RU2808373C1 - Method of surgical treatment of normotrophic and hypertrophic ptosis of the mammary glands of 2 or 3 degree - Google Patents

Abstract

FIELD: medicine; plastic surgery.

SUBSTANCE: lower dermoglandular feeding pedicle is formed, and the axillary tail of the mammary gland is resected. Next, the dermal or dermoglandular flap of the supraareolar region of the feeding pedicle is fixed with three sutures to the pectoral fascia in the area of 10, 12 and 2 o'clock position at the level of the planned position of the new upper slope of the mammary gland. A preliminary detachment of the upper skin-glandular flap is performed in the suprafascial plane and 2–3 through radial incisions are applied to the gland of this flap. Then, deep-epidermization is performed along the markings in the area of the lower slope of the mammary gland, the wounds are sutured layer by layer to form an inverted T-shaped suture or a J-suture or an L-suture.

EFFECT: method makes it possible to increase the stability of the filling of the upper pole of the mammary gland and the stability of the shape of the lower slope in the long-term postoperative period.

2 cl, 2 ex

Description

The invention relates to medicine, namely to plastic surgery, and can be used in the surgical treatment of normotrophic and hypertrophic ptosis of the mammary glands of 2-3 degrees (according to the Regnault classification).

The concept of breast reduction surgery has been evolving over the past 65 years. Depending on the source of blood supply to the nipple-areolar complex, there are methods of free transplantation, as well as transplantation with parenchymal and dermal feeding pedicles.

Removal of the lower parts of the mammary gland with free transplantation of the areola and nipple was proposed by Thorek in 1922. As modified by Rubin (1983), the operation is indicated for: a) elderly women to reduce intervention time; b) women with excess body weight and severe ptosis; c) in situations where removal of more than 1500-2000 g of tissue from each gland is required. The disadvantage is the difficulty of ensuring bilateral symmetry and stable balance of the nipple-areolar complexes.

Reduction mammoplasty using the “parenchymal pedicle” technique includes wide mobilization of the skin over the mammary gland, wedge-shaped excision of its excess, followed by transposition of the nipple-areolar complex on the parenchymal (usually central) feeding pedicle and rotation of the remaining glandular tissue to give the organ a more conical shape (Arie-Pitanguy , Penn, Hester). The technique is indicated for removing no more than 500 g of breast tissue. Transposition of the areola on a parenchymal pedicle serves as the basis for the Dufourmentel-Mouly and B-techniques according to Regnault.

Reduction mammoplasty using the “dermal legs” technique is described by Strombeck. It involves horizontal and vertical resection of glandular tissue from the lower pole and transposition of the nipple to a new position on a horizontal dermal flap with two feeding legs. In case of excess adipose tissue in the mammary glands, the author proposed to cross the lateral pedicle while preserving one medial dermal pedicle. T. Skoog, on the contrary, left a lateral dermal stalk. The disadvantages of this technique are the inconvenience caused by the correct placement of the areola and nipple (without torsion or compression of the stem), as well as poor reinnervation of the nipple.

In 1976, P. McKissock developed a method of mammoplasty with preservation of the areola on a vertical dermal flap with two feeding legs. In this case, the lower leg includes not only the dermis, but also the parenchyma. The author himself pointed out the safety of such a flap for blood supply with a pedicle length of less than 40 cm (Tsepkolenko V.A., Grubnik V.V., Pshenisnov K.P. Plastic aesthetic surgery. Modern aspects. Endoscopic plastic interventions on the face. Kiev, 2000. Chapter V, pp. 78-101).

In plastic surgery of the 21st century, there are several types of mammoplasty:

1. Augmentation mammoplasty is an operation whose purpose is to give the breasts beautiful shapes and preserve the lactation function of the mammary glands;

2. Reduction mammoplasty - an operation consisting of excision of tissue, elimination of the resulting excess stretched skin and relocation of the nipple-areola complex;

3. Isolated mastopexy - plastic surgery to lift the mammary glands when they are sagging with correction of height and shape.

Today, there are more than 600 methods of plastic surgery on the mammary gland, but only 40-50 are widely used (Zharikov K.M., Nafikov A.V., Astafiev B.V. On the issue of breast plastic surgery Bulletin of medical Internet conferences , 2019. Vol. 9. No. 4).

