Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1054_Библиотеки_им_академика_М_И_Перельмана
.pdf
260
https://t.me/medicina_free
S. P. Somashekhar et al.
Immediate Late Long Term
Flap failure Loss of skin
and NAC
sensation
causing
impact on
sexual
function.
Complications of
general
anaesthesia-DVT,
Pulmonary
embolism
myocardial
infarction.
In a
nulliparous
women-loss of
lactation due
to detachment
of NAC.
Unpleasant
scar, patient
dissatisfaction
Lymphedema
(Breast
+/− arm)
Factors Affecting Complications
Patient
factor
Surgeon
factor
Type of
Oncoplsty
Nodal
burden
-Local wound healing delayed in older
age group smokers, morbidly obese,
comorbidity such as diabetes, HTN,
hypercholesteronemia and blood clotting
disorders.
Any previous breast/axillary surgery.
Oncoplastic technique and skill,
procedures done during the learning
curve.
Higher complication in complex
oncoplasty (beyond level 3 oncoplasty)
Concomitant axillary clearance may
result in complete de-vascularisation of
axilla.
33.2 Complications Specic
toOncoplastic Procedures
A.Volume displacement technique
B.Volume replacement technique
33.2.2 Seroma
It is accepted that serous uid will accumulate in
the surgical bed in virtually all patients after
breast and axillary surgery; most are clinically
silent [2]. A clinically signicant seroma is
dened as a postoperative uid collection that
requires one or more aspirations or subsequent
drain placement [3]. In a retrospective review of
324 patients who underwent 561 breast or axillary surgeries, 8.4% developed a seroma that
required intervention [3]. Seroma rates were signicantly lower after breast-conserving surgery
than after mastectomy (6 verses 14–16%) [4]
The presence of a seroma signicantly
increased the risk of a concurrent or subsequent
surgical site infection (8.5 versus 4% in the
absence of a seroma). Prolonged seroma formation may also delay wound healing.
Seroma is also a sequela that most often presents at donor sites in case of ap based
reconstruction.
33.2.2.1 Management
A wide bore needle percutaneous aspiration in
the ofce setting during follow-up visits sufces
in most cases, while some may require radiologically guided aspiration of the collected uid.
Seroma should not be left to expand without
treatment to avoid potential wound breakdown.
Drains are left in reconstruction site until daily
drainage drops to less than 30 cc/day consistently. This is usually 1 week at the reconstruction site and 2–3weeks at the donor site.
33.2.1 Bleeding andHematoma
Bleeding and hematoma are prevented by meticulous homeostasis. Expanding ap pocket,
change in colour of ap or skin, tachycardia and
anemia are all signs that should raise suspicion.
There should be a low threshold for returning to
the operating room for evacuation when present
in the immediate postoperative period.
33.2.3 Wound Infection
Wound infection at surgical sites are rare. Preand intraoperative antibiotics should be given
routinely in this surgery. Erythema, swelling or
pruritic discharge are signs of infection that
should be aggressively treated with antibiotics
and/or surgical drainage as necessary. Breast
oncoplasty may also be associated with the relatively late occurrence of a postoperative breast
33 Oncoplastic Breast Surgery-Common Complications andManagement
https://t.me/medicina_free
261
abscess (median 5months, range 1.5–8.0months)
[5]. Necrosis of marginally viable fat in the
lumpectomy cavity may contribute to this problem (Fig.33.1).
33.2.4 Post BCT Deformity (Fig.33.2)
In certain cases with unfavourable resection
defect, if immediate reconstruction is not performed signicant breast deformities will likely
manifest following completion of the BCT regi-
men. The deformities have been stratied by two
major competing schemas.
Berrino and colleagues were the rst to
classify post-BCT deformities, by identifying
the morphology of the deformity and then referencing this to select a technique of correction [6]. They described the following
deformity types:
1. displacement of the nipple areolar complex;
(Fig.33.3).
2. localised deciency of parenchyma and/or
skin;(Fig. 33.4).
3. generalised breast contracture with no local-
ised defects; (Fig.33.5).
4. severe damage with heavily scarred paren-
chyma and skin. (Fig.33.1).
