RU2582459C1 - Method of open capsulotomy in patients with capsular contracture fibrous 3-4 degrees after augmentation mammoplasty with silicone implants - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: operate a continuous circular section of the fibrous capsule, cutting off its base, close to the chest, the rest of the (peripheral) part of it. Here the peripheral part of the capsule is applied intermittently circular cuts in which the dissection capsules full thickness alternate with portions uncut capsule. Intermittent circular incisions are arranged in successive planes parallel to the plane of the continuous circular incision and dissection of the capsule in each subsequent intermittent circular cross-section is carried out against the previous sections uncut discontinuous circular cut. In particular, the intermittent circular incisions are made inside the fibrous capsule. Every cut in a discontinuous circular cross-section has a length of 1.5-2 cm, uncut portions have a length of 0.5-1 cm distance between the broken circular cuts of 1-1.5 cm.

EFFECT: method can significantly reduce the incidence of complications in the form of re-development of fibrous capsular contracture.

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Description

The invention relates to medicine, namely to surgery.

In Europe, there are about 2 million women who have undergone endoprosthetics of their mammary glands, and their number is growing steadily. With an increase in the number of plastic surgeries, the number of complications increases, which are very diverse. According to various studies, the contracture of the fibrous capsule surrounding the implant is the most common complication of breast reconstruction or breast augmentation requiring surgical correction. Fibrous capsular contracture is understood to mean contraction, compaction and thickening of the fibrous tissue of the capsule, resulting in compression of the endoprosthesis, compaction and deformation of the mammary glands.

The etiology of capsular contracture is multifactorial. Among the causes considered local infection, hematoma, surgical errors and tactical errors during surgery. Many researchers note that the frequency of contracture is reduced when using implants with a textured surface. The fibroblastic theory of the pathogenesis of fibrotic capsular contracture is currently popular. In accordance with it, the key point in the development of contracture is the contraction of myofibroblasts and the hyperproduction of fiber structures oriented in one direction.

Fibrous capsular contracture develops a few weeks or years after surgery, but most often its appearance is noted during the first year after the intervention.

In 1976, Baker developed the classification of fibrous capsular contracture [Baker J.L. Augmentation mammaplasty // Symposium on aesthetic surgery of the breast / Ed. by J.Q. Owsley, RA. Peterson. - St. Louis: Mosby, 1978. - P. 256-263]:

1 degree - the mammary gland is soft to the touch, does not look different from a healthy one;

2 degree - the mammary gland to the touch is a little harder than a healthy one, the prosthesis is palpated, but does not yet create a deformation visible to the naked eye;

Grade 3 - the mammary gland becomes even harder to the touch, the prosthesis is well palpated, its contours or the deformation caused by it are visible;

Grade 4 - the mammary gland is very hard, rigid, inelastic, painful and cold to the touch, its significant deformation is visible.

Many researchers agree that the correction of the formed capsular contracture of the 3-4 degree is possible only surgically. Surgical treatment involves open capsulotomy and capsulectomy, as well as endoscopic dissection of the capsule.

An open capsulotomy allows you to visually determine the condition of the prosthesis, the thickness of the capsule, correct the position of the prosthesis, and also, if necessary, change the size of the pocket.

The first open capsulotomy was described by Freeman (1972), this method is described in the following work by Zoltan I. Access was through the initial incision line along the old scar with its excision. The capsule was opened (part of the circular incision was made at the base of the fibrous capsule from its outer side), the prosthesis was removed, after which the circular incision of the capsule was completed from the inside. Then, the previous prosthesis was returned to the site or a new, smaller one was implanted [Zoltan Y. Reconstruction of the female mammary gland [Text] / Y. Zoltan. - Budapest: Hungarian Academy of Sciences. - 1989. - 237 p.]. Performing a circular incision was considered sufficient for the treatment of capsular contracture.

