. 흉골상방에인접하여피하조직을박리하여정상유방쪽으로통로를만들어 PMMF가넘어올수있는공간을만든다. 2) PMMF 구득 환자의상체를 30 거상시킨상태에서대칭성을극대화할수있는공여부유선조직의양을제거될유방조직에계측하여표시 Table 2. Four-point scoring system of breast cosmesis Excellent Good Fair Poor Treated breast almost identical to untreated breast Minimal difference between the treated and untreated breasts Obvious difference between the treated and untreated breasts Major functional and esthetic sequelae in the treated breast Table 1. Regnault s classification of ptosis Grade I (minor ptosis) Grade II (moderate ptosis) Grade III (severe ptosis) Pseudoptosis Glandular ptosis Nipple at the level of the inframammary fold Nipple below the inframammary fold but above the breast contour Nipple at lower breast contour and below the fold Nipple above the fold but the breast gland is hypoplastic and hangs below the fold Nipple above the fold but the breast gland hangs below the fold

Seung Ju Lee, et al. 208 한다. 정상 유방에 유방축소술을 위한 피부 절개선을 제도하고 그 선을 따라 피부 절개를 시행한다(Fig 2).

이때 가능한 한 절제되는 유선조직과 대흉근 근막 까지의 거리가 최단 거리가 되도록 하며 흉골 쪽으로 대흉근 근막 을 박리할 때도 유방조직을 다소 남겨둠으로써 이식유선의 혈류 장애가 적도록 한다.

After design of reduction mammoplasty, donor site of the breast fat tissue is marked. Fig 4.

PMMF is transferred to the defect through the tunnel between skin and the sternum and turned it upside down.

Wide excision (free margin 1-2 cm) and axillary lymph node dissection, if sentinel node biopsy is positive, are performed through a

3 Seung Ju Lee, et al. 208 한다. 정상 유방에 유방축소술을 위한 피부 절개선을 제도하고 그 선을 따라 피부 절개를 시행한다(Fig 2). 피부 절개창을 통하여 미리 도안한 공여부에서 유선조직을 절제하고 그 하방의 대흉근 과 근막을 수술 중 흉골의 측면에서 육안 확인이 가능한 5번째에 서 7번째 늑간의 내흉동맥 천공지를 공급혈관으로 한 피판을 구 득한다(Fig 3). 이때 가능한 한 절제되는 유선조직과 대흉근 근막 까지의 거리가 최단 거리가 되도록 하며 흉골 쪽으로 대흉근 근막 을 박리할 때도 유방조직을 다소 남겨둠으로써 이식유선의 혈류 장애가 적도록 한다. PMMF의 구득이 완료되면 피판을 뒤집어 배측이 복측이 되도록 하여 흉골 상방의 통로를 통하여 이동시킨 후 적절한 위치에 고정시키고 유선조직은 자연스러운 위치에 배 치시킨다(Fig 4). Fig 2. Design of flap. After design of reduction mammoplasty, donor site of the breast fat tissue is marked. Fig 4. Reconstruction using pectoralis major myomammary flap (PMMF). PMMF is transferred to the defect through the tunnel between skin and the sternum and turned it upside down. Consequently, dorsal portion of PMMF is situated ventral portion in the defect. Fig 1. Resected breast cancer. Wide excision (free margin 1-2 cm) and axillary lymph node dissection, if sentinel node biopsy is positive, are performed through a planned skin incision. Fig 3. The prepared pectoralis major myomammary flap. After skin incision is done according to previous design line of reduction mammoplasty, breast parenchyme tissue with pectoralis major muscle and its fascia are acquired carefully without injury of perforating branch of internal thoracic artery. Fig 5. Immediate postoperative state.

