RU2735501C1 - Method for one-stage breast reconstruction in surgical treatment of breast cancer - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to oncology, surgery. First, in the standing patient's position, preoperative marking is performed, during which the outline of the excised skin is applied, as well as marking lines - median line, line of submammary fold, lines corresponding to upper and lower edges of incisions, as in Fig. 1, a section of intact skin is selected outside projection of breast tumour, which will be a donor dermal flap. Scalpel or dermatome is used to remove the epidermis on the marked skin area, and the flap is separated from the subcutaneous fat. Produced dermal flap is wound with a sterile tissue moistened in 0.9 % NaCl solution. That is followed by a mastectomy with an axillary-subclavicular lymphadenectomy. Expander bed is formed by cutting a lower edge of a greater pectoral muscle from the lateral border to a middle one-third of the sternum, a lower and lateral walls of the expander bed are formed with a dermal flap of the "hammock" type, wherein the lower edge of the dermal flap is anchored to the submammary fold. Tissue expander is installed. Then upper edge of dermal flap is fixed to lower edge of dissected large pectoral muscle, and lateral edges of dermal flap are fixed to serratus muscles and lateral edge of greater pectoral muscle. Separate drainage of tissue expander bed and axillary area is performed. Wound is sutured in layers.

EFFECT: method provides an effective one-stage breast reconstruction in surgical treatment of breast cancer, eliminates a flap rejection reaction, thereby improving engraftment, provides a good elasticity of the flap, considerably reduces the cost of the materials required for the surgical intervention.

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Description

The invention relates to oncology, surgery and can be used when performing mastectomy.

As you know, the mammary gland is a sign of femininity and sexuality. Its loss in the process of surgical treatment of breast cancer leads to unfavorable psychological changes, social, emotional maladjustment, the acquisition of addictions, family breakdown, etc. Despite the fact that overall survival and a disease-free period are the main and decisive factors in the medical care for patients with breast cancer, the quality of life of these patients is also of great importance.

Currently, surgical treatment of breast cancer in women is not only the removal of part or all of the breast, but also the restoration of the shape of the mammary glands. Breast reconstruction is performed at once or delayed. One-stage reconstruction can be performed in one stage, when it is possible to immediately install an implant. Or in two stages, when, due to skin deficiency, a tissue expander is installed at the first stage, which is replaced by an implant in the second stage after dermotension. We are considering the first stage of one-stage breast reconstruction - the installation of a tissue expander.

The known method of subcutaneous mastectomy (Malygin E.N., Malygin S.E. Mastectomy with preservation of the skin of the mammary gland with the simultaneous use of the lower recto-abdominal flap. // Annals of plastic, reconstructive and aesthetic surgery. 1997. 3. S. 47-51 ). The authors suggested performing a subcutaneous mastectomy through a circular periareolar incision with a continuation into the axillary region to remove breast tissue, subclavian, axillary and subscapularis tissue, the nipple-areola complex, and skin over the tumor, followed by reconstruction of the breast with a lower recto-abdominal flap. However, removal of the nipple-areola complex in initial cancer and lateral tumor localization is not always justified, and the presence of a postoperative scar from the areola to the axillary cavity significantly impairs the appearance of the operated organ. In addition, these scars are often retracted; contraction of the scar along its length shifts the areola outward and upward. Dissection of the skin with a removed mammary gland can initiate trophic disorders and marginal necrosis of the skin with subcutaneous tissue at the site of wound closure.

As the closest analogue of the proposed method, there is a known method of one-step reconstruction of the mammary gland with organ-preserving surgical treatment of cancer when the tumor is localized in the outer quadrant, including preoperative marking, resection of the mammary gland and axillary-subclavian-subscapularis lymphadenectomy, when the tumor is close to the skin during preoperative markings apply a clear contour of the excised skin over the tumor, taking into account the closure of the defect with a displaced skin-glandular flap, markings are carried out in the patient's standing position, determine the required volume and size of the removed sector.

