RU2444310C1 - Method of reconstructing mammary gland after radical subcutaneous mastectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgery and can be applied for primary plasty of mammary gland. Muscular recess for endo-prosthesis is formed, for this purpose applied is fragment of proximal part of abdomen rectus, which is sewed to displaced fragment of latissimus dorsi muscle from below.

EFFECT: method makes it possible to restore lower contour of mammary gland.

1 ex

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.

The modern arsenal of ways to improve the aesthetic results of simultaneous reconstruction of the breast after radical surgery for breast cancer is extensive. Currently, operations are widely used using synthetic materials (expanders and implants) and various autografts - fragments of the latissimus dorsi (hereinafter referred to as the ShMS), TRAM flap, pectoralis major muscle (hereinafter referred to as BGM).

There is a known method for reconstructing the breast, which includes replacing the deficit of the gland tissue with a fragment of ChMS on the vascular pedicle, in which, to increase the volume of the autograft, two muscle flaps are connected — fragments of ChMS and BGM (RU 2208394). The disadvantage of this method of mammoplasty is: the development of atrophy of autografts, which leads to a decrease in the volume of reconstructed MF, as well as asymmetry in the initial ptosis of MF.

There is also a known method of breast reconstruction using a TRAM flap (Gabka K.J., Bomert X. Plastic and reconstructive surgery of the breast. // M., 2010, 360 pp.). To implement the known method, the authors use the entire rectus abdominis muscle and cutaneous-subcutaneous tissue of the abdomen. To avoid further development of postoperative hernias, the authors strengthen the abdominal wall using a prolene mesh. In the area of the newly formed MF, the nipple-areolar complex and the skin of the MF are removed. As a result of surgery, there remains a postoperative scar in the abdomen. Thus, the cosmetic effect of using this flap is practically absent, since there is a skin patch on the newly formed MF, there is no nipple-areolar complex, and symmetry with the opposite MF is not always achieved. This leads to the need for further corrective operations.

Closest to the claimed is a method of primary plastic surgery of a defect in the breast, including the formation of a muscle pocket for an endoprosthesis between BGM and ShMS (RU 2392879). Adopted as a prototype. However, when using the prototype method, the MF is higher in patients compared to healthy, due to excision of the skin and lack of fullness in the lower parts of the MF, which significantly reduces the cosmetic effect.

The invention is aimed at solving the problem of improving cosmetic results after performing radical surgical aids for breast cancer.

Using in clinical practice the proposed method allows to achieve several technical (medical) results:

- the ability to make up for the missing volume of plastic material with large and medium-sized breasts and / or with insufficient development of SHMS,

- the ability to replenish the volume of the breast lost due to atrophy of the autograft in the late postoperative period,

- the possibility of using endoprostheses of various volumes and forms,

- lack of scarring in the abdomen,

- no need to use a prolene mesh to strengthen the abdomen,

- restoration of the lower contour of the breast (submammary fold), identical in height to the contralateral breast,

- the creation of natural ptosis of the breast.

These technical (therapeutic) results in the implementation of the invention are achieved due to the fact that, as well as the known method of primary plastic surgery of the breast in combination with an endoprosthesis after radical subcutaneous mastectomy, includes the formation of a muscle pocket for an endoprosthesis using SHMS and BGM.

A feature of the proposed method lies in the fact that when forming a muscle pocket for an endoprosthesis, a fragment of the proximal part of the rectus muscle of the abdomen is additionally used, which is sutured to the displaced fragment of the CMC from the bottom.

The invention consists in the following.

After performing a radical subcutaneous mastectomy, it is necessary to restore the volume of the removed breast tissue using a silicone endoprosthesis. At the same time, subcutaneous prosthetics contributes to a large percentage of complications (the formation of fistulas, the possibility of trauma to the endoprosthesis and its displacement). To prevent these complications, the preliminary creation of a submuscular pocket is advisable.

The inventors have developed a technique for primary plastic surgery of a defect in the breast with a fragment of a VMS, BGM and a silicone endoprosthesis of the required volume, as well as a fragment of the proximal rectus muscle of the abdomen after performing radical subcutaneous mastectomy.