There is a known method for removing the lower parts of the mammary gland with free transplantation of the areola and nipple, which was proposed by Thorek in 1922. As modified by Rubin (1983), the operation is indicated for: a) elderly women to reduce the intervention time; b) women with excess body weight and severe ptosis; c) in situations where it is necessary to remove more than 1500 - 2000 g of tissue from each gland (Plastic and aesthetic surgery. Recent advances: scientific publication / translated from English, edited by A.M. Borovikov. - M.: PRACTICAL Medicine , 2011. - 448 pp.).

There is a known method of reduction mammoplasty for gigantomastia, which includes making an incision according to preliminary markings, performing de-epidermization according to an inverted T-shaped pattern, characterized in that the breast tissue is resected in the lower, in the inferolateral medial sectors, and in the upper sector - between the fibrous septum and using a dermal pedicle, with transposition of the nipple-areolar complex, a new volume of the mammary gland is formed and the areola, lateral and medial flaps are sutured in layers in the form of an “anchor” (Karapetyan G. E., Pakhomova R. A., Kochetova L. V., Mavrodi T. V., Dikarev A. S., Ratushny N. A. A modified method of reduction mammoplasty for gigantomastia // Issues of reconstructive and plastic surgery. 2017. No. 3 (62)). With this technique, it is quite difficult to ensure bilateral symmetry and stable balance of the nipple-areolar complexes.

A known method for plastic surgery of the mammary gland L.L. Pavlyuk-Pavlyuchenko (patent RU2116756, published on August 10, 1998), the essence of which is that the upper flap is cut out from the skin to the fascia of the pectoralis major muscle, after which it is divided into two parts that have one nutrient pedicle: a flat cutaneous-subcutaneous and round glandular-fatty. The lower adermized flap is inserted between parts of the upper one, forming a new mammary gland. The positive aspects of this method is to obtain the mammary glands of the correct shape with a convex nipple-areolar complex at the top, eliminating nipple retraction. The disadvantage of this method is the possibility of the formation of a dermoid cyst (Complications after reduction mammoplasty Galina E.V., Stolyarzh A.B., Berlev O.V., Fadin A.S.; Annals of plastic, reconstructive and aesthetic surgery. 2006. No. 4. P. 63).

There is a known method of mammary gland plastic surgery, which includes marking the mammary gland in the form of a “keyhole”, cutting out the mammary gland along these marking lines, removing excess tissue from the lower part of the mammary gland, and placing the areola in a new position. The method allows for high cosmetic results by bringing the shape of the mammary gland closer to the natural one (patent RU2087131, published on August 20, 1997). The disadvantage is the possibility of delayed wound healing, necrosis of the areola and nipple (Complications after reduction mammoplasty. Galina E.V., Stolyarzh A.B., Berlev O.V., Fadin A.S.; Annals of Plastic, Reconstructive and Aesthetic Surgery. 2006 No. 4, p. 63).

There is a known method of surgical correction of mastoptosis from the periareolar approach according to Tenchurina (Tenchurina, T. G. Modern approaches in reconstructive plastic surgery for hypertrophic scars: abstract of thesis. Doctor of Medical Sciences: 14.00.27, 03.00.04 / Tenchurina Tatyana Gennadievna; Place of defense: Russian University of Peoples' Friendship], Moscow, 2007. - 25 p.). The method includes creating a cut, drawing the axis of the mammary gland, marking a new contour of the areola, performing deep-epidermization around the nipple-areola complex, followed by applying fixing sutures passing through the upper edge of the deep-epidermized skin, the upper edge of the gland's own tissue of the fascia of the pectoral muscles in a certain sequence. The method allows to increase the cosmetic effect and preserve the function of glandular tissue. The disadvantages of this known method are the possibility of liponecrosis, ligature abscesses, suture dehiscence, decreased sensitivity of the areola and nipple (Complications after reduction mammoplasty. Galina E.V., Stolyarzh A.B., Berlev O.V., Fadin A.S.; Annals of Plastic , reconstructive and aesthetic surgery. 2006. No. 4. P. 63).

There is a known method in which a para-areolar incision and the boundaries of para-areolar de-epithelialization of an ellipsoidal shape are marked on the skin of the mammary gland, the dimensions of which are selected individually, which allows the skin of the mammary gland to be evenly corrugated towards the areola. Advantages: there is no need for incisions and sutures on the skin of the mammary gland, which achieves the maximum cosmetic effect, since the sutures are ultimately located only along the edge of the areola, and the possibility of performing from this access both sectoral resection and immersion of glandular tissue while maintaining the volume of the mammary gland glands expands the indications for this operation, allowing it to be used for 1st and 2nd degrees of mastoptosis (patent RU2007131, publ. 02/15/1994; Apanasevich V.I. Optimization of diagnosis of breast diseases: Dis. Dr. med. Sci. Vladivostok, 2001. - 350 pp.] Disadvantages: the result is largely determined by the presence or absence of asymmetry of the mammary glands in the outcome, which normally occurs in almost all women, as well as the presence or absence of asymmetry after them.

