RU2407458C1 - Method of primary mammary gland plasty after radical subcutaneous mastectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery. It includes replacement of gland tissue deficiency with greater pectoral muscle. Greater pectoral muscle is separated from minor pectoral muscle. Greater pectoral muscle is cut off in lower parts. Mesh implant, made from partially biodegradable material, is fixed to cut off edge, silicon endoprosthesis is placed in recess formed by greater and minor pectoral muscles. Lower edge of mesh implant is fixed to fascia of anterior chest wall muscles. In case of endoprosthesis volume is less than 180 cm³, greater pectoral muscle is fixed with minor pectoral muscle in lateral part of recess. In case of endoprosthesis volume is more than 180 cm³, mesh implant is additionally fixed to lateral edge of greater pectoral muscle and to fascia of anterior chest wall.

EFFECT: method allows to reduce post-operative complications and obtain good cosmetic effect.

2 ex, 3 cl

Description

The invention relates to medicine, namely to surgery, and can be used in reconstructive plastic surgery on the mammary gland (hereinafter - MF) after radical subcutaneous mastectomy for cancer.

Known methods of using a polypropylene mesh to eliminate mammopexy both in self-use and in combination with endoprosthetics (RU No. 2339316, No. 2313287). Indications for surgery using the mesh is ptosis of 3-4 degrees, a large amount of breast. When performing known methods, excess breast tissue, excess skin are removed, the nipple-areolar complex is transferred up, fixing it in a new position. The polypropylene mesh is fixed to the fascia of the pectoralis major muscle (hereinafter - BHD) to strengthen it. In the case of combined plastics, the prosthesis is placed in the space between the mesh and the fascia of the breast. Known surgical aids cannot be used to perform radical subcutaneous mastectomy for breast cancer.

Closest to the claimed is a method of replacing a breast defect with the broadest muscle of the back (hereinafter referred to as the ShMS) and BGM, including reconstructing the breast after performing radical resection by moving the ShMS on the neurovascular leg to the area of tissue deficiency in the operated breast and connecting two muscle flaps - a ShMS fragment and BGM (RU No. 2208394). Adopted as a prototype. When performing the prototype method, the tendon part of the ShMS is crossed at the place of its attachment to the humerus, which leads to impaired function of the upper limb. In addition, the disadvantages of this method of mammoplasty are the invasiveness of the intervention and the risk of developing necrosis of the ShMS fragment, which in turn leads to the development of atrophy and a decrease in the volume of reconstructed breast.

The invention is aimed at solving the problem of improving the cosmetic and functional effect of breast reconstruction after performing radical surgical manuals for cancer.

Use in clinical practice of the proposed method allows to achieve several technical (medical) and economic results:

- the ability to make up for the missing volume of plastic material with large and medium breast volumes, as well as to make up for the autograft volume decreasing in the late postoperative period due to atrophy due to the use of silicone endoprosthesis;

- reducing the risk of early and late postoperative complications, in particular, reducing the incidence of necrosis of the autograft due to the exclusion of the movement of the muscle flap, as well as through the use of a partially absorbable mesh implant;

- prevention of deposition of excess connective tissue and the formation of scar tissue due to the use of partially absorbable mesh as an implant;

- preservation of the motor function of the upper limb by maintaining the integrity of the VMS and its tendon part;

- increase the cosmetic result of the operation due to the absence of an additional incision on the skin of the back, the absence of deformation in the back and asymmetry of the breast in the presence of ptosis of healthy breast;

- reduction in the duration of the operation.

These therapeutic and economic results in the implementation of the invention are achieved due to the fact that, as in the known method, the replacement of breast tissue deficiency by the pectoralis major muscle is carried out.

A feature of the proposed method lies in the fact that the pectoralis major is separated from the pectoralis minor muscle, the BGM is cut off in the lower sections, a mesh implant made of partially absorbable material is fixed to the cut edge, a silicone endoprosthesis is placed in a pocket formed by the pectoralis major and minor muscles, and the lower one is fixed the edge of the mesh implant to the fascia of the muscles of the anterior chest wall.

The invention consists in the following.

