RU2741205C2 - Method of reconstructing the nipple when the tumor is located in the central zone of the gland with the use of an alloimplant based on the dura mater - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to reconstructive breast surgery in breast cancer patients. Performing preoperative marking according to the type of reduction mammoplasty T-invers, according to Fig. 1: setting point "a", measuring 19-21 cm from middle clavicle to teat, then from point "a" on medial meridian is measured 2 cm and put point "b", from point "b" is measured 1 cm and put point "c", creating in form of oval lobe with size of 1.0×1.5 cm. Similarly, lateral and subcutaneous removal of breast tissue is performed in the same manner and breast is formed with the help of a silicone implant skin-subcutaneous flaps are closed in layers. Base of the future nipple is fixed with a purse-string suture with a grip of the lateral and medial lobes. Dental plex folded in the form of a roll is placed in a bed between which the dura mater (DM) flap is fixed, around which the lateral and medial lobes are fixed around the nasal sutures to form a nipple.

EFFECT: method enables one-stage nipple reconstruction in case of its removal in skin mastectomy and oncoplastic resections; delayed nipple reconstruction following conventional mastectomy; achieve a long-term aesthetic effect due to a good projection of the nipple after establishing a flap DM, symmetry of mammary glands - operated and healthy; improving quality of life of patients after complex treatment for breast cancer.

1 cl, 1 ex, 10 dwg

Description

The invention relates to medicine, namely to reconstructive surgery of the mammary gland (MF) in patients with breast cancer (BC), and consists in the reconstruction of the nipple with local tissues in combination with alloplastic material.

The patient's satisfaction with the cosmetic result after breast reconstruction largely depends on the presence of the nipple and its shape, symmetry and location relative to the other, i.e. Breast reconstruction after mastectomy is considered to be completely completed after nipple reconstruction.

Nipple reconstruction is usually performed at the last stage (second or third) of breast reconstruction. The optimal period for nipple reconstruction is considered to be 3 months after the last stage of breast reconstruction.

Historically, various autologous composite grafts have been used for nipple reconstruction, such as the earlobe, inner thigh skin, labia minora, and part of the contralateral nipple. However, at present, the most preferred surgical method of nipple reconstruction is the use of local tissues using various techniques, differing only in the scheme of skin incisions at the site of the future nipple: F flap, Z flap, Skate flap, Star flap, Fish tail flap, CV flap, S-flap and others. The essence of these techniques is that at the site of the future nipple, the skin and underlying fatty tissue are dissected according to the marking, separated to the sides and fixed to each other at right angles to the breast surface, thereby recreating the shape and projection of the nipple.

Loss of the projection of the nipple in the long term after reconstruction with local tissues is the most common problem and complaint of patients. The main reasons for the loss of the nipple projection are the absence of a rigid connective tissue support and cicatricial contracture.

In order to maintain the projection of the nipple, techniques have been proposed using autogenous and alloplastic materials. Thus, the use of ear or rib cartilage allows to achieve good cosmetic results, but it is technically difficult to perform, a longer-term technique and is often associated with complications from donor areas. Alloplastic materials are also not without drawbacks, since they, as a foreign body, often cause an increased risk of infection, extrusion and ischemia of adjacent local tissues.

The best cosmetic effect was achieved when using a ceramite implant (artificial bone) as a nipple filler - the projection of the nipples was preserved in 100% of patients.

However, it was this technique that was accompanied by the highest incidence of postoperative complications (18%), including nipple necrosis (13%) and artificial bone extrusion (5%).

The use of an acellular dermal matrix (ADM) for enlarging the projection of the nipple was first described by M. Nahabedian in 2005 (Nahabedian MY. Secondary nipple reconstruc- tion with local flaps and AlloDerm. Plast Reconstr Surg 2005; 115: 2056-61). A 10 mm × 6 mm flap is cut out of the ADM plate (the size may vary depending on the size of the skin flaps and the available space between them), then it is folded, fixed with sutures to maintain its position and shape inside the skin flap.

Thus, there are still no generally accepted techniques and materials for nipple reconstruction, which is associated with technical difficulties, longer duration of the operation and frequent complications from donor areas when using autologous tissues; high cost of alloplastic materials and complications in the form of ischemia and necrosis of the underlying local tissues, in connection with which it is necessary to search for new materials.

