RU2591784C1 - Method for prevention of extrusion of silicone implant after skin-preserving mastectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: skin-preserving mastectomy is performed. Method includes installing in a prepared bed silicone implant of appropriate size and shape. De-epidermised autodermotransplant pre-cut on front surface of abdominal wall is anchored to cellular tissue of upper and lower wound edges to overlap incisional wound at 2 cm. Then cellular tissue is sutured by intradermal suture and skin with single sutures.

EFFECT: method provides reliable prevention of extrusion silicone implant by complete isolation from skin wound wih de-epidermised autodermotransplant, reduces operation length, number of injuries of operational intervention and intraoperative blood loss volume.

1 cl, 1 ex, 7 dwg

Description

The invention relates to medicine, more specifically to oncology, and can be used for breast reconstruction after a skin-saving mastectomy with a silicone implant.

One of the serious postoperative complications of reconstructive mammoplasty with the use of a silicone implant is extrusion (extrusion) of the endoprosthesis out through an inconsistent postoperative scar. This leads to infection of the fibrous capsule and the forced removal of the implant. In this case, there is a need for long dressings for obliteration of the capsular cavity and wound healing, the aesthetic result suffers. This clinical situation does not allow to start the subsequent stages of complex oncological treatment in time, which can adversely affect general oncological indicators.

There is a method of covering the implant with a polypropylene mesh to reduce postoperative complications, which includes replacing the deficit of gland tissue with pectoralis major muscle. In this case, the pectoralis major muscle is separated from the pectoralis minor muscle. Cut the pectoralis major muscle in the lower sections. A mesh implant made of partially absorbable material is fixed to the cut edge of the muscle, a silicone endoprosthesis is placed in the pocket formed by the large, small pectoral muscles and the mesh. The lower edge of the mesh implant is fixed to the fascia of the muscles of the anterior chest wall (see patent RU No. 2407458 C1, IPC A61 B17 / 00, published on December 27, 2010, Bull. No. 36). The method using the polypropylene mesh is quite traumatic, leads to a partial dysfunction of the separated pectoralis major muscle, increases intraoperative blood loss and the risk of bleeding in the early postoperative period, increases the duration of the operation, and is also more costly. In some cases, mesh penetration through the skin is noted, prolonged friction of the implant on the mesh can lead to a violation of its integrity, the mesh is an additional foreign body.

There is a method of sheltering an endoprosthesis when it is placed under the pectoralis major and anterior dentate muscles or on the pectoralis major muscle, covering it with the mobilized latissimus dorsi muscle (see Vishnevsky A.A. et al. Plastic surgery of the mammary gland. Moscow, Medicine, 1987). However, this method of isolation of the endoprosthesis has disadvantages in the form of impaired function of mobilized muscles. The implant is located between the pectoralis major and the anterior toothed muscles, deformed during muscle contraction (animation effect), the closed muscle “cocoon” forms a dense, inactive gland with unnatural outlines of its lower slope and smoothness of the inframammary fold. To cover the implant with the broadest muscle of the back, it is necessary to perform an additional complex operation to mobilize the thoracodorsal flap with the inevitable loss of function and aesthetics of the donor zone.

The technical result of the present invention is the restoration of the natural appearance of the mammary gland, the delimitation of the implant from the skin wound after radical surgical treatment of cancer as a preventive measure for the extrusion of a silicone implant.

The technical result is achieved by installing a silicone implant of the appropriate size and shape in the prepared bed, then a de-epidermalized autoderm graft pre-cut on the anterior surface of the abdominal wall is sutured to the fiber of the upper and lower edges of the skin-fat flaps of the postoperative wound, then the tissue and skin are sutured.

To explain the implementation of the invention, the proposed drawings.

Figure 1 shows the preoperative markup (direct projection).

Figure 2 shows the preoperative markup (lateral projection).

Figure 3 shows the cutting out of an autoderm graft from the skin of the anterior abdominal wall (de-epidermisation is completed).

