超声辅助冲洗枪取出乳房内聚丙烯酰胺水凝胶临床应用

2020-01-19 孙旭 郭澍 佟爽 中国美容整形外科杂志

聚丙烯酰胺水凝胶(polyacrylamide hydmgel, PAHG)是一种无色透明胶冻状的液态化学合成物, 作为软组织填充材料,曾广泛应用于整形外科领 域[1]。经过远期临床应用后发现,该物质容易导致乳 房感染、变形、结节、囊肿、局部疼痛等并发症和后 遗症。因此,整形外科医师们一直致力于探索如何 彻底地取出乳房组织内的 PAHG。自 2017 年 6 月至 2019 年 6 月,中国医科大

聚丙烯酰胺水凝胶(polyacrylamide hydmgel, PAHG)是一种无色透明胶冻状的液态化学合成物, 作为软组织填充材料,曾广泛应用于整形外科领 域[1]。经过远期临床应用后发现,该物质容易导致乳 房感染、变形、结节、囊肿、局部疼痛等并发症和后 遗症。因此,整形外科医师们一直致力于探索如何 彻底地取出乳房组织内的 PAHG。自 2017 年 6 月至 2019 年 6 月,中国医科大学附属第一医院整形外科 在超声引导下利用高压冲洗枪对 54 例 PAHG注射 隆乳术后患者行 PAHG取出术,效果较满意。现报 道如下。

1 资料与方法

1.1 一般资料 本组共54例患者,年龄 25~57 岁, 均为双侧。单侧注射量 50~400 ml;就诊时间为注 射后 15 个月至 13 年。临床表现:乳房结节、压痛等 47 例;乳房形态不佳 34 例;注射物移位 13 例;慢性 感染 14 例;同一患者有 2 种以上症状。无明确肿瘤 发生。
1.2 手术方法 为了全面评估 PAHG分布的范围、 层次,结节的部位、大小等情况,患者术前需经过超 声或 MRI 精准定位。手术在全身麻醉下进行。经乳 晕下缘切口或乳房皱襞下切口,逐层钝性分离至注 射物所在层次,分离所有间隔,尽可能取出可流动 的凝胶状 PAHG,术中必要时须将变性、融合成半透明样的脂肪、肌肉、乳腺组织切除。使用高压冲洗水 枪(图 1)以大量生理盐水反复冲洗,冲洗量通常在 3000 ml 以上,直至冲洗液中无 PAHG颗粒。术中超 声会诊明确注射物可能残留的部位及层次,予以反 复探查取出,并加以冲洗。腔内留置负压引流管,逐 层缝合,加压包扎。

2 结果

54 例患者术后无血肿、引流不畅、继发感染等, 术前的结节、不适等症状明显改善,炎症得到控制, 无明显乳房变形。术后随访 1~12 个月,超声复查 无明显异物残留(图 2)。术后切口瘢痕位置较隐蔽, 无明显增生,患者较满意。

3 典型病例

患者女性,45 岁,10 年前于美容院行双乳注射 隆乳术,具体注射物质及剂量不详,近一年来患者 双乳胀痛明显。体格检查:T 36.5 ℃,P 75 次 /min, R 15 次 /min,BP 115/66 mmHg。查体可见,左乳较右 乳稍小,经乳头胸围约 115 cm,经乳房下皱襞胸围 约 95 cm,乳头乳晕形态良好,胸壁未见凹陷,皮肤 光滑无破溃(图 3),双乳皮下可触及数枚硬结,大小 不一,压痛(+)。MR 提示:双乳腺腺体后可见异物组 织(图 4)。术前请超声科医师会诊,并在超声引导 下,标记注射异物分部范围。手术在全身麻醉下进 行。术中取双乳下皱襞切口,左右乳各取出黏稠颗 粒样物约 100 ml(图 5),使用冲洗枪反复用大量生 理盐水冲洗,术中超声检查无明显异物残留。术后 5 d 拔除引流管,10 d 拆线。



