RU2635450C1 - Method for silicone implant fixation and stabilization after skin-preserving mastectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: perforated sheet of acellular matrix is used and active drainage is installed. A silicone implant of the appropriate size and shape is installed in the prepared bed under the mobilized large pectoral muscle. A sheet of acellular matrix is pre-perforated by linear perforations in a staggered order, so that the sheet becomes a grid with a possibility of stretching in only one direction, sewed to the lower edge of the large pectoral muscle, aponeurosis of the rectus abdominis muscle in the projection of the submammary sulcus, and laterally - to the serratus anterior. The cellular tissue is sutured with separate sutures and skin is sutured with an intradermal suture.

EFFECT: prevention of the silicone implant displacement, excluding the formation of pressure sores over the implant, palpable seals and unevenness under the breast skin, reduced likelihood of resistant seroma formation.

1 ex, 10 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 common aesthetic complications of reconstructive mammoplasty using a silicone implant is considered to be the displacement of the latter down under the influence of gravity. The lower slope of the skin-fat envelope, especially in thin women, does not withstand the pressure of the implant, stretches and becomes thinner. This leads to a deterioration in the shape of the mammary gland and the formation of a condition known as “ball in a sock” - “ball in toe”. This forces surgeons to take repeated interventions to fix and further stabilize the implant. In this case, there is a need for additional surgical intervention, an increase in the bed-day, the cost of treatment, and the aesthetic result, however, reaches very moderate values. In most cases, this clinical situation is poorly perceived by patients, and conflict situations may arise between them and the surgeon.

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 polymer mesh implant made of non-resorbable or 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. Fix the lower edge of the polymer network to the fascia of the muscles of the anterior chest wall (see patent RU No. 2407458 C1, IPC AB 17/00, publ. 12/27/2010, Bull. No. 36). The method using a polypropylene mesh in some cases leads to the penetration (extrusion) of the mesh through the skin, especially in the places of its folding when modeling around the implant, the mesh is an additional foreign body, prolonged friction of the implant on the mesh can lead to a violation of its integrity.

A known method of covering an endoprosthesis with an acellular dermal or pericardial matrix (ADM) of the trademarks Alloderm®, DermaMatrix®, Permacol®, SurgiMend®, Allomax®, FlexHD®, DermaCell®, Veritas®, and Strattice®, which are cell-free human, pig, bovine skin, as well as bovine pericardium. These derivatives are biological substances and contribute to rapid revascularization and cell repopulation. This method improves the contours of the lower slope of the gland, providing it with sufficient support and stabilization of the submammary sulcus, without interfering with radiation therapy in the adjuvant mode (Kasem A., Choy C., Mokbel K. Skin-Sparing Mastectomy and Breast Reconstruction: An Update for Clinical Practice . // Journal of Cancer Therapy, 2014, No. 5, - P. 264-280; Ho G, Nguyen TJ, Shahabi A., Hwang BH, Chan LS Wong AK A systematic review and meta-analysis of complications associated with acellular dermal matrix-assisted breast reconstruction. // Ann. Plast. Surg. 2012. No. 68, p. 346-56). It should be noted that many authors noted a high frequency of seroma formation around the implant, which proceeds very stubbornly and requires significant efforts to eliminate it. In some cases, a prolonged seroma led to the emergence of an infectious process with all the ensuing consequences - the need to remove the implant along with the matrix.

Acellular dermal matrices are an elastic, flexible, but inextensible substance, and this property does not allow a congruent fit of the implant. On the bends, “standing cones” are formed, which are palpated, and sometimes visualized through the skin. In some cases, these cones became the cause of pressure sores of the skin envelope. Cutting out the matrix and then stitching the edges improves the situation slightly. So, there are 2 negative properties of the use of acellular dermal matrices - the formation of persistent seroma around the implant due to its impermeability to liquids, as well as poor physical properties for spatial modeling.

The technical result of the present invention is the restoration of the natural appearance of the mammary gland, the effective support (stabilization) of the implant after radical surgical treatment of breast cancer, the prevention of extrusion of the silicone implant through the sores of the skin envelope and the reduction of the possibility of formation of persistent seromas around the implant.

The technical result is achieved by the fact that after the implementation of skin-preserving mastectomy mobilize the pectoralis major muscle in order to prepare the bed for the implant. A silicone implant of the appropriate size and shape is installed, then a sheet of the acellular dermal matrix is pre-punched with an autodermal grafting punch to the lower edge of the pectoralis major muscle, the aponeurosis of the rectus abdominis muscle in the projection of the submammary sulcus, and laterally to the anterior dentate muscle. Next, suturing of fiber and skin is carried out. Perforated by the proposed method, the matrix sheet acquires the necessary extensibility in the sagittal direction in order to congruently fit the implant and maintains rigidity in the frontal direction to keep it from moving down. In addition, the perforated sheet allows tissue fluid to circulate from the periprosthetic space to the subcutaneous, thereby enhancing its resorption and contributing to the prevention of persistent seromas. It should be noted that linear perforations of a sheet arranged in a checkerboard pattern, which allow it to be extensible in one direction, are fundamentally important. Round perforations cannot give such an effect.

