RU2646577C2 - Method for suturing after breast endoprosthesis replacement - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to plastic surgery. Access is made in the sub-mammary fold region to the sub-pectoral space. Implant is installed and sutures are applied to the postoperative wound first at the deep leaf of the superficial fascia, sutured to own fascia of the breast, then to the subcutaneous fat and the subdermal layer. Sub-pectoral space is sealed by applying two divergent continuous semipurse-string sutures that are superimposed on top and bottom of the dissected sub-mammary fold. Sutures start from the middle of the postoperative incision, retreating 0.5 cm to the side, the needle and thread are inserted through the deep layer of the superficial fascia from the inside outwards. Further, the suture continues with exit to the surface sheet superficial fascia, two stitches are made on the surface sheet of the superficial fascia with a stitch length of 7–9 mm and distance between the stitches of 2–3 mm. Thread is drawn in the form of a loop along both the upper edge and the lower edge of the incision. Needle with the thread pierces in the direction from the outside to the inside where the suture begins. Step of forming a similar continuous semipurse-string suture on the opposite side of the incision is successively repeated, starting the piercing of needle with the thread from the middle of the postoperative incision, after which the semipurse-string sutures are tightened successively on both sides from the middle of the surgical incision with moderate tension to the corrugating state of the suture. Ends of the threads are tied, followed by formation of the cutaneous part of the suture until the surgical wound is completely closed.

EFFECT: method improves efficiency of surgical treatment due to the reduction of operation time, reduces the length of the postoperative scar and improves its aesthetic properties.

1 cl, 5 dwg

Description

The present invention relates to medicine, in particular to plastic surgery, and can be used to close a surgical wound in the submammary area with subpectoral breast prosthetics.

Endoprosthetics of the breast with the aim of increasing it and giving it a more aesthetic shape is one of the most common operations in plastic surgery. Hundreds of thousands of such interventions are performed annually in the world, and issues of improving surgical technology continue to be the focus of attention of surgeons around the world. Placing breast endoprostheses under the pectoralis major muscle through incisions in submammary areas is the "gold standard" for performing this operation. However, insufficient attention has been paid to wound closure. Most surgeons do not provide a detailed description of this stage of the operation, limiting themselves to indicating the number of rows of sutures.

Aston S.J. and Rees T.D. (1) describe the suturing of the incision in the submammary region as the superposition of 3-4 separate sutures with Vikril 4/0 thread and the subcuticular continuous suture with Prolen 4/0 thread. Proline thread is nonabsorbable and requires removal in the postoperative period.

In later publications, suture sutures exclusively from absorbent materials, such as polydioxane, vicryl and monocryl, were used for suturing wounds. This does not require an additional patient visit to the doctor to remove the sutures and does not impair the quality characteristics of the scar.

Adams W.P. (2) describes suturing of a wound after endoprosthetics of the breast through a submammary approach as the application of three rows of sutures: deep on the superficial fascia of the breast with thread Vikril 3/0, intermediate on the subdermal tissue with thread polydioxane 4/0 and superficial subcuticular filament monocril 4/0.

The technology proposed by Hall-Findlay E J. (3) is also known, according to which the wound is sutured in three layers with Monocryl 3/0 thread, placing the seams in the same layers: deep on the superficial fascia of the chest, intermediate on subdermal tissue and superficial subcuticular. With asymmetry of the nipples, suture tends to tighten the surface fascia more strongly on the side of the higher location of the nipple.

Tebbetts, J.V. (4) proposed to sew the wound in two layers with a continuous seam of monocryl thread. He imposes the first row of sutures on the subcutaneous (superficial) fascia with 4/0 thread, and the second row on the subdermal layer with 5/0 thread. This author believes that the application of the third row of sutures enhances and lengthens the inflammatory response in the wound, but does not provide additional protection against fluid leakage and expansion of the postoperative scar.

