RU2800132C1 - Method of performing covering endoprosthesis using pectoralis minor muscle in breast reconstruction - Google Patents

Abstract

FIELD: medicine; reconstructive surgery.

SUBSTANCE: skin is incised along the edge of the areola with the transition to the outer quadrants of the mammary gland to the axillary region. In this case, the breast tissue is removed either subcutaneously or using skin-saving technology with the removal of a nipple-areolar complex. Then the formation of the pocket, and mobilization of the pectoralis major muscle from the chest wall are performed. Perforating vessels are carefully coagulated, additional isolation and mobilization of the pectoralis minor muscle are carried out. The inferolateral places of attachment of the pectoralis minor muscle to the chest are electrosurgically crossed, leaving the chest at the upper point of fixation and nutrition, after installing the endoprosthesis of its fixation on top of it, the pectoralis minor muscle is fixed with a continuous suture: medially — to the pectoralis major muscle; laterally — to the dentate muscle; downwards — to the area of intersection of the lower bundle of the pectoralis major muscle and the serratus muscle. Layer-by-layer suturing of the wound and the imposition of an aseptic bandage are performed.

EFFECT: method allows to minimize trauma, completely or to a greater extent cover the endoprosthesis with the patient’s tissues and increase the rate of patient recovery in the postoperative period, removing drainage on days 3–4 and reducing the time before the start of subsequent combined treatment, the method is also absolutely safe for oncological patients and does not affect course of cancer.

1 cl, 5 ex, 1 tbl, 5 dwg

Description

The invention relates to medicine, namely to operative surgery.

Breast cancer (BC) ranks first in the world in terms of incidence among all types of oncological diseases among the female population. According to the World Health Organization, in 2021, more than 2.2 million cases of breast cancer were registered worldwide [1].

In most cases, the disease is diagnosed in the early stages (stages I-II), due to timely diagnosis. This increases the chance of a favorable prognosis and high recurrence-free and overall survival rates.

For any woman, breast preservation is essential. Despite the desire to save the organ, it is not always technically possible. According to statistics, the percentage of women under the age of 40 shows a mastectomy in about 15% of cases. A radical operation leads to the development of depression, only every tenth woman does not experience a feeling of inferiority, about 30% - problems of a sexual nature associated with a violation of attraction, 22% - problems of family relations, up to the breakup of the family [2].

Over the past 30 years, the demand for reconstructive breast surgery has grown. This is due to the development of new methods and materials for reconstructions. Immediate or delayed breast reconstruction allows for aesthetic restoration of the organ after radical mastectomy for cancer. Reconstruction is carried out in one or two stages: installation of a tissue expander and its subsequent replacement with an implant (delayed/simultaneously). A more preferable and perfect method using allomaterials is considered to be one-stage breast reconstruction using an endoprosthesis after subcutaneous or skin-sparing mastectomy. Such operations allow patients not to feel the loss of the organ and recover faster after surgery.

Patients with asthenic physique during breast reconstruction using an endoprosthesis face a lack of their own tissues to completely cover it. In such cases, the use of allomaterials, synthetic semiabsorbable mesh, autologous flaps, biological materials (eg acellular dermal matrix - ADM; biografts - pericardium, dura mater) is known. Thus, surgeons achieve the prevention of such complications associated with tissue deficiency, such as protrusions, extrusion [4].

In acellular dermal matrix reconstruction, a continuous suture is placed between the pectoralis major muscle and the ADM, starting at the medial end. The first suture is placed at the point of attachment of the pectoralis major muscle to the sternum. The most common complications in this type of reconstruction are: necrosis of the skin flap, seroma, infection (removal of the implant), "red mammary gland syndrome" (irrational prescription of antibiotic therapy is possible). The frequency of these complications does not exceed 8.6% [3]. When using this method, the risk of developing capsular contracture after adjuvant radiation therapy is reduced [4].