Marking lines of the midline, the middle meridian of the mammary gland are applied - 1.medioclavicularis from the middle of the clavicle through the nipple, the middle of the lower slope, the submammary fold, the line of the submammary fold, mark the point of the new position of the nipple, located 20 cm from the jugular notch of the sternum to the line of the middle meridian of the milk glands, outline the medial line due to the displacement of the gland upward and laterally and connect the point of the new location of the nipple with the middle of the submammary fold, outline the lateral line due to the displacement of the gland upward and medially and connect the point of the new location of the nipple with the middle of the submammary sweet, determine the upper edge of the new location of the areola ... From the point of the new position of the nipple, 5 cm are laid along the medial and lateral lines and a marking mark is placed, from the last 6 cm are laid down along the lateral and medial lines and a marking mark is placed. From the last mark, 6 cm is laid along the medial line after the lateral displacement of the mammary gland, a horizontal line is drawn in the direction of the midline to the submammary fold, after the displacement of the mammary gland, a horizontal line is drawn medially laterally to the submammary fold, according to the marking of the sector with the tumor, skin incisions are made, the sector is removed with a tumor and skin over it to the fascia of the pectoralis major muscle, the sector is sent for an urgent morphological study, and upon receiving a response about the negative margins of the resection, proceed to the next stage. After fixing the metal staples in the tumor bed, a regional lymphadenectomy is performed from a separate incision in the axillary region, then skin incisions are made along the marking lines, de-epidermis of this zone is carried out, in the projection zone of the new areola to create the space necessary for turning the superior medial glandular pedicle, glandular tissues are removed the upper-lateral semicircle, when the tumor is localized in the upper-outer quadrant, the upper-medial and lower skin-glandular pedicles are formed with a single flap up to the fascia of the pectoralis major muscle. Using an electrocoagulator, the area of the glandular pedicle and the area of the removed sector of the mammary gland are connected to the tumor, thereby creating a tunnel for moving the glandular pedicle to the area of the removed sector, the leg is separated from the fascia to the periareolar zone and unfolded, moving to the area of the removed sector of the mammary gland, where after the formation of a donor skin flap according to the size of the defect is fixed with separate interrupted sutures with an atraumatic thread to the nearest areas of the glandular tissue in the recipient zone, and the lower lateral and medial fragments of the mammary gland are removed, the areola is moved to the level of the upper incision and fixed, after which the skin and subcutaneous flaps of the lower quadrants are layer-by-layer sutured, carrying out one-stage mastopexy. Further, the wounds in the area of the reconstructed mammary gland and axillary region are sutured in layers with the imposition of an intradermal cosmetic suture and leaving the vacuum drainages removed through the counterpertures in the axillary region and the retromammary space (RU 2623453 C2, 06/26/2017).

However, all these methods do not use an autodermal flap, which is not comparable in its extensibility to an acellular dermal flap (ADM), which allows the use of an expander, and the autodermal flap is taken from the area of the affected breast, but at the same time from the area where the skin is intact.

In the classical version of the installation of the tissue expander, the surgeon cuts off the lower edge of the pectoralis major muscle from the lateral edge, to approximately the middle third of the sternum, mobilizing the pectoralis major muscle, thus strengthening the anterior-superior wall of the expander bed.

Next, the anterior dentate muscles are separated, which strengthen the lateral wall of the expander bed.

The inferior anterior wall of the bed is usually reinforced with various types of synthetic meshes or an acellular dermal matrix (ADM). But rarely, the lower anterior semicircle is not strengthened, which may be the reason for its weakness in the pocket segment and protrusion of the implant. (Blokhin S.N., Portnoy S.M., Laktionov K.P. Primary breast reconstruction in cancer // Clinical mammology: current state of the problem / edited by E.B. Kampova-Poleva and S.S. Chistyakov. .: GEOTARMedia, 2006. S. 500-511; Ptukh E.Ya., Prikhodko K.A. Primary breast reconstruction with preservation of the nipple-areola complex // Pacific Medical Journal. 2016. No. 1. P. 86-88) ...

Before the advent of ADM, the anterior-lower wall of the implant bed was reinforced with various types of synthetic meshes. This technique is still used in many clinics.

With the advent of ADM, it became possible to use it to strengthen the anterior-inferior and lateral walls of the tissue expander bed without involving the dentate muscles.

ADM was originally created to correct the shape of the breast after augmentation in order to eliminate all irregularities and contour anomalies. The popularity of this material was facilitated by the publication of K. Breuing and A. Colwell, which described the possibility of using ADM to strengthen the lateral wall of the implant bed. Subsequently, observations of the use of ADM in two-stage reconstruction with a tissue expander were described.

Advantages of ADM: reduced intensity of postoperative pain syndrome, no damage in the donor area, improved aesthetic results. The literature also contains information about an increase in the number of postoperative infectious complications, seromas, explantation when using ADM. Currently, most dermal matrices used for breast reconstruction include human matrix, porcine matrix, or matrix from cattle. The human matrix is represented by Alloderm (LifeCell, Branchburg, USA), Flex HD (Ethicon, Sommerville, USA), Neoform (Mentor, Santa Barbara, USA), DermaMatrix (Synthes, West Chester, USA). Porcine matrix includes Strattice (LifeCell, Branchburg, USA) and Permacol (Covidien, Boulder, USA). Bovine matrix is presented in the only version on the market as Surgimend (TEI Biosciences, Boston, USA). ADM can be used both for immediate and delayed breast reconstruction (Using a biological implant for simultaneous breast reconstruction for cancer. Doctor of Medical Sciences AD ZIKIRYAKHODZHAEV, Candidate of Medical Sciences MV ERMOSHCHENKOVA. SURGERY 1, 2015, 35-40.doi: 10.17116 / hirurgia22015135-40).