Contralateral Pectoralis Major Myomammary

breast cancer and the grade II of ptosis.

color had been changed after radiotherapy.

nipple-areolar complex and the grade I of

The level of nipple and scar in both sides

(D) 60-year-old woman with the grade II of

4 Contralateral Pectoralis Major Myomammary Flap for Breast Conserving Surgery 209 A B C D Fig 6. (A) 49 year-old-woman with the grade III of ptosis. The cosmetic result was fair. (B) 45-year-old women with multicentric breast cancer and the grade II of ptosis. The cosmetic result was fair but the skin color had been changed after radiotherapy. (C) 46-year-old woman with lesion involving nipple-areolar complex and the grade I of ptosis. The cosmetic result was poor. The level of nipple and scar in both sides are different each other. (D) 60-year-old woman with the grade II of ptosis. The cosmetic result was fair but the level of nipple and breast volume in both sides are slightly different each other.

5 210 Seung Ju Lee, et al. Table 3. Overall results of all cases Case Age BMI (kg/m 2 ) Grade of ptosis Stage Operative time (min) Hospital stay (days) Complication Cosmesis I I None Fair I IIB None Fair II I None Fair I IIA Seroma Poor II IIA None Fair II I None Fair I DCIS Seroma Poor II IIA None Fair I I None Fair III IIIA None Fair II IIA None Fair II I None Fair I DCIS None Fair I IIA None Fair II IIA None Fair II DCIS None Fair I I None Fair BMI=body mass index; DCIS=ductal carcinoma in situ. Superior 결 과 Medial Fig 7. Diagram of cancer location in breast. The figure in the box means the number of cases. I=inner; U=upper; O=outer; C=central, L=lower. 3) 반대쪽유방축소성형술 먼저피부의기준봉합을시행하여유방부피를비교하여절제가더필요한지의여부를결정한다. 부피의대칭성이확보되고나면양측유두및유륜의위치와크기를고려하여새로운유두륜을만든다. 3-0 흡수봉합사를이용하여피하봉합을시행하고피부자동봉합기를이용하여피부봉합한다 (Fig 5). 4) 수술후평가 IU1 IL2 IC4 C3 OC1 Inferior OU3 OL3 Lateral 수술후 5개월째외래방문시환자들에게수술에관한주관적인만족도를 Four Point Scoring system of Breast Cosmesis 를통해조사하였다. 환자의평균나이는 54세 ( 범위 45-62세 ), 평균수술시간은 226분 ( 범위 분 ), 평균재원기간은 9일 ( 범위 6-11일 ) 이었다. 환자들의평균 BMI는 25.6 kg/m 2 으로과체중에해당하였다. 2예에서장액종이발생하였고추가적인치료없이호전되었다. 15 예의환자는 Fair 결과를얻었고 2예의환자는 Poor 로평가되었다 (Table 3, Fig 6). 9예의환자는중등도이상의유방하수를보였으나 8예의환자는경도의유방하수를보였다. 후자의경우는결손범위가넓어광배근근피판술 (latssimus dorsi musculocutaneous flap, LDMCF) 을시행해야할경우였으나환자가이를거부하였다. 종양의위치는내측중앙이 4예로가장많았으나대체로다양한분포를보였다 (Fig 7). 고찰대흉근유선피판술은 1968년에흉곽결손의재건을위해처음기술된이래두경부외과영역의재건과유방재건에이용되기시작했다.(4-6) 대흉근은흉견봉동맥 (thoracoacromial artery), 상흉동맥, 외흉동맥그리고내흉동맥등을통하여혈관공급을받고이들의분지들은대흉근내에서서로연결되어있다.(9) 이들이유방과유두에혈류를공급하게된다. 대흉근의풍부한혈관분포는구득된피판의괴사를드물게만드는것으로보고된다. (6,10,11) Denewer 등 (11) 의대흉근을이용한피판술은흉견봉동맥을공급혈관으로하여유방하수가있는정상유방의축소유