In 2019, a method was proposed for one-stage reconstruction of the mammary gland in cancer using an allo-implant based on the dura mater (DMT) [2]. The lower lateral part of the pectoralis major muscle is separated laterally up to 9 hours. The lower lateral part of the pectoralis major muscle is separated from the anterior chest wall and a subpectoral pocket is formed. The dura mater is laid along the lower zone of breast reconstruction corresponding to the lower slope of the mammary gland, the edge of the dura mater is sutured with an atraumatic thread to the free edge of the pectoralis major muscle. After being placed in the pocket of the endoprosthesis, the free edge of the dura mater is fixed to the region of the submammary fold and the serratus anterior muscle. This method reduces the risk of extrusion and protrusion. It also reduces the trauma and recovery period after surgery.

The disadvantages include: difficulty in finding the necessary material; the occurrence of undesirable reactions to the lyophilized dura mater and the high cost of consumables - dura mater.

A known method of breast reconstruction (patent No. 2705265 C2) using allomaterials. In this invention, the authors propose to use the dura mater as an additional shelter for the endoprosthesis. At the beginning, marking is carried out, during the operation, cuts are made along the planned lines. Perform a subcutaneous mastectomy. The lower part of the pectoralis major muscle is cut off from the anterior chest wall, a subpectoral pocket is formed before marking. Next, the dura mater is laid along the lower slope of the mammary gland, the edge of the dura mater is sutured to the free edge of the pectoralis major muscle. The width of the formed pocket is measured and a silicone endoprosthesis is selected. The free edge of the DM is fixed in the region of the submammary fold, the edges of the serratus anterior muscle and the DM are fixed. Next, the wound is sutured in layers and two drains are left (in the endoprosthesis bed and in the area of lymphadenectomy).

The disadvantages of this method are the following: material obtained from another type of organism; high cost of donor material.

Another method of breast reconstruction with an implant or expander (patent No. 2762205 C1), which is performed through fasciomyotomy. In the preoperative period, the mammary gland is marked. On the marked lines, cuts are made. A subpectoral pocket is formed, in the lower part, in the projection of the submammary fold, medially from the line drawn from the nipple to the midline and laterally - to the anterior axillary line, fasciomyotomy is performed. When performing this manipulation, all the fascia are dissected in an arcuate manner anteriorly to the subcutaneous fatty tissue; in the medial part, the fibers of the pectoralis major muscle are affected.

The disadvantages of this method is the risk of a lack of own muscle tissue to cover a large-volume implant (a classical reconstruction in two stages may be required).

The authors propose the following way to cover the endoprosthesis using the pectoralis minor muscle in breast reconstruction.

The technical result is an increase in the one-time volume of the endoprosthesis that can be installed in a patient, an increase in the expansion rate of the tissue expander, and a reduction in the time before the start of radiation therapy.

The drawings show;

- fig. 1. - allocation of large and small pectoral muscles;

- fig. 2. - formation of a pocket for a tissue expander;

- fig. 3. - intersection of the pectoralis minor muscle;

- fig. 4. - shelter of the endoprosthesis with a formed muscle pocket;

- fig. 5. - the final version.

The stages of surgical intervention consist in cutting the skin along the edge of the areola with the transition to the outer quadrants of the mammary gland to the axillary region (an incision is made along the postoperative suture from the midclavicular line to the anterior axillary line) (Fig. 1).

With simultaneous mastectomy and endoprosthetics, breast tissue is removed subcutaneously or skin-safely (with the removal of the nipple-areolar complex), then they begin to form a pocket (Fig. 2). The pectoralis major muscle is mobilized from the chest wall, the perforating vessels are carefully coagulated.

In order to minimize the tension of the sutured own tissues covering the endoprosthesis, additional isolation and mobilization of the pectoralis minor muscle is carried out. The inferolateral attachment sites of the pectoralis minor muscle to the chest are electrosurgically crossed, leaving it at the upper point of fixation and nutrition (Fig. 3). After the endoprosthesis is installed and fixed (if provided by the endoprosthesis model), the pectoralis minor muscle is fixed over it with a continuous suture; medially - to the pectoralis major muscle; laterally - to the dentate muscle; downward - to the area of intersection of the lower bundle of the pectoralis major muscle and the serratus muscle (Fig. 4). Produce layer-by-layer suturing of the wound and the imposition of an aseptic bandage, followed by expansion of the volume, if necessary (Fig. 3).