Many of these materials are expensive (for example, the cost of Alloderm from LifeCell, Branchburg, USA is $ 3,651) due to the labor intensity of their production, and therefore insurance companies do not always pay for the cost of these materials.

We have proposed an operation technique in which ADM and its analogs and artificial meshes can be replaced with the patient's own tissue (autodermoplasty).

The technical result of the invention is to provide an effective one-step reconstruction of the mammary gland in the surgical treatment of breast cancer due to the use of the treated dermis of the breast outside the projection of the tumor, which strengthens the anterior, lower and lateral walls of the expander bed, which eliminates the reaction of flap rejection, and, accordingly, improves engraftment, provides good elasticity of the flap, which is incomparable with ADM and even more so with artificial meshes, and, in particular, significantly reduces the cost of materials required for this surgical intervention.

The technical result of the method is achieved by carrying out preoperative marking, axillary-subclavian-subscapularis lymphadenectomy, characterized in that during the preoperative marking the contour of the excised skin is applied, the marking is carried out in the patient's standing position, marking lines are applied - the midline, the submammary fold line, the lines corresponding the upper and lower edges of the incisions, an area of intact skin is isolated outside the projection of the breast tumor, which will be a donor dermal flap, using a scalpel or a dermatome, the epidermis is removed on the marked area of the skin, using a scalpel, the flap is separated from the subcutaneous fat, the resulting dermal flap is wrapped a sterile napkin soaked in a 0.9% NaCl solution, a mastectomy is performed, a bed for a tissue expander is formed: the lower edge of the pectoralis major muscle is cut off from the lateral edge to the middle third of the sternum, the lower and lateral walls of the expander bed are formed the obtained dermal flap of the "hammock" type, while the lower edge of the dermal flap is sutured to the submammary fold, an expander is installed, the upper edge of the dermal flap is fixed to the lower edge of the cut pectoralis major muscle, and the lateral edges of the dermal flap are fixed to the dentate muscles of the major and lateral edge muscles, carry out separate drainage of the tissue expander bed and the axillary region, the wound is sutured in layers.

The proposed method is illustrated by the following figures:

- fig. 1, 1a - Preoperative marking:

a) midline and submammary fold

b) marking the tumor on the projection of the skin

c) lines corresponding to the upper and lower edges of the cuts

d) selection of a skin area outside the projection of a breast tumor, which will be a donor for autodermoplasty.

- fig. 2, 2a - De-epitalization of the marked skin flap,

- fig. 3 - Preparation of an autograft,

- fig. 4, 4a - Mobilization of the pectoralis major muscle,

- fig. 5 - Suturing the lower edge of the graft to the submammary fold,

- fig. 6 - Suturing the flap to the pectoralis major muscle,

- fig. 7 - Suturing the lateral edge to the dentate muscles.

The method is carried out as follows.

Previously, in the standing position of the patient, preoperative marking is carried out, during which the contour of the excised skin is applied, and the marking lines are also applied - the midline, the submammary fold line, the lines corresponding to the upper and lower edges of the incisions (Fig. 1). An area of intact skin is isolated outside the projection of the breast tumor, which will serve as a donor dermal flap (Fig. 1a).

Using a scalpel or a dermatome, the epidermis is removed on the marked area of the skin, the flap is separated from the subcutaneous fat (Fig. 2, 2a). The resulting dermal flap is wrapped in a sterile napkin soaked in a 0.9% NaCl solution (Fig. 3). Then a mastectomy is performed with an axillary-subclavian-subscapularis lymphadenectomy.

An expander bed is formed, for which the lower edge of the pectoralis major muscle is cut off from the lateral edge to the middle third of the sternum (Fig. 4, 4a), the lower and lateral walls of the expander bed are formed with the resulting dermal flap like a "hammock", while the lower edge of the dermal flap is sutured to the submammary fold (Fig. 5). A tissue expander is installed.

Then the upper edge of the dermal flap is fixed to the lower edge of the cut off pectoralis major muscle, and the lateral edges of the dermal flap are fixed to the dentate muscles and the lateral edge of the pectoralis major muscle (Fig. 6, 7).

Separate drainage of the tissue expander bed and the axillary area is performed. The wound is sutured in layers.

Clinical example 1.

