RU2820816C1 - Mastopexy method combined with reduction mammoplasty - Google Patents

Abstract

FIELD: medicine; plastic surgery; reconstructive surgery.

SUBSTANCE: in the projection of marking by the Wise cut, a flap including the dermis and the epidermis is excised by a sharp path, then the flap is placed in a physiological solution, then manipulations are performed to cut out a nipple-areola complex from the parenchyma. Then, a new place of projection of the areola along the middle line is found, then the parenchyma at the apex of the leg is sutured to the fascia of the greater pectoral muscle in projection of 3–4 ribs with separate interrupted sutures with prolene 4.0 suture. After that, the excised skin area is placed in sterile 0.9% sodium chloride solution heated to 98 degrees Celsius for 20 seconds. Detached epidermis is removed with a scalpel, the treated area of the dermis is fixed in the form of a hammock to the superficial fascia of the greater pectoral muscle medially in region of 3–4 ribs laterally in region of 5–6th rib and in the region of the lower pole of the remaining parenchyma. Fixation is performed with separate interrupted sutures, suture Prolene 4.0. or PDS 4.0. Excess parenchyma is excised in medial and lateral parts, skin incision is closed in layers with formation of T-shaped inverted approach.

EFFECT: method allows to prevent recurrent ptosis of mammary glands in delayed postoperative period, to preserve aesthetic parameters in the area of intervention, thereby preventing secondary complications and relapses required for repeated surgical intervention.

1 cl, 1 ex

Description

The invention relates to the field of medicine, namely to plastic and reconstructive surgery, and can be used in the surgical treatment of ptosis of the mammary glands.

The history of surgical correction of mammary gland ptosis dates back to the 19th century, and reduction mammoplasties have been performed since ancient times. Even then, people tried to solve the problem of the aesthetic appearance of the mammary glands, and this problem is still relevant. Breast ptosis is caused by several factors:

- loss of skin turgor after age-related changes and repeated stretching after feeding;

- loss of glandular tissue mass after age-related atrophy or sudden weight loss;

- loss of elasticity of the native fascia of the mammary gland and Cooper’s ligaments;

- a large mass of mammary gland parenchyma, which stretches the integumentary tissues and internal structures under its own weight.

Ptosis of the mammary glands, as well as their excessive volume, causes psychological discomfort in patients, which can lead to disruption of the psycho-emotional state and social adaptation, therefore the main task of the surgeon is to achieve the most natural shape of the mammary gland, with the least amount of scars, adequate blood supply and nervation, and The main thing is the stability of the results obtained in the long term.

An adequate method of correcting the shape of the mammary gland can eliminate all these problems, improve the patient’s quality of life, his self-esteem, physical and psycho-emotional state.

At the moment, there is not a single method of mastopexy that fully satisfies the needs of the surgeon. One of the late postoperative complications is excessive prolapse of the mammary gland with too high a position of the nipple-areolar complex, as well as loss of its aesthetic appearance. Recurrence of mammary gland ptosis is the most common complication after this type of surgery.

There are many known methods of mastopexy in combination with reduction mammoplasty.

Breast reduction surgery combined with vertical access pexy is the G. Aries - I. Pitanguy technique. The basis of the technique is the resection of a small vertical section of skin with glandular tissue in the central part of the chest. The skin edges of the wound are peeled off to a certain distance, which allows the gland with the areola to be shifted upward, and the skin downward. The edges of the wound are brought to the midline with threads, which strengthens the nipple in the upper position. The skin around the areola is pulled upward in the form of a drapery and excised in a ring shape (Pitanguy I. Surgical treatment of breast hypertrophy. - Brit. J. PI. Surg., 1967, v. 20, paragraph 1, p. 78-85).

Disadvantages of this method:

1. A good result can be obtained only with a slight or moderate degree of breast hypertrophy with ptosis.

2. Distribution of the scar below the inframammary fold. And sometimes there is a need for a short or longer transverse incision to better distribute the breast skin.

3. If there is an error in planning the resected volume of the gland, its residual weight will put strong pressure on the vertical scar, which will subsequently expand.

4. There is a high risk of recurrence of breast ptosis.

Breast reduction surgery in combination with pexy using the L.Ribeiro method is known. The basis of the technique is to mark the skin on the anterior surface of the gland from the medial to the lateral end of the inframammary fold, going around the upper half of the areola. The lower marking line is drawn 2 cm above the inframammary fold. Deep-epidermization is performed within the outlined lines, excluding the areola. The skin along the upper line is dissected to the gland and peeled off with the flap turned upward. Along the midline, the gland is dissected to the base and funnel-shaped to the center of the gland. The edges of the glandular wound are sutured behind the dermis to the center and the formed glandular tissue is sutured to the pectoral fascia. Next, the skin is stretched and sutured from above to the submammary fold. A window for a new areola is identified on this skin (Ribeiro L. A new technique for redaction mammaplasty. - PI. Rec. Surg., 1975, v.55, n.3, p.330-334). Disadvantages of this method:

1. The surgical technique is quite traumatic and risky due to the possibility of damage to the supplying vessels and innervation of the nipple-areolar complex.