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

FIG. 1 - intraoperative photo: breast tissue removed, mobilization of the lower edge of the pectoralis major muscle is carried out.

FIG. 2 - the pectoralis major muscle is mobilized (on the clamps), the bed for the implant is prepared.

FIG. 3 - leaflet ADM (Permacol) for perforation prepared.

FIG. 4 - leaf ADM (Permacol) after perforation takes the form

grids with the possibility of stretching in only one direction.

FIG. 5 - mesh sheet ADM (Permacol) is hemmed to the bottom edge

mobilized pectoralis major muscle.

FIG. 6 - mesh leaflet ADM (Permacol) evenly covers (supports and fixes) the implant, is sutured to the fascia of the rectus abdominis muscle and the anterior dentate muscle in the projection of the inframammary sulcus.

FIG. 7 - view of the patient in direct projection 2 months after surgery.

FIG. 8 - the same patient in the left semi-lateral projection.

FIG. 9 - the same patient in the left lateral projection.

FIG. 10 - the same patient in the right semi-lateral projection.

The method is as follows.

In the operating room, after preliminary marking (Fig. 1, 2), in the patient’s supine position 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, the pectoralis major muscle is mobilized in order to prepare the implant bed . A silicone implant of the appropriate size and shape is installed, then a sheet of the acellular dermal matrix (Permacol certified by Covidien in the Russian Federation) is pre-punched with a perforator for auto-transplants and sutured to the lower edge of the pectoralis major muscle, the aponeurosis of the rectus abdominis muscle in the projection of the submammary sulcus to the anterior lateral dentate muscle.

Fiber is sutured over the implant with separate sutures, the skin with an intradermal suture.

Analysis of known methods of fixation and stabilization of the implant after subcutaneous mastectomy when removing a malignant tumor of the mammary gland allows us to state the presence of novelty and differences.

The novelty of the developed method lies in the reliable fixation (stabilization) of the implant and an increase in the coating thickness due to the mesh leaf of the acellular dermal matrix, which contributes to rapid revascularization (development of granulation tissue) and population of the mesh xenograft (ADM) by cells. Reliable fixation of the silicone implant is facilitated by suturing of the mesh matrix to the lower edge of the pectoralis major muscle, aponeurosis of the rectus abdominis muscle in the projection of the submammary sulcus, and laterally to the anterior dentate muscle.

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 1970, turned to the Department of Reconstructive and Plastic Surgery of GBUZ SK SKKOD on May 17, 2016 complaining 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. Surgical intervention was performed on 05/18/2016: after preliminary marking in the supine position under endotracheal anesthesia, a skin-preserving mastectomy was performed from infra-mammary access and axillary-subscapular lymphatic dissection from a separate access, with the removal of the drug in a single unit, hemostasis was performed. The pectoralis major muscle is mobilized along the lower edge (Fig. 1, 2), a silicone implant and active drainage are installed in the formed bed. Using a perforator for autograft grafts, the sheet of the acellular dermal matrix (Permacol) was perforated (Fig. 3, 4), hemmed to the lower edge of the pectoralis major muscle (Fig. 5), the aponeurosis of the rectus abdominis muscle in the projection of the submammary sulcus, and laterally to the anterior dentate muscle (Fig. 6). Then carried out suturing of fiber and skin.

On May 23 (the 6th day) drainage tubes were removed; on May 30 (the 13th day) the skin suture was removed. The patient was discharged from the hospital in satisfactory condition with a good aesthetic effect. After 2 months, neither cicatricial deformities of the mammary gland nor subcutaneous seals were noted. The reconstructed mammary gland showed tactile uniformity both in the area of the perforated Permacol sheet and in other departments (Figs. 7, 8, 9, 10). The photographs show that the operated mammary gland is located slightly higher than the healthy one. Breast skin evenly contracted around the implant. This proves the good supporting and fixing function of the proposed method.

In this way, 5 patients were treated.

Technical and economic effectiveness of the method is as follows:

- perforated by the proposed method, the ADM leaf acquires the necessary extensibility in the sagittal direction to congruently fit the implant and maintains rigidity in the frontal direction to keep it from moving down;

- the perforated sheet of ADM allows tissue fluid to move freely from the periprosthetic space into the subcutaneous, thereby enhancing its resorption and contributing to the prevention of persistent seromas;

- the perforated ADM sheet does not form “protruding cones”, thereby preventing the extrusion of the implant through the bedsores of the skin envelope of the breast, and also does not cause tactile irregularities in the coating of the organ.

Claims (1)

A method for fixing and stabilizing a silicone implant after a skin-preserving mastectomy, comprising using a perforated sheet of the acellular matrix and installing active drainage, characterized in that a silicone implant of the appropriate size and shape is placed in the prepared bed under the mobilized pectoralis major muscle, then the sheet of the acellular matrix is pre-punched by applying linear perforations in a checkerboard pattern, so that the sheet becomes a grid with the possibility of stretching only in one direction, hem it to the lower edge of the pectoralis major muscle, the aponeurosis of the rectus abdominis muscle in the projection of the submammary sulcus, and also laterally to the anterior dentate muscle, then the tissue is sutured with separate sutures and skin with an intradermal suture.

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