Surgery is an important part of the comprehensive treatment of breast cancer. The traditional treatment will cause breast loss, change the shape, and some patients will suffer self-image disorder, low self-esteem and so on. Some studies have shown that lack of breasts will increase the sense of shame of female patients, affect the life of husband and wife, and then lead to some family problems . Patients who meet the conditions for breast conservation can choose partial mastectomy and tumor resection, remove local lesions, and retain most of the breasts. Breast-sparing surgery not only has fewer traumas, but also preserves the appearance of the breast to the maximum extent, and improves the quality of life and satisfaction of patients after operation . Although breast conservation surgery can retain part of the patient’s breast, there are still some problems, such as bilateral breast asymmetry, and large breast sagging after breast conservation surgery. The incision of an inverted T-shaped flap is a common surgical incision with large and prolapsed breasts. The incision of an inverted T-shaped flap can shrink the breast longitudinally and horizontally. The incision of an inverted T-shaped flap can not only remove the lesion, but also achieve the effect of mastoconstriction suspension and obtain the satisfactory appearance of the breast . The treatment of the subcutaneous gland is to remove the excess gland tissue in the reverse double V-shape of the breast and then hang it, and the blood supply of the nipple areola is provided by the basal pedicle of the lower breast and the horizontal double pedicle of both sides of the breast  . It reduces the damage to local blood vessels during the operation and facilitates the healing of the wound after the operation. However, most of the glands need to be removed during the operation, which will damage some small arteries and veins, and pull the flap at the incision edge for a long time and a wide range of reasons, which will easily lead to ischemic necrosis of the flap   . At present, there are few nursing studies on how to reduce skin flap necrosis after breast reduction and suspension. We summarize 5 successful cases of flap care after inverted V surgery in our department, and share them as follows.
2. Clinical Data
2.1. General Information
The five patients were diagnosed as single breast malignant tumor through preoperative imaging in our hospital from February 1, 2019 to April 30, 2019. The maximum diameter of the mass was 3cm and the distance from nipple areola to nipple areola was more than 2cm, which conformed to the indication of breast conservation. All of them were female aged from 35 to 50 years old，and with large and sigging of bilateral breasts. Partial mastectomy and axillary lymph node dissection were performed on the affected side, mastoconstriction suspension was performed on the contralateral side. There were 2 cases of medial pedicle, 1 case of vertical pedicle, and 2 cases of lateral pedicle.
2.2. Operation Method
Sentinel lymph node biopsy was performed during the operation, and axillary lymph nodes were dissected if positive. According to the preoperative measurement and positioning, taking the areola as the center, the hypertrophic glandular tissue was removed in the shape of “
2.3. Treatment Outcome
The breast volume of 5 patients in this group was basically reduced to the original plan. One patient had fat liquefaction, and the fat liquefaction tissue was removed under local anesthesia. Fifteen days later, the sutures were completely absorbed by themselves and the incision healed, and the rest of the incisions healed in the first stage. The follow-up results within one year showed that the nipple areola decreased from numbness one month after operation to normal sensation, scar hyperplasia was not obvious, and there was no secondary mastoptosis of the breast. Patients' satisfaction with postoperative breast effect and sexual life basically returned to the preoperative level.
3.1. Preoperative Preparation
Determine the new nipple position (Figure 1 and Figure 2). Methods: The patient took the standing position, selected the clavicle midpoint to the nipple line and extended to the inferior breast wrinkle wall, and the body surface projection from the lower wrinkle wall to the breast midline on the breast surface was regarded as the nipple position reference point 1; took the intersection point of the bilateral upper arm midpoint line and the breast midline as the new nipple position reference point 2, and measured the distances Sn and Xn, which are from the above two reference points to the sternal notch midpoint S and to the inferior xiphoid process midpoint X. Determine the position of the new nipple n, in which the Sn is 19 to 21 cm and the X n is 9 to 11 cm. Under the guidance of nurses, all the 5 patients in this group cooperated with doctors to locate before operation and keep the mark before operation.
3.2. Postoperative Nursing
3.2.1. Negative Pressure Drainage (Figure 3)
The intraoperative administration of indwelling negative pressure drainage tube according to the surgical area is conducive to promoting wound healing, preventing subcutaneous congestion, increasing the survival rate of flap, reducing the incidence of ischemic infection and necrosis of skin flap after operation    . On the day of the operation, the color and drainage volume of the drainage liquid should be observed every hour. If the drainage liquid is more than 100 ml within 1 hour, and the color is bright red, we should be on guard against active bleeding. After that, keep the negative pressure of the drainage
Figure 1. A schematic drawing of the new breast position.
Figure 2. The new position of the nipple before operation.
Figure 3. The postoperative renderings.
bottle every day, observe the negative pressure drainage every 2 hours, pump the drainage tube once during each shift, clean up the blood clots, fat and other massive objects in the pipe in time, keep the tube unobstructed and prevent the drainage tube from twisting . If the distension and pain in the operation area is obvious, there is purple ecchymosis under the skin, and there may be subcutaneous effusion or subcutaneous hematoma, so the doctor should be informed immediately. During the operation, according to the surgical incision, 2 to 5 drainage tubes were placed on the chest wall and armpit on the left and right sides.