The method proposed by Fino P et al is known (Breast reduction: personal technique. Fino P, Di Taranto G, Toscani M, Scuderi N. Clin Ter. 2016 NovDec;167(6): e167-e170. doi: 10.7417/CT.2016.1963 PMID: 2805183). This method combines the advantages of a round block with a vertical scar, using a skin flap that is fixed to the new breast fold. As a result, the skin flap works against the weight of the residual tissue, maintaining the fold in the desired position. The advantages of this method are a short scar and the ability to create the desired shape of the breast. The method can be used for mild to severe hypertrophy with varying degrees of ptosis.

There is a known method of mastopexy, codenamed “Snowman” (A New Reduction Mastopexy Design for Young Women: Snowman Pattern. Cil Y, Kocman AE. World J Plast Surg. 2015 Jul;4(2):110-9. PMID: 26284179) . The operation is performed using a modified technique with a superior pedicle and a vertical scar. The disadvantage is the constant wrinkling due to the vertical closure of the surgical wound.

There is a known method of mammoplasty with a reduction in the mass of the gland by more than 1000 g using the short scar technique. The procedure is based on the following:

a) a modified method of marking the mammary glands with conservative placement of the nipple-areola complex, determined not only by the level of the iliac fold, but also by the degree of volume loss of the upper pole;

b) use of liposuction to contour the lower pole;

c) vertical design of dermoglandular resection;

d) superomedial pedicle;

f) closure of the skin without tearing or collecting.

The advantage of this method is the possibility of significant reduction of the mammary gland. Disadvantages: delayed healing, necrosis of adipose tissue, hematoma (Short-Scar Mammaplasty in Severe Macromastia. Akyurek M, Chappell AG. Ann Plast Surg. 2016 Dec;77(6):609-614. PMID: 26678101).

The known method of mammoplasty is “Short scar periareolar inferior pedicle reduction” (SPAIR), which is a breast reduction technique that is based on the formation of the lower pedicle, but models the skin using a combined periareolar and vertical excision of the skin. The technique preserves the blood supply to the nipple and areola and uses a combination of periareolar and vertical skin excision to reduce the skin envelope. Aggressive suturing of the pedicle and mammary glands is used to control the shape. (The Short Scar Periareolar Inferior Pedicle Reduction (SPAIR) Mammaplasty. Hammond DC. Semin Plast Surg. 2004 Aug;18(3):231-43. doi: 10.1055/s-2004-831910. PMID: 20574479). This method is applicable to a wide range of breast problems, from simple ptosis to the extremes of macromastia. Aesthetically pleasing results are consistently and reliably obtained with few complications. It is proposed as an effective method for reducing breast scars (“The dermal internal brassiere flap,” a new modification of inferior pedicle breast reduction technique . Temel M, AO, Dokuyucu R, A. Aesthetic Plast Surg. 2015 Jun;39(3):350-8. doi: 10.1007/ s00266-015-0483-y. Epub 2015 Apr 17. PMID: 25894021). After the operation, a trace remains in the form of a comma, the lower part of which is directed towards the armpit area. As a result of the correction, an aesthetic breast with a natural lower sphere is obtained.

There is a known method of modifying this method, which consists in changing the suture. For patients who have undergone a moderate reduction (401-800 g), after sufficient glandular and skin tissue has been removed, the vertical incision is closed as follows: loose subcutaneous sutures are placed starting at the top of the incision and continuing to the bottom. At the distal corner of the incision, suturing is performed in the opposite direction before the wound has been closed. This completes the suture chain. At the top of the incision, the sutures are pulled tight to gather the skin into a short vertical scar. This method is an improvement over the existing vertical incision method, allowing faster and easier closure and resulting in better breast shape and scar length (Chain purse-string suture used to shorten the vertical incision in vertical breast reduction. Karacı S, Kose R, Baykan H, Ozkose M. Aesthetic Plast Surg. 2013 Feb;37(1):88-90. doi: 10.1007/s00266-012-0016-x. Epub 2013 Jan 4. PMID: 23288098).