The novelty lies in the fact that not only the pectoralis major and anterior serratus muscles are used to cover the endoprosthesis, but also the pectoralis minor, with its movement in relation to the pectoralis major and anterior serratus muscles on the vascular pedicle, which allows creating a cavity into which a larger endoprosthesis can be installed.

Advantages:

1. The use of separated tissues of the pectoralis minor muscle makes it possible to cover the endoprosthesis with a much larger area (about 30-50 cm ² , depending on the physique);

2. Allow to avoid additional undesirable reactions of the body to the endoprosthesis;

3. Saves money spent on mesh implants;

4. Provides reliable fixation of the endoprosthesis;

5. Reduces wound healing and patient recovery time

The proposed method is illustrated by the following examples.

Clinical Case 5

Patient B., 39 years old (Tver Regional Clinical Oncology Center). The operation is the first stage of delayed reconstruction of the right breast with the installation of an expander for cancer of the right breast, stage IV, T2N1M0, luminal A type (RE+, RP+, Her-2 neu-, Ki67-10%), complex treatment in 2020, without mts and progression for 2022.

In the position of the patient lying on his back. An incision is made along the postoperative suture from the midclavicular line to the anterior axillary line. The lateral edge of the pectoralis major muscle is isolated and the pectoralis major muscle is separated from the minor. Checking hemostasis - dry. In order to minimize the tension of the sutured own tissues covering the endoprosthesis, additional isolation and mobilization of the pectoralis minor muscle is carried out. The inferolateral attachment points of the pectoralis minor muscle to the chest are electrosurgically crossed, leaving it at the upper point of fixation and nutrition. Next, the pectoralis major muscle is lifted and the endoprosthesis is placed in the intermuscular space. After the endoprosthesis is installed, the pectoralis minor muscle is fixed on top of it with a continuous suture: medially - to the pectoralis major muscle; laterally - to the serratus muscle downwards - to the area of intersection of the lower bundle of the pectoralis major muscle and the serratus muscle. Produce layer-by-layer suturing of the wound and the imposition of an aseptic bandage.

Thus, the implementation of the reconstruction of the mammary gland according to the described method allows both for simultaneous operations and for delayed operations to minimize trauma, completely or to a greater extent cover the endoprosthesis with one's own tissues and increase the patient's recovery rate in the postoperative period. Rapid replenishment of the endoprosthesis volume leads to early removal of the drainage (by 3-4 days) and a reduction in the time before the start of the subsequent combined treatment. The proposed type of reconstruction is absolutely safe for cancer patients and does not affect the course of cancer.

Claims (2)

1. A method for covering an endoprosthesis using the pectoralis minor muscle in the reconstruction of the mammary gland during a one-stage mastectomy and endoprosthesis replacement, which consists in cutting the skin along the edge of the areola with the transition to the outer quadrants of the mammary gland to the axillary region, while the breast tissue is removed subcutaneously or skin-savingly with the removal of the nipple-areolar complex, then proceed to the formation of a pocket, mobilize the pectoralis major muscle from the chest wall, per the forant vessels carefully coagulate, carry out additional isolation and mobilization of the pectoralis minor muscle, electrosurgically cross the inferolateral places of attachment of the pectoralis minor muscle to the chest, leaving it at the upper point of fixation and nutrition; laterally - to the dentate muscle; downwards - to the area of intersection of the lower bundle of the pectoralis major muscle and the serratus muscle, layer-by-layer suturing of the wound and application of an aseptic bandage are performed. 2. The method according to p. 1, characterized in that, if necessary, the subsequent expansion of the volume of the mammary gland is carried out.