RU2567790C1 - Method for creating inframammary fold in two-stage breast reconstruction - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves marking out a planned inframammary fold in a standing patient. That is followed by incising the skin and dissecting the soft tissues up to an expander capsule, dissecting the capsule and removing the expander, and removing a first leaf of the capsule. A posterior leaf of the capsule is notched above an inferior transition fold of an expander pocket in parallel with the preoperative marking of the inframammary fold created. The soft tissues are dissected and mobilised to create a movable thoracic-epigastric flap in size sufficient to form a ptosis of the breast repaired. The mobilised posterior leaf of the capsule is pulled upwards up to the level of the preoperative marking of the inframammary fold created that induces traction of the mobilised thoracic-epigastric flap adjoining the mobilised posterior leaf of the capsule. The mobilised posterior leaf of the capsule is fixed to the remained portion of the posterior leaf of the capsule by means of non-absorbable sutures.

EFFECT: method ensures shaping the repaired breast naturally with the prominent inframammary fold, aesthetically acceptable prosis with no skin umbilications, and also enables the surgeon inspecting the inframammary fold and intensity of ptosis created before suturing that makes it possible to avoid a necessity of re-suturing.

3 cl, 9 dwg

Description

The present invention relates to medicine, namely to reconstructive surgery, oncology, and can be used in a complex of operations for the reconstruction of the mammary gland.

In the surgeon’s arsenal for breast reconstruction, there are many methods, among which the most popular method today is a two-stage breast reconstruction using allomaterials. At the first stage, a tissue expander is implanted in a subpectoral pocket formed by the large pectoral and anterior dentate muscles. In the postoperative period, the expander is stretched for 3-6 months with the surrounding tissues by introducing a sterile isotonic NaCl solution through the port. Within several months after surgery, the formation of fibrous tissue in the form of a capsule tightly covering the expander occurs. About six months after reaching the required volume, which usually exceeds the planned gland volume by about one third, the second stage of reconstruction is carried out, which consists in replacing the expander with a permanent implant. At this stage, if necessary, the formation of the inframammary fold, the nipple-areolar complex, and the correction of the contralateral mammary gland are performed.

In a two-stage breast reconstruction, a frequent problem is the absence of an inframammary fold, which is the natural lower border of the mammary gland, which greatly complicates the achievement of a good aesthetic result and causes patient dissatisfaction with the reconstructed mammary gland. In addition, the inframammary fold, being a “fixation zone”, does not allow the implant installed during reconstruction to move down. Thus, ensuring restoration of the reconstructed mammary gland form, which is close to natural, with the formed inframammary fold and aesthetically acceptable ptosis, is an urgent task.

Today, there are several alternative methods of forming an inframammary fold during a two-stage breast reconstruction using allomaterials, in which the folding is carried out at the stage of replacing the expander with a permanent implant.

So, in [Shestak / Reoperative Plastic Surgery of the Breast // Lippincott Williams & Wilkins. - 2005, p. 274] describes a method of forming an inframammary fold using the front and back sheets of a fibrous capsule formed around an expander. To do this, after removing the expander, the front and back sheets of the fibrous capsule are removed starting from the lower transitional fold (the place of transition of the front sheet of the capsule to the back) of the expander pocket to the estimated level of the formed inframammary fold corresponding to the preoperative marking. The lower edges of the anterior and posterior capsule sheets are sutured together, thereby forming an inframammary fold in this place. This method is successfully used in medicine, however, the disadvantage of the described method is the lack of aesthetically acceptable ptosis of the reconstructed mammary gland.

A known method of forming the inframammary fold [Rodby KA, Quinn KP, Mehrara B and Antony AK / Current Advances for Aesthetic Improvement in Breast Reconstruction: Mimicking the Augmented Breast // Surgery Curr Res 4: 202 .; 2014] using the back of the capsule. To do this, after removing the expander, the front leaf of the capsule is completely removed. Removing the back sheet is carried out starting from the bottom transitional fold of the expander pocket up to the expected level of the formed infra-mammary fold. Next, the skin with subcutaneous fatty tissue of the lower hemisphere of the reconstructed mammary gland is sutured to the lower edge of the posterior capsule sheet. This method is also successfully used in medical practice, however, its disadvantage is the presence of umbilical skin on the projection of the sutures, as well as the inability to form an aesthetically acceptable ptosis of the reconstructed mammary gland. In addition, in this case, an inframammary fold is formed at the stage of suturing - by hemming the skin of the lower hemisphere of the reconstructed mammary gland to the lower edge of the remaining part of the posterior sheet of the fibrous capsule. The surgeon can evaluate the formed inframammary fold and the created ptosis only after completion of suturing and in case of unsatisfactory result will be forced to re-suture.

