RU2534887C2 - Method for correction of breast volume and shape in mastoptosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: skin is incised along marking lines. The breast parenchyma is dissected horizontally along the 5^th intercostals space. The greater pectoral muscle attachment to the 6^th rib is partially preserved. An implant pocket is formed below the greater pectoral muscle. The implant is placed. The parenchyma and skin in a lower pole of the breast in parallel to the implant surface is tangentially resected.

EFFECT: restoring, increasing the breast volume and shape, providing the stable position of the implant, improving the breast aesthetics in the postoperative period.

1 ex, 12 dwg

Description

The present invention relates to medicine, namely to plastic and reconstructive surgery, and can be used to improve breast aesthetics, namely the restoration of the volume and shape of the mammary gland during mastoptosis.

Postlactational involution of the mammary glands in combination with their omission are a natural process as the female body ages. The loss of volume and shape of the breast, its flabby consistency are the cause of concern for most women and many of them are encouraged to seek the help of plastic surgeons. Meanwhile, the task of increasing the volume of the mammary glands, improving their shape and at the same time placing them in a higher position on the chest wall is, according to leading plastic surgeons, very difficult or even impossible for one operation (1).

Known methods for correcting a declining breast are largely dependent on the degree of ptosis. With a small degree of ptosis, the placement of a high-profile implant under the mammary gland or the dual plane method (double dissection plane) is widespread (2), when the implant is placed under the pectoralis major muscle, at which the lower attachment points are cut off, starting from the xiphoid process of the sternum and throughout 6 ribs, and also produce tissue dissection in the space between the mammary gland and the pectoralis major muscle.

As a result of this operation, only 25-30% of the implant is located under the muscle, and the rest of it is under the mammary gland, contributing to its better expansion over the implant. As with the subglandular (under the mammary gland) position of the implant, and with the dual plane method, after the operation, the level of the submammar fold decreases, which leads to a lower position of the chest hill on the chest.

However, the use of high-profile implants and a dual plane technique for the correction of mastoptosis is limited, first of all, by the size of the implant. So J.B. Tebbetts (1) believes that when using an implant of 350 ml, in most cases, the weight of such an implant is critical and its further increase under ptosis, when the breast tissue has already lost elasticity to a large extent, inevitably leads to negative consequences in the long-term postoperative period. Thus, the use of high-profile implants and the dual plane technique can be used only in the initial degrees of ptosis.

It is generally accepted that with large degrees of ptosis, it is necessary to move the nipple-areolar complex in the cranial direction, remove excess skin and model the mammary parenchyma. If a consensus has been established with regard to excess skin, and at present most authors recommend removing excess skin with the formation of a vertical scar, L, J, or even a T-shaped scar (3,4,5), it is not clear what to do with the lower pole parenchyma the mammary gland. Most authors (3,5,6) tend to use it to fill the upper pole of the mammary gland and form a hill.

Removal of the breast parenchyma during enlarged ptotic breasts is recommended by a few (4.7). Meanwhile, this action seems to us very logical, since the parenchyma of the mammary gland, which has fallen below the submammary fold, cannot be well fixed and, therefore, used to fill the upper pole of the mammary gland.

Closest to the proposed is the method described by E. Hall-Findlay (4), which recommends the removal of part of the parenchyma in the lower parts of the mammary glands and simultaneous breast enlargement using silicone implants placed in a submammary or subpectoral space. In the latter case, the pectoralis major muscle is completely cut off along the lower edge from the attachment to the 6th rib.

