RU2702142C1 - Method of plasty combined with lacteal gland reduction - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to reconstructive-plastic surgery. Method includes forming a cutting and a line of submammary fold, de-epidermisation of skin around nipple-areolar complex, excising excess volume of tissues by resection based on size of gland, shape and volume of excess tissues. Pocket extending from the submammary fold upwards to the third rib is formed. Mesh graft is placed under elevated breast tissue into pocket of mesh implant fixed to fascia of thoracic muscle at the level of the third intercostal space. Lower portion of intrinsic tissue of the gland is closed in the area of resection with separate sutures, tissues around the nip are anchored by a purse-blocking suture and the skin is intracutaneously sutured. Pocket is made in a retromammary space with the size of a "spot" of a mammary gland. Mesh implant is cut out of the same size, wherein material of mesh implant is "titanium silk", and fixing the implant to the fascia of the pectoral muscle is carried out along the anterior-axillary line laterally and medially along the parasternal line, the parenchyma of the mammary gland is placed above the line. Lower part of the implant is turned forward, freely laid on the lower slope of the breast without fixation.

EFFECT: method enables achieving a stable therapeutic effect, reducing recurrence rate and improving patient satisfaction with quality of medical care.

1 cl, 2 dwg, 1 ex

Description

The invention relates to medicine, namely to reconstructive plastic surgery of the mammary gland with hypermastia.

Hypermastia is an abnormality in which there is an excessive, usually bilateral increase in the volume and weight of the mammary glands. An increase in breast size occurs due to the excessive development of predominantly adipose and connective tissue. The large breast, exerting strong pressure on the chest, contributes to impaired posture, the formation of stoop, osteochondrosis, causes constant pain in the shoulders, spine, contributes to the development of chronic diseases of the mammary glands themselves, the development of diaper rash and the appearance of skin rashes in the submammary folds, which causes significant physical and psychological discomfort.

A radical method of treating this disease is surgical reconstruction of the breast - an operation aimed at reducing the excess volume of the mammary glands. There are more than 20 techniques for performing this operation, which have common principles among themselves:

- modeling, mobilization, excision of skin flaps when working with the skin "cover" of the mammary gland;

- modeling, excision, movement of parenchymal flaps of the mammary gland;

- the movement of the nipple-areolar complex with preservation of blood circulation in the latter;

- stabilization - fixation of simulated breast tissue to stable structures of the chest wall;

- the formation of a new skin cover around the mammary gland.

The main method of surgical treatment of hypermastia is reduction mammoplasty (Breast hypertrophy: varieties and methods of treatment. Http: /plastic-beauty.ru/plastic/grud/mammoplastica-gipertrofiya-moloclmyx-zhelez-raznovidnosti-i-metody-lecheniya.html.) . Several methods are used to conduct an incision. Any of them includes the solution of three main tasks of surgical intervention:

- elimination of excess tissue by resection;

- restoration of the correct position of the nipple-areolar complex;

- elimination of stretch marks on the skin, which were formed as a result of proliferation of glands.

There are many different options for this operation, but none of them gives a reliable guarantee that the newly formed volume will not go down and there will be secondary ptosis (omission) of the mammary glands, which will not satisfy the patient. In addition, the great difficulty lies in maintaining normal blood supply in the moved nipple-areolar complex.

A modified method of reduction mammoplasty is known for gigantomastia (Questions of reconstructive and plastic surgery. No. 3 (62) September 2017. P.15-19). A feature of this technique is the presence of a tunnel with walls in the form of a dermal pedicle and a fibrous septum, which avoids mechanical impact on the nutritional pedicle of the nipple-areolar complex, preserves the microcirculation of the displaced layer of the mammary gland, prevents the development of necrosis and complete denervation of the areola.

A known method of surgical treatment of breast hypertrophy (Hypermastia (gigantomastia) - causes, treatment methods (http: //novmed-opertsij/139-gipermastiya-gigantomastiya-kogda-grud-slishkom-bolshaya.html), including surgical sections along the lines that applied to the breast with a marker before the intervention, elimination of excess tissue volume by resection based on the size of the glands, shape and volume of excess tissue, while the nipple is separated so as not to disturb its blood supply and innervation. drainage.

The disadvantage of these methods is the lack of strengthening the remaining breast tissue and the lack of prevention of secondary ptosis of the mammary glands.