Closest to the claimed invention is a method of forming an inframammary fold described in [Melvin A. Shiffman / Breast Augmentation: Principles and Practice // Berlin: Springer. - 2009. p. 53], selected as a prototype. After the expander is removed, the front leaf of the capsule is completely removed and the lower third of the back leaf is removed. Then, dissection and mobilization of soft tissues is carried out starting from the fifth or sixth ribs 8-10 cm downward in the direction of the costal arch. Next, traction of the mobilized thoraco-epigastric flap upward is performed to assess the required number of flap used to form the lower pole of the reconstructed mammary gland. Then, fixing sutures are applied between the inner surface of the deep layers of the skin of the thoraco-epigastric flap at a level corresponding to the preoperative marking of the formed inframammary fold and the periosteum of the fifth to sixth ribs. Thus, the skin is pulled and fixed with subcutaneous fat to the periosteum of the fifth or sixth rib, resulting in the formation of an inframammary fold in this place. With this method, an inframammary fold is also formed at the stage of suturing by stitching the thoraco-epigastric flap to the periosteum of the ribs. As a result of hemming of the soft tissues of the thoraco-epigastric flap to the periosteum of the ribs, this method has the same drawback as the previous ones - the presence of umbilical glands on the skin in the projection of the sutures. In addition, the prototype method also does not allow to evaluate the obtained aesthetic result before suturing.

The objective of the invention is the restoration of the natural form of the reconstructed mammary gland due to the formation of an inframammary fold and an aesthetically acceptable ptosis in a way devoid of the disadvantages of analogues: in which the surgeon can observe the result (created inframammary fold and degree of ptosis) before suturing, thereby speeding up and simplifying this operation , as well as avoiding the occurrence of umbilicalizations and get a long-term and stable result.

The technical result of the invention is to use as a suspension ligament not soft tissues (skin and subcutaneous fat), but a mobilized posterior leaf of the capsule having a dense and strong structure, as well as its fixation with non-absorbable suture material to the remaining upper part of the posterior leaf of the capsule.

The technical result is achieved, and the task is solved by the proposed method of forming an inframammary fold during a two-stage reconstruction of the mammary gland, including:

- marking the future inframammary folds with the patient in an upright position at the preoperative stage,

- performing a skin incision and dissection of soft tissues to the expander capsule,

- dissection of the capsule and removal of the expander,

- removal of the front leaf of the capsule,

- notching the back leaf of the capsule,

- dissection and mobilization of soft tissues from top to bottom to obtain a mobile thoraco-epigastric flap of sufficient size necessary for the formation of ptosis of the reconstructed mammary gland,

- traction of mobilized tissues up to the level corresponding to the preoperative marking of the formed inframammary fold,

- and fixation of mobilized tissues,

whose feature is that

the posterior leaf of the capsule is incised above the lower transitional fold of the expander pocket parallel to the preoperative marking of the formed inframammary fold;

traction of mobilized tissues upward is carried out due to traction of the mobilized posterior leaf of the capsule,

the mobilized tissues are fixed by suturing between the mobilized posterior leaf of the capsule and the remaining upper portion of the posterior leaf of the capsule.

The inventive method is as follows.

