RU2817105C2 - Method for prevention of breast contour deformation after sectoral resections for new growths with localization in upper and internal quadrants - Google Patents

Abstract

FIELD: medicine; reconstructive surgery.

SUBSTANCE: invention refers to regenerative medicine of tissues after sectoral resection of mammary gland. Skin incision is performed parareolar, according to a pre-applied marking, a neoplasm with adjacent tissues of the mammary gland is removed, defect is replaced by introduction of spherogel into formed cavity. Tissue deficiency is assessed, the formed bed is marked with titanium staples, opposite edges of the wound are matched and 4 sutures are applied. Formed defect is filled with a spherogel in volume of 5 ml. Thereafter, the breast flaps are sutured in two layers: parenchyma and subcutaneous fat with absorbable suture material, the incisional wound is closed with an intradermal suture.

EFFECT: method makes it possible to restore and replenish volumes of soft tissues in the defect area by creating optimal conditions for regeneration of damaged tissues, as well as to avoid deformation of the surface of the gland due to the restored volume of soft tissues with complete visualization and monitoring of the state of the removed formation zone using ultrasound and MRI of mammary glands with intravenous contrast.

1 cl, 9 dwg

Description

The invention relates to medicine, namely to reconstructive surgery and regenerative tissue medicine after sectoral resection of the mammary gland.

Performing surgery on the mammary gland when the tumor is localized in the upper and inner quadrants is a difficult problem due to the small volume of breast tissue in these quadrants, the proximity of the décolleté, sternum and other fixed anatomical structures. Simple movement of breast tissue into the defect area that arose after removal of the sector with the formation is associated with pronounced rotation of the nipple-areolar complex, as well as retraction, incompatible with aesthetic requirements (A.D. Kaprin, A.D. Zikiryakhodzhaev. Oncoplastic breast surgery , 2017 – pp.230-235; Ivanov V.G., Volokh M.A., Fedosov S.I., Ermilova E.V., Nikolaev K.S. Is it possible to improve organ-preserving operations in the surgical treatment of breast cancer? // Malignant tumors No. 4, 2015 (15) – pp. 28-34.).

A universal heterogeneous collagen matrix (Spherogel) for implantation and a method for its preparation are known (RU 2249462 C1), which is an elastic mass obtained from two sources of collagen, one source being tissue from a vertebrate animal of one class, and the second from an animal of another class, while sources of collagen are animal tissues, for example, the mammalian class and the avian class, the matrix consists of two phases: solid - in the form of microspheres from mammalian tissue collagen, and liquid - from denatured bird tissue collagen with a phase ratio of (1-10): (1- 10), has a microsphere size of 100-300 microns, and the final products of biodegradation are CO2 and H2O. The invention provides a new heterogeneous collagen matrix, which is universal for transplantology and replacement surgery of various tissues and organs in a living body in case of tissue damage and has a controlled biodegradation period.

In contrast, hydrophilic polyacrylamide gel (PAGE), which is a non-absorbable soft tissue filler, has been used as a material for implants for breast augmentation, causing complications such as inflammation, persistent mastodynia, multiple lump formations, unsatisfactory cosmetic results, glandular atrophy and significant spread of hydrogel to surrounding tissues. (Najoua Ben Khedher, Julie David, Isabelle Trop, Suzanne Drouin, Laurence Peloquin, Lucie Lalonde. Imaging findings of breast augmentation with injected hydrophilic polyacrylamide gel: Patient reports and literature review. European Journal of Radiology 78, 2011 – pp. 104–111 ), Spherogel is a resorbable implant and has high biocompatible properties. Creates optimal conditions in the injection area for the regeneration of damaged tissues, and the drug is hypoallergenic, non-toxic, does not cause swelling in the injection area, does not migrate, and does not form fibrosis. The volume of the inserted spherogel implant depends on the size of the defect being filled. The average resorption time in the body ranges from several weeks to 1 year, depending on the particle size of the cross-linked collagen fraction.

Injection methods for correcting defects based on Spherogel after sectoral resection are not described in the literature available to us.