The closest in technical essence and chosen as a prototype is a method of surgical treatment of hypertrophic and normotrophic ptosis of the mammary glands of 2 and 3 degrees (according to the Regnault classification), including the formation of a lower dermoglandular feeding pedicle, fixation of the parenchyma with absorbable sutures to the pectoral fascia or pectoralis major muscle at the level of the 3rd rib and reduction of the skin sheath with a cicrum-vertical cut with a vertical J-shaped suture, proposed by Dennis Hammond (The Short Scar Periareolar Inferior Pedicle Reduction (SPAIR) Mammaplasty. Hammond DC. Semin Plast Surg. 2004 Aug;18(3):231 -43. doi: 10.1055/s-2004-831910. PMID: 20574479).

The presented method of reduction and tightening of the mammary glands gives a slight fullness of the upper pole of the mammary glands in the long-term period due to the fact that the sutures fixing the gland tissue lose strength and the scarring process in this case is unstable, the cut of the skin of the lower slope in the shape of the letter J gives more sagging in the postoperative period Compared to T-cut and anchor leather cuts.

The technical problem is to create a method for the surgical treatment of hypertrophic and normotrophic ptosis of the mammary glands of 2 and 3 degrees, which can increase the stability of the filling of the upper pole of the mammary gland and the stability of the shape of the lower slope in the long-term postoperative period.

The technical result consists in maintaining a more filled upper slope and stabilizing the lower slope.

The technical result is achieved due to the fact that the method of surgical treatment of hypertrophic and normotrophic ptosis of the mammary glands of 2 and 3 degrees, including the formation of a lower dermoglandular feeding pedicle, fixation of the isolated axillary tail of the gland to the upper edge of the flap or resection of the axillary tail and, if necessary, part of the parenchyma of the upper part of the flap , further fixation of the dermal or dermoglandular sheet of the supraareolar region of the feeding pedicle with three sutures to the pectoral fascia in the area of 10, 12 and 2 o'clock at the level of the planned position of the new upper slope of the mammary gland with preliminary detachment of the upper glandular skin flap in the suprafascial plane, subsequent dissection of the superficial fascia and the remainder of the gland of this flap with three radial incisions for its extensibility, further cutting of the skin with preliminary de-epidermization along the markings in the area of the lower slope, layer-by-layer suturing of the wound with the formation of an inverted T-shaped suture or a J-suture or an L-suture. The choice of skin cut type depends on the initial length of the inferior elephant gland and the direction of the nipple-areolar complex

The technical result is ensured by the fact that the fixation of the dermoglandular flap to the fascia of the mammary gland occurs due to the dermal component (the strength of the scar dermofascial joint is higher than the glandular-fascial joint). Stabilization of the lower slope is achieved by a T-shaped cut of the skin, which makes it possible to reduce the length of the formed lower pole of the mammary gland. To reduce the width (base) of the mammary gland and additional filling of the upper slope, the axillary tail is isolated and fixed to the upper edge of the flap during pexy or resected during reduction together with the lateral edge of the isolated glandular flap.

In the case of a short lower pole of the ptotic mammary gland, this method is implemented using the above techniques with a skin cut in the form of the letter J or the letter L. To reduce the width (base) of the mammary gland, the axillary tail is isolated and fixed to the upper edge of the flap during pexy or resected during reduction together with the lateral edge of the isolated glandular flap.

The claimed invention is illustrated by the following clinical examples.

Example 1

Patient E., 32 years old, came to the clinic with complaints of excessive volume, heaviness in the mammary glands, and severe asymmetry. Under ETN, surgical treatment was performed according to the stated method: a skin incision along the supra-raeolar zone of de-epidermization was used to form the lower dermoglandular pedicle, preserving the feeding vessels of the Wühringer septum and resection of the axillary tail on both sides and about 100 g of horseshoe-shaped parenchyma along the upper edge of the pedicle on the right to correct asymmetry. Formation of a suprafascial pocket in the area of the upper slope to the level of the 3rd rib with radial incisions along the posterior surface of the gland stump of the upper slope. Formation of a strip of dermal bridge about 1.4 cm wide in the area of the upper edge of the supraareolar zone of de-epidermization. Fixation of the flap from the pectoral fascia at the level of the 3rd rib with interrupted or mattress sutures using PDS 2.0 or Vicryl 2.0 thread in the 10, 12 and 2 o’clock area. Installation of Redon drainage under the flap. Applying temporary sutures Lavsan 2/0 to the vertical and horizontal components to obtain the shape. Drawing the lines of the future de-epidermization zone. Removal of temporary sutures. Deep-epidermization of the intended shape. Mobilization of the medial edge of this zone does not cover the entire thickness of the dermis and through mobilization of the lateral edge. Applying individual knots with 3.0 absorbable suture to the dermis in a vertical and horizontal position to stabilize the lower slope of the breast. Layer-by-layer suturing of the vertical and horizontal components of the skin flaps (Vicryl 3.0, Monocryl 3/0, Monocryl 5.0), suturing of the periareolar area (purse-string suture Prolene 3.0, Monocryl 3.0, 5,). Bandages. Compression underwear. The duration of the operation is 3 hours 30 minutes. The next day, drainage is removed (there are traces of discharge in the drainage). Change of bandages. Further dressings in the outpatient clinic on days 4 and 8. The postoperative period is uneventful, the pain syndrome is mild for 3-5 days. Observation at 1, 3, 6 and 12 months, the result is stable. The filling of the upper pole is adequate, more pronounced compared to the original, the inframammary fold is moderately pronounced, scars without signs of hypertrophy.