Closest to the proposed method is the technology of Calobrace M.B. et al. (5), in which the submammary incision is closed with three rows of sutures: the first is the sutured deep leaf of the superficial fascia with its own fascia of the chest, the second is sutured the superficial fascia and subcutaneous fat, and the third is the subdermal layer. The authors of this technology point out the importance of preserving the carp of the scarp fascia (the deep leaf of the superficial fascia is our note) along the lower edge of the submammary section. Subsequently, this maneuver allows you to maintain the position of the submammar fold and helps to sew up the wound. If the submammary fold does not require lowering, then the cut is quite simple to sew. But when creating a new lower position of the submammary fold, the scarp fascia is hemmed with three separate sutures to the deep fascia of the chest, which allows to stabilize the new position of the submammary fold.

Known methods of suturing after endoprosthetics of the breast can provide fairly good results in the remote postoperative period, however, in the opinion of the inventors have some disadvantages:

- the length of the postoperative scar is almost equal to the length of the incision, which reduces the aesthetic result of the operation;

- suturing according to the closest known method (5) lengthens the time required for suturing the wound;

- insufficient stabilization of the implant in the subpectoral space may in the remote postoperative period lead to its displacement in the caudal and lateral directions, which leads to the migration of the postoperative scar from the submammary fold and makes it more noticeable.

Based on the analysis of the known technologies for suturing a wound in the submammary area after subpectoral endoprosthetics of the breast and eliminating the disadvantages of the known methods, the task was set: to increase the effectiveness of surgical treatment by reducing the time of the operation, reducing the length of the postoperative scar and improving its aesthetic properties.

The task is carried out as follows:

The method of suturing after breast replacement involves access in the submammary area to the subpectoral space, installing an implant and suturing the postoperative wound. Sutures are first applied to a deep leaf of the superficial fascia, sutured to the own fascia of the breast, then subcutaneous fat and subdermal layer. New in the proposed method is that the subpectoral space is sealed at the top and bottom of the dissected submammar fold with two diverging continuous half-mesh sutures, each of which starts from the middle of the postoperative incision, 0.5 cm to the left and right. In this case, a needle with a thread is injected through the deep leaf of the superficial fascia from the inside out, then the seam is continued with access to the superficial fascia leaf, the stitch length is 7-9 mm, the distance between the stitches is 2-3 mm, with the thread in the form of a loop along the upper and lower the edge of the incision with a puncture from the outside inward at the beginning of the seam. Then, the step of forming a similar continuous half-suture suture on the opposite side of the incision is sequentially repeated, starting with a needle with a thread from the middle of the postoperative incision. Then tighten half-mesh seams sequentially on both sides from the middle of the surgical incision with moderate tension to the corrugating state of the seam and tie the ends of the threads. Then form the cutaneous part of the suture until the surgical wound is completely closed.

We explain the significant differences of the proposed method of suturing in the submammary area after subpectoral breast replacement.

In known surgical methods (5), suturing a wound in the submammary region allows stabilizing the position of the submammary fold using the first row of separate sutures between the deep leaf of the superficial fascia and the own fascia of the chest, as well as sealing the subpectoral space and adapting the edges of the skin incision using two more rows of continuous suture . The total number of stitches in this case is 22-25. Moreover, obtaining a scar of shorter length than the initial incision is never intended.

In the proposed technology, after stabilization of the position of the submammary fold by three separate sutures between the deep leaf of the superficial fascia and the own fascia of the chest at the level of the 6th rib, the sealing of the subpectoral space is provided by two diverging semi-mesh sutures. Each of these seams begins 0.5 cm outward from the middle of the cut with an injection through a deep leaf of the superficial fascia from the inside to the outside, and then two stitches per surface leaf of the superficial fascia of 7–9 mm and a distance between stitches of 2-3 mm along the bottom and the upper edge of the cut and puncture from the outside inward at the beginning of the seam. The introduction of a needle with a thread through a deep leaf of the superficial fascia from the inside to the outside and the continuation of the seam with access to the superficial fascia leaf provides a more stable scar position in the submammary fold.

