RU2183943C2 - Method to conduct primary plasty of mammary gland defect after its radical resection - Google Patents

Abstract

FIELD: medicine, surgery. SUBSTANCE: after removing a part of mammary gland by two incisions perpendicularly downwards against an external joint of half oval incisions out of which this part is removed, a future tear-shaped fragment is bordered. It is necessary to separate to a desired degree the skin with a fiber from the broadest muscle of back outwards against lateral incision towards the back. The broadest muscle of back is crossed. A tear-shaped skin-adipose fragment is formed in one block with a part of the broadest muscle of back corresponding to the size and volume of the removed mammary gland part. Fragment is taken upwards. The wound on thoracic wall is fastened in layers with sutures not separating its medial edge. Then excessive part of the broadest muscle of back is turned under the fragment by creating its larger volume. Fragment is fixed by sutures in layers onto defect site by modelling the shape of mammary gland. EFFECT: improved cosmetic results at no losses in radicalness. 2 ex, 3 dwg

Description

 The invention relates to medicine, namely to surgery, and can be used for surgical treatment and rehabilitation of patients with breast cancer of small and medium sizes.

 The defect arising after radical resection or hemimastectomy (removal of half the mammary gland) can be closed by various displaced skin-muscle flaps [thoraco-dorsal (V. P. Demidov et al. "Subtotal radical resection and primary reconstruction in breast cancer" - "Surgery ", 1997, 3, - pp. 11-14, recto-abdominal (S. N. Blokhin et al." Primary reconstructive operations in the complex treatment of breast cancer. "-" Mammology ", 1996, 2, - p. 59-60)]. The methods of these operations are quite complicated, traumatic and require knowledge good time.

 The known method of simultaneous plastic surgery of the mammary gland of small sizes after its radical resection with a skin-fat flap from the lateral surface of the chest wall (patent for invention 2127086, MKI 5 A 61 B 17/00, published 03/10/99, Bull. 7). After removal of a part of the mammary gland, the defect is replaced by cutting from the lateral surface of the chest wall perpendicularly downward from the outer point of convergence of the semi-oval sections, from which a segment of the mammary gland, corresponding to the size of a full-layer tongue-like skin-fat flap on the feeding leg, is removed, which, after mobilization, is placed in place of the defect and fixed to its edges with layered seams, which restores the shape and volume of the chest. If necessary, the subareolar zone is replaced by a cut off from the humerus and tucked by the small pectoral muscle. Excess skin in the upper inner corner of the flap is de-epithelized and immersed with cosmetic sutures inside.

 The disadvantages of this method are the relatively small amount of tissue moved, depending on the thickness of the subcutaneous fat layer on the lateral surface of the chest wall, which allows it to be used only with radical resections in patients with small sizes of the mammary gland, and the appearance of excess skin in the upper inner corner of the flap.

 The invention is aimed at solving the problem: expanding the indications for simultaneous breast plastic surgery after radical resection and hemimastectomy for cancer with medium and small sizes of the organ, improving the cosmetic effect without loss in radicality.

 These tasks are achieved by closing the defect resulting from radical resection or hemimastectomy, with the tumor localized in the lower, central or upper quadrants, by a skin-fat-muscle flap. New in the method is that cut from the lateral surface of the chest wall of the skin-fat drop-shaped flap is taken in one block with part of the latissimus dorsi and moved to the place of the defect. At the same time, the size of the skin flap corresponds to a defect in the skin on the mammary gland, and subcutaneous fat and part of the muscle correspond to the volume of the removed segment. The resulting wound on the chest wall, after mobilization of its lateral edge (at the time of isolation of the latissimus muscle), is easily sutured. The excess muscle is tucked under the flap, which together with it is fixed to the edges of the breast defect, creating its previous shape and volume.

 The method is shown in the drawing, where Fig.1-3 shows the steps of the operation when performing radical hemimastectomy of the lower quadrants of the mammary gland.

 The method is as follows.

 After removal of a part of the mammary gland (from 1/4 to 1/2) with the underlying fascia and subclavian, axillary and subscapular tissue with two cuts perpendicular to the outer corner of the connection of the semi-oval cuts from which this part was removed, through the skin and fiber (to the muscle) border the future drop-shaped flap, corresponding in size to a defect in the skin of the chest (the ratio of its width and length is 1: 2-2.5). From the lateral edge of the flap, the skin with fiber and fascia below the incision is separated from the latissimus dorsi (Fig. 1). Then the cut flap from its medial edge is separated along with the muscle from the underlying tissues towards the back to the level where it is necessary to dissect the muscle mass. The next step in this section is to divide the muscle between the fibers to the upper point of the skin incision to form a feeding leg, and cross it below. The cut flap is brought up and the defect formed on the chest wall is sutured with layered sutures after introducing vacuum drainage with additional holes into the armpit and breast defect region (Fig. 2). The medial edge of the wound is not mobilized, because the lateral one is widely separated when the latissimus dorsi muscle is secreted, which makes it easy to bring these sections closer together by layered seams. Next, that part of the latissimus muscle, which is located outside the skin-fat flap (indicated by a dotted line in FIG. 2) is tucked up, which increases the thickness of the latter. In this form, the flap is placed in place of the defect and catgut sutures connect its edges with the tissues of the mammary gland, modeling its shape. The last step is to apply cosmetic intradermal sutures with absorbable material (vicryl, polysorb, capromed, etc.) (Fig. 3).

 Examples of specific performance.