Clough etal. have altered this classication
by reordering and combining groups, emphasising reconstructive choices and including
comparison with the opposite breast [7]. The 3
types are:
Fig. 33.1 Major skin necrosis of left breast, secondary to
breast conservation surgery for carcinoma of upper outer
quadrant with reconstruction using TDAP ap
Fig. 33.2 Parrot beak deformity of left breast after breast
conservation surgery
Type 1-deformity of the affected breast with no
contour defects and leading to asymmetry
with the contralateral breast;
Type 2-deformity requiring delayed partial
reconstruction;
Type 3-severe deformity requiring mastectomy
and whole breast reconstruction.
Fig. 33.3 Nipple areolar complex deviation of the left
breast noted during immediate postoperative follow up
262
https://t.me/medicina_free
Fig. 33.4 Skin and fat necrosis of the right breast post
oncoplastic breast surgery
Fig. 33.5 Poor scar placement with contracture and distortion of breast mound
In clinical application, these classications
help to clarify the deformities which typically
result when the BCT is performed under suboptimal condition. It also guides us in reconstruction
by emphasizing on identifying what is missing or
disordered and on seeking a reasonable match
between the two breasts.
S. P. Somashekhar et al.
33.2.4.1 Management
When these post-BCT deformities occur, delayed
partial breast reconstruction must be considered.
These cases have three potential problems.
First, these patients often present with ongoing
disappointment with their breast appearance following BCT and with higher cosmetic expectations. Second, breasts previously treated with BCT
present limited options [8] for reconstruction due
to reduced breast volume, scarring, distorted anatomy and disturbed vascularity [8]. Third, postradiation changes must be approached with
cautions as correction is technically difcult and
results and complications are highly unpredictable
(breast recon myocutaneous). Studies have estimated the complication rate to be as high as 50%
[9] and the nal aesthetic result to be poor [10].
Owing to these serious concerns, the post-BCT
reconstruction is limited to contralateral symmetry
procedure, local aps or scar revisions requiring
minimal dissection of the affected breast, and
importing of distant tissues, pedicled or freest correct the skin or/and parenchyma defect.
The recruitment of distant tissues for partial
breast reconstruction is to turn rst to pedicled
aps and then to free aps if pedicled aps are
insufcient or unavailable. Conventional pedicled aps options include the latissimus dorsi
(LD) muscle or myocutaneous ap and the transverse rectus abdominis myocutaneous (TRAM)
ap.
With the development of pedicled perforator
aps for partial breast reconstruction, more
options and possibly lower donor site morbidity
through muscle sparing are now available.
Laterally based pedicled aps (i.e., LD, lateral
intercostal artery perforator, thoracodorsal artery
perforator, lateral thoracic) are not suitable for
large defects of the medial breast quadrant. The
TRAM is the only pedicled ap which reached
the medial breast quadrant easily [9]. Its use for
partial breast reconstruction, however, generally
must be discouraged because this eliminates the
use of abdominal wall aps for a local recurrence
or a new tumour in the contralateral breast.
33 Oncoplastic Breast Surgery-Common Complications andManagement
https://t.me/medicina_free
263
Indication for delayed free ap reconstruction
after BCT defects are real but limited.
For severe breast deformity (Clough Grade
III) when non-abdominal pedicled aps are inadequate or unavailable.
For large breast deformity (Clough grade II)
in the medial quadrants;
In conjunction with completion mastectomy
for difcult tumour control or major glandular
brosis post-irradiation (Berrino Grade IV).
As part of treatment consisting of contralateral mastectomy (therapeutic or prophylactic)
and correction of ipsilateral post BCT
deformity;
With aesthetic abdominoplasty procedure in a
patient with long-term follow-up and no further
risk of recurrence or developing a new breast
cancer.
33.2.5 Local Recurrence
Local recurrence is an important outcome measure; however longer-term studies are required
before any denitive conclusion can be made. It
has been proposed that local recurrence would be
less given the ability to widely excise the tumour.
This review of the literature found that on intermediate follow-up (up to 4.5years) local recurrence rate varied from 0 to 1.8% per year and
cosmetic failure rates varied from 0 to 18%.
Clough demonstrated an actuarial 5-year local
recurrence rate using this technique of 9.4% [11].
Another series of 70 patients who underwent
oncoplastic surgery for breast cancer demonstrated an actuarial 5-year local recurrence rate of
8.5% [12]
33.2.5.1 Management
Postoperative surveillance is an important
approach to detect early recurrence. One concern
has been that tissue arrangement of breast parenchyma could potentially alter the architecture and
inuence the pattern of recurrence or ability to
screen accurately. Surgical clips at the tumour
margin will identify the tumour bed to assist not
only with radiation boosts but also postoperative
surveillance and exploration, if necessary. The
other question that arises is a delay in the concept
of mammographic stabilisation or decrease in the
sensitivity of this screening tool.
