RU2764371C1 - Method for endoprosthetics of mammary glands in combination with mastopexy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to plastic surgery. After marking the anatomical structures, anesthesia and the formation of an inverted T-shaped access, a 2-3 cm thick composite flap is detached in the medial direction to the parasternal line, in the lateral direction to the anterior axillary line and in the caudal direction up to the level of 2-3 ribs, then, by access of 5 cm in the projection of the previously noted submammary fold, passed under the deep leaf of the Scarpa fascia, the inferolateral bundles of the pectoralis major muscle are opened and an isolated two-plane pocket is formed, which is drained and an implant is inserted into it, then the fascia of the mammary gland is fixed to the deep pectoral fascia, then the tissue remaining after the detachment of the composite flap is resected, the area above the areola cut out by the areolotome is de-epidermized to the upper edge of the newly marked areola, the nipple-areola complex is transferred cranially on the superior-medial vascular pedicle.

EFFECT: method allows performing endoprosthetics and breast tightening in case of ptosis of any degree, hypotrophy, tissue hypertrophy, asymmetry, tubularity in combination with ptosis, avoids the most frequent delayed complications, such as lowering of the lower pole according to the "waterfall" type, eliminates early secondary ptosis, reduce the risks of capsular contracture, exclude the contouring of the implant, allows reducing the mammary glands and achieving a long-term aesthetic effect.

5 cl, 2 ex, 7 dwg

Description

The invention relates to medicine, namely to plastic surgery, and can be used to increase the volume of the mammary glands and eliminate ptosis of the mammary glands I-III degree.

The physical and psycho-emotional health of a woman depends on the state of the mammary glands. Modern plastic surgery has the ability to restore or reproduce the mammary gland, commensurate with the body structure and age of the patient. Ptosis of the mammary glands develops due to the weakening of the structures supporting the gland: the skin and ligamentous apparatus. According to well-known classifications, there are three degrees of mastoptosis. The defining features in the classification are the location of the nipple in relation to the fold under the mammary gland (submammary fold) and the localization of the nipple on the gland. Normally, the nipple is located above the submammary fold. With grade I ptosis, the nipple is located at the level of the submammary fold, on the anterior surface of the mammary gland, at grade 2 - below the submammary fold, on the anterior surface of the mammary gland, at grade 3 - below the submammary fold, on the lower surface of the mammary gland. Such a classification in practice allows for the choice of surgical surgical technique for mastopexy (A.A. Vishnevsky, M.I. Kuzmin, V.P. Olenin; Plastic surgery of the mammary gland. M .: Medicine, 1987).

A known method of mastopexy (breast lift) in combination with breast arthroplasty, including marking anatomical formations, implantation of the endoprosthesis and performing upper retromammary mastopexy through submammary access. When marking, the parasternal line, the position of the second rib, the mid-clavicular line, the anterior axillary line, the submammary fold line and the ptosis direction line are applied. The points of pexia of the mammary gland are marked. A skin incision is made, orienting its middle at the intersection of the axis of the mammary gland and the submammary fold. Retromammary mastopexy is performed by successively fixing the upper edge of the own fascia of the mammary gland with the fascia of the pectoral muscle. In the formed bed of the retromammary space, a breast endoprosthesis is installed (patent RU 2180803 C1, publ. 27.02.2002).

The disadvantages of this method are the traumatization of breast tissue when performing retromammary mastopexy and the inability to adequately raise the mammary gland in ptosis III degree.