 Example 1

 Patient K., 42 years old (outpatient card 9810251), was admitted to the mammological department of the Perm Oblast Clinical Dispensary on 10.23.98 (medical history 3710/556) for: left breast cancer II b.st. (T2N1M0), multicentric growth (two nodes). The diagnosis was confirmed by cytological examination 25017-18 from 10/13/98 - a cytogram of breast cancer with moderate and low differentiation of cells. Both tumors were located near the border of the upper quadrants. Bra Cup Size C (3). The patient refused a mastectomy. 10/28/98 an operation was performed - Radical resection of the left breast with simultaneous plastic surgery of a skin-fat flap from the lateral surface of the chest wall with part of the latissimus dorsi muscle: under endotracheal anesthesia, a 15x8x6.5 cm breast segment was removed from two semi-oval sections in the upper quadrants in one block with subclavian, axillary and subscapular tissue. An urgent cytological examination did not reveal neoplasm cells in scrapings from the edges of the wound, there were no metastases in 8 lymph nodes. A tear-shaped flap 16x9 cm is cut out on the lateral surface of the chest wall. Skin with fiber lateral to the external incision is separated from the latissimus dorsi muscle by a distance of 9 cm, where the muscle is divided along the fibers and dissected in the lower corner of the wound. The musculocutaneous flap has been separated, laid up, the edges of the wound on the chest wall are sutured in layers. Vacuum drainage. The latissimus muscle is tucked under a flap that is laid on the site of a defect in the mammary gland and is fixed to its edges by layered seams. Bandage.

 The postoperative course is smooth. Histological examination 5958-63 from 11/14/98 - Invasive ductal cancer (two nodes 2.5 and 0.8 cm), metastasis in one axillary lymph node. From November 20, 1998 to January 18, 1999 she underwent a course of radiation therapy, and subsequently received chemotherapy courses according to the CMF scheme.

 The cosmetic effect of the operation was rated excellent by the patient.

 Example 2

 Patient D., 49 years old (outpatient card 9812818) was admitted to the mammological department of VET on 12/27/98 (medical history 4639/683) about: cancer of the right breast II b.st. (T2N1M0) with tumor localization in the lower inner quadrant. Bra Cup B (2). The diagnosis was confirmed by a cytological study 32998-9 from 12.25.98 - a cytogram of breast cancer with moderate and low differentiation of cells. 12/30/98 an operation was performed - Radical hemimastectomy on the right with simultaneous plastic surgery of a skin-fat flap from the lateral surface of the chest wall with part of the latissimus dorsi muscle: under endotracheal anesthesia from two semi-oval sections, with preliminary separation of the lower half of the areola, the lower quadrants of the mammary gland were removed (size 15x7x6 , 5 cm) with a tumor in one block with subclavian, axillary and subscapular tissue. In scrapings from the surgical wound and lymph nodes, cell complexes of mastopathy, metastasis to one lymph node. A skin-fat flap 16x7 cm in size was cut perpendicularly down from the external point of the operative wound on the lateral surface of the chest wall. Skin with fiber in the region of the outer edge was separated from the latissimus muscle by a distance of 8 cm, where the latter was crossed. The flap in the same block with the muscle after separation from the underlying tissues is taken up. Vacuum drainage. The flap was laid in place of the defect and with its layered fixation, the shape of the mammary gland was modeled. The separated part of the areola is laid on the flap, its contour is marked with a marker. In this area, de-epithelialization of the skin is made, the areola is hemmed to its edges. Cosmetic intradermal suture with vicryl. Bandage.

 The postoperative course is smooth. Histological examination 7313-15 from 01/13/99 - combined cancer (ductal with lobular elements), background - proliferative mastopathy, metastasis to one lymph node. The patient underwent radiation and polychemotherapy. The cosmetic effect is good.

 Positive effect.

 The proposed method of simultaneous plastic surgery of the mammary gland can be used not only after radical resections with small sizes of the organ, but also with medium sizes, as well as after hemimastectomies. This was made possible by cutting out a skin-fat flap from the lateral surface of the chest wall in one block with part of the latissimus dorsi, which gives a greater amount of plastic material. In addition, the presence of additional blood supply to the flap due to perforating vessels from the muscle allows us to cut out not a tongue-like, but a drop-shaped flap with a smaller size of the feeding leg, more appropriate to the shape of the removed segment. In most patients, this eliminates the need for de-epithelialization and immersion deep into the excess skin in the upper-inner corner of the flap. Our proposed method takes 1 hour - 1 hour 20 minutes and does not require moving the patient on the operating table during the intervention. Moreover, the new method allows you to get a good cosmetic result, because a skin-fat flap from the lateral surface of the chest wall with part of the broadest muscle of the back completely restores the volume of the medium-sized mammary gland. The proposed method of primary plastic surgery after radical resection and hemimastectomy expands indications for organ-sparing surgeries, it is less traumatic, simple in execution and can be easily mastered by surgeons.

 The flap withstands radiation exposure of 50-60 Gy without visible changes.

Claims (1)

 The method of primary repair of a breast defect after its radical resection by replacing the defect with a displaced flap from the lateral surface of the chest wall, characterized in that a cut-out teardrop-shaped skin-fatty flap is used in one block with a part of the latissimus dorsi, corresponding to the size and volume of the removed part of the mammary gland, why separate the skin with fiber from the latissimus dorsi muscle outward from the lateral incision to the back to the required level and here the muscle is crossed, the flap is removed px and without separation of the medial edge of the wound on the chest wall, it is sutured with layered sutures, then the excess of the broadest muscle is tucked under the flap, creating its larger volume, and it is fixed with layered sutures to the place of the defect, simulating the shape of the mammary gland.

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