In contrast to the continuous twisting suture, which is used in known surgical methods, the proposed method allows to significantly reduce the length of the wound due to corrugation, to quickly seal the subpectoral space and requires fewer sutures necessary to adapt the edges of the skin, which reduces the time of surgery and improves aesthetic properties scar. When using the proposed method, the total number of stitches is 15.

Sealing of the subpectoral space is provided by two diverging continuous half-mesh seams, and not by a twisted seam, as in the known methods. The use of two half-mesh sutures, each of which begins, 0.5 cm from the middle of the postoperative incision, to the right and left, allows you to quickly seal the subectoral cellular space, separating the implant from the external environment, due to the smaller number of necessary stitches compared to the stitching.

Sequential tightening of half-mesh seams with moderate tension on both sides and tying the ends of the threads allows you to corrugate the edges of the wound and to achieve a significant shortening of the length of the seam compared to known methods.

The technical result of the proposed method for suturing the surgical wound in the area of the submammary fold is the creation of conditions under which the postoperative scar is located in the submammary fold, which makes it less noticeable. In addition, reduce the length of the postoperative scar, reduce the time of surgery and ensure sufficient stability of the fixation of the implant.

A comparative analysis of the proposed technical solution and known technologies allows us to conclude that the proposed method differs in the above methods and meets the criteria of the invention of "novelty."

When the breast implant is subpectorally positioned, it is positioned so that the lower edge of the implant is at the level of the upper edge of the 6th rib. Therefore, the first row of sutures on the wound should ensure fixation of the submammar fold at the level of 6 ribs. This is especially necessary in cases where implant placement in patients with no excess skin on the chest and retained tissue elasticity leads to the “borrowing” of tissue from the abdominal wall to the chest hill.

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

The method comprising the claimed invention is intended for use in medicine, namely in plastic surgery. The possibility of its implementation is confirmed by the methods and means described in the application. The above gives reason to believe that the claimed technical solution meets the criteria of the invention of "industrial applicability".

The proposed method is illustrated by illustrations, which show:

FIG. 1 is a diagram of a suture in a submammary fold,

FIG. 2 is a diagram of the state of the seam after its application,

FIG. 3 - photo of the patient’s chest before surgery,

FIG. 4 - photo of the patient’s chest after access, suturing in the submammary fold and installation of the breast implant (A - wound sewn by the proposed method on the left, B - wound on the right, wired according to the prototype technology),

FIG. 5 - photo of the patient’s breast in the postoperative period after 6 months.

To illustrate the stitching pattern in FIG. 1 and 2 show the following items:

1 - leather

2 - subcutaneous tissue and superficial fascia leaf,

3 - a portion of the pectoralis major muscle covering the implant,

4 - a deep leaf of the superficial fascia of the chest,

5 - threads

6 - implant,

7 - half-net seam,

8 - loop

9 - a seam between a deep leaf of a superficial fascia and own fascia of a breast.

The essence of the proposed "Method of suturing after endoprosthetics of the breast" is as follows:

Initially, based on the measurements of the chest, the patient selects the size and shape of the implant. The height of the implant is determined by the distance from the 6th rib to the estimated upper border of the chest, which usually corresponds to the fold formed by the lower edge of the pre-axillary fat. The width of the implant is equal to 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. Next, on the surface of the skin of the chest of the patient, a preoperative marking of the incision is applied in the submammary area along the upper edge of the 6 ribs, 4.5-5.5 cm long (depending on the volume of the implant), which starts 1-1.5 cm medially from the vertical line , lowered from the inner border of the areola. The location of the section may either coincide or not coincide with the existing sub-mammary fold.

Stage of surgical treatment. According to the marked markings in the submammary area, the skin is cut through the entire thickness. The lower part of the incision is stretched with sharp hooks parallel to the submammary fold and the subcutaneous tissue and superficial fascia are dissected along the 5 intercostal space, where the pectoralis major muscle is found. The pectoralis major muscle is cut 1 cm cranial to its attachment to the 6th rib, starting from the attachment of the cartilage of the 6th rib to the sternum to the level of the outer edge of the rectus abdominis muscle, while maintaining the abdominal portion of the pectoralis major muscle, but completely separating it from the front surface of the 6th rib. In the region of the outer edge of the rectus abdominis muscle, the abdominal portion of the pectoralis major muscle and the fascia fascia covering it tightly fuse with the own fascia of the chest, forming a fastening point, and this support is determined during examination from the subpectoral space (6).