Closest to the proposed method - the prototype, is the method of mastopexy in combination with endoprosthesis of the mammary glands, which consists in marking the anatomical formations by applying the axis of the mammary gland, the line of the submammary fold, the parasternal line, the position of the second and third ribs, the anterior axillary line, marking points pexia of the mammary gland, mastopexy and endoprosthesis. At the same time, the line of the submammary fold is additionally marked from the parasternal to the anterior axillary line below the mammary gland, a new place of the areola is noted as a projection of the finger on the anterior surface of the chest when it is installed in the submammary fold on the line of the axis of the mammary gland, recede down from the lower edge of the areola by 2 cm and put a point, draw an oval that defines the outer boundaries of de-epidermization. Then deep-epidermization is carried out around the nipple-areolar complex, after which the skin and subcutaneous tissue are dissected along the periphery from the deep-epidermization zone, towards the upper squares to the level of the second rib, and in width - to the medial and lateral sides by 3 cm and down by 3 cm Fixation sutures are applied, passing through the upper edge of the deep-epidermised skin, the upper edge of the own tissue of the gland and the fascia of the pectoral muscles, with fixation in series, at the intersection of the line of the axis of the mammary gland and the second intercostal space, then, 2 cm away from the lower edge of the areola, along the axis of the mammary glands dissect their own tissue of the gland up to 4 cm long, to the depth of retromammary tissue, in the retromammary space they form a bed for the endoprosthesis, the boundaries of which are the lines: submammary fold, anterior axillary, parasternal and projection of the third rib. An endoprosthesis is installed in the formed bed, the own breast tissue is sutured over the endoprosthesis with separate sutures, the skin around the areola is sutured with a purse-string intradermal suture (patent RU 2361526 C1, publ. 20.07.2009).

The disadvantages of this method are the insufficient range of functionality, since it does not allow the formation of a submammary fold with significant ptosis and tubularity of the mammary glands, as well as a high risk of side complications due to the fact that the retromammary location of the prosthesis increases the risk of capsular contracture formation, contouring of the edges of the prosthesis and early ptosis, thinning and deformation of the gland under the influence of the gravity of the implant and its own tissues.

The objective of the proposed method is to provide the possibility of performing a breast lift and endoprosthesis replacement for ptosis of any degree and to reduce the risk of side postoperative complications.

EFFECT: expanding the functionality of the method and reducing side postoperative complications.

The proposed method is as follows.

Perform marking of the operating field on the patient in a standing position. The position of the submammary fold is marked, if necessary, aligning the contralateral sides, the position of the central axis of the mammary gland is marked. The new position of the upper edge of the areola is marked, which is located at a distance of 16-18 cm from the jugular notch. The areolar component is marked with a diameter of 5 to 7 cm. Further, by moving the mammary gland in relation to the central axis of the gland, (medially and laterally) the medial and lateral regions of the tissues compared after resection are marked. 6-7 cm are set aside from the lower edge of the areolar component and a horizontal line of comparison of the resected tissues is marked. The area of tissue from the lower edge of the newly marked areola to the horizontal line is marked as a vertical component. The submammary fold line at the extreme points (medial and lateral) of the gland spot is combined with the above horizontal line and marked as a horizontal component. In FIG. 1 shows the scheme of preoperative markup.

An inverted T-shaped access is formed. For this, a superficial skin incision of the areola to the dermis is carried out around the existing areola using an areolotome (diameter 34-40 mm). Then, retreating 2-3 cm below this incision, using a scalpel, tissue dissection is carried out to a depth of 2-3 cm, along the previously marked vertical and horizontal lines, perpendicular to the chest. Further, using a thin Colorado needle, tissue dissection is carried out perpendicular to the skin surface at a depth of 2-3 cm.

Further, parallel to the skin, directly in the thickness of the mammary gland tissues, a 2-3 cm thick flap is detached in the medial direction to the parasternal line, in the lateral direction - to the anterior axillary line and in the caudal direction up to the level of 2-3 ribs, thus forming composite flap, including breast tissue, adipose tissue and skin. In FIG. 2 shows a photo of the accesses being performed, and in Fig. 3 shows a photo of the formed composite flap.

Further, with a 5 cm access in the projection of the previously noted submammary fold, they pass under the deep sheet of the Scarpa fascia, open the inferolateral bundles of the pectoralis major muscle, and form a pocket under the pectoralis major muscle. The infero-medial bundles of the pectoralis major muscle are dissected to prevent aesthetic complications associated with the formation of a complete axillary pocket, such as animation, cranialization of the implant, or waterfall-type deformity. Intercostal blockade is carried out with a prolonged anesthetic (Naropin, Ropivocaine). Next, the formed pocket is drained with an active aspiration system according to Redon (6CH). A silicone implant (endoprosthesis) is placed in the formed pocket. The submammary fold is fixed by duplication with four sutures, absorbable suture material 3/0. The fascia of the mammary gland is fixed to the deep pectoral fascia for complete isolation of the implant in the formed two-plane pocket.