In 1998, a method of open capsulotomy was described, which was performed under general anesthesia from the old scar with its excision. The capsule was opened, making part of the circular incision at the base of the fibrous capsule from its outer side, the prosthesis was removed, after which a circular section was completed from the inside of the fibrous capsule, which separated the base of the capsule from its peripheral (domed) part. Then radial sections of the fibrous capsule were made from its center (i.e., from the top of the capsule) to the periphery, bringing the radial sections to circular. Then, the previous prosthesis was returned to the capsule; if necessary, it was changed to a more modern model [Belousov A.E. Plastic reconstructive and aesthetic surgery [Text] / A.E. Belousov. - St. Petersburg: Hippocrates. - 1998. - 672 p.] (Prototype).

As shown below, the frequency of complications in the form of re-development of fibrous capsular contracture during surgical treatment of capsular contracture with this method is higher than when treating it with the proposed method.

Since 1992, endoscopic capsulotomy has been used. The disadvantage of this method is the impossibility of replacing the prosthesis and correcting its position.

Capsulectomy is used only with a pronounced thickness of the fibrous capsule or with its calcification and implies its partial or complete removal. This intervention is quite traumatic. After capsulectomy, it is recommended to perform delayed prosthetics with a change in the localization of the implant in the tissues.

Disclosure of invention

Definition of Terms

The base of the fibrous capsule is the part of the fibrous capsule adjacent to the chest (Fig. 1, pos. 1).

The peripheral (domed) part of the fibrous capsule (Fig. 1, item 5) is the part of the fibrous capsule that is not adjacent to the chest.

The top (top) of the fibrous capsule (Fig. 1, item 4) is the site of the projection of the areola onto the fibrous capsule.

A continuous circular incision (Fig. 1, pos. 2) is a non-discontinuous (continuous) incision that completely separates the base of the fibrous capsule from its peripheral part.

Intermittent (dashed) circular sections (Fig. 1, item 3) are sections made in the peripheral part of the fibrous capsule in successive planes parallel to the plane of the continuous circular section, which is an alternation of sections of the dissection of the fibrous capsule over its entire thickness with unseparated sections of the capsule. Each subsequent plane in which the (subsequent) intermittent circular section lies is located distal to the base of the fibrous capsule and closer to the tip of the fibrous capsule.

Staggered order of performing dissections in intermittent circular sections — sections of the capsule dissection in each subsequent intermittent circular section are applied against the uncut sections of the previous circular section (Fig. 1).

The proposed method for open capsulotomy in patients with grade 3-4 fibrous capsular contracture after increasing mammoplasty with silicone prostheses includes a continuous circular incision of the fibrous capsule, separating its base adjacent to the chest from the rest (peripheral) part of it and sections of the peripheral part of the capsule. Intermittent circular cuts are applied to the peripheral part of the capsule, in which sections of the capsule along its entire thickness alternate with uncut sections of the capsule; discontinuous circular sections are arranged in successive planes parallel to the plane of the continuous circular section, and capsule dissection in each subsequent intermittent circular section is carried out against the uncut sections of the previous discontinuous circular section.

Intermittent circular cuts are performed from within the fibrous capsule.

Each section in a discontinuous circular section has a length of 1.5-2 cm, the uncut sections are 0.5-1 cm long, the distance between the discontinuous circular sections and the distance between the continuous circular section and the nearest discontinuous circular section is 1-1.5 cm.

The technical result of the proposed method is to reduce the frequency of complications in the form of re-development of fibrous capsular contracture.

Figures of illustrative material

FIG. 1. Fibrous capsule covering the breast implant (side view). Pos. 1 - the base of the fibrous capsule. Pos. 2 - a continuous circular section of the fibrous capsule. Pos. 3 - intermittent circular cuts: alternating staggered sections of the dissection of the fibrous capsule over its entire thickness with the uncut sections of the capsule. Pos. 4 - the tip of the fibrous capsule (the place of projection of the areola of the mammary gland onto the fibrous capsule). Pos. 5 - the peripheral part of the fibrous capsule.