There was a slight trend toward longer times
to mammographic stabilisation in the study group
(21.2months for BCT vs. 25.6months for oncoplastic, p = 0.23), which is expected given the
additional scarring, inammation and alteration
in parenchyma associated with reconstruction.
The time to mammographic stability in the oncoplastic group demonstrated a 95% condence
interval between 20 and 30months. Sensitivity to
mammography was not affected as parenchymal
density was similar in both groups [13] This suggests longer than 6months screening is necessary
in these patients, possibly until about 2.5–3years.
Additionally, tissue sampling (ne needle aspiration, core biopsy, etc.) is often required given the
nature of these combined procedures, and to rule
out tumour recurrence. All these issues need to be
discussed with the patient preoperatively, as well
as the multidisciplinary team.
33.2.6 Post Radiotherapy
Complications
The effect of radiation therapy is different on the
two categories of reconstruction methodologies—implants and aps.
33.2.7 In Expander/ Implant
Reconstruction
Oncoplastic principles dictate that plastic reconstruction should not delay adjuvant treatments
such as chemotherapy and radiotherapy. Hence
the patient will likely proceed with oncological
treatment before she is at full or target expansion. The plan can be placed at hold until those
ontologically indicated therapies are complete
and the patient has time to recover. Most expanders have ferromagnetic integrated ports so they
are not MRI compatible. Any MRI work up for
the contralateral breast or other body parts
should be completed prior to the placement of
the expander.
264
https://t.me/medicina_free
S. P. Somashekhar et al.
33.2.7.1 Management
The higher incidence of capsular contracture in
this situation may have to be managed with over
expansion to retard the constricting effects of the
capsule, or with capsulotomies when the expander
is exchanged for a permanent implant. There will
likely be “step off” where he radiated skin will
tend to “shrink wrap” down to the underlying
chest wall contours, creating a sharp demarcation
with the implant in the upper pole of the breast.
These contour irregularities may be corrected
with a biomaterial such as Alloderm acellular
human dermis (Lifecell, Branchburg, N) or by fat
grafts. Local aps such as thoracodorsal
perforator (TDAP) ip, lateral thoracic ap or
intercostal perforator aps can be used to recruit
vascularised tissue into the defects and ameliorate contour deformities [14]
33.2.8 In Autologous Reconstruction
Complications of autologous reconstruction are
most often related to partial or complete loss of
the transported tissues. If this happens, local tissue rearrangement may correct the problem. In
instances of total ap loss, a second ap (most
commonly a free ap) may be recruited once the
underlying cause of ap failure has been understood and resolved.
In the instance of free tissue transfer alternative donor vessels such as thoracodorsal, internal
mammary, contralateral mammary vessels or
thoracoacromial are dissected. Reconstruction
options for partial defects are very similar to
reconstruction of full defects. Occasionally
patients with a lumpectomy defect will wish to
camouage that defect with a small implant.
Often one has to place an implant in the contralateral breast as well to achieve a similar shape
and size. The implant will have to be of different
volumes to account for both the volume resected
during lumpectomy and the volume of tropic
loss from the secondary effects of
XRT. Alternatively, a woman could select for
autologous repair [11, 15].
33.3 Complications ofIndividual
Flaps
33.3.1 Latissimus Dorsi Flap
1. Donor site morbidity
The most common complications associated
with the latissimus dorsi ap are related to the
donor site.
Donor site Seroma Formation Range from
3.9% to 79 [16]. Often they are managed on an
outpatient basis with needle aspiration; however,
on rare occasion, a persistent seam may require
surgical debridement of the seroma cavity and
long-term closed suction drainage. The risk of
seroma may be increased with the extended latissimus dorsi ap (muscle sparing latissimus vs.
extended latissimus aps, the rate of seroma were
62.2% vs. 5.6%).
Delayed wound healing, contour irregularity and scar widening can occur when very large
skin paddles are used, the donor site closure may
be placed under excessive tension. These complications can be corrected with minor secondary
procedures.
33.3.1.1 Lumbar Herniation
The latissimus dorsi muscle forms the rod of the
superior lumbar triangle. During ap harvest,
inadvertent injury to the aponeurosis of the internal oblique and transverse abdominal muscles
which forms the oor of the triangle can lead to
lumbar herniation. While this complication is rarest is important to consider as surgical intervention is usually required to repair the hernia and
avoid serious complications.