Method E. Hall-Findlay (4) is as follows. When the patient is standing, a marking is applied to her breast, which determines the amount of skin removed, the distance to move the nipple-areolar complex, and its diameter. In the operating room under anesthesia, an incision is made on the areola, as well as incisions along the marking lines. Higher than the areola and 1 cm downward from it, de-epithelization of the skin is performed, after which it is cut with an electric knife to the entire thickness except for the part that subsequently forms the upper areola semicircle. Further, from the lower point of the incision around the areola, the breast parenchyma is completely dissected vertically down to the discovery of the large pectoral fascia. To increase the volume of the breast, a silicone implant is used, which is placed either under the mammary gland or under the pectoralis major muscle. In the latter case, the fascia fascia is dissected and the pectoralis major muscle is cut off throughout its attachment to the 6th rib, starting from its outer edge and moving inward to the point of attachment of the muscle to the sternum. After penetrating into the subpectoral cellular space, a container for the implant is formed here, which is installed after hemostasis. After implantation, the amount of skin and parenchyma, which must be removed in the lower pole of the mammary gland, is more accurately determined. Additional removal of fatty tissue along the submammary fold is achieved by liposuction. The wound is sutured with Monocryl 3/0 thread, applying 2-3 rows of sutures to the vertical incision of the mammary parenchyma, trying to achieve a tight suture that provides contact of the “fibrous tissues” to achieve good adhesion. Several separate sutures are applied to the deeper layers of the dermis and then the skin around the areola is sutured with a continuous suture and vertically down from it with the formation of a suture in the form of a “racket”. Corrugation of the vertical seam with the aim of shortening it E.Hall-Findlay (4) tries not to produce, rightly believing that this worsens the conditions for its healing. The wound is sealed with Micropore-type paper, which is not removed for 3-4 weeks and the patient wears a bra, which provides her with a sense of support and protection.

The known method, like some others similar to it in technology, can provide fairly good results in the remote postoperative period, however, in our opinion, they have significant disadvantages.

There is a serious contradiction in the well-known technologies when, on the one hand, the authors strive to lift the mammary gland and make its shape conical, and on the other hand to increase its weight. In this case, one has to rely on the residual elasticity of the breast tissue and on the formation of a connective tissue capsule surrounding the implant, which is currently a poorly managed and unpredictable process. The inevitable sliding of the implant down and outward under the influence of gravity often negates the efforts of surgeons in the long-term postoperative period.

Based on the existing level of surgical treatment of mastoptosis and elimination of the disadvantages of known technologies, the task was set: to create conditions for a simultaneous increase in the volume and correction of the shape of the mammary gland during ptosis, due to a more stable position of the breast implant, which will provide stable results in improving the aesthetic appearance of the mammary glands in the postoperative period.

The problem is solved as follows.

Correction of the volume and shape of the mammary gland during mastoptosis includes preoperative measurements of the anatomical state of the mammary gland, and the application of preoperative markings on the breast. The dissection of the skin within the areola according to the template, de-epithelization of the skin to move the nipple-areola complex. Further dissection of the skin throughout the thickness along the lines of preliminary marking, placing the implant under the pectoralis major muscle.

New in solving this problem is that when access is performed, the parenchyma of the breast is dissected in the horizontal direction along the 5 intercostal space. The pectoralis major muscle is partially cut off from the 6th rib, starting from the attachment point of the cartilage of the 6th rib to the sternum to the level of the midclavicular line, while retaining the attachment of the pectoralis major muscle to the 6th rib. A container for the implant is created under the pectoralis major muscle, the implant placement boundaries are: inside - the place of attachment of the pectoralis major muscle to the sternum, outside - the abdominal portion of the pectoralis major muscle and pectoral fascia, passing to the bundles of the anterior dentate and external oblique muscle of the abdomen, at the top - the hepatic acromia a bunch, below - a submammary fold and the saved place of fastening of a large pectoral muscle to the 6th rib. The implant is placed and a tangential resection of the parenchyma and skin is performed in the lower pole of the mammary gland parallel to the surface of the implant.

We explain the essential distinguishing features of the proposed "Method for the correction of the volume and shape of the mammary gland with mastoptosis."

When performing access, the skin is dissected in the vertical direction, and the mammary parenchyma in the horizontal direction along the 5 intercostal space, which allows for subsequent closure of the wound to ensure the direction of the sutures of deep tissues that does not coincide with the direction of the skin suture, and thereby optimize its healing, to prevent possible postoperative complications. To install the implant in known technologies, the gland parenchyma is cut in the vertical direction, and its subsequent suturing coincides with the direction of the suture of the skin wound.

Cutting off the pectoralis major muscle from the 6th rib is carried out only partially, starting from the attachment point of the 6th rib to the sternum to the level of the midclavicular line, while maintaining the attachment points of the pectoralis major muscle to the 6th rib located outward from this place and the abdominal portion of the muscle, which is crucial for stable implant position.