3.2.2. Application of Unarmed Lymphatic Drainage in Inverted T-Shaped Flap
Part of the lymphatic vessels may be damaged during the operation, resulting in obstruction of reflux  and swelling of the arm. After operation, there will be varying degrees of swelling in the incision area and no increase in skin temperature after 3 days, which may also be related to poor lymphatic drainage . Touching can relieve postoperative pain, promote lymphatic reflux and blood flow, which is conducive to the survival of the skin flap. During the growth period of the flap, it can reduce the discomfort such as itching and tingling of the flap, and divert the patient's attention . The newly established blood supply between the skin flap and the chest wall is unstable, and the patient is restless due to wound pain and discomfort, which can easily lead to subcutaneous bleeding and subcutaneous effusion caused by the re-separation of the skin flap attached to the chest wall after operation, thus affecting the blood supply of the flap and causing flap necrosis   . Therefore, on the first day after operation, the international lymphoedema therapist used unarmed lymphatic drainage to touch the affected side with sliding strokes, which were pushed from the dorsum of both hands to the supraclavicular lymph nodes. The strength of the touch is appropriate to the strength of the one-dollar coin on the hand, and the pressure is about 25 to 30 mmHg. Try not to cause skin wrinkles by using light, soft, and shallow touch technique. The affected breast runs along the superficial lymphatic vessels, and the sequence of unarmed lymphatic drainage is divided into four quadrants, the lymph in the upper inner quadrant of the axillary side is caressed and pushed to the supraclavicular lymphatic vessel on the ipsilateral side, and the lymph in the outer upper quadrant of the axillary side is pushed to the ipsilateral supraclavicular lymphatic vessel or cervical lymphatic vessel. The lymph in the internal and external upper quadrant of the contractile breast was pushed to the axillary lymph nodes or supraclavicular lymph nodes, the internal and external lower quadrant lymph  . In this group of 5 patients, the affected limbs showed varying degrees of pain and mild edema, which were relieved by unarmed lymphatic drainage by the international lymphoedema therapist.
3.2.3. Skin Observe
Observe the condition of inverted T-shaped skin flap every hour after operation, observe the temperature of T-shaped skin flap and the surrounding skin color, touch whether there is subcutaneous effusion, as well as finger pressure flap. The normal reaction is 1 to 3 s. If the skin is blue, swelling is severe and the reaction time of finger pressure is more than 5 s, it should be dealt with in time . Observe whether the pressure is too large or insufficient. If so, adjust it in time, and then observe the T-shaped skin flap and nipple areola every 2 hours every day, gently pinch the nipple in each shift, observe the capillary filling degree, and judge the nipple edema. The skin temperature of the affected side is measured by a skin thermometer, and compared with that of the healthy side. If the surrounding skin temperature is higher than that of the opposite side, the contrast temperature is more than 1 degree, or the skin temperature does not rise for a long time, it should be on guard against infection or ischemia . For the T-shaped neck area, evaluate the skin tension around the incision, observe the degree of swelling of the upper breast, and whether there is obvious pressure on the breast. If there is obvious pressure, the upper support can be fixed with an elastic bandage and 2 fingers should be loosened and tightened. Patients are advised to choose a semi-sitting position of 30 - 45 degrees during the day before removing the drainage tube, shake the head of the bed 15 - 30 degrees at night when rest, and do not walk with chest arch when getting out of bed, so as not to aggravate the oppression. After the pressurized bandage is loosened, it is necessary to inform the bed attendant whether to readjust it or not.
Preoperative new breast location, intraoperative flap repair and postoperative flap nursing are the keys to successful operation. Repeated clipping of blood vessels may cause pedicle injury, but the optimal time interval and cycle of ischemic preconditioning are not clear. Inflammatory reaction can also cause necrosis and ischemia of the flap, aggravate local edema, bleeding, thrombosis and so on. Therefore, reducing the inflammation of the flap can improve the survival rate of the flap.
Breast-conserving surgery combined with contralateral breast reduction surgery for breast cancer can not only achieve the therapeutic effect, but also maintain the appearance of the breast, improve the shape of the breast and improve the quality of life of patients. Nursing care of inverted T-shaped flap is the key to smooth recovery after the operation. Pay attention to the blood supply of the neck area of the T-shaped flap, finding abnormalities and deal with them in time, and guarding against ischemic necrosis of skin flap. Unarmed lymphatic drainage can relieve the pain of the affected limb after the operation, promote lymphatic reflux, reduce the edema of the skin flap, and is beneficial to the growth and survival of the flap.
This study was funded by the 2020 Medical Scientific Research Foundation of Guangdong Province of China (A2020267).
Approval was obtained from the Ethics Committee of Sun Yat-sen University Cancer Center (No. GYX2020-002). The procedures used in this study are in line with the purpose of the Declaration of Helsinki.
 Han, J., Quan, H., Liu, J.J., Yan, W.G., Ding, H.Z., Wang, C. and Paliyenka, T. (2019) Inverted-T Pattern Breast Reduction in Breast Hypertrophy Patients with or without Breast Cancer. Chinese Journal of Breast Disease (Electronic Edition), 13, 75-80.
 Han, J., Quan, H., Liu, J.J., et al. (2019) Inverted-T Pattern Breast Reduction in Breast Hypertrophy Patients with or without Breast Cancer. Chinese Journal of Breast Disease (Electronic Edition), 13, 17-22.
 Bertozzi, N., Pesce, M., Santi, P.L., et al. (2017) Tissue Expansion for Breast Reconstruction: Methods and Techniques. Annals of Medicine and Surgery, 21, 34-44.
 Schlaudraff, K.U., Pepper, M.S., Tkatchouk, E.N., Ehrenburg, I., Alizadeh, N., Montandon, D. and Pittet, B. (2008) Hypoxic Preconditioning Increases Skin Oxygenation and Viability But Does Not Alter VEGF Expression or Vascular Density. High Altitude Medicine & Biology, 9, 76-88.