Example 2

Patient A., 27 years old, came to the clinic with complaints of excessive sagging of the mammary glands and overstretched areolas. There was no birth. The shape of my breasts has changed after massive weight loss. Breast volume suits you, shape - not. Under ETN, surgical treatment was performed according to the stated method: by making a skin incision along the supra-raeolar de-epidermization zone, the lower dermoglandular pedicle was formed while preserving the feeding vessels of the Wühringer septum, the axillary tail was isolated and fixed to the upper edge of the glandular flap with Vycril 2.0 thread on both sides. Formation of a suprafascial pocket in the area of the upper slope to the level of the 3rd rib with radial incisions along the posterior surface of the gland flap of the upper slope. Fixation of the dermoglandular edge of the flap to the pectoral fascia at the level of the 3rd rib with interrupted or mattress sutures with 2.0 absorbable thread in the area of 10 12 and 2 o'clock. Installation of Redon drainage under the flap. Applying temporary sutures Lavsan 2/0 to the vertical and horizontal components to obtain the shape. Drawing the lines of the future de-epidermization zone. Removal of temporary sutures. Deep-epidermization of the intended shape. Mobilization of the medial edge of this zone does not cover the entire thickness of the dermis and through mobilization of the lateral edge. Placement of individual knotted threads with 3.0-4.0 absorbable suture material on the dermis in a vertical and horizontal position to stabilize the lower slope of the mammary gland. Layer-by-layer suturing of the vertical and horizontal components of the skin flaps (absorbable suture material 3.0-4.0), suturing of the periareolar area (purse-string suture, non-absorbable suture material 2.0-3.0, absorbable suture material 3.0-4.0). Bandages. Compression underwear. The duration of the operation is 3 hours and 10 minutes. The next day, remove the drains (there are traces of discharge in the drains), change the dressings. Further dressings in the outpatient clinic on days 4 and 8. The postoperative period was uneventful. Pain syndrome is mild for 3-5 days. Observation at 1, 3, 6 and 12 months, the result is stable. The filling of the upper pole is adequate, more pronounced compared to the original, the inframammary fold is moderately pronounced, scars without signs of hypertrophy.

Using the stated method, 176 patients aged from 23 to 51 years were operated on from March 2016 to June 2022. The quantitative distribution of complications identified in the patient population is as follows:

- deteriorated healing of the junction of vertical and horizontal sutures for a period of 1-1.5 months. after surgery - 18 patients; when treated with the ointment method, healing was observed in 7-20 days;

- permanent loss of sensitivity of the SAH - 2 patients (right);

- vascular disorders in the area of SAH/areolar necrosis - 0 (zero) patients;

- deterioration of vertical suture healing - 7 patients, conservative treatment ensured healing with minimal aesthetic defects;

- instability of shape in the postoperative period (6-12 months) - 7 patients (fatty type of structure of the mammary gland area, overextension of the skin sheath).

In the late postoperative period, 5 patients became pregnant and gave birth; no problems with lactation were observed.

Claims (2)

1. A method of surgical treatment of hypertrophic or normotrophic ptosis of the mammary glands of 2 or 3 degrees, characterized in that the lower dermoglandular feeding pedicle is formed, the axillary tail of the mammary gland is resected, then the dermal or dermoglandular leaf of the supraareolar region of the feeding pedicle is fixed with three sutures to the pectoral fascia in the area 10 . mammary gland, the wounds are sutured layer by layer to form an inverted T-shaped suture or a J-suture or an L-suture. 2. The method according to claim 1, characterized in that in addition to resection of the axillary tail of the mammary gland, resection of the parenchyma of the upper part of the feeding pedicle of the mammary gland is performed.