4 讨论

医用 PAHG进口商品名“英捷尔法勒”,国内商 品名为“奥美定”,20 世纪末曾一度被误认为是可长 期植入人体的软组织填充材料而得到广泛应用,如 隆乳、隆颊、隆臀等[2]。但在近 20 年的临床应用中, 人们逐渐发现该物质易导致结节、感染、移位、不对 称、疼痛等,更有甚者引发癌变[3-4]。2006 年,国家食 品药品监督管理局以“不能保证使用中的安全性” 禁止了其生产、销售与使用[5],但仍有很多非法机构 谎称“玻尿酸(透明质酸)”,继续使用 PAHG。有学者 认为,PAHG的毒性来自其分解形成的单体以及生 产过程中添加的有毒重金属,但医用 PAHG长期滞 留于人体,是否会导致肿瘤发生,目前尚无定论[6-7]。 该填充物的最大问题是人体注射后出现不良反应 时注射物无法完全取出而成为隐患。其引起的结节 孤立或多发成串珠状,体积大小不一,多数位于不 同层次,常伴有局部压痛,伴有感染时可产生皮温 皮色改变,严重时可出现不对称畸形[8]。 取出 PAHG 的手术关键在于彻底清除异物组 织,必要时需切除全部变性组织[9]。以往有医师采用 微创抽吸法,瘢痕轻微,但该方法往往残留异物较 多,且无法切除病变组织。反复的抽吸会使注射物 分布更加混乱,加重组织损伤[10]。切开法手术虽然瘢 痕相对较明显,但可在直视下分离注射物及病变组 织,能最大限度地将其去除达到彻底治疗的目的[11]。 内窥镜技术虽结合了两种术式的优点,但适应证有 限,且费用较高、手术时间延长,未能得到广泛应 用。由于并发症的出现及对未来的担忧,绝大部分患者心理负担较重,要求最 大限度地取出注射物,因此 目前主张开放手术的方法[12]。 术中配合大量生理盐水冲 洗,必要时辅助冲洗枪、内 窥镜等设备,达到尽可能取 出的目的。 技术要点:⑴术前定 位。所有患者均应行彩超检 查,如有条件可以做 MRI。 了解 PAHG注射层次、分布 范围、有无包块等,对于制 定手术方案至关重要。⑵切 口设计。根据注射物分布范 围,可以选择乳晕切口、乳 房下皱襞切口、腋窝切口 等,必要时选择乳房表面切口,但瘢痕较明显。⑶术 中操作。无论采用哪种入路方式,均应注意保护腺 体组织及乳头乳晕。由于注射时往往采用分层、多 点注射,造成注射物较为分散,形成多个腔隙,术中 注意钝性分离各个腔隙,挤出注射物,可使用刮匙 刮除附着于囊腔壁的材料。如发现明显硬块或硬结 形成,则一并去除变性硬结组织(腺体或胸肌),必 要时行病理检查,明确病变性质。⑷彻底冲洗。应用 大量生理盐水反复冲洗腔隙,直至冲洗液呈清亮透 明状且不含颗粒样异物成分为止。术中配合专业冲 洗枪可以大大提高冲洗效率,残留颗粒样注射物明 显减少。⑸超声确认。为确保最大程度地取出注射 物,建议术中行超声检查,明确是否存在明显的注 射物残留。如有明显残留,应及时根据超声定位再 次探查,取出注射物。⑹其他。注意术中彻底止血, 留置必要的引流管,保证引流通畅,术后加压包扎。 开放式取出 PAHG的方法,能够在直视下辨别 注射物及病变组织,配合冲洗枪冲洗,使悬浮在冲 洗液中的颗粒状植入物及时随冲洗液流出体外,最 大限度地取出注射异物。有条件的可在术中进行超 声检查,指导异物取出,从而保证手术治疗的确切 性,大大降低异物残留。

参考文献略。

原始出处:

孙旭, 郭澍, 佟爽等,超声辅助冲洗枪取出乳房内聚丙烯酰胺水凝胶临床应用[J],中国美容整形外科杂志,2019,30(12):758-760.

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    2020-01-21 tastas
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    2020-01-21 lishizhe

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