RU2741857C2 - Method for one-time breast reconstruction for cancer patients, using prepectorally installed endoprothesis - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to reconstructive-plastic surgery of the mammary gland (MG) in the treatment of patients with breast cancer. Subcutaneous mastectomy with regional lymphadenectomy, or lymphadenectomy alone, thorough hemostasis of formed pre-pectoral pocket for the endoprosthesis is performed. Mesh implant is fixed to upper edge of pectoralis major muscle with 3-4 interrupted sutures with atraumatic thread and silicone endoprosthesis with textured coating of appropriate size and shape is installed, then silicone endoprosthesis is covered with free edge of mesh implant from above and tucked under bottom of silicone endoprosthesis without additional fixation along edges and from below, after which subcutaneous fat is sutured with separate sutures and the skin with intradermal suture.EFFECT: proposed method provides less abrupt transition from contour of implant to contour of chest, thereby making it possible to achieve smoothness of upper contour of formed breast while maintaining functionality of pectoralis major muscle.1 cl, 1 ex, 8 dwg

Description

The invention relates to medicine, in particular to reconstructive plastic surgery of the mammary gland (MF) in the treatment of patients with breast cancer.

Currently, reconstructive plastic surgery of the breast plays an important role in the rehabilitation of patients with breast cancer. The most commonly performed surgical treatment is breast reconstruction using silicone implants, according to the American Association of Plastic Surgeons.

When planning surgical treatment of patients with breast cancer, one-stage reconstruction after subcutaneous / skin-preserving mastectomy is more preferable than delayed reconstruction (Perdanasari A. T. et al. -Update in Direct-to-Implant Breast Reconstruction Semin Plast Surg 2019; 33: 264-269). This is due to the fact that the patients do not feel the loss of the organ so strongly, and accordingly, it is possible to achieve a faster psychological rehabilitation of the patient. When performing reconstructive plastic surgeries using biological or allomaterials, it is possible to use various techniques for installing silicone endoprostheses: subpectoral / pre-pectoral, with / without shelter with biological materials, allomaterials, or autologous flaps. The purpose of hiding endoprostheses is to prevent protrusion / extrusion of the endoprosthesis, possible due to a deficiency of subcutaneous fat.

Subpectoral placement of silicone endoprostheses has a number of disadvantages, such as transection of the pectoralis major muscle (hereinafter referred to as BM), which increases the trauma of the operation and anesthetic time, in the postoperative period leads to increased pain, animation, deformation and dysfunction of the BM [Sigalove S., Maxwel GP et al. Prepectoral Implant-Based Breast Reconstruction: Rationale, Indications, and Preliminary Results. - PRS Global Open. 2017.R. 287, 288, 289). In the world literature, since 1971, methods of pre-rectal installation of polyurethane implants have been described (Snyderman R.K., Guthrie R.H. Reconstruction of the female breast following radical mastectomy. - Plast. Reconstr. Surg., 1971 - 47 (6): 565 - 567 p.). With this variant of reconstruction, great attention should be paid to the thickness of the skin and fat layer (Pinch test more than 1.0 cm) in order to prevent complications.

The known method of pre-dental installation of a polyurethane implant without shelter (RU 2722350 C1). According to the planned marking, a skin incision is made and the gland tissue is subcutaneously removed, the integumentary tissues are separated, the glandular tissue is separated from the pectoralis major muscle and removed, while the integrity of the pectoralis major muscle is not violated, then into the prepared musculocutaneous bed on the pectoralis major muscle, without mobilizing the latter , a silicone implant with a polyurethane coating of the appropriate size and shape is installed, without using additional methods of covering the implant, the latter is located only under the skin and subcutaneous fat, after which the subcutaneous tissue and skin are sutured with an intradermal suture with separate sutures.

However, this technique cannot be used in the case of insufficient thickness of integumentary tissues (Pinch test less than 1 cm), which limits the indications for use.