Patient X., 48 years old, with a diagnosis of right breast cancer, stage I, T1N0M0. Luminal type A.

Previously, in the standing position of the patient, preoperative marking is carried out, during which the contours of the excised skin and marking lines are drawn - the midline, the line of the submammary fold, the lines corresponding to the upper and lower edges of the incisions. An area of intact skin was isolated outside the projection of the breast tumor.

During the operation, the epidermis was removed with a scalpel on the marked area of the skin, the flap was separated from the subcutaneous fat. The resulting dermal flap was wrapped with a sterile tissue soaked in 0.9% NaCl solution. Performed a mastectomy with axillary-subclavian-subscapularis lymphadenectomy.

An expander bed was formed, for which the lower edge of the pectoralis major muscle was cut off from the lateral edge to the middle third of the sternum, the lower and lateral walls of the expander bed were formed with the resulting dermal flap like a "hammock", while the lower edge of the dermal flap was sutured to the submammary fold. We installed an expander.

The upper edge of the dermal flap was fixed to the lower edge of the dissected pectoralis major muscle, and the lateral edges of the dermal flap - to the dentate muscles and the lateral edge of the pectoralis major muscle.

The bed of the tissue expander and the axillary area were drained separately. The wound was closed in layers. An aseptic bandage was applied.

On examination from the 1st to the 7th day of the operation, healing took place by primary intention.

Clinical example 2.

Patient E., 44 years old, was admitted to the Department of Oncology and Reconstructive Plastic Surgery of the Breast and Skin with a diagnosis of Stage IIA right breast cancer, pT2M0M0.G2. Luminal type B. Her2 / neu is a negative subtype.

Previously, in the standing position of the patient, preoperative marking is carried out, during which the contours of the excised skin and marking lines are drawn - the midline, the line of the submammary fold, the lines corresponding to the upper and lower edges of the incisions. An area of intact skin was isolated outside the projection of the breast tumor.

During the operation, the epidermis was removed using a dermatome on the marked area of the skin, and the flap was separated from the subcutaneous fat. The resulting dermal flap was wrapped with a sterile tissue soaked in 0.9% NaCl solution. Performed a mastectomy with axillary-subclavian-subscapularis lymphadenectomy.

An expander bed was formed, for which the lower edge of the pectoralis major muscle was cut off from the lateral edge to the middle third of the sternum, the lower and lateral walls of the expander bed were formed with the resulting dermal flap like a "hammock", while the lower edge of the dermal flap was sutured to the submammary fold. We installed an expander.

The upper edge of the dermal flap was fixed to the lower edge of the dissected pectoralis major muscle, and the lateral edges of the dermal flap - to the dentate muscles and the lateral edge of the pectoralis major muscle.

The bed of the tissue expander and the axillary area were drained separately. The wound was closed in layers. An aseptic bandage was applied.

On examination from the 1st to the 7th day of the operation, healing took place by primary intention.

Thus, we operated on 23 patients with the diagnosis: Breast cancer of various operable stages.

None of the patients had purulent-septic complications.

There are no additional scars on the body, since the donor site of the dermis is taken from the removed breast in compliance with the principles of ablastic surgery.

The elasticity of the autodermal flap made it possible to model it according to its shape and required dimensions.

It was possible to avoid additional spending on artificial materials (mesh) and dermal matrix.

Claims (1)

A method for one-step reconstruction of the mammary gland in the surgical treatment of breast cancer, including preoperative marking, axillary-subclavian-subscapularis lymphadenectomy, characterized in that during the preoperative marking the contour of the excised skin is applied, the marking is carried out in the patient's standing position, marking lines are applied - the midline, the line of the submammary fold, the lines corresponding to the upper and lower edges of the incisions, as in Fig. 1, highlight the area of intact skin outside the projection of the breast tumor, which will be a donor dermal flap, using a scalpel or dermatome on the marked area of the skin, remove the epidermis, using a scalpel the flap is separated from the subcutaneous fat, the resulting dermal flap is wrapped with a sterile napkin soaked in a 0.9% NaCl solution, a mastectomy is performed, a bed for a tissue expander is formed: the lower edge of the pectoralis major muscle is cut off from the lateral edge to the middle third the sternum, the lower and lateral walls of the expander bed are formed by the resulting dermal flap in the "hammock" type, while the lower edge of the dermal flap is sutured to the submammary fold, the expander is installed, the upper edge of the dermal flap is fixed to the lower edge of the cut pectoralis major muscle, and the lateral edges of the dermal flap they are fixed to the dentate muscles and the lateral edge of the pectoralis major muscle, separate drainage of the tissue expander bed and the axillary region is carried out, the wound is sutured in layers.

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