In known technologies, when installing an implant, the attachment of the pectoralis major muscle to the 6th rib is completely cut off. In this case, when holding the implant in place, one has to rely on the residual elasticity of the breast tissue and on the formation of a connective tissue capsule surrounding the implant. However, both of these factors do not provide reliable fixation. The inevitable sliding of the implant under the action of gravity down and out in the remote postoperative period often negates the efforts of surgeons.

Determining the boundaries of placement under the pectoralis major muscle of the implant, while inside - the place of attachment of the pectoralis major muscle to the sternum. Outside - the abdominal portion of the pectoralis major muscle and pectoral fascia, passing to the bundles of the anterior dentate and external oblique muscle of the abdomen. Above is a hepatic acromial vascular bundle. Below is a submammar fold and the saved place of fastening of a large pectoral muscle to the 6th rib. It is the above features of the placement of the implant that ensure its stable position on the chest in the long-term follow-up of patients after correction of the volume and shape of the mammary glands, a stable aesthetic result of the operation.

Conducted patent research and analysis of scientific and medical information that reflects the current level of technologies for the operative correction of the volume and shape of the mammary gland during mastoptosis did not reveal methods identical to the proposed one. In this connection, we can conclude that the claimed technical solution meets the criteria of the invention of "novelty."

The sequence and interconnection of the methods of the proposed method ensure the achievement of a new technological medical result in solving the problem, namely: maintaining the attachment of the pectoralis major muscle to the 6th rib, creates the conditions for optimal implant placement, which is always placed under the pectoralis major muscle, it is the presence of a strong support point that prevents the displacement of the implant down and out. Such a fulcrum avoids the contradiction when, on the one hand, we strive to raise the chest and make its shape more conical, and on the other hand, increase its weight.

From the foregoing, it follows that the claimed method meets the criteria of patentability "inventive step".

The proposed method for correcting the volume and shape of the mammary gland during mastoptosis is intended for use in healthcare and can be used in plastic surgery. The possibility of its implementation is confirmed by the methods and means described in the application, therefore, the proposed solution meets the criteria of the invention "industrial applicability".

To illustrate the individual stages of mastoptosis treatment technology, we present the following figures:

Figure 1 - Preoperative marking of the breast.

Figure 2 - De-epithelialization of the skin around the areola and incisions below it.

Figure 3 - Cuts of the skin along the lines of the markup.

Figure 4 - Saving the attachment of the pectoralis major muscle to the 6th rib outward from the midclavicular line.

Figure 5 - The formation of the container for the implant under the pectoralis major muscle while maintaining attachment of the pectoralis major muscle to the 6th rib outward from the midclavicular line.

6 - The implant is installed in the container under the pectoralis major muscle.

7 is a diagram of the operation, showing the installation of the implant under the pectoralis major muscle while maintaining its attachment to the 6th rib and abdominal portion of the muscle.

Fig - Determination of excess soft tissue in the lower pole of the mammary gland.

Figure 9 - Resection of excess soft tissue in the lower pole of the mammary gland.

Figure 10 - View of the mammary gland after resection of excess tissue in its lower pole.

11 - View of the mammary gland after the operation.

Fig - The condition of the mammary glands of the patient B. before and one year after the operation, increase the volume and correction of the shape of the breast:

a - front view before surgery,

b - front view after surgery,

c, d - left view ¾ turn, respectively, before and after the operation,

d, e - side view before the operation and after, respectively,

g, h - - right view ¾ turn before the operation and after respectively.

The essence of the proposed "Method for the correction of the volume and shape of the mammary gland with mastoptosis" is as follows.

Ambulatory stage

Examination of the patient begins with a study of the tissue characteristics of the mammary glands. The skin elasticity and the amount of subcutaneous tissue, the quality and quantity of breast tissue, the symmetry of its imprint, the location of the nipple-areolar complexes and their symmetry are evaluated. On each side of the chest, they measure:

The distance from the nipple to the sternoclavicular joint.

The distance from the submammary fold to the sternoclavicular joint.

The distance from the upper border of the chest to the submammary fold.

The distance from the vertical line is 1.5 cm outwards from the median sternum to the outer edge of the pectoralis major muscle.