Obtaining the dura mater (DMA) from corpses is carried out on the basis of the federal law of the Russian Federation dated 21.11.2011 No. 323-FZ "On the basics of protecting the health of citizens in the Russian Federation", the federal law of the Russian Federation dated 22.12.1992 No. 4180-1 "On transplantation organs and (or) human tissues ".

A known method for the manufacture of biografts of the dura mater for endoscopic interventions in reconstructive surgery (RU 2506955 C1). Carry out procurement of TMO tissue from a corpse. TMO after the workpiece is immersed in a preservative solution. The dura mater biografts are thawed and cut out the biograft flaps of the required size. The obtained flaps are placed in plastic bags and lyophilized. The resulting graft is cleaved to obtain a TMO biograft with a thickness of 0.2-0.4 mm.

A known method of surgical formation of the areola and nipple on the mammary gland (RU 2647154 C1). Marking is performed in the form of an oval of the place of the areola on the newly formed mammary gland. The skin in this oval is de-epithelized and a full-thickness flap of skin is excised according to the size of the future areola and transplanted onto the de-epithelialized area of the skin in the form of an oval with its subsequent suturing to the edges of healthy breast skin. In this case, preliminary in the upper third of the inner surface of the patient's thigh in the area located on the border with the inguinal fold, a skin incision is made with a length of 0.4-0.8 cm.A tunnel with a length of 2-4 cm is formed under the skin and a silicone ball is inserted under the skin through the incision 0.8-1.3 cm in diameter to the end of the tunnel, followed by the imposition of one interrupted suture on the skin wound. Then, after 1-2 months, a flap of skin in the form of an oval with a diameter of 3-4 cm is excised, in the center of which a silicone ball is located under the skin, it is transferred to a de-epithelized area of the skin in the form of an oval and sutured to the edges of healthy skin of the mammary gland. In a particular case, markings are made on the mammary gland, and then an oval-shaped area of skin with a diameter of 3-4 cm is de-epithelized. A silicone ball is placed under the pigmented skin of the upper third of the inner thigh, located on the border with the inguinal ligament.

However, this method of nipple reconstruction has the following disadvantages:

- it is more invasive, implying surgical intervention not only directly in the nipple reconstruction zone, but also in the groin area, leading to the appearance of additional scars on the skin;

- is longer in execution time;

- is a two-stage intervention (1-2 months between two stages);

- the implanted silicone ball in the groin can cause physical discomfort in the patient, including in the sexual sphere of life;

- the silicone ball does not undergo biodegradation in the body and is not replaced by its own connective tissue, thereby implying the constant presence of a foreign body in the body.

The closest is the method of reconstruction of the nipple with the location of the tumor in the central zone of the mammary gland (RU 2020114984 A, Publ .: 06.08.2020, bull. No. 22). A skin-preserving mastectomy is performed with one-stage reconstruction with a silicone implant, or with a silicone implant in combination with a thoracodorsal flap; or delayed breast reconstruction using silicone implants or autologous flaps; or breast-conserving operations with the removal of the nipple. Before the operation, the plate of the xenopericardium BioLAB-PP / PA is prepared according to the instructions, and a figured flap is cut out from it, rolled into a roll, in accordance with the size of the only contralateral nipple. During the operation, according to preliminary marking, the skin is dissected with a shaped three-lobed "CV flap" incision to the subcutaneous fatty tissue, the skin flaps are separated with a small layer of adipose tissue and the skin frame of the future nipple is reconstructed - the edges of the donor zone in the area of the nipple base are brought together and no interrupted sutures are applied. absorbable suture material. The lateral "petals" are fixed to each other, the base of the formed cone is fixed to the edges of the reduced donor zone and in the formed cavity inside the formed cone, the future nipple, a rolled-up flap is placed from the xenopericardium plate BioLAB-PP / PA, after which the upper part of the cone the nipple is covered with a middle "petal" of the skin and fixed with three non-absorbable interrupted sutures.

However, this technique has some disadvantages:

- the impossibility of a one-stage reconstruction of the nipple after removal of the nipple-areola complex due to the need for an integral skin in the reconstruction zone for the corresponding skin incisions;

- lengthening the duration of the general anesthetic time and the patient's rehabilitation period;

- the biomaterial used in this technique (xenopericardium BioLAB-PP / PA) is twice as expensive as the biomaterial used in the claimed method (alloimplant based on the dura mater).

The technical result of the proposed invention is the development of an aesthetically satisfactory and stable long-term effect after reconstruction of the nipple.