The marking of the future inframammary fold is carried out at the preoperative stage with the patient's vertical position. In FIG. 1 schematically depicts a reconstructed mammary gland with an installed expander before surgery to replace it with a permanent implant and the formation of an inframammary fold; Inframammary fold is absent. The layout of the future inframammary fold is depicted by the lower dashed line. On the operating table, the expander is removed, usually through an incision made along the old scar (Fig. 1 is shown by the upper dashed line). After this, the anterior sheet of the fibrous capsule is completely removed, and the posterior sheet is incised 1-2 cm above the lower transition fold of the expander pocket parallel to the preoperative marking of the formed inframammary fold - in FIG. 2 schematically depicts a reconstructed mammary gland after removal of the expander and the anterior leaf of the capsule with a marked level of notching of the posterior leaf of the capsule (upper dashed line). In FIG. 3 (front view), the upper dashed line shows the notch line of the posterior leaf of the capsule, parallel to the preoperative marking of the formed inframammary fold, indicated in the diagram by the lower dashed line. The notched back leaf of the capsule is lifted and under it dissection and mobilization of soft tissues downward, in the direction of the costal arch (Fig. 4). Tissue mobilization is carried out until a sufficiently mobile thoraco-epigastric flap is obtained, which is necessary for the formation of an aesthetically acceptable ptosis. Next, traction of the mobilized back leaf of the capsule with adjacent skin and subcutaneous fat up to the level corresponding to the preoperative marking of the formed inframammary fold is produced (Fig. 5). At the same time, the surgeon performing the operation has the opportunity to observe the formed inframammary fold and the degree of ptosis before suturing and, if necessary, can slightly deviate from the level of preoperative marking, achieving the most natural appearance of the reconstructed mammary gland.

The formation of the inframammary fold is completed by fixing the mobilized back sheet to the remaining upper part of the back sheet of the capsule with interrupted sutures with non-absorbable suture material (Fig. 6).

After completion of the formation of the inframammary fold, a permanent implant is installed and layer-by-layer suturing of the surgical wound is performed.

For clarity of the proposed method, a description of the essence is illustrated by clinical examples.

Example 1

Patient B., b. 1968, Diagnosis: Cancer of the left breast pT1N1M0, stage 2a. 06/13/2013, a mastectomy was performed according to Patty with simultaneous reconstruction by an expander. In the postoperative period, the expander was gradually filled with saline in order to stretch the skin to the required volume. In FIG. 7 shows a photo of a patient with an installed expander, performed before the second stage of breast reconstruction (Fig. 7a is a right view in ¾ profile, 7b is a left view in profile), which shows the absence of an inframammary fold and ptosis.

04/23/2014, the second stage of reconstruction of the left mammary gland was performed: the expander was replaced with a permanent implant with the formation of an inframammary fold according to the proposed method, which consisted in the fact that after marking the formed inframammary fold at the preoperative stage and the expander was removed, the anterior capsule was removed, after that, the posterior capsule leaf was cut 1.5 cm above the lower transitional fold of the expander pocket, then the incision was extended in the lateral and medial direction parallel flax preoperative marking formed inframammary fold. Under the incised posterior leaf of the capsule, dissection and mobilization of soft tissues was performed 7 cm down to obtain a mobile thoraco-epigastric flap. Next, traction of the mobilized posterior leaf of the capsule with adjacent skin and subcutaneous fat up to the level corresponding to the preoperative marking of the formed inframammary fold was performed. After the formed inframammary fold reached a level symmetrical to the fold of the contralateral mammary gland, the mobilized posterior leaflet of the capsule, used as a suspension ligament, was fixed to the remaining upper part of the posterior leaflet of the capsule with nodal sutures of capron No. 4. After that, a permanent implant was installed in the subpectoral pocket and layer-by-layer suturing of the surgical wound was performed.

At the time of the examination in October 2014, the result is stable, figure 8 shows the photo of the patient, taken during the follow-up examination, on which you can observe the reconstructed mammary gland with the formed inframammary fold and aesthetically acceptable ptosis (Fig. 8a - right view in ¾ profile, 8b - view from the left in profile, 8c - view in full view). In FIG. 8g, where the mammary gland is elevated, it is seen that there are no umbilical glands (Fig. 8d is a left view in the ¾ profile). The patient is satisfied with the result.