The distance from the nipple to the submammary fold with maximum skin tension.

The thickness of the folds of tissue at the level of the upper, outer and lower borders of the mammary glands.

The sizing of the implant is based on the patient’s chest measurements:

The implant height is defined as the distance from the submammary fold to the estimated upper border of the mammary gland. Using an implant for mastoptosis allows you to significantly change the location of the upper border of the mammary gland, however, raising it above the level of the axillary fold leads to unnatural postoperative results. Typically, the height of the implant is calculated as the distance from the submammary fold to the level of the fold formed by the lower edge of the pre-axillary fat.

The width of the implant is defined as the distance from the place of attachment of the pectoralis major muscle to the sternum to the outer edge of the pectoralis major muscle at the planned level of the location of the nipple, minus the thickness of the folds of breast tissue at the level of the outer edge of the pectoralis major muscle.

The volume of the implant usually ranges from 240 to 320 ml. Low and medium-profile implants exert less pressure on the tissues in the lower pole and cause a lesser degree of atrophy of the mammary parenchyma in the long-term postoperative period. Therefore, their use is preferred.

The application of preoperative marking on the surface of the skin of the chest of the patient is carried out in the "standing" position (see the appendix to the description, figure 1).

The submammary fold will remain where it was or can be lowered by 1 cm.

The location of the nipple is determined by the meridian of the future mammary gland, and its level is up to 2 cm higher from the planned submammary fold. The exact planning of the location of the nipple depends on the tissue characteristics of the mammary gland. The more high-quality, elastic skin and dense mammary gland of the patient, the less they plan to move the nipple up.

The diameter of the areola is planned to be 4.2-4.4 cm, and, based on this, the circumference of the excised skin is 14 cm.

From the lower boundary of the half-arc, along the edges of the areola, the cut lines run vertically down to a point 2 cm higher from the proposed submammary fold. Usually this part of the incision is up to 7-8 cm. If it is longer, then it is necessary to prepare for a suture of the skin in the form of L, J or even T. This possibility is agreed upon with the patient in advance.

Stage of surgical treatment.

On the operating table, the patient lies on his back with his hands away from the body up to 90 degrees. For pain relief, epidural anesthesia or general anesthesia is used. After applying a turnstile or mammostat on the chest according to the template (4.2 cm), an incision is made on the areola, as well as incisions along the marking lines. Above the areola and 1.5 cm downward from it, de-epithelization of the skin is performed (see the appendix to the description, Fig. 2). Then, with an electric knife, the skin is cut through the entire thickness except for the part that subsequently forms the upper areola semicircle (see the appendix to the description, Fig. 3). The lower part of the incision is stretched with sharp hooks parallel to the submammary fold and the gland parenchyma is dissected along the 5 intercostal space, where the pectoralis major muscle is found. The pectoralis major muscle is not completely cut off from the 6th rib, but only partially, starting from the point of attachment of the rib to the sternum to the level of the midclavicular line, while retaining the muscle attachment to the 6th rib located outward and the abdominal portion of the pectoralis major muscle (see the appendix to the description, FIG. four). Further, in the subpectoral cellular space under the control of vision with the least possible tissue damage, a receptacle is formed to accommodate the implant (see the appendix to the description, Fig. 5). Its boundaries are: inside - this is the place of attachment of the pectoralis major muscle to the sternum, outward - the abdominal portion of the pectoralis major muscle and pectoral fascia, which passes into the bundles of the anterior dentate and external oblique muscle of the abdomen, at the top - the chest-acromial vascular bundle, below - the submammary fold and the saved place attachment of the pectoralis major muscle to the 6th rib.

After control, an implant is placed on hemostasis and the areola is sutured into the newly formed hole (see the appendix to the description, Fig.6,7). After this, it is necessary to assess the excess tissue of the mammary gland located below the areola. The easiest way to do this is by squeezing the tissue between the thumb and forefinger of the brush (see the appendix to the description, Fig. 8). Excess tissue is removed, otherwise it will inevitably undergo ptosis in the postoperative period. Resection of the parenchyma in the lower pole of the mammary gland is carried out not all over its thickness, but tangentially parallel to the surface of the implant, so that almost the entire surface of the implant remains covered by a layer of intact parenchyma along with the Wuringer′s septum (8) (see the appendix to the description, Fig.9). The application of several individual sutures with Monocryl 3/0 thread allows the subpectoral space with the implant from the skin scar to be sealed quite well (see the appendix to the description, Fig. 10). In most cases, the skin wound below the areola is sutured with the formation of a vertical scar (see the appendix to the description, Fig. 11). However, with large excesses of skin, suturing should be done with the formation of a seam in the form of L, J or even inverted T. For this, we use Monocryl 3/0 thread and 5/0 Prolene thread on the skin.