In the subpectoral cellular space under the control of vision, a container for the implant is atraumatically formed. Its boundaries are: inside - the place of attachment of the pectoralis major muscle to the sternum, outwardly - the abdominal portion of the pectoralis major muscle and pectoral fascia, passing to the bundles of the anterior dentate muscle and the external oblique muscle of the abdomen, at the top - the chest-acromial vascular bundle, below - the 6th rib and the preserved distal attachment point of the abdominal portion of the pectoralis major muscle. After control, an implant is placed on hemostasis and the wound suturing stage is started (see the appendix to the description, Fig. 1). The first row of sutures on the wound provides fixation of the submammar fold at the level of 6 ribs. To do this, use an absorbable suture (Vicryl 2.0, PDS 2.0), which, with separate seams, fix the deep leaf of the superficial fascia of the lower edge of the incision with its own fascia of the chest immediately above the 6th rib. The second row of sutures seals the subpectoral space and reduces the length of the surgical wound. Impose half-mesh seams with absorbable Vicryl 2.0 thread. Each of these seams begins 0.5 cm outward from the middle of the cut with an injection through a deep leaf of the superficial fascia from the inside to the outside, and then two stitches on the superficial fascia leaf, the length of the stitches is 7-9 mm and the distance between the stitches is 2-3 mm , along the lower and upper edge of the cut and puncture from the outside inward at the beginning of the seam. Tightening the half-mesh seams leads to a good sealing of the subpectoral space together with the implant and a significant shortening of the surgical wound due to its corrugation (wound 5 cm long is reduced to 3.5 cm). Skin folds form on each side of the wound center. The third row of sutures is applied with rapidly absorbable sutures (monocryl 4.0-5.0) 3 in separate subdermal sutures, carefully adapting the edges of the skin to each other (see the appendix to the description, Fig. 2).

The proposed method is illustrated by a clinical example.

Patient K., 28 years old, was admitted to the microsurgery department at the clinic of the Irkutsk Scientific Center for Surgery and Traumatology with complaints of loss of mammary gland volume. The mammary glands lost their shape and volume after childbirth and breastfeeding. He wears a bra with a cup “A.” He wants to have a chest with the size of a cup "C".

Diagnosis at admission: mammary gland hypoplasia.

On examination, it was found that the mammary glands are small, relatively symmetrical, skin with normal elasticity (see the appendix to the description, Fig. 3).

The implant height was determined to be 11.5 cm, width - 11 cm. Taking into account the patient’s desire to have a breast size “C”, medium profile implants of an anatomical shape with a volume of 290 ml of Eurosilicon company (France) were selected. In the submammary area, the preoperative marking of the section was performed, which in this case coincided with the existing submammary fold. Under intravenous anesthesia, incisions were made in submammary folds 5.1 cm long. Access was made to subpectoral cellular spaces, and containers for endoprostheses were formed. After control for hemostasis, endoprostheses were installed (see the appendix to the description, Fig. 4). Symmetry control. After installing the implants, we started suturing in the submammary fold. The surgical incision of the left chest was sutured according to known technology (5). The surgical incision on the right chest is sutured using the proposed technology.