The known method of covering the mammary gland after subcutaneous mastectomy (RU 2653803 C2). A skin incision is made according to the marked markings. The skin with subcutaneous tissue is separated with an electric knife along the entire length of the dome of the breast, isolating the parenchyma of the gland and removing it, an endoprosthesis enveloped in a “cap” with a mesh implant is placed in the resulting “skin cover”. The mesh is tightened at the upper pole of the endoprosthesis until tight contact with the endoprosthesis and the mesh implant is sutured with interrupted sutures at three points - the middle of the medial contour of the endoprosthesis, the lateral and upper - to the pectoralis major muscle. The operation is completed by draining the "pocket" of the endoprosthesis and layer-by-layer suturing of the wound. In the case of a mesh implant, the developed Grandmother hat system was used. The silicone implant is placed in a “skin cover” and covered with a “cap” type with a purse-string suture.

However, when using this technique, the appearance of a pronounced "step" along the upper contour of the resected breast is most often noted, which often leads to an unsatisfactory result.

The technical result of the claimed method is to obtain a natural appearance of the mammary gland, reduce trauma and maintain the functionality of the pectoralis major muscle.

The technical result is achieved in that, as in the known method, a silicone endoprosthesis with a textured coating is installed in a prepared pre-tectoral “pocket” and covered with a mesh implant.

The peculiarity of the proposed method is that a mesh implant is fixed to the upper edge of the pectoralis major muscle with 3-4 interrupted sutures with an atraumatic thread and a silicone endoprosthesis with a textured coating of the appropriate size and shape is installed, then the silicone endoprosthesis is covered with the free edge of the mesh implant on top and tucked under the bottom silicone endoprosthesis without additional fixation at the edges and bottom, after which the subcutaneous fat is sutured with separate sutures and the skin with an intradermal suture.

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

FIG. 1 - performing a subcutaneous mastectomy.

FIG. 2 is a view of the formed pre-pectoral "pocket"; the pectoralis major muscle is preserved.

FIG. 3 - photographic illustration of the course of the operation: a, b) fixing the mesh implant to the upper edge of the pectoralis major muscle with several interrupted sutures; c) view of a fixed mesh implant.

FIG. 4 - installation of a silicone endoprosthesis into the formed "pocket".

FIG. 5 - the photo illustration shows: a) covering the silicone endoprosthesis with a mesh implant; b) view after covering the silicone endoprosthesis.

FIG. 6 is a view of the formed breast.

FIG. 7 - photo of patient N., before surgery.

FIG. 8 - photo of patient N., 1 month after surgery.

The method is carried out as follows.

In the position of the patient, lying on his back, under general anesthesia, a subcutaneous / skin-preserving mastectomy (Fig. 1) with regional lymphadenectomy is performed, or lymphadenectomy, in case of metastatic lesion of the sentinel lymph node. The pectoralis major and minor muscles are preserved. A thorough hemostasis of the formed pre-tectoral pocket for the endoprosthesis is performed (Fig. 2), washed with saline and amikacin solution. A mesh implant is fixed to the upper edge of the pectoralis major muscle with 3-4 interrupted sutures with an atraumatic thread (Fig. 3 a, b, c). A textured coated silicone endoprosthesis of the appropriate size and shape is inserted (Fig. 4). The top is covered with the free edge of the mesh implant and tucked under the bottom of the silicone endoprosthesis without additional fixation at the edges and bottom (Figure 5). The postoperative wound is sutured in layers, leaving two drains installed in the endoprosthesis bed and in the axillary region - the lymphadenectomy zone (Fig. 6).

Clinical example.

Patient N., 41 years old, diagnosed with PMMZNO 1) Melanoma of the skin of the perianal region IA, pT1bN0M0. Condition after surgical treatment in 2019 without relapse and progression. 2) Cancer of the left breast IA stage cT1cN0M0G2. Luminal type A. Carrier of the CHEK2 mutation.

Histological examination of a trepan biopsy of the left breast formation: invasive lobular, G2 cancer. Immunohistochemical study: ER - 8 points, PR - 7 points, Her2 / neu - negative, Ki67 - up to 20%. Conclusion: Luminal type A.

Complaints at admission: the presence of education in the left mammary gland.