Corrugation of the seam in order to shorten its length has a very limited use. Wound drainage is not required. For the comfort of the patient, she can wear a bra, however this is not necessary.

The essence of the proposed "Method for the correction of the volume and shape of the mammary gland with mastoptosis" is illustrated by a clinical example

Patient B., age 36, was admitted to the Clinic of the Federal State Budget Scientific Institution “Scientific Center for RVH” SB RAMS on February 13, 2012 with complaints of loss of shape and volume of the mammary glands.

The mammary glands lost their shape and volume after childbirth and breastfeeding in 2001 and 2007. He wears a bra with a C cup. Desires to have a chest with the size of a C-D cup having a fuller upper chest pole and a smaller areola size.

Diagnosis at admission: Postlactational involution of the mammary glands. Mastoptosis 2 degrees.

On examination, it was established (see the appendix to the description, Fig. 12 a, c, d, g) that the mammary glands are medium-sized, relatively symmetrical, and have skin with reduced elasticity. Nipple-areolar complexes expanded to 5 cm in diameter, located 2.5 cm below the submammary folds. The thickness of the tissue fold at the level of the outer edge of the pectoralis major muscle and in the region of the superior pole is 3 cm.

The distance from the submammary folds to the nipple at maximum skin tension was 10.5 cm.

The implant height is determined - 12 cm, width - 12 cm. Taking into account the patient’s desire to have a “C-D” breast size, low-profile round implants of Eurosilicon firm with a volume of 240 ml were selected.

A marking is applied to the patient’s skin, determining the future location of the nipple and the area of skin removed in the lower pole of the mammary gland. The diameter of the areola is planned to be 42-43 mm, and, based on this, the circumference of the excised skin was 14 cm. Given the symmetry of the submammar folds, their location was chosen without change.

Surgery was performed according to the proposed technology. Under epidural anesthesia, a turnstile was placed on the chest and a 42 mm incision was made on the areola, as well as other incisions along the marking lines. Above the areola and 1.5 cm downward from it, de-epithelization of the skin was performed. Further, with an electric knife, the skin is dissected throughout the entire thickness except for the part that subsequently forms the upper areola semicircle. The lower part of the incision is stretched with sharp hooks parallel to the submammary fold, the breast parenchyma is dissected along the 5 intercostal space with an electric knife. The pectoralis major muscle is partially cut off from the 6th rib, starting from the sternum to the midclavicular line. Outside of this place, the attachment of the pectoralis major muscle to the 6th rib and the abdominal portion of the pectoralis major muscle are preserved.

Further, in the subpectoral cellular space under the control of vision, a container is formed to accommodate the implant. Its boundaries were: inside - the place of attachment of the pectoralis major muscle to the sternum, outward - the outer edge of the pectoralis major muscle and pectoral fascia, passing to the bundles of the anterior dentate and external oblique muscle of the abdomen, at the top - the chest-acromial vascular bundle, below - the submammary fold and the saved attachment site pectoralis major muscle to the 6th rib.

After testing for hemostasis, Eurosilicon implants, round, 240 ml in volume, were installed.

The areola is sewn into the newly formed hole. An excess of mammary gland tissue located below the areola was revealed by squeezing the tissue of the lower pole of the mammary gland between the thumb and forefinger. Excess tissue removed. Three seams were laid with Monocryl 3/0 thread on the parenchyma incision along the 5 intercostal space. The wound below the areola is sutured with the formation of a vertical scar with Monocryl 3/0 thread on the subcutaneous tissue and deep layers of the dermis and 5/0 Prolene thread on the skin.

Compression underwear in the postoperative period was not used. For the convenience of the patient, she used a regular soft bra.