6 Contralateral Pectoralis Major Myomammary Flap for Breast Conserving Surgery 211 방성형술, 병변부유방의재건술, 유두와유두륜의재배치를동시에시행할수있는수술방법으로제안하였고수술결과도우수한것으로보고하였다. 그러나저자들은기존의술식과는달리피부는포함하지않고내흉동맥천공지를공급혈관으로하는일부의대흉근만을이용하였고이혈관의공급을받는일부의유선조직만을포함하였다. 흉견봉동맥을보존하여정상유방의혈류를유지하려하였다. 이는 Hoch 등 (12) 이반대편흉곽결손을재건하기위해내흉동맥천공지를공급혈관으로하여대흉근을이용한방법을변형한것으로 Denewer 등 (11) 의방법을접목한것이라할수있으며기존의술식과차이를두기위해저자들은대흉근유선이식술이라명명하였다. 유방하수가있는유방암의치료시종괴절제술후유방고정술이나축소유방성형술은수술부위함몰과비대칭성을야기할수있다. 대칭성의문제를해결하기위해 LDMCF나 TRAM을이용하는것은수술후방사선치료효과를감소시키고피판의위축등으로유방모양의변형을야기할수있을뿐아니라유방하수로인한신경학적증상이상존하는문제점이있다.(1) 이와같은경우정상유방의축소유방성형술을시행함으로써상기한문제점을해결할수있을뿐아니라축소유방성형술시제거되는정상유방쪽의유방조직을이용할수있다면충분한절제연을두고종양을절제할수있을것이다. 대흉근유선이식술은동일유방조직을이용하여유방재건을하기때문에기능적인측면에서도움을줄수있다. 또한반대편유방의유선조직을사용함으로써그어떤자가조직을이용한재건술보다재건된유방의감각이훨씬자연스럽다.(11) 저자들은초기에 PMMF의적용대상을중등도이상의유방하수가있는경우시행하여좋은성적을얻었고이를바탕으로경도의유방하수가있는경우에도시행하게되었다. 이들환자의경우조기유방암임에도불구하고유방보존술후 LDMCF 를거부한환자였다. 4예의환자는유방재건의방법으로유방고정술이나축소유방성형술을계획하였으나절제연확보를위해과도한유방조직의절제로계획된수술을시행할경우심각한비대칭성과수술부위함몰을야기할위험성이있는환자였다. 기존의경우라면환자의체위를변환시켜 LDMCF를시행하여야하나수술전에환자가유방재건술의형태로 PMMF를선택한경우였다. PMMF 의경우체위변경이없기때문에수술시간이비교적짧았다. 또한 LDMCF의경우피판공여부에장액종발생률이 20-79% 이지만,(13-16) PMMF의경우 17 예의환자중 2예에서만발생하였고재원기간이짧고수술부위괴사와같은합병증이없어수술후방사선요법과항암화학요법의지연이없었다. 저자들의이전보고에서 lateral thoracodorsal fasciocutaneous flap (LTFF) 은적용기준이종양의위치가외측인경 우로국한되었으나,(17) PMMF는이와달리유방암병변이외측에국한되지않는장점을가지고있다. 이는대흉근자체가반대편흉곽모두를충분히덮을정도로면적이넓기때문이다. 실제저자들의경우에서 PMMF를시행받은환자들은유방암이정중앙에위치한경우가 3예, 내측에위치한경우가 7예, 외측에위치한경우는 7예였다. 또한혈류가풍부한복측이배측으로위치하기때문에이식조직상부에혈류장애로인한합병증은없었다. PMMF는유방조직으로유방재건을시행하기때문에유방의충실도를수술전과유사하게유지할수있고양측유방의대칭성을이룰수있으며회복기간이짧은장점을가진다. 중등도이상의유방하수가있는경우 PMMF는적절한수술로생각되나유방하수가없는경우 PMMF의적용에는논란이있을수있을것이다. 본논문의 17 예의경우미용적인결과가 Fair 또는 Poor 에그쳤으나장기적인추적관찰시흉골상방의통로로지나는근육의위축으로자연스러운형태를갖추게된다. 그러므로앞으로수술방법이숙달되고, 유방하수가심한환자가유방완전절제술을원하지않으면서 LDMCF를이용한유방재건술은거부하는경우 PMMF는그대안이될수있을것으로생각된다. 결론유방하수의정도에관계없이잘선택된환자에서반대편대흉근유선이식술을이용한재건술은유방보존과함께종양학적안정성을얻을수있다. 또한수술중체위변환의번거로움이없고 LDMCF보다수술시간이짧기때문에공여부의합병증이적은장점을가진다. 아직숙달된술기가아니어서본논문에서는 Fair 또는 Poor 의결과를얻었으나새로운시도였기에보고한다. 참고문헌 1. Newman LA, Kuerer HM, McNeese MD, Hunt KK, Gurtner GC, Robb G, et al. Reduction mammoplasty improves breast conservation therapy in patients with macromastia. Am J Surg 2001;181: Slavin SA, Halperin T. Reconstruction of the breast conservation deformity. Seminars Plast Surg 2004;18: Jobsen JJ, van der Palen J, Ong F. Effect of external boost volume in breast-conserving therapy on local control with long-term followup. Int J Radiat Oncol Biol Phys 2008;71: Hueston JT, McConchie IH. A compound pectoral flap. Aust N Z J Surg 1968;38: Ariyan S. The pectoralis major myocutaneous flap: a versatile flap