History: In 2019, surgical treatment was performed for perianal skin melanoma. Control PET / CT showed no signs of relapse or progression. In January 2020, she independently discovered a tumor formation in the left breast, turned to an oncologist at the place of residence, performed a trephine biopsy, and was diagnosed with cancer of the left breast. In March 2020, she applied to the Moscow Oncological Research Institute. P.A. Herzen for further examination and development of treatment tactics. Slides and blocks of histological preparations, incl. melanomas - revised, diagnosis confirmed. There were no data for regional and distant metastasis. The treatment tactics were discussed at the council, surgical treatment was recommended at the first stage.

Local status on admission: the skin of the mammary glands is of physiological color, edema is not observed (Fig. 7). In the left mammary gland in the lower-outer quadrant, a tumor formation about 2 cm in diameter is palpated, the skin above it is retracted. In the right mammary gland, the nodules are not palpable. The nipple-areola complexes are not changed, there is no discharge from the nipples. Lymph nodes available to palpation are not changed. In a comprehensive examination of the mammary glands on the left, at the border of the lower quadrants, a tumor formation with fuzzy contours measuring 12.6x8.6 mm at a distance of 2.5 cm from the nipple is determined.Hyperplastic lymph nodes in the axillary region on the left up to 1.6 cm, on the right - without visible structural changes.

The patient underwent surgery according to the proposed method. The patient refused the proposed balancing operation on the contralateral mammary gland.

The course of the operation: performed a subcutaneous / skin-preserving mastectomy (Fig. 1) with the study of the "sentinel" lymph node. The pectoralis major and minor muscles were preserved. Carried out a thorough hemostasis of the formed pre-tectoral pocket for the endoprosthesis (Fig. 2), washed with saline and amikacin solution. A mesh implant was fixed to the upper edge of the pectoralis major muscle with 4 interrupted sutures with an atraumatic thread (Fig. 3 a, b, c). A textured coated silicone endoprosthesis with a volume of 245 ml was inserted. (Fig. 4). From above, the silicone endoprosthesis was covered with the free edge of the mesh implant, and its edge was tucked under the bottom of the silicone endoprosthesis without fixing it along the edges and below (Fig. 5). The postoperative wound was sutured in layers, leaving two drains installed in the endoprosthesis bed and in the axillary region - the area of lymphadenectomy (Fig. 6).

Histological examination of the operating material: "Sentinel" lymph node - three fragments of adipose tissue with a total size of 4x2.4x0.5 cm, with four "sentry" soft-elastic lymph nodes with a diameter of 0.4-1 cm. On the cut, in the tissue of the gland, at the border of the lower quadrants, 0.1 cm from the subcutaneous, 2.9 cm from the lower, 0.5 cm from the fascial margins of the resection - a dense tumor node without clear boundaries, white-gray, measuring 1.4x1.1x1.2 cm. The rest of the gland tissue is represented by lobed adipose tissue with wide, whitish layers. According to the macroscopically described tumor in a fragment of breast tissue - invasive lobular breast cancer with complexes of intralobular carcinoma. In 5 lymph nodes of the axillary tissue - there are no cancer metastases, histiocytosis of the sinuses.

1 month after the operation, the patient has a good cosmetic result, the upper contour is smoothed, the functionality of the pectoralis major muscle is preserved, the pain syndrome is absent (Fig. 8).

All patients did not have gross cicatricial changes that formed at the site of the mesh implant assembly on the silicone endoprosthesis.

The proposed method, by fixing only the upper edge of the mesh implant with several interrupted sutures, leaving the rest free, provides a less abrupt transition from the contour of the implant to the contour of the chest, thereby making it possible to achieve smoothness of the upper contour of the formed mammary gland while maintaining the functionality of the pectoralis major muscle.

Claims (1)

A method of one-stage reconstruction of the breast in cancer using an endoprosthesis installed pretectoral, including the installation of a silicone endoprosthesis with a textured coating in a prepared prepectoral “pocket” and its covering with a mesh implant, characterized in that to the upper edge of the pectoralis major muscle with 3-4 interrupted sutures with an atraumatic thread the mesh implant is fixed and a silicone endoprosthesis with a textured coating of the appropriate size and shape is installed, then the top of the silicone endoprosthesis is covered with the free edge of the mesh implant and it is tucked under the bottom of the silicone endoprosthesis without additional fixation at the edges and below, after which the subcutaneous fat is sutured with separate sutures and skin with an intradermal suture.

Images