33.3.1.2 Shoulder Weakness,
Stiness andLoss
ofMobility
These are other complications which occurs as
latissimus dorsi is an important adductor of the
arm and internal rotator of the shoulder. These
33 Oncoplastic Breast Surgery-Common Complications andManagement
https://t.me/medicina_free
265
complications should be discussed with patients
preoperatively; however, in most patients who
are not athletes and bodybuilders, the loss of
strength and range of motion is negligible and
responds well to postoperative physical therapy.
2. Flap loss
The Latissimus dorsi ap has a robust axial
blood supply and reliable skin territory, making
signicant ap loss unusual. This complication is
almost universally associated with injury to the
vascular pedicle during ap dissection or twisting or kinking of the ap transposition. It is therefore very important to understand the orientation
of the pedicle before and after tunneling through
the axilla to avoid iatrogenic ap loss. Partial ap
loss has been reported with rates as high as 7 [16]
3. Implant related complications
In cases where a latissimus dorsi ap is used
in conjugation with the tissue expander or
implant, the risk of prosthetic use are added
including implant extrusion, rupture, periprosthetic infection and capsule contracture.
Furthermore, implant migration into the axilla
has been reported [16] This complication is easily avoided by securing the lateral ap to the
chest wall to close the communication between
the mastectomy cavity and ap donor site.
33.3.2 Individualised Risk
Assessment
The development of large scale, multiinstitutional data bases has allowed a recent
emphasis on individualising risk assessment
through statistical modelling. Recently, one of
the authors (JYSK) developed the Breast
Reconstruction Risk Assessment Score (BRA
Score) using widely available resources, like the
American Society of Plastic Surgeon Tracking
Operation and Outcomes of Plastic Surgeon
(TOPS) and the American college of Surgeons
National Surgical Quality Improvement
Program (NSQIP) database. This tool aims to
provide individualised and quantiable risk
assessment for patients undergoing breast
reconstruction in an effort to better inform surgical decision making and manage patient
expectation.
33.3.3 Breast Risk Assessment Score
This score is based on various factors such as:
1. Comorbidities and prior intervantions:
• Hypertension
• Diabetes
• Respiratory disease
• Smoking status
• American society of anesthesiologists
score (ASA)
• Stent placement/ ballon angioplasty
2. Previous cancer treatment:
• Chemotherapy
– Radiotherapy
– Breast reconstruction
33.3.4 Pedicled Flaps inOncoplastic
Breast Surgery
33.3.4.1 Donor Site Morbidity
After harvesting loco-regional pedicle perforator
aps for partial breast reconstruction donor site
morbidity is reduced to minimum. Only a very
limited rate of seroma formation has been
observed and treated mainly conservatively.
Wound dehiscence of the donor site has only
been observed when the wound edges are closed
under tension. This is infrequent and managed
with local wound care. Data from the recent studies shows a seroma rate of 5.5% in TDAP II aps,
compared with no seroma formation in perforator
aps. Other postoperative complications
observed were wound dehiscence (4%), infection
(2%) and hematoma (2%) [17]
33.3.4.2 Partial or Total Flap Losses
They are very rare incidents, and one must
exclude coagulopathies or other medical diseases
and conditions.
266
https://t.me/medicina_free
33.3.4.3 Palpable Fat Necrosis
(Figs.33.6, 33.7, 33.8,
and33.9)
Fat necrosis of the ap has been observed and can
be treated, if necessary by excision and primary
Fig. 33.6 Fat necrosis seen in central quadrant with
retraction of nipple areolar complex. A note of surgical
clips is made at the primary tumor site
S. P. Somashekhar et al.
Fig. 33.7 Fat necrosis with microcalcication noted on
digital mammography which can be confused with tumor
recurrence during follow up of the patient
Fig. 33.8 Fat necrosis along with skin thickening at the
site of NAC
closure or reconstruction by a local ap. If necessary by excision and primary closure or reconstruction by a local ap. If necrosis is too
extensive, a mastectomy with total breast reconstruction may be indicated. However, fat necrosis
observed during follow-up on radiological imaging warrants a biopsy to rule out recurrences.