The invention involves primary plastic surgery of a breast defect using BGM, a mesh implant and a silicone endoprosthesis after performing a radical subcutaneous mastectomy. Subcutaneous placement of the prosthesis often leads to complications in the form of bedsores, fistulas, endoprosthesis displacement. For the prevention of these complications, the preliminary formation of a muscle pocket with the help of a displaced fragment of VMS and / or BGM is necessary. The disadvantages of using for this purpose a fragment of the CMC are listed above. The use of BGM for the formation of a muscle pocket has undeniable advantages: a reduction in the duration of the operation compared to the formation of a muscle pocket from a fragment from an HMS, the physiological location of the prosthesis in the muscle pocket, a small percentage of complications due to the lack of risk of developing autograft necrosis. However, the following problems arise in the formation of a muscle pocket from BGM: high position of the prosthesis, the need for surgery on the second breast to maintain symmetry, especially in patients with breast ptosis, limiting the size of the used endoprostheses (up to 180 cm ³ ), because a larger prosthesis cannot be installed due to the small size of the muscle pocket.

The inventors have developed a technique that allows to overcome these problems by increasing the area of the BGM using a mesh implant, which is fixed with separate interrupted sutures to the separated lower edge of the BGM and to the fascia of the muscles of the anterior chest wall. A mesh implant is used from a partially absorbable material - a composite mesh. The mesh consists of equal parts of monofilament made of absorbable Polyglecapron-25 and monofilament made of non-absorbable polypropylene. After resorption of the component from Polyglecapron-25, only the polypropylene mesh remains, the structure and cell size of which optimally corresponds to physiological loads. The advantage of using a partially absorbable mesh implant is to reduce the risk of developing early and late postoperative complications. This type of implant is resistant to infection. Partial resorption by enzymatic hydrolysis in tissues occurs 84 days after installation. Due to the coarse mesh structure, a strong three-dimensional network of collagen fibers is formed. The remaining polypropylene mesh does not interfere with this process, thereby preventing the deposition of excess connective tissue and the formation of scar tissue.

The application of the proposed method allows the use of silicone endoprostheses of any volume without the use of a ShMS fragment to form a muscle pocket. Compared with the prototype method, at the end of which a smaller MF is formed in patients in comparison with a healthy MF, which leads to a decrease in the cosmetic effect, the claimed method manages to fully replenish the volume of removed MF tissue. The duration of the operation is reduced due to the absence of the stage of cutting out the flap from the ShMS fragment and is 90 minutes. The cosmetic result of the operation increases due to the absence of an additional incision on the skin of the back, there is no deformation in the back, asymmetry of the breast in the presence of ptosis of healthy breast. The increase in the functional effect of the operation occurs due to the preservation of the functions of the ShMS: extension and reduction of the humerus, its rotation in the medial direction.

The method is as follows.

The first stage, after a subcutaneous mastectomy with preservation of the skin of the breast, the nipple-areolar complex, submammary folds, the pectoralis major muscle is separated.

At the second stage of reconstruction, the BGM is cut off in the lower sections, a mesh implant made of partially absorbable material is fixed to the cut edge of the BGM.

At the third stage, the silicone endoprosthesis is placed under the BGM in the pocket formed by the pectoralis major and minor muscles and the mesh implant; the lower edge of the mesh implant is fixed to the fascia muscles of the anterior chest wall with separate interrupted sutures.

In the case of using an endoprosthesis <180 cm ³ , fix the pectoralis major with pectoral muscle by separate interrupted sutures in the lateral part of the pocket for the endoprosthesis. In the case of using an endoprosthesis> 180 cm ^{3, the} mesh implant is fixed additionally to the lateral edge of the BGM and to the fascia of the anterior chest wall to increase the pocket for the endoprosthesis.

The wound is drained with one tubular drainage located in the axillary region. The last step is to suture the subcutaneous tissue, an intracutaneous continuous suture is applied to the skin. Skin sutures are removed on the 14-16th day after surgery.

Radical subcutaneous mastectomy in combination with primary mammoplasty by the proposed method is performed according to indications in a surgical or combined treatment plan for breast cancer.

Examples of execution.

Example 1

Patient X., 31 years old, was treated in the Department of General Oncology, Moscow P.A. Herzen from 04/03/09 to 04/23/09. Diagnosis: Cancer of the right breast 0 (TisN0M0) stage. Tumor localization - the border of the upper quadrants.

04/08/09 - radical subcutaneous mastectomy on the right with simultaneous plastic surgery with a mesh implant and a silicone endoprosthesis of 170 cm ³ .