Absorbable suture (Vicryl 2.0, PDS 2.0) with 3 separate sutures fixed a deep leaf of the superficial fascia of the lower edge of the incision with its own fascia of the chest immediately above the 6th rib. The second row of sutures sealed the subpectoral space and reduced the length of the wound. Two half-net seams were applied with absorbable Vicryl 2.0 thread. Each of these seams began, departing from the middle of the cut 0.5 cm to the right and left with a needle pricked through a deep leaf of the superficial fascia, from the outside to the inside, and then two stitches to the superficial fascia leaf. The stitch length is 8 mm, the distance between the stitches is 3 mm (thread exit - loop) along the upper and lower edges of the cut. The needle is poked out from the outside inward at the start of the seam. Tightening of the corrugating half-mesh seams was performed sequentially with moderate tension and the ends of the threads were tied, which led to sealing of the subpectoral space together with the implant and reducing the length of the surgical wound due to its corrugation. A wound 5.1 cm long was reduced to 3.5 cm. A skin fold appeared on each side of the center of the wound.

The third row of sutures was imposed by rapidly absorbable sutures (monocryl 4.0) with 3 separate subdermal sutures in the places of the formed folds and in the center of the incision, adapting the edges of the skin to each other.

A bandage has been applied. It is recommended to use compression underwear. The time for suturing the surgical wound was: 310 sec on the right and 345 seconds on the left. Intraoperative measurements showed that the length of the wound after suturing: on the right - 3.5 cm, on the left - 4.5 cm (see the appendix to the description, Fig. 4).

The postoperative period was uneventful. Scar length one month after surgery: 3.1 cm on the right, 3.8 cm on the left. Scar length 6 months after the operation: 4.0 cm on the right, 4.9 cm on the left. The patient is satisfied with the result of the operation (see the appendix to the description, Fig. 5 )

The proposed method was tested in 30 patients who underwent subpectoral endoprosthetics of the breast through a submammary approach in the clinic of the Center for Intrachemical Chemistry.

In order to obtain additional data on the application of the proposed method, a study was carried out, the purpose of which was to compare the results of suturing the incision in the submammary area after subpectoral endoprosthesis replacement using known and proposed technologies.

The object of observation was 10 patients who underwent breast implant replacement with silicone anatomical implants filled with cohesive gel and textured shell for aesthetic purpose. In all cases, implants of the Eurosilicon company (France) were used. To do this, symmetrical sections of the same length were performed in submammary areas, through which the same implants were installed, but the wound on the left and right was sutured in different ways: on the one hand, according to the known technology (5), and on the other hand, according to the technology proposed in the invention. During the operation, the time required for suturing the wound and the length of the resulting suture were compared, and in terms of 1, 3, 6 months and after 1 year, the length of the formed scar, its localization and subjective assessment by the patient. The choice of side was randomized.

Exclusion criteria for patients were the presence of severe asymmetry and tubularity of the mammary glands. A slight asymmetry in the shape and volume of the mammary glands was considered acceptable if it did not require additional surgical techniques to be corrected.

The research was approved by the ethics committee of the Irkutsk Scientific Center for Surgery and Traumatology. 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, 10 patients did not experience any complications. In the distant postoperative period, a stable position of the implant was observed with respect to the submammary fold in which the postoperative scar was located. During the follow-up examination after 1 and 3 months after the operation, most patients observed typical changes in the shape of the breast associated with the subpectoral placement of the implant: an excessive projection of the upper pole of the gland, a slightly higher breast density to the touch. However, upon examination after 3 and 6 months, these phenomena stopped: the mammary gland took a natural form and became soft to the touch. The result remained stable upon examination after 6 months and a year. All patients were satisfied with the result of the operation.

A comparative study showed:

1. The average scar suturing time by the proposed method was 5 minutes 29 ± 0.04 seconds and was significantly less than with classical suturing - 6 minutes 10 ± 0.06 seconds (p <0.01).

2. The total number of stitches for seams using the known method was 24, and 15 according to the proposed one.

3. The corrugation of the surgical incision with half-mesh sutures according to the proposed method led to a reliable shortening of the postoperative suture in comparison with the classical method 3.71 ± 0.07 cm, versus 4.24 ± 0.06 cm (p <0.01).

4. In the period from 6 months to a year, the length of the scar on the side of the corrugation was 4.12 ± 0.07 cm and was significantly less than on the control side 4.68 ± 0.07 cm (p <0.05).