In the inventive methodology, only the upper part of the rectus abdominis muscle is used, without using a skin-fat abdomen flap, which avoids the need for additional sutures in the abdomen and the need to use a prolene mesh to strengthen the abdomen. To create a muscle pocket for the endoprosthesis with the restoration of the natural ptosis of the breast, a fragment of the rectus muscle is fixed to a fragment of the ShMS.

Radical subcutaneous mastectomy in combination with primary mammoplasty by the proposed method is performed according to indications in terms of surgical or combined treatment of breast cancer. When using the proposed method, it is possible to fully replenish the volume of removed breast tissue. The cosmetic result of the operation is increased due to the hemming of a fragment of the rectus abdominis muscle.

The method is as follows.

The first stage, after a subcutaneous mastectomy with preservation of the skin of the breast, nipple-areolar complex, submammary fold, is cut out a fragment of the CMC in the supine position. In the second stage, a fragment of the rectus abdominis muscle is cut out, the muscle is separated from the cartilage of the Y, YI, and YII ribs and the xiphoid process of the sternum and sent through the formed subcutaneous tunnel to the MF bed.

Then a “muscle pocket” is formed for the endoprosthesis between the BGM and the ShMS by stitching these muscles with interrupted sutures. In the lower section, a fragment of the rectus abdominis muscle is sutured to the ShMS, while the distance from the areola to the submammary fold is identical to the distance in the second breast.

A silicone endoprosthesis is installed in a pocket. The wound is drained with one tubular drainage located in the axillary region. Subcutaneous tissue is sutured as the last step, an intracutaneous continuous suture is applied to the skin wound. Skin sutures are removed on the 14-16th day after surgery.

Execution example.

Patient U., 36 years old, was treated in the Department of General Oncology, Moscow P.A. Herzen from 10/30/09 to 11/27/09.

Diagnosis: Cancer of the left breast of the PB (T2N1M0) stage. Condition after 2 courses of PCT according to the AS scheme (08.09.09 - 01.10.09). Tumor localization is the upper outer quadrant.

11/06/09 - radical subcutaneous mastectomy on the left with simultaneous grafting with a fragment of the ShMS, a fragment of the rectus abdominis muscle and a 220 cm ³ silicone endoprosthesis.

Under endotracheal anesthesia, a skin incision was made in the upper outer quadrant of the left breast. The skin, submammary fold, and the nipple-areolar complex are preserved. Access was made to axillary-subclavian-subscapular tissue. 98% of breast tissue is removed in a single block with axillary-subclavian-subscapular tissue. A fragment of the ShMS was cut in the supine position; a fragment of the rectus abdominis muscle was cut out. A muscular “pocket” has been formed: the ShMS is sewn to the BHM, a fragment of the rectus abdominis muscle is sewn to the ShMS below with separate interrupted sutures. A silicone endoprosthesis is installed in the formed “pocket” (V = 220 cm ³ ). 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. Histological examination - macro node 3.2 × 2.8 × 2.4 cm. Microinvasive ductal cancer with perivascular growth, foci of necrosis. Therapeutic pathomorphism of I degree. The tumor does not grow into the skin. Around is a non-proliferative form of mastopathy. In 1 lymph node of 15 cancer metastases without invasion beyond the capsule of the node.

IHC-RE - 0 points, RP - 0 points, reaction with ner2 / new 0.

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. The forms of both breasts are the same.

In total, according to the claimed method, in the Department of General Oncology, Moscow P.A. Herzen, 15 operations were performed. In all cases, a good and excellent cosmetic effect was obtained. Postoperative observation showed no postoperative complications.

Claims (1)

The method of primary breast plasty in combination with an endoprosthesis after radical subcutaneous mastectomy, comprising the formation of a muscle pocket for an endoprosthesis using the latissimus dorsi and pectoralis muscle, characterized in that when forming a muscle pocket for an endoprosthesis, an additional fragment of the proximal rectus muscle of the abdomen is additionally used, which hem to the displaced fragment of the latissimus dorsi muscle from below.