The tissue remaining after the detachment of the composite flap is resected. The resection is carried out keeping the fascia of the pectoralis major muscle and the deep leaf of the Scarpa fascia, all the proper tissues of the lower pole of the gland are resected. The intersections of the vertical and horizontal components (lines along which the resection was performed) are fixed along the central line to the line of the submammary fold with a screwed dermo-hypodermal suture with a 3/0 absorbable thread. Deep-epidermization of the area above the areola excised by the areolotomy is carried out to the upper edge of the newly marked areola, according to the preliminary marking. The nipple-areolar complex is transferred in the cranial direction on the superior medial vascular pedicle. The lower edge of the new areola is sutured together: the lower edge of the newly marked areola is fixed with a dermal screw-in suture with a 3/0 absorbable thread. Three absorbable 3/0 sutures are placed in the region of the vertical component, suturing the edges of the vertical component at the level of adipose tissue. A continuous 3/0 absorbable suture is applied in the deep layers of the dermis to the vertical and horizontal components. The skin is sutured with a 4/0 monofilament absorbable suture intradermally. Dermabond skin glue is applied to the skin.

The defining differences of the proposed method, compared with the prototype, are:

1. a composite flap 2-3 cm thick is formed, over the entire area of the detachment - up to the level of the 2nd-3rd rib, including subareolar tissues, which makes it possible to more effectively camouflage the implant and avoid its visualization and tissue rippling;

2. With a 5 cm access in the projection of the previously noted submammary fold, they pass under the deep sheet of the Scarpa fascia, open the inferolateral bundles of the pectoralis major muscle and form an isolated two-plane pocket under the pectoralis major muscle, which allows stabilizing the implant and preventing the formation of capsular contracture, as well as achieving a long-term aesthetic effect;

3. for complete isolation of the implant in the formed pocket, the fascia of the mammary gland is fixed to the deep pectoral fascia;

4. resection of tissues not involved in the formation of the composite flap is performed, preserving the fascia of the pectoralis major muscle and mammary gland, which avoids ptosis of the glandular and adipose tissue.

The invention is illustrated by the following examples of specific execution of the method.

Example 1

Patient S. came with complaints of prolapse and asymmetry of the mammary glands.

Anamnesis at admission: Mammary glands - ptosis of the 3rd degree. Asymmetry of the mammary glands: the level of the nipple on the left is 27 cm, on the right - 29 cm. The nipple-areolar complexes are oriented downwards. The glands are dense, with a predominance of the glandular component. The right mammary gland is larger than the left. In FIG. 4 shows a photo of the patient before the operation.

Preliminary markup done. The new position of the upper edge of the areola is noted at a distance of 16 cm from the jugular notch, the areolar component is marked with a diameter of 5 cm. The medial and lateral regions of the tissues compared after resection are marked. The horizontal line of comparison of the resected tissues is marked.

After treatment of the surgical field, skin incisions were made on both sides, according to the preliminary marking. The areolas are highlighted with an areola marker. A superficial skin incision was made around the areola to the dermis, then, retreating 2 cm below this incision, tissues were dissected to a depth of 2 cm, along previously marked vertical and horizontal lines, perpendicular to the chest, then tissues were dissected perpendicular to the skin surface at a depth of 2 cm Using electrocoagulation, a composite flap 2 cm thick was formed in the medial direction to the parasternal line, in the lateral direction - to the anterior axillary line, and in the caudal direction up to the level of the 2nd rib. Through a 5 cm access along the marked submammary fold, an isolated muscular-fascial pocket for the implant was formed. Round implants with a volume of 350 ml were installed, the folds were fixed, the formed pockets were drained with a Redon aspiration system, the pockets were sutured with 3/0 vicryl. Tissues not involved in the formation of the composite flap were resected. The volume of resection on the right is 340 g, on the left is 300 g. Layer-by-layer tissue suturing is performed using 3/0 Vicryl and 4/0 Monocryl sutures. Dermabond skin glue and sterile stickers were applied to the skin.

The stickers were removed after 1 month. The stitches healed by first intention.

The postoperative period proceeded without complications. The patient was examined after 6 months: postoperative scars are barely noticeable, the areola is above the submammary folds, the evaluation of the cosmetic effect is excellent. In FIG. 5 shows a photo of the patient 6 months after the operation in the projection at an angle of 30°. The patient is satisfied with the shape and appearance of the mammary glands.

Example 2

Patient S. came with complaints of prolapse and asymmetry of the mammary glands.