33.3.4.4 Unpleasing Scars, Flap
Contracture andVolume
Loss
They are less rare sequelae and may need secondary surgical treatment. Also, ap reconstruction
of breast defects may give a “plugged in” appearance which seems to slightly improve after radiation therapy.
Finally some patients who undergo partial
breast reconstruction with the TDAP ap docu-
33 Oncoplastic Breast Surgery-Common Complications andManagement
https://t.me/medicina_free
267
Fig. 33.9 Well circumscribed fat necrosis seen on
tomosynthesis
ment an initial decrease in forward arm elevation and passive abduction which recover over
time [17]
Many concerns have been raised about oncologic safety of oncoplastic surgery. A recent
meta-analysis showed that oncoplastic surgery
shows to be an ontologically safe procedure, with
fewer recurrent rates (4%) compared with breast
conservative surgery (7%) alone [18].
After oncoplastic resection margins are more
often negative, and if recurrence occurs, they
most often occur in the preoperative quadrant of
the tumor, and not the location after displacement
technique.
Local recurrence rates reported for oncoplastic surgery vary from 0 to 7% of patient.
Fig. 33.10 Breast asymmetry after oncoplastic breast
surgery
33.3.4.5 Breast Asymmetry
(Fig.33.10)
Different ageing processes between the two
breasts may result in breast asymmetry. The nonirradiated side may become more ptotic as compared to the radiated side. On the contrary, the
irradiated side may show signs of total breast
atrophy. When the breast asymmetry becomes
obvious, fat grafting alone or the contralateral
breast remodelling can be considered. The use of
lipolling technique, alone or in combination
with other reconstruction techniques for the treatment of breast defects after tumour resection is
gaining great popularity. Fat injection into the
breast can signicantly improve small breast
defects after lumpectomy. In larger defects, par-
268
https://t.me/medicina_free
S. P. Somashekhar et al.
tial breast reconstruction is preferred using the
tissue replacement technique. However, autologous fat grafting is a useful adjunct to improve
the nal outcome.
Fat injections into the breast can be considered primarily at the time of breast conservation
surgery to limit volume discrepancies between
the two breasts, to add fullness superomedially
for aesthetically pleasing breast cleavage or correct breast shape. In secondary procedure, fat
grafting can be performed to rene volume, projection, or colour irregularities due to ap necrosis or ap contracture. Fat grafting has also
demonstrated success in the treatment of skin
atrophy of the breast after irradiation. The mechanism of action is postulated to be mediated by
stem cells included with fat grafting in the intradermal plane. The major limitation is that it is
time consuming and prolongs operation time,
especially in inexperienced hands and the requirement of staged application.
33.3.5 Free Flaps forPartial Breast
Reconstruction
1. SGAP (Superior gluteal artery perforator
based ap)
33.3.5.1 Flap Failure
The most serious complication specic for free
ap reconstruction. Flap failure, partial or complete, can be a result from multiple factors. These
include:
hibits gluteal ap reconstruction. Patient having
had radiation may have scarred or thrombosed
IMA vessel also contributing to ap failure.
Postoperative care is important in preserving
the integrity of the ap and its perfusion.
Excessive motion or inappropriate patient positioning can compromise the ap pedicle.
Moreover, frequent ap monitoring by those with
knowledge on the signs of ap compromise can
potentially lead to a failing ap being saved.
Other complications include.
Bleeding, hematoma, seroma, infection,
wound breakdown, scarring pain and pneumothorax [19]
33.3.6 Medial Thigh Flaps
Transverse upper gracilis ap, profunda
artery perforator ap etc.
Most complications are similar to other free
aps like infection, seroma, delayed wound healing around the groin, decient ap volume, contour defects, poor scar requiring revision. Other
specic complications to these aps are:
Sensory disturbance within the medial
thigh, temporary or permanent lymphedema
given that the surgical site is over the lymphatics of the groin.
33.3.7 TRAM Flap (Transverse Rectus
Abdominis Myocutaneous
Flap)
• Microsurgical technique
• Patient anatomy
• Patient risk factors
• Postoperative care
For published series of greater than 10 SGAP
reconstruction, ap failure rate range from 0 to
7.7% [19].
Even with these listed factors, surgical tech-
nique is usually a component of every ap failure, especially complete ap loss. Meticulous
microsurgical technique can avoid anastomotic
obstruction. Occasionally, patient’s anatomy pro-
33.3.7.1 Flap Failure
Flap failure is the most serious complication.