The technical result of the proposed invention is the restoration and replenishment of the volume of the mammary gland (soft tissue) in the area of defects that require correction for an optimal and stable aesthetic result when performing surgical operations for tumors localized in the upper and inner quadrants.

In the method we propose, the technical result is achieved due to the fact that, just like in the known method (prototype), a skin incision is made parareolarly, according to pre-applied markings, in the case of a remote location from the areola, the neoplasm is removed with adjacent breast tissue, the defect is replaced by introducing Spherogel into the formed cavity.

The peculiarity of the proposed method is that tissue deficiency is assessed, the formed bed is marked with titanium staples, the opposite edges of the resulting wound are compared and 4 sutures are applied, the resulting defect is filled with spherogel in a volume of 5 ml, after which the breast flaps are stitched in two layers: parenchyma and subcutaneous - fatty tissue is used with absorbable suture material, the surgical wound is sutured with an intradermal suture.

The method is illustrated by a detailed description, clinical examples and illustrations, which show:

Fig. 1 - photo illustration of the stage of the sectoral resection operation with filling the defect with Spherogel: a) incision of the skin, subcutaneous fat; b) removal of the tumor and adjacent breast tissue; c) assessment of tissue deficiency and marking of the formation bed with titanium brackets; d) applying sutures matching the opposite edges of the wound; e) filling the defect with Spherogel.

Fig. 2 – photo illustration of patient P., 36 years old: a) before surgery; b) after surgery 4 months

Fig. 3 – MRI of the mammary glands with IV contrast a) 7 days after sectoral resection on the right with filling the cavity with Spherogel (The main volume of the gel component is located in the upper-inner quadrant with dimensions of at least 23x16x19 mm) (indicated by the arrow); b) 4 months after sectoral resection on the right with filling the cavity with Spherogel (MR signs of the condition after sectoral resection on the right, introduction of Spherogel into the area of the structural defect - complete transformation of the gel component) (indicated by the arrow).

Implementation of the method.

The indication for use of the method is the localization of the formation in the upper and inner quadrants of the mammary gland, as well as a small volume of the mammary gland.

Under general anesthesia, a skin incision is made (Fig. 1 a), periareolar on the border of the upper quadrants. The benign breast formation and adjacent tissues are removed (Fig. 1 b). Next, hemostasis is performed and 1-3 titanium staples are installed in the bed of the removed formation (Fig. 1c). Tissue deficiency is assessed. To prevent the gel from spreading into the surrounding tissues, the opposite edges of the wound are aligned and 4 sutures are applied (Fig. 1d). 5 ml of Spherogel is injected into the bed of the removed formation (cavity) once, and in the presence of more extensive soft tissue defects - up to 15 ml. (Fig. 1 d). Then the subcutaneous fatty tissue and skin are sutured with absorbable suture materials (subcutaneous fatty tissue is sutured with Vicryl 3-0 thread; skin - Monocryl 4-0) without drainage.

This method was used on 5 patients, the following results were obtained:

- the postoperative period in all cases proceeded without complications;

- the average length of stay in a hospital bed was 2.5 days;

- there was no need for dressings, since the wound was hermetically sutured with intradermal absorbable threads;

- the length of the postoperative scar is 2-4 cm.

Control was carried out using ultrasound examination at intervals: on the 1st day after surgical treatment, after 1 week and after 2 months, in order to assess the resorption of Spherogel, as well as MRI of the mammary glands with IV contrast at an interval: after 7-14 days after surgical treatment, 4 months after surgical treatment.

All patients were able to return to social life 1 week after completion of treatment.

Clinical examples of the method.

Clinical example No. 1.

Patient P., 36 years old, was hospitalized in the Department of Oncology and Reconstructive Plastic Surgery of the Breast and Skin of the Moscow Research Institute named after. P.A. Herzen with a diagnosis of fibroadenoma of the right breast.

On admission: medium-sized mammary glands. The left one is larger than the right one. The nipples and areolas are unchanged. There is no pathological discharge from the nipples. According to palpation and instrumental research methods (ultrasound and mammography), a clear nodular formation of 16x13 mm is determined at the border of the upper quadrants in the right mammary gland. Regional lymph nodes on both sides are unchanged (Fig. 2 a).