2. The impossibility of its implementation in case of severe hypertrophy of the mammary gland, gigantomastia and significant ptosis.

3. The upper quadrants of the gland remain weakly filled.

4. A long scar is formed in the area of the submammary fold.

5. There is a high risk of recurrence of breast ptosis.

There is a known method for resection and lifting of the mammary gland with a T-shaped (inverted) approach according to I. Pitanguy, which consists in de-epidermization of triangular-shaped skin with an areola in the center. From the ends of the triangle to the inframammary fold, incisions are made to form the side flaps. A new location for the areola is found in the midline after excision of excess skin and glandular tissue. The skin incision is sutured to form a T-shaped (inverted) access (Pitanguy I. et al. Functional alterations in breast hypertrophy. - Rev. Brasil. Cir., 1974, v.64, p.209).

Disadvantages of this method:

1. It is rational to use the operation in cases of mild and moderate hypertrophy.

2. A large postoperative scar remains.

3. There remains a risk of relapse of ptosis and breast flattening.

The objective of the invention is to achieve stability of fixation of the lower pole of the mammary gland and prevent secondary ptosis, due to the formation of a balcony from a free de-epidermalized flap.

The technical result of the proposed method is the development of a method of mastopexy in combination with reduction mammoplasty, which will allow achieving a stable aesthetic result that satisfies the patient in the delayed postoperative period.

The technical result is achieved by the fact that in the projection of markings using the Wise cut, a flap is sharply excised, including the dermis and epidermis, then the flap is placed in a physiological solution, then manipulations are performed to cut out the lower leg of the nipple-areolar complex from the parenchyma in a standard way, then find a new location for the projection of the areola along the midline, then the parenchyma at the apex of the leg is sutured to the fascia of the pectoralis major muscle in the projection of 3-4 ribs with separate interrupted sutures using Prolene 4.0 thread, after which the excised area of skin is placed in a sterile solution of sodium chloride 0.9%, heated to 98 degrees Celsius, for 20 seconds, the exfoliated epidermis is removed with a scalpel, the treated area of the dermis is fixed in the form of a hammock to the superficial fascia of the pectoralis major muscle medially in the area of 3-4 ribs, laterally in the area of 5-6 ribs and in the region of the lower pole of the remaining part of the parenchyma, Fixation is performed with separate interrupted sutures using Prolene 4.0 thread. or PDS 4.0, excess parenchyma is excised in the medial and lateral parts, the skin incision is sutured layer by layer to form a T-shaped inverted approach.

The novelty of this method lies in the fact that the excised area of skin, after special treatment, is fixed in the form of a hammock to the superficial fascia of the pectoralis major muscle medially in the area of 3-4 ribs, laterally in the area of 5-6 ribs and in the region of the lower pole of the remaining part of the parenchyma, thereby providing additional fixation of the parenchyma in the new position and stability of the result in the long-term postoperative period.

The method of mastopexy in combination with reduction mammoplasty is performed as follows.

In the projection of markings using the Wise cut, a flap is sharply excised, including the dermis and epidermis, then the flap is placed in a physiological solution, thorough hemostasis is carried out, then manipulations are performed to cut out the lower leg of the nipple-areolar complex from the parenchyma, according to the markings the parenchyma is dissected to the thoracic fascia from the medial part of the submammary fold, going around the nipple-areolar complex and going down to the lateral part of the submammary fold, preserving the feeding vessels coming from the submammary fold and the septa of Wühringer, excess parenchyma in the distal part of the pedicle is excised, a pocket is formed for moving the parenchyma in the cephalic direction, then a new place is found projections of the areola along the midline, then the parenchyma at the apex of the leg is sutured to the fascia of the pectoralis major muscle in the projection of 3-4 ribs with separate interrupted sutures using Prolene 4.0 thread, after which thorough hemostasis is carried out, the excised area of skin is placed in a sterile solution of sodium chloride 0.9%, heated up to 98 degrees Celsius, for 20 seconds (Yanov V.N. “Thermal treatment of autodermal flaps” V.N. Yanov “Bulletin of Surgery 1975”, No. 9, pp. 90-91), the exfoliated epidermis is removed with a scalpel, the treated area of dermis is fixed in the form of a hammock to the superficial fascia of the pectoralis major muscle medially in the area of 3-4 ribs, laterally in the area of 5-6 ribs and in the area of the lower pole of the remaining part of the parenchyma, fixation is carried out with separate interrupted sutures and Prolene 4.0 thread. or PDS 4.0, excess parenchyma in the medial and lateral parts is excised, a new shape of the mammary gland is formed, the juice-areolar complex is fixed in a new position to the skin with an intradermal Vicryl 4.0 suture, the skin incision is sutured layer by layer with Vicryl 4.0 thread to form a T-shaped inverted approach.