7 212 Seung Ju Lee, et al. for reconstruction in the head and neck. Plast Reconstr Surg 1979; 63: Denewer AT. Myomammary flap of pectoralis major muscle for breast reconstruction:new technique. World J Surg 1997;21: Pinsky MA. Radial plication in concentric mastopexy. Aesthetic Plast Surg 2005;29: Morrow M, Storm EA, Bassett LW, Dershaw DD, Fowble B, Giuliano A, et al. Standard for breast conservation therapy in the management of invasive breast carcinoma. CA Cancer J Clin 2005;52: Park HD, Min YS, Kwak HH, Youn KH, Lee EW, Kim HJ. Anatomical study concerning the origin and course of the pectoral branch of the thoracoacromial trunk for the pectoralis major flap. Surg Radiol Anat 2004;26: Kroll SS, Baldwin B. A comparison of outcome using three different methods of breast reconstruction. Plast Reconstr Surg 1992;90: Denewer A, Setit A, Farouk O. Outcome of pectoralis major myomammary flap for post-mastectomy breast reconstruction: extended experience. World J Surg 2007;31: Hoch J, Stahlenbrecher A, Elsner T. The contralateral pectoralis muscle flap: a valuable alternative to cover chest wall tissue defects. Eur J Plast Surg 2006;29: Smith BK, Cohen BE, Biggs TM, Suber J. Simultaneous bilateral breast reconstruction using latissimus dorsi myocutaneous flaps: a retrospective review of an institutional experience. Plast Reconstr Surg 2001;108: Daltrey I, Thomson H, Hussien M, Krishna K, Rayter Z, Winters ZE. Randomized clinical trial of the effect of quilting latissimus dorsi flap donor site on seroma formation. Br J Surg 2006;93: Menke H, Erkens M, Olbrisch RR. Evolving concepts in breast reconstruction with latissimus dorsi flaps: results and follow-up of 121 consecutive patients. Ann Plast Surg 2001;47: Chang DW, Youssef A, Cha S, Reece GP. Autologous breast reconstruction with the extended latissimus dorsi flap. Plast Reconstr Surg 2002;110: Koh SH, Seo HI, Bae YT. Immediate conservative breast reconstruction technique using lateral thoracodorsal fasciocutaneous flap. J Breast Cancer 2007;10:

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암센터뉴스레터1 CANCER HOSPITAL News News Letter For Yonsei University Gangnam Severance Hospital http://gs.iseverance.com 2012.06.21 2012.08.16 2012.09.19 2012.10.04 2012.10.25 CONTENTS 2012.07.27 2012.10.06 2012.11.06