There were no complications in the postoperative period, and the patient was completely satisfied with the treatment results. Comparative photographs of patient B. one year after the operation are presented (see the appendix to the description, Fig. 12 6, g, e, h).

The proposed method was tested in the Clinic of FSBI “SC RVH” SB RAMS in 5 patients. Before the operation, all of them received written voluntary informed consent for the operation, which sets out the essence of the operation and lists its possible complications.

In the immediate postoperative period, 5 patients did not experience any serious complications. In the distant postoperative period, a stable position of the implant with respect to the submammary fold was observed. During the control examination, 3-4 months after the operation, most patients observed typical changes in the shape of the breast associated with the subpectoral placement of the implant: an overhead projection of the upper pole of the gland, a slightly higher breast density to the touch. However, when examined after 5-7 months, these phenomena stopped: the mammary gland took a natural form and became soft to the touch. The result remained stable when examined after 12-16 months. All patients were satisfied with the result of the operation.

Thus, in comparison with the known surgical technologies, our proposed “Method for the correction of the volume and shape of the mammary gland during mastoptosis” has good stability of results, does not increase the time and complexity of the operation, which allows us to solve the problem of simultaneous increase in volume and correction of the breast shape during mastoptosis.

Information sources

1. Tebbetts J.B. Dual plane (DP) breast augmentation: optimizing implant-soft tissue relationship in a wide range of breast types / Tebbetts J.B. // PlastReconstr. Surg. - 2001.- vol. 107, N 5. - p.1255-1272.

2. Tebbetts J.B. Augmentation mammaplasty. Redefining the patient and surgeon experience / Tebbetts J.B. - Mosby Elsevier, 2010 .-- 601p.

3. One-stage mastopexy with breast augmentation: a review of 321 patients / Stevens W.G. [et al] .// Plast. Reconstr. Surg. - 2007, - vol. 120, N 6. - p. 1674-1679.

4. Hall-Findlay E.J. Aesthetic Breast Surgery. Concepts and techniques. / Hall-Findlay E.J.- QMP, Inc. St. Louis, Missouri, 2011 .-- 706 p.

5. Spear S.L. Augmentation mastopexy / Spear S.L., Dayan J.H., Clemens M.V. // Clin. Plast Surg. - 2009. - vol. 36. - p.105-115.

6. Hammond D.C. Augmentation mastopexy // The art of aesthetic surgery. Principles and techniques. Second Edition.- Editor F. Nahai, QMP, St. Louis, Missouri, 2011.- p.2364-2397.

7. Regnault P. The minus-plus mastopexy / Regnault P., Daniel R.K., Tirkanits B. // Clin. Plast Surg.- 1988.-Vol 15, N.- p .- 595-600.

8. Wuringer E, Mader N, Posch E, Holle J Nerve and vessel supplying ligamentous suspension of the mammary gland / Wuringer E. [et al] // Plast Reconstr Surg. - 1998. - v. 101, N6. - p. 1486-1493.

Claims (1)

A method for correcting the volume and shape of the mammary gland during mastoptosis, including preoperative measurements of the anatomical state of the mammary gland, applying preoperative markings on the chest, dissecting the skin within the areola according to the template, skin depithelization to move the nipple-areolar complex, further dissecting the skin along the entire thickness along the lines of the preliminary marking, placing the implant under the pectoralis major muscle, characterized in that when accessing the parenchyma of the mammary gland is dissected in a horizontal direction along during the 5th intercostal space, the pectoralis major muscle is partially cut off from the 6th rib, starting from the attachment site of the cartilage of the 6th rib to the sternum to the level of the midclavicular line, while retaining the attachment of the pectoralis major muscle to the 6th rib, create a container for the implant under the pectoralis major muscle, the boundaries of the implant placement are : inside - the place of attachment of the pectoralis major muscle to the sternum, outward - the abdominal portion of the pectoralis major muscle and pectoral fascia, passing to the bundles of the anterior dentate and external oblique muscle of the abdomen, at the top - hepatic vascular bundle at the bottom - the inframammary crease and the stored location of fastening to the pectoralis major rib 6 is placed implant and tangential resection carried parenchyma and in the skin of breast lower pole parallel to the implant surface.

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