The closest is the method of mastopexy in combination with breast reduction (RF Patent 2339316, IPC АВВ 17/00, publ. 2008), which consists in the formation of a cut, a line of a submammar fold, de-epidermization of the skin around the nipple-areolar complex, and excision of the excess tissue volume by resection based on the size of the gland, the shape and volume of excess tissue, the formation of a pocket extending from the submammary fold up to the third rib, placement under a raised breast tissue in a pocket of a mesh implant, which is fixed ruyut to the fascia of the pectoral muscle at the level of the third intercostal space, suturing the bottom of their own breast tissue at the site of resection sutures, suturing the skin around the nipple intradermal purse-string suture.

The disadvantage of this method is the use of mesh polypropylene implants, which give the formation of coarse scar tissue, causing deformation and discomfort in patients.

The objective of the invention is to eliminate these drawbacks, reduce the incidence of postoperative complications, prevent secondary ptosis, improve aesthetic results through the use of ultra-thin mesh implants that cause a minimal inflammatory reaction, the formation of “soft” (highly elastic) scar tissue and, as a result, the creation of a stable structure of the mammary gland, the formation of thin postoperative scars.

The problem is solved in the proposed method by forming a cut and a line of a submammary fold, de-epidermization of the skin around the nipple-areolar complex, excising excess tissue by resection based on the size of the gland, shape and volume of excess tissue, forming a pocket extending from the submammary fold up to the third rib, placing under the raised breast tissue in the pocket of the mesh implant, which is fixed to the fascia of the pectoral muscle at the level of the third intercostal space, suturing the lower part ti en prostate tissue resection in place sutures, suturing of tissue around the nipple locking purse string suture, and the skin intracutaneous seam. What is new is that the pocket is performed in a retromammary space with the size of a “spot” of the breast, the mesh implant is cut out the same size, while the material of the mesh implant is “titanium silk”, and the implant is fixed to the fascia of the pectoral muscle along the anterior axillary line laterally and medially along the parasternal line, the breast parenchyma is placed on top, and the lower part of the implant is turned forward, freely laid on the lower slope of the breast without fixation.

The fact that they use a titanium mesh implant subglandularly with approaching the lower slope of the mammary gland, which 2-3 weeks after the operation grows with a gentle connective tissue membrane, closely connected with the breast tissue, allows to obtain a strong structure and prevent secondary ptosis of the mammary gland.

In FIG. 1 shows a pattern of tissue cutting; in FIG. 2 shows the layout of the implant.

The method is as follows.

The operation is performed under general anesthesia. Carry out the formation of cutting and submammar folds. Using a special cylinder, within the existing areola, mark a circle with a diameter of, as a rule, 52 mm in size so that the center of the nipple coincides with the center of the circle. The epidermisation of the skin around the nipple-areolar complex is carried out.

Then, the excess tissue volume is excised by resection based on the size of the gland, the shape and volume of excess tissue. In this case, an incision is made around the areola along the borders of the lower leg and periareolar resection zone, then the epidermisation of the lower leg zone and periareolar resection zone in the cranial direction is carried out. Next, the parenchyma is dissected from the lateral edge of the lower leg, along the border of the zone of periareolar resection, enveloping it, and ends at the medial edge of the lower leg. Dissection is stopped upon reaching the superficial fascia of the pectoralis major muscle.

A subglandular pocket is formed with the size of a “spot” of the mammary gland extending from the submammal fold up to the third rib. Next, a titanium mesh implant from the material "titanium silk" is cut out according to the size of the "spot" of the mammary gland, taking into account the width and height and projection of the newly simulated mammary gland, placed under the raised breast tissue in a pocket on the fascia of the pectoralis major muscle at the level of the third intercostal space, fixed to with her two absorbable sutures at the level of the third intercostal space, namely in the projection of 2-3 ribs, laterally and medially along the parasternal line, the breast parenchyma is placed on top, the lower part of its own tissue is The esa at the resection site is sutured with separate sutures, the lower part of the implant is turned forward, freely laid on the lower slope of the mammary gland, without fixation, the tissues around the nipple are sutured with a purse blocking suture, and the skin with an intradermal suture. Next, the mammary gland is covered with a skin-fat cover, it is simulated, with excision of the excess, and layer-by-layer suturing of the surgical wound.

Example.

A 47-year-old patient complained of excess mammary glands, pain in the cervical and thoracic spine, diaper rash on the skin under the mammary glands. In the history of 2 births, 2 breast-feeding, more than 10 years have passed since the last lactation. During lactation, a large amount of milk was noted, in the post-lactation period - a gradual increase in the volume of the mammary glands. Recent years have been marked by evening pain in the cervical and thoracic spine. It is observed by a mammologist, an ultrasound scan or mammogram is performed annually, and in conclusion, breast hypertrophy is predominantly due to adipose tissue. Somatically healthy. Height 169 cm, weight 75 kg.