Figure 4 shows the process of hemming an autoderm graft to the lower edge of the wound.

Figure 5 shows an autoderm graft stitched to the lower edge of the wound (a silicone implant is visible in the bed).

Figure 6 shows the process of hemming an autoderm graft to the upper edge of the wound.

Figure 7 shows the postoperative aesthetic result (lateral projection).

The method is as follows.

In the operating room, after preliminary marking (Figs. 1, 2) in the position of the patient lying on his back under anesthesia, a skin-preserving radical mastectomy is performed with the removal of the regional lymphatic collector in a single unit, hemostasis is performed, active drainage is established, then a pre-epidermalized autoderm graft is cut out on the skin of the anterior abdominal wall appropriate size (figure 3).

After that, a silicone implant of the required shape and size is placed in the prepared bed, then it is covered with a de-epidermized skin graft, fixing with twisted sutures to the tissue of the edges of the surgical wound 2 cm further than the skin edge (Figs. 4, 5, 6). Then, fiber and skin are sutured over the autograft. Fiber is sutured over the autodermotransplant with separate sutures, the skin with an intradermal suture. The donor wound is sutured in layers.

An analysis of known methods for covering an endoprosthesis after a subcutaneous mastectomy while removing a malignant breast tumor allows us to state the presence of novelty and differences.

The novelty of the developed method lies in the reliable shelter (isolation) of the implant from the skin surface without damage and impaired function of the pectoralis major, anterior serratus and latissimus dorsi. Reliable sheltering of the endoprosthesis is facilitated by the hemming of the epidermal autograft graft to the fatty tissue of the upper and lower skin-fat grafts with the autograft graft overlapping the size of the postoperative wound by 2 cm or more.

In the available open Russian and foreign sources of information a similar method could not be found.

The inventive method is industrially applicable. It can be reproduced and repeated many times in specialized oncological institutions.

An example of a specific implementation of the proposed method can serve as an extract from the medical history.

Patient Sh., Born in 1955, turned to the Department of Reconstructive and Plastic Surgery of the RNII on October 27, 2014 with complaints of the presence of a tumor-like formation of the left breast. During the examination, the diagnosis was established: cancer of the left breast T2N × M0, stage II, clinical group 2.

An operative measure was performed on October 28, 2014: after preliminary marking in the supine position under endotracheal anesthesia after skin-preserving mastectomy and axillary-subscapular lymphatic dissection, hemostasis was performed, and active drainage was established.

From the skin of the anterior abdominal wall, a de-epidermized autoderm graft is cut out.

An appropriate size anatomical silicone implant is placed in the formed pocket, isolated (covered) with a de-epidermized skin graft.

The graft is reinforced with twisted sutures to the tissue of both edges of the wound with a 2 cm overlap. Cellulose is sutured over the autodermotransplant with separate sutures, the skin with an intradermal suture. A donor wound is sutured in layers.

On November 6, drainage tubes were removed; on November 15, the skin suture was removed. The patient was discharged from the hospital in satisfactory condition with a good aesthetic effect.

Six months later, neither cicatricial deformities of the mammary gland nor subcutaneous seals were noted. The restored mammary gland showed tactile uniformity both in the autoderm graft zone and in other departments (Fig. 7).

This method was treated 7 patients

Technical and economic effectiveness of the method is:

- in reliable prevention of the extrusion of a silicone implant by completely isolating it from the skin wound with a de-epidermized autoderm graft;

- to reduce the time of the operation, its morbidity and the amount of blood loss.

Claims (1)

A method for preventing the extrusion of a silicone implant after a skin-saving mastectomy, including a skin-saving mastectomy, installation of a suitable size and shape in the prepared bed of a silicone implant, characterized in that a de-epidermalized autodermal graft previously cut on the abdominal wall is sutured to the tissue of the upper and lower wound edges with 2 cm, then suturing of the fiber with an intradermal suture and skin with separate sutures is carried out.

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