Under endotracheal anesthesia, a skin incision was made in the paraareaolar region of the right breast. The skin, submammary fold, and the nipple-areolar complex are preserved. A linear incision was made along the front axillary line with a length of 11 cm. Access was made to the axillary-subclavian-subscapular tissue. 98% of the breast tissue is removed in a single block with axillary-subclavian-subscapular tissue. Separated pectoralis major from pectoralis minor muscle. The mesh implant was fixed with separate interrupted sutures to the separated lower edge of the BGM. A silicone endoprosthesis was installed (V = 170 cm ³⁾ in a pocket formed by the pectoralis major and minor muscles with cutting off the lower edge of the BGM, to which a mesh implant is fixed. Then the mesh implant is fixed to the fascia of the muscles of the anterior chest wall with separate interrupted sutures. The wound is drained by tubular drainage in the axillary region. The skin over the formed MF is sutured with absorbable material (vicryl). Bandage. The postoperative course is smooth. An excellent cosmetic result was obtained.

Example 2

Patient M., 39 years old, medical history UA-3408, was in the General Oncology Department of the Moscow Scientific Research Institute P.A. Herzen from 05.19.09 to 06.17.09

Diagnosis: Cancer of the left MF II B (T2N1M0) stage. Tumor localization - the border of the upper quadrants. MF size - 4 for bra.

05/27/09 - radical subcutaneous mastectomy on the left with simultaneous plastic surgery with a mesh implant and 360 cm ³ silicone endoprosthesis.

Under endotracheal anesthesia, a skin incision was made in the paraareaolar region of the right breast. The skin, submammary fold, and the nipple-areolar complex are preserved. A second skin incision was made along the anterior axillary line 13 cm long. Access was made to the axillary-subclavian-subscapular tissue. 98% of the breast tissue is removed in a single block with axillary-subclavian-subscapular tissue and lymph nodes. Separated pectoralis major from pectoralis minor muscle. The sizes of the BGD were measured intraoperatively: length - 18 cm, width - 10 cm, thickness - 1.2 cm.

Next, the lower edge of the BHD is cut off and a mesh implant is fixed to the cut edge (dimensions: width - 10 cm, length - 4 cm) with separate interrupted sutures. A mesh implant of partially absorbable material was used - a composite mesh. At the second stage of reconstruction, a silicone endoprosthesis (V = 360 cm ³ ) was installed in a pocket formed by the pectoralis major and minor muscles. In the third stage, the lower edge of the mesh implant is fixed to the fascia of the muscles of the anterior chest wall with separate interrupted sutures. Because If the denture is> 180 cm ³ , then an additional mesh implant is fixed in the lateral margin of the BGM with dimensions of 10 × 4 cm and is hemmed to the lateral edge of the pectoralis minor muscle.

The wound is drained by tubular drainage in the axillary region. The skin over the formed MF is sutured with absorbable material (vicryl). Bandage. Postoperative course without complications.

Morphology: P 96424-40 Macro site 3 × 2.4 × 2.2 cm. Microinvasive ductal carcinoma of the II st T2N1M0. In the surrounding tissue - fibroadenoma. The rest of the course is mastopathy, with isolated foci of low-grade carcinoma in situ with acne-like necrosis. In 1 lymph node metastasis of ductal cancer with complete replacement of the tissue of the node, without going beyond the capsule.

Immunohistochemical study No. RE + 5 points, RP + 6 points, reaction with ner2 | new 2+.

FISH negative, no amplification.

An excellent cosmetic result was obtained, the MFs are symmetrical, the nipple-areolar complex on the right is symmetrical with the left nipple-areolar complex, the submammary fold on the right and left are at the same distance from the clavicles. MF form is the same.

In total, according to the claimed method, 16 operations were performed in the Department of General Oncology at the P.A. Herzen MNIIO of them. In all cases, a good and excellent cosmetic effect was obtained. Postoperative observation showed no postoperative complications.

Thus, the claimed method has significant advantages compared with known methods of the same purpose and meets the criteria of patentability.

Claims (3)

1. The method of primary breast reconstruction after radical subcutaneous mastectomy for cancer, including replacing a deficiency of gland tissue with the pectoralis major muscle, characterized in that the pectoralis major is separated from the pectoralis minor muscle, the pectoralis major muscle is cut off in the lower sections, and a mesh implant is fixed to the cut edge made of partially absorbable material, the silicone endoprosthesis is placed in the pocket formed by the pectoralis major and minor muscles, the lower edge of the mesh implant is fixed to the fasci muscles of the anterior chest wall. 2. The method according to claim 1, characterized in that when the volume of the endoprosthesis is less than 180 cm ^{3 the} pectoralis major muscle is fixed with the pectoralis minor muscle in the lateral part of the pocket for the endoprosthesis. 3. The method according to claim 1, characterized in that when the volume of the endoprosthesis is more than 180 cm ^{3 the} mesh implant is fixed additionally to the lateral edge of the pectoralis major muscle and to the fascia of the anterior chest wall.