Based on complaints, examination, clinical data and medical history, a diagnosis was made: breast hypertrophy.

The patient was offered surgical treatment in the amount of: reduction of mammary gland tissue using titanium mesh endoprostheses.

The patient received antibiotic prophylaxis and VTEC prophylaxis in the preoperative period according to the hospital's internal protocols.

Under ETN, after preliminary treatment of the skin with a 52 mm antiseptic solution, a skin incision was made in the area of the right areola of the mammary gland, as well as along the borders of the lower leg and periareolar resection zone according to the T-inverse markup. Skin-fatty flaps were mobilized, a dissection of the mammary parenchyma from the lateral edge of the lower leg along the border of the zone of periareolar skin resection was performed, enveloping it to the medial edge of the lower leg. A subglandular pocket was formed, in accordance with the “spot” of the mammary gland, 6 × 11 cm in size, the last placed a titanium mesh implant of the material “titanium silk” with a size of 6 × 11 cm. The implant is fixed to the fascia of the pectoralis major muscle with nodal sutures with PDS II 3 thread / 0 in the projection 2-3 ribs laterally along the anterior axillary line and medially along the parasternal line, laid along the front surface of the chest with the transition to the lower slope of the mammary gland.

Hemostasis by coagulation, layered sutures for wounds (PDS II 3/0, monocryl 3 / 0.4 / 0,). The skin is sutured with an intradermal suture monocryl 4/0, 3/0. A similar operation was performed on the left mammary gland. Aseptic dressings. Compression underwear.

In the postoperative period, the patient received anti-inflammatory, hemostatic and anti-edematous therapy. The patient was discharged for outpatient treatment on the 4th day after the operation. It is recommended to continue using compression underwear for 3 weeks after surgery.

The result of surgical treatment can be assessed as satisfactory. At the control examination after 1 month, the postoperative wounds healed by first intention, the mammary glands are significantly reduced in volume. The patient notes the absence of pain in the back and neck.

According to the proposed method, 10 patients were operated on, in all cases a good clinical and aesthetic result was achieved. The fixation of the implant made of "titanium silk" according to the invention avoids severe inflammation, the implant heals well, which accordingly eliminates the formation of coarse scar tissue, the absence of deformation and the creation of a good framework supporting the mammary gland.

Thus, the proposed method allows you to:

- achieve a stable treatment result, reduce the recurrence rate, and increase patient satisfaction with the quality of medical care;

- allows you to remove the required volume of breast tissue without malnutrition and denervation of the nipple-areolar complex;

- mesh implants "titanium silk" are not palpable, patients do not cause discomfort;

- patient satisfaction with the results of surgical treatment is complete.

Mesh implants made of "titanium silk" are radiopaque, which at the next stage of the study will allow them to be visualized during computed tomography, and to assess the adequate and stable location in the tissues and the "relationship" with breast tissue.

Mesh implants made of titanium silk material can be considered as a promising group of implants for reduction mammoplasty in order to prevent the occurrence of secondary ptosis.

These innovations make it possible to achieve a stable treatment result, reduce the recurrence rate, and increase patient satisfaction with the quality of medical care.

The results obtained suggest that the method is physiological and combines the restoration of the anatomical relationships of structures and an excellent aesthetic result. Techno-economic improvement should be considered a decrease in the frequency of recurrence of ptosis and repeated surgical interventions, a reduction in rehabilitation time.

Claims (1)

The method of plasty in combination with the reduction of the mammary gland, which consists in the formation of a nesting line, a submammary fold, de-epidermisation of the skin around the nipple-areolar complex, excision of excess tissue by resection based on the size of the gland, the shape and volume of excess tissue, the formation of a pocket extending from the submammary fold up to the third rib, placing under the raised breast tissue in the pocket of the mesh implant, which is fixed to the fascia of the pectoral muscle at the level of the third intercostal space, suturing the lower part of the gland’s own tissue at the site of resection with separate sutures, hemming the skin around the nipple with a purse-string intradermal suture, characterized in that the pocket is performed in the retro-mammary space with the size of the “spot” of the mammary gland, the mesh implant is cut out the same size, using the material “titanium silk ”, And the implant is fixed to the fascia of the pectoral muscle along the anterior axillary line laterally and medially along the parasternal line, breast parenchyma is placed on top, and the lower part of the implant tucked forward, freely laid on the lower slope of the mammary gland without fixation.

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