The technical result is achieved by the fact that, as in the known method, according to preliminary marking, the skin and subcutaneous fatty tissue are dissected with the formation of two "petals" for the future nipple, fixed with interrupted sutures at the base with the formation of the nipple cone, into which an alloimplant flap based on the solid brain is placed shell, rolled in a roll type in accordance with the size of the only contralateral nipple.

A feature of the proposed method lies in the fact that preoperative marking is performed according to the type of reduction mammoplasty T-invers, according to Fig. 1, we set point "a", measuring 19-21 cm from the middle of the clavicle to the nipple, then from point "a" along the medial meridian measure 2 cm and put a point "b", measure 1 cm from point "b" and put a point "c", creating a petal in the form of an oval with a size of 1.0 × 1.5 cm, and similarly mark in the lateral part, and after subcutaneous removal of breast tissue and the formation of the mammary gland using a silicone implant, the skin and subcutaneous flaps are sutured in layers, the base of the future nipple is fixed with a purse string suture with the capture of the lateral and medial petals, in the bed between which a rolled alloimplant flap based on the dura mater is installed, around which, by means of interrupted sutures, the lateral and medial petals are fixed with the formation of the nipple.

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

FIG. 1 - scheme of preoperative marking

FIG. 2 - view of the TMO plate.

FIG. 3 - formed TMO nipple filler: a) in a straight line and b) in lateral projections.

Fig. 4 - preoperative marking: a) by the T-invers type with removal of the nipple-areola complex; b) marking the future nipple.

FIG. 5 - view of the operating wound after removal of the breast tissue: a) lower de-epidermis flap outside; b) a bed for a silicone endoprosthesis; c) removed breast tissue.

Fig. 6 is a view of the formed mammary glands using silicone endoprostheses.

FIG. 7 - installation of the TMT in the bed of the formed nipple.

FIG. 8 is the final view of the formed nipple.

Fig. 9 is a view of patient T., before the operation: a) on the left, b) on the right, and c) in direct projections.

FIG. 10 - view of patient T., on the 15th day after the operation: a) on the left, b) on the right, and c) in frontal projections.

Indications for this invention - breast cancer stages I-III when the tumor is located in the central zone of the gland - less than 3 cm from the nipple, which requires the removal of the latter - both at the 1st stage of treatment and after preoperative systemic therapy.

Restoration of the nipple using this technique is possible at all stages of breast reconstruction both after complete removal of its tissue (conventional mastectomy, skin-preserving mastectomy) and with organ-preserving treatment (oncoplastic resections).

The method is carried out as follows.

According to the attached manufacturer's instructions, the TMO-based alloimplant plate is preliminarily prepared by soaking in 0.9% sodium chloride solution at room temperature for 15 minutes (Figure 2).

A 1.0 × 0.5 cm flap is cut out of the TMO plate and wrapped like a "roll", fixing with a ligature of non-absorbable suture material (Fig. 3 a, b).

A preoperative marking is performed (Fig. 1), similar to reduction mammoplasty by the T-invers type, according to Fig. 1, point "a" is set, measuring 19-21 cm from the middle of the clavicle to the nipple, then from point "a" along the medial meridian 2 cm and point "b" is set, 1 cm is measured from point "b" and point "c" is set, creating a petal in the form of an oval 1.0 × 1.5 cm, and marking is similarly made in the lateral part.

According to the markings, the skin and subcutaneous fat are dissected.

Skin flaps are widely separated to the sides. A lower cutaneous-subcutaneous-fascial flap with dimensions of 10 × 8 cm is isolated, de-epidermisized. The mammary gland is mobilized and removed (Fig. 5 a, b, c).

A silicone implant is placed on the surface of the pectoralis major muscle. The latter is covered with a lower de-epidermis flap along the lower slope and separated medial and lateral skin-subcutaneous flaps. The wound is sutured in layers, leaving an intradermal absorbable suture (Figure 6).

In order to strengthen the base of the future nipple, an intradermal purse-string suture from non-absorbable suture material is applied with the capture of the lateral and medial "petals". In the formed cavity inside the formed cone of the future nipple, a folded "roll" flap from the TMO plate is placed (Fig. 7).

The "petals" of the skin are brought together and fixed with 5 non-absorbable interrupted sutures (Fig. 8).

The stitches are removed on the 10th day after the operation.

