RU2705265C2 - Method of one-stage breast reconstruction in cancer using an alloimplant based on a dura mater and a silicone endoprosthesis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to reconstructive plastic surgery of mammary gland. Greater pectoral muscle is mobilized by cutting off the lower edge of its attachment, laterally to the level corresponding to 9 o'clock on the clock face. Lower-lateral part of the greater pectoral muscle is separated from the anterior thoracic wall and a sub-pectoral pocket is formed by electrodissection to labeled levels along the perimeter of the formed gland. After the sub-pectoral pocket is created, a human dura mater (DM) membrane is prepared. Formed DM is laid on the lower breast reconstruction zone corresponding to the lower breast slope, DM edge is anchored with atraumatic suture to free edge of great pectoral muscle. Pocket width is selected to select a silicone endoprosthesis, followed by hemostasis in the formed sub-pectoral pocket. Silicone endoprosthesis is placed into the pocket. Free edge of DM is fixed in area of submammary fold, then edges of musculus serratus anterior and DM are fixed. Postoperative wound is closed in layers to leave two drainages installed in a bed of the endoprosthesis and in an axillary region – an area of lymphadenectomy.

EFFECT: method enables reducing the risk of postoperative ulcers and extrusion of the silicone implant, reducing traumatism and surgical intervention by eliminating the need to use autologous muscle grafts.

1 cl, 11 dwg, 1 ex

Description

The invention relates to medicine, namely to reconstructive plastic surgery of the mammary gland (MF), including in the treatment of breast cancer to strengthen the lower slope of the formed mammary gland.

Reconstructive plastic surgery occupies a major place in the rehabilitation of patients with breast cancer. To achieve a good cosmetic result and faster psychological and physical rehabilitation of patients, reconstruction must be performed simultaneously with radical surgical treatment. Currently, there are a large number of methods for performing breast reconstruction. One of the most commonly used is a radical skin-preserving mastectomy with simultaneous reconstruction with a silicone endoprosthesis.

Many patients, when performing simultaneous reconstruction of the mammary gland using a silicone endoprosthesis, do not have enough volume of their own tissues to reliably cover the endoprosthesis.

It is known that, if necessary, synthetic mesh or biological implants or autologous flaps are used to shelter and strengthen the lower slope of the reconstructed mammary gland.

As the biological implants in Russia, the acellular dermal matrix (ADM) is used - a donor dermal flap, deprived of its antigenic properties by specialized processing, as well as various mesh implants. There are several options for ADM. Permacol Pork ADM is approved for use in Russia. Currently, in foreign countries, most dermal matrices used for breast reconstruction include the human matrix, pork matrix, or cattle matrix. The human matrix is represented by Alloderm (LifeCell, Branchburg, NJ), Flex HD (Ethicon, Sommerville, NJ), Neoform (Mentor, Santa Barbara, CA), DermaMatrix (Synthes, West Chester, PA). The porcine matrix includes Strattice (LifeCell, Branchburg, NJ) and Permacol (Covidien, Boulder, CO). Human ADM in Russia is not registered and cannot be used. For breast reconstruction, ADM of animal origin based on Permacol pig skin (Covidien, Boulder, СО) is used.

The world literature contains data on the use of lyophilized dura mater (hereinafter - TMT) in neurosurgery - replacement of defects in the patient's own dura mater with autologous transplants, in abdominal surgery - strengthening of the anterior abdominal wall during hernioplasty, and oncourology. In 1971, an article was published by A. Kelami et al., Which published 7 successful clinical cases of bladder wall replacement in cancer patients with an alloimplant based on lyophilized TMT. There is also work in the world literature on the use of TMT-based allografts in the treatment of Peyronie's disease. In 1988, in the Ottawa Clinic, 17 patients from the age of 39 to 72 suffering from Peyronie's disease replaced a part of the protein coat of the penis at the site of its curvature with lyophilized dura mater material.

The most optimal method for the manufacture of TMT biografts in the Russian Federation is known (RU 2506955). This allograft is successfully used for endoscopic interventions in reconstructive surgery, including laparoscopic hernioplasty, plastic surgery of the anterior abdominal wall in the treatment of ventral hernias with anatomical deficiency, restrained and irreversible hernias.

In foreign and domestic literature, such an application of an allograft based on human TMT is not described.

The closest is the method of simultaneous reconstruction of the mammary gland in cancer using the acellular dermal matrix and silicone endoprosthesis (RU 2584133 C2). The stage of subcutaneous mastectomy and lymphadenectomy with simultaneous reconstruction with a silicone implant is performed, while the pectoralis major muscle is mobilized by cutting from the lower edge of its attachment, laterally to the level corresponding to 9 hours on the dial, the lower lateral part of the pectoralis major muscle is separated from the anterior chest wall and formed by electrodissection subpectoral pocket to marked levels around the perimeter of the formed gland and create a subpectoral pocket.