We operated on 48 patients with fibrous capsular contracture 3-4 degree. Of these, 20 patients (group 1) underwent capsulotomy using the method described by A. Belousov. (see above), and 28 patients (group 2) - the proposed method. After capsulotomy surgery, all patients were observed for various periods, but not less than 1 year. The average follow-up was 2 years 9 months in the first group and 2 years 4 months in the second group of patients.

Clinical examinations were carried out at the 1st and 6th months of observation, then every six months. The result of the operation was evaluated clinically (examination and palpation of the mammary glands), the presence of patient complaints (pain, numbness, etc.) was taken into account. According to the results of the observation, it was revealed that 6 patients (30%) from the 1st group developed repeatedly fibrous capsular contracture, and this complication was revealed in all patients within 1 year of observation. In patients from the 2nd group, repeated fibrous capsular contracture developed only in 2 cases (7%) also during the 1st year of observation.

Clinical example

Patient M., 35 years old, has a history of increasing mammoplasty of both mammary glands with silicone prostheses 3.5 years ago. 1.5 years after the operation, increasing mammoplasty drew attention to the fact that the right mammary gland to the touch is slightly harder than the left, the prosthesis is determined. The process progressed over the next two years, after which the patient sought medical help. When handling, it was found that the right mammary gland is solid, the prosthesis is well palpated; Moreover, its contours and deformations caused by the prosthesis are visible. The left mammary gland is not changed. Fibrous capsular contracture of the 3rd degree on the right was revealed.

The patient performed the operation according to the proposed method — capsulotomy on the right from the old scar (submammary), then the capsule is dissected from the outside by performing part of a circular incision that cuts off the base of the fibrous capsule from the rest (peripheral) part. The prosthesis was removed through the incision, the surgical wound was diluted with retractors, the circular incision was completed from the side of the inner surface of the capsule. Then, sequentially discontinuous circular sections of the fibrous capsule are made on the side of the inner surface of the fibrous capsule with an electric knife in planes parallel to the plane of the continuous circular section, between the continuous circular section and the tip of the fibrous capsule, which is the place of projection of the areola onto the capsule. In each intermittent circular section, sections of the capsule dissection over its entire thickness alternated with unseparated sections of the fibrous capsule. Dissection sections in discontinuous circular sections were staggered, i.e. sections of dissection in each subsequent row were opposite the undissolved sections of the previous row. Dissections were performed with a length of 1.5 to 2 cm. The distance between the sections was 0.5-1 cm, and between the rows (intermittent circular cuts) from 1 to 1.5 cm. The implant was replaced at the patient’s request. Soft tissue sutured in layers.

In the early postoperative period (the first day), the patient was in the intensive care unit, then she was transferred to a single room with constant nursing supervision and received painkillers in the form of non-narcotic analgesics, dressings, antibacterial therapy by introducing intramuscularly 1 g of ceftriaxone.

On the second day after the operation, the patient was discharged from the hospital. Before discharge, a dressing was performed. The next ligation was performed on the 3rd day. The intradermal suture was removed on the 10th day. For 3 years, the patient underwent clinical supervision, recurrence of fibrous capsular contracture was not observed.

Claims (4)

1. The method of open capsulotomy in patients with grade 3-4 fibrous capsular contracture after breast-enlarging mammoplasty with silicone prostheses, including a continuous circular incision of the fibrous capsule, cutting off its base adjacent to the chest from the rest (peripheral) part of it and sections of the peripheral part of the capsule, characterized in that intermittent circular cuts are applied to the peripheral part of the capsule, in which sections of the capsule along its entire thickness alternate with uncut sections of the capsule; discontinuous circular sections are arranged in successive planes parallel to the plane of the continuous circular section, and capsule dissection in each subsequent intermittent circular section is carried out against the uncut sections of the previous discontinuous circular section. 2. The method according to p. 1, characterized in that intermittent circular sections are performed from the inside of the fibrous capsule. 3. The method according to p. 1, characterized in that each cross-section in an intermittent circular section has a length of 1.5-2 cm, uncut sections are 0.5-1 cm long. 4. The method according to p. 1, characterized in that the distance between intermittent circular cuts is 1-1.5 cm

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