Histological examination: All structures are surrounded by a layer of basal/myoepithelial cells expressing p63 and CK5. Taking into account the IHC data, the morphological picture corresponds to peri- and intracanalicular fibroadenoma with focal proliferation of the ductal epithelium and foci of sclerosing adenosis.

On February 7, 2023, an operation involving sectoral resection of the right breast was performed. Under general anesthesia, a skin incision was made, periareolar on the border of the upper quadrants. A benign formation of the right breast and adjacent tissues were removed. Next, hemostasis was performed, and 1 titanium staple was installed in the bed of the removed lesion. Tissue deficiency was assessed. Four sutures were placed to align the opposite edges of the wound and to prevent the gel from spreading into the surrounding tissue. 5 ml of Spherogel was injected into the cavity. We completed suturing the surgical wound by applying absorbable suture material (subcutaneous fat is sutured with Vicryl 3-0 thread; skin - Monocryl 4-0) without leaving drainage. There was no need for dressings, since the wound was hermetically sutured with intradermal absorbable threads.

The postoperative period proceeded without complications, the average length of hospital stay was 2.5 days, the length of the postoperative scar was 4 cm (Fig. 2 b).

After 7 days, an MRI of the mammary glands was performed with intravenous contrast (Fig. 3 a). The main volume of the gel component is located in the upper-inner quadrant with dimensions of at least 23x16x19 mm). When performing an MRI after 4 months (Fig. 3 b), there was a complete transformation of the gel component).

Clinical example No. 2.

Patient M., 30 years old, was hospitalized in the department of oncology and reconstructive plastic surgery of the breast and skin of the Moscow Research Institute named after. P.A. Herzen with a diagnosis of fibroadenoma of the right breast.

On admission: the mammary glands are small and symmetrical. The nipples and areolas are unchanged. When pressed, there is a whitish discharge from the nipples. According to palpation and instrumental research methods (ultrasound and mammography), a formation consisting of several segments with total dimensions of 9.4 x 4.8 mm is determined at the border of the upper quadrants in the right mammary gland. Regional lymph nodes on both sides are unchanged.

Histological examination: Columns of breast tissue with focal stromal fibrosis, the presence of lobular structures and cystic dilated ducts without signs of nuclear atypia of the epithelium. Corresponds to fibroadenoma of the right breast.

On March 9, 2023, an operation involving sectoral resection of the right breast was performed. Under general anesthesia, an upper periareolar incision was made, the skin and subcutaneous fat were dissected. The sector of the right mammary gland with the formation was isolated using a blunt and sharp method. Hemostasis was performed, and 3 titanium staples were installed in the bed of the removed lesion. Tissue deficiency was assessed. The opposite edges of the wound were compared and 4 sutures were applied. 5 ml of Spherogel was introduced into the cavity. The suturing of the surgical wound was completed by applying absorbable suture material (subcutaneous fat is sutured with Vicryl 3-0 thread; skin - Monocryl 4-0) without drainage (Figure 1 a-d).

The postoperative period was uneventful, the average length of hospital stay was 2.5 days, the length of the postoperative scar was 3 cm.

The use of the proposed method in clinical practice made it possible to achieve several technical (therapeutic) results: to restore and replenish the volume of soft tissue in the defect area by creating optimal conditions for the regeneration of damaged tissue, and also to avoid deformation of the surface of the gland due to the restored volume of soft tissue with full visualization and control monitoring the condition of the area of the removed formation using ultrasound and MRI of the mammary glands with intravenous contrast.

Claims (1)

A method for preventing contour deformation of the mammary gland after sectoral resections for neoplasms localized in the upper and inner quadrants, including a parareolar skin incision, according to pre-applied markings, removing the neoplasm with adjacent mammary gland tissues, replacing the defect by introducing spherogel into the formed cavity, characterized in that that the tissue deficiency is assessed, the formed bed is marked with titanium staples, the opposite edges of the resulting wound are compared and 4 sutures are applied, the resulting defect is filled with spherogel in a volume of 5 ml, after which the breast flaps are sutured in two layers: parenchyma and subcutaneous fat with absorbable suture material, the surgical wound is sutured with an intradermal suture.