The disadvantage of this method is the use of the matrix obtained from another type of organism, as well as its cost: depending on the type of donor material, the size and thickness of the matrix, it can vary from $ 520 to $ 4,856.

The technical result of the invention is to strengthen the lower slope of the reconstructed mammary gland to reduce the risk of pressure sores, extrusion of a silicone implant, reduce the morbidity of surgical intervention during simultaneous breast reconstruction for cancer by eliminating the need for autologous muscle transplants.

The specified technical result in the implementation of the invention is achieved due to the fact that, as in the known method, they perform the stage of subcutaneous mastectomy and lymphadenectomy with simultaneous reconstruction with a silicone implant, while the pectoralis major muscle is mobilized by cutting from the lower edge of its attachment, lateral to the level corresponding to 9 hours on the dial, the lower lateral part of the pectoralis major muscle is separated from the anterior chest wall and by electrodissection form a subpectoral pocket for marked levels on the perimeter formed by the prostate and create subpektoralny pocket.

A feature of the proposed method is that a dura mater of a person is projected onto the lower zone of the reconstructed mammary gland corresponding to the lower slope, its edge is sutured with an atraumatic thread to the free edge of the pectoralis major muscle, and the width of the pocket is measured to select a silicone endoprosthesis, after which hemostasis in the formed subpectoral pocket and a silicone endoprosthesis is placed in it, the free edge of the TMT is fixed in the area of the submammary fold, then fixed the edges of the anterior dentate muscle and TMT according to a similar fixation technique with the pectoralis major muscle to create the tightness of the muscle-matrix pocket, the postoperative wound is sutured in layers, leaving two drainages installed in the endoprosthesis bed and in the axillary region - the lymphadenectomy zone.

The invention is illustrated by a detailed description, clinical example and illustrations, which depict:

FIG. 1 - a skin incision was made according to the marking.

FIG. 2 - performing a subcutaneous mastectomy.

FIG. 3 - cutting off the costal part of the pectoralis major muscle.

FIG. 4 - laying of the projection of TMT on the lower slope of the mammary gland.

FIG. 5 - fixation of TMT to the edge of the pectoralis major muscle.

FIG. 6 is a view of TMT fixed to the edge of the pectoralis major muscle.

FIG. 7 - installation of the implant in a subpectoral pocket.

Fig 8 - fixation of TMT to the submammary fold.

Figs. 9 is a view of a formed pocket with an implant installed.

FIG. 10 is a view of a patient before surgery.

FIG. 11 is a view of a patient after surgery.

The method is as follows.

In the position of the patient on the back under general anesthesia according to preliminary marking, subcutaneous mastectomy with regional lymphadenectomy is performed (Fig. 1, Fig. 2). The question of the number of levels of lymphatic dissection is decided depending on the stage of the disease, the absence or presence of metastatic lymph nodes. Lymphadenectomy is performed according to a standard technique. The pectoralis major muscle is mobilized by cutting off from the lower edge of its attachment to the chest wall laterally to the level corresponding to 9 hours on the dial. The lower lateral part of the pectoralis major muscle is separated from the anterior chest wall (Fig. 3). After the successful creation of a subpectoral pocket, the TMT plate is prepared according to the manufacturer's recommendations. For 10-15 minutes, the TMT is completely immersed in 0.9% saline solution, during which time the area of the TMT and its softening increase, which makes it possible to completely cover the lower implant policy without irregularities and sharp corners. TMT are projected onto the lower breast reconstruction zone corresponding to the lower slope (Fig. 4). The edge of the TMT is sutured with an atraumatic thread to the free edge of the pectoralis major muscle (Fig. 5). After the TMT is firmly attached to the free edge of the pectoralis major muscle (Fig. 6), the pocket width is measured to select a silicone endoprosthesis. A thorough hemostasis is carried out in the formed subpectoral pocket. A silicone endoprosthesis is placed in the latter (Fig. 7). The free edge of the TMT is fixed in the area of the submammar fold (Fig. 8). Next, the edges of the anterior dentate muscle and TMT are fixed by a similar fixation technique with the pectoralis major muscle to create a tight muscle-matrix pocket (Fig. 9). The postoperative wound is sutured in layers, leaving two drainages installed in the endoprosthesis bed and in the axillary region - the lymphadenectomy zone.

Clinical example.

Patient N. 41 years old (Fig. 10). Clinical diagnosis: Stage IIA breast cancer, stage cT2N0M0G2, pT2N0M0G2R1. Luminal type A. Condition after surgical treatment.

Immunohistochemical conclusion: ER-8, PR-8, Ki67-4%, Her2 / neu neg. Conclusion: Luminal type A.

Complaints at admission: for the presence of a tumor in the right mammary gland.