Factors that may increase the risk of ap failure
can be divided into two groups: those that are
within the control of the patient and those that are
not.
Factors that can be controlled by the surgeons
are often related to meticulous technique and
knowledge of the relevant anatomy. It is due to
arterial or venous factors. Venous occlusion due
to clot, kinking or twisting of the vascular pedicle
is characterised by a ap that becomes congested,
oedematous and tense. Arterial occlusion is less
33 Oncoplastic Breast Surgery-Common Complications andManagement
https://t.me/medicina_free
269
common and may be due to the same factors but
is characterised by a ap that is pale, ashen and
soft. Both situations require operative
re-exploration.
33.3.7.2 Flap Re-exploration
After the ap sutures are removed and ap exteriorised, the anastomosis and the vascular pedicles are inspected. With venous occlusion, the
vein is tense and dilated and may be lled with
clotted blood or may have a kink or twist, therefore, realignment of the pedicle is all that is
needed to restore circulation. If there is true
thrombosis, management includes takedown of
the anastomosis, embolectomy of the venous
limb and irrigation of the lumen with heparin. If
clot is suspected in the ap or the muscle, thrombolytic therapy is indicated. Success depends on
the relapsed time interval and is most effective
when occlusion has been less than 2h.
In case of arterial occlusion there is no pulse
and the veins are usually at. The anastomosis is
taken down and inspected for thrombin clot or
intimal damage. In some cases the vessels are
trimmed and the anastomosis is performed again.
When there is persistent disruption of ow, vascular spasm or a clotting disorder is suspected
4% lidocaine or papaverine HCL may be used
along the adventitia of the vessel to promote
vasodilation. If the ap is deemed unsalvageable,
it is removed and sometimes replaced.
Other factors that can inuence the success of
microvascular breast reconstruction are advanced
age, ASA status and length of operation are signicant predictors of postoperative morbidity
[20]. Undiagnosed hypercoagulability disorder
and radiation damage to vessels.
Donor site complications include, but are not
limited to contour abnormalities, complex scars,
delayed healing, seroma, pain and infection.
Abdominal hernia is rare, and abdominal bulge
occurs in the vast majority of the cases. The incidence ranges from 3 to 10% for unilateral cases
and 5 to 15% for bilateral cases. Chronic pain
may be due to neuroma formation due to hemoclips placed on the sensory nerves or nerve
entrapment.
33.4 Conclusion-Salient Features
• Volume displacement and volume replacement oncoplastic procedures have different
spectrum of complications. Volume displacement technique during learning curve has
high morbidity and complications, whereas
volume replacement technique has stable
outcome.
• The most signicant patient factors that affect
outcome are smoking and high BMI, apart
from the other comorbid conditions.
• Level of oncoplastic and concomitant complete axillary dissection are the two factors
which affect the outcome. Complete axillary
dissection when required, devascularized the
axillary bed parenchyma with varying
outcome.
• Improperly done oncoplastic would be disastrous and the patient may end up with mastectomy if not dealt early.
• Avascular necrosis of the glandular rotation
ap, nipple-areolar complex and the skin is
very high in an unplanned oncoplasty.
• Incision planning is the key feature in oncoplastic procedures.
• However, oncoplastic can be done safely, in
most cases with low morbidity and complications resulting in excellent cosmetic results.
References
1. De La Cruz L, Blankenship SA, Chatterjee A, Geha
R, Nocera N, Czerniecki BJ, et al. Outcomes after
Oncoplastic breast-conserving surgery in breast cancer patients: a systematic literature review. Ann Surg
Oncol. 2016 Oct;23(10):3247–58.
2. van Bemmel AJM, van de Velde CJH, Schmitz RF,
Liefers GJ.Prevention of seroma formation after axillary dissection in breast cancer: a systematic review.
Eur J Surg Oncol. 2011 Oct;37(10):829–35.
3. Boostrom SY, Throckmorton AD, Boughey JC,
Holield AC, Zakaria S, Hoskin TL, etal. Incidence of
clinically signicant seroma after breast and axillary
surgery. J Am Coll Surg. 2009 Jan;208(1):148–50.
4. Breast-conserving therapy – UpToDate (Internet).
(cited 2021 July 14). Available from: https://
www.uptodate.com/contents/breast- conservingtherapy?csi=7a791f3f- c3dd- 4709- 90cb- 556d95b8f60
7&source=contentShare
Соседние файлы в папке Библиотека им академика М.И. Перельмана