Clinical example

Patient T., 46 years old. For genetically associated cancer of the left breast (carrier of the BRCA1 gene mutation) stage IIA, cT1N1M0G3, triple negative type, from 19.12.2019 to 28.05.2020, NAPCT was performed according to the scheme 4AC + 12 injections of paclitaxel on a weekly basis. During the control examination against the background of the treatment, a positive trend was noted in the form of partial regression of the tumor node of the left breast and the metastatic lymph node of the left axillary region (Fig. 9 a, b, c).

At the II stage, surgical treatment was performed - on June 22, 2020, a subcutaneous mastectomy on the left with one-stage reconstruction with a silicone endoprosthesis with a polyurethane coating of 445 ml. Prophylactic subcutaneous mastectomy on the right with one-stage reconstruction with a 445 ml silicone endoprosthesis with a polyurethane coating.

According to preliminary marking (Fig. 1), similar to reduction mammoplasty of the T-invers type with removal of the nipple-areola complex and marking the lateral and medial "petals" of the future nipple (Fig. 4 a, b), the skin and subcutaneous adipose tissue are dissected.

Skin flaps are widely separated to the sides (Fig. 5 a, b). Highlighted the lower cutaneous-subcutaneous-fascial flap measuring 10x8 cm, de-epidermis, the thickness was 0.5-0.7 cm. The mammary gland was mobilized, removed (Fig. 5c). The wound was washed with saline with amikacin. Hemostasis, dry.

On the surface of the pectoralis major muscle is placed a silicone implant with a polyurethane coating with a volume of 445 ml (Fig. 6) The latter is covered with a lower de-epidermis flap along the lower slope and separated medial and lateral skin-subcutaneous flaps, from which a cone of the nipple is formed, into which a folded type " roll "flap TMO (Fig. 7). Layer-by-layer suturing of the postoperative wound, leaving the vacuum drainage in the lower slope of the reconstructed breast, removed through the counteropening. Suturing the formed nipple with separate interrupted non-absorbable sutures.

A separate skin incision was made in the axillary region, access to the edges of the pectoralis major and minor muscles, the tissue of the axillary and subscapularis regions was made. The fiber of the axillary-subscapularis region was removed in a single block. A silicone drainage was installed into the wound, brought out through a counterperture along the anterior axillary line. Layer-by-layer suturing of the postoperative wound (Fig. 8).

Using a similar technique, a preventive skin-preserving mastectomy on the right was performed with a one-stage reconstruction with a silicone endoprosthesis with a polyurethane coating and reconstruction of the nipple using an alloimplant based on the dura mater.

The postoperative period was uneventful. Healing of postoperative wounds by primary intention. Interrupted sutures on the reconstructed nipples were removed on the 10th day after surgery. The patient is satisfied with the received cosmetic effect (Fig. 10 a, b, c).

The use of the proposed method in clinical practice allows achieving several results:

- one-step reconstruction of the nipple in case of its removal during skin-preserving mastectomy and oncoplastic resections;

- delayed reconstruction of the nipple after a conventional mastectomy;

- a long-term aesthetic effect due to a good projection of the nipple after insertion of the dura mater flap;

- symmetry of the mammary glands - operated and healthy;

- improving the quality of life of patients after complex treatment for breast cancer.

Claims (1)

A method for reconstruction of the nipple when a tumor is located in the central zone of the gland using an alloimplant based on the dura mater, including dissection of the skin and subcutaneous adipose tissue with the formation of two petals for the future nipple according to preliminary marking and fixation with interrupted sutures at the base with the formation of a cone of the nipple into which the nipple is placed alloimplant flap based on the dura mater, folded like a roll in accordance with the size of the only contralateral nipple, characterized in that preoperative marking is performed according to the type of reduction mammoplasty T-invers, according to Fig. 1: set point "a", measuring 19-21 cm from the middle of the clavicle to the nipple, then from point "a" along the medial meridian measure 2 cm and put point "b", from point "b" measure 1 cm and put point "c", creating a petal in the form of an oval 1.0x1 , 5 cm, and similarly make markings in the lateral part and after subcutaneous removal of breast tissue and the formation of the mammary gland with the help of a silicone implant, the skin and subcutaneous flaps are sutured in layers, the base of the future nipple is fixed with a purse-string suture with the capture of the lateral and medial petals, in the bed between which a rolled alloimplant flap based on the dura mater is installed, around which it is fixed by means of interrupted sutures lateral and medial petals with the formation of the nipple.

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