Example 2

Patient M., b. 1978, Diagnosis: Cancer of the left breast pT2N0M0, stage 2a. In November 2010, a Patty mastectomy was performed with a simultaneous reconstruction of a TDL flap in combination with a Becker-35 expander. In November 2011, the second stage of reconstruction of the left breast was performed - replacing the expander with a permanent implant with the formation of an inframammary fold according to the claimed method. After preoperative marking in the vertical position of the patient and removal of the expander, the anterior leaflet of the capsule was removed, then the posterior leaflet of the capsule was cut 1.2 cm above the lower transition fold of the expander pocket, the incision was extended laterally and medially, parallel to the preoperative marking of the formed inframammary fold. Under the incised posterior leaf of the capsule, dissection and mobilization of soft tissues was performed 6 cm down to obtain a mobile thoraco-epigastric flap. Next, traction of the mobilized posterior leaf of the capsule with adjacent skin and subcutaneous fat up to the level corresponding to the preoperative marking of the formed inframammary fold was performed. After the formed inframammary fold reached a level symmetrical to the fold of the contralateral mammary gland, the mobilized posterior leaflet of the capsule was fixed to the remaining upper part of the posterior leaflet of the capsule with nodal sutures of capron No. 4. Then, a permanent implant was placed in the subpectoral pocket and the surgical wound was sutured in layers. In FIG. Figure 9 shows the patient’s photo taken on 10/14/2014, at the time of the examination the result is stable, you can observe the natural appearance of the reconstructed mammary gland with the formed inframammary fold and aesthetically acceptable ptosis (Fig. 9a - left side view in% profile), there are no umbilical infections (Fig. 9b - view in full view, the mammary gland is elevated). The patient is satisfied with the result. Preserving the stability of the result for almost three years indicates the long-term result.

The proposed method differs from the existing ones in that:

1) The mobilized back sheet of the capsule is used as the suspension ligament, and not the soft tissues - the skin and subcutaneous fat of the lower hemisphere of the reconstructed mammary gland or thoraco-epigastric flap, as described in the methods-analogues. The mobilized posterior capsule leaf is fixed to the remaining upper portion of the posterior capsule leaf. As a result, there are no umbilicalizations on the skin in the projection of the applied fixative sutures.

2) The back leaf of the capsule is a very dense and durable structure. Therefore, using it as a suspension ligament simultaneously with its fixation to the remaining part of the posterior capsule sheet with non-absorbable suture material allows achieving long-term and stable results.

3) In contrast to the prototype, where mobilized soft tissue is directly traction upward, in the inventive method, the mobilized posterior leaf of the capsule is traction, as a result of which subcutaneous fat and skin adjacent to the capsule are also pulled upward. Due to this, the formation of an inframammary fold and the degree of ptosis can be observed even before the mobilized posterior leaflet of the capsule is fixed to the remaining upper part of the posterior leaflet of the capsule, therefore, if necessary, the level of the reconstructed fold and the degree of ptosis can be adjusted at the stage prior to suturing, which prevents the need to re-weld and speeds up the operation as a whole.

Thus, a new method is proposed for the formation of an inframammary fold during a two-stage reconstruction of the mammary gland, which allows creating a reconstructed mammary gland shape that is close to natural, with aesthetically acceptable ptosis, which makes it possible to observe the result (formed inframammary fold and the degree of ptosis) before the application of fixing sutures, which prevents the need to remodel the seams, thereby speeding up and simplifying the operation, in addition, avoiding the occurrence of umbilical skin lesions in the project ii sutures and receive the long-term and stable result.

Claims (3)

1. A method of forming an inframammary fold during a two-stage reconstruction of the mammary gland, including marking the future inframammary fold with the patient in an upright position at the preoperative stage, performing a skin incision and dissecting soft tissues to the expander capsule, dissecting the capsule and removing the expander, removing the front leaf of the capsule, notching the posterior incision leaf capsule, dissection and mobilization of soft tissues down to obtain a mobile thoraco-epigastric flap of sufficient size, it is necessary for the formation of ptosis of the reconstructed mammary gland, traction of mobilized tissues up to a level corresponding to the preoperative marking of the formed inframammary fold, and fixation of mobilized tissues, characterized in that the posterior leaf of the capsule is incised above the lower transition fold of the expander pocket parallel to the preoperative marking of the formed inframammary fold tissues upward due to traction of the mobilized posterior leaf of the capsule, and the fixation of mobilized s tissues are carried out by suturing between the mobilized posterior leaf of the capsule and the remaining upper part of the posterior leaf of the capsule. 2. The method of forming the inframammary fold during a two-stage reconstruction of the mammary gland according to claim 1, characterized in that the mobilization of the tissues is carried out by applying nodal sutures. 3. The method of forming the inframammary fold during a two-stage reconstruction of the mammary gland according to claim 1, characterized in that non-absorbable material is used for suturing.

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