Medical history. In May 2018, she independently discovered a seal in the right mammary gland, an increase in size. Surveyed at the place of residence, suspected malignant process. In September 2018, she turned to the polyclinic of the P.A. Herzen, for further examination and development of treatment tactics, was comprehensively examined, a biopsy of the breast tumor was performed. In a morphological study, breast cancer was verified. According to the survey - data for distant metastasis was not identified. Discussed at the interdepartmental consultation, at the first stage, surgical treatment is recommended.

Local status upon admission. The skin of the mammary glands is clean, swelling is not observed. Nipple-areolar complexes are not changed. No discharge from the nipples. In the right mammary gland, at the border of the upper quadrants, a seal is palpated without clear contours, a dense-elastic consistency of up to 3 cm in diameter. In the left mammary gland, nodules are not palpable. Available palpations of the lymph nodes are not changed. According to a comprehensive examination of the mammary glands in the right mammary gland at the border of the upper quadrants, a hypoechoic formation of 25 × 18 × 19 mm of irregular vertical orientation with fuzzy uneven contours without blood flow with microcalcinates in the center with an acoustic shadow. Data for regional and distant metastasis have not been identified.

The patient refused the proposed symmetrizing operation on the contralateral mammary gland.

The patient underwent surgery.

In the position of the patient on the back under general anesthesia, a subcutaneous mastectomy with regional lymphadenectomy was performed (Fig. 1, Fig. 2). Lymphadenectomy was performed according to a standard technique. The pectoralis major muscle was mobilized by cutting off from the lower edge of its attachment to the chest wall laterally to the level corresponding to 9 hours on the dial. The lower lateral part of the pectoralis major muscle was separated from the anterior chest wall (Fig. 3). After creating a subpectoral pocket, the preparation of the TMT plate was carried out. TMT was projected onto the lower breast reconstruction zone corresponding to the lower slope (Fig. 4). The edge of the TMT was sutured with an atraumatic thread to the free edge of the pectoralis major muscle (Fig. 5). After the TMT was firmly attached to the free edge of the pectoralis major muscle (Fig. 6), the pocket width was measured to select a silicone endoprosthesis. Hemostasis was performed in the formed subpectoral pocket and the silicone endoprosthesis was placed there (Fig. 7). The free edge of the TMT was fixed in the area of the submammar fold (Fig. 8). Next, the edges of the anterior dentate muscle and TMT with the pectoralis major muscle were fixed to create the tightness of the muscle-matrix pocket (Fig. 9). The postoperative wound was sutured in layers, leaving two drainages installed in the endoprosthesis bed and in the axillary region — the lymphadenectomy zone (Fig. 10).

Histological examination of surgical material. In the breast tissue, a dense tumor node without clear boundaries, 2 × 2 × 2 cm in size. Axillary tissue is a piece of fatty tissue 6 × 4 × 1.5 cm in size, with 9 soft-elastic lymph nodes with a diameter of 0.2-2 cm. Accordingly macroscopically described tumors in a breast tissue fragment — lobular infiltrative cancer, G2, with lobular carcinoma structures in situ, moderate focal lymphoid infiltration in the tumor. In the surrounding breast tissue, taken near and far from the tumor node without tumor growth. In 9 examined lymph nodes of the axillary tissue - there are no metastases, histiocytosis of the sinuses, anthracosis.

The use of the dura mater based on the dura mater of the human brain made it possible to strengthen the lower slope of the reconstructed mammary gland, reduce the risk of pressure sores and extrusion of the silicone implant, and also reduce the invasiveness and time of surgical intervention by eliminating the need for autologous muscle grafts.

Claims (1)

The method of simultaneous reconstruction of the mammary gland, including the stage of subcutaneous mastectomy and lymphadenectomy with simultaneous reconstruction with a silicone implant, while the pectoralis major muscle is mobilized by cutting from the lower edge of its attachment, laterally to the level corresponding to 9 hours on the dial, the lower lateral part of the pectoralis major muscle is separated from the front the chest wall and by electrodissection form a subpectoral pocket to marked levels along the perimeter of the formed gland, characterized the fact that after creating a subpectoral pocket, the preparation of the plate of the dura mater of a person is carried out - TMT, the formed TMO is laid along the lower area of the breast reconstruction corresponding to the lower slope of the mammary gland, the edge of the TMT is sutured with an atraumatic thread to the free edge of the pectoralis major muscle, the width of the pocket is measured for selection silicone endoprosthesis, after which hemostasis is performed in the formed subpectoral pocket, the silicone endoprosthesis is placed in the pocket, the free edge of the TMT is fixed in the area of the submammary fold, then the edges of the anterior dentate muscle and TMT are fixed, the postoperative wound is sutured in layers, leaving two drainages installed in the endoprosthesis bed and in the axillary region - the lymphadenectomy zone.

Images