Anamnesis at admission: Mammary glands - ptosis of the 3rd degree. The level of the nipple on the left is 29 cm, on the right - 28 cm. The nipple-areolar complexes are oriented anteriorly. The glands are dense, with a predominance of the fatty component. The left breast is larger than the right. In FIG. 6 shows a photo of the patient before the operation.

Preliminary markup done. The new position of the upper edge of the areola is noted at a distance of 18 cm from the jugular notch, the areolar component is marked with a diameter of 7 cm. The medial and lateral regions of the tissues compared after resection are marked. The horizontal line of comparison of the resected tissues is marked.

After treatment of the surgical field, skin incisions were made on both sides, according to the preliminary marking. The areola is highlighted with an areola marker. A superficial skin incision was made around the areola to the dermis, then, retreating 3 cm below this incision, tissues were dissected to a depth of 3 cm, along previously marked vertical and horizontal lines, perpendicular to the chest, then tissues were dissected perpendicular to the skin surface at a depth of 3 cm Using electrocoagulation, a composite flap 3 cm thick was formed in the medial direction to the parasternal line, in the lateral direction to the anterior axillary line, and in the caudal direction up to the level of the 3rd rib. Through an access of 5 cm along the marked submammary fold, the formation of muscular-fascial pockets for implants was performed. Round implants with a volume of 350 ml were installed, the fold was fixed, Redon drains, pockets were sutured with 3/0 vicryl. Tissues not involved in the formation of the composite flap were resected. The volume of resection on the right is 520 g, on the left is 630 g. Layer-by-layer tissue suturing was performed using 3/0 Vicryl and 4/0 Monocryl sutures. Dermabond glue and sterile stickers were applied to the skin.

The stickers were removed after 1 month. The stitches healed by first intention.

In the dynamics after 6 months, no ptosis phenomena were detected.

In FIG. 7 shows a photo of the patient 6 months after the operation. The patient is satisfied with the shape and appearance of the mammary glands.

EFFECT: method allows to perform endoprosthesis replacement and breast lift in case of ptosis of any degree, malnutrition, tissue hypertrophy, asymmetry, tubularity in combination with ptosis, avoids the most frequent delayed complications, such as lowering of the lower pole in the "waterfall" type, eliminates early secondary ptosis, to reduce the risks of capsular contracture, exclude implant contouring, allows for reduction of the mammary glands and achieve a long-term aesthetic effect.

Claims (5)

1. A method for endoprosthesis replacement of the mammary glands in combination with mastopexy, including preoperative marking of anatomical formations, access formation, deep-epidermization, transfer of the nipple-areolar complex, endoprosthesis with subsequent imposition of fixation sutures, characterized in that an inverted T-shaped access is formed, the composite flap is detached 2-3 cm thick in the medial direction to the parasternal line, in the lateral direction - to the anterior axillary line and in the caudal direction up to the level of 2-3 ribs, then, with a 5 cm access in the projection of the previously noted submammary fold, they pass under the deep leaf of the Scarpa fascia, the lower-lateral bundles of the pectoralis major muscle are opened and an isolated two-plane pocket is formed, which is drained and the implant is installed in it, then, for complete isolation of the implant in the formed pocket, the fascia of the mammary gland is fixed to the deep pectoral fascia, then the tissue remaining after the exfoliation is resected composite flap, then the intersections of the lines along which the resection was performed, are fixed along the central line to the line of the submammary fold, de-epidermization of the area above the areola excised by the areolatomy to the upper edge of the newly marked areola, the nipple-areolar complex is transferred in the cranial direction to the upper medial vascular leg. 2. The method according to claim 1, characterized in that, when marking, the new position of the upper edge of the areola is placed at a distance of 16-18 cm from the jugular notch, and the areolar component is marked with a diameter of 5 to 7 cm. 3. The method according to p. 1, characterized in that for the prevention of aesthetic complications associated with the formation of the pocket, dissection of the lower medial bundles of the pectoralis major muscle is performed. 4. The method according to p. 1, characterized in that the drainage of the formed pocket is performed by an active Redon aspiration system. 5. The method according to claim 1, characterized in that the resection is carried out while preserving the fascia of the pectoralis major muscle and the deep sheet of the Scarpa fascia, while all the appropriate tissues of the lower pole of the gland are resected.

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