The performance of the proposed method is confirmed by the following clinical examples:

Patient G., 36 years old. Diagnosis: gigantomastia, ptosis of the mammary glands, grade 3 according to Regnault.

Treatment: Position the patient on the operating table lying on her back. After treating the surgical field with iodopirone, in the projection of the markings using the Wise cut, a sharp excision of the flap, which includes the dermis and epidermis, is carried out, then the flap is placed in a physiological solution, thorough hemostasis is carried out, then manipulations are performed to cut out the lower leg of the nipple-areolar complex from the parenchyma, according to the markings, the parenchyma is dissected to the pectoral fascia from the medial part of the submammary fold, going around the nipple-areolar complex and going down to the lateral part of the submammary fold, preserving the feeding vessels coming from the submammary fold and the septum of Würinger, excess parenchyma in the distal part of the pedicle is excised, a pocket is formed for the movement of parenchyma in the cephalic direction, then a new location for the projection of the areola is located along the midline, then the parenchyma at the apex of the leg is sutured to the fascia of the pectoralis major muscle in the projection of 3-4 ribs with separate interrupted sutures using prolene 4.0 thread, after which thorough hemostasis is carried out, the excised area of skin is placed in a sterile chloride solution sodium 0.9%, heated to 98 degrees Celsius for 20 seconds (see. Yanov V.N. “Thermal treatment of autodermal flaps” V.N. Yanov “Bulletin of Surgery 1975”, No. 9, pp. 90-91), the exfoliated epidermis is removed with a scalpel, the treated area of dermis is fixed in the form of a hammock to the superficial fascia of the pectoralis major muscle medially in the area 3-4 ribs laterally in the area of 5-6 ribs and in the area of the lower pole of the remaining part of the parenchyma, fixation is performed with separate interrupted sutures, Prolene 4.0 thread. or PDS 4.0, excess parenchyma in the medial and lateral parts is excised, a new shape of the mammary gland is formed, the juice-areolar complex is fixed in a new position to the skin with an intradermal Vicryl 4.0 suture, the skin incision is sutured layer by layer with Vicryl 4.0 thread to form a T-shaped inverted approach.

A bandage is applied to the mammary gland. In the postoperative period, the patient wears special medical compression garments for 1 month. The sutures around the areola are removed on the 10th day. Normal moderate lymphostasis in the surgical area resolves after 2 weeks.

After the operation, ptosis was eliminated. The nipple-areolar complex is projected at a level of 2.5 cm above the inframammary fold. The patient was completely satisfied with the operation.

A total of 10 patients were treated with the proposed method. In all patients, at the follow-up examination after 12 months, ptosis of the mammary gland was eliminated, the position of the nipple-areolar complex relative to the inframammary fold was normal. There is no recurrence of breast ptosis. The method is easily reproducible and can be used in departments of plastic and reconstructive surgery. Does not require large material costs.

The technical and economic result of the proposed method is that it helps prevent relapse of mammary gland ptosis in the delayed postoperative period, maintain aesthetic parameters in the area of intervention, thereby preventing secondary complications and relapses requiring repeated surgery.

Claims (1)

A method of mastopexy in combination with reduction mammoplasty, including the use of a de-epidermized skin autograft for additional fixation of the mammary gland parenchyma, characterized in that in the projection of the markings according to Wise, a sharp excision of the flap, which includes the dermis and epidermis, is carried out, then the flap is placed in a physiological solution, then manipulations are performed to cut out the nipple-areolar complex from the parenchyma of the lower leg, then a new location for the projection of the areola is found along the midline, then the parenchyma at the apex of the leg is sutured to the fascia of the pectoralis major muscle in the projection of 3-4 ribs with separate interrupted sutures using Prolene 4.0 thread, after the excised area of skin is placed in a sterile solution of sodium chloride 0.9%, heated to 98 degrees Celsius, for 20 seconds, the exfoliated epidermis is removed with a scalpel, the treated area of dermis is fixed in the form of a hammock to the superficial fascia of the pectoralis major muscle medially in the area 3-4 ribs laterally in the area of the 5th-6th rib and in the area of the lower pole of the remaining part of the parenchyma, fixation is carried out with separate interrupted sutures, Prolene 4.0 thread. or PDS 4.0, excess parenchyma is excised in the medial and lateral parts, the skin incision is sutured layer by layer to form a T-shaped inverted approach.