5. Over a period of 12 months, the scar length on the corrugation side was 4.25 ± 0.22 cm and was significantly less than on the control side 4.78 ± 0.19 cm. Corrugation led to slight scar deformation (p <0, 05).

6. The patient's subjective assessment of scar quality was higher on the experimental side (7 cases versus 3). However, this was not a statistically significant sign (p = 0.3).

Thus, when comparing with the known surgical technologies, the proposed “Method for suturing after breast replacement” has good stability of results, allows to reduce the time of surgery, reduce the length of the postoperative scar, and more reliably stabilize the implant.

Information sources

1. Aston S.J., Rees T. D. (Mammary Augmentation, Correction of Asymmetry, and Gynecomastia p. 954-995. In Aesthetic plastic Surgery 1980, vol 1. Saunders Company, p. 1072.

2. Adams W.P. (Adams, W.P. The Process of Breast Augmentation: Four Sequential Steps for Optimizing Outcomes for Patients. Plastic & Reconstructive Surgery. 2008, 122 (6): 1892-1900).

3. Hall-Findlay Ε.J. (H-Findlay E.J. Aesthetic Breast Surgery. Concept and Techiques. - QMP, St. Louis, 2011 .-- p. 706).

4. Tebbetts, J. B.; Adams, W.P. Five Critical Decisions in Breast Augmentation Using Five Measurements in 5 Minutes: The High Five Decision Support Process Plastic & Reconstructive Surgery: December 2006 - Volume 118 - Issue 7S - pp 35S-45S, Bouwer, Lesley R. M.D .; Tielemans, Hanneke J. P. M.D .; van der Lei, Berend M.D., Ph.D. The Pythagorean Theorem as a Tool for Preoperative Planning of a Concealed Scar in Augmentation Mammaplasty with Round Implants Plastic & Reconstructive Surgery: January 2015 - Volume 135 - Issue 1 - p. 110-112).

5. Calobrace, M.B. (Evolving Practices in Augmentation Operative Technique with Sientra HSC Round Implants Calobrace, M. Bradley; Kaufman, David L .; Gordon, Ashley E .; Reid, Dustin L. Less Plastic & Reconstructive Surgery. 134 (1S): 57S-67S, July 2014.

6. A method for correcting the volume and shape of the mammary gland with mastoptosis: US Pat. Grew up. Federation: IPC A61B 17/00 / Zelenin V.N., Zelenin N.V .; applicant and patent holder Federal State Budgetary Institution "Scientific Center for Reconstructive and Reconstructive Surgery" of the Siberian Branch of the Russian Academy of Medical Sciences (FSBI "NTSRVH" SB RAMS). - No. 2013111562/14; declared 03/14/2013; publ. 12/10/2014, Bull. Number 34. - 10 p., Ill. 12.

Claims (1)

A method of suturing after breast replacement, including access to the subpectoral space in the area of the submammary fold, installing an implant and suturing the postoperative wound first on a deep leaf of the superficial fascia, sutured to the own fascia of the breast, then on the subcutaneous fat and subdermal layer, characterized in that seal the subpectoral space by superimposing two diverging continuous half-mesh seams, which are laid on top and bottom of the dissected submammary folds, the seam starts from the middle of the postoperative incision, backing 0.5 cm to the side, the needle with the thread is injected through the deep leaf of the superficial fascia from the inside out, then the seam is continued with the exit to the superficial fascia leaf, two stitches are applied to the superficial fascia leaf with a stitch length of 7–9 mm and a distance between stitches of 2–3 mm, a thread in the form of a loop is brought out along both the upper edge and the lower edge of the cut, a needle with a thread is punctured from the outside inward at the start of the seam, then The stage of formation of a similar continuous semi-mesh seam from the opposite side of the incision is carefully repeated, starting with a needle with a thread from the middle of the postoperative incision, then half-mesh seams are tightened sequentially on both sides from the middle of the surgical incision with moderate tension to the corrugated condition of the seam, the ends of the threads are tied, then formed the cutaneous part